New CDC Treatment Guidelines for Sexually Transmitted Diseases

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New CDC Treatment Guidelines Critical to Preventing Health

Consequences of Sexually Transmitted Diseases "

Morbidity and Mortality Weekly Report (MMWR) (05.10.02)

The CDC has issued national guidelines to help health care

providers protect their patients from the health consequences of

sexually transmitted diseases (STDs). CDC revises the guidelines

periodically (approximately every four years). This is the fifth

CDC edition of the guidelines. Major recommendations include:

*Chlamydia screening is advised annually for sexually active

adolescent (19 years old and under) and young adult (20- to 24

years-old) women. Even without symptoms, screening is

recommended, as well as screening older women with a risk factor

for chlamydia (a new partner or multiple sexual partners). It is

also now recommended that all women with chlamydial infections be

rescreened three to four months after treatment is completed.

This is the first time CDC has recommended rescreening in

the management of chlamydia. Chlamydia is concentrated among

female adolescents. In the United States, millions of cases go

unrecognized. Reinfection with chlamydial infection is a key risk

factor for pelvic inflammatory disease (PID). PID can damage the

fallopian tubes, uterus and ovaries, and cause chronic pelvic

pain. One in five women with PID also become infertile. Moreover,

women infected with chlamydia are up to five times more likely to

become infected with HIV, if exposed. Chlamydia is the most

commonly reported infectious disease in the United States;

702,093 cases were reported in 2000.

*Alternative gonorrhea treatments in the wake of increasing drug

resistance in California. Gonorrhea is the second most common

infectious disease reported to CDC, with nearly 360,000 cases in

2000. Drug-resistant strains are becoming increasingly common in

the United States. Ciprofloxacin-resistant gonorrhea was found to

be endemic to Hawaii in 2000, when CDC recommended that the state

cease its use of fluoroquinolone antibiotics - ciprofloxacin,

ofloxacin, and levofloxacin - for treating gonorrhea.

Ciprofloxacin-resistant strains have become so common on the

west coast that the use of fluoroquinolone antibiotics to treat

gonorrhea is inadvisable in California. Previously, CDC

recommended that fluoroquinolones not be prescribed for treating

gonorrhea in Hawaii and in those patients who visited the island

state, other Pacific Islands, or Asia, because a substantial

proportion of the gonorrhea cases in those areas are resistant to

ciprofloxacin. The antibiotics cefixime and ceftriaxone are now

recommended as first-line drugs to treat gonorrhea in Hawaii and

California.

CDC made these new recommendations after examining data from

the Gonococcal Isolate Surveillance Project (GISP), a CDC-

sponsored surveillance system, which monitors drug resistance of

gonorrhea. The GISP project is limited to several areas in the

United States. It is critical therefore that local data are

available to guide prescribing recommendations. Most importantly,

data from local drug susceptibility testing are necessary to

guide local treatment recommendations. CDC requests that local

and state public health professionals and health care providers

report cases of gonorrhea that are resistant to any recommended

antibiotics. If not treated successfully, gonorrhea can cause PID

and can facilitate HIV transmission.

*Expanded risk assessment and screening among gay and bisexual

men. Recent data have shown a higher frequency of unprotected sex

and increased rates of syphilis and gonorrhea in many US cities

among men who have sex with men (MSM), many of whom are HIV

infected. To highlight the critical need for health care

providers to expand screening and treatment of STDs among MSM,

the new guidelines include detailed recommendations for this

high-risk population.

The new guidelines urge health care providers to assess the

sexual risk for all male patients, including the gender of

partners. For MSM patients who are sexually active, the

guidelines recommend annual screening for STDs - HIV, chlamydia

(anal, urethral), syphilis and gonorrhea (anal, pharyngeal,

urethral) - and vaccination against hepatitis A and B. More

frequent STD screening may be indicated for those who indicate

having multiple anonymous partners or having sex in conjunction

with illicit drug use.

*New serological tests available to help diagnose genital herpes.

An estimated one million people are newly infected with the

Herpes Simplex Virus (HSV) each year. While most people have mild

or unrecognized symptoms and remain undiagnosed, many individuals

seek medical attention when they begin to suffer from the painful

ulcers characteristic of this viral disease. Now, new testing

procedures may help providers with diagnosing and managing

genital herpes type one (HSV-1) or type two (HSV-2).

Since antiviral therapy may benefit individuals with herpes

symptoms, providers can tailor counseling and treatment plans to

best fit their needs. Patients infected with HSV-2 (the most

common) can choose from suppressive or episodic antiviral

treatments. 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 only be

needed in patients with initial symptoms.

HSV may play a major role in the spread of HIV. HSV stays in

the body indefinitely and is incurable. In the United States, an

estimated 50 million people are infected.

*Prevention of STDs. The guidelines encourage health care

providers to focus on risk assessment and counseling in addition

to the clinical aspects of STD control - screening and

treatment. Providers are encouraged to use client-centered

counseling approaches tailored for each of their patients. To

avoid the spread of STDs, the guidelines suggest patients should

abstain from oral, vaginal or anal sex. Patients who are sexually

active should be counseled to be in a mutually monogamous

relationship with an uninfected partner or use a condom during

each sexual act.

*The use of Nonoxynol-9 (N-9). Recent studies have found that

frequent use of N-9, a spermicide contraceptive, can cause

genital lesions (in the vagina) and, therefore, may increase the

risk of HIV transmission. It has also been found to cause damage

to the lining of the rectum, providing an entry point for HIV and

other STDs.

Spermicides - especially those that contain N-9 - should

not be used for STD prevention. Furthermore, N-9 lubricants

should not be used during anal intercourse. 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. 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.

The 2002 Guidelines for the Treatment of Sexually

Transmitted Diseases can be ordered at http://www.cdc.gov/std.

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