Recommended Treatment for Chlamydia
The recommended first-line treatment for chlamydia is doxycycline 100 mg orally twice daily for 7 days, which has superior efficacy (95.5% for urogenital infections and 96.9% for rectal infections) compared to alternative regimens. 1
Treatment Regimens
First-line Treatment
- Doxycycline: 100 mg orally twice daily for 7 days 1, 2
- Efficacy: 95.5% for urogenital infections, 96.9% for rectal infections 1
- Advantages: Higher efficacy, especially for rectal infections
- Disadvantages: Multi-day regimen may reduce adherence
Alternative Treatment
- Azithromycin: 1 g orally in a single dose 1
Special Populations
Pregnant Women
- Azithromycin is preferred for pregnant women as doxycycline is contraindicated during pregnancy 1
- Test of cure is required 3 weeks after treatment completion for pregnant women 1
- Pregnant women should be retested in the third trimester if diagnosed in the first trimester 1
HIV-Positive Patients
- Same treatment regimens apply as for HIV-negative patients 1
Patient Management
Administration Guidelines
- Medications should be dispensed on-site when possible 1
- First dose should be directly observed to maximize compliance 1
- For doxycycline, administer with adequate amounts of fluid to reduce risk of esophageal irritation 2
- If gastric irritation occurs, doxycycline can be given with food or milk 2
Post-Treatment Recommendations
- Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 1
- Both patient and partner(s) should complete treatment and be symptom-free before resuming sexual activity 1
- Test of cure is NOT recommended for non-pregnant patients treated with recommended regimens 1
- Retesting is recommended approximately 3 months after treatment due to high risk of reinfection (up to 39% in some studies) 1
Partner Management
- All sex partners from the preceding 60 days should be evaluated, tested, and treated 1
Clinical Pearls and Pitfalls
- Rectal infections: Doxycycline has significantly higher efficacy (99.6%) compared to azithromycin (82.9%) for rectal chlamydia, with a difference of 19.9% in favor of doxycycline 3
- Adherence concerns: While azithromycin offers the advantage of directly observed single-dose therapy, its lower efficacy, particularly for rectal infections, makes it a second-line option 1, 4
- Persistent symptoms: If symptoms persist after treatment, patients should be evaluated by culture, and any isolates should be tested for antimicrobial susceptibility 1
- Importance of partner treatment: Treatment failure often occurs due to reinfection from untreated partners rather than true treatment failure 5
The evidence strongly favors doxycycline as the first-line treatment for chlamydia due to its superior efficacy across all infection sites, with azithromycin reserved for situations where adherence is a concern or when doxycycline is contraindicated.