Sexually Transmitted Infections, Ulcerative Diseases

Sexually Transmitted Infections, Ulcerative Diseases is a topic covered in the Washington Manual of Medical Therapeutics.

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  • Current STI treatment guidelines are found at www.cdc.gov/std.
  • Treatment options for each infection can be found in Table 16-1.
    Table 16-1: Treatment of Sexually Transmitted Infections
    InfectionRecommended Regimen(s)Alternative Regimens and Notes
    Genital ulcer disease
    Herpes simplex
    First episode
    • Acyclovir 400 mg PO three times a day × 7–10 d or 200 mg PO five times 
daily × 7–10 d
    • Valacyclovir 1 g PO two times a day × 7–10 d
    • Famciclovir 250 mg PO three times a day × 7–10 d

    Recurrent episodes
    • Acyclovir 400 mg PO three times a day × 5 d or 800 mg two times a day × 5 d or 800 mg PO three times a day × 2 d
    • Valacyclovir 1 g PO once a day × 5 d or 500 mg PO two times a day × 3 d
    • Famciclovir 1 g PO two times a day × 1 d or 125 mg PO two times a day × 5 d or 500 mg once, then 250 mg two times a day × 2 d
    		In patients with HIV:
    • Acyclovir 400 mg PO three times a day × 5–10 d
    • Valacyclovir 1 g PO twice a day × 5–10 d
    • Famciclovir 500 mg PO twice a day × 5–10 d
    Suppressive therapy
    • Acyclovir 400 mg PO twice a day
    • Valacyclovir 500 mg or 1 g PO once daily
    • Famciclovir 250 mg PO twice daily
    		In patients with HIV:
    • Acyclovir 400–800 mg PO twice to three times a day
    • Valacyclovir 500 mg PO twice a day
    • Famciclovir 500 mg PO twice a day
    Syphilis
    Primary, secondary, or early latent <1 yr
    • Benzathine penicillin G 2.4 
million units IM single dose
    		Penicillin-allergic:
    • Doxycycline 100 mg PO twice daily × 14 d
    • Tetracycline 500 mg PO four times daily × 14 d
    Latent >1 yr, latent unknown duration
    • Benzathine penicillin G 2.4 
million units IM once weekly × 3 doses
    • Doxycycline 100 mg PO twice daily × 28 d
    • Tetracycline 500 mg PO four times daily × 28 d
    Neurosyphilis
    • Aqueous crystalline penicillin G 18–24 million U/d (as 3–4 million units every 4 h or continuous infusion) × 10–14 d
    • Procaine penicillin 2.4 million units IM once daily + probenecid 500 mg PO four times daily × 10–14 d
    Pregnancy
    • Penicillin is the recommended treatment—desensitize if necessary

    Chancroid
    • Azithromycin 1 g PO single dose
    • Ceftriaxone 250 mg IM single dose
    • Ciprofloxacin 500 mg PO twice daily × 3 d
    • Erythromycin base 500 mg PO twice daily × 7 d
    • Some resistance has been reported for these regimens.
    Lymphogranuloma venereum
    • Doxycycline 100 mg PO twice daily × 21 d
    • Erythromycin base 500 mg PO four times a day × 21 d
    Vaginitis/vaginosis
    Trichomonas
    • Metronidazole 2 g PO single dose
    • Tinidazole 2 g PO single dose
    		In patients with HIV (and alternative for HIV-uninfected):
    • Metronidazole 500 mg PO twice daily × 7 d
    Pregnancy
    • Metronidazole 2 g PO × 1 (not teratogenic)

    Bacterial vaginosis
    • Metronidazole 500 mg PO twice daily × 7 d
    • Clindamycin cream 2% intravaginal at bedtime × 7 d
    • Metronidazole gel 0.75% intravaginal once a day for 5 d
    • Tinidazole 2 g PO once daily × 2 d or 1 g PO once daily × 5 d
    • Clindamycin 300 mg PO twice daily × 7 d
    • Clindamycin ovules 100 mg intravaginal × 3 d
    Candidiasis
    • Intravaginal azoles in variety of strengths for 1–7 d
    • Fluconazole 150 mg PO × 1

    Severe candidiasis
    • Fluconazole 150 mg PO every 72 h × 2–3 doses
    • Intravaginal azoles for 7–14 d
    • Culture and sensitivities maybe helpful
    Recurrent candidiasis
    • Fluconazole 100, 150, or 200 mg PO once weekly × 6 mo

    Urethritis/cervicitis
    Gonorrhea
    • Ceftriaxone 250 mg IM once + azithromycin 1 g PO once even if testing for Chlamydia trachomatis is negative.
    • Given concern for antibiotic resistance, dual treatment is recommended.
    • Cefixime 400 mg PO × 1 + Azithromycin 1 g PO × 1
    • Oral cephalosporin treatment is not recommended as long as ceftriaxone is available.
    Disseminated gonococcal infection
    • Ceftriaxone 1 g IM or IV daily + Azithromycin 1 g PO × 1
    • Can switch to PO after 24–48 h if substantial improvement, treat for at least 7 d
    • Cefotaxime 1 g IV every 8 h
    • Ceftizoxime 1 g IV every 8 h + Azithromycin 1 g PO × 1
    Chlamydia
    • Azithromycin 1 g PO single dose
    • Doxycycline 100 mg PO twice daily × 7 d
    • Erythromycin base 500 mg PO or erythromycin ethylsuccinate 800 mg PO four times a day × 7 d
    • Levofloxacin 500 mg PO daily × 7 d or Ofloxacin 300 mg PO twice daily × 7 d
    • Retesting is recommended in 3 mo.
    Pelvic inflammatory disease
    Outpatient
    • Ceftriaxone 250 mg IM once + doxycycline 100 mg PO twice daily × 14 d + consider metronidazole 500 mg orally twice daily × 14 d
    • Cefoxitin 2 g IM + probenecid 1 g PO once can be substituted for ceftriaxone
    Inpatient
    • (Cefoxitin 2 g IV every 6 h or cefotetan 2 g IV every 12 h) + doxycycline 100 mg PO twice daily × 14 d + consider metronidazole 500 mg PO twice daily × 14 d
    • Clindamycin 900 mg IV every 8 h + gentamicin 2 mg/kg loading dose, then 1.5 mg/kg every 8 h + doxycycline 100 mg PO twice daily × 14 d
    • Ampicillin-sulbactam 3 g IV every 6 h + doxycycline 100 mg PO twice daily × 14 d

    See cdc.gov/std/ for the current sexually transmitted infection treatment guidelines.

-- To view the remaining sections of this topic, please or --

  • Current STI treatment guidelines are found at www.cdc.gov/std.
  • Treatment options for each infection can be found in Table 16-1.
    Table 16-1: Treatment of Sexually Transmitted Infections
    InfectionRecommended Regimen(s)Alternative Regimens and Notes
    Genital ulcer disease
    Herpes simplex
    First episode
    • Acyclovir 400 mg PO three times a day × 7–10 d or 200 mg PO five times 
daily × 7–10 d
    • Valacyclovir 1 g PO two times a day × 7–10 d
    • Famciclovir 250 mg PO three times a day × 7–10 d

    Recurrent episodes
    • Acyclovir 400 mg PO three times a day × 5 d or 800 mg two times a day × 5 d or 800 mg PO three times a day × 2 d
    • Valacyclovir 1 g PO once a day × 5 d or 500 mg PO two times a day × 3 d
    • Famciclovir 1 g PO two times a day × 1 d or 125 mg PO two times a day × 5 d or 500 mg once, then 250 mg two times a day × 2 d
    		In patients with HIV:
    • Acyclovir 400 mg PO three times a day × 5–10 d
    • Valacyclovir 1 g PO twice a day × 5–10 d
    • Famciclovir 500 mg PO twice a day × 5–10 d
    Suppressive therapy
    • Acyclovir 400 mg PO twice a day
    • Valacyclovir 500 mg or 1 g PO once daily
    • Famciclovir 250 mg PO twice daily
    		In patients with HIV:
    • Acyclovir 400–800 mg PO twice to three times a day
    • Valacyclovir 500 mg PO twice a day
    • Famciclovir 500 mg PO twice a day
    Syphilis
    Primary, secondary, or early latent <1 yr
    • Benzathine penicillin G 2.4 
million units IM single dose
    		Penicillin-allergic:
    • Doxycycline 100 mg PO twice daily × 14 d
    • Tetracycline 500 mg PO four times daily × 14 d
    Latent >1 yr, latent unknown duration
    • Benzathine penicillin G 2.4 
million units IM once weekly × 3 doses
    • Doxycycline 100 mg PO twice daily × 28 d
    • Tetracycline 500 mg PO four times daily × 28 d
    Neurosyphilis
    • Aqueous crystalline penicillin G 18–24 million U/d (as 3–4 million units every 4 h or continuous infusion) × 10–14 d
    • Procaine penicillin 2.4 million units IM once daily + probenecid 500 mg PO four times daily × 10–14 d
    Pregnancy
    • Penicillin is the recommended treatment—desensitize if necessary

    Chancroid
    • Azithromycin 1 g PO single dose
    • Ceftriaxone 250 mg IM single dose
    • Ciprofloxacin 500 mg PO twice daily × 3 d
    • Erythromycin base 500 mg PO twice daily × 7 d
    • Some resistance has been reported for these regimens.
    Lymphogranuloma venereum
    • Doxycycline 100 mg PO twice daily × 21 d
    • Erythromycin base 500 mg PO four times a day × 21 d
    Vaginitis/vaginosis
    Trichomonas
    • Metronidazole 2 g PO single dose
    • Tinidazole 2 g PO single dose
    		In patients with HIV (and alternative for HIV-uninfected):
    • Metronidazole 500 mg PO twice daily × 7 d
    Pregnancy
    • Metronidazole 2 g PO × 1 (not teratogenic)

    Bacterial vaginosis
    • Metronidazole 500 mg PO twice daily × 7 d
    • Clindamycin cream 2% intravaginal at bedtime × 7 d
    • Metronidazole gel 0.75% intravaginal once a day for 5 d
    • Tinidazole 2 g PO once daily × 2 d or 1 g PO once daily × 5 d
    • Clindamycin 300 mg PO twice daily × 7 d
    • Clindamycin ovules 100 mg intravaginal × 3 d
    Candidiasis
    • Intravaginal azoles in variety of strengths for 1–7 d
    • Fluconazole 150 mg PO × 1

    Severe candidiasis
    • Fluconazole 150 mg PO every 72 h × 2–3 doses
    • Intravaginal azoles for 7–14 d
    • Culture and sensitivities maybe helpful
    Recurrent candidiasis
    • Fluconazole 100, 150, or 200 mg PO once weekly × 6 mo

    Urethritis/cervicitis
    Gonorrhea
    • Ceftriaxone 250 mg IM once + azithromycin 1 g PO once even if testing for Chlamydia trachomatis is negative.
    • Given concern for antibiotic resistance, dual treatment is recommended.
    • Cefixime 400 mg PO × 1 + Azithromycin 1 g PO × 1
    • Oral cephalosporin treatment is not recommended as long as ceftriaxone is available.
    Disseminated gonococcal infection
    • Ceftriaxone 1 g IM or IV daily + Azithromycin 1 g PO × 1
    • Can switch to PO after 24–48 h if substantial improvement, treat for at least 7 d
    • Cefotaxime 1 g IV every 8 h
    • Ceftizoxime 1 g IV every 8 h + Azithromycin 1 g PO × 1
    Chlamydia
    • Azithromycin 1 g PO single dose
    • Doxycycline 100 mg PO twice daily × 7 d
    • Erythromycin base 500 mg PO or erythromycin ethylsuccinate 800 mg PO four times a day × 7 d
    • Levofloxacin 500 mg PO daily × 7 d or Ofloxacin 300 mg PO twice daily × 7 d
    • Retesting is recommended in 3 mo.
    Pelvic inflammatory disease
    Outpatient
    • Ceftriaxone 250 mg IM once + doxycycline 100 mg PO twice daily × 14 d + consider metronidazole 500 mg orally twice daily × 14 d
    • Cefoxitin 2 g IM + probenecid 1 g PO once can be substituted for ceftriaxone
    Inpatient
    • (Cefoxitin 2 g IV every 6 h or cefotetan 2 g IV every 12 h) + doxycycline 100 mg PO twice daily × 14 d + consider metronidazole 500 mg PO twice daily × 14 d
    • Clindamycin 900 mg IV every 8 h + gentamicin 2 mg/kg loading dose, then 1.5 mg/kg every 8 h + doxycycline 100 mg PO twice daily × 14 d
    • Ampicillin-sulbactam 3 g IV every 6 h + doxycycline 100 mg PO twice daily × 14 d

    See cdc.gov/std/ for the current sexually transmitted infection treatment guidelines.

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