What is the recommended treatment for a patient diagnosed with chlamydia, considering potential allergies and pregnancy?

Treatment for Chlamydia

First-Line Treatment Recommendations

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 achieving 97-98% cure rates. 1, 2, 3

Choosing Between First-Line Options

• Azithromycin 1 g single dose is preferred when:

  • Compliance with a 7-day regimen is questionable 1, 2
  • Follow-up is unpredictable 1, 2
  • Directly observed therapy is needed 1, 3
  • Treating young adults or populations with erratic health-care-seeking behavior 1, 2

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

  • Cost is a primary concern, as it is significantly less expensive than azithromycin 1, 2
  • The patient can reliably complete a 7-day course 2
  • There is extensive clinical experience supporting its use 3

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

• Amoxicillin 500 mg orally three times daily for 7 days is an acceptable alternative 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days can be used if azithromycin cannot be tolerated 4, 2
• If erythromycin base cannot be tolerated, use erythromycin base 250 mg orally four times daily for 14 days OR erythromycin ethylsuccinate 800 mg orally four times daily for 7 days OR erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 4

Absolute Contraindications in Pregnancy

• Doxycycline is absolutely contraindicated in pregnancy 1, 2
• All fluoroquinolones (ofloxacin, levofloxacin) are absolutely contraindicated in pregnancy 1, 2
• Erythromycin estolate is contraindicated during pregnancy due to drug-related hepatotoxicity 4

Mandatory follow-up: Test-of-cure is mandatory 3-4 weeks after treatment completion in pregnant patients due to potential maternal and neonatal complications. 2

---

Pediatric Dosing

Children ≥8 Years Weighing >45 kg (100 lbs)

• Azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days 1, 2

Children <45 kg

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 2

Neonates with Chlamydial Conjunctivitis or Pneumonia (1-3 months)

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days, with approximately 80% effectiveness 1
• A second course may be needed if the first is unsuccessful 1
• Alternative: Azithromycin suspension 20 mg/kg/day orally once daily for 3 days 1

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

---

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

Use these only when azithromycin and doxycycline cannot be used: 2

• 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 limitations: Erythromycin is less efficacious than azithromycin or doxycycline and has frequent gastrointestinal side effects that reduce compliance. 2, 3 Levofloxacin has only 88-94% efficacy compared to 97-98% for first-line agents and lacks clinical trial validation for chlamydia. 1

---

Critical Management Steps

Sexual Activity Restrictions

• 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

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

Concurrent STI Testing

• Test all patients for gonorrhea, syphilis, and HIV at the initial visit 1
• If gonorrhea is confirmed or prevalence is high, treat for both infections concurrently with ceftriaxone 250 mg IM single dose plus azithromycin 1 g orally single dose 1

---

Follow-Up and Retesting

Test-of-Cure (NOT Recommended for Most Patients)

• Do not perform routine test-of-cure for non-pregnant patients treated with recommended regimens, as treatment failure rates are extremely low: 0-3% in males, 0-8% in females 2, 3
• Test-of-cure should only be performed if therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 1, 3
• Wait at least 3 weeks after treatment before testing, as nucleic acid amplification tests can yield false-positive results from dead organisms before this time 1

Reinfection Screening (Strongly Recommended)

• 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 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

---

Common Pitfalls to Avoid

• Do not use doxycycline, ofloxacin, or levofloxacin in pregnant women or adolescents ≤17 years of age 4, 1
• Do not assume treatment failure if testing positive before 3 weeks post-treatment—this likely represents dead organism DNA, not active infection 1
• Do not skip partner treatment—up to 20% of patients will be reinfected if partners are not treated 1
• Do not forget to retest women at 3 months—this is for reinfection screening, not test-of-cure 1, 2
• Do not use erythromycin estolate in pregnancy—it causes hepatotoxicity 4