07. Cervicitis & PID

Resident Editor, 2018 Update: Kelly A. Johnson, MD, MPH

Faculty Editor, 2018 Update: Iris Huang, MD, MPH

BOTTOM LINE

✔ Diagnosing and treating cervicitis and PID can help prevent long-term complications such as infertility, ectopic pregnancy, and HIV transmission

✔ Consider treating cervicitis empirically for chlamydia +/- gonorrhea infection.

✔ Remember to empirically treat sexual partners

Background/Epidemiology

  • Cervicitis: inflammation of the cervix (often infectious)
    • Complications: pelvic inflammatory disease, increases HIV viral shedding and risk of HIV transmission
  • Pelvic inflammatory disease (PID): infection-induced inflammation of the upper female reproductive tract, caused by ascension of microorganisms from the lower genital tract
    • Spectrum of disease: endometritis, salpingitis, and tubo-ovarian abscess
    • Complications: ectopic pregnancy, infertility, and chronic abdominal pain
  • Cervicitis and PID are most common among young (< age 25) sexually active women and adolescents

Microbiology

Cervicitis

PID
  • Common: C. trachomatis, N. gonorrhoeae
  • Less common: Trichomonas, herpes simplex viruses, mycoplasma genitalium, bacterial vaginosis organisms (anaerobes such as bacteriodes species)
  • Non-infectious causes: chemical douches, spermicides, deodorants
  • Common: C. trachomatis, N. gonorrhoeae, M. genitalium
  • Less common: bacterial vaginosis organisms, respiratory and enteric microorganisms colonizing the lower genital tract
  • Infections are often polymicrobial

Signs and Symptoms

  • Cervicitis: often asymptomatic. Can cause vaginal discharge, inter-menstrual or post-coital bleeding, dyspareunia, dysuria. Unlike vaginitis, does not typically cause vaginal itching and irritation
  • PID: pelvic/lower abdominal pain, vaginal discharge, dyspareunia, dysuria, inter-menstrual or post-coital bleeding
    • Constitutional symptoms: Not often a prominent feature, but may include fever, nausea, and/or vomiting
    • Right upper quadrant pain may be seen if the infection ascends to the liver capsule resulting in inflammation and formation of adhesions (Fitz-Hugh-Curtis Syndrome)

Evaluation

  • Pelvic Exam: mucopurulent discharge, cervix may appear edematous and erythematous, and demonstrate easy bleeding when probed (friability)
    • Hallmarks of PID: reproductive organ tenderness on bimanual exam (e.g., cervical motion or adnexal tenderness)
  • Wet mount/KOH: increased numbers of WBCs, especially PMNs (e.g., >1 neutrophil per epithelial cell). Evaluate for evidence of candida, trichomonas, and/or BV
  • Pregnancy test to r/o ectopic pregnancy
  • 4th generation HIV test given risk of co-infection
  • Nucleic Acid Amplification Testing (cervical swab, vaginal swab or urine): preferred for the diagnosis of chlamydia and gonorrhea

Treatment

Diagnosis

Empiric Treatment

Cervicitis

  • Empiric treatment should be given to women <25 years old, those with high risk sexual behavior, or if follow up cannot be ensured
  • If treating empirically, cover C. trachomatis;  also consider  N. gonorrhoeae coverage if patient at high risk for gonorrhea or if high local prevalence
  • Azithromycin 1 gm PO x 1 +/- Ceftriaxone 250 mg IM x 1 dose if covering for gonorrhea (azithromycin covers chlamydia; ceftriaxone + azithromycin covers gonorrhea given increasingly resistant strains. One-time therapy also helps with treatment adherence)
  • Alternatives:

- Chlamydia: Doxycycline 100 mg BID x 7 days

- Gonorrhea (penicillin allergic): Azithromycin 2 gm PO x 1 + Gentamicin 240 mg IM x 1

 

Pelvic Inflammatory Disease Outpatient (mild-moderate symptoms, able to tolerate PO)
  •  Empirically cover both C. trachomatis and N. gonorrhoeae, often along with anaerobes
  • Doxycycline 100 mg BID x 2 weeks, +/- Metronidazole 500 mg BID x 2 weeks (metronidazole should be added for patients with Trichomonas vaginalis infection, or with recent uterine instrumentation)
  • AND one of the following:
    • Ceftriaxone 250 mg IM x 1 dose

or

  • Cefoxitin 2 g IM + probenacid 1g PO x 1 dose

or

  • Other IV 3rd generation cephalosporin (e.g., cefotaxime)

Pelvic Inflammatory Disease Inpatient (pregnant patients, severe systemic illness, inability to tolerate PO intake, poor response to oral therapy, and/or tubal abscess)
  • Cefotetan 2 g IV q12 hour (continued until 24-48 hours after clinical improvement) PLUS doxycycline 100 mg BID IV or PO (+/- metronidazole 500 mg BID) x 2 weeks

or

  • Cefoxitin 2 g IV q6 hour (continued until 24-48 hours after clinical improvement) PLUS doxycycline 100 mg BID IV or PO (+/- metronidazole 500 mg BID) x 2 weeks

or

  • Clindamycin 900 mg IV q8 hour plus gentamicin (3-5 mg/kg body weight IV once daily) while inpatient

Prevention and Screening

  • CDC and USPSTF recommendations: annual screening for chlamydia (and gonorrhea) among all sexually active women < 25 years old, and in older women with high risk sexual behavior
  • Routine screening should be performed along with safe sex counseling including regular condom use
  • Sexual partners should be treated empirically in all confirmed or suspected cases of cervicitis or PID due to STIs
    • Consider ordering additional prescriptions for the patient to give to their partner(s)
  • Recommend abstinence for at least 7 days after treatment or until both partners are symptom free
  • Gonorrhea and chlamydia cases are reported to the public health department

References

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Available at https://www.cdc.gov/std/tg2015/tg-2015-print.pdf. Accessed 29 July 2018.

Brunham RC, Gottlieb SL, and Paavonen J. Pelvic inflammatory disease. N Engl J Med 2015; 372(21): 2039-48.

Marrazzo JM and Martin DH. Management of women with cervicitis. CID 2007; 44 (Suppl 3): S102-110.

Risser WL, Risser JM, Risser AL. Current perspectives in the USA on the diagnosis and treatment of pelvic inflammatory disease in adolescents. Aolesc Health Med Ther 2017; 8: 87-94.

Wiesenfeld HC and Manhart LE. Mycoplasma genitalium in women: current knowledge and research priorities for this recently emerged pathogen. JID 2017: 216 (Suppl 2): S389-95.

Workowski KA. Centers for disease control and prevention sexually transmitted diseases treatment guidelines. CID 2015; 61 (Suppl 8): S759-62.