What is the treatment approach for an adult with a sexually transmitted disease (STD)?

Treatment for Sexually Transmitted Diseases in Adults

For adults with suspected STD exposure where the specific diagnosis is unknown or follow-up is uncertain, treat empirically with ceftriaxone 250 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days to cover both gonorrhea and chlamydia. 1

When to Treat Empirically

Empirical treatment is indicated when: 1

• The specific STD diagnosis in the sexual partner is unknown
• The patient may be difficult to locate for follow-up after test results
• The prevalence of gonorrhea and chlamydia is high (>5%) in the patient population 2

Recommended Empirical Treatment Regimen

Primary regimen: 1, 3

• Ceftriaxone 250 mg intramuscularly as a single dose (covers gonorrhea)
• PLUS Doxycycline 100 mg orally twice daily for 7 days (covers chlamydia and Mycoplasma genitalium)

Alternative for chlamydia coverage: 1, 4

• Azithromycin 1 g orally as a single dose can substitute for doxycycline, but doxycycline is preferred because it provides better coverage for Mycoplasma genitalium and other non-gonococcal urethritis pathogens

Concurrent Testing Requirements

Even when treating empirically, obtain the following tests before or concurrent with treatment: 1

• Nucleic acid amplification test (NAAT) for Neisseria gonorrhoeae
• NAAT for Chlamydia trachomatis
• Syphilis serology
• HIV testing with counseling

These tests have sensitivities of 86.1-100% and specificities of 97.1-100% for gonorrhea and chlamydia. 5

Specific STD Treatment Regimens

Chlamydia Trachomatis

Recommended: 2, 3, 4

• Azithromycin 1 g orally as a single dose
• OR Doxycycline 100 mg orally twice daily for 7 days

Both regimens are equally effective, but azithromycin offers single-dose convenience while doxycycline provides broader coverage. 2

Gonorrhea

Recommended: 2, 1

• Ceftriaxone 250 mg intramuscularly as a single dose
• PLUS treatment for chlamydia (since coinfection rates are high)

Antimicrobial resistance has eliminated oral treatment options for gonorrhea in many regions, making ceftriaxone the primary choice. 5

Mycoplasma Genitalium

First-line (without documented macrolide resistance): 6

• Azithromycin 500 mg orally on day 1, then 250 mg orally daily on days 2-5

For macrolide-resistant M. genitalium or after azithromycin failure: 6

• Moxifloxacin 400 mg orally once daily for 7 days (uncomplicated infections)
• Moxifloxacin 400 mg orally once daily for 14 days (complicated infections including PID or epididymitis)

Mucopurulent Cervicitis (MPC)

Treatment approach depends on local prevalence: 2

• High prevalence of both gonorrhea and chlamydia: Treat for both infections empirically
• Low gonorrhea prevalence but substantial chlamydia likelihood: Treat for chlamydia only
• Low prevalence of both infections with likely follow-up: Await test results before treating

Non-Gonococcal Urethritis (NGU)

Recommended: 2, 3

• Doxycycline 100 mg orally twice daily for 7 days
• OR Azithromycin 1 g orally as a single dose

For persistent or recurrent NGU after initial treatment, extend therapy to 14 days with an alternative regimen. 2

Critical Partner Management

All sexual partners within the preceding 60 days must be evaluated and treated: 2, 6, 1

• Partners receive the same treatment as the index patient (effective against both gonorrhea and chlamydia regardless of symptoms)
• If the patient's last sexual contact was >60 days before symptom onset, treat the most recent partner 2
• Patient-delivered partner therapy is an acceptable option when partner treatment cannot be ensured, except in men who have sex with men due to high risk of coexisting undiagnosed STDs or HIV 2

Sexual Abstinence Requirements

6, 1

• Patients must abstain from sexual intercourse until 7 days after completing therapy
• Partners must also abstain until completing their own treatment course
• For single-dose regimens, abstain for 7 days after the dose

Follow-Up Protocol

Return for evaluation if: 2, 1

• Symptoms persist or recur after completing therapy
• New symptoms develop

Test of cure: 6

• Not routinely recommended unless symptoms persist
• If testing is performed, wait at least 3 weeks after treatment completion to avoid false-positive results from dead organisms

Reinfection screening: 2, 1

• Consider repeat testing at 3 months after treatment due to high reinfection rates
• Retest whenever the patient next seeks medical care within 12 months, regardless of whether partners were treated

The majority of post-treatment infections result from reinfection rather than treatment failure, indicating the critical importance of partner treatment. 2

Special Populations

HIV-Infected Patients

HIV-infected patients receive the same treatment regimens as HIV-negative patients for gonorrhea, chlamydia, NGU, MPC, and Mycoplasma genitalium. 2, 6

Pregnant Women

2

• Do not use quinolones or tetracyclines
• Treat gonorrhea with ceftriaxone (recommended cephalosporin)
• Treat chlamydia with azithromycin or amoxicillin
• Women who cannot tolerate cephalosporins should receive spectinomycin 2 g intramuscularly as a single dose

Common Pitfalls to Avoid

2, 6

• Do not perform test-of-cure earlier than 3 weeks post-treatment – false-positives from dead organisms are common
• Do not rely on symptoms alone for retreatment – document signs or laboratory evidence of urethral inflammation
• Do not forget hepatitis B vaccination – recommended for all unvaccinated patients being evaluated for STDs 2
• Do not overlook asymptomatic infections – approximately 70% of HSV and trichomoniasis infections and 53-100% of extragenital gonorrhea and chlamydia infections are asymptomatic 5, 7

Prevention Counseling

2

• Consistent and correct condom use is effective in preventing most STDs, including HIV
• Both partners should be tested for STDs, including HIV, before initiating sexual intercourse
• Use a new condom with each act of sexual intercourse