Few evaluations of tests for Chlamydia trachomatis have compared nucleic acid amplification tests (NAATs)with diagnostic tests other than those by culture. In a five-city study of 3,551 women, we compared the results of commercial ligase chain reaction (LCR) and PCR tests performed on cervical swabs and urine with the results of PACE 2 tests performed on cervical swabs, using independent reference standards that included both cervical swabs and urethral swab-urine specimens. Using cervical culture as a standard, the sensitivities of PACE 2, LCR, and PCR tests with cervical specimens were 78.1, 96.9, and 89.9%, respectively, and the specificities were 99.3, 97.5, and 98.2%, respectively. Using either cervical swab or urine LCR-positive tests as the standard decreased sensitivities to 60.8% for PACE 2 and to 75.8 and 74.9% for PCR with cervical swabs and urine, respectively. Specificities increased to 99.7% for PACE 2 and to 99.7 and 99.4% for PCR with cervical swabs and urine, respectively. Sensitivities with a cervical swab-urine PCR standard were 61.9% for PACE 2 and 85.5 and 80.8% for LCR with cervical swabs and urine, respectively. Specificities were 99.6% for PACE 2 and 99.0 and 98.9% for LCR with cervical swabs and urine, respectively. Cervical swab versus urine differences were significant only for PCR specificities (P ؍ 0.034). Overall, LCR sensitivity exceeded that of PCR, and sensitivities obtained with cervical swabs exceeded those obtained with urine specimens by small amounts. These data have substantiated, using a large multicenter sample and a patient standard, that LCR and PCR tests performed on endocervical swabs and urine are superior to PACE 2 tests for screening C. trachomatis infections in women. In our study, NAATs improved the detection of infected women by 17 to 38% compared to PACE 2.Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection in the United States (6). Untreated infections can have devastating consequences for the female reproductive tract by causing pelvic inflammatory disease with serious sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain. Because the majority of infections, particularly in women, are unrecognized clinically, screening with laboratory tests followed by antibiotic treatment is the most important means of intervention and control. The diagnostics industry has responded to this large public health need with steady improvements in test technologies. Concomitantly, methodology used for evaluation of these newly developed tests has evolved in a parallel fashion.Historically, isolation of C. trachomatis in culture was used as the reference standard for classifying patients as infected or uninfected in new test evaluations (3). Culture was chosen for this purpose because it has nearly 100% specificity, resulting from the highly distinctive morphology of specifically stained chlamydial inclusion bodies grown in host cells, and because it was the most sensitive method available at the time. Thus, virtually all of th...