Treatment of Sexually Transmitted Disease: Update 2002
Source: Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 2002;51(No. RR-6): 1-80.
This report updates the CDC’s previous edition of this resource, the 1998 Guidelines for Treatment of Sexually Transmitted Diseases. The recommendations were formulated through a multi-stage process that included a three-day meeting in Atlanta in September 2000, when consultants reviewed the literature and debated the evidence. While the guidelines emphasize treatment, diagnostic and prevention strategies also are discussed.
Commentary by Stephanie B. Abbuhl, MD, FACEP
This is the "bible" of sexually transmitted diseases (STDs) and should be available in hard copy or through the Web (http://www.cdc.gov/mmwr) in every emergency department (ED). The information presented is complete, concise, and organized in a quick-reference format. Most of the recommendations have not changed dramatically; however, a few updates particularly relevant to emergency medicine practice are highlighted below.
Pelvic Inflammatory Disease (PID). Emergency physicians should continue to have a low threshold to diagnose and treat PID. Many women with PID have subtle or mild symptoms, and delay in treatment contributes to long-term sequelae. Empiric treatment should be initiated in women at risk for STDs if either uterine/adnexal tenderness or cervical motion tenderness can be found and no other cause is identified. There are additional criteria that can enhance the specificity of the diagnosis, but at the expense of sensitivity. New on the list of "additional criteria" is the finding of white blood cells (WBCs) on saline microscopy of vaginal secretions. The guidelines state, "if the cervical discharge appears normal and no WBCs are found on the wet prep, the diagnosis of PID is unlikely and an alternative cause of pain should be investigated."
Treatment of PID. The recommendation for the treatment of PID stresses the importance of covering for anaerobes in addition to gonorrhea and chlamydia. Yet the two outpatient regimens listed state "with or without metronidazole," which is less convincing than the text would suggest. Regimen A is ofloxacin 400 mg BID for 14 days or levofloxacin 500 mg QD for 14 days, with or without metronidazole 500 mg BID for 14 days. Regimen B is ceftriaxone 250 mg IM in a single dose (or cefoxitin 2 g IM with probenecid 1 g PO) plus doxycycline 100 mg BID for 14 days, with or without metronidazole 500 mg BID for 14 days. Including metronidazole in most cases would appear to be prudent. Note that, for PID, oral cephalosporins (e.g., cefixime) are not recommended (only for cervicitis), and similarly, that azithromycin is not recommended because of insufficient data to date.
Quinolone-resistant Neisseria Gonorrhea (QRNG). This entity continues to spread; quinolones no longer are recommended for gonorrhea in Hawaii or California, or for patients who may have acquired their infections in Asia or the Pacific. Emergency physicians should be attentive to surveillance statistics for QRNG in their practice area.
Bacterial Vaginosis in Pregnancy. Both bacterial vaginosis (BV) and trichomoniasis during pregnancy can cause not only unpleasant vaginal symptoms, but also have been associated with adverse pregnancy outcomes including premature rupture of the membranes, preterm delivery, and low birthweight. All symptomatic pregnant women with BV should be treated, regardless of trimester, with either metronidazole 250 mg PO BID for seven days or clindamycin 300 mg PO BID for seven days. The guidelines specifically state that metronidazole use in pregnancy has not been associated with teratogenic or mutagenic effects in newborns. Topical agents (metronidazole gel or clindamycin cream) are not recommended in pregnancy because of evidence suggesting an increase in adverse effects. The recommendation for BV treatment in asymptomatic women is less definitive, suggesting that women at high risk for adverse outcomes may be screened and treated, while the data for women at low risk are conflicting. A reasonable interpretation for the ED is that symptomatic pregnant women with BV should be treated regardless of trimester and asymptomatic women should be referred to their obstetricians for consideration of screening and treatment.
Trichomoniasis in Pregnancy. In pregnancy, the recommendations are similar to those for BV. Pregnant women who are symptomatic should be treated, regardless of trimester, with metronidazole 2g PO in a single dose. Data have not shown that treating asymptomatic women lessens the association with adverse outcomes and, therefore, pregnant women with no symptoms should not be screened. In the ED, it appears that there is no reason to look at wet preps in pregnant women who do not have symptoms of a vaginal discharge.
Dr. Abbuhl, Medical Director, Department of Emergency Medicine, The Hospital of the University of Pennsylvania; Associate Professor of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.
This report updates the CDCs previous edition of this resource, the 1998 Guidelines for Treatment of Sexually Transmitted Diseases. The recommendations were formulated through a multi-stage process that included a three-day meeting in Atlanta in September 2000, when consultants reviewed the literature and debated the evidence. While the guidelines emphasize treatment, diagnostic and prevention strategies also are discussed.
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