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 97-98% cure rates and are equally effective. 1, 2

Choosing Between First-Line Options

Select azithromycin when:

• Compliance with multi-day regimens is questionable 1, 2
• Patient has erratic health-care-seeking behavior 2
• Follow-up is unpredictable 2
• Single-dose directly observed therapy is needed 1, 2

Select doxycycline when:

• Cost is a primary concern (doxycycline is less expensive) 1, 2
• Patient can reliably complete 7-day therapy 1
• Treating rectal chlamydia (see below) 3

Critical Exception: Rectal Chlamydia

For rectal chlamydia infections, doxycycline 100 mg orally twice daily for 7 days is strongly preferred over azithromycin. 3 Meta-analysis shows azithromycin efficacy for rectal infections is only 82.9% compared to 99.6% for doxycycline—a 19.9% efficacy difference favoring doxycycline. 3

Alternative Regimens

When first-line options 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 causes significant gastrointestinal side effects leading to poor compliance, making it less desirable. 1, 2

Treatment During Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 2, 4

Alternative options for pregnancy: 1, 2

• Amoxicillin 500 mg orally three times daily for 7 days
• Erythromycin base 500 mg orally four times daily for 7 days

Contraindicated in pregnancy: 2, 4

• Doxycycline
• Ofloxacin
• All fluoroquinolones

Pediatric Dosing

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

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

Critical warning: Do not use non-culture tests (EIA, DFA) in children due to false-positive risk from cross-reaction with other organisms. 2

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 all sex partners are treated before resuming intercourse

Fluid administration: Give adequate fluids with doxycycline to reduce esophageal irritation and ulceration risk. 5 If gastric irritation occurs, doxycycline may be taken with food or milk without affecting absorption. 5

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, treat the most recent partner regardless. 1, 2

Follow-Up and Test-of-Cure

Test-of-cure is NOT recommended for patients treated with recommended regimens unless: 1, 2

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

Retest women approximately 3 months after treatment due to high reinfection risk. 1, 2 This is for detecting reinfection, not treatment failure.

Special Populations

HIV-positive patients: Receive identical treatment regimens as HIV-negative patients. 1, 4

Patients with concurrent gonorrhea: Treat presumptively for chlamydia, as coinfection is common. 2

Patients with combined chlamydia and bacterial vaginosis: Use doxycycline 100 mg orally twice daily for 7 days PLUS metronidazole 500 mg orally twice daily for 7 days. 4 Warn patients to avoid alcohol during metronidazole treatment and for 24 hours afterward due to disulfiram-like reaction risk. 4

Common Pitfalls to Avoid

• Do not rely on azithromycin for rectal chlamydia—use doxycycline instead 3
• Do not use azithromycin to treat concurrent syphilis—it cannot be relied upon at recommended chlamydia doses 6
• Do not prescribe doxycycline during pregnancy—it is contraindicated 2, 4
• Do not fail to treat sex partners—this significantly increases reinfection risk 1, 2
• Do not perform routine test-of-cure—treatment failure rates are only 0-3% in males and 0-8% in females with recommended regimens 1