An STI upsurge requires a nimble approach to care

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doi:doi: 10.12788/jfp.0641

Applied Evidence

An STI upsurge requires a nimble approach to care

J Fam Pract. 2023 July;72(6):E1-E12 | doi: 10.12788/jfp.0641

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References

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26. Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis. 2003;30:49-56. doi: 10.1097/00007435-200301000-00011

27. Stupiansky NW, Van der Pol B, Williams JA, et al. The natural history of incident gonococcal infection in adolescent women. Sex Transm Dis. 2011;38:750-754. doi: 10.1097/OLQ.0b013e31820ff9a4

28. CDC. Sexually transmitted infections treatment guidelines, 2021: Screening recommendations and considerations referenced in treatment guidelines and original sources. US Department of Health and Human Services. June 6, 2022. Accessed May 9, 2023. www.cdc.gov/std/treatment-guidelines/screening-recommen dations.htm

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32. Patel EU, Gaydos CA, Packman ZR, et al. Prevalence and correlates of Trichomonas vaginalis infection among men and women in the United States. Clin Infect Dis. 2018;67:211-217. doi: 10.1093/cid/ciy079

33. CDC. Sexually transmitted infections treatment guidelines, 2021. Mycoplasma genitalium. US Department of Health and Human Services. July 22, 2021. Accessed April 23, 2023. www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm

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Treatment. Because of greater efficacy, the treatment recommendation for women has changed from a single 2-g dose of oral metronidazole to 500 mg twice daily for 7 days. The 2-g single oral dose is still recommended for men⁷ (Table 2¹⁴ lists alternative regimens).

Mycoplasma genitalium

Infection with M genitalium is common and often asymptomatic. The disease causes approximately 20% of all cases of nongonococcal and nonchlamydial urethritis in men and about 40% of persistent or recurrent infections. M genitalium is present in approximately 20% of women with cervicitis and has been associated with PID, preterm delivery, spontaneous abortion, and infertility.

There are limited and conflicting data regarding outcomes in infected patients other than those with persistent or recurrent infection; furthermore, resistance to azithromycin is increasing rapidly, resulting in an increase in treatment failures. Screening therefore is not recommended, and testing is recommended only in men with nongonococcal urethritis.^33,34

Diagnosis. NAAT can be performed on urine or on a urethral, penile meatal, endocervical, or vaginal swab; men with recurrent urethritis or women with recurrent cervicitis should be tested. NAAT also can be considered in women with PID. Testing the specimen for the microorganism’s resistance to macrolide antibiotics is recommended (if such testing is available).

Treatment is initiated with doxycycline 100 mg twice daily for 7 days. If the organism is macrolide sensitive, follow with azithromycin 1 g orally on Day 1, then 500 mg/d for 3 more days. If the organism is macrolide resistant or testing is unavailable, follow doxycycline with oral moxifloxacin 400 mg/d for 7 days.³³

Genital herpes (mostly herpesvirus type 2)

Genital herpes, characterized by painful, recurrent outbreaks of genital and anal lesions,³⁵ is a lifelong infection that increases in prevalence with age.⁸ Because many infected people have disease that is undiagnosed or mild or have unrecognizable symptoms during viral shedding, most genital herpes infections are transmitted by people who are unaware that they are contagious.³⁶ Herpesvirus type 2 (HSV-2) causes most cases of genital herpes, although an increasing percentage of cases are attributed to HSV type 1 (HSV-1) through receptive oral sex from a person who has an oral HSV-1 lesion.

Intramuscular ceftriaxone 500 mg in a single dose cures 98% to 99% of gonococcal infections in the United States; monitoring local resistance patterns in the community is important.

Importantly, HSV-2–infected people are 2 to 3 times more likely to become infected with HIV than people who are not HSV-2 infected.³⁷ This is becauseCD4+ T cells concentrate at the site of HSV lesions and express a higher level of cell-surface receptors that HIV uses to enter cells. HIV replicates 3 to 5 times more quickly in HSV-infected tissue.³⁸

Continue to: HSV can become disseminated...