Medication Summary
Oral antibiotics effectively cure gonorrhea, chlamydia, and T vaginalis infections. Oral antivirals reduce the 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 CDC indicated that fluoroquinolone antibiotics were no longer recommended to treat gonorrhea in the United States. [27] In August 2012, the CDC further revised treatment guidelines so that oral cephalosporins were no longer recommended as first-line therapy for gonococcal infections. [26]
Antibiotics
Class Summary
Antimicrobial therapy for cervicitis must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Ceftriaxone (Rocephin)
Ceftriaxone is first-line therapy for gonococcal cervicitis. This agent is a third-generation cephalosporin with broad-spectrum, gram-negative activity. Although it has lower efficacy against gram-positive organisms, ceftriaxone has higher efficacy against resistant organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Cefixime (Suprax)
Cefixime is a third-generation cephalosporin that is effective in treating gonorrhea. By binding to 1 or more of the penicillin-binding proteins, this drug arrests bacterial cell wall synthesis and inhibits bacterial growth. Cefixime is once again available in the United States.
As previously stated, however, as a result of an update of the CDC's treatment guidelines, in August 2012, oral cephalosporins are no longer recommended for gonococcal infections. Thus, cefixime is no longer considered to be a first-line treatment for gonorrhea.
Spectinomycin (Trobicin)
Spectinomycin is an alternative regimen for the treatment of gonorrhea. This agent inhibits protein synthesis in bacterial cells. Its site of action is the 30S ribosomal subunit, and it is structurally different from related aminoglycosides. Use spectinomycin if the patient is allergic to penicillin and quinolones. Do not use spectinomycin if oropharyngeal gonorrhea is suspected.
Azithromycin (Zithromax)
Azithromycin is first-line therapy for chlamydia cervicitis. This drug is a semisynthetic macrolide antibiotic that is effective in treating chlamydia. Azithromycin also treats mild to moderate microbial infections.
Doxycycline (Vibramycin)
Doxycycline is a long-acting tetracycline derived from oxytetracycline. It inhibits protein synthesis and thus bacterial growth by binding to the 30S and possibly 50S ribosomal subunits of susceptible bacteria. This agent is effective in treating chlamydia.
Erythromycin base (E-Mycin)
Erythromycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. This agent is an alternative therapy for chlamydial cervicitis.
Erythromycin ethylsuccinate (E.E.S.)
Erythromycin ethylsuccinate inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. This agent is an alternative regimen for chlamydial cervicitis.
Metronidazole (Flagyl)
Metronidazole is a synthetic antibacterial and antiprotozoal agent. This drug provides first-line therapy for T vaginalis infections.
Levofloxacin (Levaquin)
Levofloxacin inhibits DNA gyrase activity. This agent is an alternative treatment for chlamydial cervicitis.
Ofloxacin (Floxin)
Ofloxacin inhibits bacterial DNA gyrase, which in turn inhibits DNA replication, transcription, repair, recombination, and transposition, causing bacterial cell death. This agent is an alternative treatment for chlamydial cervicitis.
Amoxicillin (Amoxil, Moxatag, Trimox)
Amoxicillin interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. This agent is an alternative treatment for chlamydial cervicitis
Antivirals
Class Summary
Nucleoside analogues 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)
Acyclovir is a synthetic purine nucleoside analogue that is indicated for genital herpes simplex virus (HSV) infections. For the first episode, begin treating within 6 days after the appearance of the first symptoms. If the episode represents a recurrence, begin treating during the prodrome or within 1 day after the onset of lesions. Suppression requires daily treatment for 1 year.
Famciclovir (Famvir)
Famciclovir is a prodrug for penciclovir (active moiety); this agent is indicated for genital HSV infections. For the first episode, begin treating within 6 days after the appearance of the first symptoms. For a recurrent attack, begin treating during the prodrome or within 1 day after the onset of lesions. Suppression requires daily treatment for 1 year.
Valacyclovir (Valtrex)
Valacyclovir is indicated for genital HSV infections. For the first episode, begin treating within 6 days after the appearance of the first symptoms. For a recurrent attack, begin treating during the prodrome or within 1 day after the onset of lesions. Suppression requires daily treatment for 1 year.
Topical Skin Products
Class Summary
Topical skin products are indicated for genital/perianal warts.
Imiquimod (Aldara)
Imiquimod is indicated for genital/perianal warts. This agent induces secretion of interferon alpha and other cytokines; however, its mechanism of action is unknown. Imiquimod may be more effective in women than in men.
Podofilox (Condylox)
Podofilox is a topical antimitotic that can be chemically synthesized or purified from the plant families Coniferae and Berberidaceae (eg, species of Juniperus and Podophyllum). Its exact mechanism of action is unknown.
Fluorouracil topical (Carac, Efudex, Fluoroplex)
Fluorouracil is a cycle-specific drug that has activity as a single agent; for many years, it has been combined with the biochemical modulator leucovorin. Fluorouracil has been shown to be effective in an adjuvant setting. A classic antimetabolite anticancer drug, it has a chemical structure similar to endogenous intermediates (the building blocks of DNA or RNA).
5-fluorouracil (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 and are as following:
Trichloroacetic acid topical (Tri-Chlor)
Topical trichloroacetic acid cauterizes skin, keratin, and other tissues. Despite its causticity, this agent causes less local irritation and systemic toxicity than do other drugs in its class. However, the response to topical trichloroacetic acid is often incomplete, and recurrence occurs frequently.
Antiprotozoal
Class Summary
Antiprotozoal agents are an alternative therapy for Trichomonas infections.
Tinidazole (Fasigyn, Tindamax)
Tinidazole is indicated to treat trichomoniasis caused by T vaginalis in males and females. This agent is a 5-nitroimidazole derivative that is used for susceptible protozoal infections. The nitro group is reduced by the cell extract of Trichomonas. The free nitro radical generated is thought to be responsible for tinidazole's antiprotozoal activity against T vaginalis.
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Normal cervix
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Cervix of a lactating woman without sexually transmitted infections. The patient had twice given birth vaginally.
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Cervical cellularity (ectopy), which is often present in adolescents, allows for greater adherence of infectious organisms in the cervix. The risk of acquiring acute salpingitis for a sexually active 15-year-old is 1:8, compared with 1:80 for women aged 24 years and older.
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Signs of chlamydial cervicitis on speculum examination may include mucopurulent endocervical discharge and spontaneous or easily induced endocervical bleeding or any zones of ectopy.
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In women with gonococcal cervicitis, the cervix may show mucopurulent or purulent cervical discharge and easily induced cervical bleeding.
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Herpes simplex virus (HSV) cervicitis may involve the exocervix or endocervix, and it may be symptomatic or asymptomatic. Usually, the cervix appears abnormal to inspection, with diffuse vesicular lesions, ulcerative lesions, erythema, or friability.
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T vaginalis can have a characteristic "frothy" gray or yellow-green vaginal discharge and pruritus. The occurrence of cervical petechiae, or "strawberry cervix," is a classic presentation that is seen in less than 2% of cases. T vaginalis may also infect the Skene glands and the urethra and may be asymptomatic in women.
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Papanicolaou (Pap) stain, high power, showing the Herpes simplex virus (HSV) infecting cells with multiple nuclei, intranuclear inclusions, and margination of the chromatin to the outer portion of the nuclei.
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Pap stain, high power, showing human papillomavirus (HPV) infecting a cell with a dark, wrinkled nucleus surrounded by a clear cytoplasmic halo.
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Pap stain, high power (under oil immersion), showing 2 pear-shaped structures representing Trichomonas. Small, pale nuclei and cytoplasmic granules are present.
