Special Feature
Treatment of Sexually Transmitted Diseases
By David J. Karras, MD, FACEP
The management of sexually transmitted diseases (STDs) is in a constant state of flux. Emergency physicians must be aware of changes in antibiotic susceptibility, modifications in dosing schedules for older drugs, and applications for a bewildering number of new antimicrobial agents. Fortunately, the Centers for Disease Control and Prevention (CDC) recognize these difficulties and have recently provided a comprehensive review of the STD literature and guidelines for management. The following is an outline of CDC treatment recommendations for STDs commonly encountered in the practice of emergency medicine.
Genital ulcers
Chancroid, caused by Haemophilus ducreyi, may present with classic signs of one or more painful genital ulcers and tender inguinal lymphadenopathy, which may be suppurative. When the diagnosis is unequivocal, therapy may be initiated empirically with azithromycin (1 g PO single dose), ceftriaxone (250 mg IM single dose), ciprofloxin* (500 mg PO bid × 3 d), or erythromycin (500 mg PO qid × 7 d). Often, however, a single lesion may be difficult to distinguish from a syphilitic chancre, and multiple lesions may resemble herpetic vesicles. Because specific tests for H. ducreyi are not widely available, treatment of equivocal cases should be deferred until a serologic test for syphilis and herpes culture of the lesion are both found to be negative. The syphilis test should be performed at least a week after the onset of the ulcers. Patients should be re-evaluated within a week of therapy for ulcer resolution. Partners of infected patients should be referred for treatment.
Herpes simplex virus (HSV) causes recurrent and incurable disease. Treatment is somewhat effective in reducing the severity of the initial episode but does not affect the frequency or severity of recurrences unless used as daily suppressive therapy. Initial outbreaks of herpetic lesions may be treated with acyclovir (400 mg PO tid × 7-10 d or 200 mg PO 5 × d for 7-10 d), famciclovir (250 mg PO tid × 7-10 d), or valacyclovir (1 g PO bid × 7-10 d). Patients with severe or complicated infections may require inpatient therapy with acyclovir (5-10 mg/kg IV q 8 h). Recurrent episodes may also benefit from therapy when started during the prodrome phase or first day after onset of lesions. The treatment of recurrences is similar to that of initial episodes, but the duration of therapy is reduced to five days. Acyclovir appears safe for use in pregnant women for initial outbreaks but is not recommended for recurrent disease in pregnancy. Partners of infected patients should be encouraged to seek evaluation and counseling but should not be treated if they are asymptomatic. Topical acyclovir is not recommended for the treatment of orogenital herpes due to a lack of proven efficacy.
Syphilis therapy has not changed in four decades. Primary syphilis, presenting as a painless chancre, is treated with benzathine penicillin G (2.4 million units IM single dose). Penicillin-allergic patients may be treated with doxycylcine_ (100 mg PO bid × 14 d). Patients should be cautioned about the possibility of developing a Jarisch-Herxheimer reaction (an acute febrile illness occurring within 24 hours of therapy). There is no specific management for this syndrome. Follow-up for partner identification, HIV testing, and serial serologic re-testing is critical. Treatment of pregnant patients and HIV-positive individuals should be discussed with a specialist, as recommendations for duration of therapy vary. Secondary and tertiary syphilis have nonspecific manifestations, and empiric therapy is rarely indicated in the ED. Partners of patients with syphilis in any stage should be referred for presumptive therapy and serologic testing.
Cervicitis and urethritis
Mucopurulent cervicitis (MPC) in females and urethritis in males are caused by infection with N. gonorrhoeae and C. trachomatis. The diseases caused by the two organisms are, in general, clinically indistinguishable. While it is common practice to presumptively treat patients for both infections, the CDC strongly recommends specific therapy based on Gram stain and/or culture result. However, this may be impractical when individuals are unlikely to return for follow-up, and the CDC acknowledges that empiric dual-therapy is often more cost-effective.
Chlamydia infection causing MPC or urethritis is effectively treated with a single dose of azithromycin (1 g PO). Doxycycline_ (100 mg PO bid × 7 d) or erythromycin base (500 mg PO qid × 7 d) remain effective but should be expected to have much lower compliance than single-dose therapy. Treated patients of either sex whose symptoms resolve do not need re-testing to document cure. Nevertheless, follow-up with a primary care physician may be encouraged for STD counseling, partner identification, and HIV testing. Partners should be referred for evaluation and treatment.
Gonorrhea infection causing MPC or urethritis has a number of acceptable therapies. The effectiveness of single-dose oral treatments renders IM therapy, with its attendant pain and risk of complications, unnecessary for uncomplicated infections. Gonorrheal infection may be treated with cefixime (400 mg PO single dose), ceftriaxone (125 mg IM single dose), ciprofloxacin* (500 mg PO single dose) or ofloxacin* (400 mg PO single dose). Each of these therapies should be accompanied by azithromycin (1 g PO single dose) or doxycycline_ (100 mg PO bid × 7 d). Treated patients need not return for re-testing if their symptoms resolve. Partners should be referred for evaluation and treatment.
Therapy for children with gonorrhea or chlamydia infections is fairly complicated and is based on age and site of infection. Evidence of such infections in pre-adolescent (non-neonatal) children should raise a strong concern about sexual abuse. Infection may be more difficult to treat, and children should always be referred for re-testing.
Table
Outpatient Therapy of PID
Regimen A
Ofloxacin* 400 mg PO bid × 14 d
plus
Metronidazole 500 mg PO bid × 14 d
Regimen B
Doxycycline_ 100 mg PO bid × 14 d (with any of the following)
plus
Ceftriaxone 250 mg IMsingle dose
or
Cefoxitin 2 g IM plus probenecid 1 g PO single dose
or
Other parenteral third generation cephalosporin (e.g. cefitzoxime or cefotaxime)
Vaginitis
Bacterial vaginosis (BV) is the most common cause of vaginal discharge or malodor; it results from overgrowth of normal vaginal flora with anaerobes, Gardnerella vaginalis, and Mycoplasma hominis. BV is diagnosed by the presence of three of the following criteria: a white discharge, clue cells, vaginal pH higher than 4.5, and positive whiff test. Classification of BV as an STD is controversial and is often more than an academic concern to the affected patient. BV is associated with having multiple sex partners, and sexually inactive women are rarely affected. It is unclear, however, if the disease is caused by a sexually transmitted organism. Diagnosis of BV does not require treatment of male partners.
In nonpregnant women, BV may be treated with metronidazole (500 mg PO bid × 7 d), clindamycin cream 2% (5 g), or metronidazole gel 0.75% (5 g intravaginally bid × 5 d). A single dose of metronidazole (2 g PO) is acceptable but is less effective than a longer course of therapy. BV should be treated in pregnant women during the early second trimester, as untreated infection increases the risk of pregnancy complications. Metronidazole (250 mg PO tid × 7 d), clindamycin (300 mg PO bid × 7 d), or metronidazole (2 g PO single dose) are acceptable in the early second trimester of pregnancy, while intravaginal clindamycin is not recommended.
Trichomoniasis is caused by infection with the protozoa T. vaginalis and typically causes a malodorous, yellow-green discharge with vulvar irritation. Therapy requires metronidazole (2 g PO single dose). Topical metronidazole is not recommended. Follow-up is unnecessary if symptoms resolve. Male partners are rarely symptomatic but should be referred for treatment.
Pelvic Inflammatory Disease
While a number of different organisms have been implicated in pelvic inflammatory disease (PID), the vast majority of cases are caused by N. gonorrhoeae and C. trachomatis. The clinical diagnosis of PID is difficult and invariably imprecise. At minimum, patients must be sexually active and have lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness (without other identifiable causes). Fever and cervical or vaginal discharge are variable signs. A definitive diagnosis requires endometrial biopsy, ultrasound, or laparoscopy and is frequently not necessary.
Few physicians still believe that a diagnosis of PID mandates hospitalization, although this had been recommended in the past. The disease has such a wide spectrum of severity that few generalizations can be made regarding disposition. Pregnancy, tubo-ovarian abscess, and severe illness with nausea, vomiting, or high fever usually indicate hospitalization. Failure of outpatient therapy, immunodeficiency, and medical noncompliance may warrant inpatient management. Patients in whom a surgical emergency cannot be excluded should be admitted for further evaluation.
Patients not requiring inpatient therapy may be treated with a number of oral regimens, as outlined in the Table. While studies have shown ofloxacin to be effective as a single agent, the CDC recommends adding metronidazole to enhance anaerobic coverage.
Follow-up examination should be scheduled within three days of initiation of outpatient therapy, at which time signs and symptoms of infection should have markedly improved. Repeat evaluation for cure at 4-6 weeks is often recommended. Male partners should be referred for evaluation and treatment.
Footnotes
* Quinolone antibiotics are contraindicated for pregnant and breastfeeding women and for all individuals younger than 18 years.
_ Doxycycline and tetracycline should be avoided in pregnant and lactating women, and in individuals younger than 8 years.
Suggested Reading
1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR Morb Mort Wkly Rep 1998;47:(RR-1).
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