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«Sexually Transmitted Diseases Treatment Guidelines, 2014 This information is distributed solely for the purpose of pre-dissemination peer review ...»

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8/20/2014 4:59 PM

Sexually Transmitted Diseases Treatment Guidelines, 2014

This information is distributed solely for the purpose of pre-dissemination peer review

under applicable information quality guidelines. It has not been formally disseminated by

the Centers for Disease Control and Prevention. It does not represent and should not be

construed to represent any agency determination or policy.




Clinical Prevention Guidance

STD/HIV Prevention Counseling

Prevention Methods

Special Populations

Partner Services

Reporting and Confidentiality

Pregnant Women



Persons in Correctional Facilities


Emerging Issues

Women Who Have Sex with Women (WSW)

Transgender Men and Women

HIV Infection: Detection, Counseling, and Referral

Hepatitis C

Diseases Characterized by Genital, Anal, or Perianal Ulcers

Mycoplasma genitalium



Management of Persons Who Have a History of Penicillin Allergy

Syphilis in Pregnancy

Diseases Characterized by Urethritis and Cervicitis

Congenital Syphilis


Chlamydial Infections

Nongonococcal Urethritis

Gonococcal Infections


Diseases Characterized by Vaginal Discharge

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Bacterial Vaginosis

Pelvic Inflammatory Disease (PID)



Human Papillomavirus (HPV) Infection

Genital Warts

HPV-Associated Cancers

Vaccine Preventable STDs

Proctitis, Proctocolitis, and Enteritis

Ectoparasitic Infections

Sexual Assault and STDs


Terms and Abbreviations Used in This Report


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Sexually Transmitted Diseases Treatment Guidelines, 2014 Prepared by Kimberly A. Workowski, MD 1,2 Gail Bolan, MD 1 1 Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 2 Emory University, Atlanta, Georgia Summary These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30–May 2,

2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR 2010;59 [No. RR–12]). Included in these updated guidelines is new information regarding 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5); 5 updated HPV counseling messages; 6) new section on the management of transgender individuals 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection.

Introduction The term sexually transmitted diseases (STDs)is used to refer to a variety of clinical syndromes and infections caused by pathogens that can be acquired and transmitted through sexual activity. Physicians and other health-care providers play a critical role in preventing and treating STDs. These guidelines for the treatment of STDs are intended to assist with that effort.

Although these guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed.

This document updates the CDC Sexually Transmitted Diseases Treatment Guidelines published in 20101.These recommendations should be regarded as a source of clinical guidance and not prescriptive standards. Health-care providers should always consider the clinical circumstances of each person in the context of local disease prevalence. These guidelines are applicable to any patient-care setting that serves individuals at risk for STDs, including familyplanning clinics, HIV-care clinics, private physicians’ offices, Federally Qualified Health Centers, and other primary-care facilities. These guidelines focus on the treatment and counseling of individuals and do not address other community services and interventions that are essential to STD/human immunodeficiency virus (HIV) prevention efforts.

3 8/20/2014 4:59 PM Methods These guidelines were developed by CDC staff and an independent workgroup selected on the basis of their expertise in the field of STDs. Members of the multidisciplinary workgroup included representation from federal, state, and local health departments, clinical and basic science researchers, and numerous professional organizations. (listed at the end of this document). All workgroup members provided conflict of interest form and several members of the workgroup acknowledged receiving financial support from companies performing clinical research All potential conflicts of interest were disclosed and managed in accordance with the editorial standards of the journals that published the scientific reports.

Specifically in 2012, CDC staff and workgroup members were asked to identify key questions regarding STD treatment and clinical management that emerged since the 2010 STD Treatment Guidelines.Development of these key questions focused on four principal outcomes of STD therapy for each individual disease or infection: 1) treatment of infection based on microbiologic eradication; 2) alleviation of signs and symptoms; 3) prevention of sequelae; and 4) prevention of transmission, 5) cost-effectiveness and other advantages and disadvantages of specific regimens. Then, CDC staff members assigned workgroup members key questions to research, and with the assistance of CDC staff, conducted an extensive and systematicliterature review using an extensive MEDLINE database evidence-based approach (e.g., published abstracts and peer-reviewed journal articles), focusing on these key questions, common STDs, and information that had become available since publication of the Sexually Transmitted Diseases Treatment Guidelines, 2010 1.

Workgroup members assigned to address key questions developed tables of evidence from peer-reviewed publications that summarized the type of study (e.g., randomized controlled trial or case series), study population and setting, treatments or other interventions, outcome measures assessed, reported findings, and weaknesses and biases in study design and analysis... This information was presented at an inperson meeting of invited experts (including public- and private-sector professionals knowledgeable in the treatment of persons with STDs) in April 2013...Each key question was discussed and relevant publications were reviewed in terms of strengths, weaknesses, and relevance to the particular key question The workgroup evaluated the quality of evidence, provided answers to the key questions and then rated the recommendations based on the United Services Preventive Services Task Forces modified rating system. After the discussion, a recommendation was proposed and adopted for consideration by CDC. More detailed description of the the search terms, key questions, systematic search, and review of the literature, evidence tables, quality of evidence and strength of the recommendations are available at www.cdc.gov/std.


Following the in person meeting,the literature was searched periodically for subssequent

–  –  –

published articles for the workgroup to consider by email or conference calls.. Draft recommendations were then developed by CDC generated from the background materials and the senior author was responsible for the overall content To confirm that the the recommendations were evidence based, a second independent panel of public health and clinical experts reviewed the draft recommendations. The recommendations for STD screening during pregnancy and cervical cancer screening were developed after CDC staff reviewed the published recommendations from other professional organizations, including the American College of Obstetricians and Gynecologists (ACOG), United States Preventive Services Task Force (USPSTF), American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP) and the Advisory Committee on Immunization Practices (ACIP). The sections on hepatitis B (HBV) and hepatitis A (HAV) infections are based on previously published recommendations. 2-4 Throughout this report, the evidence used as the basis for specific recommendations is discussed briefly. More comprehensive, annotated discussions of such evidence will appear in background papers that will be available in a supplement issue of the journal Clinical Infectious Diseases after publication of the treatment guidelines. When more than one therapeutic regimen is recommended, the sequence is alphabetized unless prioritized based on efficacy, tolerance, or costs. For infections with more than one recommended regimen, listed regimens have similar efficacy and similar rates of intolerance or toxicity unless otherwise specified. Recommended regimens should be used primarily; alternative regimens can be considered in instances of significant drug allergy or other medical contraindications to the recommended regimens.

Clinical Prevention Guidance

The prevention and control of STDs are based on the following five major strategies:

• accurate risk assessment, education and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services;

• pre-exposure vaccination of persons at risk for vaccine-preventable STDs;

• identification of asymptomatically infected persons and of persons with symptoms associated with STDs;

• effective diagnosis, treatment, counseling and follow up of infected persons; and

• evaluation, treatment, and counseling of sex partners of persons who are infected with an STD.

STD/HIV Risk Assessment:

Primary prevention of STDs includes performing a behavioral risk assessment (i.e., assessing the sexual behaviors that may place persons at risk for infection) as well as a biologic assessment of risk (i.e, testing for std risk markers for hiv acquisition or transmission).

5 8/20/2014 4:59 PM As part of the clinical encounter, health-care providers should routinely obtain sexual histories from their patients and address risk reduction as indicated in this report. Guidance in obtaining a sexual history is available on the CDC Division of STD Prevention resource page http://www.cdc.gov/std/treatment/resources.htm and in the curriculum provided by CDC’s STD/HIV Prevention Training Centers http://nnptc.org/clinical-ptcs/ Effective interviewing and counseling skills, characterized by respect, compassion, and a nonjudgmental attitude toward all patients, are essential to obtaining a thorough sexual history and to delivering prevention messages effectively. Key techniques that can be effective in facilitating rapport with patients include the use of 1) open-ended questions (e.g., “Tell me about any new sex partners you’ve had since your last visit,” and “What’s your experience with using condoms been like?”); 2) understandable, nonjudgmental language (“Are your sex partners men, women or both?”“Have you ever had a sore or scab on your penis?”); and 3) normalizing language (“Some of my patients have difficulty using a condom with every sex act. How is it for you?”). The “Five P’s” approach to obtaining a sexual history is one strategy for eliciting information concerning five key areas of interest (Box 1).

Additional information about gaining cultural competency when working with certain populations (e.g., gay, bisexual or other men who have sex with men, women who have sex with women, or transgender men and women) can be found in the respective chapters in this document.

In addition to obtaining a behavioral risk assessment described above, a comprehensive STD/HIV risk assessment should include STD screening because STDs are biological markers of risk especially for MSM.. STD screening is an essential and underutilized component of an STD/HIV risk assessment in most clinical settings. Persons seeking treatment or evaluation for a particular STD should be screened for HIV, and possibly other STDs as indicated by community prevalence and individual risk factors (see section on repeat testing, and sections on individual STDs). Individuals should be informed about all the STDs for which they are being tested and notified about tests for common STDs (e.g., genital herpes, HPV) that are available but not being performed. Efforts should be made to ensure that all persons receive care regardless of individual circumstances (e.g., ability to pay, citizenship or immigration status, language spoken, or specific sex practices).

STD/HIV Prevention Counseling

After obtaining a sexual history from their patients and all providers should encourage riskreduction through prevention counseling using various strategies, including prevention methods outlined below. Prevention counseling is most effective if provided in a nonjudgmental and empathetic manner appropriate to the patient’s culture, language, gender, sexual orientation, age, and developmental level. Prevention counseling for STD/HIV should be offered to all sexually active adolescents and to adults, who are diagnosed with an STD, have had an STD in the past year, or have multiple sexual partners.

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Box 1. The Five P’s: Partners, Prevention of Pregnancy, Protection from STDs, Practices, and Past History of STDs

1. Partners • “Do you have sex with men, women, or both?” • “In the past 2 months, how many partners have you had sex with?” • “In the past 12 months, how many partners have you had sex with?” • “Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?”

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