Cervicitis Treatment & Management

Admit women to the hospital if pelvic inflammatory disease (PID) is suspected and the patient is unable to take oral medications, is pregnant or immunocompromised, has failed prior outpatient therapy, has a tubo-ovarian abscess, or if the diagnosis is uncertain (eg, appendicitis cannot be ruled out). If disseminated infection is suspected, intensive monitoring and parenteral medication are needed, as patients may quickly become unstable.

If the patient is unable to take oral medication because of intractable nausea, vomiting, or abdominal pain, then hospitalization for intravenous medication is warranted.

In most cases, test-of-cure is not necessary, because of the high efficacy of the medications used. In the case of persistent symptoms or pregnancy, follow-up testing is recommended.

Treatment of all causes of cervicitis is medical and can be done presumptively (treatment with azithromycin or doxycycline) in infectious cases or with specific antibiotic treatment once the etiology is known; however, empiric treatment for cervicitis can also include coverage for gonorrhea if there is clinical suspicion for this condition.

Provide presumptive therapy to women at increased risk for chlamydial infection, particularly in cases in which follow-up is uncertain or in which a relatively insensitive diagnostic test is used instead of nucleic acid amplification testing (NAAT), as well as in patients who have been diagnosed with trichomoniasis and bacterial vaginosis. ^[1]

Treatment must also include the patient's sexual partners to prevent reinfection. In addition, all sexual activity must cease for 7 days until the completion of therapy; that is: (1) after initiating treatment in the patient and (2) until the partner has also been treated.

Chlamydial cervicitis

The CDC recommends the following regimens for presumptive treatment of chlamydial cervicitis ^[1] :

• Azithromycin 1 g oral (PO) in a single dose, OR

• Doxycycline 100 mg PO twice daily (bid) for 7 days

Effective alternative agents to azithromycin and doxycycline for the treatment of chlamidia include erythromycin, levofloxacin, and ofloxacin, as follows ^{[1, 12]} :

• Erythromycin base 500 mg PO four times daily (qid) for 7 days, OR

• Erythromycin ethylsuccinate 800 mg PO qid for 7 days, OR

• Levofloxacin 500 mg PO daily (qd) for 7 days, OR

• Ofloxacin 300 mg PO bid for 7 days

These patients should also be treated concurrently for gonococcal infection in areas with high gonorrhea prevalence or if the individual’s personal risk is high.  In women who defer presumptive treatment, the need for therapy depends on the results of sensitive tests for chlamydia and gonorrhea. ^[1]

Gonococcal cervicitis

For uncomplicated gonococcal infections of the cervix, the CDC updated their recommendations in August 2012, as follows ^[26] :

• Ceftriaxone 250 mg administered intramuscularly (IM) in a single dose, PLUS

• Azithromycin 1 g PO in a single dose (preferred, owing to tetracycline resistance) or doxycycline 100 mg PO bid for 7 days

Alternatively, if ceftriaxone is not an option, the following regimens are recommended ^[26] :

• Single-dose injectable cephalosporin regimens, PLUS

• Azithromycin 1 g PO in a single dose (preferred) or doxycycline 100 mg PO bid for 7 days, PLUS

• Test-of-cure in 1 week (with culture, including phenotypic antimicrobial susceptibility; if culture is unavailable, obtain NAAT)

If the patient has a severe cephalosporin allergy, azithromycin 2 g PO in a single dose plus test-of-cure in 1 week are recommended. ^[26]

Trichomoniasis

The CDC recommends metronidazole 2 g PO in a single dose or tinidazole 2 g PO in a single dose for T vaginalis infections. ^[22] Alternatively, metronidazole 500 mg PO bid for 7 days can be given.

Patients must avoid alcohol consumption during treatment with metronidazole or tinidazole, as well as for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole. ^[22] Topically applied antimicrobials are not as effective as the oral doses (eg, metronidazole) and should be avoided.

Lactating women who are administered metronidazole should withhold breastfeeding during treatment and for 12-24 hours after the last dose. ^[22] Women treated with tinidazole should also withhold breastfeeding during treatment, as well as for 3 days after the last dose.

Evaluate male partners and treat them with either tinidazole in a single dose of 2 g PO or metronidazole 500 mg PO bid for 7 days. ^[22]

Treatment during pregnancy

Do not treat pregnant women with doxycycline, ofloxacin, and levofloxacin. ^[12] Pregnant women with chlamydial cervicitis may be treated with azithromycin as above or with amoxicillin 500 mg PO three times daily (tid) for 7 days. Erythromycin may be an alternative regimen, as follows ^[12] :

• Erythromycin base 500 mg PO qid for 7 days, OR

• Erythromycin base 250 mg PO qid for 14 days, OR

• Erythromycin ethylsuccinate 800 mg PO qid for 7 days, OR

• Erythromycin ethylsuccinate 400 mg PO qid for 14 days

Pregnant women with gonococcal cervicitis should undergo the same treatment as nonpregnant women. In those who cannot tolerate a cephalosporin, consider azithromycin 2 g PO. ^[13]

Pregnant women with trichomoniasis can be treated with 2 g metronidazole in a single dose at any stage of pregnancy. ^[22] The safety of tinidazole in pregnant women has not been well evaluated.

Cervicitis and HIV coinfection

In women with concurrent cervicitis and HIV infection, the treatment regimen is the same as that for women not infected with HIV. ^[1] It is essential for these women to receive treatment to reduce cervical HIV shedding, which is increased in cervicitis, and thus reduce the potential for HIV transmission to their sex partners. ^[1]

In patients with trichomoniasis and HIV coinfection, the CDC recommends considering a multidose treatment regimen of metronidazole PO, as a study indicated the single dose of metronidazole 2 g PO was not as effective as 500 mg bid for 7 days. ^[22]

Recurrent/persistent cervicitis

Aside from reevaluation for reexposure to a sexually transmitted infection (STI), there are currently no defined treatment options for women found to have recurrent and persistent cervicitis despite the exclusion of relapse/reinfection with a specific STI, the absence of bacterial vaginosis, and the evaluation and treatment of the patient’s sex partner(s). ^[1] The efficacy of repeated or prolonged antibiotic therapy in these women is also unclear. Consider referring women with persistent symptoms clearly caused by cervicitis to gynecologic specialists. ^[1]

Women with trichomoniasis, treatment failure using metronidazole 2 g single dose, and exclusion of reinfection should be treated with metronidazole 500 mg PO bid for 7 days. ^[22] If retreatment is unsuccessful, consider tinidazole or metronidazole at 2 g PO for 5 days. If none of these treatment strategies are effective, consult with an infectious disease specialist to determine the susceptibility of the T vaginalis infection to metronidazole and tinidazole. The CDC also provides consultation (telephone: 404-718-4141; Web site: http://www.cdc.gov/std) and T vaginalis susceptibility testing. ^[22]

Antimicrobial-resistant gonorrhea

Consult an infectious disease specialist for suspected treatment failure or for the management of patients infected with a microbial strain that has demonstrated in vitro resistance. ^[13] Perform culture and susceptibility testing, retreat the patient with at least 250 mg of ceftriaxone intramuscular/intravenous (IM/IV), and treat the patient’s sex partners. In addition, notify the CDC through state and local public health authorities. ^[13]

In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions (eg, pelvic inflammatory disease [PID]), owing to the ability of N gonorrhoeae to develop resistance to microbial therapies. ^[27] The guidelines no longer recommended fluoroquinolone antibiotics to treat gonorrhea in the United States.

This change was based on analysis of new data from the CDC’s Gonococcal Isolate Surveillance Project (GISP). The GISP data showed that the proportion of fluoroquinolone-resistant gonorrhea (QRNG) cases in heterosexual men had reached 7.9% in 2010, a 13-fold increase from 0.6% in 2001. ^{[27, 28]}

As a result of another update of the CDC’s treatment guidelines, in August 2012, oral cephalosporins are no longer recommended for gonococcal infections. ^[26] Thus, cefixime at any dose is no longer a first-line treatment for such infections. ^[26]

Treatment of gonorrhea is now limited to ceftriaxone 125 mg IM once as a single dose plus a second antibiotic. 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, the Gonococcal Isolate Surveillance Project (GISP) Web site, or the May 18, 2012, video presentation, The Growing Threat of Multidrug Resistant Gonorrhea.

Follow up with women treated for cervicitis according to recommendations for the specific etiology to determine whether the condition has resolved. ^[1] Routine test-of-cure (ie, repeat testing 3-4 wk following treatment completion) is not recommended following treatment, except in the following situations ^{[1, 12]} :

• The patient is pregnant

• Symptoms persist

• Suspicion of reinfection exists

• There is questionable treatment compliance

Women with persistent symptoms following gonococcal or chlamydial infection should be reevaluated owing to the increased risk of reinfection within 6 months following treatment; ie, repeat testing should be performed 3-6 months after the initial treatment, whether or not a patient’s sex partner(s) underwent treatment. ^[1] Women treated for trichomoniasis should also be rescreened at 3 months following treatment due to the high risk for reinfection. ^[22]