[Question #6823] Chlamydia Treatment Failure

13 months ago
Hello,
A month ago I noticed discharge from my penis and went in to have it looked at. I was tested and treated in the same appointment for both Chlamydia and Gonorrhea. The treatment for Chlamydia was 1g Azithromycin and an injection for Gonorrhea. The test came back a few days later positive for Chlamydia. By that point, however, my symptoms had cleared up. I had informed my sexual partners of my test. 

About five days ago, so four weeks later, I noticed discharge again. I have not had any sex since the initial treatment, in fact I had no sex for the week leading up to the first appointment. My doctor prescribed a 7-day regimen of Doxycycline which I am now taking. I am aware of resistant strains of Gonorrhea but I wasn't aware of the same for Chlamydia. Are there resistant strains? If not, why would the Azithromycin fail? Do I need to reach out to my partners again?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Welcome to the forum. Thanks for your question. It's an interesting one and reflects common issues addressed daily by STD specialists.

You had nongonococcal urethritis (NGU) that was managed exactly as recommended: treatment for both gonorrhea and chlamydia while awaiting test resutls. You don't say whether your sex partners were treated, in addition to being tested; they should have been -- like you, without waiting for test results. And more important, you don't mention whether you had sex with anyone -- your previous partner(s) or someone new -- since being treated for chlamydia a month ago. Probably not; I imagine you would have mentioned it. The rest of this reply assumes no possible sexual reexposure.

One of two things is going on. First, azhtromycin may have failed to cure your chlamydial infection. Azithro is excellent treatment but not perfect; it fails to eradicate urethral chlamydia in males 2-3% of the time. So perhaps around 1 chance in 30-50. (This isn't because chlamydia is resistant to azithromycin. It isn't; unlike gonorrhea, antibiotic resistance of any kind is not a problem at all for chlamydia. The reason(s) for occasional treatment failure aren't known -- probably it has to do with individual variation in the concentration of antibiotic achieved in the urethra.

Second, you might have had a second infection. Chlamydia causes about 30-40% of NGU; other causes, both known and unknown, are responsible for the remainder. Nonchlamydial NGU responds less reliablty to treatment than chlamydia does. So the probable scenario is that you were infected with agent X (unknown) in addition to chlamydia. So now we come to additional evidence that your doctor knows the score and is competent in his or her STD knowledge and managment:  the exact recommendation of CDC and virtually all experts is when azithromycin fails, treat with 7 days of doxycycline. Most likely that will take care of the problem. And if you actually have persistent chlamydia, don't worry: unlike azithromycin, doxycycline for 7 days (100 mg twice daily) never fails against chlamydia.

There's no clear evidence one way or the other about the optimal treatment of sex partners in this situation. However, I would not recommend informing them or suggesting different or additional treatment for them. For the most part, the nonchlamydial causes of NGU appear to not be harmful to female partners. Indeed, some cases of nonchlamydial NGU -- perhaps even a majority -- may be caused by entirely normal bacteria, but ones that your urethra might be senstive to. In other words, nothing abnormal or harmful. And complications that gonorrhea and chlamydia can cause in women, especially fallopian tube infection (pelvic inflammatory disease, PID), are not known to occur in this situation.

A final caveat:  one cause of nonchlamydial NGU is Mycoplasma genitalium, a relatively new understanding from research in the past decade. M gen doesn't always respond to doxycycline. Also, Trichomonas vaginalis, a one-celled vaginal parasite, is an uncommon cause of NGU (under 5% of cases). If your new symptoms clear up with doxycycline and don't return soon afterward, you're home free. But in the event they don't clear or recur promptly, you may need additional treatment, ideally preceded by testing for M gen and trichomonas. In any case, plan on continuing to abstain sexually at least a couple more weeks and see how things sort out.

I hope these comments are helpful. Let know of anything isn't clear.

HHH, MD
---
---
---
13 months ago
Hello Doctor. I'm sorry if I wasn't clear but I have had no sex since being treated, as a matter of fact the last time I had sex was a week prior to being treated. My partner was given 1g of Azithromycin. Also I am MSM and have no female sexual partners. I'm not sure how that changes your responses.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Thanks for the follow-up. The sex of your partners indeed is imporrtant. Azithromycin is not reliable for rectal chlamydia, which is likely the source of your urethral infection. (Few urethral infections, if any, are from oral sex.) Azithro fails to cure 15-25% of rectal chlamydia. Expert consensus now is that only doxycycline should be used for chlamydia in MSM who have had receptive anal sex ("bottom"). CDC's upcoming modified STD guidelines, anticipated in the next few months, will recommend only doxy to treat rectal chlamydia and for most MSM. Your partner should discuss with the doctor or clinic treating him. He doesn't necessarily need to take doxy, but if not he needs to abstain sexually for at least 3 weeks and be tested for chlamydia at that time to assure the azithro was effective.

On the good side, trichomonas isn't an issue in MSM, only heterosexual women and men. M genitalium is uncertain:  there are mixed results from studies of M gen in MSM, but it appears to be less frequent than in straight couples.
---
---
---
13 months ago
Thanks Doctor. For what its worth, I did not engage in anal sex with the partner to which I'm referring, only oral. Can rectal chlamydia be transmitted in ways besides anal sex?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Interesting. You're apparently a rare case:  chlamydia is quite uncommon in the throat, and NGU following oral sex is rarely caused by chlamydia. (As it happens, I was the senior investigator on the first study to work this out: https://www.ncbi.nlm.nih.gov/pubmed/9153736). Was your partner tested with a throat swab? However, if you had insertive (top) anal sex with anyone in the month or so before your symptoms started, that's a more likely source of your infection. Which would also additional partners need treatment.

Rectal chlamydia in MSM occurs only by receptive anal sex. In theory. an initial oral infection could travel down the GI tract to the rectum, but probably rarely. This is an area of current research; we may know more in the next couple of years.

Normally threads are closed after two follow-up exchanges, but it will stay open. I'm interested in sort this out.

---
---
13 months ago
Hmm let me see if I can provide some clarity. In February I had sex with partner a, another man, and we had protected anal sex. That being said we used a condom prior to penetration but there was a lot of foreplay. I fully suspect that to be the case. Partner b, also in February, I just had oral sex. Based on your responses it seems clear that partner A was likely to have given it to me. 

I spoke to both and as far as I know they received treatment, though I know partner b received azithro as we are friends and Communicate regularly. I can’t say what partner a received as we are not in regular communication since. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Thanks for the follow-up. I would guess partner a had rectal chlamydia and was the source of your infection, but can't rule out hte others and you'll probably never know for sure -- and at this point it doesn't seem to matter. Glad to hear all were treated, but if I were your doctor (or partner a's doc) I would want him to have a rectal chlamydia test 3-4 weeks after receiving azithromycin.

That will conclude this thread. I hope the discussion has been helpful. Best wishes and stay safe!
---