Gale Burstein, MD, MPH, FAAP, FSAHM1 Amanda Jacobs, MD, FAAP,2 Dmitry Kissin, MD, MPH,3 Kimberly Workowski, MD, FACP4
1. Society for Adolescent Health and Medicine; 2. American Academy of Pediatrics; 3. American College of Obstetricians and Gynecologists, 4. Centers for Disease Control and Prevention
On behalf of the National Chlamydia Coalition
Over 19 million cases of sexually transmitted diseases (STDs) occur in the United States each year, with a disproportionate share among young people and racial and ethnic minority populations. The estimated annual direct medical costs of treating STDs and their sequelae are $17.0 billion. Left untreated, STDs can cause serious health problems ranging from infertility to increased risk of HIV infection.
To stop these silent epidemics, the 2010 STD Treatment Guidelines1, which update the 2006 Guidelines, advise health-care providers, who play a critical role in preventing and treating STDs, on the most effective treatment regimens, screening procedures, and prevention and vaccination strategies for STDs. The recommendations are developed in consultation with public and private sector professionals knowledgeable in the treatment of patients with sexually transmitted infections. CDC revises the Guidelines periodically, approximately every three to four years, using a scientific, evidence-based process.
In this article we will highlight changes that are important for clinicians who care for adolescents.
The CDC Sexually Transmitted Diseases (STD) Treatment Guidelines addresses STD screening and management needs for specific populations that may be at risk. Below are summary of several of the changes found in the 2010 Guidelines.
Prevalence rates of many sexually acquired infections are highest among adolescents. CDC updated recommendations for screening and prevention of asymptomatic adolescents. Recommendations include:
- Annual C. trachomatis screen all sexually active females aged ≤25 years. Clinicians may consider screening adolescent/young adult males in clinical settings associated with high chlamydia prevalence (e.g., adolescent clinics, correctional facilities, and STD clinics).
- Annual N. gonorrhoeae screen all sexually active females at risk for infection. Females aged <25 years are at highest risk for gonorrhea infection.
- Discuss HIV screening with all adolescents and encourage testing for those who are sexually active and who use injection drugs.
- Routinely screening adolescents who are asymptomatic for certain STDs (e.g., syphilis, trichomoniasis, BV, HSV, HPV, HAV, and HBV) is not recommended. However, young men who have sex with men and pregnant adolescent females might require more thorough evaluation.
- Cervical cancer screening should begin at age 21 years
- Encourage immunizations, including human papillomavirus, and hepatitis A and B virus.
- Provide information regarding HIV infection, testing, transmission, and implications of infection to all adolescents as part of health care.
- Integrate sexuality education into clinical practice. The U.S. Preventive task Force Services recommends high-intensity behavioral counseling to prevent STDs for all sexually active adolescents.
Persons in Correctional Facilities
CDC added a new section to present recommendation for “Persons in Correctional Facilities.”. Persons entering correctional facilities have high STDs rates, especially chlamydia and gonorrhea among females less than 35 years. Testing for gonorrhea and Chlamydia facilitates identification and treatment of persons with undetected infections and reduces prevalence among detainees who are released back into the local community. Therefore, chlamydia and gonorrhea screening for all females up to age 35 years is recommended. Syphilis screening recommendations should based on local area and institutional syphilis prevalence.
Women Who Have Sex with Women
The CDC Guidelines point out that sexual identity, sexual behaviors, sexual practices, and risk behaviors of women who have sex with women (WSW) are diverse. Most self-identified WSW (53%--99%) report having had sex with men. Adolescent WSW and females with both male and female partners, might be at increased risk for STDs and HIV.
Since syphilis transmission (likely through oral sex) between female sex partners can occur and recent data suggest that C. trachomatis infection among WSW might be more common than previously thought, providers should consider screening all females for chlamydia and syphilis, regardless of reported same sex behavior. In addition, since HPV transmission can occur from skin-to-skin or skin-to-mucosa contact during sex between females or males, all females, regardless of sexual preference or practices should be offered routine cervical cancer screening and HPV vaccine in accordance with current guidelines.
Gonorrhea and Chlamydia
New C. trachomatis and N. gonorrhoeae laboratory specimen testing options are highlighted in the 2010 Guidelines. Nucleic acid amplification tests (NAATs) are the most sensitive tests to detect C. trachomatis and recommended by CDC. NAATs are Food and Drug Administration (FDA)-cleared for use with urine, cervical, and urethral specimens. Some NAATs are cleared for use with either provider- or patient-collected vaginal swab specimens. Although NAATs are not FDA-cleared for use with rectal or oropharyngeal swab specimens, some laboratories have met Clinical Laboratory Improvement Amendments (CLIA) requirements and have validated gonorrhea and chlamydia NAAT testing on rectal swab specimens and gonorrhea NAAT testing on oral swabs.
When considering treatment, it is important to realize that gonococcal antimicrobial resistance remains an issue in the United States. Penicillin, tetracycline or quinolones are no longer gonorrhea treatment options. The recommended treatment for uncomplicated gonococcal infections of the cervix, urethra, and rectum is dual therapy with ceftriaxone 250 mg intramuscularly in a single dose PLUS either azithromycin 1g orally in a single dose OR doxycycline 100 mg twice daily for 7 days. If ceftriaxone is not an option, dual therapy with cefixime 400 mg orally plus azithromycin 1 gram in a single dose or doxycycline 100 mg twice daily for 7 days is an option. Although cefixime is administered orally, there is limited efficacy of cefixime for pharyngeal infection, if infection at this site is suspected. CDC has made a recommendation for dual therapy for gonoccocal infections at all anatomic sites , due to concerns about the possible emergence of cephalosporin resistance gonorrhea in the United States.
Since chlamydia or gonorrhea reinfection rates are high due to persons treated for chlamydia and/or gonorrhea from resuming sex with untreated partners, chlamydia and/or gonorrhea-infected females and males should be retested approximately 3 months after treatment whenever persons next present for medical care, regardless of whether they believe that their sex partners were treated.
Vaginitis diagnostic evaluation can be challenging. Bacterial vaginosis (BV) can be diagnosed by the use of clinical criteria (i.e., Amsel's Diagnostic Criteria) or Gram stain. However, Gram stain and even microscopy and pH paper are often not available in the primary care provider’s office. The sensitivity of microscopic examination of vaginal secretions immediately after the slide preparation for T. vaginalis is only 60%–70%. Clinical Laboratory Improvement Act (CLIA) - waived, more sensitive, point of care, vaginal tests include the OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, Massachusetts), an immunochromatographic capillary flow dipstick technology, and the OSOM BVBLUE Test (Genzyme Diagnostics, Cambridge, Massachusetts) that detects elevated vaginal fluid sialidase activity, an enzyme produced by bacterial pathogens associated with Bacterial Vaginosis including Gardnerella, Bacteroides, Prevotella and Mobilincus. Both rapid test results are available in 10 minutes. The Affirm™ VP III (Becton Dickenson, San Jose, California), a nucleic acid probe test, which tests for T. vaginalis, G. vaginalis, and C. albicans, is a CLIA - moderate complexity test with results available within 45 minutes. A Pap test should not be routinely used as a trichomonas screening test. An FDA approved T. vaginalis nucleic acid amplification test is available and has demonstrated enhanced sensitivity and specificity.
Two new alternative BV treatment regimens are Tinidazole 2 g orally once daily for 2 days or Tinidazole 1 g orally once daily for 5 days are options for patients who do not tolerate metronidazole or have difficulty with compliance.
Because of the high T. vaginalis reinfection rates of among patients diagnosed and treated for trichomoniasis, rescreening for T. vaginalis at 3 months following initial infection can be considered for sexually active females with trichomoniasis. No data support rescreening for males diagnosed with T. vaginalis.
Pelvic Inflammatory Disease (PID)
Azithromycin has demonstated short term effectiveness in one randomized trial and in combination with ceftriaxone 250 mg IM in a single dose ( azithromycin 1 g orally once a week for 2 weeks). Clinicians who use an alternative PID treatment regimen should consider adding metronidazole because anaerobic organisms are suspected in the etiology and metronidazole will also treat BV.
As a result of the emergence of quinolone-resistant Neisseria gonorrhoeae, regimens that include a quinolone agent are no longer recommended for PID treatment.
Human Papillomavirus (HPV)
CDC reinforces HPV vaccination for adolescents and young adults as indicated to prevent disease caused by HPV.
In addition, a new external genital warts patient-applied therapy treatment option is Sinecatechins 15% ointment. Sinecatechin ointment, a green-tea extract with an active product (catechins), should be applied three times daily (0.5-cm strand of ointment to each wart) using a finger to ensure coverage with a thin layer of ointment until complete clearance of warts for up to 16 weeks. The medication should not be washed off after use. Sexual (i.e., genital, anal, or oral) contact should be avoided while the ointment is on the skin. The most common side effects of sinecatechins 15% are erythema, pruritis/burning, pain, ulceration, edema, induration, and vesicular rash. This medication is not recommended for HIV-infected persons, immunocompromised persons, or persons with clinical genital herpes because the safety and efficacy of therapy in these settings has not been established. The safety of sinecatechins during pregnancy also is unknown.
A new first line scabies treatment option is Ivermectin 200ug/kg orally that should be repeated in 2 weeks. Ivermectin is not recommended for pregnant or lactating patients and the safety of ivermectin in children who weigh less than 15 kg has not been determined.
Sexual Assault and STDs: Adults and Adolescents
Changes for recommended sexual assault STD testing at initial examination include NAATs for C. trachomatis and N. gonorrhoeae recommended as the preferred diagnostic tests for evaluation of sexual assault victims, regardless of the sites of penetration or attempted penetration. For T. vaginalis infection testing, in addition to a wet mount or culture, a point-of-care testing of a vaginal-swab specimen may be used. The following prophylactic regimen is suggested as preventative therapy against chlamydia, gonorrhea, and trichomonas (ceftriaxone 250 mg IM in a single dose or cefixime 400 mg orally in a single dose plus azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days plus metronidazole 2 g orally in a single dose).
Sexual Assault or Abuse of Children
Changes for recommended sexual assault STD testing at initial examination provide an option for NAATs to be used for detection of C. trachomatis in vaginal specimens or urine from girls. No data are available regarding the use of NAATs in boys or for extragenital specimens (e.g., those obtained from the rectum) in boys and girls. Culture remains the preferred method for extragenital sites. Data on use of NAATs for detection of N. gonorrhoeae in children are limited, and performance is testdependent . Clinicians should consult with an expert before using NAATs in this context to minimize the possibility of cross-reaction with nongonococcal Neisseria species and other commensals . For girls, NAATs can be used as an alternative to culture with vaginal specimens or urine, whereas culture remains the preferred method for urethral specimens or urine from boys and for extragenital specimens (pharynx and rectum) from all children. All positive C. trachmoatis or N. gonorrhoeae specimens should be retained for additional testing.
Expedited Partner Therapy (EPT)
The 2010 STD Treatment Guidelines emphasize the important role of partner management for STD prevention. Partner treatment not only directly benefits the infected individual, but also prevents re-infection of the index case and disrupts STD transmission networks. As previously, the guidelines highlight the importance of expedited partner therapy (EPT) – the clinical practice of treating the sex partners of patients diagnosed with STD without previous medical evaluation of the partners. According to the STD treatment guidelines and CDC EPT guidance, EPT should be considered for the treatment of gonorrhea and chlamydia in heterosexual partners when other management strategies are impractical or unsuccessful. Since 2006, many more states made EPT legally permissible (27 states and 1 city as of January 11, 2011), and many state health departments developed guidelines for EPT implementation. In addition, EPT has been endorsed by many professional organizations, such as American Medical Association, Society for Adolescent Health and Medicine, American Academy of Pediatrics and American Bar Association. The 2010 STD Treatment Guidelines also discuss the new evidence supporting the use of internet to facilitate partner notification.
The complete treatment guidelines, as well as information on webinars, ordering information regarding Guidelines hard copies, wall charts, and pocket guides and downloading iPhone and eBook versions can be viewed and downloaded at cdc.gov/std/treatment/2010 or contact CDC-INFO at 800-CDC-INFO (800-232-4636), 24 hours/day, or email email@example.com.
1Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010; 59(RR12);1-110. Available at: http://www.cdc.gov/std/treatment/2010.