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This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Chlamydial Infections
     
     Chlamydial genital infection is common among adolescents and
young adults in the United States. Asymptomatic infection is common
among both men and women. Testing sexually active adolescent girls
for chlamydial infection should be routine during gynecologic
examination, even if symptoms are not present. Screening of young
adult women 20-24 years of age also is suggested, particularly for
those who do not consistently use barrier contraceptives and who
have new or multiple partners. Periodic surveys of chlamydial
prevalence among these groups should be conducted to confirm the
validity of using these recommendations in specific clinical
settings.

Chlamydial Infections Among Adolescents and Adults
     
     The following recommended treatment regimens or the
alternative regimens relieve symptoms and cure infection. Among
women, several important sequelae may result from C. trachomatis
infection, the most serious among them being PID, ectopic
pregnancy, and infertility. Some women with apparently
uncomplicated cervical infection already have subclinical upper
reproductive tract infection. Treatment of cervical infection is
believed to reduce the likelihood of sequelae, although few studies
have demonstrated that antimicrobial therapy reduces the risk of
subsequent ascending infections or decreases the incidence of
long-term complications of tubal infertility and ectopic pregnancy.

     Treatment of infected patients prevents transmission to sex
partners, and for infected pregnant women may prevent transmission
of C. trachomatis to infants during birth. Treatment of sex
partners will help to prevent re-infection of the index patient and
infection of other partners.

     Because of the high prevalence of coinfection with C.
trachomatis among patients with gonococcal infection, presumptive
treatment for chlamydia of patients being treated for gonorrhea is
appropriate, particularly if no diagnostic test for C. trachomatis
infection will be performed (see Gonococcal Infections).

Recommended Regimens -
     Doxycycline 100 mg orally 2 times a day for 7 days,
                       or
     Azithromycin 1 g orally in a single dose.

Alternative Regimens -
     Ofloxacin 300 mg orally 2 times a day for 7 days
                       or
     Erythromycin base 500 mg orally 4 times a day for 7 days
                       or
     Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7
     days
                       or
     Sulfisoxazole 500 mg orally 4 times a day for 10 days
     (inferior efficacy to other regimens).

     Doxycycline and azithromycin appear similar in efficacy and
toxicity; however, the safety and efficacy of azithromycin for
persons less than or equal to 15 years of age have not been
established. Doxycycline has a longer history of extensive use,
safety, efficacy, and the advantage of low cost. Azithromycin has
the advantage of single-dose administration. Ofloxacin is similar
in efficacy to doxycycline and azithromycin, but is more expensive
than doxycycline, cannot be used during pregnancy or with persons
less than or equal to 17 years of age, and offers no advantage in
dosing. Ofloxacin is the only quinolone with proven efficacy
against chlamydial infection. Sulfisoxazole is the least desirable
treatment because of inferior efficacy.

Follow-Up -
     Patients do not need to be retested for chlamydia after
completing treatment with doxycycline or azithromycin unless
symptoms persist or re-infection is suspected. Retesting may be
considered 3 weeks after completion of treatment with erythromycin,
sulfisoxazole, or amoxicillin. This is usually unnecessary if the
patient was treated with doxycycline, azithromycin, or ofloxacin.
The validity of chlamydial culture testing performed at less than
3 weeks following completion of therapy among patients failing
therapy has not been established. False-negative results may occur
because of small numbers of chlamydial organisms. In addition,
nonculture tests conducted at less than 3 weeks following
completion of therapy for patients successfully treated may
sometimes be false-positive because of the continued excretion of
dead organisms.

     Some studies have demonstrated high rates of infection among
women retested several months following treatment, presumably
because of reinfection. Rescreening women several months following
treatment may be an effective strategy for detecting further
morbidity in some populations.

Management of Sex Partners -
     Patients should be instructed to refer their sex partners for
evaluation and treatment. Because exposure intervals have received
limited evaluation, the following recommendations are somewhat
arbitrary. Sex partners of symptomatic patients with C. trachomatis
should be evaluated and treated for chlamydia if their last sexual
contact with the index patient was within 30 days of onset of the
index patient's symptoms. If the index patient is asymptomatic, sex
partners whose last sexual contact with the index patient was
within 60 days of diagnosis should be evaluated and treated.
Health-care providers should treat the last sex partner even if
last sexual intercourse took place before the foregoing time
intervals.

     Patients should be instructed to avoid sex until they and
their partners are cured. In the absence of microbiologic
test-of-cure, this means until therapy is completed and patient and
partner(s) are without symptoms.

Special Considerations -

Pregnancy -
     Doxycycline and ofloxacin are contraindicated for pregnant
women, and sulfisoxazole is contraindicated for women during
pregnancy near-term and for women who are nursing. The safety and
efficacy of azithromycin among pregnant and lactating women have
not been established. Repeat testing, preferably by culture, after
completing therapy with the following regimens is recommended
because there are few data regarding the effectiveness of these
regimens, and the frequent gastrointestinal side effects of
erythromycin may discourage a patient from complying with the
prescribed treatment.

Recommended Regimen for Pregnant Women -
     Erythromycin base 500 mg orally 4 times a day for 7 days.

Alternative Regimens for Pregnant Women -
     Erythromycin base 250 mg orally 4 times a day for 14 days
                            or
     Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7
     days
                            or
     Erythromycin ethylsuccinate 400 mg orally 4 times a day for 14
     days
                            or
     If erythromycin cannot be tolerated:
     Amoxicillin 500 mg orally 3 times a day for 7-10 days.

NOTE: Erythromycin estolate is contraindicated during
pregnancy because of drug-related hepatotoxicity. Few data exist
concerning the efficacy of amoxicillin.

HIV Infection -
     Persons with HIV infection and chlamydial infection should
receive the same treatment as patients without HIV infection.


Chlamydial Infections Among Infants
     
     Prenatal screening of pregnant women can prevent chlamydial
infection among neonates. Pregnant women less than 25 years of age
and those with new or multiple sex partners should, in particular,
be targeted for screening. Periodic surveys of chlamydial
prevalence can be conducted to confirm the validity of using these
recommendations in specific clinical settings.

     C. trachomatis infection of neonates results from perinatal
exposure to the mother's infected cervix. The prevalence of C.
trachomatis infection generally exceeds 5% among pregnant women,
regardless of race/ethnicity or socioeconomic status. Neonatal
ocular prophylaxis with silver nitrate solution or antibiotic
ointments is ineffective in preventing perinatal transmission of
chlamydial infection from mother to infant. However, ocular
prophylaxis with those agents does prevent gonococcal ophthalmia
and should be continued for that reason (see Prevention of
Ophthalmia Neonatorum).

     Initial C. trachomatis perinatal infection involves mucous
membranes of the eye, oropharynx, urogenital tract, and rectum. C.
trachomatis infection among neonates can most often be recognized
because of conjunctivitis developing 5-12 days after birth.
Chlamydia is the most frequent identifiable infectious cause of
ophthalmia neonatorum. C. trachomatis also is a common cause of
subacute, afebrile pneumonia with onset from 1 to 3 months of age.
Asymptomatic infections of the oropharynx, genital tract, and
rectum among neonates also occur.

Ophthalmia Neonatorum Caused by C. trachomatis
     A chlamydial etiology should be considered for all infants
with conjunctivitis through 30 days of age.

Diagnostic Considerations -
     Sensitive and specific methods to diagnose chlamydial
ophthalmia for the neonate include isolation by tissue culture and
nonculture tests, direct fluorescent antibody tests, and
immunoassays. Giemsa-stained smears are specific for C.
trachomatis, but are not sensitive. Specimens must contain
conjunctival cells, not exudate alone. Specimens for culture
isolation and nonculture tests should be obtained from the everted
eyelid using a dacron-tipped swab or the swab specified by the
manufacturer's test kit. A specific diagnosis of C. trachomatis
infection confirms the need for chlamydial treatment not only for
the neonate, but also for the mother and her sex partner(s). Ocular
exudate from infants being evaluated for chlamydial conjunctivitis
should also be tested for N. gonorrhoeae.

Recommended Regimen -
     Erythromycin 50 mg/kg/day orally divided into 4 doses for 10-
     14 days.

     Topical antibiotic therapy alone is inadequate for treatment
of chlamydial infection and is unnecessary when systemic treatment
is undertaken.

Follow-Up -
     The possibility of chlamydial pneumonia should be considered.
The efficacy of erythromycin treatment is approximately 80%; a
second course of therapy may be required. Follow-up of infants to
determine resolution is recommended.

Management of Mothers and Their Sex Partners -
     The mothers of infants who have chlamydial infection and the
mother's sex partners should be evaluated and treated following the
treatment recommendations for adults with chlamydial infections
(see Chlamydial Infections Among Adolescents and Adults).


Infant Pneumonia Caused by C. trachomatis
     Characteristic signs of chlamydial pneumonia among infants
include a repetitive staccato cough with tachypnea, and
hyperinflation and bilateral diffuse infiltrates on a chest
roentgenogram. Wheezing is rare, and infants are typically
afebrile. Peripheral eosinophilia, documented in a complete blood
count, is sometimes observed among infants with chlamydial
pneumonia. Because variation from this clinical presentation is
common, initial treatment and diagnostic tests should encompass C.
trachomatis for all infants 1-3 months of age who have possible
pneumonia.

Diagnostic Considerations -
     Specimens should be collected from the nasopharynx for
chlamydial testing. Tissue culture remains the definitive standard
for chlamydial pneumonia; nonculture tests can be used with the
knowledge that nonculture tests of nasopharyngeal specimens produce
lower sensitivity and specificity than nonculture tests of ocular
specimens. Tracheal aspirates and lung biopsy specimens, if
collected, should be tested for C. trachomatis.

     The microimmunofluorescence test for C. trachomatis antibody
is useful but not widely available. An acute IgM antibody titer
greater than or equal to 1:32 is strongly suggestive of C.
trachomatis pneumonia.

     Because of the delay in obtaining test results for chlamydia,
inclusion of an agent active against C. trachomatis in the
antibiotic regimen must frequently be decided on the basis of the
clinical and radiologic findings. Conducting tests for chlamydial
infection is worthwhile, not only to assist in the management of an
infant's illness, but also to determine the need for treatment of
the mother and her sex partners.

Recommended Regimen -
     Erythromycin 50 mg/kg/day orally divided into 4 doses for 10-
     14 days.

Follow-Up -
     The effectiveness of erythromycin treatment is approximately
80%; a second course of therapy may be required. Follow-up of
infants is recommended to determine that the pneumonia has
resolved. Some infants with chlamydial pneumonia have had abnormal
pulmonary function tests later in childhood.

Management of Mothers and Their Sex Partners -
     Mothers of infants who have chlamydial infection and the
mother's sex partners should be evaluated and treated according to
the recommended treatment of adults with chlamydial infections (see
Chlamydial Infections Among Adolescents and Adults).

Infants Born to Mothers Who Have Chlamydial Infection
     Infants born to mothers who have untreated chlamydia are at
high risk for infection and should be evaluated and treated as for
infants with ophthalmia neonatorum caused by C. trachomatis.

Chlamydial Infections Among Children
     
     Sexual abuse must be considered a cause of chlamydial
infection among preadolescent children, although perinatally
transmitted C. trachomatis infection of the nasopharynx, urogenital
tract, and rectum may persist beyond 1 year (see Sexual Assault or
Abuse of Children). Because of the potential for a criminal
investigation and legal proceedings for sexual abuse, diagnosis of
C. trachomatis among preadolescent children requires the high
specificity provided by isolation in cell culture. The cultures
should be confirmed by microscopic identification of the
characteristic intracytoplasmic inclusions, preferably by
fluorescein-conjugated monoclonal antibodies specific for C.
trachomatis.

Diagnostic Considerations -
     Nonculture chlamydia tests should not be used because of the
possibility of false-positive test results. With respiratory tract
specimens, false-positive test results can occur because of
cross-reaction of test reagents with Chlamydia pneumoniae; with
genital and anal specimens, false-positive test results occur
because of cross-reaction with fecal flora.

Recommended Regimen -
     Children who weigh less than 45 kg

        Erythromycin 50 mg/kg/day divided into four doses for 10-14
        days.

NOTE: The effectiveness of erythromycin treatment is
approximately 80%; a second course of therapy may be required.

     Children who weigh greater than or equal to 45 kg but who are
     less than 8 years of age

        Use the same treatment regimens for these children as the
        adult regimens of erythromycin (see Chlamydial Infections Among
        Adolescents and Adults).

     Children greater than or equal to 8 years of age

        Use the same treatment regimens for these children as the
        adult regimens of doxycycline or tetracycline (see Chlamydial
        Infections Among Adolescents and Adults). Adult regimens of
        azithromycin also may be considered for adolescents.

Other Management Considerations -
     See Sexual Assault or Abuse of Children.

Follow-Up -
     Follow-up cultures are necessary to ensure that treatment has
been effective.

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