What is the appropriate treatment for a pregnant woman who tests positive for Chlamydia trachomatis?

Treatment of Chlamydia in Pregnancy

Treat all pregnant women with positive chlamydia testing with azithromycin 1 g orally as a single dose—this is the first-line therapy with superior efficacy (94-100% cure rate), excellent compliance, and proven safety throughout pregnancy. 1, 2

First-Line Treatment

• Azithromycin 1 g orally as a single dose is the recommended first-line treatment for chlamydia in pregnancy, as stated by the American College of Obstetricians and Gynecologists 1, 2
• This regimen achieves 94-100% cure rates and eliminates compliance concerns entirely since it can be directly observed in the clinic 1, 2
• Azithromycin is FDA Pregnancy Category B with extensive clinical experience supporting its safety throughout all trimesters, including the first trimester 1
• Research confirms azithromycin's 97% efficacy (95% CI: 92.9-99.2) with no significant differences in maternal or infant complications compared to other regimens 3

Alternative Regimens (When Azithromycin Unavailable or Contraindicated)

• Amoxicillin 500 mg orally three times daily for 7 days is the preferred alternative when azithromycin cannot be used 2, 4
• Amoxicillin demonstrates 95% efficacy (95% CI: 76.2-99.9) with fewer gastrointestinal side effects than erythromycin 3
• Erythromycin-based regimens should be avoided as first-line due to significantly lower efficacy (64-77%) and high rates of gastrointestinal intolerance 1, 4

If Erythromycin Must Be Used:

• Erythromycin base 500 mg orally four times daily for 7 days 4, 5
• Erythromycin base 250 mg orally four times daily for 14 days (lower dose to reduce GI side effects) 4, 5
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 4
• Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 4

Absolute Contraindications in Pregnancy

• Doxycycline is absolutely contraindicated due to teratogenic effects 2, 4
• All fluoroquinolones (ofloxacin, levofloxacin) are contraindicated due to fetal harm 2, 4
• Erythromycin estolate is contraindicated due to drug-related hepatotoxicity in pregnancy 1, 4

Critical Pitfall to Avoid

• Do not confuse azithromycin with clarithromycin—clarithromycin is teratogenic in animals and must be avoided during pregnancy 1

Mandatory Follow-Up Testing

• All pregnant women require repeat testing 3 weeks after treatment completion to ensure cure, regardless of which regimen was used 1, 2, 4
• This test-of-cure is mandatory in pregnancy due to serious maternal and neonatal consequences of persistent infection 1, 2
• Testing should preferably be performed by culture 2, 4

Partner Management (Essential to Prevent Reinfection)

• All sexual partners from the preceding 60 days must be evaluated, tested, and treated empirically 2, 4
• Non-pregnant partners should receive doxycycline 100 mg twice daily for 7 days OR azithromycin 1 g single dose 2
• Failure to treat partners leads to reinfection in up to 20% of cases 2
• The patient must abstain from sexual intercourse until both partners complete treatment—7 days after single-dose therapy or after completion of multi-day regimens 2, 4

Consequences of Untreated Infection

• Untreated maternal chlamydia leads to perinatal transmission resulting in: 1, 4
  • Neonatal conjunctivitis (5-12 days postpartum)
  • Subacute neonatal pneumonia (1-3 months of age)
• Neonatal ocular prophylaxis with silver nitrate or antibiotic ointments does NOT prevent chlamydial transmission 4

Special Populations

• HIV-positive pregnant women receive the same treatment regimen as HIV-negative women (azithromycin 1 g single dose) 1, 4
• Pregnant women under 25 years of age are at higher risk and should be targeted for screening 1, 4

Co-Infection with Gonorrhea

• When gonorrhea is confirmed or suspected, treat both infections concurrently with ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose 2
• This dual therapy addresses the frequent co-infection pattern and prevents treatment failure 2