What is the recommended treatment for a sexually active female patient with mild lower abdominal pain, copious vaginal discharge, mucopurulent endocervical exudate, and a history of multiple male partners?

Treatment of Mucopurulent Cervicitis with Multiple Sexual Partners

This patient should be treated empirically with azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days, PLUS ceftriaxone 500 mg intramuscularly once to cover both chlamydia and gonorrhea. 1, 2, 3

Rationale for Empiric Dual Treatment

This patient meets clear criteria for presumptive treatment without waiting for test results:

• Documented mucopurulent cervicitis with visible mucopurulent endocervical exudate and cervical friability 1
• High-risk sexual behavior (multiple male partners in 6 months) placing her at substantial risk for both Chlamydia trachomatis and Neisseria gonorrhoeae 1
• Symptomatic presentation with lower abdominal pain and copious discharge 1

The CDC explicitly recommends empiric treatment when the prevalence of gonorrhea exceeds 5% in the patient population, which applies to sexually active individuals with multiple partners 1. Waiting for test results risks loss to follow-up and continued transmission 1.

Specific Treatment Regimen

For Chlamydia Coverage:

• Azithromycin 1 g orally as a single dose (preferred for compliance) 1
• OR Doxycycline 100 mg orally twice daily for 7 days (equally efficacious, less expensive) 1

For Gonorrhea Coverage:

• Ceftriaxone 500 mg intramuscularly once (current standard based on 2020 CDC update) 2, 3

The combination addresses both organisms simultaneously, which is critical given the high rate of coinfection. 1

Critical Management Steps

Partner Management:

• All sexual partners within the preceding 60 days must be notified, examined, and treated for both chlamydia and gonorrhea 1
• Partners should receive the same empiric dual therapy even if asymptomatic 1

Sexual Abstinence:

• Patient must abstain from sexual intercourse for 7 days after initiating therapy or until completion of the 7-day regimen if using doxycycline 1, 4
• This applies even if symptoms resolve earlier 1
• Partners must also complete treatment before resuming sexual activity 1

Concurrent Infections:

• Test for trichomoniasis and bacterial vaginosis given the copious discharge 1
• If trichomoniasis is detected, add metronidazole 500 mg orally twice daily for 7 days 5
• Her HSV-2 history is noted but not relevant to current cervicitis unless active lesions present 1

Follow-Up Protocol

• Return for reevaluation if symptoms persist or recur after completing therapy 1
• Test results for C. trachomatis and N. gonorrhoeae should be reviewed when available to confirm diagnosis 1
• No routine test-of-cure is needed unless symptoms persist, pharyngeal gonorrhea was present, or rectal chlamydia was treated with azithromycin 5, 3
• Consider rescreening in 3 months given high reinfection rates in this population 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for test results in high-risk patients with clinical cervicitis—this increases risk of PID, ectopic pregnancy, and infertility 1
• Do not use azithromycin monotherapy for gonorrhea coverage—resistance has risen rapidly, making dual therapy with ceftriaxone essential 2, 3
• Do not assume partner treatment occurred—directly verify that all partners completed therapy before patient resumes sexual activity 1
• Do not overlook the mild lower abdominal pain—this may represent early PID, and failure to treat adequately could lead to serious sequelae 1

Special Consideration for This Patient

Her history of depression should prompt assessment of medication adherence concerns. If compliance is questionable, strongly favor azithromycin (single-dose) over doxycycline (7-day regimen) to ensure treatment completion 1. The single-dose regimen provides directly observed therapy and eliminates the risk of incomplete treatment 1.