Saturday, 7 December 2019

ABC of Chlamydial infection


1-10-19
CHLAMYDIAL INFECTION
Chlamydial trachomatis is an obligate intracellular bacterium  that has several  serotypes including those that cause  lymphogranuloma venereum. The  most commonly  encountered strains are those that attach only to columnar or transitional   cell epithelium and   cause cervical infection. It is the most  commonly reported  infectious   disease in the United  States  with  1.4 million cases reported in 2012 .

It is  estimated however that there are approximately  2.8 million  new cases annually although most are undiagnosed  . In 2012   the incidence of chlamydial  infection  among women   was 2 ½  times  greater than among  men. Selective prenatal screening  clinics in 2011   reported a median  chlamydial infection   rate of 7.7  percent .
Although most pregnant  women have asymptomatic  infection a third have urethral syndrome , urethritis or Bartholin gland   infection  . Mucopurulent Cervicitis   may be due to chlamydial or gonococcal  infection or both.

It may also represent   normal hormonally  stimulated endocervical  glands  with abundant  mucus production. Other  chlamydial infections   not usually seen in pregnancy are endometritis  salpingitis  peritonitis  reactive  arthritis and Reiter syndrome.
The risk  of chlamydail infection  in pregnancy  complication remains  controversial . A few  studies have reported a direct  association between C trachomatis  and miscarriage  whereas  most  show no correlation.
It is  disputed whether  untreated cervical infection increases   the risk of preterm delivery preterm ruptured  membranes and perinatal mortality  reported  a twofold risk for low birth weight infants.

Chlamydial infection  has not been  associated with an increased risk of  chorioamnionitis or with pelvic infection after  cesarean delivery . Conversely   delayed postpartum uterine infection has been  described   by Hoyme and associates . The syndrome  which develops 2 to 3 weeks  postpartum   is distinct from early  postpartum  metritis . It is characterized by vaginal bleeding or discharge ., low grade fever  lower abdominal pain and uterine tenderness.
There is vertical  transmission to 30-- 50 percent  of neonates  delivered vaginally   from infected  women.  Perinatal  transmission of newborn  can cause  pneumonia .  Moreover  C  trachomatis is the most  commonly identifiable infectious  cause of ophthalmia neonatorum.
Screening and treatment
Prenatal screening for C trachamatis is a complex  issue although there is  little evidence  for its effectiveness in  asymptomatic  women who   are not in high risk   groups  . Identification and treatment of asymptomatic infected women may prevent neonatal infections but evidence of adverse pregnancy outcome   prevention  is lacking .

Currently the U.s  Preventive Services Task Force  and the CDC recommend prenatal    screening  at the first  prenatal  visit for women  at increased risk   for chlamydial infection and again  during the third   trimester if high risk behavior  continues.
In a systematic review  of repeat chlamydial infection   among women. Hosenfeld  and coworkers  reported  a reinfection rate of 14 percent and most recurred within the first 8 to 10  months.  Interestingly in another study Sheffield  and colleagues  found that almost  half of pregnant women with asymptomatic cervical   Chlamydia  underwent  spontaneous  resolution of infection.
Diagnosis   Diagnosis is made  predominantly by culture or NAAT  cultures are more expensive  and less accurate  than newer NNATs  including PCR.    Roberts and associates  evaluated nucleic  acid amplification testing of urine compared  with cervical secretions in more than 2000  pregnant women and found them to be equivalent.
Currently  recommended treatment  regimens for chlamydial infections are shown . Azithromycin is first line treatment and   has been found to be safe and effective in pregnancy. The fluoroquinolones and doxycycline are avoided  in pregnancy as is  erythromycin  estolate  because of  drug  related hepatotoxicity .  Repeat  chlamydial testing 3 to 4 weeks  after  completion of therapy  is recommended

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