Executive Summary
The Centers for Disease Control and Prevention has released the 2015 STD Treatment Guidelines. This update was written after a 2013 consultation with experts knowledgeable in the field of sexually transmitted diseases, with a peer review document released in 2014.
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Clinicians with iPhones can download the free 2015 STD Treatment (Tx) Guide app, an easy-to-use reference that combines information from the guidelines, as well as updates.
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The app features a streamlined interface so providers can easily access treatment and diagnostic information. An android app is being developed and will be available soon.
The Centers for Disease Control and Prevention (CDC) has released the 2015 STD Treatment Guidelines.1 This update was written after a 2013 consultation with experts knowledgeable in the field of sexually transmitted diseases (STDs). The peer review document was released in 2014 to obtain input on the final draft. (Contraceptive Technology Update reported on the draft guidance. See “New STD guidance on the way: Be prepared,” January 2015.)
“These recommendations should be regarded as a source of clinical guidance rather than prescriptive standards; health-care providers should always consider the clinical circumstances of each person in the context of local disease prevalence,” the guidance states.
The testing, treatment, and the prevention of STDs is constantly evolving, and the CDC’s ongoing investment in this intensive effort through development of these guidelines is commendable, said William Smith, executive director of the National Coalition of STD Directors (NCSD) in a statement. The document represents a comprehensive and authoritative source for promoting sexual health through STD prevention and treatment, he notes. The NCSD encourages clinicians to educate themselves on the new guidelines to ensure they are providing the best sexual healthcare to all patients, states Smith.
Clinicians with iPhones can download the free 2015 STD Treatment (Tx) Guide app, an easy-to-use reference that combines information from the guidelines, as well as updates. The app features a streamlined interface so providers can easily access treatment and diagnostic information. An Android app is being developed and will be available soon. (Check the guidance web page at http://1.usa.gov/1BBIUi6 for updates. Also use the link to order limited numbers of wall charts and pocket guides, as well as to print out free copies for use. Clinicians also can earn free continuing education by watching a webinar on the guidance. A link to the webinar is available on the web page under the “Highlights” heading.)
What are the key changes?
The new guidance updates previous information released in 2010. What are some of the most important changes in the new document?
Pre-exposure prophylaxis (PrEP) for the prevention of HIV is now included in the “Clinical Prevention Guidance” section, which lists methods for the prevention and control of STDs. The full CDC PrEP guidelines also include recommendations for frequent testing for other STDs for those on PrEP. The agency issued clinical guidance for use of PrEP in 2014 following data publication that shows when taken daily as directed, PrEP can reduce the risk of HIV infection by more than 90%.2-4
Make note that frontline treatment recommendations for gonorrhea are included in this update. The CDC recommends treating gonorrhea with 250 mg of ceftriaxone delivered intramuscularly plus 1 g of oral azithromycin. Treatment with ceftriaxone plus doxycycline has now been moved to an alternative treatment recommendation for use in case of azithromycin allergy.
Reasons for the change
Why was this change made? It allows for the convenience of a single-dose therapy, as well as offers a response to the increased gonococcal resistance to the class of drug that includes doxycycline.
Oral cefixime still is recommended as an alternative treatment for gonorrhea if ceftriaxone isn’t available. Oral cefixime also is indicated for expedited partner therapy (EPT) for heterosexual men and women with gonorrhea. EPT with cefixime 400 mg and azithromycin 1 g can be delivered to the partner by the patient, a disease investigation specialist, or a collaborating pharmacy as permitted by law. The guidance explicitly recommends the delivery of EPT by providing patients with appropriately packaged medication as the preferred approach, as compared to providing prescriptions, as data on the efficacy of EPT using prescriptions is very limited, and many persons don’t fill prescriptions given to them by their partners.
EPT shouldn’t be considered a routine partner management strategy in men who have sex with men (MSM) who are infected with gonorrhea, because there is a high risk for coexisting infections, especially HIV infection, and there are no data on treatment efficacy in this population, the CDC states.1
How about screening?
What do clinicians need to understand about screening for gonorrhea and chlamydia, based on the new guidance?
The CDC has harmonized with the U.S. Preventive Services Task Force’s recommendation that sexually active women younger than 25 get screened annually for chlamydia and gonorrhea, states Kimberly Workowski, MD, FACP, FIDSA, professor of medicine in the Division of Infectious Diseases at Atlanta-based Emory University. (To read about the Task Force guidance, see “Nearly 5% of young U.S. women have chlamydia,” in the STI Quarterly supplement in the December 2014 issue of Contraceptive Technology Update.) Additionally, the guidelines recommend annual chlamydia and gonorrhea screening for older women with risk factors, such as new or multiple sex partners, or a sex partner who has a sexually transmitted disease, says Workowski, who served as lead author of the guidance.
Check MSM information
The new guidance recommends the following tests on at least an annual basis in sexually active MSM, including those with HIV:
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HIV serology, if HIV status is unknown or negative and the patient himself or his sex partner(s) has had more than one sex partner since the most recent HIV test;
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syphilis serology to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, are manifesting a slow serologic response to appropriate prior therapy, or are serofast;
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a test for urethral infection with Neisseria gonorrhoeae and Chlamydia trachomatis in men who have had insertive intercourse during the preceding year. Urine testing using nucleic acid amplification testing (NAAT) is the preferred approach, the CDC recommends;
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a test for rectal infection with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse during the preceding year; a rectal specimen NAAT is preferred;
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a test for pharyngeal infection with N. gonorrhoeae in men who have had receptive oral intercourse during the preceding year, using a pharyngeal specimen for NAAT screening. Testing for C. trachomatis pharyngeal infection is not recommended;
The new guidance also highlights that sexual transmission of hepatitis C virus (HCV) can occur, especially among MSM with HIV infection. As a result, serologic screening for HCV is recommended at initial evaluation of persons with newly diagnosed HIV infection. Due to accumulating evidence of acute HCV infection acquisition among persons with HIV infection, especially MSM with HIV infection, the CDC states that MSM with HIV infection should be regularly screened for HCV.
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Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64 (No. RR-3):1-137.
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Centers for Disease Control and Prevention. Preexposure Prophylaxis for HIV Prevention in the United States — 2013: A Clinical Practice Guideline. Accessed at http://1.usa.gov/1n3IJzr.
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Centers for Disease Control and Prevention. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2014. Clinical Providers’ Supplement. Accessed at http://1.usa.gov/1n0f0If.
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Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012; 367(5):399-410.
