What are the recommended treatments for chlamydia, including cotreatment options for other sexually transmitted infections (STIs)?

Treatment Recommendations for Chlamydia and Co-infections

For uncomplicated chlamydial infections, the first-line treatment is azithromycin 1g orally in a single dose OR doxycycline 100mg orally twice daily for 7 days, with cure rates of 97-98%. 1

First-Line Treatment Options

Azithromycin Regimen

• Dosage: 1g orally in a single dose
• Advantages:
  • Single-dose therapy improves compliance
  • Can be directly observed in clinic settings
  • Particularly useful for patients with poor compliance history 1

Doxycycline Regimen

• Dosage: 100mg orally twice daily for 7 days
• Advantages:
  • May be more effective for rectal chlamydial infections 2
  • Lower cost compared to azithromycin

Co-treatment Considerations

Patients with chlamydial infections should always be tested for other STIs due to high rates of co-infection 1:

For Gonorrhea Co-infection

• Test all chlamydia patients for gonorrhea
• If positive or high suspicion:
  • Add ceftriaxone 500mg IM as a single dose

For Other STIs

• Test for syphilis and HIV in all patients with chlamydia 1
• For suspected trichomoniasis or bacterial vaginosis, perform appropriate testing and treat accordingly

Special Populations

Pregnant Patients

• Preferred treatment: Azithromycin 1g orally in a single dose 1
• Alternative: Amoxicillin or erythromycin base if azithromycin is contraindicated

Children

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

Partner Management

• All partners should be notified and treated for the STIs identified in the patient 1
• Patients should abstain from sexual intercourse:
  • Until 7 days after single-dose treatment OR
  • Until completion of 7-day treatment regimen AND
  • Until all partners have been treated 1

Follow-up Recommendations

• Routine test-of-cure is not recommended after treatment with azithromycin or doxycycline due to high efficacy rates 1
• Consider rescreening 3-4 months after treatment due to high risk of reinfection 1
• For persistent symptoms despite treatment:
  • Reevaluate for reexposure
  • Check partner treatment status
  • Consider less common causes including Mycoplasma genitalium 1

Clinical Pearls and Pitfalls

• Pitfall: Inadequate partner treatment often leads to reinfection
• Pitfall: Azithromycin may have lower efficacy for rectal chlamydial infections (82.9% vs 99.6% for doxycycline) 2
• Pearl: To maximize compliance, medications should be dispensed on site and the first dose directly observed 1
• Pearl: Cervicitis may be a sign of endometritis or PID; always assess for upper tract symptoms 1
• Caution: Antimicrobial agents used to treat chlamydia may mask or delay symptoms of incubating syphilis, so syphilis testing is essential 1