What are the etiologies and recommended treatment for cervicitis?

Cervicitis: Etiologies and Treatment

Most Common Infectious Causes

The most frequently identified pathogens in cervicitis are Chlamydia trachomatis and Neisseria gonorrhoeae, though the majority of cases—especially in women over 30 years with low STD risk—yield no identifiable organism. 1

Identified Pathogens (in order of frequency):

• Chlamydia trachomatis is the single most common identifiable cause when a pathogen is isolated 1, 2
• Neisseria gonorrhoeae ranks as the second most frequent bacterial cause 1, 2
• Trichomonas vaginalis causes cervicitis, particularly in women with concurrent trichomoniasis 1, 2
• Herpes simplex virus type 2 (HSV-2) can cause cervicitis, especially during primary infection 1, 2
• Mycoplasma genitalium has emerged as a candidate etiologic agent, though standardized commercial diagnostic tests remain unavailable 1, 3

Non-Infectious Causes:

• Frequent douching is associated with persistent cervicitis and should be discontinued 1, 2
• Chemical irritants from feminine hygiene products or spermicides can contribute to cervical inflammation 1
• Persistent abnormality of vaginal flora may cause ongoing inflammation 1, 2
• Idiopathic inflammation in the zone of ectopy can produce persistent cervicitis without an identifiable infectious cause 1, 2

Recommended Treatment Approach

For Non-Pregnant Patients:

Initiate empiric antibiotics immediately (without awaiting test results) if the patient is <25 years old, has new or multiple sexual partners, reports unprotected intercourse, lacks reliable follow-up, or resides in a high STD prevalence community. 1

First-Line Empiric Regimen:

• Azithromycin 1 g orally as a single dose 1
  • OR
• Doxycycline 100 mg orally twice daily for 7 days 1

Add Gonococcal Coverage When:

• Local gonorrhea prevalence exceeds 5% in the patient population 1
• Patient belongs to high-risk settings (young age groups, STD-clinic attendees) 1

For Pregnant Patients:

Azithromycin 1 g orally as a single dose is the preferred treatment for cervicitis in pregnancy, as it effectively covers Chlamydia trachomatis and ensures compliance through directly observed therapy. 4

Critical Contraindication:

• Doxycycline is absolutely contraindicated in pregnancy despite being standard treatment outside pregnancy 4

Essential Diagnostic Testing

Nucleic-acid amplification tests (NAATs) for C. trachomatis and N. gonorrhoeae are the preferred diagnostics and may be performed on cervical or urine specimens; NAATs have markedly higher sensitivity (≈50% for microscopy versus near 100% for NAATs). 1

Complete Diagnostic Workup:

• NAATs for chlamydia and gonorrhea on cervical or urine specimens 1, 2
• Wet-mount microscopy of vaginal secretions to assess for ≥10 WBC per high-power field (indicating endocervical inflammation) and detect Trichomonas vaginalis 1
• Test for bacterial vaginosis when present and treat concurrently 1, 2
• Syphilis and HIV testing for every patient diagnosed with a new sexually transmitted infection 1, 4

Management of Concomitant Infections

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

Partner Management Protocol

All sexual partners within the preceding 60 days must be notified, examined, treated with the same regimen as the index patient regardless of symptoms, and instructed to abstain from intercourse until therapy is completed (7 days after a single-dose regimen or after the 7-day course). 1, 4

Management of Persistent Cervicitis

Critical Clinical Pitfall:

Cervicitis can persist despite repeated courses of antimicrobial therapy, and the majority of persistent cases are NOT caused by relapse or reinfection with C. trachomatis or N. gonorrhoeae. 1

For Persistent Symptoms After Initial Treatment:

1. Re-evaluate for possible re-exposure to an STD 1
2. Reassess vaginal flora 1
3. Exclude relapse or reinfection with specific pathogens 1
4. Verify that all sex partners have been evaluated and treated 1
5. Do not continue empiric antibiotics indefinitely without an identified pathogen, as this has no proven benefit and risks adverse effects 1
6. Consider ablative therapy by a gynecologic specialist after exclusion of other causes 1

Special Populations

HIV-Infected Patients:

• HIV-infected individuals should receive the same first-line treatment regimens for cervicitis as HIV-negative individuals 1
• Prompt treatment is especially important because cervicitis in HIV-infected patients is associated with increased cervical HIV shedding, potentially enhancing HIV transmission to susceptible partners 1

Prevention of Long-Term Sequelae

Immediate administration of appropriate antibiotics is linked to reduced risk of pelvic inflammatory disease and its complications (infertility, ectopic pregnancy, chronic pelvic pain). 1, 5