Microsoft word - treatment gl table_2011 draft_redux (2) gn

STD TREATMENT GUIDELINES TABLE FOR ADULTS & ADOLESCENTS 2011 These recommendations for the treatment of STDs reflect the 2010 CDC STD Treatment Guidelines. The focus is primarily on STDs encountered in outpatient practice. This table is intended as a source of clinical guidance and is not a comprehensive list of al effective regimens. For more information, please refer to the complete CDC document at http://www.cdc.gov/std/treatment/2010/. The fol owing are available resources in New York City: Cal the NYCDOHMH at 212-788-4443 or go to http://www.nyc.gov/health/std to learn more about STDs and how to report infections; to request assistance with confidential notification of sexual partners of patients with syphilis or HIV infection; and to obtain additional information about NYC DOHMH clinical services. Health care providers can access the latest NYC public health information by joining NYC MED at http://www.nyc.gov/health/nycmed. DOSING ABBREVIATIONS: d=day; qd=once each day; bid= twice daily; tid=three times a day; qid=four times a day; po=by mouth; IM=intramuscular injection; IV=intravenous; mg-miligram; g=gram; hs=hour of sleep; prn=as needed. Uncomplicated Genital/Rectal/Pharyngeal • Azithromycin 1g po x 1 or • Erythromycin base 500mg po qid x 7 d or Erythromycin ethylsuccinate 800mg po qid x 7 d or • Ofloxacin§ 300mg po bid x 7 d or • Levofloxacin§ 500mg po qd x 7 d • Erythromycin base 500mg po qid x 7 d or Erythromycin base 250mg po qid x 14 d or Erythromycin ethylsuccinate 800mg po qid x 7 d or Erythromycin ethylsuccinate 400mg po qid x 14 d GONORRHEA3, 4 Ceftriaxone 250mg IM is the preferred treatment for adults and adolescents with uncomplicated gonorrhea infection and is the only recommended regimen for pharyngeal infections. Dual therapy with a regimen effective against C. trachomatis is routinely recommended, regardless of chlamydia test results. Uncomplicated Genital/Rectal Other single-dose injectable cephalosporin5 PLUS • Azithromycin 1g po x 1 or Doxycycline§ 100mg po BID x 7 d PLUS • Azithromycin 1g po x 1 or Doxycycline§ 100mg po BID x 7 d • Ofloxacin§,8 400mg po bid x 14 d or • Cefoxitin 2g IM x 1 with Probenecid 1g po x 1 Levofloxacin§,8 500mg po qd x 14 d with or without Azithromycin 1g po q week x 2 with or without • Erythromycin base 500mg po qid x 7 d or Erythromycin ethylsuccinate 800mg po qid x 7 d or • Levofloxacin 500mg po qd x 7 d or Ofloxacin 300mg po bid x 7 d Tinidazole 2g po x 1 PLUS • Azithromycin 1g po x 1 (if not used initial y) For men at risk for both sexual y transmitted and enteric Likely due to enteric organisms or with a negative GC • Levofloxacin 500mg po qd x 10 d or Ofloxacin 300mg po bid x 10 d Metronidazole gel 0.75%, one ful applicator (5g) Clindamycin cream14 2%, one ful applicator (5g) Clindamycin ovules 100mg intravaginal y qhs x 3d Metronidazole 250mg tid x 7 d or Clindamycin 300mg po bid x 7d § Contraindicated in pregnant and nursing women 1 Annual screening for women aged 25 years or younger. Reinfection is common; retest 3 months after treatment. 2 Test-of-cure (preferably by NAAT) 3-4 weeks after completion of therapy is recommended. Pregnant women also should be retested 3 months after treatment. 3 Annual screening for women at increased risk, e.g. aged 25 years or younger. Reinfection is common; retest 3 months after treatment. 4 For treatment failure or in vitro resistance to cephalosporins: Treat with Ceftriaxone 250mg IM (plus azithromycin 1g or doxycycline 100mg bid x 7 d); consult an ID specialist; perform culture and susceptibility studies; ensure partner treatment; and in NYC, report to the DOHMH by cal ing 212-788-4443. Obtain a test-of-cure 3 weeks after treatment. Ceftizoxime 500mg IM; or cefoxitin 2g IM with probenecid 1g PO; or cefotaxime 500mg IM Due to concerns over emerging antimicrobial resistance, use should be limited to those with severe cephalosporin al ergy or history of severe reaction to penicil in. 7 Metronidazole offers additional anaerobic coverage and wil treat BV and trichomoniasis, if present. 8 A quinolone-based regimen can be considered if a cephalosporin is not feasible and if individual risk and local prevalence of gonorrhea are low. If the test for gonorrhea is positive, the addition of azithromycin 2g po as a single dose is recommended. 9 Presumptive regimen. Co-treat for gonorrhea if local prevalence is high (>5%). Treat for BV and trichomoniasis, if present. 10 Recommended treatment for patients with persistent symptoms if compliant with initial regimen and re-exposure can be excluded. Consider testing for T.vaginalis infection. 11 Among sexual y-active men aged <35 yrs, epididymitis is more likely caused by C. trachomatis or N. gonorrheae . For men who practice insertive anal intercourse or men aged >35 yrs, epididymitis may be caused by enteric organisms. 12 7-day Metronidazole regimen may be more effective in HIV-infected women 13 Safety during pregnancy has not been established (Pregnancy Category C); interruption of breastfeeding is recommended during treatment and for 3 days after last dose. 14 Oil-based; might weaken latex condoms and diaphragms for up to 5 days after use PLUS • Doxycycline§ 100mg po bid x 7 d • Erythromycin base 500mg po qid x 21 d or • Azithromycin 1g po q week x 3 weeks Ceftriaxone 250mg IM x 1 or Ciprofloxacin§ 500mg po bid x 3 d Erythromycin base 500mg po tid x 7 d SYPHILIS Benzathine penicil in G, Bicil in®L-A, (trade name), is the preferred drug for treatment of al stages of syphilis and is the only treatment with documented efficacy for syphilis during pregnancy.17 Adults (including HIV-Co-infected)18 Primary, Secondary, and Early Latent • Benzathine penicil in G 2.4 mil ion units IM x1 • Doxycycline19,§ 100mg po bid x 14 d or • Tetracycline19,§ 500mg po qid x 14 d or • Ceftriaxone19 1g IM or IV qd x 10-14 d • Benzathine penicil in G 7.2 mil ion units, • Doxycycline19,§ 100mg po bid x 28 d or administered as 3 doses of 2.4 mil ion units IM • Tetracycline19,§ 500mg po qid x 28 d • Aqueous crystal ine penicil in G 18-24 mil ion units IV q 4 hrs or continuous infusion x • Ceftriaxone19 2g IM or IV qd x 10-14 d22 • Benzathine penicil in G 2.4 mil ion units IM x1 • None. If PCN al ergic, desensitize and treat. • Benzathine penicil in G 7.2 mil ion units, • None. If PCN al ergic, desensitize and treat. administered as doses of 2.4 mil ion units IM each, at 1-week intervals • Aqueous crystal ine penicil in G 18-24 mil ion units IV q 4 hrs or continuous infusion x ANOGENITAL WARTS (Human Papil oma Virus) • Podofilox 0.5% solution/gel24,25: apply bid x 3 d • Cryotherapy: repeat applications q1-2 weeks or fol owed by 4 d no treatment; use for up to 4 cycles. Total area treated not to exceed 10cm2 and total • Podophyl in resin§ 10%-25%: apply q1-2 weeks prn; wash off after 1-4 hours. Total area treated not to exceed 10cm2 and • Imiquimod 5% cream24,26: apply qhs 3x/week for up to 16 weeks; wash off after 6-10 hours or • Trichloroacetic acid (TCA) 80%- 90% or Bichloroacetic acid (BCA) 80%- 90%: apply q week prn • Sinechatechin 15% ointment24,25,26,27: apply tid (0.5cm strand of ointment per wart) for a maximum • Surgery—electrocautery, excision, laser, curretage • Famciclovir 250mg po tid x 7-10 d or • Valacyclovir 1g po bid x 7-10 d • Valacyclovir 500mg po qd or 1g po qd • Acyclovir 400-800mg po bid or tid or • Famciclovir 500mg po bid x 5-10 d or § Contraindicated in pregnant and nursing women 15 Examine patients by anoscopy and evaluate for infection with HSV, gonorrhea, chlamydia and syphilis 16 If painful perianal ulcers are present or mucosal ulcers detected on anoscopy, presumptive therapy should include a regimen for genital herpes and LGV. 17 Benzathine penicil in G is available in one long-acting formulation, Bicil in® L-A, which contains only benzathine penicil in G. Combination penicil in drug products, such as Bicil in® C-R, contain both long- and short-acting penicil ins and should not be used to treat syphilis. 18 Most HIV-infected persons respond appropriately to standard benzathine penicil in regimens. HIV-infected patients with syphilis should be treated according to the stage-specific recommendations for HIV-negative persons. 19 Use alternative regimens for penicil in-al ergic, non-pregnant patients only. Data to support the use of alternatives to penicil in are limited. If compliance or fol ow-up cannot be ensured, the patient should be desensitized and treated with benzathine penicil in. 20 Patients diagnosed with latent syphilis who demonstrate any of the fol owing should have a prompt CSF exam to evaluate for neurosyphilis: 1) neurologic or opthalmic signs or symptoms; 2) evidence of active tertiary syphilis; or 3) serologic or treatment failure. 21 An interval of 10-14 days between doses of benzathine penicil in for late or latent syphilis of unknown duration might be acceptable before restarting the sequence of injections. 22 Some specialists recommend an additional 2.4 mil ion units of benzathine penicil in G IM qweek for up to 3 weeks after completion of neurosyphilis treatment. 23 Mucosal genital warts (cervical, vaginal, anorectal, urethral meatus) should be managed in consultation with a specialist. 24 Safety profile during pregnancy not established; Pregnancy Category C. 25 Do not wash off after initial application. 26 May weaken condoms and diaphragms. 27 Use is not recommended for HIV-infected or other immunocompromised persons, or those with clinical genital herpes. 28 If HSV lesions persist or recur while receiving antiviral treatment, suspect antiviral resistance. Obtain a viral isolate for sensitivity testing and consult with an HIV specialist.

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