Am Fam Physician. 2022;105(4):388-396
Related Letter to the Editor: Doxycycline Preferred for the Treatment of Chlamydia
Patient information: See related handouts on chlamydia, written by the authors of this article, and on gonorrhea, which has been adapted from a previously published AFP article.
Author disclosure: No relevant financial relationships.
Infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae are increasing in the United States. Because most infections are asymptomatic, screening is key to preventing complications such as pelvic inflammatory disease and infertility and decreasing community and vertical neonatal transmission. All sexually active people with a cervix who are younger than 25 years and older people with a cervix who have risk factors should be screened annually for chlamydial and gonococcal infections. Sexually active men who have sex with men should be screened at least annually. Physicians should obtain a sexual history free from assumptions about sex partners or practices. Acceptable specimen types for testing include vaginal, endocervical, rectal, pharyngeal, and urethral swabs, and first-stream urine samples. Uncomplicated gonococcal infection should be treated with a single 500-mg dose of intramuscular ceftriaxone in people weighing less than 331 lb (150 kg). Preferred chlamydia treatment is a seven-day course of doxycycline, 100 mg taken by mouth twice per day. All nonpregnant people should be tested for reinfection approximately three months after treatment or at the first visit in the 12 months after treatment. Pregnant patients diagnosed with chlamydia or gonorrhea should have a test of cure four weeks after treatment.
Chlamydia trachomatis and Neisseria gonorrhoeae are the most common sexually transmitted infections (STIs) in the United States and are required to be reported to state health departments. Between 2015 and 2019, reported chlamydial infections increased by 19%, and reported gonococcal infections increased by 53%.1 These bacteria commonly infect the urogenital, anorectal, and pharyngeal sites but can become disseminated to affect multiple organ systems. Untreated infections may lead to pelvic inflammatory disease; scarring of fallopian tubes, which can increase the risk of ectopic pregnancy; infertility; easier transmission of new HIV infection; and vertical neonatal transmission.2
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Sexually active adolescents and adults at increased risk of acquiring a sexually transmitted infection should receive behavioral counseling to reduce their risk.6 | B | Systematic review |
| Sexually active people 24 years and younger who have a cervix should be screened for chlamydial and gonococcal infections annually.2,7 | B | Systematic reviews |
| Doxycycline should be used to treat chlamydia in nonpregnant people.2 | A | Systematic review of randomized controlled trials |
| Nonpregnant people treated for chlamydial or gonococcal infections should be tested for reinfection three months after treatment.2 | C | Consensus opinion from clinical guidelines |
| All newborns should receive ocular erythromycin 0.5% ointment to prevent gonococcal ophthalmia neonatorum.31 | A | High certainty of substantial net benefit |
Risk Factors
Young people 15 to 24 years of age account for 61% of all newly diagnosed STIs.1 Racial and ethnic minorities, men who have sex with men (MSM), and transgender and gender diverse people are at higher risk of STIs. Inequitable access to health insurance and physicians, language barriers, and distrust of medical systems because of discrimination account for some of these disparities, independent of individual sexual behavior.3,4 Other risk factors are reviewed in Table 1.2
| Age < 25 years Current sexually transmitted infection* Engaging in transactional sex* Having a new sex partner Having a sex partner with a current sexually transmitted infection Having a sex partner with other current partners Having multiple sex partners Inconsistent condom use Personal history of a sexually transmitted infection* Substance use (risk factor for men who have sex with men)* |
Taking a thorough sexual history is important to identify overall risk of infection, as well as anatomic site-specific risk factors. Physicians should create supportive spaces where patients feel safe sharing information by using open-ended questions; avoiding assumptions regarding sexual preferences, practices, and gender/sex; and normalizing diverse sexual experiences. To obtain a complete sexual history, the five P’s (partners, practices, pregnancy attitudes, previous STIs, and protection from STIs) model can be used as outlined in Table 2.2,5
| General questions | What are your pronouns? Do you think of yourself as male, female, transgender, or something else? What sex were you assigned at birth? Are there any words you would like me to use when we talk about specific body parts? Have you been sexually active in the past 12 months? |
| Partners | What gender do your partners identify as? How many sex partners have you had in the past two months? Past 12 months? Is it possible that any of your partners in the past 12 months were sexually active with someone else while they were sexually active with you? |
| Practices | How do you have sex? What parts do you use? For instance, some people engage in oral, rectal, or vaginal/frontal receptive sex. |
| Pregnancy attitudes | Would you like to have (more) children? If so, when do you think that might be? How important is it to you to prevent pregnancy? |
| Previous STIs | Have you ever had any STIs? |
| Protection from STIs | How do you protect yourself from STIs and HIV? Have you ever injected drugs? Have you ever been tested for STIs? Testing for STIs is recommended. Is it okay to do testing today? |
Prevention
The U.S. Preventive Services Task Force (USPSTF) recommends behavioral counseling on condom use, communication strategies for safer sex, and problem solving with those at increased risk of STIs.6 Adolescents and adults diagnosed with an STI in the past year, people reporting irregular condom use, and those with multiple partners or with partners belonging to a high-risk group are at increased risk. Physicians should emphasize barrier protection as the best way to prevent STIs.2
Screening
The USPSTF and Centers for Disease Control and Prevention (CDC) recommend annual screening for chlamydial and gonococcal infections to prevent infertility and pelvic inflammatory disease in sexually active people 24 years and younger with a cervix and in older people with a cervix who have risk factors.2,7 The CDC also recommends at least annual screening for MSM based on their risk factors. Screening should include the pharynx, urethra, and rectum based on reported anatomic sites of exposure. After discussion with the patient, it may be necessary to screen those sites even without reported exposure because of underreporting of sexual practices.2 Table 3 summarizes screening recommendations for chlamydial and gonococcal infections.2,8 There are significant gaps in research as it pertains to screening transgender and gender diverse patients.9 The CDC recommends screening based on an individual’s current anatomy and sexual practices.2
| Population | Age | Timing | Notes |
|---|---|---|---|
| Cisgender, heterosexual men | Insufficient evidence to recommend screening in this population | As needed | Consider screening high-risk populations, such as adolescents, patients in correctional facilities, and patients seen in sexually transmitted infection clinics |
| Cisgender men presenting to adolescent and sexually transmitted infection clinics | Young males | No evidence-based interval recommendation | — |
| High-risk* cisgender women, high-risk* transgender men, and nonbinary people with a cervix | ≥25 years | As needed | Retest three months after treatment Consider rectal screening for chlamydial and gonococcal infections and pharyngeal screening for gonococcal infection based on sexual behaviors and exposure |
| Pregnant people | ≤24 years ≥25 years if high risk* | At first prenatal visit Retest in third trimester if patient is high risk* or had a sexually transmitted infection during pregnancy | Test of cure four weeks after treatment and retest within three months |
| Men in correctional facilities | < 30 years | At intake with opt-out screening | — |
| Sexually active, cisgender women, transgender men, and nonbinary people with a cervix | ≤24 years | Annually | Retest three months after treatment Consider rectal screening for chlamydial and gonococcal infections and pharyngeal screening for gonococcal infection based on sexual behaviors and exposure |
| Sexually active men who have sex with men | All ages | Annually or every three to six months if high risk* | Urethral, rectal, and pharyngeal screening for gonococcal infection, based on anatomic site of exposure |
| Transgender/gender diverse | Screen based on anatomy and site of exposure | As needed | — |
| Women in correctional facilities | ≤35 years | At intake with opt-out screening | — |
Screening for urogenital infections only and neglecting pharyngeal and rectal sites of exposure will miss a substantial proportion of chlamydial and gonococcal infections.10 In one study of women who engaged in oral or anal sex with men, the prevalence of pharyngeal gonorrhea was 3.5%; rectal gonorrhea, 4.8%; and rectal chlamydia, 11.8%.10 Pharyngeal and rectal screening may be offered to people with female anatomy based on sexual practices and shared decision-making.2 Current evidence for screening extra-genital sites is strongest for MSM. Urine-only screening in an STI clinic misses 83% of infections among MSM.11 They should be screened at each anatomic site of sexual exposure, regardless of condom use, at least annually.2 Routine testing for chlamydial infections of the oropharynx is not recommended, but many laboratories will test for gonococcal and chlamydial infections simultaneously.2 If oropharyngeal chlamydia is diagnosed, it should be treated to decrease the risk of transmission.2
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