As 2015 rolls out, look for the publication of the newly updated Sexually Transmitted Diseases Treatment Guidelines from the Centers for Disease Control and Prevention (CDC). The proposed new guidance, which replaces information published in 2010,1 will provide the latest evidence-based treatment recommendations, says Gail Bolan, MD, director of the CDC’s Division of Sexually Transmitted Disease Prevention. Bolan presented information at the recent Contraceptive Technology Atlanta 2014 conference.2 The proposed new guidance is available for review at http://1.usa.gov/11f6Kzf. Release is projected by late 2014 or early 2015, Bolan told conference attendees.
Included in these updated guidelines is new information on such topics as:
alternative treatment regimens for Neisseria gonorrhoeae;
use of nucleic acid amplification tests for diagnosis of trichomoniasis;
alternative treatment options for genital warts;
the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications;
five updated human papillomavirus (HPV) counseling messages;
a new section on the management of transgender individuals;
recommendations for annual testing for hepatitis C in persons with HIV infection;
updated recommendations for diagnostic evaluation of urethritis;
retesting to detect repeat infection.
For uncomplicated gonococcal infections of the cervix, urethra, and rectum, the new recommended regimen includes ceftriaxone 250 mg in a single intramuscular dose plus azithromycin 1g orally in a single dose. Previous guidance called for 100 mg of doxycycline twice a day for seven days as the recommended second drug in dual therapy. As dual therapy, ceftriaxone and azithromycin should be administered together on the same day, preferably simultaneously and under direct observation, the 2014 proposed guidance advises.
If ceftriaxone is not available, the new alternative regimen is cefixime 400 mg in a single oral dose plus azithromycin 1 g orally in a single dose. When there is an allergy to azithromycin, doxycycline (100 mg orally twice a day for seven days) can be used as an alternative second antimicrobial in place of azithromycin when used in combination with cefixime.
Genital warts are soft, moist, pink or flesh-colored bumps caused by HPV infection. In women, the warts usually occur in or around the vagina, on the cervix, or around the anus. While genital warts are less common in men, they may appear on the tip of the penis.
While most genital warts are asymptomatic, patients might experience itching, pain, and bleeding with them. For patient-applied therapy, the proposed new guidelines call for use of imiquimod in 3.75% or 5% cream. Imiquimod 5% cream should be applied once at bedtime, three times a week for up to 16 weeks, while imiquimod 3.75% cream should be applied once at bedtime but is applied every night for up to eight weeks.
Use of podophyllin resin 10-25% has been moved to "alternative therapy" for genital warts, due to case reports of adverse effects with misuse, says Bolan.
For treatment of chlamydia, the proposed new guidance recommends azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for seven days. Alternative regimens include erythromycin base 500 mg orally four times a day for seven days, or erythromycin ethylsuccinate 800 mg orally four times a day for seven days, or levofloxacin 500 mg orally once daily for seven days, or ofloxacin 300 mg orally twice a day for seven days.
In patients who have erratic healthcare-seeking and follow-up behavior, or poor treatment adherence, azithromycin might be more cost-effective in treating chlamydia because it enables the provision of a single dose of directly observed therapy, the proposed guidance states.2
Due to concerns over amoxicillin use in pregnancy due to chlamydia persistence in vitro, use of the drug is listed only as an alternative regimen.
New sections added
The new guidance will include new sections on transgender men and women, as well as emerging issues, such as Mycoplasm genitalium and hepatitis C.
While the transgender population is relatively small, studies of HIV among transgender women suggest that the prevalence of HIV is the highest among subpopulation groups in the United States: 27.7% among all transgender women, and 56.3% among African American transgender women.3
Mycoplasma genitalium has become recognized as a cause of male urethritis. Research indicates it is responsible for approximately 15-20% of non-gonococcal urethritis (NGU) cases, 20-25% of non-chlamydial NGU, and approximately 30% of persistent or recurrent urethritis, says Kimberly Workowski, MD, professor of medicine in the Division of Infectious Diseases at Emory University in Atlanta.4 It also might play a role in pelvic inflammatory disease (PID). There is no commercially available test for the infection. It should be suspected in cases of persistent or recurrent urethritis, and it may be considered in persistent or recurrent cases of cervicitis and PID.
Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States, with an estimated 2.7 million persons with chronic infection.5 Recent data indicate that sexual transmission of hepatitis C can occur. All HIV-infected individuals should be tested at initial evaluation and at least annually and more frequently depending on local circumstances. Screening should be performed using HCV antibody assays.
HCV testing is recommended by the CDC and the U.S. Preventive Services Task Force for all persons born during 1945-1965 and others based on their risk for infection or on a recognized exposure, including past or current injection drug use, receipt of a blood transfusion before 1992, long-term hemodialysis, status as the child of a mother with HCV infection, intranasal drug use, receipt of an unregulated tattoo, and other percutaneous exposures, the new guidance states.
- Centers for Disease Control and Prevention. Sexually transmitted deseases treatment guidelines, 2010. MMWR 2010; 59(RR 12); 1-110.
- Bolan G. The new "2014 CDC STD Treatment Guidelines": A preview. Presented at the Contraceptive Technology Atlanta 2014 conference. Atlanta; October 2014.
- Herbst JH, Jacobs ED, Finlayson TJ, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS and Behavior 2008; 12(1):1-17.
- Taylor-Robinson D, Jensen JS. Mycoplasma genitalium: from chrysalis to multicolored butterfly. Clin Microbiol Rev 2011; 24(3):498-514.
Denniston MM, Jiles RB, Drobeniuc J, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010. Ann Intern Med 2014; 160(5):293-