What is the standard treatment coverage for sexually transmitted diseases (STDs)?

Standard Treatment Coverage for Sexually Transmitted Diseases

Core Treatment Regimens

For gonorrhea, treat with ceftriaxone 500 mg IM as a single dose (or 125 mg IM if <150 kg body weight), and always add concurrent treatment for chlamydia with doxycycline 100 mg orally twice daily for 7 days unless chlamydial infection has been definitively ruled out. 1, 2

Gonorrhea Treatment

• Ceftriaxone 125 mg IM single dose is the recommended first-line treatment for uncomplicated urogenital, anorectal, and rectal gonorrhea 1
• Updated 2020 guidelines recommend ceftriaxone 500 mg IM single dose for patients weighing ≥150 kg 2
• Quinolones (ciprofloxacin, ofloxacin, levofloxacin) should NOT be used in men who have sex with men (MSM), patients with recent foreign travel, or infections acquired in California or Hawaii due to quinolone-resistant N. gonorrhoeae (QRNG) prevalence 1
• Cefixime 400 mg orally is an alternative oral option where quinolone resistance is not a concern 1

Chlamydia Treatment

• Azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days are the recommended regimens 1, 3
• Doxycycline is now preferred over azithromycin based on recent evidence showing equal efficacy (97-98% cure rates) and lower cost 3, 4
• Single-dose azithromycin offers the advantage of directly observed therapy, improving compliance 3, 5

Dual Coverage Strategy

The critical principle is that gonorrhea and chlamydia frequently coexist, so presumptive treatment for both is recommended when either is suspected or confirmed. 1

• Coinfection rates are high enough that waiting for test results risks treatment delays and ongoing transmission 1
• In high-prevalence settings (>5% gonorrhea prevalence), treat presumptively for both organisms even before test results return 1

Cervicitis and Urethritis Coverage

Mucopurulent Cervicitis

• Treat presumptively with azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days in women at high risk (age <25 years, new or multiple partners, unprotected sex) 1
• Add gonorrhea coverage if local prevalence >5% or patient is in high-risk population 1
• Test for both C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests (NAATs), which have the highest sensitivity and specificity 1

Nongonococcal Urethritis (NGU)

• Doxycycline 100 mg orally twice daily for 7 days is first-line treatment 1, 6
• Alternative: Azithromycin 1 g orally single dose 1
• For persistent or recurrent NGU after initial treatment, extend therapy to 14 days with erythromycin base 500 mg orally 4 times daily 1

Special Populations

Pregnancy

• Azithromycin 1 g orally single dose is the preferred treatment for chlamydia in pregnancy 3, 7
• Doxycycline and quinolones are absolutely contraindicated in pregnant women 1, 7
• For gonorrhea in pregnancy, use ceftriaxone 125 mg IM; if cephalosporin allergy exists, use spectinomycin 2 g IM (though only 52% effective for pharyngeal infections) 1
• Alternative for chlamydia in pregnancy: amoxicillin 500 mg orally three times daily for 7 days 3

HIV-Infected Patients

• HIV-infected patients should receive identical treatment regimens as HIV-negative patients for all STDs 1
• Treatment of cervicitis in HIV-infected women is particularly important as it reduces cervical HIV shedding and may reduce HIV transmission 1

Partner Management

All sexual partners within the preceding 60 days must be evaluated and treated with the same regimen as the index patient. 1, 3

• If last sexual contact was >60 days before symptom onset, treat the most recent partner 1
• Patient-delivered partner therapy (expedited partner therapy) is an acceptable option for heterosexual patients when partner treatment cannot be ensured 1
• Do NOT use patient-delivered therapy in MSM due to high risk of coexisting undiagnosed STDs or HIV 1
• Both patients and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimens 1, 3

Follow-Up and Test of Cure

• No test of cure is needed for uncomplicated gonorrhea or chlamydia treated with recommended regimens 1
• Exception: Test of cure IS recommended for pharyngeal gonorrhea and rectal chlamydia treated with azithromycin 4
• Retest all patients at 3 months due to high reinfection rates (most post-treatment infections are reinfections, not treatment failures) 1, 3
• If symptoms persist after treatment, perform culture with antimicrobial susceptibility testing 1

Critical Pitfalls to Avoid

• Never use quinolones in MSM or patients with recent travel history due to widespread quinolone resistance 1
• Never withhold treatment while awaiting test results in high-risk populations or when follow-up is uncertain 1, 7
• Never forget partner treatment - this is the most common cause of reinfection and treatment failure 1, 3
• Never use doxycycline in pregnancy - this is an absolute contraindication 7
• Medications should ideally be dispensed on-site with the first dose directly observed to maximize compliance 3
• Spectinomycin is unreliable (only 52% effective) for pharyngeal gonorrhea, requiring follow-up pharyngeal culture 3-5 days post-treatment 1