What is the current recommended treatment for uncomplicated chlamydia in adults, including pregnant women and those with potential allergies or treatment failures?

Current Treatment for Chlamydia

The first-line treatment for uncomplicated chlamydia is 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

First-Line Treatment Selection

Choose azithromycin 1 g single dose when: 1, 2, 3

• Compliance with multi-day regimens is questionable
• Follow-up is unpredictable
• Directly observed therapy is needed
• Treating young adults or populations with erratic healthcare-seeking behavior
• Patient preference for single-dose therapy

Choose doxycycline 100 mg twice daily for 7 days when: 1, 2, 3

• Cost is a primary concern (doxycycline is significantly less expensive)
• Patient can reliably complete a 7-day course
• Pregnancy is ruled out (doxycycline is absolutely contraindicated in pregnancy) 1, 3

Both regimens have equivalent efficacy based on meta-analyses of randomized trials, with similar rates of mild-to-moderate gastrointestinal side effects (17-20%). 1, 2

Treatment During Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 2, 3

Alternative options for pregnant patients: 2, 3

• Amoxicillin 500 mg orally three times daily for 7 days
• Erythromycin base 500 mg orally four times daily for 7 days (if azithromycin cannot be tolerated)

Absolute contraindications in pregnancy: 1, 2, 3

• Doxycycline
• Ofloxacin
• Levofloxacin
• All fluoroquinolones

Critical pitfall: Erythromycin estolate is contraindicated during pregnancy due to drug-related hepatotoxicity. 2 Pregnant women must undergo test-of-cure 3-4 weeks after treatment completion due to potential maternal and neonatal complications. 3

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

The CDC recommends these alternatives only when azithromycin or doxycycline cannot be used: 1, 2, 3

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

Important limitations: 1, 2

• Erythromycin is less efficacious than azithromycin or doxycycline
• Gastrointestinal side effects with erythromycin frequently lead to poor compliance
• Fluoroquinolones offer no compliance advantage (require 7 days of dosing)
• Fluoroquinolones are more expensive than doxycycline without superior efficacy
• Levofloxacin has only 88-94% efficacy and lacks clinical trial validation for chlamydia

Pediatric Dosing

For children ≥8 years weighing >45 kg: 1, 2, 3

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

For children <45 kg: 1, 2, 3

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

For neonates with chlamydial conjunctivitis or pneumonia (ages 1-3 months): 1

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days (approximately 80% effective; may require second course)

Critical Implementation Steps

Medication dispensing: 1, 2, 3

• Dispense medications on-site when possible
• Directly observe the first dose to maximize compliance

Sexual abstinence requirements: 1, 2, 3

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment
• Continue abstinence until all sex partners have completed treatment

Partner management: 1, 2, 3

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

Follow-Up and Retesting

Test-of-cure is NOT recommended for: 1, 2, 3

• Non-pregnant patients treated with recommended regimens (azithromycin or doxycycline)
• Asymptomatic patients after treatment
• Treatment failure rates are extremely low: 0-3% in males, 0-8% in females

Test-of-cure IS mandatory for: 1, 3

• Pregnant women (3-4 weeks after treatment completion)
• Patients with questionable therapeutic compliance
• Patients with persistent symptoms
• Suspected reinfection cases

Critical timing consideration: 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): 1, 2, 3

• All women with chlamydia should be retested approximately 3 months after treatment, regardless of whether partners were reportedly treated
• Reinfection rates can reach 39% in some adolescent populations
• Repeat infections carry elevated risk for pelvic inflammatory disease and other complications compared to initial infection

Concurrent Gonorrhea Considerations

If gonorrhea is confirmed or prevalence is high: 1, 2

• Treat for both infections concurrently
• Coinfection rates are substantial
• Treating chlamydia alone when gonorrhea is present leads to treatment failure

Recommended concurrent treatment: 2

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

Management of Treatment Failure

If azithromycin fails, switch to: 3

• Doxycycline 100 mg orally twice daily for 7 days (first choice)
• Ofloxacin 300 mg orally twice daily for 7 days (contraindicated in pregnancy)
• Levofloxacin 500 mg orally once daily for 7 days (contraindicated in pregnancy)

Before confirming treatment failure: 3

• Wait at least 3 weeks after initial treatment before performing confirmation tests
• Reverify that all sexual partners from the last 60 days were adequately treated
• Patient must abstain from sexual intercourse for 7 complete days after starting new treatment

For persistent symptoms after completing treatment: 1

• Consider testing for Mycoplasma genitalium using NAAT on first-void urine or urethral swab
• For confirmed M. genitalium infection: moxifloxacin 400 mg orally once daily for 7 days

Common 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 retreat based on symptoms alone without documenting objective signs of urethral inflammation or laboratory evidence of infection 1
• Do NOT perform test-of-cure in asymptomatic patients treated with recommended regimens, as this wastes resources and may yield false-positive results 1
• Do NOT assume partners were treated—directly verify or use expedited partner therapy strategies 1
• Do NOT use non-culture tests (EIA, DFA) in children due to risk of false-positive results from cross-reaction with other organisms 1

Additional STI Testing

Patients diagnosed with chlamydia should be tested for gonorrhea, syphilis, and HIV at the initial visit. 1