New STD Guidelines for 2015

Kimberly Workowski, MD

Disclosures

October 05, 2015

Editorial Collaboration

Medscape &

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Hello. I am Dr Kimberly Workowski, infectious diseases specialist in the Division of STD Prevention at the Centers for Disease Control and Prevention (CDC), and lead author of the recently released 2015 Sexually Transmitted Disease (STD) Treatment Guidelines.[1]

Over the next few minutes, I will highlight some new information from the 2015 guidelines. To review the document in its entirety, please visit www.cdc.gov/std.

The STD Treatment Guidelines were developed through a rigorous evidence-based peer-review process and were created to assist healthcare providers in the appropriate management and treatment of sexually transmitted infections. Although these guidelines emphasize treatment, prevention strategies and diagnostic evaluation are also discussed.

What's new for 2015? First, gonorrhea has progressively developed antimicrobial resistance to previously recommended regimens, and current treatment options are severely limited. The recommended treatment for urogenital gonorrhea is a single dose of 250 mg of intramuscular (IM) ceftriaxone in combination with 1 g of oral azithromycin.

Two new dual treatment regimens may now be considered as alternative treatment regimens for uncomplicated urogenital gonorrhea in persons with a cephalosporin allergy. Dual treatment with a single dose of 320 mg of oral gemifloxacin plus 2 g of oral azithromycin, or dual treatment with a single dose of 240 mg of IM gentamicin plus 2 g of oral azithromycin, are alternative treatment options in the setting of a cephalosporin allergy. However, some study participants experienced gastrointestinal discomfort with these regimens, which may limit their use.

Next, the use of highly sensitive and specific tests is recommended for the diagnosis of trichomoniasis. Nucleic acid amplification tests (NAATs) are highly sensitive and can detect more infections than wet-mount microscopy.

In the 2015 STD Treatment Guidelines, a new section has been added on "Emerging Issues." One section includes information about the association of Mycoplasma genitalium with urethritis and cervicitis. M genitalium diagnostic considerations are discussed, along with treatment implications due to differences in antibiotic effectiveness.

Also included in the "Emerging Issues" section is a discussion concerning the sexual transmission of hepatitis C virus, especially among persons with HIV infection, and particularly in men who have sex with men. Hepatitis C screening should be considered at least yearly and more frequently depending on specific circumstances.

Additional treatment options for dosing genital warts include either imiquimod 3.75% or 5% cream. Podophyllin resin is no longer a recommended regimen because there are safe and effective alternative regimens, and there have been reports of severe systemic toxicity when podophyllin resin was applied to large areas of friable tissue and not washed off within 4 hours.

The guidelines now include updated recommendations for the diagnostic evaluation of urethritis. Gram staining of urethral secretions demonstrating two or more white blood cells per oil immersion field is a point-of-care diagnostic test that can be used to document urethritis. Methylene blue or gentian violet staining of urethral secretions can be used as an alternative point-of-care diagnostic test with performance characteristics similar to Gram staining.

Additionally, the 2015 STD Treatment Guidelines include updated chlamydia and gonorrhea testing recommendations for women that are consistent with the US Preventive Services Task Force's September 2014 recommendations.[2] These guidelines recommend that all sexually active women younger than age 25, or older women at increased risk for infection (such as those with a new sex partner, more than one sex partner, or a sex partner with concurrent partners), should request, or receive, annual chlamydia and gonorrhea tests. Additionally, high-intensity behavioral counseling is recommended for all sexually active adolescents and adults at increased risk for sexually transmitted infections and HIV.

The guidelines also include recently updated CDC guidance that affects persons who have, or are at risk for, STDs. This includes a March 2015 Morbidity and Mortality Weekly Report that summarized all human papillomavirus (HPV) vaccine-related recommendations,[3] a reorganized HPV counseling section, HPV prevention section, and a genital warts counseling section. In addition, there is a new section on the management of persons who are transgender, as well as retesting recommendations for persons with chlamydia, gonorrhea, or trichomonas infections.

The complete treatment guidelines can be viewed and downloaded at www.cdc.gov/std. Wall charts, pocket guides, a link to the STD Treatment Guidelines app, and updates or errata are available at www.cdc.gov/std/treatment.

Web Resources

2015 Sexually Transmitted Diseases Treatment Guidelines

Sexually Transmitted Diseases. Summary of 2015 CDC STD Treatment Guidelines (pocket guide)

Sexually Transmitted Diseases. Summary of 2015 CDC STD Treatment Guidelines (wall chart)

2015 STD Treatment Guidelines Webinars (and PPT slides)

iTunes: STD 2015 Tx Guide (app for Apple devices; Android will be available later this year)

National Network of STD Clinical Prevention Training Centers

Kimberly Workowski, MD, is a professor of medicine in the Division of Infectious Diseases at Emory University. Dr Workowski serves as the coordinator of the CDC Sexually Transmitted Diseases Treatment Guidelines. This document serves as the national and international standard for the management of sexually transmitted diseases. Dr Workowski served as a consultant in the development of guidelines for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae (CDC) and as the workgroup chair for the syphilis section of the HIV Prevention and Opportunistic Infection Guidelines (NIH, CDC). Dr Workowski provides expert assistance and technical guidance on the scientific advisory council for the clinical trials network for sexually transmitted infections.

Dr Workowski has an active role in many national professional societies, including the American Medical Association, American College of Physicians (Fellow), Infectious Diseases Society of America (Fellow), American Society of Microbiology, American Sexually Transmitted Disease Association, and the American Foundation of Clinical Research. She is the manuscript reviewer for numerous journals, served on the editorial board of Sexually Transmitted Infections, and provides consultation for numerous organizations, textbooks, and curriculum modules. She has published 101 manuscripts and public health reports, 28 book chapters, and has been the guest editor for several Clinical Infectious Diseases supplements on sexually transmitted infections (1998, 2002, 2006, 2011). Several important publications include the clinical epidemiology of genital chlamydia infections documenting the association of specific chlamydial strains/serovars with ethnicity and distinctive clinical manifestations, a prospective demonstration of the lack of persistent chlamydial infection after antimicrobial therapy, the first documentation of clinical treatment failure due to multidrug-resistant C trachomatis urogenital infection, the clinical evaluation of the first herpes simplex 2 vaccine, and a prospective clinical epidemiologic evaluation of primary genital herpes infections.

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