Gonococcal Cervicitis

Background

• Gonococcal cervicitis is a sexually transmitted infection of the cervix caused by Neisseria gonorrhoeae.
• Cervicitis is characterized by purulent or mucopurulent cervical discharge, but is frequently asymptomatic.
• The incubation period is unclear.
  • Onset of cervicitis usually occurs 5-10 days after exposure.
  • Patients may be asymptomatic until complications such as pelvic inflammatory disease occur.

Evaluation

• Symptoms may include vaginal discharge, postcoital bleeding, or dyspareunia, but asymptomatic infection is most common.
• Nucleic acid amplification tests (NAATs) are recommended by the Centers for Disease Control and Prevention (CDC) for detecting infection.
  • A vaginal swab is the optimal specimen.
  • If a speculum exam is performed, an endocervical specimen is acceptable.
  • A self-administered vaginal swab tested by nucleic acid amplification has a similar detection rate as clinician-obtained endocervical swab and higher detection rate than culture for diagnosis of gonorrhea.
• Screening:
  • Annual screening recommended for all sexually active women < 25 years old and those at increased risk for infection (for example, with a new sex partner, multiple sex partners, or partner with a sexually transmitted infection).
  • All pregnant women should be screened at their first prenatal visit if they are at risk for gonorrhea (< 25 years old, history of any sexually transmitted infection, new or multiple sex partners, history of exchanging sex for money or drugs) or living in an area in which prevalence is high.
  • Annual screening recommended for gender diverse people with a cervix and transgender men < 25 years old and those ≥ 25 years old at increased risk for infection, with additional screening at pharyngeal and rectal sites based on reported sexual behaviors and exposures.
• Patients with gonorrhea infection should be tested for other sexually transmitted infections including Chlamydia trachomatis, syphilis, and HIV.

Management

• Due to the high rates of Chlamydia trachomatis coinfection, concurrent treatment for both gonorrhea and chlamydia is recommended if chlamydia infection has not been ruled out.
• Centers for Disease Control and Prevention (CDC) recommendation for adults with gonococcal cervicitis consists of single dose of ceftriaxone:
  • 500 mg intramuscularly in a single dose for patients weighing < 150 kg (300 lbs)
  • 1 g intramuscularly in a single dose for patients weighing ≥ 150 kg (300 lbs)
  • if chlamydial coinfection has not been excluded, additional treatment recommended:
    • for nonpregnant patients, give doxycycline 100 mg orally twice daily for 7 days
    • for pregnant patients, give azithromycin 1 g orally in a single dose
• Due to the emergence of drug-resistant gonococci:
  • CDC no longer recommends oral cephalosporins as first line therapy for the treatment of gonorrhea and no longer recommends empiric azithromycin if chlamydial coinfection has been ruled out.
  • European International Union against Sexually Transmitted Infections/World Health Organization (IUSTI/WHO) recommends higher-dose ceftriaxone 1 g intramuscularly PLUS azithromycin 2 g orally in a single dose.
  • alternatives to cephalosporins include spectinomycin, gentamicin, and higher-dose azithromycin, but each has limitations
• Treatment recommendations do not differ for patients with HIV.
• Counsel patients to avoid sexual activity until treatment is complete and both patient and partner no longer have symptoms.
• Patients should be instructed to refer sex partners for evaluation and treatment.
• A test-of-cure is not routinely recommended by the CDC for patients who respond to therapy, though it is recommended by IUSTI/WHO to identify persistent or drug-resistant infection.
• Follow-up with retesting at 3 months is recommended for all patients due to high rates of reinfection.
• Recommended regimens have very high cure rate, although emergence of drug-resistant strains continues to be a concern.