What are the treatment guidelines for managing Sexually Transmitted Infections (STIs)?

STI Management Guidelines

For sexually transmitted infections, treat empirically based on clinical presentation and local epidemiology while awaiting confirmatory testing, using azithromycin 1g orally as a single dose or doxycycline 100mg orally twice daily for 7 days for chlamydia, and ceftriaxone 250mg IM for gonorrhea, with mandatory partner notification and treatment within 60 days of contact. 1, 2

Diagnostic Approach

Initial Testing Requirements

• Nucleic acid amplification tests (NAATs) are the preferred diagnostic method for gonorrhea and chlamydia, offering sensitivities of 86.1-100% and specificities of 97.1-100%, and can be performed on cervical, urethral, or urine samples 1, 3
• Collect specimens from all sites of potential exposure or penetration, including extragenital sites (pharyngeal and rectal) in men who have sex with men and transgender women 1, 4
• Perform wet mount and culture for Trichomonas vaginalis if vaginal discharge or malodor is present, noting that microscopy sensitivity is only approximately 50% 1
• Obtain syphilis serology using sequential treponemal and nontreponemal antibody testing 3
• HIV counseling and testing should be offered to all patients presenting with STI concerns 1

Treatment Regimens by Condition

Chlamydia (Chlamydia trachomatis)

Recommended regimens:

• Azithromycin 1g orally in a single dose 1, 2, 5
• OR Doxycycline 100mg orally twice daily for 7 days 1, 2

Both regimens achieve 97-98% cure rates, with azithromycin offering the advantage of directly observed single-dose therapy to improve compliance 2

Gonorrhea (Neisseria gonorrhoeae)

• Ceftriaxone 250mg IM in a single dose 1
• Must be combined with chlamydia treatment (azithromycin or doxycycline) due to high rates of coinfection 1
• Consider concurrent treatment for gonorrhea when local prevalence exceeds 5% in the patient population 1

Cervicitis (Mucopurulent)

Presumptive treatment indicated for:

• Women under 25 years of age 1
• Patients with new or multiple sex partners 1
• Patients with unprotected sexual contact 1
• Settings where follow-up cannot be ensured 1

Treatment: Same as chlamydia regimens above 1

Trichomoniasis

• Metronidazole 2g orally in a single dose 1, 3
• Treat concomitantly if detected during evaluation 1

Epididymitis

For sexually transmitted epididymitis (age <35 years):

• Ceftriaxone 250mg IM in a single dose PLUS Doxycycline 100mg orally twice daily for 10 days 1

For enteric organism epididymitis (age >35 years or recent urinary instrumentation):

• Ofloxacin 300mg orally twice daily for 10 days 1

Adjunctive measures: Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 1

Special Populations

Pregnancy

• Azithromycin 1g orally in a single dose is safe and preferred 2
• OR Amoxicillin 500mg orally three times daily for 7 days 2
• Doxycycline and ofloxacin are contraindicated in pregnancy 2

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients for uncomplicated STIs 1, 2
• Treatment of cervicitis in HIV-infected women is particularly important as it reduces cervical HIV shedding and may reduce transmission 1

Partner Management

Notification and Treatment Requirements

• All sexual partners within the previous 60 days must be referred for evaluation and treatment 2
• If the patient's last sexual contact preceded 60 days, treat the most recent partner 1
• Partners should receive the same treatment regimen as the index patient, even if asymptomatic 1, 2
• Abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimens 1, 2

Expedited Partner Therapy

• Medications should ideally be dispensed on-site with the first dose directly observed to maximize compliance 2
• Failure to treat partners is the most common cause of reinfection 2

Follow-Up Protocols

Routine Follow-Up

• Patients treated with azithromycin or doxycycline generally do not require test-of-cure unless symptoms persist 2
• Retest women approximately 3 months after treatment due to high reinfection risk 2
• If symptoms persist, evaluate for possible reexposure, partner treatment compliance, and alternative diagnoses 1, 2

Persistent Cervicitis

• Reevaluate for reexposure to STDs and reassess vaginal flora 1
• If reinfection and bacterial vaginosis are excluded and partners have been treated, management options are undefined 1
• Repeated or prolonged antibiotic therapy has unknown value for persistent symptomatic cervicitis 1
• Consider ablative therapy by a gynecologic specialist for persistent symptoms clearly attributable to cervicitis 1

Epididymitis Follow-Up

• Failure to improve within 3 days requires reevaluation of diagnosis and therapy 1
• Persistent swelling and tenderness after completing antimicrobial therapy warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, or tuberculous/fungal epididymitis 1

Common Pitfalls and Caveats

Asymptomatic Infections

• Approximately 70% of HSV and trichomoniasis infections and 53-100% of extragenital gonorrhea and chlamydia infections are asymptomatic 3
• Annual screening is recommended for all sexually active women under 25 years and older women with risk factors 1

Antimicrobial Resistance

• Antimicrobial resistance limits oral treatment options for gonorrhea and Mycoplasma genitalium 3
• Susceptibility testing should be performed when available, particularly for persistent or recurrent infections 1

Syphilis Considerations

• Azithromycin at recommended doses for chlamydia should not be relied upon to treat incubating syphilis 5
• All patients with sexually transmitted urethritis or cervicitis should have serologic testing for syphilis performed at diagnosis 5

Sexual Assault Cases

• Prophylactic treatment is recommended because follow-up is often difficult and patients may be reassured by immediate treatment 1
• Recommended prophylactic regimen: Ceftriaxone 125mg IM PLUS Metronidazole 2g orally PLUS Doxycycline 100mg orally twice daily for 7 days 1
• Follow-up examinations at 2 weeks and 12 weeks are essential for repeat testing and serologic evaluation 1