MANAGEMENT OF SEXUALLY TRANSMITTED DISEASES IN ADULTS AND ADOLESCENTS

Sexually transmitted diseases are frequently encountered in the course of a general practice. Because of changes in microbial sensitivities the recommendations for treatment change from time to time. This article deals with office management of uncomplicated STDs. It is based on the recommendations of the "Canadian Guidelines for the Prevention, Diagnosis and Management and Treatment of Sexually Transmitted Diseases in Neonates, Children, Adolescents, and Adults ". Copies are readily available at no cost from the Department of Health. A previous schedule was published in l988.

This book is an excellent reference, summarizing the most pertinent information about specific sexually transmitted diseases, as well as treatment schedules which are found in the blue pages of the book. It has good summary tables for symptoms, treatment and investigation, and where to find more information.

There are some changes in the previously recommended treatments, specifically in the area of treatment of gonorrhea. This is because of the rising proportion of penicillin resistant organisms being found. There is an up to date section on HIV and a new section dealing with genital ulcers. There is also an excellent section on outpatient and inpatient management of pelvic inflammatory disease.

As mentioned, the following recommendations are for uncomplicated infections. Refer to the included links or references for a more complete discussion of these conditions.

Gonorrhea: For urethral, endocervical and rectal infections the preferred treatment is:

Ceftriaxone 250 mg IM in a single dose

Oral regimes include:

• Cefixime 800 mg orally in a single dose
• Ciprofloxacin 500 mg or Ofloxacin 400mg orally in a single dose

All of these regimes should also include Doxycycline l00 mg bid for 7 days or Azithromycin 1gm as a single dose to cover for Chlamydia

<Chlamydia: For infections of the urethra, endocervix and rectal area the preferred treatment is:

Doxycycline l00 mg po twice a day for 7 days, or Azithromycin 1 gm orally as a single dose.

Alternate treatments are:

• Tetracycline 500 mg qid orally for 7 days
• Erythromycin 500 mg qid orally for 7 days
• Ofloxacin 300 mg bid for 7 days

Syphilis: For adults in the primary, secondary and latent (less than one year) duration the preferred treatment is:

Benzathine Penicillin G 2.4 million units IM in a single session

Alternatively:

• Tetracycline 500 mg orally four times a day for l4 days
• Doxycycline l00 mg orally twice a day for l4 days.

Genital Herpes: For the primary episode of genital herpes :

Acyclovir 200 mg. orally 5 times a day for 7 - l0 days or until healing is complete

Acyclovir 5 mg./kg. IV 3 times a day for l0 days or until healing is complete.

For chronic suppressive therapy, treatment is:

Acyclovir 200 - 400 mg. orally 2 - 5 times a day.

Genital Warts: Treatments include:

Bedofolin l0% and Podophyllin in Tensur Benzoin applied to the wart and washed off after l - 4 hours. This may be repeated once or twice weekly.

Liquid nitrogen or dry ice once or twice weekly

Electrodesecation under general anesthetic may be used for more extensive warts.

Prostatitis and Epididymitis: When a urethral discharge is detected, but culture results are not available treat with:

Ceftriaxone 250 mg. IM in a single dose plus Doxycycline l00 mg. orally twice a day for at least l0 days.

Bacterial Vaginosis: Recommended Regimen is:

Metronidazole 500 mg orally 2 times a day for 7 days.

Metronidazole 2 g orally in a single dose.

The following alternative regimens have been effective in clinical trials, although experience with these regimens is limited.

• Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days;
• Metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, 2 times a day for 5 days;
• Clindamycin 300 mg orally 2 times a day for 7 days.

Trichomoniasis: Recommended Regimen is:

Metronidazole 2 g orally in a single dose.

Alternative Regimen:

• Metronidazole 500 mg twice daily for 7 days.

The above noted summary is not meant in any way to be complete and once again you are referred to the "Canadian Guide Lines for the Prevention, Diagnosis, Management and Treatment of Sexually Transmitted Diseases in Neonates, Children, Adolescents and Adults".

- Penny Fuller

References:

Roddy RE, Zekeng L, Ryan KA, Tamoufe U, Weir SS, Wong EL. A controlled trial of nonoxynol 9 film to reduce male-to-female transmission of sexually transmitted diseases. N Engl J Med 1998, 339 (8):504

Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med 338 (7):423

Arvin AM, Prober CG. Herpes simplex virus type 2 -- a persistent problem N Engl J Med 337 (16):1158 - Editorial

Brown ZA, Selke S, Zeh J, et al. The acquisition of herpes simplex virus during pregnancy. N Engl J Med 1997;337:509-15.

Hillis SD, Wasserheit JN. Screening for chlamydia -- a key to the prevention of pelvic inflammatory disease. N Engl J Med 334 (21):1399 - Editorial

Hillis SD, Joesoef R, Marchbanks PA, Wasserheit JN, Cates W Jr, Westrom L. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol 1993;168:1503-9.

Gonorrhea in the United States, 1981-1996. Demographic and geographic trends. Sex Transm Dis. 1998 Aug; 25(7): 386-393.

The epidemiology of global antibiotic resistance among Neisseria gonorrhoeae and Haemophilus ducreyi. Lancet. 1998; 351 Suppl 3: 8-11. Review.