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
  • 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 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 nonprimary, nonsecondary syphilis <1 y
  • Benzathine penicillin G 2.4 million units IM single dose
Penicillin-allergic:
  • Doxycycline 100 mg PO twice daily × 14 d
Syphilis of unknown duration or late >1 y, tertiary
  • Benzathine penicillin G 2.4 million units IM once weekly × 3 doses
  • Doxycycline 100 mg PO twice 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
  • Azithromycin 1 g PO weekly × 3 weeks and test of cure 4 weeks after treatment
Vaginitis/vaginosis
Trichomonas
  • Metronidazole 500 mg PO twice a day × 7 days
  • Tinidazole 2 g PO single dose
For people with a penis with trichomonas
  • Metronidazole 2 g PO × 1

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
  • Secnidazole 2 g oral granules × 1 dose
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 may be helpful
Recurrent candidiasis (four or more episodes in a year)
  • Fluconazole 100, 150, or 200 mg PO every 72 h × 7–14 d followed by once weekly × 6 mo

Urethritis/cervicitis
Gonorrhea
  • Ceftriaxone 500 mg IM once + doxycycline 100 mg PO twice daily × 7 d if Chlamydia trachomatis not ruled out. If testing for C. trachomatis is negative no need for concurrent treatment
  • Azithromycin 1 g PO once is alternative treatment for concurrent C. trachomatis infection
  • Gentamicin 240 mg IM + azithromycin 2 g PO once
  • Cefixime 800 mg PO × 1 + doxycycline 100 mg PO twice daily × 7 d if chlamydia not excluded
  • Oral cephalosporin treatment is not recommended as long as ceftriaxone is available
Disseminated gonococcal infection
  • Ceftriaxone 1 g IM or IV daily 
  • 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
  • Doxycycline 100 mg PO twice daily × 7 d
  • Azithromycin 1 g PO once (less efficacious in rectal infections)
  • Levofloxacin 500 mg PO daily × 7 d or ofloxacin 300 mg PO twice daily × 7 d
  • Retesting is recommended in 3 mo
Mycoplasma genitalium
  • If macrolide resistance testing not available, doxycycline 100 mg PO twice daily × 7 d, followed by moxifloxacin 400 mg PO daily × 7 d
  • If macrolide resistance testing available, doxycycline 100 mg PO twice daily × 7 d then azithromycin 1 g PO × 1 followed by 500 mg PO × 3 d (macrolide sensitive) or moxifloxacin 400 mg PO × 7 d (macrolide resistant)

Pelvic inflammatory disease
Outpatient
  • Ceftriaxone 500 mg IM once + doxycycline 100 mg PO twice daily × 14 d + metronidazole 500 mg orally twice daily × 14 d
  • Cefoxitin 2 g IM + probenecid 1 g PO once can be substituted for ceftriaxone
Inpatient
  • Ceftriaxone 1 g IV, cefoxitin 2 g IV every 6 h, or cefotetan 2 g IV every 12 h + doxycycline 100 mg PO twice daily × 14 d + metronidazole 500 mg PO or IV 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 
  • Ampicillin–sulbactam 3 g IV every 6 h + doxycycline 100 mg IV then 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
  • 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 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 nonprimary, nonsecondary syphilis <1 y
  • Benzathine penicillin G 2.4 million units IM single dose
Penicillin-allergic:
  • Doxycycline 100 mg PO twice daily × 14 d
Syphilis of unknown duration or late >1 y, tertiary
  • Benzathine penicillin G 2.4 million units IM once weekly × 3 doses
  • Doxycycline 100 mg PO twice 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
  • Azithromycin 1 g PO weekly × 3 weeks and test of cure 4 weeks after treatment
Vaginitis/vaginosis
Trichomonas
  • Metronidazole 500 mg PO twice a day × 7 days
  • Tinidazole 2 g PO single dose
For people with a penis with trichomonas
  • Metronidazole 2 g PO × 1

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
  • Secnidazole 2 g oral granules × 1 dose
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 may be helpful
Recurrent candidiasis (four or more episodes in a year)
  • Fluconazole 100, 150, or 200 mg PO every 72 h × 7–14 d followed by once weekly × 6 mo

Urethritis/cervicitis
Gonorrhea
  • Ceftriaxone 500 mg IM once + doxycycline 100 mg PO twice daily × 7 d if Chlamydia trachomatis not ruled out. If testing for C. trachomatis is negative no need for concurrent treatment
  • Azithromycin 1 g PO once is alternative treatment for concurrent C. trachomatis infection
  • Gentamicin 240 mg IM + azithromycin 2 g PO once
  • Cefixime 800 mg PO × 1 + doxycycline 100 mg PO twice daily × 7 d if chlamydia not excluded
  • Oral cephalosporin treatment is not recommended as long as ceftriaxone is available
Disseminated gonococcal infection
  • Ceftriaxone 1 g IM or IV daily 
  • 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
  • Doxycycline 100 mg PO twice daily × 7 d
  • Azithromycin 1 g PO once (less efficacious in rectal infections)
  • Levofloxacin 500 mg PO daily × 7 d or ofloxacin 300 mg PO twice daily × 7 d
  • Retesting is recommended in 3 mo
Mycoplasma genitalium
  • If macrolide resistance testing not available, doxycycline 100 mg PO twice daily × 7 d, followed by moxifloxacin 400 mg PO daily × 7 d
  • If macrolide resistance testing available, doxycycline 100 mg PO twice daily × 7 d then azithromycin 1 g PO × 1 followed by 500 mg PO × 3 d (macrolide sensitive) or moxifloxacin 400 mg PO × 7 d (macrolide resistant)

Pelvic inflammatory disease
Outpatient
  • Ceftriaxone 500 mg IM once + doxycycline 100 mg PO twice daily × 14 d + metronidazole 500 mg orally twice daily × 14 d
  • Cefoxitin 2 g IM + probenecid 1 g PO once can be substituted for ceftriaxone
Inpatient
  • Ceftriaxone 1 g IV, cefoxitin 2 g IV every 6 h, or cefotetan 2 g IV every 12 h + doxycycline 100 mg PO twice daily × 14 d + metronidazole 500 mg PO or IV 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 
  • Ampicillin–sulbactam 3 g IV every 6 h + doxycycline 100 mg IV then PO twice daily × 14 d

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

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