The Centers for Disease Control and Prevention (CDC) has released the “1998 Guidelines for the Treatment of Sexually Transmitted Diseases.” The guidelines were developed by the CDC after consultation with a group of experts who met in Atlanta in 1997. Chair of the expert panel was David Atkins, M.D., M.P.H., of the Agency for Health Care Policy and Research.
The 116-page guidelines include prevention, diagnosis and treatment information for all common sexually transmitted diseases and are organized by syndrome. Included are new recommendations for the treatment of primary and recurrent genital herpes and management of pelvic inflammatory disease, a new patient-applied medication for the treatment of human papillomavirus infection and a revised approach to the management of victims of sexual assault. Revised sections describe the evaluation of urethritis and the diagnostic evaluation of congenital syphilis. The guidelines also include expanded sections concerning sexually transmitted diseases in infants, children and pregnant women, and the management of patients who have asymptomatic human immunodeficiency virus (HIV) infection, genital warts and genital herpes. Recommendations are also provided for diseases characterized by genital ulcers; management of patients who have a history of penicillin allergy; diseases characterized by vaginal discharge; pelvic inflammatory disease; epididymitis; human papillomavirus infection; proctitis, proctocolitis and enteritis; and vaccine-preventable sexually transmitted diseases, including recommendations for the use of hepatitis A and hepatitis B vaccines.
The 1998 guidelines update CDC recommendations from 1993 for screening, diagnosis and treatment. Some of the advances in treatment made since the last guidelines were published include the following:
Highly effective single-dose oral therapies have been developed for almost all common curable sexually transmitted diseases.
Improved treatments are now available for herpes simplex virus type 2 and human papillomavirus infection.
A simple urine test has been introduced for the diagnosis of chlamydia in clinical and nonclinical settings.
Recommendations for hepatitis A and hepatitis B include vaccination of all sexually active youth.
Improved treatments for sexually transmitted diseases in pregnant women may produce fewer side effects and reduce the number of infants born prematurely.
The following information has been excerpted from the section of the guidelines that covers special populations:
Intrauterine or perinatally transmitted sexually transmitted diseases can have fatal or severely debilitating effects on a fetus. Pregnant women and their sex partners should be questioned about sexually transmitted diseases and should be counseled about the possibility of perinatal infections. The recommended screening tests include the following:
A serologic test for syphilis should be performed in all pregnant women at the first prenatal visit. In populations in which prenatal care is not optimally used, rapid plasma reagin (RPR)-card test screening, with treatment if that test is reactive, should be performed at the time a pregnancy is confirmed. For patients at high risk, screening should be repeated in the third trimester and again at delivery. Some states also mandate screening of all women at delivery. No infant should be discharged from the hospital without the syphilis serologic status of its mother having been determined at least one time during pregnancy and, preferably, again at delivery. Any woman who delivers a stillborn infant should be tested for syphilis.
A serologic test for hepatitis B surface antigen (HBsAg) should be performed for all pregnant women at the first prenatal visit. HBsAg testing should be repeated late in the pregnancy for women who are HBsAg negative but who are at high risk for hepatitis B virus infection (e.g., injecting drug users and women who have concomitant sexually transmitted diseases).
A test for Neisseria gonorrhoeae should be performed at the first prenatal visit for women at risk of gonorrhea or for women living in an area where the prevalence of N. gonorrhoeae is high. A repeat test should be performed during the third trimester for those at continued risk.
A test for Chlamydia trachomatis infection should be performed in the third trimester for women at increased risk (i.e., women under 25 years of age and women who have a new sex partner, more than one sex partner or whose partner has other partners) to prevent maternal postnatal complications and chlamydial infection in the infant. Screening during the first trimester might enable prevention of adverse effects of chlamydia during pregnancy. However, evidence for adverse effects during pregnancy is minimal. If screening is performed only during the first trimester, a longer period exists for acquiring infection before delivery.
A test for HIV infection should be offered to all pregnant women at the first prenatal visit.
A test for bacterial vaginosis may be performed early in the second trimester for asymptomatic patients who are at high risk for preterm labor (e.g., those who have a history of a previous preterm delivery). Current evidence does not support universal testing for bacterial vaginosis.
A Papanicolaou smear should be obtained at the first prenatal visit if none has been documented during the preceding years.
Other Concerns in Pregnant Women
Pregnant women who have either primary genital herpes virus infection, hepatitis B virus infection, primary cytomegalovirus infection, or group B streptococcal infection, and women who have syphilis and who are allergic to penicillin, may need to be referred to an expert for management.
HBsAg-positive pregnant women should be reported to the local and/or state health department to ensure that they are entered into a case-management system and appropriate prophylaxis is provided for their infants. In addition, household and sexual contacts of HBsAg-positive women should be vaccinated.
In the absence of lesions during the third trimester, routine serial cultures for herpes simplex virus are not indicated for women who have a history of recurrent genital herpes. However, obtaining cultures from such women at the time of delivery may be useful in guiding neonatal management. Prophylactic cesarean section is not indicated for women who do not have active genital lesions at the time of delivery.
The presence of genital warts is not an indication for cesarean section.
For a more detailed discussion of these guidelines, physicians are referred by the CDC to “Guidelines for Perinatal Care,” 3d ed., published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in 1992.
Physicians who provide care for adolescents should be aware of several issues that relate specifically to adolescents. The rates of sexually transmitted diseases are highest among adolescents (e.g., the rate of gonorrhea is highest among females 15 to 19 years of age). Clinic-based studies have demonstrated that the prevalence of chlamydial infections, and possibly of human papillomavirus infections, also is highest in adolescents. In addition, surveillance data indicate that 9 percent of adolescents who have acute hepatitis B virus infection either have had sexual contact with a chronically infected person or with multiple sex partners or gave their sexual preference as homosexual. As part of a comprehensive strategy to eliminate hepatitis B virus transmission in the United States, the Advisory Committee on Immunization Practices has recommended that all children receive hepatitis B vaccine.
Adolescents who are at high risk for sexually transmitted diseases include male homosexuals, sexually active heterosexuals, clients in clinics for sexually transmitted diseases and injecting-drug users. Adolescents less than 15 years of age who are sexually active are at particular risk for infection. Adolescents are at greatest risk for sexually transmitted diseases because they frequently have unprotected intercourse, are biologically more susceptible to infection and face multiple obstacles to use of health care.
Several of these issues can be addressed by clinicians who provide services to adolescents. Clinicians can address the general lack of knowledge and awareness about the risks and consequences of sexually transmitted diseases and offer guidance, constituting true primary prevention, to help adolescents develop healthy sexual behaviors and prevent the establishment of behavior patterns that can undermine sexual health. With some exceptions, all adolescents can consent to the confidential diagnosis and treatment of sexually transmitted diseases. Medical care for sexually transmitted diseases can be provided to adolescents without parental consent or knowledge. Furthermore, in many states, adolescents can consent to counseling and testing for HIV infection. Consent laws for vaccination of adolescents differ by state. Physicians should consider how important confidentiality is to adolescents and should strive to follow policies that comply with state laws to ensure the confidentiality of services provided to adolescents.
The style and content of counseling and health education should be adapted for adolescents. Discussions should be appropriate for the patient's developmental level and should identify risky behaviors, such as sex and drug use. Careful counseling and thorough discussions are especially important for adolescents who may not acknowledge engaging in high-risk behaviors. Care and counseling should be direct and nonjudgmental.
Management of children who have a sexually transmitted disease requires close cooperation between the physician, laboratories and child-protection authorities. Investigations, when indicated, should be initiated promptly. Some diseases (e.g., gonorrhea, syphilis and chlamydia), if acquired after the neonatal period, are almost 100 percent indicative of sexual contact. For other diseases, such as human papillomavirus infection and vaginitis, the association with sexual contact is not as clear.
Sexual Assault and Sexually Transmitted Diseases
The following information has been excerpted from the section of the guidelines on sexual assault and sexually transmitted diseases:
Adults and Adolescents
Trichomoniasis, bacterial vaginosis, chlamydia and gonorrhea are the most frequently diagnosed infections in women who have been sexually assaulted. Because the prevalence of these diseases is substantial among sexually active women, the presence of these infections after an assault does not necessarily signify acquisition during the assault. Chlamydial and gonococcal infections in women are of special concern because of the possibility of ascending infection. In addition, hepatitis B virus infection, if transmitted to a woman during an assault, can be prevented by postexposure administration of hepatitis B vaccine.
An initial examination should include the following procedures:
Cultures for N. gonorrhoeae and C. trachomatis from specimens collected from any sites of penetration or attempted penetration.
If chlamydial culture is not available, nonculture tests, particularly the nucleic acid amplification tests, are an acceptable substitute. Nucleic acid amplification tests offer advantages of increased sensitivity if confirmation is available. If a nonculture test is used, a positive test result should be verified with a second test based on a different diagnostic principle. Enzyme-linked immunosorbent assay and direct fluorescent antibody are not acceptable alternatives, because false-negative test results occur more often with these nonculture tests, and false-positive test results may occur.
Wet mount and culture of a vaginal swab specimen for Trichomonas vaginalis infection. If vaginal discharge or malodor is evident, the wet mount also should be examined for evidence of bacterial vaginosis and yeast infection.
Collection of a serum sample for immediate evaluation for HIV, hepatitis B and syphilis.
Although it is often difficult for persons to comply with follow-up examinations weeks after an assault, such examinations are essential to detect new infections acquired during or after the assault; to complete hepatitis B immunization, if indicated; and to complete counseling and treatment for other sexually transmitted diseases. For these reasons, it is recommended that assault victims be reevaluated at follow-up examination.
Examination for sexually transmitted diseases should be repeated two weeks after the assault. Because infectious agents acquired through assault may not have produced sufficient concentrations of organisms to result in positive test results at the initial examination, a culture, wet mount and other tests should be repeated at the two-week follow-up visit unless prophylactic treatment has already been provided. Serologic tests for syphilis and HIV infection should be repeated six, 12 and 24 weeks after the assault if initial test results were negative.
Many experts recommend routine preventive therapy after a sexual assault. Most patients probably benefit from prophylaxis because the follow-up of patients who have been sexually assaulted can be difficult, and they may be reassured if offered treatment or prophylaxis for possible infection. The following prophylactic regimen is suggested as preventive therapy:
Postexposure hepatitis B vaccination (without hepatitis B immune globulin) should adequately protect against hepatitis B virus. Hepatitis B vaccine should be given to victims of sexual assault at the time of the initial examination. Follow-up doses of vaccine should be given one to two and four to six months after the first dose.
An empiric antimicrobial regimen for chlamydia, gonorrhea, trichomonas and bacterial vaginosis should be administered. The recommended regimen is as follows: ceftriaxone, 125 mg intramuscularly in a single dose, plus metronidazole, 2 g orally in a single dose, plus either azithromycin, 1 g orally in a single dose or doxycycline, 100 mg orally twice a day for seven days. Certain patients may require alternative treatments.
The efficacy of these regimens in preventing gonorrhea, bacterial vaginosis or C. trachomatis genitourinary infections after sexual assault has not been evaluated. The physician should counsel the patient as to the possible benefits and side effects of these treatment regimens.
At the initial examination and, if needed, at follow-up examinations, patients should be counseled regarding the following:
Symptoms of sexually transmitted diseases and the need for immediate examination if symptoms occur.
Abstinence from sexual intercourse until prophylactic treatment is completed.
Risk of Acquiring HIV Infection
Although HIV-antibody seroconversion has been reported in persons whose only known risk factor was sexual assault or sexual abuse, the risk for acquiring HIV infection through sexual assault is low. The overall probability depends on many factors. These may include the type of sexual intercourse; presence of oral, vaginal or anal trauma; site of exposure to ejaculate; viral load in ejaculate; and presence of a sexually transmitted disease.
In certain circumstances, the likelihood of HIV transmission also may be affected by postexposure therapy for HIV infection with antiretroviral agents. Postexposure therapy with zidovudine has been associated with a reduced risk for HIV infection in a study of health care workers who had percutaneous exposures to HIV-infected blood. However, whether these findings can be extrapolated to other HIV-exposure situations, including sexual assault, is unknown. A recommendation cannot be made regarding the appropriateness of postexposure antiretroviral therapy after sexual exposure to HIV.
Physicians who consider offering postexposure therapy should take into account the likelihood of exposure to HIV, the potential benefits and risks of such therapy, and the interval between the exposure and initiation of therapy. Because timely determination of the assailant's HIV-infection status is not possible in many sexual assaults, the physician should assess the nature of the assault, any available information about HIV-risk behaviors exhibited by persons who are sexual assailants and the local epidemiology of HIV/acquired immunodeficiency syndrome. If antiretroviral postexposure prophylaxis is offered, the following information should be discussed with the patients: the unknown efficacy and known toxicities of antiretrovirals; the critical need for frequent dosing of medications; the close follow-up that is necessary; the importance of strict compliance with the therapy; and the necessity of immediate initiation of treatment for maximal likelihood of effectiveness. If the patient decides to take postexposure therapy, clinical management of the patient should be implemented according to the guidelines for occupational mucous membrane exposure.
The guidelines were published as part of the Morbidity and Mortality Weekly Report Recommendations and Reports series (MMWR 1998;47[RR-1]:1-116). The complete guidelines can be accessed on the Internet at http://www.cdc.gov/nchstp/dstd/dstdp.html or can be requested by calling 888-232-3228. They can be ordered free of charge from the Office of Communication, NCH-STP, Centers for Disease Control and Prevention, 1600 Clifton Road, N.E., Mailstop E-06, Atlanta, GA 30333; fax order: 404-639-8628.
Professional information on sexually transmitted diseases and training for clinical and behavioral management of sexually transmitted diseases are available through the National Network of STD/HIV Prevention Training Centers. For information, call 404-639-8360 or access course information on the Internet at http://126.96.36.199/STDPTC.html. Patient information is available from the STD Hotline (800-227-8922), National Herpes Hotline (919-361-8488) or the American Social Health Association Web site at http://sunsite.unc.edu/ASHA.