Elizabeth M. Yoselevsky and Christine R. Isaacs
History of present illness
A 21-year-old gravida 0 woman presents requesting contra- ception. She began a relationship with a new sexual partner approximately one month ago and admits to being inconsist- ent with using condoms. She has no active complaints. She has regular menstrual cycles and her last menstrual period began one week ago. She has no significant past medical history or prior surgeries. She takes no medications. She is currently a senior at the university. She drinks approximately six beers on the weekends and denies tobacco or illicit drug use.
Physical examination
General appearance:Well-developed, well-nourished, thin woman in no acute distress and cooperative
Vital signs:
Temperature: 37.0°C Pulse: 80 beats/min
Blood pressure: 110/68 mmHg Respiratory rate: 14 breaths/min Oxygen saturation: 100% on room air HEENT:Unremarkable
Cardiovascular:Normal S1, S2 without murmur Lungs:Clear to auscultation bilaterally
Abdomen:Soft, nontender External genitalia:Unremarkable Vagina:Physiologic-appearing discharge
Cervix:Nulliparous, slight mucopurulent discharge from os.
Small amount of bleeding elicited with gentle swabbing with a cotton-tip probe
Uterus:Anteverted, nontender, mobile Adnexa:Nontender, no masses
Laboratory studies:Urine pregnancy test: Negative
What is your differential diagnosis and how would you manage this patient?
This patient has an asymptomatic mucopurulent discharge and is at risk for sexually transmitted infections (STIs) due to her age and inconsistent condom use. Because of this, she was advised to undergo screening for sexually transmitted diseases (STDs). The differential diagnosis for this presentation most commonly includes infection by Chlamydia trachomatis and Neisseria gonorrhoeae. Less likely causes include trichomonia- sis or herpes simplex virus infection.
The patient was tested for gonorrhea and chlamydia and her chlamydia test returned positive. She was treated with 1 g of azithromycin given as a single dose in the office to ensure compliance. She was strongly advised to abstain from sexual intercourse for one week to reduce the risk of transmission and was advised to inform all of her recent sexual partners of the diagnosis and the need for their evaluation/treatment.
She was started on oral contraceptives and counseled on the importance of consistent condom use for prevention of further STIs. She returned to the clinic three months later and had a negative test for reinfection.
Chlamydia cervicitis
Chlamydia trachomatis is the most commonly reported sexually transmitted pathogen with over 1.4 million cases reported in 2011. In the past 10 years, the incidence has been steadily increasing with the highest rates of infection found in women 15–24 years of age [1]. Cervicitis should be suspected when either a mucopurulent discharge is noted in the endo- cervical canal or if the cervix bleeds easily with manipulation or collection of specimens. While patients with chlamydia may experience urethritis, dysuria, abnormal discharge, or post-coital spotting, most women infected byC. trachomatis are asymptomatic. The sequelae of chlamydia cervicitis can be serious including pelvic inflammatory disease (PID), infertility, ectopic pregnancies, and chronic pelvic pain.
These potential long-term complications make screening, recognizing, treating, and preventing chlamydial cervicitis imperative.
When a cervical examination reveals a mucopurulent discharge and/or easy bleeding as in the case of this patient, further testing should be performed to rule out chlamydial infections. Testing can be performed by a number of methods;
however, nucleic acid amplification tests (NAATs) are the most sensitive and are Food and Drug Administration (FDA) cleared for endocervical swabs and urine samples. While cervical swab testing has a slightly higher sensitivity than urine testing, urine sampling avoids the necessity of an inva- sive pelvic examination and may provide a more feasible opportunity for screening. Before obtaining an endocervical specimen, a large swab should be used to remove all secretions and discharge from the cervical os. Once the cervix has been properly cleaned off, the cytobrush or swab provided by the test manufacturer should be inserted 1–2 cm deep into the endocervix and rotated at least 2 turns or for the length of time recommended by the test kit manufacturer. If using a
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
urine specimen to detect chlamydia, the first 10–30 mL of voided urine should be collected to test as greater amounts may dilute the sample and produce a false negative result [2].
When a patient presents with cervicitis, it is also important to assess the patient for signs of PID because cervicitis may be indicative of an upper genital tract infection, which requires different treatment and risks future sequelae. To diagnose PID, uterine tenderness, adnexal tenderness, or cervical motion ten- derness must be present. Other concerning signs include fever greater than 38.3°C, mucopurulent discharge, many white blood cells in the cervical discharge, elevated erythrocyte sedimentation rate, or elevated C-reactive protein levels [3]. While data is limited regarding the incidence, many women with uncompli- cated cervical infections already have subclinical upper- reproductive tract infections brewing. This makes obtaining a timely diagnosis essential for preventing future comorbidities.
As soon as a patient tests positive for chlamydia she needs to be treated. Treatment should follow the 2010 Centers for Dis- ease Control and Prevention (CDC) treatment guidelines for STDs (Table 23.1) [4]. Healthcare providers are encouraged to observe the patient taking the first dose of treatment, when possible. First-line treatment includes azithromycin 1 g PO once or doxycycline 100 mg PO BID for 7 days. Both treatments are equally effective, but azithromycin is more ideal to ensure com- pliance as it is a single dose. If a patient is pregnant, azithromy- cin 1 g PO once is the preferred treatment. Amoxicillin 500 mg PO TID for 7 days is an acceptable alternative but understand- ably risks issues with compliance (Table 23.2) [4].
Patients who are treated for chlamydia cervicitis will require appropriate education following their infection. First, it is important to educate patients on the prevention of future STIs by employing consistent barrier method contraception such as male condoms. Secondly, healthcare providers should counsel patients on notifying all sexual partners from within the last 60 days about the infection. If the most recent sexual contact was greater than 60 days prior, that partner should still
be notified. Treating sexual partners minimizes the chances of reinfection in women. This is important because several studies have demonstrated that the risks of complications from infection increase with each subsequent reinfection [4]. Many states have laws that allow a healthcare provider the option of Expedited Partner Therapy (EPT), such that they may write an antibiotic prescription for the partner of an infected patient without seeing the partner in the clinic. The legal status of these regulations is constantly evolving and varies from state to state. The CDC’s website (http://www.cdc.gov/std/ept/legal/
default.htm) lists recommendations by state. A patient also needs to be counseled that he or she should wait seven days from thefirst dose of antibiotics before resuming sexual inter- course regardless of the treatment regimen.
The 2010 CDC guidelines do not recommend a test-of-cure for chlamydial infections in nonpregnant patients. Patients who test positive for chlamydia should be retested 3–12 months after treatment to confirm no evidence of reinfection or exposure from a new (infected) partner. Patients should only be tested sooner if therapeutic compliance is in question, symptoms persist, or reinfection is suspected. Pregnant women should undergo repeat testing to document chlamydial eradication (preferably by NAAT) three to four weeks after completion of therapy. These women should not only receive a test-of-cure but should also be retested again three months after treatment [4].
As most women infected byC. trachomatisare asymptom- atic, it is important to annually screen age-appropriate and high-risk patients [3,4]. The current CDC recommendations are to screen all sexually active women aged 25 years or younger, or patients older than 25 years with risk factors. Risk factors include new or multiple partners, inconsistent condom use, and/or current or prior STD. These recommendations differ slightly from the United States Preventive Services Task Force (USPSTF) guidelines, which recommend annual screening in women age 24 years or younger [4]. Currently, there are nofirm guidelines regarding screening sexually active
Table 23.1 The 2010 CDC treatment guidelines forChlamydia trachomatis (in nonpregnant patients)*
Recommended regimens
Azithromycin1 g PO in a single dose or
Doxycycline100 mg PO BID for 7 days Alternative regimens
Erythromycin base500 mg PO QID for 7 days or
Erythromycin ethylsuccinate800 mg PO QID for 7 days or
Levofloxacin500 mg PO OD for 7 days or
Ofloxacin300 mg PO BID for 7 days
* Centers for Disease Control and Prevention [4].
BID, twice a day; CDC, Centers for Disease Control and Prevention; OD, once a day; PO,per os(orally); QID, four times a day.
Table 23.2 The 2010 CDC treatment guidelines forChlamydia trachomatis (in pregnant patients)*
Recommended regimens
Azithromycin1 g PO in a single dose or
Amoxicillin500 mg PO TID for 7 days Alternative regimens
Erythromycin base500 mg PO QID for 7 days or
Erythromycin base250 mg PO QID for 14 days or
Erythromycin ethylsuccinate800 mg PO QID for 7 days or
Erythromycin ethylsuccinate400 mg PO QID for 14 days
* Centers for Disease Control and Prevention [4].
BID, twice a day; CDC, Centers for Disease Control and Prevention; OD, once a day; PO,per os(orally); QID, four times a day.
Case 23: A 21-year-old woman with a new sexual partner
males, but screening may be reasonable in settings with a high prevalence of the disease such as a correctional facility or STD clinic. The data has yet to support a comprehensive screening initiative for men because there has been no strong evidence that it will improve outcomes for women [4].
Key teaching points
Chlamydia trachomatisis the most commonly reported sexually transmitted infection in the United States and its prevalence is highest in women ages 15–24.
Chlamydia is asymptomatic in most cases, but may present as urethritis, dysuria, or post-coital spotting.
There may be evidence of a mucopurulent discharge or a friable cervix.
Sequale of chlamydia may include pelvic inflammatory disease, increased risk for ectopic pregnancy, infertility, and chronic pelvic pain.
The Centers for Disease Control and Prevention (CDC) guidelines recommend that all sexually active women aged 25 years or younger (or older than age 25 with risk factors) should be screened for chlamydia annually. United States Preventive Services Task Force guidelines recommend that women 24 years of age or younger (or older and at increased risk) should be screened annually.
Nonpregnant women should be tested for reinfection 3–12 months after treatment and pregnant women should undergo a test-of-cure 3–4 weeks after treatment.
References
1. Centers for Disease Control and Prevention.Sexually Transmitted Disease Surveillance 2011. Atlanta, US Department of Health and Human Services, 2012.
2. Centers for Disease Control and Prevention. Screening tests to detect Chlamydia trachomatisandNeisseria gonorrhoeaeinfections.MMWR 2002;51(RR-15):1–27.
3. Haggerty CL, Sami L, Gottlieb BD, et al.
Risk of sequelae afterChlamydia
trachomatisgenital infection in women.
J Infect Dis2010;201:S134–55.
4. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guideline 2010.
MMWR2010;59(RR-12):40–8.