Chlamydia

Overview

Chlamydia is the most reported communicable disease in Australia.
Those < 30 years are at greatest risk.
Frequently asymptomatic.
Simple to test and treat.
Immunity to new infection is not provided by previous infection.

Symptoms
85%-90% have no symptoms
Dysuria Penile urethral discharge Vaginal discharge Testicular pain Pelvic Pain Intermenstrual bleeding Postcoital bleeding Pain with sex - dyspareunia Anorectal symptoms
Complications
Epididymo-orchitis Pelvic inflammatory disease (PID) Infertility Pregnancy - Ectopic pregnancy, Premature rupture of the membranes, preterm delivery, and low-birthweight infants Reactive arthritis: arthritis, sometimes with concurrent rash and gastrointestinal symptoms Cervicitis Conjunctivitis Perihepatitis

See STI Atlas for images.

Special considerations

May also infect the eye, anus and throat.

Site/Specimen	Test	Consideration
Urethra First pass urine (FPU)	NAAT	In people who do not have a vagina or if endocervical swab/self-collected vaginal swab cannot be taken. Less sensitive than self-collected vaginal swab
Self-collected vaginal swab	NAAT	Best test if no speculum examination
Clinician-collected endocervical swab	NAAT	Best test if examined
Anorectal swab	NAAT	Any patient with anorectal symptoms All men who have sex with men Self-collection or during clinical examination
Pharyngeal swab	NAAT	All men who have sex with men.

NAAT – Nucleic acid amplification test

Specimen collection guidance

Clinician collected | Self-collection

Asymptomatic patients can collect most samples themselves, including vaginal swabs, anorectal and throat swabs.

Investigations

NAATs are highly sensitive, can be used in non-clinical settings and are the only recommended test for chlamydia.
For asymptomatic testing or where an examination is unable to be performed, encourage patient self-collection of vaginal swabs and anorectal swabs.
Concurrent gonorrhoea testing should accompany chlamydia testing.

Principal treatment options
Infection	Recommended	Alternative
Uncomplicated genital or pharyngeal infection	Doxycycline 100 mg PO, BD 7 days	Azithromycin 1 g PO, stat. Consider where adherence to daily treatment likely to be poor especially where anorectal infection is less likely.
Anorectal infection	Doxycycline 100 mg PO, BD for 7 days if asymptomatic, but 21 days if symptomatic (see anorectal syndromes)	Azithromycin 1 g PO, stat. and repeat in 12-24 hours

BD: twice a day

PO: orally

Stat.: immediately

Treatment advice

See urethritis for immediate management of urethritis symptoms.
Immediate treatment is not recommended for all sexual contacts of chlamydia but offer testing of exposed anatomical sites and await results.
If contact treatment is initiated, use recommended treatment. Only use azithromycin if adherence likely to be poor or matches index case treatment. See Contact tracing below
If a patient has an IUD, leave it in place and treat as recommended. Seek specialist advice as needed.

For symptomatic anorectal infection, see testing and treatment recommendations.

Other immediate management

Perform a full STI check-up including HIV and syphilis serology if not done as part of initial testing.
Advise no sexual contact for 7 days after treatment is commenced, or until the course is completed and symptoms resolved, whichever is later.
Advise no sex with partners from the last 6 months until the partners have been tested and treated if necessary.
Contact tracing and patient delivered partner therapy (see contact tracing section for more information).
Provide patient with factsheet.
Notify the state or territory health department.

Special considerations

Consider seeking specialist advice before treating any complicated presentation.

Situation	Recommended
Pregnant people	Azithromycin 1 g PO, stat.
Allergy to principal treatment choice	If both principal treatment options unsuitable, seek specialist advice.
Rectal co-infection	With gonorrhoea, treatment should be given for both infections i.e. ceftriaxone 500 mg IMI, stat. in 2 mL 1% lignocaine PLUS doxycycline 100 mg PO, BD 7 days if asymptomatic, but 21 days if symptomatic (see anorectal syndromes)

BD: twice a day

PO: orally

Stat.: immediately

IMI: intramuscular injection

Contact tracing is important to prevent re-infection and reduce transmission.
All partners should be traced back for 6 months.
The diagnosing doctor is responsible for initiating and documenting a discussion about contact tracing.
Offer testing of exposed anatomical sites to all sexual contacts.
Consider presumptive treatment if there has been sexual contact within the past 2 weeks or when the person’s individual circumstances mean later treatment may not occur.

Patient delivered partner therapy

Patient delivered partner therapy is a partner notification and treatment method whereby antibiotic treatment is prescribed or supplied for the sexual partner/s of a patient diagnosed with chlamydia infection (index patient). The index patient delivers the prescription or treatment to their partner/s.
Consider using patient delivered partner therapy which is approved in some jurisdictions for heterosexual index patients with anogenital or oropharyngeal chlamydia whose partners are unlikely to seek chlamydia testing or treatment, or with repeat infections whose partners have not been treated.
Patient delivered partner therapy guidance is available in Victoria, NSW, and the NT.

See Australasian Contract Tracing Guideline– Chlamydia, for more information.

To confirm patient adherence with treatment and assess for symptom resolution.
To confirm contact tracing procedures have been undertaken or offer more contact tracing support.
Educate about condom use, contraception, HIV PrEP/PEP, safe injecting practices, consent, CST and vaccinations for HAV, HBV and HPV as indicated.

Test of cure

Not routinely recommended, except for:

Pregnant people
Anorectal infection treated with Azithromycin

Test of cure by nucleic acid amplification test (NAAT) in these situations should be performed no earlier than 4 weeks after treatment is completed to prevent false positive result due to persistent chlamydia DNA.

Test for re-infection

Re-infection is common
Retesting at 3 months is recommended to detect re-infection.

Consider testing for other STIs if not undertaken at first presentation or retesting after the window period.