| |
- Amoxicillin 500 mg po tid x 7 d
|
Monotherapy with IM ceftriaxone is recommended for all patients with uncomplicated GC, inclusive of pregnant persons. If co-infection with CT has not been excluded, add azithromycin 1 g po x 1 dose in pregnant persons
1.
Genital, Rectal Infections
|
- Ceftriaxone 500 mg IM once for persons weighing <150kg
(330 lb)
- Ceftriaxone 1g IM once for persons weighing ≥150kg
(330 lb)
|
If ceftriaxone not available or not feasibile:
- Cefixime 800 mg x 1 dose3
If cephalosporin allergy:
- Azithromycin 2 g po x 1 dose4
|
Pharygeal Infections5
|
- Ceftriaxone 500 mg IM once for persons weighing <150kg
(330 lb)
- Ceftriaxone 1g IM once for persons weighing ≥150kg
(330 lb)
|
No reliable treatment alternatives. Consult an infectious disease specialist or submit your question online the the STD Clinical Consultation Network webpage.
|
- Azithromycin 1 g po once
|
|
Pregnant patients with PID have high risk for maternal morbidity and pre-term delivery. Such patients should be hospitalized and treated with IV anitbiotics in consultation with an Infectious Disease specialist.
|
- None. Some experts7 may consider extended-dose azithromycin-only treatment (1g day 1; 500mg daily days 2, 3, and 4)*
* However, high risk of treatment failure due to macrolide resistance. Specialist consultation advised.
|
Primary, Secondary, and Early Latent
|
- Benzathine penicillin G 2.4 million units (mu) IM once10
|
|
Late Latent and Unknown Duration
|
- Benzathine penicillin G 7.2 mu, as 3 doses of 2.4 mu IM each, in 1-week intervals (not >8 days apart)9
|
|
Neurosyphilis and Ocular Syphilis
|
- Aqueous crystalline penicillin G 18–24 mu daily, administered as 3– 4 mu IV q 4 hours x 10–14 d11
|
Procaine penicillin G 2.4 mu IM daily for 10–14 d
plus Probenecid 500 mg po qid for 10–14 d
|
- Azithromycin 1 g po once weekly x 3 weeks13 or
- Erythromycin base 500 mg po qid x 21 d
|
None
|
Metronidazole15 500 mg po bid x 7 d
|
None
|
- Metronidazole15 500 mg po bid x 7 d
or
-
Metronidazole 0.75% gel 0.75%, 5 g intravaginally daily x 5 d
or
-
Clindamycin 2% cream, 5 g intravaginally qhs x
7 d
|
- Clindamycin 300 mg po bid x 7 d
or
- Clindamycin ovules16 100 mg intravaginally qhs x 3 d
|
First Clinical Episode of Herpes17
|
- Acyclovir 400 mg po tid x 7–10 d
or
- Valacyclovir18 1 g po bid x 7–10 d
|
None
|
Episodic Therapy for Recurrences
|
- Acyclovir 800 mg po bid x 5 d
or
- Acyclovir 800 mg po tid x 2 d
or
- Valacyclovir18 500 mg po bid x 3 d
or
- Valacyclovir18 1 g po daily x 5 d
|
None
|
Daily Suppressive Therapy in Pregnant Patients (start at 36 weeks gestation)
|
- Acyclovir 400 mg po tid
or
- Valacyclovir18 500 mg po bid
|
None
|
External Genital/Perianal
|
- Cryotherapy once q 1–2 weeks
or
- Trichloroacetic acid (TCA) 80%–90% once q 1–2 weeks
or
- Bichloroacetic acid (BCA) 80%–90% once q 1–2 weeks
or
- Surgical removal
|
None
|
Mucosal Genital Warts (Vaginal, Vulvar, Anal)
|
- Cyrotherapy20 or
- Surgical removal
or
- TCA or BCA 80%–90%
|
None
|
Additional Notes
Gonorrhea/Chlamydia (GC/CT)
1. CT test-of-cure follow-up by NAAT 4 weeks after completion of therapy is recommended in pregnancy.
2. See CDPH Gonorrhea Treatment Guidelines and Management of Suspected Treatment Failure (PDF) if suspect treatment failure.
3. Oral cephalosporins give lower and less-sustained bactericidal levels than ceftriaxone. Cefixime should only be used when ceftriaxone is not available.
4. Obtain a test-of-cure in 14 days if using azithromycin monotherapy.
5. Test-of-cure by culture or NAAT is recommended 14 days after treatment for pharyngeal GC.
6. Test for GC/CT, bacterial vaginosis, and trichomoniasis (consider Mycoplasma genitalium in PID). If patient lives in community with high GC prevalence, or has risk factors (e.g. age <25, new partner, partner with concurrent sex partners, or sex partner with an STI), consider empiric treatment for GC.
Mycoplasma Genitalium (MG)
7. While some studies have suggested an association between MG infection during pregnancy and complications like pre-term labor, data are limited and it is unknown whether treating MG in this context prevents pregnancy complications. Typical first-line antimicrobials for MG (doxycycline and moxifloxacin) are contraindicated during pregnancy. Experts may recommend delaying treatment for pregnant patients with MG until after delivery, particularly if the patients have minimal or no symptoms. For highly symptomatic patients who prefer not to defer treatment, experts may recommend extended-dose azithromycin-only treatment (1 g on day 1 followed by 500 mg once daily on days 2, 3, and 4). Please note that this regimen may fail, given high rates of azithromycin (macrolide) resistance among MG isolates. Mycoplasma genitalium Management in Adults - Clinical Guidelines Program.
Syphilis
8. Benzathine penicillin G is available only in one long-acting formulation, Bicillin® L-A (the trade name). Other combination products, such as Bicillin® C-R, contain long- and short-acting penicillins, and do not effectively treat syphilis.
9. Pregnant patients allergic to penicillin should be desensitized and treated with benzathine penicillin G. There are no alternatives. The optimal treatment interval in pregnancy is 7 days. If treating outside of 6-8 day intervals, the full treatment course should be restarted (PDF).
10. Some specialists recommend a second dose of benzathine penicillin G 2.4 million units IM administered 1 week after the initial dose in pregnant patients with primary, secondary, or early latent syphilis.
11. Some specialists recommend 2.4 million units of benzathine penicillin G once weekly for up to 3 weeks after completion of neurosyphilis treatment.
Lymphogranuloma venereum (LGV)
12. Perform a test-of-cure 4 weeks after the initial CT-positive NAAT test in all pregnant patients treated for LGV.
13. Because this regimen has not been rigorously studied, consider a test-of-cure four weeks after treatment. Trichomoniasis/Bacterial Vaginosis
14. For suspected drug-resistant trichomoniasis consult the 2021 CDC STI treatment guidelines, contact the CDPH Office of STIs and HCV, or consult the STD Clinical Consultation Network.
15. Although metronidazole crosses the placenta, there is no evidence of teratogenicity or mutagenic effects. Metronidazole at a dose of 500 mg PO BID for up to a week is considered compatible with breastfeeding. Drug levels peak 2-4 hours after dosing, so breastfeeding times may be shifted to peak drug levels if patient prefers.
16. May weaken latex condoms and contraceptive diaphragms. Use of such products within 72 hours after treatment with clindamycin ovules is not recommended. Anogenital Herpes
17. Treatment may be extended if healing is incomplete after 10 days.
18. Data regarding prenatal exposure to valacyclovir are limited. Animal trials indicate these drugs pose a low risk to pregnant patients. Anogenital Warts
19. Anogenital warts may proliferate and become friable during pregnancy. Although removal of warts during pregnancy can be considered, resolution might be incomplete or poor until pregnancy is complete.
20. The use of a cryoprobe in the vagina is not advised due to risk of vaginal perforation and fistula formation.