Comparing the Antibiotic Regimens
As people get into more of the information about the combination antibiotic (abx) protocols on this site, confusion can arise about what medications are used with which protocol, and even which version. In the interests of clarity, I will try to summarize and compare the 7th Stratton/Vanderbilt protocol (published on this site), the most recent version of it represented by the interview with Dr. A, and David Wheldon's most current regimen. Drs. Stratton and Wheldon have graciously replied with their overviews of protocol variations.
- Doxycycline 200mg once a day (working up to this dose as the patient can manage)
- Then adding Roxithromycin (not avail in USA) 150mg twice a day OR Rifamcin 300mg twice per day OR Azithromycin 250mg three times per week (working up to this dose as the patient can manage)
- After 2-3 months or when the patient experiences little reaction from this dual abx combo metronidazole (Flagyl) is added (tinidazole may also be used if better tolerated). First a single 400mg (it comes in 500mg in the USA) is tried for the first pulse. Then every 3-6 weeks depending on tolerance a pulse of this is done working up over time to 400mg three times a day for 5 days.
When metronidazole pulses yeild no further reactions or improvements, the goal is to do 2 week courses of the abx, with days 5-9 being also Flagyl pulses.
David has also added N-acetyl cysteine 600mg twice a day, should be taken continuously a common dietary supplement, available at health-food stores. It is an acetylated sulphur-containing amino-acid, and may help to cause chlamydial EBs to open prematurely, exposing them to starvation.
Stratton/Vanderbilt 7th version:
This somewhat outdated version lists a very definitive schedule of adding abx, which continues to be a model of care and a guide for those concerned about managing die-off effects and Cpn toxicity.
- It lists Amoxicillin 500mg working up eventually to twice a day.
- Then adding Probenecid 500mg, working up eventually to twice a day. This drug limits excretion of the amoxi in the urine, resulting in higher concentrations of it in the tissues and more EB kill effect.
- When this is tolerated, adding in graduated fashion an additional agent: Rifamcin 300mg twice a day OR Azithromycin 250mg monday/wednesday/friday OR Clarithromycin 500 mg twice a day.
Updated Stratton/Vanderbilt Protocol:
One can be pragmatic about starting with the least expensive alternative available, either doxy or amoxi.
- Doxycycline, working up to 100mg twice a day.
- Amoxicillin, working up to 500mg twice a day.
- Then Azithromycin working up to 250mg on monday/wednesday/friday.
- Adding Flagyl, working up to 500mg twice a day, which can be pulsed (as in Wheldon's protocol) or taken continuously, depending on the patient and tolerance. (Note: I don't recommend continuous use until one has done numerous pulses and knows what to expect and is quite well cleared of cryptic Cpn.)
- Then adding Rifamcin, working up to 300mg twice per day. Rifamcin has deeper tissue penetration, but must be done continuously, once dosage is reached, for a number of months. Short courses of it is highly likely to create resistant bacteria.
In this current version, the addition of amoxi and rifamcin is considered especially important to add if one has been sick longer with Cpn and has built up a high load of EB's in the intercellular tissues. Over longer times, since thousands of EB's are produced by each infected cell of your body, but only a few EB's can gain entry to a cell (proportionally) these spore-like forms build up in joints, muscles, connective tissues, and so on. If you don't clear them, you reinfect.
David Wheldon's comments on the protocol differences:
Charles Stratton's Comments on Protocol Differences
My comment on the differences in the protocol is that they reflect both a difference in the use of antimicrobial agents as well as an evolution in the approach to the therapy. For example, using metronidazole in a pulse mode appears to be just as effective and reduces the side effects. Our approach was to start slowly and work up to full therapy – the pulse approach accomplishes the same goal. N-acetyl-cysteine will break the disulfide bonds in the elementary bodies just as effectively as N-formyl-penicillamine, which is the metabolite of amoxicillin that does the same thing. It is cheaper and doesn’t require probenecid to increase the levels as it can be taken at high enough doses.
I don’t think that azithromycin versus roxithromycin makes much of a difference. Azithromycin goes off patent soon and should become very much cheaper. Doxycycline is much cheaper that rifampin. Rifampin also has drug-drug interactions that must be factored in to the therapy. So, I’m equally comfortable with both protocols. I agree completely that the supplements are important and as much a part of the therapy as the antibiotics.
I also believe that the therapy for Chlamydia pneumoniae will continue to evolve. There are newer antibiotics such as telithromycin (currently available) and rifalazil (still investigational) that may offer improvements. For example, telithromycin appears to be chlamydiacidal due to dual binding of the 23S ribosome. Whether to use telithromycin in pulse therapy (e.g., 5 days per month) or daily is not known because of it being new to medical practice. It is likely that pulse therapy will prove to be the best approach due to cost, if nothing else. Remember, the therapy of tuberculosis was several decades in its evolution. I suspect the same will be true for the therapy of chronic C. pneumoniae infections.