Chlamydia rates up — Put screening into practice
Your next patient is a 16-year-old female who says she has a burning sensation when urinating. She has a steady boyfriend, but they have never discussed condom use. What is your next move?
Screen for chlamydia. The Centers for Disease Control and Prevention (CDC) has just released new surveillance figures. More than 1.1 million chlamydia cases were reported in 2007, up from about 1 million in 2006. The increase represents the largest number of cases ever reported to CDC for any condition.1
In 2007, the chlamydia rate among women was three times that of men: 543.6 cases per 100,000 women, compared to 190 cases per 100,000 men. What can clinicians do to increase chlamydia screening and treatment?
Look to late spring 2009 for the publication of Why Screen for Chlamydia? which is a chlamydia screening implementation guide for providers developed by the National Chlamydia Coalition (NCC) and the Partnership for Prevention, says Raul Romaguera, DMD, MPH, the national chlamydia screening coordinator of the CDC's Division of STD Prevention.
The guide is designed as a brief resource for primary care providers to summarize the latest information about chlamydia screening and treatment, and provide suggestions and examples of ways chlamydia screening can be integrated into medical practice, explains Romaguera. It also includes information on issues related to providing confidential care to adolescents and tools for taking a sexual history with adolescent and young adult patients, he notes. The guide also will provide a list of online resources where providers can get up-to-date information regarding chlamydia screening and obtain access to evidence-based resources developed by other organizations, states Romaguera. (Editor's note: CTU will report further on the guide upon publication. To educate your patients on chlamydia, use a handout available on the CDC web site, www.cdc.gov. Click on "Diseases & Conditions," "Chlamydia," then "Fact Sheet." The fact sheet is available in English and Spanish.)
When talking with women about chlamydia, be sure to counsel on correct and consistent condom use. Condoms greatly reduce the risk of sexually transmitted diseases, such as chlamydia, which are transmitted to or from the penile urethra.2
The CDC recommends yearly chlamydia testing of all sexually active women age 25 or younger; older women with risk factors for chlamydial infections, such as those who have a new sex partner or multiple sex partners, and all pregnant women. An appropriate sexual risk assessment by a health care provider always should be conducted and might indicate more frequent screening for some women, the CDC advises.3
Women who are treated for chlamydia should be retested for infection about three months after treatment, advises the CDC.4 It also is recommended that when possible, expedited partner therapy should be implemented. With that therapy, antibiotic therapy is delivered by heterosexual patients to their partners, if other strategies for reaching and treating partners are not likely to succeed.
With the formation of the NCC in June 2008, what steps have been taken to increase public awareness of chlamydia screening and to identify and address provider and policy-level barriers to widespread adherence to screening guidance?
The coalition is completing an inventory of resources, including social marketing campaigns, educational materials, brochures, and posters developed by other national and local organizations to increase community and provider awareness of chlamydia screening, says Romaguera.
"The NCC has had some conversations with a few of these organizations about the possibility of adapting these campaigns or resources to different audiences or target populations," Romaguera states. "In addition, the NCC is also exploring how they can join other national efforts to promote chlamydia screening."
A woman who has been using oral contraceptives (OCs) with good control who presents with intermenstrual bleeding might need to be screened for chlamydia. Cervicitis, which can be caused by chlamydia, gonorrhea, and trichomoniasis, is an important, but largely unrecognized, source of unplanned bleeding in women using OCs.5 Women who experience intermenstrual bleeding who have been previously well controlled on OCs might have asymptomatic chlamydia cervicitis.5
In a 1993 study, researchers found that 29.2% of women who had been taking OCs for more than three months and presented with intermenstrual spotting had a positive test for Chlamydia trachomatis.6 By comparison, chlamydia cervicitis was found in 10.7% of matched controls taking OCs without spotting who were screened for symptoms of vaginitis or high-risk sexual behavior, and in 6.1% of women undergoing routine screening before the initiation of contraception.6
Smoking also has been linked to similar intermenstrual spotting while using OCs;7 despite awareness of those potential confounding factors, few studies control for cigarette smoking or chlamydial infection, even though it is common for most studies to report the proportion of smokers recruited.8 Since chlamydial cervicitis often causes abnormal bleeding and spotting, guidance from a 2005 Hormonal Contraceptives Trial Methodology Consensus Conference advised that women entering trials of hormonal contraceptives who are at risk for chlamydia should be screened for untreated chlamydia infection.9
References
- Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2007. Atlanta: U.S. Department of Health and Human Services; December 2008.
- Warner L, Steiner MJ. "Male condoms." In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 19th revised edition. New York City: Ardent Media; 2007, p. 302.
- Centers for Disease Control and Prevention. Chlamydia — CDC Fact Sheet. Accessed at www.cdc.gov/std/chlamydia/STDFact-Chlamydia.htm#prevented.
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006; 55(RR-11):40.
- Lohr PA, Creinin MD. Oral contraceptives and breakthrough bleeding: What patients need to know. J Fam Pract 2006; 55:872-880.
- Krettek JE, Arkin SI, Chaisilwattana P, et al. Chlamydia trachomatis in patients who use oral contraceptives and had intermenstrual spotting. Obstet Gynecol 1993; 81:723-731.
- Rosenberg MJ, Waugh MS, Higgins JE. The effect of desogestrel, gestodene, and other factors on spotting and bleeding. Contraception 1996; 53:85-90.
- Bachmann G, Korner P. Bleeding patterns associated with oral contraceptive use: A review of the literature. Contraception 2007; 76:182-189.
- Mishell DR, Guillebaud J, Westhoff C, et al. Recommendations for standardization of data collection and analysis of bleeding in combined hormone contraceptive trials. Contraception 2007; 75:11-15.
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