Microsoft word - 2006 std guidelines.doc

KANSAS CITY, MISSOURI HEALTH DEPARTMENT
SUMMARY OF THE 2006 CDC SEXUALLY TRANSMITTED DISEASES (STD) TREATMENT GUIDELINES

These guidelines for the treatment of STDs reflect the recommendations of the 2006 CDC STD Treatment Guidelines. These are outlines for quick reference that focus on
STDs encountered in an outpatient setting and are not an exhaustive list of effective treatments. Please refer to the complete document of the CDC for more information or call
the STD Program. These guidelines are to be used for clinical guidance and are not to be construed as standards or inflexible rules. Clinical and epidemiological services are
available through your State STD Program and staff is available to assist healthcare providers with confidential notification of sexual partners of patients infected with STDs and
HIV. Please call for any assistance 816-513-6132
DISEASE RECOMMENDED
TREATMENT ALTERNATIVES
SYPHILIS (see 2006 CDC guidelines for follow-up recommendations and management of congenital syphilis)
(For penicillin allergic non-pregnant adult patients)
PRIMARY, SECONDARY OR EARLY LATENT
Doxycycline 100 mg orally 2 times a day for 14 days OR
(< 1 YEAR)
• Benzathine penicillin G 2.4 million units IM in a single dose Ceftriaxone 1 g daily IV or IM for 8-10 days OR
-------------------------------------------------------------------------------- Azithromycin 2 g orally once1
---------------------------------------------------------------
• Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 -------------------------------------------------------------------------- Children
LATE LATENT (> 1 YEAR) OR LATENT OF
UNKNOWN DURATION
Benzathine penicillin G 2.4 million units IM for 3 doses, 1 week apart
• Doxycycline 100 mg orally 2 times a day for 28 days for
-------------------------------------------------------------------------------- ---------------------------------------------------------------
adults only
Benzathine penicillin G 50,000 units/kg IM up to the adult dose of 2.4 Children
--------------------------------------------------------------------------
million units, administered as three doses at 1 week intervals (total 150,000 units up to the adult total dose of 7.2 million units) • Aqueous crystalline penicillin G 18 - 24 million units per day, • Procaine penicillin 2.4 million units IM once daily plus
NEUROSYPHILIS
administered as 3-4 million units IV every 4 hours or continuous probenecid 500 mg orally 4 times a day, both for 10-14 • For primary, 2nd and early latent syphilis:
• The use of any alternative therapy in HIV infected persons Treat as above. Some specialists recommend three doses. has not been well studied; therefore the use of HIV INFECTION
• For late latent syphilis or latent syphilis of unknown duration:
doxycycline, ceftriaxone and azithromycin must be Perform CSF examination before treatment Penicillin is the only recommended treatment for syphilis during pregnancy. Women who are allergic should be desensitized and
PREGNANCY
then treated with penicillin. Dosages are the same as in non-pregnant patients for each stage of syphilis.2
GONOCOCCAL INFECTIONS : Treat also for chlamydial infection if not ruled out by a sensitive test (nucleic acid amplification test)
Ceftriaxone 125 mg IM in a single dose OR
Cefixime 400 mg orally in a single dose OR
Spectinomycin5 2 g IM in a single dose OR
ERVIX, URETHRA, RECTUM
• Ciprofloxacin3,4 500 orally in a single dose OR
Single-dose cephalosporins regimens OR
• Ofloxacin3,4 400 mg orally in a single dose OR
Single dose quinolones3,4 regimens
• Levofloxacin3,4 250 mg orally in a single dose
See 2006 CDC guidelines for discussion of alternative
-------------------------------------------------------------------------------- regimens
--------------------------------------------------------------
• Ceftriaxone 125 mg IM in a single dose OR
-----------------------------------------------------------------------
Ciprofloxacin3,4 500 mg orally in a single dose
MEN WHO HAVE SEX WITH MEN OR
• Ceftriaxone 125 mg IM in a single dose OR
HETEROSEXUALS WITH A HISTORY OF
• Cefixime 400 mg orally in a single dose RECENT TRAVEL
CERVIX, URETHRA, RECTUM
--------------------------------------------------------------
------------------------------------------------------------------------------------ • Ceftriaxone 125 mg IM in a single dose • Ceftriaxone 1 g IM once plus lavage the infected eye with saline CONJUNCTIVA
CHILDREN (<45KG)
• Spectinomycin5 40mg/kg IM once (maximum 2 g)
VAGINA, CERVIX, URETHRA, PHARYNX, RECTUM • Ceftriaxone 125 mg IM once OR
PREGNANCY
Spectinomycin5 2 g IM once
Cefixime 400 mg orally in a single dose CHLAMYDIAL INFECTIONS
• Erythromycin base 500 mg orally 4 times a day for 7 days OR
• Azithromycin 1 g orally single dose OR
• Erythromycin ethylsuccinate 800 mg orally 4 times a day • Doxycycline 100 mg orally 2 times a day for 7 days for 7 days OR
• Ofloxacin3 300 mg orally 2 times a day for 7 days OR
• Levofloxacin3 500 mg orally once a day for 7 days
CHILDREN
• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into < 45 KG ------------------------------------------------→
> 45 KG AND < 8 YEARS OF AGE ------------ ---------→
• Azithromycin 1 g orally single dose OR
> 8 YEARS OF AGE ------------------------------------→
• Doxycycline 100 mg orally 2 times a day for 7 days • Erythromycin base 500 mg orally 4 times a day for 7 days OR Erythromycin 250 mg orally 4 times a day for 14 days
OR
PREGNANCY
• Azithromycin 1 g orally single dose OR
• Erythromycin ethylsuccinate 800 mg orally 4 times a day • Amoxicillin 500 mg orally 3 times a day for 7 days for 7 days
OR
• Erythromycin ethylsuccinate 400mg 4 times a day for 14 1 Some patients who are allergic to penicillin may also be allergic to ceftriaxone. Doxycycline is the preferred treatment. Treatment failures with azithromycin have been reported (MMWR 2004;53:197-8). T. pallidum strains resistant
to azithromycin have been documented in various geographic areas in the USA (NEJM 2004;351:454-8.). If neither penicillin nor doxycycline can be administered, and azithromycin as a single dose oral dose of 2 g is considered,
close follow-up is essential to ensure successful treatment. There are limited clinical studies also for ceftriaxone. Close follow-up of persons receiving any alternative therapies is essential.
2 Tetracycline/doxycycline contraindicated; erythromycin not recommended because it does not reliably cure an infected fetus; data insufficient to recommend azithromycin or ceftriaxone.
3 Quinolones are contraindicated in pregnant women. No joint damage attributable to quinolone therapy has been observed in children treated with prolonged ciprofloxacin regimens. Thus children who weigh > 45 kg can be treated
with any regimen recommended for adults.
4 Quinolones should not be used for infections in men who have sex with men or in those with a history of recent foreign travel or partners’ travel, infections acquired in California or Hawaii, or infections acquired in other areas with
increased quinolone resistant Neisseria gonorrhoeae
.5 Unreliable to treat pharyngeal infections. Patients who have suspected or known pharyngeal infection should have a pharyngeal culture 3-5 days after treatment to verify eradication of infection.
6 The efficacy of treating neonatal chlamydial conjunctivitis and pneumonia is about 80%. A second course of therapy may be required. An association between oral erythromycin and infantile hypertrophic pyloric stenosis (IHPS) has
been reported in infants aged less than 6 weeks treated with this drug. Data on other macrolides (azitrhomycin, clarithromycin) for the treatment of neonatal chlamydial infection are limited. The results of one study involving a
limited number of patients suggest that a short course of azithromycin 20 mg/kg/day, 1 dose daily for 3 days may be effective for chlamydial conjunctivitis.
DISEASE RECOMMENDED
TREATMENT ALTERNATIVES
• Erythromycin base8 500 mg orally 4 times a day for 7 days
OR
• Azithromycin7 1 g orally single dose OR
• Erythromycin ethylsuccinate8 800 mg orally 4 times a day
NON-GONOCOCCAL URETHRITIS
• Doxycycline 100 mg orally 2 times a day x 7 days for 7 days OR
• Ofloxacin3 300 mg orally 2 times a day for 7 days OR
• Levofloxacin3 500 mg orally once a day for 7 days
• Ceftriaxone 250 mg IM single dose PLUS
• Ofloxacin4 300 mg orally twice daily for 10 days OR
EPIDIDYMITIS9
• Doxycycline 100 mg orally 2 times a day for 10 days levofloxacin4 500 mg orally once a day for 10 days
REGIMEN A
PELVIC INFLAMMATORY DISEASE10
Ofloxacin3,4 400 mg orally 2 times a day for 14 days OR
(outpatient management)
Levofloxacin3,4 500 mg orally once a day for 14 days
REGIMEN B
These regimens to be used with or without
Ceftriaxone 250 mg IM once OR
metronidazole 500 mg orally twice a day for 14
Cefoxitin 2 g IM once plus probenicid 1 g orally once OR
Other third generation cephalosporin
PLUS Doxycycline 100 mg orally 2 times a day for 14 days
PREGNANCY AND PID
Patients should be hospitalized and treated with the appropriate recommended parenteral IV treatments (see CDC guidelines)
• Azithromycin 1 g orally single dose OR
• Ceftriaxone 250 mg IM single dose OR
CHANCROID
• Ciprofloxacin3,4 500 mg orally 2 times a day for 3 days OR
• Erythromycin base 500 mg orally 3 times a day for 7 days (preferred by HERPES SIMPLEX VIRUS (for non-pregnant adults). See CDC 2006 guidelines for the management of herpes in pregnancy and in the neonate
• Acyclovir 400 mg orally 3 times a day for 7-10 days OR
200 mg orally 5 times a day for 7-10 days OR
First clinical episode of genital herpes Famciclovir 250 mg orally 3 times a day for 7-10 days OR
• Valacyclovir 1 g orally 2 times a day for 7-10 days
• Acyclovir 400 mg orally 2 times a day OR
• Famciclovir 250 mg orally 2 times a day OR
• Valacyclovir 500 mg orally once a day OR 1 g orally once a day
• Acyclovir 800 mg orally 2 times a day for 5 days OR
400 mg orally 3 times a day for 5 days OR
800 mg orally 3 times a day for 2 days OR
• Famciclovir 125 mg orally 2 times a day for 5 days OR
1000 mg orally 2 times a day for 1 day
• Valacyclovir 500 mg orally 2 times a day for 3 days OR
1 g orally once a day for 5 days
HIV INFECTION
Higher doses and/or longer therapy recommended. See 2006 CDC guidelines. • Permethrin 1% cream rinse applied to affected area and washed off after Malathion 0.5% lotion applied for 8-12 hours and washed 10 minutes OR
PEDICULOSIS PUBIS11
off OR
Pyrethrins with piperonyl butoxide applied to affected area and washed Ivermectin 250 ug/kg repeated in 2 weeks • Permethrin 5% cream applied to all areas of the body from the neck • Lindane12 1% 1 oz of lotion or 30 g of cream applied
down and washed off after 8-14 hours OR
thinly to all areas of the body and thoroughly washed off • Ivermectin 200ug/kg orally, repeated in 2 weeks • Metronidazole13 500 mg orally 2 times a day for 7 days OR
• Clindamycin 300 mg orally 2 times a day for 7 days OR
BACTERIAL VAGINOSIS (BV)
• Metronidazole gel 0.75% intravag. once a day for 5 days OR
Clindamycin ovules 100 g intravag. at bedtime for 3 days Clindamycin cream 2% intravag. at bedtime for 7 days • Metronidazole13 500 mg orally 2 times a day for 7 days OR
PREGNANCY AND BV13
• Metronidazole13 250 mg orally 3 times a day for 7 days OR
• Clindamycin 300 mg orally 2 times a day for 7 days
• Metronidazole 2 g orally single dose OR
TRICHOMONIASIS
Metronidazole 500 mg orally 2 times a day for 7 days Tnidazole14 2 g orally single dose
GENITAL WARTS
External
PROVIDER-ADMINISTERED
Cryotherapy with liquid nitrogen or cryoprobe. Repeat
applications every 1-2 weeks if necessary OR
Cryotherapy with liquid
Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80%
-90%. Apply small amount only to warts. Allow to dry. If excess Urethral Meatus
OR
amount applied, powder with talc, baking soda or liquid soap. Cryotherapy with liquid
TCA or BCA 80%-90%.
Repeat weekly if necessary OR
Cryotherapy with liquid
Podophyllin resin 10%-25%14 in a compound tincture of
benzoin. Allow to air dry. Limit application to < 10 cm2 and to < Cryotherapy
OR
0.5 ml. Wash off 1-4 hours after application. Repeat weekly if Podophyllin 10%-25%14 in a
OR
necessary OR
TCA or BCA 80%-90%. Apply
Surgical removal
OR
PATIENT-APPLIED
Surgical
Podofilox 0.5% solution or gel14. Apply 2 times a day for 3 days,
followed by 4 days of no therapy. This cycle can be repeated as necessary for up to 4 times. Total wart area should not exceed 10 cm2 and total volume applied daily not to exceed 0.5 ml. OR
Imiquimod 5% cream14. Apply once daily at bedtime 3 times a
week for up to 16 weeks. Wash treatment area with soap and water 6-10 hours after application. 7 Infections with M. genitalium may respond better to azithromycin.
8 If this dose cannot be tolerated, then erythromycin base 250 mg orally or erythromycin ethylsuccinate 400 mg orally 4 times a day for 14 days can be used.
9 The recommended regimen of ceftriaxone and doxycycline is for epididymitis most likely caused by GC or CT infection. The alternative regimen of ofloxacin or levofloxacin is recommended if the epididymitis is most likely caused
by enteric organisms, or for patients allergic to cephalosporins and/or tetracycline.
10 Metronidazole will also treat bacterial vaginosis, frequently associated with PID. Whether the management of immunodeficient HIV-infected women with PID requires more aggressive intervention has not been determined.
11 Lindane no longer recommended because of toxicity and is contraindicated in pregnancy. Ivermectin not recommended for pregnant and lactating women or for children who weigh < 15 kg. Pregnant or lactating women should be
treated with either permethrin or pyrethrins with piperonyl butoxide
12 Lindane no longer recommended as first line therapy because of toxicity. Lindane not to be used immediately after a bath, in persons with extensive dermatitis and women who are pregnant or lactating, or children aged < 2 years.
13 Multiple studies and meta-analyses have not demonstrated a consistent association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns. Screening for, and oral treatment of, BV in
pregnant women at high risk for premature delivery is recommended by some experts and should occur at the first prenatal visit. Intravaginal clindamycin treatment for low risk women should be used only during the first half of
pregnancy.14 Safety during pregnancy not established.

Source: http://www.kcmo.org/idc/groups/health/documents/health/007996.pdf