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 Back to top 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 Back to top Screen adolescents annually and women 20-24 years, especially if new or multiple partners. Contraindicated for pregnant and nursing women. Contraindicated for pregnant and nursing women and children < 18 years of age. 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) 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. Not recommended for pharyngeal gonococcal infection. For patients who cannot tolerate cephalosporins or quinolones; not recommended for pharyngeal gonococcal infection. Discontinue 24 hours after patient improves clinically and continue with oral therapy for a total course of 14 days. 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. Might weaken latex condoms and diaphragms because oil-based; not recommended in pregnancy. Contraindicated during pregnancy. Safety in pregnancy has not been established. Counseling especially about natural history, asymptomatic shedding, and sexual transmission is an essential component of herpes management. Patients allergic to penicillin should be treated with penicillin after desensitization. Some experts recommend a second dose of 2.4 million. Back to top   Home | Chlamydia Coalition | Syphilis Elimination | Clinical Guidelines | STD Statistics STD Publications | Partner Organizations | STD Resources © 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