What is the treatment for chlamydia?

Treatment for Chlamydia

For uncomplicated genital chlamydia in non-pregnant adults, treat with 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

First-Line Treatment Options

Choose azithromycin when:

• Compliance with multi-day regimens is questionable 1, 2
• Follow-up is unpredictable or erratic health-care-seeking behavior is expected 1
• Directly observed therapy is desired (single dose can be administered and observed in clinic) 1, 2

Choose doxycycline when:

• Cost is a primary concern (doxycycline is significantly less expensive) 1, 2
• Patient has reliable follow-up and good medication adherence 1
• Treating rectal chlamydia (see special considerations below) 3, 4

Critical Management Requirements

Sexual abstinence and partner treatment:

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment 1, 5
• All sex partners from the preceding 60 days must be evaluated, tested, and treated empirically 1, 5
• If last sexual contact was >60 days before diagnosis, the most recent partner still requires treatment 1, 2
• Sexual activity cannot resume until both patient and all partners have completed treatment 5

Medication dispensing:

• Dispense medications on-site when possible 1, 2
• Directly observe the first dose of azithromycin to maximize compliance 1, 2

Alternative Treatment Regimens

For patients who cannot tolerate first-line options: 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

Note: Erythromycin is not recommended as first-line due to poor compliance from gastrointestinal side effects 2

Treatment During Pregnancy

Recommended regimens: 1, 5

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

Contraindicated in pregnancy: 1, 5

• Doxycycline
• Ofloxacin
• Levofloxacin

Special pregnancy considerations:

• Test-of-cure is required 3 weeks after treatment completion due to potential maternal and neonatal complications 5

Pediatric Dosing

Children ≥8 years weighing >45 kg: 6, 1

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

Children <45 kg: 6, 1

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

Infants with chlamydial pneumonia (ages 1-3 months): 6

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days
• Effectiveness is approximately 80%; a second course may be required 6

Follow-Up and Retesting

Test-of-cure is NOT recommended unless: 1, 2, 5

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

Mandatory retesting at 3 months: 1, 5

• All women with chlamydial infection should be retested approximately 3 months after treatment
• Reinfection rates are high (84-92% of recurrent infections are reinfections, not treatment failures) 5
• Repeat infections confer elevated risk for pelvic inflammatory disease compared to initial infection 5

If testing earlier than 3 weeks post-treatment:

• Wait at least 3 weeks to avoid false-positives from dead organisms 5

Additional Testing at Initial Visit

All patients diagnosed with chlamydia should be tested for: 1

• Gonorrhea (coinfection is common; treat presumptively if gonorrhea is present) 1
• Syphilis
• HIV

Special Considerations for Rectal Chlamydia

Doxycycline is significantly more effective than azithromycin for rectal infections:

• Doxycycline cure rate: 95.5-99.6% 3, 4
• Azithromycin cure rate: 78.5-82.9% 3, 4
• The efficacy difference is 17-19.9% in favor of doxycycline 3, 4

For women with both rectal and vaginal chlamydia:

• Treat with doxycycline 100 mg orally twice daily for 7 days to adequately cover both sites 4

Common Pitfalls to Avoid

Failing to treat sexual partners is the single most important factor leading to treatment failure and reinfection 5

Assuming treatment failure when recurrence occurs:

• 84-92% of recurrent infections are reinfections from untreated or new partners, not antibiotic resistance 5
• True treatment failure rates are extremely low: 0-3% in males, 0-8% in females 2, 5

Allowing sexual activity before partner treatment is complete:

• Both patient and all partners must complete treatment before resuming intercourse 5

Not retesting women at 3 months:

• This is a high-risk period for reinfection with elevated PID risk 5

Using non-culture tests in children:

• Non-amplified probes (EIA, DFA) should not be used in children due to false-positive results from cross-reaction with other organisms 6, 1