Antibiotic Duration for Acute Infectious Proctitis
For acute infectious proctitis in adults, treat with ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 7 days, extending to 21 days (3 weeks) if lymphogranuloma venereum (LGV) is confirmed. 1, 2
Initial Empiric Treatment Duration
The Centers for Disease Control and Prevention recommends 7 days of doxycycline 100 mg twice daily combined with single-dose ceftriaxone 250 mg IM for patients with acute proctitis who recently practiced receptive anal intercourse. 1 This covers the most common sexually transmitted causes: Neisseria gonorrhoeae, Chlamydia trachomatis, and herpes simplex virus. 1
The FDA-approved dosing for doxycycline confirms 100 mg orally twice daily for 7 days for uncomplicated rectal infections caused by C. trachomatis. 2
Extended Duration for LGV
If C. trachomatis testing is positive, perform molecular PCR testing for LGV. 1 When LGV is confirmed, extend doxycycline treatment to a total of 3 weeks (21 days) at the same dose of 100 mg twice daily. 1 This extended duration is critical because LGV-associated proctitis can mimic rectal malignancy with severe ulceration, circumferential wall thickening, and lymphadenopathy if inadequately treated. 3
Treatment Monitoring and Follow-Up
Initiate presumptive therapy immediately while awaiting test results in patients with anorectal exudate or polymorphonuclear leukocytes on Gram stain. 1
Retest for gonorrhea or chlamydia 3 months after treatment completion to detect reinfection or treatment failure. 1, 4
Monitor for symptom resolution including rectal pain, discharge, bleeding, and tenesmus. 1, 4
Evaluate persistent symptoms after completing the 7-day course for possible reinfection, treatment failure, or LGV requiring extended therapy. 1, 4
Critical Pitfalls to Avoid
Do not stop at 7 days if LGV is confirmed—this is the most common error leading to treatment failure and severe complications including rectal strictures. 3 LGV proctitis can progress to invasive disease mimicking malignancy if the full 3-week course is not completed. 3
Obtain a detailed sexual history including receptive anal intercourse, as patients may not volunteer this information initially, leading to delayed diagnosis. 3 One case report documented a patient who only disclosed men who have sex with men (MSM) status after HIV and C. trachomatis testing returned positive. 3
Test all patients with proctitis for HIV and syphilis regardless of reported sexual history, as HIV-positive patients can develop particularly severe herpes proctitis requiring closer monitoring. 1, 4
Partner Management
Treat all sexual partners who had contact within 60 days before symptom onset presumptively with the same regimen. 1, 4 Both patient and partners must abstain from sexual intercourse until treatment completion and symptom resolution to prevent reinfection cycles. 4
Special Considerations
For HIV-positive patients with proctitis, more vigilant follow-up is warranted due to risk of more severe disease and opportunistic infections, particularly with herpes simplex virus. 4 Consider more frequent monitoring for those with low CD4+ counts. 4
The 7-day duration applies specifically to sexually transmitted infectious proctitis—do not confuse this with inflammatory bowel disease (ulcerative proctitis), which requires entirely different management with mesalamine suppositories rather than antibiotics. 5, 6