Tratamento da cervicite no puerpério

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Tratamento da cervicite no puerpério

Mensagem  Convidad em Seg Jul 08, 2013 10:58 pm

Tratamento para gestantes e nutrizes (Cadernos de Atenção básica):

Tratamento uptodate:

TREATMENT — The goals of treatment are relief of symptoms and prevention of infection of the upper genital tract.

Empiric therapy — Most women with cervicitis should receive empiric antibiotic therapy at the time of initial evaluation, without waiting for results of laboratory tests, especially if follow-up is uncertain and if a relatively insensitive diagnostic test is used in place of NAAT.

The empiric treatment regimen for cervicitis should include coverage of chlamydia at a minimum (see 'Gonorrhea, chlamydia' below), especially for women ≤25 years old, as the prevalence of this infection is highest in this age group. Other risk factors for chlamydia are new or more than one sexual partner, and inconsistent use of condoms.

The Centers for Disease Control and Prevention's Sexually Transmitted Diseases Treatment Guidelines recommend adding therapy for gonorrhea (see 'Gonorrhea, chlamydia' below), as well, if either the individual patient's risk is high or if the local prevalence is high [18]. The threshold prevalence that defines "high" is not clear, but most experts agree that >5 percent is reasonable, given the consequences of untreated infection and the ease with which treatment can be accomplished (ie, single-dose therapy) [17,18,21].

Even for women who are not at apparently high risk for sexually transmitted infection, empiric antibiotic therapy for both chlamydia and gonorrhea is reasonable if patient follow-up of test results is a concern; the patient has risk factors for, or a recent history of, chlamydia or gonorrhea infection; or the local prevalence of gonorrhea or chlamydia infection is high.

In general, patients and their sex partners should abstain from sexual intercourse until treatment has been completed (seven days after a single-dose regimen or after completion of a seven-day regimen). Treatment, follow-up, and management of sex partners depend upon the results of the diagnostic tests (see 'Sex partners' below) [17].

Treatment of specific infections — Laboratory and microscopy findings guide targeted therapy.

Gonorrhea, chlamydia — For women in whom empiric therapy of chlamydia, gonorrhea, or both is deferred, the results of sensitive tests for C. trachomatis and N. gonorrhoeae (eg, NAATs) should guide treatment subsequent to the initial evaluation.

Treatment of these infections is indicated for relief of symptoms, to prevent transmission to uninfected sexual partners, and to prevent upper genital tract disease (endometritis, PID) and its sequelae. If more than one infection is identified (eg, chlamydial cervicitis and bacterial vaginosis), all should be treated. (See "Endometritis unrelated to pregnancy" and "Treatment of pelvic inflammatory disease".)

Gonorrhea — Ceftriaxone 250 mg intramuscularly as a single dose is recommended [18,22]. When intramuscular administration of ceftriaxone is given, lidocaine hydrochloride can be used as a diluent to decrease the discomfort associated with the injection.

In addition to ceftriaxone, the Centers for Disease Control and Prevention (CDC) recommends treatment with either azithromycin or doxycycline, regardless of chlamydial coinfection status [23,24]. (See "Treatment of uncomplicated gonococcal infections", section on 'Rationale for dual therapy'.)

The management of the penicillin allergic patient depends on the clinical suspicion of true allergy and the type of allergy (eg, morbilliform rash versus IgE-mediated reactions, such as urticaria). This is discussed separately. (See "Treatment of uncomplicated gonococcal infections".)

Although spectinomycin (single dose of 2 g intramuscularly) is effective, it is no longer available. Fluoroquinolones should not be used due to increasing rates of resistance in gonococci [25,26].  
Chlamydia — Treatment options include azithromycin 1 g orally once or doxycycline 100 mg orally twice daily for seven days. (See "Genital Chlamydia trachomatis infections in women".)
Bacterial vaginosis — Oral or topical medication may be used (table 1). Treatment of sexual partners is not required. (See "Bacterial vaginosis".)

Trichomonas vaginalis — Treatment consists of metronidazole or tinidazole as a single oral dose of 2 grams (four 500 mg tablets), or metronidazole 500 mg orally twice daily for seven days. Sexual partners should be treated. (See "Trichomoniasis".)

Herpes simplex virus — Treatment options for herpes simplex virus infection include (see "Treatment of genital herpes simplex virus infection"):

Acyclovir: 400 mg orally three times per day or 200 mg PO five times per day
Famciclovir: 250 mg orally three times daily
Valacyclovir: 1000 mg orally twice daily
Sex partners — Sex partners of women with chlamydia, gonorrhea, or trichomoniasis should be treated for the sexually transmitted infection for which the woman received treatment. To avoid reinfection, patients and their sex partners should abstain from sexual intercourse until therapy is completed (seven days after a single-dose regimen or after completion of a seven-day regimen).

Women with no identifiable pathogen — Management of cervicitis in which an infectious agent has not been identified during the diagnostic evaluation is controversial, although this is a common clinical scenario. Data are sparse and there is no strong evidence to justify suggesting one treatment approach over another [27-30]. If the patient has not received any treatment, we recommend empiric treatment to cover gonorrhea and chlamydia, as discussed above. (See 'Empiric therapy' above.)

Management of women with persistent disease after this therapy is discussed below (see 'Recurrent or persistent disease' below).

Women with a foreign body/substance — For women with cervicitis that appears to be associated with a foreign body/substance, removal/avoidance of the foreign body/substance will often lead to resolution of inflammation. Therefore, chemical douches, vaginal contraceptives and deodorants, and pessaries should be discontinued and the patient followed to see if there is a therapeutic response. Topical treatment is not useful in this setting.

Asymptomatic women with inflammation on histology or cytology — Treatment is not indicated for asymptomatic women who undergo cervical biopsy for the evaluation of cervical intraepithelial neoplasia and are found to have histologic, but no clinical, evidence of cervicitis. Histological inflammation is a poor indicator of a specific infection [17,31]. Although follicular cervicitis (lymphoid follicles beneath the epithelium) suggests, but is not pathognomonic of, chlamydial cervicitis [32-36], follicular cervicitis can also occur with noninfectious cervicitis. Diagnostic testing is needed in these cases to confirm or exclude a specific infection and to guide treatment.

Inflammation on cervical cytology is also not an indication for treatment. The presence of a few lymphocytes on cytological smears is normal and should not be misdiagnosed as inflammation.

HIV/Aids, hepatites e outras DST. Cadernos de Atenção Básica - n.º 18, Brasília - DF - 2006.


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