Prepare to update your practice: updated STD guidelines released
Expanded prevention recommendations include HPV vaccination
Clinicians now have the latest guidance in managing patients who have, or are at risk for, sexually transmitted diseases (STDs) with the just-released 2010 STD Treatment Guidelines.1 The guidance was developed by the Centers for Disease Control and Prevention (CDC) after consultation with a panel of national experts who convened in April 2009.
The 2010 guidelines, which update a similar 2006 publication, serve as a source of clinical guidance and advise health care providers on the most effective treatment regimens, screening procedures, and prevention and vaccination strategies for STDs, according to CDC officials. The agency revises the guidance periodically, using a scientific, evidence-based process that includes CDC and external expert review of current scientific literature.
The guidelines are intended to assist clinicians with the management of persons who have, or are at risk for, sexually transmitted diseases, noted Kimberly Workowski, MD, infectious diseases specialist in the CDC's Division of STD Prevention, in a podcast debuting the new guidance. Although the guidelines emphasize treatment, prevention strategies and diagnostic evaluation are also discussed, said Workowski, who served as lead author for the publication.
CDC officials have been busy making sure practitioners receive the updated guidelines, says Rachel Powell, a CDC spokesperson. The agency has worked to get the word out to trade press, as well as with its prevention partners, to spread news of the new publication, she says. Powell encourages clinicians to visit the dedicated web page, www.CDC.gov/STD/treatment/2010, to download the guidance, check for updates, and access outreach tools. Printed copies, wall charts, and pocket guides will be available for order in the coming months. The web site will have updates on these materials, as well as other educational opportunities, says Powell. The site also includes the erratum contained in the Jan. 10, 2011 "Dear Colleague" letter, which contains corrections for recommended regimens for gonococcal infections, which include gonococcal dual therapy, and the alternative regimens for bacterial vaginosis.
The CDC is planning some population-specific webinars, Powell reports. An adolescent one is in the planning process, she states. Also look for iPhone and e-book applications to come, says Powell.
What's new?
The 2010 guidelines highlight expanded prevention recommendations for sexually transmitted infections, said Workowski. Some of the key changes include the prevention and treatment of human papillomavirus virus (HPV), gonorrhea, and lymphogranuloma venereum proctocolitis.
"Preexposure vaccination is one of the most effective methods to prevent transmission of HPV," noted Workowski. Clinicians have two HPV vaccines licensed for females ages 9 through 26 to prevent cervical precancer and cancer: the quadrivalent HPV vaccine, Gardasil, and the bivalent HPV vaccine, Cervarix. Gardasil also is indicated for prevention genital warts, she noted.
Routine vaccination of females ages 11 or 12 is recommended with either vaccine, as is the catch-up vaccination for females ages 13 through 26, stated Workowski. Gardasil also may be given to males ages 9 through 26 to prevent genital warts.
Neisseria gonorrhoeae, or GC, has developed resistance to many classes of antimicrobials recommended for treatment, stated Workowski. Quinolone-resistant Neisseria gonorrhoeae strains are widely disseminated throughout the United States and the world, and as a result, quinolones are not recommended for the treatment of gonorrhea.
"Although currently recommended regimens are effective for gonorrhea within the United States, the susceptibility of gonococcal isolates to cephalosporins has been decreasing, and treatment failures with oral cephalosporins have been documented in Southeast Asia," noted Workowski. "Based on prior experience with quinolone-resistant N. gonorrhoeae, it is probable that such isolates may spread to the United States."
Due to these reports, ceftriaxone 250 mg intramuscularly or cefixime 400 mg orally are recommended for urogenital infection. Since many with gonorrhea are coinfected with chlamydia, therapy with azithromycin or doxycycline is recommended.
Lymphogranuloma venereum proctocolitis (LGV) is being increasingly recognized especially among HIV-positive men who have sex with men, Workowski pointed out. In persons with painful perianal ulcers or those detected on anoscopy, presumptive therapy should include treatment for LGV, which is doxycycline 100 mg twice daily for 21 days.
Check genital wart option
A new patient-applied treatment for genital warts is available, stated Workowski. The treatment of 15% sinecatechins ointment should be applied by the patient three times daily until complete clearance of the warts. The ointment, Veregen Ointment, is manufactured by PharmaDerm, a division of Nycomed US in Florham Park, NJ.
The guidance also offers a new alternative treatment for bacterial vaginosis: 2 g of tinidazole taken daily for three days or 1 g taken daily for five days. For episodic outbreaks of herpes simplex virus, an additional treatment option is 500 mg of famciclovir followed by two days of 250 mg taken twice daily, stated Workowski.
There also are some data that moxifloxacin 400 mg daily for seven days is effective in nongonococcal urethritis treatment failures due to Mycoplasma genitalium, she stated.
Put guidance into gear
Now that clinicians have the guidance in hand, it is time to brush up on skills that can aid in obtaining a thorough sexual history and effectively delivering prevention messages.
Consider the following strategies to facilitate rapport with patients:
- Use open-ended questions, such as "Tell me about any new sex partners you've had since your last visit" and "What's your experience with using condoms been like?
- Incorporate understandable language, such as "Have you ever had a sore or scab on your penis?
- Use normalizing language, such as "Some of my patients have difficulty using a condom with every sex act. How is it for you?"
Consider using the "Five Ps" to help obtain the necessary information for a thorough sexual history. (See story, below.) Remember that effective interviewing and counseling skills, characterized by respect, compassion, and a nonjudgmental attitude toward all patients, are essential to gathering information for a successful treatment plan.1
Reference
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010; 59(RR12);1-110.
Use the five Ps in your practice Be sure to include the "five Ps" when obtaining a sexual history: Partners. Ask: Do you have sex with men, women, or both? In the past two 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? Prevention of pregnancy. Ask: What are you doing to prevent pregnancy? Protection from STDs. Ask: What do you do to protect yourself from STDs and HIV? Practices. Say: To understand your risks for STDs, I need to understand the kind of sex you have had recently. Have you had vaginal sex, meaning penis-in-vagina sex? If yes, do you use condoms: never, sometimes, or always? Have you had anal sex, meaning penis-in-rectum/anus sex? If yes, do you use condoms never, sometimes, or always? Have you had oral sex, meaning mouth on penis/vagina? For condom answers: If answer is "never," ask, "Why don't you use condoms?" If answer is "sometimes," ask, "In what situations (or with whom) do you not use condoms?" Past history of STDs. Ask: Have you ever had an STD? Have any of your partners had an STD? Additional questions to identify HIV and viral hepatitis risk include: Have you or any of your partners ever injected drugs? Have any of your partners exchanged money or drugs for sex? Is there anything else about your sexual practices that I need to know about? Source: Adapted from: Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010; 59(RR12);3. |
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content