Chlamydia trachomatis

Description

• Chlamydia trachomatis can cause a variety of infections, including sexually transmitted infection (STI) as well as eye infections.
• 80% of women with chlamydia are unaware that they have it.
• Chlamydia can lead to severe complications if left untreated.
• Gonorrhoea and chlamydia are often found together.

Chlamydia trachomatis is a common cause of bacterial sexually transmitted disease, causing both a cervicitis or urethritis (inflammation of the cervix or urethra, respectively), as well as a condition called lymphogranuloma venereum (LGV). LGV is characterised by genital ulcers and enlarged lymph nodes in the groin region. Chlamydia trachomatis is also a common case of blindness in certain areas of the world, such as North Africa and India.

The organism can be found in the mucous membrane of reproductive organs such as the cervix (the end of the uterus that protrudes into the vagina) and urethra (the tube that drains urine from the bladder). It can also exist in the throat or rectum. It can be spread from person to person, either directly (eg sexual contact or on hands), or by dust particles, flies etc (one of the routes by which the eye infection is spread).

It can be easily cured if treated with antibiotics. Unfortunately, chlamydia is often not detected as it is common for women with the sexually transmitted infection to have no symptoms. In fact, up to 80% of women with chlamydia are unaware that they have the disease until they develop serious complications. Adults with eye infections are also often only treated late in the disease - this is often a result of a combination of poor education and poor access to health care.

It is common for women with untreated chlamydia to develop pelvic inflammatory disease, an infection that spreads from the vagina and cervix to the uterus and fallopian tubes. Other complications include ectopic pregnancies and infertility. Men with chlamydia may develop epididymitis, an inflammation of the scrotal tubes that can cause sterility. Chlamydia is also associated with an increased incidence of pre-term birth. Babies born to mothers with chlamydia can be infected during passage through the infected birth canal. This can lead to pneumonia or eye problems such as conjunctivitis.

As chlamydia is hard to detect, especially in women, it is important to be tested regularly during routine annual visits and to practice safer sex to prevent transmission.

Cause

Chlamydia trachomatis is a bacterium which lives inside other cells (unlike most other bacteria). At one time, chlamydial organisms were thought to be large viruses, but they are now known to be more closely related to bacteria. The sexually transmitted disease is usually transmitted through vaginal or anal sex, or other intimate contact with the genitals, mouth or rectal area. Even if a person has no symptoms, they can still infect others with the disease.

The organism can also infect the eye as a result of accidental inoculation of the eye with infective material from the genital tract, as well as inoculation through small dust particles which have been contaminated with the organism from another infected person. Additionally, a pregnant woman may transmit the infection to her newborn during delivery.

Symptoms

Cervicits/Urethritis

In women

Women with an early infection of chlamydia usually do not have any symptoms. In some cases, the following symptoms can be present:

• Vaginal discharge
• Itching in the genital area
• Mild pain and discomfort when urinating
• Cloudy urine
• Irregular menstrual bleeding
• Lower abdominal pain
• Fever
• General tiredness

In men

• Frequent urge to urinate or a burning sensation when urinating
• Cloudy urine
• A whitish yellow discharge from the penis
• Redness or crusting at the tip of the penis

Lymphogranuloma venereum (LGV)

• Genital ulcers, occuring one to two weeks after infection. These ulcers are usually fairly small and painless, and do not occur in every case of LGV
• The ulcers often disappear on their own without treatment
• One to two weeks later, enlarged inguinal lymph nodes appear, often associated with sore joints, headache and fever
• The nodes can ulcerate, and can also cause either penile or rectal deformities in a small percentage of cases

Eye infections

Conjunctivitis

• Sometimes, infections of the eyes cause a raletively mild conjunctivits. This is the form seen in newborns infected via the birth canal, and can also sometimes be seen in adults. It seldom causes permanent damage to the eye even if untreated.

Trachoma

• Trachoma is thought to result from repeated infection with the organism, and may also be a result of an abnormal immune response to the infection
• Trachoma starts out as a conjunctivitis characterised by little follicles (white bumps) on the conjunctiva, and with repeated exposure and relapses, the cornea becomes progressively scarred and ulcerated, ultimately resulting in blindness.

Course

The incubation period (the time between exposure to the bacteria and the beginning of symptoms) can be days or months. In many cases, especially in women who acquire the organism as a sexually transmitted infection, symptoms never appear. If there are symptoms, they are usually apparent one to three weeks after exposure.

If chlamydia is detected early, it can be cured easily and there should be no long-term consequences. However, as many people do not know that they have the disease, it may take up to two years for the body to destroy the bacteria. Untreated chlamydial urethritis or cervicitis may lead to complications.

Men may develop the following complications:

• Epididymitis (inflammation of the scrotal tubes)
• Infertility
• Infection of the prostrate (prostatitis)
• Infection of the urethra (urethritis)
• Infection of the lining of the eye (conjunctivitis)
• Infection of the throat (pharyngitis)
• Reiter's syndrome (an auto-immune arthritis-like condition)

Women and their infants are more likely to develop long-term complications. Complications in women can include:

• Urethritis
• Infection of the fallopian tubes (salpingitis)
• Infection of the cervix (cervicitis)
• Abnormal cells on the cervix (cervical dysplasia)
• Infection of the lining of the uterus (endometritis)
• Infection of Bartholin's glands (Bartholinitis)
• Pelvic inflammatory disease, which can cause infertility
• Ectopic (tubal) pregnancies
• Pelvic abscess
• Conjunctivitis
• Pharyngitis
• Reiter's syndrome
• In isolated cases, perihepatitis (an infection of the area around the liver)

Pregnant women are at greater risk of the following:

• Miscarriage
• Premature birth
• Pre-term labour
• Premature rupture of the membranes
• Infection of the uterine lining (post-partum endometritis)

Approximately 50 to 70% of all newborns of women with untreated chlamydia are at risk of being infected during passage through an infected birth canal. This can lead to:

• Conjunctivitis
• Pneumonia
• Ear infection
• Infection of the urethra

Risk Factors

The risk of being infected with chlamydia from a single act of unprotected sex with an infected partner is estimated to be about 40% for women and 20% for men.

The following people are most at risk:

• People who have unprotected sex
• People who have multiple sexual partners
• Sexually active adolescent women
• People who have a history of STDs
• Women who use intrauterine devices (IUDs) or take oral contraceptives
• People who have gonorrhoea
• Babies born to women with chlamydia

When to see a Doctor

• Because many people are unaware that they have chlamydia, people who are sexually active should ask to be tested during all routine visits.
• If there are any symptoms of chlamydia, immediate medical attention is needed.
• If there are any symptoms of complications, such as high fever (37,7°C or higher), flu-like symptoms such as chills, backache, weight loss and diarrhoea, bleeding after intercourse, severe nausea, severe pelvic pain or recurring back pain.
• Although conjunctivitis is usually viral, and usually mild, if you have conjunctivitis which does not appear to be resolving or there is an associated yellowish discharge from the eye, it would be advisable to visit your doctor.

Visit preparation

• Be prepared to answer any questions about recent sexual activity.
• Make a note of any symptoms if present.
• If you are allergic to penicillin, you should inform the doctor.
• Abstain from sexual intercourse while waiting for a medical examination.
• All sexual partners should be notified as they will also need to be tested.

Diagnosis

The doctor may perform a pelvic and genital examination, followed by an analysis of cervical fluid or penile discharge. The fluids are examined under a microscope with the aid of a substance that makes the bacteria glow. As many infections of the genitals or urinary system have similar symptoms, several tests for STDs and non-STD infections may be done. Diagnosis of the eye infection is done in a similar fashion - a smear is made of the discharge from your eye, and is examined under a microscope.

Treatment

Medication

Chlamydia is easily cured if detected early and in uncomplicated cases the cure rate is 95%. It is usually treated with antibiotics such as tetracycline or doxycycline. Pregnant women should not be treated with tetracycline, but rather with erythromycin. Babies born to women with chlamydia will be treated with eye drops at birth. These eye drops contain antibiotics that should prevent further complications.

If complications such as pelvic inflammatory disease are present, stronger doses of doxycycline, as well as other drugs such as cefoxitin or penicillin derivatives will be needed. These other drugs do not treat the chlamydia, but are used in case other bacteria are also involved in the infection.

There is fortunately little resistance of the disease to antibiotics. However, it is extremely important to complete the course of antibiotics, even if the symptoms have cleared up.

All recent sexual partners have to be treated as well. People who have been exposed to chlamydia should be treated even if they have no symptoms or test negative.

Home

Sexual contact should be avoided until follow-up tests show no signs of infection.

Reinfection is common. It is therefore important to notify your sexual partner or partners of the infection. They would also have to be tested and treated if necessary.

Careful handwashing is essential to avoid transmission of the bacteria to the eyes.

Prevention

• Always use condoms during sex and foreplay to reduce the risk of infection. The female condom which is now available in South Africa can also reduce the risk of being infected.
• As drugs or alcohol can interfere with a person's ability to make responsible decisions regarding protected sex, it is best to avoid sexual intimacy when intoxicated.
• As chlamydia is often asymptomatic in women, it is extremely important to be tested during routine visits to the doctor.
• Pregnant women or those who plan to have children should be tested for chlamydia.

Reviewed by Dr Andrew Whitelaw, MBBCh (Witwatersrand), MSc (UCT), FCPath (Micro) (SA) Senior registrar, Department of Microbiology, University of Cape Town and Groote Schuur Hospital.