What antibiotics are used to treat gonorrhea and chlamydia in pregnant women?

Treatment of Gonorrhea and Chlamydia in Pregnant Women

For pregnant women with gonorrhea and chlamydia infections, the recommended treatment is ceftriaxone 250 mg IM as a single dose for gonorrhea plus azithromycin 1 g orally as a single dose for chlamydia. 1, 2, 3

First-Line Treatment Regimen

For Gonorrhea:

• Ceftriaxone 250 mg IM as a single dose
  • This is the preferred treatment due to increasing antimicrobial resistance patterns
  • Should be administered under direct observation when possible

For Chlamydia:

• Azithromycin 1 g orally as a single dose
  • Preferred due to single-dose therapy that improves compliance
  • Safe during all trimesters of pregnancy

Alternative for Chlamydia:

• Amoxicillin 500 mg orally three times daily for 7 days
  • Well-tolerated alternative if azithromycin is contraindicated or unavailable 2

Important Considerations

Contraindications in Pregnancy:

• Doxycycline, fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) are contraindicated during pregnancy 1, 2
• Erythromycin estolate is contraindicated due to risk of hepatotoxicity 2

Special Situations:

• For cephalosporin-allergic patients:
  • Consult infectious disease specialists for alternative regimens 2
  • Spectinomycin 2 g IM as a single dose may be considered, though availability may be limited 1

Follow-up Testing:

• Test of cure is recommended 3 weeks after treatment completion 2, 3
• Pregnant women with gonorrhea should be retested in the third trimester 3
• Higher risk of reinfection necessitates vigilant follow-up during pregnancy

Partner Management

• All sexual partners from the previous 60 days should be evaluated and treated 2, 4
• Patients should abstain from sexual activity until:
  • They and their partners have completed treatment
  • All symptoms have resolved

Rationale for Recommendations

• Dual therapy is essential due to:

  1. High rates of co-infection between gonorrhea and chlamydia
  2. Increasing antimicrobial resistance in N. gonorrhoeae
  3. Need to prevent vertical transmission to the neonate

• Research shows ceftriaxone has superior efficacy (95%) compared to amoxicillin with probenecid (89%) for gonorrhea treatment in pregnancy 5

• The 2021 CDC guidelines specifically recommend azithromycin for chlamydia in pregnant women, as it has better compliance than multi-day regimens 1

Common Pitfalls to Avoid

• Don't use quinolones or tetracyclines in pregnant women due to potential fetal harm
• Don't forget partner treatment - failure to treat partners is a major cause of reinfection
• Don't assume single-site testing is sufficient - consider testing for extragenital infections if clinically indicated
• Don't neglect follow-up testing - especially important in pregnancy due to risk of adverse outcomes

Remember that untreated gonorrhea and chlamydia in pregnancy can lead to serious complications including preterm birth, premature rupture of membranes, and vertical transmission causing neonatal infections such as ophthalmia neonatorum 4, 6.