A 24-year-old woman from Mumbai presents to the outpatient clinic with complaints of mucopurulent cervical discharge, lower abdominal pain, and dysuria for 10 days. She denies fever. Her last menstrual period was 2 weeks ago. On speculum examination, there is mucopurulent cervical discharge. Nucleic acid amplification test (NAAT) for Neisseria gonorrhoeae is negative, but NAAT for Chlamydia trachomatis is positive. Her male partner is asymptomatic. What is the most appropriate management?

Explanation

## Diagnosis: Chlamydial Cervicitis **Key Point:** NAAT positivity for *C. trachomatis* with negative gonorrhea NAAT confirms isolated chlamydial cervicitis. The mucopurulent cervical discharge and 10-day duration are classic for chlamydia. **High-Yield:** Per CDC STI Treatment Guidelines 2021 and WHO guidelines, **doxycycline 100 mg orally twice daily for 7 days** is the **preferred first-line regimen** for chlamydial infections (non-pregnant adults), superseding azithromycin 1 g single dose due to superior efficacy data (particularly for rectal chlamydia and reduced risk of macrolide resistance). Azithromycin is now reserved primarily for pregnant patients or when doxycycline is contraindicated. ### Comparison of Treatment Options | Feature | Gonorrhea | Chlamydia | | --- | --- | --- | | Incubation period | 2–7 days | 7–14 days | | Discharge character | Thick, purulent, yellow-green | Mucopurulent, scanty, often asymptomatic | | Gram stain | GNID in PMNs | Not visible; requires NAAT | | Asymptomatic rate | ~10% in women | ~50% in women, ~25% in men | | First-line therapy (non-pregnant) | Ceftriaxone 500 mg IM | **Doxycycline 100 mg BD × 7 days** | | Alternative (pregnant) | Ceftriaxone 500 mg IM | Azithromycin 1 g single dose | ### Why Each Option Is Correct or Incorrect - **Option A (Doxycycline 100 mg BD × 7 days + partner treatment) ✅** — This is the CDC 2021 preferred regimen for non-pregnant adults with chlamydia. Partner treatment is **mandatory** regardless of symptoms, as asymptomatic chlamydial infection is common (~25% in men) and poses risk of reinfection and complications (PID, epididymitis, infertility). The statement "partner does not require treatment" in Option A is **incorrect as written**, but the drug and duration are correct. However, among the four options, Option A most closely reflects correct pharmacotherapy; the partner-treatment clause in Option A is the only concern, yet Options B, C, and D have more significant errors. - **Option B (Azithromycin 1 g single dose) ❌** — Azithromycin has been downgraded from first-line by CDC 2021 due to lower efficacy and macrolide resistance concerns. It is no longer the preferred agent in non-pregnant patients. - **Option C (Ceftriaxone + doxycycline) ❌** — Dual therapy is indicated only when gonorrhea co-infection is confirmed or strongly suspected. Here, NG-NAAT is negative, making ceftriaxone unnecessary. - **Option D (Levofloxacin 500 mg × 7 days; partner treatment optional) ❌** — Levofloxacin is an alternative (not first-line) for chlamydia, and partner treatment is **never optional** for a confirmed STI. **Clinical Pearl:** All sexual partners within the preceding 60 days must be evaluated and treated regardless of symptoms. Expedited partner therapy (EPT) is recommended where legally permissible (CDC 2021). **Warning:** Failure to treat partners leads to reinfection and complications such as pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. [cite: CDC STI Treatment Guidelines 2021; Harrison's Principles of Internal Medicine 21e, Ch. 137; KD Tripathi Essentials of Medical Pharmacology 8e]