Treatment of Cervicitis
For presumptive treatment of cervicitis, administer either azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days, with concurrent gonococcal coverage if local prevalence exceeds 5%. 1
Initial Treatment Approach
Risk-Based Decision Making
The decision to treat presumptively versus awaiting diagnostic results depends on specific patient factors:
Treat immediately without waiting for test results in women at high risk: age <25 years, new or multiple sex partners, unprotected sex, especially when follow-up cannot be ensured or when using less sensitive diagnostic tests (not NAATs). 1
Consider awaiting NAAT results only in low-risk settings where the patient is likely to return for follow-up and comply with treatment recommendations. 2
Recommended Antibiotic Regimens
Primary treatment options (choose one):
- Azithromycin 1 g orally as a single dose - preferred when compliance is questionable, allows directly observed therapy. 1, 2, 3
- Doxycycline 100 mg orally twice daily for 7 days - equally efficacious but requires 7-day adherence, less expensive. 1, 2
Concurrent Gonococcal Coverage
Add treatment for N. gonorrhoeae when the local prevalence exceeds 5% in the patient population, particularly in young patients or high-prevalence facilities like STD clinics or adolescent populations. 1, 2
Diagnostic Testing Requirements
Before or concurrent with treatment initiation:
Obtain NAATs for both C. trachomatis and N. gonorrhoeae - these are the most sensitive and specific tests available and can be performed on cervical or urine samples. 1, 2
Evaluate for trichomoniasis and bacterial vaginosis - treat if detected, as these are additional causes of cervicitis. 1
Perform syphilis serology and HIV testing in all patients with sexually transmitted urethritis or cervicitis. 1, 2
Common Etiologic Agents
When an organism is identified, it is typically:
- C. trachomatis or N. gonorrhoeae (most common). 1, 4
- Trichomonas vaginalis (especially with concurrent trichomoniasis). 4, 5
- HSV-2 (particularly during primary infection). 4
- Mycoplasma genitalium (emerging pathogen, though standardized tests are not commercially available). 4, 5
Critical caveat: In the majority of cervicitis cases, no organism is isolated, especially in women aged >30 years or at relatively low risk for recent STD acquisition. 1, 4
Management of Persistent or Recurrent Cervicitis
Reevaluation Strategy
For women with persistent cervicitis after appropriate treatment:
Reassess for reexposure to STDs and reevaluate vaginal flora. 1
Exclude relapse or reinfection with C. trachomatis or N. gonorrhoeae through repeat testing. 1, 4
Verify partner treatment compliance - partners must receive the same treatment regimen. 1
Evaluate for bacterial vaginosis if not previously assessed. 1
Important Pitfall
The majority of persistent cervicitis cases are NOT caused by relapse or reinfection with C. trachomatis or N. gonorrhoeae. 4 Other determinants include persistent abnormality of vaginal flora, frequent douching (which should be discontinued), exposure to chemical irritants from feminine hygiene products or spermicides, or idiopathic inflammation in the zone of ectopy. 4
Do not continue empiric antibiotics indefinitely without an identified pathogen - the value of repeated or prolonged antibiotic therapy for persistent symptomatic cervicitis is unknown and has no proven benefit. 4, 2
For women with persistent symptoms clearly attributable to cervicitis after excluding reinfection and treating partners, ablative therapy may be considered by a gynecologic specialist. 1
Partner Management
Notify and treat all sexual partners within the preceding 60 days:
Partners should receive the same treatment regimen as the index patient for identified or suspected STDs (chlamydia, gonorrhea, or trichomoniasis). 1, 2
Patients and partners must abstain from sexual intercourse until therapy is completed (7 days after single-dose regimen or after completion of 7-day regimen). 1
Special Populations
HIV-Infected Patients
Use identical treatment regimens as HIV-negative patients. 1
Treatment is particularly vital because cervicitis increases cervical HIV shedding, and treating cervicitis reduces HIV shedding from the cervix, potentially reducing HIV transmission to susceptible partners. 1, 2
Pregnant Patients
Follow-Up Protocol
Instruct patients to return if symptoms persist after completing therapy. 1, 2
Reevaluate for reexposure, assess partner treatment compliance, and consider bacterial vaginosis or other non-STD causes for persistent cervicitis. 2
Follow-up should be conducted as recommended for the specific infections treated. 1