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

Treatment of Sexually Transmitted Diseases

For bacterial STDs, use single-dose azithromycin 1g for chlamydia and uncomplicated gonorrhea (though resistance patterns now often require dual therapy), while valacyclovir is the treatment of choice for viral STDs including genital herpes and herpes labialis.

Bacterial STDs

Chlamydia and Gonorrhea

• Azithromycin is FDA-approved for urethritis and cervicitis caused by Chlamydia trachomatis or Neisseria gonorrhoeae 1
• The standard regimen is a single dose, making it highly effective for patient compliance 1
• Critical caveat: All patients with sexually-transmitted urethritis or cervicitis must have serologic testing for syphilis and appropriate cultures for gonorrhea at diagnosis 1
• Azithromycin used in high doses for short periods may mask or delay symptoms of incubating syphilis, so concurrent syphilis testing is mandatory 1

Chancroid

• Azithromycin is FDA-approved for genital ulcer disease in men caused by Haemophilus ducreyi (chancroid) 1
• Important limitation: Efficacy in women has not been established due to small numbers in clinical trials 1

Syphilis Warning

• Azithromycin at recommended doses should not be relied upon to treat syphilis 1
• If syphilis is confirmed, appropriate antimicrobial therapy specific to syphilis must be initiated 1

Viral STDs

Genital Herpes (HSV)

Valacyclovir is the FDA-approved treatment for all phases of genital herpes management 2

Initial Episode

• Valacyclovir treats the initial episode of genital herpes in immunocompetent adults 2
• Must initiate within 72 hours of symptom onset for established efficacy 2

Recurrent Episodes

• Valacyclovir treats recurrent genital herpes episodes in immunocompetent adults 2
• Must initiate within 24 hours of symptom onset for established efficacy 2

Suppressive Therapy

• Valacyclovir is indicated for chronic suppressive therapy in both immunocompetent adults and HIV-1-infected adults 2
• Efficacy established for up to 1 year in immunocompetent patients and 6 months in HIV-1-infected patients 2
• For HIV-1-infected patients, only use if CD4+ count ≥100 cells/mm³ 2

Transmission Reduction

• Valacyclovir reduces transmission of genital herpes in immunocompetent adults 2
• Efficacy established for up to 8 months in discordant couples 2
• Safer sex practices must be used concurrently with suppressive therapy 2

Herpes Labialis (Cold Sores)

• Valacyclovir treats cold sores in patients ≥12 years of age 2
• Must initiate before development of clinical signs (papule, vesicle, or ulcer) for established efficacy 2

Key Clinical Pitfalls

Testing Requirements

• Always perform susceptibility testing when using azithromycin, as resistance exists 1
• Culture and susceptibility tests should be performed before treatment, though therapy may be initiated empirically and adjusted based on results 1

Timing Constraints

• Valacyclovir has strict timing windows: within 72 hours for initial genital herpes, within 24 hours for recurrent episodes, and before lesion development for cold sores 2

Population Limitations

• Valacyclovir efficacy not established in immunocompromised patients except HIV-1-infected adults with CD4+ ≥100 cells/mm³ for genital herpes suppression 2
• Valacyclovir not indicated for patients <18 years with genital herpes 2