A 17-year-old girl comes to the office for increasing malodorous vaginal discharge over the past week. The patient has had no fevers, chills, nausea, dysuria, hematuria, vulvar pruritus, or postcoital bleeding. Her last menstrual period was 2 weeks ago. The patient's menses have become irregular since a progestin-containing intrauterine device was placed 8 months ago. She has no chronic medical conditions or previous surgeries. The patient is sexually active with a male partner and has had 2 lifetime partners. She does not use tobacco, alcohol, or illicit drugs. The patient has no known drug allergies. She is currently a senior in high school and will be going to a local university in the fall. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 76/min. BMI is 20 kg/m². Pelvic examination shows normal external genitalia with no lesions, erythema, or inguinal lymphadenopathy. Bimanual examination reveals no cervical motion tenderness, a mobile uterus, and no adnexal masses. On speculum examination, there is purulent discharge from the cervical os, and the ectocervix bleeds easily when touched with a cotton swab. The intrauterine device strings are visible in the cervix. A urine pregnancy test is negative. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_bf04_8e32_8f63_93e1c65c615d_MD0005_00 This patient has purulent cervical discharge and cervical friability, findings consistent with acute cervicitis. Other symptoms of acute cervicitis include intermenstrual and/or postcoital spotting, dysuria, and dyspareunia; however, women are often asymptomatic. Nucleic acid amplification testing is indicated for all patients with suspected cervicitis to confirm infection; however, treatment is administered empirically based on examination alone and does not require waiting for results (Choices A and D). Empiric treatment allows for earlier symptomatic relief and decreases the risk for transmission to sexual partners. A delay in treatment increases the risk for ascending infection (eg, pelvic inflammatory disease) and long-term sequelae (eg, tubal scarring, infertility). acute cervicitis infertility First-line empiric treatment is dual therapy with ceftriaxone plus doxycycline, which provides coverage against the 2 most common pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae. The patient's sexual partner(s) should also be treated. To prevent reinfection, the patient and her partner(s) should abstain from sexual intercourse for a week after completion of treatment. (Choice C) Metronidazole is used in the treatment of bacterial vaginosis and trichomoniasis. Bacterial vaginosis presents with a thin, gray vaginal discharge without associated cervical inflammation. Clue cells are observed on wet mount microscopy. Trichomoniasis can present with a friable, punctate cervix (eg, strawberry cervix) and green, frothy vaginal discharge; protozoa are visualized on wet mount microscopy. Clue cells protozoa (Choice E) For patients with an intrauterine device (IUD) who develop acute cervicitis or pelvic inflammatory disease, IUD removal does not improve clinical outcomes and therefore is not indicated. However, IUD removal can be considered in a patient whose condition does not improve with antibiotics. Educational objective: Acute cervicitis typically presents with purulent cervical discharge and a friable cervix. Management includes nucleic acid amplification testing for chlamydia and gonorrhea and empiric treatment with ceftriaxone plus doxycycline. References: Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae-2014. (http://www.ncbi.nlm.nih.gov/pubmed/24622331) Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296) Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815)

A 17-Year-Old Girl Comes to the Office for Increasing Malodorous