What is the recommended treatment for Chlamydia?

Chlamydia Treatment

First-Line Treatment Recommendation

For uncomplicated genital chlamydia, use either azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days—both achieve approximately 97-98% cure rates and are equally effective. 1, 2

Choosing Between First-Line Options

Select azithromycin when:

• Compliance with a 7-day regimen is questionable 1, 2
• Single-dose directly observed therapy is feasible 1, 2
• Patient preference for convenience outweighs cost considerations 1

Select doxycycline when:

• Cost is a primary concern (doxycycline is significantly less expensive) 1
• Rectal chlamydia is present—doxycycline achieves 99.6% cure rate versus only 82.9% for azithromycin in rectal infections 3
• Patient can reliably complete 7-day therapy 1

Alternative Treatment Options

If first-line agents cannot be used, alternatives include: 1, 2

• Erythromycin base 500 mg orally four times daily for 7 days
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days
• Ofloxacin 300 mg orally twice daily for 7 days
• Levofloxacin 500 mg orally once daily for 7 days

Important caveat: Erythromycin frequently causes gastrointestinal side effects leading to poor compliance, making it a less desirable alternative. 1

Special Population: Pregnancy

Recommended options during pregnancy: 2

• Azithromycin 1 g orally as a single dose (preferred)
• Amoxicillin 500 mg orally three times daily for 7 days (alternative) 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days 1

Contraindicated in pregnancy: 2

• Doxycycline
• Ofloxacin
• All fluoroquinolones

Special Population: Children

For children ≥8 years weighing >45 kg: 2

• Azithromycin 1 g orally as a single dose OR
• Doxycycline 100 mg orally twice daily for 7 days

For children ≥8 years weighing <45 kg: 2

• Weight-based dosing required (see pediatric dosing guidelines)

Implementation Best Practices

Maximize treatment success by: 1, 2

• Dispensing medications on-site when possible
• Directly observing the first dose (especially with azithromycin)
• Instructing patients to abstain from sexual intercourse for 7 days after single-dose therapy OR until completion of 7-day regimen
• Ensuring patients abstain from sex until all partners are treated

Partner Management

All sex partners from the previous 60 days must be evaluated, tested, and treated. 1, 2 If the last sexual contact was >60 days before diagnosis, the most recent partner should still be treated. 1, 2

Follow-Up Recommendations

Test-of-cure is NOT recommended unless: 1, 2

• Therapeutic compliance is questionable
• Symptoms persist
• Reinfection is suspected

Consider retesting women approximately 3 months after treatment due to high risk of reinfection (up to 20-30% reinfection rates). 1, 2

HIV-Positive Patients

Patients with HIV should receive identical treatment regimens as HIV-negative patients—no dosing adjustments are necessary. 1, 2

Critical Pitfalls to Avoid

Do not rely on azithromycin to treat incubating syphilis—all patients with sexually transmitted urethritis or cervicitis require serologic testing for syphilis at diagnosis. 4

Avoid using azithromycin for rectal chlamydia—efficacy is only 82.9% compared to 99.6% with doxycycline, representing a 19.9% efficacy difference favoring doxycycline. 3

Treatment failure is uncommon with recommended regimens: 0-3% in males and 0-8% in females. 1 When failure occurs, consider reinfection from untreated partners rather than true treatment failure.