Am Fam Physician. 2007;75(4):560-566
Guideline source: Centers for Disease Control and Prevention
Literature search described? Yes
Evidence rating system used? No
Published source: Morbidity and Mortality Weekly Report, August 4, 2006
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
The Centers for Disease Control and Prevention (CDC) updated its 2002 guidelines for the treatment of sexually transmitted diseases (STDs) after consultation with professionals and a systematic review of the evidence. The updated guidelines contain new approaches to patient-centered counseling, expanded discussions of prevention screening for human immunodeficiency virus (HIV) and other STDs, and several diagnosis and treatment updates, discussed below.
Approaches to Prevention
The five strategies for the prevention of STDs are: (1) education and counseling of persons at risk; (2) identification of infected persons who are asymptomatic and those who are symptomatic but unlikely to seek treatment; (3) effective diagnosis and treatment of infected persons; (4) evaluation, treatment, and counseling of sex partners of infected persons; and (5) preexposure vaccination of persons at risk, when possible.
Physicians should routinely obtain sexual histories from patients and address risk-reduction management. A thorough sexual history and effective delivery of prevention messages require counseling skills marked by respect, compassion, and a nonjudgmental attitude. Effective techniques include the use of open-ended questions (e.g., “Tell me about any sex partners you've had since your last visit,” “What has your experience with using condoms been like?”), understandable language (e.g., “Have you ever had a sore or scab on your penis?”), and normalizing language (e.g., “Some of my patients have difficulty always using a condom. How is it for you?”). One approach to obtaining information is the Five Ps: Partners, Prevention of pregnancy, Protection from STDs, Practices, and Past history of STDs (Table 1).
| Partners |
| “Do you have sex with men, women, or both?” |
| “In the past two months, how many partners have you had sex with?” |
| “In the past 12 months, how many partners have you had sex with?” |
| Prevention of pregnancy |
| “Are you or your partner trying to get pregnant?” |
| If the answer is no, “What are you doing to prevent pregnancy?” |
| Protection from STDs |
| “What do you do to protect yourself from STDs and HIV?” |
| Practices |
| “To understand your risks of STDs, I need to understand the kind of sex you have had recently.” |
| “Have you ever had vaginal sex, meaning ‘penis in vagina sex’?” |
| If the answer is yes, “Do you use condoms never, sometimes, or always?” |
| “Have you had anal sex, meaning ‘penis in rectum/anus sex’?” |
| If the answer is yes, “Do you use condoms never, sometimes, or always?” |
| “Have you had oral sex, meaning ‘mouth on penis or vagina’?” |
| For answers to condom questions: |
| If the answer is never, “Why don't you use condoms?” |
| If the answer is sometimes, “In what situations, or with whom, do you not use condoms?” |
| Past history of STDs |
| “Have you ever had an STD?” |
| “Have any of your partners had an STD?” |
| Additional questions to identify HIV and hepatitis risk: |
| “Have you or your partners ever injected drugs?” |
| “Have you or your partners exchanged money or drugs for sex?” |
| “Is there anything else about your sexual practices that I need to know about?” |
Prevention counseling should incorporate risk-reduction messages that are relevant to the patient as well as education about specific actions that can reduce STD risk, such as abstinence, condom use, fewer sex partners, modifying sexual behaviors, and vaccination when appropriate. Guidance on prevention counseling and effective interventions is available at http://www.stdhivpreventiontraining.org and http://effectiveinterventions.org.
Physicians should reassure patients that treatment will be provided regardless of their circumstances (e.g., ability to pay). Although many patients requiring screening or treatment for one specific STD should be assessed for all common STDs, patients should be informed of all STDs for which they are being tested and of common STDs for which testing is not being performed.
HIV Screening
All persons who seek evaluation and treatment for STDs should be screened for HIV infection, regardless of risk factors. Consent for HIV testing should be incorporated into the general consent for care. HIV testing must be voluntary and conducted only with the patient's knowledge and understanding. However, it should be performed on an opt-out basis—patients should be informed orally or in writing that, unless they decline, HIV testing will be performed. An explanation of positive and negative test results should be given, and patients should have the opportunity to ask questions and decline testing.
HIV testing may be a good opportunity for prevention counseling to encourage and help with behavior changes; prevention counseling should be encouraged at all facilities that serve patients at high risk or that routinely obtain information on HIV risk behaviors.
HIV rapid testing allows a presumptive diagnosis of HIV-1 infection within 30 minutes and must be considered, particularly in clinics where many patients do not return for results. Positive results for HIV antibody screening must be confirmed by an additional test, such as the Western blot or an immunofluorescence assay. Patients with positive results on confirmatory tests must be given initial HIV prevention counseling before they leave the testing site. They should also receive a medical evaluation and, if indicated, behavioral and psychological services or a referral for these services.
Physicians should be alert to acute retroviral syndrome, which often occurs in the first few weeks after HIV infection, and should perform nucleic acid testing for HIV if indicated. Symptoms and signs of acute retroviral syndrome include fever, malaise, lymphadenopathy, and skin rash. HIV infection may be more easily transmitted in acutely infected persons, and these persons may still be practicing risky behaviors. Patients with recently acquired HIV infection may benefit from antiretroviral drugs and could be candidates for clinical trials; therefore, these patients should be referred for immediate consultation with an HIV subspecialist.
Because the incidence of STDs has increased in persons infected with HIV, consensus guidelines emphasize that STD and HIV risk assessment, STD screening, and patient-centered risk-reduction counseling should be provided routinely to all patients with HIV infection. Specific approaches for HIV care are described at http://effectiveinterventions.org.
Treatment
A summary of treatment recommendations for select conditions is provided in Table 2. Physicians should refer to the full guidelines for recommendations on the treatment of syphilis.
| Indication | Recommended treatments | |
|---|---|---|
| Bacterial vaginosis | ||
| Nonpregnant patients | Metronidazole (Flagyl) 500 mg orally two times per day for seven days | |
| Metronidazole 0.75% gel 5 g (one full applicator) intravaginally once per day for seven days | ||
| Clindamycin (Cleocin) 2% cream 5 g (one full applicator) intravaginally at bedtime for seven days | ||
| Alternatives: | ||
| Clindamycin 300 mg orally two times per day for seven days | ||
| Clindamycin ovules 100 mg intravaginally once at bedtime for three days | ||
| Pregnant patients | Metronidazole 500 mg orally two times per day for seven days | |
| Metronidazole 250 mg orally three times per day for seven days | ||
| Clindamycin 300 mg orally two times per day for seven days | ||
| Cervicitis, presumptive | Azithromycin (Zithromax) 1 g orally in a single dose | |
| Doxycycline (Vibramycin) 100 mg orally two times per day for seven days plus consider concurrent treatment for gonococcal infection | ||
| Chancroid | Azithromycin 1 g orally in a single dose | |
| Ceftriaxone (Rocephin) 250 mg IM in a single dose | ||
| Ciprofloxacin (Cipro) 500 mg orally two times per day for three days | ||
| Erythromycin base 500 mg orally three times per day for seven days | ||
| Chlamydia | ||
| Nonpregnant adults | Azithromycin 1 g orally in a single dose | |
| Doxycycline 100 mg orally two times per day for seven days | ||
| Alternatives: | ||
| Erythromycin base 500 mg orally four times per day for seven days | ||
| Erythromycin ethylsuccinate 800 mg orally four times per day for seven days | ||
| Ofloxacin (Floxin) 300 mg orally two times per day for seven days | ||
| Levofloxacin (Levaquin) 500 mg orally once per day for seven days | ||
| Pregnant women | Azithromycin 1 g orally in a single dose | |
| Amoxicillin 500 mg orally three times per day for seven days | ||
| Alternatives: | ||
| Erythromycin base 500 mg orally four times per day for seven days | ||
| Erythromycin base 250 mg orally four times per day for 14 days | ||
| Erythromycin ethylsuccinate 800 mg orally four times per day for seven days | ||
| Erythromycin ethylsuccinate 400 mg orally four times per day for 14 days | ||
| Epididymitis, acute | ||
| Caused by gonococcal or chlamydial infection | Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally two times per day for 10 days | |
| Caused by enteric organisms | Ofloxacin 300 mg orally two times per day for 10 days | |
| Levofloxacin 500 mg orally once per day for 10 days | ||
| Gonococcal infection, genital | Ceftriaxone 125 mg IM in a single dose | |
| Cefixime (Suprax) 400 mg orally in a single dose | ||
| Ciprofloxacin 500 mg orally in a single dose* | ||
| Ofloxacin 400 mg orally in a single dose* | ||
| Levofloxacin 250 mg orally in a single dose*plus treatment for chlamydial infection, if not ruled out | ||
| Granuloma inguinale (donovanosis) | Doxycycline 100 mg orally twice per day for at least three weeks and until all lesions have healed completely | |
| Alternatives: | ||
| Azithromycin 1 g orally once per week for at least three weeks | ||
| Ciprofloxacin 750 mg orally two times per day for at least three weeks | ||
| Erythromycin base 500 mg orally four times per day for at least three weeks | ||
| Trimethoprim/sulfamethoxazole (Bactrim, Septra) 160/800 mg (one double-strength tablet) orally two times per day for at least three weeks | ||
| Herpes, genital | ||
| First episode | Acyclovir (Zovirax) 400 mg orally three times per day for seven to 10 days | |
| Acyclovir 200 mg orally five times per day for seven to 10 days | ||
| Famciclovir (Famvir) 250 mg orally three times per day for seven to 10 days | ||
| Valacyclovir (Valtrex) 1 g orally twice per day for seven to 10 days | ||
| note: Treatment can be extended if healing is incomplete after 10 days of therapy | ||
| Suppressive therapy | Acyclovir 400 mg orally twice per day | |
| Famciclovir 250 mg orally twice per day | ||
| Valacyclovir 500 mg orally once per day | ||
| Valacyclovir 1 g orally once per day | ||
| Recurrent therapy | Acyclovir 400 mg orally three times per day for five days | |
| Acyclovir 800 mg orally twice per day for five days | ||
| Acyclovir 800 mg orally three times per day for two days | ||
| Famciclovir 125 mg orally two times per day for five days | ||
| Famciclovir 1 g orally two times per day for one day | ||
| Valacyclovir 500 mg orally two times per day for three days | ||
| Valacyclovir 1 g orally once per day for five days | ||
| Lymphogranuloma venereum | Doxycycline 100 mg orally two times per day for 21 days | |
| Alternative: | ||
| Erythromycin base 500 mg orally four times per day for 21 days | ||
| Pelvic inflammatory disease | ||
| Parenteral | Cefotetan (Cefotan) 2 g IV every 12 hours plus doxycycline 100 mg orally (preferred) or IV every 12 hours | |
| Cefoxitin (Mefoxin) 2 g IV every six hours plus doxycycline 100 mg orally (preferred) or IV every 12 hours | ||
| Clindamycin 900 mg IV every eight hours plus gentamicin loading dose 2 mg per kg IV or IM then maintenance dose 1.5 mg per kg every eight hours (single daily dosing may be substituted) | ||
| Alternatives: | ||
| Levofloxacin 500 mg IV once per day*with or without metronidazole 500 mg IV every eight hours | ||
| Ofloxacin 400 mg IV every 12 hours*with or without metronidazole 500 mg IV every eight hours | ||
| Ampicillin/sulbactam (Unasyn) 3 g IV every six hours plus doxycycline 100 mg orally or IV every 12 hours | ||
| Oral | Levofloxacin 500 mg orally once per day for 14 days* | |
| Ofloxacin 400 mg orally two times per day for 14 days* | ||
| Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally two times per day for 14 days | ||
| Cefoxitin 2 g IM in a single dose and probenecid 1 g orally in a single dose administered concurrently plus doxycycline 100 mg orally two times per day for 14 days | ||
| Other parenteral third-generation cephalosporin (e.g., ceftizoxime, cefotaxime) plus doxycycline 100 mg orally two times per day for 14 days with or without metronidazole 500 mg orally two times per day for 14 days | ||
| Prophylaxis after sexual assault | Ceftriaxone 125 mg IM in a single dose | |
| Metronidazole 2 g orally in a single dose | ||
| Azithromycin 1 g orally in a single dose | ||
| Doxycycline 100 mg orally two times per day for seven days | ||
| Trichomoniasis | Metronidazole 2 g orally in a single dose | |
| Tinidazole (Tindamax) 2 g orally in a single dose | ||
| Alternative: | ||
| Metronidazole 500 mg orally two times per day for seven days | ||
| Urethritis, nongonococcal | Azithromycin 1 g orally in a single dose | |
| Doxycycline 100 mg orally two times per day for seven days | ||
| Alternatives: | ||
| Erythromycin base 500 mg orally four times per day for seven days | ||
| Erythromycin ethylsuccinate 800 mg orally four times per day for seven days | ||
| Ofloxacin 300 mg orally two times per day for seven days | ||
| Levofloxacin 500 mg orally one per day for seven days | ||
Updates to diagnosis and treatment recommendations include expanded diagnostic evaluations for cervicitis and trichomoniasis, as well as discussion of the roles of Mycoplasma genitalium and trichomoniasis in urethritis and cervicitis. Urethritis with M. genitalium infection may respond better to azithromycin (Zithromax) than doxycycline (Vibramycin). Recommended treatment regimens for persistent urethritis include tinidazole (Tindamax) and the addition of azithromycin. Tinidazole also is recommended for treatment of trichomoniasis.
The new guidelines cite further data on the effectiveness of azithromycin for chlamydial infection during pregnancy, and azithromycin is the primary recommended regimen for this indication. The increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in men who have sex with men is discussed, with new recommendations for treating gonococcal infections in these patients (the CDC Web site contains up-to-date information on quinolone resistance at http://www.cdc.gov/std/gisp).
Other additions include expanded discussion of the criteria for spinal fluid examination in neurosyphilis evaluation; new discussions of lymphogranuloma venereum proctocolitis in men who have sex with men and the emergence of azithromycin-resistant Treponema pallidum; and revised discussions of the sexual transmission of hepatitis C and postexposure prophylaxis after sexual assault.