Primary Care 10-minute consultation

CervicalChlamydia trachomatisinfection

BMJ 2003; 327 doi: http://dx.doi.org/10.1136/bmj.327.7420.910 (Published 16 October 2003) Cite this as: BMJ 2003;327:910
  1. Pippa Oakeshott, senior lecturer in general practice (oakeshot{at}sghms.ac.uk)1,
  2. Phillip Hay, senior lecturer in genitourinary medicine2
  1. 1Department of General Practice, St George's Hospital Medical School, London SW17 0RE,
  2. 2Department of Genitourinary Medicine, St George's Hospital Medical School
  1. Correspondence to: P Oakeshott

    Introduction

    A 23 year old single mother has come back for the result of a test for chlamydial infection. The test is positive. She had seen you a week earlier for a routine smear test and mentioned some mid-cycle bleeding. She has been seeing her current boyfriend intermittently for a year. She has a four year old child, had a termination two years ago, and is on the pill.

    Examination showed mucopurulent discharge at the external os. The cervix was friable and bled easily. After the smear test you removed excess mucopus before rotating a swab gently in and aroundthe cervical os and placing it in chlamydia test transport medium. Chlamydia are intracellular bacteria, so specimens should contain columnar epithelial cells rather than discharge. You need sample collection kits appropriate for the test used in your local laboratory. Sensitive and specific chlamydia tests using nucleic acid amplification are now widely available in Britain and may allow testing of a first catch urine or self taken vaginal swab.

    What issues you should cover

    Treatment–Chlamydial infection is the commonest bacterial sexually transmittedinfection. In general practice around one in 20 sexually active women aged less than 25 years may be infected. The infection can be treated effectively with antibiotics (95% of infections treated with doxycycline are cured). As chlamydia is a sexually transmitted infection her partner (or partners) will also need treatment. To avoid reinfection she and her partner must abstain from sex until they have completed treatment. A test of cure is then unnecessary.

    Telling partners–Advise her to be open with her partner about chlamydial infection. It is often passed on by someone who is unaware of being infected. As it often has no symptoms, particularly in women, either partner could have become infected months ago. Ask whether she has slept with anyone else in the past six months: other partners should be checked and treated.

    Key points

    Indications for chlamydial screening in women:

    • Before a termination of pregnancy

    • Age < 25, especially sexually active teenagers

    • More than one sexual partner

    • Mucopurulent vaginal discharge

    • Friable cervix or bleeding after sex or between menstrual periods

    • Before fitting an intrauterine contraceptive device in a patient in a high risk group

    Management of uncomplicated cervical chlamydial infection:

    • Doxycycline 100 mg twice daily for a week

    • Notification of partners

    • No sex until both partners are treated

    • Consider referral to a genitourinary clinic

    Useful reading

    Department of Health. Chlamydia trachomatis: summary and conclusions of CMO's expert advisory group.London: DoH, 1998.

    /www.doh.gov.uk/pub/docs/doh/chlamyd.pdf

    Duncan B, Hart G, Scoular A, Bigrigg A.

    Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening. BMJ 2001;322:195-9

    Association for Genito-Urinary Medicine. Clinical effectiveness guidelines for management of Chlamydia trachomatis genital tract infection (accessible at www.agum.org.uk)

    Implications for fertility–Over 95% of women with uncomplicated chlamydial infection that is adequately treated will not develop tubal infertility. Infection of the womb and fallopian tubes, known as pelvic inflammatory disease, is more likely if she has been having pelvic pain. But even after an episode of pelvic inflammatory disease more than 85% of women remain fertile. There is also a 10% risk of ectopic pregnancy after clinical pelvic inflammatory disease. Although there will probably be no problems, she won't know for certain until she tries to get pregnant.

    Further information and support–Many women who are given a diagnosis of chlamydial infection are anxious about the stigma of having a sexually transmitted infection, about how to tell their partner, and about their future fertility. It often helps if they talk to expert health advisers at the local genitourinary clinic.

    What you should do

    • Prescribe doxycycline 100 mg twice daily for seven days. Warn her about possible interference with the pill and photosensitivity and tell her to take capsules with food. If you have doubts about compliance prescribe 1 g azithromycin to be taken immediately. If she is pregnant or lactating prescribe erythromycin 500 mg four times a day for seven days or twice daily for 14 days,but recommend that she has a test of cure three weeks later, as erythromycin is less effective than doxycycline.

    • Write a note for her to give to her partner to take to the genitourinary clinic or hisGP. Advise no sex until both have been treated. Put a reminder in her notes to review partner notification at the next consultation.

    • Consider referral to the genitourinary clinic for screening for other sexually transmitted diseases; if her history indicates multiple partners (partner notification may be complicated); or for counselling.

    • Give her information leaflets on chlamydial infection and the number of the local genitourinary clinic. Offer her condoms if they are available.

    This is part of a series of occasional articles on common problems in primary care

    The series is edited by general practitioners Ann McPherson and Deborah Waller (ann.mcpherson{at}dphpc.ox.ac.uk

    TheBMJ welcomes contributions from general practitioners to the series

    View Abstract