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

Health

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

Published

1 year ago

June 19, 2023

Harry Miller

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).

Box 1: Literature review

We conducted a targeted literature search of MEDLINE and Embase from inception to July 2022. Search terms included “Chlamydia trachomatis,” “Neisseria gonorrhoeae,” “sexually transmitted infection,” “STI,” “urethritis,” “cervicitis,” “pelvic inflammatory disease,” “proctitis,” “epididymitis,” “diagnosis,” “screening” and “treatment.” We limited the search to articles in English. Our targeted search focused on identifying clinical practice guidelines, systematic reviews and meta-analyses, although we did not place any formal restriction on article type. We selected relevant articles, and manually reviewed their references for additional articles.

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

View this table:

Table 1:

Approach to taking a sexual history^*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.

Genital symptoms

Urethritis is the most common syndrome in patients with a penis who are symptomatic. It is characterized by dysuria, urethral pruritis and discharge. Most cases of infectious urethritis are caused by C. trachomatis and N. gonorrhoeae or both. However, in almost half of cases of nongonococcal urethritis, no specific organism is identified despite extensive microbiological investigation (Box 2).14

Box 2: Infectious differential diagnosis of common clinical presentations of sexually transmitted infections

Urethritis

Neisseria gonorrhoeae
Chlamydia trachomatis
Mycoplasma genitalium
Trichomonas vaginalis
Neisseria meningitidis
Hemophilus spp.
Herpes simplex virus
Adenovirus

Cervicitis

Chlamydia trachomatis
Neisseria gonorrhoeae
Trichomoniasis
Herpes simplex virus
Mycoplasma genitalium
Bacterial vaginosis

Proctitis

Epididymitis

Patients can develop acute epididymitis from chlamydia or gonorrhea, which is characterized by unilateral, posterior testicular pain and swelling, often accompanied by symptoms of urethritis. Among men younger than 35 years, C. trachomatis and N. gonorrhoeae are the most common causative organisms, but among older men and men who engage in insertive anal intercourse, causative agents can include enteric organisms like Escherichia coli.15

Although cervicitis is often asymptomatic, symptoms may occur and include abnormal vaginal discharge or intermenstrual bleeding.16 Findings on physical examination include purulent endocervical discharge or sustained endocervical bleeding. Most cases of cervicitis have no identified cause. In as many as 25% of cases, C. trachomatis or N. gonorrhoeae is identified.17 In around 15% of female patients, pelvic inflammatory disease can develop, characterized by abdominal or pelvic pain, dyspareunia or abnormal uterine bleeding, with findings of cervical motion or adnexal tenderness on physical examination.18 Patients may have infertility as a consequence of pelvic inflammatory disease. An uncommon complication of pelvic inflammatory disease is Fitz–Hugh–Curtis syndrome, characterized by right upper quadrant pain related to inflammation of the liver capsule.17

Extragenital symptoms

Proctitis caused by chlamydia or gonorrhea may present with tenesmus, anorectal pain, bleeding and mucopurulent discharge. These infections typically occur in patients who engage in receptive anal sex, but can also be transmitted from the vagina to the anal canal.19 Chlamydia trachomatis and N. gonorrhoeae are the most commonly identified pathogens in cases of infectious proctitis.20

The lymphogranuloma venereum (LGV) serovars (L1, L2, L3) of C. trachomatis can cause invasive infections that preferentially affect lymphatic tissue. Lymphogranuloma venereum can present as small painless ulcers or painful hemorrhagic proctitis, with complications including anal fistulae and strictures.21 In the last 2 decades, LGV has emerged as an important cause of proctitis among men who have sex with men (MSM) in North America and Europe.22

Oropharyngeal infections with gonorrhea are commonly asymptomatic, although patients can present with sore throat, pharyngeal exudate or cervical lymphadenitis.23 Chlamydia is not an important cause of pharyngitis.24

Although uncommon, gonorrhea infection can cause bacteremia, leading to septic arthritis or disseminated gonococcal infection, with tenosynovitis, dermatitis or polyarthralgias.23 Reactive arthritis — characterized by polyarthritis, conjunctivitis or uveitis, and urethritis or cervicitis — can occur after an infection with chlamydia or gonorrhea, although chlamydia is the more common inciting infection.25

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.

How should patients be tested?

In asymptomatic patients, approaches to sample collection for nucleic acid amplication testing (NAAT) for chlamydia and gonorrhea include a first-void urine (first 10–20 mL, any time of day, at least 1 hour since previous void) or vaginal swab; other options include a urethral or cervical swab (Table 2). In patients with a vagina, a vaginal swab is preferred over first-void urine, as urine testing may detect 10% fewer infections.31 Those with a neovagina or gender-affirming penile reconstruction should provide a urine sample for NAAT. Extragenital testing options include a pharyngeal or rectal swab for chlamydia and gonorrhea NAAT. In symptomatic patients, first-void urine and swabs of sites of reported symptoms should be collected for chlamydia and gonorrhea NAAT, and for gonorrhea culture and sensitivity testing. Patient-collected swabs are acceptable, as studies have shown equivalence between self-and clinician-collected oral, vaginal and rectal swabs for chlamydia and gonorrhea testing.32^,33 Self-collection may also improve uptake of STI screening.13^,24

View this table:

Table 2:

Testing for chlamydia and gonorrhea

Clinicians should refer to their local microbiology laboratories for recommendations on collection and transport protocols in their region. First-void urine can be collected in a sterile urine container for chlamydia and gonorrhea NAAT. The swabs contained within chlamydia and gonorrhea NAAT kits can be used on the cervix, urethra, vagina, throat or rectum; swabs from these sites can also be sent for gonorrhea culture. Bacterial culture for chlamydia is not routinely performed in Canada.13

Genotyping of LGV serovars can be requested if a patient presents with a syndrome consistent with LGV.13 Some Canadian jurisdictions will automatically test all positive rectal chlamydia swabs for LGV serovars. However, it is important to indicate suspicion for LGV on laboratory requisitions, as automatic LGV testing is not universal, and nonrectal specimens (e.g., genital ulcers) are not automatically tested.

How should patients be treated?

Gonorrhea

Treatment of gonorrhea is challenging, as it readily develops antimicrobial resistance, and guidelines are not congruent in their recommendations. The Canadian STI guideline recommends dual therapy with ceftriaxone or cefixime, plus azithromycin or doxycycline (Table 3).13 The STI treatment guideline from the United States Centers for Disease Control and Prevention (CDC) increased the previously recommended ceftriaxone dose (Table 3).24 The CDC also recommended against dual therapy based on increasing antimicrobial resistance, and concern for impacts on the microbiome and selective pressure on other pathogens.24 It is likely that this approach will be adopted by guidelines from other jurisdictions in the future. If monotherapy with ceftriaxone is used, an increased dose of ceftriaxone is recommended, compared with that used in dual therapy (Table 3).24 Currently, given varying recommendations, clinicians should follow local guidance, which will be based on resistance patterns in their area.

View this table:

Table 3:

Treatment of chlamydia and gonorrhea

Chlamydia

The Canadian STI guideline recommends doxycycline or azithromycin as the first-line (preferred) treatment for chlamydia,13 whereas the CDC recommends doxycycline as first-line treatment, with azithromycin as a second-line (alternate) regimen (Table 3).24 The preference for doxycycline is based on a systematic review and meta-analysis comparing treatment with azithromycin and doxycycline for chlamydia, which found that treatment failed more often with azithromycin, particularly among men with rectal chlamydia.34^,35 Thus, doxycycline is the preferred agent for treating rectal chlamydia. If adherence to therapy is a concern, single-dose azithromycin may be preferred. For pregnant patients, azithromycin is the first-line treatment.13 For patients with suspected or confirmed LGV, treatment with doxycycline should be continued for 21 days.13

Other treatment considerations

Given the potential complexity of cases and the evolving treatment landscape, providers should consult with an expert in STI management when necessary. All patients being treated for chlamydia or gonorrhea should be strongly advised to abstain from sexual activity for 7 days after treatment and until all partners have been treated.13 Sexual partners from the previous 60 days should be tested and treated, or offered expedited partner treatment (i.e., clinicians can provide empiric treatment for the patient to give to their partner), which has been found to reduce the rates of recurrent or persistent infection.36 Details around indications and timing of tests of cure are discussed in Table 3. Tests of cure and repeat screening recommendations are often not followed, although they remain important for the appropriate care of the patient and to decrease transmission.37

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.

Acknowledgements

The authors gratefully acknowledge that they live and work on the ancestral, traditional and unceded territory of the Coast Salish peoples, including the Musqueam, Squamish and Tsleil-Waututh Nations.

Footnotes

Competing interests: Troy Grennan is Vice-chair of the Public Health Agency of Canada’s National Advisory Committee on Sexually Transmitted and Blood-Borne Infections and holds a Health Professional Investigator Award from Michael Smith Health Research BC. No other competing interests were declared.
This article has been peer reviewed.
Contributors: All of the authors contributed to the conception and design of the work. Clara Van Ommen drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

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Several Vitamins Recalled Due to Potential Metal Contamination, Including Products Sold at Costco and Walmart

Published

2 days ago

July 22, 2024

Harry Miller

Several types of vitamins, including some popular brands sold at major retailers like Costco and Walmart, are being recalled due to the possible presence of metal fibers. Health Canada issued three recall statements on Friday, highlighting the affected products and advising consumers on the necessary steps.

Among the brands involved in the recall is Kirkland Signature, a staple at Costco, along with Webber Naturals and other brands sold at multiple retailers across Canada, including Walmart and Shoppers Drug Mart.

The vitamins listed in the recall are:

Kirkland Signature: B100 Complex Timed Release
Life: Vitamin B Complex with Vitamin C
Option+ & Life: Prenatal Multi-vitamins 100 Tablets with Folic Acid, Spectrum Prenatal Postpartum, Multivitamins & Minerals Women, Spectrum Women 22 Vitamins & Minerals plus Lutein, Lycopene
Webber Naturals: B50 Complex Timed Release, Most Complete Multi Womens 50+ One Per Day, Most Complete Multi Mens 50+ One Per Day, Vitamin B50 Complex
Wellness by London Drugs, Option+ & Life: Multi Women/Femmes 50+ with Lycopene and Lutein Multivitamin and Mineral, Multivitamin & Minerals Women 50+, 50+ SPECTRUM Women/Femmes 50+ 23 Vitamins & Minerals plus Lutein, Lycopene
Wellquest, Equate, Option+, Wellness by London Drugs & Life: Vitamin B100 Complex, Timed Release
Natural Factors: Hi Potency B Complex, RevitalX, Super Multi® IRON FREE
VegiDay Vegan Organic ALL IN ONE: VegiDay Vegan Organic ALL IN ONE

Health Canada advises consumers who have purchased any of the affected products to consult their healthcare provider before discontinuing use and to monitor for any health concerns.

Customers with concerns or questions can contact the recall firm directly. Additionally, any side effects or health product safety complaints should be reported to Health Canada.

For more detailed information, you can access the three Health Canada notices, which are listed under the Factors Group of Nutritional Companies Inc. recall, on the Health Canada website.

This recall serves as a reminder to consumers to stay vigilant about product safety and to follow recall advisories to ensure their health and well-being.

Health

8 Tips for Incorporating More Fruits into Your Dessert

Published

2 days ago

July 22, 2024

Harry Miller

Incorporating more fruits into your desserts is not just a way to enhance flavours, but also a smart approach to add nutritional value to your treats. While desserts are often indulged as guilty pleasures, introducing fruits can transform these moments into healthier delights, enriching them with vitamins, minerals, and fibres. Whether you’re a home cook looking to improve your family’s diet or a culinary expert aiming to innovate your menu, adding fruits offers a myriad of benefits. These range from boosting the aesthetic appeal of your dishes with vibrant colours to enhancing the natural sweetness with a lower calorie count.

The tips provided here will help you seamlessly integrate more fruits into your dessert recipes, making them irresistibly wholesome and appealing to all ages. This approach not only caters to the health-conscious consumer but also opens up a palette of fresh, tantalizing flavours that can redefine what dessert means.

Explore Variety

Diversity is key in enriching desserts with fruits. Experiment with different textures and flavours, from berries to tropical fruits. This variety ensures each bite is unique and delightful. Try combining sour cherries with sweet mangoes, or add citrus segments to balance richer desserts. Even blending frozen bananas into a creamy texture can mimic ice cream. Consider adding a double fudge bar frozen dessert to your fruit platter for an indulgent twist.

Use Fresh and Seasonal Fruits

Seasonal fruits offer the best in flavour and nutrition. Incorporate fresh, local produce into your desserts to capture peak tastiness. Fresh strawberries or peaches can elevate simple dishes like ice cream or cakes. Local farmers’ markets are ideal for finding the freshest options. Remember, the closer the fruit is grown to its consumption point, the more nutrients it retains. This approach supports local agriculture as well.

Make Fruit the Star

Create desserts where fruits are the main attraction. Dishes like fruit tarts or berry-packed pavlovas highlight the natural sweetness of fruits, reducing the need for added sugars. Let fruits dictate the dessert’s flavour profile and design, focusing on the natural colours to attract the eye. This strategy can make even simple dishes feel luxurious and crafted with care. Plus, it often leads to lighter, less calorie-dense desserts.

Opt for Healthier Preparations

Instead of always baking or frying, try raw preparations or use healthier cooking methods like grilling or poaching. Grilled pineapple or poached pears offer a delightful texture and are easy to prepare. These methods preserve the integrity and nutritional value of the fruit better than baking or frying. Cooking fruit in this way can also unlock new flavours, enhancing your dessert experience. Try brushing fruit with a little honey or maple syrup before grilling for a caramelized finish.

Experiment with Spices

Spices can enhance the natural flavour of fruits. A dash of cinnamon, cardamom, or vanilla complements fruits like apples and pears beautifully, adding complexity to any dessert. Nutmeg and ginger are also excellent with juicy fruits like peaches and plums. Experimenting with spices can transform a simple fruit dish into an exotic and enticing dessert. Such additions are simple but effective ways to elevate the taste without added sugar.

Incorporate Dried Fruits

Dried fruits are concentrated in flavour and can be a great addition to desserts. Sprinkle raisins, dried cranberries, or chopped dates over oatmeal cookies or mix them into homemade granola bars for a chewy texture. Dried fruits work well in baked goods because they provide a burst of sweetness and texture. They are also perfect for decorating cakes and adding to snack mixes. Be mindful of the sugar content in store-bought dried fruits, opting for unsweetened varieties when available.

Create Colourful Fruit Layers

Layer fruits in parfaits, trifles, or cakes to create visually appealing and delicious desserts. Layers of colourful fruits not only look spectacular, but also offer varied flavours and textures. This layering technique can be applied in smoothie bowls and gelatin desserts for a stunning visual effect. Try to choose fruits that contrast in colour and texture for the most striking presentations. These desserts are particularly appealing to children and can make eating fruit more exciting for them.

Finish with A Healthy Twist

Top off your desserts with a nutritious twist, such as a dollop of Greek yogurt or a sprinkle of nuts and seeds for extra crunch and nutrients. These additions provide a contrast in textures and increase the health benefits of your dessert. Nuts add healthy fats and proteins, making the dessert more satisfying. Consider using a drizzle of natural sweeteners like honey or agave nectar to enhance flavour without resorting to refined sugars. Such finishes not only improve taste but also boost nutritional value, aligning with a healthier lifestyle.

Incorporating fruits into your desserts is an enjoyable way to make your sweet dishes healthier and more flavourful. By using fruits in various forms, from frozen to dried, and employing them in creative ways, such as natural sweeteners or vibrant toppings, you can transform any dessert into a delightful and nutritious treat. So next time you prepare a dessert, remember these tips and enjoy the added benefits of fruits in your culinary creations.

Health

5 Life-Transforming Tips to Make it More Fun-Filled

Published

2 days ago

July 22, 2024

Harry Miller

Everyone wants to make the most out of life. From personal life to establishing a successful career, enjoyment is all that people crave the most. But the key to happiness is having fun most of the time. It can be challenging to find time and moments of fun in the routine as life becomes boring and dull for many.

However, you can cultivate your mindset and embrace more pleasure and laughter in your everyday routine. To transform your boring and dull life into a fun-filled one, here are a few tips that you can consider in this blog.

Read on to explore!

1. Start Enjoying Little Moments

The fun doesn’t need to come from an extensive and spectacular event happening around your life all the time. There are so many small moments in your life that can turn into more fun. All you have to do is embrace those little times in your life and be happy.

For example, you can give yourself a little break from a hectic day and enjoy some chocolate. Or you can make time to enjoy things that you like.

2. Be Spontaneous In Life

Just like life becomes unexpected most of the time, you can be a little unpredictable with it as well. To bring fun to your life, you can work on being more open to new and unplanned experiences.

If you get an invitation for any activity, event, or sport, don’t say no to it. Getting to indulge in more social activities will help you create new memories and experience new thrills in life.

3. Bring a Furry Friend in Life

A boring life can easily distance you from fun. To embrace joy in life, having a furry company can do wonders. You can cherish love and warmth and have little moments of joy with a furry one.

If you don’t have a furry companion, you’re majorly missing joy. It’s time for you to look for the best puppy-selling company, such as Fou Fou Puppie’s website, to bring a cute puppy into your life.

4. Practice Mindfulness

Practicing mindfulness will help you to live the present to the fullest. As most people worry more about their future, it makes them overlook the current joys of life.

What you can consider best to bring fun to your life is practicing mindfulness for at least 2 minutes. Let go of all the thoughts that pop into your head and focus on the positive aspects of living.

5. Participate More in Fun Activities

There should be no excuse for having fun in life as there are many low-cost fun activities for the community that you can explore to have fun. It can be simple, but it prevents you from living a boring and less-inspiring life.

For example, you can call your group of friends to have coffee together and share more laughter, or you can go to the movies to unwind yourself. These activities will not cost you a fortune and allow you to make the most out of your day, week, and month.