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CURRENT Diagnosis & Treatment of Sexually Transmitted Diseases

Appendix: Centers for Disease Control and Prevention 2006 Treatment Guidelines for Sexually Transmitted Diseases

Jeffrey D. Klausner, MD, MPH

Centers for Disease Control and Prevention 2006 Treatment Guidelines for Sexually Transmitted Diseases

Table 1. CDC STD Treatment Guidelines for Adults and Adolescents, 2006.

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Table 1. CDC STD Treatment Guidelines for Adults and Adolescents, 2006.

Disease

Recommended Regimens

Dose/Route

Alternative Regimens

Bacterial Vaginosis

Adults and adolescents

500 mg PO twice daily for 7 d

Clindamycin, 300 mg PO twice daily for 7 d

or

or

Metronidazole gel

0.75%, one full applicator (5 g) intravaginally once daily for 5 d

Clindamycin ovules, 100 g intravaginally at bed time for 3 d

or

Clindamycin creama

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

Pregnant women

500 mg PO twice daily for 7 d

or

250 mg PO 3 times daily for 7 d

or

300 mg PO twice daily for 7 d

Cervicitisb

1 g PO

or

Doxycyclinec

100 mg PO twice daily for 7 d

Chancroid

1 g PO

or

250 mg IM

or

500 mg PO twice daily for 3 d

or

Erythromycin base

500 mg PO 3 times daily for 7 d

Chlamydia

Uncomplicated, infections adults and adolescentsd

1 g PO

Erythromycin base, 500 mg PO 4 times daily for 7 d

or

or

Doxycyclinec

100 mg PO twice daily for 7 d

Erythromycin ethylsuccinate, 800 mg PO 4 times daily for 7 d

or

Ofloxacin,c 300 mg PO twice daily for 7 d

or

Levofloxacin,c 500 mg PO once daily for 7 d

Pregnant womene

l g PO

Erythromycin base, 500 mg PO 4 times daily for 7 d

or

or

500 mg PO 3 times daily for 7 d

Erythromycin base, 250 mg PO 4 times daily for 14 d

or

Erythromycin ethylsuccinate, 800 mg PO 4 times daily for 7 d

or

Erythromycin ethylsuccinate, 400 mg PO 4 times daily for 14 d

Epididymitisb

Likely due to gonorrhea or chlamydia

250 mg IM

plus

100 mg PO twice daily for 10 d

Likely due to enteric organisms

Ofloxacinf

300 mg PO twice daily for 10 d

or

Levofloxacinf

500 mg PO once daily for 10 d

Gonorrheag

Fluoroquinolones are no longer recommended for treatment of gonococcal infections in men who have sex with men or in California or Hawaii because of increasing resistance to that class of drugs. If fluoroquinolones are the only drug available and must be used, “test-of-cure” after treatment is recommended.

Uncomplicated infections, adults and adolescents

125 mg IM

Spectinomycin, 2 g IM

or

or

Cefiximeh,i

400 mg PO

Single-dose cephalosporin regimens; cefpodoxime, 400 mg PO, or cefuroxime axetil, 1 g PO, may be additional alternatives

plus

or

Treatment for chlamydia if chlamydial infection has not been ruled out

Single-dose quinolone regimens (see note above) include ciprofloxacin, 500 mg PO (preferred); ofloxacin, 400 mg PO; levofloxacin, 250 mg PO; gatifloxacin, 400 mg PO; norfloxacin, 800 mg PO; or lomefloxacin, 400 mg PO

Pharyngeal infections

125 mg IM

or

500 mg PO

plus

Treatment for chlamydia, if chlamydial infection has not been ruled out

Pregnant women

125 mg IM

Single-dose cephalosporin

plus

or

Treatment for chlamydia, if chlamydial infection has not been ruled out

Spectinomycin, 2 g IM

Herpes Simplex Virusj

First clinical episode

400 mg PO 3 times daily for 7–10 d

or

200 mg PO 5 times daily for 7–10 d

or

250 mg PO 3 times daily for 7–10 d

or

1 g PO twice daily for 7–10 d

Episodic therapy for recurrent episodes

400 mg PO 3 times daily for 5 d

or

800 mg PO twice daily for 5 d

or

800 mg PO 3 times daily for 2 d

or

125 mg PO twice daily for 5 d

or

1000 mg PO twice daily for 1 d

or

500 mg PO twice daily for 3 d

or

1 g PO once daily for 5 d

Suppressive therapy

400 mg PO twice daily

or

250 mg PO twice daily

or

500 mg PO once daily

or

1 g PO once daily

HIV co-infectedk

Episodic therapy for recurrent episodes

400 mg PO 3 times daily for 5–10 d

or

500 mg PO twice daily for 5–10 d

or

1 g PO twice daily for 5–10 d

Suppressive therapy

400–800 mg PO 2–3 times daily

or

500 mg PO twice daily

or

500 mg PO twice daily

Human Papillomavirus

External genital warts

Patient applied

Podofiloxl 0.5% solution or gel

Twice daily for 3 d, followed by 4 d with no therapy, for a total of 4 wk

Intralesional interferon

or

or

Imiquimod,m 5% cream

Once daily at bedtime, 3 times weekly for up to 16 wk

Laser surgery

Provider administered

Cryotherapy

Repeat 1–2 wk

or

Podophyllinl resin 10—25% in tincture of benzoin

Apply, air dry, repeat weekly

or

Trichloroacetic acid (TCA)

Apply, air dry, repeat weekly

or

Bichloroacetic acid (BCA) 80–90%

Apply, air dry, repeat weekly

or

Surgical removal

Tangential scissor excision, tangential shave excision, curettage, or electrosurgery

Mucosal genital warts

Cryotherapy

Vaginal, urethral, and anal

or

TCA or BCA 80–90%

Vaginal and anal

or

Podophyllinl resin 10–25% in tincture of benzoin

Urethral

or

Surgical removal

Anal

Lymphogranuloma Venereum

Doxycyclinec

100 mg PO twice daily for 21 d

Erythromycin base, 500 mg PO 4 times daily for 21 d

Nongonococcal Urethritisb

1 g PO

Erythromycin base, 500 mg PO 4 times daily for 7 d

or

or

100 mg PO twice daily for 7 d

Erythromycin ethylsuccinate, 800 mg PO 4 times daily for 7 d

or

Ofloxacin, 300 mg PO twice daily for 7 d

or

Levofloxacin, 500 mg PO once daily for 7 d

Pelvic Inflammatory Diseaseb

Parenteraln

Parenteraln

Either cefotetan

2 g IV q 12 h

Either ofloxacin,c,f 400 mg IV q 12 h

or

with or without

2 g IV q 6 h

Metronidazole, 500 mg IV q 8 h

plus

or

Doxycyclinec

100 mg PO or IV q 12 h

Levofloxacin,c,f 500 mg IV once daily

or

with or without

900 mg IV q 8 h

Metronidazole, 500 mg IV q 8 h

plus

or

2 mg/kg IV or IM followed by 1.5 mg/kg IV or IM q 8 h

Ampicillin/sulbactam, 3 g IV q 6 h

plus

Doxycycline,c 100 mg PO or IV q 12 h

Oral/IM

Oral

• Levofloxacinc,f

500 mg PO once daily for 14 d

Either ofloxacin,c,f 400 mg PO twice daily for 14 d

or

or

Ofloxacinc,f

400 mg PO twice daily for 14 d

Levofloxacin,c,f 500 mg PO once daily for 14 d

with or without

plus

500 mg PO twice daily for 14 d

Metronidazole, 500 mg PO twice daily for 14 d

• Either ceftriaxone or

250 mg IM

2 g IM

with

1 g PO

plus

Doxycyclinec

100 mg PO twice daily for 14 d

with or without

500 mg PO twice daily for 14 d

Syphiliso

Primary, secondary, and early latent

Benzathine penicillin G

2.4 million units IM as a single dose

Doxycycline, 100 mg PO twice daily for 14 d

or

Tetracycline, 500 mg PO 4 times daily for 14 d

or

Ceftriaxone, 1 g IM or IV once daily for 8–10 d

or

Azithromycin, 2-g single oral dose

(All of the above should be used with caution and close follow-up)

Late latent and unknown duration

Benzathine penicillin G

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

Doxycycline, 100 mg PO twice daily for 28 d

or

Tetracycline 500 mg PO 4 times daily for 28 d

(All of the above should be used with caution and close follow-up)

Neurosyphilisp

Aqueous crystalline penicillin G

18–24 million units daily, administered as 3–4 million units IV q 4 h for 10–14 d

Procaine penicillin G, 2.4 million units IM once daily for 10–14 d

plus

Probenecid, 500 mg PO 4 times daily for 10–14 d

Pregnant womenq

Primary, secondary, and early latent

Benzathine penicillin G

2.4 million units IM as a single dose

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-wk intervals

None

Neurosyphilisp

Aqueous crystalline penicillin G

18–24 million units daily, administered as 3–4 million units IV q 4 h for 10–14 d

Procaine penicillin G, 2.4 million units IM once daily for 10–14 d

plus

Probenecid, 500 mg PO 4 times daily for 10–14 d

HIV co-infected

Primary, secondary and early latent

Benzathine penicillin G

2.4 million units IM

Doxycycline, 100 mg PO twice daily for 14 d

or

Tetracycline, 500 mg PO 4 times daily for 14 d

or

Ceftriaxone, 1 g IM or IV once daily for 8–10 d

or

Azithromycin, 2-g single oral dose

(All of the above should be used with caution and close follow-up)

Late latent, and unknown durationq with normal CSF examination

Benzathine penicillin G

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

None

Neurosyphilisp,q

Aqueous crystalline penicillin G

18—24 million units daily, administered as 3—4 million units IV q 4 h for 10—14 d

Procaine penicillin G, 2.4 million units IM once daily for 10—14 d

plus

Probenecid, 500 mg PO 4 times daily for 10—14 d

Trichomoniasisr

2 g PO

Metronidazole, 500 mg PO twice daily for 7 d

2 g PO

aMight weaken latex condoms and diaphragms because oil based; not recommended in pregnancy.

bTesting for gonorrhea and chlamydia is recommended because a specific diagnosis may improve compliance and partner management. These infections are reportable in all states.

cContraindicated for pregnant and nursing women.

dAnnual screening for women aged 25 years or younger. Nucleic acid amplification tests (NAATs) are recommended. Women with chlamydia should be rescreened 3–4 mo after treatment.

e“Test-of-cure” follow-up is recommended in pregnancy.

fIf gonorrhea is documented, change to a medication regimen that does not include a fluoroquinolone. “Test-of-cure” follow-up is recommended to ensure patient does not have untreated, resistant gonorrhea infection.

gCo-treatment for Chlamydia trachomatis infection is indicated unless chlamydia has been ruled out using sensitive technology or 2-g azithromycin dose is used.

hCefixime is available in liquid formulation only.

iFor patients with significant anaphylaxis-type (IgE-mediated) allergies to penicillin, in whom the use of cephalosporins is a concern, or patients with allergies to cephalosporins, spectinomycin (2 g IM) or azithromycin (2 g PO) may be used.

jCounseling about natural history, asymptomatic shedding, and sexual transmission is an essential component of herpes management.

kIf lesions persist or recur while receiving antiviral treatment, antiviral resistance should be suspected and a viral isolate should be obtained for sensitivity testing.

lContraindicated during pregnancy.

mSafety in pregnancy has not been well established.

nDiscontinue 24 h after patient improves clinically and continue with oral therapy for a total of 14 d.

oBenzathine penicillin G (the generic name) is the recommended treatment for syphilis not involving the central nervous system and is available in multiple formulations. Bicillin L-A (or long acting; the trade name) contains only benzathine penicillin G. Other combination products, such as Bicillin C-R, should not be used to treat syphilis.

pSome specialists recommend 2.4 million units of benzathine penicillin G weekly for 1–3 wk after completion of neurosyphilis treatment. Although doxycycline may be used to treat late latent syphilis in penicillin-allergic patients, this drug is not recommended for the treatment of neurosyphilis.

qPatients allergic to penicillin should be treated with penicillin after desensitization.

rIf reinfection is ruled out and persistence of trichomoniasis is documented, evaluate for metronidazole-resistant Trichomonas vaginalis. Consultation and T vaginalis susceptibility testing is available from the CDC at 770-488-4115.

CDC, Centers for Disease Control and Prevention; CSF, cerebrospinal fluid; STD, sexually transmitted disease.

Based on Centers for Disease Control and Prevention; Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55(RR-11):1–94.

Table 2. Highlights from the CDC STD Treatment Guidelines, 2006.

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Table 2. Highlights from the CDC STD Treatment Guidelines, 2006.

Topic

CDC Comment

Note

Diagnosis of cervicitis

Criteria:

1. Purulent or mucopurulent endocervical exudate visible in endocervical canal or on an endocervical swab specimen, and
2. Sustained cervical bleeding easily induced by gentle passage of a cotton swab through the cervical os

Assess for pelvic inflammatory disease and test for Chlamydia trachomatis, Neisseria gonorrhoeae, bacterial vaginosis, and trichomoniasis

Diagnosis of trichomoniasis

Diagnostic tests include microscopy, Osom Trichomonas Rapid Test, immunochromatographic capillary flow dipstick, Affirm VPIII, and culture

Commercially available assays may be more costly; culture remains the “gold standard”

Treatment of trichomoniasis

Additional treatment regimen: tinidazole 2-g PO single dose

Avoid alcohol during and up to 72 h after treatment with tinidazole

Treatment of chlamydia in pregnancy

Clinical experience and studies suggest that azithromycin (1 g PO as a single dose) is safe and effective

Pregnant women with chlamydial infection should undergo “test-of–cure” >3 wk after treatment

Role of Mycoplasma genitalium in urethritis

Ureaplasma urealyticum and M genitalium have been implicated as etiologic agents of nongonococcal urethritis in some studies; however, detection of these organisms is frequently difficult

Nucleic acid amplification tests (NAATs) may be available for M genitalium diagnosis

Role of M genitalium in cervicitis

Limited data indicate that infection with M genitalium and bacterial vaginosis as well as frequent douching may cause cervicitis

Treatment of M genitalium

Infections with M genitalium may respond better to azithromycin than to tetracyclines

Management of lymphogranuloma venereum proctocolitis in men who have sex with men

Recommended treatment regimen: doxycycline, 100 mg PO twice daily for 21 d

Sex partners within 60 d should be examined, tested, and treated with standard chlamydia regimen

CSF examination in evaluation of neurosyphilis

Patients who have syphilis and who demonstrate any of the following criteria should undergo prompt CSF examination:

• Neurologic or ophthalmic signs or symptoms
• Evidence of active tertiary syphilis (eg, aortitis and gumma)
• Treatment failure, or
• HIV infection with late latent syphilis or syphilis of unknown duration

Emergence of azithromycin-resistant Treponema pallidum

Several cases of azithromycin treatment failure have been reported, and resistance to azithromycin has been documented in several geographic areas

Azithromycin is not recommended in the treatment of syphilis

Increase in fluoroquinolone-resistant N gonorrhoeae in men who have sex with men

In 2004, quinolone-resistant N gonorrhoeae was more common among men who have sex with men than among heterosexual men (23.9% vs 2.9%)

Quinolones should not be used in the treament of gonorrhea among men who have sex with men

Sexual transmission of hepatitis C

Findings indicate that sexual transmission of hepatitis C virus is possible but inefficient

Use of postexposure prophylaxis after sexual assault

Recommended:

• Postexposure hepatitis B vaccination
• Empiric antimicrobial regimen for chlamydia, gonorrhea, trichomoniasis, and bacterial vaginosis (see next column)
• Emergency contraception, if pregnancy is possible
• Postexposure prophylaxis for HIV infection, depending on characteristics of the assailant and the assault

Suggested antimicrobial regimen after sexual assault:

Ceftriaxone, 125 mg IM as a single dose
plus
Metronidazole, 2 g PO as a single dose
plus
Azithromycin, 1 g PO as a single dose
or
Doxycycline, 100 mg PO twice daily for 7 d

STD prevention approaches

Recommended:

• Abstinence and reduction in number of sex partners
• Preexposure vaccination
• Male condoms
• Female condoms

Not recommended:

• Vaginal spermicide and diaphragms
• Condoms and N-9 vaginal spermicides
• Rectal use of N-9 spermicides
• Non–barrier contraception, surgical sterilization, and hysterectomy (offer no protection against STDs)

Emergency contraception is effective; providers should counsel women concerning the option for emergency contraception, if indicated, and provide emergency contraception in a timely fashion

Partner management

When medical evaluation, counseling, and treatment of a partner cannot be done because of the particular circumstances of a patient or partner or because of resource limitations, other partner management options can be considered; one option is patient-delivered therapy

Patient-delivered therapy is a partner management option in which partners of infected patients are treated without previous medical evaluation or prevention counseling

Patient-delivered therapy can prevent reinfection of the index case and has been associated with a higher likelihood of partner notification, compared with unassisted patient referral of partners

CDC, Centers for Disease Control and Prevention; CSF, cerebrospinal fluid; N-9, nonoxynol-9; STD, sexually transmitted disease.

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