What is the recommended treatment for chlamydia?

Treatment of Chlamydia Infection

For uncomplicated chlamydial infections, doxycycline 100 mg orally twice daily for 7 days is the preferred first-line treatment, with azithromycin 1 g orally as a single dose being an acceptable alternative. 1

First-Line Treatment Options

Adults and Adolescents (≥8 years):

• First-line: Doxycycline 100 mg orally twice daily for 7 days 1, 2
• Alternative: Azithromycin 1 g orally as a single dose 1

Children:

• <45 kg: Erythromycin base or ethylsuccinate 50 mg/kg/day divided into four doses for 14 days 1, 3
• >45 kg but <8 years: Azithromycin 1 g orally as a single dose 1
• ≥8 years: Same as adult regimen 1

Pregnant Women:

• Recommended: Azithromycin 1 g orally as a single dose 1
• Note: Doxycycline is contraindicated in pregnancy 1, 2

Treatment Considerations

Efficacy Comparison

While both treatments are effective, recent evidence suggests doxycycline may have superior efficacy for rectal chlamydia infections. The efficacy rates are:

• Doxycycline: 99.6% (95% CI 98.6%-100%) 4
• Azithromycin: 82.9% (95% CI 76.0%-89.8%) 4

Adherence Factors

• Doxycycline requires twice-daily dosing for 7 days, which may lead to adherence issues 1, 2
• Azithromycin's single-dose regimen allows for directly observed therapy, potentially improving treatment success in patients with poor adherence history 1, 5

Post-Treatment Management

Sexual Activity and Partner Treatment

• Patients should abstain from sexual intercourse until:
  • 7 days after single-dose therapy completion
  • Until completion of 7-day regimen
  • Until all partners are treated 1
• All sexual partners from the past 60 days should be notified, examined, and treated regardless of test results 1

Follow-up Testing

• Test of cure is recommended for:
  • Pregnant women
  • When alternative regimens are used
  • When there are concerns about adherence
  • Persistent symptoms
  • Suspected reinfection 1
• Test of cure should be conducted ≥3 weeks after treatment completion 1
• Rescreening is recommended 3-6 months after treatment due to high risk of reinfection 1

Common Pitfalls to Avoid

1. Failing to treat partners: Untreated partners are a major source of reinfection 1
2. Inadequate follow-up: Rescreening at 3-6 months is essential due to high reinfection rates 1
3. Not testing for co-infections: Always test for other STIs, including HIV and syphilis 1
4. Poor adherence monitoring: For multi-day regimens, emphasize the importance of completing the full course even if symptoms resolve quickly 1
5. Inappropriate treatment in pregnancy: Remember that doxycycline is contraindicated in pregnant women 1, 2

Special Situations

Rectal Infections

For rectal chlamydial infections, doxycycline is preferred over azithromycin due to higher efficacy rates (99.6% vs 82.9%) 4

Co-infection with Gonorrhea

If gonorrhea co-infection is present or not ruled out, add ceftriaxone 500 mg IM as a single dose to the chlamydia treatment 1