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 approximately 97-98%. 1, 2

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 2
• Directly observed therapy is needed 1, 3
• Treating young adults or populations with erratic health-care-seeking behavior 2

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

• Cost is a primary concern (significantly less expensive than azithromycin) 2
• The patient can reliably complete a 7-day course 2

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

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

If neither azithromycin nor doxycycline can be used, alternative options include: 1, 2

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

Important caveat: 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. 2, 3

Treatment During Pregnancy

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

Alternative options for pregnant patients: 2

• Amoxicillin 500 mg orally three times daily for 7 days
• Erythromycin base 500 mg orally four times daily for 7 days

Absolute contraindications in pregnancy: Doxycycline, ofloxacin, and levofloxacin are contraindicated due to potential fetal harm. 1, 2

Pediatric Dosing

For children ≥8 years weighing >45 kg: 1, 2

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

For children <45 kg: 1, 2

• 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

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

Critical Management Steps to Prevent Reinfection

Sexual abstinence requirements: 1, 2

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

Partner management (mandatory to prevent reinfection): 1, 2

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

Concurrent STI testing: 1

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

Follow-Up and Retesting

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

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

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

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

Reinfection screening (distinct from test-of-cure): 1, 2

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

Special Consideration: Rectal Chlamydia

Important treatment difference: For rectal chlamydia specifically, doxycycline appears significantly more effective than azithromycin. A meta-analysis found azithromycin efficacy of only 82.9% versus doxycycline efficacy of 99.6% for rectal infections. 4 While guidelines do not yet distinguish rectal from genital treatment, consider doxycycline preferentially for known rectal chlamydia when compliance can be ensured.