Chlamydial Cervicitis

Chlamydial cervicitis is cervical infection with Chlamydia trachomatis, a common bacterial sexually transmitted infection. It is often silent.

• It is most frequent in sexually active women under 25 years.
• Untreated infection ascends to cause pelvic inflammatory disease, ectopic pregnancy and tubal infertility.
• Single-dose or 7-day treatment is highly effective.

Most women have no symptoms.

• Mucopurulent discharge, post-coital or intermenstrual bleeding, dysuria and lower abdominal discomfort.
• Friable red cervix with mucopus.
• Differential diagnosis: gonococcal cervicitis, bacterial vaginosis, trichomoniasis, herpes cervicitis, Mycoplasma genitalium infection, pelvic inflammatory disease.
• Complications: pelvic inflammatory disease, tubal factor infertility, ectopic pregnancy, chronic pelvic pain, perihepatitis (Fitz-Hugh-Curtis syndrome), and neonatal conjunctivitis and pneumonia.

Diagnosis is by NAAT on a cervical or vaginal swab.

• NAAT (Xpert CT/NG where available) on an endocervical or self-collected vaginal swab.
• Gram stain showing more than 10 white blood cells per high-power field when NAAT is not available.
• Test for gonorrhoea, trichomoniasis, HIV, syphilis and hepatitis B.
• Pregnancy test.

Treat with doxycycline or azithromycin, add cover for gonorrhoea when it is not excluded, and treat partners.

• Supportive: abstain from intercourse for 7 days after treatment; partner notification and treatment of all partners in the last 60 days; condoms; counselling on screening.
• Pharmacological: doxycycline 100 mg oral 12-hourly for 7 days. Alternative: azithromycin 1 g oral single dose. Add ceftriaxone 500 mg IM single dose when gonorrhoea is not excluded. Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for pain.
• Procedures: none.
• Special groups: in pregnancy and breastfeeding give azithromycin 1 g oral single dose, or amoxicillin 500 mg oral 8-hourly for 7 days; avoid doxycycline; retest 4 weeks after treatment and again at 3 months. In HIV infection give the full doses and check that partners are treated.
• Red flags: fever, lower abdominal pain, cervical motion tenderness (give pelvic inflammatory disease treatment: ceftriaxone 500 mg IM single dose, doxycycline 100 mg oral 12-hourly for 14 days, metronidazole 400 mg oral 12-hourly for 14 days), right upper quadrant pain.
• Follow-up: retest at 3 months for reinfection; test of cure at 4 weeks in pregnancy; offer screening yearly if aged under 25.