What is the recommended treatment for uncomplicated genital Chlamydia trachomatis infection?

Treatment for Chlamydia

For uncomplicated genital chlamydia in non-pregnant adults, treat with doxycycline 100 mg orally twice daily for 7 days as first-line therapy, achieving 97-98% cure rates, or azithromycin 1 g orally as a single dose when adherence to a 7-day regimen is uncertain. 1, 2, 3

First-Line Treatment Selection

Choose between two equally effective options based on patient-specific factors:

• Doxycycline 100 mg orally twice daily for 7 days is preferred when:

  • Cost is a primary concern (significantly less expensive than azithromycin) 2
  • The patient can reliably complete a 7-day course 2
  • Treating rectal chlamydia (94-100% cure vs. 79-87% with azithromycin) 1
  • Both regimens achieve 97-98% cure rates for genital infections 1, 2, 3

• Azithromycin 1 g orally as a single dose is preferred when:

  • Compliance with multi-day regimens is questionable 1, 2
  • Follow-up is unpredictable 1, 2
  • Directly observed therapy is needed 1, 2
  • Treating populations with erratic health-care-seeking behavior (homeless individuals, young adults) 1, 2
  • Despite equivalent efficacy in trials, real-world adherence studies show only 77-85% of patients complete the full doxycycline course 4

Critical Management Steps

Medication dispensing and observation:

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

Sexual abstinence requirements:

• Patients must abstain from all sexual intercourse for 7 days after initiating treatment 1, 2, 3
• Continue abstinence until all sex partners have completed treatment 1, 2, 3

Partner management (mandatory):

• All sex partners from the preceding 60 days must be evaluated, tested, and empirically treated 1, 2, 3
• Treat the most recent partner even if last sexual contact was >60 days before diagnosis 1
• Failing to treat partners leads to reinfection in up to 20% of cases 1

Treatment During Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment during pregnancy. 1, 2, 3

Alternative regimens 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, 2

Absolute contraindications in pregnancy:

• Doxycycline (teratogenic risk) 1, 2, 3
• All fluoroquinolones including ofloxacin and levofloxacin 1, 2, 3
• Erythromycin estolate (drug-related hepatotoxicity) 1

Mandatory follow-up:

• Test-of-cure is required 3-4 weeks after treatment completion in all pregnant patients due to potential maternal and neonatal complications 1, 2, 3

Pediatric Dosing

For 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, 2, 3

For children <45 kg:

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days 1, 2, 3

Alternative Regimens (When First-Line Options Cannot Be Used)

Use only when azithromycin and doxycycline are contraindicated or not tolerated:

• Levofloxacin 500 mg orally once daily for 7 days (88-94% cure rate vs. 97-98% for first-line agents) 1, 2, 3
• Ofloxacin 300 mg orally twice daily for 7 days 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

Important caveats about alternatives:

• Erythromycin is less efficacious than first-line options and has frequent gastrointestinal side effects causing poor compliance 1, 2
• Fluoroquinolones offer no compliance advantage (require 7 days of dosing) and are more expensive than doxycycline 1

Follow-Up and Retesting

Test-of-cure (NOT routinely recommended):

• Do NOT perform test-of-cure in non-pregnant patients treated with recommended regimens, as treatment failure rates are extremely low (0-3% in males, 0-8% in females) 2, 3
• Test-of-cure is only indicated when therapeutic compliance is questionable, symptoms persist, or reinfection is suspected 1, 2
• If testing is needed, wait at least 3 weeks after treatment completion, as nucleic acid amplification tests performed earlier can yield false-positives from dead organisms 1, 2

Reinfection screening (strongly recommended):

• 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, 3
• Repeat infections carry elevated risk for pelvic inflammatory disease and other complications compared to initial infection 1, 2

Concurrent Gonorrhea Management

Test for gonorrhea at the initial visit in all patients diagnosed with chlamydia. 1

If gonorrhea is confirmed or prevalence exceeds 5% in the population:

• Treat concurrently with ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose 1, 5
• Coinfection rates are 20-40% in high-prevalence populations 1

Common Pitfalls to Avoid

• Do NOT wait for test results before treating partners—empiric treatment is mandatory for all partners from the preceding 60 days 1
• Do NOT perform test-of-cure in asymptomatic non-pregnant patients—this wastes resources and may yield false-positives 1, 2
• Do NOT assume partners were treated—directly verify or use expedited partner therapy 1
• Do NOT use fluoroquinolones or doxycycline in pregnancy—these are absolutely contraindicated 1, 2, 3
• Do NOT retreat based on symptoms alone—require objective evidence of urethral inflammation before considering treatment failure 1