Chlamydia in pregnancy: a randomized trial of azithromycin and erythromycin

Chlamydia trachomatis-An Emerging Old Entity?

Chlamydia trachomatis is an evasive pathogen that can prompt severe clinical manifestations in humans such as vaginitis, epididymitis, lymphogranuloma venereum, trachoma, conjunctivitis and pneumonia. If left untreated, chronic infections with C. trachomatis can give rise to long-lasting and even permanent sequelae. To shed some light on its widespread nature, data from original research, systematic reviews and meta-analyses from three databases was collected and analyzed in the context of chlamydial infection, related symptoms and appropriate treatment modalities. This review describes the bacterium's pervasiveness on a global scale, especially in developing countries, and suggests ways to halt its transmission and spread. Infections with C. trachomatis often go unnoticed, as many individuals are asymptomatic and unaware of their diagnosis, contributing to a delay in diagnosis and treatment. The high prevalence of chlamydial infection highlights the need for a universal screening and detection method enabling immediate treatment at its onset. Prognosis is favorable with antibiotic therapy and education for high-risk groups and their sexual partners. In the future, a quick, easily accessible, and inexpensive test should be developed to diagnose and treat infected individuals early on. Along with a vaccine against C. trachomatis, it would halt the transmission and spread of the pathogen worldwide.

Chlamydia-related knowledge, opinion to opportunistic testing, and practices of providers among different sexually transmitted infections related departments in hospitals in Shenzhen city, China

BACKGROUND

Chlamydia trachomatis (CT) infection could lead to seriously adverse outcomes if left untreated. This study aimed to determine CT-related knowledge, opinion to testing, and practices of providers among different sexually transmitted infections (STI) related departments in hospitals in Shenzhen city, China, and also to explore the differences in these responses.

MATERIALS AND METHODS

From 1st April 2018 to 15th April 2018, a cross-sectional study was conducted in Shenzhen and 64 of 66 hospitals agreed to participate in this study. In the hospital sites, all the providers from the department of obstetrics and gynecology, department of dermatology and venereology, department of urology, and anorectal surgical department were recruited. A structured paper-based questionnaire was used to obtain data on CT-related information.

RESULTS

A total of 355 providers from 64 hospitals participated in the current study. Compared to providers from the department of dermatology and venereology, those from the department of obstetrics and gynecology (OR = 0.31, 95% CI 0.16-0.62), department of urology (OR = 0.32, 95% CI 0.16-0.65), and anorectal surgical department (OR = 0.25, 95% CI 0.09-0.71) were less likely to identify that "Be in a long-term mutually monogamous relationship with a partner who has been tested and has negative STI test results." is an appropriate way for a sexually active person to reduce risk of getting CT. Also, those from the department of obstetrics and gynecology (OR = 0.45, 95% CI 0.23-0.87) were less likely to identify that "Use latex condoms the right way every time you have sex" is another appropriate way. A high proportion of providers agreed that all sexually active patients attending to their department should be screened regularly (77.1%), and they are willing to offer opportunistic CT screening (96.0%). Only 11.4% of respondents correctly identified that the appropriate time frame of the CT retesting is three months.

CONCLUSIONS

Providers among STI-related departments in hospitals showed a very high willingness to offer opportunistic CT screening. However, this study showed important gaps in providers' knowledge and practices in China, targeted training in CT-related knowledge and practice is urgently needed.

C hlamydia trachomatis during pregnancy and childhood asthma-related morbidity: a population-based prospective cohort

INTRODUCTION

Chlamydia trachomatis is the most commonly reported sexually transmitted disease and although infection during pregnancy is associated with neonatal complications, long-term respiratory consequences are unknown. We aimed to determine whether C. trachomatis infection during pregnancy is associated with asthma-related symptoms across childhood METHODS: This study among 2475 children and their mothers was embedded in a population-based prospective cohort study. Maternal urine samples were tested for C. trachomatis infection during pregnancy. Questionnaires provided information on childhood physician-attended lower respiratory tract infections and wheezing, and current asthma at age 10 years. Lung function was measured by spirometry at age 10 years.

RESULTS

The prevalence of C. trachomatis infection during pregnancy was 3.2% (78 out of 2475). C. trachomatis infection during pregnancy was not associated with lower respiratory tract infections until age 6 years, but was associated with a higher odds of wheezing in children until age 10 years (OR 1.50 (95% CI 1.10-2.03)). C. trachomatis infection during pregnancy was associated with an increased odds of asthma (OR 2.29 (95% CI 1.02-5.13)), and with a lower forced expiratory volume in 1 s/forced vital capacity and forced expiratory flow at 75% of forced vital capacity (z-score difference -0.28 (95% CI -0.52- -0.04) and -0.24 (95% CI -0.46- -0.01), respectively) in children at age 10 years. The observed associations were only partly explained by mode of delivery, gestational age at birth or birthweight.

CONCLUSIONS

C. trachomatis infection during pregnancy is associated with increased odds of wheezing, asthma and impaired lung function. The causality of the observed associations and potential underlying mechanisms need to be explored.

Interventions for treating genital Chlamydia trachomatis infection in pregnancy

BACKGROUND

Genital Chlamydia trachomatis (C.trachomatis) infection may lead to pregnancy complications such as miscarriage, preterm labour, low birthweight, preterm rupture of membranes, increased perinatal mortality, postpartum endometritis, chlamydial conjunctivitis and C.trachomatis pneumonia.This review supersedes a previous review on this topic.

OBJECTIVES

To establish the most efficacious and best-tolerated therapy for treatment of genital chlamydial infection in preventing maternal infection and adverse neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 June 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) as well as studies published in abstract form assessing interventions for treating genital C.trachomatis infection in pregnancy. Cluster-RCTs were also eligible for inclusion but none were identified. Quasi-randomised trials and trials using cross-over design are not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed trial quality and extracted the data using the agreed form. Data were checked for accuracy. Evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 15 trials (involving 1754 women) although our meta-analyses were based on fewer numbers of studies/women. All of the included studies were undertaken in North America from 1982 to 2001. Two studies were low risk of bias in all domains, all other studies had varying risk of bias. Four other studies were excluded and one study is ongoing.Eight comparisons were included in this review; three compared antibiotic (erythromycin, clindamycin, amoxicillin) versus placebo; five compared an antibiotic versus another antibiotic (erythromycin, clindamycin, amoxicillin, azithromycin). No study reported different antibiotic regimens. Microbiological cure (primary outcome) Antibiotics versus placebo: Erythromycin (average risk ratio (RR) 2.64, 95% confidence interval (CI) 1.60 to 4.38; two trials, 495 women; I² = 68%; moderate-certainty evidence), and clindamycin (RR 4.08, 95% CI 2.35 to 7.08; one trial, 85 women;low-certainty evidence) were associated with improved microbiological cure compared to a placebo control. In one very small trial comparing amoxicillin and placebo, the results were unclear, but the evidence was graded very low (RR 2.00, 95% CI 0.59 to 6.79; 15 women). One antibiotic versus another antibiotic: Amoxicillin made little or no difference in microbiological cure in comparison to erythromycin (RR 0.97, 95% CI 0.93 to 1.01; four trials, 466 women; high-certainty evidence), probably no difference compared to clindamycin (RR 0.96, 95% CI 0.89 to 1.04; one trial, 101 women; moderate-quality evidence), and evidence is very low certainty when compared to azithromycin so the effect is not certain (RR 0.89, 95% CI 0.71 to 1.12; two trials, 144 women; very low-certainty evidence). Azithromycin versus erythromycin (average RR 1.11, 95% CI 1.00 to 1.23; six trials, 374 women; I² = 53%; moderate-certainty evidence) probably have similar efficacy though results appear to favour azithromycin. Clindamycin versus erythromycin (RR 1.06, 95% CI 0.97 to 1.15; two trials, 173 women; low-certainty evidence) may have similar numbers of women with a microbiological cure between groups.Evidence was downgraded for design limitations, inconsistency, and imprecision in effect estimates. Side effects of the treatment (maternal) (secondary outcome) Antibiotics versus placebo: side effects including nausea, vomiting, and abdominal pain, were reported in two studies (495 women) but there was no clear evidence whether erythromycin was associated with more side effects than placebo and a high level of heterogeneity (I² = 78%) was observed (average RR 2.93, 95% CI 0.36 to 23.76). There was no clear difference in the number of women experiencing side effects when clindamycin was compared to placebo in one small study (5/41 versus 1/44) (RR 6.35, 95% CI 0.38 to 107.45, 62 women). The side effects reported were mostly gastrointestinal and also included resolving skin rashes. One antibiotic versus another antibiotic: There was no clear difference in incidence of side effects (including nausea, vomiting, diarrhoea and abdominal pain) when amoxicillin was compared to azithromycin based on data from one small study (36 women) (RR 0.56, 95% CI 0.24 to 1.31).However, amoxicillin was associated with fewer side effects compared to erythromycin with data from four trials (513 women) (RR 0.31, 95% CI 0.21 to 0.46; I² = 27%). Side effects included nausea, vomiting, diarrhoea, abdominal cramping, rash, and allergic reaction.Both azithromycin (RR 0.24, 95% CI 0.17 to 0.34; six trials, 374 women) and clindamycin (RR 0.44, 95% CI 0.22 to 0.87; two trials, 183 women) were associated with a lower incidence of side effects compared to erythromycin. These side effects included nausea, vomiting, diarrhoea and abdominal cramping.One small study (101 women) reported there was no clear difference in the number of women with side effects when amoxicillin was compared with clindamycin (RR 0.57, 95% CI 0.14 to 2.26; 107 women). The side effects reported included rash and gastrointestinal complaints. Other secondary outcomes Single trials reported data on repeated infections, preterm birth, preterm rupture of membranes, perinatal mortality and low birthweight and found no clear differences between treatments.Many of this review's secondary outcomes were not reported in the included studies.

AUTHORS' CONCLUSIONS

Treatment with antibacterial agents achieves microbiological cure from C.trachomatis infection during pregnancy. There was no apparent difference between assessed agents (amoxicillin, erythromycin, clindamycin, azithromycin) in terms of efficacy (microbiological cure and repeat infection) and pregnancy complications (preterm birth, preterm rupture of membranes, low birthweight). Azithromycin and clindamycin appear to result in fewer side effects than erythromycin.All of the studies in this review were conducted in North America, which may limit the generalisability of the results. In addition, study populations may differ in low-resource settings and these results are therefore only applicable to well-resourced settings. Furthermore, the trials in this review mainly took place in the nineties and early 2000's and antibiotic resistance may have changed since then.Further well-designed studies, with appropriate sample sizes and set in a variety of settings, are required to further evaluate interventions for treating C.trachomatis infection in pregnancy and determine which agents achieve the best microbiological cure with the least side effects. Such studies could report on the outcomes listed in this review.

Lipase-Sensitive Transfersomes Based on Photosensitizer/Polymerizable Lipid Conjugate for Selective Antimicrobial Photodynamic Therapy of Acne

Acne vulgaris is a common skin problem affecting nearly 90% of adolescents and its development is associated with a colonization of Propionibacterium acnes (P. acnes). Although antibiotics have commonly been used to treat acne, antibiotic resistance of P. acnes is an emerging issue to be solved. In this study, a new way of photodynamic acne therapy is developed using P. acnes lipase-sensitive transfersome (DSPE-PEG-Pheo A (DPP) transfersome). For enhanced selectivity and skin penetration efficiency, DPP transfersomes are prepared from 1,2-distearoyl-sn-glycero-3-phosphoethanolamine-N-[amino(polyethylene glycol)-2000], pheophorbide A (Pheo A), cholesterol, and Tween-80. Incorporation of Tween-80 as an edge activator increases the deformability of DPP transfersomes, enhancing skin penetration efficiency to four times that of free Pheo A. The photoactivity of Pheo A quenched by DPP transfersomes is gradually recovered by selective cleavage of the ester linkage in DPP transfersomes by P. acnes lipases. In vitro P. acnes-specific photoactivity and subsequent selective antimicrobial effect exhibit a greater than 99% loss of P. acnes viability. In vivo antiacne therapeutic effect is confirmed by reduction of swelling volume and thickness of P. acnes-induced nude mice skin. These results demonstrate that DPP transfersome-mediated photodynamic therapy can be used as an alternative method to treat bacterial skin infections.

2015 UK national guideline for the management of infection with Chlamydia trachomatis

This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of Chlamydia trachomatis genital infection. It covers the management of the initial presentation, as well the prevention of transmission and future infection. The guideline is aimed at individuals aged 16 years and older presenting to healthcare professionals working in departments offering Level 3 care in sexually transmitted infections management within the UK. However, the principles of the recommendations should be adopted across all levels, using local care pathways where appropriate.

Urogenital chlamydia infection in women: patient management tactics according to present-day foreign and Russian recommendations

The article present data on current approaches to laboratory diagnostics and treatment of urogenital chlamydia infection in women. According to Russian and foreign guidelines, azithromycin, josamycin and doxycycline monohydrate belong to the most efficient antimicrobial drugs for the treatment of urogenital chlamydia infection in non-pregnant women. As for the treatment of pregnant patients suffering from this pathology, azithromycin and josamycin are the most optimal drugs in terms of safety and treatment efficacy according to both Russian and foreign guidelines.

Approaches to the management of uncomplicated genital Chlamydia trachomatis infections

Genital chlamydial infection remains a highly prevalent sexually transmitted infection in the USA. A multifaceted approach to the management of chlamydial infection is essential to ensure cure and prevention of reinfection. This article will review current approaches to the management of uncomplicated genital chlamydial infection, discussing: the pathogen; antimicrobials that are and are not recommended for therapy by the US Centers for Disease Control and Prevention; partner treatment; follow-up; antimicrobial resistance; and potential future therapies.

On the pathway to better birth outcomes? A systematic review of azithromycin and curable sexually transmitted infections

The WHO recommends the administration of sulfadoxine-pyrimethamine (SP) to all pregnant women living in areas of moderate (stable) to high malaria transmission during scheduled antenatal visits, beginning in the second trimester and continuing to delivery. Malaria parasites have lost sensitivity to SP in many endemic areas, prompting the investigation of alternatives that include azithromycin-based combination (ABC) therapies. Use of ABC therapies may also confer protection against curable sexually transmitted infections and reproductive tract infections (STIs/RTIs). The magnitude of protection at the population level would depend on the efficacy of the azithromycin-based regimen used and the underlying prevalence of curable STIs/RTIs among pregnant women who receive preventive treatment. This systematic review summarizes the efficacy data of azithromycin against curable STIs/RTIs.

Fetal safety of macrolides

Macrolide antibiotics are largely used in pregnancy for different bacterial infections. Their fetal safety has been studied by several groups, yielding opposing results. In particular, there have been studies claiming an association between macrolides and cardiovascular malformations. Exposure in early infancy has been associated with pyloric stenosis and intussusception. This has led to an avoidance in prescribing macrolides to pregnant women in several Scandinavian countries. The Objectives of the present study was to investigate the fetal safety of this class of drug by linking a large administrative database of drug dispensing and pregnancy outcome in Southern Israel. A computerized database of medications dispensed from 1999 to 2009 to all women registered in the Clalit health maintenance organization in southern Israel was linked with two computerized databases containing maternal and infant hospitalization records. Also, medical pregnancy termination data were analyzed. The following confounders were controlled for: maternal age, ethnicity, maternal pregestational diabetes, parity, and the year the mother gave birth or went through medical pregnancy termination. First- and third-trimester exposures to macrolide antibiotics as a group and to individual drugs were analyzed. During the study period there were 105,492 pregnancies among Clalit women that met the inclusion criteria. Of these, 104,380 ended in live births or dead fetuses and 1,112 in abortion due to medical reasons. In the first trimester of pregnancy, 1,033 women were exposed to macrolides. There was no association between macrolides and either major malformations [odds ratio (OR), 1.08; 95% confidence interval (CI), 0.84 to 1.38)] or specific malformations, after accounting for maternal age, parity, ethnicity, prepregnancy diabetes, and year of exposure. During the third trimester of pregnancy, 959 women were exposed to macrolides. There was no association between such exposure and perinatal mortality, low birth weight, low Apgar score, or preterm delivery. Similarly, no associations were demonstrated with pyloric stenosis or intussusception. Use of macrolides in the first trimester of pregnancy is not associated with an increased risk of major malformations. Exposure in the third trimester is not likely to increase neonatal risks for pyloric stenosis or intussusception in a clinically meaningful manner.

Azithromycin for treating uncomplicated malaria

BACKGROUND

To prevent the development of drug resistance, the World Health Organization (WHO) recommends treating malaria with combination therapy. Azithromycin, an antibiotic with antimalarial properties, may be a useful additional option for antimalarial therapy.

OBJECTIVES

To compare the use of azithromycin alone or in combination with other antimalarial drugs with the use of alternative antimalarial drugs for treating uncomplicated malaria caused by Plasmodium falciparum or Plasmodium vivax.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (August 2010); CENTRAL (The Cochrane Library Issue 3, 2010); MEDLINE (1966 to August 2010); EMBASE (1974 to August 2010); LILACS (August 2010); the metaRegister of Controlled Trials (mRCT, August 2010); conference proceedings; and reference lists. We also contacted researchers and a pharmaceutical company.

SELECTION CRITERIA

Randomized controlled trials comparing azithromycin, either alone or combined with another antimalarial drug, with another antimalarial drug used alone or combined with another antimalarial drug, or with azithromycin combined with another antimalarial drug if different combinations or doses of azithromycin were used. The primary outcome was treatment failure by day 28, defined as parasitological or clinical evidence of treatment failure between the start of treatment and day 28. Secondary outcomes included treatment failure by day 28 corrected for new infections confirmed by polymerase chain reaction (PCR), fever and parasite clearance time, and adverse events.

DATA COLLECTION AND ANALYSIS

Two people independently applied the inclusion criteria, extracted data and assessed methodological quality. We used risk ratio (RR) and 95% confidence intervals (CI).

MAIN RESULTS

Fifteen trials met the inclusion criteria (2284 participants, 69% males, 16% children). They were conducted in disparate malaria endemic areas, with the earlier studies conducted in Thailand (five) and India (two), and the more recent studies (eight) spread across three continents (South America, Africa, Asia). The 15 studies involved 41 treatment arms, 12 different drugs, and 28 different treatment regimens. Two studies examined P. vivax.Three-day azithromycin (AZ) monotherapy did not perform well for P. vivax or P. falciparum (Thailand: P. vivax failure rate 0.5 g daily, 56%, 95% CI 31 to 78. India: P. vivax failure rate 1 g daily,12%, 95% CI 7 to 21; P. falciparum failure rate 1 g daily, 64%, 95% CI 36 to 86.) A 1 g azithromycin and 0.6 g chloroquine combination daily for three days for uncomplicated P. falciparum infections was associated with increased treatment failure in India and Indonesia compared with the combination of sulphadoxine-pyrimethamine and chloroquine (pooled RR 2.66, 95% CI 1.25 to 5.67), and compared with the combination atovaquone-proguanil in a multicentre trial in Columbia and Surinam (RR 24.72, 95% CI 6.16 to 99.20). No increased risk of treatment failure was seen in two studies in Africa with mefloquine as the comparator drug (pooled RR 2.02, 95% CI 0.51 to 7.96, P = 0.3); the pooled RR for PCR-corrected data for the combination versus mefloquine was 1.01, 95% CI 0.18 to 5.84 (P = 1.0). An increased treatment failure risk was seen when comparing azithromycin in a dose of 1.2 to 1.5 mg in combination with artesunate (200 mg per day for three days) with artemether-lumefantrine (pooled RR 3.08, 95% CI 2.09 to 4.55; PCR-corrected pooled RR 3.63, 95% CI 2.02 to 6.52).Serious adverse events and treatment discontinuation were similar across treatment arms. More adverse events were reported when comparing the 1 g azithromycin/ 0.6 g chloroquine combination with mefloquine (pooled RR 1.20, 95% CI 1.06 to 1.36) or atovaquone-proguanil (RR 1.41, 95% CI 1.09 to1.83).

AUTHORS' CONCLUSIONS

Currently, there is no evidence for the superiority or equivalence of azithromycin monotherapy or combination therapy for the treatment of P. falciparum or P. vivax compared with other antimalarials or with the current first-line antimalarial combinations. The available evidence suggests that azithromycin is a weak antimalarial with some appealing safety characteristics. Unless the ongoing dose, formulation and product optimisation process results in a universally efficacious product, or a specific niche application is identified that is complementary to the current scala of more efficacious antimalarial combinations, azithromycin's future for the treatment of malaria does not look promising.

Fetal outcome following roxithromycin exposure in early pregnancy

OBJECTIVE

Because very little information exists on the fetal safety of roxithromycin, we aimed to extend the knowledge on fetal outcome in pregnant women who were exposed to roxithromycin in early pregnancy.

METHODS

Twenty pregnant women inadvertently exposed to roxithromycin during early pregnancy were identified and prospectively followed-up. For comparison, 170 pregnant women matched by age and gravidity, not being exposed to any potential teratogenic agent during pregnancy, were recruited as controls. All gestations were confirmed by ultrasound examination, and participants were followed-up until delivery. Newborns were examined by a neonatologist.

RESULTS

Of 20 pregnant women exposed to roxithromycin during early pregnancy, information was obtained from 17 cases. The median dose of roxithromycin to which pregnant women were exposed was 300 mg/day (range 300-450 mg/day) and exposure occurred at a mean of 4.0 (range 2.8-17.6) weeks. Mean gestational age at delivery was 39.2 weeks in the exposed group and 39.4 in the controls (p = 0.6). Birth weight of babies exposed in utero to roxithromycin was not different to controls. We did not observe any major malformation in the exposed group whereas three (1.8%) occurred in the control group.

CONCLUSIONS

. Despite the limitations of the study due to the small sample size, roxithromycin appears not to be a major teratogen.

A randomized controlled pilot trial of azithromycin or artesunate added to sulfadoxine-pyrimethamine as treatment for malaria in pregnant women

Objective

New anti-malarial regimens are urgently needed in sub-Saharan Africa because of the increase in drug resistance. We investigated the safety and efficacy of azithromycin or artesunate combined with sulfadoxine-pyrimethamine used for treatment of malaria in pregnant women in Blantyre, Malawi.

Methods/Findings

This was a randomized open-label clinical trial, conducted at two rural health centers in Blantyre district, Malawi. A total of 141 pregnant women with uncomplicated Plasmodium falciparum malaria were recruited and randomly allocated to 3 treatment groups: sulfadoxine-pyrimethamine (SP; 3 tablets, 500 mg sulfadoxine and 25 mg pyrimethamine per tablet); SP plus azithromycin (1 g/day×2 days); or SP plus artesunate (200 mg/day×3 days). Women received two doses administered at least 4 weeks apart. Heteroduplex tracking assays were performed to distinguish recrudescence from new infections. Main outcome measures were incidence of adverse outcomes, parasite and fever clearance times and recrudescence rates. All treatment regimens were well tolerated. Two women vomited soon after ingesting azithromycin. The parasite clearance time was significantly faster in the SP-artesunate group. Recrudescent episodes of malaria were less frequent with SP-azithromycin [Hazard Ratio 0.19 (95% confidence interval 0.06 to 0.63)] and SP-artesunate [Hazard Ratio 0.25 (95% confidence interval 0.10 to 0.65)] compared with SP monotherapy. With one exception (an abortion in the SP-azithromycin group), all adverse pregnancy outcomes could be attributed to known infectious or obstetrical causes. Because of the small sample size, the effect on birth outcomes, maternal malaria or maternal anemia could not be evaluated.

Conclusions

Both SP-artesunate and SP-azithromycin appeared to be safe, well tolerated and efficacious for the treatment of malaria during pregnancy. A larger study is needed to determine their safety and efficacy in preventing poor birth outcomes.

Trial Registration

ClinialTrials.gov NCT00287300

The pattern of notification and testing for genitalChlamydia trachomatisinfection in Victoria, 1998-2000: an ecological analysis

OBJECTIVE

This ecological study analyses routinely collected chlamydia notification and testing data to investigate any patterns.

METHODS

Age and sex-specific chlamydia notification and testing rates for Victoria were calculated for the period 1998 to 2000.

RESULTS

Chlamydia notification and testing rates rose between 1998 and 2000. Notification rates were higher among women aged 15 to 24 years than men of the same age (p < 0.01) and higher among 25 to 44-year-olds living in metropolitan rather than rural/regional Victoria (p < 0.01). Testing rates were higher for women than men (p < 0.01) and higher in metropolitan rather than rural/regional areas (p < 0.01) in all groups except women aged 15-24 years.

CONCLUSIONS

These increasing rates highlight that chlamydia infection represents a substantial public health problem.

IMPLICATIONS

Although these data provide useful information showing these rates vary with age and sex, formal epidemiological prevalence and risk factor studies are required.

Single-dose azithromycin versus erythromycin or amoxicillin for Chlamydia trachomatis infection during pregnancy: a meta-analysis of randomised controlled trials

This review aimed to compare data regarding the effectiveness and safety of azithromycin with alternative regimens in the treatment of pregnant women with Chlamydia trachomatis infection. PubMed and Scopus databases were searched to identify relevant randomised controlled trials (RCTs). The main analysis focused on comparison of azithromycin with erythromycin. In a secondary analysis, azithromycin was compared with erythromycin or amoxicillin. Eight RCTs studying 587 pregnant women with microbiologically documented C. trachomatis infection were included in the meta-analysis. Overall, there was no difference between azithromycin and erythromycin regarding treatment success in intention-to-treat patients (pooled odds ratio (OR)=2.66, 95% confidence interval (CI) 0.69-10.29) or in clinically evaluated patients (OR=1.46, 95% CI 0.56-3.78). Furthermore, azithromycin was associated with fewer gastrointestinal adverse events (OR=0.11, 95% CI 0.07-0.18), fewer total adverse events (OR=0.11, 95% CI 0.07-0.18), a smaller proportion of patients who withdrew from the study (OR=0.12, 95% CI 0.04-0.37) and better compliance (OR=23.7, 95% CI 9.34-60.14) than erythromycin. The results of the secondary analysis comparing azithromycin with erythromycin or amoxicillin were similar to those of the main analysis. In conclusion, azithromycin was associated with similar effectiveness but less adverse events compared with erythromycin or amoxicillin in the treatment of pregnant women with C. trachomatis infection.

Management of uncomplicated Chlamydia trachomatis infections in adolescents and adults: evidence reviewed for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines

In April 2005, in preparation for the 2006 Centers for Disease Control and Prevention (CDC) sexually transmitted diseases (STD) treatment guidelines, the CDC convened an advisory group to examine recent abstracts and published literature addressing management of Chlamydia trachomatis infections in adolescents and adults. Key questions were posed and answered on the basis of quality of evidence and expert opinion. Clinical trials continue to demonstrate equivalent efficacy and tolerability of azithromycin and doxycycline regimens, and both remain recommended as first-line therapy in nonpregnant individuals. More data and clinical experience are available to support the efficacy, safety, and tolerability of azithromycin in pregnant women, and, in the upcoming guidelines, azithromycin will be recommended as first-line therapy for such patients. Evidence is building that expedited partner therapy (EPT), with provision of treatment or a prescription, may be just as effective as or more effective than standard partner referral in ensuring partner treatment and preventing chlamydia recurrence in women. Although there are more studies needed and barriers to be addressed before its widespread use, EPT will be recommended as an option for partner management.

Pregnancy outcome following gestational exposure to azithromycin

BACKGROUND

Azithromycin is an azalide antibiotic with an extensive range of indications and has become a common treatment option due to its convenient dosing regimen and therapeutic advantages. Human studies addressing gestational use of azithromycin have primarily focused on antibiotic efficacy rather than fetal safety. Our primary objective was to evaluate the possibility of teratogenic risk following gestational exposure to azithromycin.

METHODS

There were 3 groups of pregnant women enrolled in our study: 1) women who took azithromycin, 2) women exposed to non-teratogenic antibiotics for similar indications, and 3) women exposed to non-teratogenic agents. They were matched for gestational age at time of call, maternal age, cigarette and alcohol consumption. Rates of major malformations and other endpoints of interest were compared among the three groups.

RESULTS

Pregnancy outcome of 123 women in each group was ascertained. There were no statistically significant differences among the three groups in the rates of major malformations; 3.4% (exposed) versus 2.3% (disease matched) and 3.4% (non teratogen) or any other endpoints that were examined. In the azithromycin group, 88 (71.6%) women took the drug during the first trimester

CONCLUSION

Results suggest that gestational exposure to azithromycin is not associated with an increase in the rate of major malformations above the baseline of 1-3%. Our data adds to previous research showing that macrolide antibiotics, as a group, are generally safe in pregnancy and provides an evidence-based option for health professionals caring for populations with chlamydia.

An Observational Cohort Study of Chlamydia trachomatis Treatment in Pregnancy

BACKGROUND AND OBJECTIVES

Currently, azithromycin is not considered a first-line treatment for Chlamydia trachomatis in pregnant women. We evaluated the use, efficacy, and safety of azithromycin compared with erythromycin and amoxicillin in the treatment of genital chlamydial infection during pregnancy.

METHODS

This was a retrospective cohort study of pregnant women with genital chlamydial infection. Data on antibiotics prescribed, test-of-cure (TOC) results, and maternal and infant complications were collected from medical records.

RESULTS

Of the 277 women in the study sample, 69% were initially prescribed azithromycin, 9% amoxicillin, and 19% erythromycin. Eight-one percent of subjects had a TOC 7 or more days after diagnosis and before delivery. Treatment efficacy, as defined by a negative TOC, was 97% (95% confidence interval [CI], 92.9-99.2) for azithromycin, 95% (95% CI, 76.2-99.9) for amoxicillin, and 64% (95% CI, 44.1-81.4) for erythromycin. The efficacy of azithromycin was significantly higher than erythromycin (P < 0.0001). There were no significant differences in efficacy by age, race/ethnicity, concurrent sexually transmitted disease diagnosis, partner treatment, or substance use. Furthermore, there was no difference in complications for women or infants exposed to azithromycin compared with those treated with other regimens.

CONCLUSION

Clinical outcome data from this study population of women and infants support both efficacy and safety of azithromycin for treatment of C. trachomatis in pregnancy.

Surgery for Trichiasis, Antibiotics to prevent Recurrence (STAR) Clinical Trial methodology

Trachoma is the leading infectious cause of blindness worldwide. Surgery is available to correct trichiasis, which results from repeated episodes of infection with C. trachomatis. However, trichiasis recurrence rates post-surgery are very high. Methods for reducing post-surgical trichiasis recurrence need to be explored. This paper outlines the design of the Surgery for Trichiasis, Antibiotics to prevent Recurrence (STAR) Clinical Trial currently underway in Ethiopia. The STAR trial, funded by The National Eye Institute, is a randomized, controlled clinical trial of antibiotic use at time of trichiasis surgery, comparing topical tetracycline to single-dose azithromycin for the surgical patient and single-dose azithromycin for the surgical patient and all household members. The primary outcome is trichiasis recurrence at one-year. Data from this trial will be critical in helping to determine future policy on antibiotic treatment for C. trachomatis following surgery.

Treatment of sexually transmitted infections in pregnancy

Sexually transmitted infections remain a major public health concern in the United States. An estimated 19 million infections occur each year. The economic burden imposed by sexually transmitted infections is impressive: direct medical costs have been estimated as high as 15.5 billion US dollars annually. Sexually transmitted infections are relatively common during pregnancy, especially in indigent, urban populations. Education, screening, treatment, and prevention are important components of prenatal care for women at increased risk for these infections. Treatment of these sexually transmitted infections is clearly associated with improved pregnancy outcome and reductions in perinatal mortality.

PCR detection of bacteria on cardiac valves of patients with treated bacterial endocarditis

We used broad-range PCR amplification and sequencing to detect and identify bacterial DNA in 156 valves of patients treated for infective endocarditis (IE). Bacterial DNA was found more frequently in patients who underwent valve replacement while on antibiotic treatment for IE (60%) than in patients who had completed antibiotic treatment for IE (37%; P = 0.02). We found specific bacterial DNA in valves removed from 11 of 30 patients who had completed antibiotic treatment for IE. Six had no histological evidence of IE. The presence of DNA was significantly correlated with the presence of histologic lesions (P = 0.001) and with the presence of bacteria detected by Gram staining (P < 0.001). Bartonella and streptococci were detected for much longer after antibiotic treatment by PCR than other species (P = 0.047 and 0.04, respectively), and coagulase-negative staphylococci were detected for much shorter periods (P = 0.02). The finding that bacterial DNA was more likely to be detected in valves of patients with active IE than in patients who had completed antibiotic treatment for IE shows that bacterial DNA is cleared slowly. There was no significant correlation between the duration of antibiotic therapy and the presence of bacterial DNA in valves. Since the persistence of bacterial DNA in valves does not necessarily indicate the persistence of viable bacteria, the detection of bacterial DNA in valves from IE patients should be interpreted with caution, in particular in those patients with a past history of treated IE.

Prevention of iatrogenic pelvic infection during in vitro fertilization--current practice in the UK

Uterine instrumentation can provoke pelvic inflammatory disease in women infected with Chlamydia trachomatis. During an IVF treatment cycle, a fine plastic catheter is passed into the endometrial cavity to transfer the embryos. The objective of this survey was to find out what measures are being taken by IVF clinics to prevent ascending infection. Postal questionnaires were sent to 75 clinics in the UK, asking about their sexually transmitted infection screening policies and their protocols on antibiotic prophylaxis. Seventy clinics (93%) responded, of which 37 (53%) neither screen the female partner for C. trachomatis, nor give appropriate antibiotic prophylaxis. Approximately half of UK IVF clinics make no attempt to either detect or treat chlamydial infection prior to embryo transfer. More research is required to evaluate whether embryo transfer does pose a significant risk factor for pelvic inflammatory disease.

Macrolides and ketolides: azithromycin, clarithromycin, telithromycin

The advanced macrolides, azithromycin and clarithromycin, and the ketolide telithromycin are structural analogues of erythromycin. They have several distinct advantages when compared with erythromycin including enhanced spectrum of activity, more favorable pharmacokinetics and pharmacodynamics, once daily administration, and improved tolerability. This article reviews the pharmacokinetics, antimicrobial activity, clinical use, and adverse effects of these antimicrobial agents.

Chlamydia and gonorrhoea in pregnancy: effectiveness of diagnosis and treatment in Botswana

BACKGROUND

Millions of patients are prescribed drugs for sexually transmitted infections (STIs) in developing countries each year, yet the treatment effect of these prescriptions is largely unknown.

OBJECTIVES

To determine if the prescribing of erythromycin and ceftriaxone to pregnant women with STI symptoms leads to a reduction in the prevalence among these women of chlamydia and gonorrhoea, respectively.

METHODS

We compared the prevalence of chlamydia among 116 pregnant women who had been prescribed erythromycin for a history of STI symptoms in their current pregnancy with the prevalence in a control group of 557 pregnant women who had not been prescribed this drug. Similarly we compared the prevalence of gonorrhoea among 110 pregnant women who had and 561 women who had not been prescribed ceftriaxone.

RESULTS

There was no significant difference in the prevalence of chlamydia among the women who had and the women who had not been prescribed erythromycin four times daily for 10 days (7% v 8%). Contrarily, none of the women who had been prescribed a single dose of ceftriaxone had gonorrhoea, whereas 4% of the women who had not had this drug prescribed did have gonorrhoea.

CONCLUSIONS

The prescribing of erythromycin seems to have had a limited effect on chlamydia in this population, whereas the prescribing of ceftriaxone led to the curing of gonorrhoea. Ceftriaxone is provided as a single dose injection at the point of care, and the differential effectiveness between the two drugs may reflect low compliance with the complex erythromycin regimen. Interventions to increase compliance could improve cure rates. The use of a simpler drug regimen should be considered when low compliance is likely.

The Resurgence of Chlamydia trachomatis

The objective of the review is to alert reproductive-care providers to the unexpected resurgence of Chlamydia infections and to new findings related to complications associated with Chlamydia infection. Data sources consisted of national and local guidelines and literature searches of MEDLINE with the heading Chlamydia infections 2002 and 2003. The complications of Chlamydia infections are considered to be longterm, and may include debilitating pain, infertility, tubal pregnancy, cancer, and HIV infection. Only a strong disease-management response from reproductive-care providers, using new diagnostic techniques and simpler treatment regimens, as well as a strong public health reaction, will be effective to limit the scourges of Chlamydia infection in the female population.

Treatment of sexually transmitted diseases in women

Guidelines for the treatment of patients with sexually transmitted infection are developed by the Centers for Disease Control and Prevention after consultation with a group of professionals knowledgeable in the field. This article briefly introduces various infections, reviews new diagnostic information, and presents the latest guidelines for therapy. All recommended and alternative regimens are drawn from the most recent treatment guidelines. Although this article focuses primarily on therapy, it also emphasizes the importance of counseling and prevention. Clinicians have the opportunity and obligation to provide education and counseling to patients. Prevention messages should be tailored to the individual patient with consideration given to her specific risk behaviors.

Safety, efficacy and determinants of effectiveness of antimalarial drugs during pregnancy: implications for prevention programmes in Plasmodium falciparum-endemic sub-Saharan Africa

Plasmodium falciparum malaria in pregnancy poses substantial risk to a pregnant woman and her neonate through anaemia and low birth weight (LBW), respectively, and is responsible for up to 35% of preventable LBW in malaria-endemic areas. Chemoprophylaxis or intermittent preventive treatment (IPT) with an effective antimalarial can ameliorate the adverse effects of malaria during pregnancy. Current guidelines from the WHO recommend that women in highly malarious areas receive IPT with an effective antimalarial. Two central considerations in evaluating drugs for use during pregnancy are safety for the mother and her foetus and effectiveness, which is determined by efficacy, cost, availability, deliverability and acceptability of the drug. These factors may be scored and potential drugs or drug combinations ranked in order of potential effectiveness for use in prevention programmes. The seven most promising regimens are all IPT, primarily because they are more easily delivered and less expensive than chemoprophylaxis. Currently, IPT with sulphadoxine-pyrimethamine (SP) is more likely to have the best overall effectiveness in preventing adverse outcomes associated with malaria in pregnancy. Its low cost, wide availability, easy deliverability and acceptability make it the clear choice in countries where efficacy of the drug remains good. For countries where resistance to SP is rising or already high, amodiaquine (alone or in combination with SP or artesunate) artesunate + SP, chlorproguanil-dapsone (with and without artesunate) and artemether-lumefantrine require urgent evaluation for use in pregnancy.

Mediterranean spotted fever during pregnancy: case presentation and literature review

Mediterranean spotted fever (MSF) is caused by Rickettsia conorii, an obligate intracellular parasite of eukaryotic cells. Although, usually this disease has a benign course, a rapidly fatal outcome can occur even in young healthy adults. We describe a case of a 40-year-old Bedouin woman gravida 11, para 10, who was admitted at 36 weeks gestation with this rickettsial disease. During pregnancy, the treatment of choice for Mediterranean spotted fever is chloramphenicol, but it seems that Azithromycin could be another possible option.

The CDC 2002 guidelines for the treatment of sexually transmitted diseases: implications for women's health care

Persons rely on health care providers to make diagnostic and therapeutic decisions based on the most current information. With areas of practice changing rapidly, providers are challenged to keep abreast of new and changing treatment guidelines. The new Centers for Disease Control and Prevention (CDC) 2002 Sexually Transmitted Disease (STD) Treatment Guidelines provide clinical guidance in the appropriate assessment and management of STDs. This article reviews recent changes in the STD Treatment Guidelines for the most common disease entities and their sequelae encountered by women's health practitioners. The changes noted in this article include new screening recommendations, use of new diagnostics, new treatment algorithms, and changes in therapeutic regimens.

Placental passage of clarithromycin surpasses other macrolide antibiotics

OBJECTIVE

Infection of the amnion cavity with Ureaplasma urealyticum continues to be a therapeutic challenge. The transplacental transfer rates of macrolide antibiotics are low, and tetracyclines and quinolones are contraindicated in pregnancy. The aim of this study was to investigate placental transfer of clarithromycin in a well-studied placental perfusion model to determine whether clarithromycin surpasses the transfer rate of other macrolide antibiotics in similar models.

STUDY DESIGN

Ten placentas that were obtained immediately after delivery were perfused with clarithromycin (3 microg/mL) plus a reference substance (antipyrine). Open circulation placental preparations were used to evaluate steady-state pharmacodynamics and transplacental gradient formation. Drug concentrations were measured by high-performance liquid chromatography.

RESULTS

The mean transplacental transfer of clarithromycin was 6.1% (95% CI, 1.8%).

CONCLUSION

Because of its enhanced placental passage compared with other macrolide antibiotics, clarithromycin that is given after the first trimester (after embryogenesis) may be an appropriate candidate in treatment trials of genital mycoplasma and ureaplasma infections during pregnancy.

Treatment of genital Chlamydia trachomatis infection in pregnancy

This chapter gives a systematic review of the literature on treatment of Chlamydia trachomatis infections in pregnant women. The benefits of timely treatment of chlamydial infections in pregnant women are discussed. Antibiotic regimens commonly used for this purpose are identified. A meta-analysis based on randomized trials on pregnant women was performed to compare various antibiotic regimes in terms of microbiological cure, side-effects and tolerance. Data on safety related to the use of these antibiotics during pregnancy are summarized. Cost-effectiveness analyses on relevant antibiotic regimes for the treatment of uncomplicated chlamydial infection in women are identified. Their relevance and their shortcomings regarding the obstetric population are discussed. Treatment options for those who failed initial antibiotic treatment, as well as for the sexual partners of infected patients, are mentioned.

Treatment of uncomplicated genital Chlamydia trachomatis infections in adults

To prepare the 2001 sexually transmitted disease treatment guidelines of the Centers for Disease Control and Prevention, recently published articles and abstracts concerning advances in the treatment of uncomplicated Chlamydia trachomatis genital infections in adults were reviewed. Questions about treatments were posed and answered according to the results of efficacy studies and clinical trials. Recent studies have continued to demonstrate the similar efficacy of doxycycline and azithromycin. Because compliance with doxycyline remains a concern, administration of single-dose azithromycin therapy in the clinic presents a potential advantage for patients whose adherence is questionable. Because few systematically collected data have been published concerning the safety and efficacy of azithromycin use in pregnancy, the guidelines continue to recommend treatment with erythromycin or amoxicillin. Nevertheless, because of azithromycin's less frequent side effects and improved adherence, increasing numbers of obstetricians in the United States are using azithromyin to treat pregnant women with uncomplicated C. trachomatis infections.

Treatment of sexually transmitted infections with single-dose therapy: a double-edged sword

Since the advent of the antimicrobial era, single-dose therapy has been a valuable tool in the management of genital infection. Most of the common sexually transmitted infections (STIs) such as gonorrhoea, syphilis, trichomoniasis and chancroid can be treated in this way, as can genital infections which are not sexually transmitted such as bacterial vaginosis and genital tract candidiasis. Until recently, treatment for Chlamydia trachomatis infection required a multi-dose regimen, but single-dose azithromycin has now been shown to be an effective and acceptable alternative to this. Unfortunately, eradicative therapy has proven to be elusive for the viral STIs such as genital herpes simplex infection, human papilloma virus infection and human immunodeficiency virus (HIV) infection. The main advantage of single-dose therapy lies in its convenience and in its ability to ensure virtually 100% compliance. This addresses the problems of reduced clinical efficacy and the difficulties in assessing the response to therapy which complicates poor treatment compliance. However, some single-dose regimens for STIs do have drawbacks, particularly in certain situations. This may be with respect to efficacy, for example in syphilis with single-dose benzathine penicillin therapy, particularly for pregnant women and individuals infected with HI. Alternatively, it may involve toxicity, for example with single-dose metronidazole therapy for trichomoniasis or bacterial vaginosis where a higher rate of gastrointestinal adverse effects may be expected than if a lower multi-dose regimen is used. In addition, single-dose therapy, for example with nevirapine, given to the mother in labour and to the baby after delivery significantly reduces the risk of mother to child HIV transmission, but resistance mutations are frequently detected in the viral genome after the brief exposure to the drug, which could jeopardise its future use. Single-dose therapy clearly has both advantages and disadvantages. We have reviewed a range of these in a variety of situations, focussing on their applications, effectiveness, compliance and toxicity, highlighting how single-dose therapy may be a double-edged sword.

[Chlamydia trachomatis--a possible cause of premature labor]

INTRODUCTION

The aim of this study was to investigate the incidence of urogenital infection with Chlamydia trachomatis in patients with preterm delivery in relation to those with term delivery.

MATERIAL AND METHODS

The investigation included a random sample of 116 parturients. Direct immunofluorescence (DIF) test was used to diagnose Chlamydia trachomatis.

RESULTS

In the investigated group (N = 53), positive finding of Chlamydia trachomatis in the urogenital tract was established in 6 (11.32%) patients in cervix and in 5 (9.43%) patients in the urethra, whereas in the control group there were 3 (4.76%) positive findings in the cervix and 1 (1.59%) in the urethra. The control group included patients with term delivery (N = 63).

DISCUSSION AND CONCLUSION

Results of investigation point to the necessity of diagnostics and treatment of Chlamydia trachomatis in prevention of preterm delivery, particularly in women with previous unsuccessful pregnancies.

A randomized controlled trial comparing amoxicillin and azithromycin for the treatment of Chlamydia trachomatis in pregnancy

OBJECTIVE

Our goal was to compare the efficacy of azithromycin with that of amoxicillin for the treatment of Chlamydia trachomatis infection during pregnancy.

STUDY DESIGN

A randomized controlled trial of pregnant women with cervical C trachomatis infection receiving care at two inner-city, university-based prenatal clinics. Pregnant women were randomly assigned to receive either oral amoxicillin, 500 mg, three times daily for 7 days, or oral azithromycin, 1 g, in a single dose. Partners were referred for treatment. Tests of cure were scheduled 4 weeks after initiation of treatment. Statistical analysis was performed by using the Student t test and chi2 analysis.

RESULTS

One hundred twenty-nine pregnant women were enrolled, and 110 (85%) completed the protocol. There was similar treatment efficacy between amoxicillin and azithromycin (58% vs 64%, respectively,P =.56). In the amoxicillin group 3 women (5.5%) were intolerant, compared with 6 (10.9%) in the azithromycin group (P =.31).

CONCLUSION

Amoxicillin and azithromycin are equally efficacious in the treatment of cervical C trachomatis during pregnancy.

Duration of clinical symptoms in female patients with acute urethral syndrome caused by Chlamydia trachomatis treated with azithromycin or doxycycline

One hundred fifty-one female patients with acute urethral syndrome caused by Chlamydia trachomatis were examined. First, patients were divided into two groups, those with clinical symptoms present < 3 weeks before the start of treatment, and those with clinical symptoms > or = 3 weeks prior to the beginning of therapy. Then patients were further divided into groups and randomized to receive azithromycin once daily in a single dose of 1.0 g or 500 mg once daily for 6 days, or to receive doxycycline 100 mg b.i.d. for 14 days or 100 mg b.i.d. for 7 days (8 study groups in all). Clinical and bacteriological efficacy was evaluated 3 weeks after the end of therapy. In the group of patients with disease symptoms lasting for 3 weeks or longer, the eradication and clinical cure rates were significantly higher after administration of azithromycin in a dose of 1x500 mg/6 days than after a single dose of 1.0 g (p<0.01), and after administration of doxycycline 2x100 mg/14 days than by using doxycycline 2x100 mg/7 days (p<0.05).

Diagnosis and treatment of common sexually transmitted diseases in women

Chlamydia trachomatis and Neisseria gonorrhoeae are 2 very common sexually transmitted organisms, whose clinical manifestations in women can range from an asymptomatic carrier state to active pelvic inflammatory disease with known serious sequelae, including chronic pelvic pain, infertility, and ectopic pregnancy. The economic and clinical burden of these 2 infectious organisms are significant in the sexually active population. New developments in diagnosis and treatment of these infections raise great hope that substantial reduction in morbidity and disease prevalence rates can be achieved. Herpes simplex virus is probably better publicized and more feared in the sexually active population, and is far more prevalent than previously recognized; fortunately, however, it is not generally associated with significant morbidity. This article will review the current diagnoses and treatments of these conditions and consider some of the issues surrounding the impact of screening asymptomatic sexually active individuals. The treatment guidelines will emphasize the 1998 Guidelines for Treatment of Sexually Transmitted Diseases from the Centers for Disease Control and Prevention.

A randomized trial of azithromycin versus amoxicillin for the treatment of Chlamydia trachomatis in pregnancy

OBJECTIVE

To compare the compliance, side effects and efficacy of amoxicillin and azithromycin for the treatment of Chlamydia trachomatis infection in pregnancy.

METHODS

This is a randomized single-blind trial of women diagnosed with C. trachomatis before 33 weeks gestation. Women were randomlyassigned either 500 mg amoxicillin orally three times per dayfor 7 days or a single dose of 1 g azithromycin orally. Patients were interviewed by telephone approximately 3-7 days following therapy to assess compliance and side effects. Test of cure was performed at a follow-up visit 4-6 weeks following completion of therapy.

RESULTS

Thirty-nine patients were randomized with 19 receiving amoxicillin and 20 receiving azithromycin. There were no differences in baseline data between the two groups, and there were no statistically significant differences in side effects, compliance or efficacy. In the amoxicillin group 84% of women took all pills, while 100% completed the single 1 g dose of azithromycin. Side effects were common in both groups (38% overall), with 40% of the azithromycin group reporting moderate to severe gastrointestinal side effects compared to 17% in the amoxicillin group (p = 0.11). Of patients who returned for follow-up test of cure, 3 of 15 (20%) in the amoxicillin group were positive compared with 1 of 19 (5%) in the azithromycin group (p = 0.3).

CONCLUSIONS

Side effects of therapy for C. trachomatis in pregnancy are common. Amoxicillin was slightly better tolerated than azithromycin. Compliance and cure rates with both regimens was high.

Treatment of Chlamydia trachomatis infections in pregnant women

The intent of this article is to provide an overview of the epidemiology and pharmacotherapy, including cost analyses, of Chlamydia trachomatis infections in pregnant women. Chlamydia is a common sexually transmitted infection. For pregnant women, there are concerns both for the mother (post-partum endometritis, horizontal transmission) and the newborn (conjunctivitis, delayed pneumonia). Therapeutic options are restricted because of the fetus and include multi-day treatment with erythromycin, amoxicillin, clindamycin or single dose azithromycin. Clinical cure rates with these options are 86, 92, 93 and 95%, respectively. Pharmacoeconomic analyses have been conducted to determine if the initial increase in acquisition cost of azithromycin (approximately 3-fold higher than erythromycin or amoxicillin) is offset by improvement in compliance and drug efficacy. Clindamycin has received little attention because of its expense (4-fold more than azithromycin). Analyses have been retrospective. As models incorporate more complications of failure to cure, azithromycin increasingly becomes more cost effective and is our recommended treatment.

The transplacental transfer of the macrolide antibiotics erythromycin, roxithromycin and azithromycin

OBJECTIVE

To investigate the transplacental transfer of the macrolide antibiotics erythromycin, roxithromycin and azithromycin.

METHODS

Twenty-one term placentas were obtained with maternal consent immediately after delivery and a two-hour nonrecirculating perfusion of a single placental cotyledon was performed. Erythromycin (2 microg/mL), roxithromycin (2 microg/mL) and azithromycin (0.3 microg/mL) were infused to the maternal inflow at a constant rate, with antipyrine as a reference compound, and their appearance in the fetal circulation was followed. Drug concentrations were measured by high performance liquid chromatography for 120 min.

RESULTS

The mean transplacental transfers (TPT(SS)) for erythromycin, roxithromycin and azithromycin were 3.0%, 4.3% and 2.6%, respectively, calculated as the ratio between the steady state concentrations in fetal venous and maternal arterial sides. Similar results were obtained when the TPT was calculated as the absolute amount of drug transferred across the placenta during 2-hour perfusion (TPT(A)). No significant differences were found among the three macrolides in TPT(SS) (P = 0.39) or TPT(A) (P = 0.35). The TPT(SS) of erythromycin, roxithromycin and azithromycin were 41%, 35% and 32% of the freely diffusable reference compound antipyrine, respectively. Steady state was reached in 60 minutes in each perfusion indicating sufficient perfusion time.

CONCLUSION

The limited transplacental transfer of erythromycin, roxithromycin and azithromycin suggests compromised efficacy in the treatment of fetal infections. On the other hand, the placenta seems to produce an effective barrier reducing the fetal exposure when these three macrolides are used to treat maternal infections.

Sexually transmitted diseases in women. Chlamydia trachomatis and herpes simplex infections

C trachomatis infection is the most commonly reported STD in the United States, and the majority of women infected are asymptomatic. Screening is recommended for those at high risk, including women who are between 15 and 21 years of age, live in urban areas, are single, or have new or multiple sexual partners. The "gold standard" for diagnosis is chlamydial culture; however, techniques that use DNA and RNA amplification are nearly 100% sensitive and specific and may prove cost-effective. Doxycycline is a recommended first-line therapy, but certain other antibiotics may also be effective. Herpes simplex virus affects more than one third of the world's population. It is diagnosed by observation of shallow, tender ulcerations around the genitalia and by viral isolation using tissue culture. Initial treatment is with antiviral drugs, which may also be necessary episodically or as a suppressive regimen for recurrences. Patient education about prevention of these and other STDs, as well as the impact of such disease on sexual partners, is critical. Physicians should therefore become comfortable questioning and counseling patients about sexual issues and risks for STDs.

Interventions for treating genital chlamydia trachomatis infection in pregnancy

BACKGROUND

Chlamydia trachomatis is a sexually transmitted infection. Mother-to-child transmission can occur at the time of birth and may result in ophthalmia neonatorum or pneumonitis in the newborn.

OBJECTIVES

The objective of this review was to assess the effects of antibiotics in the treatment of genital infection with Chlamydia trachomatis during pregnancy with respect to neonatal and maternal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (Cochrane Library issue 1, 1999).

SELECTION CRITERIA

Randomised trials of any antibiotic regimen compared with placebo or no treatment or alternative antibiotic regimens in pregnant women with genital Chlamydia trachomatis infection.

DATA COLLECTION AND ANALYSIS

Trial quality assessments and data extraction were done independently by two reviewers. Study authors were contacted for additional information.

MAIN RESULTS

Eleven trials were included. Trial quality was generally good. Amoxycillin appeared to be as effective as erythromycin in achieving microbiological cure (odds ratio 0.54, 95% confidence interval 0.28 to 1.02). Amoxycillin was better tolerated than erythromycin (odds ratio 0.16, 95% confidence interval 0.09 to 0.30). Clindamycin and azithromycin also appear to be effective, although the numbers of women included in trials are small.

REVIEWER'S CONCLUSIONS

Amoxycillin appears to be an acceptable alternative therapy for the treatment of genital chlamydial infections in pregnancy when compared with erythromycin. Clindamycin and azithromycin may be considered if erythromycin and amoxycillin are contra-indicated or not tolerated.