Miller

Update on the Prevention and Treatment
of Sexually Transmitted Diseases
KARL E. MILLER, M.D., DAVID E. RUIZ, M.D., and J. CHRISTOPHER GRAVES, M.D.
University of Tennessee College of Medicine, Chattanooga, Tennessee
The Centers for Disease Control and Prevention (CDC) recently published updated guide-
lines that provide new strategies for the prevention and treatment of sexually transmit-
ted diseases (STDs). Patient education is the first important step in reducing the number
of persons who engage in risky sexual behaviors. Information on STD prevention should
be individualized on the basis of the patient’s stage of development and understanding
of sexual issues. Other preventive strategies include administering the hepatitis B vaccine
series to unimmunized patients who present for STD evaluation and administering
hepatitis A vaccine to illegal drug users and men who have sex with men. The CDC rec-
ommends against using any form of nonoxynol 9 for STD prevention. New treatment
strategies include avoiding the use of quinolone therapy in patients who contract gonor-
rhea in California or Hawaii. Testing for cure is not necessary if chlamydial infection is
treated with a first-line antibiotic (azithromycin or doxycycline). However, all women
should be retested three to four months after treatment for chlamydial infection, because
of the high incidence of reinfection. Testing for herpes simplex virus serotype is advised
in patients with genital infection, because recurrent infection is less likely with the type 1
serotype than with the type 2 serotype. The CDC guidelines also include new information
on the treatment of diseases characterized by vaginal discharge. (Am Fam Physician 2003;
67:1915-22. Copyright 2003 American Academy of Family Physicians.)
position to provide education and coun-seling on the prevention of STDs. Infor-mation should be individualized on the by health care workers to reduce the morbidityand mortality of sexually basis of the patient’s stage of develop- issues.3 The information should be deliv- States.1 Family physicians play a critical role in efforts to prevent or, when preven- tion fails, to treat these infections. To assist in these endeavors, the Centers for counseling has been shown to reducemisconceptions, and it also may reduce Clinical Prevention Guidelines
the occurrence of risky sexual behaviors.4 performed in an outpatient setting (i.e., gies (Table 1).2 The CDC2 notes that the tion or visit for refill of a contraceptive prescription) can be effective.5 Over the change sexual behaviors that increase the the United States: this increase suggests amous relationship with an uninfected part- Annual screening for chlamydial infection should be performed ner. The CDC2 recommends that potentialsexual partners be tested for STDs, including in all sexually active women 24 years of age and younger. human immunodeficiency virus (HIV) infec-tion, before they begin having sexual inter-course. If one of the partners is infected or the that the message on STD prevention is being infection status is unknown, a new condom heard.6 However, to reduce the incidence of should be used for each action of insertive STDs, family physicians must continue pro- Preexposure vaccination is one of the most One of the most reliable methods of avoid- effective strategies for preventing the trans- ing STD transmission is abstinence from sex- ual relations, including oral, vaginal, and anal mends that patients being evaluated for an STD receive a hepatitis B vaccine series if they risky sexual behaviors,7 particularly when were not immunized in the past. Vaccination information on sexual negotiation skills is is particularly important in adolescents, who included.8 Counseling about abstinence is generally do not consider themselves to be at crucial for patients who are receiving treat- risk for contracting hepatitis B.9 The CDC also ment for STDs or whose partners are under- recommends the administration of hepatitis A vaccine to illegal drug users and men who wish to avoid possible consequences of sexual intercourse, such as pregnancy or exposure to Another preventive strategy is the screening of selected populations. The CDC currently The other method for reducing the risk of recommends annual screening for chlamydial STD exposure is to be in a long-term monog- infection in all sexually active women 24 yearsof age and younger.2 [Evidence level C, con-sensus/expert guidelines] Screening is impor-tant even if these women are asymptomatic, because younger women are more susceptible Major Strategies for the Prevention
to chlamydial infection than older women.
and Control of STDs
Women older than 24 years should bescreened if they are at risk for chlamydial Education and counseling about safer sexual infection (e.g., new sexual partner, history of Identification of asymptomatic persons with STDs, as well as symptomatic infected persons who are unlikely to seek diagnostic and treatment services Effective diagnosis and treatment of persons reducing the transmission of STDs. However, recent studies10,11 have found that this com- Evaluation, treatment, and counseling of sexual pound provides no protection against gonor- rhea or chlamydial infection. In one study,12 Preexposure immunizations for vaccine-preventable the use of nonoxynol 9 actually increased therisk of contracting gonorrhea. Condoms STDs = sexually transmitted diseases. lubricated with nonoxynol 9 have a shortshelf life and cost more than other condoms; Adapted from Sexually transmitted diseases treatmentguidelines 2002. Centers for Disease Control and Pre- furthermore, their use may increase the risk vention. MMWR Recomm Rep 2002;51(RR-6):1-78. of urinary tract infection.2 Because of thesefactors, the CDC2 recommends against using nonoxynol 9 or condoms lubricated with this to Hawaii and parts of the West Coast. Based on epidemiology, resistance to these drugs is believed to have originated in Asia and thePacific region; the incidence of quinolone Diseases Characterized by Urethritis
resistance has been high in these areas for and Cervicitis
The diagnosis and treatment of urethritis and cervicitis are discussed in detail in the CDC gonorrhea. The CDC2 suggests that, because guidelines.2 New information includes the of the increased prevalence of resistant N. gon- wider spread of quinolone resistance to Neisse- orrhoeae, quinolone therapy is “inadvisable” ria gonorrhoeae and the need for follow-up test- ing in women treated for chlamydial infection.
Cephalosporins, specifically orally adminis- tered cefixime (Suprax) and intramuscularly GONOCOCCAL DISEASE
first-line agents for the treatment of gonococ- published, resistance to quinolones has spread cal urethritis (Table 2).2 Ceftriaxone, which TABLE 2
Treatment Recommendations for STDs Characterized by Urethritis and Cervicitis
Uncomplicated Cefixime (Suprax), 400 mg orally one time Spectinomycin (Trobicin), 2 g IM one time Ceftizoxime (Cefizox), 500 mg IM one time Cefoxitin (Mefoxin), 2 g IM one time, plus Cefotaxime (Claforan), 500 mg IM one time Ofloxacin (Floxin), 400 mg orally one time Gatifloxacin (Tequin), 400 mg orally one time Norfloxacin (Noroxin), 800 mg orally one time Lomefloxacin (Maxaquin), 400 mg orally one Erythromycin base, 500 mg orally four times Erythromycin ethylsuccinate (E.E.S.), 800 mg Ofloxacin, 300 mg orally twice daily for 7 daysLevofloxacin, 500 mg orally once daily for 7 days time, plus erythromycin base, 500 mg orally four times daily for 7 days, or erythromycin ethylsuccinate, 800 mg orally four times daily for 7 days STDs = sexually transmitted diseases; IM = intramuscularly. *—No advantage exists for use of the alternative injectable cephalosporins over ceftriaxone; in addition, no advan-tage exists for use of orally administered quinolones over the first-line quinolones, and data on their use are limited. Adapted from Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Pre-vention. MMWR Recomm Rep 2002;51(RR-6):1-78. caused by Trichomonas vaginalis or herpes Treatment for gonorrhea and chlamydial infection should be provided if empiric therapy is initiated before the test results gonococcal urethritis (e.g., chlamydial infec- are known or when patients are likely to be lost to follow-up. tion) is azithromycin (Zithromax) or doxy-cycline (Vibramycin). Alternatively, theinfection can be treated with a seven-day remains the agent of choice for other forms of course of erythromycin base or erythromycin gonococcal disease, is given intravenously to ethylsuccinate (E.E.S), ofloxacin, or lev- treat all serious or systemic infections.
ofloxacin (Levaquin).2 The CDC encourages Quinolones are safe and effective for treat- testing for C. trachomatis in all patients with ing nonresistant gonococcal infections. How- urethritis and cervicitis, and recommends ever, these drugs should be used with caution treatment of gonorrhea and chlamydial infec- when an infection may have been acquired in tion if empiric therapy is initiated before test or from Asia or the Pacific region. Cipro- results are known or when patients are likely floxacin (Cipro) and ofloxacin (Floxin) are to be lost to follow-up.2 [Evidence level C, options for the intravenous treatment of dis- seminated gonococcal infections and are givenorally for the treatment of uncomplicated PERSISTENT URETHRITIS
infections of the urethra, cervix, or rectum.2 Rarely, symptoms persist after routine ther- apy. Unfortunately, there is no proven effective NONGONOCOCCAL URETHRITIS
treatment for persistent urethritis. Recom- Etiologic agents in nongonococcal urethri- mendations include repeating the initial ther- tis include Chlamydia trachomatis, Myco- apy if the patient did not comply with the plasma genitalium, and Ureaplasma urea- original treatment plan. If the patient was lyticum. Rarely, nongonococcal urethritis is compliant, consideration can be given to swabtesting for T. vaginalis and treatment withmetronidazole (Flagyl) and erythromycin.
CHLAMYDIAL INFECTION
KARL E. MILLER, M.D., is professor in the Department of Family Medicine at the Uni-versity of Tennessee College of Medicine, Chattanooga. After graduating from the Medical College of Ohio, Toledo, Dr. Miller completed a family practice residency at chlamydial infection. Unless symptoms per- Flower Memorial Hospital, Sylvania, Ohio. He also completed a research and faculty sist, testing for cure is unnecessary when a development fellowship at Michigan State University, East Lansing. Dr. Miller is assis-tant editor of American Family Physician. chlamydial infection is treated with azith-romycin or doxycycline. If retesting is indi- DAVID E. RUIZ, M.D., is assistant professor in the Department of Family Medicine atthe University of Tennessee College of Medicine, Chattanooga. A graduate of Loma cated, it should be delayed for more than three Linda (Calif.) University School of Medicine, Dr. Ruiz completed a family practice resi- weeks after treatment is completed to reduce dency at Florida Hospital, Orlando, and a faculty development fellowship at the Uni- the possibility of a false-positive result.
versity of North Carolina at Chapel Hill.
The CDC2 notes that patients who have had J. CHRISTOPHER GRAVES, M.D., is assistant professor in the Department of Family a chlamydial infection are at high risk for rein- Medicine at the University of Tennessee College of Medicine, Chattanooga. Dr. Gravesreceived his medical degree from the University of Tennessee Center for Health Sci- fection. Therefore, all women with previous ences, Memphis, and completed family practice residencies at Saint Francis Hospital, chlamydial infection should be retested three Memphis, and Naval Hospital, Camp Pendleton, Calif.
to four months after treatment. Regardless of Address correspondence to Karl E. Miller, M.D., Department of Family Medicine, Chat- whether their sexual partner has been treated, tanooga Unit, University of Tennessee College of Medicine, 1100 E. Third St., Chat- these women should be rescreened by no later tanooga, TN 37403 (e-mail: millerkarle@hotmail.com). Reprints are not available fromthe authors. Diseases Characterized by Genital Ulcers
All women with previous chlamydial infection should be retested three to four months after treatment. causes of genital ulcers are genital herpes,syphilis, and chancroid.2,13 Each of these dis-eases is associated with an increased risk forHIV infection.2 The only significant change in The treatment of genital herpes depends on whether the infection is a first episode or a recurrence (Table 3).2 The CDC2 also hasestablished regimens for suppressive therapy GENITAL HERPES
in patients with recurrent genital herpes.
HSV infection is the most common cause of genital ulcers in this country.13 Approximately Diseases Characterized by Vaginal
45 to 50 million Americans have genital her- Discharge
pes, and an estimated 1 million new cases occur each year.2,14 Primary infection occurs mostly in adolescents and young adults. Gen- associated with vaginal discharge. Patients ital herpes is more common in women, blacks, with any of these diseases also may have vul- and persons with multiple sexual partners.
var itching or irritation and a vaginal odor.
Two HSV serotypes have been identified in humans. HSV-1 is the most common cause of BACTERIAL VAGINOSIS
oral herpes infection, and HSV-2 is the pri- Bacterial vaginosis is caused by the replace- mary pathogen in sexually transmitted genital ment of normal vaginal flora with an over- herpes. Both serotypes can be present at oralor genital sites.
episodes of latency, with asymptomatic viral Treatment Regimens for Genital Herpes
shedding, recurrent activation, and perinataland sexual transmission.15 Along with most First episode*
Acyclovir (Zovirax), 400 mg orally three times daily for 7 to 10 days, or 200 mg orally five times daily for 7 to 10 days infection increases the risk of HIV transmis- Famciclovir (Famvir), 250 mg orally three times daily for 7 to 10 days sion and is believed to play an important role Valacyclovir (Valtrex), 1 g orally twice daily for 7 to 10 days Recurrent episode
The diagnosis of genital herpes is best estab- Acyclovir, 400 mg orally three times daily for 5 days, or 200 mg orally five lished by viral culture. In the updated guide- times daily for 5 days, or 800 mg orally twice daily for 5 days lines, the CDC2 also recommends type-specific Famciclovir, 125 mg orally twice daily for 5 days Valacyclovir, 500 mg orally twice daily for 3 to 5 days, or 1 g orally once serotype has caused the genital infection. Know- ing the HSV serotype is important in counsel- Suppressive therapy
ing patients about the potential for recurrent genital herpes, because recurrent episodes are less likely with the HSV-1 serotype than with Valacyclovir, 500 mg orally once daily, or 1 g orally once daily the HSV-2 serotype. In addition, type-specificserologic tests may help confirm the diagnosis *—Antiviral drug therapy may be extended if healing is incomplete after 10 days. of genital herpes in patients with recurrent Adapted from Sexually transmitted diseases treatment guidelines 2002. Centers infection or with healing lesions, for which HSV for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78. culture results may be false-negative.
TABLE 4
Diagnostic Criteria for PID
Minimum criteria
growth of anaerobic microorganisms, Myco- plasma hominis, and Gardnerella vaginalis. This disease is the most frequent cause ofvaginal discharge, but most affected women Additional criteria
Oral temperature >38.3°C (>101°F)
Abnormal cervical or vaginal mucopurulent discharge Presence of white blood cells on saline microscopy vaginosis concerns screening for and treating this disease in pregnant women. The presence Laboratory documentation of cervical gonococcal of bacterial vaginosis during pregnancy has been associated with premature rupture of chorioamnionitis, postpartum endometritis, Specific criteria
and postcesarean section infection. However, Endometrial biopsy with histopathologic evidence routine screening for and treatment of bacte- rial vaginosis during the prenatal period have Laparoscopic abnormalities consistent with PIDTransvaginal ultrasound or MRI study showing not been shown to reduce these adverse preg- thickened, fluid-filled tubes, with or without free nancy outcomes.17-20 [References 17 and 18— Evidence level A, randomized controlled trials(RCTs); reference 19—Evidence level A, meta- PID = pelvic inflammatory disease; MRI = magnetic analysis; reference 20—Evidence level A, sys- Adapted from Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Pre- terial vaginosis in all symptomatic pregnant vention. MMWR Recomm Rep 2002;51(RR-6):1-78. women, followed by treatment if indicated.
Testing for bacterial vaginosis also may be per-formed in pregnant women who have a his-tory of preterm labor, with treatment given if moniasis should be given a single dose of disease is present. However, the optimal treat- metronidazole.21 Treatment of asymptomatic ment regimen for these patients has not been been shown to prevent preterm delivery.22[Evidence level A, RCT] TRICHOMONIASIS
Men with trichomoniasis tend to be asymp- VULVOVAGINAL CANDIDIASIS
tomatic, but infected women tend to have a Vulvovaginal candidiasis usually presents as diffuse, malodorous, yellow-green vaginal dis- charge that causes vulvar irritation. Tricho- diagnosis of this infection can be confirmed moniasis is diagnosed by the presence of mov- by finding budding yeast or hyphae under a ing flagellated organisms in vaginal secretions hydroxide solution has been added to vaginal secretions. Current treatment recommenda- not provide adequate coverage for trichomo- tions include a substantial number of over- niasis. The recommended treatment for this the-counter (OTC) antifungal agents, as well infection is metronidazole, taken orally in a as prescription fluconazole (Diflucan) taken single 2-g dose. Alternatively, metronidazole can be administered in a dosage of 500 mg quently self-diagnose vulvovaginal candidiasis incorrectly.2,23 The CDC2 notes that unneces- TABLE 5
Treatment Regimens for PID
Parenteral regimen A
Outpatient regimen A
Cefotetan (Cefotan), 2 g IV every 12 hours, Ofloxacin, 400 mg orally twice daily for or cefoxitin (Mefoxin), 2 g IV every 6 hours Metronidazole, 500 mg orally twice daily Parenteral regimen B
Clindamycin (Cleocin), 900 mg IV every 8 hours Outpatient regimen B
Ceftriaxone (Rocephin), 250 mg IM one time; Gentamicin, 2 mg per kg IV or IM (loading dose), or cefoxitin, 2 g IM, plus probenecid, I g followed by 1.5 mg per kg IM or IV every 8 hours orally administered concurrently; or other (maintenance dosage; single daily dosing may be parenterally administered third-generation cephalosporin (e.g., ceftizoxime [Cefizox],cefotaxime [Claforan]) Alternative parenteral regimens
Ofloxacin (Floxin), 400 mg IV every 12 hours, or Doxycycline, 100 mg orally twice daily for levofloxacin (Levaquin), 500 mg IV once daily Metronidazole (Flagyl), 500 mg IV every 8 hours, or Metronidazole, 500 mg orally twice daily ampicillin-sulbactam (Unasyn), 3 g IV every 6 hours Doxycycline, 100 mg orally or IV every 12 hours PID = pelvic inflammatory disease; IV = intravenously; IM = intramuscularly. Adapted from Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Pre-vention. MMWR Recomm Rep 2002;51(RR-6):1-78. sary or inappropriate use of OTC antifungal agalactiae, cytomegalovirus, M. hominis, and agents can delay correct diagnosis and treat- ment of vulvovaginitis resulting from other The CDC has developed diagnostic criteria causes. Hence, self-medication with antifun- for PID (Table 4).2 The updated CDC guide- gal agents should be done only for recurrence lines2 state that to reduce morbidity from PID, empiric therapy should be initiated in patients who have uterine or adnexal tenderness or cervical motion tenderness (minimum diag- OTC antifungal agents should be advised to nostic criteria), with treatment based on the seek medical care if their symptoms do not individual patient’s risk profile. In one recent resolve or if their symptoms recur within two study,24 adnexal tenderness was found to be months after OTC antifungal treatment.
the most sensitive diagnostic criterion. Addi-tional criteria can be used to support the diag- PELVIC INFLAMMATORY DISEASE
passes a range of inflammatory disorders that PID to include levofloxacin in the alternative affect the female upper genital tract. The most parenteral regimen and one of the outpatient common causes are C. trachomatis and N. gonorrhoeae. Other possible causes includeanaerobes, G. vaginalis, Haemophilus influen- The authors indicate that they do not have any con- zae, enteric gram-negative rods, Streptococcus flicts of interest. Sources of funding: none reported. transmitted diseases. Pediatr Clin North Am1999;46:747-66.
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