In a 22‑year‑old woman with thin purulent cervical discharge, dysuria, intermenstrual bleeding, deep dyspareunia, a friable cervix, and gram‑negative diplococci on cervical swab, what is the most likely diagnosis and appropriate treatment?

Diagnosis and Treatment of Gram-Negative Diplococci on Cervical Swab

The most likely diagnosis is mucopurulent cervicitis caused by Neisseria gonorrhoeae, and you should immediately initiate dual therapy with ceftriaxone 500 mg IM single dose plus azithromycin 1 g orally single dose (or doxycycline 100 mg orally twice daily for 7 days) to cover both gonorrhea and presumed chlamydial co-infection. 1

Clinical Diagnosis

The constellation of findings in this 22-year-old woman establishes the diagnosis of mucopurulent cervicitis:

• Gram-negative diplococci on cervical swab are highly specific (>99%) for N. gonorrhoeae infection, though sensitivity is only approximately 50% for endocervical specimens 2
• Purulent cervical discharge is one of the two cardinal signs of cervicitis 1
• Cervical friability (sustained endocervical bleeding induced by gentle swabbing) is the second cardinal diagnostic sign 1
• Intermenstrual bleeding and deep dyspareunia are typical manifestations of gonococcal cervicitis 1
• Dysuria commonly accompanies lower genital tract gonococcal infection 1

Why Immediate Treatment Is Critical

Prompt antibiotic administration directly prevents progression to pelvic inflammatory disease, which can cause infertility, ectopic pregnancy, and chronic pelvic pain. 1, 3 Delaying therapy while awaiting confirmatory test results increases the risk of upper genital tract infection 1.

Recommended Treatment Regimen

First-Line Dual Therapy

• Ceftriaxone 500 mg IM as a single dose to treat gonorrhea 1
• PLUS azithromycin 1 g orally as a single dose to cover presumed chlamydial co-infection 2, 1
• Alternative to azithromycin: doxycycline 100 mg orally twice daily for 7 days (equally effective but requires adherence) 1

Rationale for Dual Therapy

• Co-infection with Chlamydia trachomatis occurs in the majority of patients with gonorrhea, making empiric coverage mandatory 2
• C. trachomatis and N. gonorrhoeae are the two most common causes of cervicitis in young, sexually active women 1, 4, 3
• This patient meets all high-risk criteria: age <25 years, purulent discharge, cervical friability, and gram-negative diplococci on microscopy 1

Essential Diagnostic Testing

While treatment should begin immediately, obtain the following tests:

• Nucleic acid amplification tests (NAATs) for both N. gonorrhoeae and C. trachomatis from cervical or urine specimens (NAATs have markedly higher sensitivity than microscopy) 1
• Wet-mount microscopy of vaginal secretions to assess for ≥10 WBC per high-power field and to detect Trichomonas vaginalis 1
• Test for bacterial vaginosis and treat if present 1, 4
• Syphilis and HIV testing for every patient with a new sexually transmitted infection 1

Critical Management Steps

Partner Notification and Treatment

• All sexual partners within the preceding 60 days must be notified, examined, and treated with the same regimen regardless of symptoms 1
• Both patient and partners must abstain from intercourse for 7 days after completing single-dose therapy or until completing the full 7-day course 1

Follow-Up Protocol

• Patients should return if symptoms persist after completing therapy or if new symptoms develop 1
• Expect substantial clinical improvement within 3 days; lack of improvement warrants re-evaluation for reinfection, resistant organisms, or alternative diagnoses 1
• For persistent cervicitis after initial treatment, re-evaluate for possible re-exposure, reassess vaginal flora, exclude relapse or reinfection, and verify that all partners were treated 1

Common Pitfalls to Avoid

• Do not rely on Gram stain alone—the 50% sensitivity means negative microscopy does not rule out infection 2, 1
• Do not treat gonorrhea without covering chlamydia—co-infection rates are too high to omit empiric chlamydial therapy 2
• Do not delay treatment in high-risk patients—this 22-year-old with clinical cervicitis requires immediate antibiotics without awaiting NAAT results 1
• Do not forget to test for Trichomonas vaginalis, bacterial vaginosis, syphilis, and HIV—these frequently co-occur and require concurrent management 1
• Do not assume treatment failure is due to antibiotic resistance—most persistent infections result from reinfection by untreated partners 1

Additional Considerations

• Gonococcal infections in women are frequently asymptomatic, making this symptomatic presentation particularly concerning for potential upper tract involvement 2, 5
• Antibiotic resistance in N. gonorrhoeae is increasing globally, but extended-spectrum cephalosporins (ceftriaxone) remain effective 5, 6
• HIV-infected patients receive the same treatment regimens as HIV-negative individuals 1