Sunday, June 26, 2022

Sexually transmitted infections: trends and updated guidelines

 - Kenny Lin, MD, MPH

An outbreak of meningococcal disease in Florida and the continuing spread of monkeypox predominantly among men who have sex with men has called attention to the role of sexual networks in facilitating outbreaks of rare diseases. The Centers for Disease Control and Prevention (CDC) released new guidance on monkeypox that advises people to be aware of the transmission risk posed by contact with genital rashes or sores at raves, parties, clubs, and festivals. Although neither meningococcal disease nor monkeypox are thought to be directly transmitted though sex, both appear to spread more easily between close personal contacts.

Unfortunately, common sexually transmitted infections (STIs) are also on the rise in the U.S. According to the CDC's 2020 Sexually Transmitted Disease Surveillance Report released earlier this year, reported cases of gonorrhea and syphilis increased from 2019 to 2020 by 10% and 7%, respectively, while an alarming 2,148 cases of congenital syphilis occurred. Although reported chlamydia cases decreased by 13%, the CDC believes that this is most likely an artifact caused by disruptions in screening from the COVID-19 pandemic, since chlamydia is often asymptomatic. Similarly, an analysis published in last week's Morbidity and Mortality Weekly Report found that HIV testing declined by up to 50% in high-risk populations from 2019 to 2020, leading to a 17% decrease in new diagnoses that probably reflects diagnostic delays rather than a true decline in HIV incidence.

In this context, the May issue of AFP summarized important updates from the CDC's 2021 STI Treatment Guidelines. In a review article, Drs. Jessica Dalby and Bradley Stoner discussed several preventive strategies including hepatitis and human papillomavirus vaccinations, HIV preexposure prophylaxis (PrEP), and expedited partner therapy. The guidelines also emphasize antibiotic stewardship by distinguishing persons with a true IgE-mediated penicillin allergy from those who can safety receive ceftriaxone and penicillins through clinical tools such as the PEN-FAST rule. A Practice Guidelines piece highlighted more key practice points: doxycycline is preferred over azithromycin for most chlamydial infections, intramuscular ceftriaxone 500 mg (or 1 gram in patients weighing 150 kg or more) is now the standard therapy for gonorrhea, and women with trichomonas should received a 7-day course of metronidazole 500 mg twice daily rather than a single 2 gram dose.

More information for clinicians and patients on sexually transmitted infections, including techniques and tips for taking a sexual history,  is available in the AFP By Topic collection on STIs and separate collections on HIV/AIDS and Hepatitis (and Other Liver Diseases).