STIs in Pregnancy (OBRx)

• Recommended (pregnancy): azithromycin 1 g PO once.
• Alternative (pregnancy): amoxicillin 500 mg PO three times daily × 7 days.
• Test of cure: NAAT at 3–4 weeks after treatment completion during pregnancy.
• Retest: ~3 months after treatment (or in 3rd trimester / at delivery per risk & local protocol).

Chlamydia (pregnancy):
• Azithromycin 1 g PO once (recommended)
• Alternative: amoxicillin 500 mg PO TID x 7 days
Follow-up: test of cure NAAT 3–4 weeks after treatment; retest for reinfection at ~3 months.

• Ceftriaxone 500 mg IM once if <150 kg.
• If ≥150 kg: ceftriaxone 1 g IM once.
• If chlamydia not excluded: add pregnancy-appropriate chlamydia therapy: azithromycin 1 g PO once.

Gonorrhea — uncomplicated cervix/urethra/rectum:
• Ceftriaxone 500 mg IM once (<150 kg); if ≥150 kg: ceftriaxone 1 g IM once.
• If chlamydia not excluded (pregnancy): add azithromycin 1 g PO once.

• Ceftriaxone 500 mg IM once if <150 kg; 1 g if ≥150 kg.
• If chlamydia identified/not excluded: add azithromycin 1 g PO once (pregnancy).
• Test of cure: return 7–14 days after treatment (culture or NAAT).

Gonorrhea — uncomplicated pharynx:
• Ceftriaxone 500 mg IM once (<150 kg); if ≥150 kg: ceftriaxone 1 g IM once.
• If chlamydia not excluded/identified (pregnancy): add azithromycin 1 g PO once.
• Test-of-cure: 7–14 days (culture or NAAT).

• Ceftriaxone 1 g IM once.
• Consider one-time saline lavage of the infected eye.
• Because data are limited, consider ID consultation.

Gonococcal conjunctivitis:
• Ceftriaxone 1 g IM once.
• Consider one-time saline lavage of infected eye; consider ID consult.

Arthritis / arthritis-dermatitis syndrome

• Ceftriaxone 1 g IM or IV q24h.
• If chlamydia not excluded (pregnancy): add azithromycin 1 g PO once.
• May transition to an oral agent (guided by susceptibility) after clinical improvement for total ≥7 days.

DGI — arthritis / arthritis-dermatitis:
• Ceftriaxone 1 g IM/IV q24h.
• If chlamydia not excluded (pregnancy): add azithromycin 1 g PO once.
• Consider step-down to oral agent after improvement (guided by susceptibilities); total duration ≥7 days.
• Hospitalize/ID consult; evaluate for meningitis/endocarditis.

Meningitis or endocarditis

• Ceftriaxone 1–2 g IV q12–24h.
• Meningitis: treat 10–14 days (parenteral).
• Endocarditis: treat >4 weeks (parenteral).

DGI — meningitis / endocarditis:
• Ceftriaxone 1–2 g IV q12–24h.
• Meningitis: 10–14 days (parenteral).
• Endocarditis: >4 weeks (parenteral).
• Manage with ID consult; tailor to susceptibilities/clinical course.

• Screen at the first prenatal visit; repeat in the third trimester (often ~28 weeks) and at delivery per local policy/law and risk.
• Penicillin is the only recommended therapy in pregnancy that treats maternal infection and prevents fetal infection. If penicillin-allergic: desensitize and treat with penicillin.
• Warn about possible Jarisch–Herxheimer reaction (fever, myalgias; may trigger contractions). Do not delay treatment when indicated.

• Primary / Secondary / Early latent (<1 year):
  Benzathine penicillin G 2.4 million units IM × 1 dose. Some protocols consider an additional 2.4 million units IM dose 1 week later in pregnancy (specialist/local policy).
• Late latent (unknown duration) or latent >1 year:
  Benzathine penicillin G 2.4 million units IM weekly × 3 doses (total 7.2 million units).
• Neurosyphilis / ocular / otosyphilis:
  Aqueous crystalline penicillin G 18–24 million units/day IV (3–4 million units IV q4h or continuous infusion) × 10–14 days. Coordinate specialty evaluation (e.g., neurology/ophthalmology/ENT).

• Evaluate for neurosyphilis when indicated (symptoms/signs). If neurosyphilis present → treat with IV penicillin regimen.
• Without neurosyphilis: treat as late syphilis with benzathine penicillin G 2.4 million units IM weekly × 3 doses.
• Coordinate specialty care for end-organ disease; do not delay indicated penicillin therapy in pregnancy.

Tertiary syphilis (pregnancy):
• Evaluate for neurosyphilis/ocular/otosyphilis when indicated; if present → aqueous crystalline penicillin G IV x 10–14 days.
• If no neurosyphilis: benzathine penicillin G 2.4 million units IM weekly x 3 doses (total 7.2 million units).

• Regimens are the same as for persons without HIV (stage-based penicillin therapy).
• Ensure careful clinical + serologic follow-up; evaluate for neurologic/ocular/otic symptoms (consider CSF evaluation when indicated).
• If penicillin allergy in pregnancy: desensitize and treat with penicillin.

Syphilis with HIV (pregnancy):
• Treat with the same stage-based penicillin regimens as without HIV.
• Ensure careful serologic follow-up; evaluate neuro/ocular/otic symptoms and manage accordingly.
• Pregnancy: penicillin only (if allergic → desensitize).

Syphilis (pregnancy):
• Screen: first prenatal visit; repeat in 3rd trimester (~28 wks) and at delivery per local policy/risk.
• Treatment: penicillin only in pregnancy (if allergic → desensitize and treat with penicillin).

Regimens:
• Primary/secondary/early latent (<1 year): benzathine penicillin G 2.4 million units IM x 1 dose
  (some protocols consider an additional 2.4 million units IM dose 1 week later in pregnancy—specialist/local policy)
• Late latent/unknown duration or >1 year: benzathine penicillin G 2.4 million units IM weekly x 3 doses (total 7.2 million units)
  – Pregnancy timing rule: if >9 days between weekly doses, restart entire 3-dose series
• Neuro/ocular/otosyphilis: aqueous crystalline penicillin G 18–24 million units/day IV (3–4 million units IV q4h or continuous infusion) x 10–14 days + specialty coordination
• Tertiary (cardio/gummatous): evaluate for neurosyphilis when indicated; if none → treat as late syphilis with benzathine penicillin G weekly x3

Syphilis + HIV:
• Same stage-based penicillin regimens; ensure careful follow-up and neuro/ocular evaluation when indicated.

• Azithromycin 1 g PO once
• OR Ceftriaxone 250 mg IM once
• OR Erythromycin base 500 mg PO TID × 7 days

Chancroid:
• Azithromycin 1 g PO once
  OR ceftriaxone 250 mg IM once
  OR erythromycin base 500 mg PO TID x 7 days

• Acyclovir 400 mg PO TID × 7–10 days
• OR Famciclovir 250 mg PO TID × 7–10 days
• OR Valacyclovir 1 g PO BID × 7–10 days
• Extend therapy if healing is incomplete after 10 days.

Genital HSV — first clinical episode:
• Acyclovir 400 mg PO TID x 7–10 days
  OR famciclovir 250 mg PO TID x 7–10 days
  OR valacyclovir 1 g PO BID x 7–10 days
(extend if incomplete healing)

• Acyclovir 800 mg PO BID × 5 days or 800 mg PO TID × 2 days
• Valacyclovir 500 mg PO BID × 3 days or 1 g PO daily × 5 days
• Famciclovir options exist (see guideline) if used in your protocol.

Genital HSV — episodic therapy (recurrent):
• Acyclovir 800 mg PO BID x 5 d OR 800 mg PO TID x 2 d
• Valacyclovir 500 mg PO BID x 3 d OR 1 g PO daily x 5 d

• Acyclovir 400 mg PO BID
• OR Valacyclovir 500 mg PO daily (may be less effective if very frequent recurrences)
• OR Valacyclovir 1 g PO daily
• OR Famciclovir 250 mg PO BID

Genital HSV — suppressive therapy:
• Acyclovir 400 mg PO BID
  OR valacyclovir 500 mg PO daily
  OR valacyclovir 1 g PO daily
  OR famciclovir 250 mg PO BID

• Acyclovir 400 mg PO TID starting at 36 weeks until delivery
• OR Valacyclovir 500 mg PO BID starting at 36 weeks until delivery

HSV (pregnancy; recurrent) — suppressive therapy from 36 weeks:
• Acyclovir 400 mg PO TID starting at 36 weeks until delivery
  OR valacyclovir 500 mg PO BID starting at 36 weeks until delivery

• First episode / severe episodes may need longer therapy; use standard antivirals and reassess healing.
• Episodic (HIV): acyclovir 400–800 mg PO 2–3×/day × 5–10 days or valacyclovir 1 g PO BID × 5–10 days or famciclovir 500 mg PO BID × 5–10 days.
• Suppressive (HIV): acyclovir 400–800 mg PO 2–3×/day or valacyclovir 500 mg PO BID or famciclovir 500 mg PO BID.

Genital HSV with HIV:
Episodic:
• Acyclovir 400–800 mg PO 2–3x/day x 5–10 d OR valacyclovir 1 g PO BID x 5–10 d OR famciclovir 500 mg PO BID x 5–10 d
Suppressive:
• Acyclovir 400–800 mg PO 2–3x/day OR valacyclovir 500 mg PO BID OR famciclovir 500 mg PO BID

• Azithromycin 1 g PO weekly or 500 mg PO daily
• Treat for at least 3 weeks and until all lesions have completely healed.

Granuloma inguinale (donovanosis) — recommended:
• Azithromycin 1 g PO weekly OR 500 mg PO daily
• Treat ≥3 weeks and until lesions completely healed

• Erythromycin base 500 mg PO QID — ≥3 weeks and until healed

Granuloma inguinale — alternatives:
• Erythromycin base 500 mg PO QID ≥3 wks and until healed

• Pregnancy: erythromycin should be used; azithromycin may be considered.
• HIV: same regimens; responses may be slower—ensure close follow-up and consider specialist input.

• Women (including pregnancy): metronidazole 500 mg PO BID × 7 days.

Trichomoniasis (pregnancy):
• Metronidazole 500 mg PO BID x 7 days (women, including pregnancy)

• Only topical azole therapies, applied for 7 days, are recommended in pregnancy.
• A single 150 mg oral dose of fluconazole may be associated with adverse outcomes; therefore, it should not be used in pregnancy (per guideline discussion).

VVC (pregnancy):
• Treat with topical azole therapy x 7 days.
• Avoid oral fluconazole (e.g., single 150 mg dose) in pregnancy.

VVC (pregnancy): topical azole therapy preferred (7 days).
OTC intravaginal options:
• Clotrimazole 1% cream 5 g PV daily x 7–14 d
• Clotrimazole 2% cream 5 g PV daily x 3 d
• Miconazole 2% cream 5 g PV daily x 7 d
• Miconazole 4% cream 5 g PV daily x 3 d
• Miconazole suppository 100 mg PV daily x 7 d
• Miconazole suppository 200 mg PV daily x 3 d
• Miconazole suppository 1,200 mg PV x 1 d
• Tioconazole 6.5% ointment 5 g PV x 1 application
Rx intravaginal options:
• Butoconazole 2% bioadhesive cream 5 g PV x 1 application
• Terconazole 0.4% cream 5 g PV daily x 7 d
• Terconazole 0.8% cream 5 g PV daily x 3 d
• Terconazole suppository 80 mg PV daily x 3 d

• Azithromycin of 1 g orally once weekly for weekly for 3 weeks (limited published efficacy data on dose/duration.).
• OR erythromycin 500 mg orally 4 times per day for 21 days (GI side effects common).
• Test of cure: perform chlamydia NAAT 4 weeks after the initial NAAT-positive test.

LGV (pregnancy considerations):
• Consider macrolide approach discussed in STI guideline:
  – azithromycin 1 g PO weekly x 3 weeks (presumptive; limited published data on dose/duration)
  – OR erythromycin 500 mg orally 4 times per day for 21 days (GI side effects common).
• Test of cure: perform chlamydia NAAT 4 weeks after the initial NAAT-positive test.

NGU is typically a diagnosis in a partner (often related to chlamydia). Pregnancy care focuses on evaluating and treating the pregnant patient for CT/GC and other STIs as indicated.

• If chlamydia in pregnancy: azithromycin 1 g PO once (or amoxicillin alternative).
• During pregnancy: test of cure at 3–4 weeks; retest at ~3 months per protocol.
• Abstain until patient and partners are treated.

NGU (partner) — pregnancy context:
• Evaluate pregnant patient for CT/GC and other STIs as indicated.
• If chlamydia in pregnancy: azithromycin 1 g PO once; TOC 3–4 weeks; retest at ~3 months.
• Counsel abstinence until patient + partners treated.

Pediculosis pubis:
• Permethrin 1% cream rinse to affected areas; wash off after 10 minutes
  OR pyrethrin with piperonyl butoxide; wash off after 10 minutes

Scabies:
• Permethrin 5% cream neck-down; wash off after 8–14 hours

• Evaluate reproductive-aged survivors for pregnancy and offer emergency contraception as appropriate.
• Because follow-up can be poor, the guideline lists routine presumptive treatment regimens after assault.

Sexual assault (pregnancy-relevant):
• Evaluate for pregnancy; offer emergency contraception when appropriate.
• Empiric STI prophylaxis regimen listed in CDC guideline (female survivor):
  – ceftriaxone 500 mg IM x1 (1 g if ≥150 kg)
  – plus doxycycline 100 mg PO BID x 7 days
  – plus metronidazole 500 mg PO BID x 7 days
• Pregnancy-focused adaptation for chlamydia coverage: substitute azithromycin 1 g PO once for doxycycline when appropriate.
• HBV: provide postexposure hepatitis B vaccination (± HBIG depending on source HBsAg and survivor vaccination status).
• HIV PEP: case-by-case; if offered, start ASAP and <72 hours; 28-day course with specialist collaboration.

HBV postexposure prophylaxis (sexual exposure / assault):
• Start ASAP (preferably <24h); effectiveness window unlikely >14 days after sexual exposure.
• Source HBsAg positive + survivor unvaccinated: HBV vaccine series + HBIG.
• Source HBsAg unknown + survivor unvaccinated: HBV vaccine series.
• If vaccine series started but incomplete: complete series; HBIG if indicated.
• Sexual assault: administer vaccine (± HBIG) at initial exam; follow-up doses at 1–2 months and 4–6 months.

HIV PEP (post-sexual assault / sexual exposure):
• Assess risk; recommendations are case-by-case.
• If offering PEP: start ASAP and <72 hours after exposure; total 28-day course.
• Provide starter pack (3–7 days) + Rx for remainder, OR provide/Rx full 28-day supply.
• Baseline labs if PEP started: creatinine, AST, ALT.
• HIV testing: baseline; repeat at 6 weeks and 3 months (methods to identify acute HIV infection).
• Consult HIV specialist; counsel about PrEP for ongoing risk.