eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Chlamydial Infections: Treatment & Medication

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Marc James Grella, MD, Clinical Instructor, Department of Pediatrics, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Jan 21, 2009

Treatment

Medical Care

  • The key to management of chlamydial infections is correct diagnosis and assurance of compliance with treatment.
  • Because of the personal nature and time-intensive diagnosis of sexually transmitted infections (STIs), many physicians err by presuming that symptoms of an STI are caused by a urinary tract infection (UTI); therefore, patients often present with a history of multiple UTIs when, in fact, they may have had one or more STIs.
  • Adolescents are at high risk for noncompliance with treatment, especially if a patient is attempting to keep information away from parents. Single-dose, in-office treatment is increasingly being used to improve compliance and confidentiality.
  • Partner treatment is crucial to avoid reinfection.

Medication

Lower genital infections caused by chlamydia can be treated with single-dose, directly observed treatment. This practice is encouraged when possible to reduce noncompliance due to cost, confidentiality issues, motivational issues, and maturity issues.

Upper genital tract disease must be vigorously sought out because potential complications are serious, especially in adolescents. With the advent of newer, more sensitive DNA and antigen detection kits that use urine specimens instead of a pelvic examination, the potential to presume a chlamydial infection in uncomplicated lower tract disease is concerning. Inadequately treated pelvic inflammatory disease (PID) can lead to sepsis, infertility, and chronic pelvic pain. Many practitioners strongly advise admission for inpatient therapy and monitoring of response whenever PID is suspected because of a tendency of adolescents to minimize or ignore symptoms and eschew follow-up.

Inpatient regimens for PID require significant clinical improvement and confidence in completion of medical therapy prior to discharge. Upper genital infections are often treated with a 10-day course that includes treatment of gonorrhea. Some practitioners prefer to complete the entire course of treatment on an inpatient basis, usually 10-14 days.

Chlamydial conjunctivitis and pneumonia are usually treated for a total of 14 days.

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 2007 issue of the Morbidity and Mortality Weekly Report.3 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 or CDC Updated Gonococcal treatment recommendations (April 2007).

Antibiotic agents

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Azithromycin (Zithromax)

DOC for genital chlamydia infections because it is a single-dose regimen, has high tolerability, and has few contraindications. A macrolide antibiotic with activity against various different bacterial organisms. Binds to the 50S ribosomal subunit of the bacteria. This binding inhibits bacterial protein synthesis.

Adult

1 g PO once

Pediatric

<45 kg: 20 mg/kg PO once; not to exceed 1 g/dose
>45 kg: Administer as in adults

Aluminum-containing and magnesium-containing antacids decrease peak serum levels of azithromycin; do not administer antacids with azithromycin; food decreases the peak serum levels of azithromycin cap and susp but has minimal effect on the tab formulation; administer cap and susp 1 h ac or 2 h pc

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Impaired liver function; common adverse drug reactions include GI symptoms such as diarrhea, abdominal pain, nausea, and vomiting


Doxycycline (Bio-Tab, Vibramycin, Doryx)

Second DOC for genital chlamydia infections. Efficacy is good; however, because of the need for extended therapy, compliance is often poor. A tetracycline derivative. Has a limited spectrum of bacterial activity but is effective in treating chlamydial infections. Binds to the 30S and maybe the 50S ribosomal subunits of the bacteria. This binding inhibits bacterial protein synthesis.

Adult

100 mg PO bid for 7 d

Pediatric

<8 years: Not recommended (causes dental staining)
>8 years: 100 mg PO bid for 7 d

Zinc, kaolin, pectin, iron, bismuth subsalicylate, and aluminum-containing, calcium-containing, and magnesium-containing antacids may decrease doxycycline bioavailability (administer 1 h before or 2-3 h after any of these products); half-life is decreased by barbiturates, rifampin, phenytoin, and carbamazepine; enhances the effect of warfarin; milk or dairy products, calcium, and iron may decrease absorption; administer 1 h before or 2-3 h after milk, dairy products, or iron

Documented hypersensitivity; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause photosensitivity reaction; avoid prolonged exposure to sunlight or tanning equipment; associated with retardation of skeletal development in infants; common adverse drug reactions include GI symptoms such as nausea and diarrhea


Erythromycin (E.E.S., Eryc, E-Mycin)

DOC in pregnancy and in infants. A macrolide antibiotic with a large spectrum of activity. Binds to the 50S ribosomal subunit of the bacteria, which inhibits bacterial protein synthesis.

Adult

Base: 500 mg PO qid for 7 d
Erythromycin ethylsuccinate (EES): 800 mg PO qid for 7 d

Pediatric

Newborns with chlamydia conjunctivitis or pneumonia: erythromycin (base) 50 mg/kg/d PO divided qid for 14 d

Decreases clearance of terfenadine (recalled from US market), cisapride, and astemizole (recalled from US market), which may result in serious cardiac arrhythmias; decreases clearance of cyclosporin, midazolam, phenytoin, triazolam, and theophylline; may increase toxicity of warfarin and ergotamine

Hypersensitivity to macrolides; hepatic impairment; concomitant administration of terfenadine, cisapride, or astemizole

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Common adverse drug reactions include GI symptoms such as abdominal pain, diarrhea, nausea, and vomiting; administration in neonates has been associated with an increased incidence of hypertrophic pyloric stenosis; careful monitoring is prudent in the case of vomiting, which might otherwise be ascribed to macrolide-induced GI distress


Amoxicillin (Trimox, Amoxil)

Because of lower efficacy, this is indicated only when the patient is both pregnant and erythromycin-allergic. Amoxicillin is a penicillin antibiotic with activity against gram-positive and some gram-negative bacteria. Binds to PBPs, inhibiting bacterial cell wall growth.

Adult

500 mg PO tid for 7-10 d

Pediatric

30-40 mg/kg/d PO divided tid for 7-10 d

Decreases PO contraceptive efficacy; probenecid increases serum concentration of amoxicillin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use with caution in patients who are allergic to cephalosporin antibiotics


Sulfisoxazole (Gantrisin)

Less effective than most other regimens. Less convenient dosing makes this a poor choice for most adolescents.

Adult

500 mg PO qid for 10 d

Pediatric

120-150 mg/kg/d PO divided qid

May enhance anticoagulation of warfarin and hemorrhage could occur; thiopental anesthetic effects may be enhanced; risk of nephrotoxicity may increase when concurrently administered with cyclosporine; may increase serum hydantoin levels; may enhance methotrexate-induced bone marrow suppression; may increase sulfonylurea concentrations and cause hypoglycemia in patients with diabetes Coadministration with diuretics may increase incidence of thrombocytopenia with purpura; the sulfonamide-free drug concentration may be increased when concurrently administered with indomethacin; concomitant use with methenamine mandelate may form a precipitate in acidic urine; probenecid and salicylates may displace sulfonamides from plasma albumin resulting in increased free-drug concentrations potentiating its toxicity

Documented hypersensitivity; third trimester of pregnancy; newborns; nursing mothers

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use in pregnancy in last trimester (particularly near term) because of risk of kernicterus; testing for cure after 3-4 wk is advised because of low efficacy

More on Chlamydial Infections

Overview: Chlamydial Infections
Differential Diagnoses & Workup: Chlamydial Infections
Treatment & Medication: Chlamydial Infections
Follow-up: Chlamydial Infections
Multimedia: Chlamydial Infections
References
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Further Reading

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Keywords

chlamydial infection, chlamydia, bronchitis, conjunctivitis, dyspareunia, dysuria, ectopic pregnancy, epididymitis, Fitz-Hugh-Curtis syndrome, lymphogranuloma venereum, LGV, pelvic inflammatory disease, PID, pharyngitis, pneumonia, pneumonitis, proctitis, salpingitis, sexually transmitted disease, STD, sexually transmitted infection, STI, trachoma, tuboovarian abscess, upper genital tract disease, urethritis, urinary tract infection, UTI, cervicitis, C hlamydia, Chlamydia trachomatis, C trachomatis

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching

Coauthor(s)

Marc James Grella, MD, Clinical Instructor, Department of Pediatrics, Massachusetts General Hospital
Marc James Grella, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Medical Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota School of Medicine
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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