Treatment
Adults and Adolescents
For uncomplicated urethral, cervical, or rectal infections in adults or adolescents, treatment with either azithromycin [Zithromax] or doxycycline [Vibramycin, others] is recommended. Patients who are unable to take these medications may take erythromycin, levofloxacin [Levaquin], or ofloxacin [generic]. Table 80.1 provides a detailed summary of specific dosages of drugs used to treat chlamydia and other STDs.
Infection in Pregnancy
Azithromycin is the preferred treatment for C. trachomatis infection. Although doxycycline and other tetracyclines are active against C. trachomatis, these drugs are contraindicated because they can damage fetal teeth and bones. If the patient cannot take azithromycin, the approved alternatives are amoxicillin, erythromycin base, or erythromycin ethylsuccinate.
Infants
About half the infants born to women with cervical C. trachomatis acquire the infection during delivery, putting them at risk for pneumonia and conjunctivitis (ophthalmia neonatorum). Pneumonia is generally not severe and lasts about 6 weeks. Conjunctivitis does not result in blindness and spontaneously resolves in 6 months. The preferred treatment for both infections is oral erythromycin base or erythromycin ethylsuccinate. Azithromycin suspension may be given as an alternative. Although topical erythromycin, tetracycline, or silver nitrate may be given to prevent conjunctivitis, these drugs are not completely effective—and they have no effect on pneumonia.
Preadolescent Children
Although infection in preadolescent children can result from perinatal transmission, sexual abuse is the more likely cause, especially in children older than 2 years. Because of the legal implications, diagnosis must be definitive. Treatment depends on the age and weight of the child. For children who weigh less than 45 kg, the preferred treatment is oral erythromycin base or erythromycin ethylsuccinate. For children who weigh 45 kg or more, but are younger than 8 years, the preferred treatment is azithromycin. For children at least 8 years old, the preferred treatments are azithromycin or doxycycline.
Lymphogranuloma Venereum
LGV is caused by a unique strain of C. trachomatis. Transmission is strictly by sexual contact. LGV is most common in tropical countries but does occur in the United States, especially in the South. Infection begins as a small erosion or papule in the genital region. From this site, the organism migrates to regional lymph nodes, causing swelling, tenderness, and blockage of lymphatic flow. Tremendous enlargement of the genitalia may result. The enlarged nodes, called buboes, may break open and drain. The treatment of choice for genital, inguinal, and anorectal LGV is doxycycline. Erythromycin base serves as an alternative for those who cannot take tetracycline antibiotics.
Gonococcal Infections
Characteristics
Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus, often referred to as the gonococcus. Gonorrhea is second only to chlamydia as our most common STD. Gonorrhea is transmitted almost exclusively by sexual contact.
The intensity of symptoms differs between men and women. In men, the main symptoms are a burning sensation during urination and a pus-like discharge from the penis. In contrast, gonorrhea in women is often asymptomatic or may present as mild cervicitis. However, serious infection of female reproductive structures (vagina, urethra, cervix, ovaries, fallopian tubes) can occur, ultimately resulting in sterility. Among people who engage in oral sex, the mouth and throat can become infected, causing sore throat and tonsillitis. Among people who engage in receptive anal sex, the rectum can become infected, causing a purulent discharge and constant urge to move the bowels (tenesmus). Bacteremia can develop in males and females, causing cutaneous lesions, arthritis, and, rarely, meningitis and endocarditis.
Treatment
Owing to antibiotic resistance, treatment of gonorrhea has changed over the years—and undoubtedly will continue to evolve. In the 1930s, virtually all strains of the gonococcus were sensitive to sulfonamides. However, within a decade, sulfonamide resistance had become common. Fortunately, by that time penicillin had become available, and the drug was active against all gonococcal strains. However, in 1976, organisms resistant to penicillin began to emerge. More recently, resistance to fluoroquinolones has become common. As a result, in 2007 the CDC recommended against using fluoroquinolones for gonorrhea, leaving cephalosporins as the preferred treatments. This recommendation was changed yet again in 2012, also triggered by antimicrobial resistance—this time to oral cephalosporins.
Urethral, Cervical, and Rectal Infection
Because of increasing resistance to cephalosporins, preferred treatment now consists of a combination of two drugs: ceftriaxone [Rocephin] intramuscular (IM) plus azithromycin. If a patient refuses IM therapy, oral (PO) cefixime can be substituted for IM ceftriaxone; however, the CDC recommends not routinely substituting this drug because resistance to cefixime has been documented and is anticipated to increase. If a patient is allergic to azithromycin, a 7-day course of doxycycline may be substituted. For patients with cephalosporin allergies, the options are not as clear. Although prescribing double the azithromycin dose as monotherapy will cure gonorrhea in most cases, the CDC does not recommend this because of treatment failures and rapid development of resistance. Although acknowledging a lack of data for recommendation, the CDC suggests substituting gemifloxacin for the cephalosporin component, despite having recommended against using quinolones to treat gonorrhea. Spectinomycin, an aminoglycoside, has also been suggested; however, it is not currently available in the United States. For additional information on this dilemma, see http://www.cdc.gov/std/tg2015/gonorrhea.htm.
Pharyngeal Infection
Gonococcal infection of the pharynx is more difficult to treat than infection of the urethra, cervix, or rectum; therefore, parenteral therapy is recommended for all patients. The preferred treatment is ceftriaxone combined with azithromycin. Azithromycin is preferred over doxycycline because patients are more likely to adhere to a single-dose regimen of azithromycin than the full-week regimen of doxycycline taken twice a day.
Conjunctivitis
Gonococcal conjunctivitis can be reliably eradicated with ceftriaxone plus azithromycin. Treatment also includes washing the infected eye with saline solution once.
Disseminated Gonococcal Infection
Disseminated gonococcal infection (DGI) occurs secondary to gonococcal bacteremia. Symptoms include petechial or pustular skin lesions, arthritis, arthralgia, and tenosynovitis. Endocarditis and meningitis occur rarely. Strains of N. gonorrhoeae that cause DGI are uncommon in the United States. In the absence of endocarditis or meningitis, treatment consists of IM or intravenous (IV) ceftriaxone plus azithromycin. For patients with endocarditis or meningitis, the preferred treatment is IV ceftriaxone plus azithromycin.
Neonatal Infection
Neonatal gonococcal infection is acquired through contact with infected cervical exudates during delivery. Infection can be limited to the eyes or it may be disseminated.
Gonococcal neonatal ophthalmia is a serious infection. The initial symptom is conjunctivitis. Over time, other structures of the eye become involved. Blindness can result. The recommended therapy is a single dose of ceftriaxone given by either IM or IV injection.
To protect against neonatal ophthalmia, a topical antibiotic should be instilled into both eyes immediately postpartum—as required by law in most states. According to the 2015 CDC guidelines, the only approved topical agent is 0.5% erythromycin ophthalmic ointment. If this antimicrobial is not available, parenteral therapy with ceftriaxone is to be used.
In neonates, DGI is rare. Possible manifestations include sepsis, arthritis, meningitis, and scalp abscesses. There are two recommended treatments: ceftriaxone and cefotaxime. If meningitis is present, dosing is prolonged from 7 days to 10 to 14 days.
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