A 19-year-old woman comes to the office for a routine physical examination. She feels well and has no concerns. The patient has had 2 sexual partners in the past 3 months and uses condoms for contraception. She has no significant medical history, takes no medications, and has no drug allergies. Temperature is 37.2 C (99 F), blood pressure is 120/72 mm Hg, and pulse is 72/min. Pelvic examination shows normal external genitalia. The cervix has no lesions, abnormal discharge, or friability. On bimanual examination, the uterus is small and mobile and has no cervical motion or fundal tenderness. A urine pregnancy test is negative. A cervical swab sent for nucleic acid amplification testing is positive for Chlamydia trachomatis but negative for Neisseria gonorrhoeae. The patient is still asymptomatic. Which of the following is the most appropriate next step in management of this patient?
Chlamydia & gonorrhea in women | |
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*Azithromycin in pregnancy. | |
Chlamydia trachomatis and Neisseria gonorrhoeae are common sexually transmitted infections with high prevalence, particularly in patients age 14-19. Women with these infections are commonly asymptomatic. The lack of symptoms (and subsequent lack of treatment) increases the risk for long-term reproductive complications, including pelvic inflammatory disease, tuboovarian abscess, and infertility or ectopic pregnancy due to tubal scarring. In addition, the frequent absence of symptoms contributes to high rates of transmission. Therefore, annual screening for chlamydia and gonorrhea is recommended in all sexually active women age <25 and women age ≥25 with risk factors (eg, multiple sexual partners, inconsistent condom use).
The nucleic acid amplification test (NAAT) is the gold standard screening and diagnostic test for both C trachomatis and N gonorrhoeae because of its high sensitivity (96%) and specificity (99%). Treatment is indicated for a positive NAAT result in the patient and the patient's sexual partners, even in the absence of symptoms (Choice D). Confirmation testing is not required due to high test specificity (Choice E).
First-line treatment for NAAT-confirmed Chlamydia trachomatis is doxycycline; azithromycin may be used in pregnant patients for whom doxycycline is a contraindication because of potential teratogenicity.
(Choice A) Ceftriaxone and doxycycline are used for empiric treatment of symptomatic, acute cervicitis (eg, mucopurulent discharge, cervical friability) when NAAT results for gonorrhea and chlamydia are pending. This early empiric therapy covers both organisms to decrease complication rates. However, in patients with a single positive result, treatment of both infections is no longer required due to the high sensitivity and specificity of NAAT for both organisms.
(Choice B) Dual therapy with ceftriaxone and azithromycin was once recommended for gonorrhea due to concern for increasing cephalosporin resistance of N gonorrhoeae. However, N gonorrhoeae has remained susceptible to ceftriaxone, particularly with an increased dose, but resistance to azithromycin has increased. Therefore, the recommendation for the treatment of gonorrhea (when chlamydia has been excluded on testing) is ceftriaxone monotherapy.
Educational objective:
Chlamydial infection diagnosed by nucleic acid amplification testing (NAAT) is treated with doxycycline to prevent long-term reproductive complications (eg, pelvic inflammatory disease, infertility). Concurrent treatment for gonorrhea with ceftriaxone is not indicated if the gonorrhea NAAT result is negative.