Gonorrhea and Chlamydia
Margaret J. Blythe
KEY WORDS
Cervicitis
Men who have sex with men (MSM)
Pelvic inflammatory disease (PID)
Sexually transmitted infections (STIs)
Urethritis
Gonococal and chlamydial genital infections are sexually transmitted infections (STIs) frequently diagnosed in adolescents and young adults (AYAs) having the potential for serious complications.
ETIOLOGYGonorrhea is an STI caused by Neisseria gonorrhoeae, which has the following characteristics:
Small, intracellular gram-negative cocci, arranged in pairs (diplococci) typically located within or associated with polymorphonuclear (PMN) leukocytes
Physical contact required for transmission, specifically contact of mucosal surfaces; no evidence that infection can be transmitted by inantimate objects or outside of host
Differentiated from other strains, such as N. meningitidis and N. lactamica, through use of laboratory techniques as growing on chemically defined media (auxotyping), serotyping (monoclonal antibodies specific for various epitopes on outer membrane protein), antimicrobial susceptibilities, and genotyping
Possesses a number of structures on the outer membrane contributing to pathogenesis, such as reduction modifiable protein (prevents bactericidal activity), porin B protein (insertion into host cell membrane), lipooligosaccharide (tissue toxin), Opa protein (adherence), and pili (adherence to host tissue)
Evades host defenses by antigenic variation of many of the structures on the outer membrane.1
TABLE 57.1 Cases and Incidence of Gonorrhea in the US, 1977 to 2013 | ||||||||||||||||||||||||||||||||||||
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Chlamydia is an STI caused by Chlamydia trachomatis, which has the following characteristics:
Serovars B, D, E, F, G, H, I, J, K found in genital infections such as urethritis, cervicitis, salpingitis, proctitis, and newborn/adolescent conjunctivitis and serovars L1, L2, L3 in lymphogranuloma venereum
Unique developmental cycle lasting between 48 and 72 hours: initial attachment and ingestion of the infectious particle (the elementary body) into the host cell, reorganization into a reticulate body, replication, transformation to new infectious elementary bodies, and release, most often resulting in the destruction of the host cell
Pathogenesis of non-LGV serovars related to being obligate intracellular parasites limited to infection within the squamocolumnar-columnar epithelial cells with resulting cellular death, an inflammatory response and tissue damage; pathogenesis of LGV serovars related to systemic effects such as lymphoproliferative disease with associated capability to replicate within macrophages
Immune response induces both a neutralizing antibody and a T cell-mediated immune response, which neutralizes chlamydial infectivity. C. trachomatis has a heat shock protein (cHSP60) 50% homologous to human HSP60. Scarring of the fallopian tubes in pelvic inflammatory disease (PID) is thought to be a result of repeated infections and the hypersensitivity reactions specifically related to these shared proteins2
EPIDEMIOLOGYGonorrhea
Incidence
Gonorrhea is the second most frequently reported disease in the US after C. trachomatis infections. Approximately 333,004 cases were reported in 2013 or 106.1/100,000, slightly down from 2012 (106.7) (Table 57.1).
Trends
National rates decreased by 74% from 1977 to 1997 (122.4/100,000). The rate recorded in 2009 (98.1/100,000) was the lowest rate ever reported by the Centers for Disease Control and Prevention (CDC). Since 2009, the gonorrhea rate has increased slightly each year, with a slight decrease in 2013 representing a 9.6% increase overall into 2012.3
Risk Groups
Age/Gender: Highest rates in 2013 were in women 20 to 24 (541.6/100,000) and 15 to 19 years old (459.2). Young men 20 to 24 years old had the highest rate (459.4) while among young men 15 to 19 years old, the rate was 220.9. From 2012 to 2013 gonorrhea rates for 15- to 19-year-olds decreased by 13% for females and 8.9% for males, while decreasing by 4.7% for 20- to 24-year-old females and increasing 1.3% for 20- to 24-year-old males.4
Ethnicity/Gender: Rates vary dramatically among AYAs of different racial/ethnic backgrounds and in various practice settings. Incidence in Blacks, Hispanics, and Native Americans is disproportionately high compared with Whites and Asians. Historically, rates for Blacks have been the highest for both males and females in the 15- to 24-year-old age-groups. For these two age-groups in 2013, the lowest rate recorded for males was for 15- to 19-year-old Asians (21.7/100,000) while the highest rate was among 20- to 24-year-old Black males (1,734.5/100,000). The lowest rate recorded for females was for 15- to 19-year-old Asian females (40.2/100,000) while the highest rate was among 20- to 24-year-old Black females (1949.1/100,000).5
Geography
The decision by providers to “routinely screen” for gonorrhea in teens and young adults may be made on the prevalence of disease in the area of country in which the teen resides. Wide variation occurs based on region of country, state, and even city. Outside of the South and Southeast, the highest reported rates of gonorrhea are reported in the District of Columbia (DC) (391.1) and Alaska (154.3). Examples of states in the south include Louisiana (188.4), Alabama (173.7), and Mississippi (170.7). These rates compare to the lowest rates in Western states such as Wyoming (11.5), Idaho (13.2), and Montana (22.3) and in the Northeast (New Hampshire [9.2] and Vermont [15.5]).6
Chlamydia Trachomatis
Incidence
Chlamydia is the most frequently reported disease in the US with 1,401,906 infections reported to the CDC in 2013, yielding a rate of 446.6/100,000. This represents a slight decrease of 1.5% from 2012 (453.3). However, the trend since 1990 (160.2/100,000) has been a steady increase (Table 57.2).
Trends
National rates have increased steadily since 1984, when reporting for chlamydia began; more widespread testing with more sensitive techniques has resulted in population rates increasing from 1984 to 2013 (from 6.5/100,000 to 446.6 in 2013).7
TABLE 57.2 Cases and Incidence of Chlamydia in the US, 1984 to 2013 | ||||||||||||||||||||||||||||||||||||||||
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Risk Groups
Age/Gender: Highest rates in 2013 were in women 20 to 24 years (3621.1/100,000) and 15 to 19 years (3043.3); although substantially lower for young men, the highest rates are also in the 20- to 24-year-old age-group (1325.6) while for young men 15 to 19 years, the rate is 715.2/100,000. From 2012 to 2013, the chlamydia rates for young adult 20- to 24-year-old men remained about the same in 2013 compared to 2012 (1322.8) and decreased by about 9% for adolescent males. At the same time, the rates for 15- to 19-year-old women in 2013 decreased by 8.7% compared to 2012 and remained the same for 20- to 24-year-old women.8
Ethnicity/Gender: Rates vary dramatically among AYAs from different racial/ethnic backgrounds and practice settings. Incidence in Blacks, Hispanics, and Native Americans is disproportionately high compared with Whites and Asians. Different from gonorrhea, rates among females are 2 to 6 times higher than among males of similar age-group and racial/ethnic backgrounds. Similar to gonorrhea, for these two age-groups in 2013, the lowest rate recorded for males was for 15- to19-year-old Asians (71.5/100,000) while the highest rate was among 20- to 24-year-old Black males (3282.5/100,000). The lowest rate recorded for females was among 15- to 19-year-old Asian females (503.2/100,000) while the highest rate was among 20- to 24-year-old Black females (7342.7/100,000).9
Geography
Regardless of place of residence, “routine” annual screening of sexually active 15- to 24-year-old females for chlamydia is recommended, with inconsistent recommendations for screening sexually active 15- to 24-year-old males. The CDC recommends routine screening of “high-risk” males such as those attending adolescent clinics, school-based clinics, correctional systems, Job Corps, and the military.10,11 Variation in reported rates of chlamydia occurs as a function of the likelihood of testing, reporting, and in what part of the country residence occurs.12
Prevalence of Gonorrhea and Chlamydia
Reported prevalence rates will vary depending on the population and anatomical sites screened for gonorrhea and chlamydia (Table 57.3).
Opportunities for screening: At a STI clinic, routine testing of men who have sex with men (MSM) and high-risk females occurred at oropharyngeal, anorectal, and urogenital sites. Results indicated that 6.3% (154/2436) of men were positive for gonorrhea and 10.4% (254/2436) were positive for chlamydia at one or more of the sites; 76% (117/154) of positive samples for gonorrhea were at the anorectal/oropharyngeal sites while 68.5% (174/254) for chlamydia. For women, 3.1% (41/1321) were positive for gonorrhea with 58.5% (24/41) of positive samples anorectal/oropharyngeal; for chlamydia, 7% (92/1321) were positive with 22.8% (21/92) anorectal/oropharyngeal.13
TABLE 57.3 Reported Prevalence Rates for Gonorrhea and Chlamydia by Population and Anatomical Site Screened
Population
GC (%)
CT (%)
No.
Author
Males MSM
STI Clinics
Urethral
Anogenital
1.5
3.7
3.3
7.9
2436
Van Liere et al., 2013
Pharyngeal
3.4
1.1
Pharyngeal
7.0
2.3
3949
Park et al., 2012
Community Clinics
Urethral
Anogenital
0.4
3.6
2.3
7.8
3398
7061
Marcus et al., 2011
Pharyngeal
5.0
1.9
Pharyngeal
4.0-5.5
1.4
Park et al., 2012
Heterosexual/Bisexual/Gay
Job Corps
0.9 (0.0-2.6)
8.0 (2.7-13.0)
CDC, 2011
Detention Clinics
0.7 (0.0-6.0)
6.3 (0.4-19.1)
Internet
1
13
501
Chai et al., 2010
STI Clinics
14.5 (2.8-21.0)
11.3 (6.5-23.1)
CDC, 2011
Females
STI clinics
Genital
Anogenital
1.3
0.9
5.4
4.8
1321
Van Liere et al., 2013
Pharyngeal
2.3
1.4
Family-planning Clinics
0.7 (0.0-3.5)
8.4 (3.8-14.3)
CDC, 2011
Job Corps
1.0 (0.0-4.9)
10.3 (4.1-18.7)
CDC, 2011
Detention Clinics
3.4 (0.0-9.6)
13.5 (3.7-27.7)
CDC, 2011
Emergency Dept.
3.5
19.7
236
Goyal et al., 2012
Internet
9.1
1203
Gaydos et al., 2009
NHANES
2.5
7.1
404
Forhan, 2009
One study suggests that fellatio performed by women resulted in a urethral infection rate of 3.5% for chlamydia and 3.1% for gonorrhea, when no other type of sexual contact was acknowledged.14
National studies: Chlamydia prevalence among sexually active females aged 14 to 24 years is nearly three times the prevalence among those aged 25 to 39 years (NHANES 1999—2008, unpublished data, 2011). Prevalence among non-Hispanic Blacks is approximately five times the prevalence among non-Hispanic Whites.15 Among sexually active females aged 14 to 19 years, chlamydia prevalence is 7.1% overall, and for gonorrhea 2.5%.16 Estimated prevalence of gonorrhea in NHANES from 1999 to 2008 among 14- to 25-year-old females and males (0.40%; 95% confidence interval [CI], 0.20% to 0.72%) is similar to estimated 0.43% (95% CI, 0.29% to 0.63%) prevalence among 18- to 26-year-olds in the National Longitudinal Study of Adolescent Health in 2001 to 2002.17,18
MSM: Among asymptomatic MSM, 83.8% of gonorrhea and chlamydia infections would be missed if only urethral screening occurred. The fewest infections would be missed by screening the rectum and pharynx, thus helping reduce the risk of human immunodeficiency virus (HIV) acquisition and transmission.19 In one analysis, 62.7% of pharyngeal gonorrhea and 57.8% of pharyngeal chlamydia infections were in MSM who did not have a concurrent urogenital or rectal gonorrhea or chlamydia infection.20 One study reported results from screening for gonorrhea and chlamydia in 5539 MSM attending STI clinics and 895 men attending gay men’s health center; routine screening of urethral, anogenital, and pharyngeal sites found that 64% of gonococcal infections (574) were non-urethral sites as were 53% of chlamydia infections (452). Overall, of the three sites and the two infections, the highest rates and sites of infection were gonorrheal pharyngeal (9.4%) and chlamydial anogenital (8.8%). Highest rates of any infections were found in the ≤24-year-old age-group for gonorrhea (17.3%) and chlamydia (15.4%).21 An editorial addressing screening for chlamydia and gonorrhea in MSM indicated that 47% to 84% of chlamydial infections and 38% to 65% of gonorrhea infections would be missed if only urethral specimens were obtained.22
STI clinics: Across the participating STI sites, the median site-specific gonorrhea prevalence was 14.5% (range by site: 2.8% to 21.0%) while the median site-specific chlamydia prevalence was 11.3% (range by site: 6.5% to 23.1%).23
STD Surveillance Network examines the number of cases of gonorrhea and characteristics of the population to better develop strategies for control. Across all sites in 2011, 21.6% of gonorrhea cases were estimated to be among MSM, 31.0% among men having sex with women (MSW), and 47.4% among women.
STI clinics remain the most common reporting source of gonorrhea for men but for women, private physicians or health maintenance organizations were the most common. Among women, 7.7% of chlamydia cases reported were from STI clinics, while 23.6% of cases reported from men were from an STI clinic.24
Family-planning clinics in the US serving 15- to 24-year-old females: In 2011, median state-specific rate for chlamydia was 8.4% (range Vermont 3.8% to Mississippi 14.3%). In 2011, the median state-specific gonorrhea test positivity among women aged 15 to 24 years screened in selected family-planning clinics was 0.7% (range: 0.0% to 3.5%).25
National Job Corps: Among women in 2011 entering the program in 46 states, the DC, and Puerto Rico, the median state-specific chlamydia prevalence was 10.3% (range: 4.1% to 18.7%), while for men, median state-specific chlamydia prevalence was 8.0% (range: 2.7% to 13.0%). Among women entering the program, the median state-specific gonorrhea prevalence in 2011 was 1.0% (range: 0.0% to 4.9%), while for men, the median state-specific gonorrhea prevalence was 0.9% (range: 0.0% to 2.6%).26
Juvenile detention facilities: In 2011, of the 49 clinics reporting that serve teens in detention centers, the median facility-specific chlamydia positivity for females was 13.5% (range: 3.7% to 27.7%) while the median gonorrhea positivity was 3.4% (range: 0.0% to 9.6%). For males, the median facility-specific chlamydia positivity was 6.3%
(range: 0.4 to 19.1%); the median gonorrhea positivity was 0.7% (range: 0.0% to 6.0%).26
Emergency departments: Of the 236 symptomatic (e.g., vaginal discharge) 14- to 19-year-old female patients tested, 19.7% were positive for chlamydia, 9.9% trichomononas, and 3.5% gonorrhea.27
Nonclinical outreach testing: Specific program in the US demonstrated high prevalence rate of chlamydia: 9.1% overall, with 15.3% of females 15 to 19 and 11.1% of 20- to 24-year-olds infected.28 Rates of infection were higher than those in family-planning clinics. Similar program for males indicated that 1% had tested positive for gonorrhea and 13% for chlamydia.29 A review was published of 25 programs predominantly in Australia and US targeting 15- to 29-year-olds, MSM, and sex workers. Median testing rate was 79.6% with median gonorrhea rate 2.6% and chlamydia 7.7%. Participation rate was highest among those gathering in community service centers (e.g., homeless shelters) and social venues (e.g., bars, clubs). Lowest participation rates were in street/public sites.30
Systematic review and meta-analysis of studies suggest that home-based testing enhances uptake of STI screening when compared to clinic testing for gonorrhea and chlamydia for 14- to 50-year-old females.31
The Health Care Effectiveness Data and Information Set: Among sexually active women aged 16 to 24 years in commercial plans, chlamydia screening increased from 23.1% in 2001 to 45.1% in 2012; the screening rate among sexually active women aged 16 to 24 years covered by Medicaid increased from 40.4% to 57.1%.32
Host
Humans are the only natural host for N. gonorrhoeae and C. trachomatis.
Transmission
Transmission is virtually exclusively through oral, vaginal, or anal sexual contact except for occasional conjunctival mucosal infection from cross contamination with infected secretions.
Clinical Manifestations
Clinical manifestations of N. gonorrhoeae are similar to those caused by C. trachomatis, and both C. trachomatis and N. gonorrhoeae can occur together in the same individual. Susceptible sites are usually mucosal columnar epithelial areas or surfaces. The spectrum of infections includes the following:
Asymptomatic gonorrheal and chlamydial infections in males and females:
Majority of male urethral infections are asymptomatic in the general population and may persist for months if untreated; if symptoms occur, chlamydial infections are more likely milder than gonorrhea.
Most endocervical infections for females in general population are asymptomatic, but may have symptoms that are relatively short term and/or may be mistaken for symptoms of another infectious process, such as urinary tract infections and/or other causes of vaginal discharge.
Asymptomatic rectal and pharyngeal infections are a major reservoir of infections, particularly for MSM. Infection with non-LGV immune types of chlamydia as well as gonorrhea may result in asymptomatic proctitis.
Estimates are that over 90% of pharyngeal gonorrhea infections are asymptomatic.
Asymptomatic infections can involve the following for males and females:
Urethra
Endocervix (females only)
Rectum
Pharynx
Symptomatic uncomplicated infections may result in the following:
Urethritis
Cervicitis
Proctitis
Pharyngitis
Bartholinitis
Conjunctivitis
Local complications include the following:
PID
Epididymitis
Bartholin gland abscess
Infection of male accessory sex glands presenting as periurethiritis: seminal vesicles, bulbourethral glands (Cowper glands), and/or prostate gland
Perihepatitis: Complication of salpingitis (Fitz-Hugh-Curtis syndrome)
Systemic complications for gonorrhea and chlamydia might include the following:
Disseminated gonococcal infection (DGI)
Arthritis-dermatitis syndromes
Gonococcal meningitis
Gonococcal endocarditis
Genitourinary Infections
The most common clinical manifestation of gonorrhea and chlamydia is a genitourinary infection.
Males
Urethritis
Gonococcal
Incubation period: Ranges from 1 to 14 days with most men symptomatic 2 to 5 days after exposure
Symptoms: Urethral discharge, dysuria, meatal pruritus
Clinical findings: Profuse purulent urethral discharge (25% scanty, minimally purulent discharge), urethral edema, and erythema
Spontaneous resolution over several weeks without treatment
Chlamydial
Incubation period: 7 to 21 days
Symptoms: Dysuria, mild to moderate discharge
Clinical findings: Minimal urethral discharge or no findings
Both infections can spread and cause epididymitis
More than two-thirds of AYAs with epididymitis have gonorrhea and/or chlamydia.
Urethral symptoms may or may not be present.
Scrotal pain and tenderness, usually unilateral with swelling and erythemaRelated posts:
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