Treatment for Uncomplicated Chlamydia in a Homeless Woman
Give azithromycin 1 g orally as a single dose immediately, dispensed on-site with directly observed administration. 1, 2, 3
Why Single-Dose Azithromycin is Essential in This Case
For a homeless woman living in a shelter, azithromycin is strongly preferred over doxycycline because compliance with a 7-day regimen is unpredictable in populations with erratic health-care-seeking behavior. 1, 3 While both medications achieve 97-98% cure rates when compliance is ensured, the reality of homelessness makes follow-up and medication adherence extremely challenging. 1, 2, 4
Dispense the medication on-site and directly observe her taking the full 1 g dose before she leaves the clinic. 1, 3 This single intervention eliminates compliance concerns entirely and ensures treatment completion. 1
Alternative Only If Azithromycin Cannot Be Used
If azithromycin is contraindicated (documented severe allergy), use doxycycline 100 mg orally twice daily for 7 days, but recognize that treatment failure is more likely in this population due to adherence challenges. 5, 1, 6 The FDA-approved doxycycline regimen requires exactly 7 days—not shorter—to achieve the 95-98% cure rate. 6
Other alternatives (levofloxacin 500 mg daily for 7 days, ofloxacin 300 mg twice daily for 7 days, or erythromycin regimens) are inferior choices with lower efficacy (88-94% for levofloxacin), more side effects, higher cost, and no compliance advantage. 1, 3
Critical Management Steps
Sexual Activity Restrictions
She must abstain from all sexual intercourse for 7 full days after taking azithromycin and until all sex partners complete treatment. 1, 2, 3 Reinfection occurs in up to 20% of cases when partners are not treated. 1
Partner Management
All sex partners from the preceding 60 days must receive empiric treatment with the same regimen—azithromycin 1 g single dose—even if asymptomatic and without waiting for test results. 1, 2, 3 If her last sexual contact was more than 60 days ago, treat that most recent partner. 1
Consider expedited partner therapy (providing medication for partners) if direct partner evaluation is not feasible, which is common in homeless populations. 1
Additional STI Testing
Test her immediately for gonorrhea, syphilis, and HIV at this same visit. 1 Coinfection rates with gonorrhea are 20-40% in high-prevalence populations. 1 If gonorrhea prevalence is high (>5%) in your clinic population or if testing is unavailable, treat presumptively for both infections with ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose. 1, 3
Follow-Up Protocol
No Test-of-Cure Needed
Do not perform test-of-cure after azithromycin treatment unless she remains symptomatic or reinfection is suspected. 1, 2, 3 Treatment failure rates with azithromycin are only 0-8%, making routine retesting wasteful. 3 Testing before 3 weeks post-treatment yields false-positives from dead organism DNA. 1, 3
Mandatory Reinfection Screening
Schedule her to return in 3 months for repeat chlamydia testing, regardless of whether partners were reportedly treated. 1, 2, 3 Reinfection rates reach 39% in some populations, and repeat infections carry elevated risk for pelvic inflammatory disease, ectopic pregnancy, and infertility. 1, 3 This 3-month retest is distinct from test-of-cure and screens for new exposure. 1
Common Pitfalls to Avoid
- Do not prescribe doxycycline for 7 days and expect compliance in a homeless patient—you are setting her up for treatment failure. 1, 3
- Do not wait for test results before treating partners—empiric partner treatment prevents the 20% reinfection rate. 1
- Do not assume partners were treated based on patient report—directly verify or use expedited partner therapy. 1
- Do not perform test-of-cure at 1-2 weeks—nucleic acid tests will be falsely positive from residual DNA. 1, 3
- Do not skip the 3-month reinfection screen—this is when you will detect clinically significant reinfections that increase PID risk. 1, 3