PID
Normal Human Fallopian Tube Tissue
C. trachomatis Infection (PID)
C. trachomatis infection in men
• Urethritis
Majority (>50%) asymptomatic
– Symptoms/signs if present: mucoid or clear urethral discharge,
dysuria
– Incubation period unknown (probably 5-10 days in symptomatic
infection)
Chlamydia during pregnancy or infants
• Associated:
– premature birth
– low birth weight
– stillbirths
• During delivery ~50% of infants get infected:
– Conjuctivitis (5-12 days after birth)
– Pneumonia (subacute, afebrile pneumonia (1– 3 months after birth)
Laboratory testing diagnostics
Diagnostic opportunities
• Culture
• Non-culture
– Nucleic Acid Amplification Tests (NAATs)
- PCR (polymerase chain reaction)
– Non-Nucleic Acid Amplification Tests (Non-NAATs)
– Direct fluorescence antibody (DFA) (visualization against elementary
bodies)
– Enzyme immunoassay (EIA) (against chlamydial lipopolysaccharide)
– Serology
Culture
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Historically the “gold standard”
Variable sensitivity (50%-80%)
High specificity
Use in legal investigations
Not suitable for widespread screening
Non-NAATs
• Direct fluorescent antibody (DFA)- sensitivity 70%
C. Trachimatis inclusions
• Enzyme immunoassay (EIA)
• Nucleic acid hybridization (NA probe=NAP)
C.trachomatise ja N.gonorrhoeae DNA or RNA
NAATs
• NAATs amplify and detect organism-specific
genomic or plasmid DNA or rRNA
• FDA cleared for urethral swabs from men/women,
cervical swabs from women, and urine from both
Serology
• Rarely used for uncomplicated infections (results difficult to interpret)
• Criteria used in LGV diagnosis
– Complement fixation titers >1:64 suggestive
– Complement fixation titers > 1:256 diagnostic
– Complement fixation titers < 1:32 rule out
Sensitivity %
Culture
Specificity %
40-70
>99
DFA
50-70
95-99
EIA
60-70
95-99
PCR
95-98
>99
PCR – new gold standard!
Women
• Vaginal swab vs cervical swab ???
• Self-sampling or clinican???
Sensitivity
Urine
Vaginal (self)
81 %
93%
Vaginal (clinician) Cervical
93%
91%
Schachter et al, Vaginal swabs are appropriate specimens for diagnosis of genital tract infection with Chlamydia
trachomatis. J Clin Microbiol, aug 2003.
Patient vs clinician collecting sample
Schoeman SA BMJ 2012
Men
• Urine vs urethral swab???
Urine
Sensitivity
96-99%
Urethral swab
97.5-99.5%
Chernesky at al, Ability of New APTIMA CT and APTIMA GC Assays To Detect Chlamydia trachomatis and
Neisseria gonorrhoeae in Male Urine and Urethral Swabs. J Clin Microbiol 2005.
• Urethral swab discomfort
Practical recommendations
Sampling:
• Women: vaginal swab
• Men: urine (2-4 h before urination)
Patient vs clinician sampling- no difference!
Sample collection for testing during GP visit
How to collect a sample
• Vaginal swab: sampling from vagina with dry sterile swab, 10-15 turns
NB! Essential to get epithelium cells not mucus
How to collect a sample
• Urethral swab: take speciment with dry tampon 2–4 cm deep, rotating the
swab for 3-5 seconds.
• Urine: 15–30 ml first-void urine to sterile container.
STI guidelines in Estonia
Partner management
• Sex partners should be evaluated, tested, and treated if they had
sexual contact with the patient during the 60 days preceding the
onset of symptoms or diagnosis of chlamydia.
• The most recent sex partner should be evaluated and treated
even if the time of the last sexual contact was >60 days before
symptom onset or diagnosis.
Why to screen chlamydia?
• Most infections are asymptomatic
• High prevalence in selected population groups
• Preventing sequelae (incl newborn infections)
– Screening can reduce the incidence of PID for about 35%
Chlamydia screening in Estonia
• Repeat screening of women 3-4 months after treatment for C.
trachomatis infection (Estonian guideline).
• http://www.eusti.ee/STI_ravijuhis_2011.pdf
Chlamydia screening in Estonia
• Screen all pregnant women at the first prenatal visit
• Antenatal guidelines
http://www.ens.ee/
Reporting
• Chlamydia is reportable STI
• Chlamydia should be reported to Health Board (NAKIS)
• Control and prevention of infectious disease law
(https://www.riigiteataja.ee/akt/12769931)
Prevention counceling
• Nature of the infection
– Chlamydia is commonly asymptomatic in men and women.
– In women, there is an increased risk of upper reproductive tract damage
with re-infection
• Transmission issues
– Effective treatment of chlamydia may reduce HIV transmission and
acquisition.
– Abstain from sexual intercourse until partners are treated and for 7 days
after a single dose of azithromycin or until completion of a 7-day regimen.
Prevention counceling
• Risk reduction
The clinician should:
– Assess the patient’s behavior-change potential.
– Discuss prevention strategies (abstinence, monogamy, condoms, limit
number of sex partners, etc.). Latex condoms, when used consistently and
correctly, can reduce the risk of transmission of chlamydia.
– Develop individualized risk-reduction plans.
Case study
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Suzy Jones: 17-year-old college student who presents to the Student Health Center
seeking advice about contraception
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Shy talking about her sexual practices
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Has never had a pelvic exam
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Has had 2 sex partners in past 6 months
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Does not use condoms or any other contraceptives
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Her periods have been regular, but she has recently noted some spotting between
periods. Last menstrual period was 4 weeks ago.
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Denies vaginal discharge, dyspareunia, genital lesions, or sores
Physical exam
• Vital signs: blood pressure 118/68, pulse 74, respiration 18, temperature
37.1° C
• Breast, thyroid, and abdominal exam within normal limits
• Genital exam reveals normal vulva and vagina
• The cervix appears inflamed, bleeds easily, with a purulent discharge coming
from the cervical os.
• Bimanual exam is normal without cervical motion pain, uterine or adnexal
tenderness
Questions?
1. What is the initial clinical diagnosis?
2. What are the possible etiologic agents associated
with the clinical findings?
3. What is the most likely microbiologic diagnosis?
4. Which laboratory tests should be ordered or
performed?
Lab results
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NAAT for Chlamydia trachomatis: positive
NAAT for Neisseria gonorrhoeae: negative
RPR: negative
Wet mount: pH 4.2, no clue cells or trichomonads but numerous
WBCs
KOH preparation: negative for “whiff test”
HIV antibody test: negative
Pap smear: ASC-US
Pregnancy test: negative
Questions?
5. What is the final diagnosis?
6. What is the appropriate treatment at the initial visit?
7. What are the appropriate prevention and counseling
messages for Suzy?
8. Who is responsible for reporting this case to the local
health department?
Partner management
Suzy’s sex partners from the past year:
• John – Last sexual exposure 5 weeks ago
• Tom – Last sexual exposure 7 months ago
• Michael – Last sexual exposure 2 weeks ago
9. Which sex partners should be evaluated, tested, and
treated?
Follow-up
Suzy returned for a follow-up visit at 4 months.
– Her repeat Pap test came back normal.
– Her repeat chlamydia test returned positive.
– Suzy stated that her partner, Michael, went to get tested,
but the test result was negative so he was not treated.
10. What is the appropriate treatment at the 4-month follow-up
visit?
Conclusion
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Chlamydia is most common STI
Usually asymptomatic
Sample collection for testing is easy
Effective treatment
Treatment prevents complications
References
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CDC (USA) Sexually Transmitted Diseases (STDs) training resources (incl
www2a.cdc.gov/stdtraining/ready-to-use/Manuals/Chlamydia/chlamydia-slides-2010.pdf)
ECDC. Sexually transmitted infections in Europe. 2011, 2012.
Www.sharininhealth.ca
A.Uusküla et al. The prevalence of chlamydial infection in Estonia: a population-based survey. Int J STD
AIDS 2008; 19(7): 455—58.
www.cdc.gov
Schachter et al. Vaginal swabs are appropriate speciments for diagnosis of genital tract infection with
Chlamydia trachomatis. J Clin Microbiol 2003; 41(8): 3784—9.
Schoeman et al. Assessment of best single sample for finding chlamydia in women with and without
symptoms: a diagnostic test study. BMJ 2012; 345 e8013.
STI guidelines in Estonia. http://www.eusti.ee/STI_ravijuhis_2011.pdf
Antenatal guidelines in Estonia. http://www.ens.ee
Health Board. www.terviseamet.ee
Control and prevention of infectious disease law. www.riigiteataja.ee/akt/12769931