Elaine Smith, a 38-year-old English professor, visits her gynecologist’s office because she has been unable to conceive for four years following the removal of an intrauterine device. Elaine tells the office nurse that she and her husband of 12 years had delayed starting their family while they completed their doctoral degrees. She denies any past medical problems, but recalls six or seven sexual partners during her teenage years, when she didn’t practice any method of contraception.

Theresa Jones, a 19-year-old university student, comes into the school clinic with right lower quadrant pain of three days’ duration, weakness, and dizziness when standing up. She complains to the school nurse about pain during intercourse over the past two weeks, and that her menstrual period is three weeks late.

Robert Jackson, a 30-year-old divorced firefighter, registers at a local emergency department for treatment of burning on urination and an intermittent clear penile discharge. He privately discloses to the triage nurse that he is concerned that one of his sexual partners has suggested that he “get checked.”

Baby Sally, two days old, is vaginally delivered from a mother who abused intravenous drugs and received no prenatal care. The newborn nursery nurse notices drainage in both of the baby’s eyes, which have slightly inflamed sclera.

June Bowman, a 16-year-old high school student, comes to a family planning clinic for a routine gynecology exam. She has had three partners in the last year and occasionally uses condoms. She denies any abnormal vaginal discharge or abdominal pain.

Five distinctly different case scenarios, yet all should raise a high index of suspicion for the same causative pathogen — Chlamydia trachomatis.

A silent epidemic

The Centers for Disease Control and Prevention (CDC) ranked chlamydia infection first in prevalence among sexually transmitted diseases (STDs) in 1995 — the first year that chlamydia was included in the formal tracking of STDs. Recent statistical data from the CDC reveal a dramatic increase in the reported number of cases of chlamydial infection. From 1987 to 2004, the rate of chlamydial infection in women increased from 78.5 cases to 485 cases per 100,000 women.¹

Even more amazing is that due to the asymptomatic nature of this infection, an estimated 75% of females and 50% of males affected are undiagnosed and not represented in the statistical data.² Surprisingly, many nurses are unfamiliar with this infection, and its impact on individuals of reproductive age.

Chlamydia trachomatis is primarily a sexually transmitted bacteria that replicates inside the affected host cells of male and female genital tracts, ultimately resulting in cell destruction by lysis. The released intracellular products, known as elementary bodies (EB), infect adjacent cells and begin a new cycle. The average course of the cycle is 48 to 72 hours, with a majority of this time devoted to the destructive intracellular process. If left untreated in females, the disease spreads in an ascending fashion from cervix (cervicitis) to uterus (endometritis) to fallopian tubes (salpingitis). The cell lysis can result in scarring and cilia destruction in the fallopian tubes.² Once advanced beyond the cervix, symptomatic chlamydia infection is often classified as pelvic inflammatory disease (PID). Twenty percent of women who develop PID will become infertile, 18% will develop chronic pelvic pain, and 9% will experience an ectopic pregnancy.³

The problems and devastating outcomes are not confined to women. One study of adolescent males, ages 14-18, revealed that 4% were positive for chlamydial infection.⁴ This finding is significant because untreated young men are at risk for developing urethritis and epididymitis, potentially leading to sterility. More importantly, untreated asymptomatic men spread the infection unknowingly to their partners.

The organism has also been found in the lower gastrointestinal (GI) tract from anal intercourse, the oropharynx from oral sex, the eyes from direct secretion contact, and the respiratory tract as chlamydial pneumonitis.

Underreported

Demographic findings can guide health care practitioners in detecting chlamydia. For example, the highest incidence of this infection occurs in young adults, particularly those who have had sexual activity before the age of 20.⁵ Also, eight times as many black women and 12 times as many black men are diagnosed with chlamydia, which may be due to socioeconomic status, educational level, and access to health care screening.²

The CDC reports more than one million cases of chlamydia yearly, but the estimated incidence is 2.8 million.⁶ Some experts attribute the underestimation of the scope of the chlamydia problem to inaccurate data collection during interviews of health care personnel and poor compliance of individuals and institutions in reporting STDs, even though reporting chlamydia is mandatory in all 50 states.^2,5 In addition, evaluation and treatment of all sexual contacts 60 days before diagnosis is also recommended.⁵ Nevertheless, privately treated cases may not be reported in public health statistics. Also, many patients apparently do not seek treatment until discomfort or discharge from coexistent STDs compels them.

Young adults are disproportionately affected by STDs — of the 15 million STDs occurring annually in the U.S., four million are among adolescents and six million are among young adults.⁷

Yet, chlamydia often turns up in unexpected individuals. For example, recurrent infection may be a factor in women who delay childbearing and have fertility problems such as an inability to conceive or ectopic pregnancies.⁸ Newborns and children are not invulnerable to this pathogen. If a mother with active chlamydial cervicitis vaginally delivers, chlamydial conjunctivitis often results in the newborn.

When sexual abuse is suspected in a child, the caregivers must screen for chlamydial infections to reduce the risk of future reproductive problems. Concerns related to the child’s future fertility may be unaddressed or overshadowed by immediate physical and emotional needs, but should not be forgotten.⁹ The use of highly specific, not rapid bedside testing is recommended for victims of abuse, and maintaining a clear chain-of-custody for the specimens is crucial to assuring not only adequate screening, but also to support the integrity of physical evidence against the assailant.¹⁰

Reiter syndrome, a reactive type of arthritis accompanied by conjunctivitis, painless mucocutaneous lesions on the palms of the hands and the soles of the feet, urethritis in males, and cervicitis in females, is a rare complication of untreated chlamydial infections. The onset of reactive arthritis is quite rapid — within one to three weeks after chlamydial infection. Men are more likely to develop reactive arthritis — the male-to-female ratio is 5:1. The initial arthritic episode typically lasts three to four months, and rarely may last up to one year, with an asymmetrical pattern of joint involvement. While any joint may be affected, the lower extremities are the most common sites for chlamydial-related reactive arthritis.³

Dangerous impact of growing proportions

Chlamydia has left its mark on the nation — over $3 billion

is spent annually in the United States on the direct and indirect care of patients with this infection. Healthy People 2010, a vehicle for directing health care initiatives in the U.S., has set a goal to promote responsible sexual behaviors, strengthen community capacity, and increase access to quality services to prevent STDs and complications.¹¹

Because of chlamydia’s widespread prevalence and extensive fiscal and physical consequences, the CDC and the United States Preventive Services Task Force have established evidenced-based screening guidelines for the disease based on risk factors, including the number of partners, the use of barrier contraception, and the age at which sexual activity begins.¹² Evidenced-based screening recommendations have also been published for screening during pregnancy.¹³

Recent studies suggest that a relationship may exist between the cervical changes that occur with chlamydia infection and enhanced susceptibility to HIV.⁵ Clearly, behaviors that contribute to the incidence of chlamydia also increase the risk of HIV infection.^2,5 Therefore, interventions targeted at reducing chlamydia may actually be cost-effective measures that reduce HIV, and its personal, social, and economic burdens.

Poor patient compliance with antimicrobial therapy compounds problems of the asymptomatic nature of most chlamydia infections and a high incidence and recurrence rate.^2,5 Typically prescribed antibiotics require multiple daily dosages for seven to ten days and have side effects, mostly GI in nature, that often cause patients to not complete the entire dosage schedule. One-dose therapy with the antibiotic azithromycin (Zithromax) has reduced problems with compliance, yet the cost is much more than traditional therapy, placing this treatment beyond the reach of the population most at risk for the disease.⁵

A case with limited clues

The detection of chlamydia is fraught with hurdles. When the early stage of the infection involves cervicitis, women are often asymptomatic. When patients do experience symptoms, they may attribute them to a coexistent STD such as gonorrhea or a urinary tract infection (UTI). Chlamydial urethritis in males can be misdiagnosed as a UTI or gonorrhea, resulting in inadequate antimicrobial coverage being prescribed.

When making a differential diagnosis of chlamydia among other STDs, clinicians may use a process of elimination based on presented physical evidence. Abdominal or pelvic discomforts are not reliable indicators for chlamydia because all STDs can potentially cause these symptoms or mimic a UTI. However, in women, familiarity with characteristic vaginal secretions is a highly useful diagnostic tool. A mucopurulent cervical drainage without distinctive odor is characteristic of chlamydia. On the other hand, a profuse, foul- or fishy-smelling, yellow discharge and severe itching often evidence Trichomonas vaginitis. With bacterial vaginosis, the patient often complains of a moderate amount of grayish-white, fishy-smelling discharge. Candidiasis yeast infections present with intense itching and an odorless white discharge that resembles cottage cheese. The typical discharge of gonorrhea is thick, pus-like, and greenish-yellow in color, usually without itching.⁵ Some women will complain of vaginal bleeding not associated with menses, especially after intercourse. They may also report pain during intercourse. Both findings may be related to inflammation of the cervix.³

The primary evaluation for a chlamydia infection begins with a detailed history, including aspects of past and present sexual behaviors. When this infection is suspected, the nurse must ask highly personal questions in a nonjudgmental and nonthreatening manner to extract responses. The development of trust and a therapeutic relationship between the caregiver and patient is key to obtaining accurate information, compliance with therapy, and adoption of future preventative measures.

Often, the discovery of chlamydia is made during an infertility workup. Recent research indicates that it is worthwhile to have both partners screened for chlamydia. In one study, 9% of male partners of women with infertility screened positive for chlamydia, yet were asymptomatic.¹⁴

The clinician needs to obtain specimen cultures by cervical brush or swab for the female or urethral swab culture for the male. Laboratory transport media for chlamydia specimens vary, depending on the caregiver or facility’s preference. Some culture tubes contain media that require refrigeration. With a female patient, cervical specimen contamination or inadequate cervical cell samples can produce a false-negative result.

The order of specimen collection is important — when specimens for a Papanicolaou (PAP) smear are to be collected, the specimens for chlamydia should be collected first because bleeding that may interfere with testing may occur after the scraping of the cervix when the PAP specimen is obtained. When collecting a urethral specimen, it is ideal to wait at least an hour after the patient has last voided. All secretions and discharge should be wiped away before specimen collection. The urethral and endocervical collections are designed to dislodge fresh specimens — the desired sample for examination.¹⁰

The nurse must understand the importance of obtaining a properly collected and transported specimen for the accurate identification of the chlamydia organism. For the advanced chlamydia infection that may have progressed to PID, the gold standard for diagnosis is laparoscopic examination and culture of the fallopian tubes. This is a very costly procedure that is not routinely performed.

Techniques that incorporate DNA technology with urine examination have demonstrated a diagnostic sensitivity that ranges from 70% to 90% in the identification of the chlamydia trachomatis organism, as well as a reduction in discomfort and expense compared to present screening methods. These amplified DNA-probe testing methods are more sensitive, especially during pregnancy and can also be used to screen for gonorrhea.^5,10

Recently made available is a self-collection kit that screens for chlamydia and gonorrhea. The kit enables women to obtain a vaginal swab sample for laboratory analysis.¹⁰ Regardless of the technique, a positive screen for chlamydia should heighten suspicion of a coexistent STD, including HIV. The CDC, in fact, has recommended that when testing for chlamydia, gonorrhea testing should also be performed.⁵

Women who present with abdominal or pelvic pain may also need other diagnostic testing to rule out a UTI, kidney stones, bowel inflammation, appendicitis, or ectopic pregnancy. The nurse needs to provide explanations that are clear to the patient along with emotional support, since many of the procedures and exams are invasive and frightening.

When screening men for chlamydia, you’d expect to find a mild to moderate clear to white discharge that is best observed in the morning. The discharge may not be visibly apparent — to express, or “milk” a sample, pressure may need to be applied from the base of the penis to the glands. Any expressed discharge, however, should be wiped away before insertion of uretheral brushes. If they have been infected and remain untreated for a length of time, signs of epididymitis may be present, including unilateral testicular pain, scrotal edema and tenderness, and swelling over the epididymitis.³

The path to curing and caring

Many different antibiotic therapies are available for the treatment of chlamydia infection. After erythromycin, sulfisoxazole (Gantrisin), or amoxicillin, a follow-up culture should be obtained in four to six weeks to evaluate the effectiveness of therapy. Retesting is not necessary after treatment with doxycycline (Vibramycin) or azithromycin (Zithromax),⁵ unless symptoms persist. Retesting is recommended, however, in 3-4 months after treatment if a sexual partner of the treated individual failed to receive treatment.⁶

The most frequent side effects experienced with these antibiotics are nausea, vomiting, and diarrhea. Nursing measures should focus on educating patients about the importance of completing the antibiotic cycle, returning for a follow-up culture when indicated, and having sexual partners evaluated and treated to prevent reinfection. Teaching patients about compliance with their antibiotic regimen should also include instructions to avoid aluminum or magnesium liquid antacids (Maalox, Mylanta) because simultaneous ingestion can diminish absorption and effectiveness of the antibiotic. Some antibiotics, such as azithromycin, can affect the hepatic clearance of other medications. The nurse should caution patients who routinely take medications such as phenytoin (Dilantin), theophylline preparations, barbiturates, or coumadin to report any unusual side effects to their provider immediately, as absorption or excretion of these drugs may vary with antibiotic therapy.¹⁵

Closing the door on recurrent infection

Multiple controlled research studies have indicated that barrier contraception is the single most effective deterrent to chlamydia infection for the sexually active individual.⁵ Barrier contraceptives prevent sperm or seminal fluid from entering the cervical opening and include male and female condoms, the diaphragm, and the cervical cap. The diaphragm and the cervical cap must be used in combination with a spermicidal jelly for optimal effectiveness.

A health care provider needs to fit the diaphragm or the cervical cap and the patient should frequently inspect the device for defects in the integrity of the rubber or latex. The effectiveness of all barrier methods depends on commitment from patients and their partners in that the devices must be used with each incidence of sexual intercourse. Many individuals dislike the adjustment in spontaneity that all barrier methods require.

Nevertheless, patients must be fully educated about the proper use of these devices, including the concurrent use of spermicidal creams or jellies and the appropriate length of time the barriers must be left in place after intercourse. An improperly fitting or improperly used device cannot only pose a risk for pregnancy or STD transmission, but may increase the risk of vaginal trauma, irritation, UTIs, candida infections, and bacterial vaginosis. Repeated screening may be required if barrier protection is inconsistently or improperly used.⁵

Providers should discourage female patients from vaginal douching. Many women have difficulty understanding why this practice is not beneficial, particularly when vaginal discharge is present. Douching, which superficially cleanses and removes offensive odors and secretions, can facilitate the transport of pathogens from the lower reproductive structures of the vagina and cervix to the upper structures of the uterus, fallopian tubes, ovaries, and pelvic cavity and increase the risk of PID. The nurse needs to present information to the patient in a language and context that she can understand.

Good perineal hygiene should be emphasized, including the proper direction for wiping after a bowel movement (front to back), emptying the bladder before and after intercourse, frequent changing of menstrual tampons, and the avoidance of tight-fitting undergarments.

Obstacles need to be overcome in the development of a chlamydia vaccines. Chlamydia vaccines are still in the early stages of development. Chlamydia’s complexity and serological variations pose one of the challenges to vaccine development, as does determining the most cost-effective method for delivering the vaccine in order to mediate immunity.¹⁶

Nursing roles — teacher and therapist

Perhaps one of the most important roles nurses can have is in the area of primary prevention before risky sexual practices take place.^6,12 It’s especially important to address misconceptions, and stress that STDs can be contracted beginning with the very first sexual encounter.³

Chlamydia infection, and its potential complications with recurrence, present a challenge for nurses to use their patient education and psychosocial skills to deal with topics of a delicate and sometimes painful nature. The nurse needs to recognize that chlamydia infection may have a widespread impact on the patient that goes far beyond the treatment of an infectious organism. Patients often experience pain, fatigue, and intolerance to the necessary medications. Individuals may have difficulty coping with a socially unacceptable disease and feel helpless and socially isolated. Even their self-esteem may be damaged. In fact, research has indicated that low levels of self-esteem are associated with the risky behaviors that contribute to contracting STDs in the first place.¹⁷

The diagnosis of chlamydia can disrupt the relationship between patients and their partners, creating sexual dysfunction related to pain or fear of contagion and altering sexual patterns because of abstinence during initial antibiotic therapy. Abstinence is recommended for seven days after single-dose azithromycin therapy or for seven days after the last dose of multiple-day therapy.⁵ Resumption of intercourse should only take place after all partners are diagnosed and treated. Nurses must be ready to provide the necessary support and counseling.

Women with sexual partners who have not been treated are at high risk for reinfection after antibiotic therapy is completed. Women who continue to have intercourse with untreated partners should be retested for chlamydia three to four months after treatment. The CDC also recommends that women who are treated during pregnancy should be retested after treatment.⁵

The CDC recommends heightened caregiver and public awareness combined with structured screening programs for chlamydia proven effective in reducing the incidence of this disease. Also beneficial is annual screening for all sexually active adolescents in addition to all women ages 20 to 24 with new or multiple partners not using barrier contraception.⁵

Screening has proven beneficial not only to reduce the risk of devastating individual outcomes but also to provide a more realistic picture of how widespread the epidemic is. The CDC indicates that while the incidence of diagnosed cases of chlamydia has increased dramatically, the increase is most likely attributed to the identification of asymptomatic individuals through improved screening methods and recommended frequency for individuals at greatest risk.¹

Screening is particularly important in the southern and western U.S. regions where the incidence of chlamydia has increased. Aggressive screening and treatment programs in the northeastern U.S. region resulted in a decline in chlamydia’s incidence. The disease is now most prevalent in the southern region of the U.S.^2,18

Chlamydia is a silent time bomb with widespread impact on both sexually active individuals and the country as a whole. However, the financial impact and emotional devastation attributed to this organism can be controlled. Nurses, as first-line caregivers, are in a position to provide community education about preventative measures.