Detecting and treating chlamydia

This Clinical Update provides an overview of detecting and treating chlamydia; one of the most common sexually transmitted infections.

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Introduction
Chlamydia trachomatis is the most common sexually transmitted bacterial infection (STI) in Australia, and infection is notifiable in all states and territories.

The prevalence of chlamydia among young people aged 15–29 years is around 3–5%.¹

According to the Kirby Institute,² around 10% of the total chlamydia tests carried out in 2010 were found to be positive for both males and females in Australia.

In Australia, primary care is the most appropriate environment for testing, treating and preventing the disease because just over 85% of women and 65% of men aged 16–29 years present to a general practice at least once a year.³

Annual chlamydia testing is recommended for all sexually active men and women aged 15–25 who attend a general practice is recommended in the RACGP Red Book.⁴ However, research reveals less than 10% of young people in the high-risk age group for chlamydia attending general practice are tested.³

Chlamydia testing should be a routine part of the health care of young people in general practice, but currently there are clearly many missed opportunities to detect and prevent the spread of this infection.

Epidemiology
Overall it is thought that 4% of young adults are infected with chlamydia, and the likelihood of contracting chlamydia from a positive partner is estimated to be between 30–50% per sexual act.⁶

According to the Australian Chlamydia Control Effectiveness Pilot (ACCEPt), there were 62,709 chlamydia notifications in Australia in 2009, more than triple the number reported a decade prior.⁵ Some of this increase can be attributed to better testing and identification of the infection, but it is evident that real numbers of infection are on the increase.

Screening and diagnosis
Around 80% of women and 50% of men are asymptomatic when they have chlamydia.

The infection may be present for weeks, months or even years without symptoms.

The prevalence of chlamydia among young people aged 15–29 years is around 3–5%.
Chlamydia infects columnar or transitional epithelium in the urethra, endocervix, rectum, epididymis, endometrium, salpinx and peritoneum, and therefore condoms provide a high level of protection against infection.

The bacteria can also colonise the conjunctiva. It sets up chronic and intense inflammation but this is mostly asymptomatic.

However, if symptoms are present, they are usually detectable within 1–21 days and may include:

Women

• Abnormal or increased vaginal discharge
• Vaginal bleeding or spotting between periods or after sex
• Painful sexual intercourse
• Pelvic pain, like period pain
• Dysuria

Men

• Dysuria
• Discharge from the penis
• Redness at the urethral meatus.

The nurse’s role
ACCEPt recently reported that there are more than 10 million practice nurse consultations occurring annually, acknowledging the role of nurses in initiating conversations with young people about chlamydia testing, assisting with partner notification and management of recall systems.⁸

The essentials of the nurse’s role in preventing and treating chlamydia are:

• Educating young patients about the risks of chlamydia and the ease in which it can be contracted
• Promoting the use of condoms
• Encouraging regular chlamydia testing as well as opportunistic screening (e.g. when young women attend for a Pap smear or for a prescription for the oral contraceptive pill or young men for an injury or viral illness)
• Communicating the simplicity of the testing process and treatment for chlamydia.

Promoting screening
While there will be advice on national screening from ACCEPt available in 2014, it is useful to note some of the strategies that have been successful in the past and to consider whether the systems in place in your current work environment could be redesigned to increase screening rates.^{2, 9,10}

Successful strategies have included:

• Universal provision of urine jars to clients in the target age range. This would mean every patient attending the practice aged 15–25 is asked to supply a urine specimen. A receptionist could request this from them when they register and give them a jar in a discrete or maybe even a funky, graffiti-decorated bag.
• Doctors offering testing to all young male clients. This would necessitate a system that prompts the doctor to offer the test as routine to any young male, much like systems used to prompt offering a Pap smear to women. How about, “This man is aged 15–25, have you offered him an easy chlamydia test?”
• Pap smear linkage, where with every Pap test every young woman is tested for chlamydia.
• Computer alerts for doctors and other staff. Just identifying patients within the age range might be sufficient.
• Continuing professional development for clinic staff. If you have a few key facts about chlamydia you will be able to promote testing to your patients. How about: “Chlamydia is a common infection in young people your age; it is easy to test for and easy to treat. Would you like to have a simple urine test for it today?”
• Free sexual health consultations. Some communities offer services that ensure young people can access free or cheaper sexual health consultations and subsequent investigations. One ACT program pays young people $10 to provide a urine sample, and some open up clinics at universities, music venues and other events.
• Home sampling kits. They do it for bowel screening why not chlamydia? Send the jar home with all young people in the age range with instructions on collecting the sample and where to return it.
• Clinic-based registers to remind patients to return for testing.

Tests and diagnosis
Testing is easy. In most cases it requires a first-pass urine for chlamydia PCR testing. Females can alternatively provide a self-obtained vaginal swab instead of a urine sample with the same accuracy. A cervical swab can also be sent for chlamydia PCR at the time of sampling for a Pap smear.

Men who have sex with men should be tested by providing a self-obtained rectal swab, as chlamydia of the rectum is evident in this population. The samples are tested using the highly accurate and sensitive nucleic acid amplification test (NAAT); this means it is rarely missed in a sample.

Retesting for chlamydia to ensure that treatment has been effective is essential three months after a positive test. Multiple STIs are known to co-occur, so testing for concurrent infections is important. Examples of concurrent infections are gonorrhoea and syphilis and consider screening for the blood borne viruses: HIV, and hepatitis B and C. Testing in pregnant women is also of benefit because chlamydia can lead to pneumonia and/or conjunctivitis in newborns.



Treatment
Chlamydia is simple to treat with either a 1g stat dose of azithromycin or doxycycline 100mg twice daily for seven days. Both regimens have the same clinical outcome, however azithromycin is simpler to take and so promotes compliance.

If left untreated, chlamydia can progress to pelvic inflammatory disease (PID) and the associated sequelae of ectopic pregnancy and/or infertility in women.

Pelvic inflammatory disease is caused by the chlamydia micro-organism ascending from the lower genitourinary tract into the endometrium and fallopian tubes.

Where symptoms do occur the primary presenting symptom is acute pelvic pain. This pain is generally continuous, bilateral, most severe in the lower pelvis and can be exacerbated by sexual intercourse, movement or the Valsalva manoeuvre.¹¹

A low threshold of suspicion is recommended for treating pelvic inflammatory disease in order to protect fertility and prevent complications.

The recommended treatment is rest, avoidance of intercourse and a course of antibiotics including azithromycin, doxycycline and metronidazole and the addition of ceftriaxone if co-infection with gonorrhoea is suspected.

In men, chlamydia if left untreated, can cause epididymo-orchitis due to the retrograde spread of the microorganism. This is treated with a course of doxycycline.

Two other uncommon complications of chlamydia are reactive arthritis or Reiter’s syndrome.¹¹

Contact tracing
Contact tracing, also known as partner notification, is the mainstay of reducing chlamydia and other STIs because it helps stop the spread of infection. It is usual practice to trace and treat the sexual partners from the previous six months.

The Australasian Contact Tracing Manual¹¹ is an excellent resource for nurses covering the practical and legal aspects of contact tracing.

The Melbourne Sexual Health Centre’s online notification program (www.letthemknow.org.au) is also a great initiative that has resources for helping people who have a positive chlamydia test with having a face-to-face conversation or sending a letter, SMS or email message to their sexual partners.

RISK FACTORS FOR CHLAMYDIA INFECTION

• Age 15–25 years
• History of previous infection with chlamydia or another STI
• A new sexual partner, many partners or a partner who has had other partners in the previous three months
• Inconsistent use of condoms
• Cervical ectopy
• Lower socio-economic status.⁷

ACCEPt: REDUCING THE INCIDENCE OF CHLAMYDIA
THE Australian Chlamydia Control Effectiveness Pilot (ACCEPt) is an Australian government sponsored program designed to assess the feasibility, acceptability, efficacy and cost-effectiveness of annual chlamydia testing for 16- to 29-year-olds in general practice.⁵

With 126 rural and metropolitan clinics taking part, it will assess whether chlamydia testing in general practice does lead to a reduction in the incidence of chlamydia. If it proves this is the case, it might lead to the government rolling out a national chlamydia screening program.

The program is intended to report its final findings in December 2014.

This Update is by Elissa O’Keefe, RN, NP, FFACNP
Sexual Health Nurse Practitioner, Canberra Sexual Health Centre
The author has no disclosures. Any reference to products throughout this review does not constitute endorsement.