What is the recommended treatment for chlamydia?

Treatment for Chlamydia

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 achieve 97-98% cure rates and are equally effective. 1, 2, 3

First-Line Treatment Selection

Choose azithromycin 1 g single dose when: 1, 3

• Compliance with a 7-day regimen is questionable 1, 3
• Follow-up is unpredictable 1, 3
• Directly observed therapy is needed 1, 2, 3
• Treating young adults or populations with erratic health-care-seeking behavior 1, 3

Choose doxycycline 100 mg twice daily for 7 days when: 3

• Cost is a primary concern (doxycycline is significantly less expensive) 3
• The patient can reliably complete a 7-day course 3

Both medications have similar mild-to-moderate gastrointestinal side effects (17-20% of patients), so tolerability should not drive your choice. 2, 4

Critical Implementation Steps

Dispense medications on-site when possible and directly observe the first dose to maximize compliance. 1, 2, 3 This is particularly important for azithromycin single-dose therapy. 1

Patients must abstain from all sexual intercourse for 7 days after initiating treatment and continue abstinence until all sex partners have completed treatment. 1, 3 This prevents reinfection, which occurs in up to 20% of cases when partners are not treated. 1

Alternative Regimens (When First-Line Options Cannot Be Used)

Use these alternatives only when azithromycin or doxycycline are contraindicated or not tolerated: 2, 3

• Levofloxacin 500 mg orally once daily for 7 days 1, 2, 3
• Ofloxacin 300 mg orally twice daily for 7 days 1, 2, 3
• Erythromycin base 500 mg orally four times daily for 7 days 1, 2, 3
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 2, 3

Erythromycin is less efficacious than azithromycin or doxycycline and causes frequent gastrointestinal side effects leading to poor compliance—avoid when possible. 2, 3

Treatment During Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 3

Alternative options for pregnant patients: 1, 3

• Amoxicillin 500 mg orally three times daily for 7 days 1, 2, 3
• Erythromycin base 500 mg orally four times daily for 7 days 1, 3

Doxycycline, ofloxacin, and levofloxacin are absolute contraindications in pregnancy due to potential fetal harm. 1, 3

Pregnant women must undergo test-of-cure 3-4 weeks after treatment completion, preferably by culture, due to use of alternative regimens with lower efficacy. 1, 3

Pediatric Dosing

For children ≥8 years weighing >45 kg: 1, 3

• Azithromycin 1 g orally as a single dose, OR 1, 3
• Doxycycline 100 mg orally twice daily for 7 days 1, 3

For children <45 kg: 1, 3

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 3

For infants with chlamydial pneumonia (ages 1-3 months): 1

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1
• Treatment effectiveness is approximately 80%; a second course may be needed 1

Partner Management

All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated. 1, 3 If the last sexual contact was >60 days before diagnosis, still treat the most recent partner. 1, 2

Failing to treat sex partners leads to reinfection in up to 20% of cases. 1

Follow-Up and Retesting

Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens (azithromycin or doxycycline), as treatment failure rates are extremely low: 0-3% in males, 0-8% in females. 2, 3

Perform test-of-cure only when: 1, 2, 3

• Therapeutic compliance is questionable 1, 2, 3
• Symptoms persist 1, 2, 3
• Reinfection is suspected 1, 2, 3
• Patient is pregnant (mandatory) 1, 3

Testing before 3 weeks post-treatment is unreliable because nucleic acid amplification tests can yield false-positive results from dead organisms. 1

All women with chlamydia should be retested approximately 3 months after treatment to screen for reinfection, regardless of whether partners were reportedly treated. 1, 3 Reinfection rates can reach 39% in some adolescent populations. 1, 3 Repeat infections carry an elevated risk for pelvic inflammatory disease and other complications compared to initial infection. 1

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 If gonorrhea is confirmed, always treat chlamydia concurrently due to high coinfection rates. 1, 2

Important Caveat for Rectal Chlamydia

For rectal chlamydia infections, doxycycline 100 mg twice daily for 7 days is significantly more effective than azithromycin 1 g single dose (99.6% vs 82.9% efficacy). 5 Use doxycycline as first-line for rectal infections. 5