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A direct comparison of the British Association of Sexual Health and HIV (BASHH; formerly the Association for Genitourinary Medicine/Medical Society for the Study of Venereal Diseases [AGUM/MSSVD]), the Centers for Disease Control and Prevention (CDC), and the Finnish Medical Society Duodecim (FMSD) recommendations for screening and management of chlamydial infection in adults is provided in the tables below. The CDC guideline also addresses chlamydial infections in infants and children as well as other STDs characterized by urethritis and cervicitis, such as those caused by Neisseria gonorrhoeae. These latter topics, however, are not addressed in this synthesis.
A summary discussion of the areas of agreement and areas of differences among the guidelines is presented following the content comparison tables.
Abbreviations used in the text and tables follow:
TABLE 1: COMPARISON OF INTERVENTIONS AND PRACTICES CONSIDERED ("" indicates topic is addressed) |
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BASHH (2006) |
CDC (2006) |
FMSD (2006) |
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Populations to be Screened | ||||
Asymptomatic Adults |
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Asymptomatic Pregnant Women |
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Adults with Signs/Symptoms of Chlamydial Infection |
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Screening Tests | ||||
Types of Screening Tests |
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Specimen of Choice |
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Management | ||||
Antibiotic Regimens in Men and Nonpregnant Women |
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Antibiotic Regimens During Pregnancy and Breastfeeding |
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Patient Education and Preventive Counseling |
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Partner Notification and Treatment |
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Follow-up |
TABLE 3: COMPARISON OF RECOMMENDATIONS FOR CHLAMYDIAL INFECTION | |
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POPULATIONS TO BE SCREENED | |
Asymptomatic Adults | |
BASHH |
No recommendations offered |
CDC |
Chlamydial Infections Chlamydial Infections in Adolescents and Adults Asymptomatic infection is common among both men and women, and to detect chlamydial infections health-care providers frequently rely on screening tests. Annual screening of all sexually active women aged <25 years is recommended, as is screening of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners). The benefits of C. trachomatis screening in women have been demonstrated in areas where screening programs have reduced both the prevalence of infection and rates of PID. Evidence is insufficient to recommend routine screening for C. trachomatis in sexually active young men, based on feasibility, efficacy, and cost-effectiveness. However, screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, and STD clinics). An appropriate sexual risk assessment should be conducted for all persons and might indicate more frequent screening for some women or certain men. |
FMSD |
Screening for Asymptomatic Infections
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Asymptomatic Pregnant Women | |
BASHH |
No recommendations offered |
CDC |
Prenatal screening of pregnant women can prevent chlamydial infection among neonates. Pregnant women aged <25 years are at high risk for infection. Local or regional prevalence surveys of chlamydial infection can be conducted to confirm the utility of using these recommendations in particular settings. |
FMSD |
No recommendations offered |
Adults with Signs/Symptoms of Chlamydial Infection | |
BASHH |
No recommendations offered |
CDC |
|
FMSD |
Chlamydial infection can be suspected but never diagnosed on the basis of symptoms alone. A burning sensation and mucous discharge from the urethra are common symptoms in men after unprotected sexual intercourse with a temporary partner. Although Gram or methylene blue stains of plain smear specimens are usually rich in white blood cells, chlamydia is found to be the cause of the infection in only half the patients. A reliable diagnosis of chlamydial infection in both men and women can therefore be reached only by appropriate microbiological sampling. |
SCREENING TESTS | |
Types of Screening Tests | |
BASHH |
Diagnosis Nucleic Acid Amplification Technique
Medico Legal Cases For medico legal cases a NAAT should be taken from all the sites where penetration has occurred. This guideline recommends NAAT rather than culture due to the low sensitivity (60 to 80%) of culture and its lack of availability in many centres (Grade of Recommendation D).
Cell Culture
Enzyme Immunoassays (EIAs)
Direct Fluorescent Antibody (DFA)
Further Investigation All patients diagnosed with C. trachomatis should be encouraged to have screening for other STIs, including an HIV test and, where indicated, hepatitis B screening and vaccination (Grade of Recommendation C). If the patient is within the window period for HIV and syphilis, these should be repeated at an appropriate time interval. All contacts of C. trachomatis should be offered the same screening tests. |
CDC |
Chlamydial Infections in Adolescents and Adults Diagnostic Considerations Culture, direct immunofluorescence, EIA, nucleic acid hybridization tests, and NAATs are available for the detection of C. trachomatis on endocervical and male urethral swab specimens. NAATs are the most sensitive tests for these specimens and are FDA-cleared for use with urine, and some tests are cleared for use with vaginal swab specimens. The majority of tests, including NAAT and nucleic acid hybridization tests, are not FDA-cleared for use with rectal swab specimens, and chlamydia culture is not widely available for this purpose. Some non-commercial laboratories have initiated NAAT of rectal swab specimens after establishing the performance of the test to meet Clinical Laboratory Improvement Amendments (CLIA) requirements. Patients whose condition has been diagnosed as chlamydia also should be tested for other STDs. Note: Refer to the original guideline document for diagnostic considerations for chlamydial infections among infants. |
FMSD |
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Specimen of Choice | |
BASHH |
Sites to Be Sampled Women
Men
Rectal, Pharyngeal and Conjunctival Specimens, Men and Women
Medico Legal Cases For medico legal cases a NAAT should be taken from all the sites where penetration has occurred. This guideline recommends NAAT rather than culture due to the low sensitivity (60 to 80%) of culture and its lack of availability in many centres (Grade of Recommendation D).
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CDC |
Chlamydial Infections in Adolescents and Adults Diagnostic Considerations C. trachomatis urogenital infection in women can be diagnosed by testing urine or swab specimens collected from the endocervix or vagina. Diagnosis of C. trachomatis urethral infection in men can be made by testing a urethral swab or urine specimen. Rectal C. trachomatis infections in persons that engage in receptive anal intercourse can be diagnosed by testing a rectal swab specimen. Note: Refer to the original guideline document for specimen collection considerations for chlamydial infections among infants. |
FMSD |
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MANAGEMENT | |
Antibiotic Regimens in Men and Nonpregnant Women | |
BASHH |
Ideally, treatment should be effective (microbiological cure rate >95%), easy to take (not more than twice daily), with a low side effect profile, and cause minimal interference with daily lifestyle (Grade of recommendation C). Treatment of Genital, Rectal and Pharyngeal Uncomplicated Infection (see appropriate guidelines for treatment of complications) and Epidemiological Treatment Recommended Regimens: (Grade of recommendation A)
Alternative Regimens: (Grade of recommendation A) For use if either of the above treatments are contraindicated.
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CDC |
Recommended Regimens
Alternative Regimens
In populations that have erratic health-care-seeking behavior, poor treatment compliance or unpredictable follow-up, azithromycin might be more cost-effective because it enables the provision of single-dose directly observed therapy. However, doxycycline costs less than azithromycin and has no higher risk for adverse events. Erythromycin might be less efficacious than either azithromycin or doxycycline, mainly because of the frequent occurrence of gastrointestinal side effects that discourage compliance. Ofloxacin and levofloxacin are effective treatment alternatives but are more expensive and offer no advantage in the dosage regimen. Other quinolones either are not reliably effective against chlamydial infection or have not been evaluated adequately. To maximize compliance with recommended therapies, medications for chlamydial infections should be dispensed on site, and the first dose should be directly observed. To minimize transmission, persons treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen. To minimize the risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated. Special Considerations HIV Infection. Patients who have chlamydial infection and are also infected with HIV should receive the same treatment regimen as those who are HIV negative. Note: Refer to the original guideline document for treatment regimens for chlamydial infections among infants. |
FMSD |
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Antibiotic Regimens During Pregnancy and Breastfeeding | |
BASHH |
Pregnancy and Breast Feeding Recommended Regimens: (Grade of recommendation A)
Due to higher positive Chlamydia tests after treatment in pregnancy, attributed to either less efficacious treatment regime, non compliance, or re-infection, it is recommended that pregnant women must have a test of cure 5 weeks after completing therapy, 6 weeks later if given azithromycin.
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CDC |
Pregnancy. Doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnant women. However, clinical experience and studies suggest that azithromycin is safe and effective. Repeat testing (preferably by NAAT) 3 weeks after completion of therapy with the following regimens is recommended for all pregnant women to ensure therapeutic cure, considering the sequelae that might occur in the mother and neonate if the infection persists. Recommended Regimens
Alternative Regimens
Erythromycin estolate is contraindicated during pregnancy because of drug-related hepatotoxicity. The lower dose 14-day erythromycin regimens may be considered if gastrointestinal tolerance is a concern. HIV Infection. Patients who have chlamydial infection and are also infected with HIV should receive the same treatment regimen as those who are HIV negative. Note: Refer to the original guideline document for treatment regimens for chlamydial infections among infants. |
FMSD |
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Patient Education and Preventive Counseling | |
BASHH |
Management General Advice Patients should be advised to avoid sexual intercourse (including oral sex) until they and their partner(s) have completed treatment (or wait 7 days if treated with azithromycin). Advice regarding appropriate action if using hormonal contraceptives is also required. Patients should be given detailed explanation of their condition with particular emphasis on the long-term implications for them and their partner(s). This should be reinforced by giving them clear, accurate written information. Compliance with Therapy In general, compliance with therapy is improved if there is a positive therapeutic relationship between the patient and the doctor (Sanson-Fisher, Bowman & Armstrong, 1992) and/or nurse. This can probably be improved if the following are applied (Grade of recommendation C): Discuss with patient and provide clear written information on:
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CDC |
Note: For preventive education information see the NGC summary of the CDC guideline Clinical Prevention Guidance. Patients should be instructed to refer their sex partners for evaluation, testing and treatment. Patients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until 7 days after a single-dose regimen or after completion of a 7-day regimen. Timely treatment of sex partners is essential for decreasing the risk for reinfecting the index patient. |
FMSD |
No recommendations offered. |
Partner Notification and Treatment | |
BASHH |
Management of Sexual Partners
Look Back Period Only limited evaluation has taken place of the incubation period following exposure to the development of symptoms. In the United Kingdom a cut-off of 4 weeks is used to identify those sexual partner(s) potentially at risk if the index patient is symptomatic. If the index case is asymptomatic, an arbitrary cut off of 6 months, or until the last previous sexual partner (whichever is the longer time period), is used. Common sense needs to be used in assessing which sex partner(s) may have been at risk in these situations. Those at risk should be informed and invited to attend for evaluation and epidemiological treatment even if tests are negative. This may be patient-led or provider-led. |
CDC |
Patients should be instructed to refer their sex partners for evaluation, testing, and treatment. The following recommendations on exposure intervals are based on limited evaluation. Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding onset of symptoms in the patient or diagnosis of chlamydia. The most recent sex partner should be evaluated and treated even if the time of the last sexual contact was >60 days before symptom onset or diagnosis. If concerns exist that sex partners will not seek evaluation and treatment, or if other management strategies are impractical or unsuccessful, then delivery of antibiotic therapy (either a prescription or medication) by heterosexual male or female patients to their partners might be an option (see the NGC summary of the CDC guideline Clinical Prevention Guidance under the section Partner Management). Limited studies to date have demonstrated a trend toward a decrease in rates of persistent or recurrent chlamydia with this approach compared with standard partner referral. Male patients must inform female partners of their infection and be given accompanying written materials about the importance of seeking evaluation for PID (especially if symptomatic). Patient-delivered partner therapy is not routinely recommended for men who have sex with men (MSM) because of a high risk for coexisting infections, especially undiagnosed HIV infection, in their partners. Patients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until 7 days after a single-dose regimen or after completion of a 7-day regimen. Timely treatment of sex partners is essential for decreasing the risk for reinfecting the index patient. |
FMSD |
Related Evidence
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Follow-up | |
BASHH |
Follow-up by phone may be both more efficacious and cost effective than by re-attendance. This is an important part of the management of chlamydial infection and it has a number of objectives including:
Test of Cure A test of cure is not routinely recommended but should be performed in pregnancy or if non-compliance or re-exposure is suspected. It should be deferred for 5 weeks (6 weeks if azithromycin given) after treatment is completed. |
CDC |
Follow-Up Except in pregnant women, test-of-cure (repeat testing 3 to 4 weeks after completing therapy) is not recommended for persons treated with the recommended or alternative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected. Moreover, the validity of chlamydial diagnostic testing at <3 weeks after completion of therapy (to identify patients who did not respond to therapy) has not been established. False-negative results might occur because of persistent infections involving limited numbers of chlamydial organisms. In addition, NAAT conducted at <3 weeks after completion of therapy in persons who were treated successfully could yield false-positive results because of the continued presence of dead organisms. A high prevalence of C. trachomatis infection is observed in women who were treated for chlamydial infection in the preceding several months. The majority of post-treatment infections result from reinfection, frequently occurring because the patient's sex partners were not treated or because the patient resumed sex with a new partner infected with C. trachomatis. Repeat infection confers an elevated risk of PID and other complications when compared with initial infection. Therefore, recently infected women are a major priority for repeat testing for C. trachomatis. Clinicians and health-care agencies should consider advising all women with chlamydial infection to be retested approximately 3 months after treatment. Providers also are strongly encouraged to retest all women treated for chlamydial infection whenever they seek medical care within the following 3 to 12 months, regardless of whether the patient believes that her sex partners were treated. Recognizing that retesting is distinct from a test-of-cure, as discussed in this report, is vital. Limited evidence is available on the benefit of retesting for chlamydia in men previously infected; however, some specialists suggest retesting men approximately 3 months after treatment. |
FMSD |
A follow-up visit should only take place after three to four weeks because the presence of gene traces may produce a false positive result in an earlier re-test. |
TABLE 4: BENEFITS AND HARMS | |
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Benefits | |
BASHH (2006) |
Appropriate diagnosis, treatment, and management of patients with Chlamydia trachomatis genital tract infection and prevention of C. trachomatis infection in sexual partners |
CDC (2006) |
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FMSD (2006) |
Appropriate identification, diagnosis and treatment of the patient with chlamydial urethritis and cervicitis may help avoid the serious complications of prolonged or recurrent infection (e.g., pelvic inflammatory disease, infertility, ectopic pregnancy) as well as prevent the spread of infection. |
Harms | |
BASHH (2006) |
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CDC (2006) |
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FMSD (2006) |
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TABLE 5: STRENGTH OF EVIDENCE AND RECOMMENDATION GRADING SCHEMES | |
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BASHH |
Levels of Evidence Ia - Evidence obtained from meta-analysis of randomised controlled trials Ib - Evidence obtained from at least one randomised controlled trial IIa - Evidence obtained from at least one well designed controlled study without randomisation IIb - Evidence obtained from at least one other type of well designed quasi-experimental study III - Evidence obtained from well-designed non-experimental descriptive studies such as comparative studies, correlation studies, and case control studies IV - Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities Grading or Recommendations A. (Evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation. B. (Evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation. C. (Evidence level IV): Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality. |
CDC |
The type of supporting evidence is not specifically stated for each recommendation. |
FMSD |
Levels of Evidence A. Strong research-based evidence. Multiple relevant, high-quality scientific studies with homogenic results. B. Moderate research-based evidence. At least one relevant, high-quality study or multiple adequate studies. C. Limited research-based evidence. At least one adequate scientific study. D. No research-based evidence. Expert panel evaluation of other information |
The British Association of Sexual Health and HIV (BASHH; formerly the Association for Genitourinary Medicine/Medical Society for the Study of Venereal Diseases [AGUM/MSSVD]), the Centers for Disease Control and Prevention (CDC), and the Finnish Medical Society Duodecim (FMSD) present recommendations for screening and management of chlamydial infection. BASHH and FMSD provide explicit reasoning behind their judgments by ranking the level of evidence for each major recommendation. CDC briefly discusses the evidence used as the basis for specific recommendations throughout its guideline.
All of the groups address most aspects of chlamydial infection, including diagnosis, treatment, patient education, and follow-up. Unlike the other organizations, however, BASHH does not offer screening recommendations. The scope of the CDC guideline is broader than that of the others in that it includes diagnosis and management of chlamydial infections among infants and children. The CDC also addresses other sexually transmitted diseases characterized by urethritis and cervicitis, such as those caused by Neisseria gonorrhoeae and other forms of nongonococcal urethritis. These topics, however, are beyond the scope of this synthesis.
CDC and FMSD agree that routine screening should be considered in sexually active women (CDC specifies women aged 25 years or younger). In addition, these two guideline developers consider women of any age who change sexual partners at high risk for infection. They also agree that sexual partners of infected patients should be screened. Although BASHH does not make specific recommendations about screening, it does acknowledge risk factors for infection.
CDC and FMSD recommend that men and women with signs or symptoms of C. trachomatis infection (e.g., urethritis or urethral discharge in men and cervical discharge or friability in women) be tested for chlamydial infection.
All three guideline groups agree that NAATs are the most sensitive and specific diagnostic tests for chlamydial infection. NAATs include polymerase chain reaction and ligase chain reaction assays. NAATs have the additional advantage over other testing methods (cell culture, antigen detection) in that they can be performed on urine samples, thus eliminating the need for invasive testing. Although cell cultures have traditionally been held as the "gold standard," especially for medico-legal cases, NAATs have been shown to be more sensitive and easier to use than culture.
BASHH states that cervical or vulvo-vaginal swabs are specimens of choice in women undergoing examinations for chlamydial infection, and recognizes first-void urine as an alternative for women unwilling or unable to undergo speculum examinations. FMSD recommends first-void urine for both men and women, and urethral and cervical swabs as an alternative specimen when gene amplification methods are used. FMSD adds that first-void urine samples are well suited for home screening. CDC does not make specific recommendations on types of screening specimens for adults, but state that women can be diagnosed by testing urine or swab specimens collected from the endocervix or vagina and men by testing a urethral swab or urine specimen. BASHH states that in men urine samples are easy to collect, do not cause discomfort, and thus are preferable to urethral swabs.
BASHH and CDC agree that the recommended antibiotic treatment regimen for uncomplicated genital chlamydial infection is azithromycin (1 g orally as a single dose) or doxycycline (100 mg twice daily for 7 days). FMSD also recommends 1 g of azithromycin orally as the treatment of choice, and cites tetracycline and doxycycline as alternatives. Alternative antibiotics recommended by BASHH and CDC include erythromycin, ofloxacin, and levofloxacin, and other tetracyclines. Single-dose azithromycin is acknowledged by all groups as the regimen of choice in patients who may be noncompliant with multi-dose regimens. Erythromycin is indicated only when other antibiotics are contraindicated (such as during pregnancy) or not tolerated by the patient.
All three organizations recommend referral of sexual partners for screening and possible treatment. BASHH states that in patients with symptomatic chlamydial infection, all sexual partners over the four weeks prior to onset of symptoms are at risk for infection and should be referred, and in the case of asymptomatic index patients, all partners over the last 6 months should be referred. CDC states that sex partners should be evaluated, tested, and treated if they had sexual contact with an infected patient during the 60 days before onset of symptoms or diagnosis; however, they also recommend evaluation and treatment of the last sexual contact, even if that contact was more than 60 days before symptom onset. FMSD does not make specific recommendations regarding time of last sexual contact for partner notification.
All three groups offer recommendations on follow-up of patients after treatment. BASHH and CDC agree that retesting for C. trachomatis is not routinely necessary after completing treatment unless patient is pregnant, noncompliance with therapy is suspected, or patient is still symptomatic. The waiting period for retesting varies slightly between the groups, with CDC and FMSD emphasizing that any retesting should be done a minimum of 3 weeks after initiation of therapy to avoid false-positive results, while BASHH recommends that retesting should be deferred for 5 weeks (6 weeks if azithromycin given) after treatment is completed.
Although CDC does not recommend retesting after treatment (i.e., test-of-cure), the guideline does recommend that physicians advise women with chlamydial infection to be rescreened approximately three months after infection because of the high probability of reinfection. CDC also strongly recommends that health care providers rescreen all women treated for chlamydial infection whenever they present for care within 3 to 12 months of infection, regardless of whether the patient believes that her sex partners were treated. CDC adds that recognizing that retesting is distinct from a test-of-cure is vital.
BASHH states that patients with chlamydial infections should be provided with information (including written material) on the nature of the chlamydial infection, and also recommends counseling on safe sex practices, including condom use. BASHH and CDC state that patients should receive instruction on partner referral and avoiding sexual intercourse until completion of therapy and they and their sex partners are no longer symptomatic.
FMSD does not provide recommendations for patient education or preventive counseling.
There are some differences among guidelines in recommendations offered for pregnant and breast feeding patient groups.
CDC is the only group that offers specific recommendations on routine screening of asymptomatic pregnant women. They maintain that prenatal screening of pregnant women, especially those under 25 years of age, can prevent chlamydial infection among neonates. Adoption of this recommendation could depend on local or regional surveys of the prevalence of infection in this population group.
CDC recommends single-dose azithromycin or amoxicillin in pregnant or lactating women, citing erythromycin base or ethylsuccinate as alternatives. BASHH, however, cites erythromycin, amoxicillin, and azithromycin as recommended regimens, but reserves azithromycin as a last alternative among the three. BASHH explains that while the World Health Organization (WHO) Guidelines recommend single-dose azithromycin to treat C. trachomatis in pregnancy, the British National Formulary (BNF) recommends its use in this population only if no alternative is available. While FMSD agrees that amoxicillin and erythromycin are equally effective for antenatal chlamydial cervicitis, they recommend azithromycin as the treatment of choice for pregnant patients.
This synthesis was first prepared by NGC on May 29, 2001. It has been updated a number of times since then and reviewed by the respective guideline developers whose guidelines are included. It was updated on December 20, 2006 following the archiving of USPSTF's screening guideline. It was revised in October 2007 to update BASHH, CDC, and FMSD recommendations. It was revised most recently in October 2008 to remove ACPM recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Screening for and management of chlamydial infection. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2001 Nov 05 (updated 2008 Dec). [cited YYYY Mon DD]. Available: http://www.guideline.gov.