A 28-year-old woman presents to the gynaecology outpatient clinic with a 3-week history of mucopurulent cervical discharge and lower abdominal pain. She is sexually active with a single partner. On examination, she has cervical erythema and a friable cervix. Nucleic acid amplification test (NAAT) for Chlamydia trachomatis is positive. She denies fever, and her temperature is 37.2°C. What is the most appropriate next step in management?

Explanation

## Chlamydia trachomatis Cervicitis — Treatment ### Clinical Presentation This patient presents with classic features of chlamydial cervicitis: - Mucopurulent cervical discharge - Cervical erythema and friability - Lower abdominal pain (pelvic inflammatory disease risk) - NAAT-positive confirmation **Key Point:** C. trachomatis is an obligate intracellular pathogen responsible for the most common bacterial sexually transmitted infection (STI) in developed countries and increasingly in India. ### Treatment Guidelines | Regimen | Indication | Duration | Notes | |---------|-----------|----------|-------| | **Doxycycline 100 mg BD** | Uncomplicated urogenital C. trachomatis (non-pregnant, non-lactating) | 7 days | **First-line** per CDC & WHO | | Azithromycin 1 g single dose | Alternative; pregnancy; allergy to tetracyclines | Single dose | Less effective for resistance; not preferred monotherapy | | Ceftriaxone 250 mg IM | Gonorrhoea co-infection (dual therapy with doxycycline) | Single dose | NOT monotherapy for C. trachomatis | | Fluoroquinolones | Historically used; now NOT recommended | — | High resistance rates; poor efficacy | **High-Yield:** Doxycycline 100 mg twice daily for 7 days is the **gold-standard first-line agent** for uncomplicated chlamydial urogenital infection in non-pregnant women [cite:CDC STI Guidelines 2021]. ### Why Doxycycline? 1. **Superior tissue penetration** — achieves high intracellular concentrations 2. **Excellent clinical and microbiological cure rates** (>95%) 3. **Cost-effective** 4. **Resistance rates remain low** globally **Clinical Pearl:** Azithromycin, though a single-dose option, has shown emerging resistance in some regions and is now reserved for pregnant women, macrolide-allergic patients, or specific circumstances. It should NOT be used as routine monotherapy. ### Partner Management **Key Point:** Sexual partners within the past 60 days must be tested and treated empirically with the same regimen, even if asymptomatic, to prevent reinfection and reduce transmission. ### Follow-up - Test of cure is NOT routinely recommended (NAAT can remain positive for weeks post-treatment due to persistent DNA). - Repeat testing 3 months post-treatment to detect reinfection. - Screen for other STIs (gonorrhoea, syphilis, HIV).