CHLAMYDIA TRACHOMATIS INFECTION
Chlamydia Trachomatis (C. Trachomatis) is an intracellular bacteria. According to the CDC, this appears to be the most common of sexually transmitted diseases (STD).
Most authorities advocate screening all women for chlamydia during pregnancy. If screening is not performed for all patients, those with the following high-risk criteria should be tested for chlamydia.
2. History of multiple sexual partners
3. History of sexual partner with venereal disease, especially urethritis
4. Patient history of other sexually transmitted disease
5. History of preterm delivery
6. History of preterm rupture of membranes
The following are less specific risk factors:
1. Age below twenty-five years
2. Endocervical bleeding with swabbing
If patient falls within a risk group, preplan screening test. Using area “4L Chla” just below the routine lab area of the Flow Sheet, circle this area of the Flow Sheet to show that you have done the test that day. Many authorities consider retesting during the 3rd trimester for all or, at minimum, for high risk patients. If you wish to do the screen on a future visit, circle the appropriate box along that line corresponding to the date that you plan to do the test. After the test report is back, enter positive or negative in the appropriate circled box. If it is positive, preplan a repeat test post-treatment by circling the appropriate box along the same line.
It is unclear if ascending infection is responsible for preterm rupture of membranes and preterm delivery. However, an association appears to exist between primary chlamydial infection and preterm births.
When coming in contact with maternal secretions during birth, the newborn is exposed to chlamydia. This puts neonate at risk for conjunctivitis and respiratory infections.
Inclusion conjunctivitis usually appears 5-14 days after birth manifested by mucopurulent conjunctival drainage. Lower respiratory trace infections are usually pneumonia or bronchiolitis. These may appear 4 to 11 weeks after birth with cough and tachypnea. Often these infants remain afebrile. Some may require hospitalization.
For diagnostic tests and treatment for the above problems see below.
The mother is generally asymptomatic or has a purulent cervico-vaginal discharge. However, she is at higher risk for postpartum endometritis that usually presents between days 5-10 with low grade fever and uterine tenderness.
Postpartum pelvic infections are most common in the first few weeks but can occur up to 4 to 6 weeks after delivery. The infection includes irregular bleeding, modest temperature elevation, and uterine tenderness. See Section T Postpartum Endometritis, page 596.00 for further discussion.
Fluorescein-labeled monoclonal antibody test (ELISA and DFA system) have an accuracy of 78% compared to 45% for endocervical cultures and 67% for male urethral swabs. Use of newer nucleic acid-based tests ligase chain reaction (LCR) or polymerase chain reaction (PCR) have sensitivities for the above female, male specimens at 85% and 100% respectively. Urine samples (initial 10-20 cc voided) are reliable and more convenient for screening both sexes.(8-11)
Be aware that some insurance carriers will not cover the more expensive LCR or PCR tests.
Specimens can be obtained from conjunctival drainage or from a nasopharyngeal culture in suspected neonatal respiratory infection. Other tests, such as a pap smear or serology, are not accurate.
These are options with usual treatment of choice listed first, followed by alternatives.
1. Azithromycin 1 gm PO once is rapidly becoming the treatment of choice. Efficacy similar to erythromycin with less gastrointestinal side effects. However, it is considerably more expensive.
2. Erythromycin (not estolate)
a. Erythromycin base 500 mg PO qid x 7 days
b. Erythromycin base 250 mg orally four times a day for 14 days
c. Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
d. Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days
3. Amoxicillin 500 mg PO tid x 10 days.
4. Clindamycin 450 mg PO qid x 7 days.
1. Doxycycline 100 mg bid PO x 7 days
2. Azithromycin 1 gm PO once is rapidly becoming the treatment of choice
3. Erythromycin 500 mg PO qid x 7 days
5. Floxacin 300 mg PO bid x 7 days
Topical drugs may not be effective in preventing ocular chlamydial infection. For actual conjunctivitis or pneumonia, a suggested treatment is erythromycin 50 mg/kg/day divided qid x 14 days. The newborn pharynx, rectum, and/or vagina may also be infected and cultures should be considered.
If the patient has tested positive for chlamydia, enter this fact to risk factor section 31 of the Flow Sheet as: Chlamydia Infection.
Distribute the pink patient education sheet C5(3) Chlamydia Infection in Pregnancy to the patient, plus handout on specific antibiotic. Document this on back of Flow Sheet.