What is the treatment of choice for Chlamydia trachomatis infection in pregnancy?

Treatment of Choice for Chlamydia in Pregnancy

Azithromycin 1 g orally as a single dose is the treatment of choice for Chlamydia trachomatis infection in pregnancy, with cure rates of 94-100% and superior tolerability compared to all alternatives. 1, 2

First-Line Therapy

• Azithromycin 1 g orally as a single dose is the CDC-recommended first-line treatment for pregnant patients with chlamydial infection, offering the highest efficacy (94-100% cure rate) and excellent compliance due to single-dose administration. 1, 2
• Azithromycin is FDA Pregnancy Category B with extensive clinical experience supporting its safety throughout all trimesters, including first-trimester exposure. 1, 2
• The upgrade from alternative to first-line status occurred in 2006 based on accumulated safety and efficacy data, replacing the previous preference for erythromycin-based regimens. 1

Alternative Regimens (When Azithromycin Unavailable)

• Amoxicillin 500 mg orally three times daily for 7 days is the preferred alternative when azithromycin is unavailable, offering fewer gastrointestinal side effects than erythromycin with comparable efficacy (95% cure rate). 1, 3
• Erythromycin-based regimens are secondary alternatives with significantly lower efficacy (64-77%) and poor tolerability due to gastrointestinal side effects:
  • Erythromycin base 500 mg orally four times daily for 7 days 1, 3
  • Erythromycin base 250 mg orally four times daily for 14 days 1, 3
  • Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 3
  • Erythromycin ethylsuccinate 400 mg orally four times daily for 14 days 1, 3

Absolute Contraindications

• Never prescribe doxycycline, ofloxacin, or levofloxacin during pregnancy due to teratogenic risk. 1, 2, 3
• Erythromycin estolate is absolutely contraindicated due to drug-related hepatotoxicity in pregnancy. 1, 2, 3
• Clarithromycin should not be substituted for azithromycin as it is teratogenic in animal studies. 2

Mandatory Follow-Up Protocol

• Test-of-cure is mandatory 3 weeks after completing therapy using nucleic acid amplification testing to confirm eradication, given the serious maternal and neonatal consequences of persistent infection. 1, 2, 3
• This requirement is non-negotiable in pregnancy due to risks of perinatal transmission causing neonatal conjunctivitis (5-12 days after birth) and subacute pneumonia (1-3 months of age). 2, 3

Partner Management Requirements

• All sexual partners with exposure within 60 days preceding diagnosis must be evaluated, tested, and treated; the most recent partner should be treated even if last contact exceeds 60 days. 1, 2, 3
• Patients must abstain from sexual intercourse until both partners complete treatment—minimum 7 days after single-dose azithromycin or after completing multi-day regimens. 1, 2, 3
• Failure to treat partners is a common cause of apparent treatment failure and reinfection in pregnant patients. 1

Common Pitfalls to Avoid

• Do not confuse azithromycin with clarithromycin—only azithromycin is safe in pregnancy. 2
• Do not withhold azithromycin in first trimester when clinically indicated, as evidence does not support excessive caution. 1
• Do not skip the 3-week test-of-cure even if the patient is asymptomatic, as this is mandatory in pregnancy. 2, 3
• Do not use azithromycin for syphilis treatment in pregnancy—penicillin remains the only proven therapy. 1

Special Populations

• HIV-positive pregnant women receive the same azithromycin regimen as HIV-negative women. 2, 3
• Pregnant women under 25 years are at higher risk and should be targeted for screening. 2, 3