Sexually transmitted diseases

Diagnosis

STD Visual Diagnosis (Male)

• 

  Chancroid

• 

  HSV

• 

  Primary Syphilis

• 

  Painless genital ulcer from lymphogranuloma venereum

• 

  Inguinal femoral lymphadenopathy (bilateral) from lymphogranuloma venereum

STD Visual Diagnosis (Female)

• 

  Chancroid

Urethritis/Cervicitis

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

• Gonorrhea
  • Ceftriaxone IM x 1 (500mg if <150kg, 1g if ≥150kg)
• Chlamydia
  • Nonpregnant: Doxycycline 100 mg PO BID x 7 days
  • Pregnant: Azithromycin 1 g PO x 1

Ceftriaxone contraindicated

• Gonorrhea
  • Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
  • Cefixime 800 mg PO x 1
• Chlamydia^
  • Nonpregnant: doxycycline 100 mg PO BID x 7 days
  • Pregnant: azithromycin 1 g PO x 1

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

• Gonorrhea
  • Cefixime 800mg PO x 1
• Chlamydia
  • Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
  • Pregnant: azithromycin 1g PO x 1

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

• Metronidazole 500mg PO BID for 7 days
• Tinidazole 2g PO once

Pregnant

Only treat if the patient is symptomatic

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

• Female: Same as above
• Male: Metronidazole 2 gm PO x1

GC/Chlamydia Conjunctivitis

Chlamydial

• Doxycycline 100mg PO BID for 7 days OR
• Azithromycin 1g (20mg/kg) PO one time dose
• Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days or erythromycin PO 50 mg/kg/day in 4 divided doses for 14 days
  • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

• Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
• Ceftriaxone 1g IM single dose PLUS
• Azithromycin 1g PO one dose
• Newborn Treatment:
  • Prophylaxis: Erythromycin ophthalmic 0.5% x1
  • Disease manifests 1st 5 days post delivery (early onset)
  • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg or cefotaxime single dose of 100 mg/kg (preferred if the patient has hyperbilirubinemia)
  • Also requires evaluation for disseminated disease (meningitis, arthritis, etc.)

Trichomonas vaginalis

Non-Pregnant

• Metronidazole 500mg PO BID for 7 days
• Tinidazole 2g PO once

Pregnant

Only treat if the patient is symptomatic

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

• Female: Same as above
• Male: Metronidazole 2 gm PO x1

Bacterial Vaginosis

• Metronidazole 2g PO once

<45kg

• 15 mg/kg/day PO divided q8h x 7 days
• First Dose: 7 mg/kg PO x 1

>45kg

• 2 g PO x 1

Pregnancy

• Alternative: 250mg PO q8h x 7 days in pregnant patients
• 2g PO x 1 is also acceptable in pregnancy
• Multiple studies have not demonstrated teratogenicity from metronidazole use

Prophylaxis (Sexual Assault)

• Metronidazole 2 g PO x 1 OR

• Clindamycin 300mg PO BID x 7 days

Lymphogranuloma Venereum

• Doxycycline 100mg PO BID x 21 days (first choice) OR
• Erythromycin 500mg PO QID x 21 days OR
  • Preferred for pregnant and lactating females
• Azithromycin 1g PO weekly for 3 weeks OR
  • Alternative for pregnant women - poor evidence for this treatment currently
• Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
• Treat sexual partner
  • Doxycycline 100mg PO BID x 7 days OR
  • Azithromycin 1gm PO x1

Syphilis

Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year.

Treatment Options:

• Penicillin G Benzathine 2.4 million units IM x 1
  • Repeat dose after 7 days for pregnant patients and HIV infection
• Doxycycline 100mg oral twice daily for 14 days as alternative

Congenital Syphilis:

• Penicillin G 50,000 units/kg IV q4-6h x 10-14 days
• Penicillin G Procaine 50,000 units/kg IM daily x 10-14 days
• Penicillin G Benzathine 50,000 units/kg IM x 1

Older Children:

• Penicillin G Benzathine 50,000 units/kg IM x 1 (max 2.4 million units)

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease

Treatment Options:

• Penicillin G Benzathine 2.4 million units IM weekly x 3 weeks
• Doxycycline 100mg oral twice daily for 4 weeks as alternative

Neurosyphilis

There are 3 Major options with none showing greater efficacy than others:

• Penicillin G 3-4 million units IV every 4 hours x 10-14 days
• Penicillin G 24 million units continuous IV infusion x 10-14 days
• Penicillin G Procaine 2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
• Alternative:
  • Ceftriaxone 2gm IV once daily for 10-14 days

• Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)

Pregnancy

• Penicillin, dosage depends on stage

Herpes

Initial Episode

• Acyclovir 400mg PO q8hrs x 7-10 days or 200mg PO 5x/day x 7-10 days OR
• Valacyclovir 1g PO q12hrs x 7-10 days OR
• Famciclovir 250mg PO q8hrs x 7-10 days

Recurrence

• Acyclovir 400mg PO q8hrs x 5 days or 800mg PO q12hrs x 5 days or 800mg PO q8hrs x 2 days OR
• Valacyclovir 500mg PO q12hrs x 3 days or 1g PO qd x 5 days OR
• Famciclovir 125mg PO q12hrs for 5 days or 1g PO q12hrs for 1 day or 500mg PO once then 250mg PO q12hrs for 2 days

Suppressive Therapy

• Acyclovir 400mg PO q12hrs daily OR
• Famciclovir 250mg PO q12hrs daily OR
• Valacyclovir 500mg-1g PO daily (500mg may be less effective)

Epididymitis/Epididymorchitis

• For acute epididymitis likely caused by STI
  • Ceftriaxone 500 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 10 days

• For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • Ceftriaxone 500 mg IM in a single dose PLUS
  • Levofloxacin 500 mg orally once a day for 10 days

• For acute epididymitis most likely caused by enteric organisms
  • Levofloxacin 500 mg orally once daily for 10 days

For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.

Proctitis

Inflammation of the rectum (distal 10-12cm)

• Ceftriaxone 125mg IM x1 + 100mg po bid x 7d

PID

Antibiotics

• No sexual activity for 2 weeks;
• Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

• Ceftriaxone 500mg IM x1 (1g if >150kg) + Doxycycline 100mg PO BID x 14 days + Metronidazole 500mg PO BID x 14 days
• Cefoxitin 2g IM x1 plus Probenecid 1g PO + Doxycycline 100mg PO BID x 14 days + metronidazole

Inpatient Antibiotic Options

• Recommended: Ceftriaxone 1g IV q24hr OR Cefoxitin 2g IV q6hr OR Cefotetan 2g IV q12hr + Doxycycline 100mg PO or IV q12hr + Metronidazole 500mg IV or PO q12hr OR
• Clindamycin 900mg IV q8hr + Gentamicin 2mg/kg loading then 1.5mg/kg q8hr IV OR
• Ampicillin/Sulbactam 3g IV q6hr + doxycycline 100mg IV/PO q12hr
• Azithromycin 500mg IV q24h x1-2 days, then 250mg PO q24h x5-6 days

See Also

• Pelvic Inflammatory Disease (PID)
• Ulcerative STDs
• Penile diagnoses
• Pelvic pain

Source

DeBonis

Adapted from CDC 2010 Guidelines