Chapter 85. Chlamydia Cervicitis

A 17-year-old girl presents to the sexually transmitted disease (STD) clinic because her boyfriend was diagnosed with a Chlamydia urethritis. Both she and her boyfriend admit to having had sexual partners in the past before starting to be sexually active with each other. On physical examination, there is ectopy and some mucoid discharge (Figure 85-1). The cervix bled easily while obtaining discharge and cells for a wet mount and genetic probe test. The wet mount showed many white blood cells (WBCs) but no visible pathogens. The patient was treated with 1 g of azithromycin taken in front of a clinic nurse. She was sent to the laboratory for rapid plasma reagin (RPR) and HIV tests and given a follow-up appointment in 1 week. The genetic probe test was positive for Chlamydia and all the other examinations were negative. This information was given to the patient on her return visit and safe sex was discussed.

Chlamydia trachomatis causes genital infections that can result in pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. Asymptomatic infection is common among both men and women so healthcare providers must rely on screening tests to detect disease. The Centers for Disease Control and Prevention (CDC) recommends annual screening of all sexually active women ages 25 years and younger, and of older women with risk factors, such as having a new sex partner or multiple sex partners.1

• A very common STD, Chlamydia is the most frequently reported infectious disease in the United States (excluding human papillomavirus [HPV]).1 An estimated 1.2 million cases are reported to the CDC annually in the United States.2
• The World Health Organization (WHO) estimates there are 140 million cases of Chlamydia trachomatis infection worldwide every year.3
• The CDC estimates screening and treatment programs can be conducted at an annual cost of $175 million. Every dollar spent on screening and treatment saves $12 in complications that result from untreated Chlamydia.4
• It is common among sexually active adolescents and young adults.5 As many as 1 in 10 adolescent girls tested for Chlamydia is infected. Based on reports to the CDC provided by states that collect age-specific data, teenage girls have the highest rates of chlamydial infection. In these states, 15- to 19-year-old girls represent 46% of infections and 20- to 24-year-old women represent another 33%.4

• C. trachomatis is a small Gram-negative bacterium with unique biologic properties among living organisms. Chlamydia is an obligate intracellular parasite that has a distinct life-cycle consisting of two major phases: The small elementary bodies attach and penetrate into cells, and the metabolically active reticulate bodies that form large inclusions within cells.
• It has a long growth cycle, which explains why extended courses of treatment are often necessary. Immunity to infection is not long-lived, so reinfection or persistent infection is common.
• The infection may be asymptomatic and the onset often indolent. It can cause cervicitis, endometritis, PID, urethritis, epididymitis, neonatal conjunctivitis, and pediatric pneumonia. Of exposed babies, 50% develop conjunctivitis and 10% to 16% develop pneumonia.1
• Chlamydia infections may lead to reactive arthritis, which presents with arthritis, conjunctivitis, and urethritis (Chapter 155, Reactive Arthritis). Past or ongoing C. trachomatis infection may be a risk factor for ovarian cancer.6,7
• Up to 40% of women with untreated Chlamydia will develop PID. Undiagnosed PID caused by Chlamydia is common. Of those with PID, 20% will become infertile; 18% will experience debilitating, chronic pelvic pain; and 9% will have a life-threatening tubal pregnancy. Tubal pregnancy is the leading cause of first-trimester, pregnancy-related deaths in American women.4

• Adolescents and young adults.1,2,8
• Nonwhite populations.
• Multiple sexual partners.
• Poor socioeconomic conditions.
• Single marital status.
• Nonbarrier contraceptive use.
• History of prior STD.

Clinical Features

• The cervix is inflamed, friable, and may bleed easily with manipulation. The cervix may show ectopy (columnar cells on the ectocervix). The discharge is usually mucoid or mucopurulent (Figure 85-1).
• Swab test—A white cotton-tip applicator is placed in the endocervical canal and removed to view. A visible mucopurulent discharge constitutes a positive swab test for Chlamydia (Figure 85-2). This is not specific for Chlamydia as other genital infections can cause a mucopurulent discharge, and is not recommended for diagnosis.

Laboratory Testing

• A significant proportion of patients with Chlamydia are asymptomatic, providing a reservoir for infection. All pregnant women and sexually active women younger than 25 years of age should be screened with routine examinations. A wet prep is usually negative for other organisms. Only WBCs and normal flora are seen.
• Chlamydia cannot be cultured on artificial media because it is an obligate intracellular organism. Tissue culture is required to grow the live organism. When testing for Chlamydia, a wood-handled swab must not be used, as substances in wood may inhibit Chlamydia organism. Culture has sensitivity of 70% to 100% and a specificity of almost 100%, which makes it the gold standard.1
• The enzyme-linked immunosorbent assay (ELISA) technique (Chlamydiazyme) has a sensitivity of 70% to 100% and a specificity of 97% to 99%.5 Fluorescein-conjugated monoclonal antibodies test (MicroTrak) has a sensitivity of 70% to 100% and a specificity of 97% to 99%.5
• C. trachomatis can be detected using nucleic acid amplification techniques (NAATs) on swabs or voided urine specimens. These tests are often used for testing to detect gonorrhea and Chlamydia. Nucleic acid amplification tests have been used successfully in difficult-to-reach adolescents (“street kids”) as well as in pediatric emergency departments and school-based settings.9,10 Screening in school-based settings was associated with significant reduction in Chlamydia rates during a 1-year period. Self-collected vaginal swab specimens perform at least as well as with other approved specimens using NAATs.11
• Rectal and oropharyngeal C. trachomatis infection in persons engaging in anal or oral intercourse can be diagnosed by testing at the site of exposure. Although not FDA-cleared for this use, NAATs have demonstrated improved sensitivity and specificity compared with culture for the detection at rectal sites12 and at oropharyngeal sites in men.13
• Certain NAATs have been FDA-cleared for use on liquid-based cytology specimens, although test sensitivity using these specimens might be lower.14
• Persons who undergo testing for Chlamydia should be tested for other STDs as well.1

• Gonorrhea frequently coexists with Chlamydia and should be tested for when a patient is thought to have Chlamydia. The discharge of gonorrhea may be more purulent but this is not always the case (Chapter 215, Gonococcal Urethritis)
• Bacterial vaginosis—The aromatic amine odor and clue cells help to distinguish between these infections (Chapter 82, Bacterial Vaginosis).
• Trichomoniasis—Look for the strawberry cervix and Trichomonas on the wet prep. There may also be a positive whiff test (see Chapter 84, Trichomonas Vaginitis).

Nonpharmacologic

• Patients diagnosed with Chlamydia cervicitis should be tested for other STDs.1

Medications

• Table 85-1 shows CDC recommended treatments for Chlamydia. Azithromycin (Zithromax) 1000 mg one-time dose is easy and may be directly observed in the clinic.1 SOR A It is the first-line therapy for Chlamydia during pregnancy.
• Other treatments include doxycycline 100 mg PO bid × 7 days.1 SOR A Avoid dairy products around time of dosing.
• Erythromycin might be less efficacious than either azithromycin or doxycycline, mainly because of the frequent occurrence of GI side effects that can lead to nonadherence.
• Ofloxacin (Floxin) 300 mg po bid × 7 days is an alternative that should be taken on an empty stomach.1 SOR A It is contraindicated in children or pregnant and lactating women, but may also cover Neisseria gonorrhoeae infection. Levofloxacin 500 mg orally for 7 days is another fluoroquinolone alternative.1 SOR A
• A metaanalysis of 12 randomized clinical trials of azithromycin versus doxycycline for the treatment of genital chlamydial infection demonstrated that the treatments were equally efficacious, with microbial cure rates of 97% and 98%, respectively.15
• Partners need treatment. If concerns exist that sex partners will not seek evaluation and treatment, then delivery of antibiotic therapy (either a prescription or medication) to their partners is an option.1
• Medications for chlamydial infections should be dispensed on site and the first dose directly observed to maximize medication adherence.1

Referral or Hospitalization

• With evidence of complications such as a tuboovarian abscess or severe PID.

• Individuals who are sexually active should be aware of the risk of STDs and that ways of avoiding infection include mutual monogamy and appropriate barrier protection.

• Treatment failures with full primary therapies are quite rare. Reinfection is very common and is related to nontreatment of sexual partners or acquisition from a new partner.

• Test-of-cure (repeat testing 3 to 4 weeks after completing therapy) is not recommended for persons treated with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected. However, test of cure is recommended in pregnant women.1

• To minimize transmission, persons treated for Chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen.
• To minimize the risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated.1

Patient Resources

• eMedicine Health. Cervicitis—http://www.emedicinehealth.com/cervicitis/article_em.htm.
• eMedicine Health. Chlamydia—http://www.emedicinehealth.com/chlamydia/article_em.htm.
• CDC patient information—http://www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm.

Provider Resources

• CDC. Sexually Transmitted Diseases (STDs) 2010: Diseases Characterized by Urethritis and Cervicitis—http://www.cdc.gov/std/treatment/2010/urethritis-and-cervicitis.htm.
• Chlamydial Genitourinary Infections—http://emedicine.medscape.com/article/214823-overview.
• Cervicitis—http://emedicine.medscape.com/article/253402.