ID Sexually Transmitted Diseases ============================= þ Nonspecific Urethritis ("Gleets") - azithromycin preferred over doxycycline as 15 to 25% of NGU cases are caused by Mycoplasma genitalium. M. genitalium responds better to azithromycin. [MMWR Recommendations and Reports, 12/17/2010] þ CDC 2010 STD Guidelines, Treatment Summary - Chancroid: + Azithromycin 1 g orally in a single dose OR + Ceftriaxone 250 mg intramuscularly (IM) in a single dose OR + Ciprofloxacin* 500 mg orally twice a day for 3 days* OR + Erythromycin base 500 mg orally three times a day for 7 days * Ciprofloxacin is contraindicated for pregnant and lactating women. - HSV, initial infection: + Acyclovir 400 mg orally three times a day for 7--10 days OR + Acyclovir 200 mg orally five times a day for 7--10 days OR + Famciclovir 250 mg orally three times a day for 7--10 days OR + Valacyclovir 1 g orally twice a day for 7--10 days *Treatment can be extended if healing is incomplete after 10 days of therapy. - HSV, recurrent + Acyclovir 400 mg orally three times a day for 5 days OR + Acyclovir 800 mg orally twice a day for 5 days OR + Acyclovir 800 mg orally three times a day for 2 days OR + Famciclovir 125 mg orally twice daily for 5 days OR + Famciclovir 1000 mg orally twice daily for 1 day OR + Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days OR + Valacyclovir 500 mg orally twice a day for 3 days OR + Valacyclovir 1 g orally once a day for 5 days - HSV, recurrent, with HIV + Acyclovir 400 mg orally three times a day for 5--10 days OR + Famciclovir 500 mg orally twice a day for 5--10 days OR + Valacyclovir 1 g orally twice a day for 5--10 days - Nongonococcal urethritis Diagnosis: + Mucopurulent or purulent discharge on examination. + Gram stain of urethral secretions demonstrating =5 WBC per oil immersion field. The Gram stain is the preferred rapid diagnostic test for evaluating urethritis and is highly sensitive and specific for documenting both urethritis and the presence or absence of gonococcal infection. Gonococcal infection is established by documenting the presence of WBC containing GNID. + Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine sediment demonstrating =10 WBC per high-power field.) + empiric treatment of symptomatic males is recommended for men at high risk for infection who are unlikely to return for a follow-up evaluation. + Azithromycin 1 g orally in a single dose OR Treatment + Doxycycline 100 mg orally twice a day for 7 days OR: Alternative Regimens + Erythromycin base 500 mg orally four times a day for 7 days OR + Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days OR + Levofloxacin 500 mg orally once daily for 7 days OR + Ofloxacin 300 mg orally twice a day for 7 days - Recurrent and persistent urethritis after doxycycline failure: + Metronidazole 2 g orally in a single dose OR + Tinidazole 2 g orally in a single dose PLUS + Azithromycin 1 g orally in a single dose (if not used for initial episode) - Cervicitis + Azithromycin 1 g orally in a single dose OR + Doxycycline 100 mg orally twice a day for 7 days * Consider concurrent treatment for gonococcal infection if prevalence of gonorrhea is high in the patient population under assessment. - Chlamydia: + Azithromycin 1 g orally in a single dose OR + Doxycycline 100 mg orally twice a day for 7 days Alternative Regimens: + Erythromycin base 500 mg orally four times a day for 7 days OR + Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days OR + Levofloxacin 500 mg orally once daily for 7 days OR + Ofloxacin 300 mg orally twice a day for 7 days * Doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnant women. However, clinical experience and published studies suggest that azithromycin is safe and effective. - Chlamydia, pregnant: + Azithromycin 1 g orally in a single dose, OR + Amoxicillin 500 mg orally three times a day for 7 days Alternative Regimens + Erythromycin base 500 mg orally four times a day for 7 days OR + Erythromycin base 250 mg orally four times a day for 14 days OR + Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days OR + Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days - GC: cervix, urethra, rectum: + Ceftriaxone 250 mg IM in a single dose OR, IF NOT AN OPTION + Cefixime 400 mg orally in a single dose OR + Single-dose injectible cephalosporin regimens (ceftizoxime (500 mg, administered IM), cefoxitin (2 g, administered IM with probenecid 1 g orally), and cefotaxime (500 mg, administered IM) PLUS Azithromycin 1g orally in a single dose OR Doxycycline 100 mg a day for 7 days * azithromycin 2 g orally can be considered for women who cannot tolerate a cephalosporin - GC: Pharyngeal + Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1g orally in a single dose OR Doxycycline 100 mg a day for 7 days - Gonococcemia + Ceftriaxone 1 g IM or IV every 24 hours Alternative Regimens: + Cefotaxime 1 g IV every 8 hours OR + Ceftizoxime 1 g IV every 8 hours - BV: + Metronidazole 500 mg orally twice a day for 7 days* OR + Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR + Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days† *Consuming alcohol should be avoided during treatment and for 24 hours thereafter. † Clindamycin cream is oil-based and might weaken latex condoms and diaphragms for 5 days after use (refer to clindamycin product labeling for additional information). Alternative Regimens + Tinidazole 2 g orally once daily for 3 days OR + Tinidazole 1 g orally once daily for 5 days OR + Clindamycin 300 mg orally twice daily for 7 days OR + Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days *For women with multiple recurrences after completion of a recommended regimen, metronidazole gel twice weekly for 4-6 months has been shown to reduce recurrences, although this benefit might not persist when suppressive therapy is discontinued **The results of clinical trials indicate that a woman's response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner(s). Therefore, routine treatment of sex partners is not recommended. ***Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole or tinidazole. + BV in pregnacy: Treatment is recommended for all pregnant women with symptoms. Although BV is associated with adverse pregnancy outcomes, including premature rupture of membranes, preterm labor, preterm birth, intra-amniotic infection, and postpartum endometritis, the only established benefit of therapy for BV in pregnant women is the reduction of symptoms and signs of vaginal infection. Additional potential benefits include reducing the risk for infectious complications associated with BV during pregnancy and reducing the risk for other infections (other STDs or HIV. ... Regardless of the antimicrobial agent used to treat pregnant women, oral therapy is preferred because of the possibility of subclinical upper-genital--tract infection. ... Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (i.e., those with a previous preterm birth) has been evaluated by several studies, which have yielded mixed results. + Metronidazole 500 mg orally twice a day for 7 days OR + Metronidazole 250 mg orally three times a day for 7 days OR + Clindamycin 300 mg orally twice a day for 7 days - Trich: Diagnosis of vaginal trichomoniasis is usually performed by microscopy of vaginal secretions, but this method has a sensitivity of only approximately 60%--70% and requires immediate evaluation of wet preparation slide for optimal results. [a variety of fairly-rapid and more sensitive tests are available] + Metronidazole 2 g orally in a single dose OR + Tinidazole 2 g orally in a single dose OR + Metronidazole 500 mg orally twice a day for 7 days* * Patients should be advised to avoid consuming alcohol during treatment with metronidazole or tinidazole. Abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole. ** Metronidazole gel is considerably less efficacious for the treatment of trichomoniasis (<50%) than oral preparations of metronidazole. *** Sex partners of patients with T. vaginalis should be treated. **** Clinicians should counsel patients regarding the potential risks and benefits of treatment and communicate the option of therapy deferral in asymptomatic pregnant women until after 37 weeks' gestation. All symptomatic pregnant women should not only be considered for treatment regardless of pregnancy stage, but be provided careful counseling regarding condom use and the continued risk of sexual transmission. ***** Women can be treated with 2 g metronidazole in a single dose at any stage of pregnancy. Multiple studies and meta-analyses have not demonstrated an association between metronidazole use during pregnancy and teratogenic or mutagenic effects in infants (342,343,369). The safety of tinidazole in pregnant women, however, has not been well evaluated. ****** In lactating women who are administered metronidazole, withholding breastfeeding during treatment and for 12--24 hours after the last dose will reduce the exposure of the infant to metronidazole. For women treated with tinidazole, interruption of breastfeeding is recommended during treatment and for 3 days after the last dose. - Yeast + Over-the-Counter Intravaginal Agents: Butoconazole 2% cream 5 g intravaginally for 3 days, OR Clotrimazole 1% cream 5 g intravaginally for 7--14 days, OR Clotrimazole 2% cream 5 g intravaginally for 3 days, OR Miconazole 2% cream 5 g intravaginally for 7 days, OR Miconazole 4% cream 5 g intravaginally for 3 days, OR Miconazole 100 mg vaginal suppository, one suppository for 7 days, OR Miconazole 200 mg vaginal suppository, one suppository for 3 days, OR Miconazole 1,200 mg vaginal suppository, one suppository for 1 day, OR Tioconazole 6.5% ointment 5 g intravaginally in a single application + Prescription Intravaginal Agents: Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally for 1 day OR Nystatin 100,000-unit vaginal tablet, one tablet for 14 days, OR Terconazole 0.4% cream 5 g intravaginally for 7 days OR Terconazole 0.8% cream 5 g intravaginally for 3 days OR Terconazole 80 mg vaginal suppository, one suppository for 3 days + Prescription Oral Agent: Fluconazole 150 mg oral tablet, one tablet in single dose - PID: + Empiric treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness, uterine tenderness or adnexal tenderness. + The presence of signs of lower-genital--tract inflammation (predominance of leukocytes in vaginal secretions, cervical exudates, or cervical friability), in addition to one of the three minimum criteria, increases the specificity of the diagnosis. + One or more of the following additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID: - oral temperature >101° F (>38.3° C); - abnormal cervical or vaginal mucopurulent discharge; - presence of abundant numbers of WBC on saline microscopy of vaginal fluid; - elevated erythrocyte sedimentation rate; - elevated C-reactive protein; and - laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis. - PID Inpatient Rx alternatives: + Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours + Clindamycin 900 mg IV every 8 hours PLUS + Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3--5 mg/kg) can be substituted. + Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours - PID Outpatient Rx alternatives + Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days + Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days + Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days - Epididymitis + Likely STD: Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 10 days + For acute epididymitis most likely caused by enteric organisms Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice a day for 10 days - Proctitis + Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg orally twice a day for 7 days - Pubic Lice + Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes OR Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes + Alternate: Malathion 0.5% lotion applied for 8--12 hours and washed off OR Ivermectin 250 µg/kg orally, repeated in 2 weeks - Scabies + Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8--14 hours, OR Ivermectin 200ug/kg orally, repeated in 2 weeks + Lindane (1%) 1 oz. of lotion (or 30 g of cream) applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours - Sexual Assault + Ceftriaxone 250 mg IM in a single dose OR Cefixime 400 mg orally in a single dose PLUS Metronidazole 2 g orally in a single dose PLUS Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days þ Resistant GC þ Medical Letter Summary - Single dose pills for GC: disadvantages: don't cure incubating Syphilis; need for beta HCG which increases cost in women, must do tests of cure which is not true with Rocephin. Suprax: 400 mg good as 250 mg of IM Ceftriaxone; OK for pregnancy ???Single dose curative Chlamydia: compliance with doxycycline/TCN: only 8% compliance. Zithromax 1g stat as good as Doxy for 7 days; not approved for PID but probably OK. Flagyl: ------- Trich Partners: 8 (2g) stat Trich: "old" standard dosing: 250 TID x 10D. Per Sanford, 1993: 2.0 gm stat, 2.0 gm daily for 5 days if fails 2 gm stat Bacterial vaginosis: various regimes: 500 BID x 7D most common, but one meta-analysis showed that 8 (2g) stat was as effective [Lugo-Miro VI, Green M, Mazur L. Comparison of different metronidazole therapeutic regimens for bacterial vaginosis. JAMA 1992; 268(1): 92-95.] Treating Chlamydia in Pregnancy ------------------------------- Amoxicillin 500 TID for seven days as good as Erythro 500 QID for cure, and less side effects. [Silverman et al. A Randomized, Prospective Trial Comparing Amoxicillin and Erythromycin for the Tretment of Chlamydia Trachomatis in Pregnancy. Am J Obs Gyne 1994;170:829-32. Abstract: ] [Alary et al. Randomised comparison of amoxycillin and erythromycin in treatment of genital chlamydial infection in pregnancy [see comments] Lancet 1994 Nov 26;344(8935):1461-5. Abstract: ]