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TREATMENT OF STDS:
Updated guidelines from the CDC
Who should read this?
All PAs who see patients who are at risk for, or exposed to, sexually transmitted diseases (STDs).
What’s new?
More than 18 million cases of STDs are diagnosed annually. Of these, at least half occur in persons 25 years or younger, and a disproportionate share occur in racial and ethnic minorities. In 2006, the CDC developed evidence-based guidelines on screening, treating, and preventing STDs (www.cdc.gov/std/treatment/).
Why are these new guidelines important?
FIRST, they provide greater emphasis on education, counseling, and prevention of STDs—including HIV infection
—and unintended pregnancies. Strategies include identifying and treating infected persons, partners of infected persons, and those unlikely to seek treatment; reducing risk through abstinence, limiting sex partners, vaccinations, condom use, and use of emergency contraception (EC); and providing pre-exposure vaccination. To help clinicians elicit important information from the sexual history, the CDC recommends a technique called The Five Ps of Sexual Health (see Table 1).
Pre-exposure vaccination is one of the most effective methods of preventing the transmission of viral STDs. The hepatitis A vaccine is recommended for men who have sex with men (MSM) and illicit drug users. Hepatitis B virus (HBV) is frequently sexually transmitted, and vaccination is recommended for all persons being evaluated for an STD. The recent vaccine against human papillomavirus is recommended for females aged 9 to 26 years.
Voluntary screening for HIV should be routine for all patients aged 13 to 64 years. An agreement for HIV screening should be included as a part of the general consent for care. However, patients should also be informed orally or in writing and given the opportunity to refuse testing. All patients who seek evaluation and treatment for STDs should also be screened for HIV. Patients should be provided with information about HIV, the meaning of test results, and an opportunity to have their questions answered.
SECOND, the guidelines stress the role of herpes simplex virus (HSV) typing in counseling and prognosis. Genital HSV infection affects up to 50 million persons in the United States,1 resulting in a chronic, lifelong condition. HSV-1 and HSV-2 are the two types of HSV; confirming the type is important for proper counseling. The majority of cases of recurrent genital herpes are caused by HSV-2, although up to 50% of first episodes of genital herpes are caused by HSV-1.1
Most patients transmit the virus when the infection has not been diagnosed and/or there are no symptoms. Containing the spread of HSV-2 includes using type-specific serologic and virologic testing for diagnosis and treating the initial infection with antiviral agents. Daily valacyclovir as maintenance therapy can decrease (but not eliminate) the risk of HSV-2 viral shedding and sexual transmission.
THIRD, the guidelines discuss the emergence of lymphogranuloma venereum (LGV) proctolitis among MSM. LGV is caused by Chlamydia trachomatis and manifests as tender lymphadenopathy and, occasionally, a self-limited ulceration at the site of inoculation. Rectal exposure during active infection can lead to LGV proctolitis. If not treated early, this condition can produce chronic colorectal fistulas and strictures. Doxycycline is used for treatment.
FOURTH, the emergence of Treponema pallidum resistant to azithromycin is discussed.
Penicillin G is the preferred treatment for all stages of syphilis, but a single 2-g dose of azithromycin has been used for penicillin-allergic patients. Treatment failures and drug resistance have been reported. The CDC now recommends that patients be treated with alternative therapies and followed closely to ensure resolution of the infection.
FIFTH, postexposure prophylaxis (PEP) using an empiric antimicrobial regimen is recommended after sexual assault. Postexposure HBV vaccination should be provided, and EC should also be offered. Although a definitive statement of benefit cannot be made regarding PEP after sexual assault, the possibility of HIV exposure from the assault should be assessed at the time of the postassault examination. The risk of acquiring HIV after sexual assault is thought to be low; however, each case must be assessed individually, and PEP should be offered whenever appropriate. If initiated, PEP should be started as soon as possible.
 SIXTH, the diagnostic evaluation for cervicitis and trichomoniasis is expanded. Cervicitis is common and can be caused by C trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, or HSV. In many cases, no organism can be identified. Thus the cervicitis might be due to other causes, including (but not limited to) endometriosis. All women who present with a new episode of cervicitis should be assessed for signs of pelvic inflammatory disease and tested for chlamydia and gonorrhea with the most sensitive diagnostic test available, nucleic acid amplification testing. This can be performed on either urine or cervical swabs. If trichomoniasis is not identified, a finding of greater than 10 WBCs in vaginal fluid may indicate inflammation caused by
C trachomatis or N gonorrhoeae and should be treated.
FINALLY, new treatment recommendations for trichomoniasis include metronidazole (oral therapy for 7 days or vaginal cream applied for 5 days), clindamycin (oral therapy for 7 days or vaginal ovules or cream used for 3-7 days) or tinidazole, 2 g orally as a single dose. Single-dose metronidazole is no longer recommended.
What else is important to know?
New recommendations for treating gonorrhea have been released since
the 2006 guidelines were published. Fluoroquinolones (ciprofloxacin, ofloxacin, or levofloxacin) are no longer recommended for the treatment of gonococcal infections owing to widespread resistance.2 Based on recent evidence, the CDC recommends that only cephalosporins be used to treat gonorrhea.
REFERENCES
1. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1-94.
2. Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rpt. 2007;56(14):332-336.
The members and staff of CSAC include Deborah A. Gerbert, PA-C; Cynthia Goetz, PA-C; Lawrence M. Herman, MPA, PA-C; Lyle W. Larson, PhD, PA-C; Marie-Michèle Léger, MPH, PA-C; Robert McNellis, MPH, PA-C; Daniel L. O'Donoghue, PhD, PA-C; and Eileen M. Van Dyke, MPS, PA-C. This article was written by Cynthia Goetz, PA-C, and edited by Sarah Zarbock, PA-C.
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