Chlamydial Infections

Chlamydial Infection Among Adolescents and Adults

Chlamydial infection is the most frequently reported bacterial infectious disease in the United States, and prevalence is highest among persons aged ≤24 years (141,784). Multiple sequelae can result from C. trachomatis infection among women, the most serious of which include PID, ectopic pregnancy, and infertility. Certain women who receive a diagnosis of uncomplicated cervical infection already have subclinical upper genital tract infection.

Asymptomatic infection is common among both men and women. To detect chlamydial infection, health care providers frequently rely on screening tests. Annual screening of all sexually active women aged <25 years is recommended, as is screening of older women at increased risk for infection (e.g., women aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI) (149). In a community-based cohort of female college students, incident chlamydial infection was also associated with BV and high-risk HPV infection (785). Although chlamydia incidence might be higher among certain women aged ≥25 years in certain communities, overall, the largest proportion of infection is among women aged <25 years (141).

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Chlamydia screening programs have been demonstrated to reduce PID rates among women (786,787). Although evidence is insufficient to recommend routine screening for C. trachomatis among sexually active young men because of certain factors (i.e., feasibility, efficacy, and cost-effectiveness), screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, or STD specialty clinics) or for populations with a high burden of infection (e.g., MSM) (149,788). Among women, the primary focus of chlamydia screening should be to detect and treat chlamydia, prevent complications, and test and treat their partners, whereas targeted chlamydia screening for men should be considered only when resources permit, prevalence is high, and such screening does not hinder chlamydia screening efforts for women (789-791). More frequent screening than annual for certain women (e.g., adolescents) or certain men (e.g., MSM) might be indicated on the basis of risk behaviors.

Diagnostic Considerations

For women, C. trachomatis urogenital infection can be diagnosed by vaginal or cervical swabs or first-void urine. For men, C. trachomatis urethral infection can be diagnosed by testing first-void urine or a urethral swab. NAATs are the most sensitive tests for these specimens and are the recommended test for detecting C. trachomatis infection (553). NAATs that are FDA cleared for use with vaginal swab specimens can be collected by a clinician or patient in a clinical setting. Patient-collected vaginal swab specimens are equivalent in sensitivity and specificity to those collected by a clinician using NAATs (792,793), and this screening strategy is highly acceptable among women (794,795). Optimal urogenital specimen types for chlamydia screening by using NAAT include first-catch urine (for men) and vaginal swabs (for women) (553). Recent studies have demonstrated that among men, NAAT performance on self-collected meatal swabs is comparable to patient-collected urine or provider-collected urethral swabs (796-798). Patient collection of a meatal swab for C. trachomatis testing might be a reasonable approach for men who are either unable to provide urine or prefer to collect their own meatal swab over providing urine. Previous evidence indicates that the liquid-based cytology specimens collected for Pap smears might be acceptable specimens for NAAT, although test sensitivity using these specimens might be lower than that associated with use of cervical or vaginal swab specimens (799); regardless, certain NAATs have been cleared by FDA for use on liquid-based cytology specimens.

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Rectal and oropharyngeal C. trachomatis infection among persons engaging in receptive anal or oral intercourse can be diagnosed by testing at the anatomic exposure site. NAATs have been demonstrated to have improved sensitivity and specificity, compared with culture, for detecting C. trachomatis at rectal and oropharyngeal sites (553,800-804), and certain NAAT platforms have been cleared by FDA for these anatomic sites (805). Data indicate that NAAT performance on self-collected rectal swabs is comparable to clinician-collected rectal swabs, and this specimen collection strategy for rectal C. trachomatis screening is highly acceptable among men (217,806). Self-collected rectal swabs are a reasonable alternative to clinician-collected rectal swabs for C. trachomatis screening by NAAT, especially when clinicians are not available or when self-collection is preferred over clinician collection. Annual screening for rectal C. trachomatis infection should be performed among men who report sexual activity at the rectal site. Extragenital chlamydial testing at the rectal site can be considered for females on the basis of reported sexual behaviors and exposure through shared clinical decision-making by the patient and the provider. The majority of persons with C. trachomatis detected at oropharyngeal sites do not have oropharyngeal symptoms. The clinical significance of oropharyngeal C. trachomatis infection is unclear, and prevalence is low, even among populations at high risk. However, when gonorrhea testing is performed at the oropharyngeal site, chlamydia test results might be reported because certain NAATs detect both bacteria from a single specimen.

POC tests for C. trachomatis among asymptomatic persons can expedite treatment of infected persons and their sex partners. Among symptomatic patients, POC tests for C. trachomatis can optimize treatment by limiting unnecessary presumptive treatment at the time of clinical decision-making and improve antimicrobial stewardship. Thus, using a POC test will likely be a cost-effective diagnostic strategy for C. trachomatis infection (807). Newer NAAT-based POC tests have promising performance and are becoming commercially available (807-809).

Treatment

Treating persons with C. trachomatis prevents adverse reproductive health complications and continued sexual transmission. Furthermore, treating their sex partners can prevent reinfection and infection of other partners. Treating pregnant women usually prevents transmission of C. trachomatis to neonates during birth. Treatment should be provided promptly for all persons with chlamydial infection; treatment delays have been associated with complications (e.g., PID) in a limited proportion of women (810).

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