What is the recommended management of cervicitis?

Management of Cervicitis

Treat immediately with azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days if not pregnant) without awaiting test results if the patient is under 25 years old, has new or multiple sexual partners, reports unprotected intercourse, or if follow-up cannot be ensured. 1

Diagnostic Approach

Before or concurrent with treatment, obtain the following tests:

• Nucleic acid amplification tests (NAATs) for both C. trachomatis and N. gonorrhoeae are mandatory—these have markedly higher sensitivity (≈50% for microscopy vs. near 100% for NAATs) and may be performed on cervical or urine specimens 1
• Wet-mount microscopy of vaginal secretions to assess for ≥10 WBC per high-power field (indicating endocervical inflammation) and to detect Trichomonas vaginalis 1
• Test for bacterial vaginosis and treat concurrently if present 1
• Syphilis serology and HIV testing should be performed for every patient diagnosed with a new sexually transmitted infection 1

The two cardinal clinical signs are (1) sustained endocervical bleeding (cervical friability) induced by gentle swabbing and (2) purulent or mucopurulent endocervical exudate visible in the canal 1

First-Line Treatment Regimens

Non-Pregnant Patients

• Azithromycin 1 g orally as a single dose (preferred when compliance is questionable, provides directly observed therapy) 1, 2
• OR doxycycline 100 mg orally twice daily for 7 days (equally efficacious, less expensive, but requires 7-day adherence) 1, 2

Pregnant Patients

• Azithromycin 1 g orally as a single dose is the ONLY recommended treatment 3
• Doxycycline is absolutely contraindicated in pregnancy despite being standard treatment outside pregnancy 3, 2

When to Add Gonococcal Coverage

Add treatment for N. gonorrhoeae when local prevalence exceeds 5% in the patient population or in high-risk settings (young age, STD clinic populations) 4, 1

Concurrent Infection Management

• Treat identified trichomoniasis with metronidazole 2 g orally single dose 1
• Provide appropriate therapy for symptomatic bacterial vaginosis when detected 4, 1

Partner Management Protocol

All sexual partners within the preceding 60 days must be:

• Notified and examined 3, 1
• Treated with the same regimen as the index patient regardless of symptoms 1, 2
• Instructed to abstain from intercourse for 7 days after single-dose therapy or until completion of 7-day regimens 4, 3, 1

Management of Persistent Cervicitis

If symptoms persist after completing therapy:

• Re-evaluate for possible re-exposure to an STD 1
• Reassess vaginal flora and exclude bacterial vaginosis 1
• Verify that all sex partners have been evaluated and treated 1
• Exclude relapse or reinfection with specific pathogens using repeat NAATs 1

The value of repeated or prolonged administration of antibiotic therapy for persistent symptomatic cervicitis is unknown—do not continue empiric antibiotics indefinitely without an identified pathogen 1

For persistent cases without identifiable pathogens, consider:

• Frequent douching should be discontinued 1
• Chemical irritants from feminine hygiene products or spermicides may contribute to cervical inflammation 1
• Idiopathic inflammation in the zone of ectopy can produce persistent cervicitis without an infectious cause 1
• Ablative therapy may be considered by a gynecologic specialist for women with persistent symptoms clearly attributable to cervicitis after all other causes have been excluded 4

Special Populations

HIV-Infected Patients

• HIV-infected patients receive identical treatment regimens as HIV-negative patients 4, 2
• Treatment is particularly vital as cervicitis increases cervical HIV shedding and might reduce HIV transmission to susceptible sex partners 4

Evidence-Based Rationale

When a pathogen is identified in cervicitis, the most frequently isolated organisms are C. trachomatis, N. gonorrhoeae, Trichomonas vaginalis, HSV-2, and M. genitalium 1. However, in the majority of cases—especially in women >30 years with low STD risk—no organism is isolated 1.

Empiric azithromycin treatment reduces cervicitis at follow-up in populations with high prevalence of C. trachomatis and/or M. genitalium (RR=0.62,95% CI 0.39-0.97, p=0.035), but there is no significant effect in non-specific cervicitis where these pathogens are absent 5.

Critical Pitfalls to Avoid

• Do not withhold treatment while awaiting culture results in high-risk populations or when follow-up is uncertain 2
• Do not forget partner treatment—reinfection rates are higher when partners are not adequately treated 3
• Do not use doxycycline in pregnant women 3, 2
• Do not assume all cervicitis requires gonorrhea coverage when diplococci cultures are definitively negative and local prevalence is low 2
• Do not continue empiric antibiotics indefinitely for persistent cervicitis without an identified pathogen, as this has no proven benefit and risks adverse effects 1

Long-Term Implications

Immediate administration of appropriate antibiotics is linked to reduced risk of pelvic inflammatory disease and its complications (infertility, ectopic pregnancy, chronic pelvic pain) 1, 6