New Directions In STD Treatment - University of Hawaii

New Directions in STD Treatment: 

Highlights of the 2006 National STD 

Treatment Guidelines 

Gail Bolan MD 

Chief, STD Control Branch 

CA Department of Health Services 

October 5, 2006

Overview of Presentation 

� CDC STD treatment guidelines process 

� Proposed testing and treatment changes: 

�Prevention and Screening 

�Chlamydia and Gonorrhea 

�LGV 

�Genital ulcers: Syphilis, HSV 

�HPV 

�NGU, Cervicitis, PID 

�Vaginitis: Trich, BV, Yeast

CDC 2006 STD Treatment 

Guidelines Development 

� Evidence-based on 4 outcomes of STD therapy 

� microbiologic cure, clinical cure, prevention of 

sequelae and prevention of transmission 

� Recommended regimens preferred over 

alternative regimens 

� Alphabetized unless there is a priority of choice 

� Reviewed in April 2005 

� www.cdc.gov/std/treatment

Key 

Questions 

General Approach 

CDC STD Treatment Guidelines 

Enlistment of 

Subject Matter 

Expert 

Systematic 

Review of 

Evidence 

Background papers; 

Tables of evidence 

Guidelines 

Meeting 2005 

Experts in field 

as consultants 

Answer the “Key 

Questions” 

Rate the quality 

of the evidence 

Identify critical gaps 

in knowledge 

(research agenda) 

Write the 

Guidelines 

document

Challenging Management Dilemmas in the 

2006 STD Treatment Guidelines 

� Targeted screening, expedited partner treatment, 

re-testing after treatment for CT and GC 

� LGV emergence in MSM 

� Syphilis diagnosis with EIA and management in 

HIV-infected individuals 

� Antimicrobial resistance 

� GC, Syphilis and Trich 

� Age- and risk-based empiric treatment for cervicitis 

� Role of HSV serologic testing and suppressive 

therapy to prevent transmission

Prevention & Screening Issues 

� Sexual history taking and risk reduction counseling including 

the 5 P’s 

� Partners, Pregnancy prevention, Protection from STDs, Practices and 

Past History of STDs 

� Condom messages 

� Might reduce risk of developing PID and risk for transmission of HSV 

and HPV 

� Use of condoms with N-9 not recommended 

� Patents should be informed about which STDs they are 

tested for (and which not) 

� Emergency contraception should be available 

� Non-occupational PEP for HIV prevention as a result of 

sexual exposure 

� Specials population: pregnant women, adolescents, MSM, 

WSW 

� Pap smear screening recommended according to national guidelines 

for WSW 

� Trich, BV, HPV and HIV of most concern in WSW

Sexual History Taking: The 5 P’s 

1. Partners 

� Do you have sex with men, women or both? 

� In the past 12 months how many partners have you had 

sex with? 

� In the past 2 months how many partners have you had 

sex with? 

2. Pregnancy prevention 

� Are you or your partner trying to get pregnant? 

� If no, What are you doing to prevent pregnancy? 

3. Protection from STDs 

� What do you do to protect yourself from STDs and HIV?

Sexual History Taking: The 5 P’s 

4. Practices 

� To understand your risks for STDs, I need to understand the kind of sex 

you have had recently. 

� Have you had vaginal sex, meaning penis in the vagina sex? If yes, do 

you use condoms never, sometimes or always? 

� Have you had anal sex, meaning penis in the rectum/anus/butt sex? If 

yes, do you use condoms never, sometimes or always? 

� Have you had oral sex, meaning mouth on penis/vagina/rectum sex? If 

yes, do you use condoms never, sometimes or always? 

� For condoms: if never: Why don’t you use condoms? If sometimes: In 

what situations or with whom do you use or not use condoms? 

5. Past History of STDs 

� Have you ever Had an STD? 

� Have any of your partners had an STD? 

� Additional questions to identify HIV and Hepatitis risk 

� Have you or any of your partners ever injected drugs 

� Have you or any of your partners exchanged money or drugs for sex 

� Is there anything else about your sexual practices that I 

need to know about?

Recommend Nucleic Acid Amplification 

Tests for Detecting Chlamydia and 

� Highest sensitivity 

� Noninvasive 

Gonorrhea 

� Able to detect up to 40% more CT infections 

� Less dependent on specimen collection and handling 

� Urine and self-collected vaginal swabs 

� Non-clinical settings 

� Pelvic and genital exams not necessary 

� Clinic intake areas 

� Community based organizations 

� Home testing

STD Screening for Women 

� Adolescents & up to age 25 

� Annual chlamydia screening 

� Gonorrhea screening based on risk factors 

� Others STDs based on risk 

� HIV (?) 

� Women over 25 years of age 

� Based on risk factors 

� New or multiple sex partners 

� Prior history of STD or inconsistent use of barrier contraception 

� Pregnant women (first trimester) 

� HIV, Syphilis serology, Hep B sAg, and Chlamydia 

� Gonorrhea based on age and risk 

� Hep C based on risk 

� BV if high risk pregnancy

Percent Screened 

Estimated Chlamydia Screening Coverage 

(HEDIS) for Females Age 16-26 

USA and California, 1999-2004 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

1999 2000 2001 2002 2003 2004 

Natl MCO Natl Medicaid MediCal MC Cal HMO FPACT* 

*Family PACT program paid claims data

Chlamydia Screening in 

Heterosexual Males 

� Screening in heterosexual males not routinely 

recommended 

� Need evidence of reduction of infection in 

women to be cost effective 

� However, selective screening in high 

prevalence clinics (e.g. adolescent, corrections, 

STD) may be beneficial 

� Modeling suggests prevalence among males 

should be at least 6%* 

� CDC will develop separate guidance in this 

area* 

* Discussed at the 

2006 Guidelines Meeting

STD Screening for MSM 

STD Site Type of Sex 

HIV blood oral, anal 

Syphilis blood oral, anal 

GC/CT urethra or urine oral, anal 

GC/CT rectum receptive anal 

GC pharynx receptive oral 

HSV-2* blood 

* Some experts recommend 

FREQUENCY: At least at the initial visit then 

annually or more frequently based on risk

Indications for More Frequent 

Screening in MSM 

� Increased prevalence of STIs in area or patient 

population 

� Symptoms or recent history of any STI in patient 

or partner 

� Risky sexual behavior 

� Multiple or anonymous partners 

� Substance abuse especially methamphetamine 

� Risky sexual behavior in partner 

� If any of the above, then screen q 3-6 months 

MMWR 2003 52: RR 12

Prevalence of rectal chlamydia and 

gonorrhea by symptom status among MSM – 

San Francisco, 2003 

35% 

30% 

25% 

20% 

15% 

10% 

5% 

0% 

20.7% 

7.6% 

29.8% 

6.1% 

n=213 n=3579 n=212 n=3613 

Chalmydia Gonorrhea 

Symptomatic 

Asymptomatic 

Kent, CK et al. ISSTDR, July 2005

Prevalence of urethral chlamydia and 

gonorrhea by symptom status among MSM – 


35% 

30% 

25% 

20% 

15% 

10% 

5% 

0% 

15.1% 

2.7% 

26.9% 

0.8% 

n=213 n=3579 n=212 n=3613 


Symptomatic 

Asymptomatic 


Prevalence of pharyngeal chlamydia and 

gonorrhea among MSM by clinic– 


12% 

10% 

8% 

6% 

4% 

2% 

0% 

1.3% 

1.7% 

9.4% 

7.8% 

n=4658 n=719 n=4665 n=761 


STD Clinic 

Gay Men's Health 


Proportion of unidentified CT and GC 

infections if only urine/urethral screening 

performed among MSM: San Francisco – 2003 

53% 

Chlamydia 

n = 574 

47% 

64% 

Identified Not Identified 

Gonorrhea 

n = 785 

36% 


C. trachomatis NAAT Testing 

…not FDA-cleared for rectal 

or pharyngeal specimens

Chlamydia Treatment 

Adolescents and Adults 

Recommended regimens: 

� Azithromycin 1 g PO x 1 

� Doxycycline 100 mg PO BID x 7 d 

Alternative regimens: 

� Erythromycin base 500 mg PO QID x 7 d 

� Erythro ethylsuccinate 800 mg PO QID x 7 d 

� Ofloxacin 300 mg PO BID x 7 d 

� Levofloxacin 500 mg PO QD x 7 d 

** NO CHANGES FOR 2006 GUIDELINES **

Chlamydia Treatment in Pregnancy 


� Azithromycin 1 g PO x 1* 

�Amoxicillin 500 mg PO TID x 7 d 




� Erythro ethylsuccinate 800 mg PO QID x 7 d 

� Erythro ethylsuccinate 400 mg PO QID x 14 

d 

Test of cure in 3-4 weeks 

*Preferrred Preferrred

Partner Treatment Options 

� Patient referral 

� Provider or clinic referral 

� Health department referral 

� Expedited Partner Treatment (EPT) 

�Patient-delivered partner therapy (PDPT) 

�Health department-delivered therapy 

�Pharmacy-delivered therapy

Percent 

16 

14 

12 

10 

Infection During Follow-up Among Patients 

Completing the EPT Trial 

8 

6 

4 

2 

0 

Standard care 

Expedited care 

10.6 

P=.02 

3.4 

13.2 

P=.17 P=.04 

10.8 

N=358 N=1595 N=1860 

Gonorrhea Chlamydia Gonorrhea or Chlamydia 

Golden et al., NEJM 2005; 352:676-85 

13 

9.9

Chlamydia and Gonorrhea Expedited 

Partner Treatment 

� Expedited Partner Treatment (EPT) or Patient- 

Delivered Partner Treatment (PDPT) 

�Option for partner management for heterosexual 

men and women 

� Written materials should accompany medication and 

specially mention concern about PID in female 

partners 

�First line management is clinical evaluation 

�Not recommended in MSM because of concern 

regarding co-morbidities (e.g., HIV and other 

STDs) 

�CDC has developed separate guidance on 

EPT/PDPT

Provider Barriers to PDPT, CA 2002 

Incomplete care for partner* 

Dangerous without knowing hx* 

Practice not paid for 

May get me sued* 

Partners name must be provided 

Only for male partners 

*Significant predictors of no PDPT 

MD* 

NP 

0 20 40 60 80 100 

Strongly agree/agree (%) 

Data source: CA DHS STD Control Branch California Provider Survey

Recommendations for Chlamydia and 

Gonorrhea Re-Testing after Treatment 

� Prefer “re-testing” to “re-screening” 

� High rates of re-infection after treatment and for 

GC may confer an elevated risk of PID 

� Consider re-testing of females; some experts 

suggest re-testing of males for CT and consider retesting 

of males for GC 

� Time frame: 3 months after treatment and for GC 

whenever seek care within 12 months if did not 

return at 3 months 

� No test of cure except in pregnant women with CT 

and for GC if treated initially with a fluoroquinolone 

and symptoms persist or recur after treatment

Gonorrhea Screening in Females 

� Based on US Preventive Services Task Force 

� Screening recommended for women under age 

25 

� Risk factors in older women include previous 

GC infection, other STD, new/multiple partners, 

inconsistent condom use, commercial sex, drug 

use 

� CA GC Screening Guidelines recommend: 

� history of gonorrhea in past two years 

� multiple partners (>1 in past year) 

� partner with other partners 

� African American women up to age 30

for patients with gonorrhea in California…

Percent of Neisseria gonorrhoeae Isolates with 

Decreased Susceptibility or Resistance to Ciprofloxacin, 

California GISP, 1996–2004 

GC Rate per 100,000 

80 

60 

40 

20 

0 

Intermediate 

Resistant 

State GC Rate 

1996 1997 1998 1999 2000 2001 2002 2003 2004 

YEAR 

28 

24 

20 

16 

12 

8 

4 

0 

Percent

Gonorrhea – Treatment Issues 

� Fluoroquinolones NOT recommended for: 

� Acquisition in CA or Hawaii or other areas with high 

prevalence of FQ resistance 

� MSM 

� Any foreign acquisition- Europe, Middle East, Asia, 

Pacific 

� Limited options in cephalosporin allergic 

patients: 

� Spectinomycin is no longer manufactured 

� CDC recommends desensitization* 

� Could be a special case to consider azithromycin* 



Gonorrhea Treatment of Urogenital 

Infections if Fluoroquinolone Resistance 


� Ceftriaxone 125 mg IM x 1* 

� Cefixime 400 mg PO x 1* 


� Spectinomycin 2 g IM x 1** 

� Single-dose cephalosporin regimens 

� Cefpodoxime 400 mg po x 1 

� Cefuroxime 1 g po x 1 

Azithromycin 2 gm is not recommended by CDC 

Co-treat for chlamydia unless ruled out by NAAT 

* suspension may be available 

** currently not manufactured 

*Preferred and only recommended 

regimen for pharyngeal infection

California Enhanced Gonorrhea Data 

Any Fluroquinolone Use by Health Jurisdiction 

- 2004 

Use of 

Fluroquinolones 

Alameda 5% 

Fresno 6% 

Kern 12% 

Long Beach 11% 

Orange 12% 

San Bernardino 8% 

Santa Clara 21%

Lymphogranuloma Venereum 

(LGV) 

C. trachomatis serovars L1, L2, L3 

� Clinical presentation 

� Lymphadenopathy syndrome: ulcer & inguinal 

adenopathy (bubo) 

� Anorectal syndrome: proctitis/protocolitis 

� Mucoid/hemorrhagic rectal discharge, anal pain, 

constipation, tenesmus 

� Complications from destructive granulomatous 

process 

�abscesses with scarring, fistulae, strictures, 

genital elephantiasis

LGV Issues 

� LGV has been around for some time 

� May be asymptomatic 

� Clinical presentation typically includes protocolitis 

in MSM 

� Consider GC and HSV in differential 

� Diagnosis is primarily by clinical findings/history 

� Test for rectal CT 

� Swabs of rectal lesions visualized by anoscopy is 

better than blind rectal swab 

� CDC can do molecular testing of suspect rectal swabs 

/ lesions (404-639-2059) 

� Role of serologic testing is less clear

LGV Proctocolitis: 

Serologic Diagnosis 

� Microimmunofluorescence (MIF) 

� species-specific test 

� titer ≥ 1:256 is suggestive (arbitrary cut point) 

� Complement Fixation (CF) 

� genus-specific 

� positive 2 weeks after infection 

� titer ≥ 1:64 suggestive of LGV 

� high background rate of low titer reactors

LGV Proctocolitis: 

Treatment Issues 

� Presumptive treatment for LGV based on clinical 

suspicion along with other empiric treatment for 

protocolitis: (Ceftriaxone 125 mg IM plus) 

Recommended regimen: 

�Doxycycline 100 mg PO BID x 21 days 

Alternative regimen: 

�Erythromycin base 500 mg PO QID x 21 days 

Likely effective but clinical data lacking: 

�Azithromycin 1 g PO weekly for 3 weeks 

• Partners within past 60 days of onset of symptoms need 

evaluation. If no symptoms, treat with: 

Azithromycin 1 g or Doxycycline 100 mg BID x 7 days

Phil and the Penis on the Go

Syphilis 

Treponema pallidum

The Three “R”s of Syphilis 

� Recognize 

� Rx 

� Report

Syphilis Issues 

� Diagnostic issues 

� Criteria for diagnosing early latent is change to be 

consistent with the surveillance case definition 

� New EIA testing algorithms: 

� reflexive quantitative RPR/VDRL 

� alternative treponemal test for discrepancies 

� FP in low risk populations 

� Some experts recommend CSF exam for 

� All patients with latent syphilis and RPR ≥ 1:32 

� HIV-infected patients with latent syphilis and CD4 count ≤ 

350 

� Recommend against the use of azithromycin 

� Note penicillin usage problems 

� BIC shortage 

� Specify use of Bicillin L-A (NOT Bicillin C-R)

Latent Syphilis 

� No clinical manifestations: only evidence is 

positive serologic tests 

� Divided into two stages for treatment purposes 

�Early latent syphilis: 1yr duration 

* Could be treatment failure

Diagnostic Tests for Syphilis 

� Darkfield / DFA-TP 

� PCR 

� VDRL/RPR 

� FTA-abs / TP-PA (MHA-TP) 

� EIA

Syphilis EIA Tests 

�Treponemal test but test performance may be 

inferior to TP-PA (Captia and TrepChek) 

� Specificity concerns 

�Can be used for screening but if positive then 

need quantitative RPR/VDRL 

�Advantages if comparable sensitivity and 

specificity 

� Not miss prozones 

� Low cost 

�Both IgM and IgG tests available 

� No clinical value of IgM in adult syphilis diagnosis

28,366* 

Non-reactive (NR) 

275** 

Syphilis EIA Trep- Chek Testing 

Algorithm: Southern Kaiser 

Initial 

EIA 

Not 

Syphilis 


TP-PA 

Reactive (R) 

Reactive (R) or Equivocal (Eq) Repeat EIA 

(in duplicate) 

366 



RPR 

Reactive (R) 

740 

Reactive (R) or Equivocal (Eq) 

* Nov- Dec 2004 

Titer RPR 

** 1 of 192 EIA +/RPR -/TP-PA - 

Syphilis 

confirmed by CDC Immunoassay Novak et al, ASM 2006

Criteria for CSF Examination 

� Neurologic or ophthalmic symptoms/signs 

� Evidence of tertiary disease 

� aortitis, gumma, iritis 

� Treatment failure 

� HIV infection with late latent or latent of unknown 

duration 

� Some experts recommend a CSF exam in all 

patients with latent syphilis and an RPR titer 

≥ 1:32 and HIV-infected patients with CD4 

count ≤ 350

Proposed Criteria for Performing LP in 

HIV-Infected Patients with Newly 

Diagnosed Syphilis 

Stage of Syphilis 

Primary or early latent 

with RPR ≤ 1:32 

Any stage with RPR >1:32 

Late-latent or syphilis of 

unknown duration 

Positive RPR/confirmatory test 

with neurologic or ophthalmic 

symptoms and/or signs 

CD4-Cells Recommendation 

≥350 

Syphilis Resistant to Azithromycin!

Syphilis Treatment 

Primary, Secondary & Early Latent 

Recommended regimen for adults: 

� Benzathine penicillin G 2.4 million units IM 

in a single dose 

Alternatives (non-pregnant penicillin-allergic 

adults): 

� Doxycycline 100 mg po bid x 2 weeks 

� Tetracycline 500 mg po qid x 2 weeks 

� Ceftriaxone 1 g IV or IM qd x 8-10 d 

� Azithromycin 2 g po in a single dose

HSV Issues 

� Role of type-specific HSV 

serologic tests 

� Role of suppressive therapy to 

reduce transmission

Genital Herpes – Testing Issues 

� Glycoprotein G type-specific HSV-2 serology 

tests may be useful HSV-2 (HerpeSelect- 1 or 2 ELISA, 

HerpeSelect- 1 and 2 Immunoblot and HSV-2 ELISA, Biokit HSV-2, and 

SureVue HSV-2): 

� Recurrent/atypical symptoms with negative culture 

� Clinical diagnosis without lab confirmation 

� Patients with a partner with genital HSV 

� Some experts recommend serology tests: 

� As part of “comprehensive STD evaluation” in high risk 

individuals such a those with multiple partners, HIVinfected, 

MSM with high HIV risk 

� In pregnant women with no history of HSV and a 

partner with history of symptomatic HSV 

� Universal screening NOT recommended

Rates of Transmission of HSV-2 to Susceptible Partners 

is Reduced with Once-Daily Suppressive Therapy 

• 1484 heterosexual couples 

randomly assigned to take 500 mg 

of valacyclovir or placebo once 

daily for 8 months 

• Serum samples collected monthly 

from susceptible partners for HSV 

analysis 

• The valacyclovir group showed 

• decreased transmission 

• lower frequency of shedding 

• fewer copies of HSV-2 DNA 

when shedding occurred 

Percent Transmission 

4 

3.5 

3 

2.5 

2 

1.5 

1 

0.5 

0 

1.9% 

Valacyclovir 

Group 

(N=743) 

3.6% 

Control 

Group 

(N=741) 

Corey et al, NEJM 2004; 350:11-20

Genital Herpes – Treatment Issues 

� Initial Infection 

� Treat because may develop severe or prolonged symptoms later 

� Established Infection 

� Suppressive therapy discussed first as if preferred over episodic therapy 

for both HIV negative and positive individuals with recurrent outbreaks 

� Benefits of suppressive therapy now include reducing risk of 

transmission in addition to clinical benefit of decreasing symptoms and 

recurrences 

� Indication for suppressive therapy to reduce transmission include: 

� Discordant heterosexual couples where the partner has a hx of genital HSV 

� Persons with multiple partners including MSM 

� Persons who are HSV-2 seropositive without a history of genital HSV 

� No studies in discordant pregnant couples 

� Options of suppression and episodic therapy should be discussed 

� Higher doses of antivirals not recommended for rectal and oral 

infections

Genital Herpes – Treatment Issues 

� Initial Infection 

� No change in treatment recommendations 

� Suppressive therapy 

� No change in treatment recommendations 

� Episodic Treatment for recurrence: 

� ADDED Acyclovir 800 mg PO TID for 2 days 

� Famciclovir 1000 mg PO BID for 1 day 

� Valacyclovir 500 mg PO BID for 3 days 

� DELETED Acyclovir 200 mg PO 5 x a day for 5 

days 

� For Persons with HIV 

� No change for suppressive or episodic except 

deleted acyclovir 200 mg PO 5 x a day for 5-10 

days

HPV Issues 

� Clarify uses of HPV DNA test 

� No change in diagnosis or treatment of 

external genital warts 

� No discussion of HPV vaccine

HPV Issues 

� Clarify uses of HPV DNA test in women 

� No recommendations regarding HPV 

testing and anal Pap smears in MSM or 

HIV-infected patients 

� No change in diagnosis or treatment of 

external genital warts 

� No discussion of HPV vaccine

Clinical Indications for HPV DNA 

Testing 

Proven to be clinically useful for: 

� Triage of ASCUS Pap smears 

� Adjunct screening in women age 30 and over 

� 12-month f/u of LSIL in adolescents 

� Post-colposcopy and post-treatment follow-up 

NO proven benefit for: 

� Triage of ASC-H, LSIL in adults or higher grade 

lesions 

� STD screening in the general population 

� Evaluation of sex partners 

� Evaluation of genital warts

Issues Regarding Anal Cancer Screening in 

MSM or HIV-infected patients 

� Anal HPV DNA is prevalent so role of HPV testing in 

anal cancer screening is unclear 

� Little data on the natural history of anal SILs 

� Questions regarding reliability of screening methods 

� Inconsistent correlation between anal Paps and histology 

� Intraobserver variability in interpretation of anal Pap smears 

� Limited data on treatment efficacy and side effects 

� If clinicians are conducting anal cancer screening, then 

collecting useful data to inform screening 

recommendations is recommended

Nongonococcal 

Urethritis Issues 

� New etiologic agent: Mycoplasma genitalium 

� No change in diagnostic criteria 

� Treat for CT; azithromycin efficacy better for Mg 

� Recurrent/persistent NGU: 

� Consider trichomoniasis, prostatitis, non-infectious 

etiologies 

� Treat with metronidazole PLUS azithromycin if not 

used for initial infection 

� DELETED erythromycin for treating recurrent NGU

Cervicitis – 

Diagnostic Issues 

� Changed name from mucopurulent cervicitis (MPC) 

to cervicitis 

� M. genitalium, BV and douching may play a role in 

addition to CT, GC, trichomoniasis and HSV 

� Diagnostic criteria: endocervical mucopus OR 

cervical friability 

� Diagnosis: 

� Vaginal wet mount with >10 WBCs per HPF associated 

with CT and GC infection 

� Evaluate for PID, BV and trichomoniasis (culture if 

wet mount is negative) in addition to CT and GC

Cervicitis – Treatment Issues 

� New age- and risk-based empiric treatment 

� Presumptive treatment for CT: 

� Age 25 or younger 

� STD risk in older women: new/multiple partners, 

unprotected sex 

� Especially if follow-up unlikely or non-NAAT test 

used 

� Presumptive treatment for GC: 

� High prevalence (>5%) 

� Treat BV if present

Pelvic Inflammatory Disease Issues 

� Newest etiologic agent: Mycoplasma genitalium 

� Pathogenesis unclear 

� No recommendation for Mg testing 

� If no evidence of cervicitis and no WBCs on wet 

mount the diagnosis of PID is unlikely 

� Modify minimal criteria for presumptive treatment: 

� CMT OR uterine tenderness OR adnexal tenderness 

� Clarify use of metronidazole*: 

� Treatment to cover anarobes should be considered 

� If BV is present or cannot be ruled out, add 

metronidazole* 

� Azithromycin treatment mentioned “outside the box” 



Proposed PID: Oral 

Treatment Regimens * 

Recommended Regimens *: 

�Ofloxacin 400 mg PO BID** x 14 d 

�Levofloxacin 500 mg PO QD x 14 d 

�Ceftriaxone 250 mg IM (or other parenteral 

3rd generation cephalosporin) x 1 

plus 

Doxycycline 100 mg PO BID x 14 d 

�Cefoxitin 2 g IM and probenecid 1 g PO x 1 

plus 

Doxycycline 100 mg PO BID x 14 d 

* Plus metronidazole if BV or BV cannot be ruled out 

** typo in guidelines- guidelines once daily 



PID: Oral Treatment 

Regimens 

Oral regimen A: 

�Ofloxacin* 400 mg PO BID** x 14 d or 

�Levofloxacin* 500 mg PO QD x 14 d 

plus (with or without) 

�Metronidazole 500 mg PO BID x 14 d 

*Contraindicated pregnant or nursing women and in CA, if 

GC documented and flouroquinolone is used need TOC 

** typographical error in guidelines- not once daily

PID: Oral Treatment Regimens 

Continued 

Oral regimen B: 

�Ceftriaxone 250 mg IM (or other parenteral 

3rd generation cephalosporin) x 1 or 

�Cefoxitin 2 g IM and probenecid 1 g PO x 1 

plus 

�Doxycycline* 100 mg PO BID x 14 d 

with or without 

�Metronidazole 500 mg PO BID x 14 d 

*Contraindicated pregnant or nursing women

Vaginitis 

Trichomonas 

Bacterial Vaginosis 

Vulvovaginal Candidiasis

Trichomoniasis Issues 

� Diagnosis on Pap test lacks specificity; recommend 

confirm with culture if patient is at low risk 

� New point of care tests have better sensitivity but FP 

in lower prevalence population 

� OSOM Trichomonas Rapid Test and Affirm TM VP III 

� Culture is the most sensitive and specific and should 

be done if wet mount is negative and Trichomoniasis 

is suspected 

� New treatment: 

� ADD tinidazole 2 g po x 1 

� Higher cost but better tolerated 

� New management of treatment failure (after metro 2 g 

po x 1) and Metronidazole-resistant trichomonas

Tinidazole: A New Treatment 

Option 

� Second generation 5-nitroimidazole 

�92%-100% effectiveness for trichomoniasis 

�Contraindicated in pregnancy (category C) 

� Advantages versus Metronidazole 

� Greater tolerability (approx. ½ incidence of nausea, 

vomiting and other GI side effects) 

� Longer duration of action (t1/2 of 12-14 hrs vs 6-7 hrs) 

� Greater in vitro potency against protozoa and anaerobes 

� Effective in metronidazole-resistant trichomoniasis 

� 92% (22/24) cure rate in largest report 

� Enhanced penetration in genital tissues

Trichomoniasis Treatment 

Recommended regimen: 

� Metronidazole 2 g PO x 1 

� Tinidazole 2 g po x 1 

Alternative regimen: 

� Metronidazole 500 mg PO BID x 

7d 

Recommended regimen in pregnancy: 

� Metronidazole 2 g PO x 1 

� Pregnancy category B and Tinidazole 

is category C

Proposed Management Trichomoniasis 

Treatment Failure 

� Re-treat with: Metronidazole 500 mg po 

BID x 7 d or Tinidazole 2 g po x 1 

� If repeat failure, treat with: Metronidazole 

or Tinidazole 2 g po x 5 d 

� Some experts treat with: Tinidazole 2-3 g 

po x 14 d* 

� Susceptibility testing: Send isolate to CDC 

�707-488-4115 or www.cdc.gov/std for 

instructions 



Bacterial Vaginosis – Treatment 

� Treatment: 

Issues 

� Clindamycin cream may be less effective than 

metronidazole 

� DELETED metronidazole 2 g single dose alternative 

� Suppressive treatment: 

� ADDED metronidazole gel twice weekly 

� Treatment of BV in pregnancy: 

� Metronidazole 500 mg po BID in addition to 250 mg po 

TID 

� Pre-surgical screening and treatment 

� Benefit for hysterectomy and surgical abortion 

� Consider for other procedures

BV Treatment 


� Metronidazole 500 mg PO BID x 7 d * 

� Metronidazole gel 0.75% 5 g per vagina QD/BID x 5 

d 

� Clindamycin cream 2% 5 g per vagina QHS x 7 d 


� Clindamycin 300 mg PO BID x 7 d 

� Clindamycin ovules 100 mg per vagina QHS x 3 d 

Recommended regimens in pregnancy: 

� Metronidazole 500 mg PO BID x 7 days 

� Metronidazole 250 mg PO TID x 7 days 

� Clindamycin 300 mg PO BID x 7 days 

Suppressive treatment: 

� Metronidazole gel 0.75% twice weekly for 6 

* months 

Preferred

Vulvovaginal Candidiasis 

� Uncomplicated versus Complicated VVC 

� Intravaginal treatment: 

�ADD miconazole 1200 mg vaginal 

suppository x 1 day (over the counter) 

� Treatment for recurrent VVC: 

�Induction with fluconazole 100/150/200 mg 

PO q 72 h x 3, then maintenance with 

fluconazole 100/150/200 mg PO q week

STD Resources 

California STD/HIV Prevention Training 

Center 

� www.stdhivtraining.org 

National Network of STD/HIV Prevention 

Training Centers 

� www.stdhivpreventiontraining.org 

CDC Treatment Guidelines 

� www.cdc.gov/std/treatment

New Directions In STD Treatment - University of Hawaii

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