Chlamydia and LGV: Treatment and follow-up

Treatment and follow-up of Chlamydia trachomatis infections (including lymphogranuloma venereum (LGV)).

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Treatment indications

C. trachomatis

LGV

Notes:

Treatment

The following treatment options are recommended in the absence of contraindication. Consult product monographs for contraindications and side effects.

Caution: Refer to the health advisory issued by Health Canada about azithromycin and risk of cardiovascular complications and death.

Anogenital and conjunctival chlamydia

Non-pregnant and non-lactating adults

Preferred treatment Alternative treatment
  • Doxycycline 100 mg PO BID for 7 days [A-I]
    or
  • Azithromycin 1 g PO in a single dose [A-I]
  • Levofloxacin 500 mg PO once a day for 7 days  [B-III]Footnote 1

Note: Azithromycin may be preferred when poor compliance is anticipated.

Pregnant and lactating peopleFootnote 2

  • Azithromycin 1 g PO in a single dose [B-I]
    or
  • Amoxicillin 500 mg PO TID for 7 days [A-l]
    or
  • Erythromycin 2 g/day PO in divided doses for 7 days [B-l]
    or
  • Erythromycin 1g/day PO in divided doses for 14 days [B-l]

Notes:

Nine (9) to 18 years of age

Preferred treatment Alternative treatment
  • Doxycycline 5 mg/kg/day PO in divided doses (max. 100 mg BID) for 7 days [A-l]
    or
  • Azithromycin 12–15 mg/kg (max. 1 g) PO in a single dose [A-l], if poor compliance is expected
  • Erythromycin base 40 mg/kg/day PO in divided doses (max. 500 mg QID for 7 days or 250 mg QID for 14 days) [B-l]
    or
  • Sulfamethoxazole 75 mg/kg/day PO in divided doses (max. 1 g BID) for 10 days [B-ll]

Notes:

Consult with a pediatric specialist or an experienced colleague and relevant clinical guidelines when chlamydia is diagnosed in a child. Perinatally acquired C. trachomatis can persist for up to three years. Consider sexual abuse when a chlamydial infection is diagnosed in any prepubertal child.Footnote 14

Note: Suspected sexual abuse of children must be reported to the local child protection agency.

LGV

Preferred treatment Possible treatment
Doxycycline 100 mg PO BID for 21 days [B-II]Footnote 15 Azithromycin 1g PO once weekly for 3 weeks [C-III]Footnote 16

Note: In pregnancy, use Erythromycin (non-estolate preparations) 500 mg PO QID for 21 days [C-III]Footnote 15

Sexual partners of a LGV case (empirical)

  • Doxycycline 100 mg PO BID for 7 days [C-lll]
    or
  • Azithromycin 1g PO in a single dose [C-lll]

Note: Should test results confirm an LGV infection, treat as recommended for LGV cases.

Persistent and recurrent infection

Possible causes of persistent signs and symptoms after treatment:

Counselling related to treatment

People diagnosed with C. trachomatis (LVG or non-LGV genotypes) and their partners should abstain from any sexual activity without barrier protection until treatment of the person and all current partners is complete (after completion of a multiple-dose treatment or for seven days after single-dose therapy) and symptoms have resolved.

Follow-up

Test of cure

TOC for chlamydia is recommended when:

TOC using NAAT should be performed three weeks after the completion of treatment to avoid detection of non-viable organisms and false-positive results.

Follow people with LGV until C. trachomatis TOC is negative and symptoms have resolved.Footnote 17Footnote 18

Screening for reinfection

Repeat screening is recommended three months post-treatment for all people with C. trachomatis infection because the risk of reinfection is high.Footnote 19Footnote 20Footnote 21Footnote 22Footnote 23

Reporting and partner notification

National/provincial/territorial notification

C. trachomatis infections are nationally notifiable and are reportable by laboratories, physicians and designated health professionals to local public health authorities in all provinces and territories. Some provinces and territories distinguish cases caused by LGV and non-LGV genotypes in their surveillance data.

Partner notification

Case finding and partner notification are critical to the prevention and control of C. trachomatis. Notify, clinically assess, test and empirically treat partners who have had sexual contact with the index case within 60 days prior to date of specimen collection (if index case is asymptomatic) or prior to symptom onset. Empiric treatment is indicated regardless of clinical findings and without waiting for test results.

Extend the length of time for partner notification:

Screen neonates born to mothers with chlamydia, and treat as appropriate. Local public health authorities are available to assist with partner notification and help with referral for counselling, clinical evaluation, testing and treatment.

References

Footnote 1

Krahn J, Louette A, Caine V, Ha S, Wong T, Lau T, et al. Non-standard treatment for uncomplicated Chlamydia trachomatis urogenital infections: a systematic review. BMJ open 2018;8 (12):e023808:1.

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Footnote 2

Alary M, Joly JR, Mondor M, Moutquin J, Boucher M, Fortier A, et al. Randomised comparison of amoxycillin and erythromycin in treatment of genital chlamydial infection in pregnancy. The Lancet 1994;344(8935):1461-1465.

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Footnote 3

Kacmar J, Cheh E, Montagno A, Peipert JF. A randomized trial of azithromycin versus amoxicillin for the treatment of Chlamydia trachomatis in pregnancy. Infect Dis Obstet Gynecol 2001;9(4):197-202.

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Footnote 4

Wehbeh HA, Ruggeirio RM, Shahem S, Lopez G, Ali Y. Single-dose azithromycin for Chlamydia in pregnant women. J Reprod Med 1998 Jun;43(6):509-514.

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Footnote 5

Adair CD, Gunter M, Stovall TG, McElroy G, Veille J, Ernest JM. Chlamydia in pregnancy: a randomized trial of azithromycin and erythromycin. Obstetrics & Gynecology 1998;91(2):165-168.

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Footnote 6

Bush MR, Rosa C. Azithromycin and erythromycin in the treatment of cervical chlamydial infection during pregnancy. Obstet Gynecol 1994 Jul;84(1):61-63.

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Footnote 7

Genc MR. Treatment of genital Chlamydia trachomatis infection in pregnancy. Best Practice & Research Clinical Obstetrics & Gynaecology 2002;16(6):913-922.

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Footnote 8

Scheibel JH, Kristensen JK, Hentzer B, Secher L, Ullman S, Verdich J, et al. Treatment of chlamydial urethritis in men and Chlamydia trachomatis-positive female partners: comparison of erythromycin and tetracycline in treatment courses of one week. Sex Transm Dis 1982 Jul-Sep;9(3):128-131.

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Footnote 9

Bowie WR, Manzon LM, Borrie-Hume CJ, Fawcett A, Jones HD. Efficacy of treatment regimens for lower urogenital Chlamydia trachomatis infection in women. Am J Obstet Gynecol 1982 Jan 15;142(2):125-129.

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Footnote 10

Mogabgab WJ, Holmes B, Murray M, Beville R, Lutz FB, Tack KJ. Randomized comparison of ofloxacin and doxycycline for chlamydia and ureaplasma urethritis and cervicitis. Chemotherapy 1990;36(1):70-76.

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Footnote 11

Linnemann CC,Jr, Heaton CL, Ritchey M. Treatment of Chlamydia trachomatis infections: comparison of 1- and 2-g doses of erythromycin daily for seven days. Sex Transm Dis 1987 Apr-Jun;14(2):102-106.

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Footnote 12

Cramers M, Kaspersen P, From E, Moller BR. Pivampicillin compared with erythromycin for treating women with genital Chlamydia trachomatis infection. Genitourin Med 1988 Aug;64(4):247-248.

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Footnote 13

Moore DL, MacDonald NE. Preventing ophthalmia neonatorum. Canadian Journal of Infectious Diseases and Medical Microbiology 2015;26(3):122-125.

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Footnote 14

Trocmé N, MacLaurin B, Fallon B, Daciuk J, Billingsley D, Tourigny M, et al. Canadian incidence study of reported child abuse and neglect: Final report. Ottawa: Minister of Public Works and Government Services Canada 2001.

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Footnote 15

Stamm WE. Lymphogranuloma venereum. In: Holmes KK, Sparling PF, Stamm WE, editor. Sexually transmitted diseases. 4th ed. ed.: New York: Mc-Graw Hill; 2008. p. 595-606.

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Footnote 16

Hill S, Hodson L, Smith A. An audit on the management of lymphogranuloma venereum in a sexual health clinic in London, UK. Int J STD AIDS 2010;21(11):772-776.

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Footnote 17

Nieuwenhuis RF, Ossewaarde JM, Götz HM, Dees J, Thio HB, Thomeer MG, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clinical infectious diseases 2004;39(7):996-1003.

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Footnote 18

Centers for Disease Control and Prevention (CDC). Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR Morb Mortal Wkly Rep 2004 Oct 29;53(42):985-988.

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Footnote 19

Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines, 2006. MMWR Recommendations and Reports August 4, 2006;55(11):1-94.

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Footnote 20

Whittington WL, Kent C, Kissinger P, Oh MK, Fortenberry JD, Hillis SE, et al. Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: results of a multicenter cohort study. Sex Transm Dis 2001;28(2):117-123.

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Footnote 21

Schillinger JA, Kissinger P, Calvet H, Whittington WL, Ransom RL, Sternberg MR, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis 2003;30(1):49-56.

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Footnote 22

Gunn RA, Fitzgerald S, Aral SO. Sexually transmitted disease clinic clients at risk for subsequent gonorrhea and chlamydia infections: possible ‘core’transmitters. Sex Transm Dis 2000;27(6):343-349.

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Footnote 23

Rietmeijer CA, Van Bemmelen R, Judson FN, DOUGLAS JR JM. Incidence and repeat infection rates of Chlamydia trachomatis among male and female patients in an STD clinic: implications for screening and rescreening. Sex Transm Dis 2002;29(2):65-72.

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