CHLAMYDIAL INFECTIONS

Essentials of diagnosis

 Mucopurulent cervicitis.
 Salpingitis.
 Urethral syndrome.
 Nongonococcal urethritis in males.
 Neonatal infections.
 Lymphogranuloma venereum.

General Considerations

 Genital infection with this organism is the most common sexually

transmitted bacterial disease in women.
 Chlamydiae are obligate intracellular microorganisms that have a cell
wall similar to that of gram-negative bacteria
 Chlamydiae attach only to columnar epithelial cells without deep tissue
invasion
 As a result of this characteristic, clinical infection may not be apparent
 Infections of the eye, respiratory tract, or genital tract are accompanied
by discharge, swelling, erythema, and pain localized to these areas only.
 C trachomatis infections are associated with many adverse sequelae due
to chronic inflammatory changes as well as fibrosis (e.g. tubal infertility
and ectopic pregnancy).
 The proposed mechanism for the pathogenesis of chlamydial disease is
an immune-mediated response.
 Sexually active women younger than 20 years of age have chlamydial
infection rates 2-3 times higher than those of older women.
 The numbers of sexual partners, and in some studies lower
socioeconomic status, are associated with higher chlamydial infection
rates.
 Women who use oral contraceptives may have a higher incidence of
cervical infection than women not using oral contraceptives.

Symptoms and Signs

 It is not uncommon for women with chlamydial infection to be
asymptomatic.
 Women with cervical infection generally have a mucopurulent discharge
with hypertrophic cervical inflammation.
 Clinical infection in females manifests as dysuria, urethritis, vaginal
discharge, cervicitis, or PID.
 The presence of mucopus at the cervical os (mucopurulent cervicitis) is a
sign of Chlamydia or gonorrhea.
 Salpingitis may be unassociated with symptoms.
 In males, Chlamydia may be asymptomatic or manifest as dysuria,
urethritis, or epididymitis.
 Fifty percent of male patients complain of urethral discharge; in an
additional 30% a clear white discharge is revealed after milking the
penis.

Complications

 Adverse sequelae of salpingitis, specifically infertility due to tubal

obstruction and ectopic pregnancy, are the most dire complications of
these infections.
 Pregnant women with cervical chlamydial infection can transmit
infections to their newborns; there is evidence that up to 50% of infants
born to such mothers will have inclusion conjunctivitis
 This pathogen may also cause otitis media in the neonate.
 Whether or not maternal cervical infection with Chlamydia causes
significantly increased fetal and perinatal wastage by abortion, premature
delivery, or stillbirth remains uncertain.
 Increasing evidence exists that chlamydial infection in pregnancy is a risk
marker for premature delivery and postpartum infections.
 It is hypothesized that asymptomatic cervicitis predisposes to mild
amnionitis.
 This event activates phospholipase A2 to release prostaglandins, which
cause uterine contractions that may lead to premature labor.
 Chlamydial infection is associated with higher rates of early postpartum
endometritis as well as a delayed infection from Chlamydia that often
presents several weeks postpartum.

Treatment
 In most cases, Chlamydia can be eradicated from the cervix by
doxycycline, 100 mg orally twice daily for 7 days (for nonpregnant
patients), or azithromycin, 1 g orally as a single dose.
 Erythromycin base, 500 mg, or erythromycin ethylsuccinate, 800 mg,
orally 4 times a day should be given for a minimum of 7 days as an
alternate regimen
 Patients who cannot tolerate erythromycin should consider ofloxacin, 300
mg twice daily or levofloxacin 500 mg orally once daily for 7 days
 Pregnant women are advised to take erythromycin base, 500 mg, 4 times
per day for 7 days, or amoxicillin, 500 mg, 3 times a day for 7 days.
 Alternate regimens include erythromycin base 250 mg orally 4 times
daily for 14 days, erythromycin ethylsuccinate 800 mg orally 4 times
daily for 7 days, or Azithromycin 1 g orally as a single dose.