Nejm 2003;349:2424

Cause:Chlamydia trachomatis; in NSU in men, also Ureaplasma andMycoplasma sp.

Venereal; over 50% of nonspecific urethritis episodes in males; proctitis in gay males; 12% prevalence in Maine women (Maine Epigram 5/87), 7-15% in army women recruits (Nejm 1998;339:739), 4% overall in US (Jama 2004;291:2229) and highest in southwest and blacks. Transmission rates males to females and vice versa nearly equal, as are the asx infection rates (Jama 1996;276:1737)

Sx: 80-90% are asx; dysuria and urethral discharge in men, vaginal discharge in women

Si:

Urethral discharge in male; proctitis, mild in gays

Cervix shows yellow mucopurulent discharge (14% false pos—Nejm 1984;311:1) and hypertrophic cervical ectopy (ectropion)

Pharyngitis, from fellatio (Ann IM 1985;102:757)

Epididymitis (the etiology in 1/2 the cases of epididymitis); endometritis, PID, perihepatitis like Fitzhugh-Curtis syndrome of gonorrhea; male sterility (Am J Pub Hlth 1993;83:996) and female sterility (worse than gc); r/o gc and mycoplasma PID

Acute conjuctivitis in newborn (ophthalmia neonatorum) (r/o Herpes simplexw ulcerations) from gc or chlamydia, latter more common, 5% of all U Washington deliveries; a smaller % have pneumonitis, from 1 to 60 d postpartum, average 15 d, rx w erythromycin × 14 d (Med Let 1995;35:117)

Blindness in developing world, preventable with twice-a-year azithromycin rx to children which also decreases overall mortality (Jama 2009;302:962; Jama 2008;299:778)

Lab:

Bact:Single swab culture is 100% specif, 75% sens (Ann IM 1987;107:189); smears: males have >4 polys/hpf by urethral swab even if no discharge; females have 10+ polys/hpf (at 1000×), 17% false pos, 10% false neg (Holmes—Nejm 1984;311:1)

Path:Pap smear detection unreliable

Urinel:DNA amplification assay, 89% sens, 99% specif (Ann IM 2005;143:914; Nejm 1998;339:739, 768; Ann IM 1996;124:1); can be used to screen populations too

Rx:

Prevent w:

• In adult, barrier methods.
• At birth, povidone iodine 2.5% soln gtts OU is more effective, less toxic, and cheaper (Nejm 1995;332:562) than tetracycline, erythromycin, or silver nitrate gtts, which still miss some gc, hence have a 10-20% incidence of ophthalmic disease in newborns of infected mothers (Nejm 1989;320:769)

Screen (Pelvic Inflammatory Disease)

• All multiple-partnered asx men (Jama 1996;276:1737) and women to reduce PID sterilization rates from 2% to 1%/yr (Nejm 1996;334:1362), or all women under age 25-30 yr (Nejm 1998;339:739, 768; Ann IM 1998;128:277)
• All pregnant women early and at 36 wk w cultures if expected prevalence >7% (Ann IM 1987;107:188), or at least lower socioeconomic groups, and rx positives with erythromycin 500 mg qid × 7 d; this strategy decreases postnatal eye and lung infections, when given asx mothers prepartum, from infections in 50% of infants to 7% (Nejm 1986;314:276)

of active disease (Ann IM 2002;137:255; Med Let 1999;41:85) by treating patient and partner (Med Let 1994;36:1; Nejm 1978;298:490) with:

• 1st:
• Azithromycin (Zithromax) 1 gm po × 1 (Jama 1995;274:545; Nejm 1992;377:921)
• Tetracycline 500 mg qid × 7 d, 250 mg qid × 14-21 d, or doxycycline 100 mg bid × 7 d, or × 2-3 wk for proctitis
• 2nd (1st choice in pregnancy):
• Erythromycin 500 mg qid × 7 d or × 3 wk after tetracycline failure (Ann IM 1990;113:21), which may be due to tetracycline-resistant ureaplasma, for adults; nonestolated types ok in pregnancy (Med Let 1991;33:119); 12.5 mg/kg/d po or iv × 14 d for neonatal pneumonia or conjunctivitis
• Amoxicillin 500 mg tid × 7 d
• Levofloxacin 500 mg po qd × 7 d