Federal STD guidelines address shifting susceptibility

Revised gonorrhea treatment regiment and expanded STD prevention recommendation are key features in updated Sexually Transmitted Disease Control and Prevention.

The visionary of STD prevention at the National Center for HIV/AIDS, viral Hepatitis, STD and TB Prevention, chaired the effort and wrote the guidelines with numerous experts. The guidelines, last updated in 2006, are available online.

Gonorrhea treatment regimens were revised in the wake of Neisseria gonorrhea’s decrease susceptibility to cephalosporin and other antimicrobials. In 2007 the CDC recommended that fluoroqinolones not be used for gonorrhea because of resistance to that class of antimicrobials.

What we’ve been seeing over the past number of decades is change in the N. gonorrhoeae organism in different parts of the world. There have been increasing reports of isolates resistant to cephalosporin from Southeast Asia and from Norway.

Because of these developments, patients who present with an uncomplicated urogenital gonorrheal infection should be treated with single 250-mg intramuscular injection of ceftriaxone. If this is not an option, consider a single 400-mg tablet of cefixime or a single-dose cephalosporin regimen. For prevention of co-infection with Chlamydia trachomatis, treatment with azithromycin 1 g orally in a single dose or doxycline 100 mg twice a day for 7 days is recommended.

Expanded STD prevention recommendations include support for the preexposure human papillomavirus (HPV) vaccine. Two vaccines are available: the quadrivalent HPV vaccine, which also prevents genital wart, and bivalent HPV vaccine. Routine vaccination of females aged 11 or 12 years is recommended with either vaccine, as is catch-up vaccination for females aged 13-26.

Here are other departures from the 2006 guidelines:

• New treatment regimens for genital warts and bacterial vaginosis. The list of patients-applied option for treating external genital warts now includes sinecatechins 15% ointment, a green-tea extract. “We don’t know exactly how it works from a scientific standpoint” according to an associated professor of medicine at Emory University, Atlanta. “But in published studies it has done well for genital warts, so it’s another alternative.” The guidelines recommend applying a 0.5-cm strand of ointment to each wart three times per day until complete clearance of warts.” This product should not be continued for longer than 16 weeks,” the recommendation state. “The medication should not be washed off after use. Sexual ((i.e., genital, anal, or oral) contact should be avoided while the ointment is on the skin.”

The list of alternative regimens for treating bacterial vaginosis now included tinidazole 2 g orally once daily for 2 days or tinidazole 1 g orally once daily for 5 days.

• Increasing awareness of lymphogranuloma venereum proctacolitis. Lymphogranuloma venereum causes enlarged lumph nodes in the inguinalfemoral area, and it can also cause an infection in the rectum. Lymphogranuloma venereum proctocolitis can present as rectal bleeding or rectal pain and is being increasingly recognized in men who have sex with men. It should be part of the differential diagnosis in anyone who engages in receptive anal intercourse and presents with a bloody discharge or pain around the rectal area.

• The emergence of azithromycin-resistant Treponema pallidum. Penicillin remains the treatment of choice for syphilis. In those with allergy to penicillin, a 14-day course of doxycycline 100 mg orally twice daily or a 14-day course of tetracycline 500 mg four times daily is recommended. Azithromycin as a single 2-g oral dose is effective for treating early syphilis, according to the guidelines. However, T. pallidum chromosal mutations associated with azithromycin resistance and treatment failures have been documented in several areas in the United States.

• Discussion of the role of Mycoplasma genitalium and trichomoniasis in the evaluation of urethritis and cervicitis and treatment-related implications. While N. gonorrhoeae and C. trachomatis are well established as clinically important infections with urethritis. If clinic-based diagnostic tools are not available, patients should be treated with drug regimens effective against both gonorrhea and chlamydia, the guidelines state. Further testing to determine the specific etiology is recommended because both chlamydia and gonorrhea are reportable to health departments and a specific diagnostic might improve partner notification and treatment.

• Revised guidance on evaluation of neurosyphilis. Laboratory diagnosis of neurosyphilis usually depends on various combinations of reactive serologic test results, cerebrospinal fluid cell (CSF) count r protein, and a reactive CSF-Venereal Disease Research Lab (VDRL) test with or without clinical manifestations. Among persons with HIV infection, the CSF leukocyte count usually is elevated (greater than 5 white blood cell count/mm3); using a higher cutoff (greater than 20 white blood cell count/mm3) might improve the specificity of neurosyphilis diagnosis, the guidelines stated.