What is the recommended treatment for Chlamydia in a pregnant woman?

Treatment of Chlamydia in Pregnant Women

Azithromycin 1 g orally as a single dose is the first-line treatment for chlamydia in pregnancy, offering superior efficacy (94-100% cure rate), excellent compliance, and a favorable safety profile. 1, 2, 3

First-Line Treatment

• Azithromycin 1 g orally as a single dose is recommended by both the CDC and ACOG as the preferred regimen for pregnant women with chlamydia infection. 1, 2, 3
• The single-dose regimen eliminates compliance concerns entirely and can be directly observed in the clinic to ensure the patient receives treatment. 3
• Azithromycin is FDA Pregnancy Category B with extensive clinical experience supporting its safety throughout pregnancy, including the first trimester. 2
• Clinical trial data demonstrates azithromycin achieves 93.8% cure rates compared to only 72.3% with erythromycin, with significantly fewer gastrointestinal side effects (19.4% vs 65.5%). 4

Second-Line Alternative Regimens

• Amoxicillin 500 mg orally three times daily for 7 days is the preferred alternative when azithromycin is contraindicated or unavailable, offering fewer gastrointestinal side effects than erythromycin. 1, 3
• Amoxicillin demonstrates comparable efficacy to azithromycin (58-64% cure rates in head-to-head trials) with better tolerability than azithromycin in some studies. 5, 6

Erythromycin Regimens (Third-Line)

Erythromycin-based regimens have significantly lower efficacy (64-77%) and higher rates of gastrointestinal side effects, making them less desirable options: 1, 2

• Erythromycin base 500 mg orally four times daily for 7 days 1, 7
• Erythromycin base 250 mg orally four times daily for 14 days (lower dose to reduce GI intolerance) 1, 7
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1
• Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 1

Common pitfall: Erythromycin base 500 mg four times daily has only 61% completion rates due to severe gastrointestinal side effects and should be avoided when compliance is questionable. 3

Absolute Contraindications in Pregnancy

• Doxycycline, ofloxacin, and levofloxacin are absolutely contraindicated during pregnancy due to potential fetal harm. 1, 2, 3
• Erythromycin estolate is contraindicated due to drug-related hepatotoxicity in pregnancy. 1, 2
• Clarithromycin should be avoided as it is teratogenic in animals. 2

Mandatory Follow-Up Testing

• Repeat testing 3 weeks after completion of therapy is mandatory for all pregnant women to ensure cure, given the serious maternal and neonatal consequences of persistent infection. 1, 2, 3
• Recent data shows persistent or recurrent chlamydia occurs in 23% of pregnancies after azithromycin treatment (14% persistence, 9% recurrence), emphasizing the critical importance of test-of-cure. 8
• Testing should preferably be performed by culture or nucleic acid amplification testing. 1

Partner Management

• Sexual partners must be evaluated, tested, and treated if they had sexual contact during the 60 days preceding diagnosis. 1, 2, 3
• Patients must abstain from sexual intercourse until both partners complete treatment—7 days after single-dose therapy or after completion of 7-day regimens. 1, 3
• Failure to treat partners leads to reinfection in up to 20% of cases. 3

Gonorrhea Co-Infection

• For pregnant women with confirmed or suspected gonorrhea co-infection, treat both infections concurrently with ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose. 3
• This dual therapy addresses the frequent co-infection pattern and prevents treatment failure. 3

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). 1, 2, 3
• Neonatal ocular prophylaxis with silver nitrate or antibiotic ointments does not prevent chlamydial transmission but should be continued to prevent gonococcal ophthalmia. 1

Special Populations

• HIV-positive pregnant women with chlamydia receive the same treatment regimen as HIV-negative women. 1, 2
• Pregnant women under 25 years of age are at higher risk for chlamydial infection and should be targeted for screening. 1, 2
• Concomitant gonorrhea or syphilis in pregnancy is independently associated with persistent or recurrent chlamydia (adjusted OR 1.6), requiring heightened vigilance. 8