What is the recommended treatment for chlamydia management?

Chlamydia Management

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, with azithromycin preferred when compliance is uncertain and doxycycline preferred when cost is a concern. 1, 2

First-Line Treatment Options

• Azithromycin 1 g orally as a single dose achieves 97% microbial cure and is the preferred option when compliance with multi-day regimens is questionable or follow-up is unpredictable. 1, 2
• Doxycycline 100 mg orally twice daily for 7 days achieves 98% microbial cure, costs less than azithromycin, and has more extensive clinical experience. 1, 2, 3
• Both regimens are equally efficacious based on meta-analysis of 12 randomized trials, with similar rates of mild-to-moderate gastrointestinal side effects. 2
• Medications should be dispensed on-site when possible, with the first dose directly observed to maximize compliance. 1, 2

Alternative Treatment Regimens

When first-line options cannot be used, the following alternatives are recommended: 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

Erythromycin is less efficacious than azithromycin or doxycycline, and gastrointestinal side effects frequently cause poor compliance, making it a less desirable alternative. 1, 2

Treatment During Pregnancy

• Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 4
• Amoxicillin 500 mg orally three times daily for 7 days is an acceptable alternative. 1, 2
• Doxycycline, ofloxacin, and levofloxacin are absolutely contraindicated in pregnancy. 1, 4, 3
• Pregnant women require test-of-cure 3 weeks after treatment completion due to potential maternal and neonatal sequelae and the use of alternative regimens with lower efficacy. 1, 4

Pediatric Dosing

• For children ≥8 years weighing >45 kg: azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days. 1, 3
• For children ≥8 years weighing <45 kg: erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days. 1
• For infants ages 1-3 months with chlamydial pneumonia: erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days, with approximately 80% effectiveness and possible need for a second course. 1
• Non-culture tests (EIA, DFA) should not be used in children due to false-positive results from cross-reaction with other organisms. 1

Sexual Activity Restrictions 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, 4
• All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated, as failing to treat partners leads to reinfection in up to 20% of cases. 1, 2, 4
• If the last sexual contact was >60 days before diagnosis, the most recent partner should still be treated. 1, 2
• Expedited partner therapy should be considered if partners are unlikely to seek care. 4

Follow-Up and Retesting Strategy

• Test-of-cure is not recommended for non-pregnant patients treated with recommended regimens unless therapeutic compliance is questionable, symptoms persist, or reinfection is suspected. 1, 2, 4
• Testing before 3 weeks post-treatment is unreliable because nucleic acid amplification tests can yield false-positive results from dead organisms that persist after successful treatment. 1, 4
• All women with chlamydia should be retested approximately 3 months after treatment to screen for reinfection, which carries elevated risk for pelvic inflammatory disease and other complications compared to initial infection. 1, 2, 4
• Men may also benefit from retesting at approximately 3 months, though evidence is more limited. 1

Additional STI Testing

• Patients diagnosed with chlamydia should be tested for gonorrhea, syphilis, and HIV at the initial visit. 1
• When gonorrhea is confirmed, chlamydia should always be treated concurrently due to high coinfection rates. 1
• All patients with sexually-transmitted urethritis or cervicitis should have a serologic test for syphilis and appropriate cultures for gonorrhea performed at the time of diagnosis. 5

Recurrent Chlamydia Management

• Most recurrent chlamydial infections (84-92%) are reinfections from untreated or new partners, not treatment failures, with treatment failure rates being extremely low: 0-3% in males and 0-8% in females. 2, 4
• Treat recurrent chlamydia with the same first-line regimens as initial infection: azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days. 4
• The high rate of recurrence reflects partner reinfection and sexual network dynamics, not antibiotic resistance. 4

Common Pitfalls to Avoid

• Do not assume treatment failure when reinfection is more likely—most recurrences are reinfections from untreated partners, not antibiotic resistance. 4
• Failing to treat sexual partners is the single most important factor in preventing recurrent infection. 4
• Do not test too early after treatment—wait at least 3 weeks to avoid false-positives from dead organisms. 4
• Do not skip retesting women at 3 months, which is a high-risk period for reinfection and elevated PID risk. 4
• Do not allow sexual activity before partner treatment is complete—both patient and all partners must complete treatment before resuming intercourse. 4

Special Considerations for Rectal Chlamydia

• For rectal chlamydia, doxycycline 100 mg orally twice daily for 7 days is strongly preferred over azithromycin, with efficacy of 99.6% for doxycycline versus 82.9% for azithromycin. 6
• The efficacy difference of 19.9% in favor of doxycycline for rectal infections represents a clinically significant treatment gap. 6