• CDC Updates Guidance on Treatment of STIs

    August 11, 2021, 8:55 a.m. Michael Devitt — The CDC has published comprehensive updated guidance on the treatment of sexually transmitted infections. The document, the first major update to the agency’s STI treatment guidelines since 2015, provides family physicians and other health care professionals with the latest evidence-based recommendations and clinical guidance on the topic.

    physician and patient in exam room

    The update comes at a crucial moment in public health. A CDC sexually transmitted disease surveillance report released in April found that in 2019, the last year for which data were available, the overall number of reported cases of STIs increased for the sixth consecutive year, reaching an all-time high of more than 2.5 million cases of chlamydia, gonorrhea and syphilis in the United States.

    A recent analysis in the American Journal of Preventive Medicine, meanwhile, indicated that the COVID-19 pandemic contributed to significant declines in STI screening in both men and women during the first half of 2020, resulting in potentially tens of thousands of missed cases of chlamydia and gonorrhea.

    “These guidelines are extremely valuable for family physicians given the rising rates of STIs and the decreases in screening that seem to have come about in the wake of the pandemic,” said Scott Hartman, M.D., an associate professor of clinical family medicine at the University of Rochester Medical Center in Rochester, N.Y., and past chair of the AAFP’s Commission on Health of the Public and Science.

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    “The take-home message I would emphasize is that the guidelines overall are a bit more nuanced,” Hartman added. “They don’t always fit neatly into concise tables and algorithms since there are many special considerations. However, the CDC has produced some nice wall charts and pocket guides, and a smartphone app is on its way shortly.”


    The 192-page guidance document was published in the July 23 issue of the CDC’s Morbidity and Mortality Weekly Report. It serves as a complement to a 2020 agency report, Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, that focused on the treatment of STIs in primary care and specialty care settings.

    The guidance features several updates of note from the agency’s 2015 guidelines that may be of interest to family physicians, including

    • updated recommendations for the treatment of gonorrhea, chlamydia and trichomoniasis;
    • the addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease;
    • updated recommendations for the treatment of uncomplicated gonorrhea in newborns and children, and in other specific clinical situations, such as proctitis, epididymitis and instances of sexual assault;
    • alternative treatment options for bacterial vaginosis;
    • management of Mycoplasma genitalium, including new information on FDA-approved diagnostic tests;
    • an expansion of risk factors for syphilis testing in pregnant patients;
    • recommended two-step serologic testing to diagnose genital herpes simplex virus;
    • recommendations for HPV vaccination in accordance with those of the CDC’s Advisory Committee on Immunization Practices; and
    • recommended universal hepatitis C testing.

    The CDC says the guidelines “are applicable to any patient care setting that serves persons at risk for STIs,” including private physician offices, federally qualified health centers and other primary care facilities. The document also clarifies that the guidelines “are focused on treatment and counseling and do not address other community services and interventions that are essential to STI and HIV prevention efforts.”

    Hartman told AAFP News that some recommendations should be of particular interest to family physicians.

    “I would really like to highlight the HPV vaccine recommendation,” Hartman said. “HPV doesn’t cause just cervical cancer, it can cause anal dysplasia and cancer. These diagnoses have long been ignored in gay and bisexual men, and HIV+ individuals of all orientations. Additionally, HPV has been implicated in multiple other cancers. Family physicians will pay a key role in promoting universal HPV vaccination for all adolescents and adults, similar to the way that we should be promoting universal screening for HIV and hepatitis C.”

    Other recommendations that FPs should take note of, Hartman said, include those that address the use of metronidazole for PID; the expanded section on M. genitalium as a cause of urethritis and PID, which features a discussion of testing and treatment; the recommendation on universal screening for syphilis in pregnant and birthing patients; and expanded recommendations for HPV vaccination in adults through age 45.

    Hartman told AAFP News that while he didn’t think the updated guidance would result in any major changes to the way family physicians screen for and treat STIs, there are nuances to care that FPs should be aware of.

    “I would say that family doctors should always be thinking about STIs in all age groups,” Hartman said. “For example, newborns are susceptible to certain STIs via vertical transmission. And we should never assume (that) any adolescent or adult patient is not sexually active — patients will surprise us.”

    More Resources

    Among the accompanying resources for clinicians that the CDC has also published are

    Printed copies of these resources will be available from CDC-Info on Demand in the next few weeks.

    In addition, the agency is developing an updated STI treatment guidelines mobile app, which is expected to launch in the near future. Until the app is available, clinicians are invited to visit an interim mobile site, which can be accessed through the STI Treatment Guidelines Provider Resources webpage.  

    Hartman also encouraged members to review the AAFP’s Screening for Sexually Transmitted Infections practice manual, a toolkit that offers guidance on taking a patient’s sexual history and performing STI screening, among other considerations.

    Hartman also recommended that members view a webinar on diagnostic strategies for STIs, which includes additional information on taking sexual histories and screening for STIs.

    In addition, AAFP guidelines and clinical preventive services recommendations for STIs can be found at the Academy’s Clinical Recommendations webpage.