What is the recommended STD prophylaxis regimen for a female patient with a high suspicion for a sexually transmitted disease (STD)?

STD Prophylaxis Regimen for Females with High Suspicion for STD

For females with high suspicion for STD, treat immediately with azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days, and add concurrent treatment for gonorrhea with ceftriaxone 125 mg IM if local prevalence exceeds 5%. 1

When to Treat Presumptively (Without Awaiting Test Results)

Empiric treatment should be initiated immediately in the following situations:

• Age <25 years with new or multiple sex partners 1
• Unprotected sexual intercourse 1
• Follow-up cannot be ensured (patient unlikely to return for results) 1
• High-prevalence setting where gonorrhea rates exceed 5% in the patient population 1

The CDC guidelines prioritize presumptive treatment in these scenarios because the risk of untreated infection (including pelvic inflammatory disease, infertility, and ectopic pregnancy) outweighs the minimal risks of empiric antibiotics. 1

Recommended Antibiotic Regimens

For Chlamydia Coverage (Primary Treatment)

Option 1 (Preferred when compliance uncertain):

• Azithromycin 1 g orally as a single dose 1, 2

Option 2 (Cost-effective when compliance assured):

• Doxycycline 100 mg orally twice daily for 7 days 1, 3

Azithromycin and doxycycline have equivalent efficacy in clinical trials, but azithromycin ensures 100% compliance through directly observed single-dose therapy. 1, 4 This is particularly valuable in populations with erratic healthcare-seeking behavior or unpredictable follow-up. 1

For Concurrent Gonorrhea Coverage

Add ceftriaxone 125 mg intramuscularly as a single dose if:

• Local gonorrhea prevalence is >5% 1
• Patient is in a young age group where facility prevalence is high 1

The 2021 CDC guidelines now recommend ceftriaxone monotherapy (without azithromycin) for confirmed gonorrhea, but when treating presumptively for both infections, both agents should be given. 1, 4

Alternative Regimens (If First-Line Not Tolerated)

• Erythromycin base 500 mg orally four times daily for 7 days 1, 5
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 5
• Ofloxacin 300 mg orally twice daily for 7 days 1
• Levofloxacin 500 mg orally once daily for 7 days 1

Important caveat: Erythromycin has higher rates of gastrointestinal side effects that frequently discourage compliance, making it less effective in real-world practice. 1

Essential Diagnostic Testing (Obtain Before or Concurrent with Treatment)

Even when treating presumptively, obtain:

• Nucleic acid amplification tests (NAATs) for C. trachomatis and N. gonorrhoeae on cervical or urine samples 1, 6

  • NAATs have sensitivities of 86.1%-100% and specificities of 97.1%-100% 6
  • These are the most sensitive and specific tests available 1

• Wet mount microscopy for Trichomonas vaginalis 1

  • If symptomatic cervicitis with negative microscopy, obtain culture or antigen-based detection (microscopy sensitivity is only ~50%) 1

• Vaginal flora assessment for bacterial vaginosis 1

  • Treat concomitant BV or trichomoniasis if detected 1

Critical Contraindications and Special Populations

Pregnancy

• Azithromycin 1 g orally is the treatment of choice 7, 2
• Doxycycline is absolutely contraindicated 1, 7, 3
• Quinolones (ciprofloxacin, ofloxacin, levofloxacin) are contraindicated 1
• If cephalosporin allergy exists, use spectinomycin 2 g IM 1

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients 1
• Treatment is particularly vital because cervicitis increases cervical HIV shedding and may increase HIV transmission 1

Partner Management (Non-Negotiable)

All sexual partners within the preceding 60 days must be:

• Notified of exposure 1
• Examined and tested 1
• Treated with the same regimen as the index patient, regardless of symptoms 1

Abstinence requirements:

• Patient and all partners must abstain from sexual intercourse for 7 days after single-dose therapy OR until completion of 7-day regimens 1

Male partners of women with cervicitis are often asymptomatic but frequently harbor urethral infection. 1 Failure to treat partners results in high reinfection rates. 1

Expedited Partner Therapy Option

For heterosexual patients whose partners' treatment cannot be ensured, consider patient-delivered partner therapy (prescription or medication given to patient for partner). 1 This approach should include:

• Treatment for both chlamydia and gonorrhea 1
• Educational materials about symptoms 1
• Strong encouragement for partners to seek clinical evaluation 1

Do not use this approach in men who have sex with men due to high risk of coexisting undiagnosed STDs or HIV. 1

Follow-Up Protocol

• Reevaluate if symptoms persist after completing therapy 1

• Retest 3 months after treatment to detect reinfection (not treatment failure) 1

  • Most post-treatment infections result from reinfection rather than treatment failure 1
  • If patient doesn't return at 3 months, test whenever they next seek care within 12 months 1

• Test-of-cure is NOT routinely recommended for uncomplicated cervicitis treated with recommended regimens 1

Common Pitfalls to Avoid

Do not delay treatment while awaiting test results in high-risk populations or when follow-up is uncertain—the sequelae of untreated infection (PID, infertility, ectopic pregnancy) far outweigh the minimal risks of empiric antibiotics. 1

Do not use quinolones for gonorrhea in men who have sex with men, patients with recent foreign travel, or infections acquired in California or Hawaii due to quinolone-resistant N. gonorrhoeae. 1

Do not forget partner treatment—this is the leading cause of treatment failure and reinfection. 1

Do not use doxycycline in pregnant women—always use azithromycin. 1, 7

Do not assume single-dose therapy is always superior—while azithromycin ensures compliance, doxycycline is equally effective when compliance can be assured and is significantly less expensive. 1, 4