Clamidiasis

The

new england journal

of

medicine

clinical practice

Genital Chlamydial Infections
Jeffrey F. Peipert, M.D., M.P.H.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinicalrecommendations.

From the Division of Research, Department of Obstetrics and Gynecology and Community Health, Brown University Medical School and the Women and Infants Hospital, Providence, R.I. Address reprint requests to Dr. Peipert at the Division of Research, Women and Infants Hospital, 101 Dudley St., Providence, RI 02905, or at jpeipert@ wihri.org. N Engl J Med 2003;349:2424-30.
Copyright © 2003Massachusetts Medical Society.

A 19-year-old woman visits her primary care provider for counseling about contraception. She became sexually active one year previously and has had a new sexual partner for the past three months. Her partner currently uses a condom intermittently for contraception, and she inquires about oral contraceptives. She reports no medical problems and is in good health. Herphysical examination is unremarkable. Is testing for Chlamydia trachomatis indicated?

the clinical problem
Chlamydia trachomatis is the most common bacterial cause of sexually transmitted infections in the United States, responsible for an estimated 3 million new infections each year.1,2 The cost of care for untreated chlamydial infections and their complications is estimated to exceed $2billion annually.3
clinical presentation

As many as 85 to 90 percent of C. trachomatis infections in men and women are asymptomatic.4,5 Asymptomatic infections can persist for several months.5 Despite the frequent absence of symptoms, at least one third of women have local signs of infection on examination.5 The two most commonly reported signs are mucopurulent discharge from the cervix andhypertrophic cervical ectopy (Fig. 1). Signs and symptoms in men include urethral discharge of mucopurulent or purulent material, dysuria, or urethral pruritus. Clinical manifestations of C. trachomatis infections in women include acute urethral syndrome, urethritis, bartholinitis, cervicitis, upper genital tract infection (endometritis, salpingo-oophoritis, or pelvic inflammatory disease), perihepatitis(Fitz-Hugh–Curtis syndrome), and reactive arthritis.5 Symptoms depend on the site of infection. Infection of the urethra and lower genital tract may cause dysuria, abnormal vaginal discharge, or postcoital bleeding, whereas infection of the upper genital tract (e.g., endometritis or salpingitis) may be manifested as irregular uterine bleeding and abdominal or pelvic discomfort. In women, untreatedchlamydial infection can lead to severe reproductive complications. C. trachomatis is an important causal agent in pelvic inflammatory disease, with sequelae including infertility, ectopic pregnancy, and chronic pelvic pain.6 Up to two thirds of cases of tubal-factor infertility and one third of cases of ectopic pregnancy may be attributable to C. trachomatis infection.7 Chlamydial infectionduring pregnancy is associated with a number of adverse outcomes of pregnancy including preterm labor, premature rupture of the membranes, low birth weight, neonatal death, and postpartum endometritis.8,9 Chlamydial infection during pregnancy may be transmitted to the infant during de-

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n engl j med 349;25

www.nejm.org

december 18, 2003

The New England Journal of Medicine Downloadedfrom nejm.org on April 1, 2012. For personal use only. No other uses without permission. Copyright © 2003 Massachusetts Medical Society. All rights reserved.

clinical practice

Figure 1. Cervical Ectropion (White Arrow) with Mucopurulent Cervicitis (Black Arrow). Photograph courtesy of Dr. Marc Steben.

There is good evidence that screening women who are at risk for C. trachomatis...