In 2010, the CDC released an update of its Sexually Transmitted Diseases (STD) Treatment Guidelines,1 which were last updated in 2006. The guidelines are widely viewed as the most authoritative source of information on the diagnosis, treatment, and follow-up of STDs, and they are the standard for publicly and privately funded clinics focusing on sexual health.
What’s new
Some of the notable changes made since the last update in 2006 appear in TABLE 1.1,2
Uncomplicated gonorrhea. Cephalosporins are the only class of antibiotic recommended as first-line treatment for gonorrhea. (In a 2007 recommendation revision, the CDC opted to no longer recommend quinolone antibiotics for the treatment of gonorrhea, because of widespread bacterial resistance.3) Preference is now given to ceftriaxone because of its proven effectiveness against pharyngeal infection, which is often asymptomatic, difficult to detect, and difficult to eradicate. Additionally, the 2010 update has increased the recommended dose of ceftriazone from 125 to 250 mg intramuscularly. The larger dose is more effective against pharyngeal infection; it is also a safeguard against decreased bacterial susceptibility to cephalosporins, which, although still very low, has been reported in more cases recently.
The guidelines still recommend that azithromycin, 1 g orally in a single dose, be given with ceftriaxone because of the relatively high rate of co-infection with Chlamydia trachomatis and the potential for azithromycin to assist with eradicating any gonorrhea with decreased susceptibility to ceftriaxone.
Pelvic inflammatory disease. Quinolones have also been removed from the list of options for outpatient treatment of pelvic inflammatory disease. All recommended regimens now specify a parenteral cephalosporin as a single injection with doxycycline 100 mg PO twice a day for 14 days, with or without metronidazole 500 mg PO twice a day for 14 days.
Bacterial vaginosis. Tinidazole, 2 g orally once a day for 2 days or 1 g orally once a day for 5 days, is now an alternative agent for bacterial vaginosis. However, preferred treatments remain metronidazole 500 mg orally twice a day for 7 days, metronidazole gel intravaginally once a day for 5 days, or clindamycin cream intravaginally at bedtime for 7 days.
Newborn gonococcal eye infection. A relatively minor change is the elimination of tetracycline as prophylaxis for newborn gonococcal eye infections, leaving only erythromycin ointment to prevent the condition.
TABLE 1
2010 vs 2006: How have the CDC recommendations for STD treatment changed?1,2
Uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx
|
| Pelvic inflammatory disease Parenteral regimens
|
Bacterial vaginosis
|
Prophylaxis for gonococcal eye infection in a newborn
|
Single-dose therapy preferred among equivalent options
Single-dose therapy (TABLE 2), while often more expensive than other options, increases compliance and helps ensure treatment completion. Single-dose therapy administered in your office is essentially directly observed treatment, an intervention that has become the standard of care for other diseases such as tuberculosis. If the single-dose agent is as effective as alternative medications, directly observed on-site administration is the preferred option for treating STDs.
TABLE 2
Single-dose therapies for specific STDs1
| Infection or condition | Single-dose therapy |
|---|---|
| Candida | Miconazole 1200 mg vaginal suppository or Tioconazole 6.5% ointment 5 g intravaginally or Butoconazole 2% cream 5 g intravaginally or Fluconazole 150 mg PO |
| Cervicitis | Azithromycin 1 g PO |
| Chancroid | Azithromycin 1 g PO or Ceftriaxone 250 mg IM |
| Chlamydia urogenital infection | Azithromycin 1 g PO |
| Gonorrhea: conjunctivitis | Ceftriaxone 1 g IM |
| Gonorrhea: uncomplicated infection of the cervix, urethra, rectum | Ceftriaxone 250 mg IM (preferred) or Cefixime 400 mg PO or Single-dose injectable cephalosporin plus Azithromycin 1 g PO |
| Gonorrhea: uncomplicated infection of the pharynx | Ceftriaxone 250 mg IM plus Azithromycin 1 g PO |
| Nongonococcal urethritis | Azithromycin 1 g PO |
| Post-sexual assault prophylaxis | Ceftriaxone 250 mg IM or Cefixime 400 mg PO plus Metronidazole 2 g PO plus Azithromycin 1 g PO |
| Recurrent, persistent nongonococcal urethritis | Metronidazole 2 g PO or Tinidazole 2 g PO plus Azithromycin 1 g PO (if not used for initial episode) |
| Syphilis: primary, secondary, and early latent | Benzathine penicillin G 2.4 million units IM |
| Trichomoniasis | Metronidazole 2 g PO or Tinidazole 2 g PO |
Other guideline recommendations
The CDC’s STD treatment guidelines contain a wealth of useful information beyond treatment advice: recommended methods of confirming diagnoses, analyses of the usefulness of various diagnostic tests, recommendations on how to manage sex partners of those infected, guidance on STD prevention counseling, and considerations for special populations and circumstances.