Sexually transmitted diseases: Difference between revisions

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== Chart  ==
==Background==
*STD Prevalence: [[Human papillomavirus|HPV]] > [[Human papillomavirus|HSV-2]] > [[Trichomonas]] > [[Chlamydia trachomatis|Chlamydia]] > [[HIV]] > [[HBV]] > [[Neisseria gonorrhoeae|Gonorrhea]] > [[Syphilis]]
*STD New infections: HPV > Chlamydia > Trichomonas > Gonorrhea > HSV-2 > Syphilis > [[HIV]] > HBV <ref>[http://www.cdc.gov/std/stats/sti-estimates-fact-sheet-feb-2013.pdf CDC: STI Fact sheet 2013]</ref>
*It is important to treat sexual partners for all STDs
**See [[Expedited Partner Therapy]]


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==Visual Diagnosis==
|-
{{Genital images male}}
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{{Genital images female}}
'''Disorder'''


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==[[Bacterial Vaginosis]]==
'''Clinical'''
{{BV Antibiotics}}


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'''1<sup>st</sup> line'''


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==[[Cervicitis]]==
'''Alternative'''
{{Cervicitis Urethritis Antibiotics}}


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==[[Epididymitis]]/[[Epididymorchitis]]==
'''Partner'''
{{Epididymitis antibiotics}}


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'''In Pregnancy'''


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==[[GC]]/[[Chlamydia]] Conjunctivitis==
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''N. Gonorrhea''


Urethritis/
{{GC Conjunctivitis Treatment}}


Cervicitis


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==[[HSV|Herpes]]==
M: urethritis with d/c or simply dysuria;can be asymptomatic
{{Herpes antiviral treatment}}


F: purulent discharge; can be asymptomatic


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Ceftriaxone 250mg IM


OR
==[[Lymphogranuloma Venereum]]==
{{LGV antibiotics}}


Cefixime (Suprax) 400mg po x1


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==[[Proctitis]]==
Spectinomycin 2g IM x 1
{{Proctitis antibiotics}}


OR


Azithromycin 2g po x 1
==[[PID]]==
{{PID antibiotics}}


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Treat and abstinence x 7d after both treated


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==[[Syphilis]]==
CTX 250mg IM x 1
===Early Stage===
This is classified as primary, secondary, and early latent syphilis less than one year.


|-
Treatment Options:
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''N. Gonorrhea''


[[Gonorrheal Conjunctivitis|Conjunctivitis]]
{{Early Syphilis Treatment}}


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===Late Stage===
2-5d after birth
Late stage is greater than one year duration, presence of gummas, or cardiovascular disease


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Treatment Options:
Erythromycin ophthalmic 0.5% x1


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{{Late Syphilis Treatment}}
Tetracycline ophthalmic 1% x1
===Neurosyphilis===
There are 3 Major options with none showing greater efficacy than others:


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{{Neurosyphilis Treatment }}
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''N. Gonorrhea''


Disseminated
*Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)


(DGI)
===Pregnancy===
*[[Penicillin]], dosage depends on stage <ref>Mackay G. Chapter 43. Sexually Transmitted Diseases & Pelvic Infections. In:DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. New York, NY: McGraw-Hill; 2013</ref>


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Petechial, pustular acral skin lesions,


Asymmetrical arthralgias, tenosynovitis,
==[[Trichomonas vaginalis]]==
{{Trichomonas antibiotics}}


Septic arthritis


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==[[Urethritis]] (male)==
CTX 1g IM/IV q24
{{Male urethritis treatment}}
 
-continue x24-48h until improvement
 
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Cefotax 1g IV q8
 
Spectinomycin 2g IV q12
 
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''Chlamydia Trachomatis''
 
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M: urethritis with d/c or simply dysuria; can be asymptomatic
 
F: purulent discharge or cervical bleeding; can be asymptomatic
 
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Azithromycin 1g po x1
 
OR
 
Doxycycline 100mg po bid x 7d
 
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Erythromycin base 500mg po qid x 7d OR
 
Oflox 300mg po bid x 7d
 
OR
 
Levoflox 500mg po qd x 7days
 
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Treat and abstinence x 7d after both treated
 
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Azithromycin 1g po x1 or
 
Amoxicillin 500mg po tid x 7d
 
Or
 
Erythro
 
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''Chlamydia''
 
''Trachomatis''
 
Conjunctivitis
 
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5-12d after birth; silver nitrate ophthalmic only rx gonorrhea
 
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Erythromycin base 50mg/kg/day PO / 4 doses x14days
 
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''Chlamydia Trachomatis''
 
Pneumonia
 
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1-3months; afebrile, staccato cough with diffuse infiltrates on CXR; peripheral eosinophilia
 
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Erythromycin base 50mg/kg/day po / 4 doses x14days
 
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''Trichamonas vaginalis''
 
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White, thick discharge
 
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Metronidazole 2g po x 1
 
OR
 
Tinidazole 2g po x 1
 
PLUS
 
Azithro 1g po x 1
 
-intravag cream not recommended
 
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Metronidazole 500mg bid for 7days; 1-2g po qday x 7d if recurrence
 
OR
 
Topical clotrimazole for metronidazole allergy– not as effective
 
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Metronidazole 2g po x 1
 
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Rx only if symptomatic but rx partner
 
1<sup>st</sup> trimester, Clotrimazole 100mg hs for 7days
 
After 1<sup>st</sup> trimester,<span> </span>Metronidazole 2g po x 1
 
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Bacterial Vaginosis
 
''Lactobacillus''
 
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White, fishy discharge
 
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Metronidazole 500mg po bid for 7d
 
OR
 
0.75% Metronidazole gel (one full applicator 5g) intravaginal qd for 5d
 
OR
 
2% Clindamycin cream 5g qd for 7d
 
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Clindamycin 300mg po bid for 7d (recurrence)
 
OR
 
Clindamycin ovules 100mg intravaginally qhs x 3d
 
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Exam for STD
 
No rx if nl
 
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1<sup>st</sup> trimester, metronidazole 250mg po tid x7d
 
After 1<sup>st</sup> trimester, 500mg po bid for 7days or 250mg po tid x7d or Clinda 300mg po bid x 7d
 
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Candidiasis
 
(''Candida albicans''<span style="font-style: normal">)</span>
 
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Cottage cheese;
 
DM or immunocompromised
 
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Butoconazole 2% cream 5g intravaginally for 3d
 
OR
 
Butaconazole-sustained 2% intravag x1
 
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Clotrimazole 1%<span> </span>5g cream intravaginally for 7-14d (OTC)
 
OR
 
Clotrimazole 100mg intravag tablet x 7d
 
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Candicidal cream if dermatitis present
 
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Avoid fluconazole and ketoconazole.
 
Rx with cream for 7d
 
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Chancroid
 
(''H. ducreyi''<span style="font-style: normal">)</span>
 
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Painful ulcers with suppurative LAD
 
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Azithromycin 1g PO x 1
 
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CTX 250mg IM x1
 
Cipro 500mg PO bid x 3days
 
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See CDC
 
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CTX
 
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Granuloma Inguinale<span> </span>(Donvanosis)
 
''Klebsiella granulomatis''
 
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Painless lesions without LAD
 
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Doxycycline 100mg PO BID x 3wks and until all lesions heald
 
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Aizthromycin 1g po q week
 
Ciproflox 750mg PO bid x 3 weeks
 
Bactrim DS 1tab PO BID x 3 wks
 
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same
 
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Erythromycin base 500mg po qid x 3wks
 
|-
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Lymphogranuloma Venereum (LGV)
 
''C. trach'' <span style="font-style: normal">serovars L1-L3</span>
 
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Tender, unilateral LAD; can lead to proctitis, fistulas
 
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Doxycycline 100mg po bid x 3 weeks
 
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Erythromycin base 500mg po qid x 3wks
 
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Treat within 60days of exposure with standard Chlamydia Rx
 
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Erythromycin base 500mg po qid x 3wks
 
|-
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Chancre-
 
Primary
 
Syphilis
 
(''T. pallidum''<span style="font-style: normal">)</span>
 
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Painless ulcer, chancre
 
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Benzathine Penicillin G 1.2million U IM x1
 
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Doxycycline 100mg po bid x 14d
 
Tetracycline 500mg po qid x 14d
 
CTX 1g IM/IV x 8-10d
 
Azithromycin 2g po x 1?
 
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See CDC
 
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Penicillin; if allergic desensitize
 
|-
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Secondary Syphilis
 
(''T. pallidum''<span style="font-style: normal">)</span>
 
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Skin rash, mucocutaneous lesions, LAD
 
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See CDC
 
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|-
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Latent Syphilis
 
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Seroreactivity without other evidence of disease
 
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''Early''
 
''Late''
 
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Doxycycline 100mg po bid x 28d
 
Tetracycline 500mg po qid x 28d
 
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See CDC
 
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|-
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Tertiary Syphilis
 
(''T. pallidum''<span style="font-style: normal">)</span>
 
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Cardiac (aortitis), ophtho (iritis, uveitis), gumma
 
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Benzathine<span> </span>Penicillin G 2.4million U IM qweek x 3
 
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See CDC
 
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|-
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Neurosyphilis
 
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Meningitis, syphilitic eye disease
 
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Aqueous crystalline penicillin G 18-24million units/d administered as 3-4million units IV q4h or continuous infusion x 10-14days
 
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Procaine penicillin 2.4million units IM qday + Probenecid 500mg po qid<span> </span>
 
BOTH for 10-14d
 
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| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
|-
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HSV (1<sup>st</sup> episode)
 
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Vesilcular rash
 
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Acyclovir 400mg po TID x 7-10day
 
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Famciclovir 250mg po TID x 7-10d
 
Valacyclovir 1g PO BID x 7-10d
 
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| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
|-
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HSV (suppressive)
 
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Acyclovir 400mg PO BID
 
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Famciclovir 250mg po BID
 
Valacyclovir 500mg PO qday
 
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| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
|-
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Epididymitis
 
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Pain, swelling, inflammation of the epididymis
 
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CTX 250mg IM + Doxycyline 100mg po bid x 10d
 
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Oflox 300mg<span> </span>po bid x 10d + levoflox 500mg po qday x 10d
 
| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.25in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="90" | <br>
| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
|-
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Epididymorchitis
 
| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
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| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.25in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="90" | <br>
| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
|-
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Proctitis
 
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Inflammation of the rectum (distal 10-12cm)
 
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CTX 125mg IM x1 + Doxy 100mg po bid x 7d
 
| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 175.5pt; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="176" | <br>
| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.25in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="90" | <br>
| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
|-
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[[PID]]
 
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Sexually active, no other sources and: CMT OR uterine OR adnexal TTP
 
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'''Outpt:'''
 
Ceftriaxone 250mg IM x1
 
OR
 
Cefoxitin 2g IM in a single dose and probenecid 1g orally administered concurrently in single dose
 
OR
 
Other parenteral 3<sup>rd</sup> gen cephalosporin eg ceftizoxime or cefotaxime
 
PLUS
 
Doxy 100mg po bid x14d
 
+/-
 
Metronidazole 500mg po bid x 14d
 
 
 
'''Inpt:'''
 
Cefotetan 2g IV q12h
 
OR
 
Cefoxitin 2g IV q6h
 
PLUS
 
Doxycyline 100mg IV or PO q12
 
(''similar bioavailability)''
 
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'''Outpt:'''
 
Oflox 400mg po bid x 14d
 
OR
 
Levofloxacin 500mg po qday x 14d
 
+/-
 
Metronidazole 500mg po bid x 14d
 
 
 
'''Inpt:'''
 
Clinda 900mg IV q8h
 
PLUS
 
Gent load 2mgkg IV; maintenance 1.5mg/kg q8h; single daily dosing may be substituted
 
+/-
 
Metro 500mg IVq8h
 
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| style="border-right: 0.5pt solid; padding-right: 5.4pt; border-top: medium none; padding-left: 5.4pt; padding-bottom: 0in; border-left: medium none; width: 1.5in; padding-top: 0in; border-bottom: 0.5pt solid" valign="top" width="108" | <br>
|-
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Scabies
 
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Crusted rash, intertiginous areas
 
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Permethrin 5% cream applied to all areas of body from neck down and rinsed off after 8-14h
 
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Ivermectin 200mcg/kg PO, repeated in 2weeks
 
Lindane (1%) 1 ounce of lotion of 30g of cream applied in thin layer all over from neck down x 8 hours then rinse
 
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Pediculosis Pubis
 
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Puritic genitalia
 
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Permethrin 1% cream: apply to affected areas x 10mins then wash off
 
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Malathion lotion 0.5% apply x 8-12h then rinse
 
OR
 
Ivermectin<span> </span>250mcg/kg PO repeated in 2 weeks
 
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|}
 
†Test for HIV, syphilis


==See Also==
==See Also==
*[[Pelvic Inflamatory Disease (PID)]]
*[[Human Papillomavirus (HPV)]]
*[[Pelvic Inflammatory Disease (PID)]]
*[[Ulcerative STDs]]
*[[Ulcerative STDs]]
*[[Penile diagnoses]]
*[[Pelvic pain]]
*[[Expedited Partner Therapy]]


== Source  ==
==References==
DeBonis
<references/>
 
Adapted from CDC 2010 Guidelines


[[Category:GU]] [[Category:ID]] [[Category:OB/GYN]]
[[Category:Urology]] [[Category:ID]] [[Category:OBGYN]]

Revision as of 17:47, 22 April 2020

Background

Visual Diagnosis

STD Visual Diagnosis (Male)

STD Visual Diagnosis (Female)

Bacterial Vaginosis

First Line Therapy[2]

  • Metronidazole 500 mg PO BID for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally qHS for 7 days

Alternative Regimin

  • Tinidazole 2 g PO qd for 2 days OR
  • Tinidazole 1 g PO qd for 5 days OR
  • Clindamycin 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hrs)

Pregnant

Prophylaxis (Sexual Assault)


Cervicitis

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[4]

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

  • Gonorrhea
    • Ceftriaxone IM x 1
      • 500 mg, if weight <150 kg
      • 1 g, if weight ≥150 kg
  • Chlamydia


Ceftriaxone contraindicated

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

Pregnant

Only treat if the patient is symptomatic and avoid breast feeding until 24-hrs after last dose

Sexual Partner Treatment

Men

Epididymitis/Epididymorchitis

  • For acute epididymitis likely caused by STI [8]
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.


GC/Chlamydia Conjunctivitis

Chlamydial

  • Doxycycline 100mg PO BID for 7 days OR
  • Azithromycin 1g (20mg/kg) PO one time dose
  • Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days or erythromycin PO 50 mg/kg/day in 4 divided doses for 14 days [9]
    • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

  • Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
  • Ceftriaxone 250mg IM one dose PLUS
  • Azithromycin 1g PO one dose
  • Newborn Treatment:
    • Prophylaxis: Erythromycin ophthalmic 0.5% x1
    • Disease manifests 1st 5 days post delivery (early onset)
    • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg or cefotaxime single dose of 100 mg/kg (preferred if the patient has hyperbilirubinemia)
    • Also requires evaluation for disseminated disease (meningitis, arthritis, etc.)


Herpes

Initial Episode[10][11]

Recurrence[10]

  • Acyclovir OR
    • 400mg PO q8hrs x 5 days
    • or 800mg PO q12hrs x 5 days
    • or 800mg PO q8hrs x 2 days
  • Valacyclovir OR
    • 500mg PO q12hrs x 3 days
    • or 1g PO qd x 5 days
  • Famciclovir
    • 125mg PO q12hrs for 5 days
    • or 1g PO q12hrs for 1 day
    • or 500mg PO once, followed by 250mg PO q12hrs for 2 days

Suppressive Therapy[10]


Lymphogranuloma Venereum

  • Doxycycline 100mg PO BID x 21 days (first choice) OR
  • Erythromycin 500mg PO QID x 21 days OR
    • Preferred for pregnant and lactating females
  • Azithromycin 1g PO weekly for 3 weeks OR
    • Alternative for pregnant women - poor evidence for this treatment currently
  • Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
  • Treat sexual partner


Proctitis

Inflammation of the rectum (distal 10-12cm)


PID

Antibiotics

  • No sexual activity for 2 weeks;
  • Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

Inpatient Antibiotic Options


Syphilis

Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year.

Treatment Options:

  • Penicillin G Benzathine 2.4 million units IM x 1
    • Repeat dose after 7 days for pregnant patients and HIV infection
  • Doxycycline 100mg oral twice daily for 14 days as alternative

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease

Treatment Options:

Neurosyphilis

There are 3 Major options with none showing greater efficacy than others:

  • Penicillin G 3-4 million units IV every 4 hours x 10-14 days
  • Penicillin G 24 million units continuous IV infusion x 10-14 days
  • Penicillin G Procaine2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
  • Alternative:
  • Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)

Pregnancy


Trichomonas vaginalis

Non-Pregnant

Pregnant

Only treat if the patient is symptomatic and avoid breast feeding until 24-hrs after last dose

Sexual Partner Treatment

Men


Urethritis (male)

Uncomplicated Infection

Treatment to cover both gonorrhea and chlamydia Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

  • Gonorrhea
    • Ceftriaxone IM x 1
      • 500 mg, if weight <150 kg
      • 1 g, if weight ≥150 kg
  • Chlamydia


Ceftriaxone contraindicated

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

Recurrent or Persistent

Target M. genitalium

Consider coverage of trichomonas, among men who have sex with women

See Also

References

  1. CDC: STI Fact sheet 2013
  2. Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  3. 3.0 3.1 3.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
  4. Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
  5. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  6. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  7. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  8. https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
  9. Zikic A, Schünemann H, Wi T, Lincetto O, Broutet N, Santesso N. Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis. J Pediatric Infect Dis Soc. 2018 Aug 17;7(3):e107-e115. doi: 10.1093/jpids/piy060. PMID: 30007329; PMCID: PMC6097578.
  10. 10.0 10.1 10.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  11. https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
  12. Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
  13. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  14. Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  15. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  16. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  17. Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
  18. CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  19. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  20. Mackay G. Chapter 43. Sexually Transmitted Diseases & Pelvic Infections. In:DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. New York, NY: McGraw-Hill; 2013
  21. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  22. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  23. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon