What is the recommended treatment for Chlamydia (Chlamydia trachomatis)?

Recommended Treatment for Chlamydia Trachomatis

The recommended first-line treatments for uncomplicated genital chlamydial infections are doxycycline (100 mg orally twice daily for 7 days) or azithromycin (1 g orally in a single dose), with cure rates of 97-98%. 1

Treatment Algorithm for Adults with Uncomplicated Chlamydia

First-Line Options:

• Doxycycline: 100 mg orally twice daily for 7 days

  • Preferred for patients with good follow-up and compliance
  • Slightly higher efficacy (98% cure rate)
  • Lower cost

• Azithromycin: 1 g orally in a single dose

  • Preferred for patients with compliance concerns
  • Excellent efficacy (97% cure rate)
  • Advantage of directly observed therapy
  • Better for patients with unpredictable follow-up

Alternative Options (when first-line treatments cannot be used):

• Ofloxacin: 300 mg orally twice daily for 7 days 2
• Erythromycin base: 500 mg orally four times daily for 7 days 2, 3
• Erythromycin ethylsuccinate: 800 mg orally four times daily for 7 days 2

Special Populations

Pregnant Patients:

1. First choice: Azithromycin 1 g orally in a single dose 1
2. Alternative options:
   • Erythromycin base: 500 mg orally four times daily for 7 days 2, 3
   • If not tolerated: Erythromycin base 250 mg orally four times daily for 14 days 2
   • Amoxicillin: 500 mg orally three times daily for 7-10 days 2

Important: Erythromycin estolate is contraindicated during pregnancy due to risk of hepatotoxicity 2

Children:

• <45kg: Erythromycin 50 mg/kg/day orally divided into four doses for 14 days 1
• >45kg but <8 years: Azithromycin 1 g orally in a single dose 1
• >8 years: Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days 1

Post-Treatment Considerations

• Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a multi-day regimen 1
• All sexual partners should be treated to prevent reinfection 1
• Routine test-of-cure is not recommended after treatment with doxycycline or azithromycin due to high efficacy rates 1
• Consider rescreening 3-4 months after treatment due to high risk of reinfection 1

Clinical Pearls and Pitfalls

• Always test for other STIs: Patients with chlamydia should be tested for gonorrhea, syphilis, and HIV due to high rates of co-infection 1
• Compliance considerations: For patients with poor compliance history, azithromycin may be more appropriate despite higher cost 1
• Directly observed therapy: When possible, dispense medication on site and observe first dose to maximize compliance 1
• Treatment failure vs. reinfection: High rates of positive tests after treatment (up to 39% in adolescents followed for 24 months) are often due to reinfection rather than treatment failure 2
• Rectal infections: The same treatment regimens are effective for rectal chlamydial infections 2

Early and effective treatment of chlamydia is crucial to prevent complications such as pelvic inflammatory disease, infertility, and chronic pelvic pain, which significantly impact morbidity and quality of life.