WHO GUIDELINES FOR THE Treatment of Chlamydia trachomatis WHO Library Cataloguing-in-Publication Data WHO guidelines for the treatment of Chlamydia trachomatis. &RQWHQWV:HEDQQH['(YLGHQFHSURnjOHVDQGHYLGHQFHWRGHFLVLRQ framework -- Web annex E: Systematic reviews -- Web annex F: Summary RIFRQǍLFWVRILQWHUHVW 1.Chlamydia trachomatis. 2.Chlamydia Infections - drug therapy. 3.Sexually Transmitted Diseases. 4.Guideline. I.World Health Organization. ,6%1 1/0FODVVLnjFDWLRQ:& © World Health Organization 2016 All rights reserved. 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Printed by the WHO Document Production Services, Geneva, Switzerland WHO GUIDELINES FOR THE TREATMENT OF CHLAMYDIA TRACHOMATIS i CONTENTS Acknowledgements iii Abbreviations and acronyms iv Executive summary 1 Overview of the guidelines for the prevention, treatment and management of STIs 6 67,HSLGHPLRORJ\DQGEXUGHQ :K\QHZJXLGHOLQHVIRUWKHSUHYHQWLRQWUHDWPHQWDQGPDQDJHPHQWRI67,V" Approach to the revision of STI guidelines 8 References 9 WHO guidelines for the treatment of Chlamydia trachomatis 10 1. Introduction 10 (SLGHPLRORJ\EXUGHQDQGFOLQLFDOFRQVLGHUDWLRQV &OLQLFDOSUHVHQWDWLRQ Laboratory diagnosis 11 1.2 Rationale for new recommendations 11 1.3 Objectives 11 1.4 Target audience 11 1.5 Structure of the guidelines 11 2. Methods 12 *XLGHOLQH'HYHORSPHQW*URXS *'* 2.2 Questions and outcomes 12 2.3 Reviews of the evidence 12 2.4 Making recommendations 13 0DQDJHPHQWRIFRQǍLFWVRILQWHUHVW 3. Dissemination, updating and implementation of the guidelines 15 3.1 Dissemination 15 3.2 Updating the STI guidelines and user feedback 15 3.3 Implementation of the WHO guidelines for the treatment of C. trachomatis 15 Adaptation, implementation and monitoring 15 ,GHQWLI\LQJDQGSURFXULQJ67,GUXJV 4. Recommendations for treatment of chlamydial infections 17 4.1 Uncomplicated genital chlamydia 17 Recommendation 1 17 4.2 Anorectal chlamydial infection 18 Recommendation 2 18 4.3 Chlamydial infection in pregnant women 19 Recommendation 3a 19 Recommendation 3b 19 Recommendation 3c 19 /\PSKRJUDQXORPDYHQHUHXP /*9 5HFRPPHQGDWLRQ ii WHO GUIDELINES FOR THE TREATMENT OF CHLAMYDIA TRACHOMATIS &217(176 &217,18(' 2SKWKDOPLDQHRQDWRUXP 5HFRPPHQGDWLRQ 5HFRPPHQGDWLRQ Recommendation 7 21 References 22 Annex A: STI guideline development teams 23 Annex B: Detailed methods for guideline development 32 Questions and outcomes 32 Review of the evidence 35 Applying the GRADE approach to making the recommendations 38 Annex C: Lists of references for reviewed evidence 39 Recommendation 1 39 5HFRPPHQGDWLRQ Recommendation 3a, 3b, 3c 41 Recommendation 4 42 Recommendation 5 43 5HFRPPHQGDWLRQVDQG Web annexes available at: www.who.int/reproductivehealth/publications/rtis/chlamydia-treatment-guidelines/en/ :HEDQQH['(YLGHQFHSURnjOHVDQGHYLGHQFHWRGHFLVLRQIUDPHZRUNV Web annex E: Systematic reviews for chlamydia guidelines :HEDQQH[)6XPPDU\RIFRQǍLFWVRILQWHUHVW WHO GUIDELINES FOR THE TREATMENT OF CHLAMYDIA TRACHOMATIS iii ACKNOWLEDGEMENTS The Department of Reproductive Health and Research Members: <DZ 6D[ $GX6DUNRGLH$QGUHZ$PDWR DWWKH:RUOG+HDOWK2UJDQL]DWLRQ :+2 ZRXOGOLNHWR Gail Bolan, John Changalucha, Xiang-Sheng Chen, thank the members of the STI Guideline Development Harrel Chesson, Craig Cohen, Francisco Garcia, Group for their consistent availability and commitment Suzanne Garland, Sarah Hawkes, Mary Higgins, to making these guidelines possible. The Department .LQJ+ROPHV-HNjUH\.ODXVQHU'DYLG/HZLV1LFROD/RZ is also grateful to the STI External Review Group for David Mabey, Angelica Espinosa Miranda, Nelly Mugo, peer reviewing these guidelines, and appreciates Saiqa Mullick, Francis Ndowa, Joel Palefsky, the contribution of the WHO Steering Committee. .HLWK5DGFOLNjH8OXJEHN6DELURY-XGLWK6WHSKHQVRQ The names of the members of each group are listed Richard Steen, Magnus Unemo, Bea Vuylsteke, below, with full details provided in Annex A. Anna Wald, Thomas Wong and Kimberly A. Workowski Special thanks to Dr Nancy Santesso, the guideline STI GDG working group for chlamydia: methodologist who also led the systematic review Andrew Amato, Harrell Chesson, Craig Cohen, SURFHVVIRUKHUKDUGZRUNDQGnjUPFRPPLWPHQWRI Patricia Garcia, Nicola Low, David Mabey, Angelica the guideline development process. We also thank 0LUDQGD)UDQFLV1GRZD.HLWK5DGFOLNjH-XGLWK the members of the Systematic Review Team from Stephenson, Magnus Unemo, Bea Vuylsteke and McMaster University. Judith Wasserheit We appreciate the overall support of the WHO STI External Review Group: Laith Abu-Raddad, Guideline Review Committee Secretariat during the Adele Benaken-Schwartz, Mircea Betiu, Anupong guideline development process, with grateful thanks Chitwarakorn, Anjana Das, Carolyn Deal, to Dr Susan Norris. Margaret Gale-Rowe, William M. Geisler, Amina El Kettani, Mizan Kiros, Ahmed Latif, Philippe We thank Theresa Ryle for the administrative Mayaud, David McCartney, Ali M. Mir, Nuriye Ortayli, VXSSRUWDQG&RPPXQLFDWLRQVIRUDVVLVWDQFH Khantanouvieng Sayabounthavong and with the guideline design and layout. This guideline Aman Kumar Singh document was edited by Ms Jane Patten, of Green Ink, United Kingdom. WHO Steering Committee: Dr Teodora Wi led the guideline development process :+2UHJLRQDORǎFHVMassimo Ghidinelli, Hamida and Dr Nathalie Broutet co-led the process under Khattabi, Lali Khotenashvili, Ornella Lincetto Ying-Ru Lo, the supervision of Dr James Kiarie and leadership of Frank Lule and Razia Pendse Dr Ian Askew. Lee Sharkey provided support during WHO headquarters: Moazzam Ali, Avni Amin, Rachel the guideline development process. Baggaley, Venkatraman Chandra-Mouli, Jane Ferguson, 0DULR)HVWLQ0DU\/\Q*DǎHOG$QWRQLR*HUEDVH FUNDING Sami Gottlieb, Silvio Paolo Mariotti, Frances McConville, Lori Newman, Annette Mwansa Nkowane, Anita Sands, The preparation and printing of the guidelines were Igor Toskin and Marco Vitoria funded exclusively by the UNDP/UNFPA/UNICEF/ WHO/World Bank Special Programme of Research, WHO STI Secretariat: Ian Askew, Teodora Elvira Wi Development and Research Training in Human OHDGGHYHORSPHQWRIWKHJXLGHOLQHV 1DWKDOLH%URXWHW 5HSURGXFWLRQ +53 1RH[WHUQDOVRXUFHRIIXQGLQJ FROHDGGHYHORSPHQWRIWKHJXLGHOLQHV -DPHV.LDULH was solicited or utilized. and Lee Sharkey Systematic Review Team: 1DQF\6DQWHVVR OHDG CONTRIBUTORS TO WHO GUIDELINES FOR THE Housne Begum, Janna-Lina Kerth, Gian Paolo Morgano, TREATMENT OF CHLAMYDIA TRACHOMATIS Kristie Poole, Nicole Schwab, Matthew Ventresca, <XDQ=KDQJDQG$QGUHZ=LNLF PHPEHUV STI Guideline Development Group (GDG): Methodologist: Nancy Santesso. Chairpersons: Judith Wasserheit, Holger Schünemann and Patricia Garcia iv WHO GUIDELINES FOR THE TREATMENT OF CHLAMYDIA TRACHOMATIS ABBREVIATIONS AND ACRONYMS AIDS DFTXLUHGLPPXQHGHnjFLHQF\V\QGURPH AMR antimicrobial resistance DALY disability-adjusted life year DFA GLUHFWǍXRUHVFHQWDQWLERG\ DOI declaration of interests ELISA enzyme-linked immunosorbent assays GDG Guideline Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation GUD genital ulcer disease HIV KXPDQLPPXQRGHnjFLHQF\YLUXV HPV human papillomavirus HRP UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction +69 herpes simplex virus type 2 LGV lymphogranuloma venereum MSH Management Sciences for Health MSM men who have sex with men NAATs QXFOHLFDFLGDPSOLnjFDWLRQWHVWV 1$$7V PICO population, intervention, comparator, outcome POCT point-of-care test STI sexually transmitted infection UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF 8QLWHG1DWLRQV&KLOGUHQšV)XQG WHO World Health Organization WHO GUIDELINES FOR THE TREATMENT OF CHLAMYDIA TRACHOMATIS 1 WHO GUIDELINES FOR THE TREATMENT OF CHLAMYDIA TRACHOMATIS EXECUTIVE SUMMARY Sexually transmitted infections (STIs) are a PDMRUSXEOLFKHDOWKSUREOHPZRUOGZLGHDNjHFWLQJ TXDOLW\RIOLIHDQGFDXVLQJVHULRXVPRUELGLW\ and mortality. STIs have a direct impact on UHSURGXFWLYHDQGFKLOGKHDOWKWKURXJKLQIHUWLOLW\