Treatment of Sexually Transmitted Infections in Non-Pregnant Females
For non-pregnant women with suspected STIs, initiate empiric treatment with ceftriaxone 125 mg IM plus doxycycline 100 mg orally twice daily for 7 days to cover both gonorrhea and chlamydia when test results are pending or the patient may not return for follow-up, particularly in high-prevalence settings. 1, 2
Diagnostic Testing Before Treatment
Obtain nucleic acid amplification tests (NAATs) from all sites of sexual contact including cervical, vaginal, urethral, pharyngeal, and rectal specimens, as these have sensitivities of 86.1%-100% and specificities of 97.1%-100% for gonorrhea and chlamydia 1, 3, 4
Perform wet mount examination when vaginal discharge or malodor is present to evaluate for trichomoniasis, bacterial vaginosis, and candidiasis 1
Order syphilis serology and HIV testing at baseline, with repeat testing at 12 weeks if initial results are negative 5
Empiric Treatment Approach
When to Treat Empirically (Before Test Results)
- The patient is in a high-prevalence setting (>5% gonorrhea prevalence)
- The patient is unlikely to return for follow-up
- Clinical signs of mucopurulent cervicitis are present
Bacterial STI Treatment Regimens
For Chlamydia (first-line options): 5, 1, 2
- Doxycycline 100 mg orally twice daily for 7 days, OR
- Azithromycin 1 g orally as a single dose 6
For Gonorrhea and Chlamydia co-treatment: 1
- Ceftriaxone 125 mg IM PLUS doxycycline 100 mg orally twice daily for 7 days
For Trichomoniasis: 3
- Metronidazole (nitroimidazole therapy)
For Syphilis: 3
- Penicillin (specific regimen depends on stage)
Viral STI Management
For Genital Herpes (HSV): 1, 7
- Acyclovir or valacyclovir for symptomatic episodes
- Suppressive therapy available for recurrent episodes
- No cure available; treatment is suppressive only 3
For Hepatitis B exposure: 1
- Initiate hepatitis B vaccine series if not previously vaccinated
Fungal Infection Treatment
For Vulvovaginal Candidiasis: 1
- Clotrimazole 1% cream OR miconazole 2% cream as first-line topical therapy
Critical Management Considerations
Partner Notification and Treatment
Notify and treat all sexual partners from the preceding 60 days for any confirmed or suspected STI 1, 2, 8
Partners should receive the same treatment regimen as the index patient when empiric treatment was given 5
Sexual Abstinence Requirements
- Patients and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 5, 2
Follow-Up Testing
Retest at 3 months after treatment for chlamydia or gonorrhea to detect reinfection, as reinfection rates are high 2, 8, 3
Repeat HIV and syphilis serology at 12 weeks if initial testing was negative 5
Test of cure is not routinely recommended after treatment with doxycycline or azithromycin unless symptoms persist 5
Common Pitfalls to Avoid
Do not delay treatment waiting for test results in high-risk patients who may not return for follow-up 5, 2
Do not use lindane in pregnant or lactating women for ectoparasitic infections; use permethrin instead 5, 1
Do not rely on azithromycin alone for gonorrhea due to antimicrobial resistance; always use ceftriaxone 3, 4
Do not assume treatment failure is due to antimicrobial resistance without first ruling out reinfection from untreated partners 5
Special Populations
HIV-Positive Women
- Treat with the same regimens as HIV-negative women for uncomplicated STIs 5
Mycoplasma genitalium
- Consider testing for M. genitalium in cases of persistent cervicitis after standard treatment 4
- Moxifloxacin is effective treatment, though antimicrobial resistance is emerging 3
Prevention Strategies
Promote consistent barrier contraception use as transmission can occur through asymptomatic viral shedding 1
Offer HPV and hepatitis B vaccination as effective prevention measures 1
Screen high-risk women annually including all sexually active women under 25 years and those with new or multiple partners 2