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

First-Line Treatment Selection

Choose azithromycin 1 g single dose 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
• Medications can be dispensed on-site with the first dose observed to maximize compliance 1

Choose doxycycline 100 mg twice daily for 7 days 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 been validated in multiple randomized controlled trials showing equivalent efficacy, with azithromycin achieving 96% cure rates and doxycycline 98% in head-to-head comparisons. 4, 5

Treatment During Pregnancy

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

Alternative options include:

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

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 potential maternal and neonatal complications and the use of alternative regimens with lower efficacy. 2

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

• 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

Important caveat: Erythromycin is less efficacious than azithromycin or doxycycline, and gastrointestinal side effects frequently lead to poor compliance, making it a less desirable alternative. 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 the 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, as 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
• Testing must be performed 3-4 weeks after treatment completion, as nucleic acid amplification tests can yield false-positive results from dead organisms before 3 weeks 1

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, 2
• Reinfection rates can reach 39% in some adolescent populations 2
• 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

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 the risk of false-positive results from cross-reaction with other organisms 1
• Do not perform test-of-cure before 3 weeks post-treatment, as it will yield false-positive results 1
• Administer doxycycline with adequate fluid and food or milk to reduce esophageal irritation and ulceration 6