CDC Issues 2010 Treatment Guidelines for Sexually Transmitted Diseases

Laurie Barclay, MD

December 17, 2010 — The US Centers for Disease Control and Prevention (CDC) has issued updated Sexually Transmitted Diseases (STDs) Treatment Guidelines, published in the December 17 issue of the Morbidity and Mortality Weekly Report.

"The term [STDs] is used to refer to a variety of clinical syndromes caused by pathogens that can be acquired and transmitted through sexual activity," write Kimberly A. Workowski, MD, from the Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, and colleagues. "Physicians and other health-care providers play a critical role in preventing and treating STDs. These guidelines for the treatment of STDs are intended to assist with that effort."

Estimated annual US prevalence of STD infections is 19 million. Without treatment, complications of STDs may include infertility and heightened risk for HIV infection. The present guidelines represent an update of CDC's 2006 recommendations, based on consultation with a group of experts knowledgeable in the area of STDs who were convened in Atlanta on April 18 to 30, 2009.

These guidelines were developed to offer recommendations for the treatment of persons who have or who are at risk for STDs, including human papillomavirus virus (HPV) and gonorrhoea, with updated information regarding the most effective treatment regimens, screening strategies, prevention, and vaccination schedules.

Prevention and control of STDs are based on 5 major strategies:

• educating and counseling persons at risk on strategies to reduce risk for STDs by changing sexual behaviors and using recommended prevention services;


• diagnosing asymptomatic infected persons and symptomatic persons who are unlikely to obtain diagnostic and management services;


• accurately diagnosing and effectively treating and counseling persons infected with STDs;


• evaluating, treating, and counseling sex partners of persons infected with an STD; and


• pre-exposure vaccination of persons at risk for vaccine-preventable STDs.

Although HPV is the most prevalent STD, most infected individuals remain asymptomatic, and in 90% of cases, the infection resolves spontaneously within 2 years. In other cases, genital warts or cervical cancer may result, depending on the HPV strain. HPV testing can be incorporated into cervical cancer screening among women older than 30 years but is not recommended for women younger than 20 years or for men.

One of the most effective methods of preventing HPV transmission is preexposure vaccination. To prevent cervical precancerous lesions and cancer, 2 types of HPV vaccines are licensed for females aged 9 through 26 years: bivalent HPV vaccine (Cervarix; GlaxoSmithKline) and quadrivalent HPV vaccine (Gardasil; Merck), which also prevents genital warts.

Routine vaccination with either bivalent or quadrivalent HPV vaccine is recommended for girls aged 11 or 12 years, and catch-up vaccination is recommended for females aged 13 through 26 years. Males aged 9 through 26 years may also be vaccinated with quadrivalent HPV vaccine to prevent genital warts.

Reported rates of gonorrhea are at the lowest recorded in US history, but bacterial resistance has developed and is increasing to fluoroquinolones and other antimicrobial classes recommended for treatment of Neisseria gonorrhoeae. The current recommended treatment for gonorrhea is cephalosporins, which are still effective among patients in the United States, but Southeast Asia has experienced treatment failures with oral cephalosporins. Based on previous experience with antibiotic-resistant gonorrhea, the CDC anticipates that resistant strains may spread to the United States, and therefore offers updated treatment recommendations in the 2010 guidelines.

For urogenital gonorrheal infection, the new recommendations are for ceftriaxone 250 mg intramuscularly or cefixime 400 mg orally. Treatment with azithromycin or doxycycline is recommended to cover the likelihood of coinfection with Chlamydia trachomatis in patients with gonorrhoeal infection.

Azithromycin in 1 dose has also been shown to be clinically effective for treatment of chlamydial infections in pregnancy. Pregnant women should be tested again for chlamydia 3 weeks after treatment, and women treated in the first trimester should be tested again 3 months later. Annual screening for chlamydia infection is recommended for sexually active women beginning at age 25 years or younger, using nucleic acid amplification samples from the urine, vagina, or endocervix.

Updated information and recommendations in the new guidelines also include the following:

• expanded diagnostic evaluation for cervicitis, including testing for C trachomatis and N gonorrhoeae by nucleic acid amplification, and testing for bacterial vaginosis (BV) and trichomoniasis;


• new treatment recommendations for BV (metronidazole 500 mg orally twice a day for 7 days, or metronidazole gel 0.75%, 1 full applicator [5 g] intravaginally, once a day for 5 days, or clindamycin cream 2%, 1 full applicator [5 g] intravaginally, at bedtime for 7 days) and for genital warts (including waiting for spontaneous resolution, or podofilox 0.5% solution or gel, or imiquimod 5% cream, or sinecatechins 15% ointment);


• the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications (for nongonococcal urethritis not caused by C trachomatis, single-dose azithromycin or doxycycline for 7 days, followed by single-dose metronidazole or tinidazole if symptoms persist);


• lymphogranuloma venereum proctocolitis among men who have sex with men;


• criteria for spinal fluid examination to evaluate for neurosyphilis;


• emergence of azithromycin-resistant Treponema pallidum — azithromycin should not be routinely used to treat syphilis, which is still best treated with penicillin or with a 14-day course of doxycycline in penicillin-allergic patients;


• recognition of an increased role for sexual transmission of hepatitis C, especially in individuals coinfected with HIV;


• diagnostic evaluation after sexual assault by an experienced clinician in a manner that minimizes further trauma, with the decision to obtain genital or other specimens for STD diagnosis to be made on an individual basis;


• prophylaxis and treatment after sexual assault including postexposure hepatitis B vaccination without hepatitis B immune globulin, and one-time antibiotic treatment with ceftriaxone or cefixime, metronidazole, and azithromycin; and


• STD prevention approaches, including abstinence and reduction of number of sex partners, preexposure vaccination (including against hepatitis A and B), barrier methods, male circumcision, and high-intensity behavioral counseling for all sexually active adolescents and for adults at increased risk for STDs and HIV.

"These recommendations should be regarded as a source of clinical guidance and not prescriptive standards; health-care providers should always consider the clinical circumstances of each person in the context of local disease prevalence," the guidelines authors write. "They are applicable to various patient-care settings, including family-planning clinics, private physicians' offices, managed care organizations, and other primary-care facilities. These guidelines focus on the treatment and counseling of individual patients and do not address other community services and interventions that are essential to STD/human immunodeficiency virus (HIV) prevention efforts."

Morb Mortal Wkly Rep. 2010;59:1-109.

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