What are the current treatment recommendations for uncomplicated genital or rectal Chlamydia trachomatis infection in non‑pregnant adults and adolescents, pregnant patients, and children?

Treatment of Chlamydia Trachomatis Infection

For uncomplicated genital or rectal chlamydia in non-pregnant adults and adolescents, 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

First-Line Treatment Selection

Non-Pregnant Adults and Adolescents

Choose azithromycin 1 g orally as a single dose when:

• Compliance with a 7-day regimen is uncertain or unpredictable 1, 2
• The patient has erratic health-care-seeking behavior 1
• You can administer directly observed therapy in the clinic 1, 2
• The patient prefers single-dose convenience 1

Choose doxycycline 100 mg orally twice daily for 7 days when:

• Cost is a primary concern (doxycycline is less expensive) 1, 3
• The infection is rectal—doxycycline shows superior efficacy for anorectal chlamydia (94-100% cure vs. 79-87% with azithromycin) 1
• Compliance is assured and the patient can complete a 7-day course 1, 3

Both regimens are CDC-recommended first-line options with equivalent efficacy for uncomplicated urogenital infections. 1, 2 Meta-analyses confirm azithromycin and doxycycline are equally efficacious for genital chlamydial infections. 1

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: 1

• Erythromycin base 500 mg orally four times daily for 7 days 1, 4
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 4
• Ofloxacin 300 mg orally twice daily for 7 days 1
• Levofloxacin 500 mg orally once daily for 7 days (88-94% efficacy vs. 97-98% for first-line agents; lacks clinical trial validation for chlamydia) 1

Important caveat: Erythromycin is less efficacious than azithromycin or doxycycline, and gastrointestinal side effects frequently lead to poor compliance. 1 Fluoroquinolones offer no compliance advantage over doxycycline (both require 7 days) and are more expensive without superior efficacy. 1

Treatment During Pregnancy

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

Alternative option:

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

Secondary alternatives (when azithromycin and amoxicillin cannot be used):

• Erythromycin base 500 mg orally four times daily for 7 days 1, 4
• Erythromycin base 250 mg orally four times daily for 14 days 1, 4
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 4
• Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 1, 4

Absolutely contraindicated in pregnancy:

• Doxycycline 1, 5
• Ofloxacin 1
• Levofloxacin 1
• All fluoroquinolones 1
• Erythromycin estolate (causes drug-related hepatotoxicity) 1, 4

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

Pediatric Treatment

Children ≥8 Years Weighing >45 kg

• Azithromycin 1 g orally as a single dose, OR
• Doxycycline 100 mg orally twice daily for 7 days 1, 5

Children <45 kg

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 4

Infants with Chlamydial 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; a second course may be needed) 1, 4

Neonates with Chlamydial Conjunctivitis

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for at least 2 weeks 1, 4

Important diagnostic caveat: Do not use non-culture tests (EIA, DFA) in children due to false-positive results from cross-reaction with other organisms. 1

Implementation Best Practices

Medication Dispensing

• Dispense medication on-site when possible 1, 2
• Directly observe the first dose to maximize compliance 1, 2

Sexual Activity Restrictions

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment (regardless of regimen) 1, 2, 3
• Sexual activity must remain restricted until all sex partners have been treated 1, 2, 3

Partner Management

• All sex partners from the previous 60 days must be evaluated, tested, and empirically treated with a chlamydia-effective regimen, even if asymptomatic 1, 2, 3
• If the last sexual contact was >60 days before diagnosis, the most recent partner must still be treated 1, 3
• Failing to treat sex partners leads to reinfection in up to 20% of cases 1

Concurrent Gonorrhea Management

If gonorrhea is confirmed or prevalence exceeds 5% in the patient population, treat for both infections concurrently:

• Ceftriaxone 250 mg IM single dose PLUS
• Azithromycin 1 g orally single dose 1, 2, 3

Coinfection rates range from 20-40% in many populations. 1, 2, 3 All chlamydia patients should be tested for gonorrhea, syphilis, and HIV at the initial visit. 1, 2

Follow-Up and Reinfection Screening

Test-of-Cure

Test-of-cure is NOT recommended for non-pregnant patients treated with recommended regimens who are asymptomatic, as cure rates exceed 97%. 1, 2, 3

Perform test-of-cure only when:

• Therapeutic compliance is questionable 1
• Symptoms persist after treatment 1
• Reinfection is suspected 1
• The patient is pregnant (mandatory) 1

Timing: Test-of-cure should be performed 3-4 weeks after treatment completion. 1 Testing before 3 weeks is unreliable because nucleic acid amplification tests can yield false-positive results from dead organisms that persist after successful treatment. 1, 3

Mandatory 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, 3 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, 3

Men may also benefit from retesting at approximately 3 months, though evidence is more limited. 1

Critical Pitfalls to Avoid

• Do NOT wait for test results if compliance with return visit is uncertain in high-prevalence populations—treat presumptively 1, 3
• Do NOT perform test-of-cure before 3 weeks post-treatment, as nucleic acid amplification tests can yield false-positive results from dead organisms 1, 3
• Do NOT assume partners were treated—directly verify or use expedited partner therapy strategies 1, 3
• Do NOT use erythromycin as first-line treatment due to poor compliance from gastrointestinal side effects 1, 3
• Do NOT use fluoroquinolones or doxycycline in pregnancy due to teratogenic risk 1
• Do NOT omit the test-of-cure in pregnant patients—it is mandatory 1
• Do NOT use erythromycin estolate in pregnancy because of hepatotoxicity 1, 4