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Home , Chlamydia, Chlamydia (genus), Chlamydia trachomatis

Chlamydia ( trachomatis) Infection

NOTE: Culture of C. trachomatis is not 1. Etiology performed for diagnostic purposes in Manitoba, is an obligate intracellular nor is detection. If such tests were bacterium that infects mainly ocular and conducted in Manitoba residents in other genitourinary epithelium (1). There are at least 18 provinces/territories and referred to Manitoba serologic variants (serovars), including the Health, Seniors and Active Living, a positive oculogenital serovars A – K and the result would be accepted in Manitoba and the serovars L1, L2, and person considered a case, as these tests are L3 (2). Management of lymphogranuloma included in the national case definition for venereum (LGV) serovars are excluded from this chlamydia. protocol but are covered in the Manitoba Health, Seniors and Active Living Lymphogranuloma 3. Reporting and Other Venereum protocol Requirements http://www.gov.mb.ca/health/publichealth/cdc/pro tocol/lgv.pdf . Laboratory:  All positive laboratory results for C. 2. Case Definition trachomatis are reportable to the Public Health Surveillance Unit by secure fax 2.1 Confirmed Case – Genital Infections: (204-948-3044).

Detection of C. trachomatis nucleic acid in Health Professional: genitourinary specimens (e.g., ,  For Public Health investigation and to endocervical, male urethral) (3). meet the requirement for contact 2.2 Confirmed Case – Extra-genital notification under the Reporting of Infections: Diseases and Conditions Regulation in the Public Health Act, the STI Case Detection of C. trachomatis nucleic acid in Investigation Form for Chlamydia, rectum, conjunctiva, pharynx and other extra- , and LGV genital sites (3). Infections – Case Form 2.3 Confirmed Case – Perinatally Acquired http://www.gov.mb.ca/health/publichealth/ Infections: surveillance/docs/mhsu_6784.pdf must be completed for all laboratory-confirmed a) Detection of C. trachomatis nucleic acid in cases of chlamydia and returned to the nasopharyngeal or other respiratory tract Manitoba Health, Seniors and Active specimens from an in whom Living (MHSAL) Surveillance Unit develops in the first six months of life (3). confidential fax (204-948-3044) within 5 OR business days of case interview. Regional Public Health or First Nations Inuit Health b) Detection of C. trachomatis nucleic acid in Branch may assist with completion and conjunctival specimens from an infant who return of the form. develops in the first month of life  Regulations under the Public Health Act (3). require health professionals to report all known sex contacts of chlamydia cases to

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the MHSAL Surveillance Unit. The discharge and , sometimes accompanied by STBBI Contact Investigation Form (for (4). Rectal infection may manifest Contacts to Chlamydia, Gonorrhea, as a , rectal pain or blood in the Chancroid, LGV, /C, HIV and stools, but is in most cases (4). The Infections) natural history is not well defined but many http://www.gov.mb.ca/health/publichealth/ infections resolve without treatment, while many surveillance/docs/mhsu_6782.pdf must be are long-lasting (1). Complications in women completed and returned for all identified include pelvic inflammatory disease, , contacts within 5 business days of , tubal , ectopic , interview with the contact. Regional and perihepatitis (5). Public Health or First Nations Inuit Health Complications in men include epididymo- Branch may assist with completion and and reactive arthritis (5, 6). return of the form. Infection in Children:  Under the Child and Family Services Act, any person who has information that leads Prepubertal children may have conjunctival, him/her to reasonably believe that a child vaginal, urethral or rectal infection (2). (defined as under 18 years of age) is being Asymptomatic infection of the nasopharynx, abused (e.g., ) has the legal conjunctivae, vagina and rectum can be acquired duty to report their concern to the local at birth (2). Child and Family Services (CFS) agency. Infection in Pregnancy: Refer to the Reporting of Child Protection and Child Abuse: Handbook and Maternal infection is associated with serious Protocols for Manitoba Service Providers adverse outcomes in neonates including pre-term available at: birth, low birth weight, conjunctivitis, http://www.pacca.mb.ca/ESW/Files/Hand nasopharyngeal infection and pneumonia (4). book_Child_Protection_and_Child_Abuse Neonatal Infection: _Web_Links.pdf for more information. Contact information is found on pages Initial C. trachomatis neonatal infection involves 150-151. the mucous membranes of the eye, oropharynx, urogenital tract, and rectum, although infection might be asymptomatic in these locations (7). 4. Clinical Presentation/Natural develops a few days to History several weeks after infection acquired at birth (2). Chlamydia trachomatis causes and C. trachomatis can also cause subacute, afebrile in women and urethritis in men as well pneumonia (7). Perinatally acquired C. as extra-genital infections including rectal and trachomatis can persist in an infant for up to 3 oropharyngeal infections (4). Asymptomatic years (6). infection is more common than symptomatic Interrelationship between Chlamydia and HIV: infection in both men and women (4). Symptoms of uncomplicated chlamydial infection in women For people with HIV, chlamydial infection may may include abnormal , dysuria, increase the amount of HIV in bodily fluids and and post-coital and intermenstrual bleeding (4). may increase the chance of HIV to Symptomatic men usually present with urethral sex partners (8, 9). Individuals with Chlamydia

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infection may be more likely to become infected cases was 1.7 times higher in females as compared with HIV if they are exposed to HIV during sex to males; persons aged 15-29 comprised nearly (8, 9). 80% of chlamydia cases reported (11). The increases in rates are explained by a variety of 5. Epidemiology factors including a true rise in incidence as well as the implementation of improved detection 5.1 Reservoir and Source: methods such as the more sensitive nucleic acid Infected humans (4). Asymptomatic individuals amplification testing (NAAT) (11). More provide an ongoing reservoir for infection (2). effective and contact tracing practices may also have contributed to the observed rise in 5.2 Transmission: the rate of reported cases (11). In 2015, the Transmission occurs through sexual contact with reported rate of chlamydia was 325.0 per 100,000 the penis, vagina, mouth or anus of an infected population (12). Individuals aged 15-24 years partner (10). Oculogenital serovars of C. represented 56.8% of all reported chlamydia cases trachomatis can be transmitted from the genital in 2015, although they accounted for only 12.6% tract of infected mothers to their during of the overall population (12). birth (2). Acquisition occurs in approximately Manitoba: In 2014, Manitoba reported a 50% of infants born vaginally to infected mothers chlamydia rate (490.9 per 100,000) significantly and in some infants born by caesarean delivery higher than the national rate of 307.4 per 100,000 with membranes intact (2). Asymptomatic (11). For 2014, the rate of infection for women infection of the newborn can be acquired at birth was reported to be 611.1 per 100,000 compared to (2). 350.4 per 100,000 for males (13). The highest 5.3 Occurrence: incidence was reported in the 20 - 24 year age group for both males (1633.7 per 100,000) and General: Chlamydia occurs most commonly females (3028.2 per 100,000) (13). The annual among young sexually active adolescents and reported incidence of Chlamydia has remained at a adults (4). The World Health Organization high but stable annual incidence since 2009 (13). (WHO) estimates that in 2012, 131 million new In 2015, Manitoba reported a chlamydia rate of cases of Chlamydia occurred among adults and 504.6 per 100,000 population (12). adolescents aged 15 - 49 years worldwide, with a global incidence rate of 38 per 1000 females and 5.4 Incubation: 33 per 1000 males (4). The highest prevalence is The is not well defined but is in the WHO Region of the Americas and the believed to be 7 – 14 days or longer (10). WHO Western Pacific Region (4). In many Neonatal conjunctivitis develops a few days to countries, the incidence of chlamydia is highest several weeks after birth (2). Pneumonia may among adolescent girls aged 15-19 years, followed develop within the first six months of life in by young women aged 20-24 years (4). infants born to infected mothers (3). Canada: Between 2005 and 2014, the rates of 5.5 Risk Groups: reported cases of chlamydia increased by 49.3%, from 206.0 to 307.4 per 100,000 (11). The highest Geographic and racial/ethnic disparities in relative rate increase (65%) occurred among males chlamydia prevalence have been observed in some (11). In 2014, the rate of reported chlamydia countries (10). In Canada, the following risk

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factors have been observed for chlamydia Manitoba for chlamydia and gonorrhea. NAAT infection: results are acceptable for medico-legal purposes in  Sexually active youth/young adults 15 to Manitoba for diagnosis of chlamydia. In rare 24 years of age; circumstances, residual specimens may be sent to  Sexual contact with a chlamydia-infected the National Microbiological Laboratory or person; another external reference laboratory for repeat  Individuals with a new sexual partner or testing. more than two sexual partners in the past 6.1 Adult Genital Infections: year;  Adult Male/Female Urine: Urine is the  Individuals with a history of sexually preferred specimen for males and it is the transmitted infection(s); only recommended specimen for females  Vulnerable populations (e.g., including but without a (e.g., due to not limited to injection drug users, hysterectomy) or those refusing a incarcerated individuals, sex trade complete genital examination. The patient workers, street youth) (6). should not have voided for at least one hour prior to specimen collection. The 5.6 Host Susceptibility and Resistance: first 20-30 mL (not midstream) of urine Natural infection with C. trachomatis appears to should be collected in a sterile plastic confer little protection against reinfection, and the preservative-free container. Transfer the limited protection that is conferred is believed to urine as soon as possible (within 24 hours be short-lived (1). of collection) into the urine specimen transport tube provided in the CPL- 5.7 Period of Communicability: provided urine specimen collection kit. Infected individuals are presumed to be infectious Store at 2° - 30° C until transportation to (10). Without treatment, infection can persist for CPL is available. months to years (2, 10). Infection is not known to  Adult Male Urethral and Female be communicable among infants and children (2). Endocervical Swab Specimens: The CPL-provided Unisex Swab Collection 6. Diagnosis Kit is used for female endocervical and Diagnosis is based on a combination of history, male urethral swab specimens. Males physical examination and laboratory investigation. should NOT have urinated one hour prior A diagnosis of chlamydia should be considered in to specimen collection. Only the swab in anyone with signs or symptoms compatible with the NAAT kit should be used. After chlamydia. Cadham Provincial Laboratory (CPL) collection of the endocervical/urethral performs assays for both chlamydia and gonorrhea specimen, place the collection swab into only on genitourinary specimens and eye swab the swab specimen transport tube. Refer specimens submitted for Nucleic Acid to the Aptima manufacturer’s instructions Amplification Testing (NAAT). All other sources for specimen collection and handling. will only have chlamydia testing performed and 6.2 Adult Extra-genital Infections: reported by NAAT. All practitioners that perform sampling from CPL is currently the sole laboratory provider of extra-genital sites (e.g., throat, rectal, NAAT diagnostic and screening services in nasopharyngeal, eye) for C. trachomatis should

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use the Aptima Unisex Swab Collection Kit please phone Cadham Provincial Laboratory (204- (available from CPL; using the provided blue 945-7204) for advice. swab, follow specimen collection and handling steps c. to g. listed on the package). This Unisex 7. Key Investigations for Public Swab Collection Kit is identical to the one Health Response currently used for sampling of female endocervical and male urethral sites. When  Interview cases for history of exposure, submitting Unisex Collection Kit Swabs, please risk assessment, contacts and adequacy of indicate the specimen source in the “Specimen treatment. Provide education on safer sex Source” box on the CPL General Requisition. practices.  Interview contacts, offer testing and As the Aptima test is not Health Canada approved provide empiric treatment. Perform a risk for use with non-genital specimens, reports will assessment and promote safer sex include the following comment: “NAAT-based practices. detection of Chlamydia trachomatis from non- genital specimens is not Health Canada approved, 8. Control but is validated at CPL. Clinical correlation is required.” Despite this comment, studies 8.1 Management of Cases: consistently show that Aptima testing of non- Refer to Appendix A for the management of acute genital specimens is both reliable and more pelvic inflammatory disease (PID). sensitive than the MicroTrak (Direct Fluorescent  Where resources are limited, priority for ) test used previously. active follow up of cases by public health 6.3 Testing in Prepubertal Children: should be directed toward youth/young adults < 25 years of age (6), and cases For suspected genital infection in boys and girls, with identified risk factors such as first void urine (not midstream) should be pregnancy, co-infections, repeat collected and tested by NAAT. Refer to collection infections, immunocompromised, non- procedure under Section 6.1 Adult Male/Female genital infections. Urine. Urethral or vaginal swabs are not  Symptomatic individuals should be always recommended for testing in prepubertal boys and treated for BOTH chlamydia and girls. Indicate boldly on the requisition that the gonorrhea infection, without waiting for specimens are from young children (i.e., under results of laboratory testing for either. 12 years of age). Refer to Table 1 for chlamydia treatment NOTE: If a urine or discharge specimen tests and the MHSAL Gonorrhea protocol positive for chlamydia, further testing is http://www.gov.mb.ca/health/publichealth/ indicated. Refer to Section 8.1 under Children cdc/protocol/gonorrhea.pdf . for management.  Asymptomatic persons with laboratory- 6.4 Testing in Newborns: confirmed chlamydial infection and negative laboratory testing for gonorrhea Pulmonary, tracheal secretions and need not be treated for gonorrhea. nasopharyngeal aspirates should be submitted in  Serologic testing for syphilis, HIV and sterile containers. When in doubt as to procedure, hepatitis B and C is recommended if status is unknown (6, 7).

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 Lymphogranuloma venereum (LGV) Children: testing is recommended for men who have Sexual abuse must be considered when genital, sex with men (MSM) who are diagnosed rectal or pharyngeal chlamydia is diagnosed in any with anorectal chlamydia. Refer to prepubertal child; however, perinatally acquired Manitoba Health, Seniors and Active C. trachomatis infection can persist in an infant Living Lymphogranuloma Venereum for up to 3 years (6). protocol http://www.gov.mb.ca/health/publichealth/ If sexual abuse is suspected in a child with cdc/protocol/lgv.pdf . chlamydia, refer to Section 3 for reporting  Immunization against hepatitis B is requirements. ALL children under 12 years of age recommended for non-immune, non- or any child with concern of abuse should be immunized individuals (6). referred to the Child Protection Centre at the  Human papillomavirus (HPV) vaccine Children’s Hospital, Winnipeg, Manitoba (204- should be discussed with cases as per the 787-2811) PRIOR to initiating treatment and recommendations outlined in the National further testing. Staff at the centre will coordinate Advisory Statement on Immunization the forensic and medical investigation, including https://www.canada.ca/en/public- further testing, and treatment. health/services/publications/healthy- Siblings and other children possibly at risk should living/updated-recommendations-human- also be evaluated (10). papillomavirus-immunization-schedule- immunocompromised-populations.html . Refer to Table 1 below for treatment recommendations.  Cases should be instructed to abstain from unprotected intercourse until: o Seven days after initiation of Management of Chlamydial Infections in single-dose therapy or until Pregnancy, at Delivery and in the Postnatal completion of a longer Period antimicrobial regimen; o All sex partners have also  Refer to Table 1 for treatment regimens recommended for chlamydial infection completed treatment (7). during pregnancy or at delivery.  Case interviews for contact identification  All cases of conjunctivitis in the newborn should occur as soon as possible, should be tested for both N. gonorrhoeae preferably within 5 working days of and C. trachomatis because of the receiving the confirmed lab report. possibility of mixed infection.  Hospitalized cases should be managed  Women who are identified to have with Routine Practices in health care as chlamydial infection in the postnatal period per Manitoba Health, Seniors and Active should be investigated for possible co- Living’s Routine Practices and Additional existing sexually transmitted infections, Precautions: Preventing the Transmission particularly gonorrhea, but including HIV of Infection in Health Care available at: and Hepatitis B which may need to be http://www.gov.mb.ca/health/publichealth/ serologically reassessed even if tested earlier cdc/docs/ipc/rpap.pdf . in pregnancy. They should be treated appropriately with a recommended regimen. The infant should be examined carefully for

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ophthalmia neonatorum and pneumonia. If http://www.gov.mb.ca/health/publichealth/cdc/pro infection is suspected, the appropriate site(s) tocol/form11.pdf should be tested. If six weeks or more have elapsed since birth and the infant has no Follow-up of Cases: clinical evidence of disease, it may not be  Routine test of cure is not recommended. necessary to perform laboratory tests. Test of cure is indicated only in the following situations: Neonatal Infection: o of infection  Refer to Table 1 below for initial treatment are still present; recommendations. For neonatal C. o Re-exposure to an untreated trachomatis conjunctivitis, there is no partner has occurred; evidence that additional topical therapy o Compliance has been suboptimal; provides further benefit (6, 7). Consult a o An alternative treatment regimen pediatrician for infants under one week of was used; age. o In all prepubertal children; o In all pregnant women (6). Infection Prevention and Control: Hospitalized  Test of cure using a NAAT, if needed, cases should be managed with Routine Practices should be performed at 3-4 weeks after the in health care as per Manitoba Health, Seniors and completion of effective treatment to avoid Active Living’s Routine Practices and Additional false-positive results due to the presence Precautions: Preventing the Transmission of of non-viable organisms (6). Infection in Health Care available at:  Repeat testing in all individuals with C. http://www.gov.mb.ca/health/publichealth/cdc/doc trachomatis infection is recommended six s/ipc/rpap.pdf . months post-treatment, or sooner (based on clinical judgment), as reinfection risk is Treatment: high (6). Treatment recommendations for chlamydia (refer  Recurrent chlamydial infections after to Table 1 below) are based on the Canadian treatment with the recommended regimens Guidelines on Sexually Transmitted Infections may be due to reinfection, and indicate a Chlamydia Chapter. They do not provide a need for improved contact tracing and comprehensive list of all possible treatment patient education. regimens, but rather those regimens that meet general criteria of efficacy, safety, ease of administration and cost. Where possible, single dose oral therapy is preferred. Persons who have chlamydia and HIV infection should receive the same treatment regimen as those who do not have HIV infection (7).

MHSAL provides the drugs listed in Table 1 for treatment of bacterial STIs to practitioners in the provincial jurisdiction at no charge. To order the publicly-funded STI drugs, refer to the Manitoba

Health STI Medication Order Form:

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Table 1: Recommended treatment for (infants ≤ doses for at uncomplicated urethral, endocervical, rectal 2000 g) least 14 days and conjunctival chlamydia infection Based on Canadian Guidelines on Sexually Transmitted Infections https://www.canada.ca/en/public- health/services/infectious-diseases/sexual-health-sexually- Indication Preferred Alternate transmitted-infections/canadian-guidelines.html Treatment Treatment * Although there are limited data on the safety of Adults and * azithromycin during pregnancy, significant adverse adolescents 1g orally in a base 500 mg effects have not been observed. The theoretical risk & > 9 years of single dose QID for 7 days of adverse effects during pregnancy (particularly age OR OR during the first trimester) should be weighed against µ # the risk of non-compliance with the recommended 100 mg BID for 500 mg TID for alternative. 7 days 7 days µ Doxycycline is contraindicated in pregnant and # Pregnant Amoxicillin Azithromycin* lactating women (6). Women and 500 mg PO TID 1 g PO in a &The estolate formulation is contraindicated in Nursing for 7 days single dose if pregnancy. Testing after completion of therapy is Mothers OR poor recommended. & Erythromycin compliance # Limited data exist concerning the efficacy of this 2 g/day PO in with a preferred treatment, thus a test of cure is recommended. divided doses regimen is Consultation with an infectious disease specialist for 7 days expected. may be indicated. OR β As the use of erythromycin in children under 6 & Erythromycin weeks of age has been associated with infantile 1 g/day PO in hypertrophic pyloric stenosis (IHPS), it is important divided doses to monitor for signs and symptoms of IHPS (6). for 14 days Testing after completion of therapy is recommended. Children 1 Azithromycin month to 9 12-15 mg/kg years of age (maximum 1g) 8.2 Management of Contacts: orally in a single dose Where resources are limited, priority for partner Children 1 Erythromycinβ notification should be directed toward partners < week to 1 40 mg/kg/day 25 years of age. Refer to Section 3 for the month orally in 4 requirements for reporting contacts. divided doses  All partners who have had sexual contact for 14 days with the index case within 60 days prior to First week Erythromycinβ symptom onset (or date of diagnosis where of life 30 mg/kg/day asymptomatic) should be tested and (infants > orally in divided treated (6). If there is no partner during 2000 g) doses for 14 this period, then the most recent partner days should be tested and treated (6). β First week Erythromycin  Parents of infected neonates (i.e., mother of life 20 mg/kg/day and her sex partner[s]) and persons orally in divided implicated in sexual abuse cases must be

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located, clinically evaluated and treated 8.3 Preventive Measures: (6).  Instruction and encouragement for the  Contact Notification: practice of safer sex. o Public Health or health  Screening and case finding in at risk professional initiated contact groups: notification (or in combination) is o All pregnant women at their first recommended. prenatal visit. For those who are o If the contact was tested and tested positive or at high risk for negative for chlamydia, no further infection (refer to groups listed follow-up is required. If the below), rescreening in the third contact has not been tested, trimester is recommended. follow-up should occur with the o Sexually active youth/young adults contact. If the contact is known or 15 to 24 years of age. believed to be pregnant, if o Individuals with a new sex partner possible, public health may or more than two sex partners in connect with the pregnant the past year. woman’s health care provider. o Individuals with a history of o Where resources permit, public previous sexually transmitted health practitioners should infections. complete interviews for contacts o Vulnerable populations (including and contact notification for all but not limited to injection drug contacts identified within 30 days users, incarcerated individuals, sex of index case presentation to a trade workers, street youth). health care provider. While this  Cases and their contacts should refrain timeline is desirable, from until 1 week after circumstances may require 1 dose treatment or until completion of a extending this period (e.g., contact longer antimicrobial regimen (7). gets in touch after 30 days, contact  Prenatal screening and treatment of does not live in same community, pregnant women is the best method for contact is very young, or known to preventing chlamydial infection among be pregnant, delayed receipt of neonates (7). contact form). APPENDIX A: Management of Acute Pelvic Neonatal Contacts: Inflammatory Disease (PID)  Neonates born to women with chlamydial infection are at high risk of pneumonia and Early diagnosis and treatment are crucial to conjunctivitis. Infants should be examined the maintenance of (14). carefully and testing of the eyes and  Acute pelvic inflammatory disease results nasopharynx should be performed. Infants from the ascending spread of microorganisms testing positive should be treated with the from the vagina and endocervix to the upper regimens described for neonatal infection female genital tract including the under “Management of Cases”. Prophylaxis endometrium, fallopian tubes, pelvic is not recommended unless follow-up cannot peritoneum and contiguous structures (14). be guaranteed (6).

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 This syndrome includes any combination of  Definitive diagnostic criteria include: endometritis, salpingitis, tubo-ovarian o Endometrial biopsy with and pelvic peritonitis (7). histopathologic evidence of endometritis (at least 1 plasma cell per

x 120 field and at least 5 neutrophils  Etiologic agents include N. gonorrhoeae, C. per x 400 field); trachomatis and other organisms such as o Transvaginal sonography or other anaerobes, enteric Gram-negative rods, imaging techniques showing thickened streptococci and some . fluid-filled tubes, with or without free pelvic fluid or tubo-ovarian complex;  Acute PID may be difficult to diagnose or because of the wide variation in presenting o Gold standard: Laparoscopy symptoms and signs. Many women with PID demonstrating abnormalities consistent have subtle or mild symptoms. with PID, such as and/or mucopurulent

exudates (14).  There is no single historical, physical or laboratory finding that is both sensitive and Treatment: specific for the diagnosis of PID (7, 14).  Goals of treatment are to control acute infection and to prevent long-term sequelae

such as infertility, and  The minimum diagnostic criteria for PID chronic pelvic pain (14). includes the following: o Lower abdominal tenderness and o Uterine/adnexal tenderness or  Empiric treatment for PID should be initiated o Cervical motion tenderness (7, 14). in women at risk for STIs if the minimum criteria are present and no other causes for the

illness can be identified.  Additional criteria that support a diagnosis of PID and enhance the specificity of the diagnosis, in addition to the minimum criteria  The management of women with PID is include: considered inadequate unless their sexual o Oral temp > 38.3°C partners are also clinically evaluated (15). o Presence of white blood cells (WBC) on saline microscopy of vaginal  Treatment regimens should provide coverage secretions/wet mount for N. gonorrhoeae, C. trachomatis, Gram- o Elevated erythrocyte sedimentation negative facultative and streptococci. rate Anaerobic coverage (metronidazole) should be o Elevated C - reactive considered, but whether elimination of o Abnormal cervical or vaginal anaerobes from the upper tract is necessary mucopurulent discharge remains to be answered even though o Laboratory documentation of cervical anaerobes are detected in the majority of PID infection with N. gonorrhoeae or cases (14). C. trachomatis (7, 14).

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 The recommended combination treatment days after therapy is initiated (14). If no below is covered by Manitoba Health, Seniors clinical improvement has occurred, hospital and Active Living. There are other effective admission for parenteral therapy, observation treatment regimens for PID that health care and consideration for laparoscopy is required; providers may wish to prescribe; however, consultation with colleagues experienced in only the regimens described below are the care of these patients should be considered publicly-funded in Manitoba. To order the (14). publicly-funded STI drugs, refer to the

Manitoba Health STI Medication Order Form:  In patients who have completed treatment for http://www.gov.mb.ca/health/publichealth/cdc PID and have persistent symptoms, /protocol/form11.pdf . consideration should be given to Mycoplasma Ceftriaxone 250 mg IM in a single dose genitalium and as followed by possible causative organisms (9). Refer to current Canadian Guidelines on Sexually Doxycycline 100 mg orally twice a day for 14 Transmitted Infections for management. days with or without

Metronidazole 500 mg orally twice a day for  Some specialists also recommend rescreening 14 days. for N. gonorrhoeae and C. trachomatis four to Precautions: Ceftriaxone should not be given to six weeks after therapy is completed in persons with a allergy or a history women with documented infection. of immediate and/or anaphylactic reactions to penicillins (14). Doxycycline is contraindicated in  Pregnant patients with suspected PID should pregnancy, lactation and children under nine years be hospitalized for evaluation and treatment of age. Patients should not drink alcohol during with parenteral therapy; consultation with an and for 24 hours after oral therapy with expert should be sought. metronidazole because of a possible disulfram

(antabuse ) reaction (14). Additional Resources for Health For patients with contraindications to Professionals treatment with , recent evidence suggests that short course azithromycin at a dose  Nine Circles Community Health Centre, of either 250 mg PO daily for one week or 1 gram Winnipeg PO weekly for two weeks combined with oral http://ninecircles.ca/education/for-health- metronidazole is effective in producing a clinical care-professionals/ . cure for acute PID (14).  Sexuality Education Resource Centre  Some patients will require hospitalization. The (SERC) Manitoba decision of whether hospitalization is http://www.serc.mb.ca/ . necessary should be based on the assessment  STI Klinic, Klinic Community Health of the health care provider. http://klinic.mb.ca/health-care/drop-in- services/sti-klinic/  Individuals treated as outpatients need careful  Public Health Agency of Canada. follow-up and should be re-evaluated 2 to 3 Canadian Guidelines on Sexually Transmitted Infections

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https://www.canada.ca/en/public- 8. Canadian AIDS Treatment Information health/services/infectious-diseases/sexual- Exchange. What you need to know about health-sexually-transmitted- chlamydia http://www.catie.ca/en/printpdf/fact- infections/canadian-guidelines/sexually- sheets/sti/chlamydia/key-messages-chlamydia . transmitted-infections.html#toc 9. Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections References 2016 Updates Summary, April 2017 1. Batteiger BE and Tan M. Chlamydia https://www.canada.ca/content/dam/phac- trachomatis (, Genital Infections, aspc/migration/phac-aspc/std-mts/sti- Perinatal Infections, and Lymphogranuloma its/assets/pdf/updates-summary-eng.pdf . Venereum. In: Mandell, Douglas, and Bennett’s 10. Heymann David L. Chlamydial Infections (eds) Principles and Practice of Infectious In: Control of Communicable Diseases Manual th Diseases 8 ed. Elsevier, Philadelphia, 2015. 20th ed, American Public Health Association, 2. American Academy of Pediatrics. Chlamydia Washington, 2015; 99-101. trachomatis. In: Pickering LK ed. Redbook 2012 11. Public Health Agency of Canada. Report on Report of the Committee on Infectious Diseases sexually transmitted infections in Canada: 2013- th 29 ed. Elk Grove Village, IL: American 2014. Academy of Pediatrics, 2012; 276-281. 12. Choudhri Y, Miller J, Leon A and Aho J. 3. Public Health Agency of Canada. Case Chlamydia in Canada, 2010-2015. CCDR 2018; Definitions for Communicable Diseases under 44(2):49-54. National Surveillance. Canada Communicable Disease Report CCDR 2009; 35S2: 1-123. 13. Manitoba Health, Seniors and Active Living. Sexually Transmitted Infections in Manitoba 4. World Health Organization. WHO Guidelines 2014. for the Treatment of Chlamydia trachomatis 2016. http://www.gov.mb.ca/health/publichealth/surveill 5. Nwokolo NC, Dragovic B, Patel S et al. 2015 ance/docs/stim2014.pdf . UK national guideline for the management of infection with Chlamydia trachomatis. 14. Public Health Agency of Canada. Canadian International Journal of STD & AIDS 2016; Guidelines on Sexually Transmitted Infections 27(4):251-267. Section 4 – Management and Treatment of Specific 6. Public Health Agency of Canada. Canadian Syndromes: Pelvic Inflammatory Disease (PID), Guidelines on Sexually Transmitted Infections 2010. Available at: http://www.phac-aspc.gc.ca/std- mts/sti-its/cgsti-ldcits/section-4-4-eng.php . https://www.canada.ca/en/public- health/services/infectious-diseases/sexual-health- sexually-transmitted-infections/canadian- 15. Public Health Agency of Canada. Canadian guidelines.html . Guidelines on Sexually Transmitted Infections Supplementary Statement for recommendations 7. Centers for Disease Control and Prevention. related to the diagnosis, management, and follow- Sexually Transmitted Diseases Treatment up of Pelvic Inflammatory Disease March 2014. Guidelines, 2015. MMWR Recomm Rep 2015; Available at: http://www.phac-aspc.gc.ca/std- 64(No.RR-3):1-137. mts/sti-its/cgsti-ldcits/pid-aip-eng.php .

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