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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 18--30, 2009. The information in this report
updates the 2006 Guidelines for Treatment of Sexually Transmitted Diseases
(MMWR 2006;55[No. RR--11]). Included in these updated guidelines is new
information regarding 1) the expanded diagnostic evaluation for cervicitis and
trichomoniasis; 2) new treatment recommendations for bacterial vaginosis and
genital warts; 3) the clinical efficacy of azithromycin for chlamydial
infections in pregnancy; 4) the role of Mycoplasma genitalium and
trichomoniasis in urethritis/cervicitis and treatment-related implications; 5)
lymphogranuloma venereum proctocolitis among men who have sex with men; 6) the
criteria for spinal fluid examination to evaluate for neurosyphilis; 7) the
emergence of azithromycin-resistant Treponema pallidum; 8) the increasing
prevalence of antimicrobial-resistant Neisseria gonorrhoeae; 9) the sexual
transmission of hepatitis C; 10) diagnostic evaluation after sexual assault;
and 11) STD prevention approaches.
Introduction
The term sexually transmitted diseases (STDs) is used to
refer to a variety of clinical syndromes 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.
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. They are applicable to various patient-care settings,
including family-planning clinics, private physicians' offices, managed care
organizations, and other primary-care facilities. These guidelines focus on the
treatment and counseling of individual patients and do not address other
community services and interventions that are essential to STD/human
immunodeficiency virus (HIV) prevention efforts.
Methods
These guidelines were developed using a multistage process.
Beginning in 2008, CDC staff members and public and private sector experts
knowledgeable in the field of STDs systematically reviewed literature using an
evidence-based approach (e.g., published abstracts and peer-reviewed journal
articles), focusing on the common STDs and information that had become
available since publication of the 2006 Guidelines for Treatment of Sexually
Transmitted Diseases (1). CDC staff members and STD experts developed background
papers and tables of evidence 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. CDC staff
then developed a draft document on the basis of this evidence-based review. In
April 2009, this information was presented at a meeting of invited consultants
(including public- and private-sector professionals knowledgeable in the
treatment of patients with STDs), where all evidence from the literature
reviews pertaining to STD management was discussed.
Specifically, participants identified key questions regarding
STD treatment that emerged from the literature reviews and discussed the
information available to answer those questions. Discussion focused on four
principal outcomes of STD therapy for each individual disease: 1) treatment of
infection based on microbiologic eradication; 2) alleviation of signs and symptoms;
3) prevention of sequelae; and 4) prevention of transmission.
Cost-effectiveness and other advantages (e.g., single-dose formulations and
directly observed therapy [DOT]) of specific regimens also were discussed. The
consultants then assessed whether the questions identified were relevant,
ranked them in order of priority, and answered the questions using the
available evidence. In addition, the consultants evaluated the quality of
evidence supporting the answers on the basis of the number, type, and quality
of the studies.
The sections on hepatitis B virus (HBV) and hepatitis A virus
(HAV) infections are based on previously published recommendations of the
Advisory Committee on Immunization Practices (ACIP) (2--4). 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),
and ACIP.
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 published
in a supplement issue of the journal Clinical Infectious Diseases. When more
than one therapeutic regimen is recommended, the sequence is alphabetized
unless the choices for therapy are prioritized based on efficacy, convenience,
or cost. For those infections with more than one recommended regimen, almost
all 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 contraindications to the recommended regimens
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