NM Department of Health Family Planning Program

Services and Clinics

Screening and Treatment

This section contains discussion and/or specific guidelines for the following topics:

• Screening

  • Females

  • Males

• Specimen Collection

  • Cervical and Urethral Specimens

  • Urine Specimens for DNA Amplification

  • Collection of Cervical Specimen from the Female

  • Collection of Urethral Specimen from the Male

  • Common Problems with Specimen Collection and Transport

• Treatment

  • Presumptive Diagnosis and Treatment Criteria for Females

  • Treatment for Non-pregnant Females and Males

  • Treatment Options for Pregnant Females

  • PID Treatment Options

  • Follow Up of Treated Clients

  • Reporting

  • Table: Medications Commonly Used for Treating Ct

• Partner Examination and Treatment

• Summary

• Case Study

Screening

Screening is commonly defined as testing in asymptomatic populations.  Because of the frequently asymptomatic nature of chlamydial infections, screening becomes essential to controlling disease incidence and preventing potential complications.  Screening is also essential to documenting disease prevalence in subpopulations so that cost effective control strategies can be implemented.  Chlamydia screening at family planning and prenatal care clinics is particularly cost-effective because of the large number of sexually active young women who undergo pelvic examinations.

Published studies have identified certain risk factors associated with increased risk of infection.  These risk factors include the following:

• Age less than 25 years (mostly among females 15 to 19)

• New sex partner during past 60 days

• Multiple sex partners during past 60 days

• Non-use or inconsistent use of barrier forms of contraceptives

Females

The Centers for Disease Control and Prevention currently recommend that the following populations be screened for chlamydia:

• Women being seen by adolescent care providers

• Women undergoing induced abortion

• Women attending STD clinics

• Women in detention facilities.

 In Family Practice, OB-GYN, Internal Medicine and Pediatric clinics, clients who meet the following criteria should be screened:

• Women with mucopurulent cervicitis

•  Sexually active women < 20 years of age

•  Sexually active women 20-24 with one of the criteria listed below and women > 24 years of age with both criteria: 

  • No or inconsistent use of barrier contraception

  • New partner or more than one sex partner in the previous 3 months.

Males

All males with urethritis and epididymitis regardless of etiology should be screened and  treated for chlamydia.  All male contacts to women with proven chlamydia infection require treatment.  Also requiring treatment are those males whose female partners have been treated presumptively for a chlamydia associated syndrome such as mucopurulent cervicitis or PID.  To the extent possible, Family Planning programs should provide opportunities for screening, treatment and counseling to males.

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Specimen Collection

Cervical and urethral specimens

The sensitivity of all types of chlamydia tests is dramatically influenced by the quantity and quality of cells obtained on the specimen swab.  The greater the number of cells collected and the less vaginal secretion contamination, the more likely a chlamydial infection will be detected.  Careful and thorough specimen collection will increase the accuracy of client test results.  Correct specimen collection is essential to obtain samples of these columnar cells from the endocervix or the urethra.  The lack of specimen adequacy remains a serious problem in many screening programs, and periodic cytologic evaluation of specimen quality is recommended to evaluate specimen collection technique.  Some studies looking at specimen adequacy have found as many as 30% of specimens to be inadequate, in spite of extensive clinician training. 

Urine specimens for DNA amplification

Urine specimens for antigen detection and DNA amplification tests should be collected as directed by the test manufacturer.  Subjects should not have urinated within the previous hour, and females should be instructed NOT to clean the perineal area prior to urinating.  The first catch of 10 to 20 ml of urine should be collected in a clean collection cup and refrigerated immediately at 2 to 8º C.  Urines should not be left at room temperature since the low pH and high urea content rapidly denature DNA present in the specimen, especially at 25º C and above.

Collection of Cervical Specimen from the Female

• If a Pap smear is to be done, generally it should be done first.  However, blood in the specimen may interfere with chlamydia and gonorrhea testing; therefore, for women who are strongly suspected of being infected, specimen order should be at the discretion of the clinician.

• Clean contaminating vaginal secretions from the face of the exocervix with a swab, then discard that swab.

• Collect other culture specimens such as for gonorrhea before collecting chlamydia specimen.

• Always use sterile swab recommended by manufacturer.

• Insert appropriate swab into endocervix until most of tip is not visible.

• Rotate swab with firm pressure against the walls of the endocervix for at least 10 - 20 seconds (see package insert).

• Place swab in transport tube or bottle provided.

• Break off shaft of swab (raise swab well off the bottom of tube or bottle before snapping shaft).

• Cap tube or bottle tightly.

 Collection of Urethral Specimen from the Male

• Collect other specimens such as for gonorrhea and/or gram stain first.

• Insert a sterile swab recommended by manufacturer into the urethra.

• Insert the swab a minimum of 2.5 cm or 1 inch.

• Rotate at least 2 complete revolutions for 2-3 seconds.

 Common problems with specimen collection or handling

• Too much blood or mucus on Gen-Probe swab.

• Failure to adequately clean exocervix.

• Failure to obtain columnar epithelial cells on the swab.

• Touching vaginal surfaces when withdrawing swab.

• Use of any swab other than those included with collection kit.

• Collection of specimen from an unapproved site (vaginal, female urethral, rectal, pharyngeal, etc.).

• Inadequate collection of specimen using urethral discharge from males -- swab must be inserted 2-4 cm into urethra.

• Urine specimen stored at other than refrigerator temperature.

• Delay in transporting specimen to the laboratory or other improper handling of the transport tube, i.e. failing to properly seal the tube.

Americans are surprisingly uneducated about STDs.  In a 1993 national survey of 1,000 women ages 18 to 60, almost two-thirds knew very little about STDs other than HIV/AIDS.

Be sure to ask clients about their risk history.  Don’t assume that they will know to ask you.

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Treatment

The 2002 CDC Guidelines for Treatment of Sexually Transmitted Diseases provide public health oriented, concise, cost effective, and evidence based guidelines which were developed  in consultation with a group of nationally recognized experts in the STD field. The 2002 Guidelines contain a number of important revisions and new recommendations which were not in the 1993 edition.  A complete set of the 2002 Treatment Guidelines are included with this manual and should be replaced as revisions are made.

One of the significant changes from 1993 recommendations is the new emphasis on generally awaiting the results of sensitive tests (culture, DNA tests such as the Gen-Probe, or DNA amplification tests such as PCR or LCR tests) to determine the need for treatment. The reason for this is the recognition that most clinical cervicitis is not caused by either gonorrhea or chlamydia and that most female clients with MPC (mucopurulent cervicitis) do not have gonorrhea or chlamydia. Rather than treat large numbers of women unnecessarily and raise false concerns that they have a sexually transmitted disease, it is felt to be better to await specific test results.

The diagnosis of MPC is made when a purulent or mucopurulent endocervical exudate is visible in the endocervical canal or on an endocervical swab specimen (a "positive swab test"), if bleeding is easily induced by obtaining a specimen (a friable cervix), or if an ectropion appears to be inflamed and edematous. The Guidelines discourage the use of a cervical Gram stain to count leukocytes since this test has not been standardized and has a low-predictive value. It is important to emphasize that although MPC may be caused by gonorrhea or chlamydia; in most cases neither organism is identified.

The 1998 Guidelines do, however, recommend empirical treatment of MPC when:

• the prevalence of one or both of these infections is very high in the client population and

• the client is considered unlikely to return for treatment (such as young teenagers, homeless or transient people,  or clients in an urban STD clinic). In these situations a client would be treated presumptively for chlamydia and for gonorrhea.

Any client who is the sexual contact of a partner with gonorrhea or chlamydia should be examined, tested for both infections, and treated "epidemiologically" with antibiotics. If the partner is known to have gonorrhea, treat the client for both gonorrhea and chlamydia. If the partner has chlamydia, then treat only for chlamydia.

Whenever possible, clients with clinical signs or symptoms of disease should be tested for C. trachomatis infection even though presumptive treatment may be given.  Testing is recommended because a positive test can facilitate referral and treatment of sexual partners.  Additionally, testing can facilitate client management for those clients who may not respond as expected to initiated therapies.  Clients presumed to have chlamydia may be treated prior to test result using the following criteria: 

Presumptive Diagnosis Treatment Criteria for Females

• Mucopurulent cervicitis and other high risk factor (see above).

• Signs and symptoms of PID present.

• Confirmed Gonorrhea infection.

• History of recent sexual partner with confirmed Ct or GC.

• History of recent sexual partner with urethritis.

The treatment options for presumed or confirmed positive Chlamydia trachomatis infections are listed below:

Non-Pregnant Female or any Male

• Treatment of Choice

  • Doxycycline 100 mg orally 2 times a day for 7 days -or-

  • Azithromycin 1 g orally in a single dose

• Alternative Regimens–See CDC’s 2002 Guidelines for Treatment of Sexually Transmitted Diseases.

In Pregnancy

• Recommended Regimen for Pregnant Women

  • Erythromycin base 500 mg orally 4 times a day for 7 days -or-

  • Amoxicillin 500 mg orally 3 times a day for 7 days

The best treatment of chlamydia in pregnancy is not completely clear at this time.  Doxycycline and ofloxacin are contraindicated, and pregnant women frequently experience nausea and vomiting when taking erythromycin.  Both amoxicillin and azithromycin are better tolerated and have similar cure rates as erythromycin.  Azithromycin offers the significant advantage of a single dose treatment and is widely used for treating chlamydia in pregnancy.  Although it has not yet been approved by the FDA for use in pregnancy, it has been shown to be both safe and effective and its use has become standard in many communities.  Every pregnant woman diagnosed with a chlamydia infection should have a repeat test three weeks after completion of therapy regardless of which treatment regimen is used. 

PID Treatment Options

PID comprises a spectrum of inflammatory disorders of the upper genital tract among women and may include any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.  No single therapeutic regimen has been established for persons with PID.  Many experts recommend that all clients with PID be hospitalized so that supervised treatment with parenteral antibiotics can be initiated.  PID therapy must provide empiric, broad-spectrum coverage of likely pathogens.  Antimicrobial coverage should include N. Gonorrhoeae and C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci.  Refer to Pelvic Inflammatory Disease section in the 2002 Treatment Guidelines for complete treatment recommendations.

Follow Up for All Treated Clients

Clients must receive complete education regarding their medications.  Table 2  summarizes adverse reactions, contraindications, interactions, use in pregnancy and lactation, and age restrictions for the antibiotics commonly used in treating chlamydial infections.

Medications Commonly Used for Treating Chlamydial Infections

The 2002 Treatment Guidelines now recommend that all women with chlamydial infections be rescreened 3 to 4 months after treatment is completed.

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Partner Examination and Treatment

The Centers for Disease Control and Prevention has set standards for the management of sex partners to chlamydia.  These are summarized in the 2002 Guidelines for Treatment of Sexually Transmitted Diseases.  The standards include:

• Refer all sex partners within the last 60 days or most recent partner

  • Two methods of partner notification are provider referral and client self-referral.  Only where there are staff available for conducting the referral process can provider referral be accomplished.  All chlamydia positive clients should be told to have their partners evaluated and treated.  Clinics are strongly encouraged to establish systems whereby follow-up for partner treatment is tracked.

  • Not only should sex partners of known chlamydia positive clients be referred, but any woman diagnosed with PID should be told to refer her partner(s) for evaluation and treatment.  A woman whose sex partner(s) is not treated is at continued risk for persistent infection.

• Evaluate and treat all sex partners

  • No person with chlamydia can be considered adequately treated until his/her sex partner(s) is also treated.  Prevention of re-infection is critical to reducing the serious long term consequences of chlamydia, e.g., chronic pelvic pain, PID, infertility.

  • Clinics participating in the Region VI project must provide for partner evaluation and treatment of chlamydia positive clients.  If such evaluation and treatment is not provided on site, the clinic must provide to the client and any partners a list of locations where evaluation and treatment will be provided.

  • Examination of a male partner of a chlamydia positive female is strongly encouraged.  Other asymptomatic STDs may be detected on clinical exam or lab work.

• Instruct clients to abstain from sex until they and their partners are cured

  • All parties should be instructed to abstain from sex until all concerned have completed the full course of medication and any symptoms have subsided. Clients and their partners should also be counseled to complete the full course of medication, regardless of whether they have symptoms.  Inadequate treatment will result in continuation of infection. 

Partner Management and Public Health Implications

Partner management of both male and female clients is a cost-effective public health strategy for preventing Ct and its sequelae.  Re-infection can be prevented with effective partner management, and PID can be prevented with early diagnosis and treatment of female sex partners of infected men.  The extent to which PID and other sequelae can be prevented is dependent on promptly bringing in all partners before client’s therapy has been completed. 

A list of specific topics to be discussed when talking to the index client about partners is found in Section III.  At a minimum, the following items need to be addressed:

• Critical exposure periods and who should be considered an “at risk” partner

• Importance of contacting all partners
• Meaning of laboratory tests and likelihood of infection
• Where partner(s) can seek care
• Consequences to partners’ partners if not treated
• Discussion of possible partner reactions

• Suggestions of techniques of how to communicate with partner

• Return for screening in 3 to 4 months following treatment completion

Although partner notification has been a component of STD programs in the United States for many years, too many partners are not receiving timely treatment for chlamydial infections.  Infected clients must be instructed in the importance of assisting partners to seek treatment and in the importance of avoiding sexual intercourse until all parties have completed their medications.  One dose medication regimens can be problematic if clients are not carefully instructed to abstain from sexual intercourse until all of their sex partners are cured.

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Summary

Young age (< 25 ) is a significant risk factor for Ct.

Careful and thorough specimen collection will increase the accuracy of client test results.  Correct specimen collection is essential to obtain samples of these columnar cells from the endocervix or the urethra.

Whenever possible, clients should be tested for chlamydia even though presumptive treatment may be given.

The medications most commonly used to treat chlamydial infections include azithromycin, doxycycline, erythromycin, and ofloxacin.

Health care providers must assume a pro-active role in instructing clients regarding partner referral and treatment activities. 

Case Study

Case 2:  A clinician staffs your clinic only once or twice a month.  You are concerned after viewing visible pus on the swab that he/she is not adhering to proper collection techniques.

Question:  What effect will this have on the results?

Case 3:  A 26-year old female presents to your clinic because she was recently treated for chlamydia and wishes to make sure that she is cured.

Question: Is Gen-Probe appropriate to use in this situation?  Why or Why Not?

(Case Study answers found in Appendix)

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