What is the recommended treatment for chlamydia?

Treatment for Chlamydia

The first-line treatments for uncomplicated chlamydial infection are azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days, both with cure rates of approximately 97-98%. 1, 2

First-Line Treatment Options

• Azithromycin 1 g orally in a single dose offers advantages including directly observed therapy and better compliance, particularly useful when adherence to multi-day regimens is questionable 1, 2
• Doxycycline 100 mg orally twice daily for 7 days has extensive clinical experience and is generally less expensive than azithromycin 2
• Both medications have similar efficacy rates in clinical trials, with cure rates of 97-98% for uncomplicated urethral, endocervical, or rectal chlamydial infections 2, 3

Alternative Treatment Options

• Erythromycin base 500 mg orally four times a day for 7 days 4, 2
• Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days 4, 2
• Ofloxacin 300 mg orally twice a day for 7 days 4, 2
• Levofloxacin 500 mg orally once daily for 7 days 2
• Sulfisoxazole 500 mg orally four times a day for 10 days (note: efficacy is inferior to other regimens) 4

Special Populations

Pregnancy

• Azithromycin 1 g orally in a single dose is recommended during pregnancy 1, 2
• Amoxicillin 500 mg orally three times a day for 7-10 days is an alternative during pregnancy 4, 1
• Erythromycin base 500 mg orally four times a day for 7 days can be used if the above options cannot be tolerated 4
• Doxycycline and ofloxacin are contraindicated during pregnancy 4, 1
• Erythromycin estolate is contraindicated during pregnancy due to risk of hepatotoxicity 4

Children

• For children ≥8 years who weigh >45 kg: same adult regimens apply 1
• For children ≥8 years who weigh <45 kg: dosage based on weight 1

Implementation Considerations

• Medications should ideally be dispensed on-site when possible, with directly observed first dose to maximize compliance 2, 5
• Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 2
• All sex partners from the previous 60 days should be evaluated, tested, and treated to prevent reinfection 2, 5

Follow-Up Recommendations

• Test-of-cure is not routinely recommended for patients treated with the recommended regimens unless therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 2, 5
• Consider retesting women approximately 3 months after treatment due to high risk of reinfection 2

Clinical Pearls and Pitfalls

• Treatment failure is uncommon after successful completion of a ≥7-day regimen of doxycycline, with failure rates of 0-3% reported for males and 0-8% for females 4
• Single-dose azithromycin therapy can be particularly valuable in populations where compliance with multi-day regimens may be problematic 6, 7
• Recent meta-analyses suggest doxycycline may be more effective than azithromycin for rectal chlamydial infections (99.6% vs 82.9% efficacy) 8
• Untreated chlamydial infections can lead to serious sequelae in women, including PID, ectopic pregnancy, and infertility 5

Specific Considerations for Rectal Infections

• While both azithromycin and doxycycline are approved for rectal chlamydial infections, recent evidence suggests doxycycline may have superior efficacy for rectal infections 8
• Consider doxycycline as the preferred treatment for known rectal chlamydial infections when patient compliance can be ensured 8