What is the recommended treatment for Chlamydia?

Treatment for Chlamydia

For uncomplicated genital chlamydia in non-pregnant adults, use either azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days as first-line treatment. 1, 2

First-Line Treatment Options

• Azithromycin 1 g orally in a single dose achieves approximately 97% microbial cure rate and is preferred when compliance is questionable 1, 2
• Doxycycline 100 mg orally twice daily for 7 days achieves approximately 98% microbial cure rate and costs less than azithromycin 1, 2
• Meta-analyses demonstrate these two regimens are equally efficacious for genital chlamydial infections 1, 2, 3

Advantages of Azithromycin

• Single-dose therapy allows for directly observed treatment 1, 2
• Better compliance in populations with erratic health-care-seeking behavior 4
• More cost-effective when follow-up is unpredictable 4

Advantages of Doxycycline

• Lower cost than azithromycin 4, 2
• Extensive clinical experience over longer period 4
• May be superior for rectal chlamydia (see below) 5

Alternative Treatment Options

When first-line medications cannot be used: 4, 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 has lower efficacy than azithromycin or doxycycline, and gastrointestinal side effects frequently discourage compliance 4, 2

Treatment During Pregnancy

Azithromycin 1 g orally in a single dose is the preferred treatment during pregnancy. 1, 6

• Doxycycline and ofloxacin are contraindicated during pregnancy 1, 6, 7
• Amoxicillin 500 mg orally three times daily for 7 days is an alternative option 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days is another alternative 2, 8
• For women who cannot tolerate erythromycin 500 mg four times daily, use 500 mg every 12 hours or 250 mg four times daily for at least 14 days 8

Special Site Considerations: Rectal Chlamydia

For rectal chlamydia, doxycycline 100 mg twice daily for 7 days is strongly preferred over azithromycin. 5

• Pooled efficacy for azithromycin in rectal infections is only 82.9% (95% CI 76.0%-89.8%) 5
• Pooled efficacy for doxycycline in rectal infections is 99.6% (95% CI 98.6%-100%) 5
• This represents a 19.9% efficacy difference favoring doxycycline for rectal infections 5

Pediatric Dosing

For children ≥8 years weighing >45 kg: 4, 1

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

For children <45 kg: 4

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days

Implementation Best Practices

• Dispense medications on-site when possible and directly observe the first dose to maximize compliance 1, 2, 6
• Patients must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 1, 2
• Patients must abstain until all sex partners are treated 1, 2
• Administer doxycycline with adequate fluids to reduce risk of esophageal irritation and ulceration 7
• If gastric irritation occurs with doxycycline, give with food or milk (absorption is not significantly affected) 7

Partner Management

• All sex partners from the previous 60 days must be evaluated, tested, and treated 1, 2
• If 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 for patients treated with recommended regimens unless therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 1, 2
• Consider retesting women approximately 3 months after treatment due to high risk of reinfection 1, 2
• Treatment failure rates are 0-3% for males and 0-8% for females with recommended regimens 2

Common Pitfalls to Avoid

• Do not use azithromycin for rectal chlamydia - doxycycline is significantly more effective 5
• Do not prescribe doxycycline during pregnancy - it is contraindicated 1, 6, 7
• Do not rely on erythromycin as first-line - poor compliance due to gastrointestinal side effects makes it less effective in practice 4, 2
• Do not fail to treat both partners simultaneously - this significantly increases reinfection risk 1, 2
• Do not use non-culture tests (EIA, DFA) in children - false-positive results can occur due to cross-reaction with other organisms 4

Coinfection Considerations

• Patients with gonorrhea should receive presumptive treatment for chlamydia since coinfection is common 4
• Patients with HIV should receive the same treatment regimens as those who are HIV-negative 2