American Family Physician - Prevention and treatment of sexually transmitted diseases: an update
The Centers for Disease Control and Prevention recently published revised guidelines for the prevention and treatment of sexually transmitted diseases. One new treatment strategy is the use of azithromycin as a primary, rather than alternative, medication for pregnant women with Chlamydia trachomatis infection. Quinolone-resistant Neisseria gonorrhoeae infection continues to increase in the United States; therefore, quinolones are no longer recommended for treatment of this infection. Expedited partner therapy gives physicians another option when addressing the need to treat partners of persons diagnosed with N. gonorrhoeae or C. trachomatis infection. Tinidazole is now available in the United States and can be used to manage trichomoniasis, including trichomoniasis resistant to metronidazole. Shorter courses of antiviral medication can be used for episodic therapy of recurrent genital herpes. Because of increasing resistance, close follow-up is required if azithromycin is used as an alternative treatment in the management of primary or secondary syphilis. Unexpected increases in the rates of lymphogranuloma venereum have occurred in the Netherlands, and physicians should remain vigilant for symptoms of this disease in the United States. (Am Fam Physician 2007;76:1827-32, 1833-34. Copyright [C] 2007 American Academy of Family Physicians.)
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The centers for Disease control and Prevention (CDC) recently released updated guidelines for the prevention and treatment of sexually transmitted diseases (STDs).1 These guidelines were developed through a systematic review of evidence that has become available since the 2002 guidelines were issued, as well as through expert consultation.
Health Education
Education and counseling are the main strategies in the prevention and control of STDs. evaluation includes addressing key areas of sexual health referred to as the Five P’s: Partners, Prevention of pregnancy, Protection from STDs, Practices, and Past history of STDs. Addressing this information with patients creates an opportunity for physicians to provide counseling and education while taking into account each patient’s individual risk factors and goals. The use of motivational interviewing focuses on the specific behaviors of the patient and places a greater emphasis on moving toward individually defined, achievable, risk-reduction goals. Table 1 (1) lists symptoms and diagnoses of selected STDs.
A visit with a physician for the screening, diagnosis, or treatment of STDs also provides an opportunity for the physician to educate the patient about human immunodeficiency virus (HIV). Patients may not be aware that the presence of an STD may facilitate the transmission of HIV if they are exposed to the virus. Because some patients who are HIV positive are unaware of their diagnosis, the CDC now encourages HIV screening for patients in all health care settings. Although patients may choose not to be tested, written consent for testing is no longer recommended (unless mandated by the state). (2)
Chlamydia Trachomatis
Chlamydia trachomatis is the most common reportable infectious disease in the United States, with almost 1 million cases reported in 2004. (3) Few recommendations have changed for the treatment of persons infected with C. trachomatis; however, azithromycin (Zithromax) is now recommended as a primary, rather than alternative, treatment in pregnant women (Table 2). (1) This change occurred because of recent evidence supporting azithromycin as safe and effective during pregnancy. (4-6)
Neisseria Gonorrhoeae
Since the publication of the 2002 STD treatment guidelines, the rate of quinolone-resistant Neisseria gonorrhoeae has continued to increase throughout the United States. As resistance increases, recommendations continue to change. Previous recommendations focused on the high levels of resistance in areas of Asia and the Pacific, California, Hawaii, and in some specific populations in the United States (e.g., men who have sex with men). In 2004, 6.8 percent of isolates collected by the CDC’s Gonococcal isolate Surveillance Project were resistant to ciprofloxacin (cipro); when samples from California and Hawaii were excluded, 3.6 percent of isolates were resistant. (7)
Quinolone-resistant N. gonorrhoeae is more common in men who have sex with men than in men who have sex exclusively with women (23.8 versus 2.9 percent, respectively) (7); however, the rate of quinolone-resistant N. gonorrhoeae continues to increase among heterosexual persons. In heterosexual men, the prevalence rose from 0.9 percent in 2002 to 3.8 percent in 2005, (8) and preliminary data from the first six months of 2006 indicate an increase to 6.7 percent. (9) Current guidelines reflect these changes (Table 3 (1)) by no longer recommending quinolones as treatment for N. gonorrhoeae infection. (9)
Expedited Partner Treatment
It is standard practice to recommend that sex partners of patients diagnosed with an STD be treated to decrease the risk of reinfection and to decrease the incidence and prevalence of STDs among social networks. The primary goal is for the patient’s sex partners to be seen by a physician for testing, treatment, and education. however, there may be clinical situations in which this cannot be accomplished (e.g., because of patient, partner, or resource limitations). In these circumstances, the CDC recommends that physicians consider using expedited partner treatment.