CHLAMYDIA TRACHOMATIS – DIAGNOSIS AND MANAGEMENT Jess Gaddie (adapted from presentation by Rachel Coyne)

CHLAMYDIA Most common bacterial STI in Britain Caused by Chlamydia trachomatis Transmission through unprotected sexual intercourse Can be easily diagnosed and treated Undiagnosed infections may persist for months or years Risk factors : - <25s - new sexual partner - >1 sexual partner in last 12 months BRITISH SOCIETY OF SEXUAL HEALTH AND HIV UK NATIONAL GUIDELINE FOR THE MANAGEMENT OF GENITAL.

CLINICAL FEATURES WomenMen None (70%)None (50%) Vaginal dischargeUrethral discharge Irregular bleedingDysuria Abdominal pain + dysparuniaTesticular pain Dysuria Cervicitis + contact bleeding

CLINICAL FEATURES Rectal Infections - May be asymptomatic - Rectal discharge/bleeding - Anorectal discomfort Lymphgranuloma venereum (LGV) - Caused by one of 3 invasive serovars of Chlamydia tranchomatis - Seen most commonly in men who have sex with men (MSM) - Associated with more severe rectal symptoms - Requires longer courses of treatment Pharyngeal Infections - Asymptomatic WHITE J ET AL UK NATIONAL GUIDELINE FOR THE MANAGMENT OF LYMPHGRAUNOMA VENEREUM. INT J STD AIDS 2013 AUG;24(8):

COMPLICATIONS Pelvic Inflammatory Disease Est 35% caused by CT in the UK Acute pelvic pain +/- sepsis Long-term complications – chronic pelvic pain, ectopic pregnancy, subfertility PRICE MJ ET AT. PROPORTION OF PELVIC INFLAMMATORY DISEASE CAUSED BY CHLAMYDIA TRACHOMATIS; CONSISTIENT PICTURE FROM DIFFERENT METHODS. J INFECT DIS AUG 15; 21(4):617-24

COMPLICATIONS Epididymo-orchitis Adult conjunctivitis Reactive arthritis May increase the risk of transmission of HIV Increased persistence of Human Papilloma Virus (HPV) Pregnant women – neonatal conjunctivitis and pneumonia

CHLAMYDIA PREVALENCE RegionNumber Chlamydia Tests Positive testsPercent population tested Percent of tests positive Detection rate per London %8%2 200 ENGLAND %8%1 861 Data: PHE, Chlamydia testing year olds in 2015

LATestsPositives% testedDetection/ Barnet Hackney Lewisham Hackney Coverage rateLondon coverage rateEngland coverage rate 40.8%27.4%22.5% Coverage rates for CT testing 2015 in year olds

NATIONAL CHLAMYDIA SCREENING PROGRAMME (NCSP) High proportion of asymptomatic disease requires screening of ‘at risk’ individuals Screening is acceptable and sensitive. NCSP recommends screening of <25s annually or with each new sexual partner Screening should be opportunistic – e.g. non-GUM clinical settings, non-clinical settings, increased availability of home-testing - Natsal-3 survey demonstrated relatively high rates of coverage. 54% sexually active women and 35% young men had had a chlamydia test in the last year 53% of chlamydia infections in year olds were diagnosed in non-GUM settings in 2015 PUBLIC HEALTH ENGLAND. THE NATIONAL CHLAMYDIA SCREENING PROGRAMME: AN OVERVIEW. AVAILABLE ONLINE AT

IMPACT OF SCREENING Facilitates earlier diagnosis and treatment of chlamydia, and other sexually transmitted infections Reduced complications of chlamydia infection - 36% lower risk of developing PID within one year Reduced transmission to partners PUBLIC HEALTH ENGLAND. OPPORTUNISITIC CHLAMYDIA SCREENING OF YOUNG ADULTS IN ENGLAND - AN EVIDENCE SUMMARY

DIAGNOSIS Screening test must be: - Acceptable to general population - Sensitive – low rate of false negatives, ability to pick up infection in asymptomatic men and women - Specific – low rate of false positives

DIAGNOSIS – NUCLEIC ACID AMPLIFICATIONS TESTS (NAATS) Amplify nucleic acid sequences specific to the organism being detected Single sample used to screen for Chlamydia and Gonorrhoea Can produce a positive signal from even a single copy of target DNA or RNA 90-95% sensitivity for Chlamydia - Tissue culture 60-80% - Enzyme immunoassays 40-70% 95-99% specificity JOHNSON RE ET AL. SCREENING TESTS TO DETECT CHLAMYDIA TRACHOMATIS AND NEISSERIA GONORRHOEA INFECTIONS

NAATS – AVAILABLE COMMERCIAL ASSAYS Abbott RealTime PCR assay (Abbott m2000, Abbott Diagnostics) BD ProbeTec ET, Strand displacement amplification (SDA, Becton Dickinson) COBAS Taqman, Polymerase chain reaction assay (Real-time PCR, Roche Diagnostics) GenProbe Aptima assay, Transcription mediated amplification assay (TMA, GenProbe) BRITISH SOCIETY FOR SEXUAL HEALTH AND HIV. CHLAMYDIA TRACHOMATIS - UK TESTING GUIDELINES. 2010,

SITES TO BE SAMPLED - WOMEN Endocervical swabs & Vulvovaginal swab (VVS) Vulvovaginal Swabs (VVS) -Obtained by inserting the swab 2-3cm into vagina and rotating for seconds -Can be self-taken or clinician obtained - Higher sensitivity than endocervical swabs in diagnosing Chlamydia in both symptomatic and asymptomatic women: 97% vs 88%, p=< Non invasive -Easily carried out in both clinical and non clinical settings

SITES TO BE SAMPLED - MEN First voided urine -Hold urine for 1-2 hours prior to sample collection -First 15-50ml urine passed -Equal sensitivity as urethral swabs -Non invasive -Easily preformed in clinical and non-clinical settings

RECTAL AND PHARYNGEAL SAMPLES NAATs unlicensed for use at extra-genital sites Evidence suggests NAATs perform well at extra-genital sites Recommended in men who have sex with men (MSM) and commercial sex workers at risk of extra-genital chlamydia infection

WHEN TO TEST Symptoms of sexually transmitted infection Annually/ new sexual partner Timing – 2 weeks after potential exposure

TREATMENT Recommended regimens: 1g azithromycin stat 100mg doxycycline bd 7 days (contraindicated in pregnancy) Rectal and pharyngeal infection: Asymptomatic – 100mg doxycycline bd 7 days (if LGV negative) Symptomatic – 100mg doxycycline bd days Alternative regimens: Erythromycin 500mg bd days Ofloxacin 200mg bd or 400mg od 7 days BRITISH SOCIETY OF SEXUAL HEALTH AND HIV UK NATIONAL GUIDELINE FOR THE MANAGEMENT OF GENITAL.

TREATMENT No sexual intercourse for 7 days Partner notification and treatment - Patient symptomatic: Partners in last 4 weeks - Patient asymptomatic: Partners in last 6 months Retreatment if vomiting occurs within 3 hours of taking azithromycin

FOLLOW-UP Following up partner notification Reinforcing health education Ensuring compliance with treatment and abstinence from sexual intercourse until partner(s) have completed antibiotics (if treated with azithromycin waiting seven days). Re-treat non-compliant and/or re-exposed individuals. CT test may remain positive for up to 6 weeks after treatment of infection, therefore routine STI screening after 3-4 months is recommended.

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