Chlamydia Resistance?

[wishicouldturnbacktime]

Can a STD physician expert please advise me on the next step?
- I am a 36 year old male in monogamous relationship with girl A
- Both myself and girl A were negative for all STDs
- Aug 12/2012 1 unprotected vagina exposure with girl T
- Within 1 week strong symptoms of clamydia begin (did not have sexual contact with girl A after exposure)
- Test Aug 21 and get postive results for chlamydia Aug 23. Prescribed and take 4 pills (250mg) Azithromycin
- Advised not to have sex for 7 days. Refrain from all sexual contact, but following 7 days have unprotected sex with girl A again
- Roughly 1-2 weeks later symptoms of clamydia return fairly strong
- Test Sept 24 and get positive results for clamydia Sept 27. Sept 28 Prescribed Deoxycycline twice daily for 2 weeks. Girl A is prescribed Deoxycycline twice daily for 1 week (Girl A never tested, but took antibiotics due to exposure)
- Advised not to have sex for 7 days. Girl A and I completely compliant and finish antibiotics
- After 7 days on treatment (October 5 & 6th) Girl A and I have unprotected sex again
- Oct 12 finish 2nd week of deoxycycline
- 1 week later symptoms of chlamydia return fairly strong
Test Oct 17th and get positive chlamydia results Oct 21st
- Other details:
- My symptoms were relieved while on treatment but came back after discontinuation of antibiotics
- Girl T was notified and treated successfully with 1 week of Deoxcycline twice daily.
- Oct 22nd discharge and swab sent to lab for futher 'culture' analysis (I apologize, not sure of appropriate terminology) by STD clinic physician
- It's my understanding that results will guide further treatment
- I'm concerned because physicians and nurses say they don't see chlamydia treatment failures
- Further concerned about next steps and the potential ' law of diminishing returns' with repeated antibiotic use
- Currently not on treatment/experiencing symptoms. Waiting for results. Anxious that it will be permanent. Your advice would be really appreciated!

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  Thanks for this interesting question.

Something very peculiar is going on here.  I find it impossible to believe you really have persisting chlamydia in the face of the treatments you describe.  I'm not challenging your story, but I have to believe there is a problem with the test procedure, or your understanding of the tests that were done, or perhaps in understanding your doctor.  In the 4 decades since chlamydia has been recognized as a distinct STD pathogen, there has never been a strain that was so resistant to either doxycycline or azithromycin, let alone both of them -- and I cannot imagine you are the first case.

So I'm going to ask you for some more information before I try to sort out what might be going on.  Some of it might be difficult to dig out, for which I'm sorry; some of it may take several calls to your doctor's office and/or the laboratory.  But please do your best.

First, describe in detail what you mean by "strong symptoms of clamydia".  Exactly what symptoms did you have at each point in time?

Second and most important, are you sure you were tested for chlamydia, and that it wasn't just your doctor saying s/he thought you had chlamydia, i.e. a truly positive lab test for chlamydia.  If so, was it a culure test?  If not culture, tell me the exact brand name of each test done.  What specimens were tested -- urine or urethral swab?  (If it was blood, we already have the answer.  All chlamydia blood tests are worthless and the results can be ignored.)

As for a "permanent" problem, don't worry.  There is no such thing as untreatable, permanent chlamydia. If we ignore chlamydia (assuming we come up with some problem with the lab or the tests), then persistent symptoms aren't so rare.  But at least they are harmless -- so if that's what's going on, this won't be a serious health issue for you.

I look forward to helping work this out after you fill in the necessary information.

Regards--  HHH, MD

[H. Hunter Handsfield, M.D.]

I'm glad itls all working out.  You're in expert hands; carry on with them as necessary.  I'm happy to have been of help.

[wishicouldturnbacktime]

Hi Dr Handsfield,
I was notified my chlamydia culture test was negative yesterday. My physician at the Centre for Disease Control thinks the dead chlamydia organism was still being picked up by the NAAT tests. I started first treatment on Aug 24th and on Oct 17th still tested positive. Nearly 2 months seems like a long time to still test positive right? Oh well, I want to thank you very much for you insight and reassurance through this difficult time.
Regards,

[H. Hunter Handsfield, M.D.]

It is indeed possible for chlamydial DNA to persist for up to 3 weeks, giving positive test results despite succesful treatment.  At 2 weeks, this is possible but somewhat unlikely; 80-90% of successfully treated patients would have negatuve NAAT by then.  understood a 4 week interval, otherwise I would have mentioned this possibility in my original reply.

It sounds like your doctors are on top of all these issues, and your comments suggest they, believe both your positive NAAT results are real and that they suspect your pending culture will also be positive and might reflect an antibiotic-resistant strain of chlamydia.  If so, you will be contributing  to medical (however unwillingly!); there have been only one or two reported cas of true resistance of Chlamydia trachomatis to doxycycline and/or azithromycin.  If it works out that way, I would expect your doctors to write up a scientific report for publication.

I that event, I would not venture a guess about the best alternate treatment to use; that decision would rest on the lab tests to determine the best choice.n However, I still would not worry about eventual treatment success; there has never been a C. trachomatis strain resistant to all antibiotics. And I also would reemphasize my prediction that your chlamydia culture test will be negative -- in which case my advice above will remain valid.

As I said earlier, all this suggests you are in the hands of genuine experts.  They should remain your main source of advice about next steps in treatment. But please do keep me posted as the various tests play out.

[wishicouldturnbacktime]

Hi Dr Handsfield,
Thanks for your reply. There is a chance I tested too early after finishing the 2 weeks of Deoxcycline and the NAAT testing is still finding chlamydia in my body.
The clinic is doing the culture to grow the bacteria in the lab and then find which antibiotic is most effective to kill the chlamydia. The clinic said it may take up to 2 weeks.
It's my understanding the lab will be able to determine if they can infact grow the bacteria and I do truly still have chlamydia or it is a false positive. Worst case scenario, and I do still have it - what re-treatment do you recommend?

[H. Hunter Handsfield, M.D.]

Thanks for the clarifications.  This helps a lot -- although it doesn't resolve all the uncertainties.  I agree those labs probably are reliable; most likely they use a chlamydial nucleic acid amplification test (NAAT), the most accurate type of test.

You have had recurrent NGU, twice. The first time it was treated as recommended, i.e. if azithromycin is used first, switch to doxycycline. (The standard recommendation is for 7 days, but some experts give up to 2 weeks treatment.) Recurrent NGU is quite common; about 15-20% of people with chlamydial NGU have recurrent urethritis, with symptoms reappearing 1-3 weeks after treatment. However, usually the follow-up chlamydia test is negative. Even a second recurrence after repeat treatment isn’t all that rare, as you apparently had. I’m predicting that your third chlamydia test, done a few days ago, will be negative.  If it remains positive, I will have to suspect the lab is having a technical difficulty with the test. Of course re-infection always is a consideration, but I gather the partners at potential risk had also been treated.

I’m having trouble understanding what additional tests the clinic might be doing. Chlamydia culture is less sensitive than NAAT, but perhaps they also suspect a lab problem and are trying to sort it out with the additional testing.

Having had a second recurrence of NGU, and anticipating that your newest test results will indeed be negative for chlamydia, the management recommended by the US Centers for Disease Control and Prevention (CDC) is to treat with moxifloxacin (trade name Avelox) and with either tinidazole or metronidazole. Moxi covers Mycoplasma genitalium, a newly recognized cause of NGU that is often resistant to both azithro and doxy. The others treat trichomonas, an occasional cause of NGU that is difficult to diagnose in men.

It sounds like you are under the care of legitimate STD experts. Rather than assuming my advice is correct, I would suggest you print out this thread and discuss it with your doctors, then follow their advice about treatment for you and perhaps your partner(s).

Although this has all be disconcerting and confusing, don’t be overly concerned. Nonchlamydial NGU is generally harmless, with few if any serious complications for either infected men or their partners. This is an issue of convenience and symptom control, not a serious health threat.
Please return with a follow-up comment to let me know how things are going after if and when this is all sorted out.

[wishicouldturnbacktime]

Hi Dr Handsfield,

Many thanks for your prompt reply!

1) After unprotected exposure (Aug 12), I experienced the following symptoms:
-white, ***** discharge from penis
-painful, burning urination
-itchy head of penis
-general 'hot' feeling from penis head and shaft
*After treatment with Azithromycin, 1 to 2 weeks later I experienced:
-clear discharge when I pump head of penis
-urination was not painful, but urethra and opening of penis head was sensitive
-itchy head of penis
-general 'hot' feeling from penis head and shaft
-more sensitive testicles
*After 2 week treatment of Deoxycycline, 1 week later I am experiencing the same symptoms as post Azithromycin listed above

2) I was positively tested for Chlamydia Aug 21 and Sept 24 by my Provincial Centre for Disease Control in Canada. Aug 21 Urine only. Sept 24 Urine and Urethral Swab (swab checked for NGU and not sure about chlamydia). I can find out the exact brand name of each test but I imagine their testing equipment would be of the highest standard for the industry.

Due to travel, I tested on Oct 17th at a major Canadian city's department of health std clinic - urine only, but when chlamydia result came positive I went back and the attending physician swabbed the clear discharge and also my urethra for culture testing due to my history of treatment. (Presently waiting for results) Would you like the brand names of the urine and culture tests?

Would it be prudent to perform any other testing at this time? Blood work for other problems that may have an impact of antibiotic treatment?