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

Chlamydia Treatment Recommendations

For uncomplicated chlamydial infections in non-pregnant adults, doxycycline 100 mg orally twice daily for 7 days is the first-line treatment due to its superior efficacy (95.5% for urogenital infections and 96.9% for rectal infections). 1

First-Line Treatment Options

• Doxycycline: 100 mg orally twice daily for 7 days

  • Highest efficacy for both urogenital (95.5%) and rectal infections (96.9%)
  • Requires 7-day adherence to treatment regimen 1

• Azithromycin: 1 g orally in a single dose

  • Slightly lower efficacy (92% for urogenital infections, 76.4% for rectal infections)
  • Preferred when adherence is a concern - allows for directly observed therapy 1
  • Single-dose therapy eliminates compliance issues 2, 3

Special Populations

Pregnant Women

Doxycycline and azithromycin are contraindicated during pregnancy. The recommended regimens are:

• First choice: Erythromycin base 500 mg orally four times daily for 7 days 1, 4
• Alternative options if first choice is not tolerated:
  • Erythromycin base 250 mg orally four times daily for 14 days
  • Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days
  • Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days
  • Amoxicillin 500 mg orally three times daily for 7-10 days 5, 1

Adolescents

• Same regimens as adults, except ofloxacin is not recommended for those ≤17 years 5
• Single-dose azithromycin may be particularly beneficial for improving adherence 6

Partner Management

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

Follow-Up Recommendations

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

Clinical Considerations

Efficacy Comparison

Medication	Urogenital Infection	Rectal Infection	Advantages	Disadvantages
Doxycycline	95.5%	96.9%	Higher efficacy	7-day course
Azithromycin	92%	76.4%	Single-dose	Lower efficacy for rectal infections

Common Pitfalls and Caveats

1. Co-infection with gonorrhea: Consider dual therapy with ceftriaxone 125 mg IM in a single dose PLUS azithromycin or doxycycline due to increasing resistance patterns 1

2. Medication adherence: For patients with adherence concerns, directly observed therapy with single-dose azithromycin is preferable over multi-day regimens 1, 2

3. Untreated complications: Failure to treat can lead to serious sequelae, particularly in women, including:

   • Pelvic inflammatory disease (PID)
   • Ectopic pregnancy
   • Infertility
   • Chronic pelvic pain 1, 7

4. Reinfection risk: High rates of reinfection (up to 39% in some studies) necessitate partner treatment and follow-up testing 5, 1

5. Optimal administration: Erythromycin tablets are best absorbed when taken in the fasting state (at least 30 minutes and preferably 2 hours before meals) 4

By following these evidence-based treatment recommendations, clinicians can effectively manage chlamydial infections while minimizing complications and preventing transmission.