eMedicine Specialties > Infectious Diseases > Sexually Transmitted Diseases
Chlamydial Genitourinary Infections: Treatment & Medication
Updated: Apr 20, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until the end of a longer regimen.
- Patients also should refrain from sexual intercourse until all of their sex partners have been cured.
- Follow-up culture is not recommended after azithromycin or doxycycline therapy, but it may be considered in pregnancy after erythromycin or amoxicillin therapy. Nonculture tests should be avoided in this circumstance to avoid positive results from nonviable organisms.
Medication
Treatment of genitourinary chlamydial infection clearly is indicated when the infection is diagnosed or suspected. Treatment also is indicated for sex partners of the index case if the time of the last sexual encounter was within 60 days of onset, and it should be considered for longer periods for the last sexual partner. Treatment of chlamydia is indicated for patients being treated for gonorrhea, as well.
In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001.
The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.
For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.
Antibiotics
Therapy should cover all likely pathogens in the context of this clinical setting.
Azithromycin (Zithromax)
Relatively new member of the macrolide family of antimicrobials. Related to erythromycin, it is considered by many to be the treatment of choice of C trachomatis genitourinary infection because it may be administered as a 1-dose treatment, which improves adherence to treatment.
Adult
1 g PO once
Pediatric
<8 years: Not established
>8 years or >45 kilograms: Administer as in adults
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine; can inhibit metabolism of disopyramide and pimozide, leading to cardiotoxicity; inhibition of rifabutin metabolism may lead to rifabutin toxicity
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Generally not recommended for routine use during pregnancy but can be used as an alternative if failure occurs (by followup culture) after treatment with erythromycin or amoxicillin (neither are highly efficacious treatments); site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients; adverse effects are GI in origin, namely nausea, vomiting, diarrhea, and abdominal pain; less common effects include headache, dizziness, and hepatotoxicity
Doxycycline (Doryx, Vibramycin)
Well absorbed tetracycline antimicrobial. When administered for 1 wk, appears to be as effective as single-dose azithromycin for genitourinary chlamydial infections. Although the course is longer (7 d versus 1 dose) than azithromycin, the cost is less and it has been used in clinical practice for a much longer time.
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: Administer as in adults
Bioavailability minimally decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Unsafe in pregnancy
Precautions
Photosensitivity may occur rarely; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth
Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab, Erythrocin)
Macrolide antimicrobial agent that generally is considered the recommended treatment for chlamydial genitourinary infection only during pregnancy.
Adult
500 mg erythromycin base PO qid for 7 d; alternatively, 250 mg erythromycin base PO qid for 14 d or 800 mg erythromycin ethylsuccinate PO qid for 7 d or 400 mg qid for 14 d
Pediatric
<45 kilograms: 50 mg/kg/d erythromycin base divided PO qid for 10-14 d; this regimen also should be used for ophthalmia neonatorum and/or infant pneumonia due to chlamydia
As an inhibitor of the cytochrome oxidase P-450 3A4 system, can increase serum levels of atorvastatin, buspirone, carbamazepine, cerivastatin (removed from US market 8/8/01), cilostazol, cisapride, clozapine, cyclosporine, diazepam, dicumarol, dihydroergotamine, disopyramide, felodipine, fexofenadine, lovastatin, midazolam, pimozide, pravastatin, quinidine, sildenafil, triazolam, valproic acid, vinblastine, and warfarin; similar effects as doxycycline can occur with concomitant use of digoxin and oral contraceptives
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; efficacy of treatment is not as high as the standard regimens in adults; test of cure at 3 wk after completion of therapy should be considered and re-treatment may be needed
Ampicillin (Principen, Omnipen, Marcillin)
Like erythromycin, amoxicillin is considered a recommended treatment for genitourinary chlamydial infection only in pregnant women.
Adult
500 mg PO tid for 7 d
Pediatric
Not recommended
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives; coadministration with PO typhoid vaccine can affect the immunogenicity of the vaccine by inhibiting replication; methotrexate levels may be increased by penicillins
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Retesting 3 wk after therapy completion should be considered; major adverse effects include diarrhea, rash, nausea, and vomiting; Clostridium difficile infection and/or colitis may occur
More on Chlamydial Genitourinary Infections |
| Overview: Chlamydial Genitourinary Infections |
| Differential Diagnoses & Workup: Chlamydial Genitourinary Infections |
 Treatment & Medication: Chlamydial Genitourinary Infections |
| Follow-up: Chlamydial Genitourinary Infections |
| References |
| « Previous Page | Next Page » |
References
Centers for Disease Control and Prevention. Chlamydia screening among sexually active young females enrollees of health plans - United States, 2000-2007. MMWR Weekly. April 17, 2009;58(14):362-365. [Full Text].
Quinn TC, Gaydos C, Shepherd M. Epidemiologic and microbiologic correlates of Chlamydia trachomatis infection in sexual partnerships. JAMA. Dec 4 1996;276(21):1737-42. [Medline].
Bell TA, Sandstrom IK, Eschenbach DA. Treatment of Chlamydia trachomatis in pregnancy with amoxicillin. In: Mardh PA, Holmes KK, Oriel JD, Piot P, Schachter J, eds. Chlamydial Infections. New York, NY: Elsevier Biomedical; 1982:221-4.
Bowie WR. Nongonococcal urethritis. Urol Clin North Am. Feb 1984;11(1):55-64. [Medline].
CDC. Diseases characterized by urethritis and cervicitis (see update from April 13, 2007). MMWR Morb Mortal Wkly Rep [serial online]. Aug 4 2006;55(RR-11):35-49. Available at http://www.cdc.gov/std/treatment/2006/urethritis-and-cervicitis.htm#uc4.
CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].
CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
Cook RL, Hutchison SL, Østergaard L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. Jun 7 2005;142(11):914-25. [Medline].
Donders GG. Management of genital infections in pregnant women. Curr Opin Infect Dis. Feb 2006;19(1):55-61. [Medline].
Donovan B. Sexually transmissible infections other than HIV. Lancet. Feb 14 2004;363(9408):545-56. [Medline].
Dorman SA, Danos LM, Wilson DJ. Detection of chlamydial cervicitis by Papanicolaou stained smears and culture. Am J Clin Pathol. Apr 1983;79(4):421-5. [Medline].
Ehret JM, Judson FN. Susceptibility testing of Chlamydia trachomatis: from eggs to monoclonal antibodies. Antimicrob Agents Chemother. Sep 1988;32(9):1295-9. [Medline].
Hook EW 3rd, Smith K, Mullen C. Diagnosis of genitourinary Chlamydia trachomatis infections by using the ligase chain reaction on patient-obtained vaginal swabs. J Clin Microbiol. Aug 1997;35(8):2133-5. [Medline].
Katz BP, Fortenberry D, Orr DP. Factors affecting chlamydial persistence or recurrence one and three months after treatment. In: Stephens RS, Byrne GI, Christiansen G, et al, eds. Chlamydial Infections, Proceedings of the Ninth International Symposium on Human Chlamydial Infection. San Francisco, Calif: International Chlamydial Symposium; 1998:35-8.
Magat AH, Alger LS, Nagey DA. Double-blind randomized study comparing amoxicillin and erythromycin for the treatment of Chlamydia trachomatis in pregnancy. Obstet Gynecol. May 1993;81(5 ( Pt 1)):745-9. [Medline].
Martin DH, Mroczkowski TF, Dalu ZA. A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. The Azithromycin for Chlamydial Infections Study Group. N Engl J Med. Sep 24 1992;327(13):921-5. [Medline].
Rahman MU, Hudson AP, Schumacher HR Jr. Chlamydia and Reiter's syndrome (reactive arthritis). Rheum Dis Clin North Am. Feb 1992;18(1):67-79. [Medline].
Stamm WE. Chlamydia trachomatis infections: progress and problems. J Infect Dis. Mar 1999;179 Suppl 2:S380-3. [Medline].
Wehbeh HA, Ruggeirio RM, Shahem S. Single-dose azithromycin for Chlamydia in pregnant women. J Reprod Med. Jun 1998;43(6):509-14. [Medline].
Further Reading
Keywords
nongonococcal urethritis, nonspecific urethritis, postgonococcal urethritis, Chlamydia trachomatis, Chlamydia puerorum, Chlamydia psittaci, Chlamydia pneumoniae, C trachomatis, C puerorum, C psittaci, C pneumoniae, sexually transmitted diseases, STDs
