What are the treatments for sexually transmitted diseases (STDs)?

Treatment for Sexually Transmitted Diseases

Treatment for STDs must be pathogen-specific, with bacterial infections requiring targeted antibiotics and viral infections requiring antiviral therapy or supportive care, as no single universal treatment exists for all STDs.

Bacterial STDs

Chlamydia

• Doxycycline 100 mg orally twice daily for 7 days is the preferred treatment for chlamydial infections in adults 1, 2
• Azithromycin 1 g orally as a single dose is an alternative option, offering the advantage of directly observed therapy and improved compliance 1, 3
• Both regimens achieve 97-98% cure rates, though doxycycline is more cost-effective 1

Gonorrhea

• Ceftriaxone monotherapy given intramuscularly is the recommended treatment, with dosing based on body weight 2
• Test-of-cure is mandatory for all pharyngeal gonorrhea cases 2
• Partner notification and treatment are essential to prevent reinfection 4

Syphilis

• For early syphilis (<1 year duration): single dose of intramuscular penicillin G benzathine 2.4 million units 2, 5
• For late syphilis (>1 year or unknown duration): three consecutive weekly doses of intramuscular penicillin G benzathine 2.4 million units each 2
• Evaluate all patients for otic, ophthalmic, and neurologic complications, which require 10-14 days of intravenous aqueous crystalline penicillin G 2

Chancroid

• Single-dose azithromycin or ceftriaxone are suitable treatments 5
• Efficacy in women has not been well-established due to limited clinical trial data 3

Trichomoniasis

• Metronidazole 7-day regimen is the recommended treatment for vaginal trichomoniasis 2
• Single-dose metronidazole is an alternative but carries higher rates of gastrointestinal adverse effects 6

Pelvic Inflammatory Disease

• Treatment routinely includes metronidazole combined with doxycycline and increased-dose ceftriaxone 2
• This combination addresses the polymicrobial nature of PID 2

Cervicitis

• For presumptive treatment: azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 4
• Add concurrent gonorrhea treatment if prevalence exceeds 5% in the patient population 4
• Consider treatment in women at increased risk (age <25 years, new or multiple partners, unprotected sex), especially if follow-up cannot be ensured 4

Viral STDs

Genital Herpes

• Antiviral medications (acyclovir, valacyclovir) relieve symptoms but do not eliminate the virus 7, 8
• Valacyclovir is indicated for initial episodes, recurrent episodes, and chronic suppressive therapy 7
• Treatment initiated within 24 hours of symptom onset for recurrent episodes is most effective 7
• Drug resistance occurs primarily in immunocompromised patients, including HIV-infected individuals; foscarnet or cidofovir are second-line options 8

Human Papillomavirus (HPV)

• No specific antiviral target exists; treatment uses antimitotics or immunomodulators 8
• Management focuses on visible lesions rather than viral eradication 8

Hepatitis B

• Hepatitis B vaccination is recommended for all unvaccinated patients being evaluated for an STD 4
• This represents one of the most effective prevention methods for sexually transmitted infections 4

Critical Management Principles

Partner Management

• All sexual partners within the previous 60 days must be referred for evaluation and treatment 1
• Partners should receive the same treatment as the index patient 4, 1
• Both patients and partners must abstain from sexual intercourse for 7 days after completing single-dose therapy or until completion of 7-day regimens 1

Follow-Up

• Patients treated with doxycycline or azithromycin for chlamydia generally do not require retesting unless symptoms persist or reinfection is suspected 1
• Consider retesting women approximately 3 months after treatment due to high reinfection risk 1
• Test-of-cure is mandatory for pharyngeal gonorrhea and rectal chlamydia treated with azithromycin 2

Special Populations

Pregnancy:

• For chlamydia: azithromycin 1 g orally single dose OR amoxicillin 500 mg orally three times daily for 7 days 1
• Doxycycline and ofloxacin are contraindicated in pregnancy 1
• For pediculosis pubis: use permethrin or pyrethrins with piperonyl butoxide (avoid lindane) 4

HIV-Infected Patients:

• Receive the same treatment regimens as HIV-negative patients for most STDs 4, 1
• Treatment of cervicitis in HIV-infected women is vital as it reduces cervical HIV shedding 4
• Higher rates of antiviral resistance occur in immunocompromised patients with herpes 8

Common Pitfalls

• Failure to treat sexual partners is the most common cause of reinfection 1
• Medications should ideally be dispensed on-site with the first dose directly observed to maximize compliance 1
• Single-dose therapy ensures virtually 100% compliance but may have reduced efficacy in certain situations (e.g., syphilis in pregnancy or HIV-infected individuals) 6
• Do not rely on azithromycin at recommended doses to treat incubating syphilis 3
• All patients with sexually transmitted urethritis or cervicitis require serologic testing for syphilis and appropriate gonorrhea cultures at diagnosis 3