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Sexually Transmitted Diseases Treatment Guidelines

Sexually Transmitted Diseases Treatment Guidelines

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Morbidity and Mortality Weekly Report
Recommendations and ReportsMay 10, 2002 / Vol. 51 / No. RR-6
Centers for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and Prevention
SAFER  HEALSAFER • HEALSAFER • HEALSAFER • HEALSAFER • HEALTHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETHIER • PEOPLE
TM
Sexually Transmitted DiseasesTreatment Guidelines2002
 
MMWR
SUGGESTED CITATION
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002.MMWR 2002;51(No. RR-6):[inclusive pagenumbers].The
 MMWR 
series of publications is published by theEpidemiology Program Office, Centers for DiseaseControl and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.
Centers for Disease Control and Prevention
David W. Fleming, M.D.
 Acting Director 
 Julie L. Gerberding, M.D.
 Acting Deputy Director for Science and Public Health
Dixie E. Snider, Jr., M.D., M.P.H.
 Associate Director for Science 
Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc.
Director 
Office of Scientific and Health Communications
 John W. Ward, M.D.
Director Editor,
MMWR 
Series 
Suzanne M. Hewitt, M.P.A.
 Managing Editor 
Rachel J. Wilson
Project Editor 
Malbea A. HeilmanBeverly J. Holland
Visual Information Specialists 
Michele D. Renshaw Erica R. Shaver
Information Technology Specialists 
CONTENTS
Introduction.....................................................................................................1Clinical Prevention Guidelines..........................................................................2Prevention Messages ....................................................................................2Prevention Methods......................................................................................3STD/HIV Prevention Counseling....................................................................4Partner Notification ......................................................................................4Reporting and Confidentiality .......................................................................4Special Populations..........................................................................................5Pregnant Women.........................................................................................5 Adolescents..................................................................................................6Children.......................................................................................................7Men Who Have Sex with Men.......................................................................7HIV Infection: Detection, Counseling, and Referral ...........................................7Detection of HIV Infection: Diagnostic Testing ...............................................8Counseling for Patients with HIV Infection and Referral to Support Services ...9Management of Sex Partners and Injection-Drug Partners ...........................10Special Considerations ...............................................................................10Diseases Characterized by Genital Ulcers.......................................................11Management of Patients Who Have Genital Ulcers.....................................11Chancroid ..................................................................................................11Genital Herpes Simplex Virus Infections ......................................................12Granuloma Inguinale (Donovanosis) ..........................................................17Lymphogranuloma Venereum .....................................................................18Syphilis ......................................................................................................18Congenital Syphilis ........................................................................................26Evaluation and Treatment of Infants in the First Month of Life.....................26Evaluation and Treatment of Older Infants and Children.............................28Follow-Up..................................................................................................28Special Considerations...............................................................................28Management of Patients Who Have a History of Penicillin Allergy ...................28Recommendations ......................................................................................29Penicillin Allergy Skin Testing......................................................................29Diseases Characterized by Urethritis and Cervicitis .........................................30Management of Male Patients Who Have Urethritis ....................................30Etiology......................................................................................................30Confirmed Urethritis...................................................................................30Management of Patients Who Have Nongonococcal Urethritis....................31Management of Patients Who Have Mucopurulent Cervicitis (MPC).............32Chlamydial Infections.................................................................................32Gonococcal Infections................................................................................36Diseases Characterized by Vaginal Discharge.................................................42Management of Patients Who Have Vaginal Infections................................42Bacterial Vaginosis.....................................................................................42Trichomoniasis ...........................................................................................44 Vulvovaginal Candidiasis............................................................................45Pelvic Inflammatory Disease...........................................................................48Diagnostic Considerations ..........................................................................48Treatment..................................................................................................49Follow-Up ..................................................................................................51Management of Sex Partners......................................................................51Prevention..................................................................................................51Special Considerations ...............................................................................51Epididymitis ...................................................................................................52Diagnostic Considerations ..........................................................................52Treatment..................................................................................................52Follow-Up ..................................................................................................53Management of Sex Partners......................................................................53Special Considerations ...............................................................................53Human Papillomavirus Infection.....................................................................53Genital Warts .............................................................................................53Subclinical Genital HPV Infection (Without Exophytic Warts) ........................57Cervical Cancer Screening for Women Who Attend STD Clinicsor Have a History of STDs ............................................................................57Recommendations ......................................................................................58Special Considerations ...............................................................................59 Vaccine Preventable STDs..............................................................................59Hepatitis A .................................................................................................59Hepatitis B .................................................................................................61Hepatitis C ....................................................................................................64Sexual Activity ............................................................................................65Diagnosis and Treatment............................................................................65Prevention..................................................................................................65Postexposure Follow-Up .............................................................................66Proctitis, Proctocolitis, and Enteritis.................................................................66Treatment ..................................................................................................67Follow-Up ..................................................................................................67Management of Sex Partners......................................................................67Ectoparasitic Infections...................................................................................67Pediculosis Pubis........................................................................................67Scabies ......................................................................................................68Sexual Assault and STDs................................................................................69 Adults and Adolescents ..............................................................................69Evaluation for Sexually Transmitted Infections .............................................69Sexual Assault or Abuse of Children ...........................................................71References.....................................................................................................74 Abbreviations Used in This Publication...........................................................77
 
Vol. 51 / RR-6Recommendations and Reports1
Introduction
Physicians and other health-care providers play a critical rolein preventing and treating sexually transmitted diseases (STDs).These recommendations for the treatment of STDs areintended to assist with that effort. Although these guidelinesemphasize treatment, prevention strategies and diagnosticrecommendations also are discussed.This report was produced through a multi-stage process.Beginning in 2000, CDC personnel and professionals knowl-edgeable in the field of STDs systematically reviewed litera-ture (i.e., published abstracts and peer-reviewed journal articles)concerning each of the major STDs, focusing on informationthat had become available since publication of the
1998 Guide-lines for Treatment of Sexually Transmitted Diseases 
(
1
). Back-ground papers were written and tables of evidence constructedsummarizing the type of study (e.g., randomized controlledtrial or case series), study population and setting, treatmentsor other interventions, outcome measures assessed, reportedfindings, and weaknesses and biases in study design and analy-sis. A draft document was developed on the basis of the reviews.In September 2000, CDC staff members and invited con-sultants assembled in Atlanta for a 3-day meeting to presentthe key questions regarding STD treatment that emerged fromthe literature reviews and the information available to answerthose questions. When relevant, the questions focused on fourprincipal outcomes of STD therapy for each individual dis-ease: a) microbiologic cure, b) alleviation of signs and symp-toms, c) prevention of sequelae, and d) 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 thenassessed 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 the basisof the number, type, and quality of the studies.In several areas, the process diverged from that previously described. The sections concerning adolescents and hepatitis A, B, and C infections were developed by other CDC staff members knowledgeable in this field. The recommendationsfor STD screening during pregnancy were developed afterCDC staff reviewed the published recommendations fromother knowledgeable groups. The sections concerning early human immunodeficiency virus (HIV) infection are a com-pilation of recommendations developed by CDC staff mem-bers knowledgeable in the field of HIV infection. The sectionson hepatitis B virus (HBV) (
 2 
) and hepatitis A virus (HAV)(
 3
) infections are based on previously published recommenda-tions of the Advisory Committee on Immunization Practices(ACIP).
Sexually Transmitted DiseasesTreatment Guidelines2002
Prepared by Kimberly A. Workowski, M.D. William C. Levine, M.D., M.Sc.
 Summary 
These guidelines for the treatment of patients who have sexually transmitted diseases (STDs) were developed by the Centers for Disease Control and Prevention (CDC) after consultation with a group of professionals knowledgeable in the field of STDs whomet in Atlanta on September 26–28, 2000. The information in this report updates the 
1998 Guidelines for Treatment of Sexually Transmitted Diseases
MMWR 
1998;47[No. RR-1]). Included in these updated guidelines are new alternative regi-mens for scabies, bacterial vaginosis, early syphilis, and granuloma inguinale; an expanded section on the diagnosis of genital herpes (including type-specific serologic tests); new recommendations for treatment of recurrent genital herpes among persons infected with human immunodeficiency virus (HIV); a revised approach to the management of victims of sexual assault; expanded regimens for the treatment of urethral meatal warts; and inclusion of hepatitis C as a sexually transmitted infection. In addition,these guidelines emphasize education and counseling for persons infected with human papillomavirus, clarify the diagnostic evaluation of congenital syphilis, and present information regarding the emergence of quinolone-resistant 
Neisseria gonorrhoeae
and implications for treatment. Recommendations also are provided for vaccine-preventable STDs, including hepatitis A and hepatitis B.
The material in this report was prepared for publication by the National Center for HIV,STD, and TB Prevention, Harold W. Jaffe, M.D., Acting Director; and the Division of Sexually Transmitted Diseases Prevention, Harold W. Jaffe, M.D., Acting Director.

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