2010 Sexually Transmitted Diseases Treatment Guideline Partial Summary Adapted from CDC, MMWR Dec 17, 2010 Changes in recommendations highlighted in green Arial font http://www.cdc.gov/std/treatment/default.htm CHLAMYDIA & GONNORRHEA UNCOMPLICATED CERVICITIS OR URETHRITIS Chlamydia: Recommended: Azithromycin 1g PO x1 Doxycycline 100mg PO BID x 7 days Erythromycin Base 500mg PO QID x 7 days Erythromycin Ethylsuccinate 800mg PO QID x7 days Ofloxacin 300mg PO BID x 7 days Levofloxacin 500 mg PO QD for 7 days Chlamydia in Pregnancy: Recommended: Azithromycin 1g PO x 1 Amoxicillin 500mg PO TID x 7 days Erythromycin Base 500mg PO QID x 7 days Erythromycin Base 250mg PO QID x 14 days Erythromycin Ethylsuccinate 800mg PO QID x7 days Erythromycin Ethylsuccinate 400mg PO QID x14 days Gonorrhea (Dual therapy now recommended which will also cover Chlamydia) Recommended: Ceftriaxone 250 mg IM x 1 (only option in MSM,travel hx, resistant area) Or if not an option: Cexifime 400mg PO x 1 (less effective for pharyngeal infection) Ceftizoxime 500 mg IM x1 Cefotaxime 500 mg IM x1 Cefoxitin 2 g IM with Probenecid 1 g PO x1 Cefpodoxime 400mg PO x1 Cefuroxime Axetil 1g PO x1 Azithromycin 2g POx1 Gonorrhea in Pregnancy Recommended: Ceftriaxone 250mg IM x 1 Cefixime 400 mg PO x 1 Plus: Azithromycin 1g PO x 1 Erythromycin Base 500 mg PO QID TID x 7 days Amoxicillin 500mg PO TID x 7 days UNCOMPLICATED INFECTION OF PHARYNX Gonorrhea Recommended: Ceftriaxone 250mg IM x 1 Plus: Azithromycin 1g PO x 1 Doxycycline 100mg BID x 7 days
CHLAMYDIA & GONNORRHEA (continued) PELVIC INFLAMMATORY DISEASE: OUTPATIENT Regimen A: Regimen B: Regimen C: Notes: Ceftriaxone 250mg IM x1 PLUS Doxycline 100mg PO BID x 14 days with or without Metronidazole 500mg PO BID x 14d Cefoxitin 2g IM x1 and Probenecid 1g PO PLUS Doxycycline 100mg PO BID x 14 days with or without Metronidazole 500mg PO BID x 14 days Other 3 rd Generation Cephalosporin (Ceftizoxime or Cefotaxime) PLUS Doxycycline 100mg PO BID x 14 days with or without Metronidazole 500mg PO BID x 14 days Alternative to Doxycycline for 14 days: Azithromycin 1g PO Qweek for 2 weeks (1 study) Metronidazole treats anaerobes and bacterial vaginosis Fluoroquinolones no longer recommended but may be considered if IV cephalosporin not feasible, community prevalence is low, and individual risk is low: Levofloxacin 500mg PO QD for 14 days OR Ofloxacin 400mg PO BID for 14 days with or without Metronidazole 500mg PO BID x 14 days PELVIC INFLAMMATORY DISEASE: INPATIENT Regimen A: Regimen B: Cefotetan 2g IV q 12 hrs PLUS Doxycycline 100mg PO or IV q 12 h (IV more painful) Cefoxitin 2g IV q 6 hrs PLUS Doxycycline 100mg PO or IV q 12 h (IV more painful) Note: Cefotetan/Cefoxitin may be discontinued after 24hrs of clinical improvement Doxycycline 100 mg PO BID should be continued for 14 days total Clindamycin 900mg IV q 8 hrs PLUS Gentamicin 2mg/kg IV or IM loading dose followed by Gentamicin 1.5 mg/kg q 8 h maintenance dosing (single daily dosing 3-5mg/kg may be substituted) Note: Doxycycline 100 mg PO BID should be continued for 14 days total Clindamycin 450mg PO QID may also be used to complete 14days of treatment Unasyn 3g IV Q6 hours PLUS Doxycycline 100mg PO or IV Q12 Note: Doxycycline 100 mg PO BID should be continued for 14 days total EPIDIDYMITIS Recommended: IF MOST LIKELY GC OR CHLAMYDIA Ceftriaxone 250 mg IM x1 PLUS Doxycycline 100mg PO BID x 10 days IF MOST LIKELY DUE TO ENTERICS OR IF NEG GONORRHEA TESTING Ofloxacin 300mg BID x 10 days Levofloxacin 500mg PO daily x 10 days - 2
CHLAMYDIA & GONNORRHEA (continued) DISSEMINATED GONOCOCCAL INFECTION (DGI) Initial IV Rx for 24-48 hours: Recommended: Ceftriaxone 1g IM/IV every 24hours Alternative: Cefotaxime 1g IV every 8hours Ceftizoxime 1g IV every 8hours Note: Continue PO Rx for total of 1 week: Cefixime 400mg PO BID ECTOPARASITIC INFECTIONS: Pediculosis Pubis & Scabies Pubic Lice (pediculosis pubis) Recommended: Permethrin 1% cream to affected areas, rinse after 10 minutes Pyrethrins with Piperonyl Butoxide applied to affected area and rinse after 10 minutes Alternative: Malathion 0.5% lotion, apply for 8-12hrs then rinse Ivermectin 250ug/kg PO x1, repeat in 2wks Scabies Recommended: Permethrin cream (5%) from neck down, wash off after 8-14 hrs Ivermectin 200ug/kg PO, repeat in 2 wks Lindane (1%) 1 oz or 30g of cream thinly from neck down, wash off after 8 hrs (do not use after a bath in person with extensive dermatitis, or pregnant or lactating women or in children <2) HUMAN PAPILLOMAVIRUS External genital/anal warts: HPV Recommended: Patient- applied Podofilox 0.5% solution or gel BID x 3, off x 4 days, repeat as needed for max 4 cycles Note: Use 0.5ml/day max, don t cover more than 10cm 2 Imiquimod 5% cream apply Q HS for 3 times a week for up to 16 weeks, wash off with soap and water 6-10 hrs after treatment Sinecatchins 15% ointment 3x/day for maximum of 16 weeks Note: Use 0.5cm strand of ointment, do not wash off Provider-administered Cryotherapy: liquid nitrogen or cryoprobe every 1 to 2 weeks Podophyllin resin 10-25 % in compound with tincture of benzoin, wash off in 1-4 hours, repeat weekly Trichloroacetic acid (TCA) every week Bichloroacetic Acid (BCA) 80-90% every week Surgical removal by tangential scissor excision, curettage, electrosurgery or tangential shave excision Alternative: Pregnancy: Intralesional interferon Laser surgery Do not use Podophyllin, Imiquimod, or Podofilox in pregnancy, use TCA - 3
HUMAN PAPILLOMAVIRUS (continued) Vaginal Mucosal Warts: HPV Recommended: Cryotherapy: liquid nitrogen only every 1-2 weeks Trichloroacetic acid (TCA) every week Bichloroacetic Acid (BCA) 80-90% every week Urethral Meatus Warts: HPV Recommended: Cryotherapy: liquid nitrogen only every 1-2 weeks Podophyllin resin 10-25 % in compound with tincture of benzoin, may repeat weekly Anal Mucosal Warts: HPV Recommended: Cryotherapy: liquid nitrogen only every 1-2 weeks TCA or BCA 80-90% every week Surgical removal PROCTITIS, PROCTOCOLITIS, ENTERITIS Recommended: Ceftriaxone 250mg IM x 1 Plus Doxycycline 100mg PO BID x 7 days ULCERS Chancroid (Haemophilus ducreyi, painful ulcer, inguinal LAD) Recommended: Azithromycin 1g PO x1 Ceftriaxone 250mg IM x1 Ciprofloxacin 500mg PO BID x3 days (avoid in pregnant or breastfeeding women) Erythromycin base 500mg PO TID x7 days Genital Herpes (painful ulcer): 1 st clinical episode: Acyclovir 400mg PO TID x7-10 days Acyclovir 200mg PO 5X/day x7-10 days Famciclovir 250mg PO TID x7-10 days Valacyclovir 1g PO BID x7-10 days Recurrence*: *Effective treatment should begin within 1 day of lesion or during prodrome Acyclovir 800mg PO BID x5 days Acyclovir 800mg PO TID x2 days Acyclovir 400mg PO TID x5 days Famciclovir 1g PO BID x1day Famciclovir 500mg PO x1 followed by 250mg PO BID x 2 days Famciclovir 125mg PO BID x5 days Valacyclovir 500mg PO BID x3 days Valacyclovir 1g PO qd x5 days Suppression (>6 episodes per year): Acyclovir 400mg PO BID Famciclovir 250mg PO BID Valacyclovir 500mg PO QD, or 1gram QD Severe: Acyclovir 5-10mg/kg IV every 8hrs x 2-7days or until clinically improved Followed by: Acyclovir PO for total of 10days Pregnancy: Only Acyclovir, Valcyclovir or Famciclovir PO are Category B - 4
ULCERS (continued) Granuloma Inguinale (Donovanosis: Calymmatobact. granulomatis, painless progressive ulcer, without LAD) Recommended: Doxycycline 100mg BID x at least 3 weeks and until lesions healed Azithromycin 1 gram PO weekly for at least 3 weeks and until lesions healed Ciprofloxacin 750mg BID x at least 3 weeks and until lesions healed Erythromycin base 500mg QID x 3 weeks and until lesions healed (use if pregnant or lactating) Trimethoprim-sulfamethoxazole DS PO BID x at least 3 weeks and until lesions healed Lymphogranuloma Venereum (C. trachomatis, unilateral inguinal &/or femoral lymphadenopathy, self limited ulcer at site of inoculation that usually resolve prior to seeking treatment) Recommended: Doxycycline 100mg BID x 21 days Erythromycin Base 500mg QID x 21 days Syphilis Primary or Secondary: Recommended: Benzathine Penicillin G 2.4 million units IM x1 (Peds 50,000 u/kg IM, max 2.4million units) PCN Allergic: Doxycyline 100mg PO BID x14days Tetracycline 500mg PO QID x14days Early Latent: Recommended: Benzathine Penicillin G 2.4 million units IM x1 Late Latent: Recommended: Benzathine Penicillin G 7.2 million units IM total (administered as 3 doses of 2.4 million units IM each at 1 week intervals) PCN Allergic: Doxycyline 100mg PO BID x28days Tetracycline 500mg PO QID x28days Tertiary Syphilis: Recommended: Benzathine Pencillin G 7.2 million units IM total (administered as 3 doses of 2.4 million units IM each week at 1 week intervals) Neurosyphilis: Recommended: Aqueous Crystalline PCN G 18-24 million units/day (administered as 3-4 million units IV Q4hrs or continuous x 10-14days) Alternative: Procaine PCN 2.4 million units IM QD PLUS Probenecid 500mg PO QID x10-14days VAGINAL DISCHARGE Bacterial vaginosis (BV): Recommended: Metronidazole 500mg PO BID x 7d or Metronidazole gel (0.75%) 1 vaginal applicator q day x 5 d Clindamycin cream 2%, 1 vaginal applicator (5g) q HS x 7d Tinidazole 2g PO QD x2 days Tinidazole 1g PO QD x5 days Clindamycin 300mg PO BID x 7d Clindamycin ovules 100g intravaginally qhs for 3 days Bacterial Vaginosis in Pregnancy: Treatment is recommended No consistent association between metronidazole during pregnancy and teratogenic or mutogenic effects Recommended: Metronidazole 500mg PO BID x 7days Metronidazole 250mg PO TID x 7 days Clindamycin 300mg PO BID x 7d - 5
VAGINAL DISCHARGE (continued) Trichomoniasis: Recommended: Metronidazole 2g PO x 1 dose Tinidazole 2g PO x 1 dose Metronidazole 500mg PO BID x 7d Trichomonas in Pregnancy: No consistent association between metronidazole during pregnancy and teratogenic or mutogenic effects in infants. Treat as above. Trichomonas Treatment Failure with Metronidazole 2g PO x1dose: Metronidazole 500mg PO BID x 7days If that fails also: Tinidazole or Metronidazole 2g PO QD x5days Vulvovaginal Candidiasis (VVC): Recommended: Intravaginal OTC Medications Miconazole 2% cream 5g intravaginally x 7 days Miconazole 4% cream 5g intravaginally x 3 days Miconazole 200mg vaginal suppository x3 days Miconazole 100mg vaginal suppository x7 days Miconazole 1,200 mg vag supp x1 day Clotrimazole 1% cream 5g intravaginal x7-14 days Clotrimazole 2% cream 5g intravaginal x3 days Butoconazole 2% cream 5g intravaginal x 3 days Tioconozole 6.5% ointment 5g intravaginal x 1 dose Intravaginal Prescription Medications Butoconazole 2% cream single dose 5g intravaginal x1 day Terconazole 0.4% cream 5g intravaginal x7 days Terconazole 0.8% cream 5g intravaginal x3 days Terconazole 80mg vaginal suppository x 3 days Nystatin 100,000-unit vaginal tablet, one a day x14 days Oral Prescription Medications Fluconazole 150mg oral tablet x 1 may repeat if needed in 3 days VVC in Pregnancy: Only topical azole therapies applied for 7 days are recommended Recurrent VVC: 4 or more symptoms Vulvovaginal Candidiasis a year (obtain a culture before Rx) Initial: Intensive topical treatment for 10-14days Fluconazole 100mg, 150mg, or 200mg PO Q3 days for 3 doses (day 1,4,7) Maintenance: Fluconazole 100mg, 150mg, or 200mg PO Qweek for 6 months Intermittent topical treatments Severe VVC: Topical Azole x7-14 days Fluconazole 150mg PO x 2 doses (initial then 72hrs later) Erica J. Gibson, M.D. Assistant Clinical Professor of Adolescent Medicine Medical Director, NYPATH Columbia University Medical Center/Mailman School of Public Health - 6