An 18-year-old woman comes to the office for evaluation of dysuria that began 8 days ago. The patient went to urgent care a week ago and completed a 7-day course of nitrofurantoin with no relief of symptoms. She also has vaginal discharge but no fever, chills, or back pain. The patient is monogamous with a male partner and takes combination estrogen/progestin oral contraceptives. She has no chronic medical conditions or medication allergies. Temperature is 36.7 C (98.1 F), blood pressure is 118/74 mm Hg, and pulse is 68/min. On speculum examination, there is thick, yellow cervical discharge, and the cervix bleeds on contact with a swab. No pain is present on bimanual pelvic examination. The remainder of the examination is normal. Wet mount microscopy shows multiple leukocytes but no clue cells or motile organisms. Urinalysis is positive for leukocyte esterase but negative for nitrites and blood. Urine pregnancy testing is negative. Cervical swabs are obtained for further testing. Which of the following is the best next step in management of this patient?

Question

An 18-year-old woman comes to the office for evaluation of dysuria that began 8 days ago.  The patient went to urgent care a week ago and completed a 7-day course of nitrofurantoin with no relief of symptoms.  She also has vaginal discharge but no fever, chills, or back pain.  The patient is monogamous with a male partner and takes combination estrogen/progestin oral contraceptives.  She has no chronic medical conditions or medication allergies.  Temperature is 36.7 C (98.1 F), blood pressure is 118/74 mm Hg, and pulse is 68/min.  On speculum examination, there is thick, yellow cervical discharge, and the cervix bleeds on contact with a swab.  No pain is present on bimanual pelvic examination.  The remainder of the examination is normal.  Wet mount microscopy shows multiple leukocytes but no clue cells or motile organisms.  Urinalysis is positive for leukocyte esterase but negative for nitrites and blood.  Urine pregnancy testing is negative.  Cervical swabs are obtained for further testing.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d284_3867_bc81_9b72d16e25e2_MD0003_00 This patient most likely has acute cervicitis caused by Chlamydia trachomatis or Neisseria gonorrhoeae, which are highly prevalent in women age <25. The diagnosis is clinical and based on the presence of mucopurulent cervical discharge and a friable cervix (ie, bleeding on contact); some patients also have concomitant urethritis (eg, dysuria, positive leukocyte esterase with negative nitrites) due to the proximity of the urethra to the vagina. In contrast, cervical motion tenderness, a sign of ascending infection (ie, pelvic inflammatory disease), may be absent with low bacterial count or in early infection. friable cervix For patients with acute cervicitis, nucleic acid amplification testing for C trachomatis and N gonorrhoeae is recommended. However, empiric treatment prior to the return of results is needed to prevent transmission to sexual partners and to decrease the risk for long-term sequelae (eg, ectopic pregnancy, infertility) (Choice D). First-line empiric treatment is dual therapy with ceftriaxone plus doxycycline. Ceftriaxone covers N gonorrhoeae, a gram-negative diplococcus, and doxycycline covers C trachomatis, an atypical organism. (Choice A) Azithromycin and doxycycline both cover C trachomatis, but together, they are insufficient empiric treatment for acute cervicitis because neither has adequate gram-negative coverage for N gonorrhoeae. During pregnancy, azithromycin is used in place of doxycycline (a potential teratogen) for C trachomatis coverage. (Choice C) Clindamycin plus gentamicin is used to treat postpartum endometritis, a polymicrobial uterine infection caused by the ascent of normal vaginal flora during labor or delivery. Clindamycin covers gram-positive (eg, group B Streptococcus) and anaerobic (eg, Bacteroides fragilis) bacteria; gentamicin covers gram-negative bacteria, including N gonorrhoeae. However, both lack coverage for C trachomatis and therefore are not used for the empiric treatment of acute cervicitis. (Choice E) Trimethoprim-sulfamethoxazole (TMP-SMX), a sulfonamide, has gram-positive (eg, methicillin-resistant Staphylococcus aureus) and gram-negative (eg, Escherichia coli) coverage, and it can be used to treat acute simple cystitis, which can also present with dysuria but not cervicitis. However, due to high rates of asymptomatic transmission and increasing prevalence, N gonorrhoeae has acquired multidrug resistance, including resistance to sulfonamides. In addition, TMP-SMX does not cover atypical organisms such as C trachomatis. Educational objective: Acute cervicitis (eg, mucopurulent cervical discharge, friable cervix) is commonly due to infection with Chlamydia trachomatis or Neisseria gonorrhoeae. The diagnosis is clinical and requires empiric treatment with ceftriaxone and doxycycline, which cover both organisms. References: Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815) Neisseria gonorrhoeae host adaptation and pathogenesis. (http://www.ncbi.nlm.nih.gov/pubmed/29430011) Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296)

An 18-Year-Old Woman Comes to the Office for Evaluation of Dysuria