Sexually transmitted diseases
Background
It is important to treat sexual partners for all STDs
Visual Diagnosis
STD Visual Diagnosis (Male)
Primary Syphilis
Painless genital ulcer from lymphogranuloma venereum
Inguinal femoral lymphadenopathy (bilateral) from lymphogranuloma venereum
STD Visual Diagnosis (Female)
Urethritis/Cervicitis
Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[1]
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 [2]
- Tinidazole 2g PO once
Pregnant
Only treat if the patient is symptomatic
- Metronidazole 500mg PO BID for 7 days [3]
Sexual Partner Treatment
- Female: Same as above
- Male: Metronidazole 2 gm PO x1 [4]
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 [5]
- 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 [6]
- Tinidazole 2g PO once
Pregnant
Only treat if the patient is symptomatic
- Metronidazole 500mg PO BID for 7 days [7]
Sexual Partner Treatment
- Female: Same as above
- Male: Metronidazole 2 gm PO x1 [8]
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[9]
- 2g PO x 1 is also acceptable in pregnancy[9]
- Multiple studies have not demonstrated teratogenicity from metronidazole use[9]
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 [10]
Herpes
Initial Episode[11][12]
- 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[11]
- 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[11]
- 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 [13]
- 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)[14][15] + Doxycycline 100mg PO BID x 14 days + Metronidazole 500mg PO BID x 14 days[16][17]
- Cefoxitin 2g IM x1 plus Probenecid 1g PO[18] + Doxycycline 100mg PO BID x 14 days + metronidazole
Inpatient Antibiotic Options
- Recommended[19]: 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
Source
- ↑ Cyr SS et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ CDC Trichomoniasis 2021. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ Zikic A, Schünemann H, Wi T, Lincetto O, Broutet N, Santesso N. Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis. J Pediatric Infect Dis Soc. 2018 Aug 17;7(3):e107-e115. doi: 10.1093/jpids/piy060. PMID: 30007329; PMCID: PMC6097578.
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ CDC Trichomoniasis 2021. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ 9.0 9.1 9.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
- ↑ Mackay G. Chapter 43. Sexually Transmitted Diseases & Pelvic Infections. In:DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. New York, NY: McGraw-Hill; 2013
- ↑ 11.0 11.1 11.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
- ↑ https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
- ↑ https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
- ↑ Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
- ↑ Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929-37
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1-187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1-187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon