What are the treatment options for sexually transmitted diseases (STDs)?

Treatment of Sexually Transmitted Diseases

STD treatment requires pathogen-specific antimicrobial therapy, with ceftriaxone for gonorrhea, doxycycline for chlamydia, benzathine penicillin G for syphilis, metronidazole for trichomoniasis, and acyclovir/valacyclovir for genital herpes, while empiric treatment should be initiated immediately in high-risk exposures without waiting for laboratory confirmation. 1, 2, 3

Empiric Treatment Approach

For high-risk exposures (such as unprotected sex with unknown partners), initiate empiric treatment immediately with ceftriaxone 500 mg IM single dose plus doxycycline 100 mg orally twice daily for 7 days to cover both gonorrhea and chlamydia. 1 This approach is critical because:

• Most STDs are asymptomatic (70% of HSV and trichomoniasis, 53-100% of extragenital gonorrhea and chlamydia) 3
• Delaying treatment while awaiting test results risks loss to follow-up 1
• Early treatment prevents complications including HIV transmission and tubal factor infertility 3

Pathogen-Specific Treatment Regimens

Bacterial STDs

Gonorrhea:

• Ceftriaxone remains the primary treatment, though antimicrobial resistance increasingly limits oral options 3
• Parenteral cephalosporins (ceftriaxone, cefotaxime, ceftizoxime) are required for disseminated gonococcemia 2

Chlamydia:

• Doxycycline is the standard treatment 1, 3
• Azithromycin is FDA-approved for urethritis and cervicitis due to Chlamydia trachomatis 4

Syphilis:

• Single-dose benzathine penicillin G remains the gold standard 2, 3
• Other single-dose regimens are associated with clinical failure or uncertain efficacy 2

Chancroid:

• Single-dose azithromycin or ceftriaxone are effective 2
• Azithromycin is FDA-approved for genital ulcer disease in men due to Haemophilus ducreyi 4

Lymphogranuloma Venereum:

• Requires prolonged courses of doxycycline or minocycline 2

Trichomoniasis:

• Nitroimidazoles (metronidazole) are effective treatment 3

Mycoplasma genitalium:

• Moxifloxacin is effective, though antimicrobial resistance limits oral treatment options 3

Viral STDs

Genital Herpes:

• Acyclovir is the oldest approved antiviral medication for initial and recurrent genital herpes 5
• Valacyclovir is FDA-approved for treatment of initial episodes, recurrent episodes, chronic suppressive therapy in immunocompetent and HIV-infected adults, and reduction of transmission 6
• For initial episodes, treatment should be initiated within 72 hours of symptom onset 6
• For recurrent episodes, treatment should begin within 24 hours of symptom onset 6
• Foscarnet or cidofovir are second-line options for acyclovir-resistant infections in immunocompromised patients, though more toxic 5
• No cure exists for genital herpes 3

Human Papillomavirus (HPV):

• No specific antiviral target exists; treatment uses antimitotics or immunomodulators 5

Critical Testing Requirements

All patients receiving empiric STD treatment must have:

• Nucleic acid amplification tests (NAATs) for Neisseria gonorrhoeae and Chlamydia trachomatis (sensitivity 86.1-100%, specificity 97.1-100%) 1, 3
• Serologic testing for syphilis using sequential treponemal and nontreponemal antibody detection 1, 3
• HIV testing and counseling offered 1

Partner Management

All sexual partners must be notified, evaluated, and treated presumptively even without symptoms or positive laboratory results. 7 This is essential because:

• Breaking the chain of transmission is crucial for STD control 7
• Asymptomatic viral shedding occurs frequently in genital herpes 6
• Reinfection rates are high without partner treatment 1

Two notification strategies exist:

• Patient referral (index patient notifies partners) 7
• Provider referral (health department staff notify partners) 7

Essential Patient Counseling

Patients must be instructed to:

• Abstain from sexual intercourse for 7 days after initiating therapy 1
• Return for evaluation if symptoms develop or persist 1
• Understand that most STDs produce no symptoms, making screening crucial 1
• Use barrier contraception (condoms) consistently and correctly with every act of intercourse 7

For genital herpes specifically:

• Valacyclovir is not a cure 6
• Avoid contact with lesions or intercourse when lesions/symptoms are present 6
• Transmission occurs even without symptoms through asymptomatic viral shedding 6
• Use safer sex practices in combination with suppressive therapy 6
• Sex partners should be advised they might be infected even without symptoms 6

Follow-Up and Monitoring

Consider repeat testing 3-6 months after treatment due to high reinfection rates. 1 For chronic suppressive therapy of genital herpes:

• Safety and effectiveness data exist for up to 1 year in immunocompetent patients 6
• Safety and effectiveness data exist for up to 6 months in HIV-infected patients 6

Prevention Strategies

Preexposure vaccination is highly effective for vaccine-preventable STDs:

• Hepatitis B vaccination is recommended for all unvaccinated patients evaluated for STDs 7
• Hepatitis A vaccination is recommended for men who have sex with men and persons who use illegal drugs 7

Condom use when consistent and correct is effective in preventing many STDs including HIV. 7 Proper use requires:

• New condom with each act of intercourse 7
• Careful handling to avoid damage 7
• Application after erection but before genital contact 7
• Water-based lubricants only with latex condoms 7

Common Pitfalls to Avoid

• Never delay treatment while waiting for test results in high-risk patients unlikely to return for follow-up 1
• Never rely solely on patient-reported absence of symptoms - most STDs are asymptomatic 1, 3
• Never assume azithromycin alone will treat syphilis - it should not be relied upon at recommended doses 4
• Never initiate herpes treatment after clinical signs develop (papule, vesicle, ulcer) - efficacy is not established 6
• Never use valacyclovir in neonates, infants, or as suppressive therapy following neonatal HSV infection - safety not established 6

Special Populations

For injecting-drug users:

• Enroll in drug treatment programs 7
• Never use injection equipment used by another person 7
• If equipment sharing continues, clean with bleach and water (though this does not guarantee HIV inactivation) 7