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Sexually Transmitted Infections

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The CDC is the best place to check for updated STI guidelines and resistance patterns.

Chlamydia:

  • Doxycycline 100 mg orally 2 times/day for 7 days (preferred)
    • Azithromycin 1g 1 time dose (can use in pregnancy)
    • Levofloxacin 500 mg orally once daily for 7 days
    • Alt in preg: Amoxicillin 500 mg orally 3 times/day for 7 days
    • Neonates/Infants: Erythromycin base or ethylsuccinate 50 mg/kg body weight/day orally, divided into 4 doses daily for 14 days
  • Test:
    • Screen all sexually active women less than 25 years of age and at risk women over 25 years of age yearly.
      • Risk: new sex partner, more than one sex partner, a sex partner w/ concurrent partners or sexually transmitted infections
    • Pregnant women should be screened at 1st prenatal visit and in 3rd trimester.
    • MSM should be screened annually at genital and rectal sites, every 3-6 months if HIV+ or having multiple sex partners
    • Inmates <30 for men and <35 for women should be screen on intake
    • Swab preferred in women, NAAT or swab in men
    • Also test for HIV, syphilis and gonorrhea
  • Only test for cure in pregnancy, 3-4 weeks after treatment.  You must culture to test for cure. It’s not necessary to test for cure in other populations.
  • All patients should be retested in 3 months for reinfection, not for treatment failure
  • Partners for last 60 days (or last if >60 days) should be screened.
  • Abstain for duration of treatment (or for 7 days after for gonococcal infections).

Syphilis:

  • Penicillin is the recommended treatment even in allergy if patient can be desensitized.
  • Primary/Secondary Syphilis:
    • 1- Ulcers or chancre at the infection site
    • 2- Manifestations that include (but are not limited to) skin Secondary syphilis rash, mucocutaneous lesions, and lymphadenopathy
    • Benzathine penicillin G 2.4 million units IM in a single dose (adults)
    • Benzathine penicillin G 50,000 units/kg body weight IM, up to the adult dose of 2.4 million units in a single dose (infants/children)
    • This is the preferred treatment even in PCN allergy if patient can be desensitized, but doxycycline (100 mg orally 2 times/day for 14 days) can be used if not available or not appropriate
  • Tertiary
    • Tertiary syphilis refers to gummas, cardiovascular syphilis, psychiatric manifestations (e.g., memory loss or personality changes), or late neurosyphilis.
    • Tertiary Syphilis with normal CSF Examination: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals
  • Neurosyphilis
    • CNS involvement can occur during any stage of syphilis, and CSF laboratory abnormalities are common among persons with early syphilis, even in the absence of clinical neurologic findings. 
    • Aqueous crystalline penicillin G 18–24 million units per day, administered as 3–4 million units IV every 4 hours or continuous infusion for 10–14 days
    • Procaine penicillin G 2.4 million units IM once daily PLUS Probenecid 500 mg orally 4 times/day, both for 10–14 days
  • Latent
    • Latent syphilis is defined as syphilis characterized by seroreactivity without other evidence of primary, secondary, or tertiary disease. 
    • Early Latent Syphilis: Benzathine penicillin G 2.4 million units IM in a single dose
    • Late Latent Syphilis: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals
  • In more severe cases may treat weekly for 3 weeks.
  • Treat all sex partners within last 90 days.
  • If a patient with neurosyphilis is allergic to PCN, desensitization is best.  Neurosyphilis is not as vulnerable to doxy.
  • Test
    • Pregnant women should have a serologic test at the first prenatal visit (mandated in most states) and higher risk patients should be screened again at 28 weeks gestation and delivery.
    • MSM should have an annual syphilis serology (at least annually, more frequent screening (3‐6 months) is indicated in those with HIV infection if risk behaviors persist or if their sexual partners have multiple partners)
    • Inmates should be screened on the basis of local area/institutional prevalence of infectious syphilis.
  • A presumptive diagnosis of syphilis requires use of two tests the nontreponemal and treponemal:
    • False positive nontreponemal tests can be associated with other infections (e.g., HIV), autoimmune conditions, immunizations, pregnancy, injection‐drug use, and older age
    • False negative reactions can occur with the nontreponemal assays due to the Prozone effect
      • Nontreponemal tests: Venereal Disease Research Laboratory [VDRL], • Rapid Plasma Reagin [RPR]
      • Treponemal tests: Fluorescent treponemal antibody absorbed [FTA‐ABS], T. pallidum passive particle, agglutination [TP‐PA] assay, Enzyme linked immunoassays [ELISA]
  • Jarisch-Herxheimer Reaction: rigors, fever, hypotension, worsening of skin rashes occurs within 24 hours of treatment. This is not drug reaction, it’s the treponema dying. Continue drug.
  • Test for cure: Clinical serology eval at 6 and 12 months or if symptoms persist or recur.  If there is a fourfold decrease in titers (using the same test), it’s a significant response.

Gonorrhea:

  • Ceftriaxone 500 mg IM in a single dose for persons weighing <150 kg, if >=150 kg, give 1 g
    • It’s common practice to add Azithromycin 1g empirically, the azithromycin treats chlamydia coinfections, but this is no longer recommended by the CDC due to increasing resistance. It’s now recommended only if confirmed or suspected co-infection.
    • Can use cefixime 800 mg * 1 instead of ceftriaxone, but only if ceftriaxone isn’t available
    • Use higher dose ceftriaxone (1g) in conjunctivitis
    • Arthritis should have ceftriaxone 1 G IM for 7 days          
    • If you have an IgE mediated allergy to PCN, can use 240 mg IM Gent PLUS 2 grams of azithromycin (higher azithro if using alternate therapy) as a single dose.
  • Females are often asymptomatic. Males can be too.
  • Disseminated gonococcal disease should be treated longer.  Treat for 10-14 days for meningitis, >4 weeks for endocarditis, 7-14 days for arthritis.  Patients should abstain for 7 days after treatment.
  • Test:
    • Screen all sexually active women less than 25 years of age and at risk women over 25 years of age yearly.
      • Risk: new sex partner, more than one sex partner, a sex partner w/ concurrent partners or sexually transmitted infections
    • Pregnant women should be screened at 1st prenatal visit and in 3rd trimester.
    • MSM should be screened annually at genital and rectal sites, every 3-6 months if HIV+ or having multiple sex partners
    • Inmates <30 for men and <35 for women should be screen on intake
    • Also test for HIV, syphilis and chlamydia
  • Symptomatic patients should get cultures and NAAT, others can get either and susceptibility testing if positive.  MDR must be reported.
  • Test of cure is recommended for any person with pharyngeal gonorrhea, regardless of the treatment regimen.
  • Retest 3 months after treatment
  • Expediated treatment where legal: cefixime 400 mg and azithromycin 1 gram.
  • GISP tracks resistance in gonorrhea.
  • All sexual partners within the preceding 60 days should be referred for treatment.

Vaginosis:

  • Metronidazole for 7 days (trichomoniasis X 1 only)

Prostatitis:

  • Acute: hydration, analgesics, bed rest
  • Men < 35 years: Ceftriaxone 500 mg* IM X 1 dose PLUS doxycycline 100 mg orally twice daily X 10 days (probably caused by chlamydia and gonorrhea)
  • Men > 35 years: Levofloxacin 500 mg orally every 24 hr X 10 days OR ofloxacin 300 mg orally twice daily X 10 days (probably secondary infection to bacteriuria and obstruction)
  • MSM who are insertive anal sex partner at risk for enteric organisms: Ceftriaxone 500 mg* IM X 1 dose PLUS levofloxacin 500 mg orally every 24 hr X 10 days OR ofloxacin 300 mg orally twice daily X 10 days
  • If you suspect just enteric organisms: Levofloxacin 500 mg orally every 24 hr X 10 days OR ofloxacin 300 mg orally twice daily X 10 days
  • Chronic: Bactrim, but if Bactrim failure, nitrofurantoin,  fluoroquinolones if you need pseudo coverage
  • For chronic, non-bacterial: terazosin +/- valium +/- stool softeners

Pelvic Inflammatory Disease:

  • The proportion of PID cases attributable to N. gonorrhoeae or C. trachomatis is declining
  • Microorganisms that comprise the vaginal flora have also been increasingly implicated: Anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram‐negative rods, and Streptococcus agalactiae
  • There is no single diagnostic test for PID
    • Clinical criteria from a pelvic examination are often used for diagnosis, however these are not always present due to the variability in clinical presentation
  • Cefotetan 2 g IV every 12 hr PLUS doxycycline 100 mg orally/IV every 12 hr
  • Cefoxitin 2 g IV every 6 hr PLUS doxycycline 100 mg orally/IV every 12 hr
  • Ceftriaxone 1 g IV every 24 hr PLUS doxycycline 100 mg orally/IV every 12 hr PLUS metronidazole 500 mg orally/IV every 12 hr
  • Alt: Clindamycin 900 mg IV q8h PLUS gentamicin 2 mg/kg IV/IM loading dose, followed by 1.5 mg/kg IV/IM every 8 hr OR high‐dose extended interval therapy with 3‐5 mg/kg daily as maintenance therapy
  • Ampicillin‐sulbactam 3 g IV every 6 hrs plus Doxycycline 100 mg orally/IV every 12 hrs

Herpes

  • Treatment for genital warts:
    • Imiqimed 3.375% every night for 16 weeks
    • Imiqimed 5% three times a week
    • Podafilix 0.1% solution BID times 3 days then every 4 days then off
    • Sinecaatechines 5% ointment
    • Can also do cryotherapy or surgery
  • Treat first outbreak no matter how severe
    • Acyclovir 400 mg TID
    • Acyclovir 200 mg 5 times a day
    • Valacyclovir 1 g BID
    • Famciclovir 250 mg TID
    • Treat 7-10 days
  • Recurrent:
    • Acyclovir 800 mg TID for 2 days, 400 mg TID for 5 days, 800 BID for 5 days
    • Valacyclovir 500 mg BID for 3 days or 1 g QD for 5 days
    • Famiciclovir 125 mg BID for 5 days, 1 G BID 1 day, 500 mg * 1, then 250 mg BID for 2 days
  • Suppression
    • Acyclovir 400 mg BID
    • Valacyclovir – 1 G QD or 500 mg QD unless more than 10 outbreaks/year
    • Famiciclovir – 250 mg BID or 500 mg BID if HIV
    • Begin at 36 weeks of pregnancy, acyclovir 400 mg TID or valacyclovir 500 QD

HPV

  • Acyclovir – low resistance but becoming more common in immunosuppressed. Would also be resistant to vala, fami and penciclovir
    • Use IV foscarnet
  • Start vaccine at age 11 (early as 9), and may vaccinate up to 45 with discussion. Not titerable.
  • Don’t routinely screen asymptomatic pregnant women
  • HSV NAAT and PCR – PCR best choice, usually for screening with other STIs
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