What is the recommended treatment for cervicitis?

Treatment of Cervicitis

For presumptive treatment of cervicitis, treat with either azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days, with the choice depending primarily on patient adherence concerns and local gonorrhea prevalence. 1

Primary Treatment Regimens

First-Line Options

• Azithromycin 1 g orally as a single dose is the preferred choice when compliance is questionable, as it provides directly observed therapy and eliminates adherence concerns 2, 3
• Doxycycline 100 mg orally twice daily for 7 days is equally efficacious to azithromycin but requires 7-day adherence; it is less expensive and remains an excellent option when compliance can be ensured 1, 2

Both regimens demonstrate equivalent microbiological eradication rates of 97-99% for Chlamydia trachomatis, the most common identifiable pathogen in cervicitis 4, 5, 6, 7

When to Add Gonorrhea Coverage

Add concurrent treatment for Neisseria gonorrhoeae if the local prevalence exceeds 5% in your patient population (particularly in young patients, STD clinics, or adolescent settings) 1

• This decision should be based on facility-specific prevalence data and patient demographics 1
• Even with negative diplococci cultures, consider gonorrhea coverage in high-prevalence settings 2

Risk-Based Treatment Algorithm

Treat Presumptively (Without Waiting for Test Results) When:

• Patient age <25 years with new or multiple sex partners 1
• Unprotected sexual intercourse 1
• Follow-up cannot be ensured 1, 2
• High prevalence setting (STD clinic, adolescent clinic) 2
• Using a less sensitive diagnostic test (not NAAT) 1

Consider Awaiting Test Results When:

• Low prevalence setting for both gonorrhea and chlamydia 2
• Patient likely to comply with return visit recommendations 2
• NAAT testing available with rapid turnaround 1

Essential Diagnostic Testing

Obtain nucleic acid amplification tests (NAATs) for both C. trachomatis and N. gonorrhoeae before initiating treatment, as these are the most sensitive and specific tests available 1, 2

• NAATs can be performed on cervical or urine samples 1
• Also perform syphilis serology and HIV testing at initial diagnosis 2, 3
• Evaluate for bacterial vaginosis and trichomoniasis; treat if detected 1

Critical Management of Sexual Partners

All sexual partners within the preceding 60 days must be notified, examined, and treated with the same regimen as the index patient 1, 2, 8

• Both patient and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 1, 2, 8
• This prevents reinfection, which is a major cause of treatment failure 1

Alternative Regimens

When azithromycin and doxycycline cannot be used:

• Erythromycin base 500 mg orally four times daily for 7 days 8, 9
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 8
• Ofloxacin 300 mg orally twice daily for 7 days (contraindicated in pregnancy) 8

Special Populations

HIV-Infected Patients

• Use identical treatment regimens as HIV-negative patients 1, 8
• Treatment is particularly vital as cervicitis increases cervical HIV shedding and may enhance HIV transmission to partners 1

Pregnant Patients

• Avoid doxycycline and ofloxacin 2, 8
• Use azithromycin 1 g orally as a single dose as the preferred option 2, 8
• Erythromycin base or amoxicillin are alternatives 8

Management of Persistent Cervicitis

If symptoms persist after appropriate treatment:

1. Reevaluate for reexposure to an STD 1
2. Assess partner treatment compliance 2, 8
3. Reassess vaginal flora for bacterial vaginosis 1
4. Exclude relapse or reinfection with specific STDs 1

When relapse/reinfection is excluded, BV is absent, and partners have been treated, management options are undefined 1. The value of repeated or prolonged antibiotic therapy is unknown 1. In women with persistent symptoms clearly attributable to cervicitis, ablative therapy may be considered by a gynecologic specialist 1

Common Pitfalls to Avoid

• Do not withhold treatment while waiting for culture results in high-risk populations or when follow-up is uncertain 2
• Do not assume all cervicitis requires gonorrhea coverage when diplococci cultures are definitively negative in low-prevalence settings 2
• Do not forget to treat concomitant trichomoniasis or symptomatic bacterial vaginosis if detected 1
• Do not neglect partner notification and treatment, as this is the leading cause of reinfection 1, 2

Follow-Up Protocol

• Patients should return if symptoms persist after completing therapy 1, 2, 8
• Routine test-of-cure is not necessary for patients treated with azithromycin or doxycycline unless symptoms persist or reinfection is suspected 8
• Follow-up should be conducted as recommended for the specific infections treated 1