Updates on Recommendations for STI Treatments & Empiric Therapy: When to Treat and What to Treat Depending on your Patient

Updated treatment recommendations regarding the most common pathogens with increasing resistance rates of antibiotic resistance...

 Updates in STI Care

In 07/2021, the CDC released the first updates to their guidelines in 5 years on the treatment of sexually transmitted infections (STIs). These are consensus guidelines meant to provide an approach for those providers treating suspected and documented sexually transmitted infections, especially in the setting of increasing antibiotic resistance and globalization resulting in increasing prevalence of STIs previously seen mostly abroad. Although some of these guidelines have been previously stated by the CDC, this is the first comprehensive set of guidelines in the last 5 years.

Growing antibiotic resistance forces updates to recommended treatment for sexually transmitted infection

Resistance of these STIs to the effect of antibiotics has increased rapidly in recent years and has reduced treatment options. Of the 3 STIs, gonorrhoea has developed the strongest resistance to antibiotics. Strains of multidrug-resistant gonorrhoea that do not respond to any available antibiotics have already been detected. Antibiotic resistance in chlamydia and syphilis, though less common, also exists, making prevention and prompt treatment critical.

The Losing Battle Against Bacterial STDs

World Health Organization unveils new treatment guidelines to cope with antibiotic resistance.

Doxycycline vs Azithromycin: Think Twice...

When the new Centers for Disease Control and Prevention (CDC) recommendations regarding the treatment of uncomplicated gonorrhea (and indirectly chlamydia) debuted like a slice of antibiotic resistance doom, it felt like another “gift” had arrived from 2020. Intramuscular (IM) ceftriaxone dosing has increased from 250 mg to 500 mg (or 1 g for weight ≥150 kg). Empiric chlamydia coverage switched from a single dose of 1 g of azithromycin to doxycycline 100 mg PO BID for 7 days. Being deferential to CDC expertise, many providers accepted them uncritically. Compliance rates with a switch from a 1-time to a 7-day regimen are not addressed, especially worrisome for a condition that can be minimally or asymptomatic.

Expedited Partner Therapy

In cases where gonorrhea expedited partner therapy (provision of prescriptions or medications for the patient to take to his or her sex partner without the health care provider first examining the partner) is permissible by state law and the partner is unable or unlikely to seek timely treatment, the partner may be treated with a single 800 mg dose of cefixime, if a chlamydia infection in the patient has been excluded. If a chlamydia test result has not been documented, the partner may be treated with a single dose of oral cefixime 800 mg plus oral doxycycline 100 mg 2 times/day for 7 days. If adherence with multiday dosing is a considerable concern, azithromycin 1 g can be considered but has lower treatment efficacy among persons with rectal chlamydia.

Clap Back – Gonorrhea and Chlamydia Updates

New empiric treatment regimen: Ceftriaxone 500mg IM x1 + Doxycycline 100mg PO BID x7d (Remember that pregnancy and obesity (>150kg) have different recommendations).

Extra! Extra! Read all about it! 2021 Guideline Updates for Treatment of Chlamydia & Uncomplicated Gonorrhea

a single 500 mg IM dose of ceftriaxone is the new recommended regimen. For patients weighing ≥150 kg (300 lbs.), a higher dose is needed, and a single 1 gram IM dose of ceftriaxone should be administered. If ceftriaxone is not available, the alternative regimen is a single 240 mg IM dose of gentamicin plus a single 2 g oral dose of azithromycin or monotherapy of cefixime 800 mg orally in a single dose. If there is a coinfection with Chlamydia trachomatis, the recommended regimen of doxycycline 100 mg twice daily orally for 7 days should be added to the treatment plan. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.

GC and Chlamydia: Update on Testing and Treatment

For cephalosporin allergic, 2 options: – Gentamicin 240 mg IM (or 5mg/kg IM) with azithromycin 2g orally OR – Gemifloxacin 320 mg orally with azithromycin 2g orally.

No more ‘sledgehammer’: As gonorrhea grows resistant to antibiotics, researchers look to bespoke treatments

“Our ultimate goal is to have clinicians utilize a test-and-treat algorithm so that you don’t have to use these empiric therapies,” Denver said.

The Era of Cheap and Easy STD Treatment Is Over. What Went Wrong?

Gonorrhea may not seem like a big deal. Aside from HIV, sexually transmitted diseases seem like solved problems, relics of some long-ago time when sex wasn’t discussed and sexual health care was difficult to access. In fact, gonorrhea is surging back, along with its equally forgotten partner, syphilis.