A practical approach to the diagnosis and management of chlamydia and gonorrhea

KEY POINTS

• The incidence of chlamydia and gonorrhea, 2 common sexually transmitted infections, is increasing.

• Annual asymptomatic screening for chlamydia and gonorrhea should be performed in all sexually active patients younger than 30 years, with more frequent screening for higher risk patients.

• Nucleic acid amplification testing for chlamydia and gonorrhea should be performed in both asymptomatic and symptomatic patients at sites of sexual exposure, guided by a careful sexual history.

• The treatment recommendations for chlamydia and gonorrhea are evolving and clinicians should follow local guidance.

• Antimicrobial resistance in gonorrhea is increasing; optimal treatment should be guided by principles of antimicrobial stewardship.

The 2 most frequent reportable bacterial sexually transmitted infections (STIs) worldwide and in Canada are those caused by Chlamydia trachomatis and Neisseria gonorrhoeae.1^,2 Rates of both infections have been increasing over the last decade despite public health efforts aimed at prevention, testing and treatment. In 2019, 139 389 cases of chlamydia and 35 443 cases of gonorrhea were reported in Canada, an increase of 33.1% and 181.7%, respectively, since 2010.2 These increases may reflect improved diagnostics, increased screening and contact tracing or a true increase in incidence.2

Sexually transmitted infections have a substantial impact on affected individuals and communities. Chlamydia trachomatis and N. gonorrhoeae are commonly implicated pathogens in pelvic inflammatory disease and, if untreated, can lead to infertility.3 Infection with a bacterial STI is associated with increased risk of HIV acquisition or transmission.4 Perinatal transmission of C. trachomatis and N. gonorrhoeae can lead to ophthalmia neonatorum in infants, among other pathologies.5 Treatment has become more challenging, given the increase in antimicrobial resistance in gonorrhea.6

We summarize the management of chlamydia and gonorrhea in primary care as health care providers work collectively toward the goal of decreasing the frequency of these infections and reducing associated morbidity through appropriate treatment. We draw on evidence from clinical practice guidelines, systematic reviews and meta-analyses (Box 1).

Why is taking a good sexual history important?

Taking a sexual history is essential to comprehensive care in patients presenting with STI symptoms and in asymptomatic people to assess for STI risk, determine the need for screening, address concerns and provide sexual health education.

Patients have reported wanting their health care provider to inquire about sexual health, but many face considerable barriers to self-disclosure of their sexual history.7^,8 Stigma is often associated with STIs. Providers conducting a sexual history should do so in a nonjudgmental, patient-centred and trauma-informed manner.9 Syndemics theory describes how disease interacts with social constructs, which can help conceptualize how a person’s unique social, cultural and health context influences how they access STI care.10 Establishing the patient’s pronouns, sexual orientation and gender identity is necessary to create an environment of respect and trust. The components of a sexual history can be remembered by the 5 Ps: partners, practices, protection, past history and pregnancy (Table 1).11

What are common clinical presentations?

Most chlamydia and gonorrhea infections cause no symptoms.12 If symptoms develop, the incubation period for gonorrhea is 2–7 days, compared with 2–6 weeks for chlamydia.13 Chlamydia and gonorrhea may have genital or extragenital symptoms, which are generally reflective of the site of infection. The clinical presentations of chlamydia and gonorrhea overlap, and they are usually clinically indistinguishable.

Who should be screened for infection?

Opportunistic screening is critical in identifying asymptomatic chlamydia and gonorrhea infections. The Canadian Task Force on Preventive Health Care recommends annual opportunistic screening for chlamydia and gonorrhea in all sexually active people younger than 30 years.26 Although based on low-quality evidence, an opportunistic approach to screening is likely to increase the number of STIs diagnosed and destigmatize sexual health conversations.

More frequent screening should be offered to people at higher risk of acquiring STIs, although little evidence exists to guide the optimal frequency of screening. Among MSM, current guidance suggests, at minimum, anatomic site-based screening for chlamydia and gonorrhea annually.13^,24 More frequent screening (i.e., every 3–6 months) is recommended for at-risk people of any gender within groups who may be disproportionately affected by STIs, including those taking HIV pre-exposure prophylaxis (PrEP), those who have recently had an STI, those living with HIV or those with multiple sexual partners.13^,24^,27 One cohort study of 557 MSM and transgender women taking HIV PrEP found that semiannual STI screening would have led to delayed diagnosis in more than 30% of patients with chlamydia or gonorrhea, compared with quarterly screening.28 Pregnant patients should be screened at their first prenatal visit, with rescreening in the third trimester if they initially test positive for or are at ongoing risk of STIs.13^,24

Clinicians should determine appropriate anatomic sites for screening based on information from the sexual history, although they should consider screening extragenital sites (i.e., rectum and oropharynx), even in the absence of either reported symptoms or sexual exposures. Studies of people attending STI clinics have found that a considerable proportion of STIs are missed when STI testing is conducted only for patients with reported symptoms or on sites with known exposure, or when testing includes only urine.29^,30 Testing for gender-diverse patients will depend on their specific anatomy.

What about antimicrobial resistance?

Globally and in Canada, rates of antimicrobial resistance in N. gonorrhoeae are increasing, with decreasing susceptibility to cephalosporins and azithromycin.6^,38 In Canada, between 2012 and 2016, the proportion of multidrug resistant N. gonorrhoeae increased from 6.2% to 8.9%, with most isolates identified in Ontario and Quebec.39 Actions that clinicians can take to combat antimicrobial resistance are to perform gonorrhea culture and sensitivity testing when possible to limit unnecessary antimicrobial use, and to forgo dual therapy for gonorrhea when chlamydia is excluded. Whether the widespread discontinuation of dual therapy for gonorrhea would negatively affect clinical outcomes or prevent antimicrobial resistance has not yet been established, however. Treatment can be delayed until test results are available in situations where reliable patient follow-up is likely. In cases of confirmed or suspected multidrug-resistant N. gonorrhoeae, clinicians should consider consulting an expert in the management of STIs.

Conclusion

Chlamydia and gonorrhea are the most common bacterial STIs in Canada, and their incidence is increasing.2 Most infections are asymptomatic, which highlights the importance of routine screening for people who are sexually active.26 Screening and diagnostic testing in symptomatic patients should be guided by a comprehensive sexual health history, which also provides an opportunity for patient education around sexual health. However, the optimal screening frequency in different populations remains unclear. With increasing rates of antimicrobial resistance, treatment should be guided by adherence to the principles of antimicrobial stewardship.