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 between the two 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, 3
  • Follow-up is unpredictable or unlikely 1, 3
  • Directly observed therapy is needed 1, 2
  • Treating young adults or populations with erratic health-care-seeking behavior 1, 3

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

  • Cost is a primary concern, as doxycycline is significantly less expensive 3
  • The patient can reliably complete a 7-day course 3
  • Treating rectal chlamydia (doxycycline achieves 99.6% cure vs. 82.9% for azithromycin) 4

Alternative Regimens (When First-Line Cannot Be Used)

Use these only when azithromycin and doxycycline are contraindicated or not tolerated 1, 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, 3
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 3

Important caveat: Erythromycin is less efficacious than first-line agents 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 if azithromycin cannot be used 1, 3:

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

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

Pediatric Dosing

• Children ≥8 years weighing >45 kg: Azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 1, 3
• Children <45 kg: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 3
• Infants 1-3 months with chlamydial pneumonia: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days (approximately 80% effective; second course may be needed) 1

Critical Management Steps

Medication dispensing and observation:

• Dispense medications on-site when possible 1, 2
• Directly observe the first dose to maximize compliance 1, 3

Sexual abstinence requirements:

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment 1, 3
• Continue abstinence until all sex partners have completed treatment 1, 3

Partner management:

• All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated 1, 3
• 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

Additional STI Testing

At the initial visit, test all patients diagnosed with chlamydia for 1:

• Gonorrhea (treat presumptively if coinfection suspected, as coinfection is common) 1
• Syphilis 1
• HIV 1

Follow-Up and Retesting

Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens, as cure rates are 97-98% and treatment failure is rare (0-3% in males, 0-8% in females). 3

Exceptions requiring test-of-cure 3-4 weeks after treatment completion:

• Questionable therapeutic compliance 1, 3
• Persistent symptoms 1, 3
• Suspected reinfection 1, 3
• All pregnant women (mandatory) due to potential maternal and neonatal complications 3

Reinfection screening (distinct from test-of-cure):

• All women with chlamydia should be retested approximately 3 months after treatment, regardless of whether partners were reportedly treated 1, 3
• Reinfection rates can reach 39% in some adolescent populations 3
• Repeat infections carry elevated risk for pelvic inflammatory disease and 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 test before 3 weeks post-treatment: Nucleic acid amplification tests can yield false-positive results from dead organisms that persist after successful treatment 1
• Do not use non-culture tests (EIA, DFA) in children: Risk of false-positive results from cross-reaction with other organisms 1
• Do not wait for test results in high-prevalence populations if compliance is uncertain: Treat presumptively 1
• Always treat for chlamydia when gonorrhea is confirmed: Coinfection rates are substantial 1