What is the recommended treatment for Chlamydia, including partner treatment?

Chlamydia Treatment and Partner Management

Doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment for chlamydia due to its superior efficacy (95.5% for urogenital infections and 96.9% for rectal infections), with azithromycin 1 g orally in a single dose as an alternative when adherence is a concern. 1

First-Line Treatment Options

Recommended Regimens

• Doxycycline: 100 mg orally twice daily for 7 days

  • Highest efficacy for both urogenital (95.5%) and rectal infections (96.9%) 1
  • Main disadvantage: 7-day course may reduce adherence

• Azithromycin: 1 g orally in a single dose

  • Efficacy: 92% for urogenital infections, but only 76.4% for rectal infections 1
  • Advantage: Single-dose improves adherence and allows for directly observed therapy
  • Consider for patients with anticipated adherence issues

Alternative Regimens

• Erythromycin base 500 mg orally four times daily for 7 days 1, 2
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 2
• Ofloxacin 300 mg orally twice daily for 7 days 1

Treatment in Special Populations

Pregnant Women

• Recommended regimens:

  • Erythromycin base 500 mg orally four times daily for 7 days 3, 2
  • Amoxicillin 500 mg orally three times daily for 7 days 3

• Alternative regimens:

  • Erythromycin base 250 mg orally four times daily for 14 days 3
  • Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 3, 2
  • Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 3
  • Azithromycin 1 g orally in a single dose (limited data) 3

Note: Doxycycline and ofloxacin are contraindicated during pregnancy 3

HIV-Infected Patients

• Same treatment regimens as HIV-negative patients 3

Partner Management

• All sexual partners from the preceding 60 days should be evaluated, tested, and treated 3, 1
• Treat the most recent partner even if the last sexual contact was >60 days before diagnosis 3
• Patients and partners should abstain from sexual intercourse:
  • Until 7 days after single-dose therapy, OR
  • Until completion of a 7-day regimen 3, 1

Follow-Up Recommendations

• Test of cure is generally not needed after completing treatment with doxycycline or azithromycin unless symptoms persist 3, 1
• Consider test of cure 3 weeks after completion of treatment with erythromycin 3
• Retesting approximately 3 months after treatment is recommended due to high risk of reinfection 1

Clinical Pearls and Pitfalls

1. Co-infection considerations:

   • Patients with chlamydia often have concurrent gonorrhea requiring dual therapy 1
   • Consider treating for gonorrhea with ceftriaxone 125 mg IM in a single dose PLUS the chlamydia treatment 1

2. Medication adherence:

   • To maximize compliance, medications should be dispensed on site when possible 3
   • The first dose should be directly observed 3
   • Single-dose azithromycin has comparable effectiveness to doxycycline in real-world settings despite lower theoretical efficacy 4

3. Rectal infections:

   • Doxycycline is significantly more effective than azithromycin for rectal chlamydia (96.9% vs 76.4%) 1, 5
   • Consider doxycycline as the preferred treatment for patients with rectal infections

4. Risk factors for treatment failure:

   • Age ≤24 years
   • Recent new partner or multiple partners
   • Partner with multiple partners
   • Untreated partners during follow-up period 4

5. Complications of untreated infection:

   • Pelvic inflammatory disease
   • Ectopic pregnancy
   • Infertility
   • Chronic pelvic pain 1

By following these evidence-based recommendations, healthcare providers can effectively treat chlamydia infections and prevent complications while reducing transmission through appropriate partner management.