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

Treatment for Chlamydia trachomatis

The recommended first-line treatment for uncomplicated chlamydial infection is either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days, both with efficacy rates of approximately 97-98%. 1, 2, 3

First-Line Treatment Options

• Azithromycin 1 g orally in a single dose has advantages including directly observed therapy and better compliance, making it particularly useful when adherence to multi-day regimens is questionable 1, 3
• Doxycycline 100 mg orally twice daily for 7 days has advantages including lower cost and extensive clinical experience 1, 3
• Both medications are equally efficacious for genital chlamydial infections, with meta-analyses showing no statistically significant difference in microbial cure rates (97% for azithromycin vs 98% for doxycycline) 4

Alternative Treatment Options

• Erythromycin base 500 mg orally four times a day for 7 days 5, 1
• Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days 5, 1
• Ofloxacin 300 mg orally twice a day for 7 days 5, 1
• Levofloxacin 500 mg orally once daily for 7 days 5, 1

Implementation Best Practices

• Medications should be dispensed on-site when possible, with the first dose directly observed to maximize compliance 5, 1
• Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 5, 3
• Patients should also abstain from sexual intercourse until all sex partners are treated to minimize risk of reinfection 5, 1

Special Populations

Pregnancy

• Azithromycin 1 g orally in a single dose is recommended during pregnancy 2
• Amoxicillin 500 mg orally three times a day for 7 days is an alternative option during pregnancy 1, 2
• Doxycycline and fluoroquinolones (ofloxacin, levofloxacin) are contraindicated during pregnancy 2

Coinfection with Gonorrhea

• Patients with gonorrhea often have co-infection with chlamydia (20-40%), and when treating gonorrhea, treatment for both infections should be provided if chlamydial infection has not been excluded 3

Partner Management

• All sex partners from the previous 60 days should be evaluated, tested, and treated 1, 3
• If the last sexual contact was >60 days before diagnosis, the most recent partner should still be treated 1

Follow-Up Recommendations

• Test-of-cure is not routinely recommended after completing treatment with recommended regimens unless therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 1, 3
• Consider retesting women approximately 3 months after treatment due to high risk of reinfection 1, 3

Clinical Considerations and Pitfalls

• Gastrointestinal side effects are common with both treatments (25% for azithromycin vs 23% for doxycycline) but are generally mild to moderate 4
• Erythromycin often causes gastrointestinal side effects that lead to poor compliance, making it a less desirable alternative 1, 3
• Treatment failure is uncommon with recommended regimens, with failure rates of 0-3% for males and 0-8% for females 1
• When selecting between azithromycin and doxycycline, consider patient compliance factors and cost - azithromycin is preferred when compliance is a concern, while doxycycline is generally less expensive 1, 6