2021 Treatment Guidelines for Sexually Transmitted Infections

Educational Objectives

The goal of this program is to improve the diagnosis and management of sexually transmitted infections. After hearing and assimilating this program, the clinician will be better able to:

1. Interpret updated guidelines for treating and screening for sexually transmitted infections, eg, gonorrhea and chlamydia.
2. Recognize sexual behaviors that are risk factors for acquiring sexually transmitted infections.
3. Detect sex-related bacterial and viral infections using appropriate testing modalities.

Summary

Incidence of sexually transmitted infections (STIs): rates have increased every year through 2019; 2015 to 2019 data from the Centers for Disease Control and Prevention (CDC) show a 20%, 56%, and 74% increase in chlamydia, gonorrhea, and syphilis, respectively, with a high rate of congenital syphilis; rates in 2020 dropped as the COVID-19 pandemic reduced patient inflow; nucleic acid amplification tests (NAATs) decreased as manufacturers switched to COVID-19 tests; 2019 dataset is age-based; groups with the highest risk — for chlamydia, women in their late teens to early 20s; for gonorrhea, women ages 20 to 24 yr; for secondary syphilis, women in their 20s to early 30s

CDC guideline nomenclature: changed from ‘sexually transmitted disease’ (STD) to ‘STI’ guidelines; most STIs in early stages are asymptomatic, whereas diseases are symptomatic; focus is on early detection

Importance of sexual history: good care for STIs requires an intensive history of sexual behaviors; components of a good history include the 5 Ps (partners, sexual practices, protection, previous history of STIs, and pregnancy intention); inquire about partners, current sex of any kind (eg, vaginal, anal), history of ever having sex, number and genders of partners in recent months, and other partners of sexual partners; inquire about practices, eg, types of current or past sexual contact, whether partners are met online or through phone applications, and exchange of sex for, eg, drugs, money

Recommendations for gonorrhea and chlamydia screening: the US Preventive Services Task Force (USPSTF) and CDC recommend routine annual screening in sexually active nonpregnant women aged ≤24 yr and women aged ≥25 yr with increased risk; there is no recommendation for men; STD Control Branch of California Department of Public Health (CDPH) recommends screening if site-specific prevalence is ≥3% for chlamydia and ≥1% for gonorrhea (found in laboratory report of positivity rates in the previous 2 yr and broken down into 5-yr intervals)

Risk factors for targeted screening: risk factors defined by USPSTF are nonspecific, (eg, history of previous STIs, multiple sexual partners) with undefined timeframes (not very helpful); risk factors issued by CDPH have timeframes, eg, history of disease in the previous 2 yr, >1 sexual partner in the previous 12 mo, new sexual partner in the last 90 day, sexual partner with other partners in the last year, exchange of sex for needs in the previous year, and location in geographic hotspots for STIs; asking questions this way has the highest correlation with the patient having chlamydia

Screening methodology: 2015 CDC guidelines — preferred sample site for chlamydia and gonorrhea NAAT is vaginal fluid (self-sample); 2021 guidelines — multisite screening is needed; screen cis women based on their sexual history in the preceding year; if receptive anal or oral intercourse is disclosed, rectal or pharyngeal gonorrhea/chlamydia NAAT is indicated; risks and benefits of multisite screening should be discussed with the patient; 3 samples per day may be taken (covered by state insurance; 2018 clinical study of multisite screening (Tao et al) — included 5500 women; among women positive for rectal chlamydia, 65% had vaginal positivity; for those with rectal gonorrhea positivity, 40% had vaginal positivity; vaginal sampling is insufficient for anal receptive intercourse; oropharyngeal sample — patient may gag when swabbing the tonsillar pillars; rectal swabbing — use proper wrist movements to swab entirely around the anus

Treatment for chlamydia: single-dose azithromycin is recommended in previous guidelines; currently, 100 mg doxycycline twice daily for 7 day is recommended (more effective for rectal chlamydia); delayed-release doxycycline can be used once daily; second-line therapy is 1 g oral azithromycin (directly absorbed; the drug of choice in pregnancy); alternative therapy in both guidelines is 500 mg levofloxacin, once daily for 1 wk

Treatment for gonorrhea: forgonorrhea in the cervix, urethra, or rectum — provide single dose of 500 mg intramuscular (IM) ceftriaxone; for body weight >150kg, double the dose (1 g); for gonorrhea/chlamydia NAAT with positive gonorrhea and negative chlamydia, treat only gonorrhea; for suspected coinfection with chlamydia — treat both infections; ceftriaxone is given, followed by doxycycline for 1 wk; higher-dose ceftriaxone monotherapy is preferred over ceftriaxone plus azithromycin; if ceftriaxone injections are unavailable, provide 800 mg oral cefixime (Suprax) once daily; for suspected chlamydia, prescribe oral cefixime and doxycycline for 1 wk; for penicillin or cephalosporin allergy — administer gentamycin IM plus 2 g azithromycin; oral medication is useful in community clinics or small practices without injections; pharyngeal gonorrhea — difficult to treat; provide 500 mg ceftriaxone IM (double the dose for weight >150 kg); failure rate is significant even with high doses (test of cure is used); reason for change to monotherapy — there is concern for antimicrobial stewardship; CDC established the Gonococcal Isolate Surveillance Project for gonorrheal treatment selection; incidence of resistance to ceftriaxone is low, whereas resistance to azithromycin is increasing

Management for gonorrhea and chlamydia: timely treatment and screening for coinfection (eg, syphilis, HIV) are essential; ensure positive cases are reported to the health department; follow up after 3 mo to test for reinfection (not treatment failure); sex partners — it is the responsibility of the patient and physician to treat all sex partners, especially those from the previous 2 mo; contact-tracing by the health department may be available only for syphilis; sex partner can be brought in for therapy (Bring Your Own Partner) or receive therapeutic drug without office visit via prescription for extra dose of medication in the index patient’s name (Patient-Delivered or Expedited Partner Therapy [EPT]); California guidelines for EPT — state programs pay for EPT; antibiotics are dispensed to the patient for her partner (“partner pack”), or a prescription in the partner’s name is provided with enough drugs to treat patient and partner; writer “EPT” on the prescription to alert the pharmacist; in Medi-Cal and Family PACT, ≤5 partners can be treated with cefixime and, if needed, doxycycline

Mucopurulent cervicitis: presents with thick, cloudy vaginal discharge; can occur because of, eg, gonorrhea, chlamydia, herpes, trichomoniasis, Mycoplasma genitalium, or progestin effect of contraceptives, luteal phase, or pregnancy; concern for chlamydia or Ureaplasma geniatlium; treatment is 100 mg doxycycline twice daily for 1 wk, with azithromycin as alternate therapy

Outpatient treatment for pelvic inflammatory disease (PID): recommendation in current CDC guidelines is 500 mg ceftriaxone with doxycycline and metronidazole for 2 wk; another option is cefotaxime plus probenecid, followed by doxycycline for 2 wk and metronidazole for 2 wk; metronidazole was optional in earlier guidelines; randomized controlled trial by Wiesenfeld et al — 233 women with PID received ceftriaxone with doxycycline, then were randomized to metronidazole vs placebo for 2 wk; primary outcome was clinical improvement in 3 day; the addition of metronidazole was associated with less likelihood of detecting anaerobes in the endometrium and M genitalium in the cervix, and reduced cervical and pelvic motion tenderness; indications for oral medication if injection is not available include presence of a cephalosporin allergy, low community prevalence and individual risk for gonorrhea, and high likelihood for follow-up; gonorrhea positivity and presence of penicillin or cephalosporin allergy warrants infectious disease consultation; if no allergy is present, ceftriaxone IM is appropriate

Contact tracing: if a patient discloses unprotected sex with a partner she does not know well and wishes to be screened, routine screening should include gonorrhea, chlamydia, HIV, syphilis, high-risk human papillomavirus for cervical cancer, and trichomoniasis; contact tracing is not recommended for herpes; herpes type-2 serology should be performed only if the patient shows willingness to change her behavior

Hepatitis B virus (HBV): the main goal is vaccination and protection; for a patient previously vaccinated for HBV with high-risk sexual exposure, protection is important and screening is not required; nonvaccinated individuals should be vaccinated

Hepatitis C virus (HCV): the USPSTF recommends a once-in-a-lifetime test for people 18 to 79 yr of age, irrespective of risk, with periodic rescreening (HCV antibody test, confirmed with viral load test) for drug users; CDC recommends screening to avoid hepatocellular carcinoma and other sequelae of chronic HCV

Screening for HIV: people aged 15 to 65 yr should be tested once in a lifetime; for high-risk patients, use a 4th-generation HIV test to test for HIV 1, 2, and p24 antigen as it becomes positive 4 wk earlier than 3rd-generation and improves case finding; USPSTF grade-A recommendation — men having sex with men and heterosexual individuals with risk behaviors, should be counselled about availability of preexposure prophylaxis (covered by nearly all health plans with no out-of-pocket costs)

Screening for syphilis: CDPH recommendation is based on social determinants, eg, intravenous drug use, recent incarceration, sex under the influence of alcohol and drugs, unstable housing, and HIV infection; the traditional testing algorithm starts with a nontreponemal test (eg, venereal disease research laboratory or rapid plasma reagin test), then positive results are confirmed on a treponemal test, eg, treponema pallidum particle agglutination assay; the reverse sequence algorithm starts with a treponemal test, confirming positive results with a nontreponemal test (advantages include better accuracy, rapid testing, cost-effectiveness, and less occupational hazard); CDPH 2020 guidelines — screen for and manage syphilis to prevent congenital syphilis; obstetricians should screen at first prenatal visit, during third trimester, and, if screening result is unavailable, during labor

Readings

Caruso G, Giammanco A, Virruso R, et al. Current and future trends in the laboratory diagnosis of sexually transmitted infections. Int J Environ Res Public Health. 2021;18(3):1038. doi:10.3390/ijerph18031038; Guidelines for the management of sexually transmitted infections. Geneva: World Health Organization. 2001. https://www.who.int/hiv/topics/vct/sw_toolkit/guidelines_management_sti.pdf; Hogben M, Kidd S, Burstein GR. Expedited partner therapy for sexually transmitted infections. Curr Opin Obstet Gynecol. 2012;24(5):299-304. doi:10.1097/GCO.0b013e3283577e9d; LeFevre ML. U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(12):902-910. doi:10.7326/M14-1981; Reddel S, Edmiston N. Contact tracing for STIs - new resources and supportive evidence. Aust Fam Physician. 2012;41(3):128-132; Shannon CL, Klausner JD. The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Curr Opin Pediatr. 2018;30(1):137-143. doi:10.1097/MOP.0000000000000578; St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916. Published 2020 Dec 18. doi:10.15585/mmwr.mm6950a6; Tao G, Hoover KW, Nye MB, et al. Infrequent testing of women for rectal chlamydia and gonorrhea in the United States. Clin Infect Dis. 2018;66(4):570-575. doi:10.1093/cid/cix857; Tien V, Punjabi C, Holubar MK. Antimicrobial resistance in sexually transmitted infections. J Travel Med. 2020;27(1):taz101. doi:10.1093/jtm/taz101; Tucker JD, Bien CH, Peeling RW. Point-of-care testing for sexually transmitted infections: Recent advances and implications for disease control. Curr Opin Infect Dis. 2013;26(1):73-79. doi:10.1097/QCO.0b013e32835c21b0; Wiesenfeld HC, Meyn LA, Darville T, et al. A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis. 2021;72(7):1181-1189. doi:10.1093/cid/ciaa101.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Policar was recorded at the 2021 Obstetrics and Gynecology update: What Does The Evidence Tell Us?, held on October 15, 2021, and presented by the University of California, San Francisco. For information on future CME activities from this presenter, please visit cme.ucsf.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

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