Sexually Transmitted Diseases Treatment Guidelines

STD Treatment Guidelines

Generic	Brand	Form	Dosing Regimen
SEXUALLY TRANSMITTED DISEASES TREATMENT GUIDELINES
BACTERIAL VAGINOSIS¹
Recommended
clindamycin cream²	Cleocin Vaginal Cream	2% vaginal cream	Adults: 1 applicatorful intravaginally at bedtime. Nonpregnant: treat for 3 or 7 days. Pregnant (2nd or 3rd trimester): treat for 7 days
clindamycin cream²	Clindesse	2% vaginal cream	Adults: 1 applicatorful intravaginally once
metronidazole	Flagyl	scored tabs	Adults: 500mg twice daily for 7 days
	MetroGel-Vaginal	0.75% vaginal gel	Adults: 1 applicatorful once daily for 5 days
	Vandazole	0.75% vaginal gel	Adults: 1 applicatorful once daily for 5 days
Alternative
clindamycin	Cleocin	caps	Adults: 300mg twice daily for 7 days
clindamycin	Cleocin Vaginal Ovules²	100mg vaginal supp	Adults: 1 supp at bedtime for 3 days
tinidazole	Tindamax	scored tabs	Adults: 2g once daily for 2 days or 1g once daily for 5 days
CERVICITIS³
azithromycin	Zithromax	tabs, susp, packets	Adults: 1g once
doxycycline⁴	—	tabs	Adults: 100mg twice daily for 7 days
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
CHLAMYDIA
Recommended
azithromycin⁵	Zithromax	tabs, susp, packets	Adults, pregnancy, children: ≥45kg or ≥8yrs: 1g once
doxycycline⁴	—	tabs	Adults, children: ≥8yrs: 100mg twice daily for 7 days
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
erythromycin base^6,7	—	tabs	Children: <45kg, ophthalmia neonatorum, infant pneumonia: 50mg/kg/day in 4 divided doses for 14 days
	Ery-Tab	tabs
	Eryc	caps
erythromycin ethylsuccinate	E.E.S.	tabs, susp	Children: <45kg, ophthalmia neonatorum, infant pneumonia: 50mg/kg/day in 4 divided doses for 14 days
	E.E.S. Granules	susp
	EryPed	susp
Alternative
amoxicillin	—	tabs, caps, susp	Pregnancy: 500mg three times daily for 7 days
amoxicillin	Amoxil	caps, susp	Pregnancy: 500mg three times daily for 7 days
azithromycin	Zithromax	tabs, susp, packets	Neonates: Ophthalmia neonatorum, infant pneumonia: 20mg/kg/day once daily for 3 days
erythromycin base^6,7	—	tabs	Adults, pregnancy: 500mg 4 times daily for 7 days or 250mg 4 times daily for 14 days
	Ery-Tab	tabs
	Eryc	caps
erythromycin ethylsuccinate	E.E.S.	tabs, susp	Adults, pregnancy: 800mg 4 times daily for 7 days or 400mg 4 times daily for 14 days
	E.E.S. Granules	susp
	EryPed
levofloxacin⁸	—	tabs, soln	Adults: 500mg once daily for 7 days
ofloxacin	—	tabs	Adults: 300mg twice daily for 7 days
EPIDIDYMITIS⁹
Etiology: chlamydia + gonorrhea
ceftriaxone +	—	inj	Adults: ceftriaxone 250mg IM once + doxycycline100mg orally twice daily for 10 days
doxycycline⁴	—	tabs
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
Etiology: chlamydia + gonorrhea + enteric organisms
ceftriaxone +	—	inj	Adults: ceftriaxone 250mg IM once + levofloxacin 500mg orally once daily for 10 days
levofloxacin	—	tabs, soln
ceftriaxone +	—	inj	Adults: ceftriaxone 250mg IM once + ofloxacin 300mg orally twice daily for 10 days
ofloxacin	—	tabs
Etiology: enteric organisms
levofloxacin	—	tabs, soln	Adults: 500mg once daily for 10 days
ofloxacin	—	tabs	Adults: 300mg twice daily for 10 days
GENITAL HERPES SIMPLEX
acyclovir	—	tabs, caps, susp, inj	Adults: First episode: 400mg orally 3 times daily or 200mg orally 5 times daily for 7–10 days¹⁰
acyclovir	Zovirax	susp	Episodic: 400mg orally 3 times daily or 800mg orally twice daily for 5 days, or 800mg orally 3 times daily for 2 days Suppressive: 400mg orally twice daily HIV episodic: 400mg orally 3 times daily for 5–10 days HIV suppressive: 400–800mg orally 2–3 times daily Pregnancy suppressive: 400mg orally 3 times daily (start at 36wks of gestation) Neonates: 20 mg/kg IV every 8hrs for 14 days (skin, mucous membranes) or 21 days (disseminated disease involving CNS)
famciclovir	—	tabs	Adults: First episode: 250mg 3 times daily for 7–10 days¹⁰ Episodic: 125mg twice daily for 5 days or 1g twice daily for 1 day¹⁰ or 500mg once then 250mg twice daily for 2 days Suppressive: 250mg twice daily HIV episodic: 500mg twice daily for 5–10 days HIV suppressive: 500mg twice daily
valacyclovir	Valtrex	scored tabs	Adults: First episode: 1g twice daily for 7–10 days¹⁰ Episodic: 500mg twice daily for 3 days or 1g once daily for 5 days Suppressive: 500mg or 1g once daily HIV episodic: 1g twice daily for 5–10 days HIV suppressive: 500mg twice daily Pregnancy suppressive: 500mg twice daily (start at 36wks of gestation)
GENITAL WARTS (HPV)
Recommended
imiquimod²	Aldara	5% cream	Adults: Apply at bedtime 3 times a week, up to 16 weeks
imiquimod²	Zyclara	3.75% cream	Adults: Apply at bedtime daily until total clearance or for up to 8 weeks
podofilox	Condylox	0.5% gel, soln	Adults: Apply twice daily for 3 days followed by 4 day break, up to 4 cycles
sinecatechins²	Veregen	15% ointment	Adults: Apply ½ cm 3 times daily, up to 16 weeks
bichloroacetic acid	—	90% soln	Adults: Provider administered: Apply weekly if needed
trichloroacetic acid	—	80% soln	Adults: Provider administered: Apply weekly if needed
Alternative
podophyllin resin in benzoin compound tincture	—	10–25%	Adults: Provider administered: Apply weekly if needed
GONOCOCCAL INFECTIONS
Recommended
ceftriaxone	—	inj	Adults: Uncomplicated urogenital, rectal, pharyngeal, pregnancy¹¹: (<150kg): 500mg IM once; (≥150kg): 1g IM once. Conjunctivitis: ceftriaxone 1g IM once + azithromycin 1g orally once Children: Uncomplicated urogenital, rectal, pharyngeal: (≤45kg): 25–50 mg/kg IV or IM once, max 125mg
Alternative
gentamicin +	—	inj	Adults: Uncomplicated urogenital, rectal¹¹: gentamicin 240mg IM once + azithromycin 2g once
azithromycin	Zithromax	tabs, susp, packets
cefixime	Suprax	tabs, susp	Adults: Uncomplicated urogenital, rectal¹¹: cefixime 800mg once
LYMPHOGRANULOMA VENEREUM
Recommended
doxycycline⁴	—	tabs	Adults: 100mg twice daily for 21 days
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
Alternative
erythromycin base	—	tabs	Adults: 500mg 4 times daily for 21 days
	Ery-Tab	tabs
	Eryc	caps
NON-GONOCOCCAL URETHRITIS
Recommended
azithromycin	Zithromax	tabs, susp, packets	Adults: 1g once Persistent, recurrent (doxycycline-treated): 1g once
doxycycline⁴	—	tabs	Adults: 100mg twice daily for 7 days
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
moxifloxacin	Avelox	tabs	Adults: Persistent, recurrent (azithromycin failure): 400mg once daily for 7 days
metronidazole¹⁴	Flagyl	scored tabs	Adults: Persistent, recurrent (T. Vaginalis prevalent): 2g once
tinidazole	Tindamax	scored tabs	Adults: Persistent, recurrent (T. Vaginalis prevalent): 2g once
Alternative
erythromycin base	—	tabs	Adults: 500mg 4 times daily for 7 days or 250mg 4 times daily for 14 days
	Ery-Tab	tabs
	Eryc	caps
erythromycin ethylsuccinate	E.E.S.	tabs, susp	Adults: 800mg 4 times daily for 7 days or 400mg 4 times daily for 14 days
	E.E.S. Granules	susp
	EryPed	susp
levofloxacin	—	tabs, soln	Adults: 500mg once daily for 7 days
ofloxacin	—	tabs	Adults: 300mg twice daily for 7 days
PEDICULOSIS PUBIS
Recommended
permethrin	Nix	1% cream	Adults: Apply, wash off after 10mins; may repeat after ≥7 days
pyrethrins + piperonyl butoxide	Rid	0.33%/4% shampoo	Adults: Apply, wash off after 10mins; repeat in 7–10 days
Alternative
ivermectin¹⁶	Stromectol	tabs	Adults: 250mcg/kg once, repeat in 2 weeks
malathion	Ovide	0.5% lotion	Adults: Apply, wash off after 8–12hrs
PELVIC INFLAMMATORY DISEASE⁹
Recommended
cefotetan +	—	inj	Adults: cefotetan 2g IV every 12hrs + doxycycline 100mg orally or IV every 12hrs
doxycycline⁴	—	inj, tabs
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
cefoxitin +	—	inj	Adults: cefoxitin 2g IV every 6hrs + doxycycline 100mg orally or IV every 12hrs
doxycycline⁴	—	inj, tabs
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
clindamycin +	Cleocin	inj	Adults: clindamycin 900mg IV every 8hrs + gentamicin 2mg/kg IV or IM loading dose then 1.5mg/kg every 8hrs or 3–5mg/kg daily
gentamicin	—	inj
ceftriaxone +	—	inj	Adults: ceftriaxone 250mg IM once + doxycycline 100mg orally twice daily for 14 days +/– metronidazole 500mg orally twice daily for 14 days
doxycycline⁴ +/–	—	inj, tabs
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
metronidazole	Flagyl	scored tabs
cefoxitin +	—	inj	Adults: cefoxitin 2g IM once + probenecid 1g orally once in a single dose + doxycycline 100mg orally twice daily for 14 days +/– metronidazole 500mg orally twice daily for 14 days
probenecid +	—	scored tabs
doxycycline⁴ +/–	—	inj, tabs
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
metronidazole	Flagyl	scored tabs
Alternative
ampicillin/sulbactam +	Unasyn	inj	Adults: ampicillin/sulbactam 3g IV every 6hrs + doxycycline 100mg orally or IV every 12hrs
doxycycline⁴	—	inj, tabs
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
SCABIES
Recommended
ivermectin¹⁶	Stromectol	tabs	Adults: 200mcg/kg once, repeat in 2 weeks
permethrin¹⁵	—	5% cream	Adults, children: Apply, wash off after 8–14hrs
Alternative
lindane^12,13	—	1% lotion, cream	Adults: Apply 1oz. lotion or 30g cream, wash off after 8hrs
SYPHILIS
Recommended
penicillin G benzathine	Bicillin L-A	inj	Adults, pregnancy: Primary, secondary, or early latent <1yr:2.4 million units IM once Latent >1yr, unknown duration: 2.4 million units IM weekly for 3 weeks, max 7.2 million units total Children: Primary, secondary, or early latent <1yr: 50,000 units/kg IM once, max 2.4 million units Latent >1yr, unknown duration: 50,000 units/kg IM once weekly for 3 weeks, max 7.2 million units total
penicillin G aqueous crystalline	—	inj	Adults: Neurosyphilis, ocular syphilis: 3–4 million units IV every 4hrs (18–24 million units/day) or continuous infusion for 10–14 days
Alternative
doxycycline⁴	—	tabs	Adults: Primary, secondary, or early latent <1yr: 100mg twice daily for 14 days Latent >1yr, unknown duration: 100 mg twice daily for 28 days
	Doryx	del-rel tabs
	Vibramycin	caps, susp, syrup
tetracycline	—	caps	Adults: Primary, secondary, or early latent <1yr: 500mg 4 times daily for 14 days Latent >1yr, unknown duration: 500mg 4 times daily for 28 days
penicillin G procaine +	—	inj	Adults: Neurosyphilis, ocular syphilis: penicillin G procaine 2.4 million units IM once daily + probenecid 500mg orally 4 times daily, both for 10–14 days
probenecid	—	scored tabs
TRICHOMONIASIS
Recommended
metronidazole¹⁴	Flagyl	scored tabs	Adults: 2g once Persistent/recurrent: initially 500mg twice daily for 7 days; 2g once daily for 7 days if initial recurrent regimen fails
tinidazole	Tindamax	scored tabs	Adults: 2g once Persistent/recurrent: 2g once daily for 7 days if initial recurrent regimen fails
Alternative
metronidazole¹⁴	Flagyl	scored tabs	Adults: 500mg twice daily for 7 days
NOTES
Key: caps = capsules, del-rel = delayed-release, HPV = human papillomavirus, inj = injection, supp = suppository, susp = suspension, tabs = tablets ¹ Treatment is recommended for all symptomatic pregnant women. ² Oil-based formulation may weaken latex condoms and diaphragms. ³ Consider concurrent treatment for gonococcal infection if at increased risk (<25 yrs, new sex partner, multiple sex partners, or a sex partner who has a STI). ⁴ Avoid in pregnancy, lactation, or children <8yrs. ⁵ Preferred for pregnancy ⁶ Erythromycin estolate is contraindicated in pregnancy. ⁷ Effectiveness of erythromycin treatment is approximately 80%, a second course of therapy may be required. ⁸ Contraindicated in pregnant or lactating women. ⁹ No response to therapy within 72 hrs needs re-evaluation; close follow-up is essential for suspected disease. ¹⁰ Treatment may be extended if incomplete healing after 10 days of therapy. ¹¹ Oral doxycycline 100mg twice daily for 7 days is recommended if chlamydial infection has not been excluded. During pregnancy, azithromycin 1g once is recommended for chlamydia. ¹² Contraindicated in pregnant or lactating women and children <10yrs. ¹³ Do not use after a bath; should not be used by persons with extensive dermatitis. ¹⁴ Pregnant patients can be treated with 2g single dose. ¹⁵ Preferred for infants and young children. ¹⁶ Off-label indication. Not an inclusive list of medications, dosing regimens, formulations, and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling. Under certain clinical conditions (eg, impaired renal or hepatic function), the dose may need to be adjusted.
REFERENCES
Frieden TR, Jaffe HW, Cono J, et al. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recommendations and Reports. 2015;64(3):1-135. Available at: http://www.cdc.gov/std/tg2015. St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6 (Rev. 4/2021)

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