Summary of CDC STI Treatment Guidelines, 2021

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Summary of CDC STI Treatment Guidelines, 2021

This wall chart reflects recommended regimens found in CDC’s Sexually Transmitted Infections Treatment Guidelines, 2021. This summary is intended as a source of clinical guidance. When more than one
therapeutic regimen is recommended, the sequence is in alphabetical order unless the choices for therapy are prioritized based on efficacy, cost, or convenience. The recommended regimens should be used
primarily; alternative regimens can be considered in instances of substantial drug allergy or other contraindications. An important component of STI treatment is partner management. Providers can arrange for
the evaluation and treatment of sex partners either directly or with assistance from state and local health departments. Complete guidelines can be found online at www.cdc.gov/std/treatment.

DISEASE RECOMMENDED REGIMEN ALTERNATIVE REGIMEN DISEASE RECOMMENDED REGIMEN ALTERNATIVE REGIMEN
Bacterial Vaginosis metronidazole 500 mg orally 2x/day for 7 days clindamycin 300 mg orally 2x/day for 7 days Lymphogranuloma Venereum doxycycline 100 mg orally 2x/day for 21 days azithromycin 1 gm orally 1x/week for 3 weeks 20
OR metronidazole gel 0.75%, one 5 gm applicator OR clindamycin ovules 100 mg intravaginally at bedtime OR erythromycin base 500 mg orally 4x/day for
intravaginally, 1x/day for 5 days for 3 days1 21 days
OR clindamycin cream 2%, one 5 gm applicator OR secnidazole 2 gm orally in a single dose2
intravaginally, at bedtime for 7 days
Nongonococcal Urethritis (NGU) doxycycline 100 mg orally 2x/day for 7 days azithromycin 1 gm orally in a single dose
OR tinidazole 2 gm orally 1x/day for 2 days OR azithromycin 500 mg orally in a single dose, THEN
OR tinidazole 1 gm orally 1x/day for 5 days 250 mg 1x/day for 4 days
Cervicitis3 doxycycline 100 mg orally 2x/day for 7 days azithromycin 1 gm orally in a single dose Persistent or Recurrent NGU: test for Mycoplasma genitalium:
Chlamydial Infections If M. genitalium resistance testing is doxycycline 100 mg orally 2x/day for 7 days, For settings without resistance testing and when
unavailable but M. genitalium is detected FOLLOWED BY moxifloxacin 400 mg 1x/day for moxifloxacin cannot be used:
Adults and adolescents doxycycline 100 mg orally 2x/day for 7 days azithromycin 1 gm orally in a single dose by an FDA-cleared NAAT 7 days doxycycline 100 mg orally 2x/day for 7 days,
OR levofloxacin 500 mg orally 1x/day for 7 days FOLLOWED BY azithromycin 1 gm orally on first day,
FOLLOWED BY azithromycin 500 mg orally 1x/day
Pregnancy azithromycin 1 gm orally in a single dose amoxicillin 500 mg orally 3x/day for 7 days for 3 days and a test-of-cure 21 days after completion
of therapy
Infant and children <45 kg4 (nasopharynx, erythromycin base, 50 mg/kg body weight/day
urogenital, and rectal) orally, divided into 4 doses daily for 14 days If resistance testing is available, use Macrolide sensitive
OR ethylsuccinate, 50 mg/kg body weight/day orally, resistance-guided therapy doxycycline 100 mg orally 2x/day for 7 days,
divided into 4 doses daily for 14 days FOLLOWED BY azithromycin 1 gm orally initial dose,
FOLLOWED BY azithromycin 500 mg orally 1x/day
Children who weigh ≥45 kg, but who azithromycin 1 gm orally in a single dose for 3 additional days (2.5 gm total)
are aged <8 years (nasopharynx, Macrolide resistance
urogenital, and rectal) doxycycline 100 mg orally 2x/day for 7 days,
FOLLOWED BY moxifloxacin 400 mg orally
Children aged ≥8 years (nasopharynx, azithromycin 1 gm orally in a single dose 1x/day for 7 days
urogenital, and rectal) OR doxycycline 100 mg orally 2x/day for 7 days
Test for Trichomonas vaginalis in metronidazole 2 gm orally in a single dose
Neonates:5 ophthalmia and pneumonia erythromycin base, 50 mg/kg body weight/day azithromycin suspension 20 mg/kg body weight/day heterosexual men in areas where OR tinidazole 2 gm orally in a single dose
orally, divided into 4 doses daily for 14 days orally, 1x/day for 3 days infection is prevalent
OR ethylsuccinate, 50 mg/kg body weight/day orally,
divided into 4 doses daily for 14 days
Pediculosis Pubis permethrin 1% cream rinse applied to affected malathion 0.5% lotion applied to affected areas,
areas, wash after 10 minutes wash after 8–12 hours
Epididymitis OR pyrethrin with piperonyl butoxide applied to OR ivermectin 250 µg/kg body weight repeated in
affected areas, wash after 10 minutes 7–14 days
For acute epididymitis most likely caused ceftriaxone 500 mg IM in a single dose6 PLUS
by sexually transmitted chlamydia and doxycycline 100 mg orally 2x/day for 10 days Pelvic Inflammatory Disease
gonorrhea
Parenteral treatment ceftriaxone 1 gm by IV every 24 hours PLUS ampicillin-sulbactam 3 gm by IV every 6 hours PLUS
For acute epididymitis most likely caused ceftriaxone 500 mg IM in a single dose6 PLUS doxycycline 100 mg orally or by IV every 12 hours doxycycline 100 mg orally or by IV every 12 hours
by chlamydia, gonorrhea, or enteric levofloxacin 500 mg orally 1x/day for 10 days PLUS metronidazole 500 mg orally or by IV every OR clindamycin 900 mg by IV every 8 hours PLUS
organisms (men who practice insertive 12 hours gentamicin 2 mg/kg body weight by IV or IM
anal sex) OR cefotetan 2 gm by IV every 12 hours PLUS FOLLOWED BY 1.5 mg/kg body weight every 8 hours.
doxycycline 100 mg orally or by IV every 12 hours Can substitute with 3–5 mg/kg body weight 1x/day
For acute epididymitis most likely caused levofloxacin 500 mg orally 1x/day for 10 days
by enteric organisms only OR cefoxitin 2 gm by IV every 6 hours PLUS
doxycycline 100 mg orally or by IV every 12 hours
Genital Herpes Simplex
Intramuscular or oral treatment ceftriaxone 500 mg IM in a single dose6 PLUS
First clinical episode of genital herpes 7
acyclovir 400 mg orally 3x/day for 7–10 days 8 doxycycline 100 mg orally 2x/day for 14 days WITH
metronidazole 500 mg orally 2x/day for 14 days
OR famciclovir 250 mg orally 3x/day for 7–10 days
OR cefoxitin 2 gm IM in a single dose AND
OR valacyclovir 1 gm orally 2x/day for 7–10 days
probenecid 1 gm orally, administered concurrently
Suppressive therapy for recurrent genital acyclovir 400 mg orally 2x/day in a single dose PLUS doxycycline 100 mg orally
herpes (HSV-2) 2x/day for 14 days WITH metronidazole 500 mg
OR valacyclovir 500 mg orally 1x/day9 orally 2x/day for 14 days
OR valacyclovir 1 gm orally 1x/day OR Other parenteral third-generation cephalosporin
OR famciclovir 250 mg orally 2x/day (e.g., ceftizoxime or cefotaxime) PLUS
doxycycline 100 mg orally 2x/day for 14 days WITH
Episodic therapy for recurrent genital acyclovir 800 mg orally 2x/day for 5 days metronidazole 500 mg orally 2x/day for 14 days
herpes (HSV-2)10 OR acyclovir 800 mg orally 3x/day for 2 days
OR famciclovir 1 gm orally 2x/day for 1 day The complete list of recommended regimens can be found in Sexually Transmitted Infections Treatment Guidelines, 2021.
OR famciclovir 500 mg once, FOLLOWED BY Scabies permethrin 5% cream applied to all areas of the lindane 1% 1 oz of lotion or 30 gm of cream applied
250 mg 2x/day for 2 days body (from neck down), wash after 8–14 hours21 thinly to all areas of the body (from neck down), wash
OR famciclovir 125 mg 2x/day for 5 days OR ivermectin 200ug/kg body weight orally, repeated after 8 hours23
OR valacyclovir 500 mg orally 2x/day for 3 days in 14 days22
OR valacyclovir 1 gm orally 1x/day for 5 days OR ivermectin 1% lotion applied to all areas of the
body (from neck down), wash after 8–14 hours;
Daily suppressive therapy for persons with acyclovir 400-800 mg orally 2x–3x/day repeat treatment in 1 week if symptoms persist
HIV infection OR famciclovir 500 mg orally 2x/day
Syphilis24
OR valacyclovir 500 mg orally 2x/day
Primary, secondary, and early latent: adults benzathine penicillin G 2.4 million units IM in a
Episodic therapy for persons with HIV acyclovir 400 mg orally 3x/day for 5–10 days (including pregnant women and people single dose
infection OR famciclovir 500 mg orally 2x/day for 5–10 days with HIV infection)
OR valacyclovir 1 gm orally 2x/day for 5–10 days Late latent adults (including pregnant benzathine penicillin G 7.2 million units total,
Daily suppressive therapy of recurrent acyclovir 400 mg orally 3x/day women and people with HIV infection) administered as 3 doses of 2.4 million units IM
genital herpes in pregnant women11 each at 1-week intervals
OR valacyclovir 500 mg orally 2x/day
Neurosyphilis, ocular syphilis, and aqueous crystalline penicillin G 18–24 million procaine penicillin G 2.4 million units IM 1x/day
Genital Warts (Human otosyphilis units per day, administered as 3–4 million units PLUS probenecid 500 mg orally 4x/day, both for
Papillomavirus) by IV every 4 hours or continuous infusion, for 10–14 days
10–14 days
External anogenital warts12 Patient-applied
imiquimod 3.75% or 5% cream13 For children or congenital syphilis See Sexually Transmitted Infections Treatment
OR podofilox 0.5% solution or gel Guidelines, 2021.
OR sinecatechins 15% ointment13 Trichomoniasis25
Provider–administered
cryotherapy with liquid nitrogen or cryoprobe Women metronidazole 500 mg orally 2x/day for 7 days tinidazole 2 gm orally in a single dose
OR surgical removal either by tangential scissor Men metronidazole 2 gm orally in a single dose tinidazole 2 gm orally in a single dose
excision, tangential shave excision, curettage,
laser, or electrosurgery 1. Clindamycin ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and diaphragms). Use of such products within 72 hours following treatment with clindamycin
OR trichloroacetic acid (TCA) or bichloroacetic acid ovules is not recommended.
(BCA) 80%–90% solution 2. Oral granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.
3. Consider concurrent treatment for gonococcal infection if the patient is at risk for gonorrhea or lives in a community where the prevalence of gonorrhea is high (see Gonorrhea section).
Urethral meatus warts cryotherapy with liquid nitrogen 4. Data are limited regarding the effectiveness and optimal dose of azithromycin for treating chlamydial infection among infants and children who weigh <45 kg.
OR surgical removal 5. An association between oral erythromycin and azithromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported among infants aged <6 weeks. Infants treated with either of these
antimicrobials should be followed for IHPS signs and symptoms.
Vaginal warts,14 Cervical warts,15 cryotherapy with liquid nitrogen 6. For persons weighing ≥150 kg, 1 gm ceftriaxone should be administered.
Intra-anal warts16 OR surgical removal 7. Treatment can be extended if healing is incomplete after 10 days of therapy.
OR TCA or BCA 80%–90% solution 8. Acyclovir 200 mg orally five times/day is also effective but is not recommended because of the frequency of dosing.
9. Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens for persons who have frequent recurrences (i.e., ≥10 episodes/year).
Gonococcal Infections 10. Acyclovir 400 mg orally three times/day is also effective but is not recommended because of frequency of dosing.
Uncomplicated infections of the ceftriaxone 500 mg IM in a single dose17 If cephalosporin allergy: 11. Treatment recommended starting at 36 weeks’ gestation. (Source: American College of Obstetricians and Gynecologists. Clinical management guidelines for obstetrician-gynecologists.
cervix, urethra, and rectum: adults gentamicin 240 mg IM in a single dose PLUS Management of herpes in pregnancy. ACOG Practice Bulletin No. 82. Obstet Gynecol 2007;109:1489–98.)
and adolescents <150 kg6 azithromycin 2 gm orally in a single dose 12. Persons with external anal or peri-anal warts might also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination,
standard anoscopy, or high-resolution anoscopy.
If ceftriaxone administration is not available or
13. Might weaken condoms and vaginal diaphragms.
not feasible:
cefixime 800 mg orally in a single dose17 14. The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation.
15. Management of cervical warts should include consultation with a specialist. For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade squamous intraepithelial
Uncomplicated infection of the pharynx: ceftriaxone 500 mg IM in a single dose17 lesion should be performed before treatment is initiated.
adults and adolescents <150 kg6 16. Management of intra-anal warts should include consultation with a specialist.
17. If chlamydial infection has not been excluded, treat for chlamydia with doxycycline 100 mg orally two times/day for 7 days (if pregnant, treat with azithromycin 1 gm orally in a single dose).
Pregnancy ceftriaxone 500 mg IM in a single dose17
18. Providers should consider one-time lavage of the infected eye with saline solution.
Conjunctivitis ceftriaxone 1 gm IM in a single dose 18 19. When treating for the arthritis-dermatitis syndrome, the provider can switch to an oral agent guided by antimicrobial susceptibility testing (AST) 24–48 hours after substantial clinical improvement,
for a total treatment course of at least 7 days.
Disseminated gonococcal infections (DGI)19 ceftriaxone 1 gm IM or by IV every 24 hours17 cefotaxime 1 gm by IV every 8 hours 20. Because this regimen has not been validated rigorously, a test-of-cure with Chlamydia trachomatis nucleic acid amplification test (NAAT) 4 weeks after completion of treatment can be considered.
OR ceftizoxime 1 gm every 8 hours 21. Infants and young children (aged <5 years) should be treated with permethrin.
22. Oral ivermectin has limited ovicidal activity; a second dose is required for cure.
Uncomplicated gonococcal vulvovaginitis, ceftriaxone 25–50 mg/kg body weight by IV or 23. Infants and children aged <10 years should not be treated with lindane.
cervicitis, urethritis, pharyngitis, or IM in a single dose, not to exceed 250 mg IM
24. The complete list of recommendations on treating syphilis among people with HIV infection and pregnant women, as well as discussion of alternative therapy in people with penicillin allergy, can be
proctitis: infants and children ≤45 kg found in Sexually Transmitted Infections Treatment Guidelines, 2021.
Uncomplicated gonococcal vulvovaginitis, Treat with the regimen recommended for adults 25. For management of persistent or recurrent infection, refer to Sexually Transmitted Infections Treatment Guidelines, 2021.
cervicitis, urethritis, pharyngitis, or (see above) Accessible version: https://www.cdc.gov/std/treatment-guidelines/default.htm
proctitis: children >45 kg
Ocular prophylaxis in neonates erythromycin (0.5%) ophthalmic ointment in each
eye in a single application at birth
Ophthalmia in neonates and infants ceftriaxone 25–50 mg/kg body weight by IV or For neonates unable to receive ceftriaxone due to
IM in a single dose, not to exceed 250 mg simultaneous administration of intravenous calcium:
cefotaxime 100 mg/kg body weight by IV or IM as a
single dose

PubNo. 222107
CS325034-A

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