39  Chlamydia
Genital and ocular infections; infertility; atypical pneumonia
D. Mabey and R. W. Peeling
KEY POINTS
• Chlamydiae are obligate intracellular bacterial
pathogens with a unique growth cycle.
• C. trachomatis is the most common bacterial sexually
transmitted infection, and the leading infectious
cause of blindness.
• C. pneumoniae is an important cause of community
acquired pneumonia.
• Chlamydial infections are frequently asymptomatic.
• Serious sequelae of chlamydial infection (blindness,
pelvic inflammatory disease, infertility) are caused by
immune response-driven scarring and fibrosis.
• Diagnosis requires laboratory tests, preferably nucleic
acid amplification tests.
• Treatment is with doxycycline, erythromycin or
azithromycin.
• It is important to treat sexual partners of patients
with chlamydial genital tract infection.
• Prevention depends on interrupting the transmission
chain: there are no effective vaccines.
Chlamydiae are obligate intracellular bacterial patho-
gens of eukaryotic cells with a characteristic dimor-
phic growth cycle quite distinct from that of other
bacteria, involving alternation between a metaboli-
cally inert, infectious, spore-like elementary body,
which can survive in the extracellular environment,
and a metabolically active, replicating reticulate body,
which cannot. They are widely distributed in nature
and are responsible for a variety of human infections
affecting the eye, and the genitourinary and respira-
tory tracts.
Chlamydiae were first described in 1907 by Halber-
staedter and von Prowazek, who observed cytoplas-
mic inclusions in conjunctival scrapings taken from
children with trachoma and from monkeys inoculated
with ocular material from these children. They named
them Chlamydozoa, from the Greek words χλαµuς
(cloak) and ζooν (animal), because of the way in
which the inclusions were draped around the nucleus.
Similar inclusions were soon observed in conjunctival
scrapings taken from neonates with conjunctivitis,
and from the cervix of their mothers. Most human
infections are caused by Chlamydia trachomatis, which
was first grown, in mouse brain and subsequently in
eggs, from a patient with lymphogranuloma venereum
(LGV) in the 1930s. The more fastidious trachoma
biovar was not isolated until 1957. It was first grown
in tissue culture in 1965, making it possible for the first
time to study the epidemiology and clinical features
of C. trachomatis infection on a large scale.
DESCRIPTION
Classification
The Chlamydia genus (order Chlamydiales; family
Chlamydiaceae) comprises nine species of which two
are primarily human pathogens: C. trachomatis,
causing ocular and genital infections; and C. pneumo-
niae, causing mainly respiratory disease. The other
species infect animals: C. psittaci (chiefly birds); C.
abortus (sheep); C. felis (cats); C. pecorum (cattle); C.
suis (pigs); C. muridarum (mice) and C. caviae (guinea
pigs). C. psittaci, C. abortus and C. felis are occasion-
ally transmitted to man. A taxonomic reclassification,
based on ribosomal DNA sequence data, assigned C.
pneumoniae, C. psittaci and C. abortus to a new genus,
Chlamydophila. However, this new taxonomy has not
been universally accepted and is not used here.
The species C. trachomatis contains two biovars:
the more invasive LGV biovar (serovars L1–L3) rep-
licates in macrophages, invades lymph nodes and
causes a systemic infection; the more common tra-
choma biovar is largely confined to squamo-columnar
epithelial cells of the eye (serovars A–C) and genital
tract (serovars D–K) (Table 39.1). Serovars are
defined by the presence of specific epitopes on the
major outer membrane protein. Serovars A–C differ
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39 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
Table 39.1  Human infections caused by chlamydiae
Site of infection Disease
Eye Trachoma
Inclusion conjunctivitis
Ophthalmia neonatorum
Genital tract
  Male Non-specific urethritis, proctitis, epididymitis
  Female Cervicitis, urethritis, endometritis, salpingitis,
PID, perihepatitis
Abortion, premature birth
  Male and female Lymphogranuloma venereum
Respiratory tract Neonatal pneumonia
Pharyngitis, bronchitis, pneumonia
Psittacosis, ornithosis
PID, pelvic inflammatory disease.
from serovars D–K in that they are unable to synthe-
size tryptophan, owing to disruption of the trpA gene.
Chlamydiae have one of the smallest bacterial
genomes, containing around 1 million base pairs. Vir-
tually all strains of C. trachomatis also contain a
4.4-MDa plasmid of unknown function. Genomes of
several C. trachomatis serovars have been sequenced,
and show a high level of conservation of gene order
and content (>99%). A high degree of genetic cons­
ervation is also seen across Chlamydia species, with C.
trachomatis and C. muridarum, for example, being
>95% identical. The fact that chlamydiae replicate
within an intracellular vacuole probably explains
the high degree of conservation, since it does not
allow them to exchange genetic material with other
bacteria.
Biology
Chlamydiae probably evolved from host-independent,
Gram-negative ancestors. They are ‘energy parasites’
relying on the host cell for synthesis of ATP. The
chlamydial envelope possesses bacteria-like inner and
outer membranes. The infectious elementary body is
electron dense, DNA rich and approximately 300 nm
in diameter. The cell wall does not contain peptido­
glycan, and its rigidity is maintained by extensive
disulphide linking of the major outer membrane
protein, which makes up some 60% of the outer mem-
brane. The elementary body binds to the host cell and
enters by ‘parasite-specified’ endocytosis. Fusion of
the chlamydia-containing endocytic vesicle with lyso-
somes is inhibited and the elementary body begins its
unique developmental cycle within the eukaryotic cell.
382
Sequelae Organism (serovars)
Conjunctival scarring, C. trachomatis (A, B, Ba, C)
trichiasis, blindness
C. trachomatis (D–K)
C. trachomatis (D–K)
? Urethral stricture C. trachomatis (D–K)
Tubal infertility, ectopic C. trachomatis (D–K)
pregnancy
C. trachomatis (D–K)
Scarring, lymphoedema, C. trachomatis (L1–L3)
rectal stricture
C. trachomatis (D–K)
C. pneumoniae
C. psittaci
The major outer membrane protein is reduced to a
monomeric form and acts as a porin, allowing nutri-
ents to enter the organism from the host cell. After
about 8 h the elementary body differentiates into the
larger (800–1000 nm), non-infectious, metabolically
active reticulate body, which divides by binary fission.
By 20 h post-infection, a proportion of reticulate
bodies has begun to reorganize into a new generation
of elementary bodies (Fig. 39.1). These reach maturity
up to 30 h after entry into the cell and rapidly accumu-
late within the endocytic vacuole, which may contain
more than 1000 organisms. They are released by lysis
of the host cell 30–48 h after the start of the cycle.
PATHOGENESIS
After an incubation period of 5–10 days, C. trachoma-
tis elicits an acute inflammatory response with a puru-
lent exudate. A period of chronic inflammation ensues,
with the development of sub-epithelial follicles, and
this leads eventually, in some cases, to fibrosis and
scarring. This scarring process is responsible for much
of the morbidity associated with C. trachomatis, in
both the genital tract and the eye. It is particularly
likely to be seen after repeated infections.
Study of virulence determinants of C. trachomatis
is difficult, since it has not so far proved possible to
manipulate chlamydiae genetically. However, the
availability of the complete genome of several C. tra-
chomatis strains has provided some insights. The
serovar D genome contains genes homologous with
those coding for virulence factors in other bacteria,
including a cytotoxin gene, and genes encoding a type
 Chlamydia 39

Extracellular
infectious EB
Attachment and
ingestion of EB;
reduction of MOMP
Release EB

Nucleus
>40 0

DNA reorganisation;
RNA synthesis;
protein synthesis
Infectivity increases RB
with E production 40 Hours 9
(approximate)

24 18 Chlamydial antigen

DNA condensation 20 Binary fission of RBs;

within RB to form EBs; chlamydial antigen
S-S bridging MOMP released from cell
surface

Fusion of inclusions;
appearance of
initial bodies

Fig. 39.1  The growth cycle of chlamydiae. EB, elementary body; MOMP, major outer membrane protein; RB, reticulate body.

III secretion pathway (see p. 17). A conserved chlamy-
dial protease, proteasome-like activity factor, is
secreted into the host cell cytoplasm, where it inter-
feres with the assembly and surface expression of
HLA (human leucocyte antigen) molecules and inhib-
its apoptosis. In a non-human primate model genetic
variations in six C. trachomatis genes that appear to
be associated with increased virulence have been
identified.
The epidemiology of C. trachomatis infection sug-
gests that a degree of protective immunity follows
natural infection. The prevalence and bacterial load
of ocular infection is lower in adults than in children
in trachoma endemic communities, and the duration
of infection is shorter. Similarly, genital C. trachoma-
tis infection is most prevalent in the youngest sexually
active age groups, and the chlamydial isolation rate
for men with non-gonococcal urethritis is lower in
those who have had previous episodes. Killed whole
organism vaccines provide some degree of protection
against ocular C. trachomatis infection in man and
non-human primates. Serovar-specific monoclonal
antibodies to the major outer membrane protein
neutralize C. trachomatis in vitro, but there are few
data to suggest that either IgG or IgA antibody is
protective. The intracellular development of C. tra-
chomatis is inhibited by interferon-γ, and evidence
from animal models and studies of human ocular
infection suggest that cell-mediated immune responses,
mediated by CD4+ lymphocytes are important for the
clearance of infection.
Vaccine studies in primates suggest that vaccination
could provoke more severe disease on subsequent
challenge, implying that much of the damage caused
by C. trachomatis infection may be immunopathologi-
cal in origin. This would be in keeping with the his-
topathology of C. trachomatis infection, in which the
lymphoid follicle is the hallmark. Follicles contain
typical germinal centres, consisting predominantly of
B lymphocytes, with T cells, mostly CD8+, in the
parafollicular region. The inflammatory infiltrate
between follicles comprises plasma cells, dendritic
cells, macrophages, and polymorphonuclear leuco-
cytes, with T and B lymphocytes. Fibrosis is seen at a
late stage, typically in trachoma and pelvic inflamma-
tory disease. T lymphocytes are also present and out-
number B cells and macrophages.
A chlamydial heat-shock protein (hsp 60), homolo-
gous with the GroEL protein of Escherichia coli,
elicits antibody responses that are associated with the

383
39 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
damaging sequelae of C. trachomatis infections in
both the eye and genital tract. In-vitro interferon-γ
interferes with the chlamydial development cycle,
leading to persistent infection with continuing release
of hsp 60. It is not known whether the immune
response to hsp 60 is itself the cause of immunopatho-
logical damage, or merely a marker of more severe or
prolonged infection. Studies of gene expression at the
site of ocular infection have shown the importance of
innate immune pathways and NK (natural killer)
cell activation, and suggest that matrix metalloprotei-
nases 7 and 9 play an important role in the scarring
process. Polymorphisms in immune response genes
encoding tumour necrosis factor-α, interferon-γ and
interleukin-10 are associated with the development of
severe scarring following ocular C. trachomatis
infection.
CLINICAL FEATURES
Chlamydia trachomatis
Genital infection
The clinical manifestations of genital C. trachomatis
infection are similar to those of gonorrhoea, but are
usually less severe, as C. trachomatis infection elicits
a less intense acute inflammatory response than Neis-
seria gonorrhoeae. Many chlamydial infections are
asymptomatic. Long term sequelae such as infertility
and ectopic pregnancy are generally caused by fibrosis
and scarring of the fallopian tubes following pro-
longed or repeated infections, and may develop even
in those with few or no symptoms.
Infection in men.  C. trachomatis is detectable in
the urethra of up to 50% of men with symptomatic
non-gonococcal urethritis. The incubation period is
7–21 days, compared to 2–5 days for gonorrhoea.
Patients present with a history of dysuria, usually
accompanied by a mild to moderate mucopurulent
urethral discharge. C. trachomatis is responsible for a
proportion of cases of chronic (persistent or recur-
rent) non-gonococcal urethritis. Since mixed infec-
tions are common, treatment of gonococcal urethritis
with an antibiotic ineffective against C. trachomatis
may result in post-gonococcal urethritis.
C. trachomatis is responsible for up to 70% of cases
of acute epididymitis in young men (35 years of age
or less) in developed countries. Patients present with
unilateral scrotal pain, swelling and tenderness, often
accompanied by fever. Most give a history of current
or recent urethral discharge. In older patients, epidi-
dymitis and epididymo-orchitis tend to be caused by
urinary-tract pathogens. There is no good evidence
384
that chlamydial infection leads to male infertility or
to acute or chronic prostatitis.
Both LGV and non-LGV strains of C. trachomatis
can cause proctitis in those who practise receptive anal
intercourse. Non-LGV strains cause a milder disease,
which may be asymptomatic or give rise to rectal pain,
bleeding and muco-purulent anal discharge.
Infection in women.  C. trachomatis typically infects
the columnar epithelial cells of the endocervix. It does
not affect the squamous epithelium of the vagina.
Infection is associated with a mucopurulent discharge
from the cervix visible on speculum examination, and
with hypertrophic cervical ectopy that tends to bleed
on contact. Most infected women have no symptoms.
The prevalence of cervical infection is no higher
among women who complain of vaginal discharge
than among those who do not, suggesting that it is not
a cause of symptomatic vaginal discharge.
C. trachomatis has been implicated as a cause of the
urethral syndrome, characterized by dysuria, fre-
quency and sterile pyuria. Clinical signs of urethritis,
such as urethral discharge or meatal redness, are not
usually found.
Infection may spread from the endocervix to the
endometrium and fallopian tubes, causing pelvic
inflammatory disease. This is more likely to occur after
trauma to the cervix due, for example, to termination
of pregnancy, insertion of an intra-uterine contracep-
tive device, or delivery. Histologic evidence of
endometritis can be found in up to 50% of women
with mucopurulent cervicitis due to C. trachomatis,
and is more common in those with a history of abnor-
mal vaginal bleeding. Classic signs of pelvic inflam-
matory disease may be present (fever, lower abdominal
pain and tenderness, and cervical motion tenderness),
but chlamydial pelvic inflammatory disease may be
subclinical. Spread to the peritoneum may result in
perihepatitis (the Curtis–Fitz-Hugh syndrome), which
may be confused with acute cholecystitis in young
women. C. trachomatis infection has also been associ-
ated with post-partum endometritis.
C. trachomatis is the major cause of pelvic inflam-
matory disease in developed countries. Infertility may
be the first indication of asymptomatic tubal disease.
It occurs in about 10% of women following a single
upper genital tract infection and in up to 50% after
two or three episodes. Infertility may result from
endometritis, from blocked or damaged fallopian
tubes, or from abnormalities of ovum transportation
caused by damage to the ciliated epithelial surface.
Other consequences of salpingitis are chronic pelvic
pain and ectopic pregnancy. Following chlamydial
pelvic inflammatory disease, the risk of ectopic preg-
nancy increases 7–10-fold.

Some studies have shown C. trachomatis infection
to be associated with low birth weight and pre-term
delivery, but others have failed to confirm this. In
general, infection was diagnosed and treated at a later
stage of gestation in those studies which found a cor-
relation between infection and adverse birth outcome
than in those that did not.
Infection has been weakly associated with bartho-
linitis and should be considered in the absence of
other known pathogens. A significant association
between cervical chlamydial infection and cervical
squamous cell carcinoma, but not adenocarcinoma,
has been established, and it has been suggested that
chlamydial infection may enhance the effect of onco-
genic papillomaviruses.
Adult paratrachoma (inclusion conjunctivitis)
and otitis media
Adult chlamydial ophthalmia commonly results from
the accidental transfer of infected genital discharge to
the eye. It usually presents as a unilateral follicular
conjunctivitis, acute or subacute in onset. The features
are swollen lids, mucopurulent discharge, papillary
hyperplasia and later, follicular hypertrophy, and
occasionally punctate keratitis. About one-third of
patients have otitis media, and complain of blocked
ears and hearing loss. The disease is generally benign
and self-limiting. Patients and their sexual contacts
should be investigated for genital chlamydial infection
and managed appropriately.
Reactive arthritis
Arthritis occurring with or soon after non-gonococcal
urethritis is termed ‘sexually acquired reactive arthri-
tis’. Conjunctivitis and other features characteristic of
Reiter’s syndrome are seen in about one-third of
patients. C. trachomatis has also been associated with
‘seronegative’ arthritis in women. Viable chlamydiae
have not been detected in the joints of patients with
this condition, which is probably the result of immu-
nopathology. Despite this, early tetracycline therapy
has been advocated by some investigators.
Neonatal infections
Conjunctivitis appears in 20–50% of infants exposed
to C. trachomatis infecting the cervix at birth. A
mucopurulent discharge and occasionally pseudo­
membrane formation occur 1–3 weeks later. It usually
resolves without visual impairment.
About half of the infants who have conjunctivitis
also develop pneumonia, although a history of recent
conjunctivitis and bulging eardrums are found in
Chlamydia 39
only half of the cases. Chlamydial pneumonia usually
begins between the fourth and eleventh week of life,
preceded by upper respiratory symptoms. There is
tachypnoea, a prominent, staccato cough but usually
no fever, and the illness is protracted. Radiographs
show hyperinflation of the lungs with bilateral diffuse,
symmetrical, interstitial infiltration and scattered
areas of atelectasis. Children infected during infancy
are at increased risk of obstructive lung disease and
asthma.
Lymphogranuloma venereum
The clinical course of LGV can be divided into three
stages. The primary stage at the site of inoculation;
the secondary stage in the regional lymph nodes, and/
or the anorectum; and the tertiary stage of late seque-
lae affecting the genitalia and/or rectum.
Primary stage.  After an incubation period of 3–30
days, a small, painless papule, which may ulcerate,
occurs at the site of inoculation. The primary lesion
is self-limiting and may pass unnoticed by the patient.
Among patients with LGV presenting with buboes
in Thailand, more than half had not been aware of
an ulcer.
Secondary stage.  This occurs some weeks after the
primary lesion. It may involve the inguinal lymph
nodes, or the anus and rectum. The inguinal form is
more common in men than women, since the lym-
phatic drainage of the upper vagina and cervix is to
the retro-peritoneal rather than the inguinal lymph
nodes. LGV proctitis occurs in those who practise
receptive anal intercourse, probably due to direct
inoculation.
The cardinal feature of the inguinal form of LGV
is painful, usually unilateral, inguinal and/or femoral
lymphadenopathy (bubo). Enlarged lymph nodes are
usually firm and often accompanied by fever, chills,
arthralgia and headache. Biopsy reveals small discrete
areas of necrosis surrounded by proliferating epithe-
lioid and endothelial cells, which may enlarge to form
stellate abscesses that may coalesce and break down
to form discharging sinuses. In women, signs include
a hypertrophic suppurative cervicitis, backache and
adnexal tenderness.
Clinical features of anorectal disease include a
purulent anal discharge, pain and bleeding due to an
acute haemorrhagic proctitis or proctocolitis, often
with fever, chills and weight loss. Proctoscopy reveals
a granular or ulcerative proctitis. Computed tomog-
raphy or magnetic resonance imaging scans may show
pronounced thickening of the rectal wall, with enlarge-
ment of iliac lymph nodes. Enlarged inguinal nodes
may also be palpable.
385
39 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
Cervical adenopathy due to LGV has been reported
after oral sex. A follicular conjunctivitis has also been
described following direct inoculation of the eye,
which may be accompanied by pre-auricular lym-
phadenopathy. Other rare manifestations of the sec-
ondary stage include acute meningoencephalitis,
synovitis and cardiac involvement.
Tertiary stage.  This appears after a latent period
of several years, but is rare. Chronic untreated LGV
leads to fibrosis, which may cause lymphatic obstru­
ction and elephantiasis of the genitalia in either
sex, or rectal strictures and fistulae. Rarely, it can give
rise to the syndrome of esthiomene (Greek: ‘eating
away’) with widespread destruction of the external
genitalia.
Trachoma
The clinical signs of trachoma are best seen in the
conjunctival surface of the everted upper eyelid. Active
or inflammatory trachoma, which is usually seen in
children in endemic communities, is a follicular kerato-
conjunctivitis. Subjects in whom five or more follicles
of >0.5 mm diameter are seen in the central subtarsal
conjunctiva are defined by the World Health organiza-
tion (WHO) as having follicular trachoma. In some
cases the inflammation is severe enough to obscure the
conjunctival blood vessels. If more than half the blood
vessels are obscured, this is defined as intense inflam-
matory trachoma. Blood vessels may be seen growing
into the cornea, usually at its superior margin; this is
known as pannus. C. trachomatis can be detected in a
proportion of cases of follicular trachoma, but not in
all cases, since the follicles can persist for weeks or
months after the infection has resolved. Repeated epi-
sodes of inflammatory trachoma lead eventually to
conjunctival scarring. As the scars contract they cause
the lid margin to turn inwards (entropion), and the
lashes to abrade the cornea (trichiasis). This causes
extreme discomfort, damages the cornea, and leads
eventually to blindness due to corneal opacity.
C. pneumoniae
C. pneumoniae causes pneumonia, pharyngitis, bron-
chitis, otitis and sinusitis with an incubation period
of about 21 days. It may be a significant cause of
acute exacerbations of asthma, and is one of the most
common causes of community-acquired pneumonia,
but is seldom identified as the causal agent because
labo­ratory tests for its diagnosis are not widely used.
It is a chronic, often insidious, respiratory pathogen
to which there appears to be little immunity. Sero-
epidemiological studies indicate that some 60–80% of
386
people worldwide become infected with C. pneumo-
niae during their life.
C. psittaci
C. psittaci is an important cause of infections in a wide
range of birds and is shed in nasal secretions and
droppings. Nasal secretions contaminate the feathers,
where they dry and produce a highly infectious dust
in which the organism can survive for months. This
may give rise to severe pneumonia in man, called orni-
thosis or psittacosis depending on the bird species
from which the infection was derived. The agricultural
economy is also affected, as large outbreaks of orni-
thosis have been reported in turkeys, geese and ducks.
There are import controls in many countries to restrict
the movement of birds, which are rendered more
infectious by travel-induced stress.
The incubation period is about 10 days, and the
illness ranges from an ‘influenza-like’ syndrome, with
general malaise, fever, anorexia, rigors, sore throat,
headache and photophobia, to a severe illness with
delirium and pneumonia. The illness may resemble
bronchopneumonia, but the bronchioles are involved
as a secondary event and sputum is scanty. The organ-
ism disseminates through the body, and there may be
meningoencephalitis, arthritis, pericarditis or myocar-
ditis, or a predominantly typhoidal state with enlarged
liver and spleen. Endocarditis has been described.
LABORATORY DIAGNOSIS
The laboratory diagnosis of chlamydial infection
depends on detection of the organisms or their anti-
gens or nucleic acid and, to a much lesser extent, on
serology (Table 39.2). In urogenital infection the
highest bacterial load of C. trachomatis is found in the
endocervix in women and in the urethra in men. An
endocervical swab is therefore needed for the diagno-
sis of infection by culture or antigen detection assay.
However, the greater sensitivity of nucleic acid ampli-
fication tests for C. trachomatis means that self-
administered vaginal swabs and ‘first-catch’ urine
specimens give equivalent results to endocervical
swabs when using these assays. Samples to be tested
can be transported to the laboratory at room tempera-
ture, making home-based screening for C. trachomatis
possible.
Culture
Centrifugation of specimens onto cycloheximide-
treated McCoy or HeLa cell monolayers, followed
 Chlamydia 39

Table 39.2  Advantages and disadvantages of diagnostic tests for C. trachomatis

Factor considered Culture Direct fluorescent Enzyme Nucleic acid amplification

antibody immunoassay

Sensitivity <70% 70–100% <50–70% Up to 100%

Specificity 100%
Appropriate specimens Cervical/urethral/ocular
swabs
Speed/temperature for Rapid or at low temperature
transport of specimen
Storage requirements 4°C if overnight, −70°C or
liquid nitrogen if long term
Evaluation of adequacy Not possible
of specimen
Special equipment or Centrifuge, biological safety
procedure cabinet, CO2 incubator,
microscope
Processing of specimen Laborious
Reading of test Subjective and moderately
tedious
Time to result 48–72 h
Cost High
Up to 98% (reader 95–98% Up to 99%
dependent)
Cervical/urethral/ocular Cervical/urethral/ Cervical/urethral/ocular swabs,
swabs ocular swabs urine (men), vaginal swabs
Room temperature Room temperature if Room temperature if <48 h,
specimen in buffer 4°C if >48 h
4°C if short term 4°C if 3–5 days, 4°C if not processed in 7 days;
freezing if longer −70°C if long term
Host cells seen under Not possible Determine whether host DNA
microscope present
Fluorescence microscope ELISA reader Dedicated equipment for
nucleic acid amplification
and detection
Simple Relatively simple, Requires precautions against
amenable to false positive results due to
batching laboratory contamination
Subjective and tedious Objective and simple Objective and simple
30 min 3 h 2–4 h
Moderate Low Very high

by incubation and then staining with a fluorescent
monoclonal antibody or with a vital dye, to detect
inclusions, has been widely used for the diagnosis
of C. trachom­atis infection. One blind passage may
increase sensiti­vity. However, cell-culture techniques
are no more than 70% sensitive compared to nucleic
acid amplific­ation tests and are slow and labour inten-
sive. Because culture is essentially 100% specific, it still
has a role in medico-legal cases. C. pneumoniae is even
more difficult to grow than C. trachomatis. C. psittaci
is a hazard group 3 pathogen and few laboratories
attempt to grow it.
Direct immunofluorescence
Microscopic detection of elementary bodies with
species-specific fluorescent monoclonal antibodies is
rapid and, for C. trachomatis oculogenital infections,
highly sensitive and specific in the hands of skilled
observers. However, the test is laborious and interpre-
tation is subjective. It is best used in settings where
few specimens are tested, or for confirming positive
results obtained with other tests.
Nucleic acid amplification tests
By enabling amplification of a nucleic acid sequence
specific to the chlamydial species, the polymerase
chain reaction assay, the strand displacement assay
and the transcription mediated amplification tech-
nique have overcome problems of poor sensitivity.
Commercial assays for C. trachomatis based on each
of these three amplification methods are available
and widely used. The first two assays amplify nuc­
leotide sequences of the cryptic plasmid, which is
present in multiple copies in each chlamydial eleme­
ntary body. However, a rare variant of C. trachomatis
has been described which lacks the plasmid, giving rise
to false negative results with these assays. The tran-
scription mediated amplification reaction is directed
against rRNA, which is also present in multiple
copies. These sensitive assays have replaced culture
as the ‘gold standard’ for the diagnosis of C. tracho-
matis infection. Nucleic acid amplification tests for
C. pneumoniae and C. psittaci are not commercially
available.
Enzyme immunoassays
Enzyme immunoassays that detect chlamydial anti-
gens, usually the genus specific lipopolysaccharide,
have largely been replaced by the more sensitive
nucleic acid amplification test.
Point of care tests
Over 20 rapid strip tests based on the immunochro-
matographic detection of chlamydial lipopolysaccha-
ride are commercially available. They can give a
result within 15–20 min of sample collection, but most
lack sensitivity compared to nucleic acid amplification
methods.

387
39 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
Serological tests
Serological tests are of no value in uncomplicated
genital C. trachomatis infection. In pelvic inflamma-
tory disease, in LGV and in the Curtis–Fitz-Hugh
syndrome, serology may be useful if a rising titre can
be demonstrated. C. trachomatis IgM antibody is the
‘gold standard’ for the diagnosis of chlamydial pneu-
monia in babies. Pneumonia due to C. pneumoniae
and C. psittaci is usually diagnosed serologically, but
depends on the demonstration of IgM antibodies or
an IgG titre >512 by microimmunofluorescence, or
a rise in antibody titre in a convalescent sample.
Immuno­fluorescence and enzyme immuno-assays are
commercially available, but have not been rigorously
evaluated.
TREATMENT
Chlamydiae are intracellular and hence insensitive to
aminoglycosides and other antibiotics that do not
penetrate cells efficiently. Tetracyclines and mac-
rolides are the mainstay of treatment. Treatment is
often started before a microbiological diagnosis can
be established, so additional broad-spectrum antibiot-
ics are needed to cover gonococcal and, in the case of
pelvic inflammatory disease, anaerobic infections.
Treatment of sexual partners is essential to prevent
reinfection.
Uncomplicated C. trachomatis infections are treated
with a single dose of azithromycin 1 g, or with doxy-
cycline 100 mg twice daily for 7 days. Chlamydial
pelvic inflammatory disease is treated with a 14-day
course of doxycycline 100 mg twice daily. Clinically
significant resistance to these antibiotics has not been
reported. Doxycycline is contra-indicated in preg-
nancy. Azithromycin 1 g as a single dose, and amoxi-
cillin 500 mg three times daily for 7 days, are safe and
effective in pregnant women. Ofloxacin is active
against C. trachomatis at a dose of 300 mg twice daily
for 7 days, but is not widely used. Ophthalmia neona-
torum and neonatal pneumonia due to C. trachomatis
should be treated with erythromycin syrup by mouth,
50 mg/kg daily divided into four doses, for 14 days.
There has been no adequate study comparing anti-
biotic regimens for LGV, C. pneumoniae or C. psittaci
infection. Recommended treatment for LGV is doxy-
cycline 100 mg twice daily, or erythromycin 500 mg
four times daily, for 21 days. Azithromycin has been
used successfully in some cases, although a 1 g single
dose is unlikely to be sufficient. Large collections of
pus should be aspirated, using a lateral approach
through normal skin. Macrolides or tetracyclines are
388
recommended for the treatment of infection with
C. pneumoniae and C. psittaci. Prolonged courses may
be required in patients with pneumonia.
Ocular infection can be effectively treated with a
single oral dose of azithromycin (20 mg/kg, maximum
1 g) but, in trachoma endemic communities, reinfec-
tion rapidly occurs and mass treatment of entire com-
munities is therefore recommended.
EPIDEMIOLOGY
C. trachomatis is the most common bacterial sexually
transmitted infection, and the most common infec-
tious cause of blindness. Genital infection is common
in all sexually active populations, and prevalence is
usually highest in the young. In the UK, the number
of reported chlamydial infections trebled between
1996 and 2005. Similar increases were seen in other
Western countries over this period, including Sweden
and Canada, despite active screening programmes. It
is not clear to what extent this is due to an increased
incidence, or to an increase in the number of people
tested with the sensitive nucleic acid amplification
tests that have been widely used since the late 1990s.
The overall incidence of reported chlamydial infection
in the UK in 2005 was 223 per 100 000 total popula-
tion, with the highest rate (1300 per 100 000) in women
aged 16–19. The WHO has estimated that, in 2005,
there were 101 million new cases of genital chlamydial
infection.
LGV is rare in industrialized countries, but is
endemic in parts of Africa, Asia, South America and
the Caribbean. Its epidemiology is poorly defined,
because LGV is often indistinguishable clinically from
chancroid and other causes of genital ulceration with
bubo formation, and it has been difficult to obtain
laboratory confirmation. Among patients presenting
with buboes to a sexually transmitted disease clinic in
Bangkok 10% were found to have LGV, and an epi-
demic of LGV has been reported among crack cocaine
users in the Bahamas. In 2003, an outbreak of LGV
proctitis due to the L2 serovar was reported among
homosexual men in the Netherlands, and since then
over one thousand cases have been reported in homo-
sexual men in Europe and North America; most
affected men were HIV-positive.
Trachoma, caused by C. trachomatis transmitted
from eye to eye, disappeared from Europe and North
America in the 20th century as living standards
improved, but remains endemic in poor rural popula-
tions in Africa and Asia. WHO estimates that at least
40 million people have trachoma, and that 8 million
are blind or visually impaired as a result.

Molecular epidemiology
Typing isolates of C. trachomatis is potentially of
great value. It could help to map sexual networks, and
to distinguish between treatment failure and reinfec-
tion in clinical trials. If associations could be found
between particular strains and particular clinical find-
ings, it could help to identify virulence determinants
of C. trachomatis and increase understanding of the
pathogenesis of infection.
The first typing method for C. trachomatis, the
micro-immunofluoresence test, was based on the
ability of monoclonal antibodies to distinguish 13
(later increased to 17) serotypes of C. trachomatis.
More recently genital and ocular strains of C. tracho-
matis have been genotyped following amplification of
the ompA gene which encodes the major outer mem-
brane protein, either by sequencing, or by restriction
fragment length polymorphism analysis of the ampli-
fied product; but ompA genotyping is not sufficiently
discriminatory to distinguish between persistent infec-
tion and reinfection with a common genotype.
A multi-locus sequence typing method, targeting
six variable genes identified through genome sequenc-
ing projects, has been used to investigate a variant of
C. trachomatis lacking the plasmid detected by com-
monly used nucleic acid amplification tests.
CONTROL AND PREVENTION
Health education and condom promotion, especially
for the youngest sexually active age groups, may help
to reduce the incidence of genital C. trachomatis
RECOMMENDED READING
Brunham RC, Rey-Ladino J: Immunology of chlamydia infection:
implications for a Chlamydia trachomatis vaccine, Nature Reviews
Immunology 5:149–161, 2005.
Kuo CC, Jackson LA, Campbell LA, Grayston JT: Chlamydia pneumoniae
(TWAR), Clin Microbiol Rev 8:451–461, 1995.
Low N, Bender N, Nartey L, et al: Effectiveness of chlamydia screening:
systematic review, Int J Epidemiol 38:435–448, 2009.
Mabey D, Solomon A, Foster A: Trachoma, Lancet 362:223–229, 2003.
Chlamydia 39
infection. Syndromic management of symptomatic
infections, and partner notification, may also play a
role, but since a high proportion of chlamydial infec-
tions is asymptomatic in both sexes, these measures
are unlikely to be successful on their own. A screening
programme for C. trachomatis at primary health care
level in the USA has been shown to reduce the inci-
dence of upper genital tract infection and its compli-
cations in women. Screening programmes have been
introduced in some European countries, in which
young people presenting to health services for any
reason are offered a test for C. trachomatis; but the
public health impact of such opportunistic screening
programmes remains to be demonstrated. Where
reinfection rates are high retesting of positive cases
6 months after treatment has been recommended.
No vaccine is presently available. Recent research
has focused on the development of a subunit vaccine
against C. trachomatis, which provides protection
without eliciting immunopathology. Purified prepara-
tions of major outer membrane protein were protec-
tive in murine models, provided the native trimeric
structure of the protein was maintained. In non-
human primates, a similar preparation of major outer
membrane protein reduced peak shedding from the
ocular surface, but had no effect on the duration of
infection or on ocular disease.
The strategy for trachoma control recommended
by WHO is based on the acronym SAFE: Surgery
for trichiasis; mass treatment with Antibiotics;
Facial cleanliness; and Environmental improvement
to reduce the transmission of C. trachomatis from
eye to eye.
Stephens RS, Kalman S, Lammel C, et al: Genome sequence of an
obligate intracellular pathogen of humans: Chlamydia trachomatis,
Science 282:754–759, 1998.
Van der Bij AK, Spaargaren J, Morré SA, et al: Diagnostic and clinical
implications of anorectal lymphogranuloma venereum in men who
have sex with men: a retrospective case-control study, Clinical
Infectious Diseases 42:186–194, 2006.
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