Chlamydial and Gonococcal Infections: Screening, Diagnosis, and Treatment

Nicole Yonke; Miranda Aragón; Jennifer K. Phillips

NICOLE YONKE, MD, MPH, MIRANDA ARAGÓN, MD, AND JENNIFER K. PHILLIPS, MD

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.

This clinical content conforms to AAFP criteria for CME.

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

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

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

Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2019. U.S. Department of Health and Human Services; 2021. Accessed November 28, 2021. https://www.cdc.gov/std/statistics/2019/default.htm

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.

Lieberman JA, Cannon CA, Bourassa LA. Laboratory perspective on racial disparities in sexually transmitted infections. J Appl Lab Med. 2021;6(1):264-273.

Hamilton DT, Morris M. The racial disparities in STI in the U.S.: concurrency, STI prevalence, and heterogeneity in partner selection. Epidemics. 2015;11:56-61.

Savoy M, O’Gurek D, Brown-James A. Sexual health history: techniques and tips. Am Fam Physician. 2020;101(5):286-293. Accessed November 28, 2021. https://www.aafp.org/afp/2020/0301/p286.html

Krist AH, Davidson KW, Mangione CM, et al. Behavioral counseling interventions to prevent sexually transmitted infections: US Preventive Services Task Force recommendation statement. JAMA. 2020;324(7):674-681.

Cantor A, Dana T, Griffin JC, et al. Screening for chlamydial and gonococcal infections: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;326(10):957-966.

Farley TA, Cohen DA, Elkins W. Asymptomatic sexually transmitted diseases: the case for screening. Prev Med. 2003;36(4):502-509.

Van Gerwen OT, Jani A, Long DM, et al. Prevalence of sexually transmitted infections and human immunodeficiency virus in transgender persons: a systematic review. Transgend Health. 2020;5(2):90-103.

Bamberger DM, Graham G, Dennis L, et al. Extragenital gonorrhea and chlamydia among men and women according to type of sexual exposure. Sex Transm Dis. 2019;46(5):329-334.

Marcus JL, Bernstein KT, Kohn RP, et al. Infections missed by urethral-only screening for chlamydia or gonorrhea detection among men who have sex with men. Sex Transm Dis. 2011;38(10):922-924.

Tomas ME, Getman D, Donskey CJ, et al. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol. 2015;53(8):2686-2692.

Shipman SB, Risinger CR, Evans CM, et al. High prevalence of sterile pyuria in the setting of sexually transmitted infection in women presenting to an emergency department. West J Emerg Med. 2018;19(2):282-286.

Farrukh S, Sivitz AB, Onogul B, et al. The additive value of pelvic examinations to history in predicting sexually transmitted infections for young female patients with suspected cervicitis or pelvic inflammatory disease. Ann Emerg Med. 2018;72(6):703-712.e1.

Mayor MT, Roett MA, Uduhiri KA. Diagnosis and management of gonococcal infections [published correction appears in Am Fam Physician. 2013;87(3):163]. Am Fam Physician. 2012;86(10):931-938. Accessed September 22, 2021. https://www.aafp.org/afp/2012/1115/p931.html

Lunny C, Taylor D, Hoang L, et al. Self-collected versus clinician-collected sampling for chlamydia and gonorrhea screening: a systemic review and meta-analysis. PLoS One. 2015;10(7):e0132776.

Rönn MM, Mc Grath-Lone L, Davies B, et al. Evaluation of the performance of nucleic acid amplification tests (NAATs) in detection of chlamydia and gonorrhoea infection in vaginal specimens relative to patient infection status: a systematic review. BMJ Open. 2019;9(1):e022510.

U.S. Food and Drug Administration. FDA news release: FDA clears first diagnostic tests for extragenital testing for chlamydia and gonorrhea. May 23, 2019. Accessed March 10, 2021. https://www.fda.gov/news-events/press-announcements/fda-clears-first-diagnostic-tests-extragenital-testing-chlamydia-and-gonorrhea

Kersh EN, Shukla M, Raphael BH, et al. At-home specimen self-collection and self-testing for sexually transmitted infection screening demand accelerated by the COVID-19 pandemic: a review of laboratory implementation issues. J Clin Microbiol. 2021;59(11):e0264620.

Van Der Pol B, Taylor SN, Mena L, et al. Evaluation of the performance of a point-of-care test for chlamydia and gonorrhea. JAMA Netw Open. 2020;3(5):e204819.

Gaydos CA, Ako MC, Lewis M, et al. Use of a rapid diagnostic for Chlamydia trachomatis and Neisseria gonorrhoeae for women in the emergency department can improve clinical management: report of a randomized clinical trial. Ann Emerg Med. 2019;74(1):36-44.

Dombrowski JC, Wierzbicki MR, Newman LM, et al. Doxycycline versus azithromycin for the treatment of rectal chlamydia in men who have sex with men: a randomized controlled trial. Clin Infect Dis. 2021;73(5):824-831.

Mishori R, McClaskey EL, WinklerPrins VJ. Chlamydia trachomatis infections: screening, diagnosis, and management. Am Fam Physician. 2012;86(12):1127-1132. Accessed September 22, 2021. https://www.aafp.org/afp/2012/1215/p1127.html

Geisler WM, Lensing SY, Press CG, et al. Spontaneous resolution of genital Chlamydia trachomatis infection in women and protection from reinfection. J Infect Dis. 2013;207(12):1850-1856.

St Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916.

American Academy of Family Physicians. Expedited partner therapy. Accessed August 1, 2021. https://www.aafp.org/about/policies/all/expedited-partner-therapy.html

Centers for Disease Control and Prevention. Expedited partner therapy. U.S. Department of Health and Human Services; 2021. Accessed November 27, 2021. https://www.cdc.gov/std/ept/default.htm

Centers for Disease Control and Prevention. Guidance on the use of expedited partner therapy in the treatment of gonorrhea. U.S. Department of Health and Human Services; 2021. Accessed November 27, 2021. https://www.cdc.gov/std/ept/gc-guidance.htm

He W, Jin Y, Zhu H, et al. Effect of Chlamydia trachomatis on adverse pregnancy outcomes: a meta-analysis. Arch Gynecol Obstet. 2020;302(3):553-567.

Vallely LM, Egli-Gany D, Wand H, et al. Adverse pregnancy and neonatal outcomes associated with Neisseria gonorrhoeae: systematic review and meta-analysis. Sex Transm Infect. 2021;97(2):104-111.

Curry SJ, Krist AH, Owens DK, et al. Ocular prophylaxis for gonococcal ophthalmia neonatorum: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2019;321(4):394-398.

Baker CJ. Red Book: Atlas of Pediatric Infectious Diseases. 4th ed. American Academy of Pediatrics; 2020.

Car J, Koh GCH, Foong PS, et al. Video consultations in primary and specialist care during the COVID-19 pandemic and beyond. BMJ. 2020;371:m3945.

Fajardo-Bernal L, Aponte-Gonzalez J, Vigil P, et al. Home-based versus clinic-based specimen collection in the management of Chlamydia trachomatis and Neisseria gonorrhoeae infections. Cochrane Database Syst Rev. 2015;(9):CD011317.

Carnevale C, Richards P, Cohall R, et al. At-home testing for sexually transmitted infections during the COVID-19 pandemic. Sex Transm Dis. 2021;48(1):e11-e14.

Chow EPF, Bradshaw CS, Williamson DA, et al. Changing from clinician-collected to self-collected throat swabs for oropharyngeal gonorrhea and chlamydia screening among men who have sex with men. J Clin Microbiol. 2020;58(9):e01215-20.

Miller KE. Diagnosis and treatment of Neisseria gonorrhoeae infections. Am Fam Physician. 2006;73(10):1779-1784. Accessed September 22, 2021. https://www.aafp.org/afp/2006/0515/p1779.html

Miller KE. Diagnosis and treatment of Chlamydia trachomatis infection [published correction appears in Am Fam Physician. 2008;77(7) 920]. Am Fam Physician. 2006;73(8):1411-1416. Accessed September 22, 2021. https://www.aafp.org/afp/2006/0415/p1411.html

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?

Risk Factors

Prevention

Screening

Continue Reading

More in AFP

More in Pubmed

Risk Factors

Prevention

Screening

Subscribe

Issue Access

Article Only

Continue Reading

More in AFP

More in Pubmed