Treatment for Chlamydia
For uncomplicated chlamydia, treat immediately with 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
First-Line Treatment Selection
Choose azithromycin when:
- Compliance is questionable or unpredictable 1, 2
- Patient has erratic health-care-seeking behavior 1
- Directly observed therapy is needed 1, 2
- Single-dose convenience outweighs cost considerations 1
Choose doxycycline when:
- Cost is a primary concern (doxycycline is less expensive) 2
- Patient is reliable with multi-day regimens 2
- Patient has no contraindications to tetracyclines 3
Alternative Regimens
Use these only when first-line options are contraindicated: 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
Avoid erythromycin as first-line due to poor compliance from gastrointestinal side effects. 1, 2
Special Populations
Pregnancy
Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 4
- Alternative: Amoxicillin 500 mg orally three times daily for 7 days 1, 2
- Doxycycline and ofloxacin are absolutely contraindicated in pregnancy 1, 4, 3
- Pregnant women always require test-of-cure 3-4 weeks after treatment 1
Pediatric Dosing
For children ≥8 years weighing >45 kg: 1, 2
- Azithromycin 1 g orally as a single dose, OR
- Doxycycline 100 mg orally twice daily for 7 days
For children <45 kg: 1
- Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days
Never use doxycycline in children <8 years old. 3
Critical Implementation Steps
Medication Dispensing
- Dispense medications on-site whenever possible 1, 2
- Directly observe the first dose to maximize compliance 1, 2
- Administer with food or milk if gastric irritation occurs with doxycycline 3
Sexual Activity Restrictions
Patients must abstain from all sexual intercourse for 7 days after initiating treatment AND until all sex partners have been treated. 1, 2
Partner Management
All sex partners from the preceding 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
- Expedited partner therapy is cost-effective and reduces transmission 5
Concurrent Testing and Treatment
At the initial visit, test all chlamydia patients for: 1
If gonorrhea is confirmed, always treat for chlamydia concurrently due to high coinfection rates. 6, 1
Follow-Up Protocol
Test-of-Cure
Do NOT perform test-of-cure in non-pregnant patients treated with recommended regimens (azithromycin or doxycycline). 1, 2
Exceptions requiring test-of-cure at 3-4 weeks post-treatment: 1
- Questionable therapeutic compliance
- Persistent symptoms
- Suspected reinfection
- Pregnancy (always required)
Never test before 3 weeks post-treatment—nucleic acid amplification tests yield false-positives from dead organisms. 1
Reinfection Screening
Retest ALL women approximately 3 months after treatment regardless of partner treatment status. 1, 2
- This screens for reinfection, NOT treatment failure 1
- Repeat infections carry elevated risk for pelvic inflammatory disease and complications 1
- Men may also benefit from 3-month retesting, though evidence is more limited 1
Common Pitfalls to Avoid
- Failing to treat sex partners leads to reinfection in up to 20% of cases 6, 1
- Using non-culture tests (EIA, DFA) in children causes false-positives from cross-reaction with other organisms 1
- Prescribing doxycycline during pregnancy 1, 4, 3
- Performing test-of-cure too early (<3 weeks) yields false-positives 1
- Neglecting 3-month reinfection screening in women 1, 2
- Assuming partner treatment occurred without verification—always retest at 3 months 1