What is the recommended treatment for a patient diagnosed with Chlamydia?

Chlamydia Treatment

First-Line Treatment Recommendations

For uncomplicated chlamydial infection 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 97-98% cure rates and are equally effective. 1, 2, 3

Choosing Between First-Line Options

Azithromycin 1 g single dose is preferred when:

• Compliance with multi-day regimens is questionable 1, 2, 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

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

• Cost is a primary concern (significantly less expensive than azithromycin) 1, 3
• The patient can reliably complete a 7-day course 3

Critical Implementation Steps

• Dispense medications on-site when possible and directly observe the first dose to maximize compliance 1, 3
• Patients must abstain from all sexual intercourse for 7 days after initiating treatment and continue abstinence until all sex partners have completed treatment 1, 3

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Alternative Treatment Regimens

Use alternative regimens only when first-line options cannot be used (allergy, intolerance, or contraindication): 1, 3

• Levofloxacin 500 mg orally once daily for 7 days (88-94% efficacy, but lacks clinical trial validation for chlamydia) 1
• Ofloxacin 300 mg orally twice daily for 7 days (similar efficacy to first-line agents but more expensive with no compliance advantage) 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days (less efficacious with frequent GI side effects leading to poor compliance) 1, 2
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 2

Important caveat: Fluoroquinolones (levofloxacin, ofloxacin) require 7 days of treatment, offering no compliance benefit over doxycycline, and are more expensive without superior efficacy. 1

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Treatment During Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 3

Alternative options for pregnant patients:

• 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
• All fluoroquinolones (ofloxacin, levofloxacin) 1, 3
• Erythromycin estolate (drug-related hepatotoxicity) 1

Mandatory follow-up: Test-of-cure is required 3-4 weeks after treatment completion in pregnant patients due to potential maternal and neonatal complications. 3

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Pediatric Dosing

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 1, 3, 4

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 (approximately 80% effective; may need second course) 1

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

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Partner Management

All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated to prevent reinfection. 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

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Follow-Up and Retesting

Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens (azithromycin or doxycycline), as 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
• Symptoms persist 1, 2
• Reinfection is suspected 1, 2
• Patient is pregnant (mandatory 3-4 weeks after treatment) 1, 3

Critical timing: Testing before 3 weeks post-treatment is unreliable because nucleic acid amplification tests can yield false-positive results from dead organisms that persist after successful treatment. 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, as reinfection rates can reach 39% in some adolescent populations. 1, 3

• Repeat infections carry 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

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Coinfection Considerations

If gonorrhea is confirmed or prevalence is high in the patient population, treat for both infections concurrently: 1

• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose 1

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

• Gonorrhea 1
• Syphilis 1
• HIV 1

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Management of Treatment Failure

If azithromycin fails (rare, given 97% efficacy):

Switch to doxycycline 100 mg orally twice daily for 7 days as the alternative first-line treatment. 3

Before retreating:

• Wait at least 3 weeks after initial treatment before performing confirmation tests to avoid false positives 3
• Reverify that all sexual partners from the last 60 days were adequately treated 3

Patient must:

• Abstain from sexual intercourse for 7 complete days after starting new treatment 3
• Continue abstinence until all sexual partners complete their treatment 3