chlamydial infections
chlamydial infections
Infections with organism of the genus Chlamydia . Chlamydia trachomatis causes pelvic inflammatory disease (PID) including CERVICITIS and SALPINGITIS, URETHRITIS, REITER'S SYNDROME and TRACHOMA. With the exception of the last, these infections are sexually transmitted. Chlamydia psittaci causes PSITTACOSIS and is usually acquired from birds.Chlamydial Infections
| DRG Category: | 728 |
| Mean LOS: | 4 days |
| Description: | MEDICAL: Inflammation of the Male Reproductive System Without Major CC |
| DRG Category: | 758 |
| Mean LOS: | 5.4 days |
| Description: | MEDICAL: Infections, Female Reproductive System With CC |
Infection with Chlamydia trachomatis is the most common sexually transmitted infection (STI) in the United States today, with nearly 1.5 million cases reported annually. The Centers for Disease Control and Prevention (CDC) reports that from 1987 to 2011, the prevalence of chlamydial infections rose from 50.8 to 457.6 cases per 100,000 individuals. While chlamydial infections are reportable in all 50 states, underreporting of this STI is substantial due to the number of individuals who may have the infection and not know it. Because 80% of women and 50% of men with chlamydial infections are asymptomatic, they transmit the disease but are unaware that they harbor the bacteria. Untreated infections in women can result in cervicitis, endometritis, acute salpingitis, bartholinitis, irregular menses, ectopic pregnancy, pelvic inflammatory disease, and infertility. Untreated infections in men can result in nongonococcal urethritis (NGU), epididymitis, or prostatitis. Infections in either gender can result in proctitis; lymphogranuloma venereum (LGV); and, potentially, infertility and sterility.
During pregnancy, C. trachomatis may be transmitted from mother to fetus, which may cause premature rupture of the membranes, premature labor, and increased fetal morbidity and mortality. Pregnant women who deliver vaginally or by cesarean section can transmit the bacteria to their infants. These newborns can develop otitis media, conjunctivitis, blindness, meningitis, gastroenteritis, respiratory infections, and pneumonia. Because mothers are often asymptomatic, medical personnel are unaware that the maternal-infant transmission has occurred until infants become very ill.
Causes
C. trachomatis is an obligate, gram-negative, intracellular bacterium with several different immunotypes. It resembles a virus in that it requires a tissue culture for isolation, but like a bacteria, it has RNA and DNA and is susceptible to antibiotics. The chlamydial infection exists in two forms: The elementary bodies are the infectious particles that enter uninfected cells, and the reticulate bodies are the active forms of the organism that reproduce and form more elementary bodies that are released from the bursting infected cell and can then infect other cells. Replication begins only 12 hours after invasion. The pathogen invades and reproduces inside the cells that line the cervix, endometrium, fallopian tubes, and urethra. Symptoms can occur after a 1- to 3-week incubation period; however, overt symptoms often occur late in the disease.
Genetic considerations
Heritable immune responses could be protective or increase susceptibility.
Gender, ethnic/racial, and life span considerations
Both men and women are susceptible to chlamydial infection, but their symptoms differ. Although the occurrence of chlamydial infection is related more to sexual practices than to age, many women with chlamydial infection are young, under 25 years of age, and single. Women living in poverty with no prenatal care are a high-risk group. The rate of infection is also highest (17%) in females with a history of gonorrhea or chlamydia in the previous 12 months. Black/African American women in southern states have a prevalence of 14%. With more teens engaging in sexual activity, more adolescents of both genders are contracting infections. Depending on the population, 5% to 35% of pregnant women are infected with C. trachomatis. Hence, the U.S. Prevention Service Task Force recommends that all pregnant women under the age of 25 be screened for chlamydial infections.
Global health considerations
The World Health Organization estimates that there are 140 million cases of chlamydia worldwide. Prevalence ranges from 2% in South America and Italy to 13% in Sub-Saharan Africa and 17% in India. Developed nations in Australia, North America, and Western Europe have similar infection rates as found in the United States.
Assessment
History
Although sexual activity is potentially a sensitive topic, it is critical to obtain a detailed sexual and gynecological history. Inquire about the number of partners, use of barrier protection and birth control measures, participation in oral or anal intercourse, and previous STIs. Most patients who present with C. trachomatis have a history of multiple sex partners and engaging in sexual intercourse without the use of barrier protection. Often, patients are also positive for gonorrhea. Inquire if the patient has any thin or purulent discharge, burning or frequent urination, mucus-covered stools, lower abdominal pain, dyspareunia (painful sexual intercourse), headache, nausea, vomiting, chills, or bleeding after intercourse. Often, patients are asymptomatic, and some may complain only of an increase in vaginal discharge. Male patients may report dysuria, urinary frequency, and pruritus. Ask the patient if she or he is experiencing any diarrhea, tenesmus, or pruritus, any of which indicates that the infection involves the rectum.
Physical examination
Patients may be asymptomatic. Common signs are dysuria, yellow discharge, abnormal vaginal bleeding, and pain with sexual intercourse. For females, inspect the vagina, cervix, and labia and note any mucopurulent discharge. Bartholin glands may be involved. Gently touch the cervix; note any bleeding (friable cervix). Inspect males for purulent discharge at the urinary meatus. Scrotal swelling occurs if the organism has caused epididymitis. Inspect the anus for discharge and excoriation. If LGV is present, ulcerative lesions on the cervix, vagina, labia, anal/rectal area, or penis may occur. Enlarged lymph nodes also can be palpated in the groin. If these nodes rupture, they secrete a thick yellow granular substance.
Psychosocial
Assess the patient’s knowledge of STIs and the implications. Assess the patient’s ability to cope with having an STI. The diagnosis of an STI can be very upsetting to a male or female who believes he or she was involved in a monogamous relationship. Patients may feel embarrassed and guilty about their condition. Inquire about the patient’s ability to obtain condoms. Identify all partners with whom the patient has been sexually active so that they can be examined and treated. Assess the patient’s support system; this is especially important if the patient is pregnant.
Diagnostic highlights
General Comments: Enzyme-linked immunosorbent assay and antigen detection by direct fluorescent antibody slide staining are less expensive tests to diagnose chlamydia. Until recently, a tissue culture was the gold standard to diagnose chlamydia, with a sensitivity of approximately 85%. Currently, more widespread use of nucleic acid amplification tests (NAATs) have been used; although more costly, these tests have an increased sensitivity and are more comfortable to obtain because the preferred specimen is a first-void urine. Because of fetal implications, most pregnant women are screened for chlamydia.
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Cervical tissue culture (females); urethral tissue culture (males) | Negative culture | Positive culture | Growth of the organism confirms the diagnosis |
| NAATs | Negative | Positive signal | Detects chlamydia from DNA/RNA presence |
Other Tests: Because symptoms of gonorrhea resemble a chlamydial infection, diagnosis is often made on the basis of a symptomatic patient with a negative gonorrhea culture. HIV testing, Papanicolaou smear, pregnancy test.
Primary nursing diagnosis
Diagnosis
Infection related to bacterial invasionOutcomes
Risk control: Sexually transmitted diseasesInterventions
Teaching: Safe sex; Medication management; Fertility preservationPlanning and implementation
Collaborative
Chlamydial infections can easily be cured with oral antibiotics, and patients are rarely hospitalized. Patients need to know to continue to take medication as ordered, even if the symptoms subside. Follow-up with both partners is recommended to ensure that neither partner is still infected. Patients should abstain from sexual intercourse until they are infection free.
Pharmacologic highlights
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Doxycycline: Recommended as first-line drug | 100 mg PO bid for 7 days | Broad-spectrum antibiotic (tetracycline) | Effective in eliminating C. trachomatis |
| Azithromycin (all patients): Recommended as first-line drug | 1 g PO single dose | Antibiotic (macrolide) | As effective as doxycycline |
| Tetracycline (men, nonpregnant women) | 500 mg PO qid for 7 days | Broad-spectrum antibiotic | Effective in eliminating C. trachomatis |
| Erythromycin (pregnant women) | 400–800 mg PO qid for 7 days | Antibiotic (macrolide) | Safe for pregnant women to take, not as effective in eliminating C. trachomatis as doxycycline; amoxicillin preferred if nausea/vomiting occurs with other medications |
| Amoxicillin (pregnant women) | 500 mg PO tid 5 for 7 days | Antibiotic (penicillin) | |
| Erythromycin (infants) | Ointment to conjunctiva sac after delivery | Anti-infective | Prophylaxis of neonatal conjunctivitis |
Independent
Because patients are often asymptomatic, nurses need to identify those patients at risk for chlamydial infections and recommend screening. Prevention is an important nursing intervention. Teach patients that monogamous relationships with uninfected partners, use of mechanical barriers, and simultaneously treating the partner to prevent reinfection are ways to prevent transmission of C. trachomatis. Emphasize that it is possible for them to carry and transmit the bacteria even if they are asymptomatic.
Because a chlamydial infection is easily cured by oral antibiotics, teach the patient about taking the medications properly. Instruct patients to take all medication until the course of treatment is finished even if the symptoms subside. Explain that the patient should abstain from intercourse until all medication is gone to prevent reinfection. For discomfort, teach the patient about warm sitz baths and taking prescribed analgesics as ordered.
Evidence-Based Practice and Health Policy
Mania-Pramanik, J., Kerkar, S., Sonawane, S., Mehta, P., & Salvi, V. (2012). Current Chlamydia trachomatis infection, a major cause of infertility. Journal of Reproductive Infertility, 13(4), 204–210.
- When routine screening for C. trachomatis was performed among a convenience sample of 236 women with a history of infertility, the average rate of infection was 18.6%.
- In this sample of women, most of whom were asymptomatic, having a history of infertility was associated with a 2.24 increased odds of also screening positive for C. trachomatis (p = 0.00014).
Documentation guidelines
- Screening done and results if available; note if a female patient is pregnant
- Physical signs and symptoms: Discharge (amount, color, odor, location), pain, bleeding, swelling, dysuria
- Patient’s reaction to the diagnosis of an STI
- Patient’s understanding of diagnosis, treatment, and prevention