STD Treatment Guidelines

SEXUALLY TRANSMITTED DISEASES TREATMENT GUIDELINES
Generic Brand Form Dosing Regimen
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
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
Alternative
clindamycin Cleocin caps Adults: 300mg twice daily for 7 days
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
Ery-Tab tabs Children: <45kg, ophthalmia neonatorum, infant pneumonia: 50mg/kg/day in 4 divided doses for 14 days
PCE
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
Alternative
amoxicillin tabs, caps, susp Pregnancy: 500mg three times daily for 7 days
Amoxil caps, susp
azithromycin Zithromax tabs, susp, packets Neonates: Ophthalmia neonatorum, infant pneumonia:
20mg/kg/day once daily for 3 days
erythromycin
base6,7
Ery-Tab tabs Adults, pregnancy: 500mg 4 times daily for 7 days or 250mg 4 times daily for 14 days
PCE
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 Levaquin tabs, soln Adults: 500mg once daily for 7 days
ofloxacin tabs Adults: 300mg twice daily for 7 days
EPIDIDYMITIS9
Etiology: chlamydia + gonorrhea
ceftriaxone + Rocephin inj Adults: ceftriaxone 250mg IM once + doxycycline 100mg orally twice daily for 10 days
doxycycline4 tabs
Doryx del-rel tabs
Vibramycin caps, susp, syrup
Etiology: chlamydia + gonorrhea + enteric organisms
ceftriaxone + Rocephin inj Adults: ceftriaxone 250mg IM once + levofloxacin 500mg orally once daily for 10 days
levofloxacin Levaquin tabs, soln
ceftriaxone + Rocephin inj Adults: ceftriaxone 250mg IM once + ofloxacin 300mg orally twice daily for 10 days
ofloxacin tabs
Etiology: enteric organisms
levofloxacin Levaquin 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
Zovirax tabs, caps, 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
Zyclara 3.75% cream Adults: Apply at bedtime daily
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 + Rocephin inj Adults: Uncomplicated11, pharyngeal, pregnancy: ceftriaxone 250mg IM once + azithromycin 1g orally once
Conjunctivitis: ceftriaxone 1g IM once + azithromycin 1g orally once
azithromycin
Zithromax tabs, susp, packets
ceftriaxone Rocephin inj Children: ≤45 kg; uncomplicated, pharyngeal, ophthalmia neonatorum: 25–50mg/kg IV or IM once, max 125mg
Alternative
cefixime + Suprax caps, tabs, susp Adults: cefixime 400mg once + azithromycin 1g once
azithromycin
Zithromax tabs, susp, packets
gemifloxacin + Factive scored tabs Adults: gemifloxacin 320mg once + azithromycin 2g once
azithromycin
Zithromax tabs, susp, packets
gentamicin + inj Adults: gentamicin 240mg IM once + azithromycin 2g orally once
azithromycin
Zithromax tabs, susp, packets
LYMPHOGRANULOMA VENEREUM
Recommended
doxycycline4 tabs Adults: 100mg twice daily for 21 days
Doryx del-rel tabs
Vibramycin caps, susp, syrup
Alternative
erythromycin base Ery-Tab tabs Adults: 500mg 4 times daily for 21 days
PCE
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 Ery-Tab tabs Adults: 500mg 4 times daily for 7 days or 250mg 4 times daily for 14 days
PCE
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
levofloxacin Levaquin 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 10 min
pyrethrins + piperonyl butoxide R&C 0.3%/3% shampoo Adults: Apply, wash off after 10 min
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 + Rocephin 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
lindane12,13 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 CDC recommendation to treat uncomplicated gonococcal infections of the cervix, urethra, and/or rectum with dual therapy of cephalosporin plus azithromycin.

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.

(Rev. 1/2019)