From 2014 to 2019, U.S. rates of sexually transmitted infections (STIs) increased for chlamydia (19%), gonorrhea (56%), primary and secondary syphilis (74%), and congenital syphilis (279%).¹ The combined epidemics of STIs and opioid use, compounded by reduced screening and treatment opportunities during the COVID-19 pandemic, will likely further exacerbate this trend. Family physicians can reduce infection rates by discussing sexual history, especially with teens and young adults, ordering screening tests and treatment based on the 2021 Centers for Disease Control and Prevention (CDC) STI treatment guidelines (Table 1²), and collaborating with public health departments for disease reporting and partner services.

Prevention

Taking a thorough sexual history using gender-inclusive and sexual orientation–inclusive language can improve rapport, ensure appropriate screening of all sites of exposure, and allow for a focused and patient-specific discussion of risk reduction. Include the Five P's—partners, practices, protection from STIs, past STIs, and pregnancy intention— in the discussion.³ The U.S. Preventive Services Task Force recommends behavioral counseling with a focus on condom use and decreasing sexual risk behaviors.⁴ Physicians should encourage vaccination against hepatitis A, hepatitis B, and human papillomavirus, as recommended for age and additional risk factors such as sexual acts that risk fecal–oral and blood-borne exposure (Table 2).²

HIV preexposure prophylaxis (PrEP) with emtricitabine and tenofovir alafenamide (Descovy; for those with a creatinine clearance of 30 mL per minute per 1.73 m² [0.50 mL per second per m²] or more, not at risk of vaginal HIV exposure) or emtricitabine and tenofovir disoproxil fumarate (Truvada; creatinine clearance of 60 mL per minute per 1.73 m² [1.00 mL per second per m²] or more) is safe and effective. The U.S. Preventive Services Task Force recommends offering PrEP to individuals at risk, including those who have had gonorrhea or syphilis during the previous six months, those who share drug injection equipment, those who are HIV-negative but whose sex partner has HIV infection, and those with inconsistent use of condoms during receptive or insertive anal sex.⁵

Expedited partner therapy, the provision of medication to sex partners of people with STIs without examination or testing of the partner, has been shown to reduce the spread of infection at the community level and prevent reinfection of the index case.^6,7 The American Academy of Family Physicians advocates for the use of expedited partner therapy whenever possible to help address increasing rates of STIs. ⁸ Cefixime (Suprax), with a dosing increase to 800 mg, is the recommended expedited partner therapy regimen for gonorrhea (Table 1²), with the addition of doxycycline, 100 mg twice daily for seven days, if concurrent chlamydia has not been excluded. There are no changes to the recommended expedited partner therapy regimen for chlamydial infection (i.e., 1 g of azithromycin [Zithromax] in a single oral dose or 100 mg of doxycycline given twice daily for seven days).

ANTIBIOTIC STEWARDSHIP

The new guidelines highlight antibiotic stewardship in addressing patient-reported penicillin allergy.² Although as many as 10% of patients report a penicillin allergy, 90% of those patients tolerate penicillins when allergy tested.⁹ Physicians should carefully define allergies, separating those with reactions mediated by immunoglobulin E (IgE) from those experiencing common adverse effects. The PEN-FAST rule is a validated clinical tool to guide risk assessment and treatment decisions (Table 3).⁹ Physicians should use ceftriaxone and penicillins when risk of true allergy is low and consider penicillin allergy testing for those with possible allergy to preserve treatment options.

Urethritis and Cervicitis

Urethritis is characterized by dysuria, urethral pruritus or burning, and/or visible discharge. Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causes, but Mycoplasma genitalium is increasingly recognized as an important cause of urethritis, particularly in patients presumptively treated for chlamydial infection with persistent symptoms.¹⁰ Patients with suspected urethritis should be evaluated for gonorrhea and chlamydia using nucleic acid amplification testing, and patients with persistent symptoms should be tested for M. genitalium infection.^2,11 Other causative organisms, including Neisseria meningitidis and Trichomonas vaginalis, have also been implicated in urethritis.