What is the recommended in-clinic treatment for a patient presenting with chlamydia?

In-Clinic Treatment for Chlamydia

For uncomplicated chlamydial infection in non-pregnant adults, treat immediately 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

First-Line Treatment Selection

Choose azithromycin 1 g single dose when:

• Compliance with multi-day regimens is questionable 1, 2
• Follow-up is unpredictable 1
• Directly observed therapy is needed 1
• The patient population has erratic health-care-seeking behavior 1

Choose doxycycline 100 mg twice daily for 7 days when:

• Cost is a primary concern (doxycycline is less expensive) 1, 2
• The patient can reliably complete a 7-day course 1
• Pregnancy has been definitively ruled out 1, 3

Both regimens are equally efficacious based on meta-analyses of 12 randomized clinical trials, with similar rates of mild-to-moderate gastrointestinal side effects. 2

Immediate Implementation Steps

Dispense medication on-site and directly observe the first dose to maximize compliance. 1, 2 This is particularly critical for azithromycin single-dose therapy, which eliminates concerns about treatment completion. 1

Instruct patients to abstain from all sexual intercourse for 7 days after initiating treatment, regardless of which regimen is used. 1, 2 Sexual activity must not resume until all sex partners have completed treatment. 1

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

If the patient cannot tolerate azithromycin or doxycycline, use one of these alternatives: 1, 2

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

Important caveat: Erythromycin is less efficacious than first-line agents and causes gastrointestinal side effects that frequently lead to poor compliance. 1, 2 Fluoroquinolones (ofloxacin, levofloxacin) offer no compliance advantage over doxycycline, are more expensive, and have inferior evidence—levofloxacin shows only 88-94% efficacy compared to 97-98% for first-line agents. 1

Special Population Modifications

Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 2 Amoxicillin 500 mg orally three times daily for 7 days is an acceptable alternative. 1, 2

Absolutely contraindicated in pregnancy: 1, 2

• Doxycycline
• Ofloxacin
• Levofloxacin
• All fluoroquinolones
• Erythromycin estolate (causes drug-related hepatotoxicity)

Pregnant women require test-of-cure 3 weeks after treatment completion due to potential maternal and neonatal sequelae. 4

Children ≥8 Years Weighing >45 kg

Use adult dosing: azithromycin 1 g single dose or doxycycline 100 mg twice daily for 7 days. 1, 3

Children <45 kg

Use erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days. 1

Concurrent Testing and Treatment

Test all patients for gonorrhea, syphilis, and HIV at the initial visit. 1 If gonorrhea prevalence is high in your patient population or testing is unavailable, treat presumptively for both infections with ceftriaxone 250 mg IM single dose plus azithromycin 1 g orally single dose. 1

Partner Management (Critical for Treatment Success)

All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated, even if asymptomatic. 1, 2 If the 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 This is the single most important factor in preventing recurrent infection. 4 Consider expedited partner therapy if partners are unlikely to seek care. 4

Follow-Up Strategy

Do NOT perform test-of-cure in non-pregnant patients treated with recommended regimens who are asymptomatic after treatment. 1, 2 Cure rates exceed 97%, and testing before 3 weeks post-treatment yields false-positive results from dead organisms. 1

DO retest all women approximately 3 months after treatment to screen for reinfection. 1, 2, 4 Reinfection rates reach up to 39% in some adolescent populations, and repeat infections carry elevated risk for pelvic inflammatory disease and other complications compared to initial infection. 1, 4

Men may also benefit from retesting at 3 months, though evidence is more limited. 1

Critical Pitfalls to Avoid

• Do NOT wait for test results if compliance with return visit is uncertain—treat presumptively in high-prevalence populations. 1
• Do NOT assume partners were treated—directly verify or use expedited partner therapy strategies. 1
• Do NOT allow sexual activity before partner treatment is complete—both patient and all partners must complete treatment before resuming intercourse. 1, 4
• Do NOT test too early after treatment—wait at least 3 weeks to avoid false-positives. 4
• Do NOT retreat based on symptoms alone without documenting objective signs of urethral inflammation or laboratory evidence of infection. 1 Most recurrent infections (84-92%) are reinfections from untreated partners, not treatment failures. 4

Persistent Symptoms After Treatment

If symptoms persist after completing treatment, consider testing for Mycoplasma genitalium using NAAT on first-void urine or urethral swab, as this organism causes doxycycline-resistant urethritis. 1 For confirmed M. genitalium infection, moxifloxacin 400 mg orally once daily for 7 days is highly effective, particularly for macrolide-resistant strains. 1