**5. Treatment/management**

The treatment of uncomplicated chlamydial infection aims to cure the patient and prevent complications and partner transmission. Sexual partners are also treated to prevent reinfection and transmission to other partners. Risk-reduction counseling should be provided and retesting performed to detect recurrent or persistent infection [10].

As *Chlamydia* is only metabolically active in host cells, it is treated with antibiotics that have intracellular activity. Antibiotics that accumulate intracellularly are tetracyclines, macrolides, and quinolones. Patients who are diagnosed and treated generally have a high cure rate and excellent prognosis [20].

For uncomplicated urethral chlamydial infection, single-dose azithromycin 1 g or doxycycline 100 mg twice daily for 1 week is recommended as the primary treatment and is reported to have a 95% cure rate [10]. However, a Cochrane study in 2019 indicated that 7-day doxycycline yielded higher cure rates than single-dose azithromycin [3]. However, because the use of azithromycin 1 mg causes resistance in *M. genitalium*, doxycycline 100 mg twice a day is now recommended as first-line treatment. If azithromycin is administered, it is recommended to give 500 mg on the first day, followed by 250 mg daily for 4 days [2]. However, no difference has been observed between single-dose azithromycin and 7-day doxycycline in terms of the resolution of persistent urethritis symptoms. Due to the worse adverse effect profile of doxycycline and better patient adherence to single-dose azithromycin, the latter continues to be used in clinical practice [3].

In two recent randomized controlled studies conducted in the USA, the efficacy of azithromycin and doxycycline in achieving a clinical cure was found to be less than 85% [2]. The use of lymecycline 300 mg twice daily for 10 days or tetracycline 500 mg twice daily for 10 days provided >95% clinical cure rate in *Chlamydia*-positive patients. In addition, these antibiotics did not increase photosensitivity, unlike doxycycline [2]. It seems that new approaches may emerge in this direction. Other alternative antibiotic regimens for *Chlamydia* are oral tetracycline 500 mg 4 times a day for 7 days, oral erythromycin 500 mg twice a day for 7 days, or oral ofloxacin 200–400 mg 2 times a day for 7 days [29].

Chlamydial infection is often accompanied by gonococcal infection [29]. If NAAT or Gram staining demonstrates the presence of gonococci, a single-dose 250 mg intramuscular injection of ceftriaxone is added to the 1 g of azithromycin [15].

Empirical therapy should not be initiated without clarifying a diagnosis of urethritis, because this can cause the symptoms to become permanent [2]. In addition, antibiotic resistance and urethritis caused by different microorganisms are other reasons to avoid empirical therapy [14]. Empirical treatment can only be given in exceptional cases. If the test cannot be performed or if a man with a high risk of infection is severely symptomatic, empirical therapy can be initiated based on a presumed diagnosis. Treatment should cover *Chlamydia* and gonorrhea [2].

It is difficult to evaluate the effectiveness of treatment because persistent inflammation does not equate to continuing infection. Detectable inflammation can persist for an unforeseeable period even if the causative pathogen is eliminated [2]. NAATs performed in the first 3 weeks after completing treatment may yield false positive results. Therefore, follow-up testing is not recommended in this period [3].

#### *Chlamydia Infection from Androgical Perspective DOI: http://dx.doi.org/10.5772/intechopen.110045*

Men who have frequent unprotected sexual relations with men have a high risk of chlamydial urethritis and should be screened more frequently. In one study, it was found that single-dose doxycycline decreased the prevalence of chlamydial infection after suspicious intercourse between men without a condom [3]. However, this approach has not yet gained widespread acceptance. It may be beneficial to screen treated patients after 3 months and include patients in a follow-up program after discussing with them, by this has not been incorporated into routine care [10].

Partner therapy is recommended for patients with urethritis. The partners with whom the patient has had sexual intercourse within the last 60 days should be evaluated for sexually transmitted diseases and administered the same treatment regimen as the primary patient. The sexual partner should be treated in accordance with the principles of patient confidentiality [25].

Expedited treatment without examining the partner is legal in many countries and was found to be more effective than recommending partner treatment [3]. In chlamydial, gonorrheal, and trichomonal infections, partners should be called for followup testing after 3 months if possible because of the high reinfection rates [14].

Nevertheless, relapse and untreated reinfections from old or infected new partners are common [29]. Recurrent nongonococcal urethritis is defined as recurrence of symptoms within 30–90 days after acute treatment and occurs at a rate of 10–20% [2]. One study indicated that up to 20% of chlamydial infections were persistent or recurrent despite initial treatment [14].

Patients with recurrent or persistent symptoms should be reevaluated to determine whether they completed the full course of initial treatment and whether they were reexposed to the pathogen. The same initial treatment should be repeated for untreated patients, received incomplete treatment, or encountered the pathogen again [7].

If only *Chlamydia* and gonorrhea were initially tested for in men with persistent nongonococcal urethritis, NAATs for *M. genitalium* and *T. vaginalis* should also be performed [2]. *M. genitalium* is the most common cause of recurrent and persistent nongonococcal urethritis. Therefore, a treatment regimen targeting this pathogen is important [15]. Coinfection and less common pathogens should also be investigated in persistent urethritis. The possibility of a persistent postinfectious immune response should be kept in mind. If a cause cannot be identified, underlying urinary tract anomalies and urethral pathologies should be evaluated [14].
