SUMMARY OF THE 2006 CDC SEXUALLY TRANSMITTED DISEASES (STD) TREATMENT GUIDELINES
National Coalition of STD Directors
These guidelines reflect the recommendations of the 2006 CDC STD Treatment Guidelines and serve as a quick reference for STDs encountered in an outpatient setting. This is not an exhaustive list of effective treatments, so refer to the complete document from the CDC for more information or call the STD Program. These guidelines are for clinical guidance and not to be construed as standards or inflexible rules. Clinical and epidemiological services are available through your STD Program, and staff are available to assist healthcare providers with confidential notification of sexual partners of patients infected with HIV and other STIs. For assistance, please contact:
NCSD, 1275 K Street, NW, Suite 1000, Washington, DC 2005, office: 202-842-4660, fax: 202-842-4542 – www.ncsddc.org
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DISEASE |
RECOMMENDED TREATMENT |
ALTERNATIVES |
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SYPHILIS (see 2006 CDC guidelines for follow-up recommendations and management of congenital syphilis) |
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PRIMARY (1º), SECONDARY (2º) OR EARLY LATENT (<1 YEAR) Adults -------------------------------------------------------- Children |
Benzathine penicillin G 2.4 million units IM in a single dose -------------------------------------------------------------------------------- Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, in a single dose |
(For penicillin allergic non-pregnant adult patients) Doxycycline 100 mg orally 2 times a day for 14 days OR Ceftriaxone 1 g daily IV or IM for 8-10 days OR Azithromycin 2 g orally once1 |
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LATE LATENT (>1 YEAR) OR LATENT OF UNKNOWN DURATION Adults -------------------------------------------------------- Children |
Benzathine penicillin G 2.4 million units IM for 3 doses, 1 week apart (total 7.2 million units) -------------------------------------------------------------------------------- Benzathine penicillin G 50,000 units/kg IM up to the adult dose of 2.4 million units, administered as three doses at 1 week intervals (total 150,000 units up to the adult total dose of 7.2 million units) |
Doxycycline 100 mg orally 2 times a day for 28 days for adults only ------------------------------------------------------------------------- |
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NEUROSYPHILIS |
Aqueous crystalline penicillin G 18 - 24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days |
Procaine penicillin 2.4 million units IM once daily plus probenecid 500 mg orally 4 times a day, both for 10-14 days |
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HIV INFECTION |
For 1º, 2º and early latent syphilis: Treat as above. Some specialists recommend three doses. For late latent syphilis or latent syphilis of unknown duration: Perform CSF examination before treatment |
The use of any alternative therapy in HIV infected persons has not been well studied; therefore the use of doxycycline, ceftriaxone and azithromycin must be undertaken with caution. |
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PREGNANCY |
Penicillin is the only recommended treatment for syphilis during pregnancy. Women who are allergic should be desensitized and then treated with penicillin. Dosages are the same as in non-pregnant patients for each stage of syphilis.2 |
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GONOCOCCAL INFECTIONS: Treat also for chlamydial infection if not ruled out by a sensitive test (nucleic acid amplification test) |
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ADULTS Cervix, Urethra, Rectum -------------------------------------------------------- PHARYNX |
Ceftriaxone 125 mg IM in a single dose OR Cefixime 400 mg orally in a single dose4 -------------------------------------------------------------------------------- Ceftriaxone 125 mg IM in a single dose OR |
Spectinomycin5 2 g IM in a single dose4 OR Single-dose cephalosporins regimens See 2006 CDC guidelines for discussion of alternative regimens ------------------------------------------------------------------------- |
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MEN WHO HAVE SEX WITH MEN OR HETEROSEXUALS WITH A HISTORY OF RECENT TRAVEL Cervix, Urethra, Rectum -------------------------------------------------------- PHARYNX |
Ceftriaxone 125 mg IM in a single dose OR Cefixime 400 mg orally in a single dose4 ------------------------------------------------------------------------------------ Ceftriaxone 125 mg IM in a single dose |
Update to CDC’s STD Treatment Guidelines, 2006: Fluroquinolones No Longer Recommended for Treatment Of Gonococcal Infections (MMWR 4/13/2007 / 56(14);332-336 |
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CONJUNCTIVA |
Ceftriaxone 1 g IM once plus lavage the infected eye with saline solution once |
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CHILDREN (<45KG) vagina, cervix, urethra, pharynx, rectum |
Ceftriaxone 125 mg IM once |
Spectinomycin5 40mg/kg IM once (maximum 2 g) |
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PREGNANCY |
Ceftriaxone 125 mg IM once OR Cefixime 400 mg orally in a single dose |
Spectinomycin5 2 g IM once |
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CHLAMYDIAL INFECTIONS |
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ADULT |
Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally 2 times a day for 7 days |
Erythromycin base 500 mg orally 4 times a day for 7 days OR Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days OR Ofloxacin3 300 mg orally 2 times a day for 7 days OR Levofloxacin3 500 mg orally once a day for 7 days |
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CHILDREN <45 KG -----------------------------------------→
>45 KG and <8 years of age ----------------→ > 8 years of age ------------------------------→ |
Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days6 Azithromycin 1 g orally single dose Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally 2 times a day for 7 days |
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PREGNANCY |
Azithromycin 1 g orally single dose OR Amoxicillin 500 mg orally 3 times a day for 7 days |
Erythromycin base 500 mg orally 4 times a day for 7 days OR Erythromycin 250 mg orally 4 times a day for 14 days OR Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days OR Erythromycin ethylsuccinate 400 mg 4 times a day for 14 days |
1 Some patients who are allergic to penicillin may also be allergic to ceftriaxone. Doxycycline is the preferred treatment. Treatment failures with azithromycin have been reported (MMWR 2004;53:197-8). T. pallidum strains resistant to azithromycin have been documented in various geographic areas in the USA (NEJM 2004;351:454-8.). If neither penicillin nor doxycycline can be administered, and azithromycin as a single dose oral dose of 2 g is considered, close follow-up is essential to ensure successful treatment. There are limited clinical studies also for ceftriaxone. Close follow-up of persons receiving any alternative therapies is essential. 2 Tetracycline/doxycycline contraindicated; erythromycin not recommended because it does not reliably cure an infected fetus; data insufficient to recommend azithromycin or ceftriaxone. 3 Cefixime tablets and spectinomycin are not currently available in the US. 4 Quinolones should not be used for treatment of gonorrhea. 5 Unreliable to treat pharyngeal infections. Patients who have suspected or known pharyngeal infection should have a pharyngeal culture 3-5 days after treatment to verify eradication of infection. 6 The efficacy of treating neonatal chlamydial conjunctivitis and pneumonia is about 80%. A second course of therapy may be required. An association between oral erythromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported in infants aged less than 6 weeks treated with this drug. Data on other macrolides (azithromycin, clarithromycin) for the treatment of neonatal chlamydial infection are limited. The results of one study involving a limited number of patients suggest that a short course of azithromycin 20 mg/kg/day, 1 dose daily for 3 days may be effective for chlamydial conjunctivitis.
Distributed by National Coalition of STD Directors. Format courtesy of the National Network of STD/HIV Prevention Training Centers – www.stdhivpreventiontraining.org
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DISEASE |
RECOMMENDED TREATMENT |
ALTERNATIVES |
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NONGONOCOCCAL URETHRITIS |
Azithromycin7 1 g orally single dose OR Doxycycline 100 mg orally 2 times a day x 7 days |
Erythromycin base8 500 mg orally 4 times a day for 7 days OR Erythromycin ethylsuccinate8 800 mg orally 4 times a day for 7 days OR Ofloxacin4 300 mg orally 2 times a day for 7 days OR Levofloxacin4 500 mg orally once a day for 7 days |
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Epididymitis9 |
Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally 2 times a day for 10 days |
Ofloxacin4 300 mg orally twice daily for 10 days OR levofloxacin4 500 mg orally once a day for 10 days |
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PELVIC INFLAMMATORY DISEASE (PID)10 (outpatient management) These regimens to be used with or without metronidazole 500 mg orally twice a day for 14 days |
REGIMEN A Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg orally 2 times a day for 14 days REGIMEN B Ceftriaxone 250 mg IM once OR Cefoxitin 2 g IM once plus probenicid 1 g orally once OR Other third generation cephalosporin PLUS Doxycycline 100 mg orally 2 times a day for 14 days |
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PREGNANCY AND PID Patients should be hospitalized and treated with the appropriate recommended parenteral IV treatments (see CDC guidelines) |
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CHANCROID |
Azithromycin 1 g orally single dose OR Ceftriaxone 250 mg IM single dose OR Ciprofloxacin 500 mg orally 2 times a day for 3 days OR Erythromycin base 500 mg orally 3 times a day for 7 days (preferred by some experts if HIV co-infection) |
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HERPES SIMPLEX VIRUS (for non-pregnant adults). See CDC 2006 guidelines for the management of herpes in pregnancy and in the neonate |
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First clinical episode of genital herpes |
Acyclovir 400 mg orally 3 times a day for 7-10 days OR 200 mg orally 5 times a day for 7-10 days OR Famciclovir 250 mg orally 3 times a day for 7-10 days OR Valacyclovir 1 g orally 2 times a day for 7-10 days |
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Daily Suppressive therapy |
Acyclovir 400 mg orally 2 times a day OR Famciclovir 250 mg orally 2 times a day OR Valacyclovir 500 mg orally once a day OR 1 g orally once a day |
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Episodic Recurrent Infection |
Acyclovir 800 mg orally 2 times a day for 5 days OR 400 mg orally 3 times a day for 5 days OR 800 mg orally 3 times a day for 2 days OR Famciclovir 125 mg orally 2 times a day for 5 days OR 1000 mg orally 2 times a day for 1 day Valacyclovir 500 mg orally 2 times a day for 3 days OR 1 g orally once a day for 5 days |
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HIV INFECTION Higher doses and/or longer therapy recommended. See 2006 CDC guidelines. |
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PEDICULOSIS PUBIS11 |
Permethrin 1% cream rinse applied to affected area and washed off after 10 minutes OR Pyrethrins with piperonyl butoxide applied to affected area and washed off after 10 minutes |
Malathion 0.5% lotion applied for 8-12 hours and washed off OR Ivermectin 250 ug/kg repeated in 2 weeks |
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SCABIES |
Permethrin 5% cream 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 |
Lindane11 1% 1 oz of lotion or 30 g of cream applied thinly to all areas of the body and thoroughly washed off after 8 hours |
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BACTERIAL VAGINOSIS (BV) |
Metronidazole12 500 mg orally 2 times a day for 7 days OR Metronidazole gel 0.75% intravag. once a day for 5 days OR Clindamycin cream13 2% intravag. at bedtime for 7 days |
Clindamycin 300 mg orally 2 times a day for 7 days OR Clindamycin ovules 100 g intravag. at bedtime for 3 days |
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PREGNANCY AND BV12 |
Metronidazole12 500 mg orally 2 times a day for 7 days OR Metronidazole12 250 mg orally 3 times a day for 7 days OR Clindamycin 300 mg orally 2 times a day for 7 days |
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TRICHOMONIASIS |
Metronidazole12 2 g orally single dose OR Tnidazole14 2 g orally single dose |
Metronidazole12 500 mg orally 2 times a day for 7 days |
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GENITAL WARTS |
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External PROVIDER-ADMINISTERED Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1-2 weeks if necessary OR Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80% -90%. Apply small amount only to warts. Allow to dry. If excess amount applied, powder with talc, baking soda or liquid soap. Repeat weekly if necessary OR Podophyllin resin 10%-25%14 in a compound tincture of benzoin. Allow to air dry. Limit application to <10 cm2 and to <0.5 ml. Wash off 1-4 hours after application. Repeat weekly if necessary OR Surgical removal PATIENT-APPLIED Podofilox 0.5% solution or gel14. Apply 2 times a day for 3 days, followed by 4 days of no therapy. This cycle can be repeated as necessary for up to 4 times. Total wart area should not exceed 10 cm2 and total volume applied daily not to exceed 0.5 ml. OR Imiquimod 5% cream14. Apply once daily at bedtime 3 times a week for up to 16 weeks. Wash treatment area with soap and water 6-10 hours after application. |
Urethral Meatus Cryotherapy with liquid nitrogen OR Podophyllin 10%-25%14 in a compound tincture of benzoin. Treatment area must be dry before contact with normal mucosa. Repeat weekly if necessary. |
Vaginal Cryotherapy with liquid nitrogen. Cryoprobe not recommended (risk of perforation and fistula formation) OR TCA or BCA 80%-90%. Apply small amount only to warts. If excess amount applied, powder with talc, baking soda or liquid soap. Repeat weekly if necessary. |
Anal Cryotherapy with liquid nitrogen OR TCA or BCA 80%-90%. Apply small amount only to warts. If excess amount applied, powder with talc, baking soda or liquid soap. Repeat weekly if necessary. Many persons with anal warts may also have them in the rectal mucosa. Inspect rectal mucosa by digital examination or anoscopy. Warts on the rectal mucosa should be managed in consultation with a specialist. |
Oral Cryotherapy with liquid nitrogen OR Surgical removal |
7 Infections with M. genitalium may respond better to azithromycin. 8 If this dose cannot be tolerated, then erythromycin base 250 mg orally or erythromycin ethylsuccinate 400 mg orally 4 times a day for 14 days can be used. 9 The recommended regimen of ceftriaxone and doxycycline is for epididymitis most likely caused by GC or CT infection. The alternative regimen of ofloxacin or levofloxacin is recommended if the epididymitis is most likely caused by enteric organisms, or for patients allergic to cephalosporins and/or tetracycline. 10 Metronidazole will also treat bacterial vaginosis, frequently associated with PID. Whether the management of immunodeficient HIV-infected women with PID requires more aggressive intervention has not been determined. 11 Lindane no longer recommended because of toxicity and is contraindicated in pregnancy. Ivermectin not recommended for pregnant and lactating women or for children who weigh <15 kg. Pregnant or lactating women should be treated with either permethrin or pyrethrins with piperonyl butoxide. Lindane not to be used immediately after a bath, in persons with extensive dermatitis and women who are pregnant or lactating, or children aged <2 years. 12 Multiple studies and meta-analyses have not demonstrated a consistent association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns. Screening for, and oral treatment of, BV in pregnant women at high risk for premature delivery is recommended by some experts and should occur at the first prenatal visit. Intravaginal clindamycin treatment for low risk women should be used only during the first half of pregnancy. 13 Clindamycin cream is oil-based and may weaken latex condoms and diaphragms for 5 days after use. 14 Safety during pregnancy not established.