UK Chlamydia Guidelines 2015

1 Guidelines2015 UK national guideline for themanagement of infection withChlamydiatrachomatisNneka C Nwokolo1, Bojana Dragovic2, Sheel Patel1,CY William Tong3, Gary Barker4and Keith Radcliffe5 AbstractThis guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principlesneeded for the effective management ofChlamydia trachomatisgenital infection. It covers the management of the initialpresentation, as well the prevention of transmission and future infection. The guideline is aimed at individuals aged16 years and older presenting to healthcare professionals working in departments offering Level 3 care in sexuallytransmitted infections management within the UK. However, the principles of the recommendations should be adoptedacross all levels, using local care pathways where transmitted infection, Chlamydia , Chlamydia trachomatis, lymphogranuloma venereum, LGV, bacterial STIs, treat-ment, diagnosis, guidelineDate received: 13 June 2015; revised: 6th October 2015; accepted: 9 October 2015 New in the 2015 of nucleic acid amplification tests (NAATs) andpoint of care testing.

2 Advice on repeat Chlamydia testing;.Discussion of adequacy of single-dose azithromycintreatment;.Treatment of individuals co-infected with chlamydiaand gonorrhoea;.Treatment of rectal Chlamydia ;.Vertical transmission and management of and methodologyScope and purposeThis guideline offers recommendations on the diagnos-tic tests, treatment regimens and health promotionprinciples needed for the effective management ofChlamydia trachomatisgenital infection. It covers themanagement of the initial presentation, as well the pre-vention of transmission and future guideline is aimed at individuals aged 16 yearsand older (see specific guideline for under 16 year olds)presenting to healthcare professionals working indepartments offering Level 3 care in sexually trans-mitted infections (STIs) management within the , the principles of the recommendationsshould be adopted across all levels, using local carepathways where strategyThis document was produced in accordance with theguidance set out in the CEG s document Frameworkfor guideline development and assessment at has accredited the process used by BASHH to produce its European Guidelines for themanagement of Chlamydia trachomatis.

3 Accreditation is valid for 5 yearsfrom 2011. More information on accreditation can be viewed at and Westminster Hospital, London, UK2 Queen Mary s Hospital, Roehampton, UK3 Bart s Health NHS Trust, London, UK4St Helens Hospital, St Helens, UK5 British Association for Sexual Health and HIV Clinical EffectivenessGroup, London, UKCorresponding author:Nneka Nwokolo, Chelsea and Westminster Hospital, 56 Dean Street,London W1D 6AQ, : Journal of STD & AIDS2016, Vol. 27(4) 251 267!The Author(s) 2015 Reprints and : by guest on February 12, from The following reference sources were used to providea comprehensive basis for the guideline:1. Medline, Pubmed and NeLH Guidelines Databasesearches up to 1 April 2015 The search strategy comprised the following terms inthe title or abstract: Chlamydia trachomatisManagement ofChlamydia trachomatisManagement of neonatal Chlamydia infectionNatural history ofChlamydia trachomatisPelvic inflammatory diseaseChlamydia screeningChlamydia treatmentChlamydia partner notificationChlamydia sequelaeChlamydia repeat testingChlamydia treatment failureExtra genital Chlamydia infection2.

4 2006 UK National Guideline on Management ofGenital Tract Infection withChlamydia trachomatis3. 2012 BASHH statement on partner notification(PN) for sexually transmissible infections4. The Scottish Intercollegiate Guidelines Network(SIGN)5. 2015 CDC Sexually Transmitted InfectionsGuidelines6. Cochrane Collaboration Databases ( )7. 2009 NICE Guidelines on management of uncompli-cated genital chlamydia8. UK National Chlamydia Screening Programme9. 2013 UK National Guideline on the management oflymphogranuloma venereum (LGV)MethodsArticle titles and abstracts were reviewed and if relevantthe full text article obtained. Priority was given to ran-domised controlled trial and systematic review evi-dence, and recommendations made and graded on thebasis of best available evidence (Appendix 1).Piloting and consultation, including public and patientinvolvementThe initial draft of the guideline, including the patientinformation leaflet (PIL), was piloted for validation bythe CEG and a number of BASHH pilot sites.

5 A stan-dardised feedback form was completed by each pilotsite for the PIL. The final draft guideline was thenreviewed by the CEG using the AGREE instrumentbefore posting it on the BASHH website for externalpeer review for a two-month period. Concurrently, itwas reviewed by the BASHH Public and Patient received were collated by the CEG editorand sent to the guideline chair for review and final guideline was approved by the CEG, and areview date agreed before publication on the chlamydial infection is caused by the obligateintracellular bacteriumC. trachomatis. Serotypes D Kcause urogenital infection, while serovars L1-L3 is the most commonly reported curablebacterial STI in the UK. In 2013 , 208,755 cases ofinfection were reported to Public Health England(PHE formerly Health Protection Agency,England), with approximately 70% of these in sexuallyactive young adults aged less than 25 high-est prevalence rates are in 15 24-year olds and are esti-mated at in the most recent National Surveyof Sexual Attitudes and Lifestyles2and 5 10% in 6 Risk factors for infection include age under 25 years,a new sexual partner or more than one sexual partner inthe past year and lack of consistent condom ,3,7 12 Chlamydia infection has a high frequency of trans-mission, with concordance rates of up to 75% of part-ners being ,14 The natural history of Chlamydia infection is poorlyunderstood.

6 Infection is primarily through penetrativesexual intercourse, although the organism can bedetected in the conjunctiva and nasopharynx withoutconcomitant genital ,16If untreated, infection may persist or resolve 25 Studies evaluating the natural historyof untreated genitalC. trachomatisinfection haveshown that clearance increases with the duration ofuntreated infection, with up to 50% of infectionsspontaneously resolving approximately 12 monthsfrom initial 25 The exact mechanism ofspontaneous clearance ofC. trachomatisis not fullyunderstood. Both host immune responses and bio-logical properties of the organism itself have beenshown to play a ,23,26 Chlamydia infection can cause significant short- andlong-term morbidity. Complications of infection includepelvic inflammatory disease (PID), tubal infertility andectopic pregnancy.

7 A study by Aghaizu et cost of treating a single episode of PID to be of the252 International Journal of STD & AIDS 27(4) by guest on February 12, from order of 163, which in London alone, with 7000 casesper year, would equate to more than 1 m/year. Screeningprogrammes have been introduced in some countriesaimed at decreasing overallchlamydia prevalence andassociated morbidity. In England, a NationalChlamydia Screening Programme (NCSP) for sexuallyactive women and men under 25 years of age has beenin operation since April featuresThe majority of individuals with chlamydial infectionare , symptoms and signsinclude the :.Increased vaginal discharge;.Post-coital and intermenstrual bleeding;.Dysuria;.Lower abdominal pain;.Deep :.Mucopurulent cervicitis with or without contactbleeding;.Pelvic tenderness.

8 Cervical motion tenderness; (may be so mild as to be unnoticed):.Urethral discharge;.Dysuria;Signs:.Urethral infectionsRectal infectionsRectal infection is usually asymptomatic, but anal dis-charge and anorectal discomfort may of rectal infection in men who have sexwith men (MSM) have been estimated at between3% and studies of heterosexualwomen report high rates (up to ) of concurrenturogenital and anorectal infection,30 32other studies,however, report lower rates33,34with isolated rectalinfections in some ,32 Not all women withrectal Chlamydia report anal 34 Further studieswith larger numbers of patients are needed to ascertainthe utility of targeted versus routine rectal samplingin infectionsRates of Chlamydia carriage in the throat in MSM rangefrom to ; however, there is a paucity of gooddata on rates of pharyngeal infection in infection, as in the rectum, is infectionsChlamydial conjunctivitis in adults is usually sexuallyacquired.

9 The usual presentation is of unilateralchronic, low-grade irritation; however, the conditionmay be , endometritis, salpingitis;.Tubal infertility;.Ectopic pregnancy;.Sexually acquired reactive arthritis (SARA) (<1%);. the literature, the estimated risk of developingPID after genitalC. trachomatisinfection varies con-siderably, and is estimated to be from less than 1% toup to 30%.36 39 These differences in estimate are lar-gely determined by the type of the test used (culture,enzyme immunoassay [EIA] or NAAT) and popula-tions tested (symptomatic vs. asymptomatic, low riskvs. high risk). A recent analysis of all prospective stu-dies of women with treated and untreated PID byPrice et that up to 16% of womenwith untreated infection would be expected to developclinical PID. One reason for the discrepancy in PIDrates between earlier and more recent studies may bethe enhanced sensitivity of NAATs, which results inmore infections being diagnosed at an early stagebefore complications PID is associated with significant repro-ductive and gynaecologic morbidity, including infertility,ectopic pregnancy and chronic pelvic ,42 The risk of developing tubal infertility after PID isestimated to range from 1 to 20%.

10 42 Prolonged exposuretoC. trachomatis, either by persistent infection, or byfrequent re-infection is considered a major contributingfactor for tubal tissue damage,43,44and the importance ofearly diagnosis and treatment in reducing the risk ofNwokolo et by guest on February 12, from subsequent infertility cannot be people, reinfection rates of 10 30% have ;. has been described followinginfection ,47 49and recent studiesdescribe a possible association with male infertility50 54;however, the evidence for this is not (see also BASHH LGVguideline )Caused by the L1, L2 and L3 serotypes ofC. trachomatis,LGV was rare in Western Europe and the USA for manyyears, but outbreaks of infection have occurred amongstMSM since 2003. Most cases have occurred in HIV-positive 59 Most patients present with procti-tis,60,61however, asymptomatic infection may occur62(please see BASHH LGV guideline).