Table 5. Sexually Transmitted Disease Treatment Recommendations for Adults and Adolescents

Disease

Recommended Regimen(s) and Dose/Route

Alternative Regimens: To be used if medical contraindication to recommended regimen

Chlamydia

Uncomplicated genital/rectal/
pharyngeal infections1 

  • [Azithromycin] 1 g PO single dose or
  • [Doxycycline]2 100 mg PO BID x 7 days
  • [Erythromycin] base 500 mg PO QID x 7 days or
  • [Erythromycin] ethylsuccinate 800 mg PO QID x 7 days or
  • [Ofloxacin]2 300 mg PO BID x 7 days or
  • [Levofloxacin]2 500 mg PO QD x 7 days

Pregnant women3

  • [Azithromycin] 1 g PO single dose
  • [drug: Amoxicillin] 500 mg PO TID x 7 days or
  • [Erythromycin] base 500 mg PO QID x 7 days or
  • [Erythromycin] base 250 mg PO QID x 14 days or
  • [Erythromycin] ethylsuccinate 800 mg PO QID x 7 days or
  • [Erythromycin] ethylsuccinate 400 mg PO QID x 14 days

Gonorrhea [Ceftriaxone] plus [drug: azithromycin] is the recommended treatment for adult and adolescent patients with uncomplicated gonorrhea infections. [Cefixime] is no longer recommended as a first-line cephalosporin for gonorrhea treatment based on the increasing prevalence of gonococcal isolates in the United States with reduced susceptibility to [cefixime] from 2006-2011[ref: CDC STD]; however, it may be used if [ceftriaxone] is not available. In addition, fluoroquinolones are no longer recommended for treatment of gonococcal infections in the United States because of high levels of resistance.

Uncomplicated genital/urethral/ rectal infections1

  • [Ceftriaxone] 250 mg IM single dose plus [drug: azithromycin] 1 g PO single dose4
  • [Cefixime]5 400 mg PO single dose plus [drug: azithromycin] 1 g PO single dose4

Pharyngeal infections

  • [Ceftriaxone] 250 mg IM single dose plus [drug: azithromycin] 1 g PO single dose4

 

Pregnant women

  • [Ceftriaxone] 250 mg IM single dose plus [drug: azithromycin] 1 g PO single dose4

Trichomoniasis6

Nonpregnant women

  • [Metronidazole] 2 g PO single dose or
  • [Tinidazole]7 2 g PO single dose
  • [Metronidazole] 500 mg PO BID x 7 days

Pregnant women

  • [Metronidazole] 2 g PO single dose
  • [Metronidazole] 500 mg PO BID x 7 days

HIV-infected women

  • [Metronidazole] 500 mg PO BID x 7 days

 

Bacterial Vaginosis

Nonpregnant women

  • [Metronidazole] 500 mg PO BID x 7 days or
  • Metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally QD x 5 days or
  • [Clindamycin topical] cream 2%, 1 full applicator (5 g) intravaginally QD at bedtime x 7 days
  • [Tinidazole]7 2 g PO QD x 2 days or
  • [Tinidazole]7 1 g PO QD x 5 days or
  • [Clindamycin] 300 mg PO BID x 7 days or
  • [Clindamycin topical] ovules 100 mg intravaginally once at bedtime for 3 days

Pregnant women

  • [Metronidazole] 500 mg PO BID x 7 days or
  • [Metronidazole] 250 mg PO TID x 7 days or
  • [Clindamycin] 300 mg BID x 7 days

Lymphogranuloma Venereum


  • [Doxycycline]2 100 mg PO BID x 21 days
  • [Erythromycin] base 500 mg PO QID x 21 days

Anogenital Herpes8

First clinical episode of herpes

  • [Acyclovir] 400 mg PO TID x 7-10 days or
  • [drug: Acyclovir] 200 mg PO 5 times daily x 7-10 days or
  • [Famciclovir] 250 mg PO TID x 7-10 days or
  • [Valacyclovir] 1 g PO BID x 7-10 days
  • None

Established infection in the HIV-uninfected person

  • Suppressive therapy9
  • [Acyclovir] 400 mg PO BID or
  • [Famciclovir] 250 mg PO BID or
  • [Valacyclovir] 500 mg PO QD or
  • [Valacyclovir] 1 g PO QD
  • None
  • Episodic therapy for recurrent episodes
  • [Acyclovir] 400 mg PO TID x 5 days or
  • [Acyclovir] 800 mg PO BID x 5 days or
  • [Acyclovir] 800 mg PO TID x 2 days or
  • [Famciclovir] 125 mg PO BID x 5 days or
  • [Famciclovir] 1 g PO BID x 1 day or
  • [Famciclovir] 500 mg once, followed by 250 mg BID x 2 days or
  • [Valacyclovir] 500 mg PO BID x 3 days or
  • [Valacyclovir] 1 g PO QD x 5 days
  • None

Established infection in the HIV-coinfected person10

  • Suppressive therapy9
  • [Acyclovir] 400-800 mg PO BID-TID or
  • [Famciclovir] 500 mg PO BID or
  • [Valacyclovir] 500 mg PO BID
  • None
  • Episodic therapy for recurrent episodes
  • [Acyclovir] 400 mg PO TID x 5-10 days or
  • [Famciclovir] 500 mg PO BID x 5-10 days or
  • [Valacyclovir] 1 g PO BID x 5-10 days
  • None

HPV Warts

  • Anogenital (penis, groin, scrotum, vulva, perineum, external anus, and perianus)

Patient applied:

  • [drug: Imiquimod topical] 3.75% or 5% cream11 or
  • [drug: Podofilox topical] 0.5% solution or gel or
  • [drug: Sinecatechins topical] 15% ointment11

Provider administered:

  • Cryotherapy with liquid nitrogen or cryoprobe or
  • Surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser, or electrosurgery or
  • [drug: Trichloroacetic acid topical] or bichloroacetic acid 80% to 90% solution

Provider administered:

  • [drug: Podophyllum resin topical] 10% to 25% (in compound tincture of benzoin) or
  • Intralesional interferon or
  • Photodynamic therapy or
  • Topical [drug: cidofovir]
  • Urethral meatus warts
  • Cryotherapy with liquid nitrogen or
  • Surgical removal
  • None
  • Vaginal, cervical, or intra-anal warts12
  • Cryotherapy with liquid nitrogen or
  • Surgical removal or
  • [drug: Trichloroacetic acid topical] or bichloroacetic acid 80% to 90% solution
  • None

Syphilis13

Primary, secondary, and early latent

  • [Penicillin G benzathine] 2.4 million units IM single dose
  • [Doxycycline]14 100 mg PO BID x 14 days or
  • [drug: Tetracycline]14 500 mg PO QID x 14 days or
  • [Ceftriaxone]14 1-2 g IM or IV QD x 10-14 days

Late latent and latent of unknown duration or tertiary with normal CSF examination

  • [Penicillin G benzathine] 7.2 million units, administered as 3 doses of 2.4 million units IM each, at 1-wk intervals
  • [Doxycycline]14 100 mg PO BID x 28 days or
  • [drug: Tetracycline]14 500 mg PO QID x 28 days

Neurosyphilis, including ocular syphilis15

  • Aqueous crystalline penicillin G 18-24 million units daily, administered as 3-4 million units IV every 4 hrs or by continuous infusion x 10-14 days
  • [drug: Procaine penicillin] G, 2.4 million units IM QD x 10-14 days plus [drug: probenecid] 500 mg PO QID x 10-14 days, with or without [drug: penicillin G benzathine] 2.4 million units IM weekly for 3 doses after completion of above (patients who are allergic to sulfa-containing medications should not receive [drug: probenecid]; thus the [drug: procaine penicillin] regimen is not recommended for these patients) 

Pregnant women16

  • Primary, secondary, and early latent
  • [Penicillin G benzathine] 2.4 million units IM as a single dose
  • None
  • Late latent and latent of unknown duration
  • [Penicillin G benzathine] 7.2 million units, administered as 3 doses of 2.4 million units IM each, at 1-wk intervals
  • None
  • Neurosyphilis, including ocular syphilis15,17
  • Aqueous crystalline penicillin G 18-24 million units daily, administered as 3-4 million units IV every 4 hrs x 10-14 days
  • [drug: Procaine penicillin] G 2.4 million units IM QD x 10-14 days plus [drug: probenecid] 500 mg PO QID x 10-14 days, with or without [drug: penicillin G benzathine] 2.4 million units IM weekly for 3 doses after completion of above (patients who are allergic to sulfa-containing medications should not receive [drug: probenecid]; thus the [drug: procaine penicillin] regimen is not recommended for these patients)

HIV coinfected

  • Primary, secondary, and early latent
  • [Penicillin G benzathine] 2.4 million units IM single dose
  • [Doxycycline]14 100 mg PO BID x 14 days or
  • [Tetracycline]14 500 mg PO QID x 14 days
  • Late latent and latent of unknown duration with normal CSF exam
  • [Penicillin G benzathine] 7.2 million units, administered as 3 doses of 2.4 million units IM each, at 1-wk intervals
  • [Doxycycline]14 100 mg PO BID x 28 days
  • Neurosyphilis15
  • Aqueous crystalline penicillin G 18-24 million units daily, administered as 3-4 million units IV every 4 hrs or by continuous infusion x 10-14 days
  • [drug: Procaine penicillin] G 2.4 million units IM QD x 10-14 days plus [drug: probenecid] 500 mg PO QID x 10-14 days, with or without [drug: penicillin G benzathine] 2.4 million units IM weekly for 3 doses after completion of above (patients who are allergic to sulfa-containing medications should not receive [drug: probenecid]; thus the [drug: procaine penicillin] regimen is not recommended for these patients) 

BID, twice daily; IM, intramuscular; IV, intravenous; NAAT, nucleic acid amplification tests; PO, by mouth; QD, once daily; QID, 4 times daily; TID, 3 times daily.

  1. 1. Annual chlamydia screening and annual gonorrhea screening for all sexually active woman aged younger than 25 yrs and women who are older and at increased risk for infection. NAATS are recommended. All patients should be retested 3 mos after treatment for chlamydia or gonorrhea infections.
  2. 2. Contraindicated for pregnant and nursing women.
  3. 3. Test-of-cure follow-up (preferably by NAAT) 3-4 wks after completion of therapy is recommended in pregnancy.
  4. 4. [Drug: Azithromycin] preferred over [doxycycline] as second antimicrobial based on convenience of single-dose therapy and on high prevalence of [drug: tetracycline] resistance detected among Gonococcal Isolate Surveillance Project isolates.
  5. 5. Use only if [ceftriaxone] is unavailable.
  6. 6. For suspected drug-resistant trichomoniasis, rule out reinfection; see CDC Guidelines, Trichomonas Follow-up, for other treatment options, and evaluate for [metronidazole]-resistant T vaginalis. For laboratory and clinical consultations, contact CDC at: 404-718-4141, http://www.cdc.gov/std. The longer regimen of [metronidazole] is preferred in HIV-infected women, as it provides superior cure rates.[Kissinger 2010]
  7. 7. Safety in pregnancy has not been established. Animal data suggest moderate risk; therefore, [drug: tinidazole] should be avoided in pregnant women.
  8. 8. Counseling about natural history, asymptomatic shedding, and sexual transmission is an essential component of herpes management.
  9. 9. The goal of suppressive therapy is to reduce recurrent symptomatic episodes and/or to reduce sexual transmission.
  10. 10. If HSV lesions persist or recur while receiving antiviral treatment, antiviral resistence should be suspected. A viral isolate should be obtained for sensitivity testing, and consultation with an infectious disease expert is recommended.
  11. 11. May weaken condoms and vaginal diaphragms.
  12. 12. Cryoprobe use not recommended in the vagina because of risk for vaginal perforation and fistula formation. Management of intra-anal or cervical warts should include consultation with a specialist. Exophytic cervical warts must be evaluated by biopsy to exclude high-grade squamous intraepithelial lesion before initiating treatment.
  13. 13. [Penicillin G benzathine] is the recommended treatment for syphilis not involving the central nervous system and is available in only 1 long-acting formulation, [Bicillin L-A], which contains only [penicillin G benzathine]. Other combination products, such as [Bicillin C-R], contain both long- and short-acting penicillins and are not effective for treating syphilis.
  14. 14. Alternates should be used only for penicillin-allergic patients because efficacy of these therapies has not been established. Compliance with some of these regimens is difficult, and close follow-up is essential. If compliance or follow-up cannot be ensured, the patient should be desensitized and treated with [penicillin G benzathine].
  15. 15. Some specialists recommend 2.4 million units of [penicillin G benzathine] every wk for up to 3 wks after completion of neurosyphilis treatment.
  16. 16. Patients allergic to penicillin should be treated with penicillin after desensitization.
  17. 17. Additional penicillin doses may be indicated for pregnant women with early syphilis if there is evidence of fetal syphilis detected by ultrasound.