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STD TREATMENT GUIDELINES FOR ADULTS AND ADOLESCENTS

These guidelines for the treatment of patients with STDs reflect the 1998 CDC STD Treatment Guidelines and the Region IX Infertility Clinical Guidelines. The focus is primarily on STDs encountered in office practice. These guidelines are intended as a source of clinical guidance; they are not a comprehensive list of all effective regimens. To report STD infections; request assistance with confidential notification of sexual partners of patients with syphilis, gonorrhea, chlamydia or HIV infection; or to obtain additional information on the medical management of STD patients, call the County Health Department. The California STD/HIV Prevention Training Center is an additional resource for training and consultation in the area of STD clinical management and prevention (510-883-6600).

DISEASE

RECOMMENDED REGIMENS DOSE/ROUTE

ALTERNATIVE REGIMENS

CHLAMYDIA

Uncomplicated Infections

Adults/Adolescents1

• Azithromycin or

• Doxycycline2

1 g po

100 mg po bid x 7 d

Erythromycin base 500 mg po qid x 7 d or

Erythromycin ethylsuccinate 800 mg po qid x 7 d or Ofloxacin3 300 mg po bid x 7 d

Pregnant Women4

• Amoxicillin or

• Azithromycin or

• Erythromycin base

500 mg po tid x 7 d

l g po

500 mg po qid x 7 d

Erythromycin base 250 mg po qid x 14 d or

Erythromycin ethylsuccinate 800 mg po qid x 7 d or Erythromycin ethylsuccinate 400 mg po qid x 14 d

GONORRHEA5

Uncomplicated Infections

Adults/Adolescents

• Cefixime6 or

• Ceftriaxone or

• Ciprofloxacin3 or

• Ofloxacin3 plus5

• a chlamydia recommended regimen listed above

400 mg po

125 mg IM

500 mg po

400 mg po

Spectinomycin7 2 g IM plus5 a chlamydia recommended regimen

Pregnant Women

• Ceftriaxone or

• Cefixime6 plus5

• a chlamydia recommended regimen listed above

125 mg IM

400 mg po

Spectinomycin7 2 g IM plus5 a chlamydia recommended regimen

PELVIC

INFLAMMATORY

DISEASE

Parenteral8

• Cefotetan or

Cefoxitin plus

Doxycycline2 or

• Clindamycin plus

Gentamicin

Oral Treatment

• Ofloxacin3 plus

Metronidazole or

• Ceftriaxone or

Cefoxitin and

Probenecid plus

Doxycycline2

2 g IV q 12 hrs

2 g IV q 6 hrs

100 mg po or IM q 12 hrs

900 mg IV q 8 hrs

2 mg/kg IV or IM followed by

1.5 mg/kg IV or IM q 8 hrs

400 mg po bid x 14 d

500 mg po bid x 14 d

250 mg IM

2 g IM

1 g po

100 mg po bid x 14 d

Parenteral Ofloxacin3 400 mg IV q 12 hrs plus

Metronidazole 500 mg IV q 8 hrs or

Ampicillin/Sulbactam 3 g IV q 6 hrs plus

Doxycycline2 100 mg po or IV q 12 hrs or

Ciprofloxacin3 200 mg IV q 12 hrs plus

Doxycycline2 100 mg po or IV q 12 hrs plus

Metronidazole 500 mg IV q 8 hrs

MUCOPURULENT

CERVICITIS9

• Azithromycin or

• Doxycycline2

1 g po

100 mg po bid x 7 d

Erythromycin base 500 mg po qid x 7 d or

Erythromycin ethylsuccinate 800 mg po qid x 7 d or Ofloxacin3 300 mg po bid x 7 d

NONGONOCOCCAL

URETHRITIS9

• Azithromycin or

• Doxycycline2

1 g po

100 mg po bid x 7 d

Erythromycin base 500 mg po qid x 7 d or

Erythromycin ethylsuccinate 800 mg po qid x 7 d or Ofloxacin3 300 mg po bid x 7 d

EPIDIDYMITIS

Likely due to Gonorrhea or Chlamydia

• Ceftriaxone plus

Doxycycline

Likely due to enteric organisms

• Ofloxacin3

250 mg IM

100 mg po bid x 10 d

300 mg po bid x 10 d

TRICHOMONIASIS

• Metronidazole

2 g po

Metronidazole 500 mg po bid x 7 d

BACTERIAL VAGINOSIS

Adults/Adolescents

• Metronidazole or

• Clindamycin cream10 or

• Metronidazole gel

500 mg po bid x 7 d

2%, one full applicator (5g) intravaginally at bedtime x 7 d

0.75%, one full applicator (5g) intravaginally, bid x 5 d

Metronidazole 2 g po or

Clindamycin 300 mg po bid x 7 d

Pregnant Women

• Metronidazole

250 mg po tid x 7 d

Metronidazole 2 g po or
Clindamycin 300 mg po bid x 7 d

CHANCROID

• Azithromycin or

• Ceftriaxone or

• Ciprofloxacin3 or

• Erythromycin base

1 g po

250 mg IM

500 mg po bid x 3 d

500 mg po qid x 7 d

LYMPHOGRANULOMA

VENEREUM

• Doxycycline2

100 mg po bid x 21 d

Erythromycin base 500 mg po qid x 21 d




DISEASE

RECOMMENDED REGIMENS DOSE/ROUTE ALTERNATIVE REGIMENS

HUMAN PAPILLOMAVIRUS

External Genital/

Perianal Warts

Patient Applied

• Podofilox11 0.5% solution or gel or

• Imiquimod12 5% cream

Provider Administered
• Cryotherapy or

• Podophyllin11 resin 10%-25% in tincture of benzoin or

• Trichloroacetic acid (TCA)
or Bichloroacetic acid (BCA) 80%- 90% or

• Surgical removal

 

Alternative Regimen

Intralesional interferon or laser surgery

Vaginal Warts

• Cryotherapy or

• TCA or BCA 80%-90% or

• Podophyllin11 10%-25% in tincture of benzoin

 

 

Urethral Meatus Warts

• Cryotherapy or

• Podophyllin11 10%-25% in tincture of benzoin

 

 

Anal Warts

• Cryotherapy or

• TCA or BCA 80%-90% or

• Surgical removal

HERPES SIMPLEX VIRUS13

First Clinical Episode of Herpes

• Acyclovir12or

• Acyclovir12 or

• Famciclovir12 or

• Valacyclovir12

400 mg po tid x 7-10 d

200 mg po 5 x q d x 7-10 d

250 mg po tid x 7-10 d

1 g po bid x 7-10 d

Episodic Therapy for Recurrent Episodes

• Acyclovir12 or

• Acyclovir12 or

• Acyclovir12 or

• Famciclovir12 or

• Valacyclovir12

400 mg po tid x 5 d

200 mg po 5 x q d x 5 d

800 mg po bid x 5 d

125 mg bid x 5 d

500 mg po bid x 5 d

Supressive Therapy

• Acyclovir12 or

• Famciclovir12 or

• Valacyclovir12 or

• Valacyclovir12

400 mg po bid

250 mg po bid

500 mg po qd

1 g po qd

SYPHILIS

Primary, Secondary, and Early Latent

• Benzathine penicillin G

2.4 million units IM

Doxycycline2 100 mg po bid x 2 weeks or

Tetracycline2 500 mg po qid x 2 weeks

Late Latent and Unknown duration

• Benzathine penicillin G

7.2 million units, administered

as 3 doses of 2.4 million units

IM, at 1-week intervals

Doxycycline2 100 mg po bid x 4 weeks or

Tetracycline2 500 mg po qid x 4 weeks

Neurosyphilis14

• Aqueous crystalline penicillin G

18-24 million units daily, administered as 3-4 million units IV q 4 hrs x 10-14 d

Procaine penicillin G,
2.4 million units IM q d x 10-14 d plus

Probenecid 500 mg po qid x 10-14 d

Pregnant Women14

Primary, Secondary, and Early Latent15

• Benzathine penicillin G

2.4 million units IM

None

Late Latent and Unknown duration

• Benzathine penicillin G

7.2 million units, administered as 3 doses of 2.4 million units IM, at 1-week intervals

None

Neurosyphilis14

• Aqueous crystalline penicillin G

18-24 million units daily, administered as 3-4 million units IV q 4 hrs x 10-14 d

Procaine penicillin G,
2.4 million units IM q d x 10-14 d plus

Probenecid 500 mg po qid x 10-14 d

HIV Infection

Primary, Secondary and Early Latent

• Benzathine penicillin G

2.4 million units IM

Doxycycline2 100 mg po bid x 2 weeks or Tetracycline2 500 mg po qid x 2 weeks

Late Latent, and Unknown duration14 with normal CSF Exam

• Benzathine penicillin G

7.2 million units, administered as 3 doses of 2.4 million units IM, at 1-week intervals

None

Neurosyphilis14

• Aqueous crystalline penicillin G

18-24 million units daily, administered as 3-4 million units IV q 4 hrs x 10-14d

Procaine penicillin G,
2.4 million units IM q d x 10-14 d plus

Probenecid 500 mg po qid x 10-14 d

  1. Screen adolescents annually and women 20-24 years, especially if new or multiple partners.
  2. Contraindicated for pregnant and nursing women.
  3. Contraindicated for pregnant and nursing women and children < 18 years of age.
  4. Test-of-cure follow-up is recommended because the regimens are not highly efficacious (Amoxicillin and Erythromycin) or the data on safety and efficacy are limited (Azithromycin)
  5. Co-treatment for chlamydia infection is indicated if co-infection rates are high (>20%), less sensitive or no chlamydia test is done, or follow-up is uncertain.
  6. Not recommended for pharyngeal gonococcal infection.
  7. For patients who cannot tolerate cephalosporins or quinolones; not recommended for pharyngeal gonococcal infection.
  8. Discontinue 24 hours after patient improves clinically and continue with oral therapy for a total course of 14 days.
  9. Testing for gonorrhea and chlamydia is recommended beause a specific diagnosis may improve compliance and partner management and these   infections are reportable by CA State Law.
  10. Might weaken latex condoms and diaphragms because oil-based; not recommended in pregnancy.
  11. Contraindicated during pregnancy.
  12. Safety in pregnancy has not been established.
  13. Counseling especially about natural history, asymptomatic shedding, and sexual transmission is an essential component of herpes management.
  14. Patients allergic to penicillin should be treated with penicillin after desensitization.
  15. Some experts recommend a second dose of 2.4 million.

 


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© California STD Initiatives. For more information please contact:
Jas Nagra M.P.H. (California Chlamydia Action Coalition) jnagra@dhs.ca.gov
Gail Kennedy, M.P.H. (Syphilis Elimination Project) gkennedy@psg.ucsf.edu