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SExUally Transmitted Diseases ContRol Branch

California Sexually Transmitted Infections (STI) Treatment Guidelines for Adults and Adolescents

These guidelines reflect the 2021 CDC STI Treatment Guidelines for adults and adolescents who are HIV negative as well as those with HIV. Call the local health department for assistance with confidential notification of sexual partners of patients with STIs or HIV. For complex STI clinical management consultation (such as in cases of multiple allergies or treatment failure), contact the California Department of Public Health STD Control Branch via email (stdcb@cdph.ca.gov) or phone (510-620-3400) or submit your question online to the STD Clinical Consultation Network at www.stdccn.org.
Included below are recommended treatment regimens for the following STIs and conditions:
 Note: Alternative regimens included below are only to be used if there is a medical contraindication to the recommended regimen.
A PDF version of the California STI Treatment Guidelines for Adults and Adolescents is available for download.

Chlamydia (CT)

​Scenario
​Recommended Regimens
​Alternative Regimens
​Urogenital/Rectal/Pharyngeal Infections

Doxycycline1 100 mg po bid x 7 d

  • ​Azithromycin 1 g po x 1 dose OR
  • Levofloxacin 500 mg po once daily x 7 d

​Pregnant Patients2

​Azithromycin 1 g po x 1 dose

​Amoxicillin 500 mg po tid x 7 d

Gonorrhea (GC)

Monotherapy with IM ceftriaxone is recommended for all patients with gonorrhea, including pregnant patients. If co-infection with chlamydia has not been excluded, add doxycycline 100 mg po bid x 7 d for non-pregnant persons or azithromycin 1 g po x 1 dose for pregnant persons.

​Scenario
​Recomended Regimens
​Alternative Regimens
​Urogenital/Rectal Infections3

  • ​​Ceftriaxone 500 mg IM x 1 dose for persons weighing <150kg4 OR
  • Ceftriaxone 1 g IM x 1 dose for persons weighing > 150kg


If cephalosporin allergy: dual therapy with
  • Gentamicin1 240 mg IM x 1 dose PLUS Azithromycin 2 g po x 1 dose
If ceftriaxone not available or feasible, but no allergy concerns:
  • Cefixime 800mg x 1 dose5
​Pharyngeal Infections3,6
  • ​​Ceftriaxone 500 mg IM x 1 dose for persons weighing <150kg4 OR
  • Ceftriaxone 1 g IM x 1 dose for persons weighing>150kg
​No reliable treatment alternatives. Consult an infectious disease specialist or submit a question online at www.stdccn.org.

Pelvic Inflammatory Disease (PID)7

(Etiologies: CT, GC, anaerobes, possibly M. genitalium, others)
​Recommened Regimens
​Alternative Regimens
​Parenteral
  • Ceftriaxone 1 g IV q 24 hrs PLUS Doxycycline1 100 mg IV or po q 12 hrs PLUS Metronidazole 500 mg IV or po q 12 hrs OR
  • Cefotetan 2 g IV q 12 h PLUS Doxycycline1 100 mg po or IV q 12 hrs OR
  • Cefoxitin 2 g IV q 6 h PLUS Doxycycline1 100 mg po or IV q 12 hrs
IM/Oral
  • Ceftriaxone 500 mg IM x 1 dose4 (or another 3rd generation cephalosporin8) PLUS Doxycycline1 100 mg po bid x 14 d WITH Metronidazole 500 mg po bid x 14 d OR
  • Cefoxitin 2 g IM x 1 dose administered with Probenecid 1 g po x 1 dose PLUS Doxycylcline1 100 mg po bid x 14 d WITH Metronidazole 500 mg po bid x 14 d
​Parenteral
  • Ampicillin/Sulbactam 3 g IV q 6 hrs PLUS Doxycycline1 100 mg po or IV q 12 hrs OR
  • Clindamycin 900 mg IV q 8 hrs PLUS Gentamicin1 2 mg/kg IV or IM x 1 as loading dose
    FOLLOWED BY
  • Gentamicin1 1.5 mg/kg IV or IM q 8 h as maintenance dose (or can substitute with Gentamicin1 3-3 mg/kg IM or IV 1x daily)
   IM/Oral9
  • Levofloxacin 500 mg po daily WITH Metronidazole 500 mg po bid x 14 d OR
  • Moxifloxacin 400 mg po daily WITH Metronidazole 500 mg po bid x 14 d OR
  • Azithromycin 500 mg IV daily x 1-2 doses followed by 250 mg po daily WITH Metronidazole 500 mg po bid x 12-14 d

Cervicitis10

(Etiologies: CT, GC, T. vaginalis, HSV, possibly M. genitalium)
Recommended Regimens
Alternative Regimens

​Doxycycline1 100 mg po bid x 7 d

A​zithromycin 1 g po x 1 dose

Recommended Regimens
Alternative Regimens

​Doxycycline1 100 mg po bid x 7 d

  • A​zithromycin 1 g po x 1 dose OR
  • Azithromycin 500 mg po x 1 dose, then 250 mg po daily x 4 d

Recurrent/Persistent NGU 

(Etiolgies: M. genitalium (MG), T.vaginalis, other bacteria)
Recommended Regimens
​Alternative Regimens
1) Test for M. gentalium (MG)
If MG test positive but resistance testing unavailable, use:
  • Doxycyline1 100 mg po bid x 7 d
    FOLLOWED BY
  • Moxifloxacin 400 mg po daily x 7 d
If MG test positive and resistance testing is available, use:
Macrolide sensitive: 
  • Doxycycline1 100 mg po bid x 7 d
    FOLLOWED BY
  • Azithromycin 1 g po once, then 500 mg daily on next 3 d
Macrolide resistant: 
  • Doxycycline1 100 mg po bid x 7 d
    FOLLOWED BY 
  • Moxifloxacin 400 mg po daily x 7 d
2)Test and treat presumptively for T. vaginalis in men who have sex with women (MSW) in areas where infection is prevalent 
  • Metronidazole or Tinidazole 2 g po x 1 dose (applies to both medications)
​For settings without MG resistance testing and when moxifloxacin cannot be used: 
  • Doxycycline1 100 mg po bid x 7 d PLUS Azithromycin 1 g po x 1 dose on first day FOLLOWED BY
  • Azithromycin 500 mg po once daily for 3 d
    AND
  • Perform a test of cure 21 d after treatment



Proctitis

(Etiologies: GC, CT including LGV, HSV, T. pallidum, possibly M. genitalium)
Recommended Regimens
  • ​Ceftriaxone 500 mg IM x 1 dose for persons weighing <150 kg4 OR
  • Ceftriaxone 1 g IM x 1 dose for persons weighing >150 kg PLUS Doxycycline1 100 mg po bid x 7 d11
Note: There are no alternative regimens recommended for proctitis.

Lymphogranuloma Venereum (LGV)

Recommended Regimens
Alternative Regimens
​Doxycycline1 100 mg po bid x 21 d
  • ​Azithromycin 1 g po once weekly x 3 weeks12 OR
  • Erthromycin 500 mg po qid x 21 days

Trichomoniasis13
Note: Treatment recommendations fo not vary by HIV status.
Scenario
Recommended Regimens
Alternative Regimens
​Cervicovaginal infection
​Metronidazole 500 mg po bid x 7 d
  • ​Tinidazole14 2 g po x 1 dose OR
  • Secnidazole15 2 g po x 1 dose
​Penile infection
​Metronidazole 2 g po x 1 dose
  • ​Tinidazole14 2 g po x 1 dose OR
  • Secnidazole15 2 g po x 1 dose

Bacterial Vaginosis

Recommended Regimens
Alternative Regimens
  • ​Metronidazole 500 mg po bid x 7 day OR
  • Metronidazole gel 0.75% one full applicator (5 g) intravaginally once daily x 5 d OR
  • Clindamycin cream 2% one full applicator (5 g) intravaginally qhs x 7 d
  • ​Tinidazole14 2 g po daily x 2 d OR
  • Tinidazole14 1 g po daily x 5 d OR
  • Secnidazole15 2 g po x 1 dose OR
  • Clindamycin 300 mg po bid x 7 d OR
  • Clindamycin ovules16 100 mg intravaginally qhs x 3 d

Epididymitis

Recommended Regimens
​If likely due to GC or CT
  • Ceftriaxone 500 mg IM x 1 dose4 PLUS Doxycycline 100 mg po bid x 10 d
If likely due to GC, CT or enteric organisms (history of insertive anal sex)
  • Ceftriaxone 500 mg IM x 1 dose4 PLUS Levofloxacin 500 mg po daily x 10 d
If most likely due to enteric organisms alone (GC and CT tests negative)
  • Levofloxacin17 500 mg po daily x 10 d
Note: There are no alternative regimens recommended for epididymitis.

Anogenital Warts

Scenario
Recommended Regimens
​Alternative Regimens*
​External Genital/Perianal Warts
Patient-Applied
  • Imiquimod18,19 5% cream topically qhs 3x/wk up 10 16 wks OR
  • Imiquimod18,19 3.75% cream topically qhs for up to 8 wks OR
  • Podofilox 0.5% solution or gel topically bid x 3 d then 4 d off, repeat up to 4 cycles OR
  • Sinecatechins18 15% ointment topically tid for up to 16 wks
Provider-Administered
  • Cryotherapy with liquid nitrogen, apply once q 1-2 weeks OR
  • Trichloroacetic acid (TCA) 80-90%, apply once q 1-2 wks OR
  • Bichloroacetic acid (BCA) 80-90%, apply once q 1-2 wks OR
  • Surgical removal
Provider-Administered
  • Podophyllin resin20 10-25% in tincture of benzoin, applied weekly PRN OR
  • Intralesional interferon OR
  • Photodynamic therapy OR
  • Topical cidofovir
​Mucosal Genital Warts
Urethral meatus, Vaginal, Cervical, Intra-Anal
  • Cryotherapy21 with liquid nitrogen OR
  • Surgical removal OR
Vaginal, Cervical, Intra-Anal
  • TCA or BCA 80-90%
​None
*Fewer data available.
Scenario
Recommended Regimens
​First Clinical Episode of Herpes22
  • ​Acyclovir 400 mg po tid x 7-10 d OR
  • Valacyclovir 1 g po bid x 7-10 d OR
  • Famciclovir 250 mg po td x 7-10 d
​Daily Suppressive Therapy for Recurrences (if no HIV co-infection)
  • ​Acyclovir 400 mg po bid OR
  • Valacyclovir 500 mg po daily23 OR
  • Valacyclovir 1 g po daily OR
  • Famciclovir24 250 mg po bid
​Daily Supressive Therapy for Persons with HIV25
  • ​Acyclovir 400-800 mg po 2-3 times daily OR
  • Valacyclovir 500 mg po bid OR
  • Famciclovir24 500 mg po bid
​Daily Suppressive Therapy in Pregnant Patients (start at 36 weeks gestation)
  • ​Acyclovir 400 mg po tid OR
  • Valacyclovir 500 mg po bid
​Episodic Therapy for Recurrences (If no HIV co-infection)
  • ​Acyclovir 800 mg po bid x 5 d OR
  • Acyclovir 800 mg po tid x 2 d OR
  • Valacyclovir 500 mg po bid x 3 d OR
  • Valacyclovir 1 g po daily x 5 d OR
  • Famciclovir 1 gm po bid x 1 d OR
  • Famciclovir 500 mg po once, then 250 mg po bid x 2 d OR
  • Famciclovir 125 mg po bid x 5 d
​Episodic Therapy for Recurrences for Persons with HIV25
  • ​Acyclovir 400 mg po tid x 5-10 d OR
  • Valacyclovir 1 g po bid x 5-10 d OR
  • Famciclovir 500 mg po bid x 5-10 d
Note: There are no alternative regimens recommended for anogenital herpes.

Syphilis in Non-Pregnant Patients26

Treatment recommendations do not vary by HIV status.
Scenario
Recommended Regimens
Alternative Regimens
​Primary, Secondary, and Early Latent
​Benzathine penicillin G 2.4 million units IM x 1 dose
  • ​Doxycycline27 100 mg po bid x 14 d OR
  • Tetracycline27 500 mg po qid x 14 d OR
  • Ceftriaxone27 1 g IM or IV daily x 10-14 d
​Late Latent or Syphilis of Unknown Duration OR Tertiary Syphilis with normal CSF
​Benzathine penicillin G 7.2 milllion units total, administered as 3 doses of 2.4 million units IM each at 1 week intervals28
  • ​Doxycycline27 100 mg po bid x 28 d OR
  • Tetracycline27 500 mg po qid x 28 d
​Neurosyphilis and Ocular Syphilis29
​Aqueous crystalline penicillin G 18-24 million units daily, administered as 3-4 million units IV q 4 hrs or as continuous infusion x 10-14 d
  • ​Procaine penicillin G 2.4 million units IM daily x 10-14 d PLUS Probenecid 500 mg po qid x 10-14 d
OR, in the setting of severe penicillin allergy
  • Ceftriaxone27 1-2 gm IM or IV daily x 10-14 d

Syphilis in Pregnant Patients30

Pregnant patients who miss any dose of therapy must repeat the full couse of treatment.
Scenario
Recommended Regimens
​Alternative Regimens
​Primary, Secondary, and Early Latent
​Benzathine penicillin G 2.4 million units IM x 1 dose31
​None
​Late Latent or Syphilis of Unknown Duration OR Tertiary Syphilis with normal CSF
​Benzathine penicilling G 7.2 million units total, administered as 3 doses of 2.4 million units IM each, at 1-week intervals32
​None
​Neurosyphilis and Ocular Syphilis29
​Aqueous crystalline penicillin G 18-24 million units daily, administered as 3-4 million units IV q 4 hrs or as continuous infusion x 10-14 d
​Procaine penicillin G 2.4 million units IM daily x 10-14 d PLUS Probenecid 500 mg po qid x 10-14 d

1Contraindicated for pregnant patients.
2Every effort should be made to use a recommended regimen. Test-of-cure follow-up with a nucleic acid amplification test (NAAT) 4 weeks after completion of therapy is recommended in pregnancy.
3See Gonorrhea Treatment Guidelines and Management of Suspected Treatment Failure (https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/CAGCTreatmentFailureProtocol_Providers.pdf) if suspected GC treatment failure.
4For persons weighing >150 kg, use 1 gm IM ceftriaxone x 1 dose instead. 
5Oral cephalosporins give lower and less-sustained bactericidal levels than ceftriaxone. Cefixime should only be used when ceftriaxone is not available.
6Test of cure by culture or NAAT is recommended 14 days after treatment of pharyngeal GC.
7If parenteral therapy is selected initially, discontinue 24-48 hours after patient improves clinically and continue with either IM or oral therapy for a total of 14 days. 
8Other parenteral third-generation cephalosporin (e.g. cefotaxime or ceftizoxime) could be substituted for ceftriaxone.
9If allergy to cephalosporins, can consider fluoroquinolones/azithromycin for PID treatment if community prevalence and individual risk of GC is low, and follow-up is assured. Obtain NAAT testing and GC culture before using fluoroquinolone/azithromycin treatment. 
10If patient lives in community with high GC prevalence, or has risk factors (e.g. age <25 years, new partner, partner with concurrent sex partners, or sex partner with a STI), consider empiric treatment for GC.
11Extend doxycycline course to 21 days to cover LGV if perianal or mucosal ulcers, bloody rectal discharge, or tenesmus and rectal CT positive. If perianal or mucosal ulcers present, consider treating for HSV as well.
12Because this regimen has not been rigorously validated, consider a test of cure with CT NAAT four weeks after treatment. 
13For suspected drug-resistant trichomoniasis consult the 2021 CDC STI treatment guidelines, contact the CA STD Control Branch, or consult www.stdccn.org.  
14Safety in pregnancy has not been established, avoid during pregnancy. When using tinidazole, breastfeeding should be deferred for 72 hours after 2 g dose.
15Sprinkle oral granules on applesauce/yogurt/pudding before ingestion. Glass of water after dose can aid in swallowing. FDA-approved for treatment of trichomonas after the release of the CDC’s 2021 STI Treatment Guidelines.
16Clindamycin ovules may weaken latex or rubber products (such as condoms and diaphragms). Use of such products within 72 hours following use of clindamycin ovules is not recommended.
17Gonorrhea should be ruled out prior to starting a fluroquinolone-based regimen.
18May weaken condoms and vaginal diaphragms. Advise patients to follow package insert directions carefully. Imiquimod users wash area 6-10 hours after application. Sinecatechin ointment should not be washed off.
19Limited human data on imiquimod use in pregnancy; animal data suggest low risk.
20Podophyllin resin is an alternative rather than recommended regimen due to reports of severe toxicity. The safety of podophyllin in pregnancy has not been established. 
21The use of a cryoprobe in the vagina is not advised due to risk of vaginal perforation and fistula formation.
22Treatment can be extended if healing is incomplete after 10 days of antiviral therapy.
23Consider high dose valacyclovir (1 gm daily) or acyclovir in people who have frequent recurrences (i.e., 10 or more episodes annually).
24Famciclovir is somewhat less effective for suppression of viral shedding.
25If concern for resistance based on persistent HSV lesions, obtain a viral isolate for sensitivity testing. Consultation with an infectious disease expert is recommended.
26Benzathine penicillin G is available in only one long-acting formulation, Bicillin® L-A (the trade name), which contains only benzathine penicillin G. Other combination products, such as Bicillin® C-R, contain both long- and short-acting penicillins and are not effective for treating syphilis.
27Alternative regimens should be used only for penicillin-allergic patients. If compliance or follow-up cannot be ensured, the patient should be desensitized and treated with benzathine penicillin. 
28In non-pregnant patients, pharmacologic considerations reveal an interval of 7-9 days is ideal. 
29Some specialists recommend 2.4 million units of benzathine penicillin G once weekly for 1 to 3 weeks immediately after completion of neurosyphilis treatment.
30Pregnant patients allergic to penicillin should be desensitized and treated with penicillin. There are no alternatives. 
31For early syphilis, many experts give a 2nd dose of benzathine penicillin G 2.4 million units IM one week after the initial dose.
32The optimal treatment interval in pregnancy is 7 days. If treatment occurs outside of 6–8-day intervals, the full treatment course should be restarted.
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