California Family Health Council, Inc.

Sexually transmitted infections (STIs) have been in the news recently as new epidemiologic trends emerge:

• Certain strains of gonorrhea are showing resistance to traditional antibiotics.
• Syphilis rates are increasing and disproportionately affect African Americans and men who have sex with men.
• At least one in four teens have an STI.

CFHC has collaborated with staff at the California STD Branch at the California Department of Public Health to highlight important strategies for preventing and treating STIs as recommended by the CDC in their STD Treatment Guidelines. Recommendations for HPV vaccination and changes in the management of abnormal Pap tests are also noted. Providers are invited to download the 2-page California STD Treatment Summary Table (PDF) and refer to the California STD Clinical Guidelines for further information on the latest recommendations for screening, testing, treatment, and partner management for STIs in California.

STI Screening Recommendations

The chart below shows the recommended screening tests for particular populations and how often they should be tested.

POPULATION	RECOMMENDED SCREENING	NOTES
Women 25 years of age or younger	Chlamydia (at least) annually (CT) Gonorrhea annually (GC) Pap testing 3 years after sexual debut Other STIs (herpes simplex virus (HSV) type 2, syphilis, HIV) according to individual risk	CT/GC screening strongly recommended at all visits related to initial or annual exams, pregnancy testing, emergency contraception, and other visits when risk assessment indicates need for additional screening; pelvic exam not necessary with new test technologies
Women over 25 years of age	Selective CT/GC screening only Other STI screening according to individual risk Pap testing	At-risk individuals (CT/GC) include women with more than one sex partner in past 12 months, a new sex partner in past 3 months, an STI in past 12 months, women who suspect that a recent sex partner had concurrent partners in past 12 months, and African American women up to age 30 years
Pregnant Women	CT Hepatitis B Surface Antigen HIV Syphilis Pap testing Other STI according to risk: GC, hepatitis C, bacterial vaginosis (BV), HSV	Hepatitis C risks include injection drug use, blood transfusion or organ transplant before 1992 BV screening if history of preterm delivery
Women who have sex with women (WSW)	STI screening according to individual risk Pap testing	At risk individuals include WSW who also have sex with men
Men who have sex with women (MSW)	STI screening in high prevalence settings	High prevalence settings include STD clinics, corrections, possibly family planning clinics
Men who have sex with men (MSM)	Annual screening: CT/GC urethra GC pharynx (receptive oral sex) CT/GC rectum (receptive anal sex) HIV Syphilis Screening every 3-6 months according to risk	High risk includes multiple or anonymous partners, methamphetamine use, sex in conjunction with illicit drugs, partner engages in any of above

Chlamydia

In 2006, chlamydia was the most commonly reported communicable disease in California with over 130,000 cases. The highest rates of disease are among women 15-24 years of age, emphasizing the need for screening young women. Chlamydia prevalence in females attending family planning clinics remains high at over 6 percent.

Treatment regimens for chlamydia remain unchanged, with the exception of azithromycin 1g orally in a single dose as a new recommended regimen for pregnant women. Providers should retest all clients 3 months after treatment or at the next medical visit within 3 to 12 months after initial infection. Test-of-cure at 3 weeks after treatment is not recommended except in pregnant women. Partner management is critical and may include patient-delivered partner therapy.

Read the Patient-Delivered Partner Therapy for Chlamydia trachomatis and Neisseria gonorrhoeae: Guidance for Medical Providers in California (PDF).

Gonorrhea

Similar to chlamydia, the highest rates of gonorrhea are among women 15-24 years of age. In family planning settings, over 30% of clients with gonorrhea were co-infected with chlamydia, highlighting the need for continued co-treatment. Significant racial disparities exist as African Americans demonstrate gonorrhea rates over 11 times higher than among non-Latino Whites.

Fluoroquinolone-resistant Neisseria gonorrhoeae continues to rise; the current prevalence is over 30 percent at sentinel STD clinics in California . Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) for treatment of gonorrhea infections have not been recommended in California since 2002. As of April 2007, fluoroquinolones are no longer recommended by CDC for gonorrhea infections. Ceftriaxone and cefixime remain the antibiotics of choice for uncomplicated gonococcal infections (see California Gonorrhea Treatment Guidelines). Clinicians should retest all clients 3 months after treatment or at the next medical visit within 3 to 12 months after initial infection. As of 2007, partner management may include expedited partner therapy.

Read the California GC Treatment Guidelines (PDF)

Partner Management

Treatment of partners of clients with STIs reduces the risk of re-infection and may disrupt further STI transmission. At the time clients are informed of their STI test result, clinic staff should suggest they bring their partner to the clinic when they return for treatment. This strategy has been shown to be very effective. If partners are unable or unlikely to seek clinical care, the CDC endorses expedited partner therapy (EPT), which includes patient-delivered partner therapy. The California Guidelines for EPT for gonorrhea and/or chlamydia include appropriate patient selection, medications, and follow-up. Medications or prescriptions for EPT should be accompanied by treatment instructions, appropriate warnings, and advice for partners to seek medical evaluation.

Read the Patient-Delivered Partner Therapy for Chlamydia trachomatis and Neisseria gonorrhoeae: Guidance for Medical Providers in California (PDF).

Cervicitis

Clients with diagnostic signs indicative of cervicitis -- mucopurulent endocervical exudate or cervical friability (bleeding easily induced by passage of swab through the os) should be tested for gonorrhea and chlamydia. Presumptive antibiotic therapy for chlamydia should be provided. Concurrent gonorrhea treatment should be provided if local prevalence is high (>5%) or the patient is at high-risk. They should also be evaluated and treated for trichomonas and bacterial vaginosis if present. Treatment of other women should be based on individualized risk assessment and likelihood of follow-up.

Pelvic Inflammatory Disease(PID)

Empiric therapy for PID should be given if one or more of the following signs are present on pelvic examination: uterine tenderness, adnexal tenderness or cervical motion tenderness. Testing for gonorrhea and chlamydia is recommended in all cases. Although CDC does not recommend use of fluoroquinolones for PID, California guidelines allow for judicious use of fluoroquinolones as an alternative therapy given that risk of gonorrhea-related PID is generally low. Any client with documented gonococcal PID who received treatment with fluoroquinolones should immediately be re-treated with a cephalosporin-containing regimen and undergo a test-of-cure (bacterial culture) at the time of re-treatment.

Read the California GC Treatment Guidelines (PDF)

Human Papillomavirus

The quadrivalent human papillomavirus vaccine (HPV types 6, 11, 16, 18) is now licensed for females aged 9-26 for primary prevention of genital warts and cervical cancer. Ideally, females should get the vaccine before they are sexually active, because the vaccine is most effective in girls/women who have not yet acquired any of the four HPV types covered by the vaccine. The HPV vaccine is recommended for 11-12 year-old girls, and can be given to girls as young as 9. The vaccine is also recommended for 13-26 year-old girls and women who have not yet received or completed the vaccine series.

Visit the CDC HPV and HPV Vaccine - Information for Healthcare Providers

There have been no changes in the treatment or management of genital warts. However, there have been significant changes in the management of adolescents and young women (age 20 years or younger) with abnormal cervical cancer screening tests, favoring more conservative management strategies. Algorithms are available from the American Society for Colposcopy and Cervical Pathology.

VIsit the America Society for Colposcopy & Cervical Pathology (PDF)

Genital Herpes

Although screening in the general population is not recommended, serologic testing for HSV-2 may be useful in clients with: 1) recurrent or atypical symptoms and negative HSV culture results; 2) a clinical diagnosis of genital herpes without lab confirmation; 3) a partner with genital herpes; 4) HIV.

Read the CA STD/HIV Prevention Training Center's Summary Guidelines for the Use of Herpes Simplex Virus (HSV) Type 2
Serologies (PDF)

In clients with established HSV-2 infection and multiple recurrent episodes of herpes, suppressive therapy effectively reduces frequency of recurrences, improves quality of life, and decreases the risk of genital HSV-2 transmission to susceptible partners. New regimens for episodic therapy of recurrent episodes include: acyclovir 800 mg orally three times daily for two days, or famciclovir 1000 mg orally twice daily for one day. Recommended regimens for HIV-infected persons differ slightly and are detailed in the California STD Treatment Summary Table.

Read the 2007 California STD Treatment Guidelines Table for Adults & Adolescents (PDF)

Vaginitis

Bacterial Vaginosis (BV)

Single-dose metronidazole (2g orally once) is no longer recommended as an alternative regimen for treatment of BV because of its poor efficacy. Metronidazole 500 mg orally twice daily for seven days has been added as a recommended regimen for pregnant women. Clindamycin cream is not recommended for pregnant women after 20 weeks gestation, due to several studies that have demonstrated an increase in adverse pregnancy outcomes when utilized in the second half of pregnancy. Recurrent BV is common, and maintenance therapy for these women is currently being studied. One study has demonstrated that metronidazole gel 0.75% twice weekly for six months (following standard therapy) effectively prevents recurrences during the treatment timeframe.

Trichomoniasis

Tinidazole 2g orally in a single dose has been added to the recommended regimens for the treatment of clients with trichomoniasis and their sex partners. If initial treatment fails, repeat treatment with either metronidazole 500 mg orally twice daily for seven days, or tinidazole 2g orally once, is recommended. In cases of repeated treatment failure, metronidazole 2g orally for five days, or tinidazole 2g orally for five days, is recommended. If resistant trichomonas is suspected, providers should seek consultation and susceptibility testing from CDC (Phone: 770-488-4115).

Vulvovaginal candidiasis (VVC)

Single-dose miconazole 1200 mg vaginal suppositories have been added to the recommended regimens for treatment of V.V.C. Recurrent V.V.C can be treated with a longer duration of initial therapy, such as 7 to 14 days of topical therapy, or fluconazole 100 to 200 mg orally every 72 hours, for three doses (days 1, 4, 7). Maintenance with topical or oral treatment should continue for six months.

Syphilis

There have been recent increases in syphilis in the United States, primarily among men who have sex with men. Long-acting preparations of penicillin remain the treatment of choice for all stages of syphilis. The use of azithromycin as an alternative treatment is not recommended in California because of high rates of resistance. Syphilis and other genital ulcer diseases increase the risk of HIV acquisition and transmission, and HIV co-infection in clients with syphilis is common. Any client (male or female) diagnosed with syphilis should be tested for HIV.

Questions or concerns regarding these guidelines should be addressed to the STD Control Branch or to your local STD Controller.

California Department of Public Health
STD Control Branch
850 Marina Bay Parkway, Bldg P, 2nd Floor
Phone: 510-620-3400

California STD/HIV Prevention Training Center
300 Frank H. Ogawa Plaza, Suite 520
Oakland, CA 94612-2037
Phone: 510-625-6000
Email: captc@cdph.ca.gov

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