What is the recommended treatment for Chlamydia?

Chlamydia Treatment

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 are equally effective with cure rates of 97-98%. 1, 2

First-Line Treatment Selection

Choose between two equally effective options based on patient-specific factors:

Azithromycin 1 g single dose

• Preferred when compliance is uncertain (young adults, erratic healthcare-seeking behavior, homeless populations) 1, 2
• Allows directly observed therapy—patient takes the dose in front of you 1, 2
• More expensive but eliminates multi-day adherence concerns 1
• Cure rate: 97% 1, 2
• Similar mild-to-moderate gastrointestinal side effects as doxycycline (17-19%) 1, 3

Doxycycline 100 mg twice daily for 7 days

• Preferred when cost is a concern and patient is reliable 1, 2
• Cure rate: 98% 1, 2
• Requires 7-day commitment but less expensive 1, 2
• Extensive clinical experience over decades 1
• Gastrointestinal side effects in 20-33% 1, 3

Critical Implementation Steps

Immediate Actions

• Dispense medication on-site when possible and directly observe the first dose to maximize compliance 1, 2
• Test for co-infections: gonorrhea, syphilis, and HIV at the initial visit 1
• If gonorrhea is confirmed, always treat chlamydia concurrently due to high coinfection rates 1

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
• This applies to both single-dose azithromycin and 7-day doxycycline regimens 1, 2

Partner Management

• All sex partners from the previous 60 days must be evaluated, tested, and empirically treated 1, 2
• If last sexual contact was >60 days before diagnosis, still treat the most recent partner 1, 2
• Failing to treat partners leads to reinfection in up to 20% of cases 1

Alternative Regimens (When First-Line Cannot Be Used)

Use these only when azithromycin and doxycycline are contraindicated or not tolerated:

• 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 is less efficacious than first-line options and gastrointestinal side effects frequently cause poor compliance 1, 2

Treatment During Pregnancy

Doxycycline and ofloxacin are absolutely contraindicated in pregnancy. 1

Preferred Option

• Azithromycin 1 g orally as a single dose 1, 2

Alternative Option

• Amoxicillin 500 mg orally three times daily for 7 days 1, 2

Special Pregnancy Considerations

• Always perform test-of-cure in pregnant women 3-4 weeks after treatment completion, preferably by culture 1
• This is required because alternative regimens have lower efficacy and higher gastrointestinal side effects 1

Pediatric Dosing

Children ≥8 years weighing >45 kg (100 lbs)

• Azithromycin 1 g orally as a single dose OR 1, 4
• Doxycycline 100 mg orally twice daily for 7 days 1, 4

Children ≥8 years weighing <45 kg

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

Infants 1-3 months with chlamydial pneumonia

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1
• Approximately 80% effective; may need a second course 1

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

Follow-Up and Test-of-Cure

Test-of-Cure (NOT Routinely Recommended)

• Do NOT perform test-of-cure for non-pregnant patients treated with recommended regimens (azithromycin or doxycycline) due to high cure rates 1, 2
• Testing before 3 weeks post-treatment is unreliable—nucleic acid amplification tests yield false-positives from dead organisms 1

When Test-of-Cure IS Indicated

Perform test-of-cure 3-4 weeks after treatment completion only if:

• Questionable therapeutic compliance 1, 2
• Persistent symptoms 1, 2
• Suspected reinfection 1, 2
• Pregnancy (always required) 1

Reinfection Screening (Distinct from Test-of-Cure)

• All women with chlamydia should be retested approximately 3 months after treatment to screen for reinfection 1, 2
• This applies regardless of whether partners were reportedly treated 1
• Repeat infections carry elevated risk for pelvic inflammatory disease and complications compared to initial infection 1
• Men may also benefit from 3-month retesting, though evidence is more limited 1

Special Populations

HIV-Positive Patients

• Receive the same treatment regimens as HIV-negative patients 2

Rectal Chlamydia

• Doxycycline 100 mg twice daily for 7 days is significantly more effective than azithromycin for rectal chlamydia 5
• Azithromycin efficacy for rectal infection is only 82.9% vs. 99.6% for doxycycline 5
• This represents a 19.9% efficacy difference favoring doxycycline 5

Common Pitfalls to Avoid

• Not treating partners: Leads to reinfection in up to 20% of cases 1
• Using erythromycin as first-line: Lower efficacy and poor compliance due to gastrointestinal side effects 1, 2
• Testing too early after treatment: Wait at least 3 weeks to avoid false-positives 1
• Confusing test-of-cure with reinfection screening: Test-of-cure is NOT routinely recommended; 3-month reinfection screening IS recommended for women 1
• Using azithromycin for rectal chlamydia: Doxycycline is significantly more effective 5
• Forgetting to test for co-infections: Always test for gonorrhea, syphilis, and HIV 1