Sexually Transmitted Diseases Treatment Guidelines 2002
MMWR Recommendations and Reports
Volume 51, Number RR-6
Reprinted from CDC Office Of Communications
Issued Thursday, May 9, 2002
The Centers for Disease Control and Prevention (CDC) has issued national guidelines designed to help health care providers protect their patients from the health consequences that result from sexually transmitted diseases (STDs). The 2002 Guidelines for the Treatment of Sexually Transmitted Diseases integrate recommendations on the most effective treatment regimens, screening procedures and prevention strategies for STDs, which infect an estimated 15 million people each year in the United States. CDC revises the guidelines periodically (approximately every four years) using a scientific evidence-based review process. This is the fifth CDC edition of the guidelines, which were first published by CDC in 1982.
Rescreening for Chlamydia Helps Protect Young Women from Infertility
CDC has expanded its recommendation for chlamydia screening among women. These new CDC guidelines, consistent with other guidance, advise health care providers to annually screen sexually active adolescent (19 years old and under) and young adult (20- to 24 years-old) women, even if symptoms are not present, and to screen older women with a risk factor for chlamydia (a new partner or multiple sexual partners). However, it is now recommended that all women with chlamydial infections be rescreened three to four months after treatment is completed.
This is the first time CDC has recommended rescreening in the management of chlamydia. The new guidance was issued as a result of the high prevalence of chlamydia found in women who were diagnosed with the disease in the preceding several months, presumably as the result of reinfection.
Chlamydia is the most commonly reported infectious disease in the United States with 702,093 cases reported in 2000, and is asymptomatic in the majority of cases. Chlamydia is concentrated among female adolescents, who are physiologically more susceptible to a chlamydial infection than older women.
In the United States, millions of cases go unrecognized, threatening the health of young women. If not diagnosed and treated effectively, chlamydia can have serious consequences. Reinfection with chlamydial infection is a key risk factor for pelvic inflammatory disease (PID). PID can damage the fallopian tubes, uterus and ovaries, and cause chronic pelvic pain. One in five women with PID also become infertile. Moreover, women infected with chlamydia are up to five times more likely to become infected with HIV, if exposed.
Historically, chlamydia prevalence is lower in areas with long-standing screening and treatment programs. CDC's new recommendation for rescreening women diagnosed with chlamydia can help protect women from the effects of chlamydial infections and could ultimately reduce infertility in the United States.
CDC Recommends Alternative Gonorrhea Treatments in Wake of Increasing Drug Resistance in California
Gonorrhea is the second most common infectious disease reported to CDC, with nearly 360,000 cases in 2000. Drug-resistant strains are becoming increasingly common in the United States. Ciprofloxacin-resistant gonorrhea was found to be endemic to Hawaii in 2000, when CDC recommended that the state cease its use of fluoroquinolone antibiotics - ciprofloxacin, ofloxacin, and levofloxacin - for treating gonorrhea.
Now in the 2002 STD Treatment Guidelines, CDC warns providers that ciprofloxacin-resistant strains have become so common on the west coast that the use of fluoroquinolone antibiotics to treat gonorrhea is inadvisable in California. This is the first time CDC has issued this guidance in the continental United States. Previously, CDC recommended that fluoroquinolones not be prescribed for treating gonorrhea in Hawaii and in those patients who visited the island state, other Pacific Islands, or Asia, because a substantial proportion of the gonorrhea cases in those areas are resistant to ciprofloxiacin. The antibiotics cefixime and ceftriaxone are now recommended as first-line drugs to treat gonorrhea in Hawaii and California.
CDC made these new recommendations after examining data from the Gonococcal Isolate Surveillance Project (GISP), a CDC-sponsored surveillance system, which monitors drug resistance of gonorrhea. Twenty-six STD clinics participate in GISP by collecting gonorrhea cultures and submitting them to one of five regional GISP laboratories for antimicrobial susceptibility testing.
Since the GISP project is limited to several areas in the United States, it is critical that local data are available to guide prescribing recommendations. State and local public health officials must maintain the capacity to detect and monitor the prevalence of resistant strains, since prevalence can vary greatly by location. Most importantly, data from local drug susceptibility testing are necessary to guide local treatment recommendations.
To supplement GISP data, CDC requests that local and state public health professionals and health care providers report cases of gonorrhea that are resistant to any recommended antibiotics.
CDC has recommended the use of fluoroquinolone antibiotics for the treatment of gonorrhea since 1993. Previously, penicillin and tetracycline were recommended for the treatment of gonorrhea, but widespread resistance rendered these drugs ineffective. Treatment with tetracycline and penicillin was abandoned in 1985 and 1987 respectively.
If not treated successfully, gonorrhea can cause PID and can facilitate HIV transmission.
Need for Expanded Risk Assessment and Screening Among Gay and Bisexual Men
Recent data have shown a higher frequency of unprotected sex and increased rates of syphilis and gonorrhea in many U.S. cities among men who have sex with men (MSM), many of whom are HIV infected. To highlight the critical need for health care providers to expand screening and treatment of STDs among men who have sex with men (MSM), the new guidelines include detailed recommendations for this high-risk population.
The 2002 STD Treatment Guidelines urge health care providers to assess the sexual risk for all male patients, including the gender of partners. For MSM patients who are sexually active, the guidelines recommend annual screening for STDs - HIV, chlamydia (anal, urethral), syphilis and gonorrhea (anal, pharyngeal, urethral) - and vaccination against hepatitis A and B.
More frequent STD screening may be indicated for those who indicate having multiple anonymous partners or having sex in conjunction with illicit drug use.
New Serological Tests Available to Help Diagnose Genital Herpes
An estimated one million people are newly infected with the Herpes Simplex Virus (HSV) each year. While most people have mild or unrecognized symptoms and remain undiagnosed, many individuals seek medical attention when they begin to suffer from the painful ulcers characteristic of this viral disease.
Now, new testing procedures may help providers with diagnosing and managing genital herpes type one (HSV-1) or type two (HSV-2). Since antiviral therapy may benefit individuals with herpes symptoms, providers who are aware of their patient's viral serotype can tailor counseling and treatment plans to best fit their needs.
The majority of individuals with recurring genital outbreaks are infected with HSV-2, which is almost always spread during sexual contact with someone who has a genital HSV-2 infection. Patients infected with this type can choose from suppressive or episodic antiviral treatments that can prevent or shorten the duration of outbreaks. Genital HSV-1, which is often caused by oral-genital sexual contact with a person with an oral HSV-1 infection (fever blister), is much less likely to recur and treatment may only be needed in patients with initial symptoms.
Regardless of severity of symptoms, genital herpes frequently causes psychological distress in people who know they are infected. The new CDC guidelines urge providers to counsel symptomatic patients - whether they have HSV-1 or HSV-2 - about the disease, its initial and recurring manifestations, and how to avoid transmission of the virus to sexual partners and newborns. This is especially important since HSV can cause potentially fatal infections in infants if the mother is shedding virus at the time of delivery, particularly if the maternal infection was recently acquired.
HSV also may play a major role in the spread of HIV, the virus that causes AIDS. Herpes can make people more susceptible to HIV infection, and it can make HIV-infected individuals more infectious.
HSV stays in the body indefinitely and is incurable. In the United States, an estimated 50 million people are infected. For those with symptoms, resulting herpes outbreaks tend to decrease in frequency over a period of years.
Other Key Recommendations
Prevention of STDs
The guidelines encourage health care providers to focus on risk assessment and counseling in addition to the clinical aspects of STD control - screening and treatment. To assist providers with their prevention efforts, the clinical prevention guidelines have been expanded for 2002. Providers are encouraged to use client-centered counseling approaches tailored for each of their patients. To avoid the spread of STDs, the guidelines suggest patients should abstain from oral, vaginal or anal sex. Patients who are sexually active should be counseled to be in a mutually monogamous relationship with an uninfected partner or use a condom during each sexual act.
The Use of Nonoxynol-9 (N-9) - Recent studies have found that frequent use of N-9, a spermicide contraceptive, can cause genital lesions (in the vagina) and, therefore, may increase the risk of HIV transmission. It has also been found to cause damage to the lining of the rectum, providing an entry point for HIV and other STDs. According to the guidelines, spermicides - especially those that contain N-9 - should not be used for STD prevention. Furthermore, N-9 lubricants should not be used during anal intercourse.
While the level of N-9 used as a lubricant in condoms is much lower than the level found to be harmful, condoms lubricated with N-9 spermicide also are not recommended because they have a shorter shelf life, cost more and have been associated with urinary tract infections in women. However, previously purchased condoms with N-9 can be used, provided they have not passed their expiration date, since the protection provided by the condom against HIV outweighs the potential risk of N-9.
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