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For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 47, Sexually Transmitted Diseases.



  • imageDue to drug resistance, gonococcal infections are becoming increasingly difficult to treat. Dual therapy, with ceftriaxone and azithromycin or doxycycline, is recommended to improve treatment efficacy and slow the emergence and spread of resistance. Coinfections with chlamydia are common, for which azithromycin and doxycycline are also effective.

  • imageParenteral penicillin is the treatment of choice for all syphilis infections. For penicillin-allergic, few well-studied alternative agents are available, and most require prolonged courses of oral medications to be effective. Patient compliance, and thus efficacy, are a concern when alternative regimens must be used.

  • imageChlamydia genital tract infections represent the most frequently reported communicable disease in the United States. In females, these infections are frequently asymptomatic or minimally symptomatic and, if left untreated, are associated with the development of pelvic inflammatory disease and attendant complications such as ectopic pregnancy and infertility. As a result, all sexually active females younger than 25 years and sexually active women with multiple sexual partners should be screened annually for this infection.

  • imageOral acyclovir, famciclovir, and valacyclovir are effective in reducing viral shedding, duration of symptoms, and time to healing of first-episode genital herpes infections, with maximal benefits seen when therapy is initiated at the earliest stages of infection. Patient-initiated, episodic antiviral therapy started within 1 day of lesion onset or during the prodrome preceding an outbreak offers an alternative to continuous suppressive therapy of recurrent infection in some individuals.

  • imageMetronidazole and tinidazole are the only agents currently approved in the United States to treat trichomoniasis. A single 2-g dose of either agent is recommended, but should be avoided for treating recurrent infections.


Patient Care Process for Genital Infection due to Neisseria gonorrhoeae



  • Patient characteristics (eg, age, sex, pregnant)

  • Patient medical history (personal and family)

  • Social history, including sexual history

  • Current medications

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight

    • Laboratory data including urine NAATs for gonorrhea and chlamydia, and/or urethral or vaginal cultures

    • Signs and symptoms consistent with gonorrhea (dysuria, mucopurulent urethral or vagina discharge)


  • Presence of additional STIs (chlamydia, syphilis, HIV, etc.)

  • Presence of extra-genital infection

  • Ability/willingness to obtain follow-up testing as needed

  • Ability/willingness to notify sexual partners

  • Emotional status (eg, presence of anxiety, depression)


  • Drug therapy regimen including, dose, route, frequency, and duration (Table 135-4)

  • Monitoring parameters including efficacy (eg, retest 3 months after treatment) and safety, frequency and timing of follow-up

  • Patient education (eg, purpose of treatment, notification of sexual partners, safe sexual practices, drug-specific information)

  • Self-monitoring for resolution of gonorrhea symptoms, and if not resolved to seek follow-up for reevaluation

  • Referrals to other providers when appropriate (eg, HIV care, behavioral health)


  • Provide patient education ...

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