eMedicine Specialties > Obstetrics and Gynecology > Infections
Cervicitis: Treatment & Medication
Updated: Aug 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treatment of all causes of cervicitis is medical. Treatment must include the patient's sexual partners to prevent reinfection. Treatment for infectious causes of cervicitis can be done presumptively (treatment with azithromycin or doxycycline) or with specific antibiotic treatment once the etiology is known.
Activity
- No sexual activity for 7 days after initiating treatment
- No sexual activity until partner has been treated
Medication
Oral antibiotics effectively cure gonorrhea, chlamydia, and T vaginalis infections. Oral antivirals reduce duration of symptoms, lesions, and viral shedding in the first and recurrent episodes of genital herpes infections. Initially, topical therapy is used for symptomatic genital wart removal. Other options include intralesional injection and surgery.
In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions.5 Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC’s Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of fluoroquinolone-resistant gonorrhea (QRNG) cases in heterosexual men reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007 issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.
For more information, see the CDC’s Antibiotic-Resistant Gonorrhea Web site or Updated Gonococcal treatment recommendations (April 2007).
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Ceftriaxone (Rocephin)
First-line therapy for gonococcal cervicitis. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
125 mg IM once
Pediatric
Administer as in adults
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and/or aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Partner(s) must be treated; adjust dose in renal impairment; caution in allergy to penicillin; if chlamydia testing results are not available, also treat for chlamydia because 20-40% of patients with gonorrhea are co-infected
Cefixime (Suprax)
Third-generation cephalosporin effective in treating gonorrhea. By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth. This medication is once again available in the United States.
Adult
400 mg PO once
Pediatric
<45 kg: Not established
>45 kg: Administer as in adults
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects; false-positive Clinitest results
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Partner must be treated; adjust dose in renal impairment; colitis may occur
Spectinomycin (Trobicin)
Inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit and is structurally different from related aminoglycosides. Use if allergic to penicillin and quinolones. Alternative regimen for treatment of gonorrhea. Do not use if oropharyngeal gonorrhea is suspected.
Adult
2 g IM once
Pediatric
<45 kg: 40 mg/kg IM once
>45 kg: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Partner must be treated; benzyl alcohol used as a diluent is associated with fatal gasping syndrome in infants
Azithromycin (Zithromax)
First-line therapy for chlamydia cervicitis. Semisynthetic macrolide antibiotic effective in treating chlamydia. Treats mild-to-moderate microbial infections.
Adult
1 g PO once
Pediatric
<6 months: Not established
>6 months: Administer as in adults
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; use of pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Partner must be treated; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in patients who are hospitalized, elderly, or debilitated
Doxycycline (Vibramycin)
Long-acting tetracycline derived from oxytetracycline. Effective in treating chlamydia. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid for 7 d
Pediatric
<8 years: Not recommended
>8 years: Administer as in adults
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; children <8 y; severe hepatic impairment
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Partner must be treated; if pregnant, use erythromycin; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (ie, last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Erythromycin base (E-Mycin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Alternative therapy for chlamydia cervicitis.
Adult
500 mg PO bid for 7 d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Decrease clearance of alfentanil, bromocriptine, carbamazepine, cyclosporine, digoxin, disopyramide, ergot alkaloids, methylprednisolone, protease inhibitor, theophylline, and triazolam; increases anticoagulant effect of warfarin; decreases metabolism of vinblastine; serum levels increased by protease inhibitors, increased levels and rhabdomyolysis with use of lovastatin and simvastatin
Documented hypersensitivity; hepatic dysfunction; current use of pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Partner must be treated; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Erythromycin ethylsuccinate (E.E.S.)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Alternative regimen for chlamydia cervicitis.
Adult
800 mg PO qid for 7 d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Decrease clearance of alfentanil, bromocriptine, carbamazepine, cyclosporine, digoxin, disopyramide, ergot alkaloids, methylprednisolone, protease inhibitor, theophylline, and triazolam; increases anticoagulant effect of warfarin; decreases metabolism of vinblastine; serum levels increased by protease inhibitors, increased levels and rhabdomyolysis with use of lovastatin and simvastatin
Documented hypersensitivity; hepatic dysfunction; current use of pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Partner must be treated; caution in liver disease; discontinue if GI distress, malaise, or fever occurs
Metronidazole (Flagyl)
Synthetic antibacterial and antiprotozoal agent. First-line therapy for T vaginalis infections.
Adult
2 g PO once; alternatively, 500 mg PO bid for 7 d
Pediatric
<1 year: 10-30 mg/kg/d PO for 5-8 d
<12 years: 15 mg/kg/d PO in 3 divided doses for 7-10 d
>12 years: Administer as in adults
Avoid alcohol for 7 d (disulfiramlike reaction); effect decreased by phenobarbital and phenytoin; increases PT with warfarin; increases toxicity/serum level of lithium; serum level increased by cimetidine
Documented hypersensitivity; controversy exists about treatment during first trimester (category D) despite no proof of harm, some suggest waiting until second trimester to treat using 2 g PO x 1 or 500 mg PO bid for 7 d
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Partner must be treated; adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Antivirals
Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate. These molecules inhibit HSV polymerase with 30-50 times the potency of human alpha-DNA polymerase.
Acyclovir (Zovirax)
Synthetic purine nucleoside analog indicated for genital HSV infections. First episode, begin treating within 6 d after appearance of first symptoms. If recurrent attack, begin treating during prodrome or within 1 d after onset of lesions. Suppression requires daily treatment for 1 y.
Adult
First episode: 400 mg PO tid for 7-10 d; alternatively 200 mg PO 5 times qd for 7-10 d
Recurrent attack: 200 mg PO 5 times qd for 5 d; alternatively 400 mg PO tid for 5 d or 800 mg PO bid for 5 d
Suppression: 400 mg PO bid for 1 y
Pediatric
First episode: 400 mg PO tid for 7-10 d; not to exceed 80 mg/kg/d
Recurrent attack: 400 mg PO tid for 5 d; alternatively, 800 mg PO bid for 5 d; not to exceed 80 mg/kg/d
>12 years: Administer as in adults
Probenecid and zidovudine increase adverse CNS effects
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Register pregnant patients on acyclovir at 1-800-722-9292; caution in renal failure or coadministration of nephrotoxic drugs
Famciclovir (Famvir)
Prodrug for penciclovir (active moiety) indicated for genital HSV infections. For first episode, begin treating within 6 d after appearance of first symptoms. For recurrent attack, begin treating during prodrome or within 1 d after onset of lesions. Suppression requires daily treatment for 1 y.
Adult
First episode: 250 mg PO tid for 7-10 d
Recurrent attack: 125 mg PO bid for 5 d
Suppression: 250 mg PO bid for 1 y
Pediatric
Not established
Cimetidine and probenecid increase toxicity/serum level of penciclovir; increases digoxin level
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Register pregnant patients at 1-800-722-9292; caution in renal failure or coadministration of nephrotoxic drugs
Valacyclovir (Valtrex)
Indicated for genital HSV infections. For first episode, begin treating within 6 d after appearance of first symptoms. For recurrent attack, begin treating during prodrome or within 1 d after onset of lesions. Suppression requires daily treatment for 1 y.
Adult
First episode: 1 g PO bid for 7-10 d
Recurrent attack: 500 mg PO bid for 5 d
Suppression: 1 g PO qd for 1 y; alternatively, 500 mg PO qd for 1 y or 250 mg PO bid for 1 y
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Cimetidine/probenecid decrease conversion rate to acyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Register pregnant patients at 1-800-722-9292; monitor patients who are immunocompromised for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome; adjust dose in renal impairment
Topical skin products
Indicated for genital/perianal warts.
Imiquimod (Aldara)
Indicated for genital/perianal warts. Induces secretion of interferon alpha and other cytokines; mechanism of action are unknown. May be more effective in women than in men.
Adult
Apply to warts qhs 3 times/wk for up to 16 wk, rinse treatment area with soap and water 6-10 h after application
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In pregnancy, most lesions may be treated postpartally; however, consideration may be given to using topical liquid nitrogen qwk or surgical treatments (eg, excision, electrocauterization, laser vaporization); avoid contact with genital mucous membranes; burning, pain, inflammation, erosion, and pruritus have occurred
Podofilox (Condylox)
Topical antimitotic which can be chemically synthesized or purified from plant families Coniferae and Berberidaceae (eg, species of Juniperus and Podophyllum). Exact mechanism of action is unknown.
Adult
Apply bid for 3 d, no therapy for 4 d, then repeat up to 4 cycles
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid contact with eyes; if eye contact, immediately flush eye with copious quantities of water and seek medical advice; not for use on mucous membranes of genital area including urethra, rectum and vagina; do not exceed frequency of application or duration of usage
Fluorouracil (Carac, Efudex, Fluoroplex)
Cycle-specific agent that has activity as single agent and has for many years been combined with biochemical modulator leucovorin. Shown to be effective in adjuvant setting. Classic antimetabolite anticancer drug with chemical structure similar to endogenous intermediates or building blocks of DNA or RNA synthesis. 5-FU inhibits tumor cell growth through at least 3 different mechanisms that ultimately disrupt DNA synthesis or cellular viability. These effects depend on intracellular conversion of 5-FU into 5-FdUMP, 5-FUTP, and 5-FdUTP. 5-FdUMP inhibits thymidylate synthase (key enzyme in DNA synthesis). 5-FUTP is incorporated into RNA and interferes with RNA processing, and 5-FdUTP is incorporated into DNA, leading to cytotoxic DNA strandbreaks.
Adult
Apply daily, may use an applicator for urethral warts
Pediatric
Not established
None reported
Documented hypersensitivity; potentially serious infections
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Inflammatory reactions may occur with use of occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction; patients should expect inflammatory reaction with crusting
Trichloroacetic acid (Tri-Chlor)
Cauterizes skin, keratin, and other tissues. Although caustic, causes less local irritation and systemic toxicity than others in the same class. However, response is often incomplete and recurrence occurs frequently.
Adult
Apply to warts and powder with talc or sodium bicarbonate (baking soda) to remove unreacted acid; may repeat weekly
Pediatric
Not established
None reported
Documented hypersensitivity; not for use on premalignant or malignant lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
External use only; restrict use to treatment areas only
Antiprotozoal
Alternative therapy for trichomonas infections.
Tinidazole (Fasigyn, Tindamax)
5-nitroimidazole derivative used for susceptible protozoal infections. Nitro group is reduced by cell extract of Trichomonas. The free nitro radical generated is thought to be responsible for antiprotozoal activity against T vaginalis. Indicated to treat trichomoniasis caused by T vaginalis in both males and females.
Adult
Individual and sexual partner: 2 g PO once with food
Pediatric
<3 years: Not established
>3 years: 50 mg/kg PO qd for 3 d with food, not to exceed 2 g/dose
Limited data exist; interaction information based on experience with other nitroimidazole derivatives (ie, metronidazole); may prolong PT when coadministered with warfarin; avoid alcoholic beverages and preparations containing ethanol or propylene glycol during and 3 d following administration (may cause disulfiramlike reaction); may increase serum levels of lithium, phenytoin, cyclosporine, tacrolimus, and fluorouracil; CYP450 inducers (eg, phenobarbital, rifampin, phenytoin) may increase elimination; CYP450 inhibitors (eg, cimetidine, ketoconazole) may decrease elimination; concurrent administration with cholestyramine may decrease oral bioavailability; oxytetracycline may antagonize effect
Documented hypersensitivity; first trimester of pregnancy; breastfeeding women (recommend interruption during therapy and for 3 d following last dose)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in blood dyscrasias, organic neurological dysfunction, late trimesters of pregnancy, seizure disorders, and hepatic and renal impairment
Carcinogenicity has been observed in mice and rats treated chronically with metronidazole (another nitroimidazole), although not observed with tinidazole, use cautiously; may cause metallic/bitter taste, nausea, anorexia, vomiting, weakness, fatigue, dizziness, or headache; if administered on day of hemodialysis, administer additional dose equivalent to one-half of recommended dose following dialysis
More on Cervicitis |
| Overview: Cervicitis |
| Differential Diagnoses & Workup: Cervicitis |
 Treatment & Medication: Cervicitis |
| Follow-up: Cervicitis |
| References |
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References
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Wright TC Jr, Schiffman M, Solomon D, Cox JT, Garcia F, Goldie S. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstet Gynecol. Feb 2004;103(2):304-9. [Medline].
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CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].
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Griffith WF, Stuart GS, Gluck KL, Heartwell SF. Vaginal speculum lubrication and its effects on cervical cytology and microbiology. Contraception. Jul 2005;72(1):60-4. [Medline].
Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Mosby; 2007:598-600.
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Schiffman M, Khan MJ, Solomon D, Herrero R, Wacholder S, Hildesheim A. A study of the impact of adding HPV types to cervical cancer screening and triage tests. J Natl Cancer Inst. Jan 19 2005;97(2):147-50. [Medline].
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Further Reading
Keywords
cervicitis, female lower genital tract infections, mucopurulent cervicitis, sexually transmitted diseases, STDs, vulvovaginitis, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, human papillomavirus, HPV, herpes simplex virus, HSV, pelvic inflammatory disease, PID, infertility, ectopic pregnancy, spontaneous abortion, cervical cancer, preterm delivery, condylomata acuminata, Papanicolaou test, Pap smear
