What is the treatment for a patient diagnosed with a sexually transmitted disease (STD), such as chlamydia, gonorrhea, or syphilis?

Treatment of Sexually Transmitted Diseases

Immediate Treatment Recommendations

For patients diagnosed with chlamydia, gonorrhea, or syphilis, treatment should be initiated immediately upon diagnosis or when clinical criteria are met, without waiting for laboratory confirmation. 1

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Chlamydia Treatment

Recommended first-line regimens:

• Azithromycin 1 g orally as a single dose 2, 3
• OR Doxycycline 100 mg orally twice daily for 7 days 2

Alternative regimens (when first-line options cannot be used):

• Erythromycin base 500 mg orally four times daily for 7 days 2
• Erythromycin ethylsuccinate 800 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

Key clinical points:

• Single-dose azithromycin offers superior compliance and allows directly observed therapy 2
• Azithromycin is strongly preferred over doxycycline for Mycoplasma genitalium infections, with cure rates of 85-95% versus 30-40% 1
• Medications should be dispensed on-site and the first dose directly observed to maximize compliance 2

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Gonorrhea Treatment

For gonorrhea (or empiric treatment when gonorrhea cannot be excluded):

• Ceftriaxone 250 mg intramuscularly as a single dose 2, 4
• PLUS treatment for chlamydia (as above) 2, 1, 5

Critical rationale for dual therapy:

• Chlamydia coinfection occurs in a substantial proportion of gonorrhea cases 1
• Treatment cannot wait for test results, and untreated chlamydia leads to complications including epididymitis, urethral stricture, and facilitates HIV transmission 1
• Quinolones (ofloxacin, levofloxacin) should NOT be used for gonorrhea due to widespread resistance 1

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Syphilis Treatment

For early syphilis (primary, secondary, or early latent <1 year):

• Benzathine penicillin G 2.4 million units intramuscularly as a single dose 4

For late latent syphilis or syphilis of unknown duration:

• Benzathine penicillin G 2.4 million units intramuscularly weekly for 3 consecutive weeks 4

Important caveat:

• Azithromycin at doses used for chlamydia/gonorrhea will NOT adequately treat incubating syphilis 3
• All patients with sexually transmitted urethritis or cervicitis must have syphilis serology performed at diagnosis 2, 1

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Empiric Treatment Indications

Empiric treatment for both gonorrhea AND chlamydia is indicated when:

• Mucopurulent or purulent urethral discharge is present 1
• Gram stain shows ≥5 WBCs per oil immersion field 1
• First-void urine microscopy demonstrates ≥10 WBCs per high-power field 1
• Positive leukocyte esterase test on first-void urine 2, 1
• Patient is at high risk and unlikely to return for follow-up 1
• Local prevalence of gonorrhea/chlamydia is high (>15%) 5
• Sexually active women under 25 years of age with cervicitis 5

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Partner Management (Critical for Treatment Success)

All sexual partners within the preceding 60 days must be evaluated and treated empirically for both gonorrhea and chlamydia, regardless of symptoms or test results. 1, 5

• If last sexual contact was >60 days before diagnosis, treat the most recent partner 5
• Partners should receive the same treatment as the index patient 5
• Reinfection from untreated partners is the primary cause of treatment failure 1

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Abstinence Requirements

Patients must abstain from sexual intercourse:

• For 7 days after initiating single-dose therapy 2, 1
• Until completion of 7-day regimens 2, 1
• Until all symptoms have resolved 2
• Until all sex partners are treated 2, 1, 5

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Persistent or Recurrent Urethritis

If symptoms persist after standard treatment:

• Test for Mycoplasma genitalium using NAAT with macrolide resistance testing when available 1
• Consider Trichomonas vaginalis culture using intraurethral swab or first-void urine 2
• Recommended regimen for persistent cases:
  • Metronidazole 2 g orally as a single dose OR Tinidazole 2 g orally as a single dose 2
  • PLUS Azithromycin 1 g orally as a single dose (if not used initially) 2

Critical pitfall to avoid:

• Do NOT retreat based on symptoms alone without objective evidence of urethritis (≥5 WBCs on Gram stain or ≥10 WBCs on urine microscopy) 2, 1

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Mandatory Additional Testing

All patients diagnosed with an STI must receive:

• Syphilis serology 2, 1
• HIV testing with counseling 2, 1
• Testing for other STIs, as patients with one infection are at higher risk for others 1

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Follow-Up Testing

• Test of cure is NOT needed for uncomplicated gonorrhea or chlamydia treated with recommended regimens 5
• All nonpregnant patients should be retested approximately 3 months after treatment due to high reinfection risk 5
• Persistent symptoms warrant reevaluation with culture and antimicrobial susceptibility testing 5

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Special Populations

HIV-infected patients:

• Should receive the same treatment regimens as HIV-negative patients for uncomplicated gonorrhea, chlamydia, and NGU 2
• Fungi and mycobacteria are more likely causes of complications in immunosuppressed patients 2

Pregnant patients:

• Azithromycin is preferred over doxycycline (doxycycline is contraindicated in pregnancy) 3
• Erythromycin alternatives should be considered 2