Practice Guidelines

Updated CDC Guidelines for the Treatment of STDs

LIZ SMITH

The Centers for Disease Control and Prevention (CDC) updated its 2002 guidelines for the treatment of sexually transmitted diseases (STDs) after consultation with professionals and a systematic review of the evidence. The updated guidelines contain new approaches to patient-centered counseling, expanded discussions of prevention screening for human immunodeficiency virus (HIV) and other STDs, and several diagnosis and treatment updates, discussed below.

Approaches to Prevention

The five strategies for the prevention of STDs are: (1) education and counseling of persons at risk; (2) identification of infected persons who are asymptomatic and those who are symptomatic but unlikely to seek treatment; (3) effective diagnosis and treatment of infected persons; (4) evaluation, treatment, and counseling of sex partners of infected persons; and (5) preexposure vaccination of persons at risk, when possible.

Physicians should routinely obtain sexual histories from patients and address risk-reduction management. A thorough sexual history and effective delivery of prevention messages require counseling skills marked by respect, compassion, and a nonjudgmental attitude. Effective techniques include the use of open-ended questions (e.g., "Tell me about any sex partners you've had since your last visit," "What has your experience with using condoms been like?"), understandable language (e.g., "Have you ever had a sore or scab on your penis?"), and normalizing language (e.g., "Some of my patients have difficulty always using a condom. How is it for you?"). One approach to obtaining information is the Five Ps: Partners, Prevention of pregnancy, Protection from STDs, Practices, and Past history of STDs (Table 1).

table 1 The Five Ps: An Approach to Taking a Sexual History

Partners "Do you have sex with men, women, or both?" "In the past two months, how many partners have you had sex with?" "In the past 12 months, how many partners have you had sex with?"

Prevention of pregnancy "Are you or your partner trying to get pregnant?" If the answer is no, "What are you doing to prevent pregnancy?"

Protection from STDs "What do you do to protect yourself from STDs and HIV?"

Practices "To understand your risks of STDs, I need to understand the kind of sex you have had recently." "Have you ever had vaginal sex, meaning 'penis in vagina sex'?" If the answer is yes, "Do you use condoms never, sometimes, or always?" "Have you had anal sex, meaning 'penis in rectum/anus sex'?" If the answer is yes, "Do you use condoms never, sometimes, or always?" "Have you had oral sex, meaning 'mouth on penis or vagina'?" For answers to condom questions: If the answer is never, "Why don't you use condoms?" If the answer is sometimes, "In what situations, or with whom, do you not use condoms?"

Past history of STDs "Have you ever had an STD?" "Have any of your partners had an STD?" Additional questions to identify HIV and hepatitis risk: "Have you or your partners ever injected drugs?" "Have you or your partners exchanged money or drugs for sex?" "Is there anything else about your sexual practices that I need to know about?"

STD = sexually transmitted disease; HIV = human immunodeficiency virus. Information from Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55(RR-11):1-94.

Prevention counseling should incorporate risk-reduction messages that are relevant to the patient as well as education about specific actions that can reduce STD risk, such as abstinence, condom use, fewer sex partners, modifying sexual behaviors, and vaccination when appropriate. Guidance on prevention counseling and effective interventions is available at http://www.stdhivpreventiontraining.org and http://effectiveinterventions.org.

Physicians should reassure patients that treatment will be provided regardless of their circumstances (e.g., ability to pay). Although many patients requiring screening or treatment for one specific STD should be assessed for all common STDs, patients should be informed of all STDs for which they are being tested and of common STDs for which testing is not being performed.

HIV Screening

All persons who seek evaluation and treatment for STDs should be screened for HIV infection, regardless of risk factors. Consent for HIV testing should be incorporated into the general consent for care. HIV testing must be voluntary and conducted only with the patient's knowledge and understanding. However, it should be performed on an opt-out basis-patients should be informed orally or in writing that, unless they decline, HIV testing will be performed. An explanation of positive and negative test results should be given, and patients should have the opportunity to ask questions and decline testing.

HIV testing may be a good opportunity for prevention counseling to encourage and help with behavior changes; prevention counseling should be encouraged at all facilities that serve patients at high risk or that routinely obtain information on HIV risk behaviors.

HIV rapid testing allows a presumptive diagnosis of HIV-1 infection within 30 minutes and must be considered, particularly in clinics where many patients do not return for results. Positive results for HIV antibody screening must be confirmed by an additional test, such as the Western blot or an immunofluorescence assay. Patients with positive results on confirmatory tests must be given initial HIV prevention counseling before they leave the testing site. They should also receive a medical evaluation and, if indicated, behavioral and psychological services or a referral for these services.

Physicians should be alert to acute retroviral syndrome, which often occurs in the first few weeks after HIV infection, and should perform nucleic acid testing for HIV if indicated. Symptoms and signs of acute retroviral syndrome include fever, malaise, lymphadenopathy, and skin rash. HIV infection may be more easily transmitted in acutely infected persons, and these persons may still be practicing risky behaviors. Patients with recently acquired HIV infection may benefit from antiretroviral drugs and could be candidates for clinical trials; therefore, these patients should be referred for immediate consultation with an HIV subspecialist.

Because the incidence of STDs has increased in persons infected with HIV, consensus guidelines emphasize that STD and HIV risk assessment, STD screening, and patient-centered risk-reduction counseling should be provided routinely to all patients with HIV infection. Specific approaches for HIV care are described at http://effective interventions.org.

Treatment

A summary of treatment recommendations for select conditions is provided in Table 2. Physicians should refer to the full guidelines for recommendations on the treatment of syphilis.

table 2 Treatment Recommendations for Sexually Transmitted Diseases
Indication	Recommended treatments
Bacterial vaginosis
Nonpregnant patients	Metronidazole (Flagyl) 500 mg orally two times per day for seven days Metronidazole 0.75% gel 5 g (one full applicator) intravaginally once per day for seven days Clindamycin (Cleocin) 2% cream 5 g (one full applicator) intravaginally at bedtime for seven days Alternatives: Clindamycin 300 mg orally two times per day for seven days Clindamycin ovules 100 mg intravaginally once at bedtime for three days
Pregnant patients	Metronidazole 500 mg orally two times per day for seven days Metronidazole 250 mg orally three times per day for seven days Clindamycin 300 mg orally two times per day for seven days
Cervicitis, presumptive	Azithromycin (Zithromax) 1 g orally in a single dose Doxycycline (Vibramycin) 100 mg orally two times per day for seven days plus consider concurrent treatment for gonococcal infection
Chancroid	Azithromycin 1 g orally in a single dose Ceftriaxone (Rocephin) 250 mg IM in a single dose Ciprofloxacin (Cipro) 500 mg orally two times per day for three days Erythromycin base 500 mg orally three times per day for seven days
Chlamydia
Nonpregnant adults	Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally two times per day for seven days Alternatives: Erythromycin base 500 mg orally four times per day for seven days Erythromycin ethylsuccinate 800 mg orally four times per day for seven days Ofloxacin (Floxin) 300 mg orally two times per day for seven days Levofloxacin (Levaquin) 500 mg orally once per day for seven days
Pregnant women	Azithromycin 1 g orally in a single dose Amoxicillin 500 mg orally three times per day for seven days Alternatives: Erythromycin base 500 mg orally four times per day for seven days Erythromycin base 250 mg orally four times per day for 14 days Erythromycin ethylsuccinate 800 mg orally four times per day for seven days Erythromycin ethylsuccinate 400 mg orally four times per day for 14 days
Epididymitis, acute
Caused by gonococcal or chlamydial infection	Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally two times per day for 10 days
Caused by enteric organisms	Ofloxacin 300 mg orally two times per day for 10 days Levofloxacin 500 mg orally once per day for 10 days
Gonococcal infection, genital	Ceftriaxone 125 mg IM in a single dose Cefixime (Suprax) 400 mg orally in a single dose Ciprofloxacin 500 mg orally in a single dose* Ofloxacin 400 mg orally in a single dose* Levofloxacin 250 mg orally in a single dose* plus treatment for chlamydial infection, if not ruled out
Granuloma inguinale (donovanosis)	Doxycycline 100 mg orally twice per day for at least three weeks and until all lesions have healed completely Alternatives: Azithromycin 1 g orally once per week for at least three weeks Ciprofloxacin 750 mg orally two times per day for at least three weeks Erythromycin base 500 mg orally four times per day for at least three weeks Trimethoprim/sulfamethoxazole (Bactrim, Septra) 160/800 mg (one double-strength tablet) orally two times per day for at least three weeks
Herpes, genital
First episode	Acyclovir (Zovirax) 400 mg orally three times per day for seven to 10 days Acyclovir 200 mg orally five times per day for seven to 10 days Famciclovir (Famvir) 250 mg orally three times per day for seven to 10 days Valacyclovir (Valtrex) 1 g orally twice per day for seven to 10 days NOTE: Treatment can be extended if healing is incomplete after 10 days of therapy
Suppressive therapy	Acyclovir 400 mg orally twice per day Famciclovir 250 mg orally twice per day Valacyclovir 500 mg orally once per day Valacyclovir 1 g orally once per day
Recurrent therapy	Acyclovir 400 mg orally three times per day for five days Acyclovir 800 mg orally twice per day for five days Acyclovir 800 mg orally three times per day for two days Famciclovir 125 mg orally two times per day for five days Famciclovir 1 g orally two times per day for one day Valacyclovir 500 mg orally two times per day for three days Valacyclovir 1 g orally once per day for five days
Lymphogranuloma venereum	Doxycycline 100 mg orally two times per day for 21 days Alternative: Erythromycin base 500 mg orally four times per day for 21 days
Pelvic inflammatory disease
Parenteral	Cefotetan (Cefotan) 2 g IV every 12 hours plus doxycycline 100 mg orally (preferred) or IV every 12 hours Cefoxitin (Mefoxin) 2 g IV every six hours plus doxycycline 100 mg orally (preferred) or IV every 12 hours Clindamycin 900 mg IV every eight hours plus gentamicin loading dose 2 mg per kg IV or IM then maintenance dose 1.5 mg per kg every eight hours (single daily dosing may be substituted) Alternatives: Levofloxacin 500 mg IV once per day* with or without metronidazole 500 mg IV every eight hours Ofloxacin 400 mg IV every 12 hours* with or without metronidazole 500 mg IV every eight hours Ampicillin/sulbactam (Unasyn) 3 g IV every six hours plus doxycycline 100 mg orally or IV every 12 hours
Oral	Levofloxacin 500 mg orally once per day for 14 days* Ofloxacin 400 mg orally two times per day for 14 days* Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally two times per day for 14 days Cefoxitin 2 g IM in a single dose and probenecid 1 g orally in a single dose administered concurrently plus doxycycline 100 mg orally two times per day for 14 days Other parenteral third-generation cephalosporin (e.g., ceftizoxime, cefotaxime) plus doxycycline 100 mg orally two times per day for 14 days with or without metronidazole 500 mg orally two times per day for 14 days
Prophylaxis after sexual assault	Ceftriaxone 125 mg IM in a single dose Metronidazole 2 g orally in a single dose Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally two times per day for seven days
Trichomoniasis	Metronidazole 2 g orally in a single dose Tinidazole (Tindamax) 2 g orally in a single dose Alternative: Metronidazole 500 mg orally two times per day for seven days
Urethritis, nongonococcal	Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally two times per day for seven days Alternatives: Erythromycin base 500 mg orally four times per day for seven days Erythromycin ethylsuccinate 800 mg orally four times per day for seven days Ofloxacin 300 mg orally two times per day for seven days Levofloxacin 500 mg orally one per day for seven days
IM = intramuscularly; IV = intravenously. *-Quinolones should not be used in men who have sex with men, those with a history of foreign travel (themselves or a partner), or those with infections acquired in California, Hawaii, or other areas with increased prevalence of resistant organisms. Information from Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55(RR-11):1-94.

Updates to diagnosis and treatment recommendations include expanded diagnostic evaluations for cervicitis and trichomoniasis, as well as discussion of the roles of Mycoplasma genitalium and trichomoniasis in urethritis and cervicitis. Urethritis with M. genitalium infection may respond better to azithromycin (Zithromax) than doxycycline (Vibramycin). Recommended treatment regimens for persistent urethritis include tinidazole (Tindamax) and the addition of azithromycin. Tinidazole also is recommended for treatment of trichomoniasis.

The new guidelines cite further data on the effectiveness of azithromycin for chlamydial infection during pregnancy, and azithromycin is the primary recommended regimen for this indication. The increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in men who have sex with men is discussed, with new recommendations for treating gonococcal infections in these patients (the CDC Web site contains up-to-date information on quinolone resistance at http://www.cdc.gov/std/gisp).

Other additions include expanded discussion of the criteria for spinal fluid examination in neurosyphilis evaluation; new discussions of lymphogranuloma venereum proctocolitis in men who have sex with men and the emergence of azithromycin-resistant Treponema pallidum; and revised discussions of the sexual transmission of hepatitis C and postexposure prophylaxis after sexual assault.

Cough: Diagnosis and Management

LAURA COUGHLIN

On a typical day, a family physician will see at least one patient presenting with cough. Cough can be divided into three categories: acute (i.e., lasting less than three weeks), subacute (i.e., lasting three to eight weeks), and chronic (i.e., lasting longer than eight weeks).

Acute Cough

Acute cough is most commonly associated with the common cold, but it also can be associated with life-threatening conditions (e.g., pulmonary embolism, congestive heart failure, pneumonia). The first step in the treatment of acute cough is to determine if the cause of the cough is one of these serious conditions or an acute upper respiratory infection (i.e., common cold), lower respiratory tract infection, or an exacerbation of a preexisting condition (e.g., asthma, bronchiectasis, chronic obstructive pulmonary disease [COPD], or upper airway cough syndrome).

If the cough is due to the common cold, a first-generation antihistamine plus a decongestant should be prescribed. It has been shown that naproxen (Naprosyn) favorably affects cough. Newer-generation nonsedating antihistamines are not effective for reducing cough.

Patients must be symptomatic for a least one week before a diagnosis of bacterial sinusitis is made, because prior to that point bacterial overgrowth is unlikely.

Subacute Cough

The first step in diagnosing subacute cough is to determine whether the cough has followed a respiratory infection. If the cough does not appear to be postinfectious, it should be managed as if it were a chronic cough.

If the cough began with an upper respiratory tract infection and has lingered, it is usually considered a postinfectious cough. It is most probably caused by postnasal drip, upper airway irritation, mucus accumulation, or a manifestation of branchial hyperresponsiveness that may be associated with asthma. Ongoing allergen or irritant exposure, lingering effects of an infection, pneumonia, and acute exacerbation of chronic bronchitis should also be considered.

Patients suspected of being infected with B. pertussis (i.e., whooping cough) should have a nasopharyngeal swab for culture. Patients with confirmed whooping cough should receive macrolide antibiotics and should be isolated for five days beginning on the first day of treatment.

If the cough is not caused by bacterial sinusitis or Bordetella pertussis, treatment with inhaled ipratropium (Atrovent) should be initiated to attenuate the cough. If the cough persists, consider the use of inhaled corticosteroids. If the cough is severe, consider prescribing 30 to 40 mg of prednisone per day for a brief period. When other treatments fail, codeine or dextromethorphan (Delsym) should be considered.

Chronic Cough

Chronic cough is often caused by more than one condition. Figure 1 presents a diagnostic approach to chronic cough. The diagnosis should begin with a medical history, physical examination, and chest radiograph.

history and physical examination

The patient's description of the character or timing of cough is of limited diagnostic value. If the patient is taking an angiotensin-converting enzyme (ACE) inhibitor, treatment should be stopped to determine if the medication is the cause. Cough caused by an ACE inhibitor usually will stop within two weeks of ceasing the medication.

It is also important to determine if the patient is a current smoker. Smoking cessation is almost always successful in eliminating cough within four weeks. If the patient has severe COPD, cough may persist after smoking cessation. If the persistent cough is caused by an exacerbation of COPD, antibiotics or corticosteroids should be considered.

The history is also important for discovering if the patient is from an area where diseases that can cause cough (e.g., tuberculosis) are prevalent; has systemic signs of disease (e.g., fever, sweating, weight loss); or has a history of cancer, tuberculosis, or acquired immune deficiency syndrome.

chest radiography

If the radiographic findings are abnormal, treatment depends on the specific finding. If a mass is found, the patient should receive chest computed tomography (CT), a bronchoscopy or transthoracic fine-needle aspiration, and possibly a positron emission tomography scan.

Findings consistent with congestive heart failure should be followed by a cardiovascular examination and possibly an empiric attempt at diuresis.

Evidence of infection should be followed by attempts to make a microbial diagnosis.

Most patients with chronic cough are otherwise healthy, and in these patients the four most common causes of cough are upper airway cough syndrome, asthma, gastroesophageal reflux disease (GERD), and nonasthmatic eosinophilic bronchitis.

upper airway cough syndrome-induced chronic cough

Patients with chronic cough should first be treated with a first-generation antihistamine/decongestant. If the patient has complete or partial resolution of cough after one to two weeks of antihistamine/decongestant therapy, then it is assumed that upper airway cough syndrome was the cause and therapy should be continued. If the patient has persistent nasal symptoms, it is appropriate to begin a topical nasal steroid. If symptoms still persist, it is an indication for sinus imaging.

Patients with mucosal thickening should be treated for sinusitis. If the patient does not respond to sinusitis therapy, she or he should be referred to an ear, nose, and throat specialist.

If the patient has only partial resolution of cough but no signs of upper airway cough syndrome, then an evaluation for asthma should be done.

asthma-induced chronic cough

It has been shown that bronchoprovocation is useful in the evaluation for cough caused by asthma. A positive challenge usually warrants trial treatment for asthma and clinical monitoring. The majority of patients will respond to treatment with inhaled corticosteroids and beta agonists after one week of therapy; it may take up to eight weeks for complete cough resolution.

In patients who do not respond or cannot take inhaled medication, treatment with oral corticosteroids for five to 10 days is an option. Because oral leukotriene inhibitors may be effective, consideration should be given to adding a leukotriene inhibitor before an oral corticosteroid.

If treatment for upper airway cough syndrome and asthma have both failed, nonasthmatic eosinophilic bronchitis should be considered next.

nonasthmatic eosinophilic bronchitis-induced chronic cough

To diagnose nonasthmatic eosinophilic bronchitis, an induced-sputum test should be performed to determine if the patient has an increased number of eosinophils. If the patient appears to have nonasthmatic eosinophilic bronchitis, treatment with inhaled corticosteroids is recommended. Cough should resolve within four weeks of therapy.

gerd-induced chronic cough

Any patient who responds only partially or not at all to the above therapies should be empirically treated for GERD. Treatment should include an antireflux diet and other lifestyle modification and a proton pump inhibitor. Some patients will respond in as little as two weeks, whereas others may not respond for several months. If there is little or no response to therapy, prokinetic therapy should be considered.

If none of these therapies has been successful for treating the cough, then an additional work-up is necessary, possibly including 24-hour esophageal pH monitoring, upper gastrointestinal tract endoscopy, a barium swallow, or a high-resolution CT scan.

Uncommon Causes of Cough

Uncommon causes of cough include nonacid reflux disease, a swallowing disorder, congestive heart failure, and habit cough. If a complete work-up fails to find a cause for the cough, the remaining diagnosis is unexplained cough. At this point, referral to a cough specialist is appropriate.

Practice Guideline Briefs

CDC Releases Data on HIV-Related Risk Behaviors in U.S. High School Students

U.S. high school students who use illicit injection drugs or have unprotected sexual intercourse are at higher risk of human immunodeficiency virus (HIV) infection. The Centers for Disease Control and Prevention (CDC) analyzed data from eight national surveys between 1991 and 2005 to determine if there was any change in the sexual behaviors of these students. A summary of those results was published in the August 11, 2006, issue of Morbidity and Mortality Weekly Report.

Students completed questionnaires about their sexual experience, current sexual activity, their number of sex partners, condom use, and whether they had ever injected illicit drugs.

Between 1991 and 2005, sexual experience decreased from 54.1 percent to 46.8 percent among high school students. The number of students who reported having four or more sex partners in their lifetime decreased from 18.7 percent to 14.3 percent. Current sexual activity decreased from 37.4 percent to 33.9 percent.

For students who were sexually active, condom use increased from 46.2 percent to 62.8 percent, and illicit injection drug use remained less than 4 percent.

Although these results indicate that the percentage of high school students who engage in risky sexual behaviors is decreasing, many students still engage in HIV-related risk behaviors. The CDC recommends that measures targeting these behaviors should be strengthened to decrease the prevalence of HIV infection among high school students.

SHERRI DAMLO

Answers to This Issue's Clinical Quiz Q1. C Q2. D Q3. D Q4. B Q5. C Q6. D Q7. C Q8. B Q9. A, C Q10. A, C, D Q11. A, B, C Q12. B

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