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CDC Guidelines for Treatemnt STD

CDC Guidelines for Treatemnt STD

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Morbidity and Mortality Weekly Report
Recommendations and ReportsAugust 4, 2006 / Vol. 55 / No. RR-11
depardepardepardepardepartment of health and human sertment of health and human sertment of health and human sertment of health and human sertment of health and human servicesvicesvicesvicesvices
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
Sexually Transmitted DiseasesTreatment Guidelines, 2006
 
MMWR
Centers for Disease Control and Prevention
 Julie L. Gerberding, MD, MPH
Director 
Tanja Popovic, MD, PhD(
 Acting 
)
Chief Science Officer 
 James W. Stephens, PhD(
 Acting 
)
Associate Director for Science 
Steven L. Solomon, MD
Director, Coordinating Center for Health Information and Service 
 Jay M. Bernhardt, PhD, MPH
Director, National Center for Health Marketing 
 Judith R. Aguilar(
 Acting 
)
Director, Division of Health Information Dissemination
(
Proposed 
)
Editorial and Production Staff
Mary Lou Lindegren, MD
Editor,
MMWR 
Series 
Frederic E. Shaw, MD, JD
Guest Editor,
MMWR 
Series 
Suzanne M. Hewitt, MPA 
 Managing Editor,
MMWR 
Series 
Teresa F. Rutledge
Lead Technical Writer-Editor 
Patricia A. McGee
Project Editor 
Beverly J. Holland
Lead Visual Information Specialist 
Lynda G. CupellMalbea A. LaPete
Visual Information Specialists 
Quang M. Doan, MBA Erica R. Shaver
Information Technology Specialists 
Editorial Board
 William L. Roper, MD, MPH, Chapel Hill, NC, ChairmanVirginia A. Caine, MD, Indianapolis, INDavid W. Fleming, MD, Seattle, WA  William E. Halperin, MD, DrPH, MPH, Newark, NJMargaret A. Hamburg, MD, Washington, DCKing K. Holmes, MD, PhD, Seattle, WA Deborah Holtzman, PhD, Atlanta, GA  John K. Iglehart, Bethesda, MDDennis G. Maki, MD, Madison, WISue Mallonee, MPH, Oklahoma City, OK Stanley A. Plotkin, MD, Doylestown, PA Patricia Quinlisk, MD, MPH, Des Moines, IA Patrick L. Remington, MD, MPH, Madison, WIBarbara K. Rimer, DrPH, Chapel Hill, NC John V. Rullan, MD, MPH, San Juan, PR  Anne Schuchat, MD, Atlanta, GA Dixie E. Snider, MD, MPH, Atlanta, GA  John W. Ward, MD, Atlanta, GA The
 MMWR 
series of publications is published by the CoordinatingCenter for Health Information and Service, Centers for DiseaseControl and Prevention (CDC), U.S. Department of Health andHuman Services, Atlanta, GA 30333.
Suggested Citation:
Centers for Disease Control and Prevention.[Title]. MMWR 2006;55(No. RR-#):[inclusive page numbers].
CONTENTS
Introduction ..................................................................................... 1Methods .......................................................................................... 1Clinical Prevention Guidance............................................................ 2STD/HIV Prevention Counseling..................................................... 3Prevention Methods ...................................................................... 3Partner Management .................................................................... 5Reporting and Confidentiality ........................................................ 6Special Populations .......................................................................... 6Pregnant Women .......................................................................... 6 Adolescents .................................................................................. 8Children ....................................................................................... 9MSM ............................................................................................ 9 Women Who Have Sex with Women (WSW) ................................. 10HIV Infection: Detection, Counseling, and Referral .......................... 10Diseases Characterized by Genital Ulcers ....................................... 14Management of Patients Who Have Genital Ulcers....................... 14Chancroid................................................................................... 15Genital HSV Infections................................................................. 16Granuloma Inguinale (Donovanosis) ........................................... 20Lymphogranuloma Venereum...................................................... 21Syphilis....................................................................................... 22Congenital Syphilis ........................................................................ 30Evaluation and Treatment of Infants During the First Month of Life 30Evaluation and Treatment of Older Infants and Children .............. 32Management of Patients Who Have a History of Penicillin Allergy .... 33Diseases Characterized by Urethritis and Cervicitis.......................... 35Management of Male Patients Who Have Urethritis...................... 35Management of Patients Who Have Cervicitis............................... 37Chlamydial Infections.................................................................. 38Gonococcal Infections ................................................................. 42Diseases Characterized by Vaginal Discharge ................................. 49Bacterial Vaginosis ...................................................................... 50Trichomoniasis ............................................................................ 52 Vulvovaginal Candidiasis............................................................. 54Pelvic Inflammatory Disease ........................................................... 56Epididymitis ................................................................................... 61HPV Infection ................................................................................. 62Genital Warts................................................................................. 62Cervical Cancer Screening for Women Who AttendSTD Clinics or Have a History of STDs.......................................... 67 Vaccine Preventable STDs ............................................................... 69Hepatitis A..................................................................................... 69Hepatitis B ..................................................................................... 71Hepatitis C .................................................................................... 76Proctitis, Proctocolitis, and Enteritis.................................................. 78Ectoparasitic Infections ................................................................... 79Pediculosis Pubis ......................................................................... 79Scabies....................................................................................... 79Sexual Assault and STDs ................................................................ 80 Adults and Adolescents ............................................................... 80Evaluation for Sexually Transmitted Infections............................... 81Sexual Assault or Abuse of Children ............................................ 83References ..................................................................................... 86Terms and Abbreviations Used in This Report .................................. 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. 36.
 
Vol. 55 / RR-11Recommendations and Reports1
The material in this report originated in National Center for HIV/ AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), Kevin A.Fenton, MD, PhD, Director; and the Division of STD Prevention, John M.
 
Douglas, MD, Director.
Corresponding preparer:
Kimberly A. Workowski, MD, Division of STD 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: kgw2@cdc.gov.
Sexually Transmitted Diseases Treatment Guidelines, 2006
Prepared by Kimberly A. Workowski, MDStuart M. Berman, MD
Division of STD PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed)
 Summary 
These guidelines for the treatment of persons who have sexually transmitted diseases (STDs) were developed by CDC after consultation 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
(MMWR  2002;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 for chlamydial infections in pregnancy; discussion of the role of  
Mycoplasma genitalium
and trichomoniasis in urethritis/cervicitis and 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; revised discussionconcerning the sexual transmission of hepatitis C; postexposure prophylaxis after sexual assault; and an expanded discussion of  STD prevention approaches.
Introduction
Physicians 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 discussed.
Methods
This report was produced through a multistage process.Beginning 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 the
Sexually Transmitted Diseases Treatment Guidelines, 2002 
(
1
).Background papers were written and tables of evidence wereconstructed summarizing the type of study (e.g., 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 othe reviews.In 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. Cost-effectiveness and other advantages (e.g.,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 studies.In several areas, the process diverged from that previously described. 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 Advisory Committee on Immunization Practices. The recommenda-tions for STD screening during pregnancy were developedafter CDC staff reviewed the recommendations from otherknowledgeable groups.

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