Chlamydia Treatment

First-Line Treatment for Uncomplicated Urogenital Chlamydia in Non-Pregnant Adults

For uncomplicated urogenital Chlamydia trachomatis infection in otherwise healthy 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

Choosing Between First-Line Options

Azithromycin 1 g single dose is preferred when:
- Compliance with a 7-day regimen is uncertain 1, 2
- The patient has erratic health-care-seeking behavior 1
- Directly observed therapy is desired 1
- Follow-up is unpredictable 1
Doxycycline 100 mg twice daily for 7 days is preferred when:
- Cost is a primary concern (doxycycline is less expensive) 1, 2
- The patient has concurrent anorectal chlamydia infection (doxycycline shows superior efficacy at ~94% vs azithromycin at ~85% for rectal infections) 1
- The patient can reliably complete a 7-day course 1

Implementation Best Practices

Dispense medication on-site when possible and directly observe the first dose to maximize compliance 1, 2
Instruct patients to abstain from all sexual intercourse for 7 days after initiating treatment and until all sex partners have completed treatment 1, 2
All sex partners from the previous 60 days must be evaluated, tested, and empirically treated even if asymptomatic; if last contact was >60 days before diagnosis, treat the most recent partner 1, 2

Treatment During Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment for pregnant women with uncomplicated chlamydia. 1, 2

Alternative Regimens for Pregnancy (when azithromycin cannot be used)

Amoxicillin 500 mg orally three times daily for 7 days 1, 2
Erythromycin base 500 mg orally four times daily for 7 days 1, 3
Erythromycin base 250 mg orally four times daily for 14 days 1
Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 3
Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 1

Critical Contraindications in Pregnancy

Doxycycline is absolutely contraindicated in pregnancy due to teratogenic risk 1, 2, 4
All fluoroquinolones (ofloxacin, levofloxacin) are absolutely contraindicated in pregnancy 1, 2
Erythromycin estolate is contraindicated in pregnancy due to drug-related hepatotoxicity 1, 3

Mandatory Follow-Up for Pregnant Patients

All pregnant women MUST undergo test-of-cure 3-4 weeks after completing therapy, preferably by culture 1
This requirement differs from non-pregnant adults because alternative regimens have lower efficacy and higher rates of gastrointestinal side effects leading to non-compliance 1
If using nucleic acid amplification tests (NAAT), wait at least 3-4 weeks post-treatment to avoid false-positive results from residual DNA 1

Treatment During Breastfeeding

Azithromycin 1 g orally as a single dose is safe and preferred during breastfeeding (same as pregnancy recommendations). 1

Erythromycin and amoxicillin are also compatible with breastfeeding and can be used as alternatives 1, 3
Avoid doxycycline and fluoroquinolones during breastfeeding 1, 2

Alternative Regimens (when first-line options cannot be used)

Use these only when the patient has documented allergy or severe intolerance to both azithromycin and doxycycline:

Erythromycin base 500 mg orally four times daily for 7 days 1, 2, 3
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 Caveats About Alternative Regimens

Erythromycin is less efficacious than azithromycin or doxycycline, and gastrointestinal side effects frequently lead to poor compliance 1, 2
Levofloxacin has inferior evidence with only 88-94% cure rates compared to 97-98% for first-line agents, and has not been evaluated in clinical trials specifically for C. trachomatis 1
Fluoroquinolones require 7 days of treatment, offering no compliance benefit over doxycycline, and are more expensive 1

Follow-Up and Reinfection Screening

Test-of-Cure (NOT routinely recommended)

Do NOT perform test-of-cure for non-pregnant patients treated with recommended regimens (azithromycin or doxycycline) unless therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 1, 2
Testing before 3 weeks post-treatment is unreliable because NAAT can yield false-positive results from dead organisms 1

Reinfection Screening (STRONGLY recommended)

All women with chlamydia MUST 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 populations, and repeat infections carry elevated risk for pelvic inflammatory disease and other complications 1, 5
Men may also benefit from retesting at 3 months, though evidence is more limited 1

Additional STI Testing and Partner Management

Test all patients for gonorrhea, syphilis, and HIV at the initial visit 1
If gonorrhea is confirmed or prevalence is high (>5%), treat for both infections concurrently with ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose 1
Failing to treat sex partners leads to reinfection in up to 20% of cases 1

Common Pitfalls to Avoid

Do NOT wait for test results before treating partners—empiric treatment is mandatory for all partners from the previous 60 days 1
Do NOT perform test-of-cure in asymptomatic non-pregnant patients treated with recommended regimens—this wastes resources and may yield false-positive results 1
Do NOT use erythromycin estolate in pregnancy—it causes hepatotoxicity 1, 3
Do NOT assume partners were treated—directly verify or use expedited partner therapy 1
Do NOT use doxycycline or fluoroquinolones in pregnant or breastfeeding patients 1, 2, 4

What is the recommended treatment for uncomplicated urogenital Chlamydia trachomatis infection in an otherwise healthy adult, and what regimen should be used for pregnant or breastfeeding patients?

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