Sexually transmitted diseases
Background
Diagnosis
STD Visual Diagnosis (Male)
Primary Syphilis
Painless genital ulcer from lymphogranuloma venereum
Inguinal femoral lymphadenopathy (bilateral) from lymphogranuloma venereum
STD Visual Diagnosis (Female)
Management
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
DeBonis
Adapted from CDC 2010 Guidelines
- ↑ 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