Summary of 2002 Treatment Guidelines
New CDC Treatment Guidelines Critical to
Preventing Health Consequences of Sexually Transmitted Diseases
The Centers for Disease Control and Prevention (CDC) today
issued national guidelines designed to help health care providers protect their
patients from the health consequences that result from sexually transmitted
diseases (STDs). The 2002 Guidelines for the Treatment of Sexually Transmitted
Diseases integrate recommendations on the most effective treatment regimens,
screening procedures and prevention strategies for STDs, which infect an
estimated 15 million people each year in the United States. CDC revises the
guidelines periodically, (approximately every four years) using a scientific
evidence-based review process. This is the fifth CDC edition of the guidelines,
which were first published by CDC in 1982.
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Rescreening for Chlamydia Helps Protect
Young Women from Infertility
CDC has expanded its recommendation for chlamydia screening
among women. These new CDC guidelines, consistent with other guidance, advise
health care providers to annually screen sexually active adolescent (19 years
old and under) and young adult (20 to 24 years old) women, even if symptoms are
not present, and to screen older women with a risk factor for chlamydia (a new
partner or multiple sexual partners). However, it is now recommended that all
women with chlamydial infections be rescreened three to four months after
treatment is completed.
This is the first time CDC has recommended rescreening in the
management of chlamydia. The new guidance was issued as a result of the high
prevalence of chlamydia found in women who were diagnosed with the disease in
the preceding several months, presumable as the result of reinfection.
Chlamydia is the most commonly reported infectious disease in
the United States with 702,093 cases reported in 2000, and is asymptomatic in
the majority of cases. Chlamydia is concentrated among female adolescents, who
are physiologically more susceptible to a chlamydial infection than older women.
In the United States, millions of cases go unrecognized,
threatening the health of young women. If not diagnosed and treated effectively,
chlamydia can have serious consequences. Reinfection with chlamydial infection
is a key risk factor for pelvic inflammatory disease (PID). PID can damage the
fallopian tubes, uterus and ovaries, and cause chronic pelvic pain. One in five
women with PID also become infertile. Moreover, women infected with chlamydia
are up to five times more likely to become infected with HIV, if exposed.
Historically, chlamydia prevalence is lower in areas with
long-standing screening and treatment programs. CDC's new recommendation for
rescreening women diagnosed with chlamydia can help protect women from the
effects of chlamydial infections and could ultimately reduce infertility in the
United States.
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CDC Recommends Alternative Gonorrhea
Treatments in Wake of Increasing Drug Resistance in California
Gonorrhea is the second most common infectious disease reported
to CDC, with nearly 360,000 cases in 2000. Drug-resistant strains are becoming
increasingly common in the United States. Ciprofloxacin-resistant gonorrhea was
found to be endemic in Hawaii in 2000, when CDC recommended that the state cease
its use of fluoroquinolone antibiotics - ciprofloxacin, ofloxacin, and
levofloxacin - for treating gonorrhea.
Now in the 2002 STD Treatment Guidelines, CDC warns providers
that ciprofloxacin-resistant strains have become so common on the west coast
that the use of fluoroquinolone antibiotics to treat gonorrhea is inadvisable in
California. This is the first time CDC has issued this guidance in the
continental United States. Previously, CDC recommended that fluoroquinolones not
be prescribed for treating gonorrhea in Hawaii and in those patients who visited
the island state, other Pacific Islands, or Asia, because a substantial
proportion of the gonorrhea cases in those areas are resistant to ciprofloxacin.
The antibiotics cefixime and ceftriaxone are now recommended as first-line drugs
to treat gonorrhea in Hawaii and California.
CDC made these new recommendations after examining data from the
Gonococcal Isolate Surveillance Project (GISP), a CDC-sponsored surveillance
system, which monitors drug resistance of gonorrhea. Twenty-six STD clinics
participate in GISP by collecting gonorrhea cultures and submitting them to one
of five regional GISP laboratories for antimicrobial susceptibility testing.
Since the GISP project is limited to several areas in the United
States, it is critical that local data are available to guide prescribing
recommendations. State and local public health officials must maintain the
capacity to detect and monitor the prevalence of resistant strains, since
prevalence can vary greatly by location. Most importantly, data from local drug
susceptibility testing are necessary to guide local treatment recommendations.
To supplement GISP data, CDC requests that local and state
public health professionals and health care providers report cases of gonorrhea
that are resistant to any recommended antibiotics.
CDC has recommended the use of fluoroquinolone antibiotics for
the treatment of gonorrhea since 1993. Previously, penicillin and tetracycline
were recommended for the treatment of gonorrhea, but widespread resistance
rendered these drugs ineffective. Treatment with tetracycline and penicillin was
abandoned in 1985 and 1987 respectively.
If not treated successfully, gonorrhea can cause PID and can
facilitate HIV transmission.
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Need for Expanded Risk Assessment and
Screening Among Gay and Bisexual Men
Recent data have shown a higher frequency of unprotected sex and
increased rates of syphilis and gonorrhea in many U.S. cities among men who have
sex with men (MSM), many of whom are HIV infected. To highlight the critical
need for health care providers to expand screening and treatment of STDs among
men who have sex with men (MSM), the new guidelines include detailed
recommendations for this high-risk population.
The 2002 STD treatment Guidelines urge health care providers to
assess the sexual risk for all male patients, including the gender of partners.
For MSM patients who are sexually active, the guidelines recommend annual
screening for STDs - HIV, chlamydia (anal, urethral), syphilis and gonorrhea
(anal, pharyngeal, urethral) - and vaccination against hepatitis A and B.
More frequent STD screening may be indicated for those who
indicate having multiple anonymous partners or having sex in conjunction with
illicit drug use.
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New Serological Tests Available to
Help Diagnose Genital Herpes
An estimated one million people are newly infected with the
Herpes Simplex Virus (HSV) each year. While most people have mild or
unrecognized symptoms and remain undiagnosed, many individuals seek medical
attention when they begin to suffer from the painful ulcers characteristic of
this viral disease.
Now, new testing procedures may help providers with diagnosing
and managing genital herpes type one (HSV-1) or type two (HSV-2). Since
antiviral therapy may benefit individuals with herpes symptoms, providers who
are aware of their patient's viral serotype can tailor counseling and treatment
plans to best fit their needs.
The majority of individuals with recurring genital outbreaks are
infected with HSV-2, which is almost always spread during sexual contact with
someone who has a genital HSV-2 infection. Patients infected with this type can
choose from suppressive or episodic antiviral treatments that can prevent or
shorten the duration of outbreaks. Genital HSV-1, which is often caused by
oral-genital sexual contact with a person with an oral HSV-1 infection (fever
blister), is much less likely to recur and treatment may only be needed in
patients with initial symptoms.
Regardless of severity of symptoms, genital herpes frequently
causes psychological distress in people who know they are infected. The new CDC
guidelines urge providers to counsel symptomatic patients - whether they have
HSV-1 or HSV-2 - about the disease, its initial and recurring manifestations,
and how to avoid transmission of the virus to sexual partners and newborns. This
is especially important since HSV can cause potentially fatal infections in
infants if the mother is shedding virus at the time of delivery, particularly if
the maternal infection was recently acquired.
HSV also may play a major role in the spread of HIV, the virus
that causes AIDS. Herpes can make people more susceptible to HIV infection, and
it can make HIV-infected individuals more infectious.
HSV stays in the body indefinitely and is incurable. In the
United States, an estimated 50 million people are infected. For those with
symptoms, resulting herpes outbreaks tend to decrease in frequency over a period
of years.
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Other Key Recommendations
Prevention of STDs
The guidelines encourage health care providers to focus on risk
assessment and counseling in addition to the clinical aspects of STD control -
screening and treatment. To assist providers with their prevention efforts, the
clinical prevention guidelines have been expanded for 2002. Providers are
encouraged to use client-centered counseling approaches tailored for each of
their patients. To avoid the spread of STDs, the guidelines suggest patients
should abstain from oral, vaginal or anal sex. Patients who are sexually active
should be counseled to be in a mutually monogamous relationship with an
uninfected partner or use a condom during each sexual act.
The Use of Nonoxynol-9 (N-9)
Recent studies have found that frequent use of N-9, a spermicide
contraceptive, can cause genital lesions (in the vagina) and, therefore, may
increase the risk of HIV transmission. It has also been found to cause damage to
the lining of the rectum, providing an entry point for HIV and other STDs.
According to the guidelines, spermicides - especially those than contain N-9 -
should not be used for STD prevention. Furthermore, N-9 lubricants should not be
used during anal intercourse.
While the level of N-9 used as a lubricant in condoms is much
lower than the level found to be harmful, condoms lubricated with N-9 spermicide
also are not recommended because they have a shorter shelf life, cost more and
have been associated with urinary tract infections in women. However, previously
purchased condoms with N-9 can be used, provided they have not passed their
expiration date, since the protection provided by the condom against HIV
outweighs the potential risk of N-9.
The Centers for Disease Control and Prevention (CDC) protects
people's health and safety by preventing and controlling diseases and injuries;
enhances decisions by providing credible information on critical health issues;
and promotes health living through strong partnerships with local, national and
international organizations.
To order a copy of the Guidelines, please visit The Centers for
Disease Control and Prevention at
http://www.cdc.gov/std.
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NM Department of Health Family Planning Program
