What is the recommended treatment for Chlamydia (sexually transmitted infection) in pregnancy?

Treatment of Chlamydia in Pregnancy

Azithromycin 1g orally as a single dose is the recommended first-line treatment for chlamydial infection in pregnant women due to its high efficacy and excellent safety profile. 1

First-Line Treatment Options

• Azithromycin: 1g orally as a single dose
  • Advantages: Single-dose therapy ensures 100% compliance 2
  • Efficacy: Significantly higher cure rates compared to erythromycin (93.8% vs 72.3%) 3
  • Side effects: Lower incidence of gastrointestinal side effects (19.4%) compared to erythromycin (65.5%) 3

Alternative Treatment Options

If azithromycin is not available or not tolerated, the following alternatives can be considered:

1. Amoxicillin: 500mg orally three times daily for 7 days

   • Efficacy: 95% cure rate 1
   • Better tolerated than erythromycin with fewer gastrointestinal side effects (12.8% vs 31.6%) 4
   • Only 2% overall failure rate compared to 12% with erythromycin 5

2. Erythromycin options (if neither azithromycin nor amoxicillin can be used):

   • Erythromycin base 500mg orally four times daily for 7 days 1, 6
   • Erythromycin base 250mg orally four times daily for 14 days 1
   • Erythromycin ethylsuccinate 800mg orally four times daily for 7 days 1
   • Erythromycin ethylsuccinate 400mg orally four times daily for 14 days 1
   • Note: Lower efficacy rate (64%) and higher discontinuation rate (13%) due to gastrointestinal side effects 1

Contraindicated Medications

• Doxycycline: Contraindicated in pregnancy 7, 1
• Ofloxacin and other fluoroquinolones: Contraindicated in pregnancy 7, 1
• Erythromycin estolate: Contraindicated due to risk of maternal hepatotoxicity 7, 1

Follow-Up Testing and Partner Treatment

1. Test of cure:

   • Recommended 3-4 weeks after completion of therapy 1
   • Particularly important when using alternative regimens other than azithromycin

2. Partner treatment:

   • All sexual partners from the previous 60 days should be evaluated and treated 7, 1
   • Patients should abstain from sexual activity until they and their partners have completed treatment and are symptom-free 7

Special Considerations

• Co-infection with gonorrhea: If co-infection is suspected or confirmed, add ceftriaxone 250mg IM as a single dose 1

• Compliance issues: Consider the single-dose azithromycin regimen if there are concerns about medication adherence, as studies show 100% compliance with azithromycin compared to 84% with multi-day regimens 2

• Severe gastrointestinal side effects: More common with erythromycin (31%) compared to amoxicillin (6%) 5, which may affect treatment completion

Common Pitfalls to Avoid

1. Inadequate partner treatment: Failure to treat partners is a common cause of reinfection

2. Insufficient follow-up: Skipping the test of cure can miss persistent infections

3. Using contraindicated medications: Always verify that the selected antibiotic is safe in pregnancy

4. Ignoring side effects: Gastrointestinal side effects can lead to non-compliance, especially with erythromycin regimens, resulting in treatment failure 3

5. Overlooking co-infections: Always consider testing for other STIs, particularly gonorrhea, which commonly co-occurs with chlamydial infections 1