What is the recommended treatment for a pregnant woman diagnosed with Chlamydia?

Treatment of Chlamydia During Pregnancy

Azithromycin 1 g orally as a single dose is the first-line treatment for chlamydia in pregnant women, offering superior efficacy (94-100% cure rate), excellent compliance, and proven safety compared to alternative regimens. 1

Recommended First-Line Treatment

• Azithromycin 1 g orally, single dose is the preferred treatment based on its superior cure rate, safety profile, and single-dose administration that eliminates compliance issues 1, 2
• Clinical trial data demonstrates azithromycin achieves 93.8% cure rates compared to only 72.3% with erythromycin (p = 0.005), primarily due to better tolerability and compliance 2
• Azithromycin is classified as FDA Pregnancy Category B with extensive clinical experience supporting its safety throughout pregnancy, including the first trimester 3

Alternative First-Line Treatment

• Amoxicillin 500 mg orally three times daily for 7 days is an effective alternative with fewer gastrointestinal side effects than erythromycin 1, 4
• Multiple randomized trials demonstrate amoxicillin achieves 82-98% cure rates with significantly better tolerability than erythromycin 4, 5, 6
• Only 2-6% of patients discontinue amoxicillin due to side effects, compared to 13-31% with erythromycin 5, 6

Second-Line Alternative Regimens (When First-Line Options Unavailable)

The following erythromycin-based regimens have significantly lower efficacy (64-77%) and higher rates of gastrointestinal side effects 1:

• Erythromycin base 500 mg orally four times daily for 7 days 7, 8
• Erythromycin base 250 mg orally four times daily for 14 days 7, 1
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 7, 1
• Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 7, 1

Critical Contraindications

• Doxycycline, ofloxacin, and levofloxacin are absolutely contraindicated during pregnancy 7, 1
• Erythromycin estolate is contraindicated due to drug-related hepatotoxicity in pregnancy 7, 1

Mandatory Follow-Up Testing

• Repeat testing (preferably by culture) 3 weeks after completion of therapy is required for all pregnant women to ensure cure, given the serious maternal and neonatal consequences of persistent infection 7, 1
• This follow-up is particularly critical with erythromycin regimens due to their lower efficacy and frequent compliance problems 1

Partner Management and Sexual Abstinence

• Sexual partners must be evaluated, tested, and treated if they had sexual contact during the 60 days preceding diagnosis 7, 1
• Patients must abstain from sexual intercourse until both partners complete treatment 7, 1
• Abstinence continues for 7 days after single-dose therapy (azithromycin) or after completion of multi-day regimens 7, 1
• The most recent sexual partner requires evaluation and treatment even if contact occurred >60 days before diagnosis 7

Neonatal Consequences of Untreated Infection

• Untreated maternal chlamydia leads to perinatal transmission resulting in neonatal conjunctivitis (5-12 days after birth) and subacute pneumonia (1-3 months of age) 7, 1
• Neonatal ocular prophylaxis with silver nitrate or antibiotic ointments does not prevent chlamydial transmission, though it should be continued to prevent gonococcal ophthalmia 7, 1
• Chlamydia is the most frequent identifiable infectious cause of ophthalmia neonatorum 7

Special Populations

• HIV-positive pregnant women with chlamydia receive the same treatment regimen as HIV-negative women 7, 1
• Pregnant women under 25 years of age are at higher risk and should be targeted for screening 1

Common Pitfalls to Avoid

• Do not prescribe erythromycin as first-line therapy when azithromycin or amoxicillin are available—erythromycin's 65% rate of gastrointestinal side effects leads to treatment discontinuation in 13-31% of patients, resulting in treatment failure 5, 6, 2
• Do not confuse azithromycin with clarithromycin, which is teratogenic in animals and should be avoided 3
• Do not skip the 3-week test of cure—this is mandatory in pregnancy due to potential serious consequences for both mother and neonate 7, 1
• Do not use azithromycin for syphilis treatment in pregnancy—it has insufficient efficacy data and penicillin remains the only proven effective treatment 3