Chlamydial infection. Chlamydia Requirements for treatment results
For a long time, scientists did not attach due importance to these microorganisms, since they did not have a serious history. Chlamydia trachomatis is not a virus, but it is not a bacterium. It is noteworthy that chlamydia are more complex organisms compared to viruses; they are capable of simultaneously infecting the internal and external genital organs, blood vessels, joint surfaces, heart, teeth, as well as organs such as vision and hearing.
Chlamydia trachomatis mainly affects the genitourinary tract. According to statistics, about 100 million people are infected every year in the world. That is why much attention is paid to the development of medications and tests aimed at treating and earlier recognizing the disease.
Symptoms of the disease in women
The insidiousness of these bacteria is that in women, chlamydia can occur without obvious symptoms. In other cases, the following symptoms may appear: mucous or mucopurulent vaginal discharge, which may be yellow in color and have an unpleasant odor. Infection may also be accompanied by mild pain in the pelvic area, burning, itching, and intermenstrual bleeding. But all these symptoms indicate a diagnosis only indirectly, since many diseases of the genitourinary tract can have the same symptoms.
After completing the course of treatment, the patient should be observed by a doctor for another 20-30 days. During this period, control tests are taken. The difficulty in treating chlamydia lies in the ability of chlamydia to become resistant to antibacterial drugs. Therefore, it is necessary to strictly follow the doctor’s recommendations and prescriptions, not drink alcohol during this period, eat right and avoid stressful situations.
Azithromycin(sumamed) – effective for uncomplicated and sluggish course of the disease. In the first case, 1.0 g of the drug is prescribed once a day. In case of a sluggish course, the drug is prescribed according to a schedule designed for 7 days. Day 1 – 1.0 g, days 2 and 3 – 0.5 g each, days 4 to 7 – 0.25 g each.
Ciprofloxacin(Siflox, Tsiprobay) – effectively fights complicated forms. The course is 10 days, 1st dose – 500 mg, then every 12 hours – 250 mg.
In any case, your attending physician must decide on the prescription of drugs in each specific case!
Causes
Chlamydia is transmitted sexually in 50% of cases. Women are more susceptible to infectious agents. Routes of infection are vaginal, anal and oral sexual contact. Even during oral sex, you must wear a condom. Children can become infected with chlamydia during childbirth from a sick mother. Some sources deny the domestic route of infection. However, scientists have proven that chlamydia can exist for about two days on beds and other household items at a temperature of 18-20°C. Therefore, it is possible that the eyes can be infected by contact through the hands.
Types of disease
Urogenital chlamydia in acute and chronic form
Mini test- a simple and cheap option, you can buy it at a pharmacy and test for chlamydia at home. The downside of the mini-test is that its accuracy is no more than 20%.
Culture method. otherwise, culture for chlamydia is carried out simultaneously with the identification of sensitivity to antibiotics. Today this is the longest and most expensive analysis. But its results can be completely trusted; moreover, it allows you to select the most effective antibacterial drug for the treatment of chlamydia.
Prevention of chlamydia
Chlamydia in Elena Malysheva’s program “Live Healthy!”
CLASSIFICATION OF CHLAMYDIOSES
According to the severity of the flow, they are distinguished:
Based on the topography of the lesion, the following are distinguished:
ETIOLOGY AND PATHOGENESIS OF CHLAMYDIOSIS
Chlamydia is unstable in the external environment, sensitive to high temperature and quickly inactivated when dried. Highly sensitive to 70% ethanol, 2% Lysol, 0.05% silver nitrate, 0.1% potassium iodate, 0.5% potassium permanganate, 25% hydrogen peroxide, 2% chloramine, UV rays.
The humoral immune response is characterized by the production of specific IgM, IgG, IgA. IgM can be detected in the vascular bed within 48 hours after infection. Only 4-8 weeks after infection are antibodies of the IgG class detected. Secretory IgA is formed locally. The production of antibodies, as well as phagocytosis by macrophages, are possible only when chlamydia are in the elementary body (EB) stage in the intercellular space. Therefore, when chlamydia persists inside the cell at the RT stage, the amount of IgG antibodies in the blood is usually small.
The chronic course of chlamydia is characterized by the presence of IgA and IgG. Low, constantly existing titers of IgG antibodies indicate a long-standing chlamydial infection.
The most common clinical forms of chlamydia: acute urethral syndrome, bartholinitis, cervicitis, endometritis, salpingitis, conjunctivitis, salpingoophoritis, pelvioperitonitis. A serious complication of chlamydia is infertility.
Asymptomatic chlamydial infection is noted depending on the location with a frequency of up to 60–80%. Due to the common routes of transmission of pathogens in STIs, chlamydia is often accompanied by other bacteria and viruses (gonococci, trichomonas, myco, ureaplasma, HSV, CMV, human papillomavirus), which in association increase the pathogenicity of each microorganism and its resistance to treatment.
The following stages are distinguished in the pathogenesis of chlamydial infection:
SCREENING AND PRIMARY PREVENTION OF CHLAMYDIOSIS
Screening is carried out using PCR and enzyme immunoassay methods. Subject to examination:
Preventive measures should promote a healthy sexual lifestyle, inform the population about the routes of infection, early and late clinical manifestations of infection and methods of their prevention (safe sex).
DIAGNOSIS OF CHLAMYDIOSIS
Diagnosis of urogenital chlamydia is based on an assessment of the epidemiological history, clinical picture, and laboratory test results. There is a high risk of infection in people with multiple and casual sexual relationships.
Clinical manifestations of urogenital chlamydia are quite wide: from the absence of specific symptoms to the development of manifest forms of the disease. Moreover, the asymptomatic course of the disease does not exclude ascending infection of the uterine cavity and its appendages. The clinical picture of chlamydial infection is determined by the virulence of the pathogen, the duration of persistence of chlamydia, the location of lesions and the state of the human immune system.
The following options for damage to the lower genitourinary tract are possible:
Ways of spreading of ascending infection:
Clinical forms of ascending chlamydial infection:
Complications of chlamydia:
LABORATORY RESEARCH
To diagnose chlamydial infection, both direct detection of the pathogen and indirect methods - serological examination - are used.
A test to determine the sensitivity of chlamydia to antibiotics is not practical. Treatment effectiveness assessment is monitored 1 month after the end of antibiotic therapy.
DIFFERENTIAL DIAGNOSIS OF CHLAMYDIOSIS
Conducted with other STIs.
INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS
If complications develop, consultation with related specialists is required (for example, in case of Reiter's disease - an ophthalmologist, an orthopedist).
TREATMENT OF CHLAMYDIOSIS
TREATMENT GOALS
DRUG TREATMENT OF CHLAMYDIOSIS
For complicated forms of urogenital chlamydia, the same drugs are used, but the duration of treatment is at least 14–21 days.
Alternative treatment regimens for chlamydia:
In order to prevent candidiasis during antibacterial therapy for chlamydia, it is advisable to prescribe antifungal drugs: nystatin, natamycin, fluconazole, itraconazole. In case of co-infection with C. trachomatis, trichomonas, urea, mycoplasmas, anaerobic microflora (in pathogenic concentrations), the treatment regimen should include protistocidal drugs from the very beginning: metronidazole orally 500 mg 2 times a day for 7 days. Prevention of intestinal dysbiosis is carried out with eubiotic drugs orally, 30 drops 3 times a day during antibiotic therapy and 10 days after its completion.
In case of recurrent chronic chlamydia, the use of immunomodulators is pathogenetically justified, since they normalize the immune status and participate in the elimination of chlamydia by directly inhibiting their replication and transcription:
- meglumine acridone acetate, 12.5% solution 2 ml intramuscularly every other day for 5 to 10 injections;
- sodium oxodihydroacridinyl acetate (neovir ©), 250 mg intravenously per 1 ml of 0.5% procaine solution daily 10 injections;
- IFN alpha2, 1 suppository vaginally at night every day for 10 days. Enzyme preparations are used: Wobenzym©, chymotrypsin.
- negative laboratory test results;
- absence of clinical symptoms of the disease.
- non-compliance with outpatient treatment regimen;
- inadequate therapy;
- false positive test result;
- re-contact with an untreated partner;
- infection from a new partner.
- Analysis of glucose levels in the bloodstream;
- Bacterial culture from the surface of the head and leaf of the foreskin, as well as discharge from the urethra;
- Tests for syphilis and candidal balanoposthitis;
- Tests for HIV and human papilloma virus infections;
- If the disease often recurs, a biopsy is taken from the head of the penis;
- Stop promiscuity. If this is contrary to your principles, then during intimacy you must use barrier contraception.
- The best prevention of diseases of the genital area will be an annual scheduled examination by a urologist, and of the sexual partner by a gynecologist.
- Personal hygiene using neutral detergents that cannot cause allergies is the main principle of preventive measures.
- Do not overuse antibiotics and hormonal drugs.
- Control and prevention of increased blood glucose levels.
Medicines for the treatment of chlamydia*
Treatment of chlamydia should include adherence to three basic principles: chemotherapy, immunomodulation, restoration of the natural biocenosis of the vagina.
I. Chemotherapy for chlamydia
Treatment will be successful if:
¦ drugs will be used that have high anti-chlamydial activity and penetrate well into the cell in which chlamydia grows;
¦ the timing of infection (“fresh”, chronic), the clinical picture of inflammation (acute, subacute, torpid, asymptomatic course), and topical diagnosis will be taken into account.
All antichlamydial drugs are divided into three groups according to their ability to penetrate cells:
¦ low degree - penicillins, cephalosporins, nitroimidazoles;
¦ moderate degree - tetracyclines, fluoroquinolones, aminoglycosides;
¦ high degree - macrolides and azalides.
Methods of chemotherapy for chlamydia:
¦ continuous course - must cover 7 cycles of development of the pathogen - 14-21 days (use one antibiotic or change it to another during the treatment process);
¦ “pulse therapy” - three courses of intermittent treatment for 7 days each, followed by a break of 7 days; During the pause, EBs are destroyed in the intercellular spaces by phagocytes.
Azalides and macrolides:
azithromycin (sumamed) - on the 1st day 1 g (2 tablets of 500 mg each) once; on days 2-5 - 0.5 g 1 time/day;
¦ midecamycin (macropen) - 400 mg each. 3 times/day. 7 days (course dose 8 g);
¦ spiramycin (rovamycin) - 3 million units, 3 times a day. 10 days;
¦ josamycin (vilprafen) - 500 mg 2 times a day. within 10-14 days;
Rondomycin - 0.3 g 2 times a day. within 10-14 days;
¦ clarithromycin (clacid, fromilid) - orally 250-500 mg 2 times a day. within 10-14 days;
¦ roxithromycin (rulid, roxide, roxibid) - orally 150-300 mg 2 times a day. 10 days;
¦ erythromycin (erythromycin - Teva, eracin) - 500 mg 4 times a day. before meals orally, for 10-14 days;
erythromycin ethylsuccinate - 800 mg 2 times a day. 7 days.
¦ clindamycin (dalacin C) - an antibiotic of the lincosamide group; 300 mg 4 times/day. after meals, 7-10 days or IM 300 mg 3 times a day. 10 days.
Group of tetracyclines:
¦ tetracycline - orally 500 mg 4 times a day. within 14-21 days;
Doxycycline (Unidox, Vibramycin) - 1 capsule (0.1 g) 2 times a day. within 10-14 days;
- metacycline (rondomycin) - 300 mg 4 times a day. within 10-14 days.
Fluoroquinolone preparations:
- ofloxacin (zanocin, tarivid, ofloxin) - 200 mg 2 times a day. after meals, for 10-14 days;
¦ ciprofloxacin (tsifran, tsiprinol, tsiprobay, cipro-bid) - orally, intravenously, 500 mg 2 times a day. within 7 days;
¦ pefloxacin (abactal) - 600 mg with meals 1 time / day. within 7 days;
¦ levofloxacin (nolitsin, urobatsid, norbactin) - 400 mg 2 times a day. within 7-10 days;
¦ lomefloxacin (maxaquin) - 400 mg 1 time / day. 7-10 days.
Local treatment of chlamydia:
¦ tetracycline ointment (1-3%) - on tampons in the vagina 2 times a day. 10-15 days;
¦ erythromycin ointment (1%) - on tampons in the vagina 2 times a day. 10-14 days;
¦ dalacin C (2% vaginal cream) - 5 g in the vagina (dispenser) at night, for 7 days;
¦ betadine - suppositories of 200 mg of polyvidone iodide in the vagina at night, 14 days.
I. Immunomodulation
It is carried out before chemotherapy for chlamydia or in parallel with it. The basis for prescribing immunomodulation is the presence of immunological changes in the body of people affected by chlamydia: decreased activity of the interfrontal system, natural killer cells, macrophages, T-lymphocytes, etc.
For immunomodulation use (application):
¦ interphronogenesis drugs: reaferon, alfaferon, vi-feron, welferon, kipferon, laferon;
¦ interfron inducers: neovir, cycloferon, engystol, lykopid, myelopid;
¦ drugs that modulate the reactions of cellular and humoral immunity: amiksin, groprinosin, polyoxidonium, immunomax, Gepon;
¦ cytolysins: thymalin, tactivin, timoptin.
Sh. Restoration of the natural biocenosis of the vagina (see Section “Colpitis”)
FOLLOW-UP
A control study is carried out 3-4 weeks after treatment and then during 3 menstrual cycles.
Cure criteria:
If there is no positive effect from treatment, possible reasons should be considered:
FORECAST
With inadequate treatment, complications may develop.
Source: Gynecology - National Guide, ed. IN AND. Kulakova, G.M. Savelyeva, I.B. Manukhina 2009
*Practical gynecology Likhachev V.K. 2007
Diagnosis of balanoposthitis according to ICD 10 - urology and its prevention
The diagnosis of balanoposthitis according to the International Statistical Classification, Tenth Revision (ICD-10), adopted by Russia in 1999, belongs to class 14 of diseases.
If you decipher the digital and alphabetic ICD 10 codes used for designations in medical documents, then balanoposthitis refers to urology. In the ICD 10 registry, balanoposthitis is registered under code N48.1
Urology is the clinical discipline concerned with the urinary organs. Therefore, in case of inflammation of the glans penis and its foreskin, men should consult a urologist. After all, they are the ones who diagnose and treat diseases of the penis.
In order not to make a mistake in diagnosis, it is first necessary to distinguish the symptoms from other diseases that are similar in clinical picture.
Zuna balanitis. Lichen sclerosus, penile cancer, psoriasis, leukoplakia of the genital organ, Reiter's syndrome - this is an incomplete list of diseases with similar symptoms with which this disease can be confused if you make a diagnosis yourself, without contacting a urologist.
A doctor can easily diagnose balanoposthitis with a visual examination of the genital organ. But identifying the cause of the inflammatory process is more difficult. To do this, the doctor prescribes the following laboratory tests:
Based on the results of the study, the urologist will be able to make an accurate diagnosis and select effective treatment.
Prevention of balanoposthitis
Preventing disease is the wisest decision. So what should be done to prevent balanoposthitis:
Chlamydia
Symptoms of chlamydia
Symptoms of the disease in men
In men, chlamydia is either asymptomatic, or a mild inflammatory process of the urethra - urethra can be observed. During urination, burning and itching may be felt, scanty discharge is observed, especially in the morning, the so-called “morning drop”. The scrotum, lower back, and testicles may hurt. At the time of intoxication, the temperature can rise to 37°, the urine becomes cloudy, and spotting can be observed during ejaculation and urination. Any of these symptoms should be a serious reason to visit a doctor.
Treatment of chlamydia in men and women
In addition to complex drug treatment, local treatment is also indicated: baths, vaginal tampons and suppositories, douching. In parallel, physiotherapy is prescribed, for example, electrophoresis, ultrasound, iontophoresis, magnetic influence, quantum therapy. Only a doctor should prescribe treatment, doses and method of taking medications. Priority is given to intravenous and intramuscular administration of drugs.
Medicines to treat chlamydia
Doxycycline(Unidox Solutab) - prescribed for uncomplicated forms of chlamydia by mouth. At the first dose - 0.2 g, then 0.1 g twice a day for 7-14 days. It is recommended to maintain equal time intervals between doses.
Metacycline(rondomycin) – used for uncomplicated and acute forms. The recommended dose for the first dose is 600 mg, then 300 mg for 7 days at 8-hour intervals.
Pefloxacin(abactal) – prescribed for uncomplicated fresh chlamydia, 600 mg once a day for 7 days. The chronic form will require a course lasting 10-12 days.
The microorganism Chlamydia trachomatis exists in 15 varieties; only humans are susceptible to its pathogenic effects. This microorganism can cause the following diseases: urogenital chlamydia, lymphogranulomatosis venereum, trachoma, lesions of the rectum, eyes, and many others. etc.
Another species of Chlamydia Pneumoniae usually becomes the causative agent of pneumonia, pharyngitis, acute respiratory infections and other diseases associated with the respiratory system. The types of chlamydia Chlamydia Psittaci and Chlamydia Pecorum are transmitted to humans through contact with animals and birds and can cause a fatal disease for humans - psittacosis.
Chlamydia of the genitourinary system is the most common disease of all types. Urogenital chlamydia can occur in acute and chronic forms. Before the onset of the chronic form, a latent phase of urogenital chlamydia always occurs; it can last 7-20 days. The chronic form may not manifest itself in any way until some complication occurs. This can be inflammation of the prostate and bladder, impotence in men, cystitis in women and infertility in patients of both sexes. Often, improper therapy and the use of antibacterial drugs (antibiotics) in an acute course leads to a chronic form, so self-medication can lead to serious consequences. Chlamydia should be treated according to the prescribed course of therapy and under the supervision of a doctor.
Diagnostics
General smear(microscopic analysis) - with this method, analysis is taken from the urethra in men, and from the cervix, vagina and urethra in women simultaneously.
Immunofluorescence reaction - RIF. With this method, material taken from the urethra is stained and viewed with a special (fluorescent) microscope. If chlamydia is present, it will glow.
Enzyme immunoassay - ELISA. This technique uses the body’s ability to produce antibodies to infections. To perform an ELISA test, blood is taken and tested for the presence of antibodies that appear in response to chlamydia infection.
Polymerase chain reaction - PCR. PCR analysis is based on the study of a DNA molecule. PCR to detect chlamydia is carried out within 1-2 days and is 100% reliable.
Preventive measures to prevent chlamydia are similar to any other infections transmitted through sexual contact. First of all, you need to think about safety and not lead a disorderly lifestyle, use condoms, and maintain hygiene. Together with your regular partner, you need to undergo examination and exclude the possibility of infection. You should especially think about the examination before conceiving and giving birth to a child. It is necessary to be examined and treated together, since treatment of one of the partners threatens re-infection in the future.
Useful video
Epidemiology
Causes of respiratory chlamydia
Symptoms of respiratory chlamydia
Respiratory chlamydia in children often occurs as conjunctivitis, bronchitis and pneumonia.
Chlamydial conjunctivitis begins with redness of both eyes and the appearance of purulent discharge. On the conjunctiva, especially in the area of the lower transitional fold, large, bright red follicles arranged in rows are constantly found; pseudomembranous formations and epithelial punctate keratitis are possible. The general condition suffers slightly. The parotid lymph nodes are often enlarged and sometimes painful on palpation. When culturing eye discharge, bacterial flora is usually not detected. The course of chlamydial conjunctivitis can be acute or chronic. In acute cases, the symptoms of conjunctivitis completely disappear after 2-4 weeks, even without treatment. In a chronic course, clinical manifestations are detected over many months and even years.
Chlamydial bronchitis begins gradually, usually at normal body temperature. The first sign of the disease is a dry cough, often paroxysmal. The general condition suffers insignificantly. Sleep and appetite are preserved. During auscultation, scattered, predominantly medium-bubble rales are heard. Percussion changes in the lungs are usually not detected. After 5-7 days, the cough becomes wet, and its attacks stop. Recovery occurs in 10-14 days.
Chlamydial pneumonia also begins gradually, with a dry non-productive cough, which gradually intensifies, becomes paroxysmal, accompanied by general cyanosis, tachypnea, vomiting, but there are no recurrences. The general condition suffers slightly. Shortness of breath gradually increases, the number of respirations reaches 50-70 per minute. Breathing is grunting, but respiratory failure is mild. By the end of the first and during the second week, a picture of bilateral disseminated pneumonia forms in the lungs. On auscultation, crepitating rales are heard in these patients, mainly at the height of inspiration. During an objective examination, attention is drawn to the discrepancy between clinically pronounced pneumonia (shortness of breath, cyanosis, scattered crepitating rales over the entire surface of both lungs, etc.) and a relatively mild general condition with minimally expressed symptoms of intoxication. At the height of clinical manifestations, many patients have enlarged liver and spleen, and enterocolitis is possible.
X-ray examination reveals multiple fine-mesh infiltrative shadows with a diameter of up to 3 mm.
In the blood of patients with chlamydial pneumonia, pronounced leukocytosis is detected - up to 20x10 9 / l, eosinophilia (up to 10-15%); ESR is sharply increased (40-60 mm/h).
According to statistics, about 2 million new cases of chlamydial infection are recorded annually worldwide. This is facilitated by the fact that the symptoms of chlamydia in men and women appear more subdued compared to traditional sexually transmitted infections, such as gonorrhea and trichomoniasis.
In the Russian Federation, chlamydia ranks second after trichomoniasis in prevalence among all sexually transmitted infections.
The main route of transmission of urogenital chlamydia is sexual. This is due to the tropism of the pathogen to the epithelial cells of the genitourinary organs, where the main focus is often located.
Transmission of infection from mother to child during fetal development (antenatally) and during childbirth (intrapartum) is the main route of infection with chlamydia in childhood.
Non-sexual transmission routes, such as household and airborne transmission, are not clinically significant in the adult population.
Classification
According to ICD-10, urogenital chlamydia (A.56) is classified:
- chlamydial infection of the lower genitourinary system:
- cystitis;
- cervicitis;
- vulvovaginitis;
- chlamydial infection of the upper genitourinary system:
- epididymitis;
- orchitis;
- pelvic inflammatory diseases in women;
- chlamydial infection of the genitourinary system, unspecified;
- chlamydial infection, sexually transmitted infection of another location.
Clinic
It should be noted right away that in 25% of men, urogenital chlamydia is asymptomatic.
But even if there are signs of inflammation of the genitourinary system characteristic of chlamydia, there are no signs by which a diagnosis can be reliably established.
Let's consider the main inflammatory diseases of the genitourinary system and pelvic organs, which can be considered as symptoms of chlamydia in men.
Urethritis
This is an inflammation of the urethra.
Urethritis manifests itself as a sensation of itching and burning in the urethra. During the act of urination, a pain appears, which can be either slight or pronounced, causing significant discomfort.
Upon examination, hyperemia and adhesion of the terminal sponges, as well as purulent or mucopurulent discharge, are revealed.
It should be noted that in acute and subacute cases, the first symptoms of chlamydia in men, as a rule, manifest with urethritis.
Inflammation of the epididymis is a fairly common complication of urogenital chlamydial infection. The highest frequency is observed in men aged 20 to 40 years.
In 80% of cases, the disease is asymptomatic or with scant symptoms, manifested by only slight swelling of the appendage.
However, there are cases of acute epididymitis with symptoms of intoxication, febrile fever, severe pain in the epididymis, radiating to the spermatic cord, sacrum and groin. On examination, swelling, edema and redness of the epididymis are noted.
In the subacute course of epididymitis, a blurred clinical picture is noted with a slight increase in temperature and unexpressed pain. Most often, the subacute form of inflammation of the appendage is complicated by orchitis.
Prostatitis
Inflammation of the prostate gland during urogenital chlamydia in men, most often (46% of cases) occurs in tandem with inflammation of the urethra - urethroprostatitis.
With chlamydia, as a rule, prostatitis rarely manifests itself in an acute form with hectic fever, intoxication, severe pain and dysuric disorders.
As a rule, chlamydia in men gives scanty symptoms of prostatitis in the form of low-grade fever, minor urination disorders and discomfort in the perineum.
To diagnose inflammation of the prostate gland, transrectal massage is used with the collection of prostate secretions and its subsequent bacterioscopic analysis.
Vesiculitis
Inflammation of the seminal vesicles is recorded in 16% of patients with chlamydial urethroprostatitis during additional examination.
In the vast majority of cases, vesiculitis is asymptomatic, only sometimes causing minor discomfort in the perineum and increased urination.
There is a violation of sexual function in 60% of cases, of which 30% have problems with arousal.
In addition to erectile dysfunction, there are significant hormonal changes associated with a decrease in testosterone levels and an increase in prolactin levels.
In the semen of a man with symptoms of chlamydia, a photo from a microscope shows the following:
- pathological forms of sperm;
- an increase in the number of cells with an amorphous head and an abnormal flagellum;
- decrease in the number of viable sperm.
All these factors lead to the development of infertility and sexual weakness in young men.
Reiter's syndrome
Reiter's syndrome refers to systemic manifestations of chlamydial infection and is manifested by a triad of symptoms:
- arthritis;
- conjunctivitis.
Urethritis first manifests itself 2 to 4 weeks after infection. Then symptoms of inflammation of the conjunctiva appear. As a rule, joint inflammation develops last.
Chlamydial arthritis is characterized by asymmetric damage to the joints, mainly the knees and ankles. Also, the Achilles tendons and plantar fascia of the foot are often involved in the inflammatory process.
It should be noted that Reiter's syndrome develops 10 times more often in men compared to women.
Diagnostics
Considering that the clinical picture of chlamydial infection is not specific, most often erased or asymptomatic, the leading place in identifying the disease belongs to laboratory diagnostics.
The presence of inflammatory diseases of the genitourinary system allows one to suspect and refer for examination:
- orchitis;
- epididymitis;
- cystitis.
Laboratory diagnostics
Culture method
The essence of the technique is to determine the pathogen using special cell cultures (L-929, McCoy, HeLa).
The most accurate and sensitive of all available diagnostic methods. But it is limited in use due to its high cost and labor intensity.
It is used primarily for persistent urogenital chlamydia.
Linked immunosorbent assay
Determination occurs using special enzyme-labeled antibodies to the cell wall of chlamydia.
The sensitivity of the method is 60 – 90%.
Due to the ease of execution and automation of the test, it is used for screening detection of urogenital chlamydia.
Direct immunofluorescence
Fluorescein-labeled antibodies to cell membrane proteins are used. The method is specific, but shows only the components of the chlamydial cell, without indicating the presence of viable microorganisms.
A molecular diagnostic method that allows you to identify the DNA and RNA components of the pathogen.
Sensitivity 70 - 95%.
The method is simple to perform and is effectively used for diagnosing urogenital chlamydia.
Serological study
Specific chlamydial antibodies (IgG and M) are determined in the blood of the subject. Used for acute disease.
It is important to note that antibodies do not appear immediately, but only several weeks after infection.
Treatment
It should be noted right away that at the moment there is no approved treatment regimen for chlamydia.
The treatment regimen for uncomplicated chlamydia in men includes:
1. Drugs of choice:
- azithromycin 1.0 g once - for chlamydial lesions of the lower parts of the genitourinary system;
- azithromycin 1.0 g once a week for three weeks – for chlamydial lesions of the upper genitourinary system and pelvic organs;
- doxycycline 100 mg twice a day for seven days - for chlamydial lesions of the lower parts of the genitourinary system;
- doxycycline 100 mg twice a day for two weeks – for chlamydial lesions of the upper genitourinary system and pelvic organs;
2. Alternative drugs:
- ofloxacin 400 mg twice a day for a week;
- roxithromycin 150 mg twice a day for ten days;
- erythromycin 500 mg four times a day for ten days.
It should be noted that for the treatment of complicated chlamydia in men, a treatment regimen has been officially developed only for the original azithromycin - “sumamed”. Therefore, all generic azithromycin can only be used to treat uncomplicated forms of urogenital chlamydial infection.
To treat clinical complications of chlamydia in men (prostatitis, urethritis, vesiculitis, epididymitis), additional methods are used:
- drugs to enhance immunity;
- physiotherapeutic procedures;
- instillation into the urethra.
At the end of the course of antibacterial treatment, laboratory monitoring of the cure must be carried out. Moreover, it is advisable to carry out the same research method that initially identified the pathogen.
The treatment regimen for chlamydia in men is provided for informational purposes only!
In no case should you self-medicate, since depending on the characteristics of the course of the infection and the condition of the body, adjustments are almost always made to the doses and duration of antibacterial therapy.
Prevention
Primary
It is to prevent the introduction of C. Trachomatis and the development of the disease:
- use of barrier protection (condoms);
- limit the number of sexual partners;
- maintain a trusting relationship with your partner;
- do not allow conscious sexual contact with infected persons.
Laboratory diagnostic methods:
- Direct immunofluorescence (DIF) is a relatively simple method and is available to almost any laboratory. The sensitivity and specificity of the method depends on the quality of the luminescent antibodies used. Due to the possibility of obtaining false positive results, the PIF method cannot be used in forensic medical examination. In addition, this method is not recommended for the study of materials obtained from the nasopharynx and rectum.
- The cultural method - seeding with cell cultures, is considered a priority for laboratory diagnosis of chlamydial infection, especially for forensic medical examination, it is more specific than PIF, and is indispensable in determining the cure of chlamydia, since other methods can give distorted results. However, the sensitivity of the method remains low (within 40–60%).
- Enzyme-linked immunosorbent assay (ELISA) to detect antigens is rarely used for diagnosis due to low sensitivity.
- Nucleic acid amplification methods (NAAT) are highly specific and sensitive and can be used for screening, especially for the study of clinical materials obtained non-invasively (urine, ejaculate). The specificity of the methods is 100%, sensitivity is 98%. These methods do not require maintaining the viability of the pathogen, however, it is necessary to comply with strict requirements for the conditions of transportation of clinical material, which can significantly affect the result of the analysis. These methods include PCR and real-time PCR. The new and promising NASBA (Nucleic Acid Based-Amplification) method allows you to identify a viable pathogen in real time and replace the culture method.
- Serological methods (microimmunofluorescence, immunoenzyme) have limited diagnostic value and cannot be used to diagnose urogenital chlamydial infection and, especially, to monitor cure. Detection of IgM antibodies can be used to diagnose pneumonia in newborns and children in the first 3 months of life. When examining women with PID and infertility, the detection of a 4-fold increase in IgG antibody titer when examining paired blood sera is diagnostically significant. An increase in the level of IgG antibodies to chlamydia (to the serotype of lymphogranuloma venereum) is considered the basis for examining the patient to exclude lymphogranuloma venereum.
A test to determine the sensitivity of chlamydia to antibiotics is not practical. Clinical samples are taken:
- in women, samples are taken from the cervical canal (diagnostic methods: culture, PIF, PCR, ELISA) and/or urethra (culture method, PIF, PCR, ELISA) and/or vagina (PCR);
- in men, samples are taken from the urethra (culture method, PIF, PCR, ELISA) or the first portion of urine is examined (PCR, LCR). The patient should refrain from urinating for 2 hours before sample collection;
- in infected newborns, samples are taken from the conjunctiva of the lower eyelid and from the nasopharynx; Vulvar discharge in girls is also examined.
The technique for taking material depends on the methods used.
Currently, the following terminology is used when making a diagnosis: fresh (uncomplicated chlamydia of the lower parts of the genitourinary tract) and chronic (long-term, persistent, recurrent chlamydia of the upper parts of the genitourinary tract, including the pelvic organs). Next, the topical diagnosis should be indicated, including extragenital localization. Chlamydial infection appears after an incubation period that lasts from 5 to 40 days (average 21 days).
If complications develop, consultation with related specialists is required.
The procedure for a doctor to act upon a diagnosis of chlamydial infection
- Informing the patient about the diagnosis.
- Presentation of information about behavior during treatment.
- Collection of sexual history.
- Identification and examination of sexual contacts are carried out depending on the clinical manifestations of the disease and the expected duration of infection - from 15 days to 6 months.
- If chlamydia is detected in a woman in labor, a postpartum woman, or a pregnant woman who has not received timely treatment, the newborn is examined by taking material from the conjunctival sacs of both eyes. If a chlamydial infection is detected in a newborn, its parents are examined.
- If chlamydial infection of the genitals, rectum and pharynx is present in children during the postnatal period, sexual abuse should be suspected. It should be borne in mind that perinatally received C. trachomatis may persist in a child up to 3 years of age. Siblings of the infected child should also be tested. The fact of sexual violence must be reported to law enforcement authorities.
- Conducting epidemiological measures among contact persons (sanitation of the epidemiological focus) is carried out jointly with the district epidemiologist:
- inspection and examination of contact persons;
- statement of laboratory data;
- deciding on the need for treatment, its volume and duration of observation.
- If contact persons live in other territories, a work order coupon is sent to the territorial KVU.
- If there are no results from treatment, it is recommended to consider the following possible reasons:
- false positive test result;
- non-compliance with treatment regimen, inadequate therapy;
- re-contact with an untreated partner;
- infection from a new partner;
- infection with other microorganisms.
Chlamydial infection of the anorectal area (A56.3), Chlamydial infections of the lower genitourinary tract (A56.0), Chlamydial infections of the pelvic and other organs (A56.1+), Chlamydial infections of sexually transmitted diseases of other localization (A56.8) , Chlamydial conjunctivitis (H13.1*), Chlamydial pharyngitis (A56.4)
Obstetrics and gynecology, Dermatovenerology
general information
Short description
RUSSIAN SOCIETY OF DERMATOVENEROLOGISTS AND COSMETOLOGISTS
RUSSIAN SOCIETY OF OBSTETRICS-GYNECOLOGISTS
Moscow - 2015
Code according to the International Classification of Diseases ICD-10
A56, A74.0
DEFINITION
Chlamydial infection is a sexually transmitted infection caused by Chlamydia trachomatis.
Classification
A56.0 Chlamydial infections of the lower genitourinary tract
Chlamydial: cervicitis, cystitis, urethritis, vulvovaginitis
A56.1 Chlamydial infections of the pelvic organs and other genitourinary organs organs
Chlamydial(s):
- epididymitis (N51.1)
- inflammatory diseases of the pelvic organs in women (N74.4)
- orchitis (N51.1)
A56.3 Chlamydial infection of the anorectal area
A56.4 Chlamydial pharyngitis
A56.8 Chlamydial sexually transmitted infections, other localization
A74.0 Chlamydial conjunctivitis (H13.1*)
Etiology and pathogenesis
Chlamydia trachomatis- gram-negative intracellular bacterium belonging to the order Chlamydiales, family Chlamydiaceae family Chlamydia. Serotypes Chlamydia trachomatis A, B, Ba, C - trachoma pathogens; D-K - urogenital chlamydia; L1, L2, L3 - lymphogranuloma venereum.
Urogenital chlamydia is a common sexually transmitted infection (STI). The steady increase in the detection of the disease in various countries is explained by the introduction of screening for chlamydial infection and the use of sensitive diagnostic methods, such as nucleic acid amplification.
The prevalence of chlamydial infection in the population varies depending on age, with the highest incidence observed in persons under 25 years of age.
In the Russian Federation, the incidence of chlamydial infection in 2014 was 46.9 cases per 100,000 population: in persons aged 0 to 14 years - 0.7 cases per 100,000 population, in persons aged 15-17 years - 45.8 cases per 100,000 population, in persons over 18 years of age - 56.2 cases per 100,000 population. However, these figures reflect underreporting of the disease rather than the actual incidence in the country.
Clinical picture
Symptoms, course
ROUTES OF INFECTION
Uadults:
Sexual contact (infection occurs through any form of sexual contact with a patient with chlamydial infection).
In children:
Perinatal;
Sexual contact;
Contact-household (in exceptional cases, young girls can become infected if the rules of personal hygiene and child care are violated).
CLINICAL PICTURE
Chlamydial infections of the lower genitourinary tract
Women
More than 70% of women have a subjectively asymptomatic course of the disease. If clinical manifestations are present, the following may be present: subjective symptoms:
- mucopurulent discharge from the urethra and/or genital tract;
- intermenstrual bleeding;
- discomfort or pain in the lower abdomen.
Objective symptoms:
- hyperemia and swelling of the mucous membrane of the external opening of the urethra, infiltration of the walls of the urethra, mucopurulent or mucous light discharge from the urethra;
- swelling and hyperemia of the mucous membrane of the cervix, mucopurulent discharge from the cervical canal, erosion of the mucous membrane of the cervix.
Men
Subjective symptoms:
- mucopurulent or mucous, light discharge from the urethra;
- itching, burning, pain when urinating (dysuria);
- discomfort, itching, burning in the urethral area;
- pain during sexual intercourse (dyspareunia);
- frequent urination and urgency to urinate (with proximal spread of the inflammatory process);
- pain in the perineum with radiation to the rectum.
Objective symptoms:
- hyperemia and swelling of the mucous membrane of the external opening of the urethra, infiltration of the walls of the urethra;
- mucopurulent or mucous, light discharge from the urethra.
A feature of the clinical course of chlamydial infection in childhood is more pronounced subjective and objective symptoms and damage to the mucous membranes of the vulva and vagina, which is facilitated by the anatomical and physiological characteristics of the reproductive system of girls.
Chlamydial infection of the anorectal area
In persons of both sexes As a rule, there is a subjectively asymptomatic course of the disease. If clinical manifestations are present, the following may be present: subjective symptoms:
- with local damage to the rectum: itching, burning in the anorectal area, slight yellowish or reddish discharge;
- when the process is localized above the anus: painful tenesmus, pain during defecation, mucopurulent discharge, often mixed with blood, secondary constipation.
Objective symptoms:
- hyperemia of the skin folds of the anus;
- mucopurulent discharge from the rectum.
Chlamydial pharyngitis
In persons of both sexes, As a rule, there is a subjectively asymptomatic course of the disease. If clinical manifestations are present, the following may be present: subjective symptoms:
- feeling of dryness in the oropharynx;
- pain that gets worse when swallowing.
Objective symptoms:
- hyperemia and swelling of the mucous membrane of the oropharynx and tonsils.
Chlamydial conjunctivitis
In persons of both sexes
Subjective symptoms:
- slight pain in the affected eye;
- dryness and redness of the conjunctiva;
- photophobia;
Objective symptoms:
- hyperemia and swelling of the conjunctiva of the affected eye;
- scanty mucopurulent discharge in the corners of the affected eye.
Chlamydial infections of the pelvic organs and other genitourinary organs
Women
Subjective symptoms:
- vestibulitis: slight mucopurulent discharge from the genital tract, pain and swelling in the vulva area;
- salpingoophoritis: pain in the lower abdomen of a cramping nature, mucopurulent discharge from the genital tract; in the chronic course of the disease, subjective manifestations are less pronounced, and there is a disturbance in the menstrual cycle;
- endometritis: pain in the lower abdomen, usually of a pulling nature, mucopurulent discharge from the genital tract; in the chronic course of the disease, subjective manifestations are less pronounced, post- and intermenstrual scanty bleeding is often observed;
- pelvioperitonitis: sharp abdominal pain, nausea, vomiting, weakness, impaired bowel movements.
Objective symptoms:
- vestibulitis: slight mucopurulent discharge from the genital tract, hyperemia of the external openings of the ducts of the vestibular glands, pain and swelling of the ducts upon palpation;
- salpingoophoritis: in the acute course of the inflammatory process - enlarged, painful on palpation fallopian tubes and ovaries, shortening of the vaginal vaults, mucopurulent discharge from the cervical canal; in the chronic course of the disease - slight pain, compaction of the fallopian tubes;
- endometritis: in the acute course of the inflammatory process - a painful, enlarged uterus of a soft consistency, mucopurulent discharge from the cervical canal; in the chronic course of the disease - dense consistency and limited mobility of the uterus;
- pelvioperitonitis: characteristic appearance - facies hypocratica, hectic body temperature, hypotension, oliguria, severe abdominal pain on superficial palpation, tension in the abdominal wall muscles and a positive symptom of peritoneal irritation are determined in the lower parts.
Men
Subjective symptoms
- epididymo-orchitis: mucopurulent discharge from the urethra, dysuria, dyspareunia, pain in the epididymis and groin area, often unilateral; pain in the perineum radiating to the rectum, lower abdomen, and scrotum; pain can spread to the spermatic cord, inguinal canal, lumbar region, sacrum;
- prostatitis accompanying urethritis: pain in the perineum and lower abdomen with irradiation to the rectum, dysuria.
Objective symptoms
- epididymo-orchitis: mucopurulent discharge from the urethra, palpation reveals an enlarged, dense and painful testicle and its appendage, hyperemia and swelling of the scrotum in the affected area is observed;
- prostatitis accompanying urethritis: palpation reveals a painful, hardened prostate gland.
In persons of both sexes- chlamydial infection of the paraurethral glands
Subjective symptoms:
- itching, burning, pain when urinating (dysuria);
- mucopurulent discharge from the urethra;
- pain during sexual intercourse (dyspareunia);
- pain in the area of the external urethral opening.
Objective symptoms:
- mucopurulent discharge from the urethra, the presence of dense painful formations the size of millet grains in the area of the excretory ducts of the paraurethral glands.
Chlamydial infections, sexually transmitted infections, other localization
Reactive arthritis is an aseptic inflammation of the synovium of the joint, ligaments and fascia. The disease can occur in the form of urethro-oculosynovial syndrome, which classically manifests itself as a triad: urethritis, conjunctivitis, arthritis. The syndrome can also occur with damage to the skin and mucous membranes (keratoderma, circinar balanoposthitis, ulceration of the oral mucosa), as well as with symptoms of damage to the cardiovascular, nervous system and kidney pathology. With reactive arthritis, the following joints are affected in descending order: knee, ankle, metatarsophalangeal, toes, hip, shoulder, elbow and others. The disease most often occurs in the form of monoarthritis. The average duration of the first episode of the disease is 4-6 months. Reactive arthritis occurs in waves: in 50% of cases, relapses of the disease are observed at various intervals. In 20% of patients, various enthesopathies are detected: the Achilles tendon and plantar fascia are most often affected, which causes gait disturbances.
With disseminated chlamydial infection, patients of both sexes may develop pneumonia, perihepatitis, and peritonitis.
Diagnostics
It is recommended to diagnose chlamydial infection:
Persons with clinical and/or laboratory signs of an inflammatory process in the organs of the urogenital tract and reproductive system, if indicated - rectum, oropharynx, conjunctiva, joints;
- during preconception examination;
- when examining women during pregnancy;
- for upcoming surgical (invasive) manipulations on the genitals and pelvic organs;
- persons with perinatal losses and a history of infertility;
- sexual partners of patients with STIs ;
- persons who have suffered sexual violence.
If the source of infection is unknown, it is recommended to conduct a repeat serological test for syphilis after 3 months, for HIV, hepatitis B and C - after 3-6-9 months.
Clinical material for laboratory research is :
- in women: discharge (scraping) of the urethra, cervical canal, the first portion of freely released urine (when studied by molecular biological methods);
- in men: discharge (scraping) of the urethra, the first portion of freely released urine (when studied by molecular biological methods); if indicated - prostate secretion;
- in children and women who have no history of sexual intercourse with penetration - discharge from the urethra, posterior fossa of the vaginal vestibule, vagina; when examined using children's gynecological speculum - cervical canal discharge.
To obtain reliable results of laboratory tests, it is necessary to comply with a number of requirements, which include:
1. timing of obtaining clinical material, taking into account the use of antibacterial drugs: for identification C. trachomatis by RNA amplification method (NASBA) - no earlier than 14 days after the end of taking the drugs, by DNA amplification methods (PCR, real-time PCR) - no earlier than a month after the end of taking the drugs;
2. obtaining clinical material from the urethra no earlier than 3 hours after the last urination, in the presence of heavy urethral discharge - 15 to 20 minutes after urination;
3. obtaining clinical material from the cervical canal and vagina outside of menstruation;
4. compliance with the conditions for delivery of samples to the laboratory.
From the standpoint of evidence-based medicine, the use of biological, chemical and nutritional provocations in order to increase the efficiency of diagnosis is inappropriate.
Verification of the diagnosis of chlamydial infection is based on the results laboratory research molecular biological methods aimed at detecting specific fragments of DNA and/or RNA C. trachomatis, using test systems approved for medical use in the Russian Federation. The sensitivity of the methods is 98-100%, specificity is 100%. The sensitivity of the test can be influenced by various inhibitory factors, which may result in false negative results. Due to the high sensitivity of the methods, strict requirements are imposed on the organization and operating hours of the laboratory to avoid contamination of clinical material.
Selection method C. trachomatis in cell culture is not recommended for use in routine research and to establish the etiology of infertility.
Other laboratory research methods, including direct immunofluorescence (DIF), enzyme-linked immunosorbent assay (ELISA) for detecting antibodies to C. trachomatis, Microscopic and morphological methods cannot be used to diagnose chlamydial infection.
Consultations with other specialists recommended for indications in the following cases:
- obstetrician-gynecologist - when the pelvic organs are involved in the inflammatory process, when managing pregnant women, patients with chlamydial infection;
- urologist - in order to diagnose possible complications from the reproductive system, with a long course and ineffectiveness of previously carried out therapy for epididymo-orchitis, prostatitis accompanying urethritis;
- ophthalmologist, otorhinolaryngologist, proctologist, rheumatologist, in children - neonatologist, pediatrician - in order to clarify the scope and nature of the additional examination.
Differential diagnosis
Symptoms of chlamydial infection are not specific, which dictates the need for laboratory tests to exclude other urogenital diseases caused by pathogenic ( N. gonorrhoeae, T. vaginalis, M. genitalium) and opportunistic microorganisms (fungi of the genus Candida, genital mycoplasmas and microorganisms associated with bacterial vaginosis) and viruses (herpes simplex virus).
Differential diagnosis of chlamydial epididymo-orchitis is carried out with hydrocele, infectious epididymo-orchitis of other etiology (tuberculous, syphilitic, gonococcal, etc.), tumor of the scrotal organs, torsion of the testicular peduncle, etc.
Differential diagnosis of chlamydial infection of the upper parts of the reproductive system of women is carried out with ectopic pregnancy, endometriosis, complicated ovarian cyst, diseases of the abdominal organs (pancreatitis, cholecystitis, etc.).
Treatment abroad
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Treatment
Indications for treatment
The indication for treatment is identification C. trachomatis using molecular biological methods or a culture method in the patient or his sexual partner.
Simultaneous treatment of sexual partners is mandatory.
Treatment Goals
Eradication C. trachomatis;
Clinical recovery;
Preventing the development of complications;
Preventing infection of others.
General notes on therapy
The choice of drugs is carried out taking into account anamnestic data (allergic reactions, individual intolerance to drugs, the presence of concomitant infections).
From the standpoint of evidence-based medicine, systemic enzyme therapy, immunomodulatory therapy and therapy with local antiseptic drugs are not recommended.
Indications for hospitalization
Disseminated chlamydial infection (pneumonia, perihepatitis, peritonitis).
Treatment regimens
Treatment of chlamydial infections of the lower genitourinary system (A56.0), anorectal region (A 56.3), chlamydial pharyngitis (A 56.4),
chlamydial conjunctivitis (A 74.0)
Drugs of choice:
- doxycycline monohydrate 100 mg orally 2 times a day for 7 days (A)
or
- azithromycin 1.0 g orally once (A)
or
- josamycin 500 mg orally 3 times a day for 7 days (C)
Alternative drug:
- ofloxacin 400 mg orally 2 times a day for 7 days (B).
Treatment of chlamydial infections of the upper genitourinary system, pelvic organs and other organs (A 56.1, A 56.8)
The duration of the course of therapy depends on the degree of clinical manifestations of inflammatory processes in the genitourinary organs, the results of laboratory and instrumental studies. Depending on the above factors, the duration of therapy can vary from 14 to 21 days.
Drugs of choice:
- doxycycline monohydrate 100 mg orally 2 times a day for 14-21 days (A)
or
- josamycin 500 mg orally 3 times a day for 14-21 days (C).
Alternative drug:
- ofloxacin 400 mg orally 2 times a day for 14-21 days (B).
In case of complicated diseases, it is additionally recommended to prescribe pathogenetic therapy and physiotherapy.
Special situations
Treatment for pregnant women:
- josamycin 500 mg orally 3 times a day for 7 days (B)
or
- azithromycin 1.0 g orally once (A).
Treatment of pregnant women with chlamydial infection is carried out at any stage of pregnancy with antibacterial drugs, taking into account their effect on the fetus, with the participation of obstetricians and gynecologists.
Treatment of children (weight less than 45 kg):
- josamycin 50 mg per kg body weight per day, divided into 3 doses, orally for 7 days (D).
Treatment of newborns born from mothers with chlamydial infection is carried out with the participation of neonatologists.
Treatment of chlamydial infection in children weighing more than 45 kg is carried out in accordance with the prescription regimens for adults, taking into account contraindications.
Requirements for treatment results
Eradication C. trachomatis;
Clinical recovery.
Establishing the cure of chlamydial infection based on RNA amplification methods (NASBA) is carried out 14 days after the end of treatment, based on DNA amplification methods (PCR, real-time PCR) - no earlier than a month after the end of treatment.
If the examination results are negative, patients are not subject to further observation.
Tactics in the absence of treatment effect
- exclusion of reinfection;
- prescription of an antibacterial drug of another pharmacological group.
Information
Sources and literature
- Clinical recommendations of the Russian Society of Obstetricians and Gynecologists
- Clinical recommendations of the Russian Society of Dermatovenerologists and Cosmetologists
- 1. Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Sex Transm Dis 2002;29:497-502 2. Hathorn E, Opie C, Goold P. What is the appropriate treatment for the management of rectal Chlamydia trachomatis in men and women? Sex Transm Infect 2012;88:352–4. 3. Geisler WM, Koltun WD, Abdelsayed N, et al. Safety and efficacy of WC2031 versus vibramycin for the treatment of uncomplicated urogenital Chlamydia trachomatis infection: a randomized, double-blind, double-dummy, active-controlled, multicenter trial. Clin Infect Dis 2012;55:82–8. 4. CDC. Sexually Transmitted Diseases Guidelines; 2015; avaliable at: http://www.cdc.gov/std/tg2015/chlamydia.htm 5. European guideline for the management of Chlamydia trachomatis infections. avaliable at: http://www.iusti.org/regions/Europe/pdf/2010/Euro_Guideline_Chlamydia_2010.pdf 6. Adimora AA. Treatment of uncomplicated genital Chlamydia trachomatis infections in adults. Clin Infect Dis 2002;35:S183-S186. 7. Schillinger JA, Kissinger P, Calvet H, Whittington WL, Ransom RL, Sternberg MR, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis 2003;30:49-56. 8. Dreses-Werringloer U, Padubrin I, Zeidler H, Kohler L. Effects of azithromycin and rifampin on Chlamydia trachomatis infection in vitro. Antimicrob Agents Chemother 2001;45:3001-8. 9. Pitsouni E, Iavazzo C, Athanasiou S, Falagas ME. Single-dose azithromycin versus erythromycin or amoxicillin for Chlamydia trachomatis infection during pregnancy: a meta-analysis of randomized controlled trials. Int J Antimicrob Agents 2007;30:213-21. 10. Czeizel AE, Rockenbauer M, Olsen J, Sorensen HT. A case-control teratological study of spiramycin, roxithromycin, oleandomycin and josamycin. Acta Obstet Gynecol Scand 2000;79:234-7. 11. Iakubovich AI, Chuprin AE, Rakitin DA. Urogenital chlamydia infection: treatment with wilprafen. Urologiia. 2003 Jan-Feb;(1):55-8. 12. Zhu H, Wang HP, Jiang Y, Hou SP, Liu YJ, Liu QZ. Mutations in 23S rRNA and ribosomal protein L4 account for resistance in Chlamydia trachomatis strains selected in vitro by macrolide passage. Andrologia. 2010 Aug;42(4):274-80. 13. Ross JD, Cronjé HS, Paszkowski T, Rakoczi I, Vildaite D, Kureishi A, Alefelder M, Arvis P, Reimnitz P; MAIDEN Study Group. Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomized trial. Sex Transm Infect. 2006 Dec;82(6):446-51. Epub 2006 May 24. 14. Wang SX, Zhang JM, Wu K, Chen J, Shi JF. Pathogens in expressed prostatic secretion and their correlation with serum prostate specific antigen: analysis of 320 cases. Zhonghua Nan Ke Xue. 2014 Aug;20(8):715-8. 15. Molochkov VA, Mostakova NN. Vilprafene (josamycin) therapy of chronic chlamydial prostatitis. Urologiia. 2001 May-Jun;(3):34-5. 16. Soltz-Szots J, Schneider S, Niebauer B, Knobler RM, Lindmaier A. Significance of the dose of josamycin in the treatment of chlamydia infected pregnant patients. Z Hautkr 1989;64:129-31. 17. Galimova ER. Experience in the treatment of chlamydial urogenital infection in pregnant women with vilprafen. Current issues in obstetrics and gynecology 2001-2002; 1(1) 18. Rahangdale L, Guerry S, Bauer HM, Packel L, Rhew M, Baxter R, et al. An observational cohort study of Chlamydia trachomatis treatment in pregnancy. Sex Transm Dis 2006;33:106-10. 19. Brocklehurst P, Rooney G. Interventions for treating genital chlamydia trachomatis infection in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000054. DOI: 10.1002/14651858.CD000054. 20. Darville T. Chlamydia trachomatis infections in neonates and young children. Semin Pediatr Infect Dis 2005;16:235-44. 21. Wang Y, Yang WB, Yuan HY, Zhang QX, Zhu XY. Analysis of the infection status and the drug resistance of mycoplasma and chlamydiae in genitourinary tracts of children with suspected nongonococcal urethritis. Zhonghua Er Ke Za Zhi. 2009 Jan;47(1):62-4. 22. Management of patients with sexually transmitted infections and urogenital infections: Clinical guidelines. Russian Society of Dermatovenereologists and Cosmetologists. – M.: Business Express, 2012. – 112 p.
Information
Personal composition of the working group for the preparation of federal clinical recommendations in the profile "Dermatovenereology", section "X" Lamidia infection":
1. Margarita Rafikovna Rakhmatulina - Deputy Director of the Federal State Budgetary Institution "State Scientific Center for Dermatovenereology and Cosmetology" of the Russian Ministry of Health for scientific and clinical work, Doctor of Medical Sciences, Moscow.
2. Sokolovsky Evgeniy Vladislavovich - head of the department of dermatovenerology with the clinic of the First St. Petersburg State Medical University named after. Academician I.P. Pavlova, Doctor of Medical Sciences, Professor, St. Petersburg.
3. Irina Olegovna Malova - Head of the Department of Dermatovenerology, Faculty of Advanced Training and Professional Retraining of Specialists, Irkutsk State Medical University of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor, Irkutsk.
4. Apolikhina Inna Anatolyevna - head of the gynecological department of rehabilitation treatment of the Federal State Budgetary Institution Scientific Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov" of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor, Professor of the Department of Obstetrics, Gynecology, Perinatology and Reproductology of the First Moscow State Medical University named after I.M. Sechenov, Moscow.
5. Alina Grantovna Melkumyan - researcher at the Department of Microbiology and Clinical Pharmacology of the Federal State Budgetary Institution NTsAG and P named after. IN AND. Kulakova, Ministry of Health of Russia, Candidate of Medical Sciences, Moscow.
METHODOLOGY
search in electronic databases.
Description of methods used to collect/select evidence:
The evidence base for the recommendations is publications included in the Cochrane Library, EMBASE and MEDLINE databases.
Methods used to assess the quality and strength of evidence:
· Consensus of experts;
· Assessment of significance in accordance with the rating scheme (scheme attached).
Levels of Evidence | Description |
1++ | High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs) or RCTs with very low risk of bias |
1+ | Well-conducted meta-analyses, systematic ones, or RCTs with low risk of bias |
1- | Meta-analyses, systematic, or RCTs with a high risk of bias |
2++ | High-quality systematic reviews of case-control or cohort studies. High-quality reviews of case-control or cohort studies with very low risk of confounding effects or bias and moderate probability of causality |
2+ | Well-conducted case-control or cohort studies with moderate risk of confounding effects or bias and moderate probability of causality |
2- | Case-control or cohort studies with a high risk of confounding effects or bias and a moderate probability of causality |
3 | Non-analytical studies (eg: case reports, case series) |
4 | Expert opinion |
· Reviews of published meta-analyses;
· Systematic reviews with evidence tables.
Methods used to formulate recommendations:
Expert consensus.
Force | Description |
A |
At least one meta-analysis, systematic review or RCT rated 1++, directly applicable to the target population and demonstrating robustness of the results or body of evidence that includes study results rated 1+, directly applicable to the target population, and demonstrating overall robustness of the results |
IN |
A body of evidence that includes study results rated 2++, directly applicable to the target population and demonstrating overall robustness of the results or extrapolated evidence from studies rated 1++ or 1+ |
WITH |
A body of evidence that includes findings from studies rated 2+, directly applicable to the target population, and demonstrating overall robustness of the findings; or extrapolated evidence from studies rated 2++ |
D |
Level 3 or 4 evidence; or extrapolated evidence from studies rated 2+ |
Recommended good practice is based on the clinical experience of the guideline working group members.
Economic analysis:
No cost analysis was performed and pharmacoeconomics publications were not reviewed.
Chlamydia infection is a sexually transmitted disease (sexually transmitted infection) that is caused by the bacterium Chlamydia trachomatis.
Etiology and epidemiology of chlamydia
Urogenital chlamydia is one of the most common STIs in the world. Due to improved diagnostic methods, more and more cases of the disease are being reported in many developed countries. The greatest risk of the disease is in young people who are promiscuous and do not use STI prevention measures. In Russia, the incidence of chlamydia is also high, while statistical indicators do not reflect the real situation with this disease, since a large number of cases remain unregistered.
Classification of chlamydia
- A56.0 Chlamydial infections of the lower genitourinary tract.
- A56.1 Chlamydial infections of the pelvic organs and other genitourinary organs
- A56.3 Chlamydial infection of the anorectal area
- A56.4 Chlamydial pharyngitis
- A56.8 Chlamydial sexually transmitted infections, other localization
- A74.0 Chlamydial conjunctivitis (H13.1)
Ways of infection with chlamydia:
adult population
- sexual contact (any form of sexual contact).
Children:
- perinatal;
- sexual contact;
- contact-household (in rare cases, little girls become infected from sick parents, if hygiene rules are not observed when caring for the child).
Symptoms of chlamydia
Chlamydia of the lower genitourinary system:
In females:
Complaints about (subjective symptoms):
- mucopurulent discharge from the urethra and/or vagina;
- spotting (outside of menstruation);
- Painful sensations during sexual intercourse;
- Pain, itching, burning during urination;
- Pain and discomfort in the suprapubic abdominal region.
Upon examination, the following objective symptoms are revealed:
Objective symptoms upon examination:
Chlamydial infection of the anorectal area
In both men and women, in most cases it is asymptomatic.
The following complaints are possible:
- if the rectum is affected, itching, burning in the anorectal area, painful tenesmus, pain during defecation, mucopurulent discharge, often mixed with blood, constipation.
Objective symptoms:
- redness and swelling of the skin in the anal area;
- mucopurulent discharge from the rectum.
Chlamydial pharyngitis
Complaints about:
- dryness in the oropharynx;
- pain that gets worse when swallowing.
Objectively:
- redness and swelling of the mucous membrane of the oropharynx and tonsils.
Chlamydial conjunctivitis
Complaints:
- moderate pain in the area of the affected eye;
- dryness and hyperemia of the conjunctiva;
- photophobia;
Objectively:
- redness and swelling of the conjunctiva of the eye;
- scanty mucopurulent discharge in the corners of the eye.
Chlamydial infections of the pelvic organs and other genitourinary organs
Subjective symptoms of chlamydia in women
- vestibulitis: scanty mucopurulent discharge, redness and swelling in the vulva area, soreness;
- salpingo-oophoritis: cramping pain in the lower abdomen, mucopurulent discharge; there is a disturbance in the menstrual cycle; in the chronic course, complaints and manifestations are more erased.
- endometritis: nagging pain in the lower abdomen, mucopurulent discharge;
- pelvioperitonitis: nausea, vomiting, severe abdominal pain, defecation disturbance.
Objective symptoms:
- vestibulitis: scanty mucopurulent discharge, hyperemia of the openings of the ducts of the vestibular glands, pain and swelling of the ducts;
- salpingoophoritis: in acute cases - enlarged, painful fallopian tubes and ovaries, shortening of the vaginal vaults, mucopurulent discharge from the cervical canal; in the chronic course of the process - slight pain, compaction of the fallopian tubes;
- endometritis: in acute cases - painful, enlarged uterus of soft consistency, mucopurulent discharge from the cervical canal; in the chronic course of the disease - dense consistency and limited mobility of the uterus;
- pelvioperitonitis: appearance – facies hypocratica, high body temperature, hypotension, oliguria, severe abdominal pain on palpation, tension in the muscles of the abdominal wall and a positive symptom of peritoneal irritation are determined in the lower parts.
Subjective symptoms of chlamydia in men
- epididymo-orchitis: mucopurulent discharge from the urethra, urination disorders, dyspareunia, pain in the epididymis and groin area on the affected side; pain in the perineum radiating to the rectum, lower abdomen, and scrotum; pain can spread to the spermatic cord, inguinal canal, lumbar region, sacrum;
- prostatitis: pain in the perineum and lower abdomen extending to the rectal area, difficulty urinating.
Objective symptoms
- epididymo-orchitis: mucopurulent discharge from the urethra, palpation reveals an enlarged, dense and painful testicle and its appendage, redness and swelling of the scrotum in the affected area is observed;
- prostatitis accompanying urethritis: palpation reveals a painful, hardened prostate gland.
In men and women - chlamydial lesions of the paraurethral glands
Subjective symptoms:
- itching, burning, pain when urinating;
- mucopurulent discharge from the urethra;
- pain and discomfort during sexual intercourse;
- soreness in the area of the urethral opening.
Objective symptoms:
- mucopurulent discharge from the urethra, the presence of dense painful elements the size of millet grains in the area of the ducts of the paraurethral glands.
Chlamydial infections, sexually transmitted infections, other localization
Reactive arthritis is an inflammation of the synovium of the joint, ligaments and fascia. The disease often manifests itself as a triad of symptoms: urethritis, conjunctivitis, arthritis. In this case, damage to the skin and mucous membranes is possible (keratoderma, circinar balanoposthitis, ulceration of the oral mucosa), as well as with symptoms of damage to the cardiovascular, nervous system and kidney pathology. With reactive arthritis, the following joints are affected: knee, ankle, metatarsophalangeal, toes, hip, shoulder, elbow and others. The disease is characterized by monoarthritis. The average duration of the first episode of the disease is about 6 months. Half of the patients experience relapses. 20% of patients show signs of intestinal damage.
With disseminated chlamydial infection, patients of both sexes may develop pneumonia, perihepatitis, and peritonitis.
Indications for examination
- persons with clinical and/or laboratory signs of inflammation of the genitourinary system, if indicated - for diseases of the rectum, oropharynx, conjunctiva, joints;
- pre-conception examination;
- examination of pregnant women;
- upcoming surgical manipulations on the genitourinary system
- persons with a history of perinatal losses and infertility;
- sexual partners of patients with STIs;
- survivors of sexual violence.
If the source of infection is unknown, it is recommended to conduct a repeat serological test for syphilis after 3 months, for HIV, hepatitis B and C - after 3-6-9 months.
Clinical material for laboratory research is:
- in women: discharge (scraping) of the urethra, cervical canal, first portion of urine
- in men: discharge (scraping) of the urethra, the first portion of urine, prostate secretion;
- in children and women who have no history of sexual intercourse with penetration - discharge from the urethra, posterior fossa of the vaginal vestibule, vagina; when examined using children's gynecological speculum - cervical canal discharge.
For reliable diagnosis, the following requirements must be met:
- Collection of material for cultural examination no earlier than 14 days after taking antibacterial drugs; for PCR diagnostics - no earlier than a month.
- Collection of clinical material no earlier than 3 hours after urination; with a pronounced clinical picture with heavy discharge - after 15-20 minutes.
- Collection of material outside of menstruation;
- compliance with the conditions for delivery of samples to the laboratory.
Carrying out any types of provocations in order to increase the efficiency of diagnosis is inappropriate.
The recommended methods for diagnosing chlamydia are PCR diagnostics and cultural testing, while the latter method is not used in routine practice due to its laboriousness and time-consuming nature. PCR is currently the most optimal diagnostic method with a sensitivity of up to 98-100%.
Diagnostic methods: direct immunofluorescence (DIF), enzyme-linked immunosorbent assay (ELISA) for detecting antibodies to C. trachomatis, microscopic and morphological methods cannot be used to diagnose chlamydial infection.
For various clinical forms of chlamydia, consultation with the following specialists may be required:
Differential diagnosis
Manifestations of urogenital chlamydia are not specific, and therefore it is necessary to differentiate this pathology from other STIs. It is advisable to include the entire list of sexually transmitted diseases in the examination plan.
Chlamydial epididymo-orchitis is differentiated from hydrocele, infectious epididymo-orchitis of other etiologies (tuberculous, syphilitic, gonococcal, etc.), tumor of the scrotal organs, torsion of the testicular pedicle, etc.
Differential diagnosis of chlamydial infection of the upper parts of the reproductive system of women is carried out with ectopic pregnancy, endometriosis, complicated ovarian cyst, diseases of the abdominal organs (pancreatitis, cholecystitis, etc.).
Treatment of chamidiasis
Indications for treatment
The indication for treatment is identification of the pathogen by PCR or culture. All sexual partners of the patient should receive treatment.
Treatment Goals
- eradication of C. trachomatis;
- clinical recovery;
- preventing the development of complications;
- preventing infection of others.
General notes on therapy
When prescribing treatment, the following factors must be taken into account: allergic reactions, individual intolerance to drugs, the presence of concomitant diseases, including STIs.
During the treatment period, it is advisable to avoid sexual intercourse or use barrier means to prevent STIs.
Indications for inpatient treatment
Common chlamydial infection (pneumonia, perihepatitis, peritonitis).
Treatment regimens
Treatment of chlamydial infections of the lower genitourinary system (A56.0), anorectal area (A 56.3), chlamydial pharyngitis (A 56.4), chlamydial conjunctivitis (A 74.0)
Drugs of choice:
- doxycycline monohydrate 100 mg
- azithromycin 1.0 g
- josamycin 500 mg
- ofloxacin 400 mg
Treatment of chlamydial infections of the upper genitourinary system, pelvic organs and other organs (A 56.1, A 56.8) is carried out with the same drugs, but for a longer period - from 14 to 21 days.
Special situations
Treatment for pregnant women:
- josamycin 500 mg
- azithromycin 1.0 g
Treatment of pregnant women should be carried out at any stage, but always in conjunction with gynecologists.
Treatment of chlamydia in children (less than 45 kg):
- josamycin 50 mg per kg body weight per day,
- treatment of newborns only together with neonatologists.
Treatment of chlamydia in children weighing more than 45 kg is carried out similarly to the treatment of adults.
Expected treatment results
- eradication of chlamydia from the body
- disappearance of symptoms
To clarify the fact of cure, PCR diagnostics are used, but not earlier than 1 month after the end of treatment. If the test results are negative, patients do not need further observation.
Tactics in the absence of treatment effect
- avoiding re-infection;
- choosing an antibacterial drug from a different group.