INFECTIOUS DISEASE: 2015 CDC STD treatment guidelines

Part of Contemporary Pediatrics’ coverage of the 2015 AAP Annual Conference. For more coverage, click here.

New Centers for Disease Control and Prevention (CDC) sexually transmitted disease (STD) treatment guidelines cover far more than treatment, said Katherine K Hsu, MD, MPH, FAAP, during the session “The New 2015 CDC STD Treatment Guidelines in Action.” Along with evidence-based recommendations for STD testing, management, and counseling, the guidelines contain invaluable sections regarding screening of special populations at greater risk for sexually transmitted infections (STIs), including, for the first time, transgender patients.

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Due to growing antibiotic resistance among gonococci, said Arik V Marcell, MD, MPH, FAAP, guideline revisions include new treatment/coverage approaches for gonorrhea. Previous CDC guidelines recommended addressing all presumptive cases of gonorrhea with simultaneous administration of intramuscular ceftriaxone with an oral drug, either azithromycin or doxycycline. The 2015 guidelines, however, specify only a single first-line, dual-drug regimen for presumed urethritis or cervicitis: intramuscular ceftriaxone combined with oral azithromycin. Use of azithromycin as the second antimicrobial is preferred to doxycycline because of the convenience and compliance advantages of single-dose therapy, as well as an increased signal of resistance to doxycycline in gonococcal isolates in the United States. For pelvic inflammatory disease, the CDC still recommends a single dose of ceftriaxone combined with 14 days of doxycycline, with or without metronidazole.

For patients allergic to either ceftriaxone or azithromycin, alternative antibiotics for gonorrhea are generally so commercially scarce that Hsu suggested discussing options with local infectious disease specialists. Often, she added, it’s very useful to relearn how to culture for gonorrhea, a skill that, outside of academic centers, has been largely supplanted by nucleic acid amplification methods, which presently cannot be used to determine gonococcal antibiotic susceptibility.

Regarding specific populations, 2015 guidelines include beefed-up screening recommendations for all sites of potential STD exposure. These include evidence-based recommendations to screen for urogenital, rectal, and pharyngeal exposure sites in boys and men who have sex with men (MSM). Any male who engages in receptive oral or anal sex should undergo appropriate screening, Marcell said. Even if a male reports he has no symptoms, clinicians need to screen and potentially treat all potential exposure sites, based on a history of same-sex engagement, given the high prevalence of STIs within the MSM population.

Very user friendly, the 2015 guidelines are accessible in print and on the web, at www.cdc.gov/std/tg2015/. A new smartphone app is also available for iOS devices and an Android version will be available soon.

Katherine K Hsu, MD, MPH, FAAP, is an associate professor of pediatrics, Boston University Medical Center, and medical director, Division of STD Prevention and HIV/AIDS Surveillance, Massachusetts Department of Public Health.

Arik V Marcell, MD, MPH, FAAP, is an associate professor of pediatrics, The Johns Hopkins University, Baltimore, Maryland.

NEXT: Commentary and transgender children

Commentary

In the Division of Adolescent and Young Adult Medicine at Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh Medical Center, where we provide care for adolescents and young adults including transgender care, we have already reviewed in depth and integrated these new CDC guidelines into our routine care.

The emphasis on testing sites other than the urogenital area-pharyngeal and rectal exposures, specifically-is especially important for pediatricians to remember. When a young person presents with a sore throat, we should be asking about oral sex and possible exposure to STIs. Pediatricians are in a prime position to create safe and confidential spaces for young people to talk frankly about their sexual practices and to receive appropriate screening and treatment for STDs.

The inclusion of special populations, including care for transgender patients, is particularly welcome. It is also another reminder to healthcare professionals to be sure to create confidential opportunities for their adolescent and young adult patients to talk about their sexuality, their sexual practices, strategies for protection against STDs (and pregnancy if relevant), sexual consent, and healthy, respectful relationships.

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The one area that could be better emphasized in the new CDC guidelines is the impact of intimate partner and sexual violence on increased risk for contracting an STI. Being in an abusive relationship or being made to have sex that one didn’t want to have places a young person at greatly elevated risk for infections. The treatment guidelines could benefit from more discussion of how exposure to violence can increase risk for infection, and that providers should routinely assess for a young person’s safety and offer educational resources about healthy and unhealthy relationships, sexual consent, and violence-related resources in the context of STI testing and treatment.

Elizabeth Miller, MD, PhD, is chief, Division of Adolescent and Young Adult Medicine, Children’s Hospital of Pittsburgh of UPMC, Pennsylvania.

Mr. Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.