STD Quarterly: Take your STD skills to the next level with new guidelines

Check new CDC recommendations on chlamydia rescreening, herpes tests

Break the chain of sexually transmitted disease (STD) transmission by detecting and treating infection using the latest recommendations from the just-released 2002 Guidelines for the Treatment of Sexually Transmitted Diseases, issued by the Atlanta-based Centers for Disease Control and Prevention (CDC).

The publication, the fifth edition of the guidelines, are designed to advise health care providers on the most effective STD treatment regimens, screening procedures, and prevention strategies, says Stuart Berman, MD, chief of the epidemiology and surveillance branch in CDC’s Division of STD Prevention.

What are some of the most important changes in recommendations that clinicians will need to integrate in their practices? Berman and other CDC officials reviewed the revisions during a recent press briefing held at the May 2002 release date of the publication. 

Rescreen for chlamydia

The CDC now recommends that all women with chlamydial infections be rescreened three to four months after treatment is completed. This is the first time CDC has recommended such re-screening in the management of chlamydia. Why did the agency move in this direction?

Most post-treatment chlamydial infections result from reinfection, often occurring because a patient’s sex partners were not treated or because the patient resumed sex among a network of persons with a high prevalence of infection, states Kimberly Workowski, MD, lead author of the new guidelines.

"Repeat infection also confers an elevated risk of PID [pelvic inflammatory disease] and other complications when compared with initial infection," she states. "Therefore, women with chlamydial infection should be rescreened three to four months after treatment." (Contraceptive Technology Update reported on the research behind the move to rescreen for this STD; see "Rescreening can stem repeat chlamydia" in the October 2001 issue, p. 118.)

According to the CDC, chlamydia is the most commonly reported infectious disease in the United States, with 702,093 cases reported in 2000; the infection is asymptomatic in the majority of cases. Health care providers are now advised to annually screen sexually active adolescent women ages 19 and younger and young adult women, ages 20-24, even if symptoms are not present. Older women with risk factors for chlamydia, such as new partners or multiple sexual partners, also should be screened.

Use new herpes tests

The new CDC guidelines outline new testing procedures that may help providers with diagnosing and managing genital herpes type 1 (HSV-1) or type 2 (HSV-2). Since antiviral therapy may benefit individuals with herpes symptoms, providers who are aware of their patient’s viral serotype can tailor counseling and treatment plans to best fit their needs, says the CDC. (Check out information on new diagnostic methods in "Get a handle on herpes with these new tests," published in the STD Quarterly inserted in the August 2000 issue.)

Most patients with recurring genital outbreaks are infected with HSV-2, which is almost always spread during sexual contact with a partner who has a genital HSV-2 infection. Patients infected with HSV-2 can choose from suppressive or episodic antiviral treatments that can prevent or shorten the duration of outbreaks. (Read about herpes treatment in "Missed opportunities: Family planners receive call to action for herpes screening," published in the STD Quarterly inserted in the February 2002 issue.)

Genital HSV-1, which is often caused by oral-genital sexual contact with a person with an oral HSV-1 infection (fever blister), is much less likely to recur, and treatment may be needed only in patients with initial symptoms, states the CDC.

It is important to counsel symptomatic patients, regardless if they have HSV-1 or HSV-2, about herpes, its initial and recurring manifestations, and how to avoid transmission of the virus to sexual partners and newborns, the new guidelines state.

Check gonorrhea info

The 2002 STD Treatment Guidelines now warns providers that ciprofloxacin-resistant strains have become so common on the West Coast that the use of fluoroquinolone antibiotics to treat gonorrhea is inadvisable in California. These guidelines signal the first time the CDC has issued this guidance in the continental United States.

The federal agency had previously recommended that fluoroquinolones, which include ciprofloxacin, ofloxacin, and levofloxacin, not be prescribed for treating gonorrhea in Hawaii and in those patients who visited the island state, other Pacific Islands, or Asia, because many of the gonorrhea cases in those areas are resistant to ciprofloxacin. The CDC now advises the use of the antibiotics cefixime and ceftriaxone as first-line drugs to treat gonorrhea in Hawaii and California. (CTU reported on the rise of resistant strains in "Ciprofloxacin-resistant gonorrhea on the rise," in the June 2002 issue, p. 64.) If clinicians in other states have any concerns that a patient may have ciprofloxacin-resistant gonorrhea, they should use cefixime or ceftriaxone.

Gonorrhea is the second most common infectious disease reported to CDC, with nearly 360,000 cases in 2000. Since drug-resistant strains are becoming increasingly common in the United States, the agency moved to issue the warning.

Fluoroquinolone antibiotics have been recommended by the CDC for the treatment of gonorrhea since 1993. Penicillin and tetracycline once were recommended for the treatment of the STD, but widespread resistance rendered them ineffective. Treatment with tetracycline was halted in 1985, while penicillin was abandoned in 1987.

N-9: No STD prevention

Advise patients that spermicides, especially those that contain nonoxynol-9 (N-9), should not be used for STD protection, state the new guidelines. Lubricants containing N-9 should not be used during anal intercourse, the guidelines note.

Recent research indicates that the spermicide agent falls short in prevention of transmission of chlamydia and gonorrhea.1 (CTU reported on the research in "Nonoxynol-9 not protective against STDs," in the June 2002 issue, p. 63.) Frequent use of the spermicide can cause genital lesions (in the vagina) and, therefore, may increase the risk of HIV transmission. It also has been found to cause damage to the lining of the rectum, which provides an entry point for HIV and other STDs.

"While the level of N-9 used as a lubricant in condoms is much lower than the level found to be harmful, condoms lubricated with N-9 spermicide also are not recommended because they have a shorter shelf life, cost more, and have been associated with urinary tract infections in women," states the CDC.2 "However, previously purchased condoms with N-9 can be used, provided they have not passed their expiration date, since the protection provided by the condom against HIV outweighs the potential risk of N-9."

Recent increases in the rates of syphilis, gonorrhea, and chlamydia have been reported in many U.S. cities, largely among men who have sex with men (MSM) who are HIV-infected, states Workowski. Other MSMs are at high risk for STDs due to the frequency of unsafe sexual practices, she notes. To reduce the likelihood of acquisition or transmission of HIV and other STDs, providers should assess sexual risk of all male patients through nonjudgmental STD/HIV risk assessment and client-centered prevention counseling, says Workowski.

The new guidelines recommend that for those MSM patients who are sexually active, annual screening should be performed for HIV, chlamydia (anal and urethral), syphilis, and gonorrhea (anal, pharyngeal, urethral), as well as vaccination against hepatitis A and B. More frequent STD screenings may be indicated for those patients who indicate multiple anonymous partners or who have sex in conjunction with illicit drug use.

Resources

Providers have several options for checking out the Sexually Transmitted Diseases Treatment Guidelines 2002 published by the Atlanta-based Centers for Disease Control and Prevention (CDC). The guidelines can be viewed and printed online in Adobe Acrobat PDF format from the CDC web site, www.cdc.gov/std. Click on "Sexually Transmitted Diseases Treatment Guidelines 2002," and follow instructions on how to view or print the files. To submit an e-mail order for printed copies of the guidelines, e-mail stdguidelines@cdc.gov. Please include your shipping address in the e-mail. To request more than five copies of the guidelines, include a justification for your request and telephone contact information. Larger requests without accompanying justification will receive five copies.

To submit a telephone request (single copies only): call the CDC Information System at (888) 232-3228. Press the numbers 2, 5, 1, 1 when the system answers, wait for the next announcement, press 1 and follow directions. To submit orders over the Internet, visit the CDC web site, www.cdc.gov/std. Click on "Sexually Transmitted Diseases Treatment Guidelines 2002," and follow instructions on how to order on-line. To request more than five copies of the guidelines, include a justification for your request and telephone contact information. Larger requests without accompanying justification will receive five copies. Web visitors can opt to print out the order form and fax it to the Office of Communications at (404) 639-8910, or mail it to STD Treatment Guidelines, Office of Communications, NCHSTP, CDC, 1600 Clifton Road, N.E., Mailstop E-07, Atlanta, GA 30333.

References

1. Roddy RE, Zekeng L, Ryan KA, et al. Effect of non-oxynol-9 gel on urogenital gonorrhea and chlamydial infection. JAMA 2002; 287:1,117-1,122.

2. Centers for Disease Control and Prevention. New CDC Treatment Guidelines Critical to Preventing Health Consequences of Sexually Transmitted Diseases. May 9, 2002.