Chlamydia Treatment
First-Line Treatment
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 achieve 97-98% cure rates and are equally effective. 1, 2, 3
Choosing Between First-Line Options
Use azithromycin 1 g single dose when:
Use doxycycline 100 mg twice daily for 7 days when:
Implementation Best Practices
- Dispense medications on-site when possible and directly observe the first dose to maximize compliance 1, 2, 3
- Patients must abstain from all sexual intercourse for 7 days after initiating treatment and until all sex partners complete treatment 1, 2, 3
Alternative Treatment Regimens
Use alternative regimens ONLY when first-line options cannot be used due to allergy or intolerance. 1, 2
- Levofloxacin 500 mg orally once daily for 7 days (88-94% efficacy, but lacks clinical trial validation) 1, 2
- Ofloxacin 300 mg orally twice daily for 7 days (similar efficacy to first-line agents) 1, 2
- Erythromycin base 500 mg orally four times daily for 7 days 1, 2, 4
- Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 2, 4
Critical caveat: Erythromycin is less efficacious than azithromycin or doxycycline and causes frequent gastrointestinal side effects that reduce compliance—avoid as first-line treatment. 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
- Amoxicillin 500 mg orally three times daily for 7 days 1, 2, 3
- Erythromycin base 500 mg orally four times daily for 7 days (if azithromycin cannot be tolerated) 1, 2, 4
Absolute Contraindications in Pregnancy
- Doxycycline 1, 2, 3
- Ofloxacin 1, 2
- Levofloxacin 1, 2
- All fluoroquinolones 1, 2
- Erythromycin estolate (causes drug-related hepatotoxicity) 1
Pregnancy-Specific 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
Children <45 kg
- Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 2, 4
Neonates with Chlamydial Conjunctivitis or Pneumonia (Ages 1-3 Months)
- Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days (approximately 80% effective; may require a second course) 1, 4
- Alternative: Azithromycin suspension 20 mg/kg/day orally once daily for 3 days 1
Important: Do NOT use non-culture tests (EIA, DFA) in children due to false-positive results from cross-reaction with other organisms. 1
Partner Management
All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated—even if asymptomatic. 1, 2, 3
- Treat partners with the same regimen as the index patient 1
- If last sexual contact was >60 days before diagnosis, treat the most recent partner 1
- Do NOT wait for partner test results before treating—empiric treatment prevents ongoing transmission and complications 1
- Failing to treat sex partners leads to reinfection in up to 20% of cases 1
Coinfection Considerations
If gonorrhea is confirmed or prevalence is high (>5%) in your patient population, treat for BOTH infections concurrently: 1, 3
Rationale: Coinfection rates are 20-40% in high-prevalence populations. 1, 3
Additional STI Testing
- Test all chlamydia patients for gonorrhea, syphilis, and HIV at the initial visit 1
Follow-Up and Retesting
Test-of-Cure
Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens who are asymptomatic—cure rates exceed 97%. 1, 2, 3
Perform test-of-cure ONLY if: 1, 2
- Therapeutic compliance is questionable
- Symptoms persist after treatment
- Reinfection is suspected
- Patient is pregnant (mandatory)
Critical timing: Wait at least 3 weeks after treatment before testing—nucleic acid amplification tests performed earlier can yield false-positive results from dead organisms. 1, 2
Mandatory Reinfection Screening
All women with chlamydia should be retested approximately 3 months after treatment, regardless of whether partners were reportedly treated. 1, 2, 3
- Reinfection rates reach 39% in some adolescent populations 1, 2
- Repeat infections carry elevated risk for pelvic inflammatory disease and complications compared to initial infection 1, 2
- Men may also benefit from retesting at 3 months, though evidence is more limited 1
Treatment Failure Management
If azithromycin fails, switch to doxycycline 100 mg orally twice daily for 7 days. 2
Before Retreating, Verify:
- Wait at least 3 weeks after initial treatment before confirming treatment failure (avoid false-positives from dead organisms) 2
- Ensure all sexual partners from the last 60 days were adequately treated 2
- Rule out reinfection from untreated partners 2
After Retreatment:
- Patient must abstain from sexual intercourse for 7 complete days after starting new treatment 2
- Schedule repeat testing 3 months after successful treatment 2
Critical Pitfalls to Avoid
- Do NOT use erythromycin as first-line treatment—poor compliance from gastrointestinal side effects 1
- Do NOT perform test-of-cure in asymptomatic patients treated with recommended regimens—wastes resources and may yield false-positives 1
- Do NOT assume partners were treated—directly verify or use expedited partner therapy 1
- 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—document objective signs of urethral inflammation or laboratory evidence of infection 1