STDs: GC, Chlamydia, and Pelvic Inflammatory Disease Hedwige Saint Louis, M.D., MPH and Seine Chiang, MD
What STI are characterized by mucopurulent cervicitis?
• Chlamydia Trachomatis: incubation period of 1- 3 wks, with the majority of patients having asymptomatic
• Neisseria Gonorrhea: incubation period of 3-5 days, with a 70% risk of male to female transmission after
Case 1 A 25yo flight attendant presents to your office complaining mild itching in her right eye for a couple of weeks. On exam you note that she has mucopurulent cervicitis. 1. What are the most common cause(s) of mucopurulent cervicitis? GC and Chlamydia account for 40-50%
of the cases and co-infection with the 2 organisms are common.
2. What is the most common presentation of chlamydia? The majority of these women are asymptomatic
but test positive on screening. Only 15% of the women who tested positive for Chlamydia had symptoms of bleeding or mucopurulent discharge (the most common symptoms).1
3. What are other manifestations of Chlamydial infection?
• Perihepatitis or Fitz Hughe Curtis syndrome
• Reiter’s Syndrome: triad of cervicitis, seronegative arthritis and mucocutaneous lesions including
conjunctivitis, oral mucosal ulcers and dermatitis
4. What are the advantages of using nucleic acid amplification tests (LCR, PCR) for STD screening? Disadvantages?
• Advantage: High sensitivity (>90%) and specificity (99.9%), can be performed on endocervical, vaginal, or
urine specimens, can test for several STDs simultaneously (soon to include trichomonas in addition to GC and Chlamydia)
• Disadvantages: cost, false + if perform test of cure too soon after treatment (should perform test of cure 3
5. What is the CDC recommended treatment for Chlamydia? Are there issues with resistance?
• Recommended: Azithromycin 1g PO times one or Doxycycline 100mg BID for 7 days
• Alternatives: Ofloxacin 300 mg BID or Erythromycin base 500mg QID or Levofloxacin 500mg QD, all for
• No issues with antibiotic resistance with Chlamydia.
Case 2 A 35yo woman is referred to you by her 1ry care physician for abnormal uterine bleeding. On questioning the patient, she gives you a 2-month hx of intermenstrual and postcoital spotting and has had same boyfriend for the past 4 months. 1. What are the sequelae of untreated Neisseria infection?
Untreated GC may result in infertility (15%) secondary to tubal disease, increased risk of ectopic pregnancy (15%) , and chronic pelvic pain (25%).
2. What is the sensitivity & specificity of rapid testing for Neisseria?
Rapid testing with nucleic acid amplification test has a > 98% sensitivity and specificity. Rapid testing is not recommended for oropharyngial and rectal specimen which still need to be cultured on modified Thayer-Martin agar in an oxygen free environment.
3. What are the CDC recommended treatment guidelines? Any issues with resisitance?
1. Recommended: Ceftriaxone 125mg IM once or Cefixime 400mg PO once 2. Alternatives: Ciprofloxacin 500mg, or Ofloxacin 400mg, or Levofloxacin 250mg PO once 3. Fluoroquinolones (or penicillin) should not be used to treat GC acquired along the Pacific coast (including
Hawaii), from homosexual men, or foreign travel due to increasing quinolone resistance (QRNG)
4. Patients do not require test of cure unless their symptoms persist, which indicate need for reculture to rule
4. What is the data on expedited partner therapy (EPT)? EPT is a practice of physician or pharmacy initiated
STD treatment of the patient’s sexual partner and is associated with improved compliance by partner, more partners receiving treatment, and possible cost-savings compared to standard partner referral.
5. What are other considerations with expedited partner therapy? Legality (state laws), progression to PID
in female partners, unknown drug allergies in partner, missed opportunity of exam and counseling of partners.
6. What are the CDC recommendations regarding EPT? EPT should be considered an option for partner
management of heterosexual male or female patients with chlamydia or gonorrhea.
7. You send her home on hormonal management after working her up for AUB. She calls you back three days later complaining of severe lower abdominal pain with fever, and some nausea. What is the likeliest explanation for her new symptoms? More than likely she waited too long to come in for treatment and has now developed Pelvic Inflammatory Disease; at least 15- 20% of women with GC infection will develop PID. As many as 60% will have subclinical PID, 36% mild to moderate PID, and 4% severe disease. 8. What are the diagnostic criteria for PID according to the PEACH study?
1. Minimum criteria for empiric therapy in high risk women:
iii. No other identified source of illness
2. Criteria which increase specificity of diagnosis:
ii. Abnormal cervical or vaginal discharge
9. What are the CDC criteria for inpatient treatment? Uncertain diagnosis, Suspected pelvic abscess, Patient
is unreliable, Patient unable to keep anything down due to N/V, Acute abdomen or septic, Outpatient therapy fails, Patient is immunodeficient (HIV, chronic steroid use, transplant recipient etc) 10. What is the goal of treatment in patients with PID? The goal of treatment is to prevent long term
sequelae, i.e. infertility, ectopic pregnancy, chronic pelvic pain
11. What are the treatment guidelines for PID? 1. Outpatient:
Ofloxacin 400mg PO BID or Levofloxacin 500mg PO QD x 14 days +/- Flagyl 500 mg PO BID x 14 days Ceftriaxone 250mg IM or Cefoxitin 2g IM (+ Probenecid 1g PO) + Doxycycline 100mg PO BID x 14 days with or without Flagyl 500mg PO BID for 14 days 2. Inpatient:
Cefotetan 2g IV Q12° or Cefoxitin 2g IV Q6° + Doxycycline 100 mg IV Q12° then 100 mg po bid x 14 days Clindamycin 900mg IV Q8º + Gentamicin IV 2 mg/kg body weight load followed by 1 mg/ kg Q8º 12. When should a patient follow-up after outpatient treatment for PID? Within 72 hours
Reference 1. Geisler et al. Presented at the 2005 ISSTDR Congress (Amsterdam), July 2005. 2. Glass’
3. Handsfield HH. Color Atlas and Synopsis of Sexually Transmitted Diseases. New York: McGraw-Hill, Inc.
4. Havens CS, Sullivan ND. Manual of Outpatient Gynecology, 4th ed. Philadelphia: Lippincott Williams &
5. Center for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2002.
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