Approach
The main treatment goal is to eradicate the infection and follow up on sexual contacts. Delaying treatment may increase the risk of subsequent infertility and other sequelae such as reactive arthritis.
If the risk for chlamydia infection is high, treatment should be started empirically before test results are known. Patients are advised to avoid sexual contact for 7 days after the treatment has started.
Recommended treatment
The US Centers for Disease Control and Prevention (CDC) STI guidelines recommend doxycycline as the first-line antibiotic.[5][32] The UK guidelines also recommend doxycycline treatment as the first-line treatment for any diagnosed chlamydia infection, regardless of anatomical site.[2] Alternative antibiotics are azithromycin and levofloxacin.[5]
Systemic fluoroquinolone antibiotics, such as levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[33]
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Treatment during pregnancy
Azithromycin is the first-line option in pregnancy. It is safe during pregnancy and may reduce the risk of premature delivery. An alternative during pregnancy is amoxicillin. Doxycycline and fluoroquinolones should be avoided in pregnant women.[5] A Cochrane review of interventions for treating genital chlamydia infection in pregnancy concluded no difference in efficacy or pregnancy complications when comparing antibacterial agents (amoxicillin, erythromycin, clindamycin, azithromycin); however, azithromycin and clindamycin appear to have fewer side effects than erythromycin.[34]
Partner notification
All sexual contacts within the past 60 days should be advised to seek investigation and treatment for chlamydia.
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At the very least, the index case should notify sexual contacts that they may have been exposed to chlamydia. In some US states the law permits expedited partner therapy (EPT), which is the practice of treating the sex partners of persons with sexually transmitted infections (STIs) without an intervening medical evaluation or professional prevention counselling.[35]
CDC: expedited partner therapy
Opens in new window This may be considered as an option to facilitate partner management among heterosexual men and women with chlamydia infection. The American College of Obstetricians and Gynecologists has issued a statement supporting EPT in the management of chlamydial and gonorrhoea infections when the partner is unlikely or unable to otherwise receive in-person evaluation and appropriate treatment.[36]
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