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2015 European Guideline on the Management of Chlamydia Trachomatis Infections (Lanjouw E, Et Al

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2015 European Guideline on the Management of Chlamydia Trachomatis Infections (Lanjouw E, Et Al Int J STD AIDS OnlineFirst, published on November 24, 2015 as doi:10.1177/0956462415618837 Guidelines International Journal of STD & AIDS 0(0) 1–16 ! The Author(s) 2015 2015 European guideline on the Reprints and permissions: sagepub.co.uk/journalsPermissions.nav management of Chlamydia trachomatis DOI: 10.1177/0956462415618837 std.sagepub.com infections E Lanjouw1, S Ouburg2, HJ de Vries3,4,5, A Stary6, K Radcliffe7 and M Unemo8 Abstract Chlamydia trachomatis infections, which most frequently are asymptomatic, are major public health concerns globally. The 2015 European C. trachomatis guideline provides up-to-date guidance regarding broader indications for testing and treatment of C. trachomatis infections; clearer recommendation of using exclusively validated NAATs for diagnosis; advice on (repeated) C. trachomatis testing; recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection; and recommendations to identify, verify and report C. tracho- matis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of C. trachomatis patients are crucial to control its spread. For detailed background, evidence base and discussions, see the background review for the present 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS. 2015). Keywords Chlamydia trachomatis, Europe, diagnosis, treatment, antibiotic Date received: 25 October 2015; accepted: 1 November 2015 Aetiology, transmission and epidemiology 1Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands Chlamydia trachomatis is an obligate intracellular bac- 2Laboratory of Immunogenetics, Department of Medical Microbiology terium that is estimated to infect over 100 million and Infection Control, VU University Medical Center, Amsterdam, The people each year worldwide by sexual transmission. Netherlands 3Department of Dermatology, Academic Medical Centre, University of The majority of persons with anogenital C. trachomatis Amsterdam, Amsterdam, The Netherlands infection are not aware of their infection because it is 4STI Outpatient Clinic, Infectious Disease Cluster, Health Service frequently asymptomatic. Urogenital chlamydial infec- Amsterdam, Amsterdam, The Netherlands tion can lead to serious adverse outcomes in women, 5Center for Infection and Immunology Amsterdam (CINIMA), Academic e.g. pelvic inflammatory disease (PID) that can result in Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands tubal factor infertility, ectopic pregnancy and chronic 6 1 Outpatients’ Centre for Infectious Venereodermatological Diseases, pelvic pain. Urogenital chlamydial infections do not Vienna, Austria result in any sustained immunity. 7University Hospital Birmingham Foundation NHS Trust, Birmingham, Since the 1990s, an increase of urogenital C. tracho- United Kingdom 8 matis infections has been reported from several coun- WHO Collaborating Center for Gonorrhoea and other Sexually Transmitted Infections, National Reference Laboratory for Pathogenic tries, e.g. the USA, Canada, UK and the Scandinavian 2–4 Neisseria, Department of Laboratory Medicine, Microbiology, Faculty of countries. The prevalence estimates in nationally rep- Medicine and Health, O¨ rebro University, O¨ rebro, Sweden resentative samples of sexually experienced 18–26 year olds in Europe have been relatively similar in women Corresponding author: and men (estimated ranging between 3–5.3% and 2.4– M Unemo, WHO Collaborating Center for Gonorrhoea and other Sexually Transmitted Infections, National Reference Laboratory for 7.3%, respectively) and statistically consistent with 3–6 Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, those in other high income countries. The incidence Faculty of Medicine and Health, O¨ rebro University, O¨ rebro, Sweden. of diagnosed C. trachomatis cases reported to the Email: [email protected] Downloaded from std.sagepub.com by J Sherrard on January 4, 2016 2 International Journal of STD & AIDS 0(0) European Centre for Disease Prevention and Control Clinical features, complications and (ECDC) from 26 European Union (EU) and European sequelae Economic Area (EEA) countries in 2013 was 182 per 100,000 population (384,555 cases). Nevertheless, there Molano et al. described a C. trachomatis clearance was substantial variation across the EU/EEA countries (from the point of detection of the infection) in 54% in the incidence of reported C. trachomatis cases, with of untreated asymptomatic women at one year of rates ranging from below 1 to more than 600 cases per follow-up, 82% at two years, and 94% at four 100,000 population.4 Comparison between countries is years.12 In another study examining untreated asymp- considerably challenged by differences in the surveil- tomatic women, the clearance rate was similar (44.7%) lance systems, the diagnostic methods used, the access during the first year.13 The long duration of undetected to and amount of testing and screening (general screen- and untreated infection in women can result in that the ing programme or opportunistic testing) for chlamydial bacteria cross the cervix and uterus, ascend into the infection, and the proportion of underreporting.3 upper genital tract, adhere, and ultimately result in Young age (usually below 25 years of age) and behav- associated complications and sequelae such as PID, ioural risk factors such as prior C. trachomatis infec- ectopic pregnancy, and tubal factor infertility. tion, lack of consistent condom use and new or multiple Appropriate testing of symptomatic and asymptomatic partners per year are the main risk factors for acquisi- sexually active individuals is recommended to identify tion of C. trachomatis infection.7 and treat the C. trachomatis infections. Transmission of C. trachomatis usually takes place by direct mucosal contact between two individuals Urogenital infections during sexual intercourse (vaginal, anal or oral sex) or at birth through an infected cervical canal. It is Symptoms and signs in women:1 difficult to estimate the risk of sexual transmission. One transmission dynamic mathematical modeling . 70–95% asymptomatic study provided estimates,8 based on data from a . Mucopurulent cervicitis with or without contact cross-sectional heterosexual partnership study in clin- bleeding ical attendees.9 The model estimated a median trans- . Cervical friability mission probability of around 10% for a single act of . Cervical oedema vaginal coitus and around 55% over the course of a . Endocervical ulcers partnership in a population that has two partnerships . Urethritis in a six month period. Partners of people with C. Dysuria trachomatis infection are very likely to be infected . Vaginal discharge themselves,9 so contact notification and subsequent . Postcoital bleeding and intermenstrual bleeding treatment are very important. Poorly differentiated abdominal pain or lower C. trachomatis belongs to the genus Chlamydia abdominal pain (phylum Chlamydiae, order Chlamydiales, family Chlamydiaceae) together with Chlamydia muridarum and Chlamydia suis. Other chlamydiae infecting Symptoms and signs suggestive of pelvic inflammatory humans, Chlamydophila pneumoniae and disease (PID):14–16 Chlamydophila psittaci, are currently classified in a sep- arate genus.10 However, this subdivision of the family . Lower abdominal tenderness and pain – usually into the two genera Chlamydia and Chlamydophila has bilateral been discussed controversially during the past decade. Cervical motion tenderness on bimanual vaginal Recently, in the light of recent genomic data and in the examination context of the unique biological properties of these . Adnexal tenderness on bimanual vaginal microorganisms, it was proposed to classify all the 11 examination currently recognised Chlamydiaceae species in a single . Deep dyspareunia – particularly of recent onset Chlamydia genus.11 Three C. trachomatis biovars com- . Abnormal bleeding – intermenstrual bleeding, post prising all 15 classical serovars and several additional coital bleeding and menorrhagia can occur second- serovars and genovars are recognised within the C. tra- ary to associated cervicitis and endometritis chomatis species: the trachoma biovar (serovars A–C), . Abnormal vaginal or cervical discharge – as a result the urogenital biovar (serovars D–K) and the LGV of associated cervicitis, endometritis or bacterial biovar (serovars L1–L3). This guideline only covers vaginosis the urogenital and LGV biovars of C. trachomatis. Fever (>38 C) – in moderate to severe PID Downloaded from std.sagepub.com by J Sherrard on January 4, 2016 Lanjouw et al. 3 Complications in women (see also below). or pneumonia.29 The vertical transmission risk for a newborn is 50–75%.30 . PID (endometritis, salpingitis, parametritis, oophor- itis, tuboovarian abscess and/or pelvic peritonitis) . Chronic pelvic pain Lymphogranuloma venereum (LGV) . Tubal infertility . Ectopic pregnancy LGV is an invasive ulcerative disease caused by the . Sexually acquired reactive arthritis (SARA) (<1%) serovars L1, L2, or L3 of C. trachomatis.31 Since . Fitz-Hugh-Curtis syndrome (PID and perihepatitis) 2003, LGV outbreaks have been verified amongst MSM, particularly HIV positive, in several European countries.32–35 Most patients have presented with proc- Symptoms and signs in men (may be so mild that they are not titis1,36 or tenesmus, anorectal discharge (often bloody) noticed):1,17
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