Chlamydia and LGV guide: Treatment and follow-up

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

On this page

• Treatment indications
• Treatment
  • Anogenital and conjunctival chlamydia
    • Non-pregnant and non-lactating adults
    • Pregnant and lactating people
    • Nine (9) to 18 years of age
  • LGV
    • Sexual partners of a LGV case (empirical)
  • Persistent and recurrent infection
  • Counselling related to treatment
• Follow-up
  • Test of cure
  • Screening for reinfection
• Reporting and partner notification
  • National/provincial/territorial notification
  • Partner notification
• References

Treatment indications

C. trachomatis

• Positive C. trachomatis test.
• N. gonorrhoeae diagnosis (as empirical co-treatment), without waiting for test results of C. trachomatis due to high rates of co-infection. Note: Testing for N. gonorrhoea is done frequently by Nucleic Acid Amplification Tests (NAAT), which can provide results for both N. gonorrhoea and C. trachomatis.
• Suspected chlamydia in anyone presenting with a compatible syndrome (e.g. pelvic inflammatory disease, cervicitis, urethritis, conjunctivitis), without waiting for test results. 
• Diagnosis of C. trachomatis infection or a compatible syndrome in a sexual partner.

LGV

• Suspected or confirmed LGV in people with proctitis, inguinal or femoral lymphadenopathy and/or buboes.
• Sexual partner of a suspected or confirmed case of LGV.

Notes:

• Suspected cases of LGV should be treated empirically while test results are pending.
• Proctitis may be a sign of non-LGV C. trachomatis and N. gonorrhoeae infections.

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 people^{Footnote 2}

Notes:

• Data are limited regarding the use of azithromycin in pregnancy, however many experts believe it has an acceptable risk-benefit profile.^{Footnote 3Footnote 4Footnote 5Footnote 6Footnote 7}
• Data on neonatal outcomes are limited.
• Erythromycin dosage refers to the use of erythromycin base. Equivalent dosages of other formulations may be substituted.
• Estolate formulation is contraindicated in pregnancy.
• Doxycycline and quinolones are contraindicated in pregnancy and in lactating people.

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:

• Erythromycin is associated with significantly higher gastrointestinal side effects than other treatment regimens.^{Footnote 8Footnote 9Footnote 10Footnote 11Footnote 12}
• Equivalent dosages of other formulations may be substituted for erythromycin base.
• Topical therapy for conjunctivitis is inadequate, systemic treatment is sufficient.^{Footnote 13}

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)

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:

• Failure to take the medication correctly (including vomiting within one hour of taking medication) or to finish the course of therapy
• Re-exposure
• Infection with other pathogen(s)
• Non-infective etiology
• Treatment failure or drug resistance (rare)

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:

• Symptoms or signs persist post-therapy
• Compliance to the prescribed treatment is suboptimal
• Preferred treatment regimen is not used
• The person is prepubertal
• The person is pregnant

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:

• To include additional time up to the date of treatment
• If the index case states there were no partners during the recommended trace-back period (notify last partner)
• If all partners test negative (notify the partner prior to the trace-back period)

Screen neonates born to birthing parents 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