What is the recommended treatment for chlamydia?

Chlamydia Treatment

First-Line Treatment Recommendations

For uncomplicated chlamydial infection 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 with approximately 97-98% efficacy. 1, 2

Choosing Between First-Line Options

• Azithromycin 1 g single dose is preferred when:

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

• Doxycycline 100 mg twice daily for 7 days is preferred when:

  • Cost is a primary concern (doxycycline is significantly less expensive) 1, 2
  • Patient can reliably complete a 7-day course 2

• Both medications have equal efficacy based on meta-analyses of randomized clinical trials 2

Alternative Treatment Options

If first-line medications cannot be used, alternative regimens include:

• Levofloxacin 500 mg orally once daily for 7 days 1
• Ofloxacin 300 mg orally twice daily for 7 days 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days 1, 2
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 2

Important caveat: Erythromycin has poor compliance due to gastrointestinal side effects and should be avoided when possible 2

Treatment During Pregnancy

Pregnant patients should receive azithromycin 1 g orally as a single dose (preferred) or amoxicillin 500 mg orally three times daily for 7 days. 1, 3

• Doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnancy 1, 3

• Alternative pregnancy regimens if azithromycin/amoxicillin cannot be tolerated:

  • Erythromycin base 500 mg orally four times daily for 7 days 4
  • Erythromycin base 250 mg orally four times daily for 14 days 4
  • Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 4
  • Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 4

• Pregnant women require test-of-cure 3 weeks after treatment completion due to potential maternal and neonatal complications 3

Pediatric Dosing

• Children ≥8 years weighing >45 kg: Azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 1
• Children <45 kg: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1
• Infants with chlamydial pneumonia (1-3 months): Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days (approximately 80% effective; second course may be needed) 1

Critical caveat: Do not use non-culture tests (EIA, DFA) in children due to false-positive results from cross-reaction with other organisms 1

Sexual Activity and Partner Management

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment and until all sex partners have completed treatment 1, 3
• All sex partners from the preceding 60 days must be evaluated, tested, and treated empirically 1, 3
• If last sexual contact was >60 days before diagnosis, the most recent partner should still be treated 1, 2
• Consider expedited partner therapy if partners are unlikely to seek care 3

Most critical pitfall: Failing to treat sexual partners is the single most important factor leading to recurrent infection 3

Implementation Best Practices

• Dispense medications on-site when possible 1, 2
• Directly observe the first dose to maximize compliance 1, 2
• Absorption of doxycycline is not markedly influenced by food or milk; give with food if gastric irritation occurs 5
• Erythromycin should be taken on an empty stomach (at least 30 minutes, preferably 2 hours before meals) for optimal absorption 6

Follow-Up and Retesting

• Test-of-cure is NOT recommended for patients treated with recommended regimens unless therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 1, 3, 2
• Retest all women approximately 3 months after treatment due to high risk of reinfection (39% in some studies) and elevated risk for pelvic inflammatory disease with repeat infections 3, 2
• Do not test earlier than 3 weeks after treatment completion to avoid false-positives from dead organisms 3

Additional Testing at Initial Visit

• Test all patients diagnosed with chlamydia for gonorrhea, syphilis, and HIV 1
• Patients with gonorrhea should receive presumptive treatment for chlamydia due to high coinfection rates 1

Recurrent Infection Management

Most recurrent chlamydial infections (84-92%) are reinfections from untreated or new partners, not treatment failures. 3

• Treatment failure rates with recommended regimens are extremely low: 0-3% in males and 0-8% in females 3, 2
• Treat recurrent infection with the same first-line regimens as initial infection (azithromycin 1 g single dose or doxycycline 100 mg twice daily for 7 days) 3
• High recurrence rates reflect partner reinfection and sexual network dynamics, not antibiotic resistance 3

Special Populations

• HIV-positive patients: Receive the same treatment regimens as HIV-negative patients 4, 2
• Patients with renal impairment: Doxycycline at usual recommended doses does not lead to excessive accumulation 5