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 have equivalent efficacy of 97-98%. 1, 2, 3

First-Line Treatment Selection

Choose between the two equally effective first-line options based on these specific factors:

Azithromycin 1 g single dose is preferred when:

• Compliance with a 7-day regimen is questionable 1, 2
• Follow-up is unpredictable or the patient has erratic health-care-seeking behavior 1, 2
• Directly observed therapy is needed, particularly in young adults 1, 2
• You can dispense medication on-site and observe the first dose 1

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

• Cost is a primary concern, as doxycycline is significantly less expensive 2, 3
• The patient can reliably complete a 7-day course 2

Both regimens have similar mild-to-moderate gastrointestinal side effects (17-20% for azithromycin, 20-33% for doxycycline). 1, 4

Treatment During Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 2

Alternative options if azithromycin cannot be used:

• 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, 2

Absolute contraindications in pregnancy:

• Doxycycline 1, 2
• Ofloxacin 1, 2
• Levofloxacin 2

Pregnant women must undergo test-of-cure 3-4 weeks after treatment completion due to use of alternative regimens with lower efficacy and potential maternal/neonatal complications. 1, 2

Alternative Treatment Regimens

Use these only when first-line options cannot be used: 1, 2, 3

• Levofloxacin 500 mg orally once daily for 7 days 1, 2
• Ofloxacin 300 mg orally twice daily for 7 days 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

Erythromycin is less efficacious than azithromycin or doxycycline and has frequent gastrointestinal side effects that lead to poor compliance, making it a less desirable choice. 1, 2, 3

Pediatric Dosing

For children ≥8 years weighing >45 kg:

• Azithromycin 1 g orally as a single dose, OR 1, 2
• Doxycycline 100 mg orally twice daily for 7 days 1, 2

For children <45 kg:

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 2

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

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

Critical Management Steps

Sexual abstinence requirements:

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

Partner management:

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

Concurrent STI testing:

• Test for gonorrhea, syphilis, and HIV at the initial visit 1
• If gonorrhea is confirmed or prevalence is high, always treat chlamydia concurrently due to high coinfection rates 1

Follow-Up and Retesting

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

Test-of-cure IS indicated only when:

• Therapeutic compliance is questionable 1, 3
• Symptoms persist 1, 3
• Reinfection is suspected 1, 3
• Patient is pregnant (mandatory 3-4 weeks after treatment) 1, 2

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

Reinfection screening at 3 months:

• All women with chlamydia should be retested approximately 3 months after treatment, regardless of whether partners were reportedly treated 1, 2
• Reinfection rates can reach 39% in some adolescent populations 2
• Repeat infections carry elevated risk for pelvic inflammatory disease and other complications compared to initial infection 1
• Men may also benefit from retesting at 3 months, though evidence is more limited 1

Common Pitfalls to Avoid

• Do not wait for test results if compliance with return visit is uncertain in high-prevalence populations—treat presumptively 1
• Do not use non-culture tests (EIA, DFA) in children due to risk of false-positive results from cross-reaction with other organisms 1
• Administer adequate fluids with doxycycline to reduce risk of esophageal irritation and ulceration 5
• Dispense medications on-site when possible and directly observe the first dose to maximize compliance 1, 2