STI — Sexually transmitted infections

Originally published on January 15, 2021. Last updated on August 18, 2022.

Bacterial vaginosis

• Metronidazole 500 mg orally 2x/day for 7 days OR
• Metronidazole vaginal gel 0.75%, one 5 g applicator intravaginally 1x/day for 5 days OR
• Metronidazole vaginal gel 1.3%, one 5 g applicator intravaginally at bedtime for 1 day OR
• Clindamycin cream 2%, one 5 g applicator intravaginally at bedtime for 7 days.

OTC vaginal pH tests are available - abnormal result is pH >4.5.

Chlamydia

If confirmed positive OR exposure to person with Chlamydia:

• Doxycycline 100 mg orally 2x/day for 7 days OR
• Azithromycin 1 gram orally in a single dose.

Quest lab test for testing before treatment, 3 months follow-up after treatment, or annual screening:

• Chlamydia/N.Gonorrhoeae RNA TMA Urogenital #11363 — specify it’s a urine test.

If PID (pelvic inflammatory disease): refer for in-person IV/IM treatment.

Gonorrhea

If confirmed positive OR exposure to person with Gonorrhea:

• Ceftriaxone IM is the treatment of choice:
  • If cephalosporin allergy: refer for gentamicin IM treatment.
  • If chlamydia is not excluded, also add doxycycline 100 mg orally 2x/day for 7 days.
  • Cefixime 800 mg orally in a single dose is an alternative treatment.

Quest lab test for testing before treatment, three months follow-up after treatment, or annual screening:

• Chlamydia/N.Gonorrhoeae RNA TMA Urogenital #11363 — specify it’s a urine test.

If PID (pelvic inflammatory disease): refer for in-person IV/IM treatment.

Epididymitis (acute)

If gonorrhea or chlamydia cannot be excluded: refer for Ceftriaxone IM treatment.

Quest lab urine test to check for gonorrhea or chlamydia:

• Chlamydia/N.Gonorrhoeae RNA TMA Urogenital #11363 — specify it’s a urine test.
• If caused by enteric organisms such as via anal sex, without gonorrhea or chlamydia:
  • Levofloxacin 500 mg orally 1x/day for 10 days.

Genital herpes

If initial outbreak:

• Acyclovir 400 mg 3x/day for 10 days OR
• Valacyclovir 1 g orally 2x/day for 10 days OR
• Famciclovir 250 mg orally 3x/day for 10 days.

If secondary outbreak:

• Acyclovir 800mg orally 2x/day for 5 days OR
• Valacyclovir 500 mg orally 2x/day for 3 days OR
• Famciclovir 125 mg orally 2x/day for 5 days.

If uncertain herpes status, Quest lab blood test can help:

• Herpes simplex 1 and 2, IgG Type-Specific antibodies #6447.

Genital warts

Human Papilloma Virus (HPV) vaccine: most people should have been vaccinated.

• Gardasil-9 shots: refer to CVS, Walgreens, or patient’s in-person PCP or urgent care center for vaccination.

If newly diagnosed or patient is unskilled with self-applied topicals: refer for in-person treatment.

If patient is skilled in patient-applied topicals, may consider a refill.

• Use caution when treating genital warts over telemedicine, due to drug side effects
  • Sinecatechins 15% ointment
  • Podofilox 0.5% solution or gel OR
  • Imiquimod 3.75% or 5% cream OR

HIV / AIDS

A brief temporary refill is available from HealthTap's acute care clinic, but not initiation of therapy.

• Drugs chart: https://www.positivelyaware.com/sites/default/files/HIV%20Drug%20Chart%202020%20%28rev%202020-03-03%29.pdf

Quest lab blood test for HIV screening or diagnosis:

• HIV-1-2 Antigen and Antibodies, Fourth Generation, with Reflexes #91431.

PrEP (pre-exposure prophylaxis): Patient shall return to in-person PrEP program.

• A brief temporary refill is available from HealthTap's acute care clinic, but not initiation of therapy.
• Truvada — emtricitabine 200 mg with tenofovir disoproxil fumarate 300 mg, orally 1x/day OR
• Descovy — emtricitabine 200 mg with tenofovir alafenamide 25 mg, orally 1x/day.

PEP (post-exposure prophylaxis): refer for in-person PEP program.

• PEP care is not available from HealthTap’s acute care clinic.

Lymphogranuloma venereum

• Doxycycline 100 mg orally 2x/day for 21 days OR
• Erythromycin base 500 mg orally 4x/day for 21 days

If needing to identify LGV syndrome caused by Chlamydia trachomatis, consider Quest lab blood test:

• Lymphogranuloma Venereum (LGV) Differentiation Antibody Panel, MIF #19553.

Nongonococcal Urethritis

• Doxycycline 100mg orally 2x/day for 7 days OR
• Azithromycin 1 g in a single dose

Quest lab urine test for nongonococcal urethritis:

• SureSwab Mycoplasma/Ureaplasma Panel, Real-time PCR #91477 — specify it’s a urine test.

Trichomoniasis

In women:

• Metronidazole 500 mg orally 2x/day for 7 days OR
• Tinidazole 2 g orally in a single dose.

In men:

• Metronidazole 2 g orally in a single dose OR
• Tinidazole 2 g orally in a single dose.

Quest lab urine tests for trichomonas:

• Men: Trichomonas vaginalis RNA TMA #90801 — specify it’s a urine test.
• Women: SureSwab Trichomonas vaginalis RNA TMA #19550 — specify it’s a urine test.

Syphilis

Patient shall obtain an RPR titer at the lab on the day of treatment prior to initiating treatment.

• Penicillin IM is the treatment of choice.
• Primary, secondary, or early latent (<1 year) — alternative treatments
  • Tetracycline 500 mg orally 4x/day for 14 days,
  • Doxycycline 100 mg orally 2x/day for 14 days OR
• Latent (>1 year or of unknown duration) - alternative treatments
  • Tetracycline 500 mg orally 4x/day for 28 days,
  • Doxycycline 100 mg orally 2x/day for 28 days OR

Quest lab tests for use before treatment, during follow-up, or routine screening:

• RPR with Reflex to Titer #799.
• FTA-ABS #4112 (not for monitoring treatment).

Relevant infections that are not truly considered STIs

Acute cystitis (simple UTI)

First line antibiotics:

• Fosfomycin 3 g, orally in a single dose.
• Nitrofurantoin 100 mg, orally 2x/day for 5 days.
• Trimethoprim/sulfamethoxazole 160/800 mg, orally 2x/day for 3 days.

Second line antibiotics:

• Ciprofloxacin 250 mg, orally 2x/day for 3 days.
• Ciprofloxacin XR 500 mg, 1x/day for 3 days.
• Levofloxacin 250 mg, orally 1x/day for 3 days.
• Ofloxacin 200 mg, orally 1x/day for 3 days.

OTC bladder analgesics usually contain phenazopyridine.

OTC urine tests can test for nitrites, nitrites plus leukocytes, or nitrites plus protein.

Quest lab test for use before treatment or during follow-up:

• Urinalysis, Complete with Reflex to Culture #3020.

Hepatitis B

Everyone should have been vaccinated at birth or since then.

• Hep B shots: refer to CVS, Walgreens, or patient’s in-person PCP or urgent care center for vaccination.

If uncertain hepatitis B status, Quest lab blood tests can help:

• Hep B surface antibody quantitative #8475.
• Hep B core antibody total #501.
• Hep B surface antigen qualitative #498.

Lice

• Permethrin 1% lotion or cream rinse, apply to affected areas, wash off after 10 minutes, repeat one time in 10 days OR
• Pyrethrins piperonyl butoxide shampoo, apply to affected areas, wash off after 10 minutes, repeat one time in 10 days OR
• Ivermectin 250 µg/kg orally in a single dose, repeat one time in 2 weeks.
• Add topical anti-itch or oral antihistamine medication as needed.

If needing to identify an unknown arthropod (tick, louse, etc.), Quest lab can help:

• Tick and other arthropods ID, #3946 — keep bug in 70% alcohol awaiting a Quest test container.

Mono (infectious mononucleosis)

Treatment is symptomatic and includes OTC analgesics and antipyretics.

Corticosteroids are sometimes used for 3–7 days for markedly enlarged tonsils.

Patients with mono may have strep throat concurrently.

Quest lab blood tests that may be useful:

• Epstein-Barr Virus Antibody Panel (VCA-IgM, VCA-IgG, EBNA-IgG) #6421.
• Epstein-Barr Virus Early Antigen D Antibody (EA-D IgG) #15447.
• CBC with Differential #6399.
• Comprehensive Metabolic Panel #10231.

Scabies

• Permethrin 5% cream, apply to all areas of body from neck down, wash off after 8–14 hours OR
• Ivermectin 200 µg/kg orally in a single dose, repeat one time in 2 weeks.
• Add anti-itch topical or antihistamine oral medication as needed.

Vulvovaginal candidiasis

• OTC regimens: clotrimazole cream, miconazole cream or suppository, tioconazole ointment https://www.cdc.gov/std/treatment-guidelines/candidiasis.htm
• Prescription regimens:
  • Fluconazole 150 mg, orally in a single dose.
  • Terconazole 80 mg suppository, intravaginally 1x/day for 3 days.
  • Terconazole 0.8% cream, 5 g intravaginally 1x/day for 3 days.
  • Terconazole 0.4% cream, 5 g intravaginally 1x/day for 7 days.
  • Butoconazole 2% cream, 5 g intravaginally in a single application.
• Recurrent or persistent infection even after a longer duration of the above regimens: refer for in-person care.

Sources:

• CDC 2021 STI Treatment Guidelines - https://www.cdc.gov/std/treatment-guidelines/toc.htm
• CDC 2020 Gonococcal Update - https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm?s_cid=mm6950a6_w
• Quest Test Directory - https://testdirectory.questdiagnostics.com/test/home
• Positively Aware 2020 HIV Drug Chart - https://www.positivelyaware.com/sites/default/files/HIV%20Drug%20Chart%202020%20%28rev%202020-03-03%29.pdf
• Diagnosis and Treatment of Acute Uncomplicated Cystitis - https://www.aafp.org/afp/2011/1001/p771.html