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Changes in the 2010 STD Treatment Guidelines:
What Adolescent Health Care Providers Should Know
Over 19 million cases of sexually transmitted diseases (STDs) occur in
the United States each year, with a disproportionate share among young
people and racial and ethnic minority populations. The estimated annual
direct medical costs of treating STDs and their sequelae are $17.0
billion. Left untreated, STDs can cause serious health problems ranging
from infertility to increased risk of HIV infection.
To stop these silent epidemics, the 2010 STD Treatment
Guidelines1, which update the 2006 Guidelines,
advise healthcare providers who play a critical role in preventing and
treating STDs on the most effective treatment regimens, screening
procedures, and prevention and vaccination strategies for STDs. The
recommendations are developed in consultation with public and private
sector professionals knowledgeable in the treatment of patients with
sexually transmitted infections. CDC revises the Guidelines
periodically, approximately every three to four years, using a
scientific, evidence-based process.
This page highlights changes that are important for clinicians who
care for adolescents.
Special Populations:
The CDC Sexually Transmitted Diseases (STD)
Treatment Guidelines addresses STD screening and management needs for
specific populations that may be at risk. Below are summary of several
of the changes found in the 2010 Guidelines.
Adolescents
Prevalence rates of many sexually acquired
infections are highest among adolescents. CDC updated recommendations
for screening and prevention of asymptomatic adolescents.
Recommendations include:
Screening
• Annual C. trachomatis screen for all sexually active females aged ?25 years. Clinicians may consider screening adolescent/young adult males in clinical settings associated with high chlamydia prevalence (e.g., adolescent clinics, correctional facilities and STD clinics).
• Annual N. gonorrhoeae screen for all sexually active females at risk for infection. Females aged <25 years are at highest risk for gonorrhea infection.
• Discuss HIV screening with all adolescents and encourage testing for those who are sexually active and who use injection drugs.
• Routine screening of adolescents who are asymptomatic for certain STDs (e.g., syphilis, trichomoniasis, BV, HSV, HPV, HAV, and HBV) is not recommended. However, young men who have sex with men and pregnant adolescent females might require more thorough evaluation.
• Cervical cancer screening should begin at age 21 years.
Prevention
• Encourage immunizations, including human papillomavirus, and hepatitis A and B virus.
• Provide information regarding HIV infection, testing, transmission and implications of infection to all adolescents as part of health care.
• Integrate sexuality education into clinical practice. The U.S. Preventive Services Task Force recommends high-intensity behavioral counseling to prevent STDs for all sexually active adolescents.
Persons in Correctional Facilities
CDC added a new
section to present recommendations for “Persons in Correctional
Facilities.” Persons entering correctional facilities have high
STDs rates, especially chlamydia and gonorrhea among females under 35
years of age. Testing for gonorrhea and chlamydia facilitates
identification and treatment of persons with undetected infections and
reduces prevalence among detainees who are released back into the local
community. Therefore, chlamydia and gonorrhea screening for all females
up to age 35 years is recommended. Syphilis screening recommendations
should be based on local area and institutional syphilis prevalence.
Women Who Have Sex with Women
The CDC Guidelines
point out that sexual identity, sexual behaviors, sexual practices, and
risk behaviors of women who have sex with women (WSW) are diverse. Most
self-identified WSW (53-99%) report having had sex with men. Adolescent
WSW and females with both male and female partners might be at increased
risk for STDs and HIV.
Since syphilis transmission (likely through oral sex) between female sex
partners can occur and recent data suggest that C. trachomatis infection
among WSW might be more common than previously thought, providers should
consider screening all females for chlamydia and syphilis, regardless of
reported same sex behavior. In addition, since HPV transmission can
occur from skin-to-skin or skin-to-mucosa contact during sex between
females or males, all females, regardless of sexual preference or
practices, should be offered routine cervical cancer screening and HPV
vaccine in accordance with current guidelines.
Gonorrhea and Chlamydia
New C.
trachomatis and N. gonorrhoeae laboratory specimen testing options are
highlighted in the 2010 Guidelines. Nucleic acid amplification tests
(NAATs) are the most sensitive tests to detect C. trachomatis and
recommended by CDC. NAATs are Food and Drug Administration (FDA)-cleared
for use with urine, cervical and urethral specimens. Some NAATs are
cleared for use with either provider- or patient-collected vaginal swab
specimens. Although NAATs are not FDA-cleared for use with rectal or
oropharyngeal swab specimens, some laboratories have met Clinical
Laboratory Improvement Amendments (CLIA) requirements and have validated
gonorrhea and chlamydia NAAT testing on rectal swab specimens and
gonorrhea NAAT testing on oral swabs.
When considering treatment, it is important to realize that gonococcal
antimicrobial resistance remains an issue in the United States.
Penicillin, tetracycline or quinolones are no longer gonorrhea treatment
options. The recommended treatment for uncomplicated gonococcal
infections of the cervix, urethra, and rectum is dual therapy with
ceftriaxone 250 mg intramuscularly in a single dose PLUS either
azithromycin 1g orally in a single dose OR doxycycline 100 mg twice
daily for 7 days. If ceftriaxone is not an option, dual therapy with
cefixime 400 mg orally plus azithromycin 1 gram in a single dose or
doxycycline 100 mg twice daily for 7 days is an option. Although
cefixime is administered orally, there is limited efficacy of cefixime
for pharyngeal infection, if infection at this site is suspected. The
CDC has made a recommendation for dual therapy for gonoccocal infections
at all anatomic sites, due to concerns about the possible emergence of
cephalosporin resistance gonorrhea in the United States.
Since chlamydia or gonorrhea reinfection rates are high due to persons treated for chlamydia and/or gonorrhea from resuming sex with untreated partners, chlamydia and/or gonorrhea-infected females and males should be retested approximately three months after treatment whenever persons next present for medical care, regardless of whether they believe that their sex partners were treated.
Vaginitis
Vaginitis diagnostic
evaluation can be challenging. Bacterial vaginosis (BV) can be diagnosed
by the use of clinical criteria (i.e., Amsel's Diagnostic Criteria) or
Gram stain. However, Gram stain and even microscopy and pH paper are
often not available in the primary care provider’s office. The
sensitivity of microscopic examination of vaginal secretions immediately
after the slide preparation for T. vaginalis is only 60-70%. Clinical
Laboratory Improvement Act (CLIA) - waived, more sensitive, point of
care, vaginal tests include the OSOM Trichomonas Rapid Test (Genzyme
Diagnostics, Cambridge, Massachusetts), an immunochromatographic
capillary flow dipstick technology, and the OSOM BVBLUE Test (Genzyme
Diagnostics, Cambridge, Massachusetts) that detects elevated vaginal
fluid sialidase activity, an enzyme produced by bacterial pathogens
associated with Bacterial Vaginosis including Gardnerella, Bacteroides,
Prevotella and Mobilincus. Both rapid test results are available in 10
minutes. The Affirm™ VP III (Becton Dickenson, San Jose,
California), a nucleic acid probe test, which tests for T. vaginalis, G.
vaginalis, and C. albicans, is a CLIA-moderate complexity test with
results available within 45 minutes. A Pap test should not be routinely
used as a trichomonas screening test. An FDA approved T. vaginalis
nucleic acid amplification test is available and has demonstrated
enhanced sensitivity and specificity.
Two new alternative BV treatment regimens are: Tinidazole 2g orally once
daily for 2 days, or Tinidazole 1g orally once daily for 5 days. There
are options for patients who do not tolerate metronidazole or have
difficulty with compliance.
Because of the high T. vaginalis reinfection rates of among patients
diagnosed and treated for trichomoniasis, rescreening for T. vaginalis
at 3 months following initial infection can be considered for sexually
active females with trichomoniasis. No data support rescreening for
males diagnosed with T. vaginalis.
Pelvic Inflammatory Disease (PID)
Azithromycin has demonstrated short-term effectiveness in one
randomized trial and in combination with ceftriaxone 250mg IM in a
single dose (azithromycin 1g orally once a week for 2 weeks). Clinicians
who use an alternative PID treatment regimen should consider adding
metronidazole because anaerobic organisms are suspected in the etiology,
and metronidazole will also treat BV.
As a result of the emergence of quinolone-resistant Neisseria
gonorrhoeae, regimens that include a quinolone agent are no longer
recommended for PID treatment.
Human
Papillomavirus (HPV)
CDC reinforces HPV vaccination for
adolescents and young adults as indicated to prevent disease caused by
HPV.
In addition, a new external genital warts patient-applied therapy
treatment option is Sinecatechins 15% ointment. Sinecatechin ointment, a
green-tea extract with an active product (catechins), should be applied
three times daily (0.5-cm strand of ointment to each wart) using a
finger to ensure coverage with a thin layer of ointment until complete
clearance of warts for up to 16 weeks. The medication should not be
washed off after use. Sexual (i.e., genital, anal or oral) contact
should be avoided while the ointment is on the skin. The most common
side effects of sinecatechins 15% are erythema, pruritis/burning, pain,
ulceration, edema, induration and vesicular rash. This medication is not
recommended for HIV-infected persons, immune-compromised persons, or
persons with clinical genital herpes because the safety and efficacy of
therapy in these settings has not been established. The safety of
sinecatechins during pregnancy also is unknown.
Scabies
A new first line scabies
treatment option is Ivermectin 200ug/kg orally that should be repeated
in 2 weeks. Ivermectin is not recommended for pregnant or lactating
patients, and the safety of Ivermectin in children who weigh less than
15kg has not been determined.
Sexual Assault and STDs: Adults and Adolescents
Changes for recommended sexual assault STD testing at initial
examination include NAATs for C. trachomatis and N. gonorrhoeae
recommended as the preferred diagnostic tests for evaluation of sexual
assault victims, regardless of the sites of penetration or attempted
penetration. For T. vaginalis infection testing, in addition to a wet
mount or culture, a point-of-care testing of a vaginal-swab specimen may
be used. The following prophylactic regimen is suggested as preventative
therapy against chlamydia, gonorrhea and trichomonas (ceftriaxone 250mg
IM in a single dose or cefixime 400mg orally in a single dose plus
azithromycin 1g orally in a single dose or doxycycline 100mg orally
twice a day for 7 days plus metronidazole 2g orally in a single dose)
.
Sexual Assault or Abuse of Children
Changes for recommended sexual assault STD testing at initial
examination provide an option for NAATs to be used for detection of C.
trachomatis in vaginal specimens or urine from girls. No data are
available regarding the use of NAATs in boys or for extragenital
specimens (e.g., those obtained from the rectum) in boys and girls.
Culture remains the preferred method for extragenital sites. Data on use
of NAATs for detection of N. gonorrhoeae in children are limited, and
performance is test-dependent. Clinicians should consult with an expert
before using NAATs in this context to minimize the possibility of
cross-reaction with nongonococcal Neisseria species and other
commensals. For girls, NAATs can be used as an alternative to culture
with vaginal specimens or urine, whereas culture remains the preferred
method for urethral specimens or urine from boys and for extragenital
specimens (pharynx and rectum) from all children. All positive C.
trachmoatis or N. gonorrhoeae specimens should be retained for
additional testing.
Expedited Partner Therapy (EPT)
The 2010
STD Treatment Guidelines emphasize the important role of partner
management for STD prevention. Partner treatment not only directly
benefits the infected individual, but also prevents re-infection of the
index case and disrupts STD transmission networks. As previously, the
guidelines highlight the importance of expedited partner therapy (EPT)
– the clinical practice of treating the sex partners of patients
diagnosed with STD without previous medical evaluation of the partners.
According to the STD treatment guidelines and CDC EPT guidance, EPT
should be considered for the treatment of gonorrhea and chlamydia in
heterosexual partners when other management strategies are impractical
or unsuccessful. Since 2006, many more states made EPT legally
permissible (27 states and 1 city as of January 11, 2011), and many
state health departments developed guidelines for EPT implementation. In
addition, EPT has been endorsed by many professional organizations, such
as the American Medical Association, Society for Adolescent Health and
Medicine, American Academy of Pediatrics and American Bar Association.
The 2010 STD Treatment Guidelines also discuss the new evidence
supporting the use of internet to facilitate partner notification.
More Information
The complete treatment
guidelines, as well as information on webinars, ordering information
regarding Guidelines hard copies, wall charts, and pocket guides and
downloading iPhone and eBook versions can be viewed and downloaded at http://cdc.gov/std/treatment/2010.
Or contact CDC-INFO at 800-CDC-INFO (800-232-4636), 24 hours/day, or
e-mail cdcinfo@cdc.gov.
1Centers for Disease Control and Prevention.
Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010;
59(RR12);1-110. Available at: http://www.cdc.gov/std/treatment/2010.
Compiled for SAHM by:
Gale Burstein, MD, MPH, FAAP, FSAHM
Society for Adolescent Health and Medicine
Amanda Jacobs, MD, FAAP
American Academy of Pediatrics
Dmitry Kissin, MD, MPH
American College of Obstetricians and Gynecologists
Kimberly Workowski, MD, FACP
Centers for Disease Control and Prevention