ARTICLE

Sexually Transmitted Infections Part 2:

Discharge Syndromes and Pelvic
Inflammatory Disease
Diana Lemly, MD,*‡§ Nupur Gupta, MD, MPH*†§
*Division of Adolescent and Young Adult Medicine and
†
Division of Global Health, MassGeneral Hospital for Children, Boston, MA
‡
Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
§
Harvard Medical School, Boston, MA

EDUCATION GAPS

Pediatricians should be able to diagnose and manage patients presenting

with a vaginal discharge and the symptoms of pelvic inflammatory disease
(PID). Providers should be aware that chlamydia is often asymptomatic in
females and that gonorrhea may be resistant to traditional treatment. They
should know the newer diagnostic techniques for sexually transmitted
infections (STIs), recent Centers for Disease Control and Prevention (CDC)
guidelines for the treatment of STIs and PID, and the indications for
hospitalization.

OBJECTIVES After completing this article readers should be able to:

1. Identify the presentation of sexually transmitted infections (STIs) with a vaginal

AUTHOR DISCLOSURE Dr Lemly has discharge, including the symptoms of pelvic inflammatory disease (PID).
disclosed no financial relationships relevant
2. Understand the evaluation, differential diagnosis, and diagnostic
to this article. Dr Gupta is a co-editor of The
MassGeneral Hospital for Children Handbook techniques for common STIs, such as chlamydia, gonorrhea,
of Pediatric Global Health. This commentary trichomonas, and PID.
does not contain a discussion of an
unapproved/investigative use of a 3. Plan the management of these STIs and PID using the most recent
commercial product/device. Centers for Disease Control and Prevention (CDC) treatment guidelines.
(3)
ABBREVIATIONS
BV bacterial vaginosis 4. Be familiar with the indications for hospitalization in patients with PID.
CDC Centers for Disease Control and
Prevention
EPT expedited partner treatment ABSTRACT
FDA Food and Drug Administration
HIV human immunodeficiency virus
IM intramuscularly Sexually transmitted infections (STIs) disproportionately affect young people,
IUD intrauterine device with more than half of the infections occurring in youth aged 15 to 25 years.
IV intravenous (1)(2) This review, the second in a 2-part series on STIs, focuses on infections
KOH potassium hydroxide
that may cause abnormal vaginal or penile discharge, including trichomonas,
MSM men having sex with men
NAAT nucleic acid amplification test
chlamydia, gonorrhea, and pelvic inflammatory disease (PID). Most infected
PID pelvic inflammatory disease persons, however, are asymptomatic. Nucleic acid amplification tests are the
STD sexually transmitted disease most sensitive and specific for the detection of chlamydia, gonorrhea, and
STI sexually transmitted infection trichomoniasis, and they can be performed on provider- or patient-collected
VVC vulvovaginal candidiasis

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 swabs. Providers should have a low threshold for diagnosing and treating PID
because untreated PID can have serious long-term complications for young
women. Indications for hospitalization for PID include the presence of a tubo-
ovarian abscess, severe illness with systemic symptoms, pregnancy, human
immunodeficiency virus infection, and failure to respond to outpatient oral
treatment (within 48–72 hours) or inability to tolerate the oral treatment.

Common sexually transmitted infections (STIs) in ado- with secretions from the vagina and is found to be 6.5. A
lescents fall into 3 diagnostic groups: genital bumps, genital pregnancy test is negative.
ulcers, and discharge syndromes. This review is the second
in a 2-part series. For further information regarding pri-
mary and secondary prevention of all STIs and the dis- On Microscopy
cussion of STI syndromes that present as genital bumps A fishy odor is noted when the vaginal swab is dipped in the
or genital ulcers, please see “Sexually Transmitted Infec- KOH on the slide. Microscopy reveals multiple clue cells,
tions Part I: Genital Bumps and Genital Ulcers” (Pediatrics numerous polymorphic nucleocytes, and a few motile flag-
in Review, September 2020). This review addresses the ellated organisms.
diagnosis and management of discharge syndromes and pelvic
inflammatory disease (PID) using a case-based approach. Diagnosis
Trichomonas vaginalis and bacterial vaginosis (BV).

CASE (VERSION 1) Treatment

A 17-year-old girl presents to the office with a complaint of a A decision is made to treat with a single dose of metro-
“bad smell” and some genital pruritus. She has had some nidazole 2 g orally, explaining to the patient the possible
profuse, foul-smelling vaginal discharge on her underwear adverse effects of the medication, including the risk of a
for the past week. She states that she has had vaginal in- disulfiram-like reaction if alcohol is consumed while taking
tercourse a few times during the past month with a single metronidazole. The patient is also advised that because
male partner using a condom every time except once. Her trichomoniasis is sexually transmitted, her partner should
last period was 2 weeks ago. She denies abdominal pain or also be treated. Expedited partner treatment (EPT) is offered
dysuria. She recently completed a course of antibiotics for a to the patient, and consistent condom use is reinforced. The
sinus infection. A decision is made to perform a pelvic ex- patient is also advised that she and her partner should not
amination, collect samples, and perform microscopy of the resume sexual activity until both are treated and asymp-
vaginal discharge. tomatic. The patient is informed that she also has BV and
that the recommended therapy will treat both infections.
On Examination She is told that BV is not sexually transmitted but can recur
The patient is well-appearing and has no abdominal or and that treatment of partners has not been shown to
suprapubic tenderness. On speculum examination a frothy, prevent recurrences. The importance of screening for other
yellow discharge is seen in the vagina, and the cervix appears STIs, including human immunodeficiency virus (HIV),
red and irritated. She has some discomfort with the exam- is also discussed, and information about contraceptive
ination but does not have acute cervical motion tenderness or methods and emergency contraception is offered to the patient.
adnexal tenderness.
Vaginal swab specimens for nucleic acid amplification
testing (NAAT) for chlamydia and gonorrhea and specimens CAUSES OF VAGINAL DISCHARGE
for Gram-stain and culture for Trichomonas antigen are ob- Vaginal discharge can be caused by vaginitis or cervicitis.
tained. In addition, 2 cotton-tipped swabs are used to obtain The most common causes of vaginitis are vulvovaginal candi-
vaginal secretions. These are then used to prepare 2 slides diasis (VVC)/yeast vaginitis (not sexually transmitted), tricho-
(wet preps): one with normal saline and the other with 10% moniasis (sexually transmitted), and BV (not usually sexually
potassium hydroxide (KOH) for viewing under the micro- transmitted). Cervicitis is usually caused by chlamydia or
scope. Vaginal pH is also checked using a pH paper swabbed gonorrhea.

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 TRICHOMONIASIS infected will be more likely to increase shedding of the
What Causes Trichomoniasis? HIV virus. (7)
Trichomoniasis is caused by T vaginalis, an anaerobic, flag-
ellated protozoan parasite. When to Test?
Asymptomatic screening: Screening should be considered
for all high-risk individuals (multiple sex partners, men
Epidemiology who have sex with men [MSM], history of another STI,
Approximately 3.7 million individuals are infected with T
HIV positive, and those who present to STD clinics).
vaginalis, making it the “most prevalent non-viral curable,
Symptomatic screening: All women who present with a
sexually transmitted infection” in the United States. (1) The
vaginal discharge should be tested for T vaginalis. (3)
prevalence is higher in African American women (13%)
The Centers for Disease Control and Prevention (CDC)
compared with non-Hispanic white women (1.8% affected).
does not recommend rectal and oral testing for T vaginalis.
(4) Disparities in rates of STIs are often due to broader
inequities in social and economic conditions for minority
Recommended Tests
communities. (2) Trichomoniasis is more prevalent in older
Wet mount: In clinics with approved microscopy, a wet
adolescents and those who are incarcerated, have other STIs
preparation with visualization of motile trichomonads is
or BV, or use illicit drugs. (3) Patients presenting to sexually
diagnostic. Wet mount, however, is observer-dependent
transmitted disease (STD) clinics also have a higher preva-
and has sensitivity of only 51% to 65%. (8) If stored in
lence of T vaginalis infections. (5)
normal saline the specimen can be examined within an
hour, but once a slide is prepared it must be examined
Signs and Symptoms within 10 minutes (Fig 2).
Symptomatic women usually have a profuse, yellowish Culture: Culture of urine sediment or urethral swab can be
greenish, malodorous vaginal discharge with occasional performed in men, but in women culture can be per-
vulvar irritation. Speculum examination may reveal a cervix formed only on vaginal secretions. (3) Culture is rarely used
with petechiae, an appearance called a “strawberry cervix” since the development of more sensitive/specific tests.
(Fig 1). Males have symptoms of urthritis, epididymitis, or NAAT: The most sensitive/specific test is the APTIMA®
prostatitis. (6) Approximately 80% of infected persons are T vaginalis assay (Hologic Inc, Marlborough, MA), which
asymptomatic. (1)(3) Acquisition of HIV is higher in indi- has been approved by the Food and Drug Administration
viduals infected with T vaginalis, and those who are co- (FDA) for the detection of Trichomonas from vaginal swabs
(provider- or patient-collected), endocervical swabs, or
urine specimens from women (sensitivity, 95.3%–100%;
specificity, 95.2%–100%) and from urine or urethral
swabs from men. (9)(10)

Figure 1. Multiple petechiae on the cervix of a women with Figure 2. Wet prep photomicrograph shows several Trichomonas
trichomoniasis, often referred to as a strawberry cervix. (Reprinted with vaginalis protozoan parasites, oval in shape with thin flagella. (Reprinted
permission from the National STD Curriculum. Source of original image: with permission from the Centers for Disease Control and Prevention’s
Claire Stevens, University of Washington.) Public Health Image Library. Source of original image: Joe Millar, 1975.)

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Rapid tests: Point-of-care testing includes the OSOM® rapid How to Treat?
antigen detection test (Sekisui Diagnostics, Burlington, The CDC 2015 STD treatment guidelines recommend
MA), which is sensitive and specific and gives results in using metronidazole or tinidazole to treat Trichomonas
approximately 10 minutes. The rapid antigen test cannot vaginitis (Table 1). (3) If a patient does not respond
be used in males. (11)(12) to multiple regimens of these medications, swabs

Table 1. Treatment Guidelines for Vaginitis

TRICHOMONAS BACTERIAL VAGINOSIS CANDIDA ALBICANS
Treatment
Metronidazolea 2 g orally once Metronidazole 500 mg twice a day for 7 d A. Over the counter
Clotrimazole 1% or 2% cream 5 g
OR OR
intravaginally daily for 7 or 3 d, respectively
Metronidazole gel 0.75%, 2 g intravaginally at
Tinidazoleb 2 g orally once OR
night for 5 d
Miconazole 2% or 4% cream 5 g intravaginally
OR OR
daily for 7 or 3 d, respectively
Metronidazole 500 mg orally twice Clindamycin cream 2%, 2 g intravaginally at night
OR
a day for 7 d for 7 d
Miconazole 100-, 200-, or 1,200-mg vaginal
OR
suppository, one daily for 7, 3, or 1 d, respectively
Clindamycin 300 mg orally twice a day for 7 d OR
Tioconazole 6.5% ointment 5 g intravaginally
OR
as a single application
Tinidazole 2 g orally for 2 d B. Prescription
Butoconazole 2% cream, 5 g intravaginally as a
OR
single dose
Tinidazole 1 g orally once a day for 5 d OR
Terconazole 0.4% or 0.8% cream, 5 g intravaginally
OR
daily for 7 or 3 d, respectively.
Secnidazole 2 g as a single dose (granules) OR
Terconazole 80 mg vaginal suppository, 1 daily for 3 d
OR
Fluconazole 150 mg orally in a single dose
Treatment for Resistant/Recurrent Disease
Metronidazole 500 mg orally twice a day
Repeat the same treatment Initial:
for 7 d (if 1-d treatment used before)
OR OR 7–10 d of a topical therapy OR
Metronidazole gel 0.75%, twice weekly for 100-, 150-, or 200-mg oral dose of fluconazole
Metronidazole 2 g daily for 7 d
4–6 mo every third day for a total of 3 doses
OR OR Followed by:
Metronidazole 500 mg orally twice per day for
1 wk followed by 600 mg of boric acid Oral fluconazole (100-, 150-, or 200-mg dose)
Tinidazole 2 g daily for 7 d
intravaginally for 3 wk followed by 0.75% weekly for 6 mo
metronidazole gel twice weekly for 4–6 mo
a
Patients should be advised to abstain from alcohol use during treatment with oral metronidazole and tinidazole and for 24 and 72 hours after the
last dose of metronidazole and tinidazole, respectively.
b
Tinidazole is contraindicated during pregnancy.
Modified from Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015.
Diseases characterized by vaginal discharge: vulvovaginal candidiasis. MMWR Recomm Rep. 2015;64(No. RR-03):1–137.

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 should be sent to the CDC for culture and susceptibility BV-associated bacteria. These are anaerobic bacteria that
testing. replace the normal flora (lactobacilli) of the vagina. These bac-
Patients should be advised to abstain from sexual activity until teria include Gardnerella vaginalis, Atopobium vaginae, Mobi-
both partners have been treated and are without symptoms. luncus curtisii, Mycoplasma hominis, and Ureaplasma species. (13)
Testing for other STIs and HIV should also be performed. (3)
Epidemiology
Management of Sex Partners BV has a prevalence of approximately 29% in women of
All patients who test positive and are treated should be reproductive age. (14) Although most women are asymp-
counseled to communicate this diagnosis to their partner(s) tomatic, it is the most common diagnosis in women pre-
and have their partner(s) seek comprehensive STI testing senting with abnormal vaginal discharge. (13) Having new
and treatment. Some states allow EPT: the provision of or multiple partners of either sex, not using condoms,
empirical treatment (antibiotics) and educational materials to douching, or factors that reduce vaginal lactobacilli can in-
partners. The CDC map for states that allow EPT is available crease the risk of acquiring BV. (14)(15) Studies demonstrating
in the CDC 2015 guidelines for the treatment of STIs that women usually develop BV only after they are sexually
(https://www.cdc.gov/std/ept/legal/default.htm). active, and other studies showing the similarity of vaginal
bacterial flora in women in same-sex relationships, support
Follow-up the hypothesis that BV is often sexually transmitted. (16)
Because patients often are infected again with Trichomonas, Women with BV are predisposed to infection with other
repeated testing 3 months after the initial treatment is rec- STIs. Recurrence of BV is common, and treating male sex
ommended. (3) partners does not prevent recurrence. (17)

Reporting Signs and Symptoms

Trichomoniasis is not considered a reportable disease. Most women with BV are asymptomatic. Approximately 50%
of women with BV present with a white, homogenous dis-
Prevention and Patient Counseling charge that has a fishy odor. The foul odor often increases
Patients should be counseled about the following: after sexual intercourse or at the end of a menstrual cycle.
1. Trichomonas is an STI and most patients are
asymptomatic. When to Test?
2. Treatment is available and partners should also be treated. There are no guidelines to recommend testing in asymp-
Abstinence should be practiced until both partners are tomatic patients. In patients presenting with an abnormal
treated and asymptomatic for at least 7 days. discharge, specific clinical criteria with laboratory testing
3. Untreated Trichomonas infection in pregnancy increases may be used to make the diagnosis.
the likelihood of complications of pregnancy, such as 1. Amsel diagnostic criteria (18): The diagnosis of BV using
“preterm labor, premature rupture of membranes and the Amsel criteria requires 3 of the following 4 symptoms or
low birth weight.” (6) signs: homogeneous, thin, white discharge; presence of clue
4. Untreated Trichomonas infection also increases suscep- cells (vaginal epithelial cells covered with bacteria so that the
tibility to HIV acquisition. cell walls are not visible) on microscopic examination of a
5. Simultaneous consumption of metronidazole and alcohol normal saline slide of vaginal secretions (≥20% of cells in high
may cause adverse effects, such as headaches, nausea, power must be clue cells) (Fig 3); pH of vaginal fluid greater
stomachaches, and flushing. than 4.5; and presence of a fishy odor that develops after
6. Risk reduction strategies include using condoms, absti- discharge contact with 10% KOH (“the whiff test”).
nence, monogamous relationships, and limiting the num- 2. Gram-stain: This is considered the gold standard for di-
ber of sexual partners. agnosing BV. The Nugent score is a scoring system that
helps determine the proportion of lactobacilli to bacteria
associated with BV. The score ranges from 1 to 10, and BV
BACTERIAL VAGINOSIS is diagnosed if the score is between 7 and 10 (indicating a
What Causes BV? greater proportion of BV-associated bacteria compared
Although BV is not typically classified as an STI, it is often with normal flora). Using the Nugent scoring system as
associated with sexual activity and is a common cause of the gold standard, the Amsel criteria were found to have
vaginal discharge. BV is usually caused by an overgrowth of sensitivity, specificity, and positive and negative predictive

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 values of 78.72%, 92.35%, 75.51%, and 93.54%, respec- Follow-up
tively. (19) Follow-up is not routinely recommended if the patient’s
3. Other tests include the recently approved polymerase symptoms resolve. However, recurrences occur in approxi-
chain reaction test BD MAX™ vaginal panel test (BD, mately 50% of women within a year.
Franklin Lakes, NJ), which detects different causes of vag- Recurrent BV. For multiple recurrences the same treat-
initis. This has sensitivity and specificity of 89.8% and ment may be offered or other regimens are recommended
96.5%, respectively, for the detection of BV. (20) Culture and (Table 1). (24)(25)
Papanicolaou smear have very low sensitivity and specificity
and are not recommended. Indirect tests that detect enzy- Reporting
matic activity of the bacteria are also available. (21)(22) BV is not considered a reportable disease.

Prevention and Patient Counseling

How to Treat?
Patients should be counseled about the following:
Treatment is recommended for symptomatic women with
1. Women with BV often do not have symptoms; routine
BV. The CDC recommends treatment with metronidazole,
screening is not recommended. Typical symptoms in-
tinidazole, or clindamycin. Various regimens are available for
clude a foul-smelling vaginal discharge.
the treatment of primary and recurrent infections (Table 1). (3)
2. BV is caused by an overgrowth of vaginal bacteria and an
HIV infection does not change the management of BV.
associated reduction in lactobacilli.
3. Symptoms of BV usually start after the onset of sexual
What’s New? activity, and BV may be transmitted between women in
Secnidazole (2 g as a single dose) was approved in September same-sex relationships.
2017 for the treatment of BV. Secnidazole is available as 4. BV infection may increase the chance of acquiring other
granules that are sprinkled on food and must not be chewed, STIs, including HIV, and women who have both HIV and BV
crushed, or broken when swallowing. Food should be consumed may be more likely to transmit HIV to their male partners.
soon after being treated with secnidazole (within 30 minutes). (23) 5. BV has been associated with premature deliveries in preg-
nant women and with PID.

Management of Sex Partners

Male sexual partners do not need to be treated, but same-sex
VULVOVAGINAL CANDIDIASIS
female partners should be offered testing and treatment. (3)
What Causes VVC?
VVC is most commonly caused by Candida albicans. It is not
an STI but can cause clinical symptoms similar to some STIs.
The vagina is home to different Candida species that constitute a
normal part of the vaginal flora. However, with disruption of the
vaginal milieu, yeast overgrowth can cause symptomatic vaginitis.
(26) Prepubertal girls are not usually affected by candidiasis
because the vaginal lining is thin and the pH is alkaline.

Epidemiology
According to the CDC, approximately 75% of women will
“have at least one episode of VVC, and 40-45% will have two
or more episodes.” (3) “Recurrent vulvovaginal candidiasis,
defined as a minimum of four episodes per year, occurs in
about 5% to 10% of the female population.” (26)(27)
Women who are diabetic, taking repeated courses of
antibiotics or corticosteroids, on hormone replacement
Figure 3. Photomicrograph of a vaginal smear specimen depicts 2 therapy, on oral contraceptives, or have an intrauterine device
epithelial cells: a normal cell and an epithelial cell with its exterior covered
by bacteria, giving the cell a roughened, stippled appearance known as a (IUD) are predisposed to recurrent VVC. Pregnancy, spermicide
clue cell. These are typically seen in bacterial vaginosis. (Reprinted with
permission from the Centers for Disease Control and Prevention’s Public
and condom use, and HIV infection are also risk factors for
Health Image Library. Source of original image: M. Rein, 1978.) recurrent disease. (26)(27)

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 Signs and Symptoms Symptoms return in approximately 30% to 50% of women
VVC often presents with itching, burning with urination, once maintenance therapy is discontinued. (3)
vaginal discharge, and painful sexual activity. (3) The in- For severe VVC with extensive skin breakdown, edema,
fection is characterized by a white, clumpy, “cottage cheese”- and fissure formation, prolonged treatment is recommended
like discharge. Symptoms may increase before menstruation. (Table 1). (3)
VVC may be categorized as uncomplicated or complicated. (3)
Uncomplicated VVC is usually not as severe, occurs less
Treatment of Non-Albicans VVC
frequently (<4 times per year), and usually has C albicans as
The preferred treatment for non-albicans VVC has not been
the etiologic agent. Uncomplicated VVC often occurs in
identified. Use of a nonfluconazole azole for prolonged
women who are immunocompetent and not pregnant and
periods in the oral or topical form is recommended as initial
respond to all first-line treatments.
therapy. If symptoms do not resolve with this regimen then
Complicated VVC is usually recurrent or severe, often
alternative treatment with 600 mg of boric acid encapsulated
occurring in pregnant women or those who are immuno-
in gelatin (Hylafem®; US Pharmaceutical Corp, Decatur,
compromised, diabetic, or debilitated. Complicated VVC is
GA) intravaginally once daily for 2 weeks may be tried. (25)(29)
often due to non-albicans Candida species. Vaginal candi-
diasis occurring more than 4 times per year in immuno-
competent women is also treated as complicated VVC. Management of Partners
No treatment is required for asymptomatic sexual partners of
infected women. VVC is not sexually transmitted, although
When to Test?
male partners can occasionally develop candida balanitis.
Patients presenting with complaints of abnormal vaginal
discharge, pruritis, or vulvar irritation should undergo di-
agnostic evaluation. Follow-up
No specific follow-up is recommended after treatment of
How to Test? uncomplicated VVC. If symptoms return, women should
The following tests for candida can be used: return for further evaluation.
1. Vaginal pH: usually normal (<4.5).
2. Wet mount: Visualization under a microscope of budding Prevention and Patient Counseling
yeast and/or pseudohyphae can confirm the diagnosis of Patients should be counseled about the following:
VVC. A 10% KOH preparation has higher sensitivity for 1. Colonization by Candida is common; if asymptomatic,
detection of yeast compared with a saline wet mount treatment is not necessary.
because KOH breaks down other cellular material (Fig 4). 2. VVC is not sexually transmitted. Rarely, male partners can
(27) develop candida balanitis.
3. Culture: If the wet mount is negative in a symptomatic
patient, fungal cultures may be performed. A positive
culture in an asymptomatic patient may reflect coloni-
zation and is not an indication for treatment. Non-albicans
disease is often identified by culture. Fungal culture
should be performed before starting suppressive therapy
for recurrent VVC. (28)
Polymerase chain reaction testing for yeast has not been
FDA approved.

How to Treat?
The CDC 2015 STD treatment guidelines recommend
azoles, over-the-counter and by prescription, for the treat-
ment of uncomplicated VVC (Table 1). (3)
Figure 4. Photomicrograph of a wet-mounted vaginal smear specimen
For recurrent VVC (4 episodes per year), a longer initial extracted from a patient with vaginal candidiasis reveals the presence of
Candida albicans (with blastopores and pseudohyphae). (Reprinted with
course of therapy (7–14 days) followed by maintenance permission from the Centers for Disease Control and Prevention’s Public
treatment for 6 months is recommended (Table 1). (3) Health Image Library. Source of original image: Dr Stuart Brown, 1976.)

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3. Symptomatic Candida infection is usually triggered by proctocolitis or proctitis (receptive anal intercourse), or
disturbance of the normal vaginal environment. reactive arthritis (as a complication of chlamydial infection).
4. Patients should be advised to avoid repeated self-treatment
of persistent abnormal vaginal discharge with over-the-
When to Test?
counter topical antifungals or taking unnecessary antibi-
Asymptomatic: Per the CDC 2015 screening guidelines (3):
otics. Douching should also be avoided.
1. Annual screening of all sexually active women younger
than 25 years is recommended (this should be included as
a routine part of an annual examination for adolescents
CHLAMYDIA and young adults), including women who have sex with
What Causes Chlamydial Infections? women. (3)(31)
Chlamydia trachomatis is an obligate intracellular bacterium 2. Routine screening of sexually active young men is not
that resembles gram-negative organisms. mandatory; annual screening is recommended in
those presenting to clinical settings with a high
prevalence of patients with chlamydia, such as ado-
Epidemiology
lescent and STD clinics, and in MSM, in whom testing
C trachomatis is the “most prevalent bacterial sexually trans-
should be performed from both genital and rectal sites.
mitted infection” in the world, and the most frequently
(31)
reported STI in the United States, with “more than 1.5
3. Screening of transgender individuals should be based on
million cases reported in 2016.” (2)(30) Rates of reported
“age, sexual practices and current anatomy.” (3)
cases are highest among adolescents and young adult women 4. In pregnant women younger than 25 years, screening
aged 15 to 24 years. Having multiple sexual partners, using should be performed in the first and third trimesters. If
oral contraceptive pills, having another STI, and lack of testing positive, these women should be treated and tested
condom use also increase the risk of acquiring a chlamydial again at 4 weeks for a test of cure and again 3 months after
infection. (31) Overall prevalence in women aged 15 to 24 treatment. (3)
years was 4.7%. (32) 5. HIV-positive individuals (who are sexually active) should
be tested at the first visit and then every year. (3)
Symptomatic: Infections are usually asymptomatic, which is
Signs and Symptoms
why screening is so important, but testing for chlamydia
Most infected men and women are either asymptomatic or
should always be performed in a sexually active patient
minimally symptomatic.
presenting with vaginal discharge or urethritis.
Men: If symptomatic, men develop urethritis with or without
discharge, which can be mucoid, clear, or mucopurulent,
known as “nongonococcal urethritis.” Epididymitis may How to Test?
occur presenting with unilateral scrotal pain, edema, and NAATs are considered the gold standard for diagnosis of
tenderness, with or without a urethral discharge. chlamydia in both men and women. These tests are approved
Women: If symptomatic, women may present with cervicitis for first-catch urine in men and women, vaginal or endo-
causing abnormal vaginal discharge. Symptoms are cervical swabs in women, and urethral swabs in men. (3)
usually nonspecific, such as irregular bleeding or pelvic Results from vaginal swabs are better than those from NAATs
discomfort. Signs of infection include friability of the performed on urine; patient-obtained swabs are well-accepted
cervix (bleeding on touching the cervix) and mucopur- by women of all ages and are at least equivalent and sometimes
ulent cervical discharge. Urethral involvement will cause perform better than those obtained by providers. (34)
dysuria and frequency of urination. Oropharyngeal or rectal chlamydia can be diagnosed
Untreated chlamydial infections can result in complica- using NAATs (although this testing approach is not FDA
tions, including PID, ectopic pregnancy, and infertility. (33) approved), which are thought to be more sensitive than
Women presenting with right upper quadrant pain, nausea culture. Rectal swabs may also be patient collected, and re-
and vomiting, and signs of PID on physical examination may sults have been shown to be comparable with those collected
have Fitz-Hugh-Curtis syndrome or perihepatitis as a by providers. (3)(34)
complication of chlamydia. Cell culture has lower sensitivity than NAAT and is limited
Both sexes may present with conjunctivitis (due to auto- to specimens obtained during evaluations of children for
inoculation), severe pharyngitis (genital-oral contact), possible sexual assault.

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 Table 2. Treatment Guidelines for Pelvic Inflammatory Disease

Ceftriaxone 250 mg IM (single dose) OR

Cefoxitin 2 g IM (single dose) + probenecid 1 g orally
(given concurrently)
Outpatient treatment PLUS
Doxycycline 100 mg orally twice per day/14 d
PLUS
Metronidazole 500 mg orally twice per day/14 da
1. Regimen 1
Cefotetan 2 g IV every 12 h OR cefoxitin 2 g IV every 6 h
PLUS
Doxycycline 100 mg orally or IV every 12 h/14 dbc
2. Regimen 2
Clindamycin 900 mg IV every 8 h
PLUS
Gentamycin 2 mg/kg IV or IM (loading dose) followed by
Inpatient or parenteral therapy 1.5 mg/kg every 8 h (can switch to daily dosing of 3–5
mg/kg IV)
(Oral therapy with clindamycin 450 mg orally 4 times per
day or doxycycline 100 mg orally twice per day can be
used to complete the 14 d of treatment.)c
3. Regimen 3
Ampicillin sulbactam 3 g IV every 6 h
PLUS
Doxycycline 100 mg orally or IV every 12 h/14 dc
1. Regimen 1
Azithromycin 500 mg IV daily for 1–2 doses followed by
250 mg orally daily for 12–14 d
+/– Metronidazole 500 mg orally twice daily
2. Regimen 2
Ceftriaxone 250 mg IM (single dose)
PLUS
Alternative treatment Azithromycin 1 g weekly/2 wk OR doxycycline 100 mg orally
twice daily/14 d
3. Regimen 3
Levofloxacin 500 mg orally once daily OR ofloxacin 400 mg
orally twice daily OR moxifloxacin 400 mg orally once dailyd
PLUS
Metronidazole 500 mg orally twice daily
IM=intramuscular; IV=intravenous.
a
Because ceftriaxone has limited coverage of anaerobes, metronidazole use should be considered in conjunction with it and other third-generation
cephalosporins until it is established that extended anaerobic coverage is not important in the treatment of pelvic inflammatory disease.
b
Oral therapy with doxycycline should be started 24 to 48 hours after clinical improvement is noted and should be considered at all times because
intravenous doxycycline is painful.
c
If a tubo-ovarian abscess is present then clindamycin 450 mg orally 4 times per day or metronidazole 500 mg orally twice per day should be added
to complete the 14 days of therapy with doxycycline.
d
The Centers for Disease Control and Prevention does not recommend fluoroquinolone-containing regimens for routine treatment of pelvic
inflammatory disease. If a fluoroquinolone is used then testing for gonorrhea should be performed and if positive then susceptibilities must be
obtained.
Modified from Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Pelvic
inflammatory disease (PID). MMWR Recomm Rep. 2015;64(No. RR-03):1–137.

How to Treat? Other treatments include erythromycin base 500 mg or

All chlamydia-positive individuals should be treated as soon erythromycin ethylsuccinate 800 mg 4 times per day, or
as possible to prevent reproductive health complications. (35) levofloxacin 500 mg daily or ofloxacin 300 mg orally twice
Recommended treatment regimens (CDC 2015) (3) for per day for 7 days. (3) Abstinence should be practiced for
urogenital infection and oropharyngeal infection are as 7 days after treatment is complete and after sexual part-
follows: ners have been treated. Testing for other STIs, including
Treatment is with azithromycin 1 g as a single dose or HIV, should be offered to patients diagnosed as having
doxycycline 100 mg orally taken twice per day for 7 days. chlamydia.
To improve adherence, directly observed treatment with In pregnant women, azithromycin 1 g orally as a single dose
single-dose azithromycin is preferred. (3) or alternate treatment with amoxicillin or erythromycin

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 base can be used. Doxycycline and erythromycin estolate Other risk factors include having new sex partners and
are contraindicated in pregnant women. engaging in commercial sex. (2)
The rate of gonorrhea has been increasing steadily since
Management of Sex Partners 2009 from 98.1 cases per 100,000 to 145.8 cases per
Sex partners should get tested and empirically treated. In 100,000 population in 2016. (2)
patients with urogenital infections, the CDC recommends
that “all partners that the patient has had sexual relations Signs and Symptoms
with in the past 60 days and the most recent partner even if The incubation period is 1 to 14 days.
more than 60 days should be referred for testing and Men: Most men are symptomatic, presenting with symptoms
treatment.” (3) EPT should be considered for partners as of urethritis, ie, with a mucopurulent or purulent urethral
permitted by state laws because this has been shown to discharge and dysuria. Men engaging in anal sex may also
reduce the rates of recurrence or the persistence of chla- present with signs and symptoms of proctitis, including
mydial infection. (36) anal bleeding, itching, irritation, painful defecation, or a
painless purulent anal discharge. Complications in men
may include epididymitis, prostatitis, and perirectal or
Follow-up
periurethral abscess.
Test of cure is the term used to retest infected patients to
Women: Gonorrhea is often asymptomatic in women but
assess for resolution of the initial infection. Although per-
may present with cervicitis or urethritis. Complications in
forming a test of cure is no longer recommended (except in
women include infection or unilateral abscesses in the
pregnant women), repeated testing is recommended for all
accessory glands, such as the Skene glands or Bartholin
chlamydia-infected individuals 3 months after treatment to
glands, PID, or perihepatitis.
assess for repeated infection. (37)(38) A test of cure, if per-
Men and women: Ocular infections, pharyngeal infections,
formed, should not be undertaken earlier than 3 weeks after
and disseminated infections can occur in both sexes.
treatment.
Disseminated gonococcal infections are more common in
women and those who have complement deficiency.
Prevention and Patient Counseling
Usually associated with bacteremia, disseminated gono-
The patient should be counseled about 1) the importance of
coccal infection presents as a multisystem disorder that
routine screening for chlamydia to prevent reproductive
may involve the skin, joints and tendons, heart, liver, and,
health complications (especially in young women), 2) the
occasionally, meninges.
asymptomatic nature of most chlamydial infections, 3) the
importance of treatment of partners and the high rate of
When to Test?
repeated infection, 4) the need to abstain from unprotected
Asymptomatic: Per the CDC 2015 screening guidelines, (3)
sexual intercourse after treatment for at least 7 days, and 5)
annual screening is recommended for all sexually active
risk reduction strategies (as detailed in previous sections).
women younger than 25 years. In addition, screening is
recommended for men and older women at increased risk
for infection, including those with new partners or partners
GONORRHEA
with an STI, and for MSM.
What Causes Gonorrhea? Symptomatic: Most gonorrhea infections are asymptomatic
Gonorrhea is caused by a gram-negative diplococcus (Neis- in women but typically cause urethritis symptoms in men,
seria gonorrhoeae) transmitted sexually by penile-vaginal in- prompting an evaluation. (3)
tercourse, oral-genital contact, and anal intercourse and
perinatally at the time of vaginal delivery. How to Test?
1. NAAT: The preferred testing method is NAAT of endo-
Epidemiology cervical, vaginal, and urethral swabs or urine. NAATs are
After chlamydia, gonorrhea is the most commonly reported most sensitive but are not FDA cleared for rectal or
STI, with approximately 820,000 new infections in the oropharyngeal specimens, although some laboratories are
United States each year. (1) The highest rates of gonorrhea able to perform these tests with a Clinical Laboratory
are found in men aged 20 to 24 years, in the southern states, Improvement Amendments waiver.
and in African Americans and Native Americans. A history of 2. Gram-stain: In symptomatic males, a Gram-stain dem-
gonorrhea or other STIs increases the risk of a new infection. onstrating leukocytes and gram-negative diplococci from

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 a urethral specimen can be diagnostic with very high For individuals who are severely allergic to cephalosporins,
sensitivity (>95%) and specificity (>99%). A Gram-stain is alternative treatments have shown efficacy in urogenital gonor-
not recommended in asymptomatic males. (39) rhea, including combining 2 g of oral azithromycin with either
3. Culture: Culture is not as sensitive as NAAT but it has the gentamycin 240 mg IM or gemifloxacin 320 mg orally. (41)
advantage of being approved for use at extragenital sites
(rectal, oropharyngeal, and conjunctival) and for checking Management of Sex Partners
microbial susceptibility. All sexual partners of the patient (from the past 60 days)
should seek evaluation, laboratory testing, and empirical
How to Treat? treatment using 2 drugs as recommended. The most recent
The CDC 2015 recommended guidelines for gonorrhea in- sexual partner should be treated no matter when the sexual
clude the following: contact occurred (ie, even if >60 days). (3) EPT can be
1. Uncomplicated gonorrheal infections of the cervix, ure- provided to heterosexual male and female partners. EPT
thra, and rectum: consists of cefixime 400 mg with azithromycin 1 g orally in a
Ceftriaxone 250 mg intramuscularly (IM) in a single dose single dose. (36)
along with azithromycin 1 g orally in a single dose OR EPT should not be considered if 1) a female partner is
Cefixime 400 mg orally with azithromycin 1 g orally in a experiencing symptoms of PID (because that warrants a
single dose. (This should be considered only if IM complete evaluation by a clinician) or 2) MSM due to the high
ceftriaxone is not available because there is increasing risk of co-infection with syphilis or HIV, lack of efficacy data,
resistance of gonococci to cefixime.) (3) and increasing resistance to cefixime in gonococcal strains
2. Gonorrheal pharyngeal infections: isolated from this population.
Ceftriaxone 250 mg IM in a single dose along with azi- Abstinence from unprotected sexual contact should be
thromycin 1 g orally. The alternative regimen (in- recommended for 7 days after both the patient and the
cluding cefixime) is not as effective. If alternative partner have been treated and all symptoms have resolved so
regimens are used. then a test of cure must be per- that repeated infection can be prevented. (3)
formed 14 days after treatment with NAAT and culture.
If NAAT results are positive, then a culture with an- Follow-up
timicrobial sensitivities should be performed before A test of cure is recommended only for patients who have
repeated treatment. (3) pharyngeal gonorrhea and have been treated with an alter-
3. Gonococcal conjunctivitis: native regimen. A test of cure is not indicated in those treated
Ceftriaxone 1 g IM with azithromycin 1 g orally in a single for uncomplicated urogenital or rectal gonorrhea with tra-
dose. Lavaging the eye with normal saline is also ditional regimens. (3) If symptoms persist after recom-
recommended. (3) mended treatment regimens then a culture should be
4. Disseminated gonococcal infection: performed (with or without NAAT) and antimicrobial sus-
This infection requires hospital admission of the patient ceptibility should be checked on any isolate. Patients should
and consultation with infectious disease specialists because be tested again from the original anatomical site of infection
disseminated disease can have serious complications. Par- 3 months after treatment because repeated infection is
enteral therapy is indicated and consists of ceftriaxone 1 to 2 g common due to exposure to an infected partner. (3) Patients
intravenously (IV) every 12 to 24 hours for at least 7 days with with persistent symptoms or repeated NAAT-positive results
azithromycin 1 g orally in a single dose. If disseminated who deny the possibility of repeated infection should also
gonococcal infection is complicated by meningitis or endo- have a culture with sensitivities performed.
carditis, then parenteral therapy should continue for 2 or
4 weeks, respectively. (3) Prevention and Patient Counseling
The patient should be counseled about
What’s New? 1. The importance of routine screening for gonorrhea to
Gonorrhea has developed increasing resistance to certain prevent reproductive health complications of untreated
antimicrobial agents. (40) Therefore, combination therapy infections, especially in young women.
with 2 antimicrobial drugs is recommended even if patients 2. The asymptomatic nature of most gonococcal infections
are not co-infected with chlamydia. Oral cefixime is no longer in females, whereas males often present with symptoms.
recommended as an equivalent alternative to IM ceftriaxone 3. The importance of treating partners and the high risk of
but can be considered only if IM ceftriaxone is not available. (3) repeated infection.

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4. The need to abstain from intercourse after completion of syndrome (symptoms present for <30 days) or a subclinical
treatment for both partners for at least 7 days and while or chronic syndrome (symptoms present for ≥30 days).
symptomatic.
5. Risk reduction strategies, including consistent condom What Causes PID?
use, should also be emphasized. Most commonly, acute PID is caused by C trachomatis and
N gonorrhoeae. However, other organisms, including aerobic
gram-negative rods such as Escherichia coli, anaerobes such
CASE (VERSION 2) as Bacteroides, gram-positive organisms such as Streptococcus,
The same 17-year-old girl presents to the clinic with increased Mycoplasma genitalium, Ureaplasma urealyticum, and in some
foul-smelling vaginal discharge but this time also reports women bacteria related to BV, have all been implicated. (42)
lower abdominal pain and chills. The etiologic agents in chronic PID are often Mycobacterium
tuberculosis or Actinomyces species. (42)

On Examination
Epidemiology
The patient’s temperature is 100.6°F (38.1°C), blood pressure
The incidence of PID is difficult to determine because it is
is 105/65 mm Hg, and heart rate is 76 beats/min. She has
not a reportable disease, and many women may have min-
lower abdominal tenderness but no rebound or guarding. On
imal symptoms. Using self-reported data in sexually active
speculum examination a purulent discharge is seen in the
women 18 to 44 years old, the NHANES data determined that
vagina. She is uncomfortable and reports pain with move-
approximately 2.5 million females have had PID in their
ment of the cervix and left adnexal tenderness. There is no
lifetime. (43) Although the incidence of chlamydia is in-
palpable adnexal fullness or mass.
creasing, the CDC data show a decline in the incidence of
Vaginal swab specimens are sent to test for C trachomatis,
PID by approximately 70% from 2005 to 2014. (2) This is
N gonorrhoeae, and T vaginalis. A urine pregnancy test is
attributed to the increase in chlamydia screening, resulting
negative. Wet prep slides reveal many white blood cells but
in early detection, treatment, and reduction of ascending
only a few clue cells and no trichomonads.
infection, which causes PID. (44)
Risk factors for developing PID are similar to those for
Diagnosis
acquiring the STIs that often cause PID, including younger
Pelvic inflammatory disease.
age (<20 years old), having multiple sexual partners, having
chlamydia or gonorrhea or having a partner with these in-
Treatment fections, vaginal douching, using oral contraceptive pills, or
The patient is treated in the office with ceftriaxone 250 mg recent insertion of an IUD. The risk of PID increases 6-fold
IM and prescribed oral doxycycline 100 mg twice a day for in the first 3 weeks after insertion of an IUD, although it
14 days. Syphilis and HIV testing are also performed, and she returns to the baseline risk after that period. Vaginal
is advised to notify her partner to obtain testing and empirical douching causes alteration of the vaginal flora, disruption of
treatment for gonorrhea and chlamydia. the vaginal epithelium and the mucosal barrier of the cervix,
Later that day she vomits immediately after taking thus predisposing to PID. (45)(46)(47)
the doxycycline. She is admitted to the hospital for short-
term management with IV antibiotics. She responds well Signs and Symptoms
after 48 hours and is discharged to complete the oral Women with PID can be asymptomatic or can present with
course of doxycycline. She is seen in the clinic 3 days later for acute, subacute, or chronic symptoms. Acute PID is diag-
close follow-up and additional risk reduction counseling. nosed when symptoms are present for 30 days or less. Pa-
tients may present with “mild” nonspecific symptoms such
as dyspareunia, dysuria, or abdominal pain; moderate PID
PELVIC INFLAMMATORY DISEASE usually has more specific symptoms, such as pelvic or lower
PID is usually a consequence of infection by chlamydia or abdominal pain or cramping, bleeding after sexual activity,
gonorrhea in the upper female genital tract. PID results from painful urination, and vaginal discharge and is often asso-
infection and inflammation of different parts of the female ciated with specific signs of PID, including cervical motion
reproductive system, including the uterus, fallopian tubes, and uterine or adnexal tenderness. Systemic signs and
and ovaries. In most cases PID is caused by an ascending symptoms are usually present in women with severe PID and
infection from the cervix and vagina. PID may be an acute include fever, chills, purulent or mucopurulent vaginal

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 discharge, and gastrointestinal symptoms such as nausea and/or surgery, such as acute appendicitis; 2) presence of a tubo-
vomiting. Signs are similar to those seen with moderate disease. ovarian abscess; 3) severe illness with systemic symptoms; 4)
Associated laboratory findings may include an elevated white pregnancy; 5) HIV infection; and 6) failure to respond to
blood cell count, erythrocyte sedimentation rate, and C-reactive outpatient oral treatment (within 48–72 hours) or inability to
protein level. (42)(48) Acute complications include salpingitis, tolerate the oral treatment.
tubo-ovarian abscess, and perihepatitis. Chronic complications Some adolescent patients who cannot be relied on to
include ectopic pregnancy, infertility, and chronic pelvic pain. The comply with medications or do not have a support system
chances of infertility are 8%, 20%, and 50% after 1, 2, and 3 may need to be hospitalized as well. (3)(48)
episodes of PID, respectively. Women who have had PID are 6 Given the need to start treatment early and empirically, broad
times more likely to have an ectopic pregnancy. (42)(49)(50) spectrum antibiotics that provide coverage for both chlamydia
and gonorrhea and other possible pathogens are used.
How to Test/Diagnose? In acute severe PID (especially if patients are hospital-
Providers should have a low threshold for diagnosing and ized), parenteral (IV) therapy with cephalosporins and
treating PID because untreated PID can have serious long- doxycycline is used initially, followed by oral therapy within
term complications for young women. Symptoms of acute 48 to 72 hours if a clinical response to treatment is evident.
PID can mimic many other diseases, and there are no Oral therapy must be continued for 14 days (Table 2). (3)
specific symptoms, signs, or laboratory tests that can accu- In mild-moderate disease, oral/IM regimens with similar
rately diagnose this condition. (51) Laparoscopy could pos- antibiotics may be used in an outpatient or inpatient setting
sibly confirm the etiologic agent; however, this is not easily (Table 2). Outpatients receiving oral therapy must follow up at 72
available to most providers and may delay early treatment of hours for a repeated evaluation. If they do not show an im-
the condition. Most often treatment is started after a clinical provement in symptoms, then hospitalization with a switch to
diagnosis with sensitivity of 65% to 90%. (3)(52)(53)(54)(55) parenteral therapy may be indicated. Oral metronidazole should
The CDC 2015 STD treatment guidelines (3) recommend be considered, especially if anaerobic organisms are suspected. (3)
that treatment for PID should be started empirically in The CDC recommends alternative regimens for indi-
sexually active young women or others at risk for STIs viduals with cephalosporin allergies but does not recom-
presenting with pelvic or abdominal pain (in whom no other mend routine treatment with fluoroquinolones because of
cause other than PID can be identified) if they have even 1 of increasing resistance of N gonorrhea to this group of anti-
the following clinical findings: uterine tenderness, cervical biotics unless sensitivities are obtained (Table 2). (3)
motion tenderness, or adnexal tenderness. If a tubo-ovarian abscess is suspected then the patient should
One or more of the following additional criteria can help in- be hospitalized and started on broad spectrum IV antibiotics that
crease the specificity of the clinical diagnosis of PID: 1) elevated oral provide coverage for gram-negative, gram-positive, and anaerobic
temperature greater than 101°F (38.3°C), 2) elevated erythrocyte organisms (Table 2). Pelvic ultrasonography should be per-
sedimentation rate, 3) elevated C-reactive protein level, 4) formed, and the patient should be hospitalized for initial man-
presence of mucopurulent vaginal discharge or cervical fria- agement. Surgical consultation should be considered if the
bility, 5) increased white cells on saline smear of vaginal fluid, patient does not show clinical improvement or if imaging in-
and 6) positive cervical testing for chlamydia or gonorrhea (3) dicates persistence of the abscess. (3)(57)
Definitive diagnosis can be made by endometrial biopsy
showing pathologic evidence of endometritis by ultraso- Management of Sex Partners
nography or other imaging techniques to show fluid-filled All male sex partners in the past 60 days should seek evaluation,
tubes or tubo-ovarian complex or tubular hyperemia visible undergo laboratory testing, and be treated empirically for both
on Doppler, or by laparoscopy showing evidence of PID. (48) chlamydia and gonorrhea. The last sexual partner should be
treated even if the contact was more than 60 days ago. EPT
How to Treat? can be provided to partners of women with PID. (3)
Prompt diagnosis and early treatment are essential to prevent
complications. Delay in treatment by as little as 3 days can result Follow-up
in increased chances of infertility and ectopic pregnancy. (56) All patients diagnosed as having PID should be seen and ex-
When should one hospitalize the patient with PID? Acute PID amined again within 3 days of treatment initiation. If patients
may require hospitalization particularly in adolescent patients. do not demonstrate improvement in symptoms and signs of
Criteria for hospitalization include 1) inability to confirm PID, such as reduction in fever or resolution or reduction of
the diagnosis and exclude other conditions that may require abdominal/pelvic pain, cervical motion, or adnexal or uterine

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tenderness, then they should be hospitalized and treated according
to the CDC guidelines. Follow-up of all women who are chlamydia • Based on Level B and C recommendations,
or gonorrhea positive at 3 to 6 months is recommended because patients should be retested for chlamydia and
the chances of repeated infection are high. (3) gonorrhea 3 months after treatment due to the
high risk of repeated infection. (37)(38)
Prevention and Patient Counseling • As per CDC and USPSTF guidelines and Level A
Patients should be counseled that recommendation, all people aged 13 to 64 years
1. Women with PID can present with acute symptoms re- should be screened for HIV, including all patients
lated to the reproductive tract or vague, nonspecific who seek evaluation or treatment for sexually
symptoms, or they may be asymptomatic. transmitted diseases. (60)
2. Recurrent PID may present with different types of • Based on strong research evidence (strong
symptoms. (42)(48) recommendation, Level A, Level B), the
3. PID has many etiologic agents but the most common are CDC 2015 sexually transmitted diseases guidelines
C trachomatis and N gonorrhoeae transmitted from males include multiple effective treatment regimens for
to females by unprotected sexual intercourse. chlamydia, gonorrhea, trichomoniasis, bacterial
4. Abstinence from intercourse for at least 7 days after vaginosis, vulvovaginal candidiasis, and pelvic
completion of treatment and resolution of symptoms for inflammatory disease (PID). (3)
both partners is recommended. (3)
5. Delay in treatment or untreated PID can lead to chronic
• Based on Level B recommendation, providers
pelvic pain, infertility, or ectopic pregnancy. (56) should have a low threshold for diagnosing and
6. Women who have had PID are at increased risk for future treating PID because untreated PID can have
episodes of the disease. (42)(48) serious long-term complications for young women,
7. Risk reduction strategies should be emphasized. as shown in large cohort studies. (3)(53)(56)
• Based on expert consensus (Level B, Level D),
indications for hospitalization for PID include
Summary presence of a tubo-ovarian abscess, severe
• Sexually transmitted infections disproportionately illness with systemic symptoms, pregnancy,
affect young people, with more than half of the infections human immunodeficiency virus infection, and failure
occurring in youth aged 15 to 25 years. (1)(2) to respond to outpatient oral treatment (within 48–72
hours) or inability to tolerate the oral treatment. (3)
• Based on some research evidence as well as consensus
(strong recommendation, Level B all sexually active
adolescent and adult females presenting with vaginal To view teaching slides that accompany this article,
visit http://pedsinreview.aappublications.org/content/
discharge should be tested for trichomoniasis,
41/No. 10/522.
chlamydia, and gonorrhea. Bacterial vaginosis and
vulvovaginal candidiasis should also be considered
during the evaluation. (3)
• Based on research evidence (strong recommendation,
Level B), the Centers for Disease Control and Prevention
(CDC) and the US Preventive Services Task Force (USPSTF)
recommend screening for chlamydia and gonorrhea in
sexually active women 24 years and younger. (2)(3)(31)
Based on strong research evidence (strong
recommendation, Level A), nucleic acid amplification tests
are the most sensitive and specific tests available for
trichomonas, chlamydia, and gonorrhea and can be
performed on provider- or patient-collected vaginal swabs
References for this article can be found at
in women and on urine in men and women. (3)(9)(58)(59) http://pedsinreview.aappublications.org/content/41/No. 10/522.

Vol. 41 No. 10 OCTOBER 2020 535

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 PIR QUIZ

Individual CME quizzes are available via the blue CME link under the article title in the online Table of Contents
of any issue. To learn how to claim MOC points, go to: http://www.aappublications.org/content/moc-credit.

1. A 17-year-old girl presents with vaginal discharge, dysuria, and vulvar

discomfort. She has used an over-the-counter vaginal cream for 3 days with
no improvement. Two months ago her male sexual partner tested positive for
gonorrhea. They both received treatment and abstained from sexual activity for
7 days after treatment. Her sexually transmitted infection (STI) testing for
gonorrhea, chlamydia, human immunodeficiency virus, and syphilis
subsequently was negative for all. Their use of condoms has been inconsistent.
Her last menstrual period was 3 weeks ago, and a urine pregnancy test today is
negative. Examination of her genitalia discloses a copious green frothy discharge REQUIREMENTS: Learners can
that has pH 6.5. There is a foul odor and labial irritation. There is no cervical take Pediatrics in Review quizzes
motion tenderness or adnexal pain on bimanual examination. Vaginal swabs for and claim credit online only at:
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wet mount preparations and nucleic acid amplification testing (NAAT) are
obtained, and empirical treatment is initiated. Based on the clinical presentation, To successfully complete 2020
which one of the following is the most likely cause of this patient’s vaginal Pediatrics in Review articles for
discharge? AMA PRA Category 1 Credit™,
learners must demonstrate
A. Candidiasis. a minimum performance
B. Chlamydia. level of 60% or higher on this
C. Gonorrhea. assessment. If you score less
D. Group B streptococcus. than 60% on the assessment,
you will be given additional
E. Trichomoniasis.
opportunities to answer
2. A 16-year-old girl tested positive for chlamydia on a routine annual screen for questions until an overall 60%
chlamydia and gonorrhea. She and her male partner of the past 6 months have or greater score is achieved.

no history of STIs and are both asymptomatic. He has had no male partners.
This journal-based CME activity
During the past year she has had an “on and off” sexual relationship with a is available through Dec. 31,
female partner. The patient is treated today with azithromycin 1 g orally as a 2022, however, credit will be
single dose. Which one of the following is the most appropriate additional recorded in the year in which
recommendation to give at this visit? the learner completes the quiz.

A. All her sexual partners in the past 60 days should have STI testing and
receive empirical treatment for chlamydia.
B. Her sexual partners should not be provided expedited partner treatment.
C. Only her current male partner needs STI testing and empirical treatment for
chlamydia. 2020 Pediatrics in Review is
D. The patient should be tested again for recurrent infection 6 and 12 months approved for a total of 30
after treatment. Maintenance of Certification
(MOC) Part 2 credits by the
E. The patient should have a test of cure 2 weeks after treatment.
American Board of Pediatrics
3. A 17-year-old boy who has had 2 male sexual partners during the past year has (ABP) through the AAP MOC
engaged in receptive and insertive oral intercourse. He and his partners have no Portfolio Program. Pediatrics in
Review subscribers can claim
history of STIs. He has no symptoms suggestive of an STI, including no dysuria,
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gonorrhea and serologic testing for human immunodeficiency virus and syphilis quizzes (and claiming full
were performed. The results of the urine NAATs and serologic tests are negative. credit for each quiz) per year.
The oropharyngeal swab is positive for gonorrhea. The patient has no known Subscribers can start claiming
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 A. Azithromycin 2 g orally as a single dose.
B. Cefixime 400 mg orally as a single dose.
C. Ceftriaxone 250 mg intramuscularly.
D. Ceftriaxone 250 mg intramuscularly and azithromycin 1 g orally as a single
dose.
E. Levofloxacin 500 mg orally once daily for 14 days.
4. A 16-year-old girl presents to the clinic with vaginal discharge and intermittent
vaginal spotting for 2 weeks. Her last office visit was 4 months ago when she was
prescribed oral contraceptive pills. At that visit results of urine NAAT for
chlamydia and gonorrhea were negative. Her last menstrual period was 3 weeks
ago, and a urine pregnancy test today is negative. She and her male partner use
condoms most of the time. She has mild lower abdominal tenderness, and a
bimanual examination elicits mild cervical motion tenderness. The examining
clinician performs a speculum examination, obtains samples for wet mount
preparations and NAAT, and initiates empirical treatment with antibiotics. Which
one of the following additional findings, if present, will increase the specificity of
the suspected clinical diagnosis in this patient?
A. History of treatment for gonorrhea in her sexual partner.
B. History of recurrent bacterial vaginosis in the patient.
C. Cervical ectropion on speculum examination.
D. Cervical friability on speculum examination.
E. A wet mount examination that reveals clue cells.
5. A 15-year-old girl presents to the clinic with a 2-week history of lower abdominal
pain and vaginal discharge. Her pain has substantially increased during the past
48 hours. Today she has vomited twice and has fever, chills, and weakness. She
has had 2 male sexual partners and no female partners. At her last visit 4 months
ago she was treated for symptomatic BV, and the results of NAAT were positive
for chlamydia. She and her male sexual partner both received treatment with
oral azithromycin 1 g in a single dose. She did not return for the follow-up visit
scheduled for 3 months after treatment. Subsequent condom use has been
infrequent, and she has had no new partners. On physical examination she
appears uncomfortable with no respiratory distress. Her temperature is 102°F
(38.9°C), heart rate is 94 beats/min, and blood pressure is 142/78 mm Hg.
Abdominal examination shows bilateral lower abdominal pain with no rebound
pain. On bimanual examination there is cervical motion tenderness and left
adnexal pain. There is no adnexal fullness or mass. Speculum examination shows
the presence of a mucopurulent discharge at the cervical os and cervical
friability. Specimens are obtained for wet mount preparations and NAAT. In
determining the most appropriate treatment setting for this patient, which one
of the following criteria represents an indication for hospitalization?
A. Age younger than 17 years.
B. Examination findings of cervicitis.
C. History of bacterial vaginosis.
D. History of chlamydia.
E. Systemic symptoms.

Vol. 41 No. 10 OCTOBER 2020 537

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 Sexually Transmitted Infections Part 2: Discharge Syndromes and Pelvic
Inflammatory Disease
Diana Lemly and Nupur Gupta
Pediatrics in Review 2020;41;522
DOI: 10.1542/pir.2019-0078

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 Sexually Transmitted Infections Part 2: Discharge Syndromes and Pelvic
Inflammatory Disease
Diana Lemly and Nupur Gupta
Pediatrics in Review 2020;41;522
DOI: 10.1542/pir.2019-0078

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/41/10/522

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