What is the recommended treatment for chlamydia?

Treatment for Chlamydia

For uncomplicated genital chlamydia, treat with either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days, both achieving 97-98% cure rates. 1, 2

First-Line Treatment Selection

Both regimens are equally effective for uncomplicated genital chlamydia, but selection depends on specific clinical circumstances:

Azithromycin 1 g single dose is preferred when: 1, 2

• Compliance with multi-day regimens is questionable 1
• Treating young adults with erratic health-care-seeking behavior 1
• Directly observed therapy is desired to maximize compliance 1, 2
• Follow-up is unpredictable, making it more cost-effective 1

Doxycycline 100 mg twice daily for 7 days is preferred when: 1, 2

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

Alternative Treatment Options

If first-line medications cannot be used, alternatives include: 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
• Ofloxacin 300 mg orally twice daily for 7 days 1, 2
• Levofloxacin 500 mg orally once daily for 7 days 1, 2

Important caveat: Erythromycin causes significant gastrointestinal side effects leading to poor compliance, making it a less desirable alternative. 2

Treatment During Pregnancy

Doxycycline and ofloxacin are absolutely contraindicated during pregnancy. 1, 4

Recommended options for pregnant patients: 1, 2

• Azithromycin 1 g orally as a single dose (preferred) 1, 4
• Amoxicillin 500 mg orally three times daily for 7 days 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days 2

Pediatric Dosing

For children ≥8 years weighing >45 kg: 1

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

For children ≥8 years weighing <45 kg: 1

• Weight-based dosing: 2 mg/kg divided into two doses on day 1, then 1 mg/kg daily 5

For children <8 years or <45 kg: 1

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1

Critical warning: Avoid non-culture tests (EIA, DFA) in children due to false-positive results from cross-reaction with other organisms. 1

Special Considerations for Rectal Chlamydia

Doxycycline is significantly more effective than azithromycin for rectal chlamydia infections. 3

• Azithromycin efficacy for rectal chlamydia: 82.9% (95% CI 76.0%-89.8%) 3
• Doxycycline efficacy for rectal chlamydia: 99.6% (95% CI 98.6%-100%) 3
• This represents a 19.9% efficacy difference favoring doxycycline 3

For men who have sex with men with rectal chlamydia, strongly prefer doxycycline 100 mg twice daily for 7 days over azithromycin. 3

Implementation Best Practices

Medication dispensing and administration: 1, 2

• Dispense medications on-site when possible 1, 2
• Directly observe the first dose to maximize compliance 1, 2
• Administer with adequate fluids to reduce esophageal irritation risk 5
• Doxycycline may be given with food or milk if gastric irritation occurs 5

Sexual activity restrictions: 1

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment 1
• Continue abstinence until all sex partners have been treated 1, 2

Partner Management

All sex partners from the previous 60 days must be evaluated, tested, and treated empirically. 1, 2

• If last sexual contact was >60 days before diagnosis, still treat the most recent partner 1, 2
• Partner treatment is critical to prevent reinfection 1

Additional STI Testing

At the initial visit, test all chlamydia-positive patients for: 1

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

Follow-Up Recommendations

Test-of-cure is NOT recommended for patients who: 1, 2

• Received recommended treatment regimens 1, 2
• Are asymptomatic 1
• Have reliable therapeutic compliance 1, 2

Test-of-cure IS recommended when: 1, 2

• Therapeutic compliance is questionable 1, 2
• Symptoms persist 1, 2
• Reinfection is suspected 1, 2

Repeat testing at 3 months post-treatment is strongly recommended due to high reinfection rates, particularly in women. 1, 2

Common Pitfalls to Avoid

• Never use azithromycin as first-line for rectal chlamydia - treatment failure rates are unacceptably high at 17.1% 3
• Never prescribe doxycycline during pregnancy - it is absolutely contraindicated 1, 4
• Never rely on patient-reported compliance - dispense on-site and observe first dose when possible 1, 2
• Never skip partner treatment - this is the leading cause of reinfection 1
• Never use non-culture tests in children - false positives are common 1
• Never forget to test for concurrent STIs - gonorrhea coinfection is common and requires additional treatment 1