WHO GUIDELINES FORTHE

Treat ment of
Chlamydia t rachomat is
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WHO guidelines for t he t reat ment of Chlamydia t rachomat is.

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framework - - Web annex E: Syst emat ic reviews - - Web annex F: Summary
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1.Chlamydia t rachomat is. 2.Chlamydia Infect ions - drug t herapy.
3.Sexually Transmit t ed Diseases. 4.Guideline. I.World Healt h Organizat ion.
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 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS i

CONTENTS

Acknowledgement s iii

Abbreviat ions and acronyms iv

Execut ive summary 1

Overview of t he guidelines for t he prevent ion, t reat ment and management of STIs 6
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Approach to t he revision of STI guidelines 8
References 9

WHO guidelines for t he t reat ment of Chlamydia t rachomat is 10

1. Int roduct ion 10

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Laboratory diagnosis 11
1.2 Rat ionale for new recommendat ions 11
1.3 Object ives 11
1.4 Target audience 11
1.5 St ructure of t he guidelines 11

2. Met hods 12
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2.2 Quest ions and outcomes 12
2.3 Reviews of t he evidence 12
2.4 Making recommendat ions 13
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3. Disseminat ion, updat ing and implement at ion of t he guidelines 15
3.1 Disseminat ion 15
3.2 Updat ing t he STI guidelines and user feedback 15
3.3 Implement at ion of t he WHO guidelines for t he t reat ment of C. t rachomat is 15
Adapt at ion, implement at ion and monitoring 15
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4. Recommendat ions for t reat ment of chlamydial infect ions 17
4.1 Uncomplicated genit al chlamydia 17
Recommendat ion 1 17
4.2 Anorect al chlamydial infect ion 18
Recommendat ion 2 18
4.3 Chlamydial infect ion in pregnant women 19
Recommendat ion 3a 19
Recommendat ion 3b 19
Recommendat ion 3c 19
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6 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

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Recommendat ion 7 21

References 22

Annex A: STI guideline development t eams 23

Annex B: Det ailed met hods for guideline development 32

Quest ions and outcomes 32
Review of t he evidence 35
Applying t he GRADE approach to making t he recommendat ions 38

Annex C: List s of references for reviewed evidence 39

Recommendat ion 1 39
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Recommendat ion 3a, 3b, 3c 41
Recommendat ion 4 42
Recommendat ion 5 43
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Web annexes available at :

www.who.int / reproduct ivehealt h/ publicat ions/ rt is/ chlamydia- t reat ment- guidelines/ en/

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Web annex E: Syst emat ic reviews for chlamydia guidelines
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 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
ACKNOWLEDGEMENTS
The Depart ment of Reproduct ive Healt h and Research
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t hank t he members of t he STI Guideline Development
Group for t heir consistent availabilit y and commit ment
to making t hese guidelines possible. The Depart ment
is also grateful to t he STI External Review Group for
peer reviewing t hese guidelines, and appreciates
t he cont ribut ion of t he WHO Steering Commit tee.
The names of t he members of each group are list ed
below, wit h full det ails provided in Annex A.
Special t hanks to Dr Nancy Sant esso, t he guideline
met hodologist who also led t he systemat ic review
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t he guideline development process. We also t hank
t he members of t he Systemat ic Review Team from
McMaster Universit y.
We appreciate t he overall support of t he WHO
Guideline Review Commit tee Secret ariat during t he
guideline development process, wit h grateful t hanks
to Dr Susan Norris.
We t hank Theresa Ryle for t he administ rat ive
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wit h t he guideline design and layout . This guideline
document was edited by Ms Jane Pat ten, of Green Ink,
United Kingdom.
Dr Teodora Wi led t he guideline development process
and Dr Nat halie Broutet co- led t he process under
t he supervision of Dr James Kiarie and leadership of
Dr Ian Askew. Lee Sharkey provided support during
t he guideline development process.
FUNDING
The preparat ion and print ing of t he guidelines were
funded exclusively by t he UNDP/ UNFPA/ UNICEF/
WHO/ World Bank Special Programme of Research,
Development and Research Training in Human
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was solicited or ut ilized.
CONTRIBUTORS TO WHO GUIDELINES FORTHE
TREATMENT OF CHLAMYDIA TRACHOMATIS
STI Guideline Development Group (GDG):
Chairpersons: Judit h Wasserheit , Holger Schnemann
and Pat ricia Garcia
iii
Members: <DZ 6D[ $GX 6DUNRGLH $QGUHZ $PDWR
Gail Bolan, John Changalucha, Xiang- Sheng Chen,
Harrel Chesson, Craig Cohen, Francisco Garcia,
Suzanne Garland, Sarah Hawkes, Mary Higgins,
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David Mabey, Angelica Espinosa Miranda, Nelly Mugo,
Saiqa Mullick, Francis Ndowa, Joel Palefsky,
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Richard Steen, Magnus Unemo, Bea Vuylsteke,
Anna Wald, Thomas Wong and Kimberly A. Workowski
STI GDG working group for chlamydia:
Andrew Amato, Harrell Chesson, Craig Cohen,
Pat ricia Garcia, Nicola Low, David Mabey, Angelica
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Stephenson, Magnus Unemo, Bea Vuylsteke and
Judit h Wasserheit
STI Ext ernal Review Group: Lait h Abu- Raddad,
Adele Benaken- Schwart z, Mircea Bet iu, Anupong
Chit warakorn, Anjana Das, Carolyn Deal,
Margaret Gale- Rowe, William M. Geisler, Amina
El Ket t ani, Mizan Kiros, Ahmed Lat if, Philippe
Mayaud, David McCart ney, Ali M. Mir, Nuriye Ort ayli,
Khant anouvieng Sayabount havong and
Aman Kumar Singh
WHO St eering Commit t ee:
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Khat t abi, Lali Khot enashvili, Ornella Lincet to Ying- Ru Lo,
Frank Lule and Razia Pendse
WHO headquart ers: Moazzam Ali, Avni Amin, Rachel
Baggaley, Venkat raman Chandra- Mouli, Jane Ferguson,
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Sami Got t lieb, Silvio Paolo Mariot t i, Frances McConville,
Lori Newman, Annet te Mwansa Nkowane, Anit a Sands,
Igor Toskin and Marco Vitoria
WHO STI Secret ariat : Ian Askew, Teodora Elvira Wi
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and Lee Sharkey
Syst emat ic Review Team: 1DQF\ 6DQWHVVR OHDG
Housne Begum, Janna- Lina Kert h, Gian Paolo Morgano,
Krist ie Poole, Nicole Schwab, Mat t hew Vent resca,
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Met hodologist : Nancy Sant esso.
8 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

ABBREVIATIONS AND ACRONYMS

AIDS DFTXLUHG LPPXQH GHFLHQF\ V\QGURPH

AMR ant imicrobial resist ance

DALY disabilit y- adjusted life year

DFA GLUHFW XRUHVFHQW DQWLERG\

DOI declarat ion of interest s

ELISA enzyme- linked immunosorbent assays

GDG Guideline Development Group

GRADE Grading of Recommendat ions Assessment , Development and Evaluat ion

GUD genit al ulcer disease

HIV KXPDQ LPPXQRGHFLHQF\ YLUXV

HPV human papillomavirus

HRP UNDP/ UNFPA/ UNICEF/ WHO/ World Bank Special Programme of Research,
Development and Research Training in Human Reproduct ion

+69 herpes simplex virus t ype 2

LGV lymphogranuloma venereum

MSH Management Sciences for Healt h

MSM men who have sex wit h men

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PICO populat ion, intervent ion, comparator, outcome

POCT point- of- care test

STI sexually t ransmit ted infect ion

UNAIDS Joint United Nat ions Programme on HIV/ AIDS

UNFPA Unit ed Nat ions Populat ion Fund

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WHO World Healt h Organizat ion

 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 1

WHO GUIDELINES FOR

THE TREATMENT OF
CHLAMYDIA TRACHOMATIS

EXECUTIVE SUMMARY

Sexually t ransmit ted infections (STIs) are a

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and mortalit y. STIs have a direct impact on
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also have an impact on national and individual
economies. More than a million STIs are acquired
every day. In 2012, an estimated 357 million new
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cases of chlamydial infection.
2 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
Chlamydial infect ion, caused by Chlamydia t rachomat is,
is t he most common bacterial STI and result s in
subst ant ial morbidit y and economic cost worldwide.
Occurring most commonly among young sexually act ive
adult s, C. t rachomatis causes cervicit is in women and
uret hrit is in men, as well as ext ra- genit al infect ions,
including rect al and oropharyngeal infect ions.
Asymptomat ic infect ions are common in bot h men
and women. Unt reated chlamydial infect ion may
cause severe complicat ions in t he upper reproduct ive
t ract , primarily in young women, including ectopic
pregnancy, salpingit is and infert ilit y. Lymphogranuloma
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of C. t rachomat is, is increasingly prevalent among
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Maternal infect ion is associat ed wit h serious adverse
outcomes in neonates, such as preterm birt h, low birt h
weight , conjunct ivit is, nasopharyngeal infect ion and
pneumonia. C. t rachomatis can be diagnosed by culture,
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superior performance characterist ics.
RATIONALE FORTHE GUIDELINES
Since t he publicat ion of t he World Healt h Organizat ion
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epidemiology of STIs and advancement s in prevent ion,
diagnosis and t reat ment necessit ate changes in
STI management . These guidelines provide updated
t reat ment recommendat ions for common infect ions
caused by C. t rachomatis based on t he most recent
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on t reat ment s for Neisseria gonorrhoeae JRQRUUKRHD
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and Treponema pallidum V\SKLOLV ,Q DGGLWLRQ IXWXUH
work will provide guidance for syphilis screening and
t reat ment of pregnant women, STI syndromic approach,
clinical management , STI prevent ion, and t reat ment s of
ot her STIs. It is st rongly recommended t hat count ries
t ake updated global guidance into account as t hey
est ablish st andardized nat ional protocols, adapt ing
t his guidance to t he local epidemiological sit uat ion
and ant imicrobial suscept ibilit y dat a.
OBJECTIVES
The object ives of t hese guidelines are:
to provide evidence- based guidance on t reat ment
of infect ion wit h C. t rachomat is DQG
to support count ries to update t heir nat ional
guidelines for t reat ment of chlamydial infect ion.
METHODS
These guidelines were developed following t he
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guideline development . The Guideline Development
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clinicians, researchers and programme managers.
The GDG priorit ized quest ions and outcomes related
to t reat ment of chlamydial infect ions to include
in t his update, and a met hodologist and a team of
systemat ic reviewers from McMaster Universit y, t he
WHO Collaborat ing Cent re for Evidence- Informed
Policy, independent ly conducted systemat ic reviews
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chlamydial infect ions. The evidence was assessed
using t he Grading of Recommendat ions Assessment ,
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managed according to WHO guidelines and declared
before t he recommendat ions were discussed and
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by t he GDG.
RECOMMENDATIONS
The current guidelines provide nine t reat ment
recommendat ions for genit al infect ions and LGV
caused by C. t rachomat is. The recommendat ions
summarized in Table 1 apply to adult s, adolescent s
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key populat ions, including sex workers, MSM and
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also been developed for genit al chlamydial infect ion in
pregnant women and for prophylaxis and t reat ment
of opht halmia neonatorum caused by C. t rachomat is.
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 3

Table 1. Summary of recommendat ions for t reat ment of chlamydial infect ions

Recommendat ions St rengt h of

recommendat ion and
qualit y of evidence
Uncomplicat ed genit al chlamydia
Recommendat ion 1 Conditional
recommendation,
The WHO STI guideline suggest s t reat ment wit h one of t he following opt ions:
moderate qualit y
azit hromycin 1 g orally as a single dose evidence
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or one of t hese alternat ives:
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HU\WKURP\FLQ PJ RUDOO\ four t imes a day for 7 days
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pat ient s should be t reated for chlamydial infect ion, t he choice of t reat ment may
depend on t he convenience of dosage, t he cost and qualit y of t he medicines in
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is placed on convenience, azit hromycin in a single dose may be t he best choice.
A delayed- release doxycycline formulat ion may be an alternat ive to t wice daily
dosing of doxycycline, but t he high cost of t he delayed- release formulat ion may
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Anorect al chlamydial infect ion
Recommendat ion 2 Conditional
recommendation,
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low qualit y evidence
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Remarks: This recommendat ion applies to people wit h known anorect al infect ion
and to people wit h suspected anorect al infect ions wit h genit al co- infect ion.
Clinicians should ask men, women and key populat ions (e.g. men who have sex
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t reat accordingly. Doxycycline should not be used in pregnant women because
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4 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

Genit al chlamydial infect ion in pregnant women

Recommendat ion 3a Strong recommendation,
The WHO STI guideline recommends t reat ment wit h azit hromycin over eryt hromycin. moderate qualit y
evidence
Recommendat ion 3b
The WHO STI guideline suggest s t reat ment wit h azit hromycin over amoxicillin. Conditional
recommendation,
low qualit y evidence
Recommendat ion 3c
The WHO STI guideline suggest s t reat ment wit h amoxicillin over eryt hromycin. Conditional
recommendation,
Dosages:
low qualit y evidence
azit hromycin 1 g orally as a single dose
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HU\WKURP\FLQ PJ RUDOO\ four t imes a day for 7 days.
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in some set t ings. Azit hromycin is less expensive t han eryt hromycin and since
it is provided as a single dose, may result in bet ter adherence and t herefore
bet ter outcomes.
Lymphogranuloma venereum (LGV)
Recommendat ion 4 Conditional
recommendation, very
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low qualit y evidence
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have sex wit h men and for people living wit h HIV. When doxycycline is cont raindicated,
azit hromycin should be provided. When neit her t reat ment is available, eryt hromycin
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Opht halmia neonat orum
Recommendat ion 5 Strong recommendation,
very low qualit y evidence
In neonates wit h chlamydial conjunct ivit is, t he WHO STI guideline recommends
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Remarks: This is a st rong recommendat ion given t he potent ial for t he risk of
pyloric stenosis wit h t he use of eryt hromycin in neonates. In some set t ings,
azit hromycin suspension is not available and t herefore eryt hromycin may be used.
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 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 5

Recommendat ion 6 Strong recommendation,

low qualit y evidence
For all neonates, t he WHO STI guideline recommends topical ocular prophylaxis
for t he prevent ion of gonococcal and chlamydial opht halmia neonatorum.

Recommendat ion 7 Conditional

recommendation, low
For ocular prophylaxis, t he WHO STI guideline suggest s one of t he following opt ions
qualit y evidence
for topical applicat ion to bot h eyes immediately after birt h:
tet racycline hydrochloride 1% eye oint ment
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povidone iodine 2.5% solut ion
silver nit rate 1% solut ion
chloramphenicol 1% eye oint ment .
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gonococcal opht halmia neonatorum. Cost and local resist ance to eryt hromycin,
tet racycline and chloramphenicol in gonococcal infect ion may determine t he choice
of medicat ion. Caut ion should be t aken to avoid touching eye t issue when applying
t he topical t reat ment and to provide a water- based solut ion of povidone iodine.
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6 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
OVERVIEW OF THE GUIDELINES FOR THE PREVENTION,
TREATMENT AND MANAGEMENT OF STIs
STI EPIDEMIOLOGY AND BURDEN
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of life and causing serious morbidit y and mort alit y.
STIs have a direct impact on reproduct ive and child
healt h t hrough infert ilit y, cancers and pregnancy
complicat ions, and t hey have an indirect impact t hrough
t heir role in facilit at ing sexual t ransmission of human
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an impact on nat ional and individual economies. The
prevent ion and cont rol of STIs is an integral component
of comprehensive sexual and reproduct ive healt h
services t hat are needed to at t ain t he related t arget s
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(Ensure healt hy lives and promote well- being for all at all
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to end t he epidemics of AIDS and ot her communicable
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from noncommunicable diseases and promote ment al
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DFFHVV WR VH[XDO DQG UHSURGXFWLYH KHDOWK FDUH VHUYLFHV
and t arget 3.8 to achieve universal healt h coverage.
Worldwide, more t han a million curable STIs are
DFTXLUHG HYHU\ GD\ ,Q WKHUH ZHUH DQ HVWLPDWHG
357 million new cases of curable STIs among adult s aged
1549 years worldwide: 131 million cases of chlamydia,
PLOOLRQ FDVHV RI JRQRUUKRHD PLOOLRQ FDVHV RI
syphilis and 142 million cases of t richomoniasis (1).
The prevalence of some viral STIs is similarly high, wit h
an est imated 417 million people infected wit h herpes
VLPSOH[ YLUXV W\SH +69 (2), and approximately 291
million women harbouring human papillomavirus
+39 DW DQ\ SRLQW LQ WLPH (3). The burden of STIs
varies by region and gender, and is greatest in
resource- poor count ries.
When left undiagnosed and unt reated, curable STIs
can result in serious complicat ions and sequelae,
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ectopic pregnancy, miscarriage, fet al loss and
FRQJHQLWDO LQIHFWLRQV ,Q DQ HVWLPDWHG
PDWHUQDO V\SKLOLV LQIHFWLRQV UHVXOWHG LQ DGYHUVH
pregnancy outcomes, including st illbirt hs, neonat al
deat hs, preterm birt hs and infected infant s (4).
Curable STIs accounted for t he loss of nearly 11 million
GLVDELOLW\ DGMXVWHG OLIH \HDUV '$/<V LQ (5).
The psychological consequences of STIs include
st igma, shame and loss of self- wort h. STIs have also
been associat ed wit h relat ionship disrupt ion and
gender- based violence (6).
Bot h ulcerat ive and non- ulcerat ive STIs are associat ed
wit h a several- fold increased risk of t ransmit t ing or
acquiring HIV (7, 8). Infect ions causing genit al ulcers
DUH DVVRFLDWHG ZLWK WKH KLJKHVW +,9 WUDQVPLVVLRQ ULVN
in addit ion to curable ulcer- causing STIs (e.g. syphilis
DQG FKDQFURLG KLJKO\ SUHYDOHQW +69 LQIHFWLRQV
subst ant ially increase t hat risk (9). Non- ulcerat ive
STIs, such as gonorrhoea, chlamydia and t richomoniasis,
have been shown to increase HIV t ransmission t hrough
genit al shedding of HIV (10). Treat ing STIs wit h t he
right medicines at t he right t ime is necessary to reduce
HIV t ransmission and improve sexual and reproduct ive
healt h (11) (RUWV VKRXOG WKHUHIRUH EH WDNHQ WR
st rengt hen STI diagnosis and t reat ment .
WHY NEW GUIDELINES FORTHE PREVENTION,
TREATMENT AND MANAGEMENT OF STIs?
Since t he publicat ion of t he World Healt h Organizat ion
:+2 *XLGHOLQHV IRU WKH PDQDJHPHQW RI VH[XDOO\
WUDQVPLWWHG LQIHFWLRQV LQ FKDQJHV LQ WKH
epidemiology of STIs and advancement s in prevent ion,
diagnosis and t reat ment necessit ate changes in STI
management . Indeed, 88% of count ries have updated
t heir nat ional STI guidelines or recommendat ions since
(12) 8SGDWHG JOREDO JXLGDQFH UHHFWLQJ WKH PRVW
recent evidence and expert opinion is t herefore needed
to assist count ries to incorporate new development s
LQWR DQ HHFWLYH QDWLRQDO DSSURDFK WR WKH SUHYHQWLRQ
and t reat ment of STIs.
There is an urgent need to update global t reat ment
UHFRPPHQGDWLRQV WR HHFWLYHO\ UHVSRQG WR WKH
FKDQJLQJ DQWLPLFURELDO UHVLVWDQFH $05 SDWWHUQV
of STIs, especially for Neisseria gonorrhoeae.
(HFWLYH WUHDWPHQW SURWRFROV WKDW WDNH LQWR DFFRXQW
global and local resist ance pat terns are essent ial to
reduce t he risk of furt her development of AMR.
High- level gonococcal resist ance to quinolones,
D SUHYLRXVO\ UHFRPPHQGHG UVW OLQH WUHDWPHQW
is widespread and decreased suscept ibilit y to t he
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DQRWKHU UVW OLQH WUHDWPHQW IRU JRQRUUKRHD LV RQ
t he rise (13). Low- level resist ance to Trichomonas
vaginalis has also been reported for nit roimidazoles,
t he only available t reat ment . Resist ance to azit hromycin
has been reported in some st rains of Treponema
pallidum and t reat ment failures have been reported
for tet racyclines and macrolides in t he t reat ment of
Chlamydia t rachomatis (14, 15).
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
A WHO STI expert consult at ion recommended
XSGDWLQJ WKH :+2 JXLGHOLQHV IRU WKH UVW DQG
second- line t reat ment s for C. t rachomat is, increasing
WKH GRVDJH RI FHIWULD[RQH WR PJ IRU WUHDWPHQW
of N. gonorrhoeae wit h cont inued monitoring of
ant imicrobial suscept ibilit y, and considerat ion of
ZKHWKHU D]LWKURP\FLQ J VLQJOH GRVH VKRXOG EH
recommended in early syphilis (16).
The epidemiology of STIs is changing, wit h viral
pat hogens becoming more prevalent t han bacterial
HWLRORJLHV IRU VRPH FRQGLWLRQV WKLV PHDQV WKDW XSGDWHG
informat ion is required to inform locally appropriate
prevent ion and t reat ment st rategies. An increasing
proport ion of genit al ulcers are now due to viral
infect ions as previously common bacterial infect ions,
such as chancroid, approach eliminat ion in many
count ries (16, 17). As recommended during t he STI
expert consult at ion, t reat ment guidelines for genit al
XOFHU GLVHDVH *8' VKRXOG EH XSGDWHG WR LQFOXGH +69
t reat ment and a longer t reat ment durat ion for HSV-2
should be explored. In addit ion, suppressive t herapy
for HSV-2 should be considered in areas wit h high HIV
prevalence (16). The chronic, lifelong nature of viral
infect ions also requires t hat renewed at tent ion be paid
WR GHYHORSLQJ HHFWLYH SUHYHQWLRQ VWUDWHJLHV LQFOXGLQJ
expanding accessibilit y to available vaccines for HPV
and development of new vaccines for HSV-2.
,Q WKH :+2 JXLGHOLQHV D V\QGURPLF DSSURDFK
was recommended for t he management of STIs.
The approach guides t he diagnosis of STIs based on
LGHQWLFDWLRQ RI FRQVLVWHQW JURXSV RI V\PSWRPV DQG
easily recognized signs and indicates t reat ment for
t he majorit y of organisms t hat may be responsible
for producing t he syndrome. The syndromic
management algorit hms need to be updated in
response to t he changing sit uat ion. In addit ion to
changes to t he GUD algorit hm, ot her syndromes
need to be re- evaluated, part icularly vaginal discharge.
The approach to syndromes for key populat ions
also needs to be updated. For example, addit ion of
a syndromic management algorit hm for anorect al
LQIHFWLRQV LQ PHQ ZKR KDYH VH[ ZLWK PHQ 060 DQG
sex workers is urgent ly needed since a subst ant ial
number of t hese infect ions go unrecognized and
unt reated in t he absence of guidelines (16).
7
1HZ UDSLG SRLQW RI FDUH GLDJQRVWLF WHVWV 32&7V DUH
changing STI management . Rapid syphilis diagnost ic
test s are now widely available, making syphilis screening
more widely accessible and allowing for earlier init iat ion
RI WUHDWPHQW IRU WKRVH ZKR WHVW SRVLWLYH (RUWV DUH
under way to develop POCTs for ot her STIs t hat will
augment syndromic management of symptomat ic
cases and increase t he abilit y to ident ify asymptomat ic
infect ions (12). Updated guidelines are needed t hat
incorporate rapid test s into syndromic management
of STIs and provide algorit hms for test ing and
screening (16).
Alt hough recent technological advances in diagnost ics,
WKHUDSHXWLFV YDFFLQHV DQG EDUULHU PHWKRGV RHU EHWWHU
opportunit ies for t he prevent ion and care of STIs, access
to t hese technologies is st ill limited, part icularly in areas
where t he burden of infect ion is highest . For opt imal
HHFWLYHQHVV JOREDO JXLGHOLQHV IRU WKH PDQDJHPHQW
of STIs need to include approaches for set t ings wit h
limited access to modern technologies, as well as for
set t ings in which t hese technologies are available.
It is st rongly recommended t hat count ries t ake
updated global guidance into account as t hey est ablish
st andardized nat ional protocols, adapt ing t his guidance
to t he local epidemiological sit uat ion and ant imicrobial
suscept ibilit y dat a. St andardizat ion ensures t hat all
pat ient s receive adequate t reat ment at every level
of healt h- care services, opt imizes t he t raining and
supervision of healt h- care providers and facilit ates
procurement of medicines. It is recommended t hat
QDWLRQDO JXLGHOLQHV IRU WKH HHFWLYH PDQDJHPHQW RI
STIs be developed in close consult at ion wit h local STI,
public healt h and laboratory expert s.
8 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

APPROACH TO THE REVISION OF

STI GUIDELINES
7R HQVXUH HHFWLYH WUHDWPHQW IRU DOO 67,V :+2 SODQV
a phased approach to updat ing t he STI guidelines to
address a range of infect ions and issues. Four phases
have been proposed by t he WHO STI Secret ariat and
agreed upon by t he STI Guideline Development Group
*'* PHPEHUV VHH $QQH[ $ IRU PHPEHUV RI WKHVH
JURXSV 7DEOH VXPPDUL]HV WKH SURSRVHG SKDVHV
and t imeline.

Table 2: Phases for development of t he STI guidelines

Phases Topics Timeframe

Phase 1 7UHDWPHQW RI VSHFLF 67,V Chlamydia t rachomatis 1RYHPEHU $SULO
FKODP\GLD Neisseria gonorrhoeae JRQRUUKRHD +69
JHQLWDO KHUSHV DQG Treponema pallidum V\SKLOLV
Syphilis screening and t reat ment of pregnant women

STI syndromic approach

0D\ 'HFHPEHU
Clinical management package
Phase 2 STI prevent ion: condoms, behaviour change
communicat ion, biomedical intervent ions and vaccines
Phase 3 7UHDWPHQW RI VSHFLF 67,V DQG UHSURGXFWLYH WUDFW
LQIHFWLRQV 57,V QRW DGGUHVVHG LQ 3KDVH 7ULFKRPRQDV
YDJLQDOLV WULFKRPRQLDVLV EDFWHULDO YDJLQRVLV &DQGLGD
DOELFDQV FDQGLGLDVLV +HPRSKLOXV GXFUH\L FKDQFURLG
.OHEVLHOOD JUDQXORPDWLV GRQRYDQRVLV KXPDQ
SDSLOORPDYLUXV +39 JHQLWDO ZDUWV FHUYLFDO FDQFHU
6DUFRSWHV VFDELHL VFDELHV DQG 3KWKLUXV SXELV SXELF OLFH
Phase 4 STI laboratory diagnosis and screening

Phase 1 will focus on t reat ment recommendat ions
IRU VSHFLF 67,V DV ZHOO DV RWKHU LPSRUWDQW DQG XUJHQW
STI issues. Recommendat ions for t he t reat ment of
VSHFLF LQIHFWLRQV ZLOO EH GHYHORSHG DQG SXEOLVKHG
as independent modules:
Chlamydia t rachomatis FKODP\GLD
Neisseria gonorrhoeae JRQRUUKRHD
+69 JHQLWDO KHUSHV
Treponema pallidum V\SKLOLV
Syphilis screening and t reat ment of pregnant women.
In addit ion, guidelines for t he STI syndromic approach
and a clinical management package will be developed
later in Phase 1. Phase 2 will focus on guidelines for STI
prevent ion. The independent Phase 1 and 2 modules
will later be consolidated into one document and
published as comprehensive WHO guidelines on STI
case management . Phase 3 will address t reat ment of
addit ional infect ions, including Trichomonas vaginalis
WULFKRPRQLDVLV EDFWHULDO YDJLQRVLV &DQGLGD DOELFDQV
FDQGLGLDVLV +HPRSKLOXV GXFUH\L FKDQFURLG .OHEVLHOOD
JUDQXORPDWLV GRQRYDQRVLV +39 JHQLWDO ZDUWV FHUYLFDO
FDQFHU 6DUFRSWHV VFDELHL VFDELHV DQG 3KWKLUXV SXELV
SXELF OLFH 3KDVH ZLOO SURYLGH JXLGDQFH RQ ODERUDWRU\
diagnosis and screening of STIs.
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 9

REFERENCES

1. Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N et al. Global est imat es of t he
SUHYDOHQFH DQG LQFLGHQFH RI IRXU FXUDEOH VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV LQ EDVHG RQ V\VWHPDWLF
UHYLHZ DQG JOREDO UHSRUWLQJ 3/R6 2QH H GRL MRXUQDO SRQH
2. Looker KJ, Magaret AS, Turner KME, Vickerman P, Got t lieb SL, Newman LM. Global est imat es of
SUHYDOHQW DQG LQFLGHQW KHUSHV VLPSOH[ YLUXV W\SH LQIHFWLRQV LQ 3/R6 2QH H
GRL MRXUQDO SRQH

'H 6DQMRV 6 'LD] 0 &DVWHOOVDJX ; &OLRUG * %UXQL / 0XR] 1 %RVFK ); :RUOGZLGH SUHYDOHQFH
and genot ype dist ribut ion of cervical human papillomavirus DNA in women wit h normal cyt ology:
D PHWD DQDO\VLV /DQFHW ,QIHFW 'LV

4. Wijesooriya NS, Rochat RW, Kamb ML, Turlapat i P, Brout et N, Newman L. Declines in mat ernal and
FRQJHQLWDO V\SKLOLV IURP WR SURJUHVV WRZDUGV HOLPLQDWLRQ RI PRWKHU WR FKLOG WUDQVPLVVLRQ
RI V\SKLOLV /DQFHW *OREDO +HDOWK LQ SUHVV

5. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C et al. Disabilit y- adjust ed life
\HDUV '$/<V IRU GLVHDVHV DQG LQMXULHV LQ UHJLRQV D V\VWHPDWLF DQDO\VLV IRU
WKH *OREDO %XUGHQ RI 'LVHDVH 6WXG\ /DQFHW GRL 6

*RWWOLHE 6/ /RZ 1 1HZPDQ /0 %RODQ * .DPE 0 %URXWHW 1 7RZDUG JOREDO SUHYHQWLRQ RI VH[XDOO\
WUDQVPLWWHG LQIHFWLRQV 67,V WKH QHHG IRU 67, YDFFLQHV 9DFFLQH GRL M
YDFFLQH

:DVVHUKHLW -1 (SLGHPLRORJLFDO V\QHUJ\ LQWHUUHODWLRQVKLSV EHWZHHQ KXPDQ LPPXQRGHFLHQF\ YLUXV

LQIHFWLRQV DQG RWKHU VH[XDOO\ WUDQVPLWWHG GLVHDVHV 6H[ 7UDQVP 'LV
8. Sext on J, Garnet t G, Rt t ingen J- A. Met aanalysis and met aregression in int erpret ing st udy variabilit y
in t he impact of sexually t ransmit t ed diseases on suscept ibilit y t o HIV infect ion. Sex Transm Dis.

9. \ Glynn JR, Biraro S, Weiss HA. Herpes simplex virus t ype 2: a key role in HIV incidence. AIDS.
GRL 4$' E H H H

-RKQVRQ /) /HZLV '$ 7KH HHFW RI JHQLWDO WUDFW LQIHFWLRQV RQ +,9 VKHGGLQJ LQ WKH JHQLWDO
WUDFW D V\VWHPDWLF UHYLHZ DQG PHWD DQDO\VLV 6H[ 7UDQVP 'LV GRL
2/4 E H G
11. Cohen MS. Classical sexually t ransmit t ed diseases drive t he spread of HIV-1: back t o t he fut ure.
- ,QIHFW 'LV GRL LQIGLV MLV
12. Progress report of t he implement at ion of t he global st rat egy for prevent ion and cont rol of sexually
WUDQVPLWWHG LQIHFWLRQV *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ KWWS DSSV ZKR LQW
LULV ELWVWUHDP BHQJ SGI DFFHVVHG 0D\

13. Ndowa FJ, Ison CA, Lust i- Narasimhan M. Gonococcal ant imicrobial resist ance: t he implicat ions for
SXEOLF KHDOWK FRQWURO 6H[ 7UDQVP ,QIHFW 6XSSO LY GRL VH[WUDQV

14. Got t lieb SL, Low N, Newman LM, Bolan G, Kamb M, Brout et N. Toward global prevent ion of sexually
WUDQVPLWWHG LQIHFWLRQV 67,V WKH QHHG IRU 67, YDFFLQHV 9DFFLQH GRL M
YDFFLQH

0DEH\ ' (SLGHPLRORJ\ RI VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV ZRUOGZLGH 0HGLFLQH

GRL M PSPHG

5HSRUW RI WKH H[SHUW FRQVXOWDWLRQ DQG UHYLHZ RI WKH ODWHVW HYLGHQFH WR XSGDWH JXLGHOLQHV IRU WKH
PDQDJHPHQW RI VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ :+2
5+5 KWWS DSSV ZKR LQW LULV ELWVWUHDP :+2B5+5B BHQJ SGI
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10 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
1.1 EPIDEMIOLOGY, BURDEN AND CLINICAL
CONSIDERATIONS
Chlamydial infect ion, caused by Chlamydia t rachomat is,
is t he most common bacterial sexually t ransmit ted
LQIHFWLRQ 67, DQG UHVXOWV LQ VXEVWDQWLDO PRUELGLW\
and economic cost worldwide. The World Healt h
2UJDQL]DWLRQ :+2 HVWLPDWHV WKDW LQ
million new cases of chlamydia occurred among adult s
and adolescent s aged 1549 years worldwide, wit h a
JOREDO LQFLGHQFH UDWH RI SHU IHPDOHV DQG
SHU PDOHV 7KH HVWLPDWHG PLOOLRQ SUHYDOHQW
cases of chlamydia result in an overall prevalence of
4.2% for females and 2.7% for males, wit h t he highest
prevalence in t he WHO Region of t he Americas and t he
:+2 :HVWHUQ 3DFLF 5HJLRQ (1). In many count ries, t he
incidence of chlamydia is highest among adolescent
girls aged 1519 years, followed by young women aged
\HDUV 7KH WKUHH ELRYDUV RI C. t rachomat is, each
consist ing of several serovars or genot ypes, cause
genit al infect ions, lymphogranuloma venereum (LGV:
D JHQLWDO XOFHU GLVHDVH >*8'@ WKDW DHFWV O\PSKRLG
WLVVXH DQG WUDFKRPD H\H LQIHFWLRQ
CLINICAL PRESENTATION
Genit al infect ions due to C. t rachomatis are
DV\PSWRPDWLF LQ DSSUR[LPDWHO\ RI ZRPHQ DQG
RI PHQ (2). Sympt oms of uncomplicated chlamydial
infect ion in women include abnormal vaginal discharge,
dysuria, and post- coit al and intermenst rual bleeding.
Common clinical signs on speculum examinat ion
include cervical friabilit y and discharge. Sympt omat ic
men usually present wit h uret hral discharge and
dysuria, somet imes accompanied by test icular pain.
If left unt reated, most genit al infect ions will resolve
spont aneously wit h no sequelae but t hey may result in
severe complicat ions, mainly in young women. Infect ion
can ascend to t he upper reproduct ive t ract and can
FDXVH SHOYLF LQDPPDWRU\ GLVHDVH HFWRSLF SUHJQDQF\
salpingit is and tubal factor infert ilit y in women (3) and
epididymit is in men (4). The risk of complicat ions may
increase wit h repeated infect ion.
Infect ions at non- genit al sit es are common. Rect al
infect ion may manifest as a rect al discharge, rect al
pain or blood in t he stools, but is asymptomat ic in
most cases. Oropharyngeal infect ions can manifest as
pharyngit is and mild sore t hroat , but symptoms are rare.
Chlamydial infect ion in pregnancy is associat ed wit h
preterm birt h and low birt h weight . Infant s of mot hers
wit h chlamydia can be infected at delivery, result ing in
neonat al conjunct ivit is and/ or nasopharyngeal infect ion
(3). Sympt oms of opht halmia include ocular discharge
and swollen eyelids. In newborns, nasopharyngeal
infect ion can lead to pneumonit is.
LGV, caused by a more invasive serovar of
C. t rachomat is DHFWV WKH VXEPXFRVDO FRQQHFWLYH
t issue and can spread to regional lymph nodes.
It commonly present s as a unilateral, tender
inguinal or femoral lymph node and a genit al ulcer
or papule (5). Anorect al exposure may result in
proct it is, rect al discharge, pain, const ipat ion or
tenesmus. Left unt reated, LGV can lead to rect al
VWXOD RU VWULFWXUH
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 11

LABORATORY DIAGNOSIS 1.4 TARGET AUDIENCE

There have been major development s in t he
diagnosis of C. t rachomatis LQ WKH ODVW \HDUV
Alt hough C. t rachomatis can be diagnosed by
FXOWXUH GLUHFW LPPXQRXRUHVFHQFH DVVD\V ')$V
and laboratory- based and point- of- care enzyme-
OLQNHG LPPXQRVRUEHQW DVVD\V (/,6$V QXFOHLF DFLG
DPSOLFDWLRQ WHVWV 1$$7V DUH VWURQJO\ UHFRPPHQGHG
due to t heir superior performance characterist ics.
1$$7V DUH KLJKO\ VHQVLWLYH DQG VSHFLF DQG FDQ EH
used for a wide range of samples, including urine and
vulvovaginal, cervical and uret hral swabs. Several
FRPPHUFLDO 1$$7V XVLQJ GLHUHQW WHFKQRORJLHV DUH
available. The increased sensit ivit y of NAATs compared
wit h ot her diagnost ic test s, such as culture and ant igen
GHWHFWLRQ PHWKRGV ')$ DQG (/,6$ DOORZV WHVWLQJ
of non- invasive specimens, which can be collected
convenient ly at t he primary level of care. Commercially
available NAATs are not yet licensed for t he diagnosis
of ext ra- genit al samples but have shown to be reliable
for detect ion of chlamydial infect ion in rect al and
pharyngeal swabs. Several commercially available test s
for chlamydia are combined wit h test s for gonorrhoea.
Furt her informat ion is available in t he WHO publicat ion
on laboratory diagnosis of STIs including HIV (6).
1.2 RATIONALE FORNEW RECOMMENDATIONS
The guidelines for t reat ment of chlamydial infect ions
need to be updated to respond to t he changes in
epidemiology and ant imicrobial suscept ibilit y for
chlamydia t hat have occurred since t he previous WHO
Guidelines for t he management of sexually t ransmit ted
LQIHFWLRQV ZHUH SXEOLVKHG LQ (7).LGV is increasingly
SUHYDOHQW DPRQJ PHQ ZKR KDYH VH[ ZLWK PHQ 060 LQ
some set t ings, and t reat ment failure has been reported
ZLWK WHWUDF\FOLQH DQG PDFUROLGHV LQ DSSUR[LPDWHO\
of cases (8) 0RUHRYHU WKH :+2 67, JXLGHOLQHV DUH
t he only internat ional guidelines t hat st ill recommend
t reat ing chlamydial infect ions wit h amoxicillin or
tet racycline. As recommended by t he WHO STI
H[SHUW FRQVXOWDWLRQ LQ WKH UVW DQG VHFRQG OLQH
t reat ment recommendat ions for C. t rachomatis needed
to be reviewed and revised based on t he most recent
available evidence.
These guidelines are primarily intended for healt h- care
SURYLGHUV DW DOO OHYHOV SULPDU\ VHFRQGDU\ DQG WHUWLDU\
of t he healt h- care system involved in t he t reat ment
and management of people wit h STIs in low-, middle-
and high- income count ries. They are also intended for
individuals working in sexual and reproduct ive healt h
programmes, such as HIV/ AIDS, family planning,
maternal and child healt h and adolescent healt h, to
ensure appropriate STI diagnosis and management .
The guidelines are also useful for policy- makers,
PDQDJHUV SURJUDPPH RFHUV DQG RWKHU SURIHVVLRQDOV
in t he healt h sector who are responsible for
implement ing STI management intervent ions
at regional, nat ional and subnat ional levels.
1.5 STRUCTURE OF THE GUIDELINES
These guidelines provide evidence- based
UHFRPPHQGDWLRQV IRU WKH WUHDWPHQW RI VSHFLF
clinical condit ions caused by C. t rachomat is.
These guidelines provide direct ion for count ries as
WKH\ GHYHORS QDWLRQDO WUHDWPHQW UHFRPPHQGDWLRQV
however, nat ional guidelines should also t ake into
account t he local pat tern of AMR, as well as healt h
service capacit y and resources.
Updated t reat ment recommendat ions based on
t he most recent evidence are included for t he
most import ant common condit ions caused by
C. t rachomat is. Recommendat ions were not updated
for rare condit ions and ot her condit ions for which
no new informat ion has become available since t he
:+2 67, JXLGHOLQHV ZHUH LVVXHG
Treat ment recommendat ions for t he following
condit ions caused by C. t rachomatis are included
in t hese guidelines:
uncomplicated genit al infect ions
anorect al infect ions
uncomplicated genit al infect ions in pregnant women
LGV
RSKWKDOPLD QHRQDWRUXP WUHDWPHQW DQG SURSK\OD[LV

1.3 OBJECTIVES
The object ives of t hese guidelines are:
to provide evidence- based guidance on t reat ment
of infect ion wit h C. t rachomat is DQG
to support count ries to update t heir nat ional
guidelines for t reat ment of chlamydial infect ion.
12 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
7KHVH JXLGHOLQHV ZHUH GHYHORSHG IROORZLQJ WKH
methods outlined in the 2014 edition of the
:+2 KDQGERRN IRU JXLGHOLQH GHYHORSPHQW (9)
(see Annex B for a det ailed descript ion).
2.1 GUIDELINE DEVELOPMENT GROUP (GDG)
To update t he WHO guidelines for t he prevent ion,
t reat ment and management of STIs, a GDG was
est ablished, comprising 33 internat ional STI expert s,
including clinicians, researchers and programme
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t he guidelines related to chlamydia was created
wit hin t he GDG, to provide more intensive feedback
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part icipated in meet ings and teleconferences to
priorit ize t he quest ions to be addressed, discuss t he
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of t he guidelines.
1 For more informat ion, see: ht t p:// www.gradeworkinggroup.org/
2.2 QUESTIONS AND OUTCOMES
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to ident ify and agree on t he key PICO (populat ion,
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formed t he basis for t he systemat ic reviews and t he
recommendat ions. Following t his meet ing, a survey
of GDG members was conducted to priorit ize t he
quest ions and outcomes according to clinical relevance
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t he update on t he t reat ment of genit al and anorect al
chlamydial infect ions, t reat ment of LGV, and prevent ion
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These quest ions pert ained to adult s and ot her special
populat ions, namely adolescent s, pregnant women,
people living wit h HIV, and populat ions at high risk
of acquiring and t ransmit t ing STIs, such as men
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Only outcomes t hat were ranked as crit ical or import ant
to pat ient s and decision- making were included: clinical
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2.3 REVIEWS OF THE EVIDENCE
The systemat ic reviews for each priorit y quest ion
were conducted by McMaster Universit y, t he WHO
Collaborat ing Cent re for Evidence- Informed Policy.
Evidence for desirable and undesirable outcomes,
pat ient values and preferences, resources, accept abilit y,
equit y and feasibilit y were reviewed from published and
unpublished lit erature. Comprehensive searches for
previously conducted systemat ic reviews, randomized
cont rolled t rials and non- randomized studies were
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searches were conducted to ident ify studies on pat ient
values and preferences (e.g. qualit at ive research
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screened studies, ext racted and analysed t he dat a,
and assessed t he qualit y/ cert aint y of t he evidence
using t he Grading of Recommendat ions Assessment ,
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 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 13

The qualit y/ cert aint y of t he evidence was assessed
at four levels:
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In addit ion, t he direct cost s of medicines were est imated
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Internat ional drug price indicator guide (10). References
for all t he reviewed evidence are list ed in Annex C.
All evidence was summarized in GRADEevidence
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of t he recommendat ions. Following t he meet ing, t he
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elect ronically. These guidelines were subsequent ly
writ ten up in full and t hen peer reviewed. The External
Review Group approved t he met hods and agreed wit h
t he recommendat ions made by t he GDG (members
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According to t he GRADEapproach, t he st rengt h
of each recommendat ion was rated as eit her
st rong or condit ional. St rong recommendat ions are
presented using t he wording The WHO STI guideline
recommends, while condit ional recommendat ions
are worded as The WHO STI guideline suggest s
t hroughout t he guidelines. The implicat ions of t he
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clinicians and policy- makers are explained in det ail
in Table 3.

2.4 MAKING RECOMMENDATIONS

Recommendat ions were developed during a second
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facilit ated by t wo co- chairs, one wit h expert ise in
GRADEand t he ot her wit h clinical STI expert ise.
The met hodologist presented t he GRADEevidence
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meet ing. When formulat ing t he recommendat ions,
t he GDG considered and discussed t he desirable and
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placed on t he outcomes, t he associat ed cost s and use
of resources, t he accept abilit y of t he intervent ions to
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t he impact on healt h equit y and t he feasibilit y of
implement at ion. Treat ment s were judged according
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recommendat ions were agreed. The discussion was
facilit ated by t he co- chairs wit h t he goal of reaching
consensus across t he GDG. Disagreement s among t he
GDG members were noted in t he evidence- to- decision
framework for each judgement . In t he case of failure to
reach consensus for a recommendat ion, t he planned
procedure was for t he GDG to t ake a vote and record
t he result s. However, no votes were t aken because
t he GDG reached consensus during discussion for all
14 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

Table 3. Implicat ions of st rong and condit ional recommendat ions using t he GRADEapproach

Implicat ions St rong recommendat ion Condit ional recommendat ion

The WHO STI guideline recommends
For pat ient s Most individuals in t his sit uat ion would want t
he recommended course of act ion, and only
a small proport ion would not .
Formal decision aids are not likely to be needed
to help individuals make decisions consistent
wit h t heir values and preferences.
For clinicians Most individuals should receive t he
recommended course of act ion.
Adherence to t his recommendat ion according
to t he guidelines could be used as a qualit y
criterion or performance indicator.
For policy- The recommendat ion can be adopted as policy
makers in most sit uat ions.
The WHO STI guideline suggest s
The majorit y of individuals in t his sit uat ion
would want t he suggested course of act ion,
but many would not .
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choices will be appropriate for each individual
and t hat clinicians must help each individual
arrive at a management decision consistent
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Decision aids may be useful to help individuals
make decisions consistent wit h t heir values
and preferences.
Policy- making will require subst ant ial debate
and involvement of various st akeholders.

2.5 MANAGEMENT OF CONFLICTS OF INTEREST

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t hroughout t he process of guideline development . WHO
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expert s were implemented (11). DOI st atement s were
obt ained from all GDG members prior to assuming t heir
roles in t he group. At t he GDG meet ings (December
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t heir interest s, if any, at t he beginning of t he meet ing.
Their DOI st atement s are summarized in Web annex F.
After analysing each DOI, t he STI team concluded
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commercial grant s or interest s. The STI team concluded
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would exclude any member from part icipat ing fully in t he
guideline development process. Therefore, opt ions for
condit ional part icipat ion, part ial or tot al exclusion of
any GDG member were not discussed.
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
DISS
UP
IMPLE
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3.1 DISSEMINATION
These guidelines will be made available as a printed
publicat ion, as a download on t he website of t he
WHO Depart ment of Reproduct ive Healt h and
Research (where t here will also be links to all support ing
GRFXPHQWDWLRQ 2, and in t he WHO Reproduct ive
+HDOWK /LEUDU\ 5+/ 3. The recommendat ions will also
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wit h t he GRADEpro GDT soft ware. The guidelines
will be announced in t he next edit ion of t he RHL
newslet ter and in t he Reproduct ive Healt h and
Research depart ment al newslet ter, and ot her
relevant organizat ions will be requested to copy
t he announcement in t heir respect ive newslet ters.
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RFHV DQG FRXQWU\ RFHV WR HQVXUH WKDW FRXQWULHV
receive support in t he adapt at ion, implement at ion
and monitoring of t hese guidelines using t he WHO
Depart ment of Reproduct ive Healt h and Research
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guidelines and tools into nat ional programmes (12).
2 These guidelines and all support ing document s will be available at :
www.who.int / reproduct ivehealt h/ publicat ions/ rt is/ chlamydia- t reat ment- guidelines/ en/
3 RHL is available at : ht t p:// apps.who.int / rhl/ en/
15
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part ners including t he United Nat ions Populat ion
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81,&() WKH -RLQW 8QLWHG 3URJUDPPH RQ +,9 $,'6
81$,'6 QRQJRYHUQPHQWDO RUJDQL]DWLRQV 1*2V DQG
ot her agencies implement ing sexual and reproduct ive
healt h and STI services to ensure t hat t he new
recommendat ions are integrated and implemented in
sexual and reproduct ive healt h, family planning, and
maternal, neonat al, child and adolescent healt h services.
Reference to t his document will be made wit hin ot her
relevant WHO guidelines. These guidelines will also be
disseminated at major conferences related to STIs and
HIV and t he aforement ioned programme areas.
3.2 UPDATING THE GUIDELINES AND USER
FEEDBACK
A system of monitoring relevant new evidence and
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become available will be est ablished wit hin a year
of implement ing t he guidelines. An elect ronic
follow- up survey of key end- users of t he STI guidelines
will be conducted after t he release of t he guidelines.
The result s of t he survey will be used to ident ify
challenges and barriers to t he upt ake of t he guidelines,
to evaluat e t heir usefulness for improving service
delivery, and to ident ify topics or gaps in t reat ment
t hat need to be addressed in future edit ions.
3.3 IMPLEMENTATION OF THEWHO
GUIDELINES FORTHE TREATMENT OF
C. TRACHOMATIS
ADAPTATION, IMPLEMENTATION AND MONITORING
These guidelines provide recommendat ions for
t reat ment of chlamydial infect ion based on t he best
global evidence available at t he t ime of compilat ion.
However, t he epidemiology and AMRof STIs vary by
geographical locat ion and are const ant ly changing,
somet imes rapidly. It is recommended t hat count ries
conduct good qualit y studies to gat her t he informat ion
needed to adapt t hese guidelines to t he local STI
sit uat ion as t hey update t heir nat ional guidelines.
In areas lacking local dat a as a basis for adapt at ion,
t he recommendat ions in t hese guidelines can be
adopted as presented.
16 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

For furt her guidance on adapt at ion, implement at ion
and monitoring of nat ional guidelines please refer to
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and tools into nat ional programmes: principles and
processes of adapt at ion and implement at ion (12).
In adapt ing t he guidelines for nat ional use,
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of at least 95%. The criteria to be considered for
t he select ion of medicines are list ed in Box 1.
Recommended medicines should meet as many of t he
criteria as possible, t aking into account local availabilit y,
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BOX 1. CRITERIA FORTHE SELECTION OF
MEDICINES FORTHE TREATMENT OF STIS
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Low cost
Low toxicit y levels
Organism resist ance unlikely to develop
or likely to be delayed
Single dose
Oral administ rat ion
Not cont raindicated for pregnant or
lact at ing women
Appropriate medicines should be included in t he
nat ional essent ial medicines list s. When select ing
medicines, considerat ion should be given to t he
competencies and experience of healt h- care
providers.
In order to est imate t he quant it y of medicines needed,
it will be necessary to review t he medicines t hat are
recommended for t reat ment , t heir unit prices, t he
quant it y required per t reat ment and t he epidemiological
informat ion on t he prevalence of infect ion. One can
est imate medicine needs by mult iplying t he est imated
number of cases by t he tot al quant it y of medicine
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can be derived from healt h cent res providing care but
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Budget ing for medicines is crit ical. If t he nat ional
minist ry of healt h does not provide medicines for free
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t hen t here will essent ially be no possibilit y of
curt ailing t he spread of infect ion and t he occurrence
of complicat ions. At t he nat ional level it is import ant
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underst and t he need to subsidize STI medicines.
Low- cost STI medicines can be obt ained t hrough
internat ional vendors of generic product s, non-
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as UNICEF, UNFPA and UNHCR, and t hrough joint
medicine procurement schemes. By way of such
schemes, nat ional programmes can join ot her nat ional
programmes to joint ly procure medicines, t hus reducing
t he overall cost s by sharing t he overhead cost s and
t aking advant age of discount s for purchasing in bulk.
Placing STI medicines on nat ional list s of essent ial
medicines increases t he likelihood of achieving a
supply of t hese medicines at low cost .

IDENTIFYING AND PROCURING STI DRUGS

It is import ant not only to ident ify medicines t hat will
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also t he est imated quant it ies of t he medicines t hat
will be required. Quant ifying medicat ion needs is
import ant in order to est imate cost s, to reconcile
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make orders in advance so t hat t he unit and freight
cost s can be minimized.
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
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developed for opht halmia neonatorum
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4.1 UNCOMPLICATED GENITAL CHLAMYDIA
RECOMMENDATION 1
For people wit h uncomplicated genit al chlamydia,
t he WHO STI guideline suggest s one of t he
following opt ions:
azit hromycin 1 g orally as a single oral dose
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or one of t hese alternat ives:
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Condit ional recommendation, moderate qualit y evidence
17
Remarks: While good pract ice based on evidence
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t reated for chlamydial infect ion, t he choice of t reat ment
may depend on t he convenience of dosage, t he cost and
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considerat ions. When high value is placed on reducing
cost s, doxycycline in a st andard dose may be t he best
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azit hromycin in a single dose may be t he best choice.
A delayed- release formulat ion of doxycycline may be
an alternat ive to t wice daily dosing of doxycycline, but
t he high cost of t he delayed- release formulat ion may
prohibit it s use. Note t hat doxycycline, tet racycline
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Research implicat ions: The pot ent ial for resist ance
to azit hromycin, doxycycline and ot her t reat ment
opt ions should be invest igated. Fut ure research could
compare t hese t reat ment s and recommended dosages
in randomized cont rolled t rials measuring import ant
outcomes such as clinical cure, microbiological cure,
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t ransmission and acquisit ion, and part ner t ransmission
of chlamydia. Studies are also needed t hat evaluat e
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SUMMARY OF THEEVIDENCE
Evidence from a Cochrane systemat ic review was used.
This review included 25 randomized studies comparing
tet racycline, quinolones and macrolides. There are no
dat a available for amoxicillin. Overall, t here is moderate
to low qualit y evidence for most comparisons of
t reat ment s. Moderate qualit y evidence shows t rivial
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of people microbiologically cured and experiencing
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cured wit h azit hromycin versus doxycycline, ranging
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azit hromycin versus doxycycline, ranging from 42 fewer
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are shown in a recent ly published randomized study.
Delayed- release doxycycline hyclate probably leads
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microbiologically cured but probably has fewer side-
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result in fewer cures but also slight ly fewer adverse
event s compared to doxycycline. When comparing
mult iple high doses of azit hromycin (1 g weekly for 3
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18 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
t here are no dat a for adverse event s related to
very high doses. Higher doses of any tet racycline
compared wit h lower doses may lead to more cures
but will probably also lead to more adverse event s.
Tet racyclines compared wit h quinolones may lead
to fewer cures but also slight ly fewer adverse event s.
Eryt hromycin compared wit h quinolones may lead
to fewer cures and more adverse event s.
There is no evidence relat ing to pat ient values and
preferences but t he Guideline Development Group
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t he values people place on t he outcomes. Research
related to ot her condit ions indicates t hat adherence
may be improved wit h simpler medicat ion regimens.
The GDG t herefore agreed t hat azit hromycin may be
more accept able to pat ient s since it is a single dose
regimen (a majorit y of t he GDG members considered
single- dose regimens to be preferable for pat ient
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lit t le to no evidence for equit y issues and feasibilit y.
Resist ance in ot her infect ions (e.g. gonorrhoea and
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chlamydia may rest rict t he use of some medicines,
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azit hromycin and doxycycline may be large due to
greater numbers of people requiring t reat ment .
In summary, t here was moderate qualit y evidence
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azit hromycin and doxycycline, and alt hough t he cost
of azit hromycin is higher, t he single dose may make
it more convenient to use t han doxycycline. While t he
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t he evidence is low qualit y and t hese are t herefore
provided as alternat ives, wit h t he except ion of delayed-
release doxycycline, which is current ly expensive.
See Annex C for list of references of reviewed evidence,
and Web annex D for det ails of t he evidence reviewed,
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4.2 ANORECTAL CHLAMYDIAL INFECTION
RECOMMENDATION 2
In people wit h anorect al chlamydial infect ion, t he
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orally t wice daily for 7 days over azit hromycin 1 g orally
single dose.
Condit ional recommendation, low qualit y evidence
Remarks: This recommendat ion applies to people
wit h known anorect al infect ion and to people wit h
suspected anorect al infect ions wit h genit al co-
infect ion. Clinicians should ask men, women and key
populat ions (e.g. men who have sex wit h men [MSM],
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anal sex and t reat accordingly. Doxycycline should
not be used in pregnant women because of adverse
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Research implicat ions: The global incidence of
chlamydial anorect al infect ions should be determined.
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used for anorect al infect ions, part icularly azit hromycin,
which is current ly not on t he WHO essent ial medicines
list for anorect al chlamydial infect ions (13) (HFWV
should be assessed in bot h men and women, and in
key populat ions (e.g. MSM, t ransgender persons and
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SUMMARY OF THEEVIDENCE
There is low qualit y evidence from eight non-
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no dat a for amoxicillin, eryt hromycin and quinolones.
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t here are fewer women t han men in t he studies, t he
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men and women. There is no evidence relat ing to pat ient
values and preferences, but t he GDG agreed t hat
t here are no known reasons to suspect values would
YDU\ IRU GLHUHQW SHRSOH 7KHUH LV OLWWOH WR QR HYLGHQFH
for accept abilit y, but research in ot her condit ions
indicates t hat adherence may be improved wit h simpler
medicat ion regimens. There is also lit t le to no evidence
for equit y issues and feasibilit y, but azit hromycin is
more expensive and t ypically t he cost is t ransferred
to consumers. The GDG agreed t hat equit y may vary
bet ween t he medicines depending on t he populat ion:
in some populat ions, azit hromycin may be more
accept able since it is a single- dose t reat ment ,
and some people may experience st igma related to
visibilit y of a mult i- dose regimen wit h doxycycline.
Therefore, suggest ing doxycycline over azit hromycin
could create inequit y for people sensit ive to st igma
related to mult i- dose regimens. Azit hromycin is
current ly not list ed as an essent ial medicine for
anorect al chlamydial infect ion.
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
In summary, doxycycline may result in more cures,
but alt hough it is less expensive t han azit hromycin,
azit hromycin may be bet ter accepted due to t he
single- dose t reat ment .
See Annex C for list of references of reviewed evidence,
and Web annex D for det ails of t he evidence reviewed,
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IUDPHZRUNV SS
4.3 CHLAMYDIAL INFECTION IN PREGNANT
WOMEN
RECOMMENDATION 3A
In pregnant women wit h genit al chlamydial infect ion,
t he WHO STI guideline recommends using azit hromycin
over eryt hromycin.
Strong recommendation, moderate qualit y evidence
RECOMMENDATION 3B
In pregnant women wit h genit al chlamydial infect ion,
t he WHO STI guideline suggest s using azit hromycin
over amoxicillin.
Condit ional recommendation, low qualit y evidence
RECOMMENDATION 3C
In pregnant women wit h genit al chlamydial infect ion,
t he WHO STI guideline suggest s using amoxicillin
over eryt hromycin.
Condit ional recommendation, low qualit y evidence
Dosages:
azit hromycin 1 g orally as a single dose
DPR[LFLOOLQ PJ RUDOO\ WKUHH WLPHV D GD\ IRU GD\V
HU\WKURP\FLQ PJ RUDOO\ IRXU WLPHV D GD\ IRU
days.
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t reat ment but may not be available in some set t ings.
Azit hromycin is less expensive t han eryt hromycin
and since it is provided as a single dose, may result in
bet ter adherence and t herefore bet ter outcomes.
Research implicat ions: Research in pregnant women
comparing t hese t reat ment s and t he recommended
dosages should be conducted. Alt hough t hese
medicines are relat ively safe in pregnancy, maternal and
fet al complicat ions (e.g. adverse pregnancy outcomes,
IHWDO GHIHFWV ZLWK WKH XVH RI WKHVH WUHDWPHQWV IRU 67,V
and ot her infect ions should be monitored, collected
and analysed to inform updated recommendat ions in
t he future. When conduct ing t hese studies, cost s and
accept abilit y of t he t reat ment s could be measured.
19
SUMMARY OF THE EVIDENCE
Overall, t here is moderate to low qualit y evidence from
14 randomized cont rolled t rials, t wo non- randomized
comparat ive studies and t wo large cohort studies
DVVHVVLQJ WKH HHFWV RI D]LWKURP\FLQ HU\WKURP\FLQ
and amoxicillin in pregnant women wit h chlamydial
LQIHFWLRQV 7KH GLHUHQFHV LQ EHQHWV EHWZHHQ WKHVH
GLHUHQW WUHDWPHQWV DUH VPDOO DQG ZLGH FRQGHQFH
intervals included t he possibilit y of greater or lesser
EHQHWV ZLWK D]LWKURP\FLQ FRPSDUHG WR RWKHU
medicines. Moderate qualit y evidence found t hat
t here are probably 94 more people microbiologically
FXUHG SHU ZLWK D]LWKURP\FLQ YHUVXV HU\WKURP\FLQ
55 &, WR DQG ORZ TXDOLW\
evidence found t hat t here may be 72 more people
FXUHG SHU ZLWK D]LWKURP\FLQ YHUVXV DPR[LFLOOLQ
55 &, WR 7KHUH DUH SUREDEO\
IHZHU SHRSOH PLFURELRORJLFDOO\ FXUHG SHU ZLWK
HU\WKURP\FLQ YHUVXV DPR[LFLOOLQ 55 &,
WR 7KHUH PD\ EH VOLJKWO\ IHZHU VLGH HHFWV ZLWK
azit hromycin compared wit h eryt hromycin or amoxicillin
DSSUR[LPDWHO\ IHZHU EXW WKHUH PD\ EH
VXEVWDQWLDOO\ PRUH VLGH HHFWV ZLWK HU\WKURP\FLQ
YHUVXV DPR[LFLOOLQ DSSUR[LPDWHO\ PRUH
Much of t he evidence was uncert ain for fet al
outcomes as it came from indirect comparisons in
large cohort studies. There were few event s, and
FRQGHQFH LQWHUYDOV DURXQG WKH VPDOO GLHUHQFHV
included t he potent ial for fewer or more event s
bet ween comparisons.
In summary, t he GDG agreed t hat azit hromycin is
preferred over eryt hromycin because of greater
HHFWLYHQHVV DQG ORZHU FRVW DQG SUHIHUUHG RYHU
DPR[LFLOOLQ GXH WR JUHDWHU HHFWLYHQHVV $]LWKURP\FLQ
PD\ DOVR EH PRUH DFFHSWDEOH GXH WR VLQJOH GRVDJH
however, it may not be available in all set t ings due to
misconcept ions t hat it is cost ly. Amoxicillin is preferred
over eryt hromycin as it is less cost ly and may result in
JUHDWHU EHQHWV DQG IHZHU VLGH HHFWV
See Annex C for list of references of reviewed evidence,
and Web annex D for det ails of t he evidence reviewed,
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IUDPHZRUNV SS
20 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
4.4 LYMPHOGRANULOMA VENEREUM (LGV)
RECOMMENDATION 4
In adult s and adolescent s wit h LGV, t he WHO STI
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t wice daily for 21 days over azit hromycin 1 g orally,
weekly for 3 weeks.
Condit ional recommendation, very low qualit y evidence
Remarks: Good pract ice dict ates t reat ment of LGV,
LQ SDUWLFXODU IRU PHQ ZKR KDYH VH[ ZLWK PHQ 060
and for people living wit h HIV. When doxycycline is
cont raindicated, azit hromycin should be provided.
When neit her t reat ment is available, eryt hromycin
PJ RUDOO\ IRXU WLPHV D GD\ IRU GD\V LV DQ
alternat ive. Doxycycline should not be used in
SUHJQDQW ZRPHQ EHFDXVH RI DGYHUVH HHFWV
VHH UHFRPPHQGDWLRQV D F
Research implicat ions: Addit ional research for each
of t he t reat ment s and t he dosages recommended is
needed, in part icular for eryt hromycin and azit hromycin.
Randomized cont rolled t rials should be conducted,
measuring crit ical and import ant outcomes, such
as clinical cure, microbiological cure, complicat ions,
VLGH HHFWV LQFOXGLQJ DOOHUJ\ WR[LFLW\ JDVWURLQWHVWLQDO
HHFWV TXDOLW\ RI OLIH +,9 WUDQVPLVVLRQ DQG DFTXLVLWLRQ
compliance and LGV t ransmission to part ners.
7KH HHFWV RI VKRUWHU FRXUVHV RI WUHDWPHQW VKRXOG
also be invest igated.
SUMMARY OF THEEVIDENCE
There is very low qualit y evidence from 12 non-
randomized studies wit h no comparisons bet ween
t reat ment s. These studies assessed t reat ment
wit h azit hromycin and doxycycline for 21 days, and
eryt hromycin for 14 days. Evidence for doxycycline
VKRZHG WKDW WKHUH PD\ EH ODUJH EHQHWV FOLQLFDO DQG
PLFURELRORJLFDO FXUH UDWHV JUHDWHU WKDQ DQG
WULYLDO VLGH HHFWV H J SHUVLVWHQW PXFRXV PHPEUDQH
DEQRUPDOLWLHV SHULUHFWDO DEVFHVV DQG DOOHUJ\
7KH HHFWV RI D]LWKURP\FLQ DQG HU\WKURP\FLQ ZHUH
uncert ain, wit h only 14 people receiving azit hromycin
and 31 people receiving eryt hromycin in t he studies.
6LGH HHFWV DUH OLNHO\ WULYLDO DQG VLPLODU WR WKH VLGH
HHFWV RI WKHVH WUHDWPHQWV LQ SHRSOH ZLWK RWKHU
chlamydial infect ions. There is no evidence relat ing
to pat ient values and preferences, but t he GDG
agreed t hat t here are no known reasons to suspect
YDOXHV ZRXOG YDU\ IRU GLHUHQW SHRSOH 7KHUH LV OLWWOH
to no evidence for accept abilit y, but research in ot her
condit ions indicates t hat adherence may be improved
wit h simpler medicat ion regimens. There is lit t le
evidence for equit y issues and feasibilit y, but t he GDG
agreed t hat t hese may be dependent on individuals and
count ries. Dat a for medicine prices and procurement
indicate t hat doxycycline is cheaper t han azit hromycin
and eryt hromycin, alt hough t he lat ter medicines are
st ill inexpensive.
In summary, t here is very low qualit y evidence for all
medicines for t reat ment of LGV. The evidence suggest s
ODUJH EHQHWV ZLWK GR[\F\FOLQH RYHU D]LWKURP\FLQ DQG
WKH HHFWV RI HU\WKURP\FLQ DUH XQNQRZQ ,Q DGGLWLRQ
doxycycline is t he least expensive.
See Annex C for list of references of reviewed evidence,
and Web annex D for det ails of t he evidence reviewed,
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IUDPHZRUNV SS
4.5 OPHTHALMIA NEONATORUM
RECOMMENDATION 5
In neonates wit h chlamydial conjunct ivit is, t he WHO
STI guideline recommends using oral azit hromycin
PJ NJ GD\ RUDOO\ RQH GRVH GDLO\ IRU GD\V RYHU
HU\WKURP\FLQ PJ NJ GD\ RUDOO\ LQ IRXU GLYLGHG
doses daily for 14 days.
St rong recommendation, very low qualit y evidence
Remarks: This is a st rong recommendat ion given
t he potent ial for t he risk of pyloric stenosis wit h t he
use of eryt hromycin in neonates. In some set t ings,
azit hromycin suspension is not available and t herefore
HU\WKURP\FLQ PD\ EH XVHG 6LGH HHFWV VKRXOG EH
monitored wit h t he use of eit her medicat ion.
Research implicat ions: Addit ional research should be
FRQGXFWHG WR GHWHUPLQH WKH HHFWV RI WKHVH PHGLFLQHV
WR WUHDW RSKWKDOPLD QHRQDWRUXP 7KH HHFWV RI RWKHU
medicat ions such as t rimet hoprim should also be
invest igated. Pyloric stenosis should be monitored
or research conducted to evaluat e t his risk wit h
t he medicines suggested.
SUMMARY OF THEEVIDENCE
There is low qualit y evidence for a cure rate of 98% wit h
HU\WKURP\FLQ PJ NJ GD\ IRU GD\V DQG XQFHUWDLQ
HHFWV RQ WKH FXUH UDWH IRU D]LWKURP\FLQ JLYHQ WKH
small numbers of neonates receiving azit hromycin in
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qualit y evidence for 7 more inst ances of pyloric stenosis
SHU ZLWK HU\WKURP\FLQ 7KH *'* UHJDUGHG WKH
ULVN RI S\ORULF VWHQRVLV DV D VHULRXV DGYHUVH HHFW
of eryt hromycin use in children. There are no dat a
evaluat ing pyloric stenosis due to use of azit hromycin.
7KHUH DUH DOVR QR GDWD DVVHVVLQJ WKH HHFWV RI
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 21

t rimet hoprim. There is no evidence for variat ion in
pat ient values and preferences, but compliance wit h
t reat ment s ranged from 77% to 89%. The cost s for t
reat ment s are relat ively low and similar, and most
t reat ment s are current ly being used.
In summary, azit hromycin is preferred over
eryt hromycin because of t he potent ial risk of serious
adverse event s wit h eryt hromycin, and t here are no
dat a for t rimet hoprim.
See Annex C for list of references of reviewed evidence,
and Web annex D for det ails of t he evidence reviewed,
LQFOXGLQJ HYLGHQFH SUROHV DQG HYLGHQFH WR GHFLVLRQ
IUDPHZRUNV SS
SUMMARY OF THE EVIDENCE
Overall, t he qualit y of evidence is low to very low
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non- randomized study wit h t wo comparison
JURXSV 7KHUH DUH IHZ DYDLODEOH GDWD IRU WKH HHFWV
RI FKORUDPSKHQLFRO /DUJH EHQHWV ZHUH UHSRUWHG
for prophylaxis compared wit h no prophylaxis, in
part icular in babies born to women wit h known infect ion
DSSUR[LPDWHO\ UHGXFWLRQ LQ FRQMXQFWLYLWLV ZLWK
SURSK\OD[LV XVLQJ GLHUHQW PHGLFDWLRQV 7KH EHQHWV
ZLWK GLHUHQW PHGLFDWLRQV DUH VLPLODU KRZHYHU WKH ORZ
WR YHU\ ORZ TXDOLW\ HYLGHQFH LQGLFDWHV WKDW WKH EHQHWV
of tet racycline hydrochloride, eryt hromycin or povidone
iodine may be slight ly greater t han for silver nit rate.

5(&200(1'$7,21 Few dat a are available for t he incidence of non-

infect ious conjunct ivit is after prophylaxis or no
For all neonates, t he WHO STI guideline recommends
prophylaxis. Low qualit y evidence shows a slight
topical ocular prophylaxis for t he prevent ion of
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gonococcal and chlamydial opht halmia neonatorum.
EHWZHHQ DQG SHU LQIDQWV KDYH QRQ LQIHFWLRXV
St rong recommendation, low qualit y evidence FRQMXQFWLYLWLV DIWHU DSSOLFDWLRQ RI GLHUHQW SURSK\ODFWLF
medicat ions. There is lit t le evidence relat ing to pat ient
RECOMMENDATION 7 values and preferences, but t he GDG agreed t hat
WKHUH ZRXOG OLNHO\ EH OLWWOH GLHUHQFH LQ WKH KLJK YDOXH
For ocular prophylaxis, t he WHO STI guideline suggest s
placed on avoiding long- term consequences of bot h
one of t he following opt ions for topical applicat ion to
gonococcal and chlamydial conjunct ivit is. The GDG also
bot h eyes immediately after birt h:
DJUHHG WKDW WKHUH ZRXOG EH OLWWOH HHFW RQ DFFHSWDELOLW\
tet racycline hydrochloride 1% eye oint ment equit y and feasibilit y, as prophylaxis is current ly used
HU\WKURP\FLQ H\H RLQWPHQW in many count ries. The GDG reported t hat alcohol-
based povidone iodine has erroneously been used
SRYLGRQH LRGLQH VROXWLRQ ZDWHU EDVHG
as prophylaxis result ing in serious harm to babies.
silver nit rate 1% solut ion Silver nit rate is t he most expensive prophylaxis opt ion.
chloramphenicol 1% eye oint ment .
,Q VXPPDU\ WKHUH DUH ODUJH EHQHWV IRU SURSK\OD[LV WR
Condit ional recommendation, low qualit y evidence SUHYHQW RSKWKDOPLD QHRQDWRUXP DQG WKHVH EHQHWV
out weigh t he risk of non- infect ious conjunct ivit is due
Remarks: 5HFRPPHQGDWLRQV DQG DSSO\ WR WKH
to prophyalaxis wit h any of t he topical medicat ions.
prevent ion of bot h chlamydial and gonococcal
Some topical medicat ions may provide greater
opht halmia neonatorum. Cost and local resist ance
protect ion (t et racycline hydrochloride, eryt hromycin
to eryt hromycin, tet racycline and chloramphenicol
RU SRYLGRQH LRGLQH EXW DOO DUH IHDVLEOH WR SURYLGH
in gonococcal infect ion may determine t he choice of
medicat ion. Caut ion should be t aken to avoid touching See Annex C for list of references of reviewed evidence,
eye t issue when applying t he topical t reat ment and and Web annex D for det ails of t he evidence reviewed,
to provide a water- based solut ion of povidone iodine. LQFOXGLQJ HYLGHQFH SUROHV DQG HYLGHQFH WR GHFLVLRQ
Alcohol- based povidone iodine solut ion must not be IUDPHZRUNV SS
applied. The topical applicat ion should be administered
immediately after birt h.
Research implicat ions: The prevalence of gonococcal
opht halmia should be determined given t he high
prevalence of maternal gonorrhoea in some set t ings.
The st ate of resist ance to t he medicat ions should be
explored and it should be est ablished whet her t hese
organisms would be killed by ocular prophylaxis despite
resist ant st rains being est ablished in t he organisms.
0RUH UHVHDUFK FRPSDULQJ WKH EHQHWV DQG KDUPV
RI WKH GLHUHQW PHGLFDWLRQV LV QHHGHG LQ SDUWLFXODU
comparisons wit h chloramphenicol.
22 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

REFERENCES

1. Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N et al. Global est imat es of t he
SUHYDOHQFH DQG LQFLGHQFH RI IRXU FXUDEOH VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV LQ EDVHG RQ V\VWHPDWLF
UHYLHZ DQG JOREDO UHSRUWLQJ 3/R6 2QH H GRL MRXUQDO SRQH

2. Harryman L, Blee K, Horner P. Chlamydiatrachomatis and non- gonococcal uret hrit is. Medicine.
GRL M PSPHG

3. Haggert y CL, Got t lieb SL, Taylor BD, Low N, Xu F, Ness RB. Risk of sequelae aft er Chlamydia
t rachomatis JHQLWDO LQIHFWLRQ LQ ZRPHQ - ,QIHFW 'LV 6XSSO 6 GRL

4. Bbar C, de Barbeyrac B. Genit al Chlamydiatrachomatis infect ions. Clin Microbiol Infect .

GRL M [

+HUULQJ $ 5LFKHQV - /\PSKRJUDQXORPD YHQHUHXP 6H[ 7UDQVP ,QIHFW 6XSSO LY

GRL VWL
/DERUDWRU\ GLDJQRVLV RI VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV LQFOXGLQJ KXPDQ LPPXQRGHFLHQF\
YLUXV *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ KWWS DSSV ZKR LQW LULV
ELWVWUHDP BHQJ SGI DFFHVVHG 0D\

7. Guidelines for t he management of sexually t ransmit t ed infect ions. Geneva: World Healt h
2UJDQL]DWLRQ KWWS ZZZ ZKR LQW KLY SXE VWL HQ 67,*XLGHOLQHV SGI DFFHVVHG
0D\
8. Manhart LE, Gillespie CW, Lowens MS, Khosropour CM, Colombara DV, Golden MRet al. St andard
t reat ment regimens for nongonococcal uret hrit is have similar but declining cure rat es: a randomized
FRQWUROOHG WULDO &OLQ ,QIHFW 'LV GRL FLG FLV

:+2 KDQGERRN IRU JXLGHOLQH GHYHORSPHQW QG HGLWLRQ *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ
KWWS ZZZ ZKR LQW NPV KDQGERRNB QGBHG SGI DFFHVVHG 0D\

0DQDJHPHQW 6FLHQFHV IRU +HDOWK 06+ DQG :RUOG +HDOWK 2UJDQL]DWLRQ :+2 ,QWHUQDWLRQDO GUXJ
SULFH LQGLFDWRU JXLGH HGLWLRQ XSGDWHG DQQXDOO\ 0HGIRUG 0$ 06+ KWWS DSSV ZKR LQW
PHGLFLQHGRFV GRFXPHQWV V HQ V HQ SGI DFFHVVHG 0D\

:+2 JXLGHOLQHV IRU GHFODUDWLRQ RI LQWHUHVWV :+2 H[SHUWV *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ

,QWURGXFLQJ :+2V UHSURGXFWLYH KHDOWK JXLGHOLQHV DQG WRROV LQWR QDWLRQDO SURJUDPPHV SULQFLSOHV
DQG SURFHVVHV RI DGDSWDWLRQ DQG LPSOHPHQWDWLRQ *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ KWWS
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ZKR LQW VHOHFWLRQBPHGLFLQHV FRPPLWWHHV H[SHUW (0/B B),1$/BDPHQGHGB$8* SGI
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 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 23

ANNEX A:
STI GUIDELINE DEVELOPMENT TEAMS

WHO STI STEERING COMMITTEE

WHO regional STI focal point s Region

1. Massimo Ghidinelli 5HJLRQ RI WKH $PHULFDV $05
:DVKLQJWRQ '& 8QLWHG 6WDWHV RI $PHULFD 86$
2. Lali Khot enashvili (XURSHDQ 5HJLRQ (85
Copenhagen Denmark
3. <LQJ 5X /R :HVWHUQ 3DFLF 5HJLRQ :35
Manila Philippines
4. Frank Lule $IULFDQ 5HJLRQ $)5
Brazzaville Congo
5. Razia Pendse 6RXWK (DVW $VLD 5HJLRQ 6($5
and New Delhi India
Ornella Lincet t o WHO Count ry Represent at ive, Bhut an
Hamida Khat t abi and Gabriela Reidner (DVWHUQ 0HGLWHUUDQHDQ 5HJLRQ (05
Cairo Egypt
WHO headquart ers Depart ment and Team
7. Moazzam Ali Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
8. Avni Amin Depart ment of Reproduct ive Healt h and Research
Adolescent s and at- Risk Populat ions
9. Rachel Baggaley Depart ment of HIV/ AIDS
Key Populat ions and Innovat ive Prevent ion
9HQNDWUDPDQ &KDQGUD 0RXOL Depart ment of Reproduct ive Healt h and Research
Adolescent s and at- Risk Populat ions
11. Jane Ferguson Depart ment of Maternal, Newborn, Child and Adolescent
+HDOWK 5HVHDUFK DQG 'HYHORSPHQW
12. Mario Fest in Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
13. 0DU\ /\Q *DHOG Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
14. Ant onio Gerbase Depart ment of HIV/ AIDS
Key populat ions and Innovat ive Prevent ion
15. Sami Got t lieb Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
Silvo Paolo Mariot t i Depart ment of Noncommunicable Disease and
Ment al Healt h
Management of Noncommunicable Diseases, Disabilit y,
Violence and Injury Prevent ion
Blindness Deafness Prevent ion, Disabilit y and Rehabilit at ion
17. Frances McConville Depart ment of Maternal, Newborn, Child and
Adolescent Healt h
24 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

18. Lori Newman Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
19. Annet t e Mwansa Nkowane Depart ment of Healt h Workforce
Anit a Sands Essent ial Medicines and Healt h Product s,
3UHTXDOLFDWLRQ 7HDP
21. Igor Toskin Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
22. Marco Vit oria Depart ment of HIV/ AIDS
Treat ment and Care
WHO STI Secret ariat Depart ment and Team
23. Ian Askew Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
24. 1DWKDOLH %URXWHW FR OHDG RI WKH Depart ment of Reproduct ive Healt h and Research
development process) Human Reproduct ion Team
25. James Kiarie Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
Lee Sharkey Depart ment of Reproduct ive Healt h and Research
Human Reproduct ion Team
27. Teodora Elvira Wi (lead of t he Depart ment of Reproduct ive Healt h and Research
development process) Human Reproduct ion Team

METHODOLOGIST
Nancy Sant esso
Depart ment of Clinical Epidemiology and Biost at ist ics
McMaster Universit y
0DLQ 6WUHHW :HVW
Hamilton, Ont ario L8N 3Z5
Canada

SYSTEMATIC REVIEW TEAM:

MCMASTERUNIVERSITY
Team lead: Nancy Sant esso
Team members: Housne Begum, Janna- Lina Kert h,
Gian Paolo Morgano, Krist ie Poole, Nicole Schwab,
Mat t hew Vent resca, Yuan Zhang, Andrew Zikic
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 25

STI GUIDELINE DEVELOPMENT GROUP

Chairpersons: Judit h Wasserheit , Holger Schnemann, Pat ricia Garcia

Name and address Region Sex

1. <DZ 6D[ $GX 6DUNRGLH AFR M
School of Medical Sciences
.ZDPH 1NUXPDK 8QLYHUVLW\ RI 6FLHQFH DQG 7HFKQRORJ\ .1867
PO Box 1934, Bant ama Kumasi
Ghana
2. Andrew Amat o EUR M
European Cent re for Disease Prevent ion and Cont rol
Tomtebodavgen 11a
171 83 Stockholm
Sweden
3. Gail Bolan AMR F
Centers for Disease Cont rol and Prevent ion
&OLIWRQ 5G
$WODQWD *$
USA
4. John Changalucha AFR M
Nat ional Inst it ute for Medical Research
Mwanza Medical Research Cent re
32 %R[
Mwanza
Tanzania
5. ;LDQJ 6KHQJ &KHQ WPR M
Nat ional Center for STD Cont rol
Chinese Academy of Medical Sciences and Peking Union Medical College
12 Jiangwangmiao St reet
1DQMLQJ
China
Harrel Chesson AMR M
Division of STI Prevent ion
Centers for Disease Cont rol and Prevent ion
&OLIWRQ 5G
$WODQWD *$
USA
7. Craig Cohen AMR M
Universit y of California, San Francisco
%HDOH 6WUHHW 6XLWH
San Francisco, CA 94117
USA
8. Francisco Garcia AMR M
Pima Count y Healt h Depart ment
6 &RXQWU\ &OXE 5RDG
6XLWH
Tucson, AZ 85714
USA
26 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

9. 3DWULFLD *DUFLD &R &KDLU AMR F

School of Public Healt h and Administ rat ion
Universidad Peruana Cayet ano Heredia
$YH +RQRULR 'HOJDGR
31 AP, 4314 Lima
Peru
Suzanne Garland WPR F
5R\DO :RPHQV +RVSLWDO /HYHO
%OGJ %LR ,QVWLWXWH
Flemington Road, Parkville
Victoria
Aust ralia
11. Sarah Hawkes EUR F
Universit y College London
Inst it ute for Global Healt h
London
United Kingdom
12. Mary Higgins EUR F
Internat ional Confederat ion of Midwives
/DDQ YDQ 0HHUGHUYRRUW
2517 AN The Hague
The Net herlands
13. King Holmes AMR M
Depart ment of Global Healt h and Depart ment of Medicine
Universit y of Washington
Harborview Medical Center
325 9t h Ave., Box 359931
6HDWWOH :$
USA
14. -HUH\ .ODXVQHU AMR M
Division of Infect ious Diseases and Program in Global Healt h
'DYLG *HHQ 6FKRRO RI 0HGLFLQH DQG )LHOGLQJ 6FKRRO RI 3XEOLF +HDOWK
Universit y of California, Los Angeles
USA
15. David Lewis WPR M
Western Sydney Sexual Healt h Cent re
Marie Bashir Inst it ute for Infect ious Diseases and Biosecurit y
Sydney Medical School
West mead, Universit y of Sydney
Sydney
Aust ralia
Nicola Low EUR F
Epidemiology and Public Healt h
Universit y of Bern
Inst it ute of Social and Prevent ive Medicine
Finkenhubelweg 11
%HUQ
Swit zerland
17. David Mabey EUR M
Communicable Diseases
/RQGRQ 6FKRRO RI +\JLHQH DQG 7URSLFDO 0HGLFLQH /6+70
Keppel St reet
London WC1E 7HT
United Kingdom
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 27

18. Angelica Espinosa Miranda AMR F

Ncleo de Doenas Infecciosas
Universidade Federal do Espirito Santo
Av. Marechal Campos
0DUXSH
9LWULD (6 &(3
Brazil
19. Nelly Mugo AFR F
Kenya Medical Research Inst it ute
Mbagat hi Rd.
32 %R[ 1DLUREL
Kenya
Saiqa Mullick AFR F
Implement at ion Science
Universit y of t he Wit watersrand
Hillbrow Healt h Precinct
Hillbrow, Johannesburg
Sout h Africa
21. Francis Ndowa AFR M
7KDPHV 5RDG
Vainona, Harare
Zimbabwe
22. Joel Palefsky AMR M
Division of Infect ious Diseases
%R[
3DUQDVVXV $YH 5RRP 6
Universit y of California, San Francisco
San Francisco, CA 94143
USA
23. .HLWK 5DGFOLH EUR M
European STI Guidelines Project
,QWHUQDWLRQDO 8QLRQ DJDLQVW 6H[XDOO\ 7UDQVPLWWHG ,QIHFWLRQV ,867,
Royal Societ y of Medicine
1 Wimpole St reet
/RQGRQ : * $(
United Kingdom
24. Ulugbek Sabirov EUR M
Nat ional STI Program
Republican Center for Dermato- Venereology
Tashkent
Uzbekist an
25. +ROJHU 6FKQHPDQQ &R &KDLU AMR M
Depart ment of Clinical Epidemiology and Biost at ist ics
McMaster Universit y
0DLQ 6WUHHW :HVW
Hamilton, Ont ario L8N 3Z5
Canada
Richard St een EUR M
Localit Cassaluvo
Diano San Piet ro
,PSHULD
It aly
28 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

27. Judit h St ephenson EUR F

Universit y College London
Gower St reet
London
United Kingdom
28. Magnus Unemo EUR M
Depart ment of Laboratory Medicine
Microbiology
rebro Universit y Hospit al
6( UHEUR
Sweden
29. Bea Vuylst eke EUR F
Inst it ute of Tropical Medicine
Nat ionalest raat 155
$QWZHUS
Belgium
Anna Wald AMR F
Universit y of Washington
Virology Research Clinic
Harborview Medical Center
325 9t h Ave, Box 359928
6HDWWOH :$
USA
31. -XGLWK :DVVHUKHLW &R &KDLU AMR F
Depart ment of Global Healt h
Professor of Global Healt h and Medicine
Adjunct Professor of Epidemiology
Universit y of Washington
+DUULV +\GUDXOLFV %XLOGLQJ 5RRP '
1( 3DFLF 6WUHHW
%R[
6HDWWOH :$
USA
32. Thomas Wong AMR M
Division of Communit y Acquired Infect ions
Cent re for Communicable Diseases and Infect ion Cont rol
Public Healt h Agency of Canada
5RRP (JODQWLQH 'ULYHZD\
7XQQH\V 3DVWXUH $/ &
2WWDZD 2QWDULR . $ /
Canada
33. Kimberly A. Workowski AMR F
&HQWHUV IRU 'LVHDVH &RQWURO DQG 3UHYHQWLRQ &'&
Division of Infect ious Diseases
Emory Universit y School of Medicine
&OLIWRQ 5G
$WODQWD *$
USA

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 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 29

STI Guideline Development Group: Working group for chlamydia

1. Andrew Amato
2. Harrell Chesson
3. Craig Cohen
4. Pat ricia Garcia
5. Nicola Low
David Mabey
7. Angelica Miranda
8. Francis Ndowa
9. .HLWK 5DGFOLH
Judit h Stephenson
11. Magnus Unemo
12. Bea Vuylsteke
13. Judit h Wasserheit

STI Ext ernal Review Group: Working group for chlamydia

Name and address Region Sex

1. /DLWK $EX 5DGGDG EMR M
Biost at ist ics, Epidemiology and Biomat hemat ics Research Core
Infect ious Disease Epidemiology Group
Depart ment of Public Healt h
Weill Cornell Medical College
Cornell Universit y
Qat ar Foundat ion Educat ion Cit y
Qat ar
2. $GHOH %HQDNHQ 6FKZDUW] AMR F
Minist ry of Healt h
STI, AIDS and Viral Hepat it is Depart ment
SAF Sul Trecho 2, Ed. Premium
Torre I, Trreo, Sala 12
%UDVOLD ')
Brazil
3. Mircea Bet iu EUR M
1LFRODH 7HVWHPLDQX 6WDWH 8QLYHUVLW\ RI 0HGLFLQH DQG 3KDUPDF\
Republic of Moldova
4. Anupong Chit warakorn SEAR M
Depart ment of Diseases Cont rol
Bureau of AIDS, TB and STIs
Minist ry of Public Healt h
Nont haburi
Thailand
30 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

5. Anjana Das SEAR F

)+,
New Delhi
India
Carolyn Deal AMR F
1DWLRQDO ,QVWLWXWH RI $OOHUJ\ DQG ,QIHFWLRXV 'LVHDVHV 1,$,'
United St ates Depart ment of Healt h and Human Services
Nat ional Inst it utes of Healt h
Washington, DC
USA
7. 0DUJDUHW *DOH 5RZH AMR F
Professional Guidelines and Public Healt h Pract ice Division
Cent re for Communicable Diseases and Infect ion Cont rol
Public Healt h Agency of Canada
Ot t awa, Ont ario
Canada
8. William M. Geisler AMR M
Medicine and Epidemiology
Universit y of Alabama at Birmingham
Division of Infect ious Diseases
WK 6WUHHW 6RXWK
Zeigler Research Building, Room 242
%LUPLQJKDP $/
USA
9. Amina El Ket t ani EMR F
'LUHFWLRQ GH O(SLGPLRORJLH
Service des MST- sida
Minist ry of Healt h
71 Avenue Ibn Sinaa, Agdal
Rabat
Morocco
Ahmed Lat if AFR M
Public Healt h Consult ant
Zimbabwe
11. Mizan Kiros AFR M
Disease Prevent ion and Cont rol Directorate
Federal Minist ry of Healt h
Et hiopia
12. Philippe Mayaud EUR M
Clinical Research Depart ment
)DFXOW\ RI ,QIHFWLRXV DQG 7URSLFDO 'LVHDVHV
London School of Hygiene and Tropical Medicine
Keppel St reet
London WC1E 7HT
United Kingdom
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 31

13. David McCart ney EUR M

Research and Technical Support
,QWHUQDWLRQDO 3ODQQHG 3DUHQWKRRG )HGHUDWLRQ ,33)
4 Newhams Row, London SE1 3UZ
United Kingdom
14. Ali M. Mir SEAR M
Populat ion Council
1R 6WUHHW 6HFWRU )
Islamabad
Pakist an
15. Nuriye Ort ayli AMR F
8QLWHG 1DWLRQV 3RSXODWLRQ )XQG 81)3$
7KLUG $YHQXH UG RRU
1HZ <RUN 1<
USA
Khant anouvieng Sayabount havong WPR M
Minist ry of Healt h
/DR 3HRSOHV 'HPRFUDWLF 5HSXEOLF
17. Aman Kumar Singh SEAR M
'HSDUWPHQW RI $,'6 &RQWURO 1DWLRQDO $,'6 &RQWURO 2UJDQL]DWLRQ
Minist ry of Healt h and Family Welfare
Government of India
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1HZ 'HOKL
India

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32 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

ANNEX B:
DETAILED METHODS FOR GUIDELINE DEVELOPMENT

QUESTIONS AND OUTCOMES
To determine which recommendat ions to update,
LQ 'HFHPEHU WKH :RUOG +HDOWK 2UJDQL]DWLRQ
:+2 'HSDUWPHQW RI 5HSURGXFWLYH +HDOWK DQG
Research reviewed current recommendat ions of key
internat ional guidelines:
Sexually t ransmit ted diseases t reat ment guidelines,
'HSDUWPHQW RI +HDOWK DQG +XPDQ 6HUYLFHV
United St ates Centers for Disease Cont rol and
3UHYHQWLRQ &'& 4
United Kingdom nat ional guidelines for t he
management of sexually t ransmit ted infect ions,
Brit ish Associat ion for Sexual Healt h and HIV
%$6++ 5 guidelines t hat are part of ot her nat ional guidelines,
Canadian guidelines on sexually t ransmit ted
infect ions, Public Healt h Agency of Canada,
European sexually t ransmit ted infect ions guidelines,
Internat ional Union of Sexually Transmit ted
,QIHFWLRQV ,867, 7
Nat ional management guidelines for sexually
t ransmissible infect ions, Sexual Healt h Societ y
RI 9LFWRULD $XVWUDOLD 8
Nat ional guideline for t he management and cont rol
RI VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV 67,V 1DWLRQDO
'HSDUWPHQW RI +HDOWK 6RXWK $IULFD 9 and
Nat ional guidelines on prevent ion, management
and cont rol of reproduct ive t ract infect ions including
sexually t ransmit ted infect ions, Minist ry of Healt h
and Family Welfare, Government of India,
$XJXVW
Based on t he review, four proposed categories
RI VH[XDOO\ WUDQVPLWWHG LQIHFWLRQ 67, FRQGLWLRQV
were priorit ized:
D 67, FRQGLWLRQV LQFOXGHG LQ WKH :+2 67,
guidelines11 t hat were selected by t he GDG to be
reviewed and updated in t he new WHO STI guidelines.
These are import ant and common condit ions.
E 67, FRQGLWLRQV QRW LQFOXGHG LQ WKH :+2 67,
guidelines t hat were selected by t he GDG to be
reviewed and added in t he new WHO STI guidelines.
These are import ant and common condit ions.
F 67, FRQGLWLRQV LQFOXGHG LQ WKH :+2 67,
guidelines t hat were not updated but were selected
by t he GDG to be included in t he new WHO STI
guidelines. These STI condit ions are rare and
diagnosis is not often made in t he majorit y of
set t ings, or it is unlikely t hat t here is new informat ion
available as a basis for making any changes to t he
:+2 67, UHFRPPHQGDWLRQV
G 67, FRQGLWLRQV QRW LQFOXGHG LQ WKH :+2 67,
but were not selected by t he GDG to be included
in t he new WHO STI guidelines. These condit ions
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of set t ings, or it is unlikely t hat new research or
LQIRUPDWLRQ KDV EHFRPH DYDLODEOH WKHUH DUH H[LVWLQJ
recommendat ions for t hese condit ions t hat can be
applied in ot her set t ings (e.g. reference hospit als
WKDW PDQDJH FRPSOLFDWHG FRQGLWLRQV
$ PHHWLQJ ZDV KHOG LQ 'HFHPEHU DW ZKLFK WKH
*XLGHOLQH 'HYHORSPHQW *URXS *'* GLVFXVVHG DQG
decided on t he init ial list of populat ion, intervent ion,
FRPSDUDWRU DQG RXWFRPH 3,&2 TXHVWLRQV LGHQWLHG
by WHO. After t he meet ing, surveys pert aining to each
of t he four STI topic areas (i.e. gonorrhoea, chlamydia,
V\SKLOLV DQG KHUSHV VLPSOH[ YLUXV W\SH >+69 @ ZHUH
administered among subgroups of t he GDG members
wit h expert ise relat ing to t he relevant STIs. The goal
of t he surveys was to rank t he populat ion, intervent ions
DQG RXWFRPHV IRU HDFK VSHFLF 67, FRQGLWLRQ E\
import ance. The surveys required t he members of
t he STI subgroups to rank t he populat ion, intervent ions
and outcomes on a scale of 1 to 9, from lowest to
highest priorit y.

$YDLODEOH DW KWWS ZZZ FGF JRY VWG WUHDWPHQW VWG WUHDWPHQW UU SGI
$YDLODEOH DW KWWS ZZZ EDVKK RUJ %$6++ *XLGHOLQHV *XLGHOLQHV %$6++ *XLGHOLQHV *XLGHOLQHV DVS["KNH\ F HG H E E D F H IEG GH
$YDLODEOH DW KWWS ZZZ SKDF DVSF JF FD VWG PWV VWL LWV FJVWL OGFLWV LQGH[ HQJ SKS
7 Available at : ht t p:// www.iust i.org/ regions/ europe/ euroguidelines.ht m
0HOERXUQH 6H[XDO +HDOWK &HQWUH 7UHDWPHQW *XLGHOLQHV DYDLODEOH DW KWWS PVKF RUJ DX +HDOWK3URIHVVLRQDO 06+&7UHDWPHQW*XLGHOLQHV WDELG 'HIDXOW
/HZLV '$ 0DUXPD ( 5HYLVLRQ RI WKH QDWLRQDO JXLGHOLQH IRU UVW OLQH FRPSUHKHQVLYH PDQDJHPHQW DQG FRQWURO RI VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV ZKDWV QHZ
DQG ZK\" 6RXWK $IU - (SLGHPLRO ,QIHFW KWWS DSSV ZKR LQW PHGLFLQHGRFV GRFXPHQWV V HQ V HQ SGI DFFHVVHG -XQH
$YDLODEOH DW KWWS ZZZ LOR RUJ ZFPVS JURXSV SXEOLF HGBSURWHFW SURWUDY LORBDLGV GRFXPHQWV OHJDOGRFXPHQW ZFPVB SGI
*XLGHOLQHV IRU WKH PDQDJHPHQW RI VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ KWWS ZZZ ZKR LQW KLY SXE VWL HQ
67,*XLGHOLQHV SGI DFFHVVHG 0D\
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 33

)RXU GLHUHQW SULRULW\ 67, VXUYH\V ZHUH FRQGXFWHG
DQG HDFK VXUYH\ DWWDLQHG D UHVSRQVH UDWH
from t he STI subgroup members. The survey result s for
priorit y populat ions, intervent ions and outcomes were
analysed. Populat ions, intervent ions and outcomes wit h
DQ DYHUDJH UDWLQJ RI WR ZHUH FRQVLGHUHG FULWLFDO
WKRVH ZLWK DQ DYHUDJH UDWLQJ RI WR ZHUH FRQVLGHUHG
LPSRUWDQW DQG WKRVH ZLWK DQ DYHUDJH UDWLQJ RI WR
3 were considered not import ant and were t hus not
covered in t he guidelines. Some quest ions t hat scored
less t han 7 were kept for consistency.
The number of comparisons in each quest ion was also
UHGXFHG RQO\ FULWLFDO LQWHUYHQWLRQV ZHUH FRPSDUHG
wit h each ot her and wit h import ant intervent ions.
Thus, import ant intervent ions were not compared
to each ot her.
A revised list of quest ions was t hen compiled and all
members of t he full STI GDG were requested to review
t he priorit y quest ions. The priorit y quest ions were
t hen revised based on t his feedback.
6L[ TXHVWLRQV ZHUH LGHQWLHG IRU WKH XSGDWH RI WKH
chlamydial infect ions guideline. Each quest ion is
framed using t he PICO format (populat ion, intervent ion,
FRPSDUDWRU DQG RXWFRPH (DFK TXHVWLRQ FRUUHVSRQGV
to a recommendat ion.

PRIORITY QUESTIONS AND OUTCOMES

FOR CHLAMYDIA TRACHOMATIS
1. Uncomplicat ed genit al (cervix, uret hra) chlamydial
infect ions in adult s and adolescent s

Populat ion Int ervent ion Comparat or Out come

Adult s and Azit hromycin 1 g orally Doxycycline extended release Crit ical: Clinical cure,
adolescent s wit h x 1 dose (5 PJ GDLO\ [ GD\V microbiological cure, STI
uncomplicated 'R[\F\FOLQH PJ (U\WKURP\FLQ PJ RUDOO\ FRPSOLFDWLRQV VLGH HHFWV
genit al (cervix, t wice daily x 7 days four t imes daily x 7 days (including allergy, toxicit y,
XUHWKUD Eryt hromycin et hylsuccinate JDVWUR FRPSOLDQFH
chlamydial (6 PJ RUDOO\ IRXU WLPHV
Import ant : Qualit y of life, HIV
infect ions daily x 7 days
t ransmission and acquisit ion,
(U\WKURP\FLQ PJ RUDOO\
part ner t ransmission
WZLFH GDLO\ [ GD\V
$PR[LFLOOLQ PJ RUDOO\
t hrice daily x 7 days
Quinolones

2. Uncomplicat ed anorect al chlamydial infect ions in adult s and adolescent s,

excluding lymphogranuloma venereum (LGV)

Populat ion Int ervent ion Comparat or Out come

Adult s and Azit hromycin 1 g orally 'R[\F\FOLQH (5 PJ GDLO\ Crit ical: Clinical cure,
adolescent s wit h x 1 dose x 7 days microbiological cure, STI
uncomplicated 'R[\F\FOLQH PJ (U\WKURP\FLQ PJ RUDOO\ FRPSOLFDWLRQV VLGH HHFWV
anorect al t wice daily x 7 days four t imes daily x 7 days (including allergy, toxicit y,
chlamydial (U\WKURP\FLQ (6 PJ RUDOO\ JDVWUR FRPSOLDQFH
infect ions four t imes daily x 7 days
Import ant : Qualit y of life, HIV
H[FOXGLQJ /*9 (U\WKURP\FLQ PJ RUDOO\
t ransmission and acquisit ion,
WZLFH GDLO\ [ GD\V
part ner t ransmission
$PR[LFLOOLQ PJ RUDOO\ WKULFH
daily x 7 days
Quinolones
34 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

3ac. Chlamydia in pregnancy

Populat ion Int ervent ion Comparat or Out come

Pregnant women Azit hromycin 1 g orally
wit h chlamydia x 1 dose
(U\WKURP\FLQ PJ
orally, four t imes daily x
7 days
$PR[LFLOOLQ PJ RUDOO\ WKULFH
daily x 7 days
(U\WKURP\FLQ PJ RUDOO\
t wice daily x 14 days
(U\WKURP\FLQ PJ RUDOO\
four t imes daily x 14 days
(U\WKURP\FLQ (6 PJ RUDOO\
four t imes daily x 7 days
(U\WKURP\FLQ (6 PJ RUDOO\
four t imes daily x 14 days
Crit ical: Fet al outcomes (e.g.
WHUDWRJHQLFLW\ WR[LFLW\ IHWDO
loss, prematurit y/ low birt h
weight , chorioamnionit is,
infant pneumonit is/ neonat al
opht hamia, post partum
endomet rit is, microbiological
FXUH VLGH HHFWV LQFOXGLQJ
DOOHUJ\ WR[LFLW\ JDVWUR FOLQLFDO
FXUH V\PSWRPV FRPSOLDQFH
Import ant : HIV acquisit ion,
qualit y of life, t ransmission
to part ner

4. Lymphogranuloma venereum (LGV) in all populat ions

Populat ion Int ervent ion Comparat or Out come

Adult s and 'R[\F\FOLQH PJ
adolescent s wit h t wice daily x 21 days
LGV Azit hromycin 1 g orally
once a week x 13 orally, four t imes daily x 21 days
weeks
'R[\F\FOLQH PJ WZLFH GDLO\
x 14 days
(U\WKURP\FLQ EDVH PJ
Crit ical: Clinical cure,
microbiological cure
Import ant : STI complicat ions,
VLGH HHFWV LQFOXGLQJ DOOHUJ\
WR[LFLW\ JDVWUR TXDOLW\ RI
life, HIV t ransmission and
acquisit ion, compliance, LGV
t ransmission to part ner

5. Opht halmia neonat orum t reat ment

Populat ion Int ervent ion and comparat or Out come

Neonates Eryt hromycin in 4 divided doses orally, daily x 14 days: Crit ical: Clinical cure,
wit h neonat al PJ NJ GD\ PJ NJ GD\ RU PJ NJ GD\ microbiological cure,
conjunct ivit is $]LWKURP\FLQ PJ NJ GD\ RUDOO\ GDLO\ [ GD\V &RPSOLFDWLRQV VLGH HHFWV
7ULPHWKRSULP PJ VXOID PJ RUDOO\ WZLFH GDLO\ (including allergy, toxicit y,
[ GD\V JDVWUR DQWLPLFURELDO
resist ance, compliance

6 and 7. Opht halmia neonat orum prophylaxis

Populat ion Int ervent ion and comparat or Out come

Neonates at risk Opht halmic oint ment in each eye at t he t ime of delivery: Crit ical: Absence of
for opht halmia (U\WKURP\FLQ conjunct ivit is, kerat it is,
neonatorum Silver nit rate 1% complicat ions, blindness,
Chloramphenicol corneal scarring, ant imicrobial
Tet racycline 1% resist ance
Povidone iodine 2.5%
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 35

REVIEWS OF THE EVIDENCE

SEARCH FOREVIDENCE FOREFFECTS Primary studies were searched for in t he Cochrane

OF INTERVENTIONS &HQWUDO 5HJLVWHU RI &RQWUROOHG 7ULDOV &(175$/
MEDLINEand Embase dat abases. Search end dates for
To avoid duplicat ion of reviews t hat have been each PICO quest ion varied bet ween March and October
previously published, evidence was searched using
VHH OLVW EHORZ 7KH VWUDWHJLHV LQFOXGHG VHDUFKLQJ
D KLHUDUFKLFDO DSSURDFK 7KH WHDP UVW VHDUFKHG IRU for subject headings and text words t hat included
synt hesized evidence t hen searched t he primary FKODP\GLD DQG VSHFLF LQWHUYHQWLRQV H J PHGLFDWLRQ
studies for all t he factors needed to complete t he QDPHV DQG FODVVHV $GGLWLRQDO VWUDWHJLHV LQFOXGHG
evidence- to- decision framework for each quest ion checking reference list s and consult ing wit h t he GDG
L H EHQHWV DQG KDUPV SDWLHQW YDOXHV DFFHSWDELOLW\ for any missed art icles. We searched for RCTs for crit ical
IHDVLELOLW\ HTXLW\ DQG FRVWV and import ant outcomes, and non- randomized studies
The hierarchical approach consisted of ident ifying for crit ical outcomes when no evidence was available
pre- exist ing synt hesized evidence, including from from RCTs.
previously published guidelines t hat included systemat ic Search end dat es:
reviews of t he lit erature. When synt hesized evidence
DERXW EHQHWV DQG KDUPV IRU DQ LQWHUYHQWLRQ ZDV QRW 8QFRPSOLFDWHG JHQLWDO FHUYL[ XUHWKUD FKODP\GLDO
available or t he synt hesized evidence was not up to date, LQIHFWLRQV LQ DGXOWV DQG DGROHVFHQWV XS WR 0DUFK
a new systemat ic review of randomized cont rolled t rials Uncomplicated anorect al chlamydial infect ions
5&7V DQG QRQ UDQGRPL]HG VWXGLHV ZDV FRQGXFWHG H[FOXGLQJ /*9 LQ DGXOWV DQG DGROHVFHQWV XS WR
-XQH
The search st rategies were developed by an informat ion
specialist t rained in systemat ic reviews. The st rategies &KODP\GLD LQ SUHJQDQF\ XS WR -XQH XS WR
included t he use of keywords from t he cont rolled 'HFHPEHU IRU QRQ UDQGRPL]HG FRPSDUDWLYH
vocabulary of t he dat abase and text words based st udies
on t he PICO quest ions. There were no rest rict ions Lymphogranuloma venereum in all populat ions:
based on language, publicat ion st atus or study design. XS WR -XQH
RCTs were included for crit ical and import ant outcomes, 2SKWKDOPLD QHRQDWRUXP WUHDWPHQW XS WR 0D\
and non- randomized studies for crit ical outcomes
Opht halmia neonatorum prevent ion: up to
when no evidence was available from RCTs. Addit ional
2FWREHU
st rategies included cont act ing Cochrane review groups
and aut hors of study protocols.
The Cochrane Library suite of dat abases (Cochrane
Dat abase of Systemat ic Reviews [CDSR], Dat abase
RI $EVWUDFWV RI 5HYLHZV RI (HFWV >'$5(@ +HDOWK
Technology Assessment [HTA] dat abase and t he
$PHULFDQ &ROOHJH RI 3K\VLFLDQV >$&3@ -RXUQDO &OXE
was searched for published systemat ic reviews and
SURWRFROV IURP WR
Search st rat egy:
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36 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
SCREENING STUDIES, DATA EXTRACTION
AND ANALYSIS
Two researchers independent ly screened t it les and
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dat abase searching to determine studies eligible for
inclusion in t he analysis. Disagreement s were resolved
by discussing study inclusion wit h a t hird member of
t he research team. Dat a were ext racted using a pilot-
tested form for pat ient characterist ics (including t he
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Two invest igators independent ly abst racted dat a.
Risk of bias of each study was also assessed using risk
of bias tools appropriate for RCTs (ht t p:// handbook.
cochrane.org/ chapter_8/ 8_assessing_risk_of_bias_
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analysed using RevMan 5.2.12
For dichotomous outcomes, we calculat ed relat ive risks
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randomized studies wit h one group were included, a
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were calculat ed across t he studies using t he generic
inverse variance. For cont inuous outcomes, a mean
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was calculated. When possible, t he forest plot s of t he
met a- analyses were made available to t he GDG.
When dat a could not be pooled across studies, narrat ive
synt hesis met hods were used (see ht t p:// met hods.
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PATIENT VALUES AND PREFERENCES,
ACCEPTABILITY, EQUITY AND FEASIBILITY
St udies on pat ient values and preferences, accept abilit y,
equit y and feasibilit y were searched for and screened
using t wo met hods. First , while screening studies for
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Secondly, a separate search was conducted in MEDLINE,
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used in combinat ion wit h words such as preference,
adherence, sat isfact ion, at t it udes, healt h ut ilit ies
and value, equit y and feasibilit y. The result s
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for full text ret rieval. Any study design was included
t hat addressed equit y or feasibilit y. In addit ion,
when adherence was measured in RCTs or non-
randomized studies, t he dat a were collected,
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for each PICO quest ion.
The following study designs were included:
a. Pat ient ut ilit ies and healt h st atus values studies:
These studies examine how pat ient s value alternat ive
healt h st ates and t heir experiences wit h t reat ment .
The measurement techniques used can include:
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scale, or mapping result s based on generic surveys
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wit h decision aids: These studies examine t he
choices pat ient s make when presented wit h decision
aids for management opt ions (i.e. probabilist ic
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c. Studies on non- ut ilit y measurement of healt h st at es:
7KHVH VWXGLHV TXDQWLWDWLYHO\ H[DPLQH SDWLHQWV views,
at t it udes, sat isfact ion or preferences t hrough
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decision aids. Pat ient s are asked about how
desirable or aversive a part icular outcome is for
t hem. This category includes some studies t hat
use quest ionnaires or scales.
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views, at t it udes, sat isfact ions or preferences related
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research met hods including focus group discussions,
interviews, etc.
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 37

From t he search, we included 17 studies report ing

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dat a for all infect ions informed t he evidence for
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RESOURCES
We searched t he published lit erature for evidence
on use of resources and obt ained dat a on direct cost s
of medicines.
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t he GDG, an est imate of t he cost associat ed wit h each
alternat ive was calculated. This cost ing est imate refers
only to t he actual market price of t he medicat ion and
does not include t he cost s of ot her resources t hat
could be involved, such as syringes, inject ion t ime or
needle disposal.
Dat a were presented in a t able and included: t reat ment ,
dose per day, t reat ment durat ion, days, medicine cost
per dose, medicine cost per full course of t reat ment ,
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price for a full course of t reat ment for each medicine by
dosage was calculat ed as t he number of doses per day,
mult iplied by t he number of days of t he t reat ment , plus
25% of t he procurement cost s for t he medicines used.
The unit price of t he medicine was obt ained from t he
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drug price indicator guide and informat ion available
on t he Internet . In order to determine a precise and
reliable est imate, t he price per unit (all expressed in
86 GROODUV ZDV SURYLGHG RQO\ ZKHQ WKH LQIRUPDWLRQ
available matched t he dosage of interest (grams per
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based on assumpt ions about t he cost per unit of
hypot het ical packaging not list ed in t he directory.
The major medical dat abases were also searched
(MEDLINE, Embase and t he Cochrane Library for
Economic Evaluat ion and Technology Assessment
UHSRUWV IURP -DQXDU\ WR -XO\ 7KUHH VWXGLHV
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st rategies for chlamydia. In addit ion, while screening
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and abst racted dat a regarding possible resources to be
considered during t he decision- making process.

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38 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
APPLYING THE GRADE APPROACH TO
MAKING THE RECOMMENDATIONS
EVIDENCE PROFILES
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qualit y of evidence according to t he GRADEdomains
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approach assesses t he qualit y of evidence for t reat ment
intervent ions using well- est ablished criteria for
t he design, risk of bias, inconsistency, indirect ness,
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t he evidence. Two invest igators used t he GRADE
approach to assess t he qualit y and level of
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each recommendat ion are available in Web annex D.
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Evidence- to- decision frameworks were also developed
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Evidence- to- decision frameworks present t he desirable
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of t he outcomes, t he cost s and resource use, t he
accept abilit y of t he intervent ions to all st akeholders,
t he impact on healt h equit y, and t he feasibilit y of
implement at ion (i.e. t he GRADEcriteria for making
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are based on a populat ion perspect ive for t hese
recommendat ions. All GRADEcriteria were
considered from t his perspect ive.
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+DPLOWRQ 2QWDULR 0F0DVWHU 8QLYHUVLW\ DQG (YLGHQFH 3ULPH ,QF
(ht t p:// gdt .guidelinedevelopment .org/ cent ral_prod/_design/ client /
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MAKING THE RECOMMENDATIONS
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recommendat ions. This meet ing was facilit ated by
t wo co- chairs one wit h expert ise in GRADEand t he
ot her wit h clinical expert ise of chlamydia. During t he
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frameworks were presented by t he met hodologist s.
The GDG discussed each GRADE crit erion and judged
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and guideline recommendat ion was developed.
The goal was to arrive at agreement across all members
of t he GDG and t his was facilit ated by t he chairpersons
t hrough discussion. When t here was disagreement for a
criterion, it was noted in t he evidence- to- decision
framework for t he relevant judgement . If t here was
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t he plan was for t he GDG to vote and t he numbers to
be recorded. Because t here was no disagreement
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were not t aken or reported in t hese guidelines.
The GDG made a st rong or condit ional recommendat ion
for or against each intervent ion and described special
circumst ances in t he remarks. Research implicat ions
were also developed and presented, based on t he gaps
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elect ronically. All decisions and discussions from t he
GDG for each recommendat ion are available in t he
evidence- to- decision frameworks in Web annex D.
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
ANNEX C:
LISTS OF REFERENCES FOR REVIEWED EVIDENCE
RECOMMENDATION 1
Treat ment s for adult s and adolescent s wit h
uncomplicat ed genit al (cervix, uret hra)
chlamydial infect ions
Syst emat ic review
1. Pez- Canro C, Mart inez- Mart inez F, Alzat e JP, Let haby A, Gait n
HG. Ant ibiot ics for t reat ing genit al Chlamydiatrachomatis
LQIHFWLRQ LQ PHQ DQG QRQ SUHJQDQW ZRPHQ SURWRFRO
&RFKUDQH 'DWDEDVH 6\VW 5HY &'
Included st udies
1. Bowie WR, Yu JS, Fawcet t A, Jones HD. Tet racycline in
nongonococcal uret hrit is. Comparison of 2 g and 1 g daily
IRU VHYHQ GD\V %U - 9HQHU 'LV
2. Campbell WF, Dodson MG. Clindamycin t herapy for Chlamydia
t rachomatis LQ ZRPHQ $P - 2EVWHW *\QHFRO
3. Cramers M, Kaspersen P, From E, Mller BR. Pivampicillin
compared wit h eryt hromycin for t reat ing women wit h
genit al Chlamydiatrachomatis infect ion. Genit ourin
0HG
4. Csng PA, Gundersen T, Anest ad G. Doxycycline in t he
t reat ment of chlamydial uret hrit is: a t herapeut ic st udy.
3KDUPDWKHUDSHXWLFD
5. Fong IW, Lint on W, Simbul M, Thorup R, McLaughlin B, Rahm V,
HW DO 7UHDWPHQW RI QRQJRQRFRFFDO XUHWKULWLV ZLWK FLSURR[DFLQ
$P - 0HG $ XUHWKULWLV DQG FHUYLFLWLV 6H[ 7UDQVP 'LV
*HLVOHU :0 .ROWXQ :' $EGHOVD\HG 1 %XULJR - 0HQD / 7D\ORU
61 HW DO 6DIHW\ DQG HFDF\ RI :& YHUVXV YLEUDP\FLQ
for t he t reat ment of uncomplicat ed urogenit al Chlamydia
t rachomatis infect ion: a randomized, double- blind, double-
dummy act ive- cont rolled, mult icent er t rial. Clin Infect Dis.
GRL FLG FLV
7. Guven MA, Gunyeli I, Dogan M, Ciragil P, Bakaris S, Gul M.
7KH GHPRJUDSKLF DQG EHKDYLRXUDO SUROH RI ZRPHQ ZLWK
cervicit is infect ed wit h Chlamydiatrachomatis, Mycoplasma
hominis and Ureaplasma urealyt icum and t he comparison of t wo
PHGLFDO UHJLPHQV $UFK *\QHFRO 2EVWHW
8. Hammerschlag MR, Golden NH, Oh MK, Gelling M, St urdevant
M, Brown PR, et al. Single dose of azit hromycin for t he t reat ment
of genit al chlamydial infect ions in adolescent s. J Pediat r.
9. Hawkins DA, Taylor- Robinson D, Evans RT, Furr PM, Harris JR.
Unsuccessful t reat ment of non- gonococcal uret hrit is wit h
rosoxacin provides informat ion on t he aet iology of t he disease.
*HQLWRXULQ 0HG
+RRWRQ 70 5RJHUV 0( 0HGLQD 7* .XZDPXUD /( (ZHUV &
5REHUWV 3/ HW DO &LSURR[DFLQ FRPSDUHG ZLWK GR[\F\FOLQH
IRU QRQJRQRFRFFDO XUHWKULWLV ,QHHFWLYHQHVV DJDLQVW
Chlamydiatrachomatis due t o relapsing infect ion. JAMA.
39
11. Ibsen HH, Mller BR, Halkier- Srensen L, From E. Treat ment
RI QRQJRQRFRFFDO XUHWKULWLV FRPSDULVRQ RI RR[DFLQ DQG
HU\WKURP\FLQ 6H[ 7UDQVP 'LV
12. Kitchen VS, Donegan C, Ward H, Thomas B, Harris JR, Taylor-
5RELQVRQ ' &RPSDULVRQ RI RR[DFLQ ZLWK GR[\F\FOLQH LQ WKH
t reat ment of non- gonococcal uret hrit is and cervical chlamydial
LQIHFWLRQ - $QWLPLFURE &KHPRWKHU 6XSSO '
13. Lauharant a J, Saarinen K, Must onen MT, Happonen HP.
Single- dose oral azit hromycin versus seven- day doxycycline
in t he t reat ment of non- gonococcal uret hrit is in males. J
$QWLPLFURE &KHPRWKHU 6XSSO (
14. List er PJ, Balechandran T, Ridgway GL, Robinson AJ.
Comparison of azit hromycin and doxycycline in t he t reat ment
of non- gonococcal uret hrit is in men. J Ant imicrob Chemot her.
6XSSO (
15. Manhart LE, Gillespie CW, Lowens MS, Khosropour CM,
Colombara DV, Golden MR, et al. St andard t reat ment regimens
for nongonococcal uret hrit is have similar but declining
cure rat es: a randomized cont rolled t rial. Clin Infect Dis.
0DUWLQ '+ 0URF]NRZVNL 7) 'DOX =$ 0F&DUW\ - -RQHV
RB, Hopkins SJ, et al. A cont rolled t rial of a single dose of
azit hromycin for t he t reat ment of chlamydial uret hrit is and
cervicit is. The Azit hromycin for Chlamydial Infect ions St udy
*URXS 1 (QJO - 0HG
17. McCormack WM, Dalu ZA, Mart in DH, Hook EW 3rd, Laisi R,
.HOO 3 HW DO 7URYDR[DFLQ &KODP\GLDO 8UHWKULWLV &HUYLFLWLV
6WXG\ *URXS 'RXEOH EOLQG FRPSDULVRQ RI WURYDR[DFLQ DQG
doxycycline in t he t reat ment of uncomplicat ed Chlamydial
18. McCormack WM, Mart in DH, Hook EW 3rd, Jones RB. Daily oral
JUHSDR[DFLQ YV WZLFH GDLO\ RUDO GR[\F\FOLQH LQ WKH WUHDWPHQW RI
Chlamydiatrachomatis endocervical infect ion. Infect Dis Obst et
DQG *\QHFRO
19. Nilsen A, Halsos A, Johansen A, Hansen E, Trud E, Moseng
D, et al. A double blind st udy of single dose azit hromycin and
doxycycline in t he t reat ment of chlamydial uret hrit is in males.
*HQLWRXULQ 0HG
3HUHLUD &$ 0RQWDJQLQL 6' $ SURVSHFWLYH UDQGRPL]HG WULDO RI
RR[DFLQ YV GR[\F\FOLQH LQ WKH WUHDWPHQW RI QRQJRQRFRFFDO
uret hrit is caused by Chlamydiatrachomatis. Arquivos brasileiros
GH PHGLFLQD
21. Robson HG, Shah PP, Lalonde RG, Hayes L, Senikas VM.
Comparison of rosaramicin and eryt hromycin st earat e for
t reat ment of cervical infect ion wit h Chlamydiatrachomatis.
6H[ 7UDQV 'LV
22. St amm WE, Hicks CB, Mart in DH, Leone P, Hook EW 3rd,
Cooper RH, et al. Azit hromycin for empirical t reat ment of t he
nongonococcal uret hrit is syndrome in men. A randomized
GRXEOH EOLQG VWXG\ -$0$
23. Thambar IV, Simmons PD, Thin RN, Darougar S, Yearsley P.
Double- blind comparison of t wo regimens in t he t reat ment of
nongonococcal uret hrit is. Seven- day vs 21- day course of t riple
WHWUDF\FOLQF 'HWHFOR %U - 9HQHU 'LV
40 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

24. Topic A, Skerk V, Punt aric A, Milavec Puret ic V, Beus A, Begovac RECOMMENDATION 2
- $]LWKURP\FLQ RU JUDP GRVH LQ WKH WUHDWPHQW RI
pat ient s wit h asympt omat ic urogenit al chlamydial infect ions. J
&KHPRWKHU Treat ment s in adult s and adolescent s wit h
uncomplicat ed anorect al chlamydial infect ions
25. van der Willigen AH, Polak- Vogelzang AA, Habbema L,
:DJHQYRRUW -+ &OLQLFDO HFDF\ RI FLSURR[DFLQ YHUVXV
(excluding lymphogranuloma venereum
doxycycline in t he t reat ment of non- gonococcal uret hrit is
LQ PDOHV (XU - &OLQ 0LFURELRO ,QIHFW 'LV Syst emat ic review

1. Kong FY, Tabrizi SN, Fairley CK, Vodst rcil LA, Hust on WM, Chen
3DWLHQW YDOXHV DQG SUHIHUHQFHV DFFHSWDELOLW\ DQG FRVW VSHFLF WR 0 HW DO 7KH HFDF\ RI D]LWKURP\FLQ DQG GR[\F\FOLQH IRU WKH
chlamydial infect ions t reat ment of rect al chlamydia infect ion: a syst emat ic review
DQG PHWD DQDO\VLV - $QWLPLFURE &KHPRWKHU
1. Dixon- Woods M, Stokes T, Young B, Phelps K, Windridge
GRL MDF GNX
K, Shukla R. Choosing and using services for sexual healt h:
a qualit at ive st udy of women's views. Sex Transm Infect .
Included st udies

,QWHUQDWLRQDO GUXJ SULFH LQGLFDWRU JXLGH HGLWLRQ XSGDWHG 1. Ding A, Challenor R. Rect al chlamydia in het erosexual women:
DQQXDOO\ 0HGIRUG 0$ 0DQDJHPHQW 6FLHQFHV IRU +HDOWK PRUH TXHVWLRQV WKDQ DQVZHUV ,QW - 67' $,'6
KWWS HUF PVK RUJ GPSJXLGH SGI 'UXJ3ULFH*XLGHB SGI GRL
DFFHVVHG -XQH
2. Drummond F, Ryder N, Wand H, Guy R, Read P, McNult y AM, et
3. Sahin- Hodoglugil NN, Woods R, Pet t ifor A, Walsh J. A al. Is azit hromycin adequat e t reat ment for asympt omat ic rect al
FRPSDULVRQ RI FRVW HHFWLYHQHVV RI WKUHH SURWRFROV IRU FKODP\GLD" ,QW - 67' $,'6 GRL
diagnosis and t reat ment of gonococcal and chlamydial infect ions LMVD
LQ ZRPHQ LQ $IULFD 6H[ 7UDQVP 'LV
3. Elgalib A, Alexander S, Tong CY, Whit e JA. Seven days of
GR[\F\FOLQH LV DQ HHFWLYH WUHDWPHQW IRU DV\PSWRPDWLF UHFWDO
Pat ient values and preferences, accept abilit y and cost : ot her Chlamydiatrachomatis LQIHFWLRQ ,QW - 67' $,'6
sexually t ransmit t ed infect ions and condit ions GRL LMVD
1. Kingst on M, Carlin E. Treat ment of sexually t ransmit t ed 4. Hat horn E, Opie C, Goold P. What is t he appropriat e t reat ment
infect ions wit h single- dose t herapy: a double- edged sword. for t he management of rect al Chlamydiatrachomatis in men
'UXJV DQG ZRPHQ" 6H[ 7UDQV ,QIHFW GRL
VH[WUDQV
2. Nagarkar A, Mhaskar P. A syst emat ic review on t he prevalence
and ut ilizat ion of healt h care services for reproduct ive t ract 5. Khosropour CM, Dombrowski JC, Barbee LA, Manhart LE,
infect ions/ sexually t ransmit t ed infect ions: evidence from India. Golden MR. Comparing azit hromycin and doxycycline for
,QGLDQ - 6H[ 7UDQVP 'LV GRL t he t reat ment of rect al chlamydial infect ion: a ret rospect ive
FRKRUW VWXG\ 6H[ 7UDQVP 'LV GRL
2/4
3. Ryan R, Sant esso N, Lowe D, Hill S, Grimshaw J, Prict or M,
HW DO ,QWHUYHQWLRQV WR LPSURYH VDIH DQG HHFWLYH PHGLFLQHV .KRVURSRXU &0 'XDQ 5 0HWVFK /5 )HDVWHU '- *ROGHQ
use by consumers: an overview of syst emat ic reviews. MR. Persist ent / recurrent chlamydial infect ion among STD
&RFKUDQH 'DWDEDVH 6\VW 5HY &' clinic pat ient s t reat ed wit h CDC- recommended t herapies.
Abst ract s of t he STI and AIDS World Congress, Vienna,
Addit ional references $XVWULD 6H[ 7UDQVP ,QIHFW 6XSSO $ GRL
VH[WUDQV
1. Amin A, Garcia Moreno C. Addressing gender- based violence
WR UHGXFH ULVN RI 67, DQG +,9 6H[ 7UDQVP ,QIHFW 7. St eedman NM, McMillan A. Treat ment of asympt omat ic rect al
6XSSO $ GRL VH[WUDQV Chlamydiatrachomatis LV VLQJOH GRVH D]LWKURP\FLQ HHFWLYH" ,QW
- 67' $,'6 GRL LMVD
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K, Shukla R. Choosing and using services for sexual healt h:
4. Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo
a qualit at ive st udy of women's views. Sex Transm Infect .
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Pat ient values and preferences, accept abilit y and cost : ot her
sexually t ransmit t ed infect ions and condit ions
1. Nagarkar A, Mhaskar P. A syst emat ic review on t he prevalence
and ut ilizat ion of healt h care services for reproduct ive t ract
infect ions/ sexually t ransmit t ed infect ions: evidence from India.
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violence t o reduce risk of STI and HIV. Sex Transm Infect .
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M, Low N, et al. Global est imat es of t he prevalence and
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1. Brocklehurst P, Gordon A, Heat ley E, Milan SJ. Ant ibiot ics for t
reat ing bact erial vaginosis in pregnancy. Cochrane Dat abase
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Included st udies
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Chlamydia in pregnancy: a randomized t rial of azit hromycin and
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2. Alary M, Joly JR, Mout quin JM, Mondor M, Boucher M, Fort ier A,
et al. Randomised comparison of amoxicillin and eryt hromycin in
t reat ment of genit al chlamydial infect ion in pregnancy. Lancet .
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5. Bush MR, Rosa C. Azit hromycin and eryt hromycin in t he
t reat ment of cervical chlamydial infect ion during pregnancy.
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Sweet RL. Amoxicillin t herapy for Chlamydiatrachomatis in
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7. Edwards MS, Newman RB, Cart er SG, Leboeuf FW, Menard MK,
Rainwat er KP. Randomized clinical t rial of azit hromycin for t he t
reat ment of Chlamydia cervicit is in pregnancy. Infect Dis
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8. Jacobson GF, Aut ry AM, Kirby RS, Liverman EM, Mot ley RU.
A randomized cont rolled t rial comparing amoxicillin and
azit hromycin for t he t reat ment of Chlamydiatrachomatis in
SUHJQDQF\ $P - 2EVWHW *\QHFRO
9. Kacmar J, Cheh E, Mont agno A, Peipert JF. A randomized
t rial of azit hromycin versus amoxicillin for t he t reat ment of
Chlamydiatrachomatis in pregnancy. Infect Dis Obst et Gynecol.
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blind randomized st udy comparing amoxicillin and eryt hromycin
for t he t reat ment of Chlamydiatrachomatis in pregnancy. Obst et
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chlamydial infect ion in pregnancy. Infect Dis Obst et Gynecol.
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17. Silverman NS, Sullivan M, Hochman M, Womack M, Jungkind
DL. A randomized, prospect ive t rial comparing amoxicillin and
eryt hromycin for t he t reat ment of Chlamydiatrachomatis in
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st udy comparing eryt hromycin, amoxicillin and clindamycin for t
he t reat ment of Chlamydiatrachomatis in pregnancy. Infect Dis
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0RUHQF\ $0 %XMROG ( 7KH HHFW RI VHFRQG WULPHVWHU DQWLELRWLF
t herapy on t he rate of pret erm birt h. J Obst et Gynaecol Treat ment s for adult s and adolescent s wit h
&DQ lymphogranuloma venereum
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GRL M [
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DFFHVVHG -XQH syphilis and venereal lymphogranulomat osis wit h doxycycline].
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3. Pit souni E, Iavazzo C, At hanasiou S, Falagas ME. Single- dose
azit hromycin versus eryt hromycin or amoxicillin for Chlamydia +LOO 6& +RGVRQ / 6PLWK $ $Q DXGLW RQ WKH PDQDJHPHQW
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of randomised cont rolled t rials. Int J Ant imicrob Agent s. /RQGRQ 8. ,QW - 67' $,'6 GRL
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7. Kamarashev J, Riess CE, Mosimann J, Luchlf S.

Pat ient values and preferences, accept abilit y and cost : ot her Lymphogranuloma venereum in Zurich, Swit zerland: Chlamydia
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infect ions/ sexually t ransmit t ed infect ions: evidence from (FDF\ RI VWUHSWRP\FLQ FKORUDPSKHQLFRO FR WULPR[D]ROH
,QGLD ,QGLDQ - 6H[ 7UDQVP 'LV and doxycycline in lymphogranuloma venereum. Indian J Sex
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regional, and nat ional incidence, prevalence, and years lived -0 5RGUJXH] & +HOOLQ 7 HW DO &OLQLFDO DQG HSLGHPLRORJLFDO
ZLWK GLVDELOLW\ IRU DFXWH DQG FKURQLF GLVHDVHV DQG LQMXULHV LQ charact erizat ion of a lymphogranuloma venereum out break
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Audit of t he clinical management of lymphogranuloma venereum
in t hree inner- cit y genit ourinary medicine clinics. Int ernat ional
Journal of STD and AIDS, Conference, 11t h Spring Meet ing of
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2. Sahin- Hodoglugil NN, Woods R, Pet t ifor A, Walsh J. A
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LQ ZRPHQ LQ $IULFD 6H[ 7UDQVP 'LV
Pat ient values and preferences, accept abilit y and cost
1. Nagarkar A, Mhaskar P. A syst emat ic review on t he prevalence
and ut ilizat ion of healt h care services for reproduct ive t ract
infect ions/ sexually t ransmit t ed infect ions: evidence from India.
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Included st udies
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JE. Treat ment of neonat al chlamydial conjunct ivit is wit h
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Nelson JD. Oral v t opical eryt hromycin t herapies for
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in newborns and adult s wit h eryt hromycin and roxit hromycin.
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chlamydial infect ions
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'DUOLQJ (. 0F'RQDOG + $ PHWD DQDO\VLV RI WKH HFDF\ RI RFXODU
prophylact ic agent s used for t he prevent ion of gonococcal
and chlamydial opht halmia neonat orum. J Midwifery Womens
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Chlamydiatrachomatis causing neonat al conjunct ivit is in a
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Included st udies Resist ance dat a

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3HGLDWU ,QIHFW 'LV -

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of silver nit rat e, t et racycline, eryt hromycin and no prophylaxis.
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povidone iodine 2.5% and t et racycline 1% in prevent ion of
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as prophylaxis against opht halmia neonat orum. N Engl J Med.
3. Ison CA, Terry P, Bendayna K, Gill MJ, Adams J, Woodford N.
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St at es of st rains of Neisseriagonorrhoeae wit h plasmid-
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Chiang WT, Kout sky L, et al. Eryt hromycin oint ment $ FRVW HHFWLYHQHVV DQDO\VLV RI WKH &KODP\GLD 0RQGD\ D
communit y- based int ervent ion t o decrease t he prevalence of
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