Approach

The main goal of treatment is to prevent sequelae of disease such as pelvic inflammatory disease, tubo-ovarian abscess, ectopic pregnancy, and infertility. During pregnancy, goals of treatment also include prevention of peripartum complications and neonatal infection. Antibiotics that may be given as a single observed dose are preferred, particularly for any patient who may be noncompliant or pregnant.[1]​​

There is no consensus on how to manage women with nonspecific or persistent cervicitis.

For all women with cervicitis, every effort should be made to ensure that the patient's sex partners from the preceding 60 days are notified, evaluated, and treated with a recommended regimen that is tailored for the specific infection identified or suspected. If there has been no sexual partner within the preceding 60 days, then the most recent sexual partner should be assessed.[1]​[15]​​​​​​ Intercourse should be avoided for 7 days, and repeat testing should be offered 3 months later.[1]​​

Expedited partner therapy is the practice of delivering medications or prescriptions to the partner through the patient without the partner being examined by a healthcare provider.[1][27]​ ​This approach should be considered for heterosexual patients with chlamydia or gonorrhea infection if it cannot be ensured that all of a patient's sex partners from the prior 60 days will be evaluated and treated.[27]​ Treating sexual partners might also have a role in the management of trichomoniasis infection; however, different partner management interventions (e.g., patient referral, provider referral, contract referral, or expedited partner therapy) have similar efficacies.[1][27]​ Laws governing expedited partner therapy vary by state. Patients should contact their local health department to determine the legality of this practice in their area.[1]​ These programs are controversial because, while effective for reducing transmission of gonorrhea and chlamydia, they omit the opportunity to provide in-person contact, counseling, detection of other STIs, or detection of antibiotic allergies. CDC: expedited partner therapy Opens in new window

Nonpregnant, high-risk adults

High-risk patients (<25 years of age; those with a new sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection [STI]) should be treated with a presumptive course of antibiotics that cover Chlamydia trachomatis and Neisseria gonorrhoeae, as these infections frequently appear concomitantly.[1]​​

Therapy is based on the Centers for Disease Control and Prevention (CDC) STIs treatment guidelines, which recommend a 7-day course of oral doxycycline.[1]​ Treatment for gonococcal infection with a single dose of intramuscular ceftriaxone is also recommended if the patient is at risk of gonorrhea or the prevalence of gonorrhea is high locally.[1]​ Trichomoniasis and bacterial vaginosis should be treated if present. Metronidazole is added to the recommended drug regimen for women who have a history of sexual abuse.[1]​​

Nonpregnant, non-high-risk adults

Treatment is only provided to patients at lower risk of STIs once infection is confirmed by diagnostic testing.[1]​​

Recommended treatments for specific infections include:

Chlamydial infection

  • Oral doxycycline is the agent of choice for chlamydial infection.[1]​ 

  • Azithromycin or levofloxacin is a suitable alternative.

  • Systemic fluoroquinolone antibiotics, such as levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[28] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, and unavailability). Consult your local guidelines and drug formulary for ​more information on suitability, contraindications, and precautions.

  • For concurrent gonococcal infection, the CDC recommends adding treatment with a single dose of intramuscular ceftriaxone to the regimen.[1]​​

Gonorrhea infection

  • First-line treatment is a single dose of intramuscular ceftriaxone.[1]​​

  • In patients who have a cephalosporin allergy, a single dose of intramuscular gentamicin plus oral azithromycin may be considered; however, gastrointestinal adverse effects may limit the use of this regimen.[1]​ An infectious disease specialist should be consulted if there is known penicillin/cephalosporin allergy.

  • A single dose of oral cefixime is a suitable alternative regimen if ceftriaxone is not available.[1]​​

  • Patients who have persistent symptoms after treatment for gonorrhea should be retested by culture (preferably with simultaneous nucleic acid amplification testing), and if these cultures are positive for gonococcus, isolates should be submitted for resistance testing.[1]​ Recurrent or resistant gonorrhea infections should be treated with a single dose of intramuscular ceftriaxone, and an infectious disease specialist should be consulted, particularly if resistance to cephalosporins is suspected.[1]​ A test of cure should be repeated 7-14 days after retreatment. Treatment failures should be reported to the CDC through the local or state health department within 24 hours of diagnosis.[1]​ 

  • If chlamydial infection has not been excluded, patients should receive oral doxycycline for 7 days in addition to the cephalosporin.[1]​​

Trichomoniasis

  • Metronidazole and tinidazole are the only known effective drugs for the treatment of trichomoniasis, with success rates of 84% to 98% and 92% to 100%, respectively.[1]​​

Bacterial vaginosis

  • First-line treatment options include oral or vaginal metronidazole and clindamycin intravaginal cream. Tinidazole or secnidazole and oral preparations or intravaginal ovules of clindamycin are second-line options.[1]​​

Herpes simplex virus (HSV) type 2

  • Acyclovir, famciclovir, and valacyclovir are recommended first-line agents.

Pregnant

The main goal of treatment is avoiding maternal, postpartum, and neonatal infection and preventing peripartum complications. Treatment of cervicitis in pregnant women is the same as the regimen for those who are not pregnant.[1]​ Sexual partners must be evaluated and treated; to prevent reinfection, sex partners should avoid intercourse until they are both treated.

Recommended treatments for specific organisms include:

Chlamydial infection

  • Azithromycin is recommended as the first-line option.[1]​ 

  • Amoxicillin can be used as an alternative agent.[1]​ 

  • Pregnant women diagnosed during the first trimester should be tested to confirm eradication of Chlamydia, and should be retested 3 months after treatment.[1]​ Women at high risk for reinfection should be retested during the third trimester.[1]​​

  • For concurrent gonorrhea infection, the CDC recommends treatment with a single dose of intramuscular ceftriaxone in addition to a single dose of azithromycin.[1]​  

Gonorrhea

  • The CDC recommends intramuscular ceftriaxone monotherapy as a first-line regimen in pregnant women, preferably given under direct observation.[1]​​

  • A single dose of azithromycin may be added to treat chlamydia, if chlamydial infection has not been excluded.[1]​​

  • Consultation with an infectious disease specialist is recommended if the patient has a cephalosporin allergy or there are any other considerations that preclude treatment with this regimen.

Trichomoniasis

  • Metronidazole is the recommended agent.[1]​ Tinidazole is not recommended in pregnancy.

  • There is no evidence to suggest a negative effect on the neonate, but there is a lack of information to support its use.

  • In lactating women, it is best to defer breastfeeding for 12 to 24 hours after treatment with metronidazole.

Bacterial vaginosis

  • Treatment is recommended for all symptomatic pregnant women. Metronidazole or clindamycin may be used.[1]​ Tinidazole is not recommended during pregnancy.

HSV type 2, primary or recurrent

  • Treatment of HSV infection in pregnancy is indicated to decrease symptoms of recurrent infection and to decrease viral shedding at term.[1]​ 

  • Initiation of prophylaxis with acyclovir or valacyclovir at 36 weeks' gestation has been shown to decrease the rate of cesarean sections for active HSV infections at term, although it has not been shown to affect neonatal morbidity or mortality.[1]​ 

  • Dosing varies between primary and recurrent episodes of infection.

Pediatric

The main goal of treatment is to prevent acute disease. Presumptive treatment is not indicated due to the low risk of infection. In all US states, medical care for STI can be provided to adolescents without parental consent or knowledge. HIV counseling and testing is also available confidentially to adolescents in most US states.

The detection of certain STIs (such as gonorrheal or chlamydial infection, syphilis, trichomoniasis, and HSV type 2) in preadolescent children carries a high likelihood of sexual assault.[1]​ Other infections such as human papillomavirus or vaginitis do not carry the same probability. Specially trained physicians should attempt to collect any evidence of sexual abuse and report these findings to the proper authorities.

C trachomatis may infect the neonate, resulting in conjunctivitis or pneumonitis.

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