Chlamydiae are nonmotile, obligate intracellular bacteria. They contain DNA, RNA, and ribosomes and make their own proteins and nucleic acids. However, they depend on the host cell for 3 of their 4 nucleoside triphosphates and use host adenosine triphosphate (ATP) to synthesize chlamydial protein.
The genus Chlamydia now contains 12 species; 3 of them cause human disease:
Chlamydia trachomatis
Chlamydia pneumoniae
Chlamydia psittaci
Chlamydial species can cause persistent infection, which is often subclinical.
Chlamydia trachomatis
C. trachomatis has 18 immunologically defined serovars:
D through K cause sexually transmitted infections (STIs) localized to mucosal surfaces.
L1, L2, and L3 cause STIs that lead to invasive lymph node disease (lymphogranuloma venereum Lymphogranuloma Venereum (LGV) Lymphogranuloma venereum (LGV) is a disease caused by 3 unique strains of Chlamydia trachomatis and characterized by a small, often asymptomatic skin lesion, followed by regional lymphadenopathy... read more ).
In the United States, C. trachomatis is the most common bacterial cause of STIs, including
Nongonococcal urethritis Chlamydia and Mycoplasmal Mucosal Infections Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis (that are not due to gonorrhea) are caused predominantly by chlamydiae and less frequently by mycoplasmas. Chlamydiae... read more
and epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more
in men
Cervicitis Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include cervical or vaginal discharge and cervical erythema and friability. Diagnosis is with tests for cervical... read more
, urethritis, and pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be caused by sexually... read more in women
Proctitis Proctitis Proctitis is inflammation of the rectal mucosa, which may result from infection, inflammatory bowel disease, or radiation. Symptoms are rectal discomfort and bleeding. Diagnosis is by proctoscopy... read more , lymphogranuloma venereum Lymphogranuloma Venereum (LGV) Lymphogranuloma venereum (LGV) is a disease caused by 3 unique strains of Chlamydia trachomatis and characterized by a small, often asymptomatic skin lesion, followed by regional lymphadenopathy... read more , and reactive arthritis Reactive Arthritis Reactive arthritis is an acute spondyloarthropathy that often seems precipitated by an infection, usually genitourinary or gastrointestinal. Common manifestations include asymmetric arthritis... read more
(Reiter syndrome) in all patients
Maternal transmission of C. trachomatis causes neonatal conjunctivitis Neonatal Conjunctivitis Neonatal conjunctivitis is watery or purulent ocular drainage due to a chemical irritant or a pathogenic organism. Prevention with antigonococcal topical treatment at birth is routine. Diagnosis... read more and neonatal pneumonia Neonatal Pneumonia Neonatal pneumonia is lung infection in a neonate. Onset may be within hours of birth and part of a generalized sepsis syndrome or after 7 days and confined to the lungs. Signs may be limited... read more . Universal prenatal screening and treatment of pregnant women have greatly reduced the incidence of infant C. trachomatis infection in the United States (1 General reference Three species of Chlamydia cause human disease, including sexually transmitted infections and respiratory infections. Diagnosis depends on species; culture, nucleic acid amplification... read more ).
The organism can be isolated from the rectum and throat in adults (usually in men who have sex with men [MSM]). Rectal infection with L2 strains can cause severe proctocolitis that can mimic acute inflammatory bowel disease in MSM who are HIV-positive.
Chlamydia pneumoniae
C. pneumoniae can cause pneumonia (especially in children and young adults) that may be clinically indistinguishable from pneumonia caused by Mycoplasma pneumoniae. In some patients with C. pneumoniae, pneumonia, hoarseness, and sore throat may precede coughing, which may be persistent and complicated by bronchospasm.
Approximately 6 to 19% of community-acquired pneumonia Community-Acquired Pneumonia Community-acquired pneumonia is defined as pneumonia that is acquired outside the hospital. The most commonly identified pathogens are Streptococcus pneumoniae, Haemophilus influenzae... read more cases are due to C. pneumoniae. Outbreaks of C. pneumoniae pneumonia pose a particular risk for people in congregate settings (eg, nursing homes, schools, military installations, prisons). No seasonal variations in occurrence have been observed.
C. pneumoniae has also been implicated as an infectious trigger of reactive airway disease.
Chlamydia psittaci
(See also the Centers for Disease Control and Prevention's [CDC] Psittacosis: For Clinicians and Laboratorians.)
C. psittaci causes psittacosis. Strains causing human disease are usually acquired from psittacine birds (eg, parrots), causing a disease characterized by pneumonitis. Patients may have severe headache and abnormal liver blood tests.
Psittacosis is a rare infection. Since 2010, typically < 10 cases/year are reported to the CDC (see also the CDC's Psittacosis). However, psittacosis might be underdiagnosed because mild cases do happen. History of epidemiologic exposure is very important, eg, pet bird owners, veterinarians, and workers in the poultry industry. Outbreaks have occurred among workers who handle turkeys and ducks in poultry processing plants.
General reference
1. Kohlhoff S, Roblin PM, Clement S, et al: Universal prenatal screening and testing and Chlamydia trachomatis conjunctivitis in infants. Sex Transm Dis 48(9):e122–e123, 2021. doi: 10.1097/OLQ.0000000000001344
Diagnosis of Chlamydia
For C. trachomatis, nucleic acid–based testing
For C. pneumoniae, culture or nucleic acid–based testing
For C. psittaci, serologic tests or polymerase chain reaction (PCR; where available)
(See also the CDC's 2021 Sexually Transmitted Infections Treatment Guidelines: Chlamydial Infections.)
C. trachomatis STIs are best identified in genital samples using nucleic acid amplification tests (NAATs) because these tests are more sensitive than cell culture and have less stringent sample handling requirements. Currently, NAATs are available for testing genital and urine specimens from adults and adolescents. NAATs for genital infection can be done using urine or vaginal swabs obtained by the patient or clinician. Several commercially available NAATs have been approved for extragenital infections (eg, those in the rectum or pharynx).
Serologic tests are of limited value except for diagnosing lymphogranuloma venereum and psittacosis.
C. pneumoniae is diagnosed by culture of respiratory tract specimens or by NAAT testing. Two NAATs for C. pneumoniae are available as part of panels that simultaneously test for multiple respiratory pathogens.
A primary clue to the diagnosis of C. psittaci infection is close contact with birds, typically pet birds such as parrots or parakeets, including veterinarians and workers in turkey and duck processing plants. Diagnosis is confirmed by serologic tests. Culture is not generally available. There are no commercially available NAATs for C. psittaci, but PCR can be done by the Centers for Disease Control and Prevention (CDC) and some specialty laboratories. (See also the CDC's different methods for diagnosing psittacosis.)
Diagnosis reference
1. Kohlhoff S, Roblin PM, Clement S, et al: Universal prenatal screening and testing and Chlamydia trachomatis conjunctivitis in infants. Sex Transm Dis 48(9):e122–e123, 2021. doi: 10.1097/OLQ.0000000000001344
Screening
Because chlamydial genital infection is so common and often asymptomatic or causes only mild or nonspecific symptoms (particularly in women), routine screening of asymptomatic people at high risk of STIs is recommended by the CDC (see the 2021 Sexually Transmitted Infections Treatment Guidelines: Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources: Chlamydia).
See also Screening for Chlamydia Screening for Chlamydia Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis (that are not due to gonorrhea) are caused predominantly by chlamydiae and less frequently by mycoplasmas. Chlamydiae... read more for a summary of screening recommendations.
Treatment of Chlamydia
For nonpregnant people, doxycycline
For pregnant women, azithromycin
Doxycycline 100 mg orally 2 times a day for 7 days is the recommended treatment for urogenital chlamydia in adolescents and adults who are not pregnant (1 Treatment references Three species of Chlamydia cause human disease, including sexually transmitted infections and respiratory infections. Diagnosis depends on species; culture, nucleic acid amplification... read more ). A review of randomized trials that compared doxycycline and azithromycin for treating urogenital chlamydial infection found that microbiologic treatment failure among men was higher for azithromycin than for doxycycline (2 Treatment references Three species of Chlamydia cause human disease, including sexually transmitted infections and respiratory infections. Diagnosis depends on species; culture, nucleic acid amplification... read more ). The recommendation also is based on studies that showed a 7-day course of doxycycline was superior to a single dose of azithromycin for treatment of rectal infection in men who have sex with men (3 Treatment references Three species of Chlamydia cause human disease, including sexually transmitted infections and respiratory infections. Diagnosis depends on species; culture, nucleic acid amplification... read more ). The recommendations for use of doxycycline were expanded to include women because rectal infection is not routinely screened for in this population.
A single dose of azithromycin 1 g orally is an alternative treatment option. Azithromycin may be useful in populations that may have problems with compliance and may not be able to tolerate a 7-day course of multidose doxycycline.
Pregnant women can be given only a single dose of azithromycin 1 g orally.
Current sex partners should be treated. Patients should abstain from sexual intercourse until they and their partners have been treated for ≥ 1 week.
When gonorrhea Gonorrhea Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more is present and chlamydial infection has not been excluded (uncommon, because all currently available NAATs for gonococcal infection are duplexed with a test for C. trachomatis), concurrent treatment for gonorrhea Treatment Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more
is recommended.
Screening and treatment of pregnant women is the most effective way to prevent neonatal chlamydial infection, including conjunctivitis and pneumonia. Neonatal ocular prophylaxis with erythromycin or other preparations does not prevent neonatal chlamydial conjunctivitis.
Azithromycin and doxycycline are first-line antibiotics for treatment of C. pneumoniae and psittacosis.
Specific infections are discussed elsewhere in THE MANUAL: Lymphogranuloma venereum Lymphogranuloma Venereum (LGV) Lymphogranuloma venereum (LGV) is a disease caused by 3 unique strains of Chlamydia trachomatis and characterized by a small, often asymptomatic skin lesion, followed by regional lymphadenopathy... read more and urethritis, pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be caused by sexually... read more , epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more , reactive arthritis Reactive Arthritis Reactive arthritis is an acute spondyloarthropathy that often seems precipitated by an infection, usually genitourinary or gastrointestinal. Common manifestations include asymmetric arthritis... read more
, neonatal conjunctivitis Neonatal Conjunctivitis Neonatal conjunctivitis is watery or purulent ocular drainage due to a chemical irritant or a pathogenic organism. Prevention with antigonococcal topical treatment at birth is routine. Diagnosis... read more
and neonatal pneumonia Neonatal Pneumonia Neonatal pneumonia is lung infection in a neonate. Onset may be within hours of birth and part of a generalized sepsis syndrome or after 7 days and confined to the lungs. Signs may be limited... read more , trachoma Trachoma Trachoma is a chronic conjunctivitis caused by Chlamydia trachomatis and is characterized by progressive exacerbations and remissions. It is the leading cause of preventable blindness... read more
, and inclusion conjunctivitis Adult Inclusion Conjunctivitis Adult inclusion conjunctivitis is caused by sexually transmitted Chlamydia trachomatis. Symptoms include chronic unilateral hyperemia and mucopurulent discharge. Diagnosis is clinical... read more .
Treatment references
1. Centers for Disease Control and Prevention: Sexually Transmitted Infections Treatment Guidelines, 2021: Chlamydial Infections: Chlamydial Infection Among Adolescents and Adults. Accessed 03/30/2023.
2. Páez-Canro C, Alzate JP, González LM, et al: Antibiotics for treating urogenital Chlamydia trachomatis infection in men and non-pregnant women. Cochrane Database Syst Rev 1(1):CD010871, 2019. doi: 10.1002/14651858.CD010871.pub2
3. Dombrowski JC, Wierzbicki MR, Newman LM, et al: Doxycycline versus azithromycin for the treatment of rectal chlamydia in men who have sex with men: A randomized controlled trial. Clin Infect Dis 73(5):824–831, 2021. doi: 10.1093/cid/ciab153
Key Points
C. trachomatis causes trachoma or STIs; maternal transmission can cause neonatal conjunctivitis and/or pneumonia.
C. pneumoniae can cause pneumonia (especially in children and young adults and in enclosed populations).
C. psittaci is a rare cause of pneumonia (psittacosis) that is usually acquired from psittacine birds (eg, parrots).
Diagnose C. trachomatis and C. pneumoniae infections using nucleic acid amplification tests.
Screen high-risk, asymptomatic patients for sexually transmitted chlamydial infection.
Treat nonpregnant people with doxycycline, and treat pregnant women with azithromycin.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Centers for Disease Control and Prevention (CDC): 2021 Sexually Transmitted Infections Treatment Guidelines: Chlamydial Infections
CDC: Psittacosis
Avian Chlamydiosis: A resource providing information about zoonotic risk of avian chlamydiosis
Drugs Mentioned In This Article
Drug Name | Select Trade |
---|---|
doxycycline |
Acticlate, Adoxa, Adoxa Pak, Avidoxy, Doryx, Doxal, Doxy 100, LYMEPAK, Mondoxyne NL, Monodox, Morgidox 1x, Morgidox 2x , Okebo, Oracea, Oraxyl, Periostat, TARGADOX, Vibramycin, Vibra-Tabs |
azithromycin |
Azasite, Zithromax, Zithromax Powder, Zithromax Single-Dose , Zithromax Tri-Pak, Zithromax Z-Pak, Zmax, Zmax Pediatric |