What is the first line treatment for chlamydia?

First-Line Treatment for Chlamydia

Either azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days are equally effective first-line treatments for uncomplicated chlamydial infection, with cure rates of approximately 97-98%. 1, 2

Choosing Between First-Line Options

Both regimens are equivalent in efficacy based on multiple clinical trials and meta-analyses, so the choice depends on practical considerations 1, 2:

Choose Azithromycin when:

• Compliance is questionable or unpredictable – single-dose therapy eliminates adherence issues 3, 1
• Patient has erratic health-care-seeking behavior or poor follow-up 3, 2
• Directly observed therapy is desired – can be administered on-site 1, 2
• Treating adolescents or populations with historically poor compliance 4

Choose Doxycycline when:

• Cost is a primary concern – doxycycline is significantly less expensive 3, 2
• Patient has reliable follow-up and good medication adherence 3
• Longer clinical experience is preferred 3

Critical Implementation Details

Maximize treatment success by: 1, 2

• Dispensing medications on-site whenever 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 to prevent reinfection

Alternative Regimens

If first-line options cannot be used, alternatives include 3, 1:

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

Important caveat: Erythromycin has lower efficacy than azithromycin or doxycycline, and gastrointestinal side effects frequently lead to poor compliance 3, 2

Special Population: Pregnancy

Doxycycline and ofloxacin are contraindicated in pregnancy. 3, 1

For pregnant patients, use 1, 2:

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

Follow-Up Recommendations

Test-of-cure is NOT routinely recommended after treatment with azithromycin or doxycycline unless 3, 1, 2:

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

However, consider retesting women approximately 3 months after treatment due to high rates of reinfection in this population 3, 1, 2

Partner Management

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

Common Pitfalls to Avoid

• Failing to treat partners – this is the primary cause of reinfection and treatment failure 3, 5
• Testing too early after treatment – nonculture tests performed <3 weeks after therapy can yield false-positive results from dead organisms 3
• Using erythromycin without counseling – patients often discontinue due to gastrointestinal side effects 3, 2
• Prescribing fluoroquinolones to adolescents ≤17 years – ofloxacin is not recommended in this age group 3