What is the recommended treatment for a male patient with a chlamydia infection?

Treatment of Chlamydia Infection in Males

For uncomplicated chlamydial urethritis in males, 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 first-line options. 1, 2, 3

First-Line Treatment Selection

Choose between two equally effective regimens based on compliance concerns and cost:

• Azithromycin 1 g orally, 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
  • The patient has erratic health-care-seeking behavior 1

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

  • Cost is a primary concern (significantly less expensive than azithromycin) 2, 3
  • The patient can reliably complete a 7-day course 2
  • Rectal chlamydia is present or suspected (see below) 4, 5

Critical Implementation Steps

Maximize treatment success with these mandatory practices:

• Dispense medications on-site when possible and directly observe the first dose 1, 2, 3
• Instruct the patient to abstain from all sexual intercourse for 7 days after initiating treatment 6, 1, 2
• Continue abstinence until all sex partners have completed treatment 1, 2, 3

Partner Management (Non-Negotiable)

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 more than 60 days before diagnosis, still treat the most recent partner. 1, 3

Failing to treat sex partners leads to reinfection in up to 20% of cases. 1

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

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

• Levofloxacin 500 mg orally once daily for 7 days 6, 1, 2
• Ofloxacin 300 mg orally twice daily for 7 days 6, 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days 6, 1, 2
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 6, 1, 2

Important caveats about alternatives:

• Erythromycin is less efficacious than first-line agents and causes frequent gastrointestinal side effects that reduce compliance 1, 2, 3
• Levofloxacin has only 88-94% efficacy (inferior to 97-98% for first-line agents) and lacks clinical trial validation for chlamydia 1
• Fluoroquinolones offer no compliance advantage over doxycycline (both require 7 days) and are more expensive 1

Special Consideration: Rectal Chlamydia

If rectal chlamydia is diagnosed or suspected in men who have sex with men, strongly prefer doxycycline over azithromycin. 4, 5

Recent high-quality evidence demonstrates:

• Doxycycline achieves 96.9% cure rate for rectal chlamydia versus 76.4% for azithromycin (adjusted risk difference 19.9 percentage points, P<0.001) 4
• Azithromycin-treated men had 5.2 times higher risk of persistent/recurrent rectal infection at 14-90 days compared to doxycycline 5

Follow-Up and Retesting

Do NOT perform routine test-of-cure for men treated with recommended regimens who are asymptomatic after treatment—cure rates exceed 97%. 1, 2, 3

DO perform repeat testing at 3 months after treatment for all men diagnosed with chlamydia, as reinfection rates are high (up to 39% in some populations). 1, 2, 3

Test-of-cure is only indicated when:

• Therapeutic compliance is questionable 1, 3
• Symptoms persist after treatment 1, 3
• Reinfection is suspected 1, 3

If test-of-cure is performed, wait at least 3 weeks after treatment completion, as nucleic acid amplification tests performed earlier can yield false-positive results from dead organisms. 1, 2

Persistent or Recurrent Urethritis

If symptoms persist after completing treatment:

• Do NOT retreat based on symptoms alone without documenting objective signs of urethral inflammation or laboratory evidence of infection 1
• Consider testing for Mycoplasma genitalium using nucleic acid amplification test on first-void urine or urethral swab, as this organism causes doxycycline-resistant urethritis 1
• For confirmed M. genitalium infection, treat with moxifloxacin 400 mg orally once daily for 7 days 1
• Reverify that all sexual partners from the last 60 days were adequately treated 2

Concurrent Gonorrhea

If gonorrhea is confirmed or prevalence is high in the patient population, treat for both infections concurrently with ceftriaxone 250 mg IM single dose plus azithromycin 1 g orally single dose. 1 Coinfection rates are substantial, and treating chlamydia alone when gonorrhea is present leads to treatment failure. 1

Additional STI Testing

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