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Chlamydia - top tips on diagnosis, treatment and management

Genitourinary physician Dr Olwen Williams offers her advice on this common STI

Genitourinary physician Dr Olwen Williams offers her advice on this common STI

1 Young people are more predisposed to acquiring chlamydia but age is no bar to contracting a sexually transmitted infection. Over the past 10 years STI rates in the over-45s have doubled – but it is 16- to 24-year-old females and 20- to 24-year-old males who have the highest rates of chlamydia.

2 Chlamydia screening in England varies from area to area, so check what's happening in yours. Screening programmes have been rolled out across England – one in 10 individuals screened aged under 25 have been found to be infected. Reinfection rates within nine months are high. Visit the National Chlamydia Screening Programme website to find out what's happening in your area. Scotland, Wales and Northern Ireland have not gone down this route.

3 Remember, false positives can be a nightmare to deal with. Chlamydia tests have varying sensitivities and specificities. Most UK laboratories use a nucleic acid amplification test (NAAT). Urine tests using these methods give excellent results in men but are less sensitive in women – here a self-taken vulval swab is recommended. If you are tempted to use a point-of-care chlamydia kit make sure it has a quoted sensitivity and specificity otherwise you may as well toss a coin...

4 Consider taking a travel history alongside the sexual history to identify the possibility of a new genetic chlamydia variant. It first came to light in Sweden in 2006 when a significant drop in the incidence of chlamydia in one region alerted clinicians to a problem. The mutant strain was not detectable via two commercially available tests and also exhibited resistance to azithromycin. The variant has been identified in the UK – all laboratories are aware of the issue.

5 Consider chlamydia when the next male with dysuria with or without discharge consults you. Primary care has excelled in the diagnosis and management of chlamydia in women, with 25% of all UK tests in 2004 being done by GPs and 75% of cases being managed without referral. But things are not so good for men and GPs do only 5% of all tests. For chlamydia urine testing just use the first-pass urine – the midstream portion can go in the MSSU bottle.

6 Single-dose azithromycin 1g versus doxycycline 100mg twice daily for a week are as efficacious as each other at seven days. If adherence is an issue then go for the single dose but the patient should be advised to refrain from any penetrative intercourse – even with a condom – until a whole week has lapsed since treatment. This is the time it takes for ‘clinical cure'.

7 Partner notification is essential to break the chain of infection and to minimise reinfection. In symptomatic men, all sexual partners for the month prior to symptoms should be advised to attend for testing and ‘epidemiological treatment'. In asymptomatic women and men all partners over the previous six months should be seen. The concept of giving antimicrobial therapy to an individual because they may have been exposed to an infection may seem alien but this is one way to reduce onward infection.

8 The impact of chlamydial infection on fertility may have been overestimated. Infertility has always been considered the major sequela to untreated chlamydial infection in women. But it is not inevitable, as some young women have assumed. Some have not used contraception, believing they are unable to conceive. Recent reviews of the literature suggest the risk has been overestimated. It may be that the risk of progressing to pelvic inflammatory disease (PID) is closer to 1% rather than the 20% historically quoted. Much research needs to be done in this area but we are very unlikely to get a prospective observational trial, purely on ethical grounds.

9 GPs are far more likely to see the sequelae of chlamydia infection in men than I am in a sexual health clinic. SARA (seronegative arthropathy) is probably the most common condition that should be considered. The symptoms – urethritis accompanied by small to medium joint arthropathy, conjunctivitis and a plethora of dermatological manifestations – may not necessarily be something one would consider to be the result of chlamydia. This is especially true when the genital symptoms may precede the joint or skin problem by weeks or even months. SARA is thought to occur in 5% of male chlamydia cases but in my own experience

I rarely see men with this condition walk into clinic – they are much more likely to be attending primary care.

10 Guidelines for the management of genital chlamydial infection are available. Go to the British Association for Sexual Health and HIV website to download them. Patient leaflets can be downloaded from National Library for Health. Organisations such as fpa, Brook and Terrence Higgins Trust also have age-specific leaflets.

Dr Olwen Williams is clinical director of the integrated sexual health service at North Wales NHS Trust. She has a special interest in STDs in adolescents and children. She was awarded an OBE in 2006 for services to medicine in Wales

Competing interests: none declared

Chlamydia trachomatis in an infected cell Chlamydia trachomatis in an infected cell

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