Azithromycin no longer first choice treatment for chlamydia

Azithromycin pack photo
You can no longer buy azithromycin online for chlamydia infections from Dr Fox.

Guidelines about chlamydia treatment have recently (Sept 2018) been updated.

A 7-day course of doxycycline is now the recommended antibiotic for chlamydia infections.
Doxycyline for chlamydia

  • Have you recently tested positive for chlamydia?
  • Do you need help and advice regarding treatment?

If so, read on – we can help!

Chlamydia – the facts

Chlamydia trachomatis remains the most common bacterial Sexually Transmitted Infection (STI) in the UK.

Young people are particularly at risk from chlamydia complications. They have much to lose, especially because they often have no symptoms, hence they are often unaware they have the infection. They may have been infected for long periods of time before it is diagnosed. In addition, young people are likely to have not yet tried for a pregnancy, and their future fertility is extremely important.

The National Chlamydia Screening Programme aims to test all young people under the age of 25. The service is free and confidential. Click here to find out more about the programme and if it is available in your area.

Alternatively you can be tested at a Sexual Health Clinic, at your GP surgery, or you may prefer to purchase a chlamydia test online.

What if my chlamydia test is positive?

If you test positive to chlamydia, here’s the good news! Chlamydia can be successfully treated. This means that after proper treatment, the infection will have completely disappeared from your body.

However, it is extremely important you get treated without delay.

You need the right advice, the right medication, and the right support.

Why is chlamydia treatment so important?

If you are diagnosed with chlamydia, it is vitally important you get the right treatment promptly. You must take the medication correctly, and also make sure you follow specific advice about what to do, and what not to do, while taking the medication.

In the UK, doctors and other healthcare providers are advised to follow the evidence based treatment recommendations for chlamydia, published by The British Association of Sexual Health & HIV (BASHH). These recommendations were updated in September 2018, and are outlined in this article.

  • Treating chlamydia promptly and effectively, will reduce the risk of long complications.

Chlamydial infection, causes intense inflammation within certain body tissues – which become, red, swollen, and then scar tissue may develop. A range of unpleasant symptoms, can then develop, as well as certain medical conditions.

Long term complications of chlamydia in females

In women, a chlamydia test may be positive from a swab / urine test even though you have no symptoms. In 70% of women who test positive, chlamydia symptoms are absent. If left untreated, the infection may persist and then affect the pelvic organs – the uterus (womb), the Fallopian Tubes and ovaries.

  • An ectopic pregnancy is a pregnancy which implants outside of the uterus. Most often the pregnancy develops within the Fallopian Tube. This is dangerous because the developing pregnancy causes the tube to stretch as it grows, meaning the tube is at risk of rupture. If this does occur, this is a life threatening emergency.
  • Chlamydia can affect the liver in women – causing perihepatitis.

Long term complications of chlamydia in males

In men, chlamydia can be diagnosed from a urine test / swab, even if you have no symptoms. In 50% of men who test positive, chlamydia symptoms are absent. However if untreated, because chlamydia also causes inflammation in the male genital tract, this may result in the following.

  • Urethritis – pain within the penis and on passing urine, often with discharge
  • Epididymo-orchitis – painful, swollen testicles
  • Prostatitis – a painful, swollen, prostate gland
  • Chlamydial infection also affects male fertility. Semen is poorer quality, and as it is packed full of inflammatory cells, sperm are less ability to swim freely.

Long term complications of chlamydia in males and females

  • Chlamydia can affect the eye, and cause conjunctivitis. This is a major cause of blindness in under developed countries.
  • Chlamydia also affect the joints, causing a painful arthritis called Sexually Acquired Reactive Arthritis (SARA).
  • Reiter’s syndrome is a medical condition which is often precipitated by an episode of chlamydial infection. Patients develop a triad of symptoms: urethritis, uveitis, and arthritis.

If you are diagnosed with chlamydia, don’t ignore it – you must seek help without delay.


What are the new recommendations for treating chlamydia?

British Association for Sexual Health and HIV logo

Chlamydia is a bacterial infection and is treated with antibiotics. The advice about how best to treat chlamydia was updated in September 2018 by the British Association of Sexual Health & HIV (BASHH).

The updated advice is summarised as follows –

First choice chlamydia treatment

If however you are pregnant or breastfeeding, you are not permitted to take doxycycline.

Second choice chlamydia treatment

  • Azithromycin 1g, immediately, then 500mg each day, for 2 days.

Azithromycin 1g for chlamydia infection not available online – please visit your GP or local Sexual Health or GUM clinic, or telephone NHS 111.

Alternative chlamydia treatment options

The following are alternative possible options, if the first and second choice treatments are unsuitable:

  • Erythromycin 500mg, twice a day, for 10–14 days
  • Ofloxacin 200mg, twice a day, for 7 days

Why change advice about chlamydia treatment?

In the past, chlamydia was often treated with a single dose of the antibiotic azithromycin.

Azithromycin was felt to be a good first choice, because taking just the 1mg dose results in very good antibiotic levels in the blood stream for several days, without the need to take further tablets.

Azithromycin taken as a single dose, was also ideal, because it was easier for patients to take all their treatment at once. The alternative treatment option, was a 7-day course of doxcycline, but in fact, many people never finish a 7-day course of antibiotics.

In a clinic setting, the doctor/nurse would often watch you swallow the azithromycin tablets there and then, meaning this ensured the complete regime had been taken.

What’s changed?

Having reviewed the up-to-date medical evidence, The British Association of Sexual Health & HIV (BASHH) issued a statement in September 2018, with new advice about treating chlamydia.

In summary:

There is concern about treatment failures from azithromycin. Although it’s difficult to be certain, one reason for this is because the chlamydia bacteria are becoming resistant to the antibiotic effect of azithromycin.

There are also some additional, new factors to consider.

3%–15% of those diagnosed with chlamydia, will also be infected with another organism called Mycoplasma genitalium. This infection has been known about for some time, but it is only recently that a commercial test has become available.

New BASHH 2018 Guidelines, were recently issued about testing for M. Genitalium in the UK, but testing is not yet available in the majority of sexual health clinics.

To address this problem, it is important that any antibiotic used to treat chlamydia, is likely to also treat mycoplasma.

Mycoplasma is frequently resistant to azithromycin and other similar, related antibiotics.

It is not uncommon for women who have had chlamydia diagnosed from the cervix/vagina, to also have chlamydia in their rectumeven in the absence of having anal sex.

This could be due to finger spread, or simply be because after sex, infected sperm drips down the genital area towards the anus and rectum.

The single dose azithromycin regime has been shown to be ineffective at treating rectal chlamydia. This is important as if the infection is not properly treated, chlamydia may remain in the rectum, and act as a reservoir for further infections.

Doxycycline for 7 days, is however an effective treatment for rectal chlamydia. By using doxycycline as a first choice in anyone testing positive for chlamydia at any site, this has the additional benefit that it will cover a rectal chlamydia infection, if this is inadvertently present.

If you are known to have rectal chlamydia, you should take a 7-day course of doxycycline, and then also have a test of cure (repeat chlamydia test), no sooner than 3 weeks after finishing the antibiotics.

It is important to wait for 3 weeks after completing treatment before you are retested, as the test detects dead organisms, and you may still test positive in the immediate weeks after treatment. If tested too early, this may cause confusion if the tests is still positive, but is likely to be a false positive test.

It is not routine practice to test for chlamydia in the rectum. This is usually only done if there are rectal symptoms, high risk anal sex, or sexual assault.

Follow treatment advice – make sure chlamydia is properly treated

  1. Take the antibiotic treatment given to you, as directed, and without delay.
  2. Do not miss out doses.
  3. Finish the course.
  4. No sex on treatment – not even sex with a condom. This is because the condom does not give 100% protection from STI’s and it is still possible, until the full 7 days have elapsed, to transmit the infection, or become reinfected.
  5. Any current sexual partners should be treated as they are contacts. This applies to all sexual partners in the past 3 months.

However, the sexual partner may opt to be tested for chlamydia and wait for their results. If they do this, there should be no sexual activity while waiting to be tested, until their results are available, and then for the time period to complete treatment, if they test positive.

In many ways, including the fact no tests are 100% accurate, it is preferable for both of you to be treated, and the easiest option, is to take your antibiotics both at the same time. This is called epidemiological treatment, and is good medical practice.

If all the tablets were taken correctly and there has been no sex on treatment, there is no need to repeat the chlamydia test (test of cure).

However a test of cure should be performed if:

  • there is chlamydia in the rectum,
  • it chlamydia is treated in pregnancy,
  • it chlamydia is treated with erythromycin,
  • if you have symptoms when diagnosed with chlamydia, and these symptoms have not resolved, or
  • if any of the rules about taking treatment were not followed.

If a test of cure is taken, you should wait at least 3 weeks from completing treatment to do the test.

  1. All patients with a positive chlamydia test, and any contacts are recommended to have a full STI screen, including an HIV test.
  2. HIV positive patients who test positive to chlamydia are treated in the same way.
  3. Do continue taking your usual method of contraception – for example – there is no need to stop taking your pill while you are on treatment.
  4. Young people aged 25 and under are advised to have another chlamydia test in 3–6 months.
  5. If you are female, and test positive to chlamydia, and have symptoms suggestive of PID such as lower abdominal/pelvic pain, pain having sex, or bleeding during or after sex – the treatment regime is different. You must see a doctor for an assessment and they will give you further advice.

Taking doxycycline to treat chlamydia

Dose: Doxycycline, one 100mg capsule twice a day for 7 days.

Your doctor or other health professional will assess your suitability for doxycycline – or an alternative.

Taking doxycycline

  • Swallow the capsules whole – do not break, chew, or crush the capsules.
  • If you take it with food you are less likely to feel sick.
  • Stay upright while swallowing it – ie standing, or sitting – not lying down.
  • The most common side effects are headaches, and nausea.

Special precautions

Stay out of sunlight while taking the tablets as it’s possible to get skin rashes.

Do not take doxycycline if:

  • You are under 12 years old as it can stain your teeth.
  • You are pregnant.
  • You are allergic to it.
  • You have kidney or liver disease.
  • Or if you have
    • Oesophagitis
    • Lupus
    • Myasthenia gravis

Do not drink alcohol with doxcycline.

Chlamydia treatment

It is now possible to purchase a 7-day course of doxycycline from Dr Fox online. This is safe, quick and convenient. In the light of this new advice, Dr Fox has now discontinued selling azithromycin for chlamydia infection.

Any further advice?

You may feel very distressed after an STI diagnosis, and need psychological support. The Sexual Health Advisor at your local Sexual Health Clinic is there to help you.

The most important thing about being diagnosed with chlamydia – is to try not to get it again! Find out more about how to practice safer sex.

Always check that any new partner has been tested before you have any sexual contact. If this isn’t possible, at least use barrier contraceptiona condom (male and female condoms are available free of charge from sexual health clinics) – before each and every sexual encounter.

Do remember however that although condoms greatly reduce the risk of transmitting STI’s, they do not remove the risk completely, and even couples who always use condoms, can get STI’s. It’s very important to get tested for STI’s preferably before you have sex with any new partner.