What is the recommended treatment for chlamydia management?

Chlamydia Management

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, 3
• 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 (doxycycline is significantly less expensive) 3
• The patient can reliably complete a 7-day course 3
• Treating rectal chlamydia (see special considerations below) 4, 5

Critical Management Steps

Medication dispensing and observation:

• Dispense medications on-site when possible 1, 3
• 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 sex partners leads to reinfection in up to 20% of cases 1

Alternative Treatment Regimens

Use only when first-line options cannot be used: 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, 3
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 3

Important caveat: Erythromycin is less efficacious than azithromycin or doxycycline and has frequent gastrointestinal side effects leading 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, 3

Alternative options include:

• 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

Absolute contraindications in pregnancy:

• Doxycycline 1, 3
• Ofloxacin 1, 3
• Levofloxacin 3

Mandatory test-of-cure: Pregnant women must undergo test-of-cure 3-4 weeks after treatment completion, preferably by culture, due to potential maternal and neonatal complications. 1, 3

Pediatric Dosing

For children ≥8 years weighing >45 kg:

• Azithromycin 1 g orally as a single dose, OR 1, 3
• Doxycycline 100 mg orally twice daily for 7 days 1, 3

For children <45 kg:

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 3

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, 3
• Effectiveness is approximately 80% and a second course may be needed 1

Critical diagnostic caveat: Do not use non-culture tests (EIA, DFA) in children due to false-positive results from cross-reaction with other organisms. 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. 1, 3

Test-of-cure IS indicated when:

• Therapeutic compliance is questionable 1, 2, 3
• Symptoms persist 1, 2, 3
• Reinfection is suspected 1, 2, 3
• Patient is pregnant (mandatory) 1, 3

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):

• 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 1, 3
• 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

Additional STI Testing

At the initial visit, patients diagnosed with chlamydia should be tested for:

• Gonorrhea 1
• Syphilis 1
• HIV 1

Coinfection consideration: If gonorrhea is confirmed, always treat chlamydia concurrently due to high coinfection rates. 1 In high-prevalence populations or when testing is unavailable, treat presumptively for both infections. 1

Special Considerations for Rectal Chlamydia

For asymptomatic rectal chlamydia, doxycycline is strongly preferred over azithromycin. A 2021 randomized controlled trial demonstrated doxycycline achieved 96.9% cure rate versus 76.4% for azithromycin (risk difference 19.9 percentage points, P<0.001). 5 A 2015 meta-analysis similarly showed pooled efficacy of 99.6% for doxycycline versus 82.9% for azithromycin. 4

Preventive Counseling

Offer at the initial visit:

• HPV vaccination referral 1
• Smoking cessation counseling 1
• Influenza vaccine 1
• Document patient refusal if declined 1

Common Clinical 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 erythromycin as first-line treatment due to poor compliance from gastrointestinal side effects. 1
• Do not perform test-of-cure before 3 weeks post-treatment due to false-positive results. 1
• Do not forget to treat sex partners empirically—up to 20% reinfection rate if partners are not treated. 1