What are the treatment options for a patient diagnosed with a sexually transmitted disease (STD), including chlamydia, gonorrhea, syphilis, herpes, and human papillomavirus (HPV)?

Treatment for Sexually Transmitted Diseases

For bacterial STDs (chlamydia, gonorrhea, syphilis), use pathogen-specific antibiotic regimens; for viral STDs (herpes, HPV), use suppressive antiviral therapy or ablative procedures, as no cure exists for viral infections. 1, 2

Bacterial STD Treatment

Chlamydia

• First-line treatment: Azithromycin 1 g orally as a single dose OR Doxycycline 100 mg orally twice daily for 7 days 1, 3
• Single-dose azithromycin ensures virtually 100% compliance, which is critical for preventing complications like pelvic inflammatory disease, ectopic pregnancy, and infertility 1, 4
• Doxycycline remains equally effective but requires 7 days of adherence 1
• Annual screening is mandatory for all sexually active women under 25 years, as asymptomatic infection is common and can lead to subclinical upper reproductive tract infection 1

Gonorrhea

• Ceftriaxone 250 mg intramuscularly as a single dose 1, 5
• Always treat presumptively for concurrent chlamydia infection, as coinfection rates exceed 50% in many populations 1
• Oral fluoroquinolones are no longer recommended due to widespread antimicrobial resistance 2
• Critical pitfall: Gonorrhea resistance to oral agents limits treatment options; parenteral cephalosporins remain the only reliable first-line therapy 6, 2

Syphilis

• Parenteral penicillin remains the only proven effective treatment for all stages of syphilis 5, 6
• Benzathine penicillin G as a single intramuscular dose treats primary, secondary, and early latent syphilis 5, 6
• Warning: Single-dose benzathine penicillin has documented clinical failures in pregnant women and HIV-infected individuals 4
• All patients with urethritis or cervicitis must receive serologic testing for syphilis at diagnosis, as high-dose short-course antibiotics for other STDs may mask incubating syphilis 3

Viral STD Treatment

Genital Herpes (HSV)

• Three FDA-approved antivirals provide clinical benefit but do not cure infection: acyclovir, valacyclovir, and famciclovir 5, 7, 2
• Initiate treatment at the first sign of prodromal symptoms (tingling, itching, burning) for maximum effectiveness 8
• Treatment initiated after clinical lesions develop (papule, vesicle, ulcer) has no proven benefit 8
• For recurrent episodes, therapy must begin within 24 hours of symptom onset 8
• Chronic suppressive therapy reduces transmission risk but does not eliminate asymptomatic viral shedding 8
• Valacyclovir and famciclovir are not recommended during pregnancy 5
• Acyclovir resistance occurs in immunocompromised patients, including those with HIV; second-line agents (foscarnet, cidofovir) carry higher toxicity 7

Human Papillomavirus (HPV)

• No specific antiviral medication exists for HPV; treatment targets visible lesions using antimitotics or immunomodulators 7
• Ablative therapy (cryotherapy, surgical excision) removes visible warts but does not eradicate the virus 1
• Most HPV infections are asymptomatic and resolve spontaneously without intervention 1

Risk-Stratified Empiric Treatment

Treat empirically for both gonorrhea and chlamydia when:

• Local prevalence exceeds 5% for gonorrhea or 15% for both infections 1, 9
• Patient age is under 25 years with new or multiple sexual partners 1, 9
• Patient is unlikely to return for follow-up or test results 1, 9
• Patient presents to an STD clinic or high-prevalence setting 9

Recommended empiric regimen: Ceftriaxone 250 mg IM plus Azithromycin 1 g orally (or Doxycycline 100 mg twice daily for 7 days) 1

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated for the same infections as the index patient 1, 9
• If last sexual contact occurred more than 60 days before diagnosis, treat the most recent partner 9
• Partners of empirically treated patients receive identical treatment regardless of symptoms 9
• Patients and partners must abstain from sexual intercourse until therapy is completed (7 days after single-dose regimen or completion of multi-day regimen) and both are asymptomatic 1, 9

Follow-Up Requirements

• Test of cure is not needed for uncomplicated gonorrhea or chlamydia treated with recommended regimens 9
• All nonpregnant patients require retesting approximately 3 months after treatment due to reinfection rates exceeding 20% 9
• Persistent symptoms after treatment warrant reevaluation with culture and antimicrobial susceptibility testing 9
• Persistent cervicitis after excluding reinfection may not benefit from additional antibiotics; consider non-infectious causes like cervical ectopy inflammation 1, 9

HIV-Infected Patients

• HIV-infected patients receive identical treatment regimens for bacterial STDs 1
• Treatment of cervicitis in HIV-infected women is critical because it increases cervical HIV shedding and transmission risk 1
• Fungi and mycobacteria cause epididymitis more frequently in immunosuppressed patients than in immunocompetent individuals 1

Prevention Counseling

• Preexposure vaccination for hepatitis B is recommended for all unvaccinated patients evaluated for STDs 1
• Hepatitis A vaccination is indicated for men who have sex with men and persons who use illegal drugs 1
• Consistent and correct condom use prevents most STDs transmitted between mucosal surfaces, including HIV, gonorrhea, and chlamydia 1
• Condoms are less effective against infections transmitted by skin-to-skin contact (HSV, HPV) because they do not cover all exposed areas 1