What is the recommended treatment for a pregnant female with chlamydia, doxycycline (tetracycline) or azithromycin (macrolide)?

Treatment of Chlamydia in Pregnant Women

For pregnant women with chlamydia infection, azithromycin 1 g orally in a single dose is the recommended first-line treatment due to its superior efficacy, safety profile, and excellent compliance. 1

First-Line Treatment Options

• Azithromycin 1 g orally in a single dose is now considered the first-line treatment for chlamydia in pregnancy, with efficacy rates of 91-97% in clinical studies 1, 2, 3
• Amoxicillin 500 mg orally three times a day for 7 days is an effective alternative with comparable efficacy (58-95%) 1, 2, 4

Contraindicated Medications

• Doxycycline is contraindicated in pregnant women due to potential adverse effects on fetal development 5, 1
• Ofloxacin and levofloxacin are also contraindicated during pregnancy 5, 1
• Erythromycin estolate specifically is contraindicated during pregnancy because of drug-related hepatotoxicity 5, 1

Treatment Algorithm

1. First choice: Azithromycin 1 g orally in a single dose 5, 1

   • Advantages: Single-dose administration ensures compliance
   • Safety: FDA Pregnancy Category B - no evidence of harm to fetus in animal studies 6
   • Efficacy: 97% cure rate in observational studies 2

2. Second choice: Amoxicillin 500 mg orally three times a day for 7 days 5, 1

   • Consider when azithromycin is not tolerated or contraindicated
   • Efficacy comparable to azithromycin in randomized trials 4

3. Third choice (if above options cannot be used): Erythromycin base 500 mg orally four times a day for 7 days 5

   • Less preferred due to frequent gastrointestinal side effects (45% of patients) 3
   • Lower efficacy (64-77%) compared to azithromycin 2, 3

Follow-Up Testing

• Repeat testing (test of cure) is recommended 3 weeks after completion of therapy for all pregnant women 5, 1
• This is particularly important given the potential sequelae that might occur in both mother and neonate if the infection persists 5, 1
• Recent studies show persistent or recurrent chlamydia in nearly 1 in 4 pregnancies after azithromycin treatment, highlighting the importance of follow-up testing 7

Partner Management

• Sexual partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding diagnosis 5, 1
• Patients should abstain from sexual intercourse until both they and their partners have completed treatment 5
• Partner treatment is essential for preventing reinfection 5, 1

Clinical Pearls and Pitfalls

• Concomitant gonorrhea or syphilis in pregnancy is associated with higher rates of persistent or recurrent chlamydia (adjusted odds ratio 1.6) 7
• Pregnant women under 25 years of age are at higher risk for chlamydial infection and should be targeted for screening 5, 1
• HIV-positive pregnant women with chlamydia should receive the same treatment regimen as HIV-negative women 5, 1
• Untreated chlamydial infection can lead to perinatal transmission to the neonate, resulting in conjunctivitis and pneumonia 5, 1
• Neonatal ocular prophylaxis with silver nitrate or antibiotic ointments does not prevent chlamydial transmission but should be continued to prevent gonococcal ophthalmia 5, 1