Should a patient with green vaginal discharge be treated for chlamydia and gonorrhea?

Treatment for Chlamydia and Gonorrhea in Green Vaginal Discharge

Empiric treatment for both gonorrhea and chlamydia should be initiated in patients with green vaginal discharge when the local prevalence of these infections is high (>15%), when the patient is unlikely to return for follow-up, or when the patient is at high risk for infection. 1

Risk-Stratified Treatment Algorithm

High-Risk Populations - Treat Empirically for Both

• Patients seen in STD clinics or settings with high prevalence (>15%) of gonorrhea and chlamydia should receive dual treatment immediately 1
• Sexually active women under 25 years of age 1
• Patients unlikely to return for follow-up or test results 1
• Patients with concurrent Trichomonas vaginalis on wet prep (strongly associated with gonorrhea/chlamydia coinfection) 2

Moderate-Risk Populations - Consider Testing First

• If local gonorrhea prevalence is low but chlamydia likelihood is substantial, treat for chlamydia only while awaiting gonorrhea results 1
• If both infection prevalences are low AND the patient is likely to return for follow-up, obtain testing and await results before treating 1

Recommended Treatment Regimens

For Gonorrhea

• Ceftriaxone 500 mg IM single dose (for patients <150 kg) 3, 4
• Note: The 2020 CDC update increased the dose from 250 mg to 500 mg 3

For Chlamydia (if not excluded)

• Doxycycline 100 mg orally twice daily for 7 days (preferred) 5, 3, 4, 6
• Alternative: Azithromycin 1 g orally single dose (for adherence concerns) 7, 4
• Doxycycline is superior to azithromycin for rectal chlamydia, which often coexists with vaginal infection 6

Critical Clinical Context

Understanding Mucopurulent Cervicitis (MPC)

• Green or yellow endocervical discharge characterizes MPC, but most women with gonorrhea or chlamydia do NOT have MPC 1
• Conversely, MPC is not a sensitive predictor of infection - in most MPC cases, neither organism can be isolated 1
• Non-infectious causes include inflammation in cervical ectopy, which can produce persistent discharge despite negative testing 8

Testing Recommendations

• All patients with green vaginal discharge should be tested for both Chlamydia trachomatis and Neisseria gonorrhoeae using nucleic acid amplification tests (NAAT) 1, 9
• Testing should also include Trichomonas vaginalis 9, 2
• Nucleic acid amplification tests have sensitivities of 86.1%-100% and specificities of 97.1%-100% 10

Common Pitfalls to Avoid

Overtreatment Concerns

• ED providers empirically overtreat approximately 20 uninfected patients for every one laboratory-confirmed infection 2
• Subjective vaginal discharge, abdominal pain, dysuria, cervical motion tenderness, and positive leukocyte esterase are NOT associated with gonorrhea or chlamydia infection 2
• After excluding relapse and reinfection, persistent MPC may not benefit from additional antimicrobial therapy 1, 8

Undertreatment Concerns

• Coinfection with chlamydia and gonorrhea is common, particularly at genital sites 11
• Treating only for chlamydia when gonorrhea is present leads to persistent symptoms and continued transmission 11
• Untreated infections can cause pelvic inflammatory disease, ectopic pregnancy, and infertility 1, 3

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated for both infections 1, 11
• If last sexual contact was >60 days before diagnosis, treat the most recent partner 1, 11
• Partners of empirically treated patients should receive the same treatment as the index patient 1, 11
• Patients must abstain from sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 11

Follow-Up Considerations

• Test of cure is not needed for uncomplicated gonorrhea treated with recommended regimens 11
• All nonpregnant patients should be retested approximately 3 months after treatment due to high reinfection risk 11, 4
• Persistent symptoms warrant reevaluation with culture and antimicrobial susceptibility testing 11