By: Dr. Geoffrey Modest
The CDC just updated their guidelines on the treatment of sexually transmitted diseases (see here).
They offer the usual advice to do detailed risk assessment for STDs and HIV, counseling about prevention, making sure immunizations are up to date (eg HPV, hepatitis A and B — they do limit hepatitis A vaccine to MSM, injection drug users, and those with HIV or chronic liver disease; though those of you privy to my prior blogs know that I strongly favor all getting hepatitis A vaccine, given the occasional outbreaks in the US, the increasing travel to countries where hep A is prevalent, the lack of adverse effects from the vaccine, and the fact that it is now being given to all little kids). They also comment on the use of treating HIV aggressively (treatment as prevention, also see here) and the utility of pre-exposure prophylaxis (the recent CROI meetings had several important papers on this, including the IPERGAY trial, which showed that 2 tabs of tenofovir/emtracitibine (truvada) 2-24 hours before unprotected sex in serodiscordant couples, then 1 tab in 24 hours, and another in 48 hours was stopped early because of efficacy).
Here are some of the changes over previous guidelines:
–sections on transgender men and women (noting the high prevalence of HIV in transgender women — ie, transgender male to female)
–mycoplasma genitalium, in 15-20% of male urethritis, and 30% of men with recurrent urethritis (ie more common than gonorrhea and chlamydia). Pathogenic role in women less clear, though is found in both asymptomatic and symptomatic women (10-30% of cases of clinical cervicitis and 2-22% of PID cases). Does not respond to beta-lactams such as penicillins/cephalosporins, responds inadequately to a 7-day course of doxycycline (31% cure rate), but does respond to 1-g single dose of azithromycin (though resistance is emerging). If treatment-resistant, can try moxifloxacin (400mg daily for 7,10, or 14 days). Not tested extensively, but small reports of very high cure rates. Consider 14-d course if treatment-resistant PID. Treat sex-partners.
–patients with HIV should have annual screening for hepatitis C in those at high risk for infection
–urethritis: best test for men is NAAT (nucleic acid amplification test) in urine for GC/chlamydia. Same treatment (azithro 1 gm once or doxycycline 100 bid for 7 days), though M gentalium (the most common cause of persistent or recurrent non-gonococcal urethritis) responds better to azithro (see above). Also consider trichomonas. No NAAT is FDA-approved for men, but can still do a urinary test or just treat empirically (and I have seen several cases of symptomatic presumptive trich urethritis in men, responding to treatment with metronidazole)
–cervicitis: test for cervicitis or PID with NAAT of vaginal, cervical, or urine samples (though you should check with your lab. Ours finds lower sensitivity with urine specimens). First catch urines are more sensitive, esp for chlamydia. Or can do self-collected vaginal swabs. Also evaluate women with cervicitis for BV and trichomonas. Consider treating M genitalium, as above, if persistent cervicitis after using azithro or doxycycline.
–gonorrhea: as in prior guidelines, given emergence of resistance, should be treated with both ceftriaxone 250mg IM, and azithro 1 g (though can use cefixime 400mg if ceftriaxone is not available).
–vaginal discharge: no signif changes that i detect, but they do note that BV can be associated with ureaplasma and mycoplasma, and that all women with BV should be tested for other STDs and HIV. For trich infections: 70-85% have minimal or no symptoms, 2-3x increased risk for HIV acquisition, and NAAT is the preferred diagnostic method (picking up 3-5x more infections than wet mounts). Candida: nonalbicans candida is pretty common, >50% of women with it are minimally or not symptomatic, and treatment remains unclear (?longer duration of nonfluconazole azoles, using 600mg boric acid).
–PID: now <50% associated with gonorrhea or chlamydia. Lots of “normal” vaginal microorganisms and others (mycoplasma, ureaplasma, CMV, M genitalium) have been implicated. no change in management
–HPV updated section on vaccines and alternative treatments. advised not to use podophyllin (irritation, occ severe systemic toxicity)
–anal cancer screening: data insufficient to recommend routine screening for people with HIV, MSM without HIV, general population
–section on sexual assault and abuse/STDs: pretty complete (to me), includes using NAATs for chlamydia and gonorrhea at sites of penetration, as well as trich. Also check HIV, hep B and syphilis
Overall, this is a very comprehensive, 110-page document (138-page, if include references), with pretty much everything related to STDs including clear and highlighted treatment regimens, and, I think, would be reasonable to download onto your computer desktop if you see patients with sexually transmitted diseases…