Am Fam Physician. 1999;60(5):1387-1394
This is Part I of a two-part article on drug treatment of common sexually transmitted diseases. Part II, “Vaginal Infections, Pelvic Inflammatory Disease and Genital Warts,” will appear in the next issue of AFP.
In 1998, the Centers for Disease Control and Prevention released guidelines for the treatment of sexually transmitted diseases. Several treatment advances have been made since the previous guidelines were published. Part I of this two-part article describes current recommendations for the treatment of genital ulcer diseases, urethritis and cervicitis. Treatment advances include effective single-dose regimens for many sexually transmitted diseases and improved therapies for herpes infections. Two single-dose regimens, 1 g of oral azithromycin and 250 mg of intramuscular ceftriaxone, are effective for the treatment of chancroid. A three-day course of 500 mg of oral ciprofloxacin twice daily may be used to treat chancroid in patients who are not pregnant. Parenteral penicillin continues to be the drug of choice for treatment of all stages of syphilis. Three antiviral medications have been shown to provide clinical benefit in the treatment of genital herpes: acyclovir, valacyclovir and famciclovir. Valacyclovir and famciclovir are not yet recommended for use during pregnancy. Azithromycin in a single oral 1-g dose is now a recommended regimen for the treatment of nongonococcal urethritis.
Several advances have been made in the treatment of sexually transmitted diseases (STDs). These advances have been incorporated into the “1998 Guidelines for the Treatment of Sexually Transmitted Diseases,” published by the Centers for Disease Control and Prevention (CDC).1
Highly effective single-dose oral therapies are now available for most common curable STDs. Single-dose regimens may be used for the treatment of chancroid, nongonococcal urethritis, uncomplicated gonococcal infections, bacterial vaginosis, trichomoniasis, candidal vaginitis and chlamydial infections.
Improved therapies are now available for the treatment of genital herpes and human papillomavirus (HPV) infections. New regimens have been approved for the use of acyclovir (Zovirax) in the treatment of genital herpes. In addition, two new antiviral agents, valacyclovir (Valtrex) and famciclovir (Famvir), have been labeled for the treatment of genital herpes. Patient-applied therapies are now recommended for management of HPV.
A new testing method for the diagnosis of chlamydial infections employs an extremely accurate urine test that can easily be incorporated into screening programs. Hepatitis A and hepatitis B vaccines are now recommended for all sexually active adolescents and young adults.
Treatments for STDs in pregnant women have been improved, producing fewer side effects and reducing the number of premature births. Treatment guidelines for the management of STDs in special patient populations, including pregnant women, were recently published in this journal.2
Genital Ulcer Diseases
Before a genital ulcer is treated, an accurate diagnosis with appropriate testing is essential. Concomitant testing for human immunodeficiency virus (HIV) infection should be considered.
CHANCROID
The goals of therapy for chancroid are to cure the infection, resolve symptoms and prevent transmission. Four recommended drug regimens for the treatment of chancroid are shown in Table 1. Two are single-dose regimens consisting of either azithromycin (Zithromax) or ceftriaxone (Rocephin). Erythromycin, which continues to be recommended for the treatment of chancroid, requires a seven-day dosing regimen. Ciprofloxacin (Cipro) has been added to the guidelines for the treatment of chancroid. However, ciprofloxacin is contraindicated for use in pregnant and lactating women, and in patients under 18 years of age. All four regimens are effective for treatment of chancroid in patients with or without HIV. Of note, several isolates of chancroid with intermediate resistance to either ciprofloxacin or erythromycin have been reported. Patients should be re-examined within three to seven days after initiation of therapy. Symptomatic improvement should be reported within three days if treatment is successful.
| Regimens | |||||
|---|---|---|---|---|---|
| Disease | Agent | Dosage | Cost* | ||
| Chancroid | Azithromycin (Zithromax) | 1 g orally in a single dose | $ 20.50 (brand) | ||
| Ceftriaxone (Rocephin) | 250 mg IM in a single dose | 13.00 (brand) | |||
| Ciprofloxacin (Cipro) | 500 mg orally twice daily for 3 days | 24.00 (brand) | |||
| Erythromycin base | 500 mg orally four times daily for 7 days | 6.50 to 9.00 (generic) | |||
| Granuloma inguinale | |||||
| Recommended regimen | Trimethoprim/sulfamethoxazole (Bactrim, Septra) | Double strength, taken orally twice daily for 21 days | 54.00 (brand) 14.00 to 25.00 (generic) | ||
| or | |||||
| Doxycycline (Vibramycin) | 100 mg orally twice daily for 21 days | 167.00 (brand) | |||
| Alternative regimen | Ciprofloxacin | 750 mg orally twice daily for 21 days | 168.00 (brand) | ||
| or | |||||
| Erythromycin base plus (during pregnancy) | 500 mg orally four times daily for 21 days | 19.50 to 27.00 (generic) | |||
| Aminoglycoside (i.e., gentamicin) | 1 mg per kg IV three times daily for 21 days | 337.00 (brand) 66.00 to 312.00 (generic) | |||
| Lymphogranuloma venereum | |||||
| Recommended regimen | Doxycycline | 100 mg orally twice daily for 21 days | 80.00 (brand) 5.50 to 26.50 (generic) | ||
| Alternative regimen (including pregnancy) | Erythromycin base | 500 mg orally four times daily for 21 days | 42.00 (brand) 20.50 to 27.50 (generic) | ||
| Herpes simplex virus | |||||
| First episode | Acyclovir (Zovirax) | 400 mg orally three times daily for 7 to 10 days | 53.00 (brand) 37.50 to 43.00 (generic) | ||
| or | |||||
| 200 mg orally five times daily for 7 to 10 days | 45.00 (brand) 32.00 to 37.00 (generic) | ||||
| Famciclovir (Famvir) | 250 mg orally three times daily for 7 to 10 days | 70.00 (brand) | |||
| Valacyclovir (Valtrex) | 1 g orally twice daily for 7 to 10 days | 56.00 (brand) | |||
| Recurrent episodes | Acyclovir | 400 mg orally three times daily for 5 days | 38.00 (brand) 27.00 to 31.00 (generic) | ||
| or | |||||
| 200 mg orally five times daily for 5 days | 32.50 (brand) 23.00 to 26.50 (generic) | ||||
| or | |||||
| 800 mg orally twice daily for 5 days | 50.00 (brand) 35.00 to 40.00 (generic) | ||||
| Famciclovir | 125 mg orally twice daily for 5 days | 28.00 (brand) | |||
| Valacyclovir | 500 mg orally twice daily for 5 days | 31.00 (brand) | |||
| Daily suppressive therapy | Acyclovir | 400 mg orally twice daily | 5.00 (brand)† 3.50 to 4.00 (generic) | ||
| Famciclovir | 250 mg orally twice daily | 6.50 (brand) | |||
| Valacyclovir | 500 mg orally once daily (in patients with < 10 episodes per year) | 3.00 (brand) | |||
| Valacyclovir | 1,000 mg orally once daily (in patients with > 10 episodes per year) | 6.00 (brand) | |||
| Syphilis | |||||
| Primary and secondary disease | Benzathine penicillin G | 2.4 million units IM in a single dose | 24.00 (brand) | ||
| Penicillin allergy | Doxycycline | 100 mg orally twice daily for 14 days | 111.00 (brand) 6.00 to 25.00 (generic) | ||
| Tetracycline | 500 mg orally four times daily for 14 days | 3.50 to 6.00 (generic) | |||
| Early latent disease | Benzathine penicillin G | 2.4 million units IM in a single dose | 24.00 (brand) | ||
| Late latent, unknown duration, tertiary disease | Benzathine penicillin G | 7.2 million units IM total, divided into three weekly doses of 2.4 million units each | 71.50 (brand) | ||
| Neurosyphilis | Aqueous crystalline penicillin G | 18 to 24 million units IV daily, divided as 3 to 4 million units every 4 hours for 10 to 14 days | 12.00 (generic) | ||
| Procaine penicillin plus probenecid | 2.4 million units of penicillin daily, plus 500 mg probenecid orally four times daily, both for 10 to 14 days | 277.00 (generic) | |||
GENITAL HERPES
Genital herpes is a recurrent, incurable viral disease. Patient counseling should include information about recurrent episodes, asymptomatic viral shedding, perinatal transmission and sexual transmission. Episodic antiviral therapy during outbreaks may shorten the duration of the lesions, and suppressive antiviral therapy may prevent recurrences.
During the first clinical episode, the goal of systemic antiviral drug therapy is to control the signs and symptoms of genital herpes. Daily suppressive therapy is recommended for use in patients who have six or more recurrences per year. Three antiviral medications have been proved in randomized trials to provide clinical benefit in patients with genital herpes: acyclovir, valacyclovir and famciclovir. Clinical experience with systemic acyclovir in the treatment of genital herpes has been substantial. Topical therapy is less effective than systemic therapy, and its use is not recommended. Two newer antiviral agents are valacyclovir and famciclovir.3,4 Valacyclovir is a valine ester of acyclovir with enhanced absorption properties when administered orally. Famciclovir, a prodrug of penciclovir, also has high oral bioavailability. The safety of antiviral therapy in pregnant women has not been established, but extensive clinical experience with acyclovir has been reassuring. Severe or first-episode disease that occurs during pregnancy may be treated with acyclovir. However, the routine administration of antiviral agents in pregnant women with uncomplicated or recurrent genital herpes is not recommended.
SYPHILIS
Syphilis is a systemic disease caused by the sexual transmission of Treponema pallidum. It can present as primary, secondary or tertiary disease. Primary disease presents with one or more painless ulcers or chancres at the inoculation site. Secondary disease manifestations include rash and adenopathy. Cardiac, neurologic, ophthalmic, auditory or gummatous lesions characterize tertiary infections. Latent disease may be detected by serologic testing, without the presence of signs and symptoms. Early latent disease is defined as disease acquired within the preceding year. All other cases of latent syphilis are considered late latent disease or disease of unknown duration.
The recommended treatment regimens have not changed since the 1993 CDC Guidelines. Parenteral penicillin G is still the preferred drug for treating all stages of syphilis, including disease in pregnant women. Table 1 outlines the different penicillin preparations and the proper dosages and durations of therapy, depending on the stage of syphilis at patient presentation. Patients with early disease and penicillin allergy may be desensitized first and then treated with penicillin or treated with another recommended regimen. Patients with HIV infection require treatment with penicillin at all stages of syphilis. Treatment may be associated with the Jarisch-Herxheimer reaction. This reaction is an acute febrile illness that may occur within the first 24 hours of therapy and includes symptoms such as headache and myalgias. Concomitant antipyretic therapy may be beneficial.
GRANULOMA INGUINALE AND LYMPHOGRANULOMA VENEREUM
Granuloma inguinale and lymphogranuloma venereum are rare in the United States. Granuloma inguinale presents as a painless, highly vascular ulcer that is caused by Calymmatobacterium granulomatis. Patients with lymphogranuloma venereum present most often with regional lymphadenopathy; it is often a diagnosis of exclusion. The disease is caused by L serogroup strains of Chlamydia trachomatis. The diagnosis is usually made clinically and serologically. Treatment regimens for these diseases are given in Table 1.
Diseases Characterized by Urethritis and Cervicitis
URETHRITIS
Urethritis is an infection characterized by mucopurulent or purulent discharge and burning during urination. Neisseria gonorrhoeae and C. trachomatis are the most common bacterial pathogens associated with urethritis. Empiric treatment is recommended in high-risk patients and those unlikely to return for follow-up. Treatment guidelines are outlined in Table 2.
| Regimens | |||||
|---|---|---|---|---|---|
| Disease | Agent | Dosage | Cost† | ||
| Nongonococcal urethritis | |||||
| Recommended regimens | Azithromycin (Zithromax) | 1 g orally (single dose) | $ 20.50 (brand) | ||
| Doxycycline (Vibramycin) | 100 mg orally twice daily for 7 days | 55.50 (brand) 2.50 to 19.00 (generic) | |||
| Alternative regimens | Erythromycin base | 500 mg orally four times daily for 7 days | 6.50 to 9.00 (generic) | ||
| or | |||||
| Erythromycin ethylsuccinate | 800 mg orally four times daily for 7 days | 10.00 to 22.00 (generic) | |||
| or | |||||
| Ofloxacin (Floxin) | 300 mg orally twice daily for 7 days | 62.50 (brand) | |||
| If high-dose erythromycin is not tolerated: | |||||
| Erythromycin base | 250 mg orally four times daily for 14 days | 8.00 to 24.00 (generic) | |||
| or | |||||
| Erythromycin ethylsuccinate | 400 mg orally four times daily for 14 days | 5.00 to 11.00 (generic) | |||
| Recurrent/persistent urethritis | |||||
| Metronidazole (Flagyl) | 2 g orally in a single dose | 11.50 (brand) 1.50 to 3.00 (generic) | |||
| plus either | |||||
| Erythromycin base | 500 mg orally four times daily for 7 days | 6.50 to 9.00 (generic) | |||
| or | |||||
| Erythromycin ethylsuccinate | 800 mg orally four times daily for 7 days | 10.00 to 22.00 (generic) | |||
| Chlamydial infection | |||||
| Recommended regimens | Azithromycin | 1 g orally (single dose) | 20.50 (brand) | ||
| or | |||||
| Doxycycline | 100 mg orally twice daily for 7 days | 55.50 (brand) 2.50 to 19.00 (generic) | |||
| Alternative regimens | Erythromycin base | 500 mg orally four times daily for 7 days | 6.50 to 9.00 (generic) | ||
| or | |||||
| Erythromycin ethylsuccinate | 800 mg orally four times daily for 7 days | 10.00 to 22.00 (generic) | |||
| or | |||||
| Ofloxacin | 300 mg orally twice daily for 7 days | 62.50 (brand) | |||
| Gonococcal infection | |||||
| Uncomplicated infections of the cervix, urethra and rectum | Cefixime (Suprax) | 400 mg orally in a single dose | $ 7.50 (brand) | ||
| or | |||||
| Ceftriaxone (Rocephin) | 125 mg IM in a single dose | 14.00 per 250-mg vial (brand) | |||
| or | |||||
| Ciprofloxacin (Cipro) | 500 mg orally in a single dose | 4.00 (brand) | |||
| or | |||||
| Ofloxacin | 400 mg orally in a single dose | 5.00 (brand) | |||
| plus | |||||
| Azithromycin | 1 g orally in a single dose | 20.50 (brand) | |||
| or | |||||
| Doxycycline | 100 mg orally twice daily for 7 days | 55.50 (brand) 2.50 to 19.00 (generic) | |||
| Uncomplicated infection of the pharynx | Ceftriaxone | 125 mg IM in a single dose | 14.00 per 250-mg vial (brand) | ||
| or | |||||
| Ciprofloxacin | 500 mg orally in a single dose | 4.00 (brand) | |||
| or | |||||
| Ofloxacin | 400 mg orally in a single dose | 5.00 (brand) | |||
| plus | |||||
| Azithromycin | 1 g orally in a single dose | 20.50 (brand) | |||
| or | |||||
| Doxycycline | 100 mg orally twice daily for 7 days | 55.50 (brand) 2.50 to 19.00 (generic) | |||
MUCOPURULENT CERVICITIS
Mucopurulent cervicitis is often asymptomatic. It may be detected by the presence of purulent or mucopurulent endocervical exudate. Some women with this condition have an abnormal vaginal discharge and report vaginal bleeding after sexual intercourse. C. trachomatis or N. gonorrhoeae usually cause mucopurulent cervicitis, but in many cases neither organism can be isolated. Patients with positive cultures or nucleic acid amplification tests for the presence of C. trachomatis or N. gonorrhoeae always require treatment. Empiric therapy is recommended when the likelihood of infection with either organism is high or when patients are unlikely to return for treatment. Recommended treatment regimens are outlined in Table 2.
Uncomplicated Chlamydial and Gonoccocal Infections
CHLAMYDIAL INFECTION
Chlamydial genital infections are common among adolescents and young adults who are sexually active. C. trachomatis infection may be associated with pelvic inflammatory disease (PID), ectopic pregnancy and infertility. Since chlamydial infection is often asymptomatic and the sequelae can be serious, routine screening for disease during annual examinations is recommended. Single-dose therapy with azithromycin is as effective as a seven-day course of doxycycline (Vibramycin). Doxycycline is less expensive, but azithromycin may be cost-beneficial because it provides single-dose, directly observed therapy. Erythromycin and ofloxacin (Floxin) also may be used to treat C. trachomatis. Erythromycin is less efficacious than azithromycin and doxycycline, and its adverse gastrointestinal effects may decrease patient compliance. Ofloxacin is as effective as the recommended regimens but offers no dosing or cost advantages. Doxycycline and ofloxacin are contraindicated in pregnant women. In addition, the safety and efficacy of azithromycin in pregnant women has not been established; therefore, a seven-day course of either erythromycin or amoxicillin is recommended in this group. Since neither regimen is considered highly effective, cultures should be repeated in three weeks.
GONOCOCCAL INFECTION
Men with a gonococcal infection experience symptoms that require treatment, but women often are asymptomatic until complications of the infection, such as PID, occur. For this reason, screening is recommended in high-risk patients. Co-infection with C. trachomatis often occurs in patients with gonococcal infections. The cost of doxycycline therapy for C. trachomatis is less expensive than testing for the organism, so empiric treatment of co-infection is becoming routine. Also, dual therapy with doxycycline and azithromycin may decrease the development of antimicrobial-resistant N. gonorrhoeae, because most gonococci are susceptible to both drugs. Quinolone-resistant N. gonorrhoeae has been reported in the United States and is becoming more widespread in Asia. At this time, fluoroquinolone regimens can be used with confidence, but continued monitoring of emerging resistance will be important.
Table 2 outlines therapy for gonococcal infections. Four single-dose regimens are now available for treatment of uncomplicated gonococcal infections of the cervix, urethra and rectum. They include cefixime (Suprax), ceftriaxone, ciprofloxacin and ofloxacin. Cefixime, ciprofloxacin and ofloxacin are given orally, while ceftriaxone is administered intramuscularly. Gonococcal infections of the pharynx are more difficult to eradicate but, with the exception of cefixime, the recommended therapy is the same as for urogenital and anorectal infections, and should include concomitant treatment for chlamydial infection.