9/2/05njm

**Q. Should we do a test of cure for Chlamydia in pregnancy? If so,
when?**

A. Yes, you should do a test of cure in pregnancy. See the details below

Yes, you should perform a test of (TOC) at least 3 weeks after treatment
in pregnancy.

One needs to think this issue through a little bit though because
testing for C. trachomatis following treatment with azithromycin or
doxycycline is not recommended outside of pregnancy.

The 2002 CDC guidelines appear a little vague\....

On page 34 of the CDC 2002 Treatment Guidelines, the recommendation is
that all pregnant women with chlamydia get a test of cure, even if they
were treated with 1 gm Azithromycin.  This TOC recommendation appears in
the second sentence of the page and further down that column under
Special Considerations -- pregnancy\....

<http://www.cdc.gov/STD/treatment/4-2002TG.htm#Chlamydia>

But the 2006 guidelines should be more clear, though they are not due
out till early summer 2006 \.....\"women diagnosed with Chlamydia during
pregnancy should definitely have a test of cure\" so to speak.

Doxycycline, the fluoroquinolones, and erythromycin estolate are
contraindicated for pregnant women. Recommended regimens for use during
pregnancy include erythromycin base (500 mg PO QID for 7 days) and
amoxicillin (500 mg PO TID for 7 days). Alternative regimens include
azithromycin (1 g PO as a single dose), erythromycin base (250 mg PO
four times a day for 14 days), or erythromycin ethylsuccinate (800 mg PO
four times a day for seven days or 400 mg PO four times a day for 14
days). Sex partners should also be treated according to standard adult
regimens.

[Please note]{.underline}:

DNA / PCR, or non-culture, tests performed prior to 3 weeks are
inconclusive.

If a test for cure is performed, this should be done more than three
weeks after the completion of therapy. Earlier testing suffers from both
false positive (non-culture tests which are still positive due to
shedding of nonviable organisms) and false negative results (persistence
of small numbers of viable organisms which are not detected).

(See **New testing technology** below)

**Q. Should we repeat a Chlamydia screen at 36 weeks?**

The above recommendation is not actually in the 2002 CDC guidelines at
this time, but it very reasonable to do.

That type of recommendation seems to be an offshoot of another CDC
recommendation to re-screen 'high risk individuals' for re-infection 3-4
months after a Chlamydia ('read as' Adolescents)

In our practice, roughly 1/2 of our pregnant patients are
[\<]{.underline} 21 yo, and the majority of pregnant women are \< 25
yo......

...so just by age alone the majority of our patients would fit into the
36 week re-test category by the CDC STD guidelines. In addition, most
would fall under the USPSTF recommendation to screen women
[\<]{.underline} 25 yo anyway and those who have a new sex partner and
those with multiple sex partners.

[In summary]{.underline}, yes, I suggest re-testing at 3 weeks.

I think it is also very reasonable re-screen all patients at high risk
of re-infection 3-4 months later. (at the very least adolescents
[\<]{.underline} 21 yo)

If it is easier in your system just to re-screen everyone at 36 weeks,
then that would be fine, though it adds a few unnecessary tests to those
patients not at high risk of re-infection.

**Q. Can this these tests of cure be performed by aptima type urine
testing?**

A. Yes it reasonable to use the urine aptima type test for 'retesting'.
Please recall that the aptima type tests are performed on
[non]{.underline}-clean catch specimens.

**Q. Is a TOC is not recommended for pregnant women with gonorrhea?**

A. No, a TOC is not recommended for pregnant women with gonorrhea.

**Background**

**Special considerations**

"Repeat testing (preferably by culture) 3 weeks after completion of
therapy with the following regimens is recommended for all pregnant
women, because these regimens may not be highly efficacious and the
frequent side effects of erythromycin might discourage patient
compliance with this regimen"\*

\*

***" Special Considerations***

**Pregnancy.** Doxycycline and ofloxacin are contraindicated in pregnant
women. However, clinical experience and preliminary data suggest that
azithromycin is safe and effective. Repeat testing (preferably by
culture) 3 weeks after completion of therapy with the following regimens
is recommended for all pregnant women, because these regimens may not be
highly efficacious and the frequent side effects of erythromycin might
discourage patient compliance with this regimen.

***Recommended Regimens***

![](media/image1.wmf){width="45.50694444444444in" height="0.0in"}

**Erythromycin base** 500 mg orally four times a day for 7 days\
     **OR\
Amoxicillin** 500 mg orally three times daily for 7 days.

![](media/image2.wmf){width="45.50694444444444in" height="0.0in"}

***Alternative Regimens***

![](media/image2.wmf){width="45.50694444444444in" height="0.0in"}

**Erythromycin base** 250 mg orally four times a day for 14 days,\
     **OR\
Erythromycin ethylsuccinate** 800 mg orally four times a day for 7
days,\
     **OR\
Erythromycin ethylsuccinate** 400 mg orally four times a day for 14
days,\
     **OR\
Azithromycin** 1 g orally, single dose

**Chlamydia: Sexually Transmitted Diseases Treatment Guidelines 2002,
CDC**

<http://www.cdc.gov/STD/treatment/4-2002TG.htm#Chlamydia>

**\*New testing technology** --- Advances in chlamydia-screening
technology since the early 1980s have resulted in easy, readily
available chlamydia screening. Before 1984, chlamydia testing was
available only by tissue culture, which is expensive and cumbersome. In
1984, the first antigen-detection test based upon either fluorescent
antibody or ELISA technologies were licensed and became widely available
in the United States. This has been superseded by the development of
genetic-probe technologies and, more recently, the development of DNA
and other nucleic acid amplification technologies that can be performed
both on anogenital specimens and on urine.

The development of new, noninvasive urine-based and nucleic-acid based
technologies will result in substantial expansion of screening
activities because of the reduced need to perform clinical exams. The
most common testing methods now in use include:

  ![](media/image3.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Culture --- traditional \"gold
standard\", now basically limited to research and reference
laboratories. Should be clinically used routinely only in case of
forensic investigation (rape, child abuse).\
\
  ![](media/image3.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Antigen detection (direct fluorescent
antibody, ELISA) --- still requires a swab from the cervix or urethra.
Sensitivity 80 to 95 percent compared to culture.\
\
  ![](media/image3.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Genetic probe methods (hybridization
methods) --- based on direct specimen swab from cervix, or urethra.
Sensitivity 80 to 95 percent compared to culture.\
\
  ![](media/image3.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Nucleic acid amplification --- Two
tests in use include polymerase chain reaction (PCR) and ligase chain
reaction (LCR). Other technologic approaches are also in the licensing
process. Sensitivity and specificity \>95 percent for direct specimen
swab. LCR is also licensed for male and female urine and
self-administered vaginal swabs.

**Resources**

**Sexually Transmitted Diseases Treatment Guidelines 2002, CDC**

Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 2002;
51(No. RR-6):1

<http://www.cdc.gov/STD/treatment/TOC2002TG.htm>

**Chlamydia: Sexually Transmitted Diseases Treatment Guidelines 2002,
CDC**

<http://www.cdc.gov/STD/treatment/4-2002TG.htm#Chlamydia>

**Genital Chlamydia trachomatis infections in women: UpToDate**

<http://www.uptodateonline.com/application/topic.asp?file=stds/6404&type=A&selectedTitle=2~60>