What is the treatment regimen for chlamydia and gonorrhea?

Treatment Regimens for Chlamydia and Gonorrhea

For uncomplicated chlamydia, treat with doxycycline 100 mg orally twice daily for 7 days as first-line therapy, and for uncomplicated gonorrhea, treat with ceftriaxone 500 mg intramuscularly as a single dose, with concurrent treatment for both infections when coinfection is suspected or confirmed. 1

Chlamydia Treatment

First-Line Regimens

• Doxycycline 100 mg orally twice daily for 7 days is the preferred first-line treatment, achieving a 98% cure rate 2, 1, 3
• Azithromycin 1 g orally as a single dose achieves a 97% cure rate and should be reserved for situations where compliance with multi-day regimens is questionable 2, 1, 3
• Doxycycline is significantly superior to azithromycin for rectal chlamydia infections (96.9% vs 76.4% cure rate), making it the clear choice for rectal infections in men who have sex with men 1

Alternative Regimens (when first-line options cannot be used)

• Erythromycin base 500 mg orally four times daily for 7 days 4, 2
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 4, 2
• Levofloxacin 500 mg orally once daily for 7 days 4, 2
• Ofloxacin 300 mg orally twice daily for 7 days 4, 2

Important caveat: Erythromycin is less efficacious than azithromycin or doxycycline, and gastrointestinal side effects frequently lead to poor compliance 2, 3

Gonorrhea Treatment

First-Line Regimen

• Ceftriaxone 500 mg intramuscularly as a single dose for all uncomplicated urogenital, anorectal, and pharyngeal gonococcal infections in patients weighing <150 kg (331 lb) 1, 5
• This achieves >90% cure rates for pharyngeal infections 1

Dual Therapy for Coinfection

Critical principle: Because coinfection rates range from 20-40%, always treat presumptively for chlamydia when treating gonorrhea 1

Recommended Dual Therapy Approach

• Ceftriaxone 500 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days 1
• If compliance is a concern, substitute azithromycin 1 g orally as a single dose for doxycycline 1
• When gonorrhea is confirmed, chlamydia should always be treated concurrently due to high coinfection rates 3

Special Populations

Pregnancy

• Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy 2, 3
• Amoxicillin 500 mg orally three times daily for 7 days is an alternative option 2, 3
• Doxycycline and all fluoroquinolones (ofloxacin, levofloxacin) are absolutely contraindicated in pregnancy 2, 3, 6
• Pregnant patients must have a test-of-cure 4 weeks after treatment due to use of alternative regimens with lower efficacy 2, 5

Children

• For children ≥8 years weighing >45 kg: azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days 2, 1, 3
• For children <45 kg: erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 2

HIV-Positive Patients

• Use the same treatment regimens as HIV-negative patients for both chlamydia and gonorrhea 3

Implementation Best Practices

Medication Administration

• Dispense medications on-site when possible, with the first dose directly observed to maximize compliance 2, 1, 3
• This is particularly important for single-dose azithromycin therapy 4

Sexual Abstinence Requirements

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment (or until completion of 7-day regimens) 2, 1, 3
• Abstinence must continue until all sex partners are treated 2, 1, 3
• Failing to treat sex partners leads to reinfection in up to 20% of cases 3

Partner Management

• All sex partners from the previous 60 days must be evaluated, tested, and empirically treated for both gonorrhea and chlamydia 2, 1, 3
• If the last sexual contact was >60 days before diagnosis, the most recent partner should still be treated 2, 3

Follow-Up and Testing

Test-of-Cure

• Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens due to high cure rates of 97-98% 2, 3
• Testing before 3 weeks post-treatment is unreliable because nucleic acid amplification tests can yield false-positive results from dead organisms 2
• Test-of-cure should only be performed if therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 2, 3

Reinfection Screening

• All women with chlamydia should be retested approximately 3 months after treatment to screen for reinfection, regardless of whether partners were reportedly treated 2, 3
• Repeat infections carry an elevated risk for pelvic inflammatory disease and other complications compared to initial infection 2, 3
• All nonpregnant patients should be tested for reinfection approximately 3 months after treatment or at the first visit within 12 months after treatment 5

Additional STI Testing

• Patients diagnosed with chlamydia or gonorrhea should be tested for syphilis and HIV at the initial visit 2

Common Pitfalls to Avoid

• Do not use azithromycin for rectal chlamydia infections - doxycycline is significantly more effective (96.9% vs 76.4%) 1
• Do not wait for test results if compliance with return visit is uncertain in high-prevalence populations—treat presumptively 1
• Do not use fluoroquinolones in pregnancy - they are absolutely contraindicated 2, 3
• Do not perform test-of-cure before 3 weeks post-treatment - false positives from dead organisms are common 2
• Do not treat gonorrhea without concurrent chlamydia treatment unless chlamydia has been definitively ruled out, given 20-40% coinfection rates 1