WHO GUIDELINES FORTHE

Treat ment of
Chlamydia t rachomat is
WHO Library Cat aloguing- in- Publicat ion Dat a

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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Recommendat ion 7
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 SURFHVV IRU KHU KDUG ZRUN DQG
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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.
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 infect ions (STIs) are a

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and mort alit 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
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cases of chlamydial infect ion.
2 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

Chlamydial infect ion, caused by Chlamydia t rachomat is, OBJECTIVES

is t he most common bacterial STI and result s in
subst ant ial morbidit y and economic cost worldwide. The object ives of t hese guidelines are:
Occurring most commonly among young sexually act
to provide evidence- based guidance on t reat
ive adult s, C. t rachomatis causes cervicit is in women
ment of infect ion wit h C. t rachomat is DQG
and uret hrit is in men, as well as ext ra- genit al infect
ions, including rect al and oropharyngeal infect ions. to support count ries to update t heir nat ional
Asymptomat ic infect ions are common in bot h men guidelines for t reat ment of chlamydial infect
and women. Unt reated chlamydial infect ion may ion.
cause severe complicat ions in t he upper reproduct
ive t ract , primarily in young women, including METHODS
ectopic
These guidelines were developed following t he
pregnancy, salpingit is and infert ilit y. Lymphogranuloma
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guideline development . The Guideline Development
of C. t rachomat is, is increasingly prevalent among
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clinicians, researchers and programme managers.
Maternal infect ion is associat ed wit h serious adverse
outcomes in neonates, such as preterm birt h, low birt h The GDG priorit ized quest ions and outcomes
weight , conjunct ivit is, nasopharyngeal infect ion and related to t reat ment of chlamydial infect ions to
pneumonia. C. t rachomatis can be diagnosed by culture, include
GLUHFW LPPXQRXRUHVFHQFH DVVD\V ')$V DQG HQ]\PH in t his update, and a met hodologist and a team of
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he WHO Collaborat ing Cent re for Evidence-
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Informed Policy, independent ly conducted systemat
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RATIONALE FORTHE GUIDELINES chlamydial infect ions. The evidence was assessed
Since t he publicat ion of t he World Healt h Organizat ion using t he Grading of Recommendat ions Assessment ,
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epidemiology of STIs and advancement s in prevent ion, managed according to WHO guidelines and declared
before t he recommendat ions were discussed and
diagnosis and t reat ment necessit ate changes in
STI management . These guidelines provide updated QDOL]HG 5HVHDUFK LPSOLFDWLRQV ZHUH DOVR GHYHORSHG
t reat ment recommendat ions for common infect by t he GDG.
ions caused by C. t rachomatis based on t he most
recent HYLGHQFH WKH\ IRUP RQH RI VHYHUDO PRGXOHV RECOMMENDATIONS
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The current guidelines provide nine t reat ment
IRFXV
recommendat ions for genit al infect ions and LGV
on t reat ment s for Neisseria gonorrhoeae JRQRUUKRHD
caused by C. t rachomat is. The recommendat ions
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summarized in Table 1 apply to adult s, adolescent s
and Treponema pallidum V\SKLOLV ,Q DGGLWLRQ IXWXUH
work will provide guidance for syphilis screening and \HDUV RI DJH SHRSOH OLYLQJ ZLWK +,9 DQG
key populat ions, including sex workers, MSM and
t reat ment of pregnant women, STI syndromic
approach, clinical management , STI prevent ion, and t WUDQVJHQGHU SHUVRQV 6SHFLF UHFRPPHQGDWLRQV KDYH
also been developed for genit al chlamydial infect ion
reat ment s of ot her STIs. It is st rongly recommended t
in pregnant women and for prophylaxis and t reat
hat count ries
ment of opht halmia neonatorum caused by C. t
t ake updated global guidance into account as t hey
rachomat is.
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.
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
recommendatio
The WHO STI guideline suggest s t reat ment wit h one of t he following opt ions:
n, moderate
azit hromycin 1 g orally as a single dose qualit y
GR[\F\FOLQH PJ RUDOO\ WZLFH D GD\ IRU GD\V evidence

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 GLHUHQW VHWWLQJV DQG HTXLW\ FRQVLGHUDWLRQV :KHQ KLJK YDOXH LV
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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
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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
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t reat accordingly. Doxycycline should not be used in pregnant women because
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Genit al chlamydial infect ion in pregnant women
Recommendat ion 3a St rong
The WHO STI guideline recommends t reat ment wit h azit hromycin over eryt recommendation,
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
Recommendat ion 3c
evidence
The WHO STI guideline suggest s t reat ment wit h amoxicillin over eryt
Conditional
hromycin. Dosages:
recommendation
azit hromycin 1 g orally as a single dose , low qualit y
DPR[LFLOOLQ PJ RUDOO\ WKUHH WLPHV D GD\ IRU GD\V evidence

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,
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very low qualit y
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evidence
Remarks: *RRG SUDFWLFH GLFWDWHV HHFWLYH WUHDWPHQW RI /*9 LQ SDUWLFXODU IRU PHQ
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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 St rong
recommendation,
In neonates wit h chlamydial conjunct ivit is, t he WHO STI guideline
very low qualit y
recommends WUHDWPHQW ZLWK D]LWKURP\FLQ PJ NJ GD\ RUDOO\ RQH GRVH
evidence
GDLO\ IRU GD\V RYHU HU\WKURP\FLQ PJ NJ GD\ RUDOO\ LQ IRXU GLYLGHG GRVHV
GDLO\ IRU GD\V
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.
Recommendat ion 6 St rong rec
For all neonates, t he WHO STI guideline recommends topical ocular prophylaxis for t he prevent ion of gonococcal and chlamydial opht

Recommendat ion 7
For ocular prophylaxis, t he WHO STI guideline suggest s one of t he following opt ions for topical applicat ion to bot h eyes immediately
Conditiona
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 .
Remarks: 5HFRPPHQGDWLRQV DQG DSSO\ WR WKH SUHYHQWLRQ RI ERWK FKODP\GLDO DQG
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
t he topical t reat ment and to provide a water- based solut ion of povidone iodine.
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OVERVIEW OF THE GUIDELINES FOR THE
PREVENTION, TREATMENT AND MANAGEMENT OF STIs
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STI EPIDEMIOLOGY AND BURDEN The psychological consequences of STIs include
6H[XDOO\ WUDQVPLWWHG LQIHFWLRQV 67,V DUH D PDMRU st igma, shame and loss of self- wort h. STIs have also
SXEOLF KHDOWK SUREOHP ZRUOGZLGH DHFWLQJ TXDOLW\ been associat ed wit h relat ionship disrupt ion and
of life and causing serious morbidit y and mort alit gender- based violence (6).
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 LPPXQRGHFLHQF\ YLUXV +,9 DQG WKXV WKH\ DOVR
KDYH
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 DJHV LQFOXGLQJ WDUJHW WR HQG SUHYHQWDEOH
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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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and t arget 3.8 to achieve universal healt h coverage.
Worldwide, more t han a million curable STIs are
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357 million new cases of curable STIs among adult s
aged 1549 years worldwide: 131 million cases of
chlamydia,
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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,
VXFK DV SHOYLF LQDPPDWRU\ GLVHDVH LQIHUWLOLW\
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

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
H[WHQGHG VSHFWUXP WKLUG JHQHUDWLRQ FHSKDORVSRULQV
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).
A WHO STI expert consult at ion recommended 1HZ UDSLG SRLQW RI FDUH GLDJQRVWLF WHVWV 32&7V DUH
XSGDWLQJ WKH :+2 JXLGHOLQHV IRU WKH UVW DQG changing STI management . Rapid syphilis diagnost ic
second- line t reat ment s for C. t rachomat is, increasing test s are now widely available, making syphilis
WKH GRVDJH RI FHIWULD[RQH WR PJ IRU WUHDWPHQW screening more widely accessible and allowing for
of N. gonorrhoeae wit h cont inued monitoring of earlier init iat ion RI WUHDWPHQW IRU WKRVH ZKR WHVW
ant imicrobial suscept ibilit y, and considerat ion of
SRVLWLYH (RUWV DUH
ZKHWKHU D]LWKURP\FLQ J VLQJOH GRVH VKRXOG
under way to develop POCTs for ot her STIs t hat will
EH augment syndromic management of symptomat ic
recommended in early syphilis (16). cases and increase t he abilit y to ident ify asymptomat
The epidemiology of STIs is changing, wit h viral ic infect ions (12). Updated guidelines are needed t hat
pat hogens becoming more prevalent t han bacterial incorporate rapid test s into syndromic management
HWLRORJLHV IRU VRPH FRQGLWLRQV WKLV PHDQV WKDW XSGDWHG of STIs and provide algorit hms for test ing and
informat ion is required to inform locally appropriate screening (16).
prevent ion and t reat ment st rategies. An Alt hough recent technological advances in diagnost ics,
increasing proport ion of genit al ulcers are now due WKHUDSHXWLFV YDFFLQHV DQG EDUULHU PHWKRGV RHU EHWWHU
to viral opportunit ies for t he prevent ion and care of STIs,
infect ions as previously common bacterial infect access to t hese technologies is st ill limited, part icularly
ions, such as chancroid, approach eliminat ion in in areas where t he burden of infect ion is highest . For
many count ries (16, 17). As recommended during t opt imal HHFWLYHQHVV JOREDO JXLGHOLQHV IRU WKH
he STI expert consult at ion, t reat ment guidelines
PDQDJHPHQW
for genit al
of STIs need to include approaches for set t ings wit h
XOFHU GLVHDVH *8' VKRXOG EH XSGDWHG WR LQFOXGH +69
limited access to modern technologies, as well as for
t reat ment and a longer t reat ment durat ion for HSV-
set t ings in which t hese technologies are available.
2 should be explored. In addit ion, suppressive t
herapy for HSV-2 should be considered in areas wit h It is st rongly recommended t hat count ries t ake
high HIV prevalence (16). The chronic, lifelong nature updated global guidance into account as t hey est ablish
of viral st andardized nat ional protocols, adapt ing t his
infect ions also requires t hat renewed at tent ion be paid guidance to t he local epidemiological sit uat ion and ant
WR GHYHORSLQJ HHFWLYH SUHYHQWLRQ VWUDWHJLHV LQFOXGLQJ imicrobial suscept ibilit y dat a. St andardizat ion
expanding accessibilit y to available vaccines for HPV ensures t hat all
and development of new vaccines for HSV-2. pat ient s receive adequate t reat ment at every level
of healt h- care services, opt imizes t he t raining and
,Q WKH :+2 JXLGHOLQHV D V\QGURPLF DSSURDFK
supervision of healt h- care providers and facilit ates
was recommended for t he management of STIs.
procurement of medicines. It is recommended t hat
The approach guides t he diagnosis of STIs based on
QDWLRQDO JXLGHOLQHV IRU WKH HHFWLYH PDQDJHPHQW RI
LGHQWLFDWLRQ RI FRQVLVWHQW JURXSV RI V\PSWRPV DQG
STIs be developed in close consult at ion wit h local STI,
easily recognized signs and indicates t reat ment
public healt h and laboratory expert s.
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).
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
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 :
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1 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
LABORATORY DIAGNOSIS to support count ries to update t heir nat ional
guidelines for t reat ment of chlamydial infect ion.
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.

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
1.4 TARGET AUDIENCE
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

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
PDQDJHUV $QQH[ $ $ FRUH VXEJURXS WR IRFXV RQ
t he guidelines related to chlamydia was created
wit hin t he GDG, to provide more intensive feedback
WKURXJKRXW WKH SURFHVV $QQH[ $ 7KH *'*
part icipated in meet ings and teleconferences to
priorit ize t he quest ions to be addressed, discuss t
he HYLGHQFH UHYLHZV DQG QDOL]H WKH
UHFRPPHQGDWLRQV 7KH *'* UHYLHZHG DQG DSSURYHG
WKH QDO YHUVLRQ
of t he guidelines.
2.2 QUESTIONS AND OUTCOMES
,Q 'HFHPEHU WKH UVW *'* PHHWLQJ ZDV KHOG
to ident ify and agree on t he key PICO (populat ion,
LQWHUYHQWLRQ FRPSDUDWRU RXWFRPH TXHVWLRQV WKDW
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
DQG LPSRUWDQFH 6L[ 3,&2 TXHVWLRQV ZHUH LGHQWLHG IRU
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 SHUIRUPHG IURP 0DUFK WR 2FWREHU
$GGLWLRQDO
searches were conducted to ident ify studies on pat ient
values and preferences (e.g. qualit at ive research
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screened studies, ext racted and analysed t he dat a,
and assessed t he qualit y/ cert aint y of t he evidence
using t he Grading of Recommendat ions Assessment
, 'HYHORSPHQW DQG (YDOXDWLRQ *5$'( DSSURDFK 1
1 For more informat ion, see: ht t p:// www.gradeworkinggroup.org/
The qualit y/ cert aint y of t he evidence was
assessed at four levels:
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OLHV FORVH WR WKDW RI WKH HVWLPDWH RI WKH HHFW
0RGHUDWH :H DUH PRGHUDWHO\ FRQGHQW LQ WKH
HHFW HVWLPDWH WKH WUXH HHFW LV OLNHO\ WR EH FORVH
WR WKH HVWLPDWH RI WKH HHFW EXW WKHUH LV D SRVVLELOLW\
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of t he recommendat ions. Following t he meet ing, t he
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DQG QDO DSSURYDO ZDV REWDLQHG IURP DOO *'*
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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 DUH OLVWHG LQ $QQH[ $

/RZ 2XU FRQGHQFH LQ WKH HHFW HVWLPDWH LV According to t he GRADEapproach, t he st rengt h

OLPLWHG WKH WUXH HHFW PD\ EH VXEVWDQWLDOO\ of each recommendat ion was rated as eit her
GLHUHQW IURP WKH HVWLPDWH RI WKH HHFW st rong or condit ional. St rong recommendat ions are
presented using t he wording The WHO STI guideline
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recommends, while condit ional recommendat ions
HHFW HVWLPDWH WKH WUXH HHFW LV OLNHO\ WR EH
are worded as The WHO STI guideline suggest s
VXEVWDQWLDOO\ GLHUHQW IURP WKH HVWLPDWH RI HHFW
t hroughout t he guidelines. The implicat ions of t he
In addit ion, t he direct cost s of medicines were est GLHULQJ VWUHQJWKV RI UHFRPPHQGDWLRQV IRU SDWLHQWV
imated clinicians and policy- makers are explained in det ail
XVLQJ WKH 0DQDJHPHQW 6FLHQFHV IRU +HDOWK 06+ in Table 3.
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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DQQH[HV ' DQG (

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 DOO VWDNHKROGHUV LQFOXGLQJ SHRSOH DHFWHG E\
67,V
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
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 The recommendat ion can be adopted as
policy- policy in most sit uat ions.
makers
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 ZLWK WKH LQGLYLGXDOV
YDOXHV DQG SUHIHUHQFHV
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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UHODWHG WR 67, WUHDWPHQW 2WKHU QRWLHG LQWHUHVWV ZHUH
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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
TH
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
JXLGDQFH RQ ,QWURGXFLQJ :+2V UHSURGXFWLYH KHDOWK
guidelines and tools into nat ional programmes (12).
1
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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.
1 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
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/
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, HFDF\ URXWH DQG IUHTXHQF\ RI DGPLQLVWUDWLRQ
BOX 1. CRITERIA FORTHE SELECTION OF MEDICINES FORTHE TREATMENT
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Low cost
Low toxicit y levels
Organism resist ance unlikely to develop or likely to be delayed underst and t he need to subsidize STI medicines.
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 essentSURW
IDENTIFYING AND PROCURING STI DRUGS
It is import ant not only to ident ify medicines t hat will
EH UHFRPPHQGHG DV UVW OLQH WUHDWPHQW IRU 67,V EXW
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.
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 DQG WKH SDWLHQW FDQQRW DRUG WR EX\ WKH
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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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Low- cost STI medicines can be obt ained t hrough
internat ional vendors of generic product s, non-
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ial medicines ZLWKselect
list s. When SURFXUHPHQW VFKHPHV
ing medicines, VXFK ion should be giv
considerat
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 .

RECOM
FOR
OF
I release formulat ion may prohibit it s use. Note t hat
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developed for opht halmia neonatorum
caused by C. t rachomat is.
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
GR[\F\FOLQH PJ RUDOO\ WZLFH D GD\ IRU GD\V
or one of t hese alternat ives:
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HU\WKURP\FLQ PJ RUDOO\ IRXU WLPHV D GD\ IRU
GD\V
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Condit ional recommendation, moderate qualit y
evidence
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 TXDOLW\ RI WKH PHGLFLQHV LQ GLHUHQW VHWWLQJV
DQG HTXLW\
considerat ions. When high value is placed on
reducing cost s, doxycycline in a st andard dose may
be t he best FKRLFH ZKHQ KLJK YDOXH LV SODFHG RQ
FRQYHQLHQFH
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-
doxycycline, tet racycline DQG RR[DFLQ DUH
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VHH UHFRPPHQGDWLRQV D F
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, FRPSOLFDWLRQV VLGH HHFWV
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FRPSOLDQFH TXDOLW\ RI OLIH +,9
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
GLHUHQFHV EHWZHHQ D]LWKURP\FLQ J DQG GR[\F\FOLQH
PJ RUDOO\ WZLFH D GD\ IRU GD\V LQ WKH QXPEHUV
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-
HHFWV WKDQ VWDQGDUG GRVH GR[\F\FOLQH 2R[DFLQ PD\
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
ZHHNV WR D VLQJOH GRVH PRUH SHRSOH PD\ EH FXUHG
EXW
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
*'* DJUHHG WKDW WKHUH LV SUREDEO\ QR YDULDELOLW\ LQ
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 FRPSOLDQFH RYHU PXOWL GRVH UHJLPHQV
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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
0\FRSODVPD JHQLWDOLXP WKDW RIWHQ FR RFFXU ZLWK
chlamydia may rest rict t he use of some medicines,
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FRVWV PD\ GLHU EHWZHHQ FRXQWULHV LQ SODFHV ZLWK
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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
GLHUHQFHV DUH DOVR WULYLDO ZLWK WKH RWKHU PHGLFLQHV
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, LQFOXGLQJ HYLGHQFH SUROHV DQG HYLGHQFH WR
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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], WUDQVJHQGHU SHUVRQV DQG IHPDOH VH[
ZRUNHUV DERXW
anal sex and t reat accordingly. Doxycycline should
not be used in pregnant women because of
adverse HHFWV VHH UHFRPPHQGDWLRQV D F
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
IHPDOH VH[ ZRUNHUV
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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PLFURELRORJLFDO FXUHV SHU SHRSOH ZLWK
D]LWKURP\FLQ
FRPSDUHG ZLWK GR[\F\FOLQH 55 &,
WR (YLGHQFH IURP VWXGLHV RI JHQLWDO LQIHFWLRQV
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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
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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.
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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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.
St rong 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.
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
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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
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WR 7KHUH PD\ EH VOLJKWO\ IHZHU VLGH HHFWV
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azit hromycin compared wit h eryt hromycin or amoxicillin
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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
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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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2 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

4.4 LYMPHOGRANULOMA VENEREUM (LGV) condit ions indicates t hat adherence may be improved
wit h simpler medicat ion regimens. There is lit t le
RECOMMENDATION 4 evidence for equit y issues and feasibilit y, but t he GDG

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
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alternat ive. Doxycycline should not be used in
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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,
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compliance and LGV t ransmission to part ners.
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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
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OLWWOH
to no evidence for accept abilit y, but research in ot her
 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS
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, LQFOXGLQJ HYLGHQFH SUROHV DQG
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4.5 OPHTHALMIA NEONATORUM
RECOMMENDATION 5
In neonates wit h chlamydial conjunct ivit is, t he
WHO STI guideline recommends using oral azit
hromycin
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RYHU HU\WKURP\FLQ PJ NJ GD\ RUDOO\ LQ IRXU
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doses daily for 14 days.
2
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
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small numbers of neonates receiving azit hromycin in
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qualit y evidence for 7 more inst ances of pyloric stenosis
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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
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,
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5(&200(1'$7,21
For all neonates, t he WHO STI guideline recommends
topical ocular prophylaxis for t he prevent ion of
gonococcal and chlamydial opht halmia neonatorum.
St rong recommendation, low qualit y evidence
RECOMMENDATION 7
For ocular prophylaxis, t he WHO STI guideline suggest
s one of t he following opt ions for topical applicat ion
to bot h eyes immediately after birt h:
tet racycline hydrochloride 1% eye oint ment
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SRYLGRQH LRGLQH VROXWLRQ ZDWHU EDVHG
silver nit rate 1% solut ion
chloramphenicol 1% eye oint ment .
Condit ional recommendation, low qualit y evidence
Remarks: 5HFRPPHQGDWLRQV DQG DSSO\ WR WKH
prevent ion of bot h chlamydial and 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.
Alcohol- based povidone iodine solut ion must not be
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.
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RI WKH GLHUHQW PHGLFDWLRQV LV QHHGHG LQ
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comparisons wit h chloramphenicol.
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.
Few dat a are available for t he incidence of non-
infect ious conjunct ivit is after prophylaxis or no
prophylaxis. Low qualit y evidence shows a slight
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EHWZHHQ DQG SHU LQIDQWV KDYH QRQ LQIHFWLRXV
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medicat ions. There is lit t le evidence relat ing to pat
ient values and preferences, but t he GDG agreed t
hat WKHUH ZRXOG OLNHO\ EH OLWWOH GLHUHQFH LQ WKH KLJK
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placed on avoiding long- term consequences of bot h
gonococcal and chlamydial conjunct ivit is. The GDG also
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equit y and feasibilit y, as prophylaxis is current ly
used in many count ries. The GDG reported t hat
alcohol- based povidone iodine has erroneously
been used
as prophylaxis result ing in serious harm to babies.
Silver nit rate is t he most expensive prophylaxis opt
ion.
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SUHYHQW RSKWKDOPLD QHRQDWRUXP DQG WKHVH EHQHWV
out weigh t he risk of non- infect ious conjunct ivit is
due to prophyalaxis wit h any of t he topical medicat
ions.
Some topical medicat ions may provide greater
protect ion (t et racycline hydrochloride, eryt hromycin
RU SRYLGRQH LRGLQH EXW DOO DUH IHDVLEOH WR SURYLGH
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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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

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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
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Manila Philippines
4. Frank Lule $IULFDQ 5HJLRQ $)5
Brazzaville Congo
5. Razia 6RXWK (DVW $VLD 5HJLRQ 6($5
Pendse New Delhi India
and WHO Count ry Represent at ive, Bhut an
Ornella Lincet t o
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
 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
development process) Research 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 Depart ment of Reproduct ive Healt h and
he development process) Research Human Reproduct ion Team

METHODOLOGIST
Nancy Sant esso

Depart ment of Clinical Epidemiology and Biost at ist ics

McMaster Universit y
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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
STI GUIDELINE DEVELOPMENT GROUP

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

Name and address Region Sex

1. <DZ 6D[ $GX 6DUNRGLH AFR M
School of Medical Sciences
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PO Box 1934, Bant ama
Kumasi Ghana
2. Andrew Amat o EUR M
European Cent re for Disease Prevent ion and
Cont rol Tomtebodavgen 11a
171 83
Stockholm
Sweden
3. Gail Bolan AMR F
Centers for Disease Cont rol and Prevent ion
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$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
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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
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
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Swit zerland
17. David Mabey EUR M
Communicable Diseases
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Keppel St reet
London WC1E
7HT United
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 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS 2

18. Angelica Espinosa Miranda AMR F

Ncleo de Doenas Infecciosas
Universidade Federal do Espirito
Santo Av. Marechal Campos
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Brazil
19. Nelly Mugo AFR F
Kenya Medical Research Inst it
ute Mbagat hi Rd.
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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
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Universit y of California, San
Francisco San Francisco, CA 94143
USA
23. .HLWK 5DGFOLH EUR M
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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
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Hamilton, Ont ario L8N
3Z5 Canada
Richard St een EUR M
Localit
Cassaluvo
Diano San Piet
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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
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Anna Wald AMR F
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Washington Virology
Research Clinic
Harborview Medical
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Depart ment of Global Healt h
Professor of Global Healt h and
Medicine Adjunct Professor of
Epidemiology Universit y of
Washington
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Division of Communit y Acquired Infect ions
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rol Public Healt h Agency of Canada
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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
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Minist ry of Healt h
STI, AIDS and Viral Hepat it is Depart
ment SAF Sul Trecho 2, Ed. Premium
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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
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5. Anjana Das SEAR F

)+,
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Delhi
India
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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
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Service des MST-
sida Minist ry of
Healt h
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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
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London School of Hygiene and Tropical
Medicine Keppel St reet
London WC1E
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ANNEX B:
DETAILED METHODS FOR GUIDELINE DEVELOPMENT
QUESTIONS AND OUTCOMES
To determine which recommendat ions to update,
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ions, Brit ish Associat ion for Sexual Healt h and
HIV
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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
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t ransmissible infect ions, Sexual Healt h Societ y
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were priorit ized:
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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.
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guidelines t hat were selected by t he GDG to be
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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
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guidelines t hat are part of ot her nat ional guidelines,
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of set t ings, or it is unlikely t hat new research or
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recommendat ions for t hese condit ions t hat can be
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decided on t he init ial list of populat ion, intervent ion,
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by WHO. After t he meet ing, surveys pert aining to
each of t he four STI topic areas (i.e. gonorrhoea,
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>+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
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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.
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7 Available at : ht t p:// www.iust i.org/ regions/ europe/ euroguidelines.ht m
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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
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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
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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.
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chlamydial infect ions guideline. Each quest ion is
framed using t he PICO format (populat ion, intervent ion,
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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 Doxycycline extended release Crit ical: Clinical cure,
adolescent s orally x 1 dose (5 PJ GDLO\ [ GD\V microbiological cure, STI
wit h 'R[\F\FOLQH PJ (U\WKURP\FLQ PJ FRPSOLFDWLRQV VLGH
uncomplicated t wice daily x 7 days RUDOO\ HHFWV
genit al four t imes daily x 7 days (including allergy, toxicit y,
(cervix, Eryt hromycin et hylsuccinate JDVWUR FRPSOLDQFH
XUHWKUD (6 PJ RUDOO\ IRXU WLPHV
Import ant : Qualit y of life,
chlamydial daily x 7 days
HIV t ransmission and
infect ions (U\WKURP\FLQ PJ
acquisit ion, part ner t
RUDOO\ WZLFH GDLO\ [
ransmission
GD\V
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t hrice daily x 7

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

3ac. Chlamydia in pregnancy

Populat ion Int ervent ion Comparat or Out come

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

4. Lymphogranuloma venereum (LGV) in all populat ions

Populat ion Int ervent ion Comparat or Out come

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

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
wit h PJ NJ GD\ PJ NJ GD\ RU PJ NJ GD\ cure,
neonat al $]LWKURP\FLQ PJ NJ GD\ RUDOO\ GDLO\ [ GD\V microbiological
conjunct 7ULPHWKRSULP PJ VXOID PJ RUDOO\ WZLFH cure,
ivit is GDLO\ &RPSOLFDWLRQV VLGH HHFWV
[ GD\V (including allergy, toxicit y,
JDVWUR DQWLPLFURELDO

6 and 7. Opht halmia neonat orum prophylaxis

Populat ion Int ervent ion and comparat or Out come

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

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

OF INTERVENTIONS &HQWUDO 5HJLVWHU RI &RQWUROOHG 7ULDOV &(175$/
To avoid duplicat ion of reviews t hat have been MEDLINEand Embase dat abases. Search end dates for
previously published, evidence was searched using each PICO quest ion varied bet ween March and
D KLHUDUFKLFDO DSSURDFK 7KH WHDP UVW VHDUFKHG October
IRU VHH OLVW EHORZ 7KH VWUDWHJLHV LQFOXGHG VHDUFKLQJ
for subject headings and text words t hat included
synt hesized evidence t hen searched t he primary
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studies for all t he factors needed to complete t he
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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
IHDVLELOLW\ HTXLW\ DQG FRVWV
ical and import ant outcomes, and non- randomized
The hierarchical approach consisted of ident ifying studies for crit ical outcomes when no evidence was
pre- exist ing synt hesized evidence, including from available
previously published guidelines t hat included systemat ic from RCTs.
reviews of t he lit erature. When synt hesized evidence
Search end dat es:
DERXW EHQHWV DQG KDUPV IRU DQ LQWHUYHQWLRQ ZDV QRW
available or t he synt hesized evidence was not up to 8QFRPSOLFDWHG JHQLWDO FHUYL[ XUHWKUD FKODP\GLDO
date, a new systemat ic review of randomized cont rolled LQIHFWLRQV LQ DGXOWV DQG DGROHVFHQWV XS WR 0DUFK
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
The search st rategies were developed by an informat ion -XQH
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, and non- randomized studies for crit ical 2SKWKDOPLD QHRQDWRUXP WUHDWPHQW XS WR 0D\
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:
1. chlamydia.mp.
2. t rachomat is.mp.
3. ct infect ion*.t
w. 4. or/ 1-3
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_ LQBLQFOXGHGBVWXGLHV KWP
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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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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 WKH HHFWV RI WUHDWPHQWV DQG FRVWV WZR
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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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VFUHHQHG WKH VWXGLHV DQG VWXGLHV ZHUH LGHQWLHG
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, V\QWKHVL]HG DQG SUHVHQWHG LQ WKH
HYLGHQFH SUROHV
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: VWDQGDUG JDPEOH WLPH WUDGH R YLVXDO
DQDORJXH 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 TXHVWLRQQDLUHV RU VFDOHV WKHVH DUH QHLWKHU
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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
WR GLHUHQW WUHDWPHQW RSWLRQV EDVHG RQ TXDOLWDWLYH
research met hods including focus group
discussions, interviews, etc.

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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 , DQG RI SURFXUHPHQW FRVWV DV
GHQHG LQ WKH 06+ ,QWHUQDWLRQDO GUXJ SULFH
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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 PHGLDQ SULFHV SURYLGHG LQ WKH 06+
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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
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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
DGGUHVVHG WKH FRVW HHFWLYHQHVV RI GLHUHQW WUHDWPHQW
st rategies for chlamydia. In addit ion, while screening
VWXGLHV IRU WKH HHFWV RI WUHDWPHQWV WZR LQYHVWLJDWRUV
DOVR LGHQWLHG VWXGLHV RI SRWHQWLDO UHOHYDQFH IRU FRVWV
and abst racted dat a regarding possible resources to be
considered during t he decision- making process.
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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,
LPSUHFLVLRQ HHFW VL]H GRVHUHVSRQVH FXUYH DQG
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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.
(9,'(1&( 72 '(&,6,21 )5$0(:25.6
Evidence- to- decision frameworks were also developed
XVLQJ *5$'(SUR VRIWZDUH ZZZ JUDGHSUR RUJ
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 GHFLVLRQV 7KH HYLGHQFH
WR GHFLVLRQ IUDPHZRUNV
are based on a populat ion perspect ive for t hese
recommendat ions. All GRADEcriteria were
considered from t his perspect ive.
MAKING THE RECOMMENDATIONS
,Q 2FWREHU WKH *'* PHW WR PDNH WKH
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.
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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 LGHQWLHG LQ WKH HYLGHQFH )ROORZLQJ WKH
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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.
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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 $ doxycycline in t he t reat ment of uncomplicat ed Chlamydial
*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.
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
XUHWKULWLV DQG FHUYLFLWLV 6H[ 7UDQVP 'LV
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
4 WHO GUIDELINES FORTHE TREATMENT OF CHLAMYDIA TRACHOMATIS

24. Topic A, Skerk V, Punt aric A, Milavec Puret ic V, Beus A, Begovac

- $]LWKURP\FLQ RU JUDP GRVH LQ WKH WUHDWPHQW RI RECOMMENDATION 2
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
25. van der Willigen AH, Polak- Vogelzang AA, Habbema L, uncomplicat ed anorect al chlamydial infect ions
: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

3DWLHQW YDOXHV DQG SUHIHUHQFHV DFFHSWDELOLW\ DQG FRVW VSHFLF WR 1.
chlamydial infect ions
1. Dixon- Woods M, Stokes T, Young B, Phelps K, Windridge
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 1.
XSGDWHG DQQXDOO\ 0HGIRUG 0$ 0DQDJHPHQW 6FLHQFHV IRU
+HDOWK
KWWS HUF PVK RUJ GPSJXLGH SGI 'UXJ3ULFH*XLGHB SGI
DFFHVVHG -XQH 2.
3. Sahin- Hodoglugil NN, Woods R, Pet t ifor A, Walsh J. A
FRPSDULVRQ RI FRVW HHFWLYHQHVV RI WKUHH SURWRFROV IRU
diagnosis and t reat ment of gonococcal and chlamydial infect ions
LQ ZRPHQ LQ $IULFD 6H[ 7UDQVP 'LV 3.
Pat ient values and preferences, accept abilit y and cost : ot her
sexually t ransmit t ed infect ions and condit ions
Kong FY, Tabrizi SN, Fairley CK, Vodst rcil LA, Hust on WM, Chen
0 HW DO 7KH HFDF\ RI D]LWKURP\FLQ DQG GR[\F\FOLQH IRU WKH
t reat ment of rect al chlamydia infect ion: a syst emat ic
review DQG PHWD DQDO\VLV - $QWLPLFURE &KHPRWKHU
GRL MDF GNX
Ding A, Challenor R. Rect al chlamydia in het erosexual women:
PRUH TXHVWLRQV WKDQ DQVZHUV ,QW - 67' $,'6
GRL
Drummond F, Ryder N, Wand H, Guy R, Read P, McNult y AM,
et al. Is azit hromycin adequat e t reat ment for asympt omat
ic rect al FKODP\GLD" ,QW - 67' $,'6 GRL
LMVD
Elgalib A, Alexander S, Tong CY, Whit e JA. Seven days of
GR[\F\FOLQH LV DQ HHFWLYH WUHDWPHQW IRU DV\PSWRPDWLF UHFWDO
Chlamydiatrachomatis LQIHFWLRQ ,QW - 67' $,'6
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
infect ions wit h single- dose t herapy: a double- edged sword. ment for t he management of rect al Chlamydiatrachomatis in
'UXJV men 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' $,'6 GRL LMVD
*OREDO %XUGHQ RI 'LVHDVH 6WXG\ &ROODERUDWRUV *OREDO
regional, and nat ional incidence, prevalence, and years lived 8. Whit e JA. Manifest at ions and management of lymphogranuloma
ZLWK GLVDELOLW\ IRU DFXWH DQG FKURQLF GLVHDVHV DQG LQMXULHV YHQHUHXP &XUU 2SLQ ,QIHFW 'LV GRL
LQ FRXQWULHV D V\VWHPDWLF DQDO\VLV IRU WKH *OREDO 4&2 E H D DH
%XUGHQ RI 'LVHDVH 6WXG\ /DQFHW
GRL 6 3DWLHQW YDOXHV DQG SUHIHUHQFHV DFFHSWDELOLW\ DQG FRVW VSHFLF WR
chlamydial infect ions
3. Holmes K. Sexually t ransmit t ed diseases, 4t h edit ion. New York
1< 0F*UDZ +LOO 1. Dixon- Woods M, Stokes T, Young B, Phelps K, Windridge
K, Shukla R. Choosing and using services for sexual healt h:
4. Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo
a qualit at ive st udy of women's views. Sex Transm Infect .
M, Low N, et al. Global est imat es of t he prevalence and
LQFLGHQFH RI IRXU FXUDEOH VH[XDOO\ WUDQVPLWWHG LQIHFWLRQV LQ
based on syst emat ic review and global report ing. PLoS One. ,QWHUQDWLRQDO GUXJ SULFH LQGLFDWRU JXLGH HGLWLRQ XSGDWHG
H GRL MRXUQDO SRQH DQQXDOO\ 0HGIRUG 0$ 0DQDJHPHQW 6FLHQFHV IRU +HDOWK
KWWS HUF PVK RUJ GPSJXLGH SGI 'UXJ3ULFH*XLGHB SGI
DFFHVVHG -XQH
Pat ient values and preferences, accept abilit y and cost : ot
5. Bush MR, Rosa C. Azit hromycin and eryt hromycin in t he
her sexually t ransmit t ed infect ions and condit ions
t reat ment of cervical chlamydial infect ion during pregnancy.
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ions: evidence from
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13. Vas A, Leight on J, Saxon C, Lebari D, Stot t C, Ahmad S, et al.

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Topical sulfacet amide vs oral eryt hromycin for neonat al
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JE. Treat ment of neonat al chlamydial conjunct ivit is wit
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in newborns and adult s wit h eryt hromycin and roxit hromycin.
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Chlamydiatrachomatis causing neonat al conjunct ivit is in a
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St at es of st rains of Neisseriagonorrhoeae wit h plasmid-
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8. Fischer PR, Ret a BB. Prevent ion of neonat al conjunct ivit is in

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9. Hammerschlag MR, Cummings C, Roblin PM, Williams TH,
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Addit ional references

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