1. Sexually Transmitted Disease Treatment Guidelines
John Kulig, MD, MPH
Lead Medical Specialist
Job Corps Health and Wellness Webinar
May 11th & 12th, 2011

2. Learning Objectives Participants will be able to:
List Job Corps PRH requirements for STD screening
Implement current CDC treatment recommendations for STDs on center
Describe appropriate follow-up and contact notification following treatment of STDs

3. Evolution in Terminology
Venereal Disease (VD)
Sexually Transmitted Disease (STD)
Sexually Transmitted Infection (STI)
Sexually Acquired Infection (SAI)

5. PRH requirements for STD testing upon entry
Females
HIV antibody
Chlamydia:
endocervical or urine
Gonorrhea:
Optional
Syphilis serology
Males
HIV antibody
Urine dipstick
Chlamydia: urine
Gonorrhea: urine
if leukocyte esterase +
Optional
Syphilis serology

6. Urine dipstick testing on center

7. Job Corps nationally contracted laboratory: Center for Disease Detection, San Antonio, Texas

8. Chlamydia — Prevalence among 16- to 24-year-old women entering the National Job Training Program by state of residence: United States and outlying areas, 2008
*Less than 100 women residing in these states/areas and entering the National Job Training Program were screened for chlamydia in 2008.
SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

9. Chlamydia — Prevalence among 16- to 24-year-old men entering the National Job Training Program by state of residence: United States and outlying areas, 2008
*Less than 100 men residing in these states/areas and entering the National Job Training Program were screened for chlamydia in 2008.
SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

10. Mucoid discharge with Chlamydia
Purulent discharge with gonorrhea

11. Treatment recommendations for Chlamydia urogenital infection
azithromycin 1 g orally in a single dose OR
doxycycline 100 mg orally twice a day for 7 days

12. Clinical efficacy of azithromycin for Chlamydial infections in pregnancy
doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnant women
clinical experience and published studies suggest that azithromycin is safe and effective
repeat testing to document eradication (preferably by NAAT) three weeks after completion of therapy is recommended for all pregnant women to ensure therapeutic cure

13. Gonorrhea — Prevalence among 16- to 24-year-old women entering the National Job Training Program by state of residence: United States and outlying areas, 2008
*Less than 100 women residing in these states/areas and entering the National Job Training Program were screened for gonorrhea by the national contract laboratory in 2008.
Note: Many training centers test female students for gonorrhea using local laboratories; these results are not available to CDC. For this map, gonorrhea test results for students at centers submitting specimens to the national contract laboratory were included if the number of gonorrhea tests submitted was greater than 90% of the number of chlamydia tests submitted.
SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

14. Gonorrhea — Prevalence among 16- to 24-year-old men entering the National Job Training Program by state of residence: United States and outlying areas, 2008
*Less than 100 men residing in these states/areas and entering the National Job Training Program were screened for gonorrhea by the national contract laboratory in 2008.
Note: Many training centers test male students for gonorrhea using local laboratories; these results are not available to CDC. For this map, gonorrhea test results for students at centers submitting specimens to the national contract laboratory were included if the number of gonorrhea tests submitted was greater than 90% of the number of chlamydia tests submitted.
SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

15. Increasing prevalence of antimicrobial-resistant Neisseria gonorrhoeae
quinolones, as of April 2007, are no longer recommended in the United States for the treatment of gonorrhea and associated conditions, such as PID
only one class of antimicrobials, the cephalosporins, is recommended and available for the treatment of gonorrhea in the United States

16. Treatment of uncomplicated Neisseria gonorrhoeae infection
Cervix, urethra, rectum:
ceftriaxone 250 mg IM in a single dose OR, IF NOT AN OPTION
cefixime 400 mg orally in a single dose
Pharynx:
ceftriaxone 250 mg IM in a single dose PLUS
azithromycin 1g orally in a single dose OR
doxycycline 100 mg orally twice a day for 7 days

17. Primary syphilis

18. Secondary syphilis

19. Treatment recommendations for primary and secondary syphilis
benzathine penicillin G 2.4 million units IM in a single dose NO
YES

20. Ectopic sebaceous glands
HSV
HSV
HSV
Ectopic sebaceous glands

21. Treatment recommendations for primary genital herpes infection
acyclovir 400 mg orally three times a day for 7–10 days OR
acyclovir 200 mg orally five times a day for 7–10 days
famciclovir 250 mg orally three times a day for 7–10 days
valacyclovir 1 g orally twice a day for 7–10 days

22. Treatment recommendations for recurrent genital herpes infection
Acyclovir 400 mg orally three times a day for 5 days OR
Acyclovir 800 mg orally twice a day for 5 days
Acyclovir 800 mg orally three times a day for 2 days
Famciclovir 125 mg orally twice daily for 5 days
Famciclovir 1000 mg orally twice daily for 1 day
Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days OR
Valacyclovir 500 mg orally twice a day for 3 days
Valacyclovir 1 g orally once a day for 5 days

23. Treatment recommendations for genital herpes prophylaxis
acyclovir 400 mg orally twice a day OR
famciclovir 250 mg orally twice a day
valacyclovir 500 mg orally once a day*
valacyclovir 1 g orally once a day
* valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e. ≥10 episodes per year).

24. Trichomonads
Clue cell
Saline wet mount examination of vaginal discharge

25. Treatment recommendations for trichomonas infection
metronidazole 2 g orally in a single dose OR
tinidazole 2 g orally in a single dose
Caution: Avoid alcohol consumption during treatment and for 24 hours after completion of metronidazole or 72 hours after tinidazole.

26. Diagnostic criteria for bacterial vaginosis
3 of the following 4 symptoms or signs:
homogeneous, thin, white discharge that smoothly coats the vaginal walls
presence of clue cells on microscopic examination
pH of vaginal fluid > 4.5
a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test)

27. Treatment recommendations for bacterial vaginosis
metronidazole 500 mg orally twice a day for 7 days (caution – alcohol) OR
metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days (caution oil-based)

28. Genital warts

29. Treatment recommendations for external genital warts
Patient-Applied:
podofilox 0.5% solution or gel OR
imiquimod 5% cream
sinecatechins 15% ointment

30. Treatment recommendations for external genital warts
Provider–Administered:
Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2 weeks. OR
Podophyllin resin 10%–25% in a compound tincture of benzoin
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90%
Surgical removal

31. Oral treatment recommendations for pelvic inflammatory disease
ceftriaxone 250 mg IM in a single dose
PLUS
doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
metronidazole 500 mg orally twice a day for 14 days

32. Empiric treatment recommendations for acute epididymitis
ceftriaxone 250 mg IM in a single dose
PLUS
doxycycline 100 mg orally twice a day for 10 days

33. Sexual transmission of hepatitis
hepatitis A via fecal-oral transmission – vaccine preventable
hepatitis B via unprotected sex and injection drug use – vaccine preventable
hepatitis C via injection drug use and unprotected sex (10%) – not vaccine preventable

34. Diagnostic evaluation after sexual assault
NAATs for C. trachomatis and N. gonorrhoeae. These tests are preferred for the diagnostic evaluation of sexual assault victims, regardless of the sites of penetration or attempted penetration.
Wet mount and culture or point-of-care testing of a vaginal-swab specimen for T. vaginalis infection. The wet mount also should be examined for evidence of bacterial vaginosis and candidiasis, especially if vaginal discharge, malodor, or itching is evident.
A serum sample for immediate evaluation for HIV infection, hepatitis B, and syphilis.

35. Prophylaxis after sexual assault
ceftriaxone 250 mg IM in a single dose OR
cefixime 400 mg orally in a single dose
PLUS
metronidazole 2 g orally in a single dose
azithromycin 1 g orally in a single dose
doxycycline 100 mg orally twice a day for 7 days

36. Postexposure HIV prophylaxis assessment after sexual assault
Assistance with PEP-related decisions can be obtained by calling the National Clinician’s Post-Exposure Prophylaxis Hotline (PEP Line) (telephone: )

37. STD prevention approaches
Education and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services
Identification of asymptomatically infected persons and of symptomatic persons unlikely to seek diagnostic and treatment services
Effective diagnosis, treatment, and counseling of infected persons
Evaluation, treatment, and counseling of sex partners of persons who are infected with an STD
Pre-exposure vaccination of persons at risk for vaccine-preventable STDs

38. STD prevention counseling: The Five Ps
Partners – gender and number
Prevention of pregnancy
Protection from STDs
Practices – vaginal, oral, anal sex – condom use – injection drug use – sex for money or sex for drugs
Past history of STDs – patient and partner(s)

39. Notification and follow-up
Patient
Partner(s)
Health Department – state and/or local
Test-of-cure vs test for reinfection
NAAT may remain positive for 3-4 weeks after treatment

40. Expedited Partner Therapy (EPT)
Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed with Chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.

41. Expedited Partner Therapy (EPT)
permissible in 27 states
potentially allowable in 15 states/DC/PR
prohibited in 8 states: Arkansas, Florida, Kentucky, Michigan, Ohio, Oklahoma, South Carolina, West Virginia

42. Questions?