Sexually transmitted diseases

Disorder	Clinical	1st line	Alternative	Partner	In Pregnancy
N. Gonorrhea Urethritis/ Cervicitis	M: urethritis with d/c or simply dysuria;can be asymptomatic F: purulent discharge; can be asymptomatic	Ceftriaxone 125mg IM OR Cefixime (Suprax) 400mg po x1	Cipro 500po x 1 – not acceptable in MSM, travel, California, Hawaii OR Spectinomycin 2g IM x 1 OR Azithromycin 2g po x 1	Treat and abstinence x 7d after both treated	CTX 125mg IM x 1
N. Gonorrhea Conjunctivitis	2-5d after birth	Erythromycin ophthalmic 0.5% x1	Tetracycline ophthalmic 1% x1
N. Gonorrhea Disseminated (DGI)	Petechial, pustular acral skin lesions, Asymmetrical arthralgias, tenosynovitis, Septic arthritis	CTX 1g IM/IV q24 -continue x24-48h until improvement	Cefotax 1g IV q8 Spectinomycin 2g IV q12
Chlamydia Trachomatis	M: urethritis with d/c or simply dysuria; can be asymptomatic F: purulent discharge or cervical bleeding; can be asymptomatic	Azithromycin 1g po x1 OR Doxycycline 100mg po bid x 7d	Erythromycin base 500mg po qid x 7d OR Oflox 300mg po bid x 7d OR Levoflox 500mg po qd x 7days	Treat and abstinence x 7d after both treated	Azithromycin 1g po x1 or Amoxicillin 500mg po tid x 7d Or Erythro
Chlamydia Trachomatis Conjunctivitis	5-12d after birth; silver nitrate ophthalmic only rx gonorrhea	Erythromycin base 50mg/kg/day PO / 4 doses x14days
Chlamydia Trachomatis Pneumonia	1-3months; afebrile, staccato cough with diffuse infiltrates on CXR; peripheral eosinophilia	Erythromycin base 50mg/kg/day po / 4 doses x14days
Trichamonas vaginalis	White, thick discharge	Metronidazole 2g po x 1 OR Tinidazole 2g po x 1 PLUS Azithro 1g po x 1 -intravag cream not recommended	Metronidazole 500mg bid for 7days; 1-2g po qday x 7d if recurrence OR Topical clotrimazole for metronidazole allergy– not as effective	Metronidazole 2g po x 1	Rx only if symptomatic but rx partner 1st trimester, Clotrimazole 100mg hs for 7days After 1st trimester, Metronidazole 2g po x 1
Bacterial Vaginosis Lactobacillus	White, fishy discharge	Metronidazole 500mg po bid for 7d OR 0.75% Metronidazole gel (one full applicator 5g) intravaginal qd for 5d OR 2% Clindamycin cream 5g qd for 5d	Clindamycin 300mg po bid for 7d (recurrence) OR Clindamycin ovules 100mg intravaginally qhs x 3d	Exam for STD No rx if nl	1st trimester, metronidazole 250mg po tid x7d After 1st trimester, 500mg po bid for 7days or 250mg po tid x7d or Clinda 300mg po bid x 7d
Candidiasis (Candida albicans)	Cottage cheese; DM or immunocompromised	Butoconazole 2% cream 5g intravaginally for 3d OR Butaconazole-sustained 2% intravag x1	Clotrimazole 1% 5g cream intravaginally for 7-14d (OTC) OR Clotrimazole 100mg intravag tablet x 7d	Candicidal cream if dermatitis present	Avoid fluconazole and ketoconazole. Rx with cream for 7d
Chancroid (H. ducreyi)	Painful ulcers with suppurative LAD	Azithromycin 1g PO x 1	CTX 250mg IM x1 Cipro 500mg PO bid x 3days	See CDC	CTX
Granuloma Inguinale (Donvanosis) Klebsiella granulomatis	Painless lesions without LAD	Doxycycline 100mg PO BID x 3wks and until all lesions heald	Aizthromycin 1g po q week Ciproflox 750mg PO bid x 3 weeks Bactrim DS 1tab PO BID x 3 wks	same	Erythromycin base 500mg po qid x 3wks
Lymphogranuloma Venereum (LGV) C. trach serovars L1-L3	Tender, unilateral LAD; can lead to proctitis, fistulas	Doxycycline 100mg po bid x 3 weeks	Erythromycin base 500mg po qid x 3wks	Treat within 60days of exposure with standard Chlamydia Rx	Erythromycin base 500mg po qid x 3wks
Chancre- Primary Syphilis (T. pallidum)	Painless ulcer, chancre	Benzathine Penicillin G 1.2million U IM x1	Doxycycline 100mg po bid x 14d Tetracycline 500mg po qid x 14d CTX 1g IM/IV x 8-10d Azithromycin 2g po x 1?	See CDC	Penicillin; if allergic desensitize
Secondary Syphilis (T. pallidum)	Skin rash, mucocutaneous lesions, LAD			See CDC
Latent Syphilis	Seroreactivity without other evidence of disease	Early: Benzathine Penicillin G 2.4 million U IM x1 Late: Benzathine Penicillin G 2.4million U IM qweek x 3	Doxycycline 100mg po bid x 28d Tetracycline 500mg po qid x 28d	See CDC
Tertiary Syphilis (T. pallidum)	Cardiac (aortitis), ophtho (iritis, uveitis), gumma	Benzathine Penicillin G 2.4million U IM qweek x 3		See CDC
Neurosyphilis	Meningitis, syphilitic eye disease	Aqueous crystalline penicillin G 18-24million units/d administered as 3-4million units IV q4h or continuous infusion x 10-14days	Procaine penicillin 2.4million units IM qday + Probenecid 500mg po qid BOTH for 10-14d
HSV (1st episode)	Vesilcular rash	Acyclovir 400mg po TID x 7-10day	Famciclovir 250mg po TID x 7-10d Valacyclovir 1g PO BID x 7-10d
HSV (suppressive)		Acyclovir 400mg PO BID	Famciclovir 250mg po BID Valacyclovir 500mg PO qday
Epididymitis	Pain, swelling, inflammation of the epididymis	CTX 250mg IM + Doxycyline 100mg po bid x 10d	Oflox 300mg po bid x 10d + levoflox 500mg po qday x 10d
Epididymorchitis
Proctitis	Inflammation of the rectum (distal 10-12cm)	CTX 125mg IM x1 + Doxy 100mg po bid x 7d
PID	Sexually active, no other sources and: CMT OR uterine OR adnexal TTP	Outpt: Ceftriaxone 250mg IM x1 OR Cefoxitin 2g IM in a single dose and probenecid 1g orally administered concurrently in single dose OR Other parenteral 3rd gen cephalosporin eg ceftizoxime or cefotaxime PLUS Doxy 100mg po bid x14d +/- Metronidazole 500mg po bid x 14d Parenteral: Cefotetan 2g IV q12h OR Cefoxitin 2g IV q6h PLUS Doxycyline 100mg IV or PO q12 (similar bioavailability)	Outpt: Oflox 400mg po bid x 14d OR Levofloxacin 500mg po qday x 14d +/- Metronidazole 500mg po bid x 14d Parenteral: Clinda 900mg IV q8h PLUS Gent load 2mgkg IV; maintenance 1.5mg/kg q8h; single daily dosing may be substituted Oflox 400mg IV q12h OR Levoflox 500mg IV qday +/- Metro 500mg IVq8h OR Unasyn 3g IV q6h PLUS Doxy 100mg IV or PO q12h
Scabies	Crusted rash, intertiginous areas	Permethrin 5% cream applied to all areas of body from neck down and rinsed off after 8-14h	Ivermectin 200mcg/kg PO, repeated in 2weeks Lindane (1%) 1 ounce of lotion of 30g of cream applied in thin layer all over from neck down x 8 hours then rinse
Pediculosis Pubis	Puritic genitalia	Permethrin 1% cream: apply to affected areas x 10mins then wash off	Malathion lotion 0.5% apply x 8-12h then rinse OR Ivermectin 250mcg/kg PO repeated in 2 weeks

*BV: in pregnancy, associated with premature rupture of membranes, chorioamnionitis, preterm birth, postpartum infxn

†Test for HIV, syphilis

DeBonis

Adapted from CDC 2006

Disorder

Clinical

1st line

Alternative

Partner

In Pregnancy

N. Gonorrhea

Urethritis/

Cervicitis

M: urethritis with d/c or simply dysuria;can be asymptomatic

F: purulent discharge; can be asymptomatic

Ceftriaxone 125mg IM

OR

Cefixime (Suprax) 400mg po x1

Cipro 500po x 1 – not acceptable in MSM, travel, California, Hawaii

OR

Spectinomycin 2g IM x 1 OR

Azithromycin 2g po x 1

Treat and abstinence x 7d after both treated

CTX 125mg IM x 1

N. Gonorrhea

Conjunctivitis

2-5d after birth

Erythromycin ophthalmic 0.5% x1

Tetracycline ophthalmic 1% x1

N. Gonorrhea

Disseminated

(DGI)

Petechial, pustular acral skin lesions,

Asymmetrical arthralgias, tenosynovitis,

Septic arthritis

CTX 1g IM/IV q24

-continue x24-48h until improvement

Cefotax 1g IV q8

Spectinomycin 2g IV q12

Chlamydia Trachomatis

M: urethritis with d/c or simply dysuria; can be asymptomatic

F: purulent discharge or cervical bleeding; can be asymptomatic

Azithromycin 1g po x1

OR

Doxycycline 100mg po bid x 7d

Erythromycin base 500mg po qid x 7d OR

Oflox 300mg po bid x 7d

OR

Levoflox 500mg po qd x 7days

Treat and abstinence x 7d after both treated

Azithromycin 1g po x1 or

Amoxicillin 500mg po tid x 7d

Or

Erythro

Chlamydia

Trachomatis

Conjunctivitis

5-12d after birth; silver nitrate ophthalmic only rx gonorrhea

Erythromycin base 50mg/kg/day PO / 4 doses x14days

Chlamydia Trachomatis

Pneumonia

1-3months; afebrile, staccato cough with diffuse infiltrates on CXR; peripheral eosinophilia

Erythromycin base 50mg/kg/day po / 4 doses x14days

Trichamonas vaginalis

White, thick discharge

Metronidazole 2g po x 1

OR

Tinidazole 2g po x 1

PLUS

Azithro 1g po x 1

-intravag cream not recommended

Metronidazole 500mg bid for 7days; 1-2g po qday x 7d if recurrence

OR

Topical clotrimazole for metronidazole allergy– not as effective

Metronidazole 2g po x 1

Rx only if symptomatic but rx partner

1st trimester, Clotrimazole 100mg hs for 7days

After 1st trimester, Metronidazole 2g po x 1

Bacterial Vaginosis

Lactobacillus

White, fishy discharge

Metronidazole 500mg po bid for 7d

OR

0.75% Metronidazole gel (one full applicator 5g) intravaginal qd for 5d

OR

2% Clindamycin cream 5g qd for 5d

Clindamycin 300mg po bid for 7d (recurrence)

OR

Clindamycin ovules 100mg intravaginally qhs x 3d

Exam for STD

No rx if nl

1st trimester, metronidazole 250mg po tid x7d

After 1st trimester, 500mg po bid for 7days or 250mg po tid x7d or Clinda 300mg po bid x 7d

Candidiasis

(Candida albicans)

Cottage cheese;

DM or immunocompromised

Butoconazole 2% cream 5g intravaginally for 3d

OR

Butaconazole-sustained 2% intravag x1

Clotrimazole 1% 5g cream intravaginally for 7-14d (OTC)

OR

Clotrimazole 100mg intravag tablet x 7d

Candicidal cream if dermatitis present

Avoid fluconazole and ketoconazole.

Rx with cream for 7d

Chancroid

(H. ducreyi)

Painful ulcers with suppurative LAD

Azithromycin 1g PO x 1

CTX 250mg IM x1

Cipro 500mg PO bid x 3days

See CDC

CTX

Granuloma Inguinale (Donvanosis)

Klebsiella granulomatis

Painless lesions without LAD

Doxycycline 100mg PO BID x 3wks and until all lesions heald

Aizthromycin 1g po q week

Ciproflox 750mg PO bid x 3 weeks

Bactrim DS 1tab PO BID x 3 wks

same

Erythromycin base 500mg po qid x 3wks

Lymphogranuloma Venereum (LGV)

C. trach serovars L1-L3

Tender, unilateral LAD; can lead to proctitis, fistulas

Doxycycline 100mg po bid x 3 weeks

Erythromycin base 500mg po qid x 3wks

Treat within 60days of exposure with standard Chlamydia Rx

Erythromycin base 500mg po qid x 3wks

Chancre-

Primary

Syphilis

(T. pallidum)

Painless ulcer, chancre

Benzathine Penicillin G 1.2million U IM x1

Doxycycline 100mg po bid x 14d

Tetracycline 500mg po qid x 14d

CTX 1g IM/IV x 8-10d

Azithromycin 2g po x 1?

See CDC

Penicillin; if allergic desensitize

Secondary Syphilis

(T. pallidum)

Skin rash, mucocutaneous lesions, LAD

See CDC

Latent Syphilis

Seroreactivity without other evidence of disease

Early: Benzathine Penicillin G 2.4 million U IM x1

Late: Benzathine Penicillin G 2.4million U IM qweek x 3

Doxycycline 100mg po bid x 28d

Tetracycline 500mg po qid x 28d

See CDC

Tertiary Syphilis

(T. pallidum)

Cardiac (aortitis), ophtho (iritis, uveitis), gumma

Benzathine Penicillin G 2.4million U IM qweek x 3

See CDC

Neurosyphilis

Meningitis, syphilitic eye disease

Aqueous crystalline penicillin G 18-24million units/d administered as 3-4million units IV q4h or continuous infusion x 10-14days

Procaine penicillin 2.4million units IM qday + Probenecid 500mg po qid

BOTH for 10-14d

HSV (1st episode)

Vesilcular rash

Acyclovir 400mg po TID x 7-10day

Famciclovir 250mg po TID x 7-10d

Valacyclovir 1g PO BID x 7-10d

HSV (suppressive)

Acyclovir 400mg PO BID

Famciclovir 250mg po BID

Valacyclovir 500mg PO qday

Epididymitis

Pain, swelling, inflammation of the epididymis

CTX 250mg IM + Doxycyline 100mg po bid x 10d

Oflox 300mg po bid x 10d + levoflox 500mg po qday x 10d

Epididymorchitis

Proctitis

Inflammation of the rectum (distal 10-12cm)

CTX 125mg IM x1 + Doxy 100mg po bid x 7d

PID

Sexually active, no other sources and: CMT OR uterine OR adnexal TTP

Outpt:

Ceftriaxone 250mg IM x1

OR

Cefoxitin 2g IM in a single dose and probenecid 1g orally administered concurrently in single dose

OR

Other parenteral 3rd gen cephalosporin eg ceftizoxime or cefotaxime

PLUS

Doxy 100mg po bid x14d

+/-

Metronidazole 500mg po bid x 14d

Parenteral:

Cefotetan 2g IV q12h

OR

Cefoxitin 2g IV q6h

PLUS

Doxycyline 100mg IV or PO q12

(similar bioavailability)

Outpt:

Oflox 400mg po bid x 14d

OR

Levofloxacin 500mg po qday x 14d

+/-

Metronidazole 500mg po bid x 14d

Parenteral:

Clinda 900mg IV q8h

PLUS

Gent load 2mgkg IV; maintenance 1.5mg/kg q8h; single daily dosing may be substituted

Oflox 400mg IV q12h

OR

Levoflox 500mg IV qday

+/-

Metro 500mg IVq8h

OR

Unasyn 3g IV q6h

PLUS

Doxy 100mg IV or PO q12h

Scabies

Crusted rash, intertiginous areas

Permethrin 5% cream applied to all areas of body from neck down and rinsed off after 8-14h

Ivermectin 200mcg/kg PO, repeated in 2weeks

Lindane (1%) 1 ounce of lotion of 30g of cream applied in thin layer all over from neck down x 8 hours then rinse

Pediculosis Pubis

Puritic genitalia

Permethrin 1% cream: apply to affected areas x 10mins then wash off

Malathion lotion 0.5% apply x 8-12h then rinse

OR

Ivermectin 250mcg/kg PO repeated in 2 weeks

• BV: in pregnancy, associated with premature rupture of membranes, chorioamnionitis, preterm birth, postpartum infxn

†Test for HIV, syphilis

DeBonis

Adapted from CDC 2006