What is the treatment for a sexually transmitted disease (STD) causing eye infection in a sexually active adult with a history of previous STDs?

Treatment of Sexually Transmitted Eye Infections

For gonococcal conjunctivitis in adults, treat with ceftriaxone 1 g IM as a single dose plus saline lavage of the infected eye, and add doxycycline 100 mg orally twice daily for 7 days to cover presumptive chlamydial co-infection. 1

Diagnostic Approach

When evaluating a sexually active adult with eye infection and STD history, test specifically for:

• Neisseria gonorrhoeae via culture and PCR 2
• Chlamydia trachomatis via PCR 2
• Consider syphilis serology if uveitis or other intraocular inflammation is present 3

Co-infection with both gonorrhea and chlamydia occurs frequently in sexually active adults with conjunctivitis, and delayed treatment can lead to corneal complications and potential blindness. 2

Treatment Protocol

For Gonococcal Conjunctivitis

Primary regimen:

• Ceftriaxone 1 g IM in a single dose 1
• Perform saline lavage of the infected eye once 1
• Add doxycycline 100 mg orally twice daily for 7 days to cover presumptive chlamydial co-infection 1, 4

This CDC guideline recommendation is based on a study showing 100% response rate (12/12 patients) to single-dose ceftriaxone for gonococcal conjunctivitis. 1

For Chlamydial Conjunctivitis

If chlamydia is confirmed or suspected:

• Doxycycline 100 mg orally twice daily for 7 days 4
• Alternative: Azithromycin 1 g orally as a single dose 5, 6

For Dual Infection (Common Scenario)

Since co-infection is common in sexually active adults, empiric treatment should cover both pathogens:

• Ceftriaxone 1 g IM (for gonorrhea) 1
• Plus doxycycline 100 mg orally twice daily for 7 days (for chlamydia) 1, 4
• Saline lavage once 1

Special Considerations

Pregnancy

• Do NOT use doxycycline or quinolones 1
• Use ceftriaxone 1 g IM for gonorrhea 1
• Use erythromycin or amoxicillin for chlamydia 1

Cephalosporin Allergy

• Use spectinomycin 2 g IM as alternative for gonorrhea 1
• Note: Spectinomycin is only 52% effective against pharyngeal infections, but this is less relevant for ocular infections 1

HIV-Positive Patients

• Use the same treatment regimen as HIV-negative patients 1

Critical Management Steps

Partner Notification and Treatment

• All sexual partners within 60 days before symptom onset must be evaluated and treated for both gonorrhea and chlamydia 1
• Instruct patient to avoid sexual intercourse until both patient and partners complete therapy and are symptom-free 1

Referral to Sexual Health Services

• Mandatory referral to sexual health clinic for comprehensive STD screening and partner notification 2
• Test for syphilis and HIV at time of diagnosis 1

Common Pitfalls to Avoid

Do not delay treatment waiting for culture results - the risk of corneal complications with gonococcal infection is too high. 2

Do not treat with topical antibiotics alone - systemic therapy is essential for both gonorrhea and chlamydia. 2

Do not forget chlamydial coverage - most patients with gonococcal conjunctivitis should receive presumptive treatment for chlamydia given high co-infection rates. 1, 2

Do not apply pediculosis treatments to the eyes - if pubic lice affect the eyelashes (which can occur with STD exposure), use occlusive ophthalmic ointment to eyelid margins twice daily for 10 days instead. 1

Follow-Up

• Re-evaluate within 48-72 hours to ensure clinical improvement 2
• If symptoms persist or worsen, consider corneal involvement and obtain urgent ophthalmology consultation 2
• Patients with corneal thinning or perforation risk require hospitalization and intensive treatment 2