The Centers for Disease Control and Prevention (CDC) has published the 2002 guidelines for treating sexually transmitted diseases (STDs). The full report is available online (www.cdc.gov) and in the May 10, 2002 recommendations and reports series of Morbidity and Mortality Weekly Report.
This report updates the guidelines from 1998, focusing on the information that has become available since then. The updates include new alternative regimens for scabies, bacterial vaginosis (BV), early syphilis, and granuloma inguinale; an expanded section on the diagnosis of genital herpes; new recommendations for treatment of recurrent genital herpes among persons infected with human immunodeficiency virus (HIV); a revised approach to the management of victims of sexual assault; expanded regimens for the treatment of urethral meatal warts; and inclusion of hepatitis C as an STD.
Diseases Characterized by Vaginal Discharge
Vaginal infection is usually characterized by a vaginal discharge or vulvar itching and irritation, and a vaginal odor may be present. Trichomoniasis, BV, and candidiasis are most frequently associated with vaginal discharge. Although vulvovaginal candidiasis and BV are not usually transmitted sexually, they are included in this section because these infections are often diagnosed in women being evaluated for STDs.
BV is the most prevalent cause of vaginal discharge or malodor, but up to 50 percent of patients may not report any symptoms. BV is associated with having multiple sex partners, douching, and lack of vaginal lactobacilli. It is unclear whether BV results from acquiring a sexually transmitted pathogen. Women who have never been sexually active are rarely affected. Treatment of the male sex partner has not been beneficial in preventing the recurrence of BV.
All women who have symptomatic disease require treatment. The benefits of therapy for BV in nonpregnant women are to relieve vaginal symptoms and signs of infection, and reduce the risk for infectious complications after abortion or hysterectomy. The recommended treatment regimen includes oral or topical metronidazole or clindamycin cream. Follow-up visits are unnecessary if symptoms resolve, but recurrence is not unusual and patients should return for additional treatment if symptoms recur.
All symptomatic pregnant women should be tested and treated because BV is associated with premature rupture of the membranes, preterm labor, preterm birth, and post-partum endometritis. The benefits of therapy for BV in pregnant women are to relieve vaginal symptoms and signs of infection, reduce the risk for infectious complications associated with BV during pregnancy, and reduce the risk for other infections. Oral metronidazole or clindamycin are the recommended options for treatment. Because of the possibility of adverse pregnancy outcomes, a follow-up evaluation should be done one month after completion of treatment to verify that therapy was effective.
Patients who have BV and also are infected with HIV should receive the same treatment regimen as those who are not infected with HIV.
Most men who are infected with Trichomonas vaginalis do not have symptoms, but others may have nongonococcal urethritis. Many infected women have a diffuse, malodorous, yellow-green discharge with vulvar irritation, but some have minimal or no symptoms. Treatment of patients and sex partners results in relief of symptoms, microbiologic cure, and reduction of transmission. Patients should be treated with oral metronidazole. The recommended regimens have resulted in cure rates of about 90 to 95 percent, which might increase if the treatment of sex partners is ensured. Patients should be instructed to avoid sex until they and their sex partners are cured.
Follow-up is unnecessary for men and women who are initially asymptomatic or become asymptomatic after treatment. In pregnant women, vaginal trichomoniasis has been associated with premature rupture of the membrane, preterm delivery, and low birth weight. Women who are symptomatic should be treated to relieve symptoms and may be treated with oral metronidazole. Patients who have trichomoniasis and are infected with HIV should receive the same therapy as those who are not infected with HIV.
Typical symptoms of vulvovaginal candidiasis (VVC) include pruritus and vaginal discharge, and possibly vaginal soreness, vulvar burning, dyspareunia, and external dysuria. Approximately 75 percent of women will have at least one episode of VVC, and 40 to 45 percent will have two or more episodes. Depending on clinical presentation, microbiology, host factors, and response to therapy, VVC can be uncomplicated or complicated.
Uncomplicated VVC is sporadic or infrequent, mild to moderate, likely to be caused by Candida albicans, and present in nonimmunocompromised women. The diagnosis is suggested by pruritus and erythema in the vulvovaginal area, and a white discharge may be present. Short-course topical formulations of azoles result in relief of symptoms and negative cultures in 80 to 90 percent of patients who complete therapy. Patients should return for follow-up visits only if symptoms persist or recur within two months of onset of initial symptoms. VVC is not normally acquired through sexual intercourse, but treatment of sex partners may be considered in women who have recurrent infection.
Complicated VVC is recurrent (four or more episodes per year), severe, caused by nonalbicans candidiasis, and present in women who are pregnant or who have uncontrolled diabetes, debilitation, or immunosuppression. For treatment, each episode responds well to short-term azole therapy. To maintain clinical and mycologic control, a longer duration of initial therapy is recommended to achieve remission before beginning a maintenance anti-fungal regimen. Maintenance regimens include clotrimazole, ketoconazole, fluconazole, and itraconazole, and they should be continued for six months.
VVC commonly occurs during pregnancy, and only seven-day topical azole therapies are recommended for pregnant women. Therapy for VVC in women infected with HIV should not differ from that for women not infected with HIV.
Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) comprises a variety of inflammatory disorders of the upper female genital tract, including endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis, are implicated in many cases. Empiric treatment should be initiated in sexually active patients at risk for STDs if uterine, adnexal, or cervical motion tenderness is present and no other cause of illness can be identified. Other symptoms include oral temperature higher than 38.3°C (101°F); abnormal cervical or vaginal mucopurulent discharge; presence of white blood cells on saline microscopy of vaginal secretions; elevated erythrocyte sedimentation rate; elevated C-reactive protein; and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
Treatment must provide empiric, broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci. Prevention of long-term sequelae has been linked directly with immediate administration of appropriate antibiotics. When selecting therapy, physicians should consider availability, cost, patient acceptance, and antimicrobial susceptibility. Patients who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and be given parenteral therapy. Parenteral therapy may be discontinued 24 hours after a patient improves clinically, and oral therapy with doxycycline should continue to complete 14 days of therapy. Patients should demonstrate substantial improvement within three days after starting therapy. Those who do not improve within this time usually require hospitalization, additional tests, and surgical intervention.
Male sex partners should be examined and treated if they had sexual contact with the patient during the 60 days before the patient's onset of symptoms. Evaluation and treatment are important because of the risk for reinfection of the patient and the strong likelihood of urethral gonococcal or chlamydial infection in the partner. Pregnant women who have suspected PID should be hospitalized and treated with parenteral antibiotics because of the high risk for maternal morbidity, fetal wastage, and preterm delivery. It has not been determined if patients infected with HIV and PID require more aggressive therapy than patients not infected with HIV.