COMMENTARY

New STI Guidelines: Chlamydia, Gonorrhea, and Pelvic Inflammatory Disease

Neil Skolnik, MD

Disclosures

September 13, 2021

This transcript has been edited for clarity.

I'm Dr Neil Skolnik, and today I'm going to talk about the just-released 2021 CDC Sexually Transmitted Infection (STI) Guidelines. These are important guidelines, being released at a time when STIs have never been at a higher rate in the United States.

I love this topic. There is no other topic in medicine where diagnosis is as clear, treatment is as effective, and the way we handle these problems with patients makes a huge difference to the patients we take care of. The topic of STIs perfectly combines personal and public health.

Today I am going to discuss chlamydia, gonorrhea, and pelvic inflammatory disease (PID).

Chlamydia and Gonorrhea

The main consequence of undiagnosed chlamydia and gonorrhea is progression to PID. Fortunately, screening asymptomatic women can stop that progression.

Recommendations for screening are:

  • Annual screening of all sexually active women aged < 25 years

  • Screening women over age 25 who have more than one sex partner or a new sex partner since the last time they were screened

  • Annual screening for rectal chlamydia and gonorrhea should be performed in men who report sexual activity at the rectal site, and selectively in women based on history

Treatment. Treatment for chlamydia has changed since the previous guideline. Azithromycin single dose has been relegated to alternative treatment because it's now as effective as what is now the primary recommended first-line treatment: doxycycline, 100 mg orally twice daily for 7 days. Azithromycin single dose or levofloxacin for 7 days are now alternative therapies. The main reason is the lower cure rates with azithromycin.

The recommendations for treatment of gonorrhea have also changed, primarily out of concern for emerging resistance, which we saw a lot of to fluoroquinolones in the early 2000s. A recommendation has been added for an increase in the dose of ceftriaxone used to treat gonococcal cervicitis and urethritis from the previous 250 mg to 500 mg IM. The old guidelines recommended dual treatment with azithromycin as well, but the current guidelines say that azithromycin should only be used if treating chlamydia in addition to gonorrhea.

Partner treatment. For both gonorrhea and chlamydia, partners should be referred for evaluation and presumptive treatment if they have had sexual contact with the index patient within the past 60 days. And depending upon your comfort level and the laws in your state, expedited partner therapy can be considered, in which you give a prescription and information to your patient to be given to their sex partner. Patients should be instructed to abstain from sexual activity for 7 days and until their sex partner or partners have completed their treatment.

There is no need for a test of cure; in fact, if you test < 4 weeks after completion of therapy, the presence of nonviable organisms can lead to false-positive results. Re-test is recommended at 3 months to look for re-infection. It's also suggested to take a detailed sexual history, providing an opportunity to discuss pre-exposure prophylaxis for HIV when indicated.

Pelvic Inflammatory Disease

We think of PID as being sexually transmitted, but in reality it's only sexually transmitted about 50% of the time.

We need a high index of suspicion and a low threshold for diagnosis in women who present with abdominal or pelvic pain, because the consequences of untreated PID are significant: an increased risk for infertility, ectopic pregnancy, and chronic pelvic pain. Because of this, we'll accept overdiagnosis and treatment.

Outpatient treatment for PID includes an initial IM injection of 500 mg of ceftriaxone, cefoxitin, or another parenteral third-generation cephalosporin. This should be followed by doxycycline 100 mg twice a day for 14 days and metronidazole 500 mg twice daily for 14 days. The routine addition of metronidazole to the outpatient regimen is new compared with the previous guidelines where it was recommended as an option. Metronidazole provides extended coverage for anaerobes and also treats bacterial vaginosis, which is often associated with PID.

All women with PID should be tested for other STIs and re-tested for gonorrhea and chlamydia re-infection at 3 months, and their sex partners should be referred for treatment for gonorrhea and chlamydia. If the patient has an IUD, it does not have to be removed unless she is not improving by 48-72 hours after starting treatment.

This is a lot of important, new information. Next month, I will discuss herpes, trichomonas, and bacterial vaginosis.

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