Guidelines

WHO Guidelines on the Treatment of Chlamydia trachomatis Infection

Guidelines on treatment of Chlamydia trachomatis infection by the World Health Organization (WHO) are summarized below. [63]

Uncomplicated Genital Chlamydia

WHO recommendations for the treatment of uncomplicated genital chlamydia are as follows:

  • Azithromycin 1 g orally as a single dose or
  • Doxycycline 100 mg orally twice a day for 7 days or one of these alternatives: tetracycline 500 mg orally 4 times a day for 7 days, erythromycin 500 mg orally twice a day for 7 days, or ofloxacin 200-400 mg orally twice a day for 7 days

Anorectal Chlamydial Infection

In anorectal chlamydial infection, the WHO recommends doxycycline 100 mg orally twice a day for 7 days over azithromycin 1 g orally as a single dose.

Chlamydial Infection in Pregnant Women

WHO recommendations for the treatment of chlamydial infection in pregnancy are as follows:

  • Azithromycin recommended over erythromycin
  • Azithromycin recommended over amoxicillin
  • Amoxicillin recommended over erythromycin
  • Azithromycin 1 g orally as a single dose or
  • Amoxicillin 500 mg orally 3 times a day for 7 days or
  • Erythromycin 500 mg orally twice a day for 7 days

Lymphogranuloma Venereum

WHO recommendations for the treatment of lymphogranuloma venereum (LGV) are as follows:

  • In adults and adolescents with LGV, the guidelines suggest doxycycline 100 mg orally twice daily for 21 days over azithromycin 1 g orally weekly for 3 weeks.
  • Good practice dictates treatment of LGV, particularly for men who have sex with men and for people with HIV infection.
  • When doxycycline is contraindicated, azithromycin should be provided.
  • When neither treatment is available, erythromycin 500 mg orally 4 times a day for 21 days is an alternative.
  • Doxycycline should not be used in pregnant women.

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Agents used in the management of chlamydial genitourinary infections are treated primarily by administering antibiotics. Treatment of genitourinary chlamydial infection clearly is indicated when the infection is diagnosed or suspected; for sexual partners of the index case; and for patients being treated for gonorrhea.

Antibiotics, Other

Class Summary

The Centers for Disease Control and Prevention (CDC) recommends azithromycin and doxycycline as first-line drugs for the treatment of chlamydial infection. Second-line drugs (eg, erythromycin, penicillins, and sulfamethoxazole) are less effective and have more adverse effects.

Azithromycin (Zithromax, Zmax)

Azithromycin is a relatively new member macrolide antibiotic that possesses activity against various different bacterial organisms. It binds to the 50S ribosomal subunit of the bacteria, thereby inhibiting bacterial protein synthesis. Related to erythromycin, azithromycin is considered by many to be the treatment of choice for Chlamydia trachomatis genitourinary infection because it may be administered in a single dose, which improves adherence to treatment.

Doxycycline (Adoxa, Doryx, Monodox, Avidoxy, Vibramycin)

Doxycycline, a well-absorbed tetracycline derivative, is the second drug of choice for genital chlamydia infections. It has a limited spectrum of bacterial activity but is effective in treating chlamydial infections. Doxycycline binds to the 30S and, possibly, 50S ribosomal subunits of the bacteria, thereby inhibiting bacterial protein synthesis.

One week of doxycycline appears to be as effective as a single dose of azithromycin for treating genitourinary chlamydial infections. Although the course is longer than that of azithromycin, the cost is less, and doxycycline has been used in clinical practice for a much longer time. Because of the need for extended therapy, compliance is often poor.

Levofloxacin (Levaquin)

For pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.

Ofloxacin

Penetrates prostate well and is effective against N gonorrhea and C trachomatis.

A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.

Erythromycin (E.E.S., Ery-Tab, Erythrocin, EryPed, PCE)

Erythromycin is a macrolide antibiotic with a large spectrum of activity. It binds to the 50S ribosomal subunit of the bacteria, thereby inhibiting bacterial protein synthesis. Generally, erythromycin is considered a recommended treatment for chlamydial genitourinary infection only in pregnant women. Some recommend it in infants as well.

Cefoxitin (Mefoxin)

Second-generation cephalosporin with activity against some gram-positive cocci, gram-negative rod infections, and anaerobic bacteria. Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death.

Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

Ampicillin

Like erythromycin, ampicillin is considered a recommended treatment for genitourinary chlamydial infection only in pregnant women. Ampicillin binds to penicillin-binding proteins, which inhibit bacterial cell wall synthesis by inhibiting the final transpeptidation step of peptoglycan synthesis in bacterial cell wall. This in turn causes the bacteria to lyse due to ongoing activity of cell wall autolytic enzymes.

Amoxicillin (Moxatag)

Because of its lower efficacy, amoxicillin is indicated only when the patient is both pregnant and erythromycin-allergic. Amoxicillin is a penicillin antibiotic with activity against gram-positive and some gram-negative bacteria. It binds to penicillin-binding proteins, thereby inhibiting bacterial cell wall growth.

Cefotetan

Second-generation cephalosporin used as single-drug therapy to provide broad gram-negative coverage and anaerobic coverage. Also provides some coverage of gram-positive bacteria. Half-life is 3.5 h. Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death.

Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism.

Clindamycin (Cleocin, CLIN Single Use)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Gentamicin

Gentamicin is an aminoglycoside antibiotic for gram-negative coverage. It is used in combination with an agent against gram-positive organisms and one that covers anaerobes.

Ampicillin/sulbactam (Unasyn)

This combination of a beta-lactamase inhibitor and ampicillin interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Metronidazole (Flagyl, Flagyl ER, Metro)

Metronidazole is active against various anaerobic bacteria and protozoa. It appears to be absorbed into the cells; the intermediate metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.

Presentation

How are chlamydial genitourinary infections (chlamydia) diagnosed?

What are the USPSTF recommendations for routine screening of women for chlamydial genitourinary infections (chlamydia)?

What is the prevalence of chlamydial genitourinary infections (chlamydia) in men?

What are the signs and symptoms of chlamydial genitourinary infections (chlamydia)?

What history should be noted in patients with suspected chlamydial genitourinary infection (chlamydia)?

What should be noted in the history of females with suspected chlamydial genitourinary infection (chlamydia)?

What may be noted in the history of males with suspected chlamydial genitourinary infection (chlamydia)?

What should be noted in the history of newborns with suspected chlamydial infection (chlamydia)?

What should be noted in the history of mothers diagnosed with or suspected of having chlamydial genitourinary infection (chlamydia) during pregnancy?

What are the signs of chlamydial genitourinary infection (chlamydia) in women?

What are the signs of chlamydial genitourinary infection (chlamydia) in men?

What are the signs of chlamydial genitourinary infection (chlamydia) in newborns?

What are signs of lymphogranuloma venereum (LGV) chlamydial genitourinary infection (chlamydia)?

What are the possible sequelae of chlamydial genitourinary infection (chlamydia) in women?

What is the risk of ectopic pregnancy in women who have had pelvic inflammatory disease (PID) caused by chlamydial genitourinary infection (chlamydia)?

What is Fitz-Hugh-Curtis syndrome (perihepatitis) and how is it associated with chlamydial genitourinary infections (chlamydia)?

Which disorders are women with chlamydial genitourinary infections (chlamydia) at an increased risk of acquiring?

How is chlamydial pneumonia or chlamydial conjunctivitis transmitted to infants?

What is Reiter syndrome and how is chlamydial genitourinary infection (chlamydia) a risk factor?

What are potential complications of chlamydial genitourinary infections (chlamydia)?

DDX

What conditions should be included in the differential diagnoses of chlamydial genitourinary infections (chlamydia)?

Workup

Which patients should be evaluated for chlamydial genitourinary infections (chlamydia)?

Which specimens should be obtained and assayed in the workup of Chlamydia trachomatis (C trachomatis) infection?

Which lab tests should be performed in infants with suspected chlamydial pneumonia?

Which lab tests should be performed in infants with suspected chlamydial conjunctivitis?

When is treatment indicated in infants of mothers with untreated chlamydial infection (chlamydia) during pregnancy?

What is the role of a CBC in the workup of chlamydial genitourinary infection (chlamydia)?

When is a pregnancy test indicated in women with suspected chlamydial genitourinary infection (chlamydia)?

What is the role of cytology in the workup of chlamydial genitourinary infections (chlamydia)?

What is the role of cell culture in the workup of chlamydial genitourinary infections (chlamydia)?

How should specimens be obtained for molecular testing in the workup of chlamydial genitourinary infections (chlamydia)?

What is the role of direct fluorescent antibody (DFA) testing in the workup of chlamydial genitourinary infections (chlamydia)?

What is the role of ELISA in the workup of chlamydial genitourinary infections (chlamydia)?

How is chlamydial DNA detected in the workup of chlamydial genitourinary infection (chlamydia)?

What is the role of PCR testing in the workup of chlamydial genitourinary infections (chlamydia)?

What is the role of nucleic acid amplification testing (NAAT) in the workup of chlamydial genitourinary infections (chlamydia)?

Which nucleic acid amplification tests (NAATs) are used in the workup of chlamydial genitourinary infections (chlamydia)?

What are the CDC recommendations for the use of nucleic acid amplification tests (NAATs) in the diagnosis of chlamydial genitourinary infections (chlamydia)?

What are the disadvantages of nucleic acid amplification tests (NAATs) in the diagnosis of chlamydial genitourinary infections (chlamydia)?

Which serologic findings suggest chlamydial genitourinary infections (chlamydia)?

What is the prevalence of antichlamydia immunoglobulin M (IgM) in sexually active adults and what does it suggest?

What is the efficacy of serologic studies for the diagnosis of chlamydial genitourinary infections (chlamydia)?

What is the role of imaging studies in the workup of chlamydial genitourinary infections (chlamydia)?

What is the role of a chest radiograph in infants with suspected chlamydial pneumonia?

What are the USPSTF recommendations for the screening of chlamydial genitourinary infections (chlamydia)?

What screening test may be used for chlamydial genitourinary infections (chlamydia) in asymptomatic males?

Treatment

What is the key to successful management of chlamydial genitourinary infections (chlamydia)?

What is the disease progression of untreated chlamydial genitourinary infection (chlamydia)?

Which condition is often misdiagnosed as chlamydial genitourinary infections (chlamydia)?

Which patients are at high risk for noncompliance with treatment for chlamydial genitourinary infections (chlamydia)?

When is hospitalization indicated in the treatment of chlamydial genitourinary infections (chlamydia)?

When is antibiotic therapy for chlamydial genitourinary infection (chlamydia) initiated?

When are specialist consultations indicated in the management of chlamydial genitourinary infections (chlamydia)?

What are two categories of genital Chlamydia trachomatis (C trachomatis) infection?

What are the treatment options for chlamydial genitourinary infections (chlamydia)?

What is standard therapy for uncomplicated genital tract chlamydial genitourinary infections (chlamydia)?

What is the role of azithromycin in the treatment of chlamydial genitourinary infections (chlamydia)?

What is the treatment of lower genital infections caused by Chlamydia?

What are the disadvantages of DNA and antigen detection kits for the diagnosis of chlamydial genitourinary infections (chlamydia)?

What is the sequelae of inadequately treated pelvic inflammatory disease (PID) caused by chlamydial genitourinary infections (chlamydia)?

What should be in included in the management of pelvic inflammatory disease (PID) in patients with chlamydial genitourinary infections (chlamydia)?

What are the parenteral regimens for the inpatient treatment of pelvic inflammatory disease (PID) in patients with chlamydial genitourinary infections (chlamydia)?

What are outpatient regimens for treatment of pelvic inflammatory disease (PID) in patients with chlamydial genitourinary infections (chlamydia)?

What are the treatment options and duration for chlamydial conjunctivitis and chlamydial pneumonia?

What are the CDC treatment guidelines for gonococcal infection and chlamydial genitourinary infections (chlamydia)?

What are the CDC guidelines for treatment of chlamydial genitourinary infections (chlamydia) during pregnancy?

What is included in posttherapy care for chlamydial genitourinary infections (chlamydia)?

How are chlamydial genitourinary infections (chlamydia) prevented?

What are the ACOG guidelines on partner therapy for chlamydial and gonorrheal sexually transmitted diseases?

What monitoring is needed during and after treatment for chlamydial genitourinary infections (chlamydia)?

Guidelines

What are the WHO guidelines on treatment of uncomplicated chlamydial genitourinary infections (chlamydia)?

What are the WHO recommendations for treating anorectal chlamydial infection?

What are the WHO recommendations in the treatment of chlamydial genitourinary infections (chlamydia) in pregnancy?

What are the WHO recommendations in the treatment of lymphogranuloma venereum (LGV)?

Medications

What are the goals of pharmacotherapy for chlamydial genitourinary infections (chlamydia)?

Which medications in the drug class Antibiotics, Other are used in the treatment of Chlamydia (Chlamydial Genitourinary Infections)?

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