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CDC releases updated STD treatment guidelines

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June 4, 2015

The CDC announced today that it has updated national guidelines to inform health care providers on strategies to prevent, diagnose and treat sexually transmitted diseases.

Kimberly A. Workowski, MD, professor of medicine in the division of infectious diseases at Emory University, said updates to the CDC's Sexually Transmitted Diseases Treatment Guidelines are critical as chlamydia and gonorrhea continue to be number one and number two, respectively, in terms of reportable infections, and as syphilis cases continue to rise.

“It’s really exciting to get this information out to providers who will take care of people at risk and those who have sexually transmitted infections,” Workowski told Infectious Disease News. “It’s an evidence-based document ... it’s used as the standard for STD management here in the United States as well as worldwide.”

Major updates — which revise 2010 guidelines — include alternative treatment options to help fight gonorrhea, which has become increasingly drug resistant. Specifically, the combination treatment of oral gemifloxacin 320 mg plus oral azithromycin 2 g, or dual treatment with single doses of intramuscular gentamicin 240 mg plus oral azithromycin 2 g, has been shown to be effective against uncomplicated urogenital gonorrhea, Workowski said, with cure rates reaching 99.5% and 100%, respectively. The updated guidelines suggest these regimens can be used in place of cephalosporin.

“[Gonorrhea] is very savvy at developing resistance to antibiotics,” Workowski said. “It’s a really important addition to this version of the guidelines ... especially in people who have allergies to the only known remaining antimicrobial, which is cephalosporin.”

The updated CDC guidelines also address expedited partner therapy (EPT) in the treatment of gonorrhea and chlamydia. Workowski said EPT is important with regard to gonorrhea and chlamydia because it enables people to get treated who either cannot access a physician or refuse to do so.

“That method has really been shown to be effective at reducing reinfection rates among women,” she said. “The proviso is that state laws vary, so providers really need to check whether their states will allow them to do EPT.”

STDs cause approximately 20 million infections a year in the United States, half of which occur in those aged under 24 years, Workowski said, noting that they can be of special concern for women due to potential reproductive health issues. WHO estimates there are anywhere from 350 to 400 million infections annually. – by David Jwanier

Disclosure: The researchers report no relevant financial disclosures.

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The difficulty in treating gonococcal infections continues to resurface. From sulfonamide resistance in the 1940s to penicillin resistance in the 1970s to second-generation fluoroquinolone resistance in the 2000s, Neisseria gonorrhoeae is now developing resistance to the latest treatment, cefixime. This development limits the options for oral therapy.

New data support the use of combination regimens. Gemifloxacin and azithromycin, both given in single doses orally, were very effective. Similarly, intramuscular gentamicin and oral azithromycin, again both single dose, were effective. Of course, the latter regimen requires an intramuscular injection. Consequently, the gentamicin/azithromycin regimen really only helps those with severe beta-lactam allergies to avoid ceftriaxone. The gemifloxacin/azithromycin data are tempered by the fact that 17.1% of the isolates had increased minimum inhibitory concentrations (MIC) to gemifloxacin.

The meaning of this is unclear. However, given N. gonorrhoeae’s history of adaptation, one may conclude that widespread use of gemifloxacin will quickly result in even higher, average MIC levels and treatment failure. Clearly, we are still in need of new drug(s) to safely, easily and effectively treat gonococcal infections. N. gonorrhoeae will, for the foreseeable future, continue to be an annoying, irritating foe.

Stephen Smith, MD
Infectious Disease News Editorial Board member,
Director, The Smith Center for Infectious Diseases and Urban Health

Disclosure: Smith reports no relevant financial disclosures.