Sexually Transmitted Infections (STI) in Adolescents — STI Treatment Recommendations for Patients > 13 Years of Age — Clinical Pathway: Emergency and Primary Care

Sexually Transmitted Infections (STI) in Adolescents Clinical Pathway — Emergency Department and Primary Care

STI Treatment Recommendations for Patients ≥ 13 Years of Age and ≥ 45 kg

For alternative treatment regimens and treatment of special circumstances such as HIV infection, pregnancy refer to: Sexually Transmitted Infections: Summary of CDC Treatment Guidelines 2021  .

For patients < 13 years of age and < 45 kg refer to the Sexual Abuse Concerns Clinical Pathway for treatment recommendations.

Chlamydia

Treatment Alternative Treatments Special Considerations
  • Doxycycline, PO
    • 100 mg twice daily for 7 days
  • Azithromycin, PO
    • 1,000 mg as a single dose
  • Provide empiric treatment for both GC and chlamydia if test results unknown
  • Consider narrowing therapy to organism once results are available

Gonorrhea: Cervical, Urethral, Rectal, Pharyngeal

Treatment Alternative Treatments Special Considerations
  • Ceftriaxone, IM or IV
    • 500 mg as a single dose
    • ≥ 150 kg:
      1,000 mg as a single dose
  • Gentamicin, IM
    • 240 mg as a single dose
Plus
  • Azithromycin, PO
    • 2,000 mg as a single dose
  • Provide empiric treatment for both GC and chlamydia if test results unknown
  • Pharyngeal GC
    • Re-test patients 4 weeks after treatment

Trichomoniasis

Treatment Alternative Treatments
  • Tinidazole, PO
    • 2,000 mg as a single dose
  • Females:
    • Metronidazole, PO
      • 500 mg twice daily for 7 days
  • Males:
    • Metronidazole, PO
      • 2,000 mg as a single dose

PID

Pelvic Inflammatory Disease

Treatment Special Considerations
  • Outpatient:
    • Ceftriaxone, IM or IV
      • 500 mg as a single dose
    • ≥ 150 kg:
      1,000 mg as a single dose
      Plus
    • Doxycycline, PO
      100 mg twice daily for 14 days
      Plus
    • Metronidazole, PO
      500mg twice daily for 14 days
  • Inpatient:
    • Ceftriaxone, IV
      • 1,000 mg every 24 hours
        Plus
  • Doxycycline, IV or PO
    • 100 mg twice daily
      Plus
    • Metronidazole, IV or PO
      • 500 mg twice daily
  • Cover for:
    • N. gonorrhoeae, C. trachomatis, anaerobic Bacteria
  • Consider Inpatient Treatment for:
    • Pregnancy
    • Concern for surgical emergencies
    • Tubo-ovarian abscess
    • Severe illness
      • Nausea and vomiting
      • Oral temperature > 38.5° C
      • Pain control
    • Unable to tolerate PO regimen
  • No clinical response to PO therapy
  • Note: PO and IV regimens have similar efficacy for treatment of mild/moderate disease

Epididymitis

Treatment Alternative Treatments
  • Likely Cause GC, Chlamydia:
    • Ceftriaxone, IM
      • 500 mg as a single dose
      • ≥ 150 kg:
        1,000 mg as a single dose
        Plus
    • Doxycycline, PO
      • 100 mg twice daily for 10 days
  • Likely Cause GC, Chlamydia, Enteric Organisms:
    • Ceftriaxone, IM
      • 500 mg as a single dose
      • ≥ 150 kg:
        1,000 mg as a single dose
        Plus
    • Levofloxacin, PO
      • 500 mg once daily for 10 days
  • Most Likely Cause Enteric Organisms Only:
    • Levofloxacin, PO
      • 500 mg once daily for 10 days

Bacterial Vaginitis (BV)

Treatment Alternative Treatments Special Considerations
  • Metronidazole, PO
    • 500 mg twice daily for 7 days
  • Chronic BV:
    • Metronidazole, PO
      • 500 mg twice daily for 7 days
        Followed by
    • Intravaginal boric acid, OTC
      • 600 mg daily for 21 days
        Plus
    • Suppressive Therapy
      • Metronidazole gel, 0.75%
        • Twice weekly for 4-6 months
  • Clindamycin, PO
    • 300 mg twice daily for 7 days
  • Tinidazole, PO
    • 2,000 mg once daily for 2 days
  • Chronic BV:
    • Limited data in women with multiple recurrences

Vulvovaginal Candidia (VVC)

Treatment Alternative Treatments Special Considerations
  • Oral Treatment:
    • Fluconazole 150 mg once
      or
  • Intravaginal Treatment Options:
    • Tioconazole 6.5% ointment
      • 5 g intravaginally in a single application
    • For additional OTC or prescription treatment options, please refer to CDC Guidelines  
  • Recurrent VVC or Severe VVC:
    • Topical azole therapy for 7 to 14 days
      or
    • Fluconazole, PO
      • 150 mg once on day 1, 4, and 7
    • Maintenance for Recurrent VVC:
      • Fluconazole, PO
        • 150 mg once weekly for 6 months
    • Recurrent VVC:
      • Three or more episodes of symptomatic VVC in < 1 year
    • Severe VVC:
      • Extensive vulvar erythema, edema, excoriation, and fissure formation
  • Order chronic treatments to the pharmacy, not from the family planning supply
  • Creams and suppositories are oil-based and might weaken latex condoms and diaphragms
  • If symptoms persist after using OTC preparation or symptoms recur < 2 months after treatment, reevaluate patient clinically, consider test to confirm clinical diagnosis and identify non–albicans Candida
  • Unnecessary use of OTC preparations is common and may lead to a delay in treatment of other etiologies, which can affect adverse outcomes

Genital Herpes

Treatment Special Considerations
  • 1st Episode:
    • Acyclovir, PO
      • 400 mg three times daily for 7-10 days
        or
    • Valacyclovir, PO
      • 1,000 mg twice daily for 7-10 days
  • Pain Control:
    • Sitz baths, topical lidocaine jelly NSAIDs
  • Severe Pain:
    • Assess for dehydration, urinary retention
    • Consider admission for IV fluids, pain control
  • During Initial Regimen:
    • Provide prescription for episodic treatment
    • Start treatment with viral prodrome
    • Pain, tingling, itching, burning or lesions occur
  • Episodic Therapy for Recurrent Genital Herpes:
    • Acyclovir, PO
      • 800 mg twice daily for 5 days
        or
      • 800 mg three times daily for 2 days
        or
    • Valacyclovir, PO
      • 500 mg twice daily for 3 days
        or
      • 1,000 mg once daily 5 days
 Most effective if started during prodrome period or on day 1 of visible lesions
  • Daily Suppressive Therapy:
    • Acyclovir, PO
      • 400 mg twice daily
        or
    • Valacyclovir, PO
      • 500 mg or 1,000 mg once daily

        Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens for persons who have frequent recurrences (e.g., ≥ 10 episodes/year)
  • May decrease transmission and improve quality of life
  • Discuss maintenance of suppressive therapy with patient annually

Syphilis Primary and Secondary

Treatment Special Considerations
  • Benzathine penicillin G, IM
    • 2.4 million units as a single dose
  • If asymptomatic and no prior RPR in last year, consult local health department as patient may need 3-dose treatment for late latent syphilis
  • If neurologic symptoms or findings on examination, consult ID or Adolescent to discuss the need for LP and neurosyphilis treatment