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

Treatment of Chlamydia trachomatis Infection

The first-line treatment for Chlamydia trachomatis infection is either doxycycline 100 mg orally twice daily for 7 days or azithromycin 1 g orally in a single dose. 1

First-Line Treatment Options

Both treatment options are equally efficacious for chlamydia treatment, with cure rates of 95-100% reported in clinical studies:

• Doxycycline: 100 mg orally twice daily for 7 days
• Azithromycin: 1 g orally in a single dose

Considerations for Treatment Selection

When deciding between these two first-line options, consider:

• Adherence concerns: Azithromycin may be preferred when compliance is a concern due to its single-dose administration 1
• Pregnancy status: Doxycycline is contraindicated in pregnant women 1
• Concurrent infections: If the patient has both chlamydia and bacterial vaginosis, consider doxycycline plus metronidazole 1

Alternative Treatment Options

For patients who cannot tolerate first-line treatments, the CDC recommends:

• Erythromycin base 500 mg orally four times daily for 7 days
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days
• Ofloxacin 300 mg orally twice daily for 7 days 1

Erythromycin Dosing for Urogenital Infections

For adults with uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis when tetracycline is contraindicated or not tolerated:

• 500 mg of erythromycin by mouth four times a day for at least 7 days 2

Special Populations

Pregnant Women

• Azithromycin 1 g orally in a single dose is the preferred treatment 1
• Alternative: Erythromycin 500 mg orally four times daily for at least 7 days
  • For women who cannot tolerate this regimen, a decreased dose of erythromycin 500 mg orally every 12 hours or 250 mg orally four times daily should be used for at least 14 days 2

Children

• For patients weighing <45kg: erythromycin base or ethylsuccinate 50mg/kg/day divided into four doses for 14 days
• For patients weighing >45kg but <8 years: azithromycin 1g orally, single dose
• For patients ≥8 years: azithromycin 1g orally single dose OR doxycycline 100mg twice daily for 7 days 1

Partner Management

• All sexual partners from the past 60 days should be notified, examined, and treated 1
• Partners should be treated regardless of their test results to prevent reinfection 1
• Patients should abstain from sexual intercourse until treatment is completed and all partners have been treated 1

Follow-up Recommendations

• Test of cure is not routinely recommended for non-pregnant patients treated with recommended regimens
• If symptoms persist, follow-up testing 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 and Caveats

1. Incomplete treatment: Emphasize the importance of completing the full course of doxycycline, even if symptoms resolve quickly
2. Untreated partners: Failure to treat partners is a common cause of reinfection
3. Premature resumption of sexual activity: Patients should abstain from sexual intercourse until 7 days after single-dose therapy or until completion of 7-day regimen 1
4. Missed concurrent infections: Always test for other STIs, including gonorrhea, HIV, and syphilis 1
5. Macrolide resistance concerns: Azithromycin monotherapy is contraindicated for patients with current non-tuberculous mycobacterial (NTM) infection 1

The evidence strongly supports both doxycycline and azithromycin as equally effective treatments for chlamydia, with the choice between them depending primarily on concerns about adherence, pregnancy status, and concurrent infections.