Urogenital chlamydia - description, causes, symptoms (signs), diagnosis, treatment. Chlamydia infection Causes of respiratory chlamydia

According to statistics, about 2 million new cases of chlamydial infection are recorded annually worldwide. This is facilitated by the fact that the symptoms of chlamydia in men and women appear more subdued compared to traditional sexually transmitted infections, such as gonorrhea and trichomoniasis.

In the Russian Federation, chlamydia ranks second after trichomoniasis in prevalence among all sexually transmitted infections.

The main route of transmission of urogenital chlamydia is sexual. This is due to the tropism of the pathogen to the epithelial cells of the genitourinary organs, where the main focus is often located.

Transmission of infection from mother to child during fetal development (antenatally) and during childbirth (intrapartum) is the main route of infection with chlamydia in childhood.

Non-sexual transmission routes, such as household and airborne transmission, are not clinically significant in the adult population.

Classification

According to ICD-10, urogenital chlamydia (A.56) is classified:

- chlamydial infection of the lower genitourinary system:

• cystitis;
• cervicitis;
• vulvovaginitis;

- chlamydial infection of the upper genitourinary system:

• epididymitis;
• orchitis;
• pelvic inflammatory diseases in women;
• chlamydial infection of the genitourinary system, unspecified;
• chlamydial infection, sexually transmitted infection of another location.

Clinic

It should be noted right away that in 25% of men, urogenital chlamydia is asymptomatic.

But even if there are signs of inflammation of the genitourinary system characteristic of chlamydia, there are no signs by which a diagnosis can be reliably established.

Let's consider the main inflammatory diseases of the genitourinary system and pelvic organs, which can be considered as symptoms of chlamydia in men.

Urethritis

This is an inflammation of the urethra.

Urethritis manifests itself as a sensation of itching and burning in the urethra. During the act of urination, a pain appears, which can be either slight or pronounced, causing significant discomfort.

Upon examination, hyperemia and adhesion of the terminal sponges, as well as purulent or mucopurulent discharge, are revealed.

It should be noted that in acute and subacute cases, the first symptoms of chlamydia in men, as a rule, manifest with urethritis.

Inflammation of the epididymis is a fairly common complication of urogenital chlamydial infection. The highest frequency is observed in men aged 20 to 40 years.

In 80% of cases, the disease is asymptomatic or with scant symptoms, manifested by only slight swelling of the appendage.

However, there are cases of acute epididymitis with symptoms of intoxication, febrile fever, severe pain in the epididymis, radiating to the spermatic cord, sacrum and groin. On examination, swelling, edema and redness of the epididymis are noted.

In the subacute course of epididymitis, a blurred clinical picture is noted with a slight increase in temperature and unexpressed pain. Most often, the subacute form of inflammation of the appendage is complicated by orchitis.

Prostatitis

Inflammation of the prostate gland during urogenital chlamydia in men, most often (46% of cases) occurs in tandem with inflammation of the urethra - urethroprostatitis.

With chlamydia, as a rule, prostatitis rarely manifests itself in an acute form with hectic fever, intoxication, severe pain and dysuric disorders.

As a rule, chlamydia in men gives scanty symptoms of prostatitis in the form of low-grade fever, minor urination disorders and discomfort in the perineum.

To diagnose inflammation of the prostate gland, transrectal massage is used with the collection of prostate secretions and its subsequent bacterioscopic analysis.

Vesiculitis

Inflammation of the seminal vesicles is recorded in 16% of patients with chlamydial urethroprostatitis during additional examination.

In the vast majority of cases, vesiculitis is asymptomatic, only sometimes causing minor discomfort in the perineum and increased urination.

There is a violation of sexual function in 60% of cases, of which 30% have problems with arousal.

In addition to erectile dysfunction, there are significant hormonal changes associated with a decrease in testosterone levels and an increase in prolactin levels.

In the semen of a man with symptoms of chlamydia, a photo from a microscope shows the following:

• pathological forms of sperm;
• an increase in the number of cells with an amorphous head and an abnormal flagellum;
• decrease in the number of viable sperm.

All these factors lead to the development of infertility and sexual weakness in young men.

Reiter's syndrome

Reiter's syndrome refers to systemic manifestations of chlamydial infection and is manifested by a triad of symptoms:

• arthritis;
• conjunctivitis.

Urethritis first manifests itself 2 to 4 weeks after infection. Then symptoms of inflammation of the conjunctiva appear. As a rule, joint inflammation develops last.

Chlamydial arthritis is characterized by asymmetric damage to the joints, mainly the knees and ankles. Also, the Achilles tendons and plantar fascia of the foot are often involved in the inflammatory process.

It should be noted that Reiter's syndrome develops 10 times more often in men compared to women.

Diagnostics

Considering that the clinical picture of chlamydial infection is not specific, most often erased or asymptomatic, the leading place in identifying the disease belongs to laboratory diagnostics.

The presence of inflammatory diseases of the genitourinary system allows one to suspect and refer for examination:

• orchitis;
• epididymitis;
• cystitis.

Laboratory diagnostics

Culture method

The essence of the technique is to determine the pathogen on special cell cultures (L-929, McCoy, HeLa).

The most accurate and sensitive of all available diagnostic methods. But it is limited in use due to its high cost and labor intensity.

It is used primarily for persistent urogenital chlamydia.

Linked immunosorbent assay

Determination occurs using special enzyme-labeled antibodies to the cell wall of chlamydia.

The sensitivity of the method is 60 – 90%.

Due to the ease of execution and automation of the test, it is used for screening detection of urogenital chlamydia.

Direct immunofluorescence

Fluorescein-labeled antibodies to cell membrane proteins are used. The method is specific, but shows only the components of the chlamydial cell, without indicating the presence of viable microorganisms.

A molecular diagnostic method that allows you to identify the DNA and RNA components of the pathogen.

Sensitivity 70 - 95%.

The method is simple to perform and is effectively used for diagnosing urogenital chlamydia.

Serological study

Specific chlamydial antibodies (IgG and M) are determined in the blood of the subject. Used for acute disease.

It is important to note that antibodies do not appear immediately, but only several weeks after infection.

Treatment

It should be noted right away that at the moment there is no approved treatment regimen for chlamydia.

The treatment regimen for uncomplicated chlamydia in men includes:

1. Drugs of choice:

• azithromycin 1.0 g once - for chlamydial lesions of the lower parts of the genitourinary system;
• azithromycin 1.0 g once a week for three weeks – for chlamydial lesions of the upper genitourinary system and pelvic organs;
• doxycycline 100 mg twice a day for seven days - for chlamydial lesions of the lower parts of the genitourinary system;
• doxycycline 100 mg twice a day for two weeks – for chlamydial lesions of the upper genitourinary system and pelvic organs;

2. Alternative drugs:

• ofloxacin 400 mg twice a day for a week;
• roxithromycin 150 mg twice a day for ten days;
• erythromycin 500 mg four times a day for ten days.

It should be noted that for the treatment of complicated chlamydia in men, a treatment regimen has been officially developed only for the original azithromycin - “sumamed”. Therefore, all generic azithromycin can only be used to treat uncomplicated forms of urogenital chlamydial infection.

To treat clinical complications of chlamydia in men (prostatitis, urethritis, vesiculitis, epididymitis), additional methods are used:

• drugs to enhance immunity;
• physiotherapeutic procedures;
• instillation into the urethra.

At the end of the course of antibacterial treatment, laboratory monitoring of the cure must be carried out. Moreover, it is advisable to carry out the same research method that initially identified the pathogen.

The treatment regimen for chlamydia in men is provided for informational purposes only!

In no case should you self-medicate, since depending on the characteristics of the course of the infection and the condition of the body, adjustments are almost always made to the doses and duration of antibacterial therapy.

Prevention

Primary

It is to prevent the introduction of C. Trachomatis and the development of the disease:

• use of barrier protection (condoms);
• limit the number of sexual partners;
• maintain a trusting relationship with your partner;
• do not allow conscious sexual contact with infected persons.

Laboratory diagnostic methods:

• Direct immunofluorescence (DIF) is a relatively simple method and is available to almost any laboratory. The sensitivity and specificity of the method depends on the quality of the luminescent antibodies used. Due to the possibility of obtaining false positive results, the PIF method cannot be used in forensic medical examination. In addition, this method is not recommended for the study of materials obtained from the nasopharynx and rectum.
• The cultural method - seeding with cell cultures, is considered a priority for laboratory diagnosis of chlamydial infection, especially for forensic medical examination, it is more specific than PIF, and is indispensable in determining the cure of chlamydia, since other methods can give distorted results. However, the sensitivity of the method remains low (within 40–60%).
• Enzyme-linked immunosorbent assay (ELISA) to detect antigens is rarely used for diagnosis due to low sensitivity.
• Nucleic acid amplification methods (NAAT) are highly specific and sensitive and can be used for screening, especially for the study of clinical materials obtained non-invasively (urine, ejaculate). The specificity of the methods is 100%, sensitivity is 98%. These methods do not require maintaining the viability of the pathogen, however, it is necessary to comply with strict requirements for the conditions of transportation of clinical material, which can significantly affect the result of the analysis. These methods include PCR and real-time PCR. The new and promising NASBA (Nucleic Acid Based-Amplification) method allows you to identify a viable pathogen in real time and replace the culture method.
• Serological methods (microimmunofluorescence, immunoenzyme) have limited diagnostic value and cannot be used to diagnose urogenital chlamydial infection and, especially, to monitor cure. Detection of IgM antibodies can be used to diagnose pneumonia in newborns and children in the first 3 months of life. When examining women with PID and infertility, the detection of a 4-fold increase in IgG antibody titer when examining paired blood sera is diagnostically significant. An increase in the level of IgG antibodies to chlamydia (to the serotype of lymphogranuloma venereum) is considered the basis for examining the patient to exclude lymphogranuloma venereum.

A test to determine the sensitivity of chlamydia to antibiotics is not practical. Clinical samples are taken:

• in women, samples are taken from the cervical canal (diagnostic methods: culture, PIF, PCR, ELISA) and/or urethra (culture method, PIF, PCR, ELISA) and/or vagina (PCR);
• in men, samples are taken from the urethra (culture method, PIF, PCR, ELISA) or the first portion of urine is examined (PCR, LCR). The patient should refrain from urinating for 2 hours before sample collection;
• in infected newborns, samples are taken from the conjunctiva of the lower eyelid and from the nasopharynx; Vulvar discharge in girls is also examined.

The technique for taking material depends on the methods used.

Currently, the following terminology is used when making a diagnosis: fresh (uncomplicated chlamydia of the lower parts of the genitourinary tract) and chronic (long-term, persistent, recurrent chlamydia of the upper parts of the genitourinary tract, including the pelvic organs). Next, the topical diagnosis should be indicated, including extragenital localization. Chlamydial infection appears after an incubation period that lasts from 5 to 40 days (average 21 days).

If complications develop, consultation with related specialists is required.

The procedure for a doctor to act upon a diagnosis of chlamydial infection

1. Informing the patient about the diagnosis.
2. Presentation of information about behavior during treatment.
3. Collection of sexual history.
4. Identification and examination of sexual contacts are carried out depending on the clinical manifestations of the disease and the expected duration of infection - from 15 days to 6 months.
5. If chlamydia is detected in a woman in labor, a postpartum woman, or a pregnant woman who has not received timely treatment, the newborn is examined by taking material from the conjunctival sacs of both eyes. If a chlamydial infection is detected in a newborn, its parents are examined.
6. If chlamydial infection of the genitals, rectum and pharynx is present in children during the postnatal period, sexual abuse should be suspected. It should be borne in mind that perinatally received C. trachomatis may persist in a child up to 3 years of age. Siblings of the infected child should also be tested. The fact of sexual violence must be reported to law enforcement authorities.
7. Conducting epidemiological measures among contact persons (sanitation of the epidemiological focus) is carried out jointly with the district epidemiologist:
   • inspection and examination of contact persons;
   • statement of laboratory data;
   • deciding on the need for treatment, its volume and duration of observation.
8. If contact persons live in other territories, a work order coupon is sent to the territorial KVU.
9. If there are no results from treatment, it is recommended to consider the following possible reasons:
   • false positive test result;
   • non-compliance with treatment regimen, inadequate therapy;
   • re-contact with an untreated partner;
   • infection from a new partner;
   • infection with other microorganisms.

Urogenital chlamydia is the most common disease transmitted primarily through sexual contact. Frequency. It is registered in 30-60% of women and 15% of men suffering from non-gonococcal inflammatory diseases of the genitourinary organs, as well as in 5-20% of people seeking medical help. Incidence: 121.5 per 100,000 population in 2001.

Code according to the international classification of diseases ICD-10:

Predominant age- 16-40 years old.

Causes

Symptoms (signs)

Clinical picture

Men... The disease occurs in the form of subacute or torpid urethritis. When the infection is mixed with gonococci, the clinical picture of acute urethritis is more often observed. Without treatment, chlamydia persists in the urethra indefinitely and causes various complications. Chronic prostatitis is one of the most common complications: chlamydia is found in the secretions and tissue of the prostate gland. Epididymitis is an inflammation of the epididymis, most often occurs subacutely; with a bilateral process, partial or complete obstructive aspermia occurs. Damage to the seminal vesicles (vesiculitis), bulbourethral glands (cooperitis), urethral glands and lacunae (littreitis, morganitis) and other local complications are weakly expressed and do not have specific features.. Ophthalmochlamydia occurs in the form of simple or follicular conjunctivitis (paratrachoma) and develops as usually as a result of the introduction of chlamydia from the genitourinary source of infection with contaminated hands. Reiter's syndrome is damage to the genitourinary organs, eyes, joints (more often occurs in carriers of Ag HLA - B27).

Women.. Endocervicitis is a common and typical manifestation of urogenital chlamydia. More often it is asymptomatic, sometimes pain in the lower abdomen and vaginal discharge are noted. Cervix - erosion, mucous-purulent discharge. Often, peculiar lymphoid follicles are found in the pharynx area, which are not detected in other urogenital infections. Endometritis sometimes occurs in the postpartum or post-abortion period. Salpingitis and salpingoophoritis are the most common manifestations of ascending chlamydial infection. They often occur subclinically and are identified during examination due to infertility. More severe complications are pelvioperitonitis and perihepatitis. Ophthalmochlamydia, pharyngitis, proctitis, urethritis occur similarly to similar manifestations in men. Urogenital chlamydia in women can lead to ectopic pregnancy, spontaneous abortion, fetal malnutrition, premature rupture of amniotic fluid, and chorioamnionitis.

Children... More often, infection with chlamydia occurs during the passage of the genital tract of a sick mother, less often - in utero. Conjunctivitis (20% of newborns with chlamydia), pharyngitis, eustacheitis, bronchitis, pneumonia, concomitant lesions of the pharynx and gastrointestinal tract are noted.

Diagnostics

Laboratory research. Collection of material: it is necessary to take a scraping of cells (obtained using a Volkmann spoon), and not inflammatory discharge, because The pathogen is located intracellularly. Isolation of the pathogen in cell culture is an expensive method, sensitivity is 60-80%. Direct immunofluorescence with monoclonal antibodies is the main method for diagnosing chlamydia, currently used, sensitivity is 55-75%.

Special studies: PCR, ligase chain reaction test.

Differential diagnosis. Gonorrhea. Trichomoniasis. Mycoplasmosis. Inflammatory diseases of the pelvic organs.

Treatment

TREATMENT

Lead tactics. Testing for syphilis. HIV testing. Examination and treatment of sexual partners.

Drug therapy. Tetracycline 500 mg 4 times a day for 7-14 days. Doxycycline 0.1 g 2 times / day for 7-14 days (if infected with gonococci or anaerobic bacteria, ceftriaxone 250 mg IM 1 time / day, cefoxitin, other 3rd generation cephalosporins or quinolones are simultaneously prescribed). Erythromycin 500 mg 4 times a day for 7-14 days. Azithromycin 1 g once (for fresh acute chlamydia), 250 mg/day for 10 days (in other cases). Ofloxacin 300 mg 2 times a day for 7 days. Pefloxacin 400 mg 2 times a day for 10-14 days. For chronic and complicated forms of chlamydia, the duration of treatment is at least 14 days.

Complications. In women, the likelihood of developing complications is very high. The most common complications are endometritis and salpingitis, rarely accompanied by fever. Endometritis can cause dysfunctional uterine bleeding. Due to the ascending spread of infection from the pelvis, perihepatitis may occur. In men, if urethritis is left untreated, epididymitis may occur. The pathogenetic role of chlamydia in the development of prostatitis is considered insignificant, but cannot be ruled out. Reactive arthritis (urogenic arthritis, Reiter's disease) occurs equally often in both men and women.

Course and prognosis. The prognosis with early treatment is favorable. However, due to the asymptomatic course of the early stages of the disease, chronic inflammatory diseases of the pelvic organs may develop.

Pregnancy. Perinatal infection can lead to neonatal pneumonia and/or conjunctivitis. Tetracyclines and ofloxacin are contraindicated during pregnancy. It is recommended to take erythromycin.

ICD-10 . A55 Chlamydial lymphogranuloma (venereal). A56 Other chlamydial sexually transmitted diseases

Application. Trachoma- a chronic infectious disease characterized by diffuse infiltration of the lymphoid tissue of the conjunctiva and the formation of trachomatous grains with their subsequent disintegration and scarring, damage to the cornea with the development of pannus; can lead to the formation of cicatricial entropion, trichiasis, clouding of the cornea and blindness. Endemic areas - Africa, Middle East, Asia, Central America. Etiology: causative agent is the bacterium Chlamydia trachomatis. Clinical picture: photophobia, pain, lacrimation. Flow usually acute progressive. Treatment- locally in the form of eye ointments and drops, tetracycline, erythromycin, sulfonamide drugs. ICD-10. A71 Trachoma.

Urogenital chlamydia is one of the most common sexually transmitted infections. The number of people affected by chlamydia is steadily increasing, with 90 million cases of the disease being recorded annually worldwide. The wide prevalence of chlamydia is due to the erasure of clinical symptoms, the complexity of diagnosis, the emergence of strains resistant to antibiotics, as well as social factors - an increase in the frequency of extramarital sexual relations, increased population migration, prostitution, etc. Chlamydia often causes non-gonococcal urethritis (up to 50%), infertility, inflammatory diseases of the pelvic organs, pneumonia and conjunctivitis of newborns.

What provokes Urogenital chlamydia:

Chlamydia are unstable in the external environment and are easily killed when exposed to antiseptics, ultraviolet rays, boiling, and drying.

Infection occurs mainly through sexual contact with an infected partner, transplacentally and intranatally, rarely through household means through toilet items, underwear, or a shared bed. The causative agent of the disease exhibits a high affinity for columnar epithelial cells (endcervix, endosalpinx, urethra). In addition, chlamydia, absorbed by monocytes, spreads through the bloodstream and settles in tissues (joints, heart, lungs, etc.), causing multifocal lesions. The main pathogenetic link of chlamydia is the development of a scar-adhesive process in the affected tissues as a consequence of the inflammatory reaction.

Chlamydial infection causes pronounced changes in both cellular (activation of T-helper cells) and humoral immunity, including the formation of immunoglobulins of classes A, M, G. The ability of chlamydia, under the influence of inadequate therapy, to transform into L-forms and/or change its antigenic structure, which complicates the diagnosis and treatment of the disease.

Urogenital chlamydia during pregnancy can lead to a number of serious complications - spontaneous abortion, premature birth, intrauterine infection or fetal death, untimely rupture of amniotic fluid.

Pathogenesis (what happens?) during Urogenital chlamydia:

There is no generally accepted clinical classification. There are fresh (disease duration up to 2 months) and chronic (disease duration more than 2 months) chlamydia; cases of carriage of chlamydial infection have been reported. In addition, the disease is divided into uncomplicated chlamydia of the lower parts of the genitourinary system, upper parts of the genitourinary system and pelvic organs, and chlamydia of other localizations.

Symptoms of Urogenital chlamydia:

The incubation period for chlamydia ranges from 5 to 30 days, averaging 2-3 weeks. Urogenital chlamydia is characterized by polymorphism of clinical manifestations, the absence of specific signs, an asymptomatic or minimally symptomatic long-term course, and a tendency to relapse. Patients usually consult a doctor when complications develop. Acute forms of the disease have been observed in mixed infections.

Most often, chlamydial infection affects the mucous membrane of the cervical canal. Chlamydial cervicitis most often remains asymptomatic. Sometimes patients note the appearance of serous-purulent discharge from the genital tract, and when urethritis occurs, itching in the urethral area, painful and frequent urination, purulent discharge from the urethra in the morning (the “morning drop” symptom).

Ascending urogenital chlamydial infection determines the development of salpingitis, salpingoophoritis, pelvioperitonitis, peritonitis, which do not have specific signs other than a protracted “erased” course with chronic inflammatory process. The consequences of chlamydia of the pelvic organs include adhesions in the area of ​​the uterine appendages, infertility and ectopic pregnancy.

Extragenital chlamydia includes Reiter's disease, which includes the triad: arthritis, conjunctivitis, urethritis.

Chlamydia in newborns manifests itself as vulvovaginitis, urethritis, conjunctivitis, and pneumonia.

Diagnosis of Urogenital chlamydia:

Examination of the cervix using mirrors and colposcopy reveals serous-purulent discharge from the cervical canal, hyperemia and swelling of the mucous membrane around the external pharynx, and pseudo-erosion. The inflammatory process of the pelvic organs causes swelling and pain of the uterine appendages during a two-hand gynecological examination (salpingoophoritis), symptoms of peritoneal irritation (pelvioperitonitis, peritonitis). Suspicion of chlamydial infection is caused by planar adhesions between the liver and parietal peritoneum (perihepatitis), called Fitz-Hugh-Curtis syndrome. They are discovered during laparoscopy or laparotomy.

Due to scant and/or nonspecific symptoms, it is impossible to recognize the disease based on the clinical picture. The diagnosis of chlamydia is made only on the basis of the results of laboratory research methods. According to WHO recommendations, patients are examined for chlamydia:

• . with chronic inflammatory diseases of the genitourinary system;
• . with pseudo-erosion of the cervix;
• . with menstrual irregularities such as metrorrhagia;
• . using intrauterine contraceptives;
• . frequently changing sexual partners;
• . having a history of spontaneous or induced abortions;
• . with reactive arthritis, chronic conjunctivitis;
• . with atypical pneumonia;
• . with fever of unknown origin, as well as newborns with established chlamydial infection in the mother, etc.

In order to clarify the diagnosis and determine the phase of the disease, the detection of chlamydial antibodies of classes A, M, G in blood serum is used. In the acute phase of chlamydial infection, the IgM titer increases; during the transition to the chronic phase, the IgA and then IgG titers increase. A decrease in titers of chlamydial antibodies of classes A and G during treatment serves as an indicator of its effectiveness.

Treatment of Urogenital chlamydia:

All sexual partners are subject to mandatory examination and, if necessary, treatment. During the period of treatment and follow-up, it is recommended to abstain from sexual intercourse or use a condom.

• . azithromycin 1.0 g orally once;
• . doxycycline 200 mg orally 1 time, then 100 mg 2 times a day for 7-10 days or
• . erythromycin 500 mg orally 4 times a day for 7-10 days;
• . ofloxacin 300 mg orally 2 times a day for 7-10 days or 400 mg orally once a day for 7-10 days;
• . roxithromycin 150 mg orally 2 times a day for 7-10 days;
• . lomefloxacin 600 mg orally once a day for 7-10 days.

For chlamydia of the pelvic organs, the same treatment regimens are used, but lasting at least 14-21 days.

It is preferable to prescribe azithromycin 1.0 g orally once a week for 3 weeks.

During pregnancy use:

• . erythromycin 500 mg orally every 6 hours for 7-10 days or 250 mg orally every 6 hours for 14 days;
• . spiramycin 3 million units orally 3 times a day for 7-10 days;
• . azithromycin 1.0 orally once;
• . amoxicillin (can be with clavulanic acid) 500 mg orally every 8 hours for 7-10 days.

Newborns and children weighing up to 45 kg are prescribed erythromycin 50 mg/kg orally 4 times a day for 10-14 days. For children under 8 years of age weighing over 45 kg and over 8 years of age, erythromycin and azithromycin are used according to adult treatment regimens.

If treatment is ineffective, antibiotics of other chemical groups are used.

Due to the decrease in immune and interferon status in chlamydia, along with etiotropic treatment, it is advisable to include interferon preparations (viferon, reaferon) or inducers of endogenous interferon synthesis (cycloferon, neovir, ridostin, amixin). In addition, antioxidants, vitamins, physiotherapy are prescribed, and vaginal microbiocenosis is corrected with eubiotics.

The criterion for cure is the resolution of clinical manifestations and eradication of Chlamydia trachomatis according to laboratory tests carried out after 7-10 days, and then after 3-4 weeks.

Prevention of Urogenital chlamydia:

Prevention of urogenital chlamydia involves identifying and timely treating patients and excluding casual sexual contact.

Urogenital chlamydia (UGC)- highly contagious STI.

ICD-10 CODE A56 Other chlamydial sexually transmitted diseases.

• A56.0 Chlamydial infections of the lower genitourinary tract.
• A56.1 Chlamydial infections of the pelvic organs and other genitourinary organs.
• A56.2 Chlamydial infection of the genitourinary tract, unspecified.
• A56.3 Chlamydial infection of the anorectal area.
• A56.4 Chlamydial pharyngitis.
• A56.8 Chlamydial sexually transmitted infections, other localization.

EPIDEMIOLOGY OF CHLAMYDIOSIS

Chlamydial infection occupies one of the leading places in the structure of all STIs. Every year, about 90 million new diseases are registered worldwide. In Russia, more than 1.5 million people become ill with urogenital chlamydia every year (incidence records have been kept since 1993). Most often, men and women of sexually active age (20–40 years) suffer from chlamydia; the incidence rate has increased among adolescents aged 13–17 years. The frequency of infection in pregnant women ranges from 10 to 40%, and with a complicated gynecological history (salpingo-oophoritis, TPB, miscarriage) - from 49 to 63%. The source of infection is persons with manifest or asymptomatic urogenital chlamydia.

Routes of transmission of chlamydial infection.

• Contact: ♦sexual; ♦non-sexual (domestic, possibly family).
• Vertical: ♦antenatal; ♦intranatal.

CLASSIFICATION OF CHLAMYDIOSES

According to the severity of the flow, they are distinguished:

• fresh chlamydia (uncomplicated chlamydia of the lower genitourinary tract);
• chronic chlamydia (long-term, recurrent, persistent chlamydia of the upper genitourinary tract, including the pelvic organs).

Based on the topography of the lesion, the following are distinguished:

• chlamydial lesions of the lower genitourinary tract (urethritis, bartholinitis, endocervicitis, vaginitis);
• ascending chlamydial infection (endometritis, salpingitis, salpingoophoritis, pelvioperitonitis, perihepatitis).

ETIOLOGY AND PATHOGENESIS OF CHLAMYDIOSIS

Chlamydia is unstable in the external environment, sensitive to high temperature and quickly inactivated when dried. Highly sensitive to 70% ethanol, 2% Lysol, 0.05% silver nitrate, 0.1% potassium iodate, 0.5% potassium permanganate, 25% hydrogen peroxide, 2% chloramine, UV rays.

The humoral immune response is characterized by the production of specific IgM, IgG, IgA. IgM can be detected in the vascular bed within 48 hours after infection. Only 4-8 weeks after infection are antibodies of the IgG class detected. Secretory IgA is formed locally. The production of antibodies, as well as phagocytosis by macrophages, are possible only when chlamydia are in the elementary body (EB) stage in the intercellular space. Therefore, when chlamydia persists inside the cell at the RT stage, the amount of IgG antibodies in the blood is usually small.

The chronic course of chlamydia is characterized by the presence of IgA and IgG. Low, constantly existing titers of IgG antibodies indicate a long-standing chlamydial infection.

The most common clinical forms of chlamydia: acute urethral syndrome, bartholinitis, cervicitis, endometritis, salpingitis, conjunctivitis, salpingoophoritis, pelvioperitonitis. A serious complication of chlamydia is infertility..

Asymptomatic chlamydial infection is noted depending on the location with a frequency of up to 60–80%. Due to the common routes of transmission of pathogens in STIs, chlamydia is often accompanied by other bacteria and viruses (gonococci, trichomonas, myco, ureaplasma, HSV, CMV, human papillomavirus), which in association increase the pathogenicity of each microorganism and its resistance to treatment.

The following stages are distinguished in the pathogenesis of chlamydial infection:

• infection;
• formation of the primary focus of infection;
• progression of the inflammatory process with multiple lesions of epithelial cells and the appearance of clinical symptoms of the disease;
• functional and organic changes in various organs and systems against the background of developing immunopathological reactions.

SCREENING AND PRIMARY PREVENTION OF CHLAMYDIOSIS

Screening is carried out using PCR and enzyme immunoassay methods. Subject to examination:

• persons who have had sexual contact with patients with urogenital chlamydia;
• persons being tested for other STIs;
• women with mucopurulent discharge from the cervical canal, symptoms of adnexitis, infertility, miscarriage;
• newborns from mothers who have had a chlamydial infection during pregnancy;
• men with mucopurulent discharge from the urethra, symptoms of dysuria.

Preventive measures should promote a healthy sexual lifestyle, inform the population about the routes of infection, early and late clinical manifestations of infection and methods of their prevention (safe sex).

DIAGNOSIS OF CHLAMYDIOSIS

Diagnosis of urogenital chlamydia is based on an assessment of the epidemiological history, clinical picture, and laboratory test results. There is a high risk of infection in people with multiple and casual sexual relationships.

Clinical manifestations of urogenital chlamydia are quite wide: from the absence of specific symptoms to the development of manifest forms of the disease. Moreover, the asymptomatic course of the disease does not exclude ascending infection of the uterine cavity and its appendages. The clinical picture of chlamydial infection is determined by the virulence of the pathogen, the duration of persistence of chlamydia, the location of lesions and the state of the human immune system.

The following options for damage to the lower genitourinary tract are possible:

• urethritis (more often in children and men);
• paraurethritis;
• bartholinitis;
• endocervicitis;
• vaginitis

Ways of spreading of ascending infection:

• canalicular (through the cervical canal, uterine cavity, fallopian tubes to the peritoneum and abdominal organs);
• hematogenous (extragenital lesions; for example, pharynx, joint capsules);
• lymphogenous (via lymphatic capillaries);
• sperm;
• via VMC.

Clinical forms of ascending chlamydial infection:

• salpingitis and salpingoophoritis (most often they have a subacute, long-term course without a tendency to worsen);
• endometritis (rarely acute, often chronic);
• infertility (sometimes this is the patient’s only complaint).

Complications of chlamydia:

• ectopic pregnancy;
• complete or partial obstruction of the fallopian tubes;
• adhesions in the pelvis;
• miscarriage;
• perihepatitis;
• Reiter's disease (cervicitis, arthritis, conjunctivitis).

LABORATORY RESEARCH

To diagnose chlamydial infection, both direct detection of the pathogen and indirect methods - serological examination - are used.

• Cultural method - seeding with cell cultures (considered a priority, especially when determining the cure of chlamydia, for forensic examination, if a persistent infection is suspected).
• PCR method (highly specific and sensitive).
• Direct immunofluorescence method.
• Serological method - detection of anti-chlamydial antibodies in blood serum (IgG, IgA). Based on serological methods alone, it is impossible to make a diagnosis of UGC, since IgG to C. trachomatis can remain in the body for a long time (5–10 years) after the disease. Only the presence of specific IgA or IgG seroconversion (4-fold increase in antibody titer when examining paired sera) may indicate an ascending chlamydial infection. Only the simultaneous combination of two different methods, one of which is PCR, provides the necessary accuracy in diagnosing UGC both for primary diagnosis and for monitoring cure.

A test to determine the sensitivity of chlamydia to antibiotics is not practical. Treatment effectiveness assessment is monitored 1 month after the end of antibiotic therapy.

DIFFERENTIAL DIAGNOSIS OF CHLAMYDIOSIS

Conducted with other STIs.

INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS

If complications develop, consultation with related specialists is required (for example, in case of Reiter's disease - an ophthalmologist, an orthopedist).

TREATMENT OF CHLAMYDIOSIS

TREATMENT GOALS

• Etiotropic, complex therapy aimed at eliminating the pathogen.
• Treatment of concomitant genitourinary infections, intestinal dysbiosis and immune system disorders.

DRUG TREATMENT OF CHLAMYDIOSIS

• azithromycin, orally 1 g once for an uncomplicated form, for a complicated form - 500 mg 2 times a day for 7–10 days;
• doxycycline, orally 100 mg 2 times a day for 7 days;
• josamycin, orally 500 mg 3 times a day for 7 days;
• clarithromycin, orally 250 mg 2 times a day for 7 days;
• roxithromycin, orally 150 mg 2 times a day for 7 days;
• ofloxacin, orally 200 mg 2 times a day for 7 days.

For complicated forms of urogenital chlamydia, the same drugs are used, but the duration of treatment is at least 14–21 days.

Alternative treatment regimens for chlamydia:

• erythromycin, orally 250 mg 4 times a day for 14 days;
• lomefloxacin, 400 mg once a day for 7–10 days.

In order to prevent candidiasis during antibacterial therapy for chlamydia, it is advisable to prescribe antifungal drugs: nystatin, natamycin, fluconazole, itraconazole. In case of co-infection with C. trachomatis, trichomonas, urea, mycoplasmas, anaerobic microflora (in pathogenic concentrations), the treatment regimen should include protistocidal drugs from the very beginning: metronidazole orally 500 mg 2 times a day for 7 days. Prevention of intestinal dysbiosis is carried out with eubiotic drugs orally, 30 drops 3 times a day during antibiotic therapy and 10 days after its completion.

In case of recurrent chronic chlamydia, the use of immunomodulators is pathogenetically justified, since they normalize the immune status and participate in the elimination of chlamydia by directly inhibiting their replication and transcription:

• meglumine acridone acetate, 12.5% ​​solution 2 ml intramuscularly every other day for 5 to 10 injections;
• sodium oxodihydroacridinyl acetate (neovir©), 250 mg intravenously per 1 ml of 0.5% procaine solution daily 10 injections;
• IFN alpha2, 1 suppository vaginally at night every day for 10 days. Enzyme preparations are used: Wobenzym©, chymotrypsin.

Medicines for the treatment of chlamydia*

Treatment of chlamydia should include adherence to three basic principles: chemotherapy, immunomodulation, restoration of the natural biocenosis of the vagina.

I. Chemotherapy for chlamydia

All antichlamydial drugs are divided into three groups according to their ability to penetrate cells:
♦ low degree - penicillins, cephalosporins, nitroimidazoles;
♦ moderate degree - tetracyclines, fluoroquinolones, aminoglycosides;
♦ high degree - macrolides and azalides.

Methods of chemotherapy for chlamydia:
♦ continuous course - must cover 7 cycles of development of the pathogen - 14-21 days (use one antibiotic or change it to another during the treatment process);
♦ “pulse therapy” - three courses of intermittent treatment for 7 days each, followed by a break of 7 days; During the pause, EBs are destroyed in the intercellular spaces by phagocytes.

Azalides and macrolides:
♦ azithromycin (sumamed) - on the 1st day 1 g (2 tablets of 500 mg each) once; on days 2-5 - 0.5 g 1 time/day;
♦ midecamycin (macropen) - 400 mg, 3 times a day, 7 days (course dose 8 g);
♦ spiramycin (rovamycin) - 3 million units, 3 times/day, 10 days;
♦ josamycin (vilprafen) - 500 mg 2 times a day, for 10-14 days;
♦ Rondomycin - 0.3 g 2 times a day, for 10-14 days;
♦ clarithromycin (clacid, fromilid) - orally 250-500 mg 2 times a day, for 10-14 days;
♦ roxithromycin (rulid, roxide, roxibid) - orally 150-300 mg 2 times a day, 10 days;
♦ erythromycin (erythromycin - Teva, eracin) - 500 mg 4 times a day. before meals orally, for 10-14 days;
♦ erythromycin ethylsuccinate - 800 mg 2 times a day, 7 days.
♦ clindamycin (dalacin C) - an antibiotic of the lincosamide group; 300 mg 4 times/day. after meals, 7-10 days or IM 300 mg 3 times a day, 10 days.

Group of tetracyclines:
♦ tetracycline - orally 500 mg 4 times a day, for 14-21 days;
♦ doxycycline (Unidox, Vibramycin) - 1 capsule (0.1 g) 2 times a day, for 10-14 days;
♦ metacycline (rondomycin) - 300 mg 4 times a day, for 10-14 days.

Fluoroquinolone preparations:
♦ ofloxacin (zanocin, tarivid, ofloxin) - 200 mg 2 times a day. after meals, for 10-14 days;
♦ ciprofloxacin (tsifran, tsiprinol, tsiprobay, cipro-bid) - orally, intravenously, 500 mg 2 times a day, for 7 days;
♦ gatifloxacin (Tebris) - 400 mg 1 time/day, 7-14 days;
♦ pefloxacin (abactal) - 600 mg with food 1 time/day, for 7 days;
♦ levofloxacin (nolicin, urobatsid, norbactin) - 400 mg 2 times a day, for 7-10 days;
♦ lomefloxacin (maxaquin) - 400 mg 1 time/day, 7-10 days.

Local treatment of chlamydia:
♦ tetracycline ointment (1-3%) - on tampons in the vagina 2 times a day, 10-15 days;
♦ erythromycin ointment (1%) - on tampons in the vagina 2 times a day, 10-14 days;
♦ dalacin C (2% vaginal cream) - 5 g in the vagina (dispenser) at night, for 7 days;
♦ Betadine - suppositories of 200 mg of polyvidone iodide in the vagina at night, 14 days.

I. Immunomodulation

It is carried out before chemotherapy for chlamydia or in parallel with it. The basis for prescribing immunomodulation is the presence of immunological changes in the body of people affected by chlamydia: decreased activity of the interfrontal system, natural killer cells, macrophages, T-lymphocytes, etc.
For immunomodulation use (application):
♦ interphronogenesis drugs: reaferon, alfaferon, vi-feron, welferon, kipferon, laferon;
♦ interfron inducers: neovir, cycloferon, engystol, lykopid, myelopid;
♦ drugs that modulate the reactions of cellular and humoral immunity: amixin, groprinosine, polyoxidonium, immunomax, Gepon;
♦ cytolysins: thymalin, tactivin, timoptin.

Sh. Restoration of the natural biocenosis of the vagina (see Section “ Colpitis")

FOLLOW-UP

A control study is carried out 3-4 weeks after treatment and then during 3 menstrual cycles.

Cure criteria:

• negative laboratory test results;
• absence of clinical symptoms of the disease.

If there is no positive effect from treatment, possible reasons should be considered:

• non-compliance with outpatient treatment regimen;
• inadequate therapy;
• false positive test result;
• re-contact with an untreated partner;
• infection from a new partner.

FORECAST

With inadequate treatment, complications may develop.