Changes in the

2015 STD Treatment Guidelines:

What Adolescent Healthcare Providers Should Know


US Transgender Men and Women STD/HIV Epi


• Transgender women estimated HIV prevalence = 28%
- 56% estimated HIV prevalence among black transgender women
• Transgender men
- Fewer data
- Lower HIV prevalence than transgender women
 

Transgender Men and Women


• Assess STD- and HIV-related risks based on current anatomy and sexual behaviors
- Diversity of transgender persons regarding surgical affirming procedures, hormone use, and their patterns of sexual behavior
- Providers must remain aware of common STD Sx and screen for STDs on basis of behavior and sexual practices

HCV Epi


• HCV most common U.S. chronic bloodborne infection
- 2.7 million persons living with chronic HCV
• HCV not efficiently transmitted via sex
- Acute HCV incidence among MSM with HIV infection
• CDC and USPSTF recommended HCV screening
- All persons born during 1945–1965
- Injection drug use
- Receiving a blood transfusion before 1992,
- Long-term hemodialysis,
- Being born to a mother with HCV infection
- Intranasal drug use
- Unregulated tattoo and other percutaneous exposures 
 

Mycoplasma Genitalium


• First isolated in 1981
• Genital and reproductive tract disease
• Frequency
- More common than N. gonorrhoeae but less common than C. trachomatis

M. Genitalium in Females

• M. genitalium’s pathogenic role less definitive in females vs males
- Can be found in vagina, cervix, and endometrium
• M. genitalium in females commonly Asx
• Detected in clinical cervicitis and PID cases
- Evidence suggests that M. genitalium can cause PID, but less frequently than C. trachomatis
 

M. Genitalium Treatment

• M. genitalium lacks cell wall

- Antibiotics that target cell-wall biosynthesis are ineffective

• Beta-lactams including penicillins and cephalosporins
 

• Given diagnostic challenges, most M. genitalium treatment will occur in context of management for STD syndromes

Treatment of M. Genitalium

Randomized Controlled Trials
  Doxycycline (100mg bid x 7d) vs. Azithromycin (1g) 




M. Genitalium and Urethritis and Cervicitis

•Consider M gent Rx in persistent /recurrent urethritis and in persistent cervicitis and PID

•Azithromycin 1 gm more effective

- Doxy ineffective
- AZ Resistance emerging

•For Rx failures with azithro1 gm, Moxifloxacin (400 mg daily x 7-14 days)

Chlamydia Treatment


• Rx not changed
• Effectiveness: azithromycin < doxycycline
- Data from several studies and meta-analysis
• Pooled cure rates: doxy=97.5% vs azithro=94.4%
• Conclusion: doxy marginally superior to azithro
• Doxycycline delayed release 200 mg tabs (Doryx)
- Less GI upset
- Qday x 7 days
- More $

Oropharyngeal Chlamydia


• Clinical significance unclear
• Routine oropharyngeal CT screening not recommended
• Can be sexually transmitted to genital sites
• Treat oropharyngeal chlamydia with azithro or doxy

Antibiotic-Resistant Gonorrhea

 

 

Gonorrhea Dual Therapy: Uncomplicated Genital, Rectal, or Pharyngeal Infections


 PLUS 

• Doxy no longer recommended as 2nd antimicrobial for GC Rx
- Substantially ­­ prevalence of GC resistance to tetracycline vs azithromycin

Dual Therapy:
• Ceftriaxone and azithromycin administered on the same day
- Preferably simultaneously and under direct observation
- Challenge if ceftriaxone IM in office and Rx for azithro to fill in pharmacy
 

Gonorrhea Treatment Alternatives 2010

Anogenital Infections
 
ALTERNATIVE CEPHALOSPORINS:

►Cefixime 400 mg orally once
PLUS
►Dual treatment w/ azithromycin 1 g
OR
►Doxycycline 100 mg BID x 7 days

Gonorrhea Treatment Alternatives 2015

Anogenital Infections
 
ALTERNATIVE CEPHALOSPORINS:

►Cefixime 400 mg orally once
PLUS
►Dual treatment w/ azithromycin 1 g
OR
►Doxycycline 100 mg BID x 7 days

Gonorrhea Treatment Alternatives

Anogenital Infections

IN CASE OF SEVERE ALLERGY:
  • Azithromycin 2 g orally once (Caution: GI intolerance, emerging resistance)

Alternative Urogenital GC Regimens


  • Non-comparative randomized trial in adults with urethral or cervical gonorrhea
- Gentamicin 240 mg IM + azithromycin 2 g PO, or
- Gemifloxacin 320 mg PO + azithromycin 2 g PO
  • Rationale for regimens
  • Additive effect between gentamicin and azithromycin (in vitro) 
  • Gemifloxacin more active against GC with known ciprofloxacin resistance 

New Regimen Challenges

 
• Nausea common
- 27% for gentamicin + AZ
- 37% for gemifloxacin + AZ
- 3% and 7% in each group vomited <1hr after administration
• Gemiflox no longer available
• FDA recently approved (6/15/2015)  generic which may take several months to launch 
• Updates on the availability can be found at: www.cdc.gov/std/treatment/drugnotices/gemifloxacin.htm

 

GC Test of Cure


• Patients with pharyngeal GC treated with an alternative regimen
- Obtain test of cure 14 days after treatment, using either culture or NAAT
• Cases of suspected treatment failure
- Culture and simultaneous NAAT
- Call local health department!

Cephalosporin treatment failures


• Oral cephalosporin treatment failures reported worldwide
- Japan, Hong Kong, England, Austria, Norway, France, South Africa, and Canada
• Ceftriaxone treatment failures in pharyngeal gonorrhea and a few isolates with high-level ceftriaxone resistance reported

Suspected GC Treatment Failure After Recommended Dual Therapy: What do I do?
 

 

STI Screen Recommendations - Available on the 2015 STD Treatment Guidelines Home Page

STD Clinical Consultation Network


The CDC-sponsored STD Clinical Consultation Network provides STD clinical consultation services within 1-3 business days or receiving the request, depending on urgency, to healthcare providers nationally.

There are 8 regional PTCs across the country, so the PTC  serving your area is ready to answer your questions. The NYC STD/HIV PTC serves Indiana, Michigan, New Jersey, New York, Ohio, Puerto Rico, and the US Virgin Islands.

More Information

You can view and download a more complete PDF of the 2015 updates on the CDC website. Also included are a wall chart and pocket guide.


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 on the CDC website. Or contact CDC-INFO at 800-CDC-INFO (800-232-4636), 24 hours/day, or via e-mail.


Compiled for SAHM by:

Gale Burstein, MD, MPH, FAAP, FSAHM
Society for Adolescent Health and Medicine

Kimberly Workowski, MD
Centers for Disease Control and Prevention

Ina Park, MD, MS
California Department of Public Health

Lisa E. Manhart, PhD
University of Washington


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