STI Updates

Gonorrhea and chlamydia management changed with the 2020 CDC STI guidelines: gonorrhea now centers on higher-dose ceftriaxone, while doxycycline has overtaken azithromycin for many chlamydial infections. Pelvic inflammatory disease is broader than GC/CT alone, and a normal self-swab does not rule it out.

Gonorrhea and Chlamydia Updates

• Ceftriaxone first-line shift: Uncomplicated urogenital, rectal, and pharyngeal gonorrhea is now treated with ceftriaxone 500 mg IM, reflecting pharmacokinetic targets and rising resistance rather than a simple preference change.
• Dual therapy abandoned: Azithromycin is no longer routine second-agent therapy for gonorrhea; the move away from dual treatment reflects stewardship concerns and poorer performance at some extragenital sites.
• Doxycycline preferred for chlamydia: Doxycycline 100 mg twice daily for 7 days now leads for suspected chlamydial coinfection, with rectal-chlamydia data showing 100% microbiologic cure versus 74% with azithromycin in one trial.
• Fallback regimens matter: Oral cefixime 800 mg is the main backup when IM ceftriaxone is not feasible, but pharyngeal gonorrhea remains the weak spot and severe allergy cases need a different plan we get into in the episode.
• No more ED one-and-done: A practical change is that STI care no longer ends with a single ED dose; every treated patient needs a prescription because companion therapy now extends beyond the visit.

PID Diagnosis and Testing Limits

• PID is polymicrobial: Pelvic inflammatory disease is not just gonorrhea and chlamydia; anaerobes, bacterial vaginosis flora, and Mycoplasma genitalium all contribute, which is why metronidazole now matters.
• Pelvic exam still essential: If PID is on the table, a pelvic exam is required because CDC minimum criteria hinge on cervical motion, uterine, or adnexal tenderness rather than lab confirmation alone.
• Self-swab has boundaries: Vaginal self-swabs perform well for cervicitis testing, with one ED study showing about 95% sensitivity, but they cannot assess for TOA, cervical friability, or pelvic tenderness.
• Urine testing sex difference: Urine NAAT performs much better in men than women for gonorrhea, with male sensitivity around 90% to 100% versus roughly 75% in women, making specimen choice clinically important.
• Upper versus lower infection: Lower-tract STI treatment and PID are no longer interchangeable: suspected upper-tract disease adds metronidazole and extends doxycycline duration. We walk through that distinction in the chapter.

Partner Therapy and Public Health

• Expedited partner therapy: Expedited partner therapy is now allowed or potentially allowed across all US states and territories, letting you treat exposed partners even when they are not in front of you.
• Partner prescription practicalities: For EPT, the prescription can simply say expedited partner therapy without the partner's name, a small workflow detail that removes a common barrier to actually breaking the reinfection cycle.
• Screening beyond symptoms: Asymptomatic infection is common enough that ED prevalence in general patients has approached 10%, which is why symptom-based testing misses a meaningful number of cases we discuss in the episode.
• Pregnancy exception remains: Azithromycin still keeps an important role in pregnancy for chlamydia, even as doxycycline becomes the default in many nonpregnant patients.

References:

1. St Cyr S, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020 Dec 18;69(50):1911-1916. PMID: 33332296.
2. Mehta SD. Gonorrhea and Chlamydia in emergency departments: screening, diagnosis, and treatment. Curr Infect Dis Rep. 2007 Mar;9(2):134-42. PMID: 17324351.
3. Cook RL, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005 Jun 7;142(11):914-25. Review. PubMed PMID: 15941699.
4. Laboratory Diagnostic Testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Association of Public Health Laboratories. Link.
5. Haggerty CL, Taylor BD. Mycoplasma genitalium: an emerging cause of pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2011;2011:959816. PMID: 22235165.
6. Dombrowski JC, et al. Doxycycline Versus Azithromycin for the Treatment of Rectal Chlamydia in Men Who Have Sex With Men: A Randomized Controlled Trial. Clin Infect Dis. 2021 Sep 7;73(5):824-831. PMID: 33606009.
7. Khosropour CM, et al. Comparing azithromycin and doxycycline for the treatment of rectal chlamydial infection: a retrospective cohort study. Sex Transm Dis. 2014 Feb;41(2):79-85. PMID: 24413484.
8. Páez-Canro C, et al. Antibiotics for treating urogenital Chlamydia trachomatis infection in men and non-pregnant women. Cochrane Database Syst Rev. 2019 Jan 25;1(1):CD010871. PMID: 30682211.
9. Kong FY, et al. Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. Clin Infect Dis. 2014 Jul 15;59(2):193-205. PMID: 24729507.