Review Question - QID 103438

This patient is presenting with a cervical discharge which is concerning for cervicitis. Cervicitis is a clinical diagnosis and the patient should be treated with azithromycin and ceftriaxone to cover for chlamydia/gonorrhea.

Chlamydia/gonorrhea presents with vaginal discharge and cervical motion tenderness in the setting of a purulent cervical discharge. It is common in sexually active patients and the diagnosis can be made clinically with classic features. The typical first-line agents for chlamydial infections are doxycycline and azithromycin. It is critical to treat these infections as early as possible in pregnancy, as Chlamydia trachomatis can cause preterm labor, postnatal fetal infections, and endometritis. The treatment of choice in pregnancy is azithromycin. If the patient is allergic to azithromycin, then amoxicillin can be used. With classic symptoms of cervicitis, coverage should empirically cover for Neisseria gonorrhea as well with the most common treatment being ceftriaxone.

Figure A is the physical exam finding of cervicitis with notable purulence from the cervix.

Incorrect Answers
Answer 1: Amoxicillin may be an appropriate treatment in pregnancy for Lyme disease (instead of doxycycline) which presents with erythema migrans, facial nerve palsy, malaise, myalgias, and arthralgias. It could also be given for a chlamydia infection if the patient cannot tolerate azithromycin.

Answer 3: Cefepime is a broad-spectrum antibiotic that also covers for Pseudomonas aeruginosa. This patient does not need such broad coverage.

Answer 4: Doxycycline is avoided in pregnancy and children (in general) given the risk it has on bone/teeth development.

Answer 5: Erythromycin is not a preferred treatment for chlamydia. Topical erythromycin at birth may protect the newborn from conjunctivitis from chlamydia.

Bullet Summary:
The treatment of chlamydia in pregnancy is azithromycin or amoxicillin if the patient cannot tolerate azithromycin.