What is the recommended treatment for Chlamydia (Chlamydia trachomatis)?

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 achieve approximately 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, 2
• Follow-up is unpredictable or unlikely 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
• There is extensive clinical experience with this regimen 3

Critical Management Steps

Medication dispensing and observation:

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

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 (non-negotiable):

• All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated 1, 2
• If last sexual contact was >60 days before diagnosis, still treat the most recent partner 1
• Failing to treat partners leads to reinfection in up to 20% of cases 1

Treatment During Pregnancy

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

Alternative options if azithromycin cannot be used:

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

Absolute contraindications in pregnancy:

• Doxycycline 1, 2
• Ofloxacin 1, 2
• Levofloxacin 1, 2

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

Use these only when azithromycin and doxycycline are contraindicated or not tolerated:

• 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. 1, 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%; a second course may be needed 1

Follow-Up and Retesting

Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens. 1, 2

• Treatment failure rates are extremely low: 0-3% in males, 0-8% in females 2
• Testing before 3 weeks post-treatment is unreliable due to false-positive results from dead organisms 1

Test-of-cure IS mandatory in these situations:

• All pregnant patients (test 3-4 weeks after treatment completion) 1, 2
• Questionable therapeutic compliance 1, 2
• Persistent symptoms 1, 2
• Suspected reinfection 1, 2

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 1, 2
• Repeat infections carry elevated risk for pelvic inflammatory disease and other complications 1

Additional STI Testing

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

• Gonorrhea 1
• Syphilis 1
• HIV 1

Common pitfall: If gonorrhea is confirmed or prevalence is high in the patient population, always treat presumptively for both infections, as coinfection rates are substantial. 1