This patient most likely has cervicitis and should be treated with ceftriaxone and azithromycin. It is important to differentiate cervicitis from vaginitis because the treatments differ. Cervicitis, characterized by an inflamed and friable cervix, is typically caused by gonorrhea and chlamydia. Vaginitis refers to inflammation of the vagina and is caused by infections such as candidiasis and trichomoniasis or by noninfectious conditions such as atrophic vaginitis or vaginal irritation. Bacterial vaginosis is a syndrome that appears noninflammatory, is characterized by alterations in the microbial composition of the vaginal flora, and may cause vaginal discharge and odor. In this patient with cervicitis, it is appropriate to give empiric therapy to cover Neisseria gonorrhoeae and Chlamydia trachomatis. The regimen of choice is a single intramuscular dose of ceftriaxone, 250 mg, and a single oral dose of azithromycin, 1 g. Oral cefixime can be used but only if ceftriaxone is unavailable; cefixime is associated with increasing minimum inhibitory concentrations of N. gonorrhoeae.

Cefotetan plus doxycycline is preferred for the treatment of patients with pelvic inflammatory disease who require hospitalization. The absence of cervical motion, uterine, or adnexal tenderness makes ascending genital tract infection unlikely in this patient.

Fluconazole is used to treat Candida vaginitis, a disease that would not result in clinical findings of cervicitis. Additionally, fungal organism would be visualized on the potassium hydroxide preparation.

Metronidazole is used to treat bacterial vaginosis and trichomonas. The pH of vaginal secretions would be elevated, clue cells would be visible on the wet mount (rather than numerous leukocytes), and the whiff test would have a positive result in bacterial vaginosis. Trichomonas would result in numerous leukocytes on the wet mount, but motile organisms would also be visible; the clinical findings should include vulvar and vaginal mucosal erythema.