Organizational and Socio-Psychological Difficulties of Management of Patients with Chlamydia Infection

Abstract

Lack of detection of chlamydia infection does not correspond to the high prevalence of its clinical manifestations. It is associated with a frequent asymptomatic course, the prevalence of persistent forms of infection and difficulties in their diagnosis. Unification of approaches to diagnosis and therapy of chlamydial infections without taking into account the topical diagnosis leads to insufficient therapy. It is difficult to find a balance between the need for long-term antibiotic therapy for chlamydial persistence and the dangers of its consequences. Difficulties in the treatment of chlamydia infection are also associated with socio-psychological factors: low efficiency and even inexpediency of etiotropic therapy of chlamydia in polygamous relationships, promiscuous behavior; poor synchronization of partner therapy, often treating only one partner in a couple; orientation of patients towards short-term “pill” therapy, which is not sufficiently effective for chronic persistent chlamydia with significant morphological changes in the genitals; low compliance of male partners to therapy in a couple “by contact” in the absence of clinically apparent manifestations; peculiarities of public consciousness regarding chlamydia infection. As a result, therapy often only stops exacerbations of inflammation and does not eliminate the infection completely.

1. Introduction

Genital infection caused by Chlamydia trachomatis is considered one of the most common sexually transmitted infections in the world. C. trachomatis is an obligate intracellular parasite with a unique intracellular development cycle. The peculiarities of the pathogen itself, the imperfection of the immune response to it, and the characteristic course of the disease determine the difficulties of its diagnosis and treatment.

Chlamydia infection is asymptomatic in most cases, more than 2/3 of women and men. Symptoms of the acute form of the disease (short-term urethritis, moderate discharge) often go unnoticed. This is the reason for the late visit to the doctor and the widespread spread of infection. Without timely and adequate therapy, the infection becomes a chronic persistent form.

Persistent chlamydia infection is widespread and presents the greatest difficulties for doctors. It is associated with a large number of diseases accompanied by chronic inflammation and fibrosis—chronic cervicitis and salpingitis, chronic recurrent urethritis, including “postcoital” urethritis in women, chronic prostatitis, chronic epididymitis, and orchoepididymitis. Clinical manifestations are poorly expressed, or absent altogether, or appear only with exacerbations. As the infection exists, fibrosis processes occur with the formation of adhesions in the appendages of the uterus and pelvis, intrauterine synechiae, and sclerosing processes of the male genital sphere. Pronounced dysfunctional changes in the anti-infective protection system can lead to the translocation of chlamydia from the genitourinary tract to the extra-genital areas of the body. Fibrous changes can hinder the development of the acute phase of inflammation, but lead to infertility in both women (violation of the patency of the fallopian tubes, miscarriage of pregnancy) and men (violations of the morphology and function of sperm), to the formation of chronic pelvic pain syndrome.

Chronic endometritis is also a frequent cause of infertility. Nowadays, it is a widespread disease. It is thought to occur in ¼ of women [1]. Currently, there is no definitive opinion on the role of bacterial factor and chlamydia inclusive in the development and maintenance of chronic endometritis. However, clinical practice gives us some evidence of their important role. Some evidence-based studies show an increase in the frequency of implantation and an improvement in reproductive outcomes in assisted reproductive technology programs after antibiotic therapy [2, 3].

Patients’ subjective underestimation of their condition is one of the reasons for the late detection of chlamydia infection. Often, it is diagnosed only when a woman applies for infertility, miscarriage, or other chronic conditions, and men are examined as a partner. As a result, most men and women with chlamydia infection go to the doctor already with the development of deep lesions of the genital area, pronounced adhesive processes, with decompensation of the body’s defense mechanisms. The detection of chlamydia infection by routine methods may be difficult at this stage, and it remains unrecognized.

In clinical practice, the physician is faced with a mismatch between the widespread clinical and anatomical manifestation characteristic of chlamydia and its low detectability [4, 5, 6]. It can be assumed that this occurs against the background of an increase in the frequency of persistent species C. trachomatis, which develops primarily due to irrational antibiotic therapy [6].

2. Diagnostic methods and detectability of chlamydia infection in the light of a socio-psychological approach

Laboratory diagnostic method of chlamydia infection is of paramount importance due to the frequent absence of specific clinical manifestations. The gold standard for the diagnosis of chlamydia infection is currently considered to be the nucleic acid amplification test (NAAT), which is positioned as highly sensitive (99%) and specific (WHO 2016). Its undoubted advantages are accessibility, speed, and the possibility of mass examination of a large group of patients. The quality of diagnostics depends on the quality of test systems used, the quality of sampling, and storage of biomaterial.

Other diagnostic methods are culture, direct fluorescence of antibodies, enzyme immunoassay, and immunohistochemical assays.

The cultural method, previously considered a reference due to its high specificity, has receded into the background. This is due to the labor intensity, high cost, strict rules for the transportation of clinical samples, high requirements for the qualification of medical personnel, as well as low sensitivity (33–85%). The detection rate of chlamydia is low in inactive stage and chronic ascending infection. Currently, it is not used in routine diagnostics, but is carried out mainly for special indication.

The method of direct immunofluorescence of antibodies is highly specific, fast, but “good in the right hands.” It depends on the quality of the test systems used, the quality of biomaterial sampling, and requires high professionalism of a specialist in luminescent microscopy. This method is highly sensitive and highly specific mainly when performed correctly by an experienced laboratory technician. Otherwise, it is impossible to exclude both false-positive and false-negative results of the study.

Enzyme immunoassay determines the presence and titer in the blood of antibodies to chlamydia—Ig G, Ig M, Ig A. It allows us to find out the stages and nature of the course of infection, its activity. However, chlamydia antigens have weak immunogenicity, so the production and accumulation of antibodies to them occur in small quantities. Antibodies to chlamydia are found only in about half of patients. The absence of immunoglobulins does not allow us to talk about the absence of chlamydia infection in the body. If only Ig G to chlamydia is detected, it is impossible to diagnose an existing disease, but only to assert that the body has met with the pathogen. Enzyme immunoassay may be appropriate for verification of persistent infection.

All these methods are among the additional ones and in most countries are not included in the most common health insurance programs. The clinical guidelines recommend a single method, nucleic acid amplification test (NAAT), for suspected chlamydial urogenital infections. It is positioned as highly sensitive and highly specific, and available and adequate. Has the problem of diagnosis of chlamydia infection been solved?

Unfortunately, it is not that simple. The detectability of chlamydia infection has sharply decreased with the transition exclusively to the NAAT method. This is particularly true in cases of ascending infection, chronic persistent course, and fibrosis processes in women (chronic cervicitis and endometritis, adhesions in the pelvis, obstruction of the fallopian tubes, reproductive losses). Many researchers note the difficulties when diagnosing widespread forms of chlamydia infection with a prolonged, recurrent nature of the course. Persistent forms of chlamydia are difficult to verify by microbiological methods due to changes in metabolism and antigenic structure. The pathogen is often inaccessible for diagnosis in complicated ascending infection. In these cases, in order to reliably verify the pathogen, it is necessary to expand the list of clinical specimens obtained not only from the cervical canal and urethra, but also from other organs.

An important diagnostic criterion may be an enzyme immunoassay that determines antibodies to chlamydia in the blood. Unfortunately, a suppressed immune response may also limit the possibilities of serodiagnosis. Against this background, the focus of specialists has shifted toward viruses, bacterial films, and non-specific opportunistic flora identified in such patients. However, the possibility of a chronic persistent chlamydial infection undetected by NAAT cannot be excluded. The latter assumption may be supported by cases of C. trachomatis isolation in such patients using a culture method and its detection also by a culture method in partners. In clinical practice, patients with recurrent exacerbations of chronic genital inflammatory diseases and negative NAAT of urethral and cervical duct material are often found to have C. trachomatis Ig A, indicating an active course of chlamydial infection, C. trachomatis Ig G, and C. trachomatis heat shock protein Ig G (cHSP60) in their blood by enzyme immunoassay [6, 7].

The problems of diagnosing chlamydia infection are related to the fact that there is currently no unified algorithm for examining patients with suspected chronic, persistent chlamydia infection. It is this form that occurs most often. A comprehensive competent approach to the diagnosis of chlamydia using several methods and a scientifically based assessment of the results obtained may be optimal. Detection of chlamydia, determination of the nature of the infectious and inflammatory process, and the extend of the lesion are important for the correct choice of therapy.

What happens in practice? The possibilities of using the entire set of tests for the diagnosis of chlamydia infection are small. This is expensive, not covered by health insurance programs. Doctors who work in insurance medicine cannot use additional tests if the NAAT test is negative. Ethical and financial problems are also important. Is it ethical to offer patients additional tests if they are not included in clinical guidelines, there are no other approved algorithms of examination in chronic ascending processes, and NAAT methods are positioned as highly effective?

It is also worth noting the psychological problems of patients. When several diagnostic tests are used and a chlamydial infection is found in only one of them or in only one of the partners, questions almost always arise. Why focus on tests that show the presence of a chlamydial infection and not those that do not? Why was one partner diagnosed with chlamydia, and the other did not? What does all this mean? These questions cause patients to doubt the correctness of the diagnosis, the competence of the physician and medicine in general, and difficulties in achieving compliance with the physician about the therapy. The result can be refusal of therapy, violation of doctor’s recommendations, development of stress and anxiety disorders in patients, conflicts between partners (each may have his own opinion and his own motivation for treatment), and lack of faith in the cure.

3. Problems of therapy of chlamydia infection

Research in recent years recommends that in the treatment of chronic inflammatory diseases of the genitals, efforts should be directed toward the elimination of pathogens instead of the classical empirical prescription of broad-spectrum antibiotics [8]. This is especially true for chlamydial infections. Analysis of the problems of diagnosis of chlamydia infection clearly shows that the prevalence of chlamydia infection, especially chronic persistent forms of it, is much wider than the results of the NAAT examination show. This is reflected in the choice of therapy and its results. Patients with chronic inflammatory diseases of the genital area and undiagnosed chlamydia infection either do not receive therapy or receive insufficiently adequate therapy. The use of broad-spectrum antibiotics capable of penetrating cells in the treatment of such cases to a certain extent makes it possible to compensate for diagnostic deficiencies. However, antibiotic therapy is not sufficiently effective in cases of persistent forms of chlamydia. Other factors are also important.

Chlamydiosis is a sexually transmitted disease. It requires the treatment of both partners, the use of protection during sexual intercourse until both partners are tested negative for chlamydia. There are no such requirements for the treatment of genital inflammatory processes caused presumably by viruses and opportunistic microorganisms. In undiagnosed chlamydial infections, renewed sexual contact with a previous partner or partners leads to reinfection after therapy.

Another problem of chlamydia therapy is associated with the tendency to unify therapeutic approaches without taking into account the topical diagnosis, and pathoanatomic and clinical features of the course of the disease. The Clinical Guidelines for the treatment of chlamydia indicates the sufficiency of prescribing 1 g of azithromycin once or 200 mg of doxycycline for 7–10 days. The efficacy of such therapy in a long-standing chlamydial process with chronic inflammation and fibrosis is unlikely, and diagnostic problems often do not allow this to be seen.

Analysis of the clinical studies shows that researchers pay little attention to the comparison of the choice of an antibacterial drug, the duration and regimen of its administration, and the possibility of reinfection in the treatment of chlamydial infection [9]. The difficulties of such a comparative analysis can be explained not only by the different clinical course of chlamydial infections, but also by various socio-psychological factors.

The sexually transmissible nature of chlamydial infections dictates that sexual partners must be examined and treated. Examination of partners is necessary regardless of the presence or absence of complaints and clinical symptoms. It is optimal not only to try to identify the pathogen, but also to clarify the clinical form, the presence of structural changes, and assess the duration of persistence of the infection. This is necessary for the correct choice of the duration and composition of therapy. Treatment of sexual partners is advisable even in cases where chlamydia is not detected (“contact therapy”). It is highly probable that in these cases there is a chronic ascending infection, a persistence of chlamydia, which requires more attention. Often, however, the partners are examined formally or not at all. They are given a short course of antibiotics without regard to the nature of the process. Such treatment “by contact” may not be effective enough. It does not eliminate the chronic infection, but rather turns it into a chronic form.

4. Socio-psychological and partner problems of chlamydia infection therapy

The most difficult and intractable are the socio-psychological and partnership problems of chlamydia infection therapy. Therapy of chlamydial infection is carried out on the principle of voluntariness. Patients may not follow the recommendations. Sexual partners often shy away from examination and treatment, especially if they have no clinically expressed complaints, they are not interested in therapy and have other sexual contacts.

Many patients have their own understanding of the disease and its impact on health, their own past individual experiences of sexuality and treatment, and their own vision of therapy. It is purely subjective and often determined by motives other than maintaining health. Chlamydia infection is widely discussed on the Internet and everyone can find confirmation of their views. The notion that today’s evolving pharmacotherapy can easily and quickly solve any problem is strong. There is a lot of information about the negative impact of antibacterial therapy on the immune system, liver function. As a result, many patients are focused on a short course of antibacterial therapy and expect a guaranteed cure. The need for a deeper examination and long-term treatment for fibrotic processes is not understood by either patients or health care organizers. In the current situation, doctors have to find a satisfactory balance in each case among the expediency of a full-fledged examination, the duration of antibacterial therapy for chlamydia persistence, and the widely discussed negative consequences of antibiotic therapy, between their professional views and perceptions and fears of the patient to achieve compliance.

It may be difficult to cooperate with a specialist who is treating a sexual partner due to individual differences in views on the clinical situation. Unified approaches to the diagnosis and therapy of chlamydia infection, on the one hand, help when working with a partner couple (e.g., they position the mandatory treatment of a partner when a chlamydia infection is detected) and, on the other hand, limit the possibilities of an individual approach. For example, complex treatment of a patient with chronic long-term chlamydia infection may be useless if the partner is not examined, receives only a short course of antibiotics, does not take medications, or does not use protection against STIs.

Etiotropic therapy of chlamydia infection is not very effective in polygamous relationships. Promiscuity behavior is quite widespread among young people. The search for a variety of sexual experiences, the constant change of partners, and the predominance of relaxation motives often precede the establishment of a partner sexual relationship. During this period, the correct and consistent use of protective equipment (condoms) is important. Unfortunately, condoms are often used from time to time or incorrectly [10]. The main focus of the partners is on HIV prevention, everything else is considered irrelevant. If a man or woman is subjectively convinced that his or her partner is not HIV-positive, condoms can stop being used.

Men are often not interested in the examination and treatment of STIs, which are asymptomatic. There is an opinion that chlamydia infection is widespread, there is a high probability of infection when changing partners, so it is inexpedient to be examined and treated only after establishing monogamous partnerships and planning a pregnancy. This pattern is supported by the common notion that a chlamydial infection can be easily cured by taking 1 g of azithromycin.

Therapy of chronic chlamydia infection is difficult in couples in which at least one partner has other sexual contacts and plans to keep them. A full-fledged examination and therapy of all patients from the chain of contacts, as a rule, is unrealistic.

It is necessary to take into account some features of public consciousness regarding chlamydia infection. Among them are two opposing views “chlamydia cannot be completely cured, chlamydia remains” and “a short course of antibiotics is enough to guarantee a cure.” Both of these views prevent the responsible implementation of the doctor’s recommendations.

Chlamydia is a common cause of reproductive dysfunction. Traditionally, concern for reproductive health is more characteristic of women. They visit a gynecologist more often than men visit an urologist, conduct examinations more often, and are more focused on conducting therapy. Less interest of men and their resistance can nullify the therapeutic efforts of a couple.

5. Conclusion

Successful management of chlamydia is possible only with its timely and complete detection.

The peculiarities of the clinical course of chlamydia infection, the difficulties of its diagnosis, and therapy in chronic persistent forms determine the difficulties of patient curation.

The prevalence of chlamydial infection, especially its persistent forms, is probably much higher than its detection rate.

A standardized approach to diagnosis and therapy is optimal for acute chlamydia infection.

The tactics of examination and treatment of patients with chronic persistent forms are not systematized, not generalized, and require a personalized approach. The latter is complicated, associated with high material costs, and may be insufficiently effective due to a number of socio-psychological and partner factors. The current practice of managing patients is aimed more at controlling exacerbations of chlamydial infection than at eliminating it.

The affective control of the spread of chlamydia infection requires raising public awareness about its nature, clinical manifestations, consequences, diagnostic capabilities, and preventive measures.

Simple educational activities about the importance and rules of condom use—counseling, broader educational programs aimed at individuals or couples—are appropriate. These can raise awareness and promote consistent use. Communication training on sex education and teaching young people and adolescents how to resist provocative offers of sex without a condom can also be useful [9].

An important direction may be the reorientation of the doctor-patient interaction model from a biomedical health model to a biopsychosocial one, in which the patient is informed and consciously makes decisions regarding his health. This will require improving the communication competence of health care workers to achieve the necessary result.