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These guidelines for the treatment of patients with stds reflect the 2002 cdc std treatment guidelines and the region ix infer

CALIFORNIA STD TREATMENT GUIDELINES TABLE FOR ADULTS & ADOLESCENTS 2012
These guidelines reflect recent updates to the 2010 CDC STD Treatment Guidelines and the Region IX Infertility Clinical Guidelines. The focus is primarily on STDs encountered in of ice practice. These guidelines are intended as a source of clinical guidance; they are not a comprehensive list of all ef ective regimens and are not intended to substitute for use of the full 2010 STD treatment guidelines document. Call the local health department to report STD infections; to request assistance with confidential notification of sexual partners of patients with syphilis, gonorrhea, chlamydia or HIV infection; or to obtain additional information on the medical management of STD patients. The California STD/HIV Prevention Training Center is a resource for
training and consultation about STD clinical management and prevention (510-625-6000) or www.stdhivtraining.org.
RECOMMENDED REGIMENS
DOSE/ROUTE
ALTERNATIVE REGIMENS: To be used if medical
contraindication to recommended regimen. CHLAMYDIA
•      Azithromycin  or
•  Erythromycin  base  500  mg  po  qid  x  7  d  or
•  Erythromycin  ethylsuccinate  800  mg  po  qid  x  7  d  or
•  Levofloxac0 mg po qd x 7 d or
•      Azithromycin  or
•  Erythromycin  base  500  mg  po  qid  x  7  d  or
•  Erythromycin  base  250  mg  po  qid x 14 d or
•  Erythromycin  ethylsuccinate  800  mg  po  qid  x  7  d  or
•  Erythromycin  ethylsuccinate  400  mg  po  qid  x  14  d   GONORRHEA: Ceftriaxone is the preferred treatment for adults and adolescents with uncomplicated gonorrhea. Dual therapy with ceftriaxone 250 mg IM (increased from
125 mg) Plus azithromycin 1 g po or doxycycline 100 mg po bid x 7 d is recommended for al patients with gonorrhea regardless of chlamydia test results. 4
Uncomplicated
Dual therapy with
Dual therapy with
•      Azithromycin  or
• Azithromycin 6 1g po or Doxycycline 100 mg po bid x 7d If allergic to cephalosporins or severe penicil in al ergy
Dual therapy with
• Azithromycin 6 2 g po in a single dose •      Azithromycin  or
Dual therapy with
If allergic to cephalosporins or severe penicil in al ergy
Azithromycin 6 2 g po in a single dose
Parenteral 9
Parenteral 9•  Ampicillin/Sulbactam  3  g  IV  q  6  hrs  plus
INFLAMMATORY
•        Either Cefotetan or
DISEASE 4, 7, 8
Cefoxitin plus
• Levofloxacin 2 500 mg po qd x 14 d or
•     Clindamycin  plus
• Ofloxacin 2 400 mg po bid x 14 d or
• Ceftriaxone 250 mg IM in a single dose and Azithromycin 1 g po once a week for 2 weeks •        Either Ceftriaxone or
• Metronidazole 500 mg po bid x 14 d if BV is present or Cefoxitin with Probenecid plus
Doxycycline 2 plus
CERVICITIS 4, 7, 11
•      Azithromycin  or
• Doxycycline 2 plus
• Metronidazole if BV or trichomoniasis is NONGONOCOCCAL
•      Azithromycin  or
•  Erythromycin  base  500  mg  po  qid  x  7  d  or
URETHRITIS 7
•  Erythromycin  ethylsuccinate  800  mg  po  qid  x  7  d  or
•  Levofloxacin  500  mg  po qd x 7 d or
•  Ofloxacin  300  mg  po  bid  x  7  d  
EPIDIDYMITIS 4, 7
•      Ceftriaxone  plus
•      Levofloxacin  12 or
CHANCROID
•      Azithromycin or
• Ceftriaxone or
•      Ciprofloxacin 2 or
LYMPHOGRANULOMA
•  Erythromycin  base  500  mg  po  qid  x  21  d  or
VENEREUM
•  Azithromycin  1  g  po  q  week  x  3  weeks TRICHOMONIASIS 13,14
Non-pregnant women
• Metronidazole or
1. Annual screening for women aged 25 years or younger. Nucleic acid amplification tests (NAATs) are recommended. Al patients should be re-tested 3 months after treatment for chlamydia or gonorrhea. 2. Contraindicated for pregnant and nursing women. 3. Every effort to use a recommended regimen should be made. Test-of-cure fol ow-up (preferably by NAAT) 3-4 weeks after completion of therapy is recommended in pregnancy. 4. If treatment failure is suspected because GC has been documented, the patient has been treated with a recommended regimen for GC, and symptoms have not resolved, then perform a test-of-cure using culture and antibiotic susceptibility testing and report to the local health department. For clinical consult, cal the CA STD Control Branch at 510-620-3400. For further guidance, go t(“STD  Guidelines”). 5. Oral cephalosporins give lower and less-sustained bacteriocidal levels than ceftriaxone 250 mg and have limited efficacy for treating pharyngeal GC. Therefore, ceftriaxone is the preferred medication. 6. For patients with cephalosporin al ergy, or severe penicil in al ergy, (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis), azithromycin is an option. However, because of GI intolerance and concerns regarding emerging resistance, it should be used with caution. 7. Testing for gonorrhea and chlamydia is recommended because a specific diagnosis may improve compliance and partner management, and because these infections are reportable by California law. 8. Evaluate for bacterial vaginosis. If present or cannot be ruled out, also use metronidazole. 9. Discontinue 24 hours after patient improves clinical y and continue with oral therapy for a total of 14 days. 10. Fluoroquinolones can be considered for PID if the risk of GC is low, a NAAT test for GC is performed, and fol ow-up of the patient can be assured. If GC is documented, the patient should be re-treated with the recommended ceftriaxone and doxycycline regimen. If cephalosporin therapy is not an option, the addition of azithromycin 2 g oral y as a single dose to a quinolone-based PID regimen is recommended. 11. If local prevalence of gonorrhea is greater than 5%, treat empirical y for gonorrhea infection. 12. If gonorrhea is documented, change to a medication regimen that does not include a fluoroquinolone. 13. For suspected drug-resistant trichomoniasis, rule out re-infection; see 2010 CDC Guidelines, Trichomonas Fol ow-up , p. 60, for other treatment options, and evaluate for metronidazole-resistant T. vaginalis. For laboratory and clinical consultations, contact CDC at 404-718-414 14. For HIV-positive women with trichomoniasis, metronidazole 500 mg po bid x 7 d is more ef ective than metronidazole 2 g oral y. 15. Safety in pregnancy has not been established; pregnancy category C. Developed by the California STD/HIV Prevention Training Center and California Department of Public Health STD Control Branch Updated September 2012 RECOMMENDED REGIMENS
DOSE/ROUTE
ALTERNATIVE REGIMENS: To be used if medical
BACTERIAL VAGINOSIS
Adults/Adolescents
•      Metronidazole or
•  Tinidazole 15 2 g po qd x 2 d or
•      Metronidazole gel or
•  Tinidazole  15 1 g po qd x 5 d or
•  Clindamycin  300  mg  po  bid  x  7  d  or
•  Clindamycin  ovules  100 mg intravaginally qhs x 3 d •      Metronidazole  or
•      Metronidazole  or
ANOGENITAL WARTS
Patient-Applied
Alternative Regimen
•         Imiquimod 15,16 5% cream or
•  Intralesional  interferon  or
•         Podofilox 15 0.5% solution or gel or
Topically bid x 3 d followed by 4 d no tx •  Laser  surgery or
•  Photodynamic  therapy  or
•         Sinecatechins 15 15% ointment Provider-Administered
•         Cryotherapy or
•         Podophyllin 15 resin 10%-25% in tincture of benzoin or
•         Trichloroacetic acid (TCA) 80%-90% or
•         Bichloroacetic acid (BCA) 80%-90% or
•         Cryotherapy or
•         TCA or BCA 80%-90% or
•         Podophyllin 15 resin 10%-25% in tincture of benzoin or
ANOGENITAL HERPES 18
•      Acyclovir  or
•      Acyclovir  or
•      Famciclovir  or
•          Acyclovir or
•          Famciclovir 19 or
•      Valacyclovir  or
•          Acyclovir or
•          Acyclovir or
•          Acyclovir or
•      Famciclovir  or
•      Famciclovir  or
•      Famciclovir  or
•      Valacyclovir  or
HIV Co-Infected 20
•      Acyclovir   or
•      Famciclovir 19 or
•      Acyclovir or
•      Famciclovir or
SYPHILIS 21, 22
•  Doxycycline 23 100 mg po bid x 14 d or
•  Tetracycline 23 500 mg po qid x 14 d or
•  Ceftriaxone  23 1 g IM or IV qd x 10-14 d •  Doxycycline 23 100 mg po bid x 28 d or
•  Tetracycline  23 500 mg po qid x 28 d •      Aqueous  crystalline  penicillin  G 2.4 million units IM qd x 10-14 d plus
Probenecid 500 mg po qid x 10-14 d or
•  Ceftriaxone  23 2 g IM or IV qd x 10-14 d Pregnant Women 25
and Early Latent
Late Latent and
•      Benzathine  penicillin  G   •      Aqueous  crystalline  penicillin  G 2.4 million units IM qd x 10-14 d plus
15. Safety in pregnancy has not been established; pregnancy category C. 16. May weaken latex condoms and contraceptive diaphragms. 17. Cervical and intra-anal warts should be managed in consultation with specialist. 18. Counseling about natural history, asymptomatic shedding, and sexual transmission is an essential component of herpes management. 19. The goal of suppressive therapy is to reduce recurrent symptomatic episodes and/or to reduce sexual transmission. Famciclovir appears somewhat less ef ective for suppression of viral shedding.
20. If HSV lesions persist or recur during antiviral treatment, drug resistance should be suspected. Obtaining a viral isolate for sensitivity testing and consulting with an infectious disease expert is recommended.
21. Benzathine penicil in G (generic name) is the recommended treatment for syphilis not involving the central nervous system and is available in only one long-acting formulation, Bicil in® L-A (the trade name),
which contains only benzathine penicil in G. Other combination products, such as Bicil in® C-R, contain both long- and short-acting penicil ins and are not effective for treating syphilis. 22. Persons with HIV infection should be treated according to the same stage-specific recommendations for primary, secondary, and latent syphilis as used for HIV-negative persons. Available data demonstrate that additional doses of benzathine penicil in G, amoxicil in, or other antibiotics in early syphilis do not result in enhanced efficacy, regardless of HIV status. 23. Alternates should be used only for penicil in-al ergic patients because ef icacy of these therapies has not been established. Compliance with some of these regimens is difficult, and close fol ow-up is essential. If compliance or fol ow-up cannot be ensured, the patient should be desensitized and treated with benzathine penicil in. 24. Some specialists recommend 2.4 mil ion units of benazthine penicil in G q week for up to 3 weeks after completion of neurosyphilis treatment. 25. Pregnant women allergic to penicil in should be treated with penicil in after desensitization. Developed by the California STD/HIV Prevention Training Center and California Department of Public Health STD Control Branch Updated September 2012

Source: http://www.northbaysymposium.com/downloads/Adler/California%20STD%20Treatment%20Guidelines%20Handout%20-%20STD%20Talk%20by%20Dr.%20Adler.pdf

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Richard J. Fruncillo, M.D., Ph.D. 7 Lakeview Place Newtown Square, PA 19073 CURRICULUM VITAE EDUCATION Mercy Catholic Medical Center, Darby, PA Thomas Jefferson University, Philadelphia, PA The Hahnemann Medical College, Philadelphia, PA The Hahnemann Medical College Hospital, Philadelphia, PA The Hahnemann Medical College, Philadelphia, PA The University of Pennsylvania,

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