In 2010, the CDC published updated guidelines for the diagnosis and treatment of sexually transmitted diseases (STDs).1 Primary care clinicians should recognize and incorporate these new guidelines into their medical practice to provide optimal care to patients who present with STDs.
CERVICITIS
The new CDC guidelines note that women seeking treatment for new cases of cervicitis should be evaluated for signs of pelvic inflammatory disease and tested for Chlamydia trachomatis and Neisseria gonorrhoeae infections with the most sensitive and specific tests available. Nucleic acid amplification tests (NAATs) are both sensitive and specific and can be performed on vaginal, endocervical, or urine samples. Women with cervicitis should also be evaluated and treated for bacterial vaginosis (BV) and trichomoniasis if detected. Microscopic evaluation of vaginal secretions for trichomoniasis has a sensitivity of only 60% to 70% and requires immediate evaluation of the wet preparation for optimal sensitivity. Alternatives to wet preparation include a Trichomonas vaginalis culture and the FDA-approved OSOM Trichomonas Rapid Test and Affirm VPIII.
NUCLEIC ACID AMPLIFICATION TESTS
NAATs modified to detect T vaginalis in vaginal or endocervical swabs and in urine from women and men are available, including a polymerase chain reaction assay (Amplicor, Roche Diagnostic Corp.) and transcription-mediated amplification (APTIMA COMBO2 T vaginalis Analyte Specific Reagent (ASR), Gen-Probe, Inc.) at laboratories that have conducted the necessary Clinical Laboratory Improvement Act verification studies. Both NAATs are FDA-approved for the detection of C trachomatis and N gonorrhoeae and have high sensitivities and acceptable specificities for the detection of T vaginalis in men, for whom diagnostic tests are severely limited, as well as women. The guidelines recommend that women infected with HIV should receive routine screening at the time of entry into care and annually, and the 7-day metronidazole regimen (500 mg orally twice a day) should be considered for use over the 2-g single stat dose in this population.
BACTERIAL VAGINOSIS
The new CDC guidelines note that BV can be diagnosed clinically or by Gram stain, and treatment is now recommended for all women with symptoms of BV. New regimens include tinidazole 2 g daily for 2 days and tinidazole 1 g daily for 5 days. Since recurrence of BV remains a problem, several suppressive regimens are discussed.
GENITAL WARTS
Genital warts are frequently asymptomatic but when painful or pruritic should be treated to ameliorate symptoms and remove the warts. In most patients, treatment can produce wart-free periods.1 Sinecatechins 15% ointment, a green tea extract with an active product (catechins), has been added to the list of recommended regimens. The CDC recommends that females and males ages 9 to 26 years receive HPV vaccination prior to sexual debut (Gardasil for males and females; Cervarix for females) in order to maximize benefit from the vaccine. However, persons in the designated age range who are already sexually active, as well as those who have had genital warts and/or abnormal findings on Pap smears, should still receive HPV vaccination.
AZITHROMYCIN
Studies have previously shown that azithromycin is safe and effective for the treatment of chlamydia infection in pregnant women. Given the severe sequelae that are possible in mothers and neonates if the infection persists, the CDC now recommends testing for eradication 3 weeks after the completion of therapy with a single dose of 1 g azithromycin orally or amoxicillin 500 mg orally 3 times a day for 7 days. When chlamydial infection is diagnosed during the first trimester of pregnancy, the patient should be retested 3 months after treatment.
The CDC also addresses the absence of a recognized pathogen in many cases of nonchlamydial, nongonococcal urethritis (NGU), particularly in cases that fail to respond to recommended first-line therapy. Mycoplasma genitalium is believed to produce symptoms of urethritis and urethral inflammation and accounts for 15% to 25% of NGU cases in the United States.1 While azithromycin and doxycycline are effective for treating chlamydial urethritis and cervicitis, infections with M genitalium respond better to azithromycin.1 Recurrent and persistent NGU should be treated with an agent that is active against T vaginalis plus azithromycin (if not used for the initial episode). Moxifloxacin 400 mg orally once daily may be considered in men with a low likelihood of trichomonas infection (eg, men who have sex with men [MSM]).
GI SYNDROMES
Proctocolitis, a sexually transmitted GI syndrome, can be associated with symptoms of proctitis, diarrhea, or abdominal cramps and inflammation of the colonic mucosa extending from the anus to 12 cm within the rectum. Depending on the pathogen involved, fecal leukocytes may or may not be detected on stool examination. When painful perianal ulcers are present or mucosal ulcers are detected on anoscopy, the CDC recommends presumptive therapy that includes—in addition to coverage with ceftriaxone 250 mg IM once for N gonorrhoeae—a regimen for genital herpes and lymphogranuloma venereum (LGV), an infection caused by C trachomatis serovars L1, L2, or L3. Diagnostic testing for LGV should be conducted in accordance with state or federal guidelines, and the recommended treatment is doxycycline 100 mg orally twice daily for 3 weeks.
SYPHILIS
CNS involvement can occur during any stage of syphilis infection. CSF laboratory abnormalities are common in persons with early syphilis, even in the absence of clinical neurological findings, but no evidence exists to support changes in the recommended treatment regimen for these patients. A CSF examination is recommended if clinical evidence of neurologic involvement is observed regardless of stage, in the setting of symptomatic late syphilis and treatment failure. When CSF pleocytosis is initially present, a CSF examination should be repeated every 6 months until the cell count returns to normal. If the cell count has not decreased after 6 months or if the CSF cell count or protein is not normal after 2 years, retreatment should be considered.1
Parenterally administered penicillin G is the preferred drug to treat all stages of syphilis, and it is the only therapy with documented efficacy for the treatment of syphilis during pregnancy. Azithromycin as a single 2-g oral dose has been utilized as an alternative regimen for early syphilis in patients allergic to penicillin; this regimen should be used only when treatment with penicillin or doxycycline is not feasible.
GONORRHEA
The CDC now recommends single-dose ceftriaxone 250 mg IM injection, which extensive clinical experience has proven to be safe and effective for the treatment of uncomplicated gonorrhea at all anatomic sites. Ceftriaxone can cure 99.2% of uncomplicated urogenital and anorectal infections and 98.9% of pharyngeal infections.1 The new guidelines emphasize the inadequacy of available oral cephalosporins to treat gonococcal infections of the pharynx and indicate that all gonorrhea treatments should be dispensed on site.
HEPATITIS C
Although mainly contracted through injection drug use, recent data indicate that hepatitis C virus (HCV) infection obtained through sexual contact may be more prevalent than previously thought, especially among HIV-infected persons. CDC data demonstrate that 10% of persons with acute HCV infection report contact with a known HCV-infected sex partner as their only risk for infection.1 Sexual transmission of HCV has been reported recently among HIV-infected MSM in numerous European cities and in New York City. Common practices associated with these clusters that may account for transmission of the infection include serosorting, group sex, and the use of cocaine and other non-IV drugs during sex. Unprotected sexual contact is also believed to facilitate the spread of HCV.
SEXUAL ASSAULT EVALUATION
The guidelines suggest that the decision to obtain genital and other specimens for STD diagnosis should be made on an individual basis during the initial evaluation; laws in all 50 states dictate the specific format of the procedure. Clinicians should be aware that an identified STD may have been acquired prior to the assault and should recognize the importance of properly managing the patient's psychological and medical issues regardless.
Trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydial infection are the most frequently diagnosed infections in sexually assaulted women. If the patient or clinician decides to defer testing during the initial encounter, prophylactic treatment should still be provided. Compliance with follow-up visits is poor among sexual assault victims, so the CDC recommends that all patients receive preventive therapy. In addition, sexual assault victims should be assessed for postexposure HIV prophylaxis if they present within 72 hours of the incident.
COMMENT
As always, these revised recommendations should be considered a source of clinical guidance rather than an absolute prescriptive standard. The CDC notes that these guidelines are applicable to care settings that include family-planning clinics, private physicians' offices, managed care organizations, and other facilities involved in the practice of primary care medicine. JAAPA
Patricia Jennings is a professor and program director of the Surgical Physician Assistant Program at the University of Alabama, Birmingham. Laura Bachmann is an associate professor of medicine, infectious diseases section, at the W.G. (Bill) Hefner VA Medical Center in Salisbury and at Wake Forest University Baptist Medical Center in Winston-Salem, both in North Carolina. The authors have indicated no relationships to disclose relating to the content of this article.
REFERENCE
1. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.