Focused Issue of This Month Treatment and Management of Sexually Transmitted Diseases Tak Kim, MD Department of Obstetrics and Gynecology, Korea University College of Medicine E - mail : tkim@kumc.or.kr J Korean Med Assoc 2008; 51(10): 884-896 Abstract Sexually transmitted diseases (STDs) are the most common group of identifiable infectious diseases in many countries. Adolescents and young adults (15-24 years old) comprise only 25% of the sexually active population but represent almost 50% of all newly acquired STDs. In a law for prevention of infectious diseases in Korea, STDs include syphilis, gonorrhea, chancroid, nongonococcal urethritis, clamydial infection, genital herpes, and genital wart. Bacterial vaginosis, trichomoniasis, candidiasis, amebiasis, scabies, phthiriasis, granuloma inguinale, AIDS, and high risk human papilloma virus are also included in the STDs. Individuals infected with STDs are 5-10 times more likely than uninfected individuals to acquire or transmit HIV through sexual contacts. Their control is important considering the high incidences of acute infections, complications, and sequelae, their socioeconomic impact, and their role in increasing transmission of the HIV. The purpose of this paper is to summarize the treatment and management of STDs on the basis of Centers for Disease Control and Prevention treatment guidelines for sexually transmitted diseases published in 2006. Keywords: Sexually transmitted disease; Treatment; Management 884
Treatment and Management of STD Table 1. Recommended regimens for chancroid* Azithromycin 1 g orally in a single dose Ceftriaxone 250 mg intramuscularly(im) in a single dose Ciprofloxacin 500 mg orally twice a day for 3 days Erythromycin base 500 mg orally three times a day for 7 days * Ciprofloxacin is contraindicated for pregnant and lactating women. Azithromycin and ceftriaxone offer the advantage of single-dose therapy. Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported. Table 2. Recommended regimens for genital herpes* Acyclovir 400 mg orally three times a day for 7~10 days Acyclovir 200 mg orally five times a day for 7~10 days Famciclovir 250 mg orally three times a day for 7~10 days Valacyclovir 1 g orally twice a day for for 7~10 days * Treatment might be extended if healing is incomplete after 10 days of therapy. ~ - - - - 885
Kim T Table 3. Recommended regimens for suppressive therapy of genital herpes Acyclovir 400 mg orally twice a day Famciclovir 250 mg orally twice a day Valacyclovir 500 mg orally once a day Valacyclovir 1 g orally once a day Table 4. Recommended regimens for episodic therapy of genital herpes Acyclovir 400 mg orally three times a day for 5 days Acyclovir 800 mg orally twice a day for 5 days Acyclovir 800 mg orally three times a day for 2 days Famciclovir 125 mg orally twice a day for 5 days Famciclovir 1000 mg orally twice a day for 1 day Valacyclovir 500 mg orally twice a day for 3 days Valacyclovir 1.0 g orally once a day for 5 days - - ~ Table 5. Recommended regimens for daily suppressive therapy in persons infected with HIV Acyclovir 400~800 mg orally twice to three times a day Famciclovir 500 mg orally twice a day Valacyclovir 500 mg orally twice a day Table 6. Recommended regimens for episodic infection in persons infected with HIV Acyclovir 400 mg orally three times a day for 5~10 days Famciclovir 500 mg orally twice a day for 5~10 days Valacyclovir 1.0 grams orally twice a day for 5~10 days - - 886
Treatment and Management of STD Table 7. Recommended regimen and alternative regimens for granuloma inguinale Recommended Regimen Doxycycline 100 mg orally twice a day for at least 3 weeks and until all lesions have completely healed Azithromycin Azithromycin 1g orally once per week for at least 3 weeks and until all lesions have completely healed Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed ~ Erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a day for at least 3 weeks and until all lesions have completely healed - - 887
Kim T Table 8. Recommended regimen for primary and secondary syphilis Recommended Regimen for Adults Benzathine penicillin G 2.4 million units IM in a single dose Recommended Regimen for Children Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose Table 9. Recommended regimen for latent syphilis for Adults Early Latent Syphilis Benzathine penicillin G 2.4 million units IM in a single dose Late Latent Syphilis or Latent Syphilis of Unknown Duration Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals for Children Early Latent Syphilis Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose Late Latent Syphilis or Latent Syphilis of Unknown Duration Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, administered as 3 doses at 1-week intervals (total 150,000 units/kg up to the adult total dose of 7.2 million units) 888
Treatment and Management of STD Table 10. Recommended regimen for tertiary syphilis Recommended Regimen Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals ~ Table 11. Oral desensitization protocol for patients with a positive skin test* Penicillin V suspension Amount Cumulative dose (units/ml) ml Units dose (units) 1 1,000 0.1 100 100 2 1,000 0.2 200 300 3 1,000 0.4 400 700 4 1,000 0.8 800 1,500 5 1,000 1.6 1,600 3,100 6 1,000 3.2 3,200 6,300 7 1,000 6.4 6,400 12,700 8 10,000 1.2 12,000 24,700 9 10,000 2.4 24,000 48,700 10 10,000 4.8 48,000 96,700 11 80,000 1.0 80,000 176,700 12 80,000 2.0 160,000 336,700 13 80,000 4.0 320,000 656,700 14 80,000 8.0 640,000 1,296,700 Observation period: 30 minutes before parenteral administration of penicillin * Reprinted with permission from the New England Journal of Medicine. SOURCE: Wendel GO Jr. Stark BJ, Jamison RB, Melina RD, Sullivan TJ. Penicillin allergy and desensitization in serious infections during pregnancy. N Engl J Med 1985; 312; 1229-1232. Interval between doses: 15 minutes; elapsed time: 3 hours and 45 minutes; and cumulative dose: 1.3 million units. The specific amount of drug was diluted in approximately 30mL of water amd then administered orally. ~ 889
Kim T Table 12. Treatment regimens for nongonococcal urethritis Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice a day for 7 days Erythromycin base 500 mg orally four times a day for 7 days Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days Ofloxacin 300 mg orally twice a day for 7 days Levofloxacin 500 mg orally once daily for 7 days - ~ Table 13. Recommended regimens for recurrent and persistent nongonococcal urethritis Metronidazole 2 g orally in a single dose Tinidazole 2 g orally in a single dose PLUS Azithromycin 1 g orally in a single dose (if not used for initial episode) 890
Treatment and Management of STD Table 14. Treatment regimens for chlamydial infections Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice a day for 7 days Erythromycin base 500 mg orally four times a day for 7days Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days Ofloxacin 300 mg orally twice a day for 7 days Levofloxacin 500 mg orally once daily for 7 days Table 15. Treatment regimens for chlamydial infections in pregnant women Azithromycin 1 g orally in a single dose Amoxicillin 500 mg orally three times a day for 7 days Erythromycin base 500mg orally four times a day for 7days Erythromycin base 250mg orally four times a day for 14 days Erythromycin ethylsuccinate 800mg orally four times a day for 7 days Erythromycin ethylsuccinate 400mg orally four times a day for 14 days 891
Kim T Table 16. Treatment regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum Ceftriaxone 125 mg IM in a single dose Cefixime 400 mg orally in a single dose Ciprofloxacin 500 mg orally in a single dose Ofloxacin 400 mg orally in a single dose Levofloxacin 250 mg orally in a single dose PLUS Treatment for chlamydia if chlamydial infection is not ruled out Spectinomycin 2 g in a single IM dose Single-dose cephalosporin regimens (other than ceftriaxone 125 mg IM and cefixime 400 mg orally) that are safe and highly effective against uncomplicated urogenital and anorectal gonococcal infections include ceftizoxime (500 mg, administered IM), cefoxitin (2g, administered IM with probenecid 1 g orally), and cefotaxime (500 mg, administered IM). None of the injectable cephalosporins offer any advantage over ceftriaxone. Single-dose quinolone regimens include gatifloxacin 400 mg orally, norfloxacin 800 mg orally, and lomefloxacin 400 mg orally. These regimens appear to be safe and effective for the treatment of uncomplicated gonorrhea, but data regarding their use are limited. None of the regimens appear to offer any advantage over ciprofloxacin, ofloxacin, or levofloxacin, and they are not effective against QRNG. Table 17. Treatment regimens for bacterial vaginosis Metronidazole 500 mg orally twice a day for 7 days Metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days Clindamycin 300 mg orally twice a day for 7 days Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days 892
Treatment and Management of STD Table 18. Treatment regimens for pregnant women of bacterial vaginosis Metronidazole 500 mg orally twice a day for 7 days Metronidazole 250 mg orally three times a day for 7 days PLUS Clindamycin 300 mg orally twice a day for 7 days Table 19. Treatment regimens for trichomoniasis Metronidazole 2 g orally in a single dose Tinidazole 2 g orally in a single dose Alternative Regimen Metronidazole 500 mg orally twice a day for 7 days ~ ~ Table 20. Treatment Regimens for Vulvovaginal Candidiasis Intravaginal Agents: Butoconazole 2% cream 5 g intravaginally for 3 days Butoconazole 2% cream 5 g (Butaconazole1- sustained release), single intravaginal application Clotrimazole 1% cream 5 g intravaginally for 7~14 days Clotrimazole 100 mg vaginal tablet for 7 days Clotrimazole 100 mg vaginal tablet, two tablets for 3 days Miconazole 2% cream 5 g intravaginally for 7 days Miconazole 100 mg vaginal suppository, one suppository for 7 days Miconazole 200 mg vaginal suppository, one suppository for 3 days Miconazole 1,200 mg vaginal suppository, one suppository for 1 day Nystatin 100,000- vaginal tablet, one tablet for 14 days Tioconazole 6.5% ointment 5 g intravaginally in a single application Terconazole 0.4% cream 5 g intravaginally for 7 days Terconazole 0.8% cream 5 g intravaginally for 3 days Terconazole 80 mg vaginal suppository, one suppository for 3 days Oral Agent: Fluconazole 150 mg oral tablet, one tablet in single dose ~ 893
Kim T Table 21. Treatment regimens for external genital warts Patient - Applied: Podofilox 0.5% solution or gel. Patients should apply podofilox solution with a cotton swab, or podofilox gel with a finger, to visible genital warts twice a day for 3 days, followed by 4 days of no therapy. This cycle may be repeated, as necessary, for up to four cycles. The total wart area treated should not exceed 10cm 2, and the total volume of podofilox should be limited to 0.5 ml per day. If possible, the health-care provider should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated. The safety of podofilox during pregnancy has not been established Imiquimod 5% cream. Patients should apply imiquimod cream once daily at bedtime, three times a week for up to 16 weeks. The treatment area should be washed with soap and water 6~10 hours after the application. The safety of imiquimod during pregnancy has not been established. Provider- Administered: Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1~2 weeks. Podophyllin resin 10~25% in a compound tincture of benzoin. A small amount should be applied to each wart and allowed to air dry. The treatment can be repeated weekly, if necessary. To avoid the possibility of complications associated with systemic absorption and toxicity, two important guidelines should be followed: 1) application should be limited to <0.5mL of podophyllin or an area of <10cm 2 of warts per session, and 2) no open lesions or wounds should exist in the area to which treatment is administered. Some specialists suggest that the preparation should be thoroughly washed off 1~4 hours after application to reduce local irritation. The safety of podophyllin during pregnancy has not been established. Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80~90%. A small amount should be applied only to the warts and allowed to dry, at which time a white frosting develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate (i.e., baking soda), or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary. Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery Intralesional interferon Laser surgery Table 22. Treatment regimens for scabies Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8~14 hours Ivermectin 200ug/kg orally, repeated in 2 weeks Lindane (1%) 1 oz. of lotion or 30 g of cream applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours ~ - 894
Treatment and Management of STD Table 23. Treatment Regimens for Pediculosis Pubis Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes Malathion 0.5% lotion applied for 8~12 hours and washed off Ivermectin 250ug/kg repeated in 2 weeks 11. UNAIDS. Force for change: World AIDS Campaign with young people. UNAIDS 1998 theme. AIDS Anal Afr 1998; 8: 8-9. 12. Hillis SD and Wasserheit JN. Screening for Chlamydia-A Key to the prevention of pelvic inflammatory disease. New England Journal of Medicine 1996; 334: 1399-1401. 13. Centers for Disease Control. Sexually transmitted disease treatment guidelines, 2006, MMWR 2006; 55: 11. 895
Kim T Peer Reviewers Commentary 896