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Chlamydia | Questions & Answers | 2010 Treatment Guidelines

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Question 1: I am concerned about “residual reinfection” for azithromycin-resistant chlamydia. Are there studies underway comparable to GISP to determine continued efficacy of azithromycin in treating chlamydia? Can we be sure that individuals treated for chlamydia who retest positive three months later are truly reinfected, or might some of these infections be due to treatment failure?

Answer: Persistent chlamydia infections and treatment failures are being studied in ongoing randomized trials at several U.S. research institutions, however, a GISP variant for chlamydia infection does not exist. Recently published studies indicate that some "reinfections" may indeed be treatment failures and that treatment failure may be more common for azithromycin than for doxycycline. Regardless, whether the current infection is a true reinfection or a persistent infection, retreatment with a regimen that is different from the first treatment is indicated.

Question 2: What is the prevalence of ocular chlamydia in the U.S.? How and when do you recommend screening for it, and how should it be treated?

Answer: Conjunctivitis caused by sexually-transmitted chlamydia serovars occurs in neonates through transmission in the birth canal of infected mothers and in adults, presumably through digital (auto)inoculation from infected genital sites in either the patient or the patient’s sex partner. There are no data on the prevalence of this condition in the U.S. Establishing a definitive diagnosis is hampered by the fact that NAAT testing is not FDA approved for ocular specimens and chlamydia culture is no longer widely available. Despite the lack of FDA clearance, research studies suggest that NAATs will effectively diagnose ocular chlamydia. There are no recommendations for screening of ocular infections. The diagnosis should be considered when conjunctivitis symptoms are present in a patient or a patient’s partner who has a genital chlamydia infection. Topical treatment is insufficient and systemic antibiotics should be given per guidelines for genital infections. There are no data to suggest that prolonged treatment beyond the standard one-week dosing scheme improves cure rates among adults. Conjunctivitis in neonates is discussed in the 2010 STD Treatment Guidelines, page 47. Trachoma, caused by nonsexually transmitted chlamydia serovars, does not occur in the U.S.

Question 3: Since most men do not show symptoms with chlamydia, do we treat a male partner without symptoms?

Answer: Yes, per 2010 STD Treatment Guidelines, page 44. Untreated asymptomatic male partners are at risk for reinfecting the female index patient, putting her at greater risk for chlamydia-related complications (page 46), as well as forming a source for ongoing transmission to other sexual partners.

Question 4: Is a single 1 g. dose of azithromycin given orally acceptable treatment for non-LGV (lymphogranuloma venereum) chlamydia proctitis?

Answer: It probably is, however, this is a rather theoretical question as the determination of an LGV diagnosis through genotyping will take considerable time (if possible at all) from the time of presentation. When a patient, especially an MSM, presents with proctitis signs and symptoms, he should be given treatment to cover both gonorrhea and chlamydia if an exudate is present and/or a gram-stained smear shows > 10 PMNL/HPF. The current guidelines suggest a single 250 mg. intramuscularly injected dose of ceftriaxone, accompanied by doxycycline 100 mg. orally twice daily for MSM with clinical proctitis syndromes. If painful ulcerations are present perianally or on anoscopy, then treatment for herpes should be considered, in addition to three weeks of doxycycline therapy to cover for LGV while lab tests are pending (2010 STD Treatment Guidelines, page 88).

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