This is the current release of the guideline.

Chlamydia trachomatis infection

Prevention
Screening

Family Practice
Internal Medicine
Obstetrics and Gynecology
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Allied Health Personnel
Nurses
Physician Assistants
Physicians
Public Health Departments

To present a practice policy statement on screening for Chlamydia trachomatis

Women and men who are sexually active, particularly females between the ages of 15 and 24 and all pregnant women

1. Assessment of risk factors for Chlamydia trachomatis infection in all sexually active women
2. Screening for Chlamydia trachomatis using cervical or urine specimens by:
   • Culture
   • Immunoassay, such as enzyme immunoassay (EIA) with positive confirmation, rapid office-based immunoassay), or direct immunofluorescent antibody (DFA)
   • Deoxyribonucleic acid (DNA) probe
   • DNA amplification, such as polymerase chain reaction (PCR), ligase chain reaction (LCR), or amplified DNA probe (strand displacement amplification)
   • Ribonucleic acid (RNA) amplification, such as transcription-mediated amplification (TMA)
   • Dipstick, such as leukocyte esterase with "trace cutoff"
3. Screening pregnant women for Chlamydia

• Sensitivity and specificity of chlamydia testing methods
• Prevalence of Chlamydia trachomatis infections
• Prevalence of pelvic inflammatory disease caused by Chlamydia trachomatis
• Rate of preterm contractions, premature rupture of membranes, low birth weight, fetal and infant morbidity and mortality associated with Chlamydia trachomatis infections
• Cost-effectiveness of screening procedures

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The guideline developer performed a Medline search and used the reference lists from key articles to collect evidence.

Not stated

Subjective Review

Not stated

Review

Not stated

Not stated

Not applicable

The cost-effectiveness of screening for Chlamydia trachomatis depends on its prevalence in the population being screened. Moreover, it is affected by the cost and accuracy (sensitivity and specificity) of the screening test. Although optimal screening strategies vary in different populations, the economic benefit to society of screening compared to no screening has been demonstrated in several cost-effectiveness analyses. One study compared culture, nonculture nonamplification, and amplification methods in a large population of women aged <30 years. Screening with any method was cost saving compared with a no-screening strategy. A screening strategy combining the use of deoxyribonucleic acid (DNA) amplification on cervical specimens in women receiving pelvic examinations and DNA amplification of urine in other women prevented the most cases of pelvic inflammatory disease (PID) and provided the most savings. Another study compared three screening strategies—screening according to Centers for Disease Control and Prevention (CDC) criteria (testing all women with mucopurulent cervicitis, all women <20 years of age, as well as testing all women >20 years who have not consistently used barrier contraception or have had a new sex partner or >1 sex partner during the past 90 days); screening all women <30 years of age; and universal screening of women. The results suggested that age-based screening provided the greatest cost savings. Similarly, a recent study compared targeted screening of women aged <25 years with universal screening and universal empiric antibiotic treatment in female military recruits. Targeted screening by age provided the greatest cost savings. Another recent study compared screening women aged 15 to 19 years using the enzyme immunoassay (EIA) method or DNA hybridization probe with a no-screening strategy. The prevalence of infection in this population was 12.6%, and DNA-probe screening proved to be most cost-effective.

Three additional studies suggest that to ensure cost savings of a screening program, the prevalence of chlamydial infection must be >3% to 7%. A fourth study, however, concluded that a universal screening program of 15- to 40-year-old asymptomatic women in the Netherlands was not cost-effective unless prevalence exceeded 41.8%.

Comparison with Guidelines from Other Groups
Peer Review

Guidelines/recommendations from the following groups were reviewed:

• American Medical Association (AMA)
• American Academy of Pediatrics
• Centers for Disease Control (CDC)
• U.S. Preventive Services Task Force
• Canadian Task Force on the Periodic Health Examination

• Assessment of risk factors for infection with Chlamydia trachomatis should be performed during every routine healthcare contact of sexually active women.
• Sexually active women with risk factors should be screened annually by any well-validated, laboratory-based amplification or antigen method, using cervical or urine specimens. Risk factors include age <25 years, a new male sex partner or two or more partners during the preceding year, inconsistent use of barrier contraception, history of a prior sexually transmitted disease (STD), African-American race, and cervical ectopy. All partners of women with positive tests should be tested for Chlamydia trachomatis. Women with mucopurulent discharge, suggestive of cervicitis, should be tested immediately.
• Pregnant women should be screened during their first trimester or at their first prenatal visit. Those with risk factors should be re-screened during their third trimester.
• Recommended research priorities include well-designed, randomized controlled trials studying the long-term effects of screening and treatment of various populations, prevalence studies of asymptomatic males, and cost-effectiveness studies of office-based rapid tests.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• Chlamydia trachomatis urogenital infections are highly prevalent among adolescents and young adults. Sequelae of undetected, untreated infections account for substantial healthcare costs. Treatment is effective, simple, and well tolerated. The majority of infected women and many men are asymptomatic; thus, screening is necessary for detection. Recently screening for Chlamydia trachomatis was simplified through the development of noninvasive, highly sensitive, amplification screening tests.
• Chlamydia trachomatis screening programs can be effective, both in lowering disease prevalence and decreasing the incidence of sequelae.

• Invasiveness of some screening procedures
• Potential for patient anxiety, embarrassment, and the risk of unnecessary treatment of patients with false-positive results, including potential side effects of drugs.

An implementation strategy was not provided.

Staying Healthy

Effectiveness

Not applicable: Guideline was not adapted from another source.

2003 Apr

American College of Preventive Medicine - Medical Specialty Society

American College of Preventive Medicine (ACPM)

Practice Guidelines Committee

Primary Authors: Katerina Hollblad-Fadiman, MD, MPH; Samuel M. Goldman, MD, MPH

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on October 30, 2003. The information was verified by the guideline developer on November 24, 2003.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.