Treatment regimens should be effective against N. gonorrhoeae and C. trachomatis because of the high frequency of coinfection. Increasing rates of resistance to fluoroquinolones limit treatment options. A single IM dose of ceftriaxone (250 mg) is recommended for uncomplicated gonococcal infections of the cervix, urethra, and rectum. Hospitalization and treatment with ceftriaxone are recommended for disseminated gonococcal infections. For all gonococcal infections, azithromycin or doxycycline also should be administered unless chlamydial infection is excluded.
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Chlamydiae are obligate intracellular bacteria with a biphasic life cycle, existing as relatively inert elementary bodies in their extracellular form and as reticulate bodies when phagocytosed and replicating within a phagosome. Reticulate bodies divide by binary fission and, after 48 to 72 hours, reorganize into elementary bodies that are released from the cell. Chlamydia infects nonciliated squamocolumnar cells and the transitional epithelial cells that line the mucosa of the urethra, cervix, rectum, and conjunctiva.
C. trachomatis serovars D through K cause urethritis, cervicitis, PID, inclusion conjunctivitis in newborns, and infant pneumonia. C. trachomatis serovars L1–3 cause lymphogranuloma venereum, an infrequent STI characterized by unilateral, painful inguinal lymphadenitis. C. trachomatis serovars A, B, Ba, and C produce trachoma (hyperendemic blinding), which eventually leads to blindness from extensive local scarring.
Chlamydia is the most frequently diagnosed bacterial STI in adolescents and accounts for most cases of nongonococcal urethritis and cervicitis (see Table 116-1). There is a 5:1 female-to-male ratio. Males often have dysuria and a mucopurulent discharge, although approximately 25% may be asymptomatic. Women are more often asymptomatic (approximately 70%) or may have minimal symptoms including dysuria, mild abdominal pain, or vaginal discharge. Prepubertal girls may have vaginitis. At least 30% of persons with gonococcal cervicitis, urethritis, proctitis, or epididymitis have C. trachomatis coinfection.
Chlamydia infection usually is diagnosed by the detection of bacterial nucleic acids (polymerase chain reaction [PCR] tests, using ligase chain reaction and transcription-mediated amplification) of cervical, urethral, and early morning first-voided urine specimens. Amplification tests have supplanted less sensitive culture and enzyme-linked immunosorbent assay tests. Because of false positive results, only culture should be used for medicolegal purposes to confirm C. trachomatis infection in cases of suspected sexual abuse.
Treatment regimens should be effective against C. trachomatis and N. gonorrhoeae because of the high frequency of coinfection. A single oral dose of azithromycin (1 g) or doxycycline for 7 days is recommended, which can be combined with a single dose of ceftriaxone (250 mg) to treat concomitant gonorrhea infection.
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