Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Chlamydial Infections Among Adolescents and Adults
     
     The following recommended treatment regimens or the
alternative regimens relieve symptoms and cure infection. Among
women, several important sequelae may result from C. trachomatis
infection, the most serious among them being PID, ectopic
pregnancy, and infertility. Some women with apparently
uncomplicated cervical infection already have subclinical upper
reproductive tract infection. Treatment of cervical infection is
believed to reduce the likelihood of sequelae, although few studies
have demonstrated that antimicrobial therapy reduces the risk of
subsequent ascending infections or decreases the incidence of
long-term complications of tubal infertility and ectopic pregnancy.

     Treatment of infected patients prevents transmission to sex
partners, and for infected pregnant women may prevent transmission
of C. trachomatis to infants during birth. Treatment of sex
partners will help to prevent re-infection of the index patient and
infection of other partners.

     Because of the high prevalence of coinfection with C.
trachomatis among patients with gonococcal infection, presumptive
treatment for chlamydia of patients being treated for gonorrhea is
appropriate, particularly if no diagnostic test for C. trachomatis
infection will be performed (see Gonococcal Infections).

Recommended Regimens -
     Doxycycline 100 mg orally 2 times a day for 7 days,
                       or
     Azithromycin 1 g orally in a single dose.

Alternative Regimens -
     Ofloxacin 300 mg orally 2 times a day for 7 days
                       or
     Erythromycin base 500 mg orally 4 times a day for 7 days
                       or
     Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7
     days
                       or
     Sulfisoxazole 500 mg orally 4 times a day for 10 days
     (inferior efficacy to other regimens).

     Doxycycline and azithromycin appear similar in efficacy and
toxicity; however, the safety and efficacy of azithromycin for
persons less than or equal to 15 years of age have not been
established. Doxycycline has a longer history of extensive use,
safety, efficacy, and the advantage of low cost. Azithromycin has
the advantage of single-dose administration. Ofloxacin is similar
in efficacy to doxycycline and azithromycin, but is more expensive
than doxycycline, cannot be used during pregnancy or with persons
less than or equal to 17 years of age, and offers no advantage in
dosing. Ofloxacin is the only quinolone with proven efficacy
against chlamydial infection. Sulfisoxazole is the least desirable
treatment because of inferior efficacy.

Follow-Up -
     Patients do not need to be retested for chlamydia after
completing treatment with doxycycline or azithromycin unless
symptoms persist or re-infection is suspected. Retesting may be
considered 3 weeks after completion of treatment with erythromycin,
sulfisoxazole, or amoxicillin. This is usually unnecessary if the
patient was treated with doxycycline, azithromycin, or ofloxacin.
The validity of chlamydial culture testing performed at less than
3 weeks following completion of therapy among patients failing
therapy has not been established. False-negative results may occur
because of small numbers of chlamydial organisms. In addition,
nonculture tests conducted at less than 3 weeks following
completion of therapy for patients successfully treated may
sometimes be false-positive because of the continued excretion of
dead organisms.

     Some studies have demonstrated high rates of infection among
women retested several months following treatment, presumably
because of reinfection. Rescreening women several months following
treatment may be an effective strategy for detecting further
morbidity in some populations.

Management of Sex Partners -
     Patients should be instructed to refer their sex partners for
evaluation and treatment. Because exposure intervals have received
limited evaluation, the following recommendations are somewhat
arbitrary. Sex partners of symptomatic patients with C. trachomatis
should be evaluated and treated for chlamydia if their last sexual
contact with the index patient was within 30 days of onset of the
index patient's symptoms. If the index patient is asymptomatic, sex
partners whose last sexual contact with the index patient was
within 60 days of diagnosis should be evaluated and treated.
Health-care providers should treat the last sex partner even if
last sexual intercourse took place before the foregoing time
intervals.

     Patients should be instructed to avoid sex until they and
their partners are cured. In the absence of microbiologic
test-of-cure, this means until therapy is completed and patient and
partner(s) are without symptoms.

Special Considerations -

Pregnancy -
     Doxycycline and ofloxacin are contraindicated for pregnant
women, and sulfisoxazole is contraindicated for women during
pregnancy near-term and for women who are nursing. The safety and
efficacy of azithromycin among pregnant and lactating women have
not been established. Repeat testing, preferably by culture, after
completing therapy with the following regimens is recommended
because there are few data regarding the effectiveness of these
regimens, and the frequent gastrointestinal side effects of
erythromycin may discourage a patient from complying with the
prescribed treatment.

Recommended Regimen for Pregnant Women -
     Erythromycin base 500 mg orally 4 times a day for 7 days.

Alternative Regimens for Pregnant Women -
     Erythromycin base 250 mg orally 4 times a day for 14 days
                            or
     Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7
     days
                            or
     Erythromycin ethylsuccinate 400 mg orally 4 times a day for 14
     days
                            or
     If erythromycin cannot be tolerated:
     Amoxicillin 500 mg orally 3 times a day for 7-10 days.

NOTE: Erythromycin estolate is contraindicated during
pregnancy because of drug-related hepatotoxicity. Few data exist
concerning the efficacy of amoxicillin.

HIV Infection -
     Persons with HIV infection and chlamydial infection should
receive the same treatment as patients without HIV infection.

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