Chlamydia trachomatis infections are often asymptomatic. The most common manifestations are cervicitis in women and urethritis in men. Urethritis presents with dysuria and urethral discharge. Complications include epididymitis, which can cause infertility if untreated. Symptoms of cervicitis include vaginal irritation, discharge, or spotting, particularly with intercourse, and the cervix may appear friable. If untreated, pelvic inflammatory disease (PID) may develop, which can be complicated by tubo-ovarian abscess (TOA) formation. Fallopian tube scarring from TOA increases risk for future ectopic pregnancy and infertility. Exposed neonates may develop chlamydial conjunctivitis within 5 to 14 days of delivery. Symptoms include mild swelling and watery to mucopurulent discharge.
Management and Disposition
Preferred treatment for urethritis and cervicitis is a single dose of oral azithromycin 1 g. Doxycycline 100 mg orally twice daily for 7 days is equally effective but should not be used if there are concerns about medication compliance. Alternative regimens include 7 days of oral ofloxacin 300 mg twice daily or levofloxacin 500 mg once daily.
Treat uncomplicated PID with a 14-day course of oral doxycycline 100 mg twice daily in conjunction with a single IM dose of ceftriaxone 250 mg IM. Complicated PID with TOA or other sequelae requires gynecologic consultation for possible surgical intervention and admission for parenteral antibiotics. Treat neonatal chlamydial conjunctivitis with erythromycin 50 mg/kg per day divided four times daily for 14 days. All sexual partners should be notified and treated empirically. Chlamydia is a reportable disease.
Due to common coinfection, empirically treat any patient with chlamydia for gonorrhea.
Chlamydia is not detected by routine urinalysis or culture. Therefore, dysuria with pyuria but without bacteriuria should prompt consideration of chlamydial infection in sexually active patients.
Male Chlamydial Urethritis. Thin urethral discharge of chlamydial urethritis. (Photo contributor: Walter Stamm, MD. From Handsfield HH, ed. Atlas of Sexually Transmitted Diseases, 3rd ed. New York, NY: McGraw Hill; 2011.)
Chlamydial Cervicitis. Mucopurulent cervicitis from chlamydial infection. (Photo contributor: Claire E. Stevens, PA. From Handsfield HH, ed. Atlas of Sexually Transmitted Diseases, 3rd ed. New York, NY: McGraw Hill; 2011.)
Chlamydia Conjunctivitis. Follicles (focal areas of conjunctival inflammation) and a thin watery discharge are seen typical of chlamydia conjunctivitis. This is usually an indolent course lasting weeks to months. Follicles and inflammation are best seen on the upper tarsal conjunctiva. (Photo contributor: Jeffrey Goshe, MD.)