Are You Familiar with the Treatment Changes for Sexually Transmitted Infections?

The Centers for Disease Control and Prevention revised its recommendations for the treatment of sexually transmitted infections (STIs) late last year. At a seminar at the 2011 American College of Obstetri - cians and Gynecologists meeting, Linda O. Eckert, MD, Associate Professor, Department of Obstetrics and Gynecology, University of Wash - ington, Seattle, discussed what clinicians most need to know about the current guidelines. Key revisions to the guidelines include:

• Change in dosage for gonorrhea.
• Change in outpatient regimen for pelvic inflammatory disease (PID)
• Change in testing recommendations for cervicitis.
• More discussion of rapid test use.
• Emphasis on screening pregnant women for STIs
• Less importance on screening for asymptomatic bacterial vaginitis (BV).

Chlamydia

Dr Eckert emphasized the need to routinely screen for Chlamydia trachomatis, because 80% of chlamydial infection is asymptomatic, no pelvic examination is required, the nucleic acid diagnostic tests are highly sensitive and specific, and uncomplicated infection is easily treated with 1 dose of azithromycin 1 g. “If you screen all your patients, you will prevent PID,” she noted.

Screening is recommended for women with cervicitis, for sexually active females aged ≤25 years, and for women aged ≥25 years with inconsistent use of barrier contraception, at least 1 sexual partner, or a new partner in the past 3 months.

“Women should also be offered a treatment pack to take home to their partner. Not all states allow this, but it prevents reinfection,” she added.

Gonorrhea

In the 2010 guidelines, fluoroquinolones are no longer recommended for the treatment of gonococcal infections. The recommended treatment is 1 dose of oral cefixime 400 mg or, preferably, one 250-mg intramuscular (IM) injection of ceftriaxone (a better treatment for pharyngeal gonorrhea), plus 1 dose of oral azithromycin 1 g or oral doxycycline 100 mg twice daily for 7 days.

“When specific test results are not available, if the patient has gonorrhea, you empirically treat for chlamydia as well,” she noted. “If the patient has chlamydia, you should treat for gonorrhea as well if the local prevalence rate is 5% or higher.”

Cervicitis

Cervicitis remains a clinical diagnosis. Women who test negative for gonorrhea and chlamydia should be evaluated for BV and Trichomonas vaginalis. If the wet mount is negative, patients should be further tested with culture or another US Food and Drug Ad - min istration (FDA)-cleared method, “because studies have associated these 2 conditions with cervicitis,” she said.

Mycoplasma genitalium can also cause cervical inflammation and should be considered as an etiologic agent, although there is no FDA-approved test. Therapy is with doxycycline or azithromycin.

Pelvic Inflammatory Disease

In earlier guidelines, levofloxacin was a single-agent treatment for PID, but this has changed. Levofloxacin or ofloxacin is used only in cases of non–gonococcal- associated PID.

Outpatient treatment is now with a single IM dose of 250-mg ceftriaxone, cefoxitin 2 g IM plus oral probenecid 1 g, or another third-generation cepha - losporin. These are given with oral doxycycline 100 mg twice daily for 14 days, with or without metronidazole 500 mg twice daily for 14 days.

“What is a good change is that ceftriaxone 250 mg IM is now used for both cervicitis and PID. You just have to remember this 1 dose,” Dr Eckert said.

Hospitalization is necessary under a variety of circumstances, but the hospitalization of nulliparous women is no longer recommended, because it has not been shown to enhance pregnancy and pain outcomes.

Vaginitis Testing and Treatment

Diagnosing vaginitis is still challenging. “Microscopy remains important, but there is no place for bacterial cultures,” Dr Eckert stressed. “They do not give relative quantitative amounts, and all women have many types of bacteria. It’s like opening Pandora’s box to use cultures to diagnose bacterial vaginitis.”

Diagnostic tests discussed in the 2010 updates include the Affirm VPIII DNA probe for high concentrations of Gardnerella vaginalis, proline-iminopeptidase (Pip) test card (rarely used), and Gram stain (a research tool).

“Don’t spend a lot of money on molecular diagnostics for specific vaginal bacteria,” she emphasized. The presence of clinical criteria is more important.

Collection of vaginal pH (best done on the vaginal side wall) is underutilized, she added, although it is a “cheap, immediate, and useful triage tool.” A pH of 4.0 essentially rules out vaginitis and points to yeast.

No major changes were made in the treatment of acute and recurrent vaginitis, she said

Trichomoniasis

Molecular testing, including the use of newer rapid tests, is useful only in the diagnosis of trichomoniasis. FDA cleared tests for trichomoniasis include the OSOM Trichomonas Rapid Test (10 minutes) and the Affirm VPIII, a nucleic acid probe test that evaluates for T vaginalis, G vaginalis, and Candida albicans (45 minutes). Each of these tests, which are performed on vaginal secretions, have a sensitivity of >83% and a specificity of >97%.

Treatment of trichomoniasis is with oral metronidazole or tinidazole 2 g as a single dose or with oral metronidazole 500 mg twice daily for 7 days as an alternative.

Yeast Infections

Treatment of vulvovaginal candidiasis is based on whether it is uncomplicated uncomplicated (ie, mild-to-moderate symptoms, sporadic, C albicans) or complicated (ie, severe symptoms, recurrent [≥4 episodes/year], non–C albicans, abnormal host immunology). The recommended treatment for uncomplicated infection is oral fluconazole 150 mg as a single dose; any 3- to 7-day intravaginal imidazole; a single dose of intravaginal butoconazole, miconazole, or tiocon - azole sustained-release cream; or nystatin 100,000-U vaginal tablet daily for 14 days.

Treatment failure is predicted by a history of recurrent severe infection and symptoms. Severe cases should be treated initially with 7 to 14 days of topical azole, or oral fluconazole, 150 to 200 mg in 2 doses, 72 hours apart.

Recurrent Bacterial Vaginitis and Yeast Infections

“The management of recurrent BV and yeast infections follows the same strategy,” Dr Eckert said. “You control for risk factors, if possible, and treat for a prolonged period initially. Suppressive therapy can be given for 4 to 6 months. Treatment of the partner is usually not helpful.” Unfortunately, there is no way to clinically alter the vaginal lactobacilli or pH level clinically, and symptom recurrence is not unusual. Cultures can be taken for recurrent yeast infections to look for sensitivities to treatment. Several regimens that may reduce the recurrence of yeast infections include:

• Induction therapy: vaginal imidazole daily for 14 days or fluconazole 100 to 200 mg on days 1, 4, and 7
• Maintenance therapy: oral fluconazole 100 to 200 mg weekly for 6 months or clotrimazole 500 mg intravaginally weekly or 200 mg twice weekly.
• Symptom relief: low-potency topical steroids, nystatin cream, and sitz baths.

Non–C albicans infections that are refractory to azoles may respond to topical boric acid (intravaginal capsules), nystatin, or flucytosine. Recurrence may be controlled by alternate-day, then twice-weekly, boric acid.

For recurrent BV, longer therapy with antibiotics may be helpful, and the addition of boric acid to suppressive metronidazole treatment has been shown to be helpful.