What is the treatment for a patient with Herpes Simplex Virus (HSV) and Chlamydia?

Treatment for HSV and Chlamydia Co-infection

Treat both infections simultaneously with azithromycin 1 g orally as a single dose for chlamydia, plus valacyclovir 1 g orally twice daily for 7-10 days for initial HSV infection (or appropriate episodic/suppressive therapy if recurrent HSV). 1, 2

Chlamydia Treatment

For chlamydia, use one of these recommended first-line regimens:

• Azithromycin 1 g orally as a single dose (preferred for compliance concerns) 2
• Doxycycline 100 mg orally twice daily for 7 days (equally efficacious, less expensive) 2

Both regimens achieve 97-98% microbial cure rates. 2 Azithromycin is preferred when compliance with multi-day dosing is questionable, as it allows directly observed single-dose therapy. 2 Doxycycline costs less and has been used extensively with no higher risk for adverse events. 2

Alternative regimens if first-line options are contraindicated:

• Erythromycin base 500 mg orally four times daily for 7 days 2
• Levofloxacin 500 mg orally once daily for 7 days 2
• Ofloxacin 300 mg orally twice daily for 7 days 2

Note that erythromycin is less efficacious due to gastrointestinal side effects that discourage compliance. 2

HSV Treatment

Treatment depends on whether this is initial or recurrent HSV infection:

For Initial HSV Episode:

• Valacyclovir 1 g orally twice daily for 7-10 days (first-line) 1, 3, 4
• Acyclovir 400 mg orally three times daily for 7-10 days (equally effective alternative) 1, 3, 4
• Famciclovir 250 mg orally three times daily for 7-10 days (acceptable alternative) 4

Extend treatment beyond 10 days if healing is incomplete. 1, 3

For Recurrent HSV Episodes (Episodic Therapy):

• Valacyclovir 500 mg orally twice daily for 5 days 1, 3
• Acyclovir 400 mg orally three times daily for 5 days 1, 3
• Famciclovir 125 mg orally twice daily for 5 days 1, 3

Episodic therapy is most effective when started during prodrome or within 24 hours of lesion onset. 3, 4 Provide the patient with a prescription to self-initiate at first sign of recurrence. 1, 4

For Frequent HSV Recurrences (≥6 episodes/year):

Consider daily suppressive therapy, which reduces recurrence frequency by ≥75%: 1, 3, 4

• Valacyclovir 1 g orally once daily 3
• Valacyclovir 500 mg orally once daily (may be less effective with ≥10 episodes/year) 1, 3
• Acyclovir 400 mg orally twice daily 3

After 1 year of continuous suppressive therapy, discontinue to reassess recurrence frequency. 3

Critical Management Points

Medication dispensing and adherence:

• Dispense chlamydia medications on-site and directly observe the first dose to maximize compliance. 2
• Never use topical acyclovir alone—it is substantially less effective than oral systemic therapy. 1, 3, 4

Sexual abstinence instructions:

• Instruct patients to abstain from sexual intercourse for 7 days after single-dose chlamydia therapy or until completion of 7-day regimen. 2
• Patients must abstain until all sex partners are treated to minimize reinfection risk. 2
• For HSV, abstain when lesions or prodromal symptoms are present. 3, 4

Partner management:

• Treat all sex partners for chlamydia to prevent reinfection. 2
• Counsel HSV-infected patients to inform partners about their infection and use condoms during all sexual exposures. 1, 3

Patient Counseling Essentials

For chlamydia:

• Retest approximately 3 months after treatment due to high prevalence of reinfection. 2
• Test-of-cure is not recommended unless compliance is questionable, symptoms persist, or reinfection is suspected. 2

For HSV:

• Inform patients that HSV is a chronic, incurable infection with potential for recurrent episodes. 1, 3, 4
• Explain that asymptomatic viral shedding occurs and transmission can happen during asymptomatic periods. 1, 3
• Discuss the risk of neonatal infection with all patients, including men. 1, 3
• Emphasize that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences. 3, 4

Common Pitfalls to Avoid

• Do not delay HSV treatment pending laboratory confirmation—clinical diagnosis warrants immediate treatment. 4
• Do not use topical acyclovir as monotherapy—it provides no improvement in systemic symptoms. 1, 3, 4
• Do not delay episodic HSV treatment beyond 72 hours—efficacy decreases significantly. 1
• Do not forget to retest chlamydia patients at 3 months—reinfection rates are high, and repeat infections increase PID risk. 2