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

Recommended Treatment for Chlamydia

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 achieving 97-98% cure rates. 1, 2

First-Line Treatment Options

Azithromycin 1 g orally, single dose is preferred when:

• Compliance with multi-day regimens is uncertain 1, 2
• Directly observed therapy is needed 1
• The patient has erratic health-care-seeking behavior 1
• Cure rate: approximately 97% 1, 2

Doxycycline 100 mg orally twice daily for 7 days is equally effective when:

• Cost is a primary concern (doxycycline is less expensive) 1, 2
• The patient can reliably complete a 7-day course 2
• Cure rate: approximately 98% 1, 2, 3

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

Alternative Treatment Regimens

Use these only when first-line options cannot be tolerated: 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
• Ofloxacin 300 mg orally twice daily for 7 days 1, 2
• Levofloxacin 500 mg orally once daily for 7 days 1, 2

Important caveat: Erythromycin has lower efficacy than azithromycin or doxycycline, and gastrointestinal side effects frequently cause poor compliance. 1, 2 Levofloxacin shows only 88-94% efficacy and lacks clinical trial validation for chlamydia treatment. 1

Treatment During Pregnancy

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

Alternative option:

• Amoxicillin 500 mg orally three times daily for 7 days 1, 2, 4

Absolutely contraindicated in pregnancy: 1, 2

• Doxycycline
• Ofloxacin
• Levofloxacin
• All fluoroquinolones

Pregnant women must have a test-of-cure 3-4 weeks after treatment completion due to use of alternative regimens with lower efficacy. 1

Pediatric Dosing

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

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

For children <45 kg: 1, 2

• 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
• Effectiveness: approximately 80%; a second course may be needed 1

Implementation Best Practices

Dispense medications on-site when possible and directly observe the first dose to maximize compliance. 1, 2

Patients must abstain from all sexual intercourse for 7 days after initiating treatment (regardless of single-dose or 7-day regimen) and until all sex partners are treated. 1, 2

Partner Management

All sex partners from the previous 60 days must be evaluated, tested, and empirically treated with the same chlamydia-effective regimen, even if asymptomatic. 1, 2 If the last sexual contact was >60 days before diagnosis, treat the most recent partner. 1, 2

Critical pitfall: Failing to treat sex partners leads to reinfection in up to 20% of cases. 1 Do not wait for the partner's test results before treating—the increased prevalence of chlamydia among sex partners warrants immediate empiric treatment. 1

Coinfection Considerations

If gonorrhea is confirmed or prevalence is high (>5%) in the patient population, treat for both infections concurrently: 1

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

Coinfection rates are 20-40% in populations with high gonorrhea prevalence. 1

Follow-Up Recommendations

Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens (azithromycin or doxycycline) who are asymptomatic after treatment, as cure rates exceed 97%. 1, 2

Test-of-cure IS indicated when: 1, 2

• Therapeutic compliance is questionable
• Symptoms persist after treatment
• Reinfection is suspected
• Patient is pregnant

Timing: Test-of-cure should be performed 3-4 weeks after treatment completion, as testing before 3 weeks is unreliable due to false-positive results from dead organisms. 1

Reinfection screening: All women with chlamydia should be retested approximately 3 months after treatment to screen for reinfection, regardless of whether partners were reportedly treated. 1, 2 Reinfection rates reach up to 39% in some adolescent populations. 1 Repeat infections carry elevated risk for pelvic inflammatory disease and other complications compared to initial infection. 1

Additional STI Testing

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

Common Pitfalls to Avoid

• Do not wait for test results if compliance with return visit is uncertain in high-prevalence populations—treat presumptively. 5
• Do not assume partners were treated—directly verify or use expedited partner therapy strategies. 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 retreat based on symptoms alone without documenting objective signs of urethral inflammation or laboratory evidence of infection. 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

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