Experience with the routine use of erythromycin for chlamydial infections in pregnancy

Chlamydia trachomatis Screening and Treatment in Pregnancy to Reduce Adverse Pregnancy and Neonatal Outcomes: A Review

Chlamydial trachomatis infection has been associated with adverse pregnancy and neonatal outcomes such as premature rupture of membranes, preterm birth, low birth weight, conjunctivitis, and pneumonia in infants. This review evaluates existing literature to determine potential benefits of antenatal screening and treatment of C. trachomatis in preventing adverse outcomes. A literature search revealed 1824 studies with 156 full-text articles reviewed. Fifteen studies were selected after fulfilling inclusion criteria. Eight studies focused on chlamydial screening and treatment to prevent adverse pregnancy outcomes such as premature rupture of membranes, preterm birth, low birth weight, growth restriction leading to small for gestational age infants, and neonatal death. Seven studies focused on the effects of chlamydial screening and treatment on adverse infant outcomes such as chlamydial infection including positive mucosal cultures, pneumonia, and conjunctivitis. Given the heterogeneity of those studies, this focused review was exclusively qualitative in nature. When viewed collectively, 13 of 15 studies provided some degree of support that antenatal chlamydial screening and treatment interventions may lead to decreased adverse pregnancy and infant outcomes. However, notable limitations of these individual studies also highlight the need for further, updated research in this area, particularly from low and middle-income settings.

Chlamydia trachomatis Infection in Pregnancy: The Global Challenge of Preventing Adverse Pregnancy and Infant Outcomes in Sub-Saharan Africa and Asia

Screening and treatment of sexually transmitted infections (STIs) in pregnancy represents an overlooked opportunity to improve the health outcomes of women and infants worldwide. Although Chlamydia trachomatis is the most common treatable bacterial STI, few countries have routine pregnancy screening and treatment programs. We reviewed the current literature surrounding Chlamydia trachomatis in pregnancy, particularly focusing on countries in sub-Saharan Africa and Asia. We discuss possible chlamydial adverse pregnancy and infant health outcomes (miscarriage, stillbirth, ectopic pregnancy, preterm birth, neonatal conjunctivitis, neonatal pneumonia, and other potential effects including HIV perinatal transmission) and review studies of chlamydial screening and treatment in pregnancy, while simultaneously highlighting research from resource-limited countries in sub-Saharan Africa and Asia.

Chlamydial Lytic Exit from Host Cells Is Plasmid Regulated

Chlamydia trachomatis is an obligate intracellular bacterium that is a globally important human pathogen. The chlamydial plasmid is an attenuating virulence factor, but the molecular basis for attenuation is not understood. Chlamydiae replicate within a membrane-bound vacuole termed an inclusion, where they undergo a biphasic developmental growth cycle and differentiate from noninfectious into infectious organisms. Late in the developmental cycle, the fragile chlamydia-laden inclusion retains its integrity by surrounding itself with scaffolds of host cytoskeletal proteins. The ability of chlamydiae to developmentally free themselves from this cytoskeleton network is a fundamental virulence trait of the pathogen. Here, we show that plasmidless chlamydiae are incapable of disrupting their cytoskeletal entrapment and remain intracellular as stable mature inclusions that support high numbers of infectious organisms. By using deletion mutants of the eight plasmid-carried genes (Δpgp1 to Δpgp8), we show that Pgp4, a transcriptional regulator of multiple chromosomal genes, is required for exit. Exit of chlamydiae is dependent on protein synthesis and is inhibited by the compound C1, an inhibitor of the type III secretion system (T3S). Exit of plasmid-free and Δpgp4 organisms, which failed to lyse infected cells, was rescued by latrunculin B, an inhibitor of actin polymerization. Our findings describe a genetic mechanism of chlamydial exit from host cells that is dependent on an unknown pgp4-regulated chromosomal T3S effector gene.

IMPORTANCE

Chlamydia's obligate intracellular life style requires both entry into and exit from host cells. Virulence factors that function in exiting are unknown. The chlamydial inclusion is stabilized late in the infection cycle by F-actin. A prerequisite of chlamydial exit is its ability to disassemble actin from the inclusion. We show that chlamydial plasmid-free organisms, and also a plasmid gene protein 4 (pgp4) null mutant, do not disassociate actin from the inclusion and fail to exit cells. We further provide evidence that Pgp4-regulated exit is dependent on the chlamydial type III secretion system. This study is the first to define a genetic mechanism that functions in chlamydial lytic exit from host cells. The findings also have practical implications for understanding why plasmid-free chlamydiae are highly attenuated and have the ability to elicit robust protective immune responses.

Double-Blind Placebo-Controlled Treatment Trial of Chlamydia trachomatis Endocervical Infections in Pregnant Women

Objective: The purpose of this study was to determine if treatment of pregnant women with Chlamydia trachomatis infection would lower the incidence of preterm delivery and/or low birth weight.

Methods: Pregnant women between the 23rd and 29th weeks of gestation were randomized in double-blind fashion to receive either erythromycin 333 mg three times daily or an identical placebo. The trial continued until the end of the 35th week of gestation.

Results: When the results were examined without regard to study site, erythromycin had little impact on reducing low birth weight (8% vs. 11%, P = 0.4) or preterm delivery (13% vs. 15%, P = 0.7). At the sites with high persistence of C. trachomatis in the placebo-treated women, low birth weight infants occurred in 9 (8%) of 114 erythromycin-treated and 18 (17%) of 105 placebo-treated women (P = 0.04) and delivery <37 weeks occurred in 15 (13%) of 115 erythromycin-treated and 18 (17%) of 105 placebo-treated women (P = 0.4).

Conclusions: The results of this trial suggest that the risk of low birth weight can be decreased by giving erythromycin to some women with C. trachomatis. Due to the high clearance rate of C. trachomatis in the placebo group, these data do not provide unequivocal evidence that erythromycin use in all C. trachomatis-infected women prevents low birth weight.

Randomized trial of erythromycin and azithromycin for treatment of chlamydial infection in pregnancy

Objective: The purpose of this study was to compare erythromycin and azithromycin in the treatment of chlamydial cervicitis during pregnancy with regard to efficacy, side effects, and compliance.

Methods: In a prospective manner, 48 pregnant patients with cervical chlamydial infections diagnosed by routine screening tests were randomly assigned to receive either erythromycin, 500 mg q.i.d. for 7 days (N = 24), or azithromycin, 1 g as a one-time dose (N = 24). All sexual partners were given prescriptions for doxycycline, 100 mg b.i.d. for 7 days. The treatment efficacy was assessed by follow-up chlamydia testing 3 weeks after the therapy was completed. The side effects, intolerance to therapy, and overall compliance were evaluated by means of a standardized posttreatment questionnaire.

Results: There was no significant difference in cure rates noted between the erythromycin group and the azithromycin group (77% vs. 91%, respectively; P = 0.24). Gastrointestinal side effects were reported more frequently among patients treated with erythromycin compared with patients treated with azithromycin (45% vs. 17%, respectively; P = 0.004). The patients who received erythromycin reported intolerance to therapy secondary to side effects more frequently than patients who received azithromycin (23% vs. 4%, respectively; P = 0.07). Furthermore, the patients in the azithromycin group were more likely to complete their course of therapy as prescribed than the patients in the erythromycin group (100% vs. 61%, respectively; P = 0.002).

Conclusions: Azithromycin is efficacious and well tolerated for the treatment of chlamydial cervicitis in pregnancy. Erythromycin, though efficacious, is poorly tolerated, as demonstrated by the number of patients reporting significant side effects during the course of therapy. Since the cost of azithromycin is comparable to that of generic erythromycin, the present study supports the use of azithromycin as an alternative to erythromycin for the treatment of chlamydial cervicitis in pregnancy.

Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants

BACKGROUND

Chlamydia trachomatis is the most common sexually transmitted pathogen in adults, which at delivery may be transmitted from mother to child and cause conjunctivitis and pneumonia. In The Netherlands, prenatal chlamydial screening and treatment of pregnant women is not routine practice. The contribution of C. trachomatis to neonatal ophthalmic disease has not been studied in The Netherlands and remains unclear.

METHODS

At the Sophia Children's Hospital and Rotterdam Eye Hospital, 2 cohorts of infants <3 months of age presenting with conjunctivitis were studied, 1 retrospectively (July 1996 to July 2001) and 1 prospectively (September 2001 to September 2002). Laboratory diagnosis was based on bacterial culture and polymerase chain reaction for C. trachomatis.

RESULTS

C. trachomatis was detected in 27 (64%) of 42 retrospectively studied infants and 14 (61%) of 23 prospectively studied infants. Mucopurulent discharge was present in 35 (95%) of 37, swelling of the eyes in 27 (73%) of 37, conjunctival erythema in 24 (65%) of 37, respiratory symptoms in 14 (38%) of 37, and feeding problems in 5 (14%) of 37 infants respectively. Before microbiological diagnosis, general practitioners prescribed antichlamydial antibiotics locally to 5 (12%) of 41 and systemically to 4 (10%) of 41 infants who tested positive for chlamydia, and ophthalmologists prescribed to 21 (51%) of 41 and 7 (17%) of 41, respectively.

CONCLUSIONS

C. trachomatis was the major cause of bacterial conjunctivitis in this population. Clinically, differentiation from other pathogens was not possible. Many infants who tested positive for chlamydia did not receive appropriate antibiotic treatment.

Neonatal chlamydial infections: prevention and treatment

Neonatal chlamydial infection, which manifests principally as ophthalmia neonatorum (ON) or pneumonia, is a significant cause of neonatal morbidity. Widespread use of silver nitrate drops resulted in a dramatic decline in the incidence of gonococcal ophthalmia but had much less impact on the incidence of neonatal chlamydial infection. Chlamydia trachomatis has become the most common infectious cause of ON in developed countries.A number of prophylactic antibiotic or antiseptic agents have been used to prevent ON. Prophylaxis with 1% silver nitrate ophthalmic drops, 0.5% erythromycin ophthalmic ointment, or 1% tetracycline ointment has comparable efficacy for the prevention of chlamydial ophthalmia but does not offer protection against nasopharyngeal colonization or the development of pneumonia. Erythromycin or tetracycline topically have been used as prophylactic agents because of their allegedly superior activity for the prevention of ON and because they produced less chemical conjunctivitis compared with silver nitrate. However, the relative efficacy of these agents for chlamydial infection and the emergence of beta-lactamase-producing Neisseria gonorrheae has raised questions regarding their effectiveness when applied topically for prophylaxis of ON. Compared with these agents, a 2.5% povidone-iodine ophthalmic solution has been found to have greater efficacy for the prevention of ON generally, and chlamydial ophthalmia specifically. In countries where the incidence of ON is very low, an alternative strategy is to institute prenatal screening and treatment of infected mothers, forgo routine neonatal prophylaxis, and follow-up infants after birth for the possible development of infection. For the treatment of chlamydial ophthalmia or pneumonia, oral erythromycin for 2 weeks is recommended; additional topical therapy is unnecessary. However, in approximately 20-30% of infants, therapy will not eradicate the organism and the infant may require a repeat oral course of antibiotics. The few published studies on the use of the new oral macrolide antibiotics, such as azithromycin, roxithromycin, or clarithromycin for chlamydial infections in neonates suggest that these agents may be effective; however, more data on their tolerability and efficacy in this patient group are warranted.

Confirming positive results of nucleic acid amplification tests (NAATs) for Chlamydia trachomatis: all NAATs are not created equal

The Centers for Disease Control and Prevention recommended confirming positive screening tests for Chlamydia trachomatis when positive predictive values are <90%. It is accepted that less sensitive tests (i.e., culture and immunoassays) should not be used to confirm the results of more sensitive nucleic acid amplification tests (NAATs). We show that the same principle applies when NAATs are used for confirmation.

A Swedish cost-effectiveness analysis of community-based Chlamydia trachomatis PCR testing of postal urine specimens obtained at home

AIMS

A study was undertaken to assess the cost-effectiveness of identifying and treating asymptomatic carriers of Chlamydia trachomatis when using community-based testing of urine specimens obtained at home and mailed to a central laboratory.

METHODS

A total of 100 males and 100 females aged 20-24 living in Umeå were randomly sampled from the population registry. A societal cost-effective analysis was carried out, based on screening and medical care costs in Sweden.

RESULTS

With a participation rate of 55% (45% males and 65% females), the female screening became cost-saving as the C. trachomatis prevalence exceeded 5.1%, and the male screening became cost-saving with over 12.3% prevalence.

CONCLUSION

Postal screening for C. trachomatis in an asymptomatic young population can be cost-effective only at prevalences higher than at present.

Effect of treatment for Chlamydia trachomatis during pregnancy

OBJECTIVES

To screen and treat chlamydial infection in pregnant women in order to assess the effects of therapeutic intervention on the outcome of Chlamydia trachomatis-infected pregnancy.

METHODS

Enrolled in the study were 350 women in the first to third trimesters of pregnancy. Endocervical swabs were collected for C. trachomatis diagnosis by DFA and PCR. A few STD infections, viz.: Neisseria gonorrhoeae, Candida spp., bacterial vaginosis, Trichomonas vaginalis and Treponema pallidum were ruled out. After excluding 22 patients infected with other sexually transmitted infections, a cohort of 328 pregnant women comprised the study population. Anti-chlamydial treatment (viz.: oral therapy with erythromycin stearate, 500 mg 4 times daily for 7 days) was given to 17 women (group I) and their partners. Fifteen patients of group I were retested by DFA and PCR assay for C. trachomatis infection 2 weeks following therapy. Other Chlamydia-positive patients (n=42) who were lost to follow-up were classified as untreated positive cases (group II) while group III included C. trachomatis negative cases (n=269). Data on obstetric outcome were recorded in a total of 164 cases. Statistical comparison of the data were done using the chi(2)-test and means were compared using Student's t-test.

RESULTS

Among the 350 pregnant women enrolled initially for the study, C. trachomatis positivity was found to be 18.8% (n=66) in the endocervix by DFA and PCR assay. Co-infection with Candida spp., bacterial vaginosis, T. vaginalis and T. pallidum was 2.0%, 1.7%, 1.7% and 0.5%, respectively. None of the pregnant women was infected with N. gonorrhoeae. Pregnant women at an increased risk of chlamydial infection included those who had multiple births and were in second trimester of pregnancy. Fifteen patients of group I became Chlamydia-negative following treatment. Data on obstetric outcome were recorded in 11, 26 and 127 patients of groups I, II and III, respectively. The mean duration of gestation for premature deliveries was found to be significantly higher in group I in comparison with group II [35.5 vs. 33.1 weeks (P<0.05)], thereby showing an improved effect of treatment on pregnancy outcome. The mean of low birth weight births was higher in group I compared with group II (2200.0 vs. 2113.3 g), however, this was statistically non-significant. Stillbirths were significantly higher among group II in comparison with group III [11.5% vs. 4.7% (chi(2)=1.79; P<0.5)]. No stillbirths were recorded in patients who had taken anti-chlamydial treatment.

CONCLUSIONS

Our findings suggest that routine screening and treatment of C. trachomatis infection in pregnant women, especially those in high risk groups, should be mandatory to reduce the adverse effects on obstetric outcome.

Influence of infection with Chlamydia trachomatis on pregnancy outcome, infant health and life-long sequelae in infected offspring

This chapter deals with genital chlamydial infections in pregnancy and postpartum. There is increasing evidence that Chlamydia trachomatis infection may result in a number of adverse pregnancy outcomes, including early and late abortion, intrauterine infections of the fetus, stillbirth, prematurity, premature rupture of the membranes (PROM) and postpartum endometritis. Ectopic pregnancy is commonly associated with a previous tubal chlamydial infection where immunological reactions seem to play a role. C. trachomatis infection may be acquired as an intrauterine infection, as well as during transit through the birth channel, and this may result in neonatal conjunctivitis and/or pneumonia. The role of chlamydial infection in the sudden death syndrome has also been considered, but evidence so far is minimal. Neonatal chlamydial infection may cause life-long sequelae, such as obstructive lung disease. Genital chlamydial infections have been associated with problems in insemination and attempts at in vitro fertilization. The chapter also deals with screening of pregnant women for C. trachomatis and the treatment of infected mothers and their offspring.

Is the prevention of genital chlamydial infections by community involvement possible?

This chapter presents different means by which community initiatives have been undertaken to reduce the prevalence and incidence of genital and allied infections caused by Chlamydia trachomatis. As most of these infections in the majority of infected individuals do not produce symptoms that are likely to urge them to attend any health care unit, screening programmes are mandatory to be able to influence the epidemic of infections with this agent. In many societies there has been a skewed gender distribution in the number of chlamydia-positive persons; this probably indicates that diagnostic service activities have been directed more against one gender than the other. The important role of partner notification, as in the case of other sexually transmitted infections, has been documented. Different means of community initiative have included counselling of school children and groups of persons more likely to be infected. Counselling by the pharmacy has an important role in many societies. Selected cohorts have been offered - via the mass media, Internet, radio and television programmes - sampling kits which can be mailed to a laboratory for testing. The establishment of youth clinics has been found effective for detecting teenagers harbouring C. trachomatis, similarly to screening at antenatal clinics. The offer of free consultations, aetiological tests and therapy has been a part of community initiatives, mimicking the services offered for some of the classic sexually transmitted infections. This chapter considers the usefulness of different test methods and stresses the need to retest those found to be positive. Barriers to the successful introduction of screening activities and diagnostic services are also considered.

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.

Cost-effectiveness of widespread screening for Chlamydia trachomatis

Screening for sexually transmitted diseases is included in routine health care for several infectious agents in many western European countries. Current considerations on extensions of these programs include widespread screening strategies for Chlamydia trachomatis. In women, C. trachomatis infection may lead to sequelae such as infertility and ectopic pregnancy. This paper reviews the goal of screening and subsequent therapy and the available compounds for testing and treating. Furthermore, the current best practice - in particular with respect to economic performance - is discussed, and those factors that most crucially influence the economic profile are described. Illustrations are drawn from recent work in The Netherlands, which may also be representative for other settings.

Health and cost-benefits of chlamydia screening in young women

BACKGROUND

The Health Plan Employer Data and Information Set (HEDIS) is a set of performance measures used to assess the quality of care delivered in managed care plans. New measures that address unevaluated areas of care are continuously being developed. Chlamydia screening among young women is one new measure that was recently adopted by the National Committee for Quality Assurance (NCQA) for inclusion in HEDIS. An essential criterion for new measures is that the clinical intervention is beneficial to health and cost-effective.

GOAL

To assess the health benefits and cost-effectiveness of chlamydia screening among young women.

STUDY DESIGN

A focused review of the literature was performed using Medline. Articles addressing the epidemiology of chlamydia infection, its health consequences, and the benefits, problems, and cost-effectiveness associated with chlamydia screening are reviewed.

RESULTS

The literature reviewed shows scientific and cost-effectiveness data that support the adoption of the HEDIS measure for chlamydia screening among young women.

CONCLUSION

The National Committee for Quality Assurance's recent adoption of the measure for chlamydia screening among young women into the formal HEDIS measurement set is justifiable from a health benefit standpoint and from a cost-effectiveness standpoint.

Perinatally acquired Chlamydia trachomatis associated morbidity in young infants

OBJECTIVE

This study was designed to evaluate the spectrum of morbidity associated with perinatally acquired Chlamydia trachomatis in infants < or =12 weeks of age, and to determine its relationship to maternal Chlamydia trachomatis status.

METHODS

DESIGN

Retrospective review of maternal and infant records.

SETTING

Large inner city teaching hospital.

PATIENTS

A cohort of 530 symptomatic infants < or =12 weeks of age who were tested for Chlamydia trachomatis infection in the upper respiratory tract during a 2-year period from January 1993 to December 1994.

RESULTS

During the study period, 70/530 (13.2%) patients tested positive for Chlamydia trachomatis from the conjunctiva and/or the nasopharynx. Complete medical records of 66 of these infants were available for review. Forty-eight of 66 (73%) infants had conjunctivitis, 13/66 (20%) had pneumonia, 5/66 (7%) had both conjunctivitis and pneumonia. Thirteen of 66 (20%) infants were hospitalized, 7 for pneumonia and 6 for ophthalmia, accounting for 68 hospital days. In 55/66 (83%), maternal records were available for review. Nineteen of 55 (35%) mothers had documented Chlamydia trachomatis infection at delivery or during pregnancy that had not been treated; 16/55 (29%) mothers tested negative for Chlamydia trachomatis sometime during pregnancy but were not retested at delivery, 8/55 (14%) were treated for Chlamydia trachomatis during pregnancy but status at delivery regarding reinfection was not evaluated. In 12/55 (22%) mothers, no prenatal testing was documented.

CONCLUSIONS

This study demonstrates significant morbidity in early infancy associated with perinatally acquired Chlamydia trachomatis infection. There is need for studies evaluating the importance of adequate maternal testing and treatment to reduce perinatal transmission.

Outcome of the Vaginal Infections and Prematurity Study: results of a clinical trial of erythromycin among pregnant women colonized with group B streptococci

OBJECTIVE

Our purpose was to determine whether erythromycin treatment of pregnant women colonized with group B streptococci would reduce the occurrence of low birth weight (< 2500 gm) and preterm (< 37 completed weeks) birth.

STUDY DESIGN

In a double-blind clinical trial, 938 carriers of group B streptococci were randomized to receive erythromycin base (333 mg three times a day) or matching placebo beginning during the third trimester and before 30 weeks and continuing for 10 weeks or until 35 weeks 6 days of pregnancy.

RESULTS

Pregnancy outcomes were available for 97% of randomized women; 14% of subjects withdrew from the trial. Birth weight < 2500 gm occurred in 8.6% of the erythromycin and 6.1% of the placebo recipients (relative risk 1.4, 0.9 to 2.2, p = 0.16). Preterm delivery occurred in 11.4% of women randomized to erythromycin and in 12.3% randomized to placebo (relative risk 0.9, 95% confidence limits 0.6 to 1.3, p = 0.65). Greater benefit of erythromycin in reducing these outcomes was not observed among women reporting the best compliance.

CONCLUSIONS

In this study of pregnant women colonized with group B streptococci treatment with erythromycin was not shown to be effective at prolonging gestation or reducing low birth weight. Greater than anticipated complicating factors, including spontaneous clearance of the organism, use of nontrial antibiotics, and density of colonization, may have resulted in population sizes too small to detect a benefit of treatment. Future studies should take these factors into account in determining sample sizes.

Randomised comparison of amoxycillin and erythromycin in treatment of genital chlamydial infection in pregnancy

Erythromycin, the standard treatment for chlamydial infection in pregnant women, commonly causes side-effects, which limits its efficacy. In a randomised, double-blind study, we compared amoxycillin with erythromycin in this setting. 210 pregnant women with Chlamydia trachomatis infection were randomly assigned 7 days' treatment with amoxycillin (500 mg three times daily) or erythromycin (500 mg four times daily). Control cultures were obtained 21 days after treatment, during late pregnancy, and from the infant within a week of birth. Treatment was judged a failure if any post-treatment culture was positive or if the patient had to stop therapy because of severe side-effects. 11 women (5.2%) were lost to follow-up. 1 (of 100) amoxycillin-treated women had to stop treatment because of severe side-effects compared with 12 (of 99) erythromycin-treated women (p = 0.002). 1 woman in the amoxycillin group had a positive culture at the third-trimester examination. No positive post-treatment culture was found in the erythromycin group. Severe gastrointestinal side-effects were more common in women who received erythromycin (31 vs 6%, p < 0.001). The overall failure rate was therefore 2% in the amoxycillin group and 12% in the erythromycin group (p = 0.005). These results suggest that amoxycillin is an acceptable alternative to erythromycin for C trachomatis infection in pregnant women.

Self-esteem, problem solving, and sexual risk behavior among women with and without Chlamydia

Self-esteem and problem-solving appraisal were evaluated as an explanation of sexual risk behavior for the sexually transmitted disease (STD), chlamydia. Chlamydia, the most prevalent bacterial STD in the United States, is linked to a variety of problems which affect women, their offspring, and their sex partners. Data were collected by two nurse practitioners during scheduled gynecology visits for 105 military women. There was a statistical association among women with chlamydia (chi 2 = 3.623, df = 1, p = .057) and trichomonas (chi 2 = 12.83, df = 1, p = < .001) and a friable cervix. With a 10% prevalence of chlamydia, accurate diagnosis and treatment are imperative. No differences between the prevalence of chlamydia and self-esteem and problem-solving appraisal were noted. These findings support the strategies for diagnoses, treatment, and prevention of chlamydia recommended by the Centers for Disease Control.

A randomized, prospective trial comparing amoxicillin and erythromycin for the treatment of Chlamydia trachomatis in pregnancy

OBJECTIVE

Our purpose was to evaluate the efficacy of amoxicillin as an alternative therapy to erythromycin for the treatment of cervical chlamydial infections during pregnancy.

STUDY DESIGN

A randomized, prospective trial of two treatment regimens for Chlamydia trachomatis was performed in a cohort of pregnant women enrolled for care in an inner-city, university-based prenatal clinic, with an alternate-therapy crossover arm for primary treatment failures. Pregnant women diagnosed with chlamydial infection by McCoy cell culture of cervical swabs were assigned to receive either 500 mg of amoxicillin three times daily or 500 mg of erythromycin four times daily for 7 days. Patients' partners were treated with doxycycline. Compliance information was obtained by a standardized questionnaire at a posttherapy follow-up visit. Patients with positive follow-up cultures were crossed over into the alternate treatment arm and recultured at a later visit.

RESULTS

During the study period 74 women consented to participate in this trial; 36 were treated with amoxicillin and 38 with erythromycin. Initial cure rates of 82.3% (28/34) for the amoxicillin group and 84.6% (27/32) for erythromycin were obtained before crossover (p = 0.91); four patients in each group were lost to follow-up. Overall cure rates after crossover were 84.6% (33/39) for amoxicillin and 84.2% (32/38) for erythromycin (p = 0.83). In the amoxicillin group 12.8% of patients reported side effects compared with 31.6% treated with erythromycin (p = 0.09), although seven erythromycin-treated patients compared with none of those in the amoxicillin arm stopped therapy because of side effects (p = 0.02).

CONCLUSION

Amoxicillin offers a reasonable alternative to erythromycin for the treatment of Chlamydia trachomatis in pregnancy, on the basis of both cure rates and patient compliance.

Chlamydia trachomatis infections: implications for pregnant adolescents and their infants

Objective: Chlamydia trachomatis infections are common in pregnant adolescents. Previous studies have shown that treating pregnant women of all ages with erythromycin prevents transmission of this infection to their infants. However, there are no published studies on the efficacy of aggressive screening and treatment of C. trachomatis in pregnant adolescents. This study was undertaken to determine if aggressive screening for C. trachomatis in pregnant adolescents and early treatment with erythromycin can prevent complications in their newborn infants.

Methods: A group of pregnant adolescents enrolled at Teen Pregnancy Service of Milwaukee was evaluated prospectively for the presence of C. trachomatis infection. Screening was performed during the 1st and 3rd trimesters by enzyme immunoassay. Adolescents with positive enzyme immunoassays for Chlamydia were treated with erythromycin for 10 days. Those with negative enzyme immunoassays were enrolled as controls. All infants born to adolescents in both groups were followed for episodes of conjunctivitis, pneumonia, and wheezing during their 1st year of life.

Results: Ninety mother/infant pairs were followed during the study period. Twenty-eight mothers (31%) had positive enzyme assay tests and all received erythromycin therapy. Nasopharyngeal cultures were obtained from 60 (67%) infants; all were negative. There were no significant differences in general characteristics, development of conjunctivitis (relative risk 1.27), wheezing (relative risk 0.91), or pneumonia (relative risk 1.12) between infants born to adolescents in either group.

Conclusions: We conclude that aggressive screening and treatment of C. trachomatis infection in pregnant adolescents may prevent complications in their offspring.

Chlamydial cervical infection in jailed women

OBJECTIVES

The prevalence of Chlamydia trachomatis cervical infection in incarcerated adult women has not been reported. To develop a policy for testing and treatment, we determined the prevalence of and risk factors for chlamydial infection in women in a New York City jail.

METHODS

Interviews and cervical cultures for C trachomatis were obtained from 101 consenting female inmates.

RESULTS

Positive cultures for C trachomatis were found in 27% of the participants. Mucopurulent cervical discharge and education of 8 years or less were two independent risk factors for infection, but only 63% of the infected women had one or both of these factors. If pelvic tenderness were considered as a third factor, an additional 7% of the infected women would have been identified.

CONCLUSIONS

The prevalence of chlamydial infection in this population was as high as that in populations for which presumptive treatment is recommended. Although the optimal policy for detection and treatment of chlamydial infection may vary depending on practical considerations, we suggest that women entering correctional facilities should be screened or offered presumptive therapy for C trachomatis infection.

Infection due to Chlamydia trachomatis in pregnancy and the newborn

Bacteria in the genus Chlamydia comprise three species, C. trachomatis, C. psittaci and C. pneumoniae. C. trachomatis infection is common, varying in prevalence in women from 0% to 37%. In the United States, the prevalence rate is estimated currently to be about 5%. Pregnancy may predispose to an increased chance of infection with C. trachomatis, through physiological immunosuppression and/or cervical ectopy. Maternal antibodies to C. trachomatis provide limited, if any, protection for the newborn. C. trachomatis causes pelvic inflammatory disease--which can result in tubal infertility or ectopic pregnancy and postabortal or late postpartum endometritis. It may also cause chorioamnionitis and premature delivery of the fetus. The incidence of vertical transmission of chlamydiae from mother to baby varies; if the mother is untreated, 20-50% of the newborns will develop conjunctivitis and 10-20% will develop pneumonia. C. psittaci infection in pregnancy is rare, but can cause spontaneous abortion. Whether C. pneumoniae infection in pregnancy has any influence on the outcome has not been ascertained. C. trachomatis can be detected by one or more of several methods; enzyme immunoassays are the least sensitive, but the most widely used. Screening for C. trachomatis in pregnancy may be of benefit in areas of high prevalence, and is generally regarded as being cost-effective if the prevalence rate is more than 5%. Pregnant women are best treated with erythromycin, 250 mg four times daily for 7 days. This will prevent infection of the newborn in more than 90% of cases. The infected neonate should be treated with erythromycin, given systemically and also with topical tetracycline if conjunctivitis is present.

Evaluation of two ELISA's for detecting Chlamydia trachomatis from endocervical swabs

Two enzyme immunoassays (EIAs) detecting Chlamydia trachomatis from endocervical swabs, Syva MicroTrak (MT) and Abbott Chlamydiazyme (CZ), were compared with a tissue culture (TC) standard. Initially, 8% (100 of 1250) of specimens were TC positive, yielding sensitivities of 94% (94 of 100) for MT and 79% (79 of 100) for CZ with identical 98% specificities (1129 of 1150 for MT and 1130 of 1150 for CZ). Discrepant specimens were retested by both EIAs and assayed for elementary bodies (EBs) by a fluorescent antibody test. After discrepancy analysis, 9.5% (118) of 1240 patients were either TC or EB positive, yielding sensitivities of 94.1% for MT (111 of 118) and 79.7% for CZ (94 of 118) with identical specificities of 100% (1122 of 1122). These results indicate that the MT is significantly more sensitive (p less than 0.05, McNemar test) than CZ in detecting C. trachomatis from endocervical swabs.

A study of the incidence of urogenital Chlamydia trachomatis in patients attending specialized departments of Rome, Milan and Turin, Italy

A study of Chlamydia trachomatis was conducted in 5270 subjects seen at clinics of the Faculty of Medicine and Surgery at La Sapienza University in Rome, the S. Anna Hospital in Turin, and the Provincial Maternity Hospital Institute in Milan. In these areas, C. trachomatis was present in 5.8% of the cases examined; in addition it was present with statistically significant frequencies in cases of salpingitis (49.1) and epididymitis (21.7). It may also be found in cases of extrauterine pregnancy, sterility and abortion. Those most affected were women who had begun their sexual activity at an early age, were under 25, had several sexual partners and who used the coil and/or spermicides. A routine check for C. trachomatis should be considered for those women with those risk factors.

Chlamydiae as pathogens--an overview of diagnostic techniques, clinical features, and therapy of human infections

Chlamydiae are Gram-negative bacteria with obligate intracellular reproduction and disability to synthesize high-energy compounds such as ATP. Their cycle of development is unique among the prokaryotes: the host cells, mainly epithelial cells, are infected by so-called elementary bodies (EB) which undergo reorganization to form metabolically active reticulate bodies (RB). These RB multiply by binary fission, and after transition into infectious EB they are released within 48-72 hours. Chlamydiae cause prolonged subclinical infections of the conjunctiva, lung, cervix, and urethra. Complications in newborns are inclusion conjunctivitis, nasopharyngitis and pneumonia; in females, salpingitis, infertility, and perihepatitis; in male patients, epididymitis and prostatitis; and in both sexes, Chlamydiae-induced arthritis. Identification of the pathogenic agent confirms clinical diagnosis; tissue culture identification remains the diagnostic method of choice. Therapeutical drugs are tetracycline, erythromycin, josamycin, and in certain cases quinolone derivatives.

Comparative efficacy of clindamycin versus erythromycin in eradication of antenatal Chlamydia trachomatis

Antenatal Chlamydia trachomatis infections are associated with both maternal and neonatal morbidity. Erythromycin, the only drug recommended for treatment during pregnancy, is often poorly tolerated, thus preventing successful cure. We have done a prospective, randomized, double-blind, placebo-controlled trial to compare the efficacy of clindamycin with that of erythromycin base in eradication of antenatal chlamydia. A total of 126 patients with documented cervical infection were enrolled before 24 weeks' gestation to receive clindamycin (450 mg), erythromycin (333 mg), or placebo orally four times daily for 14 days. Partners received doxycycline, 100 mg, twice daily for 7 days. Both clindamycin and erythromycin were effective agents with cure rates of 92.7% and 83.8%, respectively. Erythromycin therapy was associated with significantly more gastrointestinal complaints than was placebo therapy (23.1% (9/39) vs. 2.4% (1/41), p less than 0.02) whereas clindamycin was not. Patients who experienced side effects were more likely to be poorly compliant (p less than 0.03) and patients with moderate-to-good compliance were more likely to be cured than were women who were poorly compliant (p less than 0.002). Results of test of cure cultures performed immediately on completion of therapy did not differ significantly from those taken 4 weeks later.

New treatments for Chlamydia trachomatis

Standard regimens of tetracycline, doxycycline, or erythromycin, if compiled with, appear to be effective against Chlamydia trachomatis infections under most circumstances. However, the organism may sometimes persist despite what would seem to be adequate therapy. How often this occurs, to what extent noncompliance is the issue, and the role antibiotic resistance plays remain to be determined. Among newer antibiotics, azithromycin appears to be effective in the treatment of uncomplicated urogenital C. trachomatis infections. Single-dose therapy with azithromycin may be especially useful in overcoming compliance problems associated with the treatment of sexually transmitted disease.

Chlamydia trachomatis infection during pregnancy

Although transmission of Chlamydia trachomatis to infants during vaginal birth can result in conjunctivitis and pneumonitis, there is uncertainty about other adverse effects of chlamydial infection during pregnancy. There is some evidence that it may contribute to adverse complications such as premature rupture of membranes, preterm labor and birth, low birth weight, and still birth. Infection with C. trachomatis is also implicated in postabortal, postcesarean section, and postpartum maternal infections. Treatment of chlamydial infection during pregnancy has proved beneficial in the prevention of neonatal morbidity and is now recommended by the Centers for Disease Control.

Cost-effectiveness of prenatal testing for Chlamydia trachomatis

We investigated the cost-effectiveness of strategies for screening pregnant women for Chlamydia trachomatis. Screening was not cost-effective unless certain conditions were met. Direct antigen testing of all pregnant women would be cost-effective if the test cost less than $6.30 or the prevalence of infection exceeded 6%. However, the positive predictive value of the test was only 51%. Culturing was not cost-effective until the prevalence of infection exceeded 14.8%. If a direct antigen test cost less than $3.90 or prevalence exceeded 8.7%, direct antigen testing of all women and using culture to confirm positive direct antigen tests would be cost-effective. If a direct antigen test cost $8.00 and culture cost $25.00, the excess cost of performing a direct antigen test in all women and confirming positive results with culture would be $2.09 per pregnant woman. Screening all pregnant women for chlamydia is not cost-effective, but the excess cost is modest when direct antigen tests are used.

Detection of Chlamydia trachomatis, Mycoplasma hominis and Ureaplasma urealyticum in pregnant Dutch women

A prospective study was performed to determine the prevalence of endocervical infection by Chlamydia trachomatis and vaginal colonization by Mycoplasma hominis and Ureaplasma urealyticum in pregnant women seeking routine obstetrical care in two clinics in the southern part of the Netherlands. C. trachomatis was detected using the direct immunofluorescence staining technique. For the genital mycoplasmata, generally accepted culture methods were used. Evaluable samples were obtained from 691 of 770 women in the first trimester of pregnancy. C. trachomatis was detected in 2.3%, M. hominis in 5.2% and U. urealyticum in 23.9% of the women. The isolation percentages of C. trachomatis and U. urealyticum were almost equally distributed in the different age groups. The prevalence of all three micro-organisms did not seem to be related to parity. Smoking and alcohol consumption seemed to influence the isolation rate of M. hominis and U. urealyticum.

Chlamydia trachomatis infection in late pregnancy: a prospective study

During a 1-year period, 3309 women were screened in pregnancy for Chlamydia trachomatis infection. A cervical swab was taken and chlamydial antigen was detected, using a monoclonal antibody ELISA technique, in 198 women (6%). The prevalence of chlamydial infection was high in women under 20 years (14.5%), single women (14.2%) and black women (16.8%). Binomial regression of these data estimates a relative risk of 2.9 for women under 20 years compared with women aged 25 and over. There was an interaction between race and marital status with a high risk in single white and single asian women (2.3, 4.5 respectively) but a similar risk in black single and black married women (3.0, 4.0 respectively). Parity and social class did not effect the prevalence of antigen carriage. There was no demonstrable effect of maternal antigen carriage on outcome of pregnancy, gestation or admission to neonatal unit. Infants of 174 antigen-positive mothers were followed-up. Tissue culture for Chlamydia trachomatis was positive in 43 (24%) infants. Complications occurred in 23 (53%): 17 had conjunctivitis, three had lower respiratory tract infection and three both complications. Amongst 131 chlamydia-negative infants, complications occurred in 21 (16%). Since this infection, in infants, responds promptly to erythromycin therapy, screening and treatment in pregnancy will convey little benefit in prevention of perinatal morbidity or perinatal mortality.

Chlamydia trachomatis infections

The diversity in chlamydial syndromes and their consequences especially the impact on human reproduction and fertility, the asymptomatic characteristics of infections and the ever-increasing incidence have been the focus of considerable attention in the 1980s. The current status of the clinical spectrum of ocular-genital infections due to Chlamydia trachomatis and the laboratory tests for accurate, rapid diagnosis and effective treatment are reviewed.

Chlamydia trachomatis infection in infants: a prospective study

In a prospective study of Chlamydia trachomatis infection in pregnancy, 198 mothers positive for chlamydial antigen were identified; the infants of 174 were followed for up to six months and C trachomatis was recovered in cell culture from 43 infants (25%). Conjunctivitis occurred in significantly more infants who were positive for C trachomatis (20 of 43, 47%) than in those who were negative (18 of 131, 14%). There were also significantly more lower respiratory tract infections among infants with positive cultures (six of 43, 14%, compared with three of 131, 2%). The chlamydial antigen enzyme linked immunosorbent assay (ELISA) was positive in 61 of 131 infants from whom C trachomatis was not recovered in cell culture. False positive results were usually associated with the isolation of Staphylococcus aureus from samples of pharyngeal aspirate. Our results confirm that C trachomatis infection is a common cause of neonatal conjunctivitis, and respiratory infection in the first few months of life, with an incidence of 8.2/1000 live births. Because the infection is easily treated by oral erythromycin, however, screening during pregnancy is not warranted.

Efficacy of neonatal ocular prophylaxis for the prevention of chlamydial and gonococcal conjunctivitis

Opinions differ concerning the efficacy of prophylaxis against neonatal chlamydial and gonococcal conjunctivitis. From January 1986 through June 1988, we gave all infants born at Kings County Hospital Medical Center one of three prophylactic agents -- silver nitrate drops, erythromycin ophthalmic ointment, or tetracycline ophthalmic ointment. The treatments were rotated monthly. Gonococcal ophthalmia occurred in 8 of the 12,431 infants born during the study (0.06 percent), 1 in the silver nitrate group, 4 in the erythromycin group, and 3 in the tetracycline group (P not significant). Seven of these infants were born to women who had received no prenatal care. From September 1985 through December 1987, we screened 4357 pregnant women for cervical chlamydial infection, of whom 341 (8 percent) had positive cultures. Of their offspring, 230 were evaluated for neonatal chlamydial conjunctivitis; the incidence was 20 percent in the silver nitrate group, 14 percent in the erythromycin group, and 11 percent in the tetracycline group (P not significant). We conclude that neonatal ocular prophylaxis with either erythromycin or tetracycline ophthalmic ointment does not significantly reduce the incidence of chlamydial conjunctivitis in the offspring of mothers with chlamydial infection as compared with silver nitrate, and that better management of maternal chlamydial infection is therefore required. We also conclude that there is a small but appreciable incidence of neonatal gonococcal ophthalmia that could be prevented by better prenatal screening and treatment of maternal gonococcal infection.

Asymptomatic chlamydia during pregnancy

Data were collected by certified nurse midwives during routine antepartum visits for 111 low-income women. There was a significant difference between the incidence of chlamydia n = 25 (22.5%) and gonorrhea n = 2 (1.8%), Z-score = 4.7; p less than .01. If current practices for selective screening were used 19 of the 25 women who had a positive chlamydia would not have been tested. Given the complications associated with chlamydia for women and their offspring, early detection, treatment, and education programs are justified.

Practical applications of decision analysis

The number and complexity of available tests and therapies is expanding and financial resources are shrinking. Clinicians must now consider how to give the best care while limiting health expenses. Decision analysis is a tool used to guide clinicians in the practice of medicine, and to supplement and enhance intuitive decision making based on clinical experience.

Infectious flare-ups and serious sequelae following endodontic treatment: a prospective randomized trial on efficacy of antibiotic prophylaxis in cases of asymptomatic pulpal-periapical lesions

Without peritreatment antibiotics, infectious flare-ups (about 15% incidence) and serious sequelae follow endodontic treatment of asymptomatic teeth with necrotic pulps and associated periapical lesions. Antibiotics administered after endodontic treatment (4-day regimen) reduce the flare-up incidence to about 2%, but hypersensitivity responses, sensitization, resistant microbes, and drug-taking compliance are potential problems. To ascertain whether a specific prophylactic antibiotic (high-dose, 1-day regimen) would preferentially maintain this low flare-up incidence while overcoming antibiotic-related problems, 315 patients with quiescent pulpal necrosis and an associated periapical lesion were randomly given either penicillin V or erythromycin (base or stearate). Evaluations of flare-up after endodontic treatment were done at 1 day, 1 week, and 2 months. A 2.2% flare-up incidence was found, with no statistically significant differences for penicillin (0.0%), base (2.9%), and stearate (3.8%). No hypersensitivity responses occurred. Gastrointestinal side effects were found primarily with the erythromycins (12.4%). A comparative analysis of the data from our first study (no peritreatment antibiotics) and the pooled data from our last two investigations (including the current trial) showed that peritreatment antibiotic coverage significantly reduced flare-ups and serious sequelae after endodontic treatment (p less than 0.001).

Chlamydia trachomatis infection and pregnancy outcome

Chlamydia trachomatis is now recognized as the most common sexually transmitted disease organism in the United States. Although the potential for vertical transmission of C. trachomatis from pregnant women to their infants is well established, the extent to which infection adversely affects pregnancy and causes perinatal complications remains controversial. We report herein the results of a prospective study of 270 pregnant women with endocervical C. trachomatis compared with 270 matched control subjects (age +/- 1 year, race, and socioeconomic status). Among the entire group (n = 540), the rates of pregnancy complications were: premature rupture of the membranes, 54/270 (10%); preterm delivery, 55 (11%); amnionitis, 20 (4%); intrapartum fever, 23 (4.3%); small for gestational age, 76 (14.5%); postpartum endometritis, 31 (6%); and neonatal sepsis, 10 (1.8%). No statistically significant differences were noted between cases and controls for any of these variables. In the subset of women with recent or invasive chlamydial infection, indicated by the presence of IgM antibody against C. trachomatis, preterm delivery occurred in 13/67 IgM-positive versus 8/99 IgM-negative (p = 0.03) cases. Premature rupture of the membranes was present in 13/67 IgM-positive versus 8/99 IgM-negative (p = 0.03).