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 approximately 97-98%. 1, 2, 3

First-Line Treatment Selection

Choose azithromycin 1 g single dose when:

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

Choose doxycycline 100 mg twice daily for 7 days when:

• Cost is a primary concern, as doxycycline is significantly less expensive 1, 3
• The patient can reliably complete a 7-day course 3
• Treating rectal chlamydia (see below) 4

Critical Implementation Steps

Dispense medications on-site when possible and directly observe the first dose to maximize compliance. 1, 2, 3

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

All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated—failing to treat partners leads to reinfection in up to 20% of cases. 1, 3

Alternative Treatment Regimens

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

• Levofloxacin 500 mg orally once daily for 7 days 1, 3
• Ofloxacin 300 mg orally twice daily for 7 days 1, 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 has frequent gastrointestinal side effects leading to poor compliance, making it a less desirable choice. 1, 2, 3

Treatment During Pregnancy

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

Alternative options include: 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, 5

Pregnant women must undergo test-of-cure 3-4 weeks after treatment completion, preferably by culture, due to the 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
• Doxycycline 100 mg orally twice daily for 7 days

For children <45 kg: 1, 3

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

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

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days
• Treatment effectiveness is approximately 80% and may require a second course 1, 3

Special Consideration: Rectal Chlamydia

For asymptomatic rectal chlamydia in men who have sex with men, doxycycline 100 mg twice daily for 7 days is superior to azithromycin 1 g single dose. 4

A high-quality 2021 randomized controlled trial demonstrated microbiologic cure in 96.9% with doxycycline versus 76.4% with azithromycin (risk difference 19.9 percentage points, P<0.001). 4 This finding is supported by a 2015 meta-analysis showing pooled efficacy of 99.6% for doxycycline versus 82.9% for azithromycin in rectal infections. 6

Follow-Up and Retesting

Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens, as treatment failure rates are extremely low: 0-3% in males, 0-8% in females. 1, 3

Test-of-cure IS indicated when: 1, 3

• Therapeutic compliance is questionable
• Symptoms persist
• Reinfection is suspected
• Patient is pregnant (mandatory)

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, regardless of whether partners were reportedly treated, as 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

Concurrent Gonorrhea Management

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

In high-prevalence populations or when gonorrhea testing is unavailable, treat presumptively for both infections—do not wait for test results if compliance with return visit is uncertain. 1

All patients diagnosed with chlamydia should be tested for gonorrhea, syphilis, and HIV at the initial visit. 1