​Kembara Xtra - Medicine - Chlamydia Infection ( Sexually Transmitted Disease)

​Kembara Xtra - Medicine - Chlamydia Infection ( Sexually Transmitted Disease) 
Introduction
Chlamydia trachomatis is a prokaryotic bacterium linked to the intracellular membrane. The word "chlamydia" comes from the Greek for "cloak."
The most typical bacterial STI (sexually transmitted infection) in the US is chlamydia.
Transmitted vertically during vaginal delivery; transmitted orally, anally, or vaginally.
The majority of cases, particularly in females, are asymptomatic.
Ectopic pregnancy, infertility, and pelvic inflammatory disease (PID) can all result from untreated illness.
Affected systems: reproductive
pregnant women's issues
Neonatal pneumonia and/or conjunctivitis can develop as a result of perinatal acquisition.

Incidence and prevalence in Epidemiology 

Incidence
Since mandatory reporting was introduced in 1985, the incidence has generally been steadily rising.
1.8 million cases were reported in 2019 (the most latest CDC data). Instead of a significant rise in disease burden, rising incidence is due to improved testing, wider screening, and better reporting.
First discovered in 2006, the Swedish novel variety of C. trachomatis (nvCT) frequently results in false-negative testing and is primarily seen in Nordic countries.
Prevalence
553/100,000 people live in the US.
Ages 15 to 19 had the second-highest prevalence, followed by 20 to 24 among young females and ethnic minorities.
Females are more prevalent than men. The stated incidence and prevalence are 2 times higher for females than for males.
This is probably due to more females testing. The detection of males may rise with the adoption of the urine screening test for very sensitive nucleic acid amplification (NAAT).
Black people have six times the infection rates of white people.
Greater urban regions have greater rates.
Highest male prevalence among heterosexual teens; estimated to impact 2% of young Americans who are sexually active.


Pathophysiology and Etiology 

Serotypes D to K of C. trachomatis linked to genital tract infections. Chlamydia is an organism that must live inside cells.
Chlamydia's life cycle is biphasic. exists extracellularly as an infectious and metabolically inactive elementary body (EB). The EB prevents lysosomal phagocytosis once it has been taken up by the host cell (usually the columnar epithelium of the genital tract) and converts into the reticulate body (RB), which needs energy from the host cell to generate RNA, DNA, and proteins. After moving into the host cell, EB are discharged and have the ability to infect other cells or transmit the infection via sex.

Risk Elements 

Men who have sex with men (MSM) may be at higher risk for rectal and pharyngeal chlamydia than other groups; consider testing with NAAT when appropriate. Risk correlates with: Number of lifetime sexual partners and number of concurrent sexual partners No use of barrier contraception during intercourse.


Prevention 

 At least once a year, screen populations with a prevalence of over 5%.
It is advised to get screened if you have had more than one sexual partner in the last six months, are a teen, visit a family planning, STD, or abortion clinic, or go to a clinic in a jail or other detention facility. Test all people with urethral or cervical discharge; screen for rectal pain, discharge, or tenesmus. Every sexually active woman under the age of 25 should undergo screening at least once per year. For those who test positive, a second test should be done within three months because the risk of reinfection is substantial regardless of whether the sexual partner has received treatment.
Consider screening sexually active men under the age of 25, especially in high-risk areas. Every year, do genital and extragenital screening on high-risk MSM. In all cases, with the exception of boy-on-boy child sexual abuse and prepubescent girl rectal/oropharyngeal testing, NAAT is the screening test of choice. Susceptibility tests and culture are preferred in these circumstances.
It is acceptable to test women for chlamydia on the same day that an intrauterine device (IUD) is placed; if a positive result is found, the IUD need not be removed.


Conditions Related to Females
- PID: If untreated, 10% of people will develop PID within a year.
Chronic pelvic discomfort, ectopic pregnancy, infertility, and urethral syndrome (dysuria, frequency, and pyuria without infection)
Arthritis (less prevalent)
- Involuntary abortion
● Males
- Reiter disease (HLA-B27) with nongonococcal urethritis in the epididymis
Neonatal proctitis and inclusion conjunctivitis (40% of exposed infants develop these conditions)
- Medial otitis
lung disease
- Pharyngitis - Conditions brought on by different chlamydial species
- LGV, or lymphogranuloma venereum Trachoma: C. trachomatis serotypes A to C, C. trachomatis serotypes L1 to L3,

Diagnosis 
There are many asymptomatic patients.

pregnant women's issues

At the initial prenatal visit, test all patients.
For all pregnant patients with a proven chlamydial infection, repeat testing should be done 3 to 4 weeks after treatment.
Test once more 3 months later.
Repeat screening in high-risk patients during the third trimester.


Complete sexual history must be presented, including the number of partners had both in the past year and over the course of a lifetime, any prior STI history, the use of barrier protection, any commercial sex work, oral or anal receptive intercourse, and relationship fidelity.
The most frequent signs and symptoms in females include: - Mucopurulent vaginal discharge; dysuria (urethral syndrome); bartholinitis; abdominopelvic pain (endometritis, salpingitis/PID); and right upper quadrant discomfort (Fitz-Hugh-Curtis syndrome). Dysuria, urethral discharge (urethritis), scrotal discomfort (epididymitis), rectal pain or discharge (proctitis), and acute arthritis (Reiter syndrome) are the most prevalent symptoms in men.

clinical assessment 
Women: cervix (discharge, motion tenderness), bimanual examination for cervical motion tenderness, uterine, ovarian/adnexal tenderness or mass LGV (C. trachomatis serovars L1, L2, or L3): Primary lesion is a small papule that may ulcerate at the site of transmission after an incubation period of 3 to 30 days. Men and women should be checked for these symptoms as well.
Tender lymphadenopathy on one side only. LGV results in an invasive proctocolitis when transmitted rectorially.

Neisseria gonorrhoeae differential diagnosis: proctitis, epididymitis, cervicitis, urethritis, PID, and Bartholin abscess
Mycoplasma or Ureaplasma urealyticum: PID, Reiter illness, epididymitis, and urethritis

 Trichomoniasis caused by C. trachomatis (serotypes L1 to L3): LGV, proctitis

Diagnostic tests and laboratory results 

Initial examinations (lab, imaging)
NAAT: >95% sensitivity, >99% specificity

Although it is preferable to collect urine on initial catch, urine tests are equally sensitive to cervical swabs. Lab results may stay positive for 3 weeks after successful treatment. Self-collected vaginal swabs are most sensitive.
Test for STIs that are present at the same time, such as gonorrhea, HIV, and syphilis; follow recommended procedures for cervical cancer (Pap smear) screening.

Follow-Up Examinations & Particular Considerations.
Management of Treatment 
Provide patients with concurrent testing for syphilis, HIV, and perhaps gonorrhea (after counseling and agreement). Ensure that women receive the necessary annual screenings for cervical cancer.

Consider using empirical treatment for gonorrhea.

Test and treat the most recent partner as well as all partners who have been together for less than 60 days.

The First Line of Medicine
Treatment options for chlamydial urethritis and cervicitis include giving a sexual partner of an infected person either a single dose of 1 g of azithromycin or a seven-day course of 100 mg of doxycycline per day.
Outpatient first-line PID therapy
(Please note updated uncomplicated gonorrhea treatment guidelines published December 2020, which recommend 500 mg of ceftriaxone IM for patients under 150 kg, and 1 g for patients over 150 kg.) - Ceftriaxone 250 mg IM + 1 + doxycycline 100 mg PO for 14 days with or without metronidazole 500 mg PO BID for 14 days;
- Cefoxitin 2 g IM, 1 g PO, 1 mg BID of probenecid, 100 mg PO, and doxycycline for 14 days, with or without metronidazole,
To treat both chlamydia and gonorrhea, azithromycin and ceftriaxone may be administered at the same time in the doctor's office. Thus, nonadherence is decreased.
Doxycycline 100 mg BID for 7 days is the most effective treatment for asymptomatic rectal chlamydia. Even though azithromycin 1 g for 1 day is slightly less effective, it can still be utilized, especially if medication compliance or accessibility are problems.

Caution

Patients who have bradycardia, known QT prolongation, hypokalemia, hypomagnesemia, or who are presently on antiarrhythmic medication should use azithromycin with caution.

pregnant women's issues
Pregnant women should not take tetracyclines (doxycycline) or quinolones (ofloxacin, levofloxacin).
Think about the following:
- 500 mg of erythromycin base or 1 g of azithromycin or 500 mg of amoxicillin or 500 mg of erythromycin base TID for 7 days
ALERT
Young children should not use tetracyclines or quinolones:
Erythromycin base or ethinyl succinate 500 mg/kg/day PO QID for 14 days if you are under 45 kg; azithromycin 1 g PO once you are over 45 kg; and adult medication if you are over 8 years old.
● In youngsters with chlamydial infections, rule out sexual abuse.
Next Line
Erythromycin base 500 mg PO QID for 7 days OR erythromycin ethylsuccinate 800 mg PO QID for 7 days; Levofloxacin 500 mg PO daily for 7 days OR ofloxacin 300 mg PO BID for 7 days; for chlamydial urethritis/cervicitis.
ADVANCED THERAPIES
EPT lowers recurrence more successfully than partner referral in comparison to patient-delivered partner treatment (PDPT) or accelerated partner therapy (EPT), which involves giving sexual partners of STI-infected people prescriptions or drugs to take without first doing a clinical assessment.


Admission
If you have PID, treat it as an outpatient condition unless you are moderately or severely ill. Inpatient treatment of PID: pregnancy, inability to respond to or intolerance to oral medications, suspicion of poor compliance, severe clinical illness, pelvic abscess, and possible need for surgical intervention.

Take Action 
For at least 7 days following therapy (single-dose medication) or up until the end of the complete course of other antibiotics, refrain from sexual activity.

patient observation
The only time a cure test is typically advised is during pregnancy. Avoid repeating NAAT 3 weeks after testing since it could result in a false positive from nonviable organisms.
Pregnancy cure tests are performed in 3 to 4 weeks, and reinfection tests are performed in 3 months.
Even if the initial screening is negative, think about rescreening higher risk pregnant women in the third trimester.
Test for reinfection (not cure) three months following treatment or, if that is not possible, at the time of your next visit to the doctor if it is within a year.
Sexual partners need to be respected. EPT is allowed in some states.
Complete an antibiotic treatment for the patient and their partners. Provide advice on safe sexual behavior, barrier protection, and abstinence.

Prognosis After treatment, the prognosis is favorable.

Complications
Chlamydial infection increases HIV transmission and vulnerability in both sexes.
Females: tubal infertility, tubal (ectopic) pregnancy, and chronic pelvic pain - annual screening of sexually active women would avoid 61% of chlamydia-related PID.
Males: postepididymitis and transitory oligospermia (rare) urethral stricture