Sexually Transmitted Diseases Treatment Guidelines, …

1 Morbidity and Mortality Weekly ReportRecommendations and ReportsAugust 4, 2006 / Vol. 55 / No. RR-11depardepardepardepardepartment of health and human sertment of health and human sertment of health and human sertment of health and human sertment of health and human servicesvicesvicesvicesvicesCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionSexually Transmitted DiseasesTreatment Guidelines, 2006 MMWRC enters for Disease Control and PreventionJulie L. Gerberding, MD, MPHD irectorTanja Popovic, MD, PhD(Acting) Chief Science OfficerJames W. Stephens, PhD(Acting) Associate Director for ScienceSteven L.

2 Solomon, MDDirector, Coordinating Center for Health Information and ServiceJay M. Bernhardt, PhD, MPHD irector, National Center for Health MarketingJudith R. Aguilar(Acting) Director, Division of Health Information Dissemination (Proposed)Editorial and Production StaffMary Lou Lindegren, MDEditor, MMWR SeriesFrederic E. Shaw, MD, JDGuest Editor, MMWR SeriesSuzanne M. Hewitt, MPAM anaging Editor, MMWR SeriesTeresa F. RutledgeLead Technical Writer-EditorPatricia A. McGeeProject EditorBeverly J. HollandLead Visual Information SpecialistLynda G. CupellMalbea A. LaPeteVisual Information SpecialistsQuang M. Doan, MBAE rica R. ShaverInformation Technology SpecialistsEditorial BoardWilliam L. Roper, MD, MPH, Chapel Hill, NC, ChairmanVirginia A. Caine, MD, Indianapolis, INDavid W.

3 Fleming, MD, Seattle, WAWilliam E. Halperin, MD, DrPH, MPH, Newark, NJMargaret A. Hamburg, MD, Washington, DCKing K. Holmes, MD, PhD, Seattle, WADeborah Holtzman, PhD, Atlanta, GAJohn K. Iglehart, Bethesda, MDDennis G. Maki, MD, Madison, WISue Mallonee, MPH, Oklahoma City, OKStanley A. Plotkin, MD, Doylestown, PAPatricia Quinlisk, MD, MPH, Des Moines, IAPatrick L. Remington, MD, MPH, Madison, WIBarbara K. Rimer, DrPH, Chapel Hill, NCJohn V. Rullan, MD, MPH, San Juan, PRAnne Schuchat, MD, Atlanta, GADixie E. Snider, MD, MPH, Atlanta, GAJohn W. Ward, MD, Atlanta, GAThe MMWR series of publications is published by the CoordinatingCenter for Health Information and Service, Centers for DiseaseControl and prevention (CDC), Department of Health andHuman Services, Atlanta, GA Citation: Centers for Disease Control and prevention .

4 [Title]. MMWR 2006;55(No. RR-#):[inclusive page numbers].CONTENTSI ntroduction .. 1 Clinical prevention Guidance .. 2 STD/HIV prevention 3 prevention 3 Partner 5 Reporting and 6 Special 6 Pregnant 6 Adolescents .. 8 Children .. 9 MSM .. 9 Women Who Have Sex with Women (WSW) .. 10 HIV Infection: Detection, Counseling, and 10 Diseases Characterized by Genital 14 Management of Patients Who Have Genital Ulcers .. 14 Chancroid .. 15 Genital HSV Infections .. 16 Granuloma Inguinale (Donovanosis) .. 20 Lymphogranuloma 21 Syphilis .. 22 Congenital 30 Evaluation and Treatment of Infants During the First Month of Life 30 Evaluation and Treatment of Older Infants and Children .. 32 Management of Patients Who Have a History of Penicillin Allergy.

5 33 Diseases Characterized by Urethritis and 35 Management of Male Patients Who Have Urethritis .. 35 Management of Patients Who Have 37 Chlamydial Infections .. 38 Gonococcal 42 Diseases Characterized by Vaginal Discharge .. 49 Bacterial Vaginosis .. 50 Trichomoniasis .. 52 Vulvovaginal Candidiasis .. 54 Pelvic Inflammatory Disease .. 56 Epididymitis .. 61 HPV Infection .. 62 Genital Warts .. 62 Cervical Cancer Screening for Women Who AttendSTD Clinics or Have a History of STDs .. 67 Vaccine Preventable STDs .. 69 Hepatitis A .. 69 Hepatitis B .. 71 Hepatitis C .. 76 Proctitis, Proctocolitis, and 78 Ectoparasitic 79 Pediculosis Pubis .. 79 Sexual Assault and STDs .. 80 Adults and 80 Evaluation for Sexually Transmitted 81 Sexual Assault or Abuse of Children.

6 83 References .. 86 Terms and Abbreviations Used in This 93 This report has been corrected and does not correspond tothe electronic PDF version that was published on August 4,2006. An erratum was published in the MMWR Weekly issuedated September 15, 2006, Vol. 55, No. 55 / RR-11 Recommendations and Reports1 The material in this report originated in National Center for HIV/AIDS, viral Hepatitis, STD, and TB prevention (proposed), Kevin , MD, PhD, Director; and the Division of STD prevention ,John M. Douglas, MD, preparer: Kimberly A. Workowski, MD, Division ofSTD prevention , National Center for HIV/AIDS, viral Hepatitis, STD,and TB prevention , 10 Corporate Square, Corporate Square Blvd., MSE-02, Atlanta, GA 30333. Telephone: 404-639-1898; Fax: 404-639-8610; E-mail: Transmitted Diseases Treatment Guidelines, 2006 Prepared byKimberly A.

7 Workowski, MDStuart M. Berman, MD Division of STD PreventionNational Center for HIV/AIDS, viral Hepatitis, STD, and TB prevention (proposed)SummaryThese guidelines for the Treatment of persons who have Sexually Transmitted Diseases (STDs) were developed by CDC afterconsultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta, Georgia, during April 19 21,2005. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2002 (MMWR2002;51[No. RR-6]). Included in these updated guidelines are an expanded diagnostic evaluation for cervicitis and trichomo-niasis; new antimicrobial recommendations for trichomoniasis; additional data on the clinical efficacy of azithromycin forchlamydial infections in pregnancy; discussion of the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitisand Treatment -related implications; emergence of lymphogranuloma venereum proctocolitis among men who have sex with men(MSM); expanded discussion of the criteria for spinal fluid examination to evaluate for neurosyphilis; the emergence of azithromycin-resistant Treponema pallidum; increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM.

8 Revised discussionconcerning the sexual transmission of hepatitis C; postexposure prophylaxis after sexual assault; and an expanded discussion ofSTD prevention and other health-care providers play a criticalrole in preventing and treating Sexually Transmitted Diseases (STDs). These guidelines for the Treatment of STDs are in-tended to assist with that effort. Although these guidelinesemphasize Treatment , prevention strategies and diagnostic rec-ommendations also are report was produced through a multistage in 2004, CDC personnel and professionals knowl-edgeable in the field of STDs systematically reviewed evidence,including published abstracts and peer-reviewed journal ar-ticles concerning each of the major STDs, focusing on infor-mation that had become available since publication of theSexually Transmitted Diseases Treatment Guidelines, 2002 (1).

9 Background papers were written and tables of evidence wereconstructed summarizing the type of study ( , randomizedcontrolled trial or case series), study population and setting,treatments or other interventions, outcome measures assessed,reported findings, and weaknesses and biases in study designand analysis. A draft document was developed on the basis ofthe April 2005, CDC staff members and invited consultantsassembled in Atlanta, Georgia, for a 3-day meeting to presentthe key questions regarding STD Treatment that emerged fromthe evidence-based reviews and the information available toanswer those questions. When relevant, the questions focusedon four principal outcomes of STD therapy for each indi-vidual disease: 1) microbiologic cure, 2) alleviation of signsand symptoms, 3) prevention of sequelae, and 4) preventionof transmission.

10 Cost-effectiveness and other advantages ( ,single-dose formulations and directly observed therapy of spe-cific regimens) also were discussed. The consultants then as-sessed whether the questions identified were relevant, rankedthem in order of priority, and attempted to arrive at answersusing the available evidence. In addition, the consultants evalu-ated the quality of evidence supporting the answers on thebasis of the number, type, and quality of the several areas, the process diverged from that previouslydescribed. The sections on hepatitis B virus (HBV) and hepa-titis A virus (HAV) infections are based on previously or re-cently approved recommendations (2 4) of the AdvisoryCommittee on Immunization Practices. The recommenda-tions for STD screening during pregnancy were developedafter CDC staff reviewed the recommendations from otherknowledgeable 4, 2006 Throughout this report, the evidence used as the basis forspecific recommendations is discussed briefly.