Overview

In emergency department (ED) patients who clinical presentation suggests gonorrhea, specimens from
likely sites of infection should be sent to the laboratory to be cultured for N
gonorrhoeae and Chlamydia species. Nucleic acid amplification tests (NAATs) may be used in addition to
or in place of culture depending on availability and laboratory preferences. [1] The possibility of other sexually
transmitted diseases (STDs) should be evaluated.
Begin appropriate antibiotic therapy for gonorrhea as soon as possible. Chlamydial infection is found
frequently in patients with gonorrhea; thus, empiric antibiotic therapy should always provide coverage for
both infections in any patients other than newborns. Gonococcal infection in HIV-positive patients is treated
with the same regimen used for the general population.
Pain relief may be needed for patients with epididymitis, pelvic inflammatory disease, and disseminated
gonococcal infection (DGI). Aspiration of purulent joint effusions may improve the patients comfort and
recovery.
Partner diagnosis and treatment is important to prevent reinfection and complications. Counsel patients to
abstain from sexual activity until after full treatment and testing and treatment of partners is complete.
Patients should receive information and counseling to help them avoid future STDs and unwanted
pregnancies.
Social services should be consulted immediately in cases of suspected sexual assault, child abuse,
or elder abuse. Clinicians should be aware, however, that gonorrhea can be transmitted to children
nonsexually (eg, spread of infection can occur via contaminated hands of infected caregivers). [2]
For more information, see the Medscape Reference topic Gonorrhea.

Consultations
Consult a gynecologist for patients with severe pelvic inflammatory disease and for any pregnant patient
with a sexually transmitted infection (STD). Consult a pediatrician for any child with an STD.
Consult an ophthalmologist for every patient with gonococcal conjunctivitis (see image below). This disease
may progress rapidly and can cause permanent loss of vision.
Patient presented with gonococcal urethritis, which became systemically disseminated, leading to

gonococcal conjunctivitis of the right eye. Courtesy of the CDC/Joe Miller, VD

Antibiotic Treatment
Because of resistance with oral cephalosporins, only 1 regimen, dual treatment with ceftriaxone IM and
azithromycin PO, is recommended for treatment of gonorrhea in the United States. Dual therapy with
ceftriaxone and azithromycin should be administered together on the same day, preferably simultaneously
and under direct observation. In addition, persons infected with N gonorrhoeae frequently are coinfected
with C trachomatis; this finding has led to the longstanding recommendation that persons treated for
gonococcal infection also be treated with a regimen that is effective against uncomplicated genital C
trachomatis infection, further supporting the use of dual therapy that includes azithromycin. [3]
Because of the persistent increase in multidrug-resistant gonorrhea, the CDC 2015 recommendations'
preferred dual-drug regimen consists of the following:[4]

Ceftriaxone 250 mg IM PLUS

Azithromycin 1 g PO
The 250-mg IM dose of ceftriaxone is recommended over the 125-mg dose, given concern for resistance,
prior lower-dose ceftriaxone dose failures, and seemingly improved efficacy in pharyngeal infections.
Ceftriaxone is safe and effective in pregnant women and probably destroys incubating syphilis. Its major
drawback is the necessity for IM administration.
Since 2007, the Centers for Disease Control and Prevention (CDC) has not recommended fluoroquinolone
antibiotics for the treatment of gonorrhea in the United States because of bacterial resistance.
In August 2012, the CDC announced changes to 2010 sexually transmitted disease guidelines for
gonorrhea treatment. The Gonococcal Isolate Surveillance Project (GISP) described a decline in cefixime
susceptibility among urethral N gonorrhoeaeisolates in the United States during 2006-2011. Because of

cefiximes lower susceptibility, new guidelines were issued that no longer recommend oral cephalosporins
for first-line gonococcal infection treatment. [5]

Alternate treatment options

If ceftriaxone is unavailable, patients can be given a single dose of cefixime 400 mg PO plus a single dose
of azithromycin 1 g PO.
If cephalosporin allergic, consider alternant dual therapy with single doses of gemifloxacin PO 320 mg plus
azithromycin 2 g PO, or gentamicin 240 mg IM plus azithromycin 2 g PO.
Another alternative regimen for patients intolerant of cephalosporins is spectinomycin (2 g IM).
Spectinomycin may be costly and is currently unavailable in the United States.
If azithromycin allergic, doxycycline (100 mg PO BID for 7 days) can be used in place of azithromycin as an
alternative second antimicrobial when used in combination with ceftriaxone (preferably) or cefixime.

Drug resistance
Although cephalosporins remain an effective treatment for gonococcal infections, the CDC has reported
that resistance to cefixime increased from 0.2% in 2000 to 1.4% in 2010 and back down to 0.4% in 2013,
and resistance to ceftriaxone increased from less than 0.1% to 0.4% in 2011 and back down to 0.05% in
2013.[4]However, the reported rates of resistance to ceftriaxone have been much higher in countries such as
Japan, Spain, and France.[4] Oral cephalosporins are no longer recommended as first-line treatment for
gonorrhea because of increasing resistance. Additionally, a high prevalence of tetracycline resistance
among GISP isolates was observed, particularly among patients with elevated MICs to cefixime. [5]

Spectinomycin
Spectinomycin (Trobicin) is indicated for patients with beta-lactam intolerance. It is a second-line choice
due to poor efficacy in pharyngitis. This drug is currently unavailable in the United States.

Gentamicin
A review of the literature identified trials using single-dose gentamicin, an aminoglycoside, in the treatment
of uncomplicated gonococcal infections in patients older than 16 years owing to the increase in antibiotic
resistance. Although the primary outcome was the microbiological cure of N gonorrhoeae infection, further
randomized trials are indicated.[6]
For more information see, CDC Sexually Transmitted Diseases Treatment Guidelines, 2015.

Hospital Admission
Hospitalization is recommended for initial treatment of disseminated gonococcal infection (especially for
patients who are unlikely to return for follow-up doses of antibiotics), purulent joint infections, meningitis,
and endocarditis.[4]
Hospitalization is recommended for initial treatment of pelvic inflammatory disease (PID) cases in the
presence of the following factors:

Tubo-ovarian abscess
Pregnancy
Failure of outpatient treatment
Severe symptoms, such as severe pain, high fever, or persistent nausea and vomiting
Immunodeficiency
Gonococcal conjunctivitis (see image below)
Uncertain diagnosis, with any possibility of ectopic pregnancy or appendicitis masquerading as
PID

Abdominal peritonitis or perihepatitis

Patient presented with gonococcal

urethritis, which became systemically disseminated, leading to gonococcal conjunctivitis of the right eye. Courtesy of
the CDC/Joe Miller, VD

Further Outpatient Care

Patients with disseminated gonococcal infection or pelvic inflammatory disease who are treated on an
outpatient basis must receive follow-up care within 72 hours. Early follow-up care and culture with antibiotic
sensitivities is indicated for patients with unresolved or recurrent symptoms.
Follow-up for test of cure is indicated for all pharyngitis cases treated with spectinomycin, as its efficacy is
less than 60%.
Recurrent symptoms may result from re-infection rather than treatment failure. However, if treatment failure
is suspected, culture of isolates is recommended. [4]
Instruct patients with uncomplicated cases to follow up with a primary care or public health provider to
reduce the risk of future infection.

Deterrence/Prevention
All patients with gonococcal infection should refer all their sex partners (whether symptomatic or
asymptomatic) for evaluation and treatment.
All infants born to mothers with untreated gonococcal infection should be treated prophylactically with a
single dose of ceftriaxone 25-50 mg/kg IV or IM, not to exceed 125 mg. All neonates should undergo
prophylaxis for ophthalmia neonatorum with silver nitrate (1%) aqueous solution OU once
or erythromycin(0.5%) ophthalmic ointment OU once.
Condoms offer partial protection against gonococcal infection and should be recommended. [7]

Approach Considerations
Trichomoniasis is not a nationally mandated reported sexually transmitted disease, although other sexually
transmitted disease reporting requirements vary by state. [6]Evaluation is typically conducted in the
outpatient setting.
Treatment should be instituted immediately and, whenever possible, in conjunction with all sexual partners.
[6]
Patient-delivered partner therapy is a safe and effective means of treating the sexual partners of patients
diagnosed with trichomoniasis.[83]Both patient and partner should abstain from sex until pharmacological
treatment has been completed and they have no symptoms.
Patients undergoing pharmacotherapy should be advised to avoid alcohol consumption during the course
of treatment and for an appropriate amount of time after the completion of their medication.

Because trichomoniasis is an infection of multiple sites (eg, vaginal epithelium, Skene glands, Bartholin
glands, and urethra), systemic treatment is needed. Because of the high rate of coinfection with other
sexually transmitted infections (STIs), the healthcare provider should consider empiric treatment
of gonorrhea andchlamydia. Patients should also be offered counseling and testing for HIV.
In clinical practice, repeat testing is rarely performed unless symptoms do not improve with drug treatment.
However, the CDC recommends rescreening at 3 months post therapy for sexually active women, as they
have a high rate of reinfection.[81] Currently, no data are available on rescreening men.
Inpatient therapy is usually not required but may be indicated when resistance is present and intravenous
(IV) therapy is indicated. For patients in whom treatment fails and in whom reinfection is ruled out,
consultation with experts from the CDC may be advisable (770-488-4115). Consultation with an infectious
diseases specialist, a gynecologist, or both may be helpful.

HIV
Patients who are HIV positive should generally receive the same treatment as those who are HIV negative.
The notable exception is that the multiday treatment drug regimen (metronidazole 500 mg twice daily for 7
days) was recently shown to be more effective in treating T vaginalis in HIV-positive women than a singledose treatment (metronidazole 2 g single dose). [84] Thus, the CDC recommends considering the multidose
treatment in HIV-positive women with trichomoniasis.[9]
The CDC recommends rescreening at 3 months after the completion of therapy for HIV-positive women
due to the likelihood of recurrent or persistent infection and the increased risk of HIV transmission with
comorbid trichomonal infection.[9, 38, 85, 86]

Pregnancy
Failure to treat trichomoniasis during pregnancy may result in preterm birth, low birth weight, and other
adverse fetal outcomes.[1] Accordingly, pregnant women should seek prompt treatment during pregnancy.
Routine screening for trichomoniasis in asymptomatic pregnant women is not currently recommended. [6]
The CDC recommends that infected symptomatic pregnant women be considered for treatment, as
metronidazole has not been definitively shown to be harmful during pregnancy and may prevent
transmission to the newborn.[87, 88] Infected asymptomatic pregnant women may wish to defer treatment to
after 37 weeks gestation.[9] Pregnant women should be treated with 2 g metronidazole in a single dose,
according to the CDC. The safety of tinidazole in pregnancy is not known.
Transmission of trichomoniasis from an infected mother during delivery is rare, but respiratory or genital
infection of the newborn is possible.[9] An infected infant may present with fever.
In breastfeeding women, the CDC recommends stopping breastfeeding during the course of metronidazole
treatment and for 12-24 hours after the last day. For treatment with tinidazole, the CDC recommends
stopping breastfeeding for the course of treatment and for 3 days after the last dose. [9]

Pediatric populations
T vaginalis infection in a pediatric patient may suggest child abuse. Young girls may present with vaginal
discharge.

History

C trachomatis is a sexually transmitted microorganism that is responsible for a wide spectrum of diseases,
including cervicitis, salpingitis, endometritis, urethritis, epididymitis, conjunctivitis, and neonatal pneumonia.
In chlamydial infection, unlike gonorrhea, most men and women who are infected are asymptomatic; thus,
diagnosis is delayed until a positive screening result is obtained or a symptomatic partner discovered.
Chlamydia screening programs have been demonstrated to reduce the rates of PID in women. [26, 27]
The US Preventive Services Task Force has made the following recommendations with regard to screening
women for chlamydial infection[6, 7] :

Screen for chlamydial infection in all sexually active nonpregnant young women aged 24 years or
younger and for older nonpregnant women who are at increased risk

Screen for chlamydial infection in all pregnant women aged 24 years or younger and in older
pregnant women who are at increased risk

Do not routinely screen for chlamydial infection in women aged 25 years or older, regardless of
whether they are pregnant, if they are not at increased risk
Chlamydia has been isolated in approximately 40-60% of males presenting with nongonococcal urethritis.
Epidemiologic studies indicate a high prevalence of asymptomatic men who act as a reservoir for
chlamydial infections. A 1996 study by Quinn et al (1996) estimated that the transmission probability was
68% in both men and women.[28]
Although genitourinary carriage of chlamydiae is often asymptomatic, certain manifestations of disease are
commonly seen, including local mucosal inflammation associated with a discharge, urethritis in males, and
urethritis/vaginitis/cervicitis in females.
The following may be noted in all patients with chlamydial infection:

Possible history of sexually transmitted diseases (STDs)

Dysuria
Yellow mucopurulent discharge from the urethra
The following may be noted in females with chlamydial infection:

Vaginal discharge
Abnormal vaginal bleeding (postcoital or unrelated to menses)
Dyspareunia
History of sexual activity without condoms or condom failure
Proctitis, rectal discharge, or both in cases of receptive anal intercourse
Slow onset and progression of lower abdominal pain
Fever (in pelvic inflammatory disease [PID])
No symptoms (in 80%)
The following may be noted in males with chlamydial infection:

Urethral discharge
History of sexual activity without condoms or condom failure
Proctitis, rectal discharge, or both in cases of receptive anal intercourse
Unilateral pain and swelling of the scrotum
Fever
No symptoms (in 50%)
The following may be noted in newborns with chlamydial infection:

Symptoms of pneumonia (if present), beginning at 1-3 months

Symptoms of conjunctivitis (if present), developing at 1-2 weeks
In pneumonia, cough and fever (though the classic description is afebrile)
In conjunctivitis, eye discharge, eye swelling, or both
The following may be noted in mothers diagnosed with or suspected of having a chlamydial infection during
pregnancy:

Injected conjunctivae
Mucopurulent discharge from the eyes
Bilateral involvement of the eyes

Physical Examination
Signs of chlamydial infection in women may include the following:

Cervical friability (easy bleeding on manipulation)

Intermenstrual bleeding
Mucopurulent cervical or vaginal discharge
Urethral discharge (usually thin and mucoid)
Mucopurulent rectal discharge (from anal intercourse)
Cervical motion tenderness
Dysuria
Adnexal fullness or tenderness, associated with progression to PID
Lower abdomen tender to palpation
Upper right quadrant abdominal tenderness (Fitz-Hugh-Curtis syndrome)
Signs of chlamydial infection in men may include the following:

Mucopurulent urethral discharge (elicited by having the examiner or patient milk the urethra)
Mucopurulent rectal discharge (from anal intercourse)
Urinary frequency or urgency
Dysuria
Scrotal pain, tenderness, or swelling (sometimes unilateral)
Perineal fullness (related to prostatitis)
Signs of chlamydial infection in newborns may include the following:

Fever, cough, wheezing, and crackles (in pneumonia)

Conjunctival erythema, mucoid discharge, or periorbital swelling (in conjunctivitis), often bilateral
Signs of lymphogranuloma venereum (LGV) may include the following:

Localized inguinal adenopathy or buboes

Genital ulceration
Groove sign Separation of the inguinal and femoral lymph nodes by the inguinal ligament (seen
in 15-20% of patients)

Complications
Chlamydial infection is one of the leading causes of infertility in women. It is also a leading cause of PID.
PID is a serious disease that often requires hospitalization for inpatient care, including intravenous (IV)
antibiotics, testing to rule out tubo-ovarian abscess, and intensive counseling on the complications of
recurrent infections.
The risk of ectopic pregnancy in women who have had PID is 7-10 times greater than that for women
without a history of PID. In 15% of women who have contracted PID, chronic abdominal pain is a long-term
manifestation that most likely is related to pelvic adhesions in the ovaries and fallopian tubes.
Fitz-Hugh-Curtis syndrome (perihepatitis) is a rare complication of PID that is 5 times more likely to be
caused by Chlamydia than by N gonorrhoeae. It frequently presents without the typical examination
findings associated with PID (ie, the pelvic examination is normal).
Women with a chlamydial infection (especially one caused by serotype G) are at increased risk for the
development of cervical cancer; the risk is as much as 6.5 times greater than it is in women without
infection. Chlamydial infections also increase the risk of acquiring HIV infection by increasing genital
mucosal inflammation.
Pregnant women with a chlamydial infection can pass the infection on to their infants during delivery, and
this may develop into chlamydial pneumonia or chlamydial conjunctivitis. Untreated neonatal conjunctivitis
can result in blindness.
Reiter syndrome, a reactive arthritis secondary to an immune-mediated response, has been associated
with a primary chlamydial infection. It may present as asymmetric polyarthritis, urethritis, inflammatory eye
disease, mouth ulcers, circinate balanitis, and keratoderma blennorrhagica. Its etiology may not be
completely clear, but 2 strong associations are observed: Reiter syndrome usually follows an infectious
episode, and 80% of affected patients are positive for human leukocyte antigen (HLA)-B27.
Other potential complications of chlamydial infection are miscarriage, [29] preterm delivery,[30] and urethral
scarring in men.

Approach Considerations
The keys to management of chlamydial infections are (1) arriving at the correct diagnosis and (2) ensuring
that the patient complies with treatment.
Undiagnosed chlamydia can progress to pelvic inflammatory disease (PID), which may lead to relative or
absolute infertility. This may be tragic if it occurs early in life before childbearing. Diagnostically evaluate all
cases of suspected sexual abuse using chlamydial culture, not nonculture techniques.
Because of the personal nature and time-intensive diagnosis of sexually transmitted diseases (STDs),
many physicians err by presuming that symptoms of an STI are caused by a urinary tract infection (UTI);
therefore, patients often present with a history of multiple UTIs when, in fact, they may have had 1 or more
STDs.
Adolescents are at high risk for noncompliance with treatment, especially if a patient is attempting to keep
information away from parents. Single-dose, in-office treatment is increasingly being used to improve
compliance and confidentiality. Partner treatment is crucial for prevention of reinfection.
Many clinicians err on the side of caution and hospitalize patients whenever PID is a concern or
compliance with therapy is problematic. Consider PID an absolute indication for admission because of the
potential for infertility and the poor compliance of many adolescents with prolonged treatment regimens.
Begin antibiotic therapy as soon as possible. Consider compliance, cost, and potential adverse effects.
Consider treatment for possible gonorrhea coinfection. Send specimens from sites of infection to the lab for
culture. Perform a pregnancy test; this can alter antibiotic treatment and patient follow-up care.
Consult obstetrics/gynecology for any patient with severe PID and any pregnant patient with chlamydial
infection. Consult ophthalmology for patients with chlamydial conjunctivitis. Provide information and
counseling to prevent future STDs, and consider referral for HIV testing. Encourage the patient to abstain
from sexual intercourse until after treatment and testing of all partners is completed.

Antibiotic Therapy
Two broad anatomical treatment categories of genital C trachomatis infection are recognized, as follows:

C trachomatis cervicitis/urethritis/epididymitis (D-K biovars): Lower genital tract or uncomplicated

C trachomatis salpingitis/endometritis (D-K biovars): Upper genital tract or complicated
Treatment of genitourinary chlamydial infection is clearly indicated when the infection is diagnosed or
suspected. Chlamydiae are susceptible to antibiotics that interfere with DNA and protein synthesis,
including tetracyclines, macrolides, and quinolones.[47] CDC recommends azithromycin and doxycycline as
first-line drugs for the treatment of chlamydial infection.[33, 40] Medical treatment with these agents is 95%
effective. Alternative agents include erythromycin, levofloxacin, and ofloxacin. [33] Rifalazil, a rifamycin that is
highly active against C trachomatis and has a long half-life, has shown promise as a single-dose treatment
for chlamydial nongonococcal urethritis and is currently being evaluated in women with uncomplicated
genital infection.[48]
For many years, standard therapy for uncomplicated genital tract infection has been doxycycline 100 mg
orally twice daily for 7 days. However, azithromycin given as a single 1-g dose is as effective as a 7-day
course of doxycycline.[49, 50] The FDA released a warning on March 12, 2013, that azithromycin can cause
potentially life-threatening arrhythmias. Patients with known QT-interval abnormalities or who take drugs to
treat arrhythmias should receive doxycycline instead. Test of cure after treatment is unnecessary, but
retesting is recommended at 3 months after therapy because of the high risk of reinfection in women and
men.[40]
Azithromycin has also been shown to be effective in the treatment of nongonococcal urethritis, whether
related to C trachomatis, genital mycoplasmas, or other organisms.[51] Ofloxacin 300 mg twice daily for 7
days and levofloxacin 500 mg once daily for 7 days are included as alternative agents in the 2015 CDC
treatment guidelines[33] Azithromycin is now available as a generic drug, and its cost in the authors STD
clinic (Indianapolis, IN) of about 60 cents per 1-g does is comparable to a 7-day course of doxycycline. A
once-daily preparation of doxycycline (WC2031) was shown to be noninferior to the standard twice-daily
regimen in both men and women and has been FDA approved for treatment of uncomplicated chlamydial
genital infection in men and women.[52]

Lower genital infections caused by Chlamydia can be treated with single-dose, directly observed treatment.
This practice is encouraged when possible to reduce noncompliance due to cost, confidentiality issues,
motivational issues, and maturity issues.
Upper genital tract disease must be vigorously sought out because potential complications are serious,
especially in adolescents. With the advent of newer, more sensitive DNA and antigen detection kits that use
urine specimens instead of a pelvic examination, the potential to presume a chlamydial infection in
uncomplicated lower tract disease is concerning.
Inadequately treated PID can lead to sepsis, infertility, and chronic pelvic pain. Many practitioners strongly
advise admission for inpatient therapy and monitoring of response whenever PID is suspected because of
a tendency of adolescents to minimize or ignore symptoms and eschew follow-up.
The management of PID, even when gonorrhea is present, should always include therapy directed
against C trachomatis, as well as N gonorrhoeae and anaerobic bacteria. Randomized trials have shown
that parenteral and oral regimens have similar clinical efficacy for mild to moderate PID, although
doxycycline is given orally if possible because intravenous infusion is painful. [40]
With inpatient regimens for PID, evidence of significant clinical improvement and confidence in completion
of medical therapy must be present before the patient is discharged. Recommended parenteral regimens
include cefoxitin or cefotetan along with a 14-day course of doxycycline or, alternatively, clindamycin plus
gentamicin or ampicillin-sulbactam plus doxycycline. [40]
Outpatient regimens for PID include initial single-dose intramuscular therapy with a second- or thirdgeneration cephalosporin plus 14 days of doxycycline, with or without metronidazole 500 mg twice daily for
14 days. Because of the emergence of quinolone-resistant N gonorrhoeae, regimens that include a
quinolone are no longer recommended for PID treatment.
Chlamydial conjunctivitis and pneumonia are usually treated for a total of 14 days.
Treatment also is indicated for sexual partners of the index case if the time of the last sexual encounter was
within 60 days of onset, and it should be considered for longer periods for the last sexual partner.
Treatment of chlamydial infection is indicated for patients being treated for gonorrhea, as well.
In June 2015, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for
gonococcal infection and associated conditions. Fluoroquinolone antibiotics remain not recommended to
treat gonorrhea in the United States. The recommendation was based on analysis of new data from the
CDCs Gonococcal Isolate Surveillance Project (GISP), which showed that the percentage of
fluoroquinolone-resistant gonorrhea cases in heterosexual men 6.7% in 2007, an 11-fold increase from
0.6% in 2001.[53, 40]
Pregnancy treatment considerations
Guidelines from the CDC recommend azithromycin 1 g orally as a single dose. Alternatives include
amoxicillin 500 mg orally three times a day for 7 days as the preferred drug regimens for treating
chlamydial infections in pregnancy,[54, 55] with erythromycin as another alternative.[40, 56, 57] Doxycycline,
ofloxacin, and levofloxacin are contraindicated in pregnancy. Clindamycin is only partially effective in
eradicating C trachomatis in men with nongonococcal urethritis, but it appears to be as efficacious as
erythromycin in pregnant and nonpregnant women with C trachomatis infection.[58, 59, 60] Test-of-cure to
document chlamydial eradication (preferably via NAAT) 3-4 weeks after therapy completion is
recommended.

Posttherapy care
Follow-up culture is not recommended after azithromycin or doxycycline therapy, but it may be considered
in pregnancy after erythromycin or amoxicillin therapy. Nonculture tests should be avoided in this
circumstance to avoid positive results from nonviable organisms.
Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until the end of a
longer regimen. Patients also should refrain from sexual intercourse until all of their sex partners have been
cured.

Prevention
Individuals who are sexually active should be aware of the risks posed not only of genitourinary chlamydia
infection but also by the whole gamut of STDs. Patients should be tested for other STDs or referred for

other STD testing as appropriate. All sexual contacts should also be referred for testing and, if necessary,
treatment.
In addition, patients should be aware that the most effective way of avoiding infection, other than abstaining
from sexual activity, is to practice safe sex. This means using appropriate barrier protection (ie, latex
condoms) with each sexual encounter.
The American College of Obstetricians and Gynecologists (ACOG) has released guidelines on expedited
partner therapy for chlamydial and gonorrheal sexually transmitted diseases (STDs). [61, 62] While designed to
prevent reinfection with chlamydia and gonorrhea, the recommendations can also be applied to other
STDs. The ACOG recommendations include the following:

Expedited partner therapy to prevent reinfection, with legalization of expedited partner therapy
Counsel partners to undergo screening for HIV infection and other STDs
Expedited partner therapy contraindicated in cases of suspected abuse or compromised patient
safety; pretreatment evaluation for abuse potential recommended
Expedited partner therapy medications and protocols based on CDC, state, and/or local guidelines

Long-Term Monitoring
Patients with PID should be rechecked in 1-2 days to look for signs of clinical improvement. All patients
treated for chlamydial infection should receive follow-up care with a primary care provider to reduce the risk
of further infection and to screen for cervical cancer.
Test for chlamydial cure is not strictly necessary unless the patient thinks he or she may have been
reinfected. However, follow-up at 3-4 weeks to repeat the examination and test for cure is advised because
recurrent or persistent cases can lead to infertility. Retesting before 3-4 weeks may lead to a false-positive
result on nonculture tests as a result of the shedding of dead organisms.
Perform partner testing and treatment to prevent reinfection.

Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Agents used in the
management of chlamydial genitourinary infections are treated primarily by administering antibiotics.
Treatment of genitourinary chlamydial infection clearly is indicated when the infection is diagnosed or
suspected; for sexual partners of the index case; and for patients being treated for gonorrhea.

Antibiotics, Other
Class Summary
The Centers for Disease Control and Prevention (CDC) recommends azithromycin and doxycycline as firstline drugs for the treatment of chlamydial infection. Second-line drugs (eg, erythromycin, penicillins, and
sulfamethoxazole) are less effective and have more adverse effects.
View full drug information

Azithromycin (Zithromax, Zmax)

Azithromycin is a relatively new member macrolide antibiotic that possesses activity against various
different bacterial organisms. It binds to the 50S ribosomal subunit of the bacteria, thereby inhibiting
bacterial protein synthesis. Related to erythromycin, azithromycin is considered by many to be the
treatment of choice for Chlamydia trachomatis genitourinary infection because it may be administered in a
single dose, which improves adherence to treatment.
View full drug information

Doxycycline (Adoxa, Doryx, Monodox, Avidoxy, Vibramycin)

Doxycycline, a well-absorbed tetracycline derivative, is the second drug of choice for genital chlamydia
infections. It has a limited spectrum of bacterial activity but is effective in treating chlamydial infections.
Doxycycline binds to the 30S and, possibly, 50S ribosomal subunits of the bacteria, thereby inhibiting
bacterial protein synthesis.
One week of doxycycline appears to be as effective as a single dose of azithromycin for treating
genitourinary chlamydial infections. Although the course is longer than that of azithromycin, the cost is less,
and doxycycline has been used in clinical practice for a much longer time. Because of the need for
extended therapy, compliance is often poor.
View full drug information

Levofloxacin (Levaquin)
For pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.
View full drug information

Ofloxacin
Penetrates prostate well and is effective against N gonorrhea and C trachomatis.
A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.
View full drug information

Erythromycin (E.E.S., Ery-Tab, Erythrocin, EryPed, PCE)

Erythromycin is a macrolide antibiotic with a large spectrum of activity. It binds to the 50S ribosomal subunit
of the bacteria, thereby inhibiting bacterial protein synthesis. Generally, erythromycin is considered a
recommended treatment for chlamydial genitourinary infection only in pregnant women. Some recommend
it in infants as well.
View full drug information

Cefoxitin (Mefoxin)
Second-generation cephalosporin with activity against some gram-positive cocci, gram-negative rod
infections, and anaerobic bacteria. Inhibits bacterial cell wall synthesis by binding to one or more of the
penicillin-binding proteins; inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell
wall death.
Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
View full drug information

Ampicillin
Like erythromycin, ampicillin is considered a recommended treatment for genitourinary chlamydial infection
only in pregnant women. Ampicillin binds to penicillin-binding proteins, which inhibit bacterial cell wall

synthesis by inhibiting the final transpeptidation step of peptoglycan synthesis in bacterial cell wall. This in
turn causes the bacteria to lyse due to ongoing activity of cell wall autolytic enzymes.
View full drug information

Amoxicillin (Moxatag)
Because of its lower efficacy, amoxicillin is indicated only when the patient is both pregnant and
erythromycin-allergic. Amoxicillin is a penicillin antibiotic with activity against gram-positive and some gramnegative bacteria. It binds to penicillin-binding proteins, thereby inhibiting bacterial cell wall growth.
View full drug information

Cefotetan
Second-generation cephalosporin used as single-drug therapy to provide broad gram-negative coverage
and anaerobic coverage. Also provides some coverage of gram-positive bacteria. Half-life is 3.5 h. Inhibits
bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; inhibits final
transpeptidation step of peptidoglycan synthesis, resulting in cell wall death.
Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility
of causative organism.
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Clindamycin (Cleocin, CLIN Single Use)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Effective against
aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking
dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
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Gentamicin
Gentamicin is an aminoglycoside antibiotic for gram-negative coverage. It is used in combination with an
agent against gram-positive organisms and one that covers anaerobes.
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Ampicillin/sulbactam (Unasyn)
This combination of a beta-lactamase inhibitor and ampicillin interferes with bacterial cell wall synthesis
during active replication, causing bactericidal activity against susceptible organisms.
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Metronidazole (Flagyl, Flagyl ER, Metro)

Metronidazole is active against various anaerobic bacteria and protozoa. It appears to be absorbed into the
cells; the intermediate metabolized compounds that are formed bind DNA and inhibit protein synthesis,
causing cell death.