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Chlamydial genital tract infections

Prevention

The main strategy for the prevention of chlamydial genital tract infections is education about the dangers of unprotected sexual intercourse [i.e. pelvic inflammatory disease, infertility and ectopic pregnancy] and the need to practise safer sex [see: safer sex]. This is supplemented by antibiotic treatment [the "bug and drug" approach] of persons with recognized genital tract infection. This strategy has been a mixed success.

On the negative side, in both sexes, chlamydial genital tract infection is frequently asymptomatic so that the victim concerned often does not seek medical treatment before they have spread the infection to further persons or have themselves developed upper genital tract disease. The continuing high prevalence of C. trachomatis infection in young sexually active women age 15 to 25 years, in inner city populations and in women seeking termination of pregnancy suggests that the health education approach, with few exceptions, has been of limited success. Thus, a recent study in the US of 103 women at high or actual risk of sexually transmitted infection and its complications showed  that 33% had never heard of pelvic inflammatory disease and 79.6% could not identify any of the problems which might arise. In particular, 65% were unaware that pelvic inflammatory disease increases the risk of ectopic [tubal] pregnancy and 56% were unaware that it could result in chronic pelvic pain. Furthermore, when asked if they knew of any methods to prevent or reduce their risk of sexually transmitted disease, only 18% mentioned barrier contraception (condoms) and over 57% of respondents could not name a way to prevent them [Whiteside et al., 2001]. 

On the positive side, in most developed countries, the incidence of pelvic inflammatory disease and of ectopic pregnancy now appears to have peaked [Bjartling et al., 2000] and tubo-ovarian abscess is now much less common in the developed world, perhaps because of better antibiotics and greater physician awareness of the problem. In the developing world, chlamydial infection and infertility due to tubal obstruction remains a major problem [Gerbase et al., 1998].

An alternative strategy is to actively screen for chlamydial genital tract infection in high risk sectors of the population. This strategy should preferably be based on an analysis of the risk markers and risk factors for chlamydial genital tract infection in the target population [Washington et al., 1990]. An excellent example of such a strategy in some 13,000 US female military recruits has already been referred to [see: chlamydial cervicitis].  In that particular study, the prevalence of chlamydial infection was of the order of 9.2%. The authors point out that over 98.2% of this infection would have been prevented had a proper screening program for women age 18 - 25 been in place [Gaydos et al., 1998]. 

The cost benefit analysis of introducing a screening program for chlamydial genital tract infection in young women age 15 - 25 [depending on the country and its customs] has been reviewed in a number of different settings. All are essentially agreed that the benefits in both costs and health are significant if the prevalence of chlamydial infection in young women is > 3 to 5 % [Henry-Suchet, 1997; Welte et al., 2000].

In an interesting comparison of these strategies, Low et al., 1999 compared an area near London England, where the main strategy has been health education plus treatment in free of charge, confidential, specialist genito-urinary clinics with Uppsala County in Sweden where there has been an active program of screening for chlamydial infection i young women backed up by high standard laboratory testing, plus health education, particularly in schools. 

Following a prominent law case in the US, there has been concern for many years that the insertion of an intrauterine device may be a risk factor for upper genital tract chlamydial and other bacterial infections. This has tended to reduce the intrauterine device, which is otherwise an effective contraceptive. In clinical practice it is common to give prophylactic antibiotic before the insertion of an iud. In a Cochrane meta-analysis, Grimes and Schulz, 2001 found no evidence that either doxycycline 200 mg or azithromycin 500 mg by mouth before IUD insertion conferred significant benefit. The odds ratios for pelvic inflammatory disease associated with the use of prophylactic doxycycline or azithromycin compared with placebo or no treatment was 0.89 (95%CI 0.53-1.51).

[MEW} Updated March 2002

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References

Bjartling, C., Osser, S. & Persson, K. (2000). The frequency of salpingitis and ectopic pregnancy as epidemiologic markers of Chlamydia trachomatis. Acta Obstetrica Gynecologica Scandinavica 79, 123 - 128.

Gaydos, C. A., Howell, M. R., Pare, B., Clark, K. L., Ellis, D. A., Hendrix, R. M., Gaydos, J. C., McKee, K. T. Jr. & Quinn, T. C. (1998). Chlamydia trachomatis infections in female military recruits. New England Journal of Medicine 339, 739 - 744.

Gerbase, A. C., Rowley, J. T., Heymann, D. H., Berkley, S. F. & Piot P. (1998). Global prevalence and incidence estimates of selected curable STDs. Sexually Transmitted Infections 74, Suppl 1: S12 - 16.

Grimes, D. A. & Schulz, K. F. (2001). Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Systematic Reviews 2001;(2):CD001327.

Henry-Suchet, J. (1997). Hormonal contraception and pelvic inflammatory disease. European Journal of Contraception & Reproductive Health Care 2, 263 - 267.

Low, N., Egger, M., Simms, I. & Herrmann B. (1999). Contrasting trends in rates of genital chlamydial infection and ectopic pregnancy in South East Thames Region, England and Uppsala County, Sweden: ecological study. Journal of Epidemiology and Community Health 53, 438 - 439. Full article (restricted access).  

Washington, A. E., Aral, S. O., Wolner-Hanssen, P., Grimes, D. A.. &  Holmes, K. K. (1990). Assessing risk for pelvic inflammatory disease and its sequelae. Journal of the American Medical Association (JAMA) 266, 2581 - 2586.

Welte, R., Kretzschmar, M., Leidl, R., van den Hoek, A., Jager, J. C. Postma, M. J. (2000). Cost-effectiveness of screening programs for Chlamydia trachomatis: a population-based dynamic approach. Sexually Transmitted Diseases 27, 518 - 529.

Westrom, L. R., Joesoef, R., Reynolds, G., Hagdu, A. & Thompson, S. E. (1992). Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sexually Transmitted Diseases 19, 185 - 192. 

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