MorbidityandMortalityWeeklyReport(MMWR)

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SexuallyTransmittedDiseasesTreatmentGuidelines,2010
Pleasenote:Anerratumhasbeenpublishedforthisarticle.Toviewtheerratum,pleaseclickhere.

RecommendationsandReports
December17,2010/59(RR12)1110
Preparedby
KimberlyA.Workowski,MD1,2
StuartBerman,MD1
1DivisionofSTDPrevention
NationalCenterforHIV/AIDS,ViralHepatitis,STD,andTBPrevention
2EmoryUniversity,Atlanta,Georgia
CorrespondingAuthor:KimberlyWorkowski,MD,DivisionofSTDPrevention,NationalCenterforHIV/AIDS,ViralHepatitis,
STD,andTBPrevention,10CorporateSquare,CorporateSquareBlvd,MSE02,Atlanta,GA30333.Telephone:4046391898
Fax:4046398610kgw2@cdc.gov.

Summary
Theseguidelinesforthetreatmentofpersonswhohaveorareatriskforsexuallytransmitteddiseases(STDs)wereupdatedby
CDCafterconsultationwithagroupofprofessionalsknowledgeableinthefieldofSTDswhometinAtlantaonApril1830,2009.
Theinformationinthisreportupdatesthe2006GuidelinesforTreatmentofSexuallyTransmittedDiseases(MMWR200655[No.
RR11]).Includedintheseupdatedguidelinesisnewinformationregarding1)theexpandeddiagnosticevaluationforcervicitis
andtrichomoniasis2)newtreatmentrecommendationsforbacterialvaginosisandgenitalwarts3)theclinicalefficacyof
azithromycinforchlamydialinfectionsinpregnancy4)theroleofMycoplasmagenitaliumandtrichomoniasisin
urethritis/cervicitisandtreatmentrelatedimplications5)lymphogranulomavenereumproctocolitisamongmenwhohavesex
withmen6)thecriteriaforspinalfluidexaminationtoevaluateforneurosyphilis7)theemergenceofazithromycinresistant
Treponemapallidum8)theincreasingprevalenceofantimicrobialresistantNeisseriagonorrhoeae9)thesexualtransmissionof
hepatitisC10)diagnosticevaluationaftersexualassaultand11)STDpreventionapproaches.

Introduction
Thetermsexuallytransmitteddiseases(STDs)isusedtorefertoavarietyofclinicalsyndromescausedbypathogensthatcanbe
acquiredandtransmittedthroughsexualactivity.Physiciansandotherhealthcareprovidersplayacriticalroleinpreventingand
treatingSTDs.TheseguidelinesforthetreatmentofSTDsareintendedtoassistwiththateffort.Althoughtheseguidelines
emphasizetreatment,preventionstrategiesanddiagnosticrecommendationsalsoarediscussed.
Theserecommendationsshouldberegardedasasourceofclinicalguidanceandnotprescriptivestandardshealthcareproviders
shouldalwaysconsidertheclinicalcircumstancesofeachpersoninthecontextoflocaldiseaseprevalence.Theyareapplicableto
variouspatientcaresettings,includingfamilyplanningclinics,privatephysicians'offices,managedcareorganizations,andother
primarycarefacilities.Theseguidelinesfocusonthetreatmentandcounselingofindividualpatientsanddonotaddressother
communityservicesandinterventionsthatareessentialtoSTD/humanimmunodeficiencyvirus(HIV)preventionefforts.

Methods
Theseguidelinesweredevelopedusingamultistageprocess.Beginningin2008,CDCstaffmembersandpublicandprivatesector
expertsknowledgeableinthefieldofSTDssystematicallyreviewedliteratureusinganevidencebasedapproach(e.g.,published
abstractsandpeerreviewedjournalarticles),focusingonthecommonSTDsandinformationthathadbecomeavailablesince
publicationofthe2006GuidelinesforTreatmentofSexuallyTransmittedDiseases(1).CDCstaffmembersandSTDexperts
developedbackgroundpapersandtablesofevidencethatsummarizedthetypeofstudy(e.g.,randomizedcontrolledtrialorcase
series),studypopulationandsetting,treatmentsorotherinterventions,outcomemeasuresassessed,reportedfindings,and
weaknessesandbiasesinstudydesignandanalysis.CDCstaffthendevelopedadraftdocumentonthebasisofthisevidencebased
review.InApril2009,thisinformationwaspresentedatameetingofinvitedconsultants(includingpublicandprivatesector

professionalsknowledgeableinthetreatmentofpatientswithSTDs),whereallevidencefromtheliteraturereviewspertainingto
STDmanagementwasdiscussed.
Specifically,participantsidentifiedkeyquestionsregardingSTDtreatmentthatemergedfromtheliteraturereviewsanddiscussed
theinformationavailabletoanswerthosequestions.DiscussionfocusedonfourprincipaloutcomesofSTDtherapyforeach
individualdisease:1)treatmentofinfectionbasedonmicrobiologiceradication2)alleviationofsignsandsymptoms3)prevention
ofsequelaeand4)preventionoftransmission.Costeffectivenessandotheradvantages(e.g.,singledoseformulationsanddirectly
observedtherapy[DOT])ofspecificregimensalsowerediscussed.Theconsultantsthenassessedwhetherthequestionsidentified
wererelevant,rankedtheminorderofpriority,andansweredthequestionsusingtheavailableevidence.Inaddition,the
consultantsevaluatedthequalityofevidencesupportingtheanswersonthebasisofthenumber,type,andqualityofthestudies.
ThesectionsonhepatitisBvirus(HBV)andhepatitisAvirus(HAV)infectionsarebasedonpreviouslypublishedrecommendations
oftheAdvisoryCommitteeonImmunizationPractices(ACIP)(24).TherecommendationsforSTDscreeningduringpregnancy
andcervicalcancerscreeningweredevelopedafterCDCstaffreviewedthepublishedrecommendationsfromotherprofessional
organizations,includingtheAmericanCollegeofObstetriciansandGynecologists(ACOG),UnitedStatesPreventiveServicesTask
Force(USPSTF),andACIP.
Throughoutthisreport,theevidenceusedasthebasisforspecificrecommendationsisdiscussedbriefly.Morecomprehensive,
annotateddiscussionsofsuchevidencewillappearinbackgroundpapersthatwillbepublishedinasupplementissueofthejournal
ClinicalInfectiousDiseases.Whenmorethanonetherapeuticregimenisrecommended,thesequenceisalphabetizedunlessthe
choicesfortherapyareprioritizedbasedonefficacy,convenience,orcost.Forthoseinfectionswithmorethanonerecommended
regimen,almostallregimenshavesimilarefficacyandsimilarratesofintoleranceortoxicityunlessotherwisespecified.
Recommendedregimensshouldbeusedprimarilyalternativeregimenscanbeconsideredininstancesofsignificantdrugallergyor
othercontraindicationstotherecommendedregimens.

ClinicalPreventionGuidance
ThepreventionandcontrolofSTDsarebasedonthefollowingfivemajorstrategies:
educationandcounselingofpersonsatriskonwaystoavoidSTDsthroughchangesinsexualbehaviorsanduseof
recommendedpreventionservices
identificationofasymptomaticallyinfectedpersonsandofsymptomaticpersonsunlikelytoseekdiagnosticandtreatment
services
effectivediagnosis,treatment,andcounselingofinfectedpersons
evaluation,treatment,andcounselingofsexpartnersofpersonswhoareinfectedwithanSTDand
preexposurevaccinationofpersonsatriskforvaccinepreventableSTDs.
PrimarypreventionofSTDsbeginswithchangingthesexualbehaviorsthatplacepersonsatriskforinfection.Healthcareproviders
haveauniqueopportunitytoprovideeducationandcounselingtotheirpatients(5,6).Aspartoftheclinicalinterview,healthcare
providersshouldroutinelyandregularlyobtainsexualhistoriesfromtheirpatientsandaddressmanagementofriskreductionas
indicatedinthisreport.GuidanceinobtainingasexualhistoryisavailableinContraceptiveTechnology,19thedition(7)andinthe
curriculumprovidedbyCDC'sSTD/HIVPreventionTrainingCenters(http://www.stdhivpreventiontraining.org ).Effective
interviewingandcounselingskills,characterizedbyrespect,compassion,andanonjudgmentalattitudetowardallpatients,are
essentialtoobtainingathoroughsexualhistoryandtodeliveringpreventionmessageseffectively.Keytechniquesthatcanbe
effectiveinfacilitatingrapportwithpatientsincludetheuseof1)openendedquestions(e.g.,"Tellmeaboutanynewsexpartners
you'vehadsinceyourlastvisit,"and"What'syourexperiencewithusingcondomsbeenlike?")2)understandablelanguage("Have
youeverhadasoreorscabonyourpenis?")and3)normalizinglanguage("Someofmypatientshavedifficultyusingacondom
witheverysexact.Howisitforyou?").The"FiveP's"approachtoobtainingasexualhistoryisanexampleofaneffectivestrategy
forelicitinginformationconcerningfivekeyareasofinterest(Box1).
Effortsshouldbemadetoensurethatallpatientsaretreatedregardlessofindividualcircumstances(e.g.,abilitytopay,citizenship
orimmigrationstatus,languagespoken,orspecificsexpractices).PatientsseekingtreatmentorscreeningforaparticularSTD
shouldbeevaluatedforallcommonSTDs.AllpatientsshouldbeinformedaboutalltheSTDsforwhichtheyarebeingtestedand
notifiedabouttestsforcommonSTDs(e.g.,genitalherpes)thatareavailablebutnotbeingperformed.

STD/HIVPreventionCounseling
USPSTFrecommendshighintensitybehavioralcounselingforallsexuallyactiveadolescentsandforadultsatincreasedriskfor
STDsandHIV(5,6).Allprovidersshouldroutinelyobtainasexualhistoryfromtheirpatientsandencourageriskreductionusing
variousstrategieseffectivedeliveryofpreventionmessagesrequiresthatproviderscommunicategeneralriskreductionmessages
relevanttotheclientandthatproviderseducatetheclientaboutspecificactionsthatcanreducetheriskforSTD/HIVtransmission
(e.g.,abstinence,condomuse,limitingthenumberofsexpartners,modifyingsexualpractices,andvaccination),eachofwhichis
discussedseparatelyinthisreport(seePreventionMethods).Preventioncounselingismosteffectiveifprovidedinanonjudgmental
andempatheticmannerappropriatetothepatient'sculture,language,sex,sexualorientation,age,anddevelopmentallevel.
Interactivecounselingapproachesdirectedatapatient'spersonalrisk,thesituationsinwhichriskoccurs,andtheuseof
personalizedgoalsettingstrategiesareeffectiveinSTD/HIVprevention(5,6).Onesuchapproach,knownasclientcentered

STD/HIVpreventioncounseling,involvestailoringadiscussionofriskreductiontothepatient'sindividualsituation.Client
centeredcounselingcanincreasethelikelihoodthatthepatientundertakesorenhancescurrentriskreductionpractices,especially
amongpersonsseekingSTDcare.Onesuchapproach,knownasProjectRESPECT,demonstratedthatabriefcounseling
interventionledtoareducedfrequencyofSTD/HIVriskrelatedbehaviorsandresultedinloweredacquisitionratesforcurable
STDs,includingtrichomoniasis,chlamydia,gonorrhea,andsyphilis(8,9).PracticemodelsbasedonProjectRESPECThavebeen
successfullyimplementedinclinicbasedsettings.Otherapproachesusemotivationalinterviewingtomoveclientstoward
achievableriskreductiongoals.CDCprovidesadditionalinformationontheseandothereffectivebehavioralinterventionsat
http://effectiveinterventions.org .
Interactivecounselingcanbeusedeffectivelybyallhealthcareproviders,counselors,andotherclinicalstafftrainedincounseling
approaches.Extensivetrainingisnotaprerequisiteforeffectiveriskreductioncounselinghowever,thequalityofcounselingis
improvedwhenprovidersreceivetraininginpreventioncounselingmethodsandskillbuildingapproaches,providersare
periodicallyobservedwhenprovidingcounselingandgivenimmediatefeedbackbypersonswithexpertiseinthecounseling
approach,counselorsareperiodicallyevaluatedandpatientsaskedtoevaluatetheirlevelofsatisfaction,andprovidershaveaccess
toexpertassistanceorreferralforchallengingsituations.TraininginclientcenteredcounselingisavailablethroughtheCDC
STD/HIVPreventionTrainingCenters(http://www.stdhivpreventiontraining.org ).
Inadditiontoindividualpreventioncounseling,videosandlargegrouppresentationscanprovideexplicitinformationconcerning
STDsandinstructiontoreducediseasetransmission(e.g.,howtousecondomscorrectly).Groupbasedstrategieshavebeen
effectiveinreducingtheoccurrenceofadditionalSTDsamongpersonsathighrisk,includingthoseattendingSTDclinics(10).
BecausetheincidenceofsomeSTDs,notablysyphilis,ishigherinHIVinfectedpersons,theuseofclientcenteredSTDcounseling
forHIVinfectedpersonshasbeenstronglyencouragedbypublichealthagenciesandotherhealthorganizations.Consensus
guidelinesissuedbyCDC,theHealthResourcesandServicesAdministration,theHIVMedicineAssociationoftheInfectious
DiseasesSocietyofAmerica,andtheNationalInstitutesofHealthemphasizethatSTD/HIVriskassessment,STDscreening,and
clientcenteredriskreductioncounselingshouldbeprovidedroutinelytoHIVinfectedpersons(11).Severalspecificmethodshave
beendesignedfortheHIVcaresetting(1214),andadditionalinformationregardingtheseapproachesisavailableat
http://effectiveinterventions.org .

PreventionMethods
AbstinenceandReductionofNumberofSexPartners
AreliablewaytoavoidtransmissionofSTDsistoabstainfromoral,vaginal,andanalsexortobeinalongterm,mutually
monogamousrelationshipwithanuninfectedpartner.ForpersonswhoarebeingtreatedforanSTD(orwhosepartnersare
undergoingtreatment),counselingthatencouragesabstinencefromsexualintercourseuntilcompletionoftheentirecourseof
medicationiscrucial.Amorecomprehensivediscussionofabstinenceandothersexualpracticesthancanhelppersonsreducetheir
riskforSTDsisavailableinContraceptiveTechnology,19thEdition(7).Forpersonsembarkingonamutuallymonogamous
relationship,screeningforcommonSTDsbeforeinitiatingsexmightreducetheriskforfuturediseasetransmission.

PreexposureVaccination
PreexposurevaccinationisoneofthemosteffectivemethodsforpreventingtransmissionofsomeSTDs.Twohuman
papillomavirus(HPV)vaccinesareavailableforfemalesaged926yearstopreventcervicalprecancerandcancer(15,16):the
quadrivalentHPVvaccine(Gardasil)andthebivalentHPVvaccine(Cervarix).Gardasilalsopreventsgenitalwarts.Routine
vaccinationoffemalesaged11or12yearsisrecommendedwitheithervaccine,asiscatchupvaccinationforfemalesaged1326
years.Gardasilcanbeadministeredtomalesaged926yearstopreventgenitalwarts(17).DetailsregardingHPVvaccinationare
availableatwww.cdc.gov/std/hpv.
HepatitisBvaccinationisrecommendedforallunvaccinated,uninfectedpersonsbeingevaluatedforanSTD(3,4).Inaddition,
hepatitisAandBvaccinesarerecommendedformenwhohavesexwithmen(MSM)andinjectiondrugusers(IDUs)(24)eachof
thesevaccinesshouldalsobeadministeredtoHIVinfectedpersonswhohavenotyetbeeninfectedwithoneorbothtypesof
hepatitisvirus.DetailsregardinghepatitisAandBvaccinationareavailableathttp://www.cdc.gov/hepatitis.

MaleCondoms
Whenusedconsistentlyandcorrectly,malelatexcondomsarehighlyeffectiveinpreventingthesexualtransmissionofHIV
infection.Inheterosexualserodiscordantrelationships(i.e.,thoseinvolvingoneinfectedandoneuninfectedpartner)inwhich
condomswereconsistentlyused,HIVnegativepartnerswere80%lesslikelytobecomeHIVinfectedcomparedwithpersonsin
similarrelationshipsinwhichcondomswerenotused(18).
Moreover,studiesshowcondomscanreducetheriskforotherSTDs,includingchlamydia,gonorrhea,andtrichomoniasisby
limitinglowergenitaltractinfections,condomsalsomightreducetheriskforwomendevelopingpelvicinflammatorydisease(PID)
(19,20).Inaddition,consistentandcorrectuseoflatexcondomsalsoreducestheriskforgenitalherpes,syphilis,andchancroid
whentheinfectedareaorsiteofpotentialexposureiscovered,althoughdataforthiseffectaremorelimited(2124).Additional
informationisavailableatwww.cdc.gov/condomeffectiveness/latex.htm.
CohortstudieshavedemonstratedthatcondomsprotectagainsttheacquisitionofgenitalHPVinfection.Aprospectivestudyamong
newlysexuallyactivewomenwhowereattendingcollegedemonstratedthatconsistentandcorrectcondomusewasassociatedwith
a70%reductioninriskforHPVtransmission(25).UseofcondomsalsoappearstoreducetheriskforHPVassociateddiseases

(e.g.,genitalwartsandcervicalcancer)andmitigatetheadverseconsequencesofinfectionwithHPV.Condomusehasbeen
associatedwithhigherratesofregressionofcervicalintraepithelialneoplasia(CIN)andclearanceofHPVinfectioninwomen(26)
andwithregressionofHPVassociatedpenilelesionsinmen(27).
CondomsareregulatedasmedicaldevicesandaresubjecttorandomsamplingandtestingbytheU.S.FoodandDrug
Administration(FDA).EachlatexcondommanufacturedintheUnitedStatesistestedelectronicallyforholesbeforepackaging.
Ratesofcondombreakageduringsexualintercourseandwithdrawalareapproximatelytwobrokencondomsper100condomsused
intheUnitedStates.ThefailureofcondomstoprotectagainstSTDtransmissionorunintendedpregnancyusuallyresultsfrom
inconsistentorincorrectuseratherthancondombreakage(28).
MalecondomsmadeofmaterialsotherthanlatexareavailableintheUnitedStates.Twogeneralcategoriesofnonlatexcondoms
exist.ThefirsttypeismadeofpolyurethaneorothersyntheticmaterialandprovidesprotectionagainstSTDs/HIVandpregnancy
equaltothatoflatexcondoms(29).Thesecanbesubstitutedforlatexcondomsbypersonswithlatexallergy.Althoughtheyhave
hadhigherbreakageandslippagerateswhencomparedwithlatexcondomsandareusuallymorecostly,thepregnancyratesamong
womenwhosepartnersusethesecondomsaresimilartothoseasociatedwithuseoflatexcondoms(30).
Thesecondtypeisnaturalmembranecondoms(frequentlycalled"natural"condomsor,incorrectly,"lambskin"condoms).These
condomsareusuallymadefromlambcecumandcanhaveporesupto1,500nmindiameter.Althoughtheseporesdonotallowthe
passageofsperm,theyaremorethan10timesthediameterofHIVandmorethan25timesthatofHBV(29).Moreover,laboratory
studiesdemonstratethatviralSTDtransmissioncanoccurwithnaturalmembranecondoms(29).Useofnaturalmembrane
condomsforpreventionofSTDsisnotrecommended.
ProvidersshouldadvisetheirpatientsthatcondomsmustbeusedconsistentlyandcorrectlytobeeffectiveinpreventingSTDs
providinginstructionsaboutthecorrectuseofcondomscanbeuseful.Communicatingthefollowingrecommendationscanhelp
ensurethatpatientsusemalecondomscorrectly:
Useanewcondomwitheachsexact(i.e.,oral,vaginal,andanal).
Carefullyhandlethecondomtoavoiddamagingitwithfingernails,teeth,orothersharpobjects.
Putthecondomonafterthepenisiserectandbeforeanygenital,oral,oranalcontactwiththepartner.
Useonlywaterbasedlubricants(e.g.,KYJelly,Astroglide,AquaLube,andglycerin)withlatexcondoms.Oilbasedlubricants
(e.g.,petroleumjelly,shortening,mineraloil,massageoils,bodylotions,andcookingoil)canweakenlatexandshouldnotbe
used.
Ensureadequatelubricationduringvaginalandanalsex,whichmightrequiretheuseofexogenouswaterbasedlubricants.
Topreventthecondomfromslippingoff,holdthecondomfirmlyagainstthebaseofthepenisduringwithdrawal,and
withdrawwhilethepenisisstillerect.

FemaleCondoms
Laboratorystudiesindicatethatthefemalecondom(Reality)isaneffectivemechanicalbarriertoviruses,includingHIV,andto
semen.ThefirstfemalecondomapprovedforuseintheUnitedStatesconsistedofalubricatedpolyurethanesheathwitharingon
eachendthatisinsertedintothevagina.AnewerversionmadefromnitrileisnowavailableintheUnitedStates.
AlimitednumberofclinicalstudieshaveevaluatedtheefficacyoffemalecondomsinprovidingprotectionfromSTDs,including
HIV(31,32).Althoughfemalecondomsarecostlycomparedwithmalecondoms,sexpartnersshouldconsiderusingafemale
condomwhenamalecondomcannotbeusedproperly.ThefemalecondomalsohasbeenusedforSTDs/HIVprotectionduring
receptiveanalintercourse(33)althoughitmightprovidesomeprotectioninthissetting,itsefficacyremainsunknown.

CervicalDiaphragms
Inobservationalstudies,diaphragmusehasbeendemonstratedtoprotectagainstcervicalgonorrhea,chlamydia,and
trichomoniasis(34).Arecenttrialexaminedtheeffectofuseofadiaphragmpluspolycarbophil(Replens)lubricantonHIV
acquisitioninwomeninAfricarelativetomalecondomusealone.Thestudyrevealedthatneitherthediaphragmnorthelubricant
gelprovidedadditionalprotectiveeffectwhencomparedwiththeuseofcondomsalone(35).Likewise,nodifferencebystudyarmin
therateofacquisitionofchlamydiaorgonorrheaoccurredhowever,datafromparticipantswhoreportedfollowingtheprotocolfor
theuseoftheseproductssuggestedthatconsistentuseofthediaphragmplusgelmightreduceacquisitionofgonorrhea(36).
DiaphragmsshouldnotbereliedonasthesolesourceofprotectionagainstHIVinfection.Diaphragmandnonoxynol9(N9)
spermicideusehavebeenassociatedwithanincreasedriskforbacterialurinarytractinfectionsinwomen(37).

TopicalMicrobicidesandSpermicides
StudiesexaminingnonspecifictopicalmicrobicidesforthepreventionofHIVandSTDhavedemonstratedthattheseproductsare
ineffective(38,39).StudiesofspermicidescontainingN9havedemonstratedthattheyshouldnotberecommendedforSTDs/HIV
prevention(40),andmorerecentrandomizedcontrolledtrialshavefailedtoshowaprotectiveeffectagainstHIVacquisitionfor
BufferGel(avaginalbufferingagent),Carraguard(acarrageenanderivative)(41),cellulosesulfate(anHIVentryinhibitor),(42)and
SAVVY(1.0%C31G,asurfactant)(43,44).
Initialresultsfromastudyinwhichparticipantsused0.5%PRO2000vaginalgel(asyntheticpolyanionpolymerthatblockscellular

entryofHIV)onadailybasisappearedpromising,reducingtherateofHIVacquisitionby30%relativetonogel(45).However,a
recentrandomizedtrialofapproximately9,000womenfailedtoshowanyprotectiveeffect(46).
TopicalantiretroviralagentsforthepreventionofHIVappearmorepromising.Useoftenofovirgelduringsexualintercourse
significantlyreducedtherateofHIVacquisition(i.e.,by39%)inastudyofSouthAfricanwomen(47).Additionalstudiesarebeing
undertakentoelucidatetheoptimaldosingregimensforthisdrug.
Otherproductsremainunderstudy,includingVivaGel,atopicalvaginalmicrobicide.Alistofproductsunderdevelopmentis
maintainedbytheAllianceforMicrobicideDevelopmentatwww.microbicide.org .

CondomsandN9VaginalSpermicides
Condomslubricatedwithspermicidesarenomoreeffectivethanotherlubricatedcondomsinprotectingagainstthetransmissionof
HIVandotherSTDs(www.cdc.gov/condomeffectiveness/latex.htm).Furthermore,frequentuseofspermicidescontainingN9has
beenassociatedwithdisruptionofthegenitalepithelium,whichmightbeassociatedwithanincreasedriskforHIVtransmission
(40).Therefore,useofcondomslubricatedwithN9isnotrecommendedforSTD/HIVpreventioninaddition,spermicidecoated
condomscostmore,haveashortershelflifethanotherlubricatedcondoms,andhavebeenassociatedwithurinarytractinfection
inyoungwomen(37).

RectalUseofN9Spermicides
N9candamagethecellsliningtherectum,whichmightprovideaportalofentryforHIVandothersexuallytransmissibleagents.
Therefore,itshouldnotusedasamicrobicideorlubricantduringanalintercoursebyMSMorbywomen.

NonbarrierContraception,SurgicalSterilization,andHysterectomy
ContraceptivemethodsthatarenotmechanicalbarriersoffernoprotectionagainstHIVorotherSTDs.Sexuallyactivewomenwho
usehormonalcontraception(i.e.,oralcontraceptives,Norplant,andDepoProvera),haveintrauterinedevices(IUDs),havebeen
surgicallysterilized,orhavehadhysterectomiesshouldbecounseledregardingtheuseofcondomsandtheriskforSTDs,including
HIVinfection,becausethesewomenmightincorrectlyperceivethattheyarenotatriskforthesediseases.Womenwhotakeoral
contraceptivesandareprescribedcertainantibioticsshouldbecounseledaboutpotentialinteractions(7).

MaleCircumcision
AlthoughmalecircumcisionshouldnotbesubstitutedforotherHIVriskreductionstrategies,ithasbeenshowntoreducetherisk
forHIVandsomeSTDsinheterosexualmen.Threerandomized,controlledtrialsperformedinregionsofsubSaharanAfricawhere
generalizedHIVepidemicsinvolvingpredominantlyheterosexualtransmissionwereoccurringdemonstratedthatmale
circumcisionreducedtheriskforHIVacquisitionamongmenby50%60%(4850).Inthesetrials,circumcisionwasalso
protectiveagainstotherSTDs,includinghighriskgenitalHPVinfectionandgenitalherpes(5154).Despitethesedata,male
circumcisionhasnotbeendemonstratedtoreducetheriskforHIVorotherSTDsamongMSM(55).TheWorldHealthOrganization
(WHO)andtheJointUnitedNationsProgrammeonHIV/AIDS(UNAIDS)haverecommendedthatmalecircumcisionbescaledup
asaneffectiveinterventionforthepreventionofheterosexuallyacquiredHIVinfection(56).Theseorganizationsalsorecommend
thatcountrieswithhyperendemicandgeneralizedHIVepidemicsandlowprevalenceofmalecircumcisionexpandaccesstosafe
malecircumcisionserviceswithinthecontextofensuringuniversalaccesstocomprehensiveHIVprevention,treatment,care,and
support.SimilarrecommendationshavenotbeenmadeintheUnitedStates,althoughevidenceregardingtherole
ofmalecircumcisioninthepreventionofHIV/AIDSisunderreview(57).

EmergencyContraception(EC)
WomenwhomighthavebeenexposedtoSTDsduringarecentactofunprotectedintercoursealsoareatriskforpregnancy.
ProvidersmanagingsuchwomenshouldoffercounselingabouttheoptionofECifpregnancyisnotdesired.IntheUnitedStates,
ECproductsareavailableoverthecountertowomenaged17yearsandbyprescriptiontoyoungerwomen.IftheseECpill
productsarenotreadilyaccessible,manycommonlyavailablebrandsoforalcontraceptivepillscaneffectivelyprovideEC,but
womenmustbeinstructedtotakeanappropriateandspecifiednumberoftabletsatonetime.AlloralECregimensareefficacious
wheninitiatedassoonaspossibleafterunprotectedsex,buthavesomeefficacyaslongas5dayslater.ECisineffective(butisalso
notharmful)ifthewomanisalreadypregnant(58).MoreinformationaboutECisavailableinthe19theditionofContraceptive
Technology(7)orhttp://ec.princeton.edu/emergencycontraception.html .
InsertionofanIUDupto7daysafterunprotectedsexcanreducepregnancyriskbymorethan99%(7).However,thismethodisnot
advisableforawomanwhomayhaveuntreatedcervicalgonorrheaorchlamydia,whoisalreadypregnant,orwhohasother
contraindicationstoIUDuse.

PostexposureProphylaxis(PEP)forHIVandSTD
GuidelinesfortheuseofPEPaimedatpreventingHIVinfectionasaresultofsexualexposureareavailableandarediscussedinthis
report(seeSexualAssaultandSTDs).Genitalhygienemethods(e.g.,vaginalwashinganddouching)aftersexualexposureare
ineffectiveinprotectingagainstHIVandSTDandmightincreasetheriskforbacterialvaginosis,someSTDs,andHIV(59).

PreexposureProphylaxis(PrEP)forHIVandSTD
Antiretroviraltherapy(ART)hasthepotentialtoimpacttransmissionandacquisitionofHIV.InHIVinfectedpersons,ARTreduces
viralloadandpresumablyreducesinfectiousness(60).InHIVuninfectedpersons,ARTmightreducesusceptibilitytoinfection,a
conceptsupportedbothbyanimalstudiesandbyastudyofsafetyandacceptabilityinvolvingWestAfricanwomen(61,62).A

randomized,placebocontrolledtrialinvolvingSouthAfricanwomenrecentlydemonstratedthatuseoftenofovirgelassociatedwith
sexualintercoursesignificantlyreducedtherateofHIVandherpessimplexvirustype2(HSV2)acquisitionby39%and51%,
respectively(47,63).
SeverallargerandomizedcontrolledtrialsofPrEPareeitherunderwayorplanned.Theseinvolvetheoraluseofnonnucleoside
reversetranscriptaseinhibitors(tenofovirortenofoviremtricitabine)orvaginaluseof1%tenofovirgel.

RetestingtoDetectRepeatInfections
Retestingseveralmonthsafteradiagnosisofchlamydiaorgonorrheacandetectrepeatinfectionandpotentiallycanbeusedto
enhancepopulationbasedprevention(64).Furtherdetailsonretestingcanbefoundinthespecificsectionsonchlamydiaand
gonorrheawithinthisreport.

PartnerManagement
Partnermanagementreferstoacontinuumofactivitiesdesignedtoincreasethenumberofinfectedpersonsbroughttotreatment
anddisrupttransmissionnetworks.Partofthiscontinuumispartnernotificationtheprocessbywhichprovidersorpublichealth
authoritieslearnaboutthesexandneedlesharingpartnersofinfectedpatientsandhelptoarrangeforpartnerevaluationand
treatment.Clinicalcareproviderscanobtainthisinformationandhelptoarrangeforevaluationandtreatmentofsexpartners
directlyorbycooperatingwithstateandlocalhealthdepartments.Thetypesandcomprehensivenessofexistingpartnerservices
andthespecificSTDsforwhichtheyareofferedvarybyprovider,publichealthagency,andgeographicarea.Ideally,persons
referredtosuchservicesshouldalsoreceivehealthcounselingandshouldbereferredforotherhealthservicesasappropriate.
DataarelimitedregardingwhetherpartnernotificationeffectivelydecreasesexposuretoSTDsandwhetheritreducestheincidence
andprevalenceoftheseinfectionsinacommunity.Nevertheless,evaluationsofpartnernotificationinterventionshavedocumented
theimportantcontributionthisapproachcanmaketocasefindinginclinicalandcommunitycontexts(65).Whenpartnersare
treated,indexpatientshavereducedriskforreinfection.Therefore,providersshouldencouragepersonswithSTDstonotifytheir
sexpartnersandurgethemtoseekmedicalevaluationandtreatment.Further,providerscanaskpatientstobringpartnerswith
themwhenreturningfortreatment.Timespentwithindexpatientstocounselthemontheimportanceofnotifyingpartnersis
associatedwithimprovednotificationoutcomes(66).
Whenpatientsdiagnosedwithchlamydiaorgonorrheaindicatethattheirpartnersareunlikelytoseekevaluationandtreatment,
providerscanofferpatientdeliveredpartnertherapy(PDPT),aformofexpeditedpartnertherapy(EPT)inwhichpartnersof
infectedpersonsaretreatedwithoutpreviousmedicalevaluationorpreventioncounseling.BecauseEPTmightbeprohibitedin
somestatesandisthetopicofongoinglegislationinothers(67),providersshouldvisitwww.cdc.gov/std/epttoobtainupdated
informationfortheirindividualjurisdiction.AnymedicationorprescriptionprovidedforPDPTshouldbeaccompaniedby
treatmentinstructions,appropriatewarningsabouttakingmedications(ifthepartnerispregnantorhasanallergytothe
medication),generalhealthcounseling,andastatementadvisingthatpartnersseekpersonalmedicalevaluation,particularly
womenwithsymptomsofSTDsorPID.
TheevidencesupportingPDPTisbasedonthreeclinicaltrialsthatincludedheterosexualmenandwomenwithchlamydiaor
gonorrhea.Thetrialsandmetaanalysesrevealedthatthemagnitudeofreductioninreinfectionofindexcasepatientscompared
withpatientreferraldifferedaccordingtotheSTDandthesexoftheindexcasepatient(6871).However,acrosstrials,reductions
inchlamydiaprevalenceatfollowupwereapproximately20%reductionsingonorrheaatfollowupwereapproximately50%.
RatesofnotificationincreasedinsometrialsandwereequivalenttopatientreferralwithoutPDPTinothers.Existingdatasuggest
thatPDPTalsomighthavearoleinpartnermanagementfortrichomoniasishowever,nosinglepartnermanagementintervention
hasbeenshowntobemoreeffectivethananyotherinreducingreinfectionrates(72,73).NodatasupporttheuseofPDPTinthe
routinemanagementofpatientswithsyphilis.NostudieshavebeenpublishedinvolvingPDPTforgonorrheaorchlamydiaamong
MSM.
PublichealthprograminvolvementwithpartnernotificationservicesvariesbylocaleandbySTD.Someprogramshaveconsidered
partnernotificationinabroadercontext,developinginterventionstoaddresssexualandsocialnetworksinwhichpersonsare
exposedtoSTDs.Prospectiveevaluationsincorporatingtheassessmentofvenues,communitystructure,andsocialandsexual
contactsinconjunctionwithpartnernotificationeffortshaveimprovedcasefindingandillustratedtransmissionnetworks(74,75).
Whilesucheffortsarebeyondthescopeofindividualclinicians,supportofandcollaborationwithSTDprogramsbycliniciansare
criticaltothesuccessofsocialnetworkbasedinterventions.
Certainevidencesupportstheuseoftheinternettofacilitatepartnernotification(76),especiallyamongMSMandincaseswhereno
otheridentifyinginformationisavailable,andmanyhealthdepartmentsnowconductformalinternetpartnernotification(IPN)
(http://www.ncsddc.org/upload/wysiwyg/documents/NGuidelinesforInternet.htm ).Clinicalprovidersareunlikelytoparticipate
directlyinIPN.However,whendiscussingpartnernotificationapproacheswithpatients,theyshouldbeawareofthevalueofthe
internetinthistypeofcommunicationandshouldknowwheretoreferpatientswhoareinterestedinusingtheinternettonotify
partnersabouttheirdiagnosis.

ReportingandConfidentiality
TheaccurateandtimelyreportingofSTDsisintegraltoeffortstoassessmorbiditytrends,allocatelimitedresources,andassistlocal
healthauthoritiesinpartnernotificationandtreatment.STD/HIVandacquiredimmunodeficiencysyndrome(AIDS)casesshould
bereportedinaccordancewithstateandlocalstatutoryrequirements.Syphilis,gonorrhea,chlamydia,chancroid,HIVinfection,
andAIDSarereportablediseasesineverystate.BecausetherequirementsforreportingotherSTDsdifferbystate,cliniciansshould

befamiliarwiththereportingrequirementsapplicablewithintheirjurisdictions.
Reportingcanbeproviderorlaboratorybased.Clinicianswhoareunsureofstateandlocalreportingrequirementsshouldseek
advicefromstateorlocalhealthdepartmentsorSTDprograms.STDsandHIVreportsarekeptstrictlyconfidential.Inmost
jurisdictions,suchreportsareprotectedbystatutefromsubpoena.BeforeconductingafollowupofapositiveSTDtestresult,
publichealthprofessionalsshouldconsultthepatient'shealthcareprovidertoverifythediagnosisandtodeterminethetreatments
beingreceived.

SpecialPopulations
PregnantWomen
IntrauterineorperinatallytransmittedSTDscanhaveseverelydebilitatingeffectsonpregnantwomen,theirpartners,andtheir
fetuses.AllpregnantwomenandtheirsexpartnersshouldbeaskedaboutSTDs,counseledaboutthepossibilityofperinatal
infections,andprovidedaccesstotreatment,ifneeded.

RecommendedScreeningTests
AllpregnantwomenintheUnitedStatesshouldbescreenedforHIVinfectionasearlyinpregnancyaspossible(77).Screening
shouldbeconductedafterthewomanisnotifiedthatshewillbescreenedforHIVaspartoftheroutinepanelofprenataltests,
unlessshedeclines(i.e.,optoutscreening).ForwomenwhodeclineHIVtesting,providersshouldaddresstheirobjections,and
whenappropriate,continuetoencouragetestingstrongly.Womenwhodeclinetestingbecausetheyhavehadaprevious
negativeHIVtestshouldbeinformedoftheimportanceofretestingduringeachpregnancy.Testingpregnantwomenand
treatingthosewhoareinfectedarevitalnotonlytomaintainthehealthofthepatient,buttoreduceperinataltransmissionof
HIVthroughavailableantiretroviralandobstetricalinterventions.Retestinginthethirdtrimester(preferablybefore36weeks'
gestation)isrecommendedforwomenathighriskforacquiringHIVinfection(e.g.,womenwhouseillicitdrugs,haveSTDs
duringpregnancy,havemultiplesexpartnersduringpregnancy,liveinareaswithhighHIVprevalence,orhaveHIVinfected
partners).RapidHIVscreeningshouldbeperformedonanywomaninlaborwhohasanundocumentedHIVstatusunlessshe
declines.IfarapidHIVtestresultispositiveinthesewomen,antiretroviralprophylaxisshouldbeadministeredwithout
waitingfortheresultsoftheconfirmatorytest(78).
Aserologictestforsyphilisshouldbeperformedonallpregnantwomenatthefirstprenatalvisit(79).Inpopulationsinwhich
theamountofprenatalcaredeliveredisnotoptimal,rapidplasmareagin(RPR)cardtestscreening(andtreatment,ifthattest
isreactive)shouldbeperformedatthetimethatapregnancyisconfirmed.Womenwhoareathighriskforsyphilis,livein
areasofhighsyphilismorbidity,orarepreviouslyuntestedshouldbescreenedagainearlyinthethirdtrimester(at
approximately28weeks'gestation)andatdelivery.Somestatesrequireallwomentobescreenedatdelivery.Infantsshould
notbedischargedfromthehospitalunlessthesyphilisserologicstatusofthemotherhasbeendeterminedatleastonetime
duringpregnancyandpreferablyagainatdelivery.Anywomanwhodeliversastillborninfantshouldbetestedforsyphilis.
AllpregnantwomenshouldberoutinelytestedforhepatitisBsurfaceantigen(HBsAg)duringanearlyprenatalvisit(i.e.,avisit
duringthefirsttrimester),eveniftheyhavebeenpreviouslyvaccinatedortested(80).Womenwhowerenotscreened
prenatally,thosewhoengageinbehaviorsthatputthemathighriskforinfection(e.g.,havinghadmorethanonesexpartnerin
theprevious6months,evaluationortreatmentforanSTD,recentorcurrentinjectiondruguse,andanHBsAgpositivesex
partner)andthosewithclinicalhepatitisshouldberetestedatthetimeofadmissiontothehospitalfordelivery.Pregnant
womenatriskforHBVinfectionalsoshouldbevaccinated.ToavoidmisinterpretingatransientpositiveHBsAgresultduring
the21daysaftervaccination,HBsAgtestingshouldbeperformedbeforevaccineadministration.Alllaboratoriesthatconduct
HBsAgtestsshoulduseanFDAclearedHBsAgtestandperformtestingaccordingtothemanufacturer'slabeling,including
testingofinitiallyreactivespecimenswithalicensedneutralizingconfirmatorytest.Whenpregnantwomenaretestedfor
HBsAgatthetimeofadmissionfordelivery,shortenedtestingprotocolscanbeused,andinitiallyreactiveresultsshould
promptexpeditedadministrationofimmunoprophylaxistoinfants(80).
AllpregnantwomenshouldberoutinelyscreenedforChlamydiatrachomatis(seeChlamydiaInfections,Diagnostic
Considerations)duringthefirstprenatalvisit(81).Womenaged25yearsandthoseatincreasedriskforchlamydia(e.g.,
womenwhohaveanewormorethanonesexpartner)alsoshouldberetestedduringthethirdtrimestertopreventmaternal
postnatalcomplicationsandchlamydialinfectionintheinfant.Womenfoundtohavechlamydialinfectionduringthefirst
trimestershouldberetestedwithinapproximately36months,preferablyinthethirdtrimester.Screeningduringthefirst
trimestermightpreventtheadverseeffectsofchlamydiaduringpregnancy,butsupportiveevidenceforsuchscreeningis
lacking.
AllpregnantwomenatriskforgonorrheaorlivinginanareainwhichtheprevalenceofNeisseriagonorrhoeaeishighshould
bescreenedatthefirstprenatalvisitforN.gonorrhoeae(82).Womenaged<25yearsareathighestriskforgonorrhea
infection.Otherriskfactorsforgonorrheaincludeapreviousgonorrheainfection,otherSTDs,newormultiplesexpartners,
inconsistentcondomuse,commercialsexwork,anddruguse.Pregnantwomenfoundtohavegonococcalinfectionduringthe
firsttrimestershouldberetestedwithinapproximately36months,preferablyinthethirdtrimester.Uninfectedpregnant
womenwhoremainathighriskforgonococcalinfectionalsoshouldberetestedduringthethirdtrimester.
AllpregnantwomenathighriskforhepatitisCinfectionshouldbescreenedforhepatitisCantibodies(seeHepatitisC,
DiagnosticConsiderations)atthefirstprenatalvisit.Womenathighriskincludethosewithahistoryofinjectiondruguseand
thosewithahistoryofbloodtransfusionororgantransplantionbefore1992.
PregnantwomenshouldundergoaPapanicolau(Pap)testatthesamefrequencyasnonpregnantwomen,although
recommendationsfortheirmanagementdiffer(83,84).

OtherTests
Evidencedoesnotsupportroutinetestingforbacterialvaginosis(BV)inpregnancy.Forasymptomaticpregnantwomenathigh

riskforpretermdelivery,evidenceisinsufficienttoassessthebalanceofbenefitsandharmsofscreeningforBV(85).
Symptomaticwomenshouldbeevaluatedandtreated(seeBacterialVaginosis).
EvidencedoesnotsupportroutinescreeningforTrichomonasvaginalisinasymptomaticpregnantwomen.Womenwhoreport
symptomsshouldbeevaluatedandtreatedappropriately(seeTrichomonas).
EvidencedoesnotsupportroutineHSV2serologicscreeningamongpreviouslyundiagnosedwomenduringpregnancy.

OtherConcerns
PregnantwomenwhoareHBsAgpositiveshouldbereportedtothelocalorstatehealthdepartmenttoensurethattheyare
enteredintoacasemanagementsystemandthattimelyandappropriateprophylaxisisprovidedfortheirinfants.Information
concerningthepregnantwoman'sHBsAgstatusshouldbeprovidedtothehospitalinwhichdeliveryisplannedandtothe
healthcareproviderwhowillcareforthenewborn.Inaddition,householdandsexcontactsofwomenwhoareHBsAgpositive
shouldbevaccinated.
WomenwhoareHBsAgpositiveshouldbeprovidedwith,orreferredfor,appropriatecounselingandmedicalmanagement.
PregnantwomenwhoareHBsAgpositiveshouldreceiveinformationregardinghepatitisBthataddresses:
modesoftransmission
perinatalconcerns(e.g.,breastfeedingisnotcontraindicated)
preventionofHBVtransmission,includingtheimportanceofpostexposureprophylaxisforthenewborninfantandhepatitis
Bvaccinationforhouseholdcontactsandsexpartnersand
evaluationforandtreatmentofchronicHBVinfection.
NotreatmentisavailableforpregnantwomeninfectedwithhepatitisCvirus(HCV).However,allwomenwithHCVinfection
shouldreceiveappropriatecounselingandsupportivecareasneeded(seeHepatitisC,Prevention).Novaccineisavailableto
preventHCVtransmission.
Intheabsenceoflesionsduringthethirdtrimester,routineserialculturesforherpessimplexvirus(HSV)arenotindicatedfor
womenwhohaveahistoryofrecurrentgenitalherpes.Prophylacticcesareandeliveryisnotindicatedforwomenwhodonot
haveactivegenitallesionsatthetimeofdelivery.
Thepresenceofgenitalwartsisnotanindicationforcesareandelivery.
ForamoredetaileddiscussionofSTDtestingandtreatmentamongpregnantwomen,refertothefollowingreferences:Prenatal
screeningforHIV:AReviewoftheevidencefortheU.S.PreventiveServicesTaskForce(86)RevisedRecommendationsforHIV
TestingofAdults,Adolescents,andPregnantWomeninHealthCareSetting(77)GuidelinesforPerinatalCare(87)RapidHIV
AntibodyTestingDuringLaborandDeliveryforWomenofUnknownHIVStatus:APracticalGuideandModelProtocol(88)
ViralHepatitisinPregnancy(89)HepatitisBVirus:AComprehensiveStrategyforEliminatingTransmissionintheUnited
StatesRecommendationsoftheImmunizationPracticesAdvisoryCommittee(ACIP)(4)ScreeningforChlamydialInfection:
U.S.PreventiveServicesTaskForceRecommendationStatement(81)Canadianguidelinesonsexuallytransmittedinfections
(90)USPSTFrecommendationsforSTIscreening(91)andScreeningforBacterialVaginosisinPregnancytoPreventPreterm
Delivery:U.S.PreventiveServicesTaskForceRecommendationStatement(85).
RecommendationstoscreenpregnantwomenforSTDsarebasedondiseaseseverityandsequelae,prevalenceinthepopulation,
costs,medicolegalconsiderations(e.g.,statelaws),andotherfactors.Thescreeningrecommendationsinthisreportaregenerally
broader(i.e.,iffollowed,morewomenwillbescreenedformoreSTDsthanwouldbyfollowingotherscreeningrecommendations)
andarealsoconsistentwithotherCDCguidelines.

Adolescents
IntheUnitedStates,prevalenceratesofmanysexuallyacquiredinfectionsarehighestamongadolescents(92,93).Forexample,the
reportedratesofchlamydiaandgonorrheaarehighestamongfemalesaged1519years,andmanypersonsacquireHPVinfection
duringtheiradolescentyears.
PersonswhoinitiatesexearlyinadolescenceareathigherriskforSTDs,alongwithpersonsresidingindetentionfacilities,
attendingSTDclinics,youngmenhavingsexwithmen(YMSM),andyouthwhouseinjectiondrugs.Factorscontributingtothis
increasedriskduringadolescenceincludehavingmultiplesexualpartnersconcurrently,havingsequentialsexualpartnershipsof
limitedduration,failingtousebarrierprotectionconsistentlyandcorrectly,havingincreasedbiologicsusceptibilitytoinfection,and
experiencingmultipleobstaclestoaccessinghealthcare(92).
All50statesandtheDistrictofColumbiaexplicitlyallowminorstoconsentfortheirownhealthservicesforSTDs.Nostaterequires
parentalconsentforSTDcareorrequiresthatprovidersnotifyparentsthatanadolescentminorhasreceivedSTDservices,except
inlimitedorunusualcircumstances.
Protectingconfidentialityforsuchcare,particularlyforadolescentsenrolledinprivatehealthinsuranceplans,presentsmultiple
problems.Afteraclaimhasbeenreported,manystatesmandatethathealthplansprovideawrittenstatementtoabeneficiary
indicatingthebenefitsandchargescoveredornotcoveredbythehealthplan(i.e.,explanationofbenefit[EOB]).Inaddition,federal
lawsobligatenoticestobeneficiarieswhenclaimsaredenied,includingalertingconsumerswhoneedtopayforcareuntilthe
allowabledeductableisreached.ForSTDdetectionandtreatmentrelatedcare,anEOBormedicalbillthatisreceivedbyaparent
mightdiscloseservicesprovidedandlistanylaboratorytestsperformed.Thistypeofmandatednotificationbreeches
confidentiality,andataminimum,couldpromptparentsandguardianstoquestionthecostsandreasonsforserviceprovision.

Despitethehighratesofinfectionsdocumentedintheadolescentpopulation,providersfrequentlyfailtoinquireaboutsexual
behaviors,assessSTDrisks,provideriskreductioncounseling,andultimately,failtoscreenforasymptomaticinfectionsduring
clinicalencounters.Sexualhealthdiscussionsshouldbeappropriateforthepatient'sdevelopmentallevelandshouldbeaimedat
identifyingriskbehaviors(e.g.,unprotectedoral,anal,orvaginalsexanddrugusebehaviors).Careful,nonjudgmental,and
thoroughcounselingisparticularlyvitalforadolescentswhomightnotfeelcomfortableacknowledgingtheirengagementin
behaviorsthatplacethemathighriskforSTDs.

ScreeningRecommendations
RoutinelaboratoryscreeningforcommonSTDsisindicatedforsexuallyactiveadolescents.Thefollowingscreening
recommendationssummarizepublishedfederalagencyandmedicalprofessionalorganizations'clinicalguidelinesforsexually
activeadolescents:
RoutinescreeningforC.trachomatisofallsexuallyactivefemalesaged25yearsisrecommendedannually(81).Evidenceis
insufficienttorecommendroutinescreeningforC.trachomatisinsexuallyactiveyoungmenbasedonfeasibility,efficacy,and
costeffectiveness.However,screeningofsexuallyactiveyoungmenshouldbeconsideredinclinicalsettingsassociatedwith
highprevalenceofchlamydia(e.g.,adolescentclinics,correctionalfacilities,andSTDclinics)(81,94).
RoutinescreeningforN.gonorrhoeaeinallsexuallyactivewomenatriskforinfectionisrecommendedannually(82).Women
aged<25yearsareathighestriskforgonorrheainfection.Otherriskfactorsthatplacewomenatincreasedriskincludea
previousgonorrheainfection,thepresenceofotherSTDs,newormultiplesexpartners,inconsistentcondomuse,commercial
sexwork,anddruguse.
HIVscreeningshouldbediscussedwithalladolescentsandencouragedforthosewhoaresexuallyactiveandthosewhouse
injectiondrugs(77,95).
TheroutinescreeningofadolescentswhoareasymptomaticforcertainSTDs(e.g.,syphilis,trichomoniasis,BV,HSV,HPV,
HAV,andHBV)isnotrecommended.However,YMSMandpregnantadolescentfemalesmightrequiremorethorough
evaluation.
GuidelinesfromUSPSTFandACOGrecommendthatcervicalcancerscreeningbeginatage21years(96,97),a
recommendationbasedonthelowincidenceofcervicalcancerandlimitedutilityofscreeningforyoungeradolescents(98).
However,theAmericanCancerSociety(ACS)recommendsthatwomenstartcervicalscreeningwithPaptests3yearsafter
initiatingsexualactivity,butbynolaterthanage21years(99).

PrimaryPreventionRecommendations
PrimarypreventionandanticipatoryguidancetorecognizesymptomsandbehaviorsassociatedwithSTDsarestrategiesthatcanbe
incorporatedintoanyoralltypesofhealthcarevisits.ThefollowingrecommendationsforprimarypreventionofSTDs(i.e.,
vaccinationandcounseling)arebasedonpublishedfederalagencyandmedicalprofessionalorganizations'clinicalguidelinesfor
sexuallyactiveadolescents:
TheHPVvaccine,eitherCervarixorGardasil,isrecommendedfor11and12yearoldfemales.Thevaccineseriescanbestarted
at9yearsofage.Catchupvaccinationisrecommendedforfemalesaged1326yearswhohavenotyetreceivedorcompleted
thevaccineseries(16).Thequadrivalent(Gardasil)HPVvaccinecanalsobeusedinmalesandfemalesaged926yearsto
preventgenitalwarts(17).
TheHBVvaccinationseriesisrecommendedforalladolescents.AdolescentswhohavenotpreviouslyreceivedhepatitisB
vaccineshouldbevaccinatedroutinelyatanyagewithanappropriatedoseandschedule(3,4).
TheHAVvaccinationseriesforchildrenandadolescentsaged218yearsshouldbeofferedinareaswithexistinghepatitisA
vaccinationprograms.InareaswithoutexistinghepatitisAvaccinationprograms,catchupvaccinationofunvaccinated
childrenaged218yearscanbeconsidered(2).
InformationregardingHIVinfection,testing,transmission,andimplicationsofinfectionshouldberegardedasanessential
componentoftheanticipatoryguidanceprovidedtoalladolescentsaspartofhealthcare(77).
Healthcareproviderswhocareforchildrenandadolescentsshouldintegratesexualityeducationintoclinicalpractice.
ProvidersshouldcounseladolescentsaboutthesexualbehaviorsthatareassociatedwithriskforacquiringSTDsandshould
educatepatientsusingevidencebasedpreventionstrategies,allofwhichincludeadiscussionaboutabstinenceandotherrisk
reductionbehaviors(e.g.,consistentandcorrectcondomuse).USPSTFrecommendshighintensitybehavioralcounselingto
preventSTIs*forallsexuallyactiveadolescents(6).

Children
ManagementofchildrenwhohaveSTDsrequiresclosecooperationbetweenclinicians,laboratorians,andchildprotection
authorities.Officialinvestigations,whenindicated,shouldbeinitiatedpromptly.Certaindiseases(e.g.,gonorrhea,syphilis,and
chlamydia),ifacquiredaftertheneonatalperiod,arevirtually100%indicativeofsexualcontact.Forotherdiseases(e.g.,HPV
infectionsandvaginitis),theassociationwithsexualcontactisnotasclear(seeSexualAssaultandSTDs).

PersonsinCorrectionalFacilities
MultiplestudieshavedemonstratedthatpersonsenteringcorrectionalfacilitieshavehighratesofSTDs(includingHIV)andviral
hepatitis,especiallythoseaged35years(93).Incarceratedpersonsaremorelikelytohavelowsocioeconomicstatus,liveinurban
areas,andbeethnicandracialminorities.RiskbehaviorsforcontractingSTDs(e.g.,havingunprotectedsexhavingmultiplesexual

partnersusingdrugsandalcoholandengagingincommercial,survival[prostitutiontoearnmoneyforfood,shelter,ordrugs],or
coercedsex)arecommonamongincarceratedpopulations.Beforeincarceration,manyhavehadlimitedaccesstomedicalcare,
especiallytocommunitybasedclinicalpreventionservices.
AlthoughnocomprehensivenationalguidelinesregardingSTDcareandmanagementhavebeendevelopedforcorrectional
populations,theutilityofexpandedSTDservicesincorrectionalsettingshasbeenreported(100).CapacitytoprovideSTDcarealso
variesbytypeofcorrectionalfacility.Forexample,localjuveniledetentionfacilitiesandjailsareshorttermfacilities(oftenhousing
entrantsfor1year)whereuptohalfofallentrantsarereleasedbacktothecommunitywithin48hoursofarrest,thereby
complicatingeffortstoprovidecomprehensiveSTDservices.Theseservicesarelikelymoreconducivetoprisonsandstatejuvenile
confinementfacilities,whicharelongterm,securefacilitieswhereentrantsareheldforalongerperiodoftime.
Mostinstitutions,especiallythoseforadults,donotroutinelyscreenforSTDs.Diagnostictestingofinmateswithsymptoms
indicativeofanSTDisthemorecommonpracticeinjuveniledetentionandjailfacilities.However,screeningforasymptomatic
infectionsfacilitatestheidentificationandtreatmentofpersonswithotherwiseundetectedinfections,whichnotonlyeliminates
complicationsfortheindividual,butreducestheprevalenceofinfectionamongdetaineeswhoarereleasedbackintothelocal
community.
Femalesinjuveniledetentionfacilitiesandyoungwomen35yearsofagehavebeenreportedtohavehighratesofchlamydia(101)
andgonorrhea(93).Syphilisseroprevalencerates,whichcanindicatepreviousinfection,areconsiderablyhigheramongadultmen
andwomenthaninadolescents,consistentwiththeoverallnationalsyphilistrends(102).

ChlamydiaandGonorrheaScreening
Universalscreeningofadolescentfemalesforchlamydiaandgonorrheashouldbeconductedatintakeinjuveniledetentionorjail
facilities.Universalscreeningofadultfemalesshouldbeconductedatintakeamongadultfemalesupto35yearsofage(oronthe
basisoflocalinstitutionalprevalencedata).

SyphilisScreening
Universalscreeningshouldbeconductedonthebasisofthelocalareaandinstitutionalprevalenceofearly(primary,secondary,and
earlylatent)infectioussyphilis.

MSM
SubgroupsofMSMareathighriskforHIVinfectionandotherviralandbacterialSTDs.Thefrequencyofunsafesexualpractices
andthereportedratesofbacterialSTDsandincidentHIVinfectiondeclinedsubstantiallyinMSMfromthe1980sthroughthemid
1990s.However,sincethattime,increasedratesofearlysyphilis(primary,secondary,orearlylatent),gonorrhea,andchlamydial
infectionandhigherratesofunsafesexualbehaviorshavebeendocumentedamongMSMintheUnitedStatesandvirtuallyall
industrializedcountries(103,104).TheeffectofthesebehavioralchangesonHIVtransmissionhasnotbeenascertained,but
preliminarydatasuggestthattheincidenceofHIVinfectionisincreasingamongMSMinsomeurbancenters,particularlyamong
MSMfromracialandethnicminoritygroups(105)andamongthosewhousenonprescriptiondrugsduringsex,particularly
methamphetamineandvolatilenitrites(alsoknownas"poppers").Theseadversetrendslikelyreflectthe1)changingattitudes
concerningHIVinfectionthathaveaccompaniedadvancesinHIVtherapy,resultinginimprovedqualityoflifeandsurvivalfor
HIVinfectedpersons2)changingpatternsofsubstanceabuse3)demographicshiftsinMSMpopulationsand4)changesinsex
partnernetworksresultingfromnewvenuesforpartneracquisition(e.g.,theinternet).IncreasesinbacterialSTDsarenot
necessarilyaccompaniedbyincreasesinHIVincidenceforexample,oralsexmaypermitefficientspreadofbacterialSTDsbutnot
HIV,asdoesserosorting(preferentialselectionofsexpartnersofthesameserostatus)amongHIVinfectedMSM(106,107).
CliniciansshouldassesstheSTDrelatedrisksforallmalepatients,includingaroutineinquiryaboutthesexofsexpartners.MSM,
includingthosewithHIVinfection,shouldroutinelyundergononjudgmentalSTD/HIVriskassessmentandclientcentered
preventioncounselingtoreducethelikelihoodofacquiringortransmittingHIVorotherSTDs.Cliniciansshouldbefamiliarwith
thelocalcommunityresourcesavailabletoassistMSMathighriskinfacilitatingbehavioralchangeandtoenabletheconductof
partnernotificationactivities.CliniciansalsoshouldroutinelyasksexuallyactiveMSMaboutsymptomsconsistentwithcommon
STDs,includingurethraldischarge,dysuria,genitalandperianalulcers,regionallymphadenopathy,skinrash,andanorectal
symptomsconsistentwithproctitis,includingdischargeandpainondefecationorduringanalintercourse.Cliniciansshould
performappropriatediagnostictestingonallsymptomaticpatients.
RoutinelaboratoryscreeningforcommonSTDsisindicatedforallsexuallyactiveMSM.Thefollowingscreeningtestsshouldbe
performedatleastannuallyforsexuallyactiveMSM:
HIVserology,ifHIVnegativeornottestedwithinthepreviousyear
syphilisserology,withaconfirmatorytestingtoestablishwhetherpersonswithreactiveserologieshaveincidentuntreated
syphilis,havepartiallytreatedsyphilis,oraremanifestingaslowserologicresponsetoappropriatepriortherapy
atestforurethralinfectionwithN.gonorrhoeaeandC.trachomatisinmenwhohavehadinsertiveintercourseduringthe
precedingyeartestingoftheurineusingnucleicacidamplificationtesting(NAAT)isthepreferredapproach
atestforrectalinfectionwithN.gonorrhoeaeandC.trachomatisinmenwhohavehadreceptiveanalintercourse*duringthe
precedingyear(NAATofarectalswabisthepreferredapproach)and
atestforpharyngealinfectionwithN.gonorrhoeaeinmenwhohavehadreceptiveoralintercourseduringthepreceding

year(NAATisthepreferredapproach).TestingforC.trachomatispharyngealinfectionisnotrecommended.
EvaluationforHSV2infectionwithtypespecificserologictestsalsocanbeconsideredifinfectionstatusisunknownknowledgeof
HSV2serostatusmightbehelpfulinidentifyingpersonswithpreviouslyundiagnosedgenitaltractinfection.Becauseofthe
increasedincidenceofanalcancerinHIVinfectedMSM,screeningforanalcytologicabnormalitiescanbeconsideredhowever,
evidenceislimitedconcerningthenaturalhistoryofanalintraepithelialneoplasias,thereliabilityofscreeningmethods,thesafety
andresponsetotreatments,andtheprogrammaticsupportneededforsuchascreeningactivity.
MorefrequentSTDscreening(i.e.,at36monthintervals)isindicatedforMSMwhohavemultipleoranonymouspartners.In
addition,MSMwhohavesexinconjunctionwithillicitdruguse(particularlymethamphetamineuse)orwhosesexpartners
participateintheseactivitiesshouldbescreenedmorefrequently.
AllMSMshouldbetestedforHBsAgtodetectHBVinfection.PromptidentificationofchronicinfectionwithHBVisessentialto
ensurenecessarycareandservicestopreventtransmissiontoothers(108).HBsAgtestingshouldbemadeavailableinSTD
treatmentsettings.Inaddition,screeningamongpastorcurrentdrugusersshouldincludeHCVandHBVtesting.
VaccinationagainsthepatitisAandBisrecommendedforallMSMinwhompreviousinfectionorvaccinationcannotbe
documented(2,3).PreimmunizationserologictestingmightbeconsideredtoreducethecostofvaccinatingMSMwhoarealready
immunetotheseinfections,butthistestingshouldnotdelayvaccination.VaccinatingpersonswhoareimmunetoHAVorHBV
infectionbecauseofpreviousinfectionorvaccinationdoesnotincreasetheriskforvaccinerelatedadverseevents(seeHepatitisB,
PrevaccinationAntibodyScreening).SexualtransmissionofhepatitisCvirusinfectioncanoccur,especiallyamongHIVinfected
MSM.SerologicscreeningforhepatitisCinfectionisrecommendedatinitialevaluationofnewlydiagnosedHIVinfectedpersons.
HIVinfectedMSMcanalsoacquireHCVafterinitialscreeningtherefore,menwithnewandunexplainedincreasesinalanine
aminotransferase(ALT)shouldbetestedforacuteHCVinfection.TodetectacuteHCVinfectionamongHIVinfectedMSMwith
highrisksexualbehaviorsorconcomitantulcerativeSTDs,routineHCVtestingofHIVinfectedMSMshouldbeconsidered.

WomenWhoHaveSexwithWomen
Womenwhohavesexwithwomen(WSW)areadiversegroupwithvariationsinsexualidentity,sexualbehaviors,sexualpractices,
andriskbehaviors.RecentstudiesindicatethatsomeWSW,particularlyadolescents,youngwomen,andwomenwithbothmaleand
femalepartners,mightbeatincreasedriskforSTDsandHIVasaresultofcertainreportedriskbehaviors(109112).WSWareat
riskforacquiringbacterial,viral,andprotozoalinfectionsfromcurrentandpriorpartners,bothmaleandfemale.WSWshouldnot
bepresumedtobeatlowornoriskforSTDsbasedonsexualorientation.Effectivescreeningrequiresthatprovidersandtheir
femaleclientsengageinacomprehensiveandopendiscussionnotonlyaboutsexualidentify,butsexualandbehavioralrisks.
FewdataareavailableontheriskforSTDstransmittedbysexbetweenwomen,butriskprobablyvariesbythespecificSTDand
sexualpractice(e.g.,oralgenitalsexvaginaloranalsexusinghands,fingers,orpenetrativesexitemsandoralanalsex[113,114]).
Practicesinvolvingdigitalvaginalordigitalanalcontact,particularlywithsharedpenetrativesexitems,presentapossiblemeans
fortransmissionofinfectedcervicovaginalsecretions.Thispossibilityismostdirectlysupportedbyreportsofmetronidazole
resistanttrichomoniasis(115)andgenotypeconcordantHIVtransmittedsexuallybetweenwomenwhoreportedthesebehaviors
(116)andbythehighprevalenceofBVamongmonogamousWSW(117).
TransmissionofHPVcanoccurwithskintoskinorskintomucosacontact,whichcanoccurduringsexbetweenwomen.HPV
DNAhasbeendetectedthroughpolymerasechainreaction(PCR)basedmethodsfromthecervix,vagina,andvulvain13%30%of
WSW,andhighandlowgradesquamousintraepitheliallesions(SIL)havebeendetectedonPaptestsinWSWwhoreportedno
previoussexwithmen(118).However,mostselfidentifiedWSW(53%99%)reporthavinghadsexwithmenandindicatethatthey
mightcontinuethispracticeinthefuture(119).Therefore,routinecervicalcancerscreeningshouldbeofferedtoallwomen,
regardlessofsexualpreferenceorsexualpractices,andwomenshouldbeofferedHPVvaccineinaccordancewithcurrent
guidelines.
LimiteddatademonstratethatHSV2genitaltransmissionbetweenfemalesexpartnersisprobablyinefficientbutcanoccur.The
relativelyfrequentpracticeoforogenitalsexamongWSWmightplacethemathigherriskforgenitalinfectionwithherpessimplex
virustype1(HSV1),ahypothesissupportedbytherecognizedassociationbetweenHSV1seropositivityandnumberoffemale
partnersamongWSW(120).
AlthoughtherateoftransmissionofC.trachomatisbetweenwomenremainslargelyunknown,infectionalsocanbeacquiredfrom
pastorcurrentmalepartners.RecentdatasuggestthatC.trachomatisinfectionamongWSWmightbemorecommonthan
previouslythought(121)transmissionofsyphilisbetweenfemalesexpartners(likelythroughoralsex)alsohasbeenreported.
Therefore,reportofsamesexbehaviorinwomenshouldnotdeterprovidersfromscreeningthesewomenforSTDs,including
chlamydiaandsyphilis,asrecommended.
BViscommonamongwomeningeneralandevenmoresoamongwomenwithfemalepartners.Sexualbehaviorsthatfacilitatethe
transferofvaginalfluidand/orbacteriabetweenpartnersmightbeinvolvedinthepathogenesisofBV.Arecentstudydemonstrated
thatfemalesexpartnersfrequentlyshareidenticalgenitalLactobacillusstrains(122).AlthoughBViscommoninWSW,routine
screeningforBVisnotrecommended,noristhetreatmentofpartnersofwomenwithBV.Encouragingawarenessofsignsand
symptomsofBVinwomenandencouraginghealthysexualpractices(e.g.,cleaningsharedsextoysbetweenuses)mightbehelpful.

HIVInfection:Detection,Counseling,andReferral

HIVinfectionrepresentsaspectrumofdiseasethatcanbeginwithabriefacuteretroviralsyndromethattypicallytransitionstoa
multiyearchronicandclinicallylatentillness.Withouttreatment,thisillnesseventuallyprogressestoasymptomatic,life
threateningimmunodeficiencydiseaseknownasAIDS.Inuntreatedpatients,thetimebetweenHIVinfectionandthedevelopment
ofAIDSvaries,rangingfromafewmonthstomanyyearswithanestimatedmediantimeofapproximately11years(123).HIV
replicationispresentduringallstagesoftheinfectionandprogressivelydepletesCD4lymphocytes,whicharecriticalfor
maintenanceofeffectiveimmunefunction.WhentheCD4cellcountfallsbelow200cells/L,patientsareathighriskforlife
threateningAIDSdefiningopportunisticinfections(e.g.,Pneumocystispneumonia,Toxoplasmagondiiencephalitis,disseminated
Mycobacteriumaviumcomplexdisease,tuberculosis,andbacterialpneumonia).Intheabsenceoftreatment,virtuallyallHIV
infectedpersonswilldieofAIDS.
EarlydiagnosisofHIVinfectionisessentialtoensuringthatpatientsarereferredpromptlyforevaluation,providedtreatment(if
indicated),andlinkedintocounselingandrelatedsupportservicestohelpthemreducetheirriskfortransmittingHIVtoothers.
Diagnosingpersonsduringacuteinfectionisparticularlyimportant.ItisduringthisphasethatHIVinfectedpersonsaremost
infectious(124126),buttestnegativeforHIVantibodiesandthereforeunknowinglycontinuetoengageinthosehighrisk
behaviorsassociatedwithHIVtransmission.ProvidersareinaparticularlygoodpositiontodiagnosepersonsduringacuteHIV
infectionbecausesuchpersonsmightpresentforassessmentandtreatmentofaconcomitantlyacquiredSTDduringthisphaseof
thedisease.KnowingthatapatientisinfectedwithHIVhasimportantclinicalimplicationsbecauseHIVinfectionaltersthe
immunesystemandtherebyaffectsthediagnosis,evaluation,treatment,andfollowupofotherSTDs.
Evenintheeraofhighlyeffectiveantiretroviraltherapy(HAART),HIVinfectionisoftendiagnosedinpersonswithadvanced
infection(i.e.,personswithlowCD4cellcounts).Nationally,theproportionofpatientsdiagnosedwithAIDSatorwithin12months
oftheirHIVdiagnosisin2007was32%(127).Since2006,CDChasendorsedeffortstoincreaseHIVtestingbystreamliningthe
consentprocessandexpandingoptouttestingtoallhealthcaresettings,especiallySTDclinics(77).However,ratesoftesting
remainunacceptablylow:in2006,only40%ofsurveyedadultshadeverbeentested,and<25%ofhighriskadultshadbeentested
duringthepreceding12months(128).
PropermanagementofHIVinfectionrequiresmedicaltherapy,whichformanypatientsshouldbecoupledwithbehavioraland
psychosocialservices.ComprehensiveHIVtreatmentservicesareusuallynotavailableinfacilitiesfocusingprimarilyonSTD
treatment(e.g.,STDclinics)therefore,patientsdiagnosedinthesesettingsideallyshouldbereferredtoahealthcareprovideror
facilityexperiencedincaringforHIVinfectedpatients.Nonetheless,providersworkinginSTDtreatmentfacilitiesshouldbe
knowledgeableaboutthetreatmentoptionsavailableintheircommunities,educatepersonswhotestpositiveforHIVaboutthe
illness,andknowwheretorefertheirpatientsforsupportservicesandHIVcare.
AdetaileddiscussionofthecomplexissuesrequiredforthemanagementofHIVinfectionisbeyondthescopeofthisreport
howeverthisinformationisavailableinotherpublishedresources(129131).Insubsequentsectionsofthisreport,additionaltypes
ofHIVrelatedinformationaboutthediagnosisofHIVinfection,counselingofHIVinfectedpatients,referralofpatientsforsupport
services(includingmedicalcare),andmanagementofsexandinjectiondrugpartnersinSTDtreatmentfacilitiesisprovided.In
addition,thisreportdiscussesHIVinfectionduringpregnancyandamonginfantsandchildren.

DetectionofHIVInfection:ScreeningandEstablishingaDiagnosis
AllpersonswhoseekevaluationandtreatmentforSTDsshouldbescreenedforHIVinfection.Screeningshouldberoutine,
regardlessofwhetherthepatientisknownorsuspectedtohavespecificbehavioralrisksforHIVinfection.

ConsentandPretestInformation
CDCrecommendsHIVscreeningforpatientsaged1364yearsinallhealthcaresettings(77).Patientsshouldbenotifiedthat
testingwillbeperformed,butgiventheoptiontodeclineordefertesting(i.e.,providedwithoptouttesting)(128).Assentis
inferredunlessthepatientverballydeclinestesting.SeparatewrittenconsentforHIVtestingshouldnotberequiredinmost
facilities,generalconsentformedicalcareisconsideredsufficienttoencompassconsentforHIVtesting.Providingprevention
counselingalongwithHIVdiagnostictestingoraspartofHIVscreeningprogramsisnotarequirementwithinhealthcaresettings.
Inaddition,routineoptouttesting(insteadoftraditionalwritteninformedconsentwithpreandposttestcounseling)mightbe
precludedinsomejurisdictionsbylocallawsandregulations,althoughmanystateandlocalauthoritieshaveupdatedlawsand
regulationstofacilitateadoptionofroutineoptouttesting.Informationaboutregulationsinspecificjurisdictionsisavailable
throughtheNationalCliniciansConsultationCenteratwww.nccc.ucsf.edu .

PreventionCounseling
Preventioncounselingshouldbeofferedandencouragedinallhealthcarefacilitiesthatservepatientsathighrisk(e.g.,STD
clinics),becausethesefacilitiesroutinelyelicitinformationaboutthebehaviorsthatplacepersonsathighriskforHIV.Prevention
counselingneednotbeexplicitlylinkedtoHIVtesting.However,somepatientsmightbemorelikelytothinkaboutHIVand
considertheirriskrelatedbehaviorwhenundergoinganHIVtest.HIVtestingpresentsanexcellentopportunitytoprovideor
arrangeforpreventioncounselingtoassistwithbehaviorchangesthatcanreduceriskforacquiringHIVinfection.

EstablishingtheDiagnosisofHIVInfection
HIVinfectioncanbediagnosedbyserologicteststhatdetectantibodiesagainstHIV1andHIV2andbyvirologicteststhatcan
detectHIVantigensorribonucleicacid(RNA).Antibodytestingbeginswithasensitivescreeningtest(e.g.,theconventionalor
rapidenzymeimmunoassay[EIA]).Currentlyavailableserologictestsarebothhighlysensitiveandspecificandcandetectall
knownsubtypesofHIV1.MostcanalsodetectHIV2anduncommonvariantsofHIV1(e.g.,GroupOandGroupN).Theadventof

HIVrapidserologictestinghasenabledclinicianstomakeanaccuratepresumptivediagnosisofHIVinfectionwithinhalfanhour,
whichcouldpotentiallyfacilitatetheidentificationoftheapproximately250,000personsestimatedtobelivingwithundiagnosed
HIVintheUnitedStates(127).
Reactivescreeningtestsmustbeconfirmedbyasupplementalantibodytest(i.e.,Westernblot[WB]andindirect
immunofluorescenceassay[IFA])orvirologictest(i.e.,theHIV1RNAassay)(132).Aconfirmedpositiveantibodytestresult
indicatesthatapersonisinfectedwithHIVandcapableoftransmittingthevirustoothers.HIVantibodyisdetectableinatleast
95%ofpatientswithin3monthsafterinfection.Althoughanegativeantibodytestresultusuallyindicatesthatapersonisnot
infected,antibodytestscannotexcluderecentinfection.VirologictestsforHIV1RNAcanalsobeusedtoidentifyacuteinfectionin
personswhoarenegativeforHIVantibodies.
ThemajorityofHIVinfectionsintheUnitedStatesarecausedbyHIV1.However,HIV2infectionshouldbesuspectedinpersons
whohaveepidemiologicriskfactorsoranunusualclinicalpresentation.EpidemiologicfactorsassociatedwithHIV2infection
includehavinglivedinorhavingasexpartnerfromanHIV2endemicarea(e.g.,WestAfricaandsomeEuropeancountriessuchas
Portugal,whereHIV2prevalenceisincreasing),havingasexpartnerknowntobeinfectedwithHIV2,orhavingreceivedablood
transfusionornonsterileinjectioninanHIV2endemicarea.SpecifictestingforHIV2isalsoindicatedwhenclinicalevidenceof
HIVinfectionexistsbuttestsforHIV1antibodiesorHIV1viralloadarenegative,orwhenHIV1WBresultsexhibittheunusual
indeterminatepatternofgag(p55,p24,p17)pluspol(p66,p51,p31)bandsintheabsenceofenv(gp160,gp120,gp41)bands.
HealthcareprovidersshouldbeknowledgeableaboutacuteHIVinfectionandthesymptomsandsignsofacuteretroviral
syndrome,whichdevelopsin50%80%ofacutelyinfectedpatients.Acuteretroviralsyndromeischaracterizedbynonspecific
symptoms,includingfever,malaise,lymphadenopathy,andskinrash.ItfrequentlyoccursinthefirstfewweeksafterHIVinfection,
beforeantibodytestresultsbecomepositive.Suspicionofacuteretroviralsyndromeshouldresultinpromptnucleicacidtesting
(HIVplasmaRNA)inadditiontoanHIVantibodytesttodetectthepresenceofHIV.ApositiveHIVnucleicacidtestshouldbe
confirmedbysubsequentantibodytestingtodocumentseroconversion.Acutelyinfectedpatientsarehighlycontagiousduringthis
stageofinfectionbecausetheconcentrationofvirusinplasmaandgenitalsecretionsisextremelyelevated(125,133).Antiretroviral
therapymightbenefitthehealthofpersonswithrecentlyacquiredHIVinfectionandreducetheirinfectiousnesstoothers,but
evidencetosupportthisrecommendationisstillinconclusiveandawaitstheoutcomesofseveralclinicaltrialscurrentlyunderway
(129).Notwithstanding,patientswithacuteHIVinfectionshouldbereferredimmediatelytoanHIVclinicalcareprovider.
DiagnosisofHIVinfectionshouldprompteffortstoreducebehaviorsthatcouldtransmitHIVtoothers(134).
ThefollowingarespecificrecommendationsthatapplytotestingforHIVinfection:
HIVscreeningisrecommendedforallpersonswhoseekevaluationandtreatmentforSTDs.
HIVtestingmustbevoluntaryandfreefromcoercion.Patientsmustnotbetestedwithouttheirknowledge.
HIVscreeningafternotifyingthepatientthatanHIVtestwillbeperformed(unlessthepatientdeclines)isrecommendedinall
healthcaresettings.
SpecificsignedconsentforHIVtestingshouldnotberequired.Inmostsettings,generalinformedconsentformedicalcareis
consideredsufficienttoencompassinformedconsentforHIVtesting.
UseofrapidHIVtestsshouldbeconsidered,especiallyinclinicswhereahighproportionofpatientsdonotreturnforHIVtest
results.
PositivescreeningtestsforHIVantibodymustbeconfirmedbyasupplementaltestbeforethediagnosisofHIVinfectioncanbe
established.
ProvidersshouldbealerttothepossibilityofacuteHIVinfectionandperformanucleicacidtestinadditiontoanantibodytest
forHIV,ifindicated.PersonssuspectedofrecentlyacquiredHIVinfectionshouldbereferredforimmediateconsultationwith
aninfectiousdiseasespecialist.
PersonswithnewlydiagnosedHIVinfectionwhoreceivecareintheSTDtreatmentsettingshouldbeinformedoftheimportanceof
promptlyinitiatingmedicalcare,theeffectivenessofHIVtreatments,andaboutwhattoexpectastheyentermedicalcareforHIV
infection(131).Innonemergentsituations,theinitialevaluationofHIVpositivepatientsusuallyincludesthefollowing:
Detailedmedicalhistory,includingsexualandsubstanceabusehistoryvaccinationhistorypreviousSTDstravelhistoryand
assessmentforspecificHIVrelatedsymptomsordiagnoses
physicalexamination,includingagynecologicexaminationforwomen
testingforN.gonorrhoeaeandC.trachomatis(inwomenperformPaptestandwetmountexaminationorcultureofvaginal
secretionsforTrichomonasvaginalis)
completebloodandplateletcounts,bloodchemistryprofile,andlipidprofile
toxoplasmaantibodytest
testingforantibodiestohepatitisCvirus
testingforpreviousorpresentinfectionswithHAVorHBVinfection(recommendedifdeterminedtobecosteffectivebefore
consideringvaccination)(seeHepatitisAandHepatitisB)

syphilisserology
CD4TlymphocyteanalysisanddeterminationofHIVplasmaviralload
HIVgenotypicresistancetesting
tuberculinskintest(sometimesreferredtoasapurifiedproteinderivative)
urinalysisand
chestradiograph.
TypespecifictestingforHSV2infectioncanbeconsideredifherpesinfectionstatusisunknown.AfirstdoseofhepatitisAand
hepatitisBvaccineshouldbeadministeredatthisfirstvisitforpreviouslyunvaccinatedpersonsforwhomvaccineisrecommended
(seeHepatitisAandHepatitisB).Insubsequentvisits,whentheresultsoflaboratorytestsareavailable,antiretroviraltherapycan
beofferedbasedonexistingguidance(129).Recommendationsfortheprophylaxisofopportunisticinfectionsandvaccinationsin
HIVinfectedadultsandadolescentsareavailable(130,131).
ProvidersshouldbealerttothepossibilityofneworrecurrentSTDsandshouldtreatsuchconditionsaggressively.Diagnosisofan
STDinanHIVinfectedpersonindicatesongoingorrecurrenthighriskbehaviorandshouldpromptreferralforcounseling.
BecausemanySTDsareasymptomatic,routinescreeningforcurableSTDs(e.g.,syphilis,gonorrhea,andchlamydia)shouldbe
performedatleastannuallyforallsexuallyactive,HIVpositivepersons.Womenshouldbescreenedannuallyforcervicalcancer
precursorlesionsbycervicalPaptests.MorefrequentSTDscreeningmightbeappropriatedependingonindividualriskbehaviors,
thelocalepidemiologyofSTDs,andwhetherincidentSTDsaredetectedbyscreeningorbythepresenceofsymptoms.
RecentlyidentifiedHIVinfectionmightnothavebeenrecentlyacquiredpersonsnewlydiagnosedwithHIVmightbeatanystageof
infection.Therefore,healthcareprovidersshouldbealertforsymptomsorsignsthatsuggestadvancedHIVinfection(e.g.,fever,
weightloss,diarrhea,cough,shortnessofbreath,andoralcandidiasis).Thepresenceofanyofthesesymptomsshouldprompt
urgentreferraltoaninfectiousdiseasesprovider.Similarly,providersshouldbealertforsignsofpsychologicaldistressandbe
preparedtoreferpatientsaccordingly(seeCounselingforPatientswithHIVInfectionandReferraltoSupportServices).

CounselingforPatientswithHIVInfectionandReferraltoSupportServices
ThosepersonswhotestpositiveforHIVshouldreceivepreventioncounselingbeforeleavingthetestingsite.Suchpersonsshould
receiveorbereferredforamedicalevaluationand,ifindicated,beprovidedwithbehavioralandpsychologicalservicesas
determinedbyathoroughpsychosocialevaluation,whichcanalsobeusedtoidentifyhighriskbehaviors.Providerswhorefertheir
HIVpositivepatientstootherprofessionalsshouldestablishmeanstoensurethatthesepatientsarelinkedsuccessfullytosuch
services,especiallytoongoingmedicalcare.
ProvidersshouldexpectpersonstobedistressedwhenfirstinformedofapositiveHIVtestresult.Suchpersonsfacemultiplemajor
adaptivechallenges,includingcopingwiththereactionsofotherstoastigmatizingillness,developingandadoptingstrategiesfor
maintainingphysicalandemotionalhealth,initiatingchangesinbehaviortopreventHIVtransmissiontoothers,andreducingthe
riskforacquiringadditionalSTDs.Manypersonswillrequireassistancewithmakingreproductivechoices,gainingaccesstohealth
services,andcopingwithchangesinpersonalrelationships.Therefore,behavioralandpsychosocialservicesareanintegralpartof
healthcareforHIVinfectedpersons.
PatientstestingpositiveforHIVhaveuniqueneeds.Somepatientsrequirereferralforspecificbehavioralinterventions(e.g.,a
substanceabuseprogram),mentalhealthdisorders(e.g.,depression),oremotionaldistress.Othersmightrequireassistancewith
securingandmaintainingemploymentandhousing.Womenshouldbecounseledorappropriatelyreferredregardingreproductive
choicesandcontraceptiveoptions,andpatientswithmultiplepsychosocialproblemsmightbecandidatesforcomprehensiverisk
reductioncounselingandservices.
ThefollowingarespecificrecommendationsforHIVcounselingandreferral:
PersonswhotestpositiveforHIVantibodyshouldbecounseled,eitheronsiteorthroughreferral,concerningthebehavioral,
psychosocial,andmedicalimplicationsofHIVinfection.
Healthcareprovidersshouldbealertformedicalorpsychosocialconditionsthatrequireimmediateattention.
Providersshouldassesstheneedsofnewlydiagnosedpersonsforimmediatemedicalcareorsupportandshouldlinkthemto
servicesprovidedbyhealthcarepersonnelexperiencedinprovidingcareforHIVinfectedpersons.Suchpersonsmightneed
medicalcareorservicesforsubstanceabuse,mentalhealthdisorders,emotionaldistress,reproductivecounseling,risk
reductioncounseling,andcasemanagement.Providersshouldfollowuptoensurethatpatientshavereceivedtheneeded
services.
Patientsshouldbeeducatedabouttheimportanceoffollowupmedicalcareaswellaswhattoexpect.
Severalsuccessful,innovativeinterventionsforHIVpreventionhavebeendevelopedfordiverseatriskpopulations,andthesecan
belocallyreplicatedoradapted(1114,135,136).Involvementofnongovernmentorganizationsandcommunitybasedorganizations
mightcomplementsucheffortsintheclinicalsetting.

ManagementofSexPartnersandInjectionDrugPartners

CliniciansevaluatingHIVinfectedpersonsshoulddeterminewhetheranypartnersshouldbenotifiedconcerningpossibleexposure
toHIV(77,137).InthecontextofHIVmanagement,theterm"partner"includesnotonlysexpartners,butpersonswhoshare
syringesorotherinjectionequipment.Partnernotificationisanimportantcomponentofdiseasemanagement,becauseearly
diagnosisandtreatmentofHIVinfectionmightreducemorbidityandprovidetheopportunitytoencourageriskreduction
behaviors.PartnernotificationforHIVinfectionshouldbeconfidential.Specificguidanceregardingspousalnotificationvariesby
jurisdiction.Detailedrecommendationsconcerningidentification,notification,diagnosis,andtreatmentofexposedpartnersare
availableinRecommendationsforPartnerServicesProgramsforHIVInfection,Syphilis,Gonorrhea,andChlamydialInfections
(137).
Twocomplementarynotificationprocesses,patientreferralandproviderreferral,canbeusedtoidentifypartners.Withpatient
referral,patientsdirectlyinformtheirpartnersoftheirexposuretoHIVinfection,whereaswithproviderreferral,trainedhealth
departmentpersonnellocatepartnersonthebasisofinformationprovidedbythepatient.Duringtheproviderreferralnotification
process,theconfidentialityofpatientsisprotectedtheirnamesarenotrevealedtopartnerswhoarenotified.Manystateandlocal
healthdepartmentsprovidetheseservices.
Thefollowingarespecificrecommendationsforimplementingpartnernotificationprocedures:
HIVinfectedpatientsshouldbeencouragedtonotifytheirpartnersandtoreferthemforcounselingandtesting.Ifrequested
bythepatient,healthcareprovidersshouldassistinthisprocess,eitherdirectlyorbyreferraltohealthdepartmentpartner
notificationprograms.
Ifpatientsareunwillingtonotifytheirpartnersoriftheycannotensurethattheirpartnerswillseekcounseling,physiciansor
healthdepartmentpersonnelshoulduseconfidentialpartnernotificationprocedures.
Partnerswhohavebeenreachedandwereexposedtogenitalsecretionsand/orbloodofanHIVinfectedpartnerthoughsexor
injectiondrugusewithinthepreceding72hoursshouldbeofferedpostexposureprophylaxiswithcombinationantiretrovirals
(78).

SpecialConsiderations
Pregnancy
AllpregnantwomenintheUnitedStatesshouldbetestedforHIVinfectionasearlyduringpregnancyaspossible.Asecondtest
duringthethirdtrimester,preferablyat<36weeks'gestation,shouldbeconsideredforallpregnantwomenandisrecommendedfor
womenknowntobeathighriskforacquiringHIV,thosewhoreceivehealthcareinjurisdictionswithelevatedincidenceofHIVor
AIDSamongwomen,andwomenlivinginfacilitiesinwhichprenatalscreeningidentifiesatleastoneHIVinfectedpregnantwomen
per1,000womenscreened(77).AnRNAtestshouldbeusedinconjunctionwithanHIVantibodytestforwomenwhohavesignsor
symptomsconsistentwithacuteHIVinfection.ThepatientshouldfirstbeinformedthatshewillbetestedforHIVaspartofthe
panelofprenataltests,unlessshedeclines,oroptsout,ofscreening(77,86).Forwomenwhodecline,providersshouldcontinueto
stronglyencouragetestingandaddressconcernsthatposeobstaclestotesting.Womenwhodeclinetestingbecausetheyhavehada
previousnegativeHIVtestshouldbeinformedabouttheimportanceofretestingduringeachpregnancy.Testingpregnantwomenis
particularlyimportantnotonlytomaintainthehealthofthepatient,butbecauseinterventions(i.e.,antiretroviralandobstetrical)
canreducetheriskforperinataltransmissionofHIV.
AfterapregnantwomanhasbeenidentifiedasbeingHIVinfected,sheshouldbeeducatedabouttheriskforperinatalinfection.
Evidenceindicatesthat,intheabsenceofantiretroviralandotherinterventions,15%25%ofinfantsborntoHIVinfectedmothers
willbecomeinfectedwithHIVsuchevidencealsoindicatesthatanadditional12%14%ofinfantsborntoinfectedmotherswho
breastfeedintothesecondyearoflifewillbecomeinfected(138,139).
TheriskforperinatalHIVtransmissioncanbereducedto<2%throughtheuseofantiretroviralregimensandobstetrical
interventions(i.e.,zidovudineornevirapineandelectivecesareansectionat38weeksofpregnancy)andbyavoidingbreastfeeding
(138,140).PregnantwomenwhoareHIVinfectedshouldbecounseledconcerningtheiroptions(eitheronsiteorbyreferral),given
appropriateantenataltreatment,andadvisednottobreastfeedtheirinfants.

HIVInfectionAmongInfantsandChildren
DiagnosisofHIVinfectioninapregnantwomanindicatestheneedtoconsiderwhetherthewoman'sotherchildrenmightbe
infected.InfantsandyoungchildrenwithHIVinfectiondifferfromadultsandadolescentswithrespecttothediagnosis,clinical
presentation,andmanagementofHIVdisease.Forexample,becausematernalHIVantibodypassesthroughtheplacenta,antibody
testsforHIVareexpectedtobepositiveintheseraofbothinfectedanduninfectedinfantsborntoseropositivemothers.Adefinitive
determinationofHIVinfectionforaninfantaged<18monthsisusuallybasedonHIVnucleicacidtesting(141).Managementof
infants,children,andadolescentswhoareknownorsuspectedtobeinfectedwithHIVrequiresreferraltophysiciansfamiliarwith
themanifestationsandtreatmentofpediatricHIVinfection(142,143).

DiseasesCharacterizedbyGenital,Anal,orPerianalUlcers
IntheUnitedStates,mostyoung,sexuallyactivepatientswhohavegenital,anal,orperianalulcershaveeithergenitalherpesor
syphilis.Thefrequencyofeachconditiondiffersbygeographicareaandpopulationhowever,genitalherpesisthemostprevalentof
thesediseases.Morethanoneetiologicagent(e.g.,herpesandsyphilis)canbepresentinagenital,anal,orperianalulcer.Less
commoninfectiouscausesofgenital,anal,orperianalulcersincludechancroidanddonovanosis.HSV,syphilis,andchancroidhave
beenassociatedwithanincreasedriskforHIVtransmission,andgenital,anal,orperianallesionsmightbeassociatedwith

conditionsthatarenotsexuallytransmitted(e.g.,yeast,trauma,carcinoma,aphthae,fixeddrugeruption,andpsoriasis).
Adiagnosisbasedonlyonthepatient'smedicalhistoryandphysicalexaminationfrequentlyisinaccurate.Therefore,allpatients
whohavegenital,anal,orperianalulcersshouldbeevaluatedwithaserologictestforsyphilisandadiagnosticevaluationforgenital
herpesinsettingswherechancroidisprevalent,atestforHaemophilusducreyishouldalsobeperformed.Specifictestsfor
evaluationofgenital,anal,orperianalulcersinclude1)syphilisserologyanddarkfieldexamination2)cultureforHSVorPCR
testingforHSVand3)serologictestingfortypespecificHSVantibody.
NoFDAclearedPCRtesttodiagnoseeitherherpesorsyphilisisavailableintheUnitedStateshowever,suchtestingcanbe
performedbyclinicallaboratoriesthathavedevelopedtheirowntestsandhaveconductedaClinicalLaboratoryImprovement
Amendment(CLIA)verificationstudy.TypespecificserologyforHSV2mightbehelpfulinidentifyingpersonswithgenitalherpes
(seeGenitalHerpes,TypeSpecificSerologicTests).Inaddition,biopsyofgenital,anal,orperianalulcerscanhelpidentifythecause
ofulcersthatareunusualorthatdonotrespondtoinitialtherapy.HIVtestingshouldbeperformedonallpersonswithgenital,
anal,orperianalulcerswhoarenotknowntohaveHIVinfection(seeDiagnosticConsiderations,sectionsonSyphilis,Chancroid,
andGenitalHerpesSimplexVirus).
Healthcareprovidersfrequentlymusttreatpatientsbeforetestresultsareavailable,becauseearlytreatmentdecreasesthe
possibilityofongoingtransmissionandbecausesuccessfultreatmentofgenitalherpesdependsonpromptinitiationoftherapy.The
clinicianshouldempiricallytreatforthediagnosisconsideredmostlikelyonthebasisofclinicalpresentationandepidemiologic
circumstances(includingtravelhistory)evenaftercompletediagnosticevaluation,atleast25%ofpatientswhohavegenitalulcers
havenolaboratoryconfirmeddiagnosis.

Chancroid
TheprevalenceofchancroidhasdeclinedintheUnitedStates(93).Wheninfectiondoesoccur,itisusuallyassociatedwithsporadic
outbreaks.Worldwide,chancroidappearstohavedeclinedaswell,althoughinfectionmightstilloccurinsomeregionsofAfricaand
theCaribbean.Chancroid,aswellasgenitalherpesandsyphilis,isariskfactorinthetransmissionofHIVinfection(144).
AdefinitivediagnosisofchancroidrequirestheidentificationofH.ducreyionspecialculturemediathatisnotwidelyavailable
fromcommercialsourcesevenwhenthesemediaareused,sensitivityis<80%(145).NoFDAclearedPCRtestforH.ducreyiis
availableintheUnitedStates,butsuchtestingcanbeperformedbyclinicallaboratoriesthathavedevelopedtheirownPCRtestand
haveconductedaCLIAverificationstudy.
Thecombinationofapainfulgenitalulcerandtendersuppurativeinguinaladenopathysuggeststhediagnosisofchancroid(146).A
probablediagnosisofchancroid,forbothclinicalandsurveillancepurposes,canbemadeifallofthefollowingcriteriaaremet:1)
thepatienthasoneormorepainfulgenitalulcers2)thepatienthasnoevidenceofT.palliduminfectionbydarkfieldexamination
ofulcerexudateorbyaserologictestforsyphilisperformedatleast7daysafteronsetofulcers3)theclinicalpresentation,
appearanceofgenitalulcersand,ifpresent,regionallymphadenopathyaretypicalforchancroidand4)atestforHSVperformedon
theulcerexudateisnegative.

Treatment
Successfultreatmentforchancroidcurestheinfection,resolvestheclinicalsymptoms,andpreventstransmissiontoothers.In
advancedcases,scarringcanresult,despitesuccessfultherapy.
RecommendedRegimens
Azithromycin1gorallyinasingledose
OR
Ceftriaxone250mgintramuscularly(IM)inasingledose
OR
Ciprofloxacin*500mgorallytwiceadayfor3days*
OR
Erythromycinbase500mgorallythreetimesadayfor7days
*Ciprofloxaciniscontraindicatedforpregnantandlactatingwomen.
Azithromycinandceftriaxoneoffertheadvantageofsingledosetherapy.Worldwide,severalisolateswithintermediateresistanceto
eitherciprofloxacinorerythromycinhavebeenreported.However,becauseculturesarenotroutinelyperformed,dataarelimited
regardingthecurrentprevalenceofantimicrobialresistance.

OtherManagementConsiderations
MenwhoareuncircumcisedandpatientswithHIVinfectiondonotrespondaswelltotreatmentaspersonswhoarecircumcisedor
HIVnegative.PatientsshouldbetestedforHIVinfectionatthetimechancroidisdiagnosed.Iftheinitialtestresultswerenegative,
aserologictestforsyphilisandHIVinfectionshouldbeperformed3monthsafterthediagnosisofchancroid.

FollowUp
Patientsshouldbereexamined37daysafterinitiationoftherapy.Iftreatmentissuccessful,ulcersusuallyimprove
symptomaticallywithin3daysandobjectivelywithin7daysaftertherapy.Ifnoclinicalimprovementisevident,theclinicianmust
considerwhether1)thediagnosisiscorrect,2)thepatientiscoinfectedwithanotherSTD,3)thepatientisinfectedwithHIV,4)the
treatmentwasnotusedasinstructed,or5)theH.ducreyistraincausingtheinfectionisresistanttotheprescribedantimicrobial.
Thetimerequiredforcompletehealingdependsonthesizeoftheulcerlargeulcersmightrequire>2weeks.Inaddition,healingis
slowerforsomeuncircumcisedmenwhohaveulcersundertheforeskin.Clinicalresolutionoffluctuantlymphadenopathyisslower
thanthatofulcersandmightrequireneedleaspirationorincisionanddrainage,despiteotherwisesuccessfultherapy.Although
needleaspirationofbuboesisasimplerprocedure,incisionanddrainagemightbepreferredbecauseofreducedneedfor
subsequentdrainageprocedures.

ManagementofSexPartners
Regardlessofwhethersymptomsofthediseasearepresent,sexpartnersofpatientswhohavechancroidshouldbeexaminedand
treatediftheyhadsexualcontactwiththepatientduringthe10daysprecedingthepatient'sonsetofsymptoms.

SpecialConsiderations
Pregnancy
Ciprofloxaciniscontraindicatedduringpregnancyandlactation.Noadverseeffectsofchancroidonpregnancyoutcomehavebeen
reported.
HIVInfection
HIVinfectedpatientswhohavechancroidshouldbemonitoredcloselybecause,asagroup,theyaremorelikelytoexperience
treatmentfailureandtohaveulcersthathealmoreslowly.HIVinfectedpatientsmightrequirerepeatedorlongercoursesof
therapythanthoserecommendedforHIVnegativepatients,andtreatmentfailurescanoccurwithanyregimen.Becausedataare
limitedconcerningthetherapeuticefficacyoftherecommendedceftriaxoneandazithromycinregimensinHIVinfectedpatients,
theseregimensshouldbeusedforsuchpatientsonlyiffollowupcanbeensured.

GenitalHSVInfections
Genitalherpesisachronic,lifelongviralinfection.TwotypesofHSVhavebeenidentifiedascausinggenitalherpes:HSV1and
HSV2.MostcasesofrecurrentgenitalherpesarecausedbyHSV2,andatleast50millionpersonsintheUnitedStatesareinfected
withthistypeofgenitalherpes(147).However,anincreasingproportionofanogenitalherpeticinfectionsinsomepopulationshas
beenattributedtoHSV1infection.
MostpersonsinfectedwithHSV2havenotbeendiagnosedwithgenitalherpes.Manysuchpersonshavemildorunrecognized
infectionsbutshedvirusintermittentlyinthegenitaltract.Asaresult,themajorityofgenitalherpesinfectionsaretransmittedby
personsunawarethattheyhavetheinfectionorwhoareasymptomaticwhentransmissionoccurs.ManagementofgenitalHSV
shouldaddressthechronicnatureofthediseaseandgobeyondthetreatmentofacuteepisodesofgenitalulcers.

DiagnosisofHSVInfection
Theclinicaldiagnosisofgenitalherpesisbothnonsensitiveandnonspecific.Theclassicalpainfulmultiplevesicularorulcerative
lesionsareabsentinmanyinfectedpersons.HSV1iscausinganincreasingproportionoffirstepisodesofanogenitalherpesin
somepopulations(e.g.,youngwomenandMSM)andmightnowaccountformostoftheseinfections(148,149).Recurrencesand
subclinicalsheddingaremuchlessfrequentforgenitalHSV1infectionthanforgenitalHSV2infection(150,151).Apatient's
prognosisandthetypeofcounselingneededdependsonthetypeofgenitalherpes(HSV1orHSV2)causingtheinfection
therefore,theclinicaldiagnosisofgenitalherpesshouldbeconfirmedbylaboratorytesting(152).Bothvirologicandtypespecific
serologictestsforHSVshouldbeavailableinclinicalsettingsthatprovidecareforpersonsdiagnosedwithoratriskforSTDs.

VirologicTests
CellcultureandPCRarethepreferredHSVtestsforpersonswhoseekmedicaltreatmentforgenitalulcersorothermucocutaneous
lesions.Thesensitivityofviralcultureislow,especiallyforrecurrentlesions,anddeclinesrapidlyaslesionsbegintoheal.PCR
assaysforHSVDNAaremoresensitiveandareincreasinglyusedinmanysettings(153,154).PCRisthetestofchoicefordetecting
HSVinspinalfluidfordiagnosisofHSVinfectionofthecentralnervoussystem(CNS).Viralcultureisolatesshouldbetypedto
determinewhichtypeofHSViscausingtheinfection.FailuretodetectHSVbycultureorPCRdoesnotindicateanabsenceofHSV
infection,becauseviralsheddingisintermittent.TheuseofcytologicdetectionofcellularchangesofHSVinfectionisaninsensitive
andnonspecificmethodofdiagnosis,bothforgenitallesions(i.e.,Tzanckpreparation)andforcervicalPapsmearsandtherefore
shouldnotbereliedupon.

TypeSpecificSerologicTests
BothtypespecificandnontypespecificantibodiestoHSVdevelopduringthefirstseveralweeksafterinfectionandpersist
indefinitely.AccuratetypespecificHSVserologicassaysarebasedontheHSVspecificglycoproteinG2(HSV2)andglycoprotein
G1(HSV1).Suchassaysfirstbecamecommerciallyavailablein1999,butolderassaysthatdonotaccuratelydistinguishHSV1from
HSV2antibody(despiteclaimstothecontrary)remainonthemarket(155)providersshouldspecificallyrequestserologictype
specificglycoproteinG(gG)basedassayswhenserologyisperformedfortheirpatients(156158).

BothlaboratorybasedassaysandpointofcareteststhatprovideresultsforHSV2antibodiesfromcapillarybloodorserumduring
aclinicvisitareavailable.ThesensitivitiesoftheseglycoproteinGtypespecifictestsforthedetectionofHSV2antibodyvaryfrom
80%98%,andfalsenegativeresultsmightbemorefrequentatearlystagesofinfection.Thespecificitiesoftheseassaysare96%.
Falsepositiveresultscanoccur,especiallyinpatientswithalowlikelihoodofHSVinfection.Repeatorconfirmatorytestingmight
beindicatedinsomesettings,especiallyifrecentacquisitionofgenitalherpesissuspected.IgMtestingforHSVisnotuseful,
becausetheIgMtestsarenottypespecificandmightbepositiveduringrecurrentepisodesofherpes(159).
BecausenearlyallHSV2infectionsaresexuallyacquired,thepresenceoftypespecificHSV2antibodyimpliesanogenital
infection.Inthisinstance,educationandcounselingappropriateforpersonswithgenitalherpesshouldbeprovided.Thepresence
ofHSV1antibodyaloneismoredifficulttointerpret.MostpersonswithHSV1antibodyhaveoralHSVinfectionacquiredduring
childhood,whichmightbeasymptomatic.However,acquisitionofgenitalHSV1appearstobeincreasing,andgenitalHSV1also
canbeasymptomatic(147149).LackofsymptomsinanHSV1seropositivepersondoesnotdistinguishanogenitalfromorolabial
orcutaneousinfection,andregardlessofsiteofinfection,thesepersonsremainatriskforacquiringHSV2.
TypespecificHSVserologicassaysmightbeusefulinthefollowingscenarios:1)recurrentgenitalsymptomsoratypicalsymptoms
withnegativeHSVcultures2)aclinicaldiagnosisofgenitalherpeswithoutlaboratoryconfirmationor3)apartnerwithgenital
herpes.HSVserologictestingshouldbeconsideredforpersonspresentingforanSTDevaluation(especiallyforthosepersonswith
multiplesexpartners),personswithHIVinfection,andMSMatincreasedriskforHIVacquisition.ScreeningforHSV1andHSV2
inthegeneralpopulationisnotindicated.

ManagementofGenitalHerpes
Antiviralchemotherapyoffersclinicalbenefitstomostsymptomaticpatientsandisthemainstayofmanagement.Counseling
regardingthenaturalhistoryofgenitalherpes,sexualandperinataltransmission,andmethodstoreducetransmissionisintegralto
clinicalmanagement.
Systemicantiviraldrugscanpartiallycontrolthesignsandsymptomsofherpesepisodeswhenusedtotreatfirstclinicaland
recurrentepisodes,orwhenusedasdailysuppressivetherapy.However,thesedrugsneithereradicatelatentvirusnoraffectthe
risk,frequency,orseverityofrecurrencesafterthedrugisdiscontinued.Randomizedtrialshaveindicatedthatthreeantiviral
medicationsprovideclinicalbenefitforgenitalherpes:acyclovir,valacyclovir,andfamciclovir(160168).Valacycloviristhevaline
esterofacyclovirandhasenhancedabsorptionafteroraladministration.Famcicloviralsohashighoralbioavailability.Topical
therapywithantiviraldrugsoffersminimalclinicalbenefit,anditsuseisdiscouraged.

FirstClinicalEpisodeofGenitalHerpes
Newlyacquiredgenitalherpescancauseaprolongedclinicalillnesswithseveregenitalulcerationsandneurologicinvolvement.
Evenpersonswithfirstepisodeherpeswhohavemildclinicalmanifestationsinitiallycandevelopsevereorprolongedsymptoms.
Therefore,allpatientswithfirstepisodesofgenitalherpesshouldreceiveantiviraltherapy.
RecommendedRegimens*
Acyclovir400mgorallythreetimesadayfor710days
OR
Acyclovir200mgorallyfivetimesadayfor710days
OR
Famciclovir250mgorallythreetimesadayfor710days
OR
Valacyclovir1gorallytwiceadayfor710days
*Treatmentcanbeextendedifhealingisincompleteafter10daysoftherapy.

EstablishedHSV2Infection
AlmostallpersonswithsymptomaticfirstepisodegenitalHSV2infectionsubsequentlyexperiencerecurrentepisodesofgenital
lesionsrecurrencesarelessfrequentafterinitialgenitalHSV1infection.Intermittentasymptomaticsheddingoccursinpersons
withgenitalHSV2infection,eveninthosewithlongstandingorclinicallysilentinfection.Antiviraltherapyforrecurrentgenital
herpescanbeadministeredeitherassuppressivetherapytoreducethefrequencyofrecurrencesorepisodicallytoameliorateor
shortenthedurationoflesions.Somepersons,includingthosewithmildorinfrequentrecurrentoutbreaks,benefitfromantiviral
therapytherefore,optionsfortreatmentshouldbediscussed.Manypersonsmightprefersuppressivetherapy,whichhasthe
additionaladvantageofdecreasingtheriskforgenitalHSV2transmissiontosusceptiblepartners(169,170).
SuppressiveTherapyforRecurrentGenitalHerpes
Suppressivetherapyreducesthefrequencyofgenitalherpesrecurrencesby70%80%inpatientswhohavefrequentrecurrences
(166169)manypersonsreceivingsuchtherapyreporthavingexperiencednosymptomaticoutbreaks.Treatmentalsoiseffective
inpatientswithlessfrequentrecurrences.Safetyandefficacyhavebeendocumentedamongpatientsreceivingdailytherapywith

acyclovirforaslongas6yearsandwithvalacyclovirorfamciclovirfor1year(171,172).Qualityoflifeisimprovedinmanypatients
withfrequentrecurrenceswhoreceivesuppressivetherapyratherthanepisodictreatment.
Thefrequencyofrecurrentgenitalherpesoutbreaksdiminishesovertimeinmanypatients,andthepatient'spsychological
adjustmenttothediseasemightchange.Therefore,periodicallyduringsuppressivetreatment(e.g.,onceayear),providersshould
discusstheneedtocontinuetherapywiththepatient.
Treatmentwithvalacyclovir500mgdailydecreasestherateofHSV2transmissionindiscordant,heterosexualcouplesinwhichthe
sourcepartnerhasahistoryofgenitalHSV2infection(170).Suchcouplesshouldbeencouragedtoconsidersuppressiveantiviral
therapyaspartofastrategytopreventtransmission,inadditiontoconsistentcondomuseandavoidanceofsexualactivityduring
recurrences.Suppressiveantiviraltherapyalsoislikelytoreducetransmissionwhenusedbypersonswhohavemultiplepartners
(includingMSM)andbythosewhoareHSV2seropositivewithoutahistoryofgenitalherpes.
RecommendedRegimens
Acyclovir400mgorallytwiceaday
OR
Famiciclovir250mgorallytwiceaday
OR
Valacyclovir500mgorallyonceaday*
OR
Valacyclovir1gorallyonceaday
*Valacyclovir500mgonceadaymightbelesseffectivethanothervalacycloviroracyclovirdosingregimensinpatientswhohave
veryfrequentrecurrences(i.e.,10episodesperyear).
Acyclovir,famciclovir,andvalacyclovirappearequallyeffectiveforepisodictreatmentofgenitalherpes,butfamciclovirappears
somewhatlesseffectiveforsuppressionofviralshedding(163167,173).Easeofadministrationandcostalsoareimportant
considerationsforprolongedtreatment.
EpisodicTherapyforRecurrentGenitalHerpes
Effectiveepisodictreatmentofrecurrentherpesrequiresinitiationoftherapywithin1dayoflesiononsetorduringtheprodrome
thatprecedessomeoutbreaks.Thepatientshouldbeprovidedwithasupplyofdrugoraprescriptionforthemedicationwith
instructionstoinitiatetreatmentimmediatelywhensymptomsbegin.
RecommendedRegimens
Acyclovir400mgorallythreetimesadayfor5days
OR
Acyclovir800mgorallytwiceadayfor5days
OR
Acyclovir800mgorallythreetimesadayfor2days
OR
Famciclovir125mgorallytwicedailyfor5days
OR
Famciclovir1000mgorallytwicedailyfor1day
OR
Famciclovir500mgonce,followedby250mgtwicedailyfor2days
OR
Valacyclovir500mgorallytwiceadayfor3days
OR
Valacyclovir1gorallyonceadayfor5days

SevereDisease

Intravenous(IV)acyclovirtherapyshouldbeprovidedforpatientswhohavesevereHSVdiseaseorcomplicationsthatnecessitate
hospitalization(e.g.,disseminatedinfection,pneumonitis,orhepatitis)orCNScomplications(e.g.,meningoencephalitis).The
recommendedregimenisacyclovir510mg/kgIVevery8hoursfor27daysoruntilclinicalimprovementisobserved,followedby
oralantiviraltherapytocompleteatleast10daysoftotaltherapy.Acyclovirdoseadjustmentisrecommendedforimpairedrenal
function.

Counseling
Counselingofinfectedpersonsandtheirsexpartnersiscriticaltothemanagementofgenitalherpes.Thegoalsofcounseling
include1)helpingpatientscopewiththeinfectionand2)preventingsexualandperinataltransmission(174,175).Althoughinitial
counselingcanbeprovidedatthefirstvisit,manypatientsbenefitfromlearningaboutthechronicaspectsofthediseaseafterthe
acuteillnesssubsides.Multipleresources,includingwebsites(http://www.ashastd.org )andprintedmaterials,areavailableto
assistpatients,theirpartners,andclinicianswhobecomeinvolvedincounseling.
AlthoughthepsychologicaleffectofaserologicdiagnosisofHSV2infectioninapersonwithasymptomaticorunrecognizedgenital
herpesappearsminimalandtransient(176),someHSVinfectedpersonsmightexpressanxietyconcerninggenitalherpesthatdoes
notreflecttheactualclinicalseverityoftheirdiseasethepsychologicaleffectofHSVinfectionfrequentlyissubstantial.Common
concernsregardinggenitalherpesincludetheseverityofinitialclinicalmanifestations,recurrentepisodes,sexualrelationshipsand
transmissiontosexpartners,andabilitytobearhealthychildren.ThemisconceptionthatHSVcausescancershouldbedispelled.
ThefollowingrecommendationsapplytocounselingofpersonswithgenitalHSVinfection:
Personswhohavegenitalherpesshouldbeeducatedconcerningthenaturalhistoryofthedisease,withemphasisonthe
potentialforrecurrentepisodes,asymptomaticviralshedding,andtheattendantrisksofsexualtransmission.
Personsexperiencingafirstepisodeofgenitalherpesshouldbeadvisedthatsuppressivetherapyisavailableandeffectivein
preventingsymptomaticrecurrentepisodesandthatepisodictherapyoftenisusefulinshorteningthedurationofrecurrent
episodes.
AllpersonswithgenitalHSVinfectionshouldbeencouragedtoinformtheircurrentsexpartnersthattheyhavegenitalherpes
andtoinformfuturepartnersbeforeinitiatingasexualrelationship.
SexualtransmissionofHSVcanoccurduringasymptomaticperiods.Asymptomaticviralsheddingismorefrequentingenital
HSV2infectionthangenitalHSV1infectionandismostfrequentduringthefirst12monthsafteracquiringHSV2.
Allpersonswithgenitalherpesshouldremainabstinentfromsexualactivitywithuninfectedpartnerswhenlesionsor
prodromalsymptomsarepresent.
TheriskforHSV2sexualtransmissioncanbedecreasedbythedailyuseofvalacyclovirbytheinfectedperson.Episodic
therapydoesnotreducetheriskfortransmissionanditsuseshouldbediscouragedforthispurposeamongpersonswhose
partnersmightbeatriskforHSV2acquisition.
Infectedpersonsshouldbeinformedthatmalelatexcondoms,whenusedconsistentlyandcorrectly,mightreducetheriskfor
genitalherpestransmission(2123).
Sexpartnersofinfectedpersonsshouldbeadvisedthattheymightbeinfectedeveniftheyhavenosymptoms.Typespecific
serologictestingoftheasymptomaticpartnersofpersonswithgenitalherpesisrecommendedtodeterminewhethersuch
partnersarealreadyHSVseropositiveorwhetherriskforacquiringHSVexists.
TheriskforneonatalHSVinfectionshouldbeexplainedtoallpersons,includingmen.Pregnantwomenandwomenof
childbearingagewhohavegenitalherpesshouldinformtheirproviderswhocareforthemduringpregnancyandthosewhowill
carefortheirnewborninfantabouttheirinfection.PregnantwomenwhoarenotknowntobeinfectedwithHSV2shouldbe
advisedtoabstainfromintercoursewithmenwhohavegenitalherpesduringthethirdtrimesterofpregnancy.Similarly,
pregnantwomenwhoarenotknowntobeinfectedwithHSV1shouldbecounseledtoavoidgenitalexposuretoHSV1during
thethirdtrimester(e.g.,oralsexwithapartnerwithoralherpesandvaginalintercoursewithapartnerwithgenitalHSV1
infection).
AsymptomaticpersonsdiagnosedwithHSV2infectionbytypespecificserologictestingshouldreceivethesamecounseling
messagesaspersonswithsymptomaticinfection.Inaddition,suchpersonsshouldbeeducatedabouttheclinical
manifestationsofgenitalherpes.
WhenexposedtoHIV,HSV2seropositivepersonsareatincreasedriskforHIVacquisition.Patientsshouldbeinformedthat
suppressiveantiviraltherapydoesnotreducetheincreasedriskforHIVacquisitionassociatedwithHSV2infection(177,178).

ManagementofSexPartners
Thesexpartnersofpatientswhohavegenitalherpescanbenefitfromevaluationandcounseling.Symptomaticsexpartnersshould
beevaluatedandtreatedinthesamemanneraspatientswhohavegenitallesions.Asymptomaticsexpartnersofpatientswhohave
genitalherpesshouldbequestionedconcerninghistoriesofgenitallesionsandofferedtypespecificserologictestingforHSV
infection.

SpecialConsiderations
Allergy,Intolerance,andAdverseReactions
Allergicandotheradversereactionstoacyclovir,valacyclovir,andfamciclovirarerare.Desensitizationtoacyclovirhasbeen
described(179).

HIVInfection
Immunocompromisedpatientscanhaveprolongedorsevereepisodesofgenital,perianal,ororalherpes.LesionscausedbyHSV
arecommonamongHIVinfectedpatientsandmightbesevere,painful,andatypical.HSVsheddingisincreasedinHIVinfected
persons.Whereasantiretroviraltherapyreducestheseverityandfrequencyofsymptomaticgenitalherpes,frequentsubclinical
sheddingstilloccurs(180).Clinicalmanifestationsofgenitalherpesmightworsenduringimmunereconstitutionafterinitiationof
antiretroviraltherapy.
SuppressiveorepisodictherapywithoralantiviralagentsiseffectiveindecreasingtheclinicalmanifestationsofHSVamongHIV
positivepersons(181183).TheextenttowhichsuppressiveantiviraltherapywilldecreaseHSVtransmissionfromthispopulation
isunknown.HSVtypespecificserologiescanbeofferedtoHIVpositivepersonsduringtheirinitialevaluationifinfectionstatusis
unknown,andsuppressiveantiviraltherapycanbeconsideredinthosewhohaveHSV2infection.
RecommendedRegimensforDailySuppressiveTherapyinPersonswithHIV
Acyclovir400800mgorallytwicetothreetimesaday
OR
Famciclovir500mgorallytwiceaday
OR
Valacyclovir500mgorallytwiceaday
RecommendedRegimensforEpisodicInfectioninPersons
withHIV
Acyclovir400mgorallythreetimesadayfor510days
OR
Famciclovir500mgorallytwiceadayfor510days
OR
Valacyclovir1gorallytwiceadayfor510days
Acyclovir,valacyclovir,andfamcicloviraresafeforuseinimmunocompromisedpatientsinthedosesrecommendedfortreatment
ofgenitalherpes.ForsevereHSVdisease,initiatingtherapywithacyclovir510mg/kgIVevery8hoursmightbenecessary.
Iflesionspersistorrecurinapatientreceivingantiviraltreatment,HSVresistanceshouldbesuspectedandaviralisolateshouldbe
obtainedforsensitivitytesting(184).SuchpersonsshouldbemanagedinconsultationwithanHIVspecialist,andalternatetherapy
shouldbeadministered.Allacyclovirresistantstrainsareresistanttovalacyclovir,andthemajorityareresistanttofamciclovir.
Foscarnet,40mg/kgIVevery8hoursuntilclinicalresolutionisattained,isfrequentlyeffectivefortreatmentofacyclovirresistant
genitalherpes.Intravenouscidofovir5mg/kgonceweeklymightalsobeeffective.Imiquimodisatopicalalternative,asistopical
cidofovirgel1%,whichisnotcommerciallyavailableandmustbecompoundedatapharmacy.Thesetopicalpreparationsshouldbe
appliedtothelesionsoncedailyfor5consecutivedays.
ClinicalmanagementofantiviralresistanceremainschallengingamongHIVinfectedpatients,andotherpreventativeapproaches
mightbenecessary.However,experiencewithanothergroupofimmunocompromisedpersons(hematopoieticstemcellrecipients)
demonstratedthatpersonsreceivingdailysuppressiveantiviraltherapywerelesslikelytodevelopacyclovirresistantHSV
comparedwiththosewhoreceivedepisodictherapywithoutbreaks(185).

GenitalHerpesinPregnancy
Mostmothersofinfantswhoacquireneonatalherpeslackhistoriesofclinicallyevidentgenitalherpes(186).Theriskfor
transmissiontotheneonatefromaninfectedmotherishigh(30%50%)amongwomenwhoacquiregenitalherpesnearthetimeof
deliveryandlow(<1%)amongwomenwithhistoriesofrecurrentherpesattermorwhoacquiregenitalHSVduringthefirsthalfof
pregnancy(187).However,becauserecurrentgenitalherpesismuchmorecommonthaninitialHSVinfectionduringpregnancy,
theproportionofneonatalHSVinfectionsacquiredfrommotherswithrecurrentherpesissubstantial.Preventionofneonatal
herpesdependsbothonpreventingacquisitionofgenitalHSVinfectionduringlatepregnancyandavoidingexposureoftheinfant
toherpeticlesionsduringdelivery.BecausetheriskforherpesishighininfantsofwomenwhoacquiregenitalHSVduringlate
pregnancy,thesewomenshouldbemanagedinconsultationwithaninfectiousdiseasespecialist.
Womenwithoutknowngenitalherpesshouldbecounseledtoabstainfromintercourseduringthethirdtrimesterwithpartners
knownorsuspectedofhavinggenitalherpes.Inaddition,pregnantwomenwithoutknownorolabialherpesshouldbeadvisedto
abstainfromreceptiveoralsexduringthethirdtrimesterwithpartnersknownorsuspectedtohaveorolabialherpes.Some
specialistsbelievethattypespecificserologictestsareusefultoidentifypregnantwomenatriskforHSVinfectionandtoguide
counselingregardingtheriskforacquiringgenitalherpesduringpregnancyandthatsuchtestingshouldbeofferedtouninfected
womenwhosesexpartnerhasHSVinfection.However,theeffectivenessofantiviraltherapytodecreasetheriskforHSV

transmissiontopregnantwomenbyinfectedpartnershasnotbeenstudied.
Allpregnantwomenshouldbeaskedwhethertheyhaveahistoryofgenitalherpes.Attheonsetoflabor,allwomenshouldbe
questionedcarefullyaboutsymptomsofgenitalherpes,includingprodromalsymptoms,andallwomenshouldbeexamined
carefullyforherpeticlesions.Womenwithoutsymptomsorsignsofgenitalherpesoritsprodromecandelivervaginally.Although
cesareansectiondoesnotcompletelyeliminatetheriskforHSVtransmissiontotheinfant,womenwithrecurrentgenitalherpetic
lesionsattheonsetoflaborshoulddeliverbycesareansectiontopreventneonatalHSVinfection.
Thesafetyofsystemicacyclovir,valacyclovir,andfamciclovirtherapyinpregnantwomenhasnotbeendefinitivelyestablished.
Availabledatadonotindicateanincreasedriskformajorbirthdefectscomparedwiththegeneralpopulationinwomentreatedwith
acyclovirduringthefirsttrimester(188)findingsthatprovideassurancetowomenwhohavehadprenatalexposuretoacyclovir.
However,dataregardingprenatalexposuretovalacyclovirandfamcicloviraretoolimitedtoprovideusefulinformationon
pregnancyoutcomes.Acyclovircanbeadministeredorallytopregnantwomenwithfirstepisodegenitalherpesorsevererecurrent
herpesandshouldbeadministeredIVtopregnantwomenwithsevereHSVinfection.Acyclovirtreatmentlateinpregnancyreduces
thefrequencyofcesareansectionsamongwomenwhohaverecurrentgenitalherpesbydiminishingthefrequencyofrecurrencesat
term(189191)theeffectofantiviraltherapylateinpregnancyontheincidenceofneonatalherpesisnotknown.Nodatasupport
theuseofantiviraltherapyamongHSVseropositivewomenwithoutahistoryofgenitalherpes.

NeonatalHerpes
InfantsexposedtoHSVduringbirth,asdocumentedbymaternalvirologictestingorpresumedbyobservationofmaternallesions,
shouldbefollowedcarefullyinconsultationwithapediatricinfectiousdiseasespecialist.Surveillanceculturesofmucosalsurfaces
todetectHSVinfectionmightbeconsideredbeforethedevelopmentofclinicalsignsofneonatalherpes.Inaddition,administration
ofacyclovirmightbeconsideredforinfantsborntowomenwhoacquiredHSVneartermbecausetheriskforneonatalherpesis
highfortheseinfants.Allinfantswhohaveneonatalherpesshouldbepromptlyevaluatedandtreatedwithsystemicacyclovir.The
recommendedregimenforinfantstreatedforknownorsuspectedneonatalherpesisacyclovir20mg/kgIVevery8hoursfor21
daysfordisseminatedandCNSdiseaseorfor14daysfordiseaselimitedtotheskinandmucousmembranes.

GranulomaInguinale(Donovanosis)
GranulomainguinaleisagenitalulcerativediseasecausedbytheintracellulargramnegativebacteriumKlebsiellagranulomatis
(formerlyknownasCalymmatobacteriumgranulomatis).ThediseaseoccursrarelyintheUnitedStates,althoughitisendemicin
sometropicalanddevelopingareas,includingIndiaPapua,NewGuineatheCaribbeancentralAustraliaandsouthernAfrica
(192,193).Clinically,thediseaseiscommonlycharacterizedaspainless,slowlyprogressiveulcerativelesionsonthegenitalsor
perineumwithoutregionallymphadenopathysubcutaneousgranulomas(pseudoboboes)mightalsooccur.Thelesionsarehighly
vascular(i.e.,beefyredappearance)andbleedeasilyoncontact.Theclinicalpresentationalsocanincludehypertrophic,necrotic,or
scleroticvariants.Extragenitalinfectioncanoccurwithextensionofinfectiontothepelvis,oritcandisseminatetointraabdominal
organs,bones,orthemouth.Thelesionsalsocandevelopsecondarybacterialinfectionandcancoexistwithothersexually
transmittedpathogens.
Thecausativeorganismisdifficulttoculture,anddiagnosisrequiresvisualizationofdarkstainingDonovanbodiesontissuecrush
preparationorbiopsy.NoFDAclearedmoleculartestsforthedetectionofK.granulomatisDNAexist,butsuchanassaymightbe
usefulwhenundertakenbylaboratoriesthathaveconductedaCLIAverificationstudy.

Treatment
Severalantimicrobialregimenshavebeeneffective,butonlyalimitednumberofcontrolledtrialshavebeenpublished(192).
Treatmenthasbeenshowntohaltprogressionoflesions,andhealingtypicallyproceedsinwardfromtheulcermarginsprolonged
therapyisusuallyrequiredtopermitgranulationandreepithelializationoftheulcers.Relapsecanoccur618monthsafter
apparentlyeffectivetherapy.
RecommendedRegimen
Doxycycline100mgorallytwiceadayforatleast3weeksanduntilalllesionshavecompletelyhealed
AlternativeRegimens
Azithromycin1gorallyonceperweekforatleast3weeksanduntilalllesionshavecompletelyhealed
OR
Ciprofloxacin750mgorallytwiceadayforatleast3weeksanduntilalllesionshavecompletelyhealed
OR
Erythromycinbase500mgorallyfourtimesadayforatleast3weeksanduntilalllesionshavecompletelyhealed
OR
Trimethoprimsulfamethoxazoleonedoublestrength(160mg/800mg)tabletorallytwiceadayforatleast3weeksanduntil
alllesionshavecompletelyhealed

Theadditionofanaminoglycoside(e.g.,gentamicin1mg/kgIVevery8hours)totheseregimenscanbeconsideredifimprovement
isnotevidentwithinthefirstfewdaysoftherapy.

FollowUp
Patientsshouldbefollowedclinicallyuntilsignsandsymptomshaveresolved.

ManagementofSexPartners
Personswhohavehadsexualcontactwithapatientwhohasgranulomainguinalewithinthe60daysbeforeonsetofthepatient's
symptomsshouldbeexaminedandofferedtherapy.However,thevalueofempirictherapyintheabsenceofclinicalsignsand
symptomshasnotbeenestablished.

SpecialConsiderations
Pregnancy
Pregnancyisarelativecontraindicationtotheuseofsulfonamides.Pregnantandlactatingwomenshouldbetreatedwiththe
erythromycinregimen,andconsiderationshouldbegiventotheadditionofaparenteralaminoglycoside(e.g.,gentamicin).
Azithromycinmightproveusefulfortreatinggranulomainguinaleduringpregnancy,butpublisheddataarelacking.Doxycycline
andciprofloxacinarecontraindicatedinpregnantwomen.
HIVInfection
PersonswithbothgranulomainguinaleandHIVinfectionshouldreceivethesameregimensasthosewhoareHIVnegative
however,theadditionofaparenteralaminoglycoside(e.g.,gentamicin)canalsobeconsidered.

LymphogranulomaVenereum
Lymphogranulomavenereum(LGV)iscausedbyC.trachomatisserovarsL1,L2,orL3(194).Themostcommonclinical
manifestationofLGVamongheterosexualsistenderinguinaland/orfemorallymphadenopathythatistypicallyunilateral.Aself
limitedgenitalulcerorpapulesometimesoccursatthesiteofinoculation.However,bythetimepatientsseekcare,thelesionshave
oftendisappeared.RectalexposureinwomenorMSMcanresultinproctocolitis,includingmucoidand/orhemorrhagicrectal
discharge,analpain,constipation,fever,and/ortenesmus(195,196).LGVisaninvasive,systemicinfection,andifitisnottreated
early,LGVproctocolitiscanleadtochronic,colorectalfistulasandstrictures.GenitalandcolorectalLGVlesionscanalsodevelop
secondarybacterialinfectionorcanbecoinfectedwithothersexuallyandnonsexuallytransmittedpathogens.
Diagnosisisbasedonclinicalsuspicion,epidemiologicinformation,andtheexclusionofotheretiologiesforproctocolitis,inguinal
lymphadenopathy,orgenitalorrectalulcers.C.trachomatistestingalsoshouldbeconducted,ifavailable.
Genitalandlymphnodespecimens(i.e.,lesionswaborbuboaspirate)canbetestedforC.trachomatisbyculture,direct
immunofluorescence,ornucleicaciddetection.NAATsforC.trachomatisarenotFDAclearedfortestingrectalspecimens,
althoughsomelaboratorieshaveperformedtheCLIAvalidationstudiesthatareneededtoprovideresultsforclinicalmanagement.
Additionalmolecularprocedures(e.g.,PCRbasedgenotyping)canbeusedtodifferentiateLGVfromnonLGVC.trachomatis,but
thesearenotwidelyavailable.
Chlamydiaserology(complementfixationtiters>1:64)cansupportthediagnosisofLGVintheappropriateclinicalcontext.
Comparativedatabetweentypesofserologictestsarelacking,andthediagnosticutilityofserologicmethodsotherthan
complementfixationandsomemicroimmunofluorescenceprocedureshasnotbeenestablished.Serologictestinterpretationfor
LGVisnotstandardized,testshavenotbeenvalidatedforclinicalproctitispresentations,andC.trachomatisserovarspecific
serologictestsarenotwidelyavailable.
IntheabsenceofspecificLGVdiagnostictesting,patientswithaclinicalsyndromeconsistentwithLGV,includingproctocolitisor
genitalulcerdiseasewithlymphadenopathy,shouldbetreatedforLGVasdescribedinthisreport.

Treatment
Treatmentcuresinfectionandpreventsongoingtissuedamage,althoughtissuereactiontotheinfectioncanresultinscarring.
Buboesmightrequireaspirationthroughintactskinorincisionanddrainagetopreventtheformationofinguinal/femoral
ulcerations.Doxycyclineisthepreferredtreatment.
RecommendedRegimen
Doxycycline100mgorallytwiceadayfor21days
AlternativeRegimen
Erythromycinbase500mgorallyfourtimesadayfor21days
Althoughclinicaldataarelacking,azithromycin1gorallyonceweeklyfor3weeksisprobablyeffectivebasedonitschlamydial
antimicrobialactivity.Fluoroquinolonebasedtreatmentsmightalsobeeffective,butextendedtreatmentintervalsarelikely
required.

FollowUp
Patientsshouldbefollowedclinicallyuntilsignsandsymptomshaveresolved.

ManagementofSexPartners
PersonswhohavehadsexualcontactwithapatientwhohasLGVwithinthe60daysbeforeonsetofthepatient'ssymptomsshould
beexamined,testedforurethralorcervicalchlamydialinfection,andtreatedwithachlamydiaregimen(azithromycin1gmorally
singledoseordoxycycline100mgorallytwiceadayfor7days).

SpecialConsiderations
Pregnancy
Pregnantandlactatingwomenshouldbetreatedwitherythromycin.AzithromycinmightproveusefulfortreatmentofLGVin
pregnancy,butnopublisheddataareavailableregardingitssafetyandefficacy.Doxycyclineiscontraindicatedinpregnantwomen.
HIVInfection
PersonswithbothLGVandHIVinfectionshouldreceivethesameregimensasthosewhoareHIVnegative.Prolongedtherapy
mightberequired,anddelayinresolutionofsymptomsmightoccur.

Syphilis
SyphilisisasystemicdiseasecausedbyTreponemapallidum.Onthebasisofclinicalfindings,thediseasehasbeendividedintoa
seriesofoverlappingstages,whichareusedtohelpguidetreatmentandfollowup.Personswhohavesyphilismightseektreatment
forsignsorsymptomsofprimaryinfection(i.e.,ulcerorchancreattheinfectionsite),secondaryinfection(i.e.,manifestationsthat
include,butarenotlimitedto,skinrash,mucocutaneouslesions,andlymphadenopathy),neurologicinfection(i.e.,cranialnerve
dysfunction,meningitis,stroke,acuteorchronicalteredmentalstatus,lossofvibrationsense,andauditoryorophthalmic
abnormalities,whichmightoccurthroughthenaturalhistoryofuntreatedinfection),ortertiaryinfection(i.e.,cardiacor
gummatouslesions).Latentinfections(i.e.,thoselackingclinicalmanifestations)aredetectedbyserologictesting.Latentsyphilis
acquiredwithintheprecedingyearisreferredtoasearlylatentsyphilisallothercasesoflatentsyphilisareeitherlatelatentsyphilis
orlatentsyphilisofunknownduration.Treatmentforbothlatelatentsyphilisandtertiarysyphilismightrequirealongerduration
oftherapybecauseorganismsmightbedividingmoreslowlyhowever,thevalidityofthisconcepthasnotbeenassessed.

DiagnosticConsiderations
DarkfieldexaminationsandteststodetectT.palliduminlesionexudateortissuearethedefinitivemethodsfordiagnosingearly
syphilis(197).AlthoughnoT.pallidumdetectiontestsarecommerciallyavailable,somelaboratoriesprovidelocallydevelopedPCR
testsforthedetectionofT.pallidum.Apresumptivediagnosisofsyphilisispossiblewiththeuseoftwotypesofserologictests:1)
nontreponemaltests(e.g.,VenerealDiseaseResearchLaboratory[VDRL]andRPR)and2)treponemaltests(e.g.,fluorescent
treponemalantibodyabsorbed[FTAABS]tests,theT.pallidumpassiveparticleagglutination[TPPA]assay,variousEIAs,and
chemiluminescenceimmunoassays).Theuseofonlyonetypeofserologictestisinsufficientfordiagnosis,becauseeachtypeoftest
haslimitations,includingthepossibilityoffalsepositivetestresultsinpersonswithoutsyphilis.Falsepositivenontreponemaltest
resultscanbeassociatedwithvariousmedicalconditionsunrelatedtosyphilis,includingautoimmuneconditions,olderage,and
injectiondruguse(198,199)therefore,personswithareactivenontreponemaltestshouldreceiveatreponemaltesttoconfirmthe
diagnosisofsyphilis.
Nontreponemaltestantibodytitersmaycorrelatewithdiseaseactivity,andresultsshouldbereportedquantitatively.Afourfold
changeintiter,equivalenttoachangeoftwodilutions(e.g.,from1:16to1:4orfrom1:8to1:32),isconsiderednecessaryto
demonstrateaclinicallysignificantdifferencebetweentwonontreponemaltestresultsthatwereobtainedusingthesameserologic
test.Sequentialserologictestsinindividualpatientsshouldbeperformedusingthesametestingmethod(e.g.,VDRLorRPR),
preferablybythesamelaboratory.TheVDRLandRPRareequallyvalidassays,butquantitativeresultsfromthetwotestscannotbe
compareddirectlybecauseRPRtitersfrequentlyareslightlyhigherthanVDRLtiters.Nontreponemaltesttitersusuallydeclineafter
treatmentandmightbecomenonreactivewithtimehowever,insomepersons,nontreponemalantibodiescanpersistforalong
periodoftimearesponsereferredtoasthe"serofastreaction."Mostpatientswhohavereactivetreponemaltestswillhave
reactivetestsfortheremainderoftheirlives,regardlessoftreatmentordiseaseactivity.However,15%25%ofpatientstreated
duringtheprimarystagereverttobeingserologicallynonreactiveafter23years(200).Treponemaltestantibodytitersshouldnot
beusedtoassesstreatmentresponse.
Someclinicallaboratoriesandbloodbankshavebeguntoscreensamplesusingtreponemaltests,typicallybyEIAor
chemiluminescenceimmunoassays(201,202).Thisstrategywillidentifybothpersonswithprevioustreatmentforsyphilisand
personswithuntreatedorincompletelytreatedsyphilis.Thepositivepredictivevalueforsyphilisassociatedwithatreponemal
screeningtestresultmightbeloweramongpopulationswithalowprevalenceofsyphilis.
Personswithapositivetreponemalscreeningtestshouldhaveastandardnontreponemaltestwithtiterperformedreflexivelybythe
laboratorytoguidepatientmanagementdecisions.Ifthenontreponemaltestisnegative,thenthelaboratoryshouldperforma
differenttreponemaltest(preferablyonebasedondifferentantigensthantheoriginaltest)toconfirmtheresultsoftheinitialtest.
Ifasecondtreponemaltestispositive,personswithahistoryofprevioustreatmentwillrequirenofurthermanagementunless
sexualhistorysuggestslikelihoodofreexposure.Thosewithoutahistoryoftreatmentforsyphilisshouldbeofferedtreatment.
Unlesshistoryorresultsofaphysicalexaminationsuggestarecentinfection,previouslyuntreatedpersonsshouldbetreatedforlate

latentsyphilis.Ifthesecondtreponemaltestisnegative,furtherevaluationortreatmentisnotindicated.
FormostHIVinfectedpersons,serologictestsareaccurateandreliableforthediagnosisofsyphilisandforfollowingapatient's
responsetotreatment.However,atypicalsyphilisserologictestresults(i.e.,unusuallyhigh,unusuallylow,orfluctuatingtiters)can
occurinHIVinfectedpersons.Whenserologictestsdonotcorrespondwithclinicalfindingssuggestiveofearlysyphilis,useofother
tests(e.g.,biopsyanddarkfieldmicroscopy)shouldbeconsidered.
Clinicalsignsofneurosyphilis(i.e.,cranialnervedysfunction,meningitis,stroke,acuteorchronicalteredmentalstatus,lossof
vibrationsense,andauditoryorophthalmicabnormalities)warrantfurtherinvestigationandtreatmentforneurosyphilis.
Laboratorytestingishelpfulinsupportingthediagnosisofneurosyphilishowever,nosingletestcanbeusedtodiagnose
neurosyphilisinallinstances.Cerebrospinalfluid(CSF)laboratoryabnormalitiesarecommoninpersonswithearlysyphilis.The
VDRLincerebrospinalfluid(CSFVDRL),whichishighlyspecificbutinsensitive,isthestandardserologictestforCSF.When
reactiveintheabsenceofsubstantialcontaminationofCSFwithblood,itisconsidereddiagnosticofneurosyphilishoweverinearly
syphilis,itcanbeofunknownprognosticsignificance(203).Mostothertestsarebothinsensitiveandnonspecificandmustbe
interpretedinrelationtoothertestresultsandtheclinicalassessment.Therefore,thelaboratorydiagnosisofneurosyphilisusually
dependsonvariouscombinationsofreactiveserologictestresults,CSFcellcountorprotein,andareactiveCSFVDRLwithor
withoutclinicalmanifestations.AmongpersonswithHIVinfection,theCSFleukocytecountusuallyiselevated(>5whitebloodcell
count[WBC]/mm3)usingahighercutoff(>20WBC/mm3)mightimprovethespecificityofneurosyphilisdiagnosis(204).The
CSFVDRLmightbenonreactiveevenwhenneurosyphilisispresenttherefore,additionalevaluationusingFTAABStestingonCSF
canbeconsidered.TheCSFFTAABStestislessspecificforneurosyphilisthantheCSFVDRLbutishighlysensitiveneurosyphilis
ishighlyunlikelywithanegativeCSFFTAABStest(205).

Treatment
PenicillinG,administeredparenterally,isthepreferreddrugfortreatingallstagesofsyphilis.Thepreparationused(i.e.,
benzathine,aqueousprocaine,oraqueouscrystalline),thedosage,andthelengthoftreatmentdependonthestageandclinical
manifestationsofthedisease.Selectionoftheappropriatepenicillinpreparationisimportant,becauseT.pallidumcanresidein
sequesteredsites(e.g.,theCNSandaqueoushumor)thatarepoorlyaccessedbysomeformsofpenicillin.Combinationsof
benzathinepenicillin,procainepenicillin,andoralpenicillinpreparationsarenotconsideredappropriateforthetreatmentof
syphilis.Reportshaveindicatedthatpractitionershaveinadvertentlyprescribedcombinationbenzathineprocainepenicillin
(BicillinCR)insteadofthestandardbenzathinepenicillinproduct(BicillinLA)widelyusedintheUnitedStates.Practitioners,
pharmacists,andpurchasingagentsshouldbeawareofthesimilarnamesofthesetwoproductstoavoidusingtheinappropriate
combinationtherapyagentfortreatingsyphilis(206).
Theeffectivenessofpenicillinforthetreatmentofsyphiliswaswellestablishedthroughclinicalexperienceevenbeforethevalueof
randomizedcontrolledclinicaltrialswasrecognized.Therefore,nearlyalltherecommendationsforthetreatmentofsyphilisare
basednotonlyonclinicaltrialsandobservationalstudies,butapproximately50yearsofclinicalexperience.
ParenteralpenicillinGistheonlytherapywithdocumentedefficacyforsyphilisduringpregnancy.Pregnantwomenwithsyphilisin
anystagewhoreportpenicillinallergyshouldbedesensitizedandtreatedwithpenicillin(seeManagementofPatientsWhoHavea
HistoryofPenicillinAllergy).
TheJarischHerxheimerreactionisanacutefebrilereactionfrequentlyaccompaniedbyheadache,myalgia,fever,andother
symptomsthatusuallyoccurwithinthefirst24hoursaftertheinitiationofanytherapyforsyphilis.Patientsshouldbeinformed
aboutthispossibleadversereaction.TheJarischHerxheimerreactionoccursmostfrequentlyamongpatientswhohaveearly
syphilis,presumablybecausebacterialburdensarehigherduringthesestages.Antipyreticscanbeusedtomanagesymptoms,but
theyhavenotbeenproventopreventthisreaction.TheJarischHerxheimerreactionmightinduceearlylabororcausefetaldistress
inpregnantwomen,butthisshouldnotpreventordelaytherapy(seeSyphilisDuringPregnancy).

ManagementofSexPartners
SexualtransmissionofT.pallidumisthoughttooccuronlywhenmucocutaneoussyphiliticlesionsarepresent.Althoughsuch
manifestationsareuncommonafterthefirstyearofinfection,personsexposedsexuallytoapatientwhohassyphilisinanystage
shouldbeevaluatedclinicallyandserologicallyandtreatedwitharecommendedregimen,accordingtothefollowing
recommendations:
Personswhowereexposedwithinthe90daysprecedingthediagnosisofprimary,secondary,orearlylatentsyphilisinasex
partnermightbeinfectedevenifseronegativetherefore,suchpersonsshouldbetreatedpresumptively.
Personswhowereexposed>90daysbeforethediagnosisofprimary,secondary,orearlylatentsyphilisinasexpartnershould
betreatedpresumptivelyifserologictestresultsarenotavailableimmediatelyandtheopportunityforfollowupisuncertain.
Forpurposesofpartnernotificationandpresumptivetreatmentofexposedsexpartners,patientswithsyphilisofunknown
durationwhohavehighnontreponemalserologictesttiters(i.e.,>1:32)canbeassumedtohaveearlysyphilis.Forthepurpose
ofdeterminingatreatmentregimen,however,serologictitersshouldnotbeusedtodifferentiateearlyfromlatelatentsyphilis
(seeLatentSyphilis,Treatment).
Longtermsexpartnersofpatientswhohavelatentsyphilisshouldbeevaluatedclinicallyandserologicallyforsyphilisand
treatedonthebasisoftheevaluationfindings.
Sexualpartnersofinfectedpatientsshouldbeconsideredatriskandprovidedtreatmentiftheyhavehadsexualcontactwiththe

patientwithin3monthsplusthedurationofsymptomsforpatientsdiagnosedwithprimarysyphilis,6monthsplusdurationof
symptomsforthosewithsecondarysyphilis,and1yearforpatientswithearlylatentsyphilis.

PrimaryandSecondarySyphilis
Treatment
ParenteralpenicillinGhasbeenusedeffectivelyformorethan50yearstoachieveclinicalresolution(i.e.,thehealingoflesionsand
preventionofsexualtransmission)andtopreventlatesequelae.However,nocomparativetrialshavebeenadequatelyconductedto
guidetheselectionofanoptimalpenicillinregimen(i.e.,thedose,duration,andpreparation).Substantiallyfewerdataareavailable
fornonpenicillinregimens.
RecommendedRegimenforAdults*
BenzathinepenicillinG2.4millionunitsIMinasingledose
*RecommendationsfortreatingsyphilisinHIVinfectedpersonsandpregnantwomenarediscussedlaterinthisreport(see
SyphilisamongHIVInfectedPersonsandSyphilisinPregnancy).
AvailabledatademonstratethatadditionaldosesofbenzathinepenicillinG,amoxicillin,orotherantibioticsinearlysyphilis
(primary,secondary,andearlylatent)donotenhanceefficacy,regardlessofHIVstatus.
RecommendedRegimenforInfantsandChildren
Infantsandchildrenaged1monthdiagnosedwithsyphilisshouldhaveaCSFexaminationtodetectasymptomaticneurosyphilis,
andbirthandmaternalmedicalrecordsshouldbereviewedtoassesswhethersuchchildrenhavecongenitaloracquiredsyphilis
(seeCongenitalSyphilis).Childrenwithacquiredprimaryorsecondarysyphilisshouldbeevaluated(e.g.,throughconsultationwith
childprotectionservices)(seeSexualAssaultorAbuseofChildren)andtreatedbyusingthefollowingpediatricregimen.
RecommendedRegimenforInfantsandChildren
BenzathinepenicillinG50,000units/kgIM,uptotheadultdoseof2.4millionunitsinasingledose
OtherManagementConsiderations
AllpersonswhohavesyphilisshouldbetestedforHIVinfection.IngeographicareasinwhichtheprevalenceofHIVishigh,
personswhohaveprimarysyphilisshouldberetestedforHIVafter3monthsifthefirstHIVtestresultwasnegative.
Patientswhohavesyphilisandsymptomsorsignssuggestingneurologicdisease(e.g.,meningitisandhearingloss)orophthalmic
disease(e.g.,uveitis,iritis,neuroretinitis,andopticneuritis)shouldhaveanevaluationthatincludesCSFanalysis,ocularslitlamp
ophthalmologicexamination,andotologicexamination.Treatmentshouldbeguidedbytheresultsofthisevaluation.
InvasionofCSFbyT.pallidumaccompaniedbyCSFlaboratoryabnormalitiesiscommonamongadultswhohaveprimaryor
secondarysyphilis(203).Therefore,intheabsenceofclinicalneurologicfindings,noevidenceexiststosupportvariationfromthe
recommendedtreatmentregimenforearlysyphilis.Symptomaticneurosyphilisdevelopsinonlyalimitednumberofpersonsafter
treatmentwiththepenicillinregimensrecommendedforprimaryandsecondarysyphilis.Therefore,unlessclinicalsignsor
symptomsofneurologicorophthalmicinvolvementarepresentortreatmentfailureisdocumented,routineCSFanalysisisnot
recommendedforpersonswhohaveprimaryorsecondarysyphilis.
FollowUp
Treatmentfailurecanoccurwithanyregimen.However,assessingresponsetotreatmentfrequentlyisdifficult,anddefinitive
criteriaforcureorfailurehavenotbeenestablished.Inaddition,nontreponemaltesttitersmightdeclinemoreslowlyforpersons
whopreviouslyhavehadsyphilis(207).Clinicalandserologicevaluationshouldbeperformed6monthsand12monthsafter
treatmentmorefrequentevaluationmightbeprudentiffollowupisuncertain.
Patientswhohavesignsorsymptomsthatpersistorrecurorwhohaveasustainedfourfoldincreaseinnontreponemaltesttiter
(i.e.,comparedwiththemaximumorbaselinetiteratthetimeoftreatment)probablyfailedtreatmentorwerereinfected.These
patientsshouldberetreatedandreevaluatedforHIVinfection.Becausetreatmentfailureusuallycannotbereliablydistinguished
fromreinfectionwithT.pallidum,aCSFanalysisalsoshouldbeperformed.
Althoughfailureofnontreponemaltesttiterstodeclinefourfoldwithin612monthsaftertherapyforprimaryorsecondarysyphilis
mightbeindicativeoftreatmentfailure,clinicaltrialdatahavedemonstratedthat>15%ofpatientswithearlysyphilistreatedwith
therecommendedtherapywillnotachievethetwodilutiondeclineinnontreponemaltiterusedtodefineresponseat1yearafter
treatment(208).PersonswhosetitersdonotdeclineshouldbereevaluatedforHIVinfection.Optimalmanagementofsuchpatients
isunclear.Ataminimum,thesepatientsshouldreceiveadditionalclinicalandserologicfollowup.Ifadditionalfollowupcannotbe
ensured,retreatmentisrecommended.BecausetreatmentfailuremightbetheresultofunrecognizedCNSinfection,CSF
examinationcanbeconsideredinsuchsituations.
Forretreatment,weeklyinjectionsofbenzathinepenicillinG2.4millionunitsIMfor3weeksisrecommended,unlessCSF
examinationindicatesthatneurosyphilisispresent(seeNeurosyphilis).Inrareinstances,serologictitersdonotdeclinedespitea

negativeCSFexaminationandarepeatedcourseoftherapy.Inthesecircumstances,theneedforadditionaltherapyorrepeatedCSF
examinationsisunclear,butisnotgenerallyrecommended.
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy
Datatosupporttheuseofalternativestopenicillininthetreatmentofearlysyphilisarelimited.However,severaltherapiesmight
beeffectiveinnonpregnant,penicillinallergicpatientswhohaveprimaryorsecondarysyphilis.Doxycycline100mgorallytwice
dailyfor14days(209,210)andtetracycline(500mgfourtimesdailyfor14days)areregimensthathavebeenusedformanyyears.
Complianceislikelytobebetterwithdoxycyclinethantetracycline,becausetetracyclinecancausegastrointestinalsideeffects.
Althoughlimitedclinicalstudies,alongwithbiologicandpharmacologicevidence,suggestthatceftriaxone(1gdailyeitherIMorIV
for1014days)iseffectivefortreatingearlysyphilis,theoptimaldoseanddurationofceftriaxonetherapyhavenotbeendefined
(211).Azithromycinasasingle2goraldoseiseffectivefortreatingearlysyphilis(212214).However,T.pallidumchromosomal
mutationsassociatedwithazithromycinresistanceandtreatmentfailureshavebeendocumentedinseveralgeographicalareasin
theUnitedStates(215217).Assuch,theuseofazithromycinshouldbeusedwithcautiononlywhentreatmentwithpenicillinor
doxycyclineisnotfeasible.AzithromycinshouldnotbeusedinMSMorpregnantwomen.Closefollowupofpersonsreceivingany
alternativetherapiesisessential.
Personswithapenicillinallergywhosecompliancewiththerapyorfollowupcannotbeensuredshouldbedesensitizedandtreated
withbenzathinepenicillin.Skintestingforpenicillinallergymightbeusefulinsomecircumstancesinwhichthereagentsand
expertiseareavailabletoperformthetestadequately(seeManagementofPatientsWhoHaveaHistoryofPenicillinAllergy).
Pregnancy
Pregnantpatientswhoareallergictopenicillinshouldbedesensitizedandtreatedwithpenicillin(seeManagementofPatientsWho
HaveaHistoryofPenicillinAllergyandSyphilisDuringPregnancy).
HIVInfection
SeeSyphilisAmongHIVInfectedPersons.

LatentSyphilis
Latentsyphilisisdefinedassyphilischaracterizedbyseroreactivitywithoutotherevidenceofdisease.Patientswhohavelatent
syphilisandwhoacquiredsyphilisduringtheprecedingyearareclassifiedashavingearlylatentsyphilis.Patients'conditionscanbe
diagnosedasearlylatentsyphilisif,duringtheyearprecedingtheevaluation,theyhad1)adocumentedseroconversionorfourfold
orgreaterincreaseintiterofanontreponemaltest2)unequivocalsymptomsofprimaryorsecondarysyphilisor3)asexpartner
documentedtohaveprimary,secondary,orearlylatentsyphilis.Inaddition,forpersonswhoseonlypossibleexposureoccurred
duringtheprevious12months,reactivenontreponemalandtreponemaltestsareindicativeofearlylatentsyphilis.Intheabsenceof
theseconditions,anasymptomaticpersonshouldbeconsideredtohavelatelatentsyphilisorsyphilisofunknownduration.
Nontreponemalserologictitersusuallyarehigherduringearlylatentsyphilisthanlatelatentsyphilis.However,earlylatentsyphilis
cannotbereliablydistinguishedfromlatelatentsyphilissolelyonthebasisofnontreponemaltiters.Allpatientswithlatentsyphilis
shouldhavecarefulexaminationofallaccessiblemucosalsurfaces(i.e.,theoralcavity,perianalarea,perineumandvaginain
women,andunderneaththeforeskininuncircumcisedmen)toevaluateforinternalmucosallesions.Allpatientswhohavesyphilis
shouldbetestedforHIVinfection.
Treatment
Becauselatentsyphilisisnottransmittedsexually,theobjectiveoftreatingpatientswiththisstageofdiseaseistoprevent
complications.Althoughclinicalexperiencesupportstheeffectivenessofpenicillininachievingthisgoal,limitedevidenceis
availabletoguidechoiceofspecificregimens.
ThefollowingregimensarerecommendedforpenicillinnonallergicpatientswhohavenormalCSFexaminations(ifperformed).
RecommendedRegimensforAdults*
EarlyLatentSyphilis
BenzathinepenicillinG2.4millionunitsIMinasingledose
LateLatentSyphilisorLatentSyphilisofUnknownDuration
BenzathinepenicillinG7.2millionunitstotal,administeredas3dosesof2.4millionunitsIMeachat1weekintervals
*RecommendationsfortreatingsyphilisinHIVinfectedpersonsandpregnantwomenarediscussedlaterinthisreport(see
SyphilisamongHIVInfectedPersonsandSyphilisinPregnancy).

AvailabledatademonstratenoenhancedefficacyofadditionaldosesofpenicillinG,amoxicillin,orotherantibioticsinearly
syphilis,regardlessofHIVstatus.
Infantsandchildrenaged1monthwhohavebeendiagnosedwithsyphilisshouldhaveaCSFexaminationtoexclude
neurosyphilis.Inaddition,birthandmaternalmedicalrecordsshouldbereviewedtoassesswhetherchildrenhavecongenitalor
acquiredsyphilis(seeCongenitalSyphilis).Olderchildrenwithacquiredlatentsyphilisshouldbeevaluatedasdescribedforadults
andtreatedusingthefollowingpediatricregimens(seeSexualAssaultorAbuseofChildren).Theseregimensareforpenicillin
nonallergicchildrenwhohaveacquiredsyphilisandwhohavenormalCSFexaminationresults.
RecommendedRegimensforChildren
EarlyLatentSyphilis
BenzathinepenicillinG50,000units/kgIM,uptotheadultdoseof2.4millionunitsinasingledose
LateLatentSyphilisorLatentSyphilisofUnknownDuration
BenzathinepenicillinG50,000units/kgIM,uptotheadultdoseof2.4millionunits,administeredas3dosesat1week
intervals(total150,000units/kguptotheadulttotaldoseof7.2millionunits)
OtherManagementConsiderations
PatientsdiagnosedwithlatentsyphiliswhodemonstrateanyofthefollowingcriteriashouldhaveapromptCSFexamination:
Neurologic(e.g.,auditorydisease,cranialnervedysfunction,acuteorchronicmeningitis,stroke,acuteorchronicaltered
mentalstatus,andlossofvibrationsense)orophthalmicsignsorsymptoms(e.g.,iritisanduveitis)
evidenceofactivetertiarysyphilis(e.g.,aortitisandgumma)or
serologictreatmentfailure.
Ifapatientmissesadoseofpenicillininacourseofweeklytherapyforlatesyphilis,theappropriatecourseofactionisunclear.
Pharmacologicconsiderationssuggestthatanintervalof1014daysbetweendosesofbenzathinepenicillinforlatesyphilisor
latentsyphilisofunknowndurationmightbeacceptablebeforerestartingthesequenceofinjections.Misseddosesarenot
acceptableforpregnantpatientsreceivingtherapyforlatelatentsyphilis.Pregnantwomenwhomissanydoseoftherapymust
repeatthefullcourseoftherapy.
FollowUp
Quantitativenontreponemalserologictestsshouldberepeatedat6,12,and24months.ACSFexaminationshouldbeperformedif
1)titersincreasefourfold,2)aninitiallyhightiter(1:32)failstodeclineatleastfourfold(i.e.,twodilutions)within1224months
oftherapy,or3)signsorsymptomsattributabletosyphilisdevelop.Insuchcircumstances,eveniftheCSFexaminationisnegative,
retreatmentforlatentsyphilisshouldbeinitiated.Inrareinstances,despiteanegativeCSFexaminationandarepeatedcourseof
therapy,serologictitersmightfailtodecline.Inthesecircumstances,theneedforadditionaltherapyorrepeatedCSFexaminations
isunclear.
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy
Theeffectivenessofalternativestopenicillininthetreatmentoflatentsyphilishasnotbeenwelldocumented.Nonpregnantpatients
allergictopenicillinwhohaveclearlydefinedearlylatentsyphilisshouldrespondtotherapiesrecommendedasalternativesto
penicillinforthetreatmentofprimaryandsecondarysyphilis(seePrimaryandSecondarySyphilis,Treatment).Theonlyacceptable
alternativesforthetreatmentoflatelatentsyphilisorlatentsyphilisofunknowndurationaredoxycycline(100mgorallytwice
daily)ortetracycline(500mgorallyfourtimesdaily),bothfor28days.Thesetherapiesshouldbeusedonlyinconjunctionwith
closeserologicandclinicalfollowup.Basedonbiologicplausibilityandpharmacologicproperties,ceftriaxonemightbeeffectivefor
treatinglatelatentsyphilisorsyphilisofunknownduration.However,theoptimaldoseanddurationofceftriaxonetherapyhave
notbeendefined,andtreatmentdecisionsshouldbediscussedinconsultationwithaspecialist.Somepatientswhoareallergicto
penicillinalsomightbeallergictoceftriaxoneinthesecircumstances,useofanalternativeagentmightberequired.Theefficacyof
thesealternativeregimensinHIVinfectedpersonshasnotbeenwellstudied.
Pregnancy
Pregnantpatientswhoareallergictopenicillinshouldbedesensitizedandtreatedwithpenicillin(seeManagementofPatientsWho
HaveaHistoryofPenicillinAllergyandSyphilisDuringPregnancy).
HIVInfection

SeeSyphilisAmongHIVInfectedPersons.

TertiarySyphilis
Tertiarysyphilisreferstogummaandcardiovascularsyphilisbutnottoallneurosyphilis.Patientswhoarenotallergictopenicillin
andhavenoevidenceofneurosyphilisshouldbetreatedwiththefollowingregimen.
RecommendedRegimen
BenzathinepenicillinG7.2millionunitstotal,administeredas3dosesof2.4millionunitsIMeachat1weekintervals
OtherManagementConsiderations
PatientswhohavesymptomaticlatesyphilisshouldbegivenaCSFexaminationbeforetherapyisinitiated.Someproviderstreatall
patientswhohavecardiovascularsyphiliswithaneurosyphilisregimen.Thesepatientsshouldbemanagedinconsultationwithan
infectiousdiseasespecialist.
FollowUp
Limitedinformationisavailableconcerningclinicalresponseandfollowupofpatientswhohavetertiarysyphilis.
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy
Patientsallergictopenicillinshouldbetreatedinconsultationwithaninfectiousdiseasespecialist.
Pregnancy
Pregnantpatientswhoareallergictopenicillinshouldbedesensitizedandtreatedwithpenicillin(seeManagementofPatientsWho
HaveaHistoryofPenicillinAllergyandSyphilisDuringPregnancy).
HIVInfection
SeeSyphilisAmongHIVInfectedPersons.

Neurosyphilis
Treatment
CNSinvolvementcanoccurduringanystageofsyphilis.However,CSFlaboratoryabnormalitiesarecommoninpersonswithearly
syphilis,evenintheabsenceofclinicalneurologicalfindings.Noevidenceexiststosupportvariationfromrecommendedtreatment
forearlysyphilisforpatientsfoundtohavesuchabnormalities.Ifclinicalevidenceofneurologicinvolvementisobserved(e.g.,
cognitivedysfunction,motororsensorydeficits,ophthalmicorauditorysymptoms,cranialnervepalsies,andsymptomsorsignsof
meningitis),aCSFexaminationshouldbeperformed.
Syphiliticuveitisorotherocularmanifestationsfrequentlyareassociatedwithneurosyphilisandshouldbemanagedaccordingto
thetreatmentrecommendationsforneurosyphilis.Patientswhohaveneurosyphilisorsyphiliticeyedisease(e.g.,uveitis,
neuroretinitis,andopticneuritis)shouldbetreatedwiththerecommendedregimenforneurosyphilisthosewitheyediseaseshould
bemanagedincollaborationwithanophthalmologist.ACSFexaminationshouldbeperformedforallpatientswithsyphiliticeye
diseasetoidentifythosewithabnormalitiespatientsfoundtohaveabnormalCSFtestresultsshouldbeprovidedfollowupCSF
examinationstoassesstreatmentresponse.
RecommendedRegimen
AqueouscrystallinepenicillinG1824millionunitsperday,administeredas34millionunitsIVevery4hoursor
continuousinfusion,for1014days
Ifcompliancewiththerapycanbeensured,thefollowingalternativeregimenmightbeconsidered.
AlternativeRegimen
Procainepenicillin2.4millionunitsIMoncedaily
PLUS
Probenecid500mgorallyfourtimesaday,bothfor1014days
Thedurationsoftherecommendedandalternativeregimensforneurosyphilisareshorterthanthedurationoftheregimenusedfor
latesyphilisintheabsenceofneurosyphilis.Therefore,benzathinepenicillin,2.4millionunitsIMonceperweekforupto3weeks,

canbeconsideredaftercompletionoftheseneurosyphilistreatmentregimenstoprovideacomparabletotaldurationoftherapy.
OtherManagementConsiderations
Otherconsiderationsinthemanagementofpatientswhohaveneurosyphilisareasfollows:
AllpersonswhohavesyphilisshouldbetestedforHIV.
Althoughsystemicsteroidsareusedfrequentlyasadjunctivetherapyforotologicsyphilis,suchdrugshavenotbeenprovento
bebeneficial.
FollowUp
IfCSFpleocytosiswaspresentinitially,aCSFexaminationshouldberepeatedevery6monthsuntilthecellcountisnormal.Follow
upCSFexaminationsalsocanbeusedtoevaluatechangesintheCSFVDRLorCSFproteinaftertherapyhowever,changesinthese
twoparametersoccurmoreslowlythancellcounts,andpersistentabnormalitiesmightbelessimportant(219,220).Theleukocyte
countisasensitivemeasureoftheeffectivenessoftherapy.Ifthecellcounthasnotdecreasedafter6monthsoriftheCSFcellcount
orproteinisnotnormalafter2years,retreatmentshouldbeconsidered.Limiteddatasuggestthatinimmunocompetentpersons
andHIVinfectedpersonsonhighlyactiveantiretroviraltherapy,normalizationoftheserumRPRtiterpredictsnormalizationof
CSFparameters(220).
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy
Limiteddatasuggestthatceftriaxone2gdailyeitherIMorIVfor1014dayscanbeusedasanalternativetreatmentforpatients
withneurosyphilis(221,222).However,thepossibilityofcrossreactivitybetweenceftriaxoneandpenicillinexists.Otherregimens
havenotbeenadequatelyevaluatedfortreatmentofneurosyphilis.Therefore,ifconcernexistsregardingthesafetyofceftriaxone
forapatientwithneurosyphilis,skintestingshouldbeperformed(ifavailable)toconfirmpenicillinallergyand,ifnecessary,
desensitizationinconsultationwithaspecialist.
Pregnancy
Pregnantpatientswhoareallergictopenicillinshouldbedesensitizedandtreatedwithpenicillin(seeSyphilisDuringPregnancy).
HIVInfection
SeeSyphilisAmongHIVInfectedPersons.

SyphilisAmongHIVInfectedPersons
DiagnosticConsiderations
Althoughtheyareuncommon,unusualserologicresponseshavebeenobservedamongHIVinfectedpersonswhohavesyphilis.
Mostreportshaveinvolvedserologictitersthatwerehigherthanexpected,butfalsenegativeserologictestresultsanddelayed
appearanceofseroreactivityalsohavebeenreported(223).Regardless,bothtreponemalandnontreponemalserologictestsfor
syphiliscanbeinterpretedintheusualmannerformostpatientswhoarecoinfectedwithT.pallidumandHIV.
Whenclinicalfindingsaresuggestiveofsyphilisbutserologictestsarenonreactiveortheirinterpretationisunclear,alternativetests
(e.g.,biopsyofalesion,darkfieldexamination,andPCRoflesionmaterial)mightbeusefulfordiagnosis.Neurosyphilisshouldbe
consideredinthedifferentialdiagnosisofneurologicdiseaseinHIVinfectedpersons.
Treatment
ComparedwithHIVnegativepatients,HIVpositivepatientswhohaveearlysyphilismightbeatincreasedriskforneurologic
complications(224)andmighthavehigherratesofserologictreatmentfailurewithcurrentlyrecommendedregimens.The
magnitudeoftheserisksisnotdefinedprecisely,butislikelysmall.Notreatmentregimensforsyphilishavebeendemonstratedto
bemoreeffectiveinpreventingneurosyphilisinHIVinfectedpatientsthanthesyphilisregimensrecommendedforHIVnegative
patients(208).Carefulfollowupaftertherapyisessential.
PrimaryandSecondarySyphilisAmongHIVInfectedPersons
Treatment
TreatmentofprimaryandsecondarysyphilisamongHIVinfectedpersonsisbenzathinepenicillinG,2.4millionunitsIMinasingle
dose.
AvailabledatademonstratethatadditionaldosesofbenzathinepenicillinG,amoxicillin,orotherantibioticsinearlysyphilisdonot
resultinenhancedefficacy,regardlessofHIVstatus(208).

OtherManagementConsiderations
MostHIVinfectedpersonsrespondappropriatelytostandardbenzathinepenicillinforprimaryandsecondarysyphilis.CSF
abnormalities(e.g.,mononuclearpleocytosisandelevatedproteinlevels)arecommoninHIVinfectedpersons,eveninthose
withoutneurologicsymptoms,althoughtheclinicalandprognosticsignificanceofsuchCSFabnormalitieswithprimaryand
secondarysyphilisisunknown.SeveralstudieshavedemonstratedthatamongpersonsinfectedwithbothHIVandsyphilis,clinical
andCSFabnormalitiesconsistentwithneurosyphilisareassociatedwithaCD4countof350cells/mLand/oranRPRtiterof1:32
(204,225,226)however,unlessneurologicsymptomsarepresent,CSFexaminationinthissettinghasnotbeenassociatedwith
improvedclinicaloutcomes.
TheuseofantiretroviraltherapyaspercurrentguidelinesmightimproveclinicaloutcomesinHIVinfectedpersonswithsyphilis
(220,227,228).
FollowUp
HIVinfectedpersonsshouldbeevaluatedclinicallyandserologicallyfortreatmentfailureat3,6,9,12,and24monthsafter
therapy.
HIVinfectedpersonswhomeetthecriteriafortreatmentfailure(i.e.,signsorsymptomsthatpersistorrecurorpersonswhohavea
sustainedfourfoldincreaseinnontreponemaltesttiter)shouldbemanagedinthesamemannerasHIVnegativepatients(i.e.,a
CSFexaminationandretreatment).CSFexaminationandretreatmentalsoshouldbestronglyconsideredforpersonswhose
nontreponemaltesttitersdonotdecreasefourfoldwithin612monthsoftherapy.IfCSFexaminationisnormal,treatmentwith
benzathinepenicillinGadministeredas2.4millionunitsIMeachatweeklyintervalsfor3weeksisrecommended.
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy.HIVinfected,penicillinallergicpatientswhohaveprimaryorsecondarysyphilisshouldbemanaged
accordingtotherecommendationsforpenicillinallergic,HIVnegativepatients.Patientswithpenicillinallergywhosecompliance
withtherapyorfollowupcannotbeensuredshouldbedesensitizedandtreatedwithpenicillin(seeManagementofPatientsWho
HaveaHistoryofPenicillinAllergy).TheuseofalternativestopenicillinhasnotbeenwellstudiedinHIVinfectedpatients.These
therapiesshouldbeusedonlyinconjunctionwithcloseserologicandclinicalfollowup.
LatentSyphilisAmongHIVInfectedPersons
Treatment
HIVinfectedpersonswithlatentsyphilisshouldbetreatedaccordingtothestagespecificrecommendationsforHIVnegative
persons.
TreatmentofearlylatentsyphilisamongHIVinfectedpersonsisbenzathinepenicillinG,2.4millionunitsIMinasingledose.
TreatmentoflatelatentsyphilisorsyphilisofunknowndurationamongHIVinfectedpersonsisbenzathinepenicillinG,at
weeklydosesof2.4millionunitsfor3weeks.
OtherManagementConsiderations
AllHIVinfectedpersonswithsyphilisandneurologicsymptomsshouldundergoimmediateCSFexamination.Somestudieshave
demonstratedthatclinicalandCSFabnormalitiesconsistentwithneurosyphilisaremostlikelyinHIVinfectedpersonswhohave
beendiagnosedwithsyphilisandhaveaCD4countof350cells/mland/oranRPRtiterof1:32(204,225,226)howeverunless
neurologicsymptomsarepresent,CSFexaminationinthissettinghasnotbeenassociatedwithimprovedclinicaloutcomes.
FollowUp
Patientsshouldbeevaluatedclinicallyandserologicallyat6,12,18,and24monthsaftertherapy.If,atanytime,clinicalsymptoms
developornontreponemaltitersrisefourfold,arepeatCSFexaminationshouldbeperformedandtreatmentadministered
accordingly.Ifduring1224monthsthenontreponemaltiterdoesnotdeclinefourfold,CSFexaminationshouldbestrongly
consideredandtreatmentadministeredaccordingly.
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy.TheefficacyofalternativenonpenicillinregimensinHIVinfectedpersonshasnotbeenwellstudied.Patients
withpenicillinallergywhosecompliancewiththerapyorfollowupcannotbeensuredshouldbedesensitizedandtreatedwith
penicillin(seeManagementofPatientsWhoHaveaHistoryofPenicillinAllergy).Thesetherapiesshouldbeusedonlyin
conjunctionwithcloseserologicandclinicalfollowup.Limitedclinicalstudies,alongwithbiologicandpharmacologicevidence,

suggestthatceftriaxonemightbeeffective(229,230).However,theoptimaldoseanddurationofceftriaxonetherapyhavenotbeen
defined.
NeurosyphilisAmongHIVInfectedPersons
Treatment
HIVinfectedpatientswithneurosyphilisshouldbetreatedaccordingtotherecommendationsforHIVnegativepatientswith
neurosyphilis(seeNeurosyphilis).
FollowUp
IfCSFpleocytosiswaspresentinitially,aCSFexaminationshouldberepeatedevery6monthsuntilthecellcountisnormal.Follow
upCSFexaminationsalsocanbeusedtogaugeresponseaftertherapy.LimiteddatasuggestthatchangesinCSFparametersmight
occurmoreslowlyinHIVinfectedpatients,especiallythosewithmoreadvancedimmunosuppression(219,227).Ifthecellcount
hasnotdecreasedafter6monthsoriftheCSFisnotnormalafter2years,retreatmentshouldbeconsidered.
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy.HIVinfected,penicillinallergicpatientswhohaveneurosyphilisshouldbemanagedaccordingtothe
recommendationsforpenicillinallergic,HIVnegativepatientswithneurosyphilis.Severalsmallobservationalstudiesconductedin
HIVinfectedpatientswithneurosyphilissuggestthatceftriaxone12gIVdailyfor1014daysmightbeeffectiveasanalternate
agent(218,229,230).

SyphilisDuringPregnancy
Allwomenshouldbescreenedserologicallyforsyphilisearlyinpregnancy.Moststatesmandatescreeningatthefirstprenatalvisit
forallwomen(231)antepartumscreeningbynontreponemalantibodytestingistypical,butinsomesettings,treponemalantibody
testingisbeingused.Pregnantwomenwithreactivetreponemalscreeningtestsshouldhaveconfirmatorytestingwith
nontreponemaltestswithtiters.Inpopulationsinwhichuseofprenatalcareisnotoptimal,RPRtestscreeningandtreatment(ifthe
RPRtestisreactive)shouldbeperformedatthetimethatpregnancyisconfirmed(232).Forcommunitiesandpopulationsinwhich
theprevalenceofsyphilisishighandforpatientsathighrisk,serologictestingshouldbeperformedtwiceduringthethirdtrimester
(ideallyat2832weeks'gestation)andatdelivery.Anywomanwhodeliversastillborninfantafter20weeks'gestationshouldbe
testedforsyphilis.Noinfantshouldleavethehospitalwithoutthematernalserologicstatushavingbeendeterminedatleastonce
duringpregnancy.
DiagnosticConsiderations
Seropositivepregnantwomenshouldbeconsideredinfectedunlessanadequatetreatmenthistoryisdocumentedclearlyinthe
medicalrecordsandsequentialserologicantibodytitershavedeclined.Serofastlowantibodytitersmightnotrequiretreatment
however,persistenthighertiterantibodytestsmightindicatereinfection,andtreatmentmightberequired.
Treatment
Penicilliniseffectiveforpreventingmaternaltransmissiontothefetusandfortreatingfetalinfection(233).Evidenceisinsufficient
todetermineoptimal,recommendedpenicillinregimens(234).
RecommendedRegimen
Pregnantwomenshouldbetreatedwiththepenicillinregimenappropriatefortheirstageofinfection.
OtherManagementConsiderations
Someevidencesuggeststhatadditionaltherapycanbebeneficialforpregnantwomeninsomesettings(e.g.,aseconddoseof
benzathinepenicillin2.4millionunitsIMadministered1weekaftertheinitialdoseforwomenwhohaveprimary,secondary,or
earlylatentsyphilis)(235).Whensyphilisisdiagnosedduringthesecondhalfofpregnancy,managementshouldincludea
sonographicfetalevaluationforcongenitalsyphilis,butthisevaluationshouldnotdelaytherapy.Sonographicsignsoffetalor
placentalsyphilis(i.e.,hepatomegaly,ascites,hydrops,fetalanemia,orathickenedplacenta)indicateagreaterriskforfetal
treatmentfailure(231)suchcasesshouldbemanagedinconsultationwithobstetricspecialists.Evidenceisinsufficientto
recommendspecificregimensforthesesituations.
Womentreatedforsyphilisduringthesecondhalfofpregnancyareatriskforprematurelaborand/orfetaldistressifthetreatment
precipitatestheJarischHerxheimerreaction(236).Thesewomenshouldbeadvisedtoseekobstetricattentionaftertreatmentif
theynoticeanyfever,contractions,ordecreaseinfetalmovements.Stillbirthisararecomplicationoftreatment,butconcernfor
thiscomplicationshouldnotdelaynecessarytreatment.AllpatientswhohavesyphilisshouldbeofferedtestingforHIVinfection.
FollowUp

Coordinatedprenatalcareandtreatmentarevital.Serologictitersshouldberepeatedat2832weeks'gestationandatdeliveryas
recommendedforthediseasestage.Providersshouldensurethattheclinicalandantibodyresponsesareappropriateforthe
patient'sstageofdisease,althoughmostwomenwilldeliverbeforetheirserologicresponsetotreatmentcanbeassessed
definitively.Inadequatematernaltreatmentislikelyifdeliveryoccurswithin30daysoftherapy,ifclinicalsignsofinfectionare
presentatdelivery,orifthematernalantibodytiteratdeliveryisfourfoldhigherthanthepretreatmenttiter.Serologictiterscanbe
checkedmonthlyinwomenathighriskforreinfectionoringeographicareasinwhichtheprevalenceofsyphilisishigh
ManagementofSexPartners
SeeGeneralPrinciples,ManagementofSexPartners.
SpecialConsiderations
PenicillinAllergy
Fortreatmentofsyphilisduringpregnancy,noprovenalternativestopenicillinexist.Pregnantwomenwhohaveahistoryof
penicillinallergyshouldbedesensitizedandtreatedwithpenicillin.Oralstepwisepenicillindosechallengeorskintestingmightbe
helpfulinidentifyingwomenatriskforacuteallergicreactions(seeManagementofPatientsWhoHaveaHistoryofPenicillin
Allergy).
Tetracyclineanddoxycyclineusuallyarenotusedduringpregnancy.Erythromycinandazithromycinshouldnotbeused,because
neitherreliablycuresmaternalinfectionortreatsaninfectedfetus(234).Dataareinsufficienttorecommendceftriaxonefor
treatmentofmaternalinfectionandpreventionofcongenitalsyphilis.
HIVInfection
PlacentalinflammationfromcongenitalinfectionmightincreasetheriskforperinataltransmissionofHIV.AllHIVinfectedwomen
shouldbeevaluatedforsyphilisandreceivetreatmentasrecommended.Dataareinsufficienttorecommendaspecificregimenfor
HIVinfectedpregnantwomen(seeSyphilisAmongHIVInfectedPatients).

CongenitalSyphilis
Effectivepreventionanddetectionofcongenitalsyphilisdependsontheidentificationofsyphilisinpregnantwomenand,therefore,
ontheroutineserologicscreeningofpregnantwomenduringthefirstprenatalvisit.Incommunitiesandpopulationsinwhichthe
riskforcongenitalsyphilisishigh,serologictestingandasexualhistoryalsoshouldbeobtainedat28weeks'gestationandat
delivery.Moreover,aspartofthemanagementofpregnantwomenwhohavesyphilis,informationconcerningthetreatmentofsex
partnersshouldbeobtainedtoassesstheriskforreinfection.
Routinescreeningofnewbornseraorumbilicalcordbloodisnotrecommended.Serologictestingofthemother'sserumispreferred
ratherthantestingoftheinfant'sserumbecausetheserologictestsperformedoninfantserumcanbenonreactiveifthemother's
serologictestresultisoflowtiterorthemotherwasinfectedlateinpregnancy(seeDiagnosticConsiderationsandUseofSerologic
Tests).Screeningcanbeperformedusingeitheranontreponemalortreponemaltest.Ifeitherscreeningtestispositive,testingmust
beperformedimmediatelyusingtheothercomplimentarytest(i.e.,nontreponemaltestfollowedbytreponemaltestorviceversa).
Noinfantormothershouldleavethehospitalunlessmaternalserologicstatushasbeendocumentedatleastonceduringpregnancy
incommunitiesandpopulationsinwhichtheriskforcongenitalsyphilisishigh,documentationshouldalsooccuratdelivery.

EvaluationandTreatmentofInfantsDuringtheFirstMonthofLife
ThediagnosisofcongenitalsyphilisiscomplicatedbythetransplacentaltransferofmaternalnontreponemalandtreponemalIgG
antibodiestothefetus,whichcancomplicatetheinterpretationofreactiveserologictestsforsyphilisininfants.Therefore,
treatmentdecisionsfrequentlymustbemadeonthebasisof1)identificationofsyphilisinthemother2)adequacyofmaternal
treatment3)presenceofclinical,laboratory,orradiographicevidenceofsyphilisintheinfantand4)comparisonofmaternal(at
delivery)andinfantnontreponemalserologictitersusingthesametestconductedpreferablybythesamelaboratory.
Allinfantsborntomotherswhohavereactivenontreponemalandtreponemaltestresultsshouldbeevaluatedwithaquantitative
nontreponemalserologictest(RPRorVDRL)performedoninfantserum,becauseumbilicalcordbloodcanbecomecontaminated
withmaternalbloodandyieldafalsepositiveresult.Conductingatreponemaltest(i.e.,TPPA,FTAABS,EIA,or
chemiluminescenceassay)onanewborn'sserumisnotnecessary.Nocommerciallyavailableimmunoglobulin(IgM)testcanbe
recommended.
Allinfantsborntowomenwhohavereactiveserologictestsforsyphilisshouldbeexaminedthoroughlyforevidenceofcongenital
syphilis(e.g.,nonimmunehydrops,jaundice,hepatosplenomegaly,rhinitis,skinrash,andpseudoparalysisofanextremity).
Pathologicexaminationoftheplacentaorumbilicalcordusingspecificfluorescentantitreponemalantibodystainingissuggested.
Darkfieldmicroscopicexaminationofsuspiciouslesionsorbodyfluids(e.g.,nasaldischarge)alsoshouldbeperformed.
Thefollowingscenariosdescribetheevaluationandtreatmentofinfantsforcongenitalsyphilis.
Scenario1
Infantswithprovenorhighlyprobablediseaseand
1. anabnormalphysicalexaminationthatisconsistentwithcongenitalsyphilis

2. aserumquantitativenontreponemalserologictiterthatisfourfoldhigherthanthemother'stiteror
3. apositivedarkfieldtestofbodyfluid(s).
RecommendedEvaluation
CSFanalysisforVDRL,cellcount,andprotein**
Completebloodcount(CBC)anddifferentialandplateletcount
Othertestsasclinicallyindicated(e.g.,longboneradiographs,chestradiograph,liverfunctiontests,cranialultrasound,
ophthalmologicexamination,andauditorybrainstemresponse)
RecommendedRegimens
AqueouscrystallinepenicillinG100,000150,000units/kg/day,administeredas50,000units/kg/doseIVevery12hours
duringthefirst7daysoflifeandevery8hoursthereafterforatotalof10days
OR
ProcainepenicillinG50,000units/kg/doseIMinasingledailydosefor10days
Ifmorethan1dayoftherapyismissed,theentirecourseshouldberestarted.Dataareinsufficientregardingtheuseofother
antimicrobialagents(e.g.,ampicillin).Whenpossible,afull10daycourseofpenicillinispreferred,evenifampicillinwasinitially
providedforpossiblesepsis.Theuseofagentsotherthanpenicillinrequirescloseserologicfollowuptoassessadequacyoftherapy.
Inallothersituations,thematernalhistoryofinfectionwithT.pallidumandtreatmentforsyphilismustbeconsideredwhen
evaluatingandtreatingtheinfant.
Scenario2
Infantswhohaveanormalphysicalexaminationandaserumquantitivenontreponemalserologictiterthesameorlessthan
fourfoldthematernaltiterandthe
1. motherwasnottreated,inadequatelytreated,orhasnodocumentationofhavingreceivedtreatment
2. motherwastreatedwitherythromycinoranothernonpenicillinregimenor
3. motherreceivedtreatment<4weeksbeforedelivery.
RecommendedEvaluation
CSFanalysisforVDRL,cellcount,andprotein
CBC,differential,andplateletcount
Longboneradiographs
Acompleteevaluationisnotnecessaryif10daysofparenteraltherapyisadministered,althoughsuchevaluationsmightbeuseful.
Forinstance,alumbarpuncturemightdocumentCSFabnormalitiesthatwouldpromptclosefollowup.Othertests(e.g.,CBC,
plateletcount,andboneradiographs)canbeperformedtofurthersupportadiagnosisofcongenitalsyphilis.Ifasingledoseof
benzathinepenicillinGisused,thentheinfantmustbefullyevaluated(i.e.,byCSFexamination,longboneradiographs,andCBC
withplatelets),thefullevaluationmustbenormal,andfollowupmustbecertain.Ifanypartoftheinfant'sevaluationisabnormal
ornotperformedoriftheCSFanalysisisrendereduninterpretablebecauseofcontaminationwithblood,thena10daycourseof
penicillinisrequired.
RecommendedRegimens
AqueouscrystallinepenicillinG100,000150,000units/kg/day,administeredas50,000units/kg/doseIVevery12hours
duringthefirst7daysoflifeandevery8hoursthereafterforatotalof10days
OR
ProcainepenicillinG50,000units/kg/doseIMinasingledailydosefor10days
OR
BenzathinepenicillinG50,000units/kg/doseIMinasingledose
Ifthemotherhasuntreatedearlysyphilisatdelivery,10daysofparenteraltherapycanbeconsidered.
Scenario3
Infantswhohaveanormalphysicalexaminationandaserumquantitativenontreponemalserologictiterthesameorlessthan

fourfoldthematernaltiterandthe
1. motherwastreatedduringpregnancy,treatmentwasappropriateforthestageofinfection,andtreatmentwasadministered
>4weeksbeforedeliveryand
2. motherhasnoevidenceofreinfectionorrelapse.
RecommendedEvaluation
Noevaluationisrequired.
RecommendedRegimen
BenzathinepenicillinG50,000units/kg/doseIMinasingledose*
*Anotherapproachinvolvesnottreatingtheinfant,butratherprovidingcloseserologicfollowupinthosewhosemother's
nontreponemaltitersdecreasedfourfoldafterappropriatetherapyforearlysyphilisorremainedstableorlowforlatesyphilis.
Scenario4
Infantswhohaveanormalphysicalexaminationandaserumquantitativenontreponemalserologictiterthesameorlessthan
fourfoldthematernaltiterandthe
1. mother'streatmentwasadequatebeforepregnancyand
2. mother'snontreponemalserologictiterremainedlowandstablebeforeandduringpregnancyandatdelivery(VDRL<1:2
RPR<1:4).
RecommendedEvaluation
Noevaluationisrequired.
RecommendedRegimen
Notreatmentisrequiredhowever,benzathinepenicillinG50,000units/kgasasingleIMinjectionmightbeconsidered,
particularlyiffollowupisuncertain.

EvaluationandTreatmentofOlderInfantsandChildren
Olderinfantsandchildrenaged1monthwhoareidentifiedashavingreactiveserologictestsforsyphilisshouldhavematernal
serologyandrecordsreviewedtoassesswhethertheyhavecongenitaloracquiredsyphilis(seePrimaryandSecondarySyphilisand
LatentSyphilis,SexualAssaultorAbuseofChildren).Anychildatriskforcongenitalsyphilisshouldreceiveafullevaluationand
testingforHIVinfection.
RecommendedEvaluation
CSFanalysisforVDRL,cellcount,andprotein
CBC,differential,andplateletcount
Othertestsasclinicallyindicated(e.g.,longboneradiographs,chestradiograph,liverfunctiontests,abdominalultrasound,
ophthalmologicexamination,andauditorybrainstemresponse)
RecommendedRegimen
AqueouscrystallinepenicillinG200,000300,000units/kg/dayIV,administeredas50,000units/kgevery46hoursfor10
days
Ifthechildhasnoclinicalmanifestationsofdisease,theCSFexaminationisnormal,andtheCSFVDRLtestresultisnegative,
treatmentwithupto3weeklydosesofbenzathinepenicillinG,50,000U/kgIMcanbeconsidered.
Anychildwhoissuspectedofhavingcongenitalsyphilisorwhohasneurologicinvolvementshouldbetreatedwithaqueous
penicillinG.AsingledoseofbenzathinepenicillinG,50,000units/kgIMafterthe10daycourseofIVaqueouspenicillincanbe
considered.Thistreatmentalsowouldbeadequateforchildrenwhomighthaveothertreponemalinfections.
FollowUp
Allseroreactiveinfants(orinfantswhosemotherswereseroreactiveatdelivery)shouldreceivecarefulfollowupexaminationsand
serologictesting(i.e.,anontreponemaltest)every23monthsuntilthetestbecomesnonreactiveorthetiterhasdecreased
fourfold.Nontreponemalantibodytitersshoulddeclinebyage3monthsandshouldbenonreactivebyage6monthsiftheinfantis
notinfected(i.e.,ifthereactivetestresultwascausedbypassivetransferofmaternalIgGantibody)orwasinfectedbutadequately
treated.Theserologicresponseaftertherapymightbeslowerforinfantstreatedaftertheneonatalperiod.Ifthesetitersarestableor
increaseafterage612months,thechildshouldbeevaluated(e.g.,givenaCSFexamination)andtreatedwitha10daycourseof

parenteralpenicillinG.
Treponemaltestsshouldnotbeusedtoevaluatetreatmentresponse,becausetheresultsforaninfectedchildcanremainpositive
despiteeffectivetherapy.Passivelytransferredmaternaltreponemalantibodiescanbepresentinaninfantuntilage15months
therefore,areactivetreponemaltestafterage18monthsisdiagnosticofcongenitalsyphilis.Ifthenontreponemaltestis
nonreactiveatthistime,nofurtherevaluationortreatmentisnecessary.Ifthenontreponemaltestisreactiveatage18months,the
infantshouldbefully(re)evaluatedandtreatedforcongenitalsyphilis.
InfantswhoseinitialCSFevaluationsareabnormalshouldundergoarepeatlumbarpunctureapproximatelyevery6monthsuntil
theresultsarenormal.AreactiveCSFVDRLtestorabnormalCSFindicesthatcannotbeattributedtootherongoingillnessrequires
retreatmentforpossibleneurosyphilis.
Followupofchildrentreatedforcongenitalsyphilisafterthenewbornperiodshouldbeconductedasrecommendedforneonates.
SpecialConsiderations
PenicillinAllergy
Infantsandchildrenwhorequiretreatmentforsyphilisbutwhohaveahistoryofpenicillinallergyordevelopanallergicreaction
presumedsecondarytopenicillinshouldbedesensitized,ifnecessary,andthentreatedwithpenicillin(seeManagementofPatients
WithaHistoryofPenicillinAllergy).Dataareinsufficientregardingtheuseofotherantimicrobialagents(e.g.,ceftriaxone)ifa
nonpenicillinagentisused,closeserologicandCSFfollowupareindicated.
PenicillinShortage
Duringperiodswhentheavailabilityofpenicilliniscompromised,thefollowingisrecommended(see
http://www.cdc.gov/nchstp/dstd/penicillinG.htm).
1. Forinfantswithclinicalevidenceofcongenitalsyphilis(Scenario1),checklocalsourcesforaqueouscrystallinepenicillinG
(potassiumorsodium).IfIVpenicillinGislimited,substitutesomeoralldailydoseswithprocainepenicillinG(50,000
U/kg/doseIMadayinasingledailydosefor10days).
IfaqueousorprocainepenicillinGisnotavailable,ceftriaxone(indosesappropriateforageandweight)canbeconsidered
withcarefulclinicalandserologicfollowup.Ceftriaxonemustbeusedwithcautionininfantswithjaundice.Forinfantsaged
30days,use75mg/kgIV/IMadayinasingledailydosefor1014dayshowever,doseadjustmentmightbenecessarybased
oncurrentweight.Forolderinfants,thedoseshouldbe100mg/kgadayinasingledailydose.Evidenceisinsufficientto
supporttheuseofceftriaxoneforthetreatmentofcongenitalsyphilis.Therefore,ceftriaxoneshouldbeusedinconsultation
withaspecialistinthetreatmentofinfantswithcongenitalsyphilis.ManagementmayincludearepeatCSFexaminationat
age6monthsiftheinitialexaminationwasabnormal.
2. Forinfantswithoutanyclinicalevidenceofinfection(Scenario2andScenario3),use
a.procainepenicillinG,50,000U/kg/doseIMadayinasingledosefor10days
or
b.benzathinepenicillinG,50,000U/kgIMasasingledose.
Ifanypartoftheevaluationforcongenitalsyphilisisabnormal,CSFexaminationisnotinterpretable,CSFexaminationwas
notperformed,orfollowupisuncertain,procainepenicillinGisrecommended.Asingledoseofceftriaxoneisinadequate
therapy.
3. Forprematureinfantswhohavenootherclinicalevidenceofinfection(Scenario2andScenario3)andmightnottolerateIM
injectionsbecauseofdecreasedmusclemass,IVceftriaxonecanbeconsideredwithcarefulclinicalandserologicfollowup
(seePenicillinShortage,Number1).Ceftriaxonedosingmustbeadjustedaccordingtoageandbirthweight.
HIVInfection
EvidenceisinsufficienttodeterminewhetherinfantswhohavecongenitalsyphilisandwhosemothersarecoinfectedwithHIV
requiredifferentevaluation,therapy,orfollowupforsyphilisthanisrecommendedforallinfants.

ManagementofPersonsWhoHaveaHistoryofPenicillinAllergy
Noprovenalternativestopenicillinareavailablefortreatingneurosyphilis,congenitalsyphilis,orsyphilisinpregnantwomen.
Penicillinalsoisrecommendedforuse,wheneverpossible,inHIVinfectedpatients.OftheadultU.S.population,3%10%have
experiencedanimmunoglobulinE(IgE)mediatedallergicresponsetopenicillin(238,239),suchasurticaria,angioedema,or
anaphylaxis(i.e.,upperairwayobstruction,bronchospasm,orhypotension).Readministrationofpenicillintothesepatientscan
causesevere,immediatereactions.Becauseanaphylacticreactionstopenicillincanbefatal,everyeffortshouldbemadetoavoid
administeringpenicillintopenicillinallergicpatients,unlesstheyundergoacutedesensitizationtoeliminateanaphylactic
sensitivity.
Althoughanestimated10%ofpersonswhoreportahistoryofsevereallergicreactionstopenicillincontinuetoremainallergictheir
entirelives,withthepassageoftime,mostpersonswhohavehadaseverereactiontopenicillinstopexpressingpenicillinspecific
IgE(238,239).Thesepersonscanthenbetreatedsafelywithpenicillin.Penicillinskintestingwiththemajorandminor
determinantsofpenicillincanreliablyidentifypersonsathighriskforpenicillinreactions(238,239).Althoughthesereagentsare
easilygeneratedandhavebeenavailableformorethan30years,onlybenzylpenicilloylpolyLlysine(PrePen[i.e.,themajor
determinant])andpenicillinGhavebeenavailablecommercially.Thesetwotestsidentifyanestimated90%97%ofthecurrently

allergicpatients.However,becauseskintestingwithouttheminordeterminantswouldstillmiss3%10%ofallergicpatientsand
becauseseriousorfatalreactionscanoccuramongtheseminordeterminantpositivepatients,cautionshouldbeexercisedwhen
thefullbatteryofskintestreagentsisnotavailable(Box2).ManufacturersareworkingtoensurebetteravailabilityofthePrePen
skintestreagentaswellasanaccompanyingminordeterminantmixture.

Recommendations
Ifthefullbatteryofskintestreagentsisavailable,includingbothmajorandminordeterminants(seePenicillinAllergySkin
Testing),patientswhoreportahistoryofpenicillinreactionandwhoareskintestnegativecanreceiveconventionalpenicillin
therapy.Skintestpositivepatientsshouldbedesensitizedbeforeinitiatingtreatment.
Ifthefullbatteryofskintestreagents,includingtheminordeterminants,isnotavailable,thepatientshouldbeskintestedusing
benzylpenicilloylpolyLlysine(i.e.,themajordeterminant)andpenicillinG.Patientswhohavepositivetestresultsshouldbe
desensitized.Oneapproachsuggeststhatpersonswithahistoryofallergywhohavenegativetestresultsshouldberegardedas
possiblyallergicanddesensitized.Anotherapproachinthosewithnegativeskintestresultsinvolvestestdosinggraduallywithoral
penicillininamonitoredsettinginwhichtreatmentforanaphylacticreactioncanbeprovided.
Ifthemajordeterminant(PrePen)isnotavailableforskintesting,allpatientswithahistorysuggestingIgEmediatedreactionsto
penicillin(e.g.,anaphylaxis,angioedema,bronchospasm,orurticaria)shouldbedesensitizedinahospitalsetting.Inpatientswith
reactionsnotlikelytobeIgEmediated,outpatientmonitoredtestdosescanbeconsidered.

PenicillinAllergySkinTesting
Patientsathighriskforanaphylaxis,includingthosewho1)haveahistoryofpenicillinrelatedanaphylaxis,asthma,orother
diseasesthatwouldmakeanaphylaxismoredangerousor2)arebeingtreatedwithbetaadrenergicblockingagents,shouldbe
testedwith100folddilutionsofthefullstrengthskintestreagentsbeforebeingtestedwithfullstrengthreagents.Inthese
situations,patientsshouldbetestedinamonitoredsettinginwhichtreatmentforananaphylacticreactionisavailable.Ifpossible,
thepatientshouldnothavetakenantihistaminesrecently(e.g.,chlorpheniraminemaleateorfexafenadineduringthepreceding24
hours,diphenhydramineHClduringthepreceding4days,orhydroxyzineorphenathiazinesduringthepreceding3weeks).

Procedures
Dilutetheantigenseither100foldforpreliminarytesting(ifthepatienthashadalifethreateningreactiontopenicillin)or10fold
(ifthepatienthashadanothertypeofimmediate,generalizedreactiontopenicillinwithintheprecedingyear).

Epicutaneous(Prick)Tests
Duplicatedropsofskintestreagentareplacedonthevolarsurfaceoftheforearm.Theunderlyingepidermisispiercedwitha26
gaugeneedlewithoutdrawingblood.Anepicutaneoustestispositiveiftheaveragewhealdiameterafter15minutesis4mmlarger
thanthatofnegativecontrolsotherwise,thetestisnegative.Thehistaminecontrolsshouldbepositivetoensurethatresultsarenot
falselynegativebecauseoftheeffectofantihistaminicdrugs.

IntradermalTest
Ifepicutaneoustestsarenegative,duplicate0.02mLintradermalinjectionsofnegativecontrolandantigensolutionsaremadeinto
thevolarsurfaceoftheforearmbyusinga26or27gaugeneedleonasyringe.Themarginsofthewhealsinducedbytheinjections
shouldbemarkedwithaballpointpen.Anintradermaltestispositiveiftheaveragewhealdiameter15minutesafterinjectionis>2
mmlargerthantheinitialwhealsizeandalsois>2mmlargerthanthenegativecontrols.Otherwise,thetestsarenegative.

Desensitization
Patientswhohaveapositiveskintesttooneofthepenicillindeterminantscanbedesensitized(Table1).Thisisastraightforward,
relativelysafeprocedurethatcanbeperformedorallyorIV.Althoughthetwoapproacheshavenotbeencompared,oral
desensitizationisregardedassaferandeasiertoperform.PatientsshouldbedesensitizedinahospitalsettingbecauseseriousIgE
mediatedallergicreactionscanoccur.Desensitizationusuallycanbecompletedinapproximately412hours,afterwhichtimethe
firstdoseofpenicillinisadministered.Afterdesensitization,patientsmustbemaintainedonpenicillincontinuouslyforthe
durationofthecourseoftherapy.

DiseasesCharacterizedbyUrethritisandCervicitis
Urethritis
Urethritis,ascharacterizedbyurethralinflammation,canresultfrominfectiousandnoninfectiousconditions.Symptoms,if
present,includedischargeofmucopurulentorpurulentmaterial,dysuria,orurethralpruritis.Asymptomaticinfectionsare
common.AlthoughN.gonorrhoeaeandC.trachomatisarewellestablishedasclinicallyimportantinfectiouscausesofurethritis,
Mycoplasmagenitaliumhasalsobeenassociatedwithurethritis(240243).Ifclinicbaseddiagnostictools(e.g.,Gramstain
microscopy,firstvoidurinewithmicroscopy,andleukocyteesterase)arenotavailable,patientsshouldbetreatedwithdrug
regimenseffectiveagainstbothgonorrheaandchlamydia.Furthertestingtodeterminethespecificetiologyisrecommended
becausebothchlamydiaandgonorrheaarereportabletohealthdepartmentsandaspecificdiagnosismightimprovepartner
notificationandtreatment.Culture,nucleicacidhybridizationtests,andNAATsareavailableforthedetectionofbothN.
gonorrhoeaeandC.trachomatis.Cultureandhybridizationtestsrequireurethralswabspecimens,whereasNAATscanbe
performedonurinespecimens.Becauseoftheirhighersensitivity,NAATsarepreferredforthedetectionofC.trachomatis(197).

Etiology
Severalorganismscancauseinfectiousurethritis.ThepresenceofGramnegativeintracellulardiplococci(GNID)onurethralsmear
isindicativeofgonorrheainfection,whichisfrequentlyaccompaniedbychlamydialinfection.Nongonoccocalurethritis(NGU),
whichisdiagnosedwhenexaminationfindingsormicroscopyindicateinflammationwithoutGNID,iscausedbyC.trachomatisin
15%40%ofcaseshowever,prevalencevariesbyagegroup,withalowerburdenofdiseaseoccurringamongoldermen(244).
ComplicationsofNGUamongmalesinfectedwithC.trachomatisincludeepididymitisandReiter'ssyndrome.Documentationof
chlamydialinfectionisessentialbecauseoftheneedforpartnerreferralforevaluationandtreatment.
InmostcasesofnonchlamydialNGU,nopathogencanbedetected.M.genitalium,whichappearstobesexuallytransmitted,is
associatedwithbothsymptomsofurethritisandurethralinflammationandaccountsfor15%25%ofNGUcasesintheUnited
States(240243).T.vaginalis,HSV,andadenovirusalsocancauseNGU,butdatasupportingotherMycoplasmaspeciesand
Ureaplasmaasetiologicagentsareinconsistent(244247).Diagnosticandtreatmentproceduresfortheseorganismsarereserved
forsituationsinwhichtheseinfectionsaresuspected(e.g.,contactwithtrichomoniasis,genitallesions,orseveredysuriaand
meatitis,whichmightsuggestgenitalherpes)orwhenNGUisnotresponsivetotherapy.Entericbacteriahavebeenidentifiedasan
uncommoncauseofNGUandmightbeassociatedwithinsertiveanalintercourse(244).

ConfirmedUrethritis
Cliniciansshouldattempttoobtainobjectiveevidenceofurethralinflammation.However,ifclinicbaseddiagnostictools(e.g.,
Gramstainmicroscopy)arenotavailable,patientsshouldbetreatedwithdrugregimenseffectiveagainstbothgonorrheaand
chlamydia.
Urethritiscanbedocumentedonthebasisofanyofthefollowingsignsorlaboratorytests:
Mucopurulentorpurulentdischargeonexamination.
Gramstainofurethralsecretionsdemonstrating5WBCperoilimmersionfield.TheGramstainisthepreferredrapid
diagnostictestforevaluatingurethritisandishighlysensitiveandspecificfordocumentingbothurethritisandthepresenceor
absenceofgonococcalinfection.GonococcalinfectionisestablishedbydocumentingthepresenceofWBCcontainingGNID.
Positiveleukocyteesterasetestonfirstvoidurineormicroscopicexaminationoffirstvoidurinesedimentdemonstrating10
WBCperhighpowerfield.
Ifnoneofthesecriteriaarepresent,testingforN.gonorrhoeaeandC.trachomatisusingNAATsmightidentifyadditional
infections(248).Iftheresultsdemonstrateinfectionwitheitherofthesepathogens,theappropriatetreatmentshouldbegivenand
sexpartnersreferredforevaluationandtreatment.Ifnoneofthesecriteriaarepresent,empirictreatmentofsymptomaticmalesis
recommendedonlyformenathighriskforinfectionwhoareunlikelytoreturnforafollowupevaluation.Suchpatientsshouldbe
treatedwithdrugregimenseffectiveagainstgonorrheaandchlamydia.Partnersofpatientstreatedempiricallyshouldbeevaluated
andtreated,ifindicated.

NongonococcalUrethritis
Diagnosis
Allpatientswhohaveconfirmedorsuspectedurethritisshouldbetestedforgonorrheaandchlamydia.Testingforchlamydiais
stronglyrecommendedbecauseoftheincreasedutilityandavailabilityofhighlysensitiveandspecifictestingmethods(e.g.,NAATs)
andbecauseaspecificdiagnosismightenhancepartnernotificationandimprovecompliancewithtreatment,especiallyinthe
exposedpartner.

Treatment
Treatmentshouldbeinitiatedassoonaspossibleafterdiagnosis.Azithromycinanddoxycyclinearehighlyeffectiveforchlamydial
urethritishowever,infectionswithM.genitaliumrespondbettertoazithromycin(249,250).Singledoseregimenshavethe
advantageofimprovedcomplianceanddirectlyobservedtreatment.Tomaximizecompliancewithrecommendedtherapies,
medicationsshouldbedispensedonsiteintheclinic,andthefirstdoseshouldbedirectlyobserved.
RecommendedRegimens
Azithromycin1gorallyinasingledose
OR
Doxycycline100mgorallytwiceadayfor7days
AlternativeRegimens
Erythromycinbase500mgorallyfourtimesadayfor7days
OR
Erythromycinethylsuccinate800mgorallyfourtimesadayfor7days

OR
Levofloxacin500mgorallyoncedailyfor7days
OR
Ofloxacin300mgorallytwiceadayfor7days
Tominimizetransmission,mentreatedforNGUshouldbeinstructedtoabstainfromsexualintercoursefor7daysaftersingledose
therapyoruntilcompletionofa7dayregimen,providedtheirsymptomshaveresolved.Tominimizetheriskforreinfection,men
shouldbeinstructedtoabstainfromsexualintercourseuntilalloftheirsexpartnersaretreated.
PersonswhohavebeendiagnosedwithanewSTDshouldreceivetestingforotherinfections,includingsyphilisandHIV.

FollowUp
Patientsshouldbeinstructedtoreturnforevaluationifsymptomspersistorrecuraftercompletionoftherapy.Symptomsalone,
withoutdocumentationofsignsorlaboratoryevidenceofurethralinflammation,arenotasufficientbasisforretreatment.Providers
shouldbealerttothepossibilityofchronicprostatitis/chronicpelvicpainsyndromeinmalepatientsexperiencingpersistentpain
(perineal,penile,orpelvic),discomfort,irritativevoidingsymptoms,painduringorafterejaculation,ornewonsetpremature
ejaculationlastingfor>3months.
Unlessapatient'ssymptomspersistortherapeuticnoncomplianceorreinfectionissuspectedbytheprovider,atestofcure(i.e.,
repeattesting34weeksaftercompletingtherapy)isnotrecommendedforpersonswithdocumentedchlamydiaorgonococcal
infectionswhohavereceivedtreatmentwithrecommendedoralterativeregimens.However,becausemenwithdocumented
chlamydialorgonococcalinfectionshaveahighrateofreinfectionwithin6monthsaftertreatment(251,252),repeattestingofall
mendiagnosedwithchlamydiaorgonorrheaisrecommended36monthsaftertreatment,regardlessofwhetherpatientsbelieve
thattheirsexpartnersweretreated(251).

PartnerReferral
Aspecificdiagnosismightfacilitatepartnerreferral.Therefore,testingforgonorrheaandchlamydiaisencouraged.Becausea
substantialproportionoffemalepartnersofmaleswithnonchlamydialNGUareinfectedwithchlamydia,partnermanagementis
recommendedformaleswithNGUregardlessofwhetheraspecificetiologyisidentified.Allsexpartnerswithinthepreceding60
daysshouldbereferredforevaluation,testing,andempirictreatmentwithadrugregimeneffectiveagainstchlamydia.Expedited
partnertreatmentandpatientreferralarealternativeapproachestotreatingpartners(71).

RecurrentandPersistentUrethritis
Objectivesignsofurethritisshouldbepresentbeforetheinitiationofantimicrobialtherapy.Inpersonswhohavepersistent
symptomsaftertreatmentwithoutobjectivesignsofurethritis,thevalueofextendingthedurationofantimicrobialshasnotbeen
demonstrated.Personswhohavepersistentorrecurrenturethritiscanberetreatedwiththeinitialregimeniftheydidnotcomply
withthetreatmentregimenoriftheywerereexposedtoanuntreatedsexpartner.Persistenturethritisafterdoxycyclinetreatment
mightbecausedbydoxycyclineresistantU.urealyticumorM.genitalium.T.vaginalisisalsoknowntocauseurethritisinmena
urethralswab,firstvoidurine,orsemenforcultureoraNAAT(PCRorTMA)onaurethralswaborurinecanbeperformed.If
compliantwiththeinitialregimenandreexposurecanbeexcluded,thefollowingregimenisrecommendedwhileawaitingthe
resultsofthediagnostictests.
RecommendedRegimens
Metronidazole2gorallyinasingledose
OR
Tinidazole2gorallyinasingledose
PLUS
Azithromycin1gorallyinasingledose(ifnotusedforinitialepisode)
StudiesinvolvingalimitednumberofpatientswhoexperiencedNGUtreatmentfailureshavedemonstratedthatMoxifloxacin400
mgorallyoncedailyfor7daysishighlyeffectiveagainstM.genitalium(253,254).MenwithalowprobabilityofT.vaginalis(e.g.,
MSM)areunlikelytobenefitfromtheadditionofmetronidazoleortinidazole.
Urologicexaminationsusuallydonotrevealaspecificetiologyforurethritis.AfourglassMearesStameylowerurinarytract
localizationprocedure(orfourglasstest)mightbehelpfulinlocalizingpathogenstotheprostate(255).Asubstantialproportionof
menwithchronicnonbacterialprostatitis/chronicpelvicpainsyndromehaveevidenceofurethralinflammationwithoutany
identifiablemicrobialpathogens.Estimatesvaryconsiderablydependingonthesourceandsensitivityoftheassay,butonestudy
demonstratedthatin50%ofmenwiththissyndrome,5WBCsperhighpowerfieldweredetectedinexpressedprostaticsecretions
(256).Referraltoaurologistshouldbeconsideredformenwhoexperiencepainformorethan3monthswithina6monthperiod.
Ifmenrequiretreatmentwithanewantibioticregimenforpersistenturethritisandasexuallytransmittedagentisthesuspected

cause,allpartnersinthepast60daysbeforetheinitialdiagnosisandanyinterimpartnersshouldbereferredforevaluationand
appropriatetreatment.

SpecialConsiderations
HIVInfection
Gonococcalurethritis,chlamydialurethritis,andnongonococcal,nonchlamydialurethritismightfacilitateHIVtransmission.
PatientswhohaveNGUandalsoareinfectedwithHIVshouldreceivethesametreatmentregimenasthosewhoareHIVnegative.

Cervicitis
Twomajordiagnosticsignscharacterizecervicitis:1)apurulentormucopurulentendocervicalexudatevisibleintheendocervical
canaloronanendocervicalswabspecimen(commonlyreferredtoasmucopurulentcervicitisorcervicitis)and2)sustained
endocervicalbleedingeasilyinducedbygentlepassageofacottonswabthroughthecervicalos.Eitherorbothsignsmightbe
present.Cervicitisfrequentlyisasymptomatic,butsomewomencomplainofanabnormalvaginaldischargeandintermenstrual
vaginalbleeding(e.g.,aftersexualintercourse).Afindingofleukorrhea(>10WBCperhighpowerfieldonmicroscopicexamination
ofvaginalfluid)hasbeenassociatedwithchlamydialandgonococcalinfectionofthecervix.Intheabsenceofinflammatory
vaginitis,leukorrheamightbeasensitiveindicatorofcervicalinflammationwithahighnegativepredictivevalue(257,258).
AlthoughsomespecialistsconsideranincreasednumberofpolymorphonuclearleukocytesonendocervicalGramstainasbeing
usefulinthediagnosisofcervicitis,thiscriterionhasnotbeenstandardized.Inaddition,ithasalowpositivepredictivevalue(PPV)
forinfectionwithC.trachomatisandN.gonorrhoeaeandisnotavailableinmostclinicalsettings.Finally,althoughthepresenceof
GNIDonGramstainofendocervicalfluidisspecificforthediagnosisofgonococcalcervicalinfection,itisnotasensitiveindicator,
becauseitisobservedinonly50%ofwomenwiththisinfection.

Etiology
Whenanetiologicorganismisisolatedinthepresenceofcervicitis,itistypicallyC.trachomatisorN.gonorrhoeae.Cervicitisalso
canaccompanytrichomoniasisandgenitalherpes(especiallyprimaryHSV2infection).However,inmostcasesofcervicitis,no
organismisisolated,especiallyinwomenatrelativelylowriskforrecentacquisitionoftheseSTDs(e.g.,womenaged>30years).
LimiteddataindicatethatinfectionwithM.genitaliumandBVandfrequentdouchingmightcausecervicitis(259263).For
reasonsthatareunclear,cervicitiscanpersistdespiterepeatedcoursesofantimicrobialtherapy.Becausemostpersistentcasesof
cervicitisarenotcausedbyrelapseorreinfectionwithC.trachomatisorN.gonorrhoeae,otherfactors(e.g.,persistentabnormality
ofvaginalflora,douching[orexposuretoothertypesofchemicalirritants],oridiopathicinflammationinthezoneofectopy)might
beinvolved.

Diagnosis
Becausecervicitismightbeasignofuppergenitaltractinfection(endometritis),womenwhoseekmedicaltreatmentforanew
episodeofcervicitisshouldbeassessedforsignsofPIDandshouldbetestedforC.trachomatisandforN.gonorrhoeaewiththe
mostsensitiveandspecifictestavailable.WomenwithcervicitisalsoshouldbeevaluatedforthepresenceofBVandtrichomoniasis,
andiftheseorganismsaredetected,theyshouldbetreated.BecausethesensitivityofmicroscopytodetectT.vaginalisisrelatively
low(approximately50%),symptomaticwomenwithcervicitisandnegativemicroscopyfortrichomonadsshouldreceivefurther
testing(i.e.,cultureorotherFDAclearedmethod).AlthoughHSV2infectionhasbeenassociatedwithcervicitis,theutilityof
specifictesting(i.e.,cultureorserologictesting)forHSV2inthissettingisunknown.StandardizeddiagnostictestsforM.
genitaliumarenotcommerciallyavailable.
Asdiscussed,NAATshouldbeusedfordiagnosingC.trachomatisandN.gonorrhoeaeinwomenwithcervicitisthistestingcanbe
performedoneithervaginal,cervical,orurinesamples(197).Afindingof>10WBCinvaginalfluid,intheabsenceof
trichomoniasis,mightindicateendocervicalinflammationcausedspecificallybyC.trachomatisorN.gonorrhoeae(264,265).

Treatment
Severalfactorsshouldaffectthedecisiontoprovidepresumptivetherapyforcervicitisortoawaittheresultsofdiagnostictests.
TreatmentwithantibioticsforC.trachomatisshouldbeprovidedforthosewomenatincreasedriskforthiscommonSTD(e.g.,
thoseaged25years,thosewithnewormultiplesexpartners,andthosewhoengageinunprotectedsex),especiallyiffollowup
cannotbeensuredandifarelativelyinsensitivediagnostictestisusedinplaceofNAAT.ConcurrenttherapyforN.gonorrhoeaeis
indicatediftheprevalenceofthisinfectionis>5%(thoseinyoungeragegroupsandthoselivingincertainfacilities).
TrichomoniasisandBVshouldalsobetreatedifdetected.Forwomeninwhomanycomponentof(orall)presumptivetherapyis
deferred,theresultsofsensitivetestsforC.trachomatisandN.gonorrhoeae(e.g.,NAATs)shoulddeterminetheneedfortreatment
subsequenttotheinitialevaluation.
RecommendedRegimensforPresumptiveTreatment*
Azithromycin1gorallyinasingledose
OR
Doxycycline100mgorallytwiceadayfor7days
*Considerconcurrenttreatmentforgonococcalinfectionifprevalenceofgonorrheaishighinthepatientpopulationunder

assessment.

RecurrentandPersistentCervicitis
WomenwithpersistentcervicitisshouldbereevaluatedforpossiblereexposuretoanSTD.Ifrelapseand/orreinfectionwitha
specificSTDhasbeenexcluded,BVisnotpresent,andsexpartnershavebeenevaluatedandtreated,managementoptionsfor
persistentcervicitisareundefinedinaddition,theutilityofrepeatedorprolongedadministrationofantibiotictherapyfor
persistentsymptomaticcervicitisremainsunknown.Womenwhoreceivesuchtherapyshouldreturnaftertreatmentsothata
determinationcanbemaderegardingwhethercervicitishasresolved.Researchisneededontheetiologyofpersistentcervicitis
includingthepotentialroleofM.genitalium(266).Inwomenwithpersistentsymptomsthatareclearlyattributabletocervicitis,
referraltoagynecologicspecialistcanbeconsidered.

FollowUp
Followupshouldbeconductedasrecommendedfortheinfectionsforwhichawomanistreated.Ifsymptomspersist,women
shouldbeinstructedtoreturnforreevaluationbecausewomenwithdocumentedchlamydialorgonococcalinfectionshaveahigh
rateofreinfectionwithin6monthsaftertreatment.Therefore,repeattestingofallwomenwithchlamydiaorgonorrheais
recommended36monthsaftertreatment,regardlessofwhethertheirsexpartnersweretreated(267).

ManagementofSexPartners
ManagementofsexpartnersofwomentreatedforcervicitisshouldbeappropriatefortheidentifiedorsuspectedSTD.Partners
shouldbenotifiedandexaminedifchlamydia,gonorrhea,ortrichomoniasiswasidentifiedorsuspectedintheindexpatientthese
partnersshouldthenbetreatedfortheSTDsforwhichtheindexpatientreceivedtreatment.Toavoidreinfection,patientsandtheir
sexpartnersshouldabstainfromsexualintercourseuntiltherapyiscompleted(i.e.,7daysafterasingledoseregimenorafter
completionofa7dayregimen).Expeditedpartnertreatmentandpatientreferral(seePartnerManagement)arealternative
approachestotreatingmalepartnersofwomenthathavechlamydiaorgonococcalinfections(68,69,71).

SpecialConsiderations
HIVInfection
PatientswhohavecervicitisandalsoareinfectedwithHIVshouldreceivethesametreatmentregimenasthosewhoareHIV
negative.TreatmentofcervicitisinHIVinfectedwomenisvitalbecausecervicitisincreasescervicalHIVshedding.Treatmentof
cervicitisinHIVinfectedwomenreducesHIVsheddingfromthecervixandmightreduceHIVtransmissiontosusceptiblesex
partners(268270).

ChlamydialInfections
ChlamydialInfectionsinAdolescentsandAdults
ChlamydialgenitalinfectionisthemostfrequentlyreportedinfectiousdiseaseintheUnitedStates,andprevalenceishighestin
personsaged25years(93).SeveralimportantsequelaecanresultfromC.trachomatisinfectioninwomen,themostseriousof
whichincludePID,ectopicpregnancy,andinfertility.Somewomenwhohaveuncomplicatedcervicalinfectionalreadyhave
subclinicalupperreproductivetractinfectionupondiagnosis.
Asymptomaticinfectioniscommonamongbothmenandwomen.Todetectchlamydialinfections,healthcareprovidersfrequently
relyonscreeningtests.Annualscreeningofallsexuallyactivewomenaged25yearsisrecommended,asisscreeningofolder
womenwithriskfactors(e.g.,thosewhohaveanewsexpartnerormultiplesexpartners).InJune2007,USPSTFreviewedand
updatedtheirchlamydiascreeningguidanceandfoundthattheepidemiologyofchlamydialinfectionintheUnitedStateshadnot
changedsincethelastreview(81,271).Inissuingrecommendations,USPSTFmadethedecisiontoaltertheagegroupsusedto
demonstratediseaseincidence(i.e.,frompersonsaged25yearstothoseaged24years).CDChasnotchangeditsagecutoff,and
thuscontinuestorecommendannualchlamydiascreeningofsexuallyactivewomenaged25years.
ScreeningprogramshavebeendemonstratedtoreduceboththeprevalenceofC.trachomatisinfectionandratesofPIDinwomen
(272,273).AlthoughevidenceisinsufficienttorecommendroutinescreeningforC.trachomatisinsexuallyactiveyoungmen
becauseofseveralfactors(includingfeasibility,efficacy,andcosteffectiveness)(94),thescreeningofsexuallyactiveyoungmen
shouldbeconsideredinclinicalsettingswithahighprevalenceofchlamydia(e.g.,adolescentclinics,correctionalfacilities,andSTD
clinics).Amongwomen,theprimaryfocusofchlamydiascreeningeffortsshouldbetodetectchlamydiaandpreventcomplications,
whereastargetedchlamydiascreeninginmenshouldonlybeconsideredwhenresourcespermitanddonothinderchlamydia
screeningeffortsinwomen(274275).Anappropriatesexualriskassessmentshouldbeconductedforallpersonsandmightindicate
morefrequentscreeningforsomewomenorcertainmen(seeMSM).

DiagnosticConsiderations
C.trachomatisurogenitalinfectioninwomencanbediagnosedbytestingurineorbycollectingswabspecimensfromthe
endocervixorvagina.DiagnosisofC.trachomatisurethralinfectioninmencanbemadebytestingaurethralswaborurine
specimen.RectalC.trachomatisinfectionsinpersonsthatengageinreceptiveanalintercoursecanbediagnosedbytestingarectal
swabspecimen.NAATs,cellculture,directimmunofluorescence,EIA,andnucleicacidhybridizationtestsareavailableforthe
detectionofC.trachomatisonendocervicalspecimensandurethralswabspecimensfrommen(197).NAATsarethemostsensitive
testsforthesespecimensandareFDAclearedforusewithurine.SomeNAATsareclearedforusewithvaginalswabspecimens,
whichcanbecollectedbyaproviderorselfcollectedbyapatient.Selfcollectedvaginalswabspecimensperformatleastaswellas

withotherapprovedspecimensusingNAATs(276,277),andwomenfindthisscreeningstrategyhighlyacceptable.Rectaland
oropharyngealC.trachomatisinfectioninpersonsengaginginreceptiveanalororalintercoursecanbediagnosedbytestingatthe
anatomicsiteofexposure.Mosttests,includingNAATandnucleicacidhybridizationtests,arenotFDAclearedforusewithrectal
ororopharyngealswabspecimens,andchlamydiacultureisnotwidelyavailableforthispurpose.However,NAATshave
demonstratedimprovedsensitivityandspecificitycomparedwithcultureforthedetectionofC.trachomatisatrectalsites(278
280)andatoropharyngealsitesamongmen(278281).SomelaboratorieshavemetCLIArequirementsandhavevalidatedNAAT
testingonrectalswabspecimensforC.trachomatis.Recentevidencesuggeststhattheliquidbasedcytologyspecimenscollectedfor
PapsmearsmightbeacceptablespecimensforNAATtesting,althoughtestsensitivityusingthesespecimensmightbelowerthan
thoseresultingfromtheuseofcervicalswabspecimens(282)regardless,certainNAATshavebeenFDAclearedforuseonliquid
basedcytologyspecimens.PersonswhoundergotestingandarediagnosedwithchlamydiashouldbetestedforotherSTDs.

Treatment
Treatinginfectedpatientspreventssexualtransmissionofthedisease,andtreatingallsexpartnersofthosetestingpositivefor
chlamydiacanpreventreinfectionoftheindexpatientandinfectionofotherpartners.Treatingpregnantwomenusuallyprevents
transmissionofC.trachomatistoinfantsduringbirth.Chlamydiatreatmentshouldbeprovidedpromptlyforallpersonstesting
positiveforinfectiondelaysinreceivingchlamydiatreatmenthavebeenassociatedwithcomplications(e.g.,PID)inalimited
proportionofchlamydiainfectedsubjects(283).CoinfectionwithC.trachomatisfrequentlyoccursamongpatientswhohave
gonococcalinfectiontherefore,presumptivetreatmentofsuchpatientsforchlamydiaisappropriate(seeGonococcalInfection,
DualTherapyforGonococcalandChlamydialInfections).Thefollowingrecommendedtreatmentregimensandalternative
regimenscureinfectionandusuallyrelievesymptoms.
RecommendedRegimens
Azithromycin1gorallyinasingledose
OR
Doxycycline100mgorallytwiceadayfor7days
AlternativeRegimens
Erythromycinbase500mgorallyfourtimesadayfor7days
OR
Erythromycinethylsuccinate800mgorallyfourtimesadayfor7days
OR
Levofloxacin500mgorallyoncedailyfor7days
OR
Ofloxacin300mgorallytwiceadayfor7days
Ametaanalysisof12randomizedclinicaltrialsofazithromycinversusdoxycyclineforthetreatmentofgenitalchlamydialinfection
demonstratedthatthetreatmentswereequallyefficacious,withmicrobialcureratesof97%and98%,respectively(284).These
studieswereconductedprimarilyinpopulationsinwhichfollowupwasencouraged,adherencetoa7dayregimenwaseffective,
andcultureorEIA(ratherthanthemoresensitiveNAAT)wasusedfordeterminingmicrobiologicaloutcome.Azithromycinshould
alwaysbeavailabletotreatpatientsforwhomcompliancewithmultidaydosingisuncertain.Theclinicalsignificanceand
transmissibilityofC.trachomatisdetectedatoropharyngealsitesisunclear(285),andtheefficacyofdifferentantibioticregimens
inresolvingoropharyngealchlamydiaremainsunknown.
Inpatientswhohaveerratichealthcareseekingbehavior,poortreatmentcompliance,orunpredictablefollowup,azithromycin
mightbemorecosteffectiveintreatingchlamydiabecauseitenablestheprovisionofasingledoseofdirectlyobservedtherapy
(284).Erythromycinmightbelessefficaciousthaneitherazithromycinordoxycycline,mainlybecauseofthefrequentoccurrenceof
gastrointestinalsideeffectsthatcanleadtononcompliance.Levofloxacinandofloxacinareeffectivetreatmentalternativesbutare
moreexpensiveandoffernoadvantageinthedosageregimen.Otherquinoloneseitherarenotreliablyeffectiveagainstchlamydial
infectionorhavenotbeenevaluatedadequately.
Tomaximizecompliancewithrecommendedtherapies,medicationsforchlamydialinfectionsshouldbedispensedonsite,andthe
firstdoseshouldbedirectlyobserved.Tominimizediseasetransmissiontosexpartners,personstreatedforchlamydiashouldbe
instructedtoabstainfromsexualintercoursefor7daysaftersingledosetherapyoruntilcompletionofa7dayregimen.To
minimizetheriskforreinfection,patientsalsoshouldbeinstructedtoabstainfromsexualintercourseuntilalloftheirsexpartners
aretreated.

FollowUp
Exceptinpregnantwomen,testofcure(i.e.,repeattesting34weeksaftercompletingtherapy)isnotadvisedforpersonstreated

withtherecommendedoralterativeregimens,unlesstherapeuticcomplianceisinquestion,symptomspersist,orreinfectionis
suspected.Moreover,thevalidityofchlamydialdiagnostictestingat<3weeksaftercompletionoftherapy(toidentifypatientswho
didnotrespondtotherapy)hasnotbeenestablished.Falsenegativeresultsmightoccurinthepresenceofpersistentinfections
involvinglimitednumbersofchlamydialorganisms.Inaddition,NAATconductedat<3weeksaftercompletionoftherapyin
personswhoweretreatedsuccessfullycouldyieldfalsepositiveresultsbecauseofthecontinuedpresenceofnonviableorganisms
(197).
AhighprevalenceofC.trachomatisinfectionhasbeenobservedinwomenandmenwhoweretreatedforchlamydialinfection
duringtheprecedingseveralmonths(251,267,286288).Mostposttreatmentinfectionsresultfromreinfectioncausedbyfailureof
sexpartnerstoreceivetreatmentortheinitiationofsexualactivitywithanewinfectedpartner.Repeatinfectionsconferanelevated
riskforPIDandothercomplications.Unlikethetestofcure,whichisnotrecommended,repeatC.trachomatistestingofrecently
infectedwomenormenshouldbeapriorityforproviders.Chlamydiainfectedwomenandmenshouldberetestedapproximately3
monthsaftertreatment,regardlessofwhethertheybelievethattheirsexpartnersweretreated(251,267).Ifretestingat3monthsis
notpossible,cliniciansshouldretestwheneverpersonsnextpresentformedicalcareinthe12monthsfollowinginitialtreatment.

ManagementofSexPartners
Patientsshouldbeinstructedtorefertheirsexpartnersforevaluation,testing,andtreatmentiftheyhadsexualcontactwiththe
patientduringthe60daysprecedingonsetofthepatient'ssymptomsorchlamydiadiagnosis.Althoughtheexposureintervals
definedfortheidentificationofatrisksexpartnersarebasedonlimitedevaluation,themostrecentsexpartnershouldbeevaluated
andtreated,evenifthetimeofthelastsexualcontactwas>60daysbeforesymptomonsetordiagnosis.
Amongheterosexualpatients,ifconcernsexistthatsexpartnerswhoarereferredtoevaluationandtreatmentwillnotseekthese
services(orifothermanagementstrategiesareimpracticalorunsuccessful),patientdeliveryofantibiotictherapytotheirpartners
canbeconsidered(seePartnerManagement).Comparedwithstandardpartnerreferral,thisapproach,whichinvolvesdeliveringa
prescriptionorthemedicationitself,hasbeenassociatedwithatrendtowardadecreaseinratesofpersistentorrecurrent
chlamydia(68,69,71).Patientsmustalsoinformtheirpartnersoftheirinfectionandprovidethemwithwrittenmaterialsaboutthe
importanceofseekingevaluationforanysymptomssuggestiveofcomplications(e.g.,testicularpaininmenandpelvicorabdominal
paininwomen).PatientdeliveredpartnertherapyisnotroutinelyrecommendedforMSMbecauseofahighriskforcoexisting
infections,especiallyundiagnosedHIVinfection,intheirpartners.
Patientsshouldbeinstructedtoabstainfromsexualintercourseuntiltheyandtheirsexpartnershavecompletedtreatment.
Abstinenceshouldbecontinueduntil7daysafterasingledoseregimenoraftercompletionofamultipledoseregimen.Timely
treatmentofsexpartnersisessentialfordecreasingtheriskforreinfectingtheindexpatient.

SpecialConsiderations
Pregnancy
Doxycycline,ofloxacin,andlevofloxacinarecontraindicatedinpregnantwomen.However,clinicalexperienceandpublishedstudies
suggestthatazithromycinissafeandeffective(289291).Repeattestingtodocumentchlamydialeradication(preferablybyNAAT)
3weeksaftercompletionoftherapywiththefollowingregimensisrecommendedforallpregnantwomentoensuretherapeutic
cure,consideringtheseveresequelaethatmightoccurinmothersandneonatesiftheinfectionpersists.Womenaged<25yearsand
thoseatincreasedriskforchlamydia(i.e.,womenwhohaveanewormorethanonesexpartner)alsoshouldberetestedduringthe
thirdtrimestertopreventmaternalpostnatalcomplicationsandchlamydialinfectionintheinfant(81).Pregnantwomendiagnosed
withachlamydialinfectionduringthefirsttrimestershouldnotonlyreceiveatesttodocumentchlamydialeradication,butbe
retested3monthsaftertreatment.
RecommendedRegimens
Azithromycin1gorallyinasingledose
OR
Amoxicillin500mgorallythreetimesadayfor7days
AlternativeRegimens
Erythromycinbase500mgorallyfourtimesadayfor7days
OR
Erythromycinbase250mgorallyfourtimesadayfor14days
OR
Erythromycinethylsuccinate800mgorallyfourtimesadayfor7days
OR
Erythromycinethylsuccinate400mgorallyfourtimesadayfor14days

Thefrequentgastrointestinalsideeffectsassociatedwitherythromycincanresultinnoncompliancewiththealternativeregimens.
Althougherythromycinestolateiscontraindicatedduringpregnancybecauseofdrugrelatedhepatotoxicity,thelowerdose14day
erythromycinregimenscanbeconsideredifgastrointestinaltoleranceisaconcern.
HIVInfection
PatientswhohavechlamydialinfectionandalsoareinfectedwithHIVshouldreceivethesametreatmentregimenasthosewhoare
HIVnegative.

ChlamydialInfectionsAmongInfants
Prenatalscreeningandtreatmentofpregnantwomencanpreventchlamydialinfectionamongneonates.Pregnantwomenaged<25
yearsareathighriskforinfection.
C.trachomatisinfectionofneonatesresultsfromperinatalexposuretothemother'sinfectedcervix.Althoughneonatalocular
prophylaxiswithsilvernitratesolutionorantibioticointmentsdoesnotpreventperinataltransmissionofC.trachomatisfrom
mothertoinfant,ocularprophylaxiswiththeseagentsdoespreventgonococcalophthalmiaandthereforeshouldbeadministered
(seeOphthalmiaNeonatorumProphylaxis).
InitialC.trachomatisperinatalinfectioninvolvesthemucousmembranesoftheeye,oropharynx,urogenitaltract,andrectum,
althoughinfectionmightbeasymptomaticintheselocations.Instead,C.trachomatisinfectioninneonatesismostfrequently
recognizedbyconjunctivitisthatdevelops512daysafterbirth.C.trachomatisalsocancauseasubacute,afebrilepneumoniawith
onsetatages13months.AlthoughC.trachomatishasbeenthemostfrequentidentifiableinfectiouscauseofophthalmia
neonatorum,perinatalchlamydialinfections(includingophthalmiaandpneumonia)haveoccurredlessfrequentlybecauseofthe
institutionofwidespreadprenatalscreeningandtreatmentofpregnantwomen.

OphthalmiaNeonatorumCausedbyC.trachomatis
Achlamydialetiologyshouldbeconsideredforallinfantsaged30dayswhohaveconjunctivitis,especiallyifthemotherhasa
historyofuntreatedchlamydiainfection.
DiagnosticConsiderations
Sensitiveandspecificmethodsusedtodiagnosechlamydialophthalmiaintheneonateincludebothtissuecultureandnonculture
tests(e.g.,directfluorescenceantibody[DFA]tests,EIA,andNAAT).MostnonculturetestsarenotFDAclearedforthedetectionof
chlamydiafromconjunctivalswabs,andclinicallaboratoriesmustverifytheprocedureaccordingtoCLIAregulations.Specimens
forcultureisolationandnonculturetestsshouldbeobtainedfromtheevertedeyelidusingadacrontippedswabortheswab
specifiedbythemanufacturer'stestkit,andtheymustcontainconjunctivalcells,notexudatealone.SpecificdiagnosisofC.
trachomatisinfectionconfirmstheneedfortreatmentnotonlyfortheneonate,butalsoforthemotherandhersexpartner(s).
OcularspecimensfrominfantsbeingevaluatedforchlamydialconjunctivitisalsoshouldbetestedforN.gonorrhoeae.
RecommendedRegimen
Erythromycinbaseorethylsuccinate50mg/kg/dayorallydividedinto4dosesdailyfor14days*,
*Anassociationbetweenoralerythromycinandinfantilehypertrophicpyloricstenosis(IHIS)hasbeenreportedininfantsaged<6
weekswhoweretreatedwiththisdrug.InfantstreatedwitherythromycinshouldbefollowedforsignsandsymptomsofIHPS.
Dataonuseofothermacrolides(e.g.,azithromycinandclarithromycin)forthetreatmentofneonatalchlamydiainfectionare
limited.Theresultsofonestudyinvolvingalimitednumberofpatientssuggestthatashortcourseofazithromycin,20mg/kg/day
orally,1dosedailyfor3days,mightbeeffective(292).
Topicalantibiotictherapyaloneisinadequatefortreatmentofchlamydialinfectionandisunnecessarywhensystemictreatmentis
administered.
FollowUp
Becausetheefficacyoferythromycintreatmentisonlyapproximately80%,asecondcourseoftherapymightberequired.Therefore,
followupofinfantsisrecommendedtodeterminewhetherinitialtreatmentwaseffective.Thepossibilityofconcomitantchlamydial
pneumoniashouldbeconsidered.
ManagementofMothersandTheirSexPartners
Themothersofinfantswhohavechlamydialinfectionandthesexpartnersofthesewomenshouldbeevaluatedandtreated(see
ChlamydialInfectioninAdolescentsandAdults).

InfantPneumoniaCausedbyC.trachomatis
Characteristicsignsofchlamydialpneumoniaininfantsinclude1)arepetitivestaccatocoughwithtachypneaand2)hyperinflation
andbilateraldiffuseinfiltratesonachestradiograph.Inaddition,peripheraleosinophilia(400cells/mm3)occursfrequently.
Wheezingisrare,andinfantsaretypicallyafebrile.Becauseclinicalpresentationsdiffer,initialtreatmentanddiagnostictests
shouldincludeC.trachomatisforallinfantsaged13monthswhoaresuspectedofhavingpneumonia(especiallythosewhose

mothershaveuntreatedchlamydialinfection).
DiagnosticConsiderations
Specimensforchlamydialtestingshouldbecollectedfromthenasopharynx.Tissuecultureisthedefinitivestandardforchlamydial
pneumonia.Nonculturetests(e.g.,EIA,DFA,andNAAT)canbeused,althoughnonculturetestsofnasopharyngealspecimenshave
alowersensitivityandspecificitythannonculturetestsofocularspecimens.DFAistheonlyFDAclearedtestforthedetectionofC.
trachomatisfromnasopharyngealspecimens.Trachealaspiratesandlungbiopsyspecimens,ifcollected,shouldbetestedforC.
trachomatis.
Becausetestresultsforchlamydiaoftenarenotavailableinatimelymanner,thedecisiontoprovidetreatmentforC.trachomatis
pneumoniamustfrequentlybebasedonclinicalandradiologicfindings.Theresultsoftestsforchlamydialinfectionassistinthe
managementofaninfant'sillnessandcanhelpdeterminetheneedfortreatingthemotherandhersexpartner(s).
RecommendedRegimen
Erythromycinbaseorethylsuccinate50mg/kg/dayorallydividedinto4dosesdailyfor14days
FollowUp
TheeffectivenessoferythromycinintreatingpneumoniacausedbyC.trachomatisisapproximately80%asecondcourseof
therapymightberequired.Followupofinfantsisrecommendedtodeterminewhetherthepneumoniahasresolved,althoughsome
infantswithchlamydialpneumoniacontinuetohaveabnormalpulmonaryfunctiontestslaterinchildhood.
ManagementofMothersandTheirSexPartners
Mothersofinfantswhohavechlamydiapneumoniaandthesexpartnersofthesewomenshouldbeevaluatedandtreatedaccording
totherecommendedtreatmentofadultsforchlamydialinfections(seeChlamydialInfectioninAdolescentsandAdults).
InfantsBorntoMothersWhoHaveChlamydialInfection
Infantsborntomotherswhohaveuntreatedchlamydiaareathighriskforinfectionhowever,prophylaticantibiotictreatmentis
notindicated,andtheefficacyofsuchtreatmentisunknown.Infantsshouldbemonitoredtoensureappropriatetreatmentif
symptomsdevelop.

ChlamydialInfectionsAmongChildren
Sexualabusemustbeconsideredacauseofchlamydialinfectioninpreadolescentchildren,althoughperinatallytransmittedC.
trachomatisinfectionofthenasopharynx,urogenitaltract,andrectummightpersistfor>1year(seeSexualAssaultorAbuseof
Children).

DiagnosticConsiderations
Nonculture,nonamplifiedprobetestsforchlamydia(EIAandDFA)shouldnotbeusedbecauseofthepossibilityoffalsepositive
testresults.Withrespiratorytractspecimens,falsepositiveresultscanoccurbecauseofcrossreactionoftestreagentswithC.
pneumoniaewithgenitalandanalspecimens,falsepositiveresultsmightoccurasaresultofcrossreactionwithfecalflora.
RecommendedRegimenforChildrenWhoWeigh<45kg
Erythromycinbaseorethylsuccinate50mg/kg/dayorallydividedinto4dosesdailyfor14days
RecommendedRegimenforChildrenWhoWeigh45kgbutWhoAreAged<8Years
Azithromycin1gorallyinasingledose
RecommendedRegimensforChildrenAged8years
Azithromycin1gorallyinasingledose
OR
Doxycycline100mgorallytwiceadayfor7days

OtherManagementConsiderations
SeeSexualAssaultorAbuseofChildren.

FollowUp
Followupculturesarenecessarytoensurethattreatmenthasbeeneffective.

GonococcalInfections
GonococcalInfectionsinAdolescentsandAdults

IntheUnitedStates,anestimated700,000newN.gonorrhoeaeinfectionsoccureachyear(93,293).Gonorrheaisthesecondmost
commonlyreportedbacterialSTD.ThemajorityofurethralinfectionscausedbyN.gonorrhoeaeamongmenproducesymptoms
thatcausethemtoseekcurativetreatmentsoonenoughtopreventserioussequelae,buttreatmentmightnotbesoonenoughto
preventtransmissiontoothers.Amongwomen,gonococcalinfectionsmightnotproducerecognizablesymptomsuntil
complications(e.g.,PID)haveoccurred.PIDcanresultintubalscarringthatcanleadtoinfertilityorectopicpregnancy.
Theprevalenceofgonorrheavarieswidelyamongcommunitiesandpopulationshealthcareprovidersshouldconsiderlocal
gonorrheaepidemiologywhenmakingscreeningdecisions.Althoughwidespreadscreeningisnotrecommendedbecausegonococcal
infectionsamongwomenarefrequentlyasymptomatic,targetedscreeningofyoungwomen(i.e.,thoseaged<25years)atincreased
riskforinfectionisaprimarycomponentofgonorrheacontrolintheUnitedStates.Forsexuallyactivewomen,includingthosewho
arepregnant,USPSTF(82)recommendsthatcliniciansprovidegonorrheascreeningonlytothoseatincreasedriskforinfection
(e.g.,womenwithpreviousgonorrheainfection,otherSTDs,newormultiplesexpartners,andinconsistentcondomusethosewho
engageincommercialsexworkanddrugusewomenincertaindemographicgroupsandthoselivingincommunitieswithahigh
prevalenceofdisease).USPSTFdoesnotrecommendscreeningforgonorrheainmenandwomenwhoareatlowriskforinfection
(82).

DiagnosticConsiderations
Becauseofitshighspecificity(>99%)andsensitivity(>95%),aGramstainofamaleurethralspecimenthatdemonstrates
polymorphonuclearleukocyteswithintracellularGramnegativediplococcicanbeconsidereddiagnosticforinfectionwithN.
gonorrhoeaeinsymptomaticmen.However,becauseoflowersensitivity,anegativeGramstainshouldnotbeconsideredsufficient
forrulingoutinfectioninasymptomaticmen.Inaddition,Gramstainofendocervicalspecimens,pharyngeal,orrectalspecimens
alsoarenotsufficienttodetectinfection,andthereforearenotrecommended.SpecifictestingforN.gonorrhoeaeisrecommended
becauseoftheincreasedutilityandavailabilityofhighlysensitiveandspecifictestingmethodsandbecauseaspecificdiagnosis
mightenhancepartnernotification.
SpecificdiagnosisofinfectionwithN.gonorrhoeaecanbeperformedbytestingendocervical,vaginal,urethral(menonly),orurine
specimens.Culture,nucleicacidhybridizationtests,andNAATsareavailableforthedetectionofgenitourinaryinfectionwithN.
gonorrhoeae(197).Cultureandnucleicacidhybridizationtestsrequirefemaleendocervicalormaleurethralswabspecimens.
NAATsallowtestingofthewidestvarietyofspecimentypesincludingendocervicalswabs,vaginalswabs,urethralswabs(men),and
urine(frombothmenandwomen),andtheyareFDAclearedforuse.However,productinsertsforeachNAATvendormustbe
carefullyexamined,becausespecimentypesthatareFDAclearedforusevarybytest.NAATtestsarenotFDAclearedforuseinthe
rectum,pharynx,andconjunctivahowever,somepublicandprivatelaboratorieshaveestablishedperformancespecificationsfor
usingNAATwithrectalandpharyngealswabspecimens,therebyallowingresultstobeusedforclinicalmanagement.Laboratories
thatestablishperformancespecificationsfortheuseofNAATswithnongenitalspecimensmustensurethatspecificityisnot
compromisedbycrossreactionwithnongonococcalNeisseriaspecies.ThesensitivityofNAATsforthedetectionofN.gonorrhoeae
ingenitalandnongenitalanatomicsitesissuperiortoculturebutvariesbyNAATtype(197,278281).
Becausenonculturetestscannotprovideantimicrobialsusceptibilityresults,incasesofsuspectedordocumentedtreatmentfailure,
cliniciansshouldperformbothcultureandantimicrobialsusceptibilitytesting.
AllpersonsfoundtohavewhohavegonorrheaalsoshouldbetestedforotherSTDs,includingchlamydia,syphilis,andHIV.

DualTherapyforGonococcalandChlamydialInfections
PatientsinfectedwithN.gonorrhoeaefrequentlyarecoinfectedwithC.trachomatisthisfindinghasledtotherecommendation
thatpatientstreatedforgonococcalinfectionalsobetreatedroutinelywitharegimenthatiseffectiveagainstuncomplicatedgenital
C.trachomatisinfection(294).BecausemostgonococciintheUnitedStatesaresusceptibletodoxycyclineandazithromycin,
routinecotreatmentmightalsohinderthedevelopmentofantimicrobialresistantN.gonorrhoeae.Limiteddatasuggestthatdual
treatmentwithazithromycinmightenhancetreatmentefficacyforpharyngealinfectionwhenusingoralcephalosporins(295,296).

AntimicrobialResistantN.gonorrhoeae
GonorrheatreatmentiscomplicatedbytheabilityofN.gonorrhoeaetodevelopresistancetoantimicrobialtherapies(297).
QuinoloneresistantN.gonorrhoeaestrainsarenowwidelydisseminatedthroughouttheUnitedStatesandtheworld(298).Asof
April2007,quinolonesarenolongerrecommendedintheUnitedStatesforthetreatmentofgonorrheaandassociatedconditions,
suchasPID(299).Consequently,onlyoneclassofantimicrobials,thecephalosporins,isrecommendedandavailableforthe
treatmentofgonorrheaintheUnitedStates.TheCDCwebsite(http://www.cdc.gov/std/gisp)andstatehealthdepartmentscan
providethemostcurrentinformation.
TheproportionofisolatesinCDC'sGonococcalIsolateSurveillanceProject(GISP)demonstratingdecreasedsusceptibilityto
ceftriaxoneorcefiximehasremainedverylowovertimeduring19872008,onlyfourisolateswerefoundtohavedecreased
susceptibilitytoceftriaxone,and48isolateshaddecreasedsusceptibilitytocefixime.In2008,noisolatesdemonstrateddecreased
susceptibilitytoceftriaxonecefiximewasnotpartoftestpanelduringthatyear(93).Althoughonlytwocasesofsuspected
treatmentfailurewithceftriaxonehavebeenreported(300),approximately50patientsarethoughttohavefailedoral
cephalosporintreatment(301304).
MostofthetreatmentfailuresresultingfromuseoforalcephalosporinshavebeenreportedfromAsiancountries,althoughone
possiblecasewasreportedinHawaiiin2001(305).Toensureappropriateantibiotictherapy,cliniciansshouldaskpatientstesting
positiveforgonorrheaaboutrecenttraveltoandsexualactivityinthesecountries.

DecreasedsusceptibilityofN.gonorrhoeaetocephalosporinsandotherantimicrobialsisexpectedtocontinuetospreadtherefore,
stateandlocalsurveillanceforantimicrobialresistanceiscrucialforguidinglocaltherapyrecommendations(297).GISP,which
samplesapproximately3%ofallU.S.menwhohavegonococcalinfections,isamainstayofsurveillance.However,surveillanceby
cliniciansalsoiscritical.ClinicianswhodiagnoseN.gonorrhoeaeinfectioninapatientwithsuspectedcephalosporintreatment
failureshouldperformcultureandsusceptibilitytestingofrelevantclinicalspecimens,consultaspecialistforguidanceinclinical
management,andreportthecasetoCDCthroughstateandlocalpublichealthauthorities.Healthdepartmentsshouldprioritize
partnernotificationandcontacttracingofpatientswithN.gonorrhoeaeinfectionthoughttobeassociatedwithcephalosporin
treatmentfailureorassociatedwithpatientswhoseisolatesdemonstratedecreasedsusceptibilitytocephalosporin.

UncomplicatedGonococcalInfectionsoftheCervix,Urethra,andRectum
RecommendedRegimens
Ceftriaxone250mgIMinasingledose
OR,IFNOTANOPTION
Cefixime400mgorallyinasingledose
OR
Singledoseinjectiblecephalosporinregimens
PLUS
Azithromycin1gorallyinasingledose
OR
Doxycycline100mgadayfor7days
Tomaximizecompliancewithrecommendedtherapies,medicationsforgonococcalinfectionsshouldbedispensedonsite.
Ceftriaxoneinasingleinjectionof250mgprovidessustained,highbactericidallevelsintheblood.Extensiveclinicalexperience
indicatesthatceftriaxoneissafeandeffectiveforthetreatmentofuncomplicatedgonorrheaatallanatomicsites,curing99.2%of
uncomplicatedurogenitalandanorectaland98.9%ofpharyngealinfectionsinpublishedclinicaltrials(306,307).A250mgdoseof
ceftriaxoneisnowrecommendedovera125mgdosegiventhe1)increasinglywidegeographicdistributionofisolates
demonstratingdecreasedsusceptibilitytocephalosporinsinvitro,2)reportsofceftriaxonetreatmentfailures,3)improvedefficacy
ofceftriaxone250mginpharyngealinfection(whichisoftenunrecognized),and4)theutilityofhavingasimpleandconsistent
recommendationfortreatmentregardlessoftheanatomicsiteinvolved.
A400mgoraldoseofcefiximedoesnotprovideashigh,norassustained,abactericidallevelasthatprovidedbythe250mgdose
ofceftriaxone.Inpublishedclinicaltrials,the400mgdosecured97.5%ofuncomplicatedurogenitalandanorectal(95%CI=
95.4%99.8%)and92.3%ofpharyngealgonococcalinfections(95%CI=74.9%99.1%)(306,307).Althoughcefiximecanbe
administeredorally,thisadvantageisoffsetbythelimitedefficacyofcefixime(aswellasotheroralcephalosporins)fortreating
gonococcalinfectionsofthepharynx.Providersshouldinquireaboutoralsexualexposureandifreported,treatthesepatientswith
ceftriaxonebecauseofthisdrug'swelldocumentedefficacyintreatingpharyngealinfection.
Singledoseinjectiblecephalosporinregimens(otherthanceftriaxone250mgIM)thataresafeandhighlyeffectiveagainst
uncomplicatedurogenitalandanorectalgonococcalinfectionsincludeceftizoxime(500mg,administeredIM),cefoxitin(2g,
administeredIMwithprobenecid1gorally),andcefotaxime(500mg,administeredIM).Noneoftheinjectiblecephalosporinsoffer
anyadvantageoverceftriaxoneforurogenitalinfection,andefficacyforpharyngealinfectionislesscertain(306,307).

AlternativeRegimens
SeveralotherantimicrobialsareactiveagainstN.gonorrhoeae,butnonehavesubstantialadvantagesovertherecommended
regimens,andtheyshouldnotbeusedifpharyngealinfectionissuspected.Someevidencesuggeststhatcefpodoxime400mgorally
canbeconsideredanalternativeinthetreatmentofuncomplicatedurogenitalgonorrheathisregimenmeetstheminimumefficacy
criteriaforalternativeregimensforurogenitalinfection(demonstratedefficacyof95%inclinicaltrialswithlower95%CIof
>90%)(307).Inoneclinicaltrial,cefpodoxime400mgorallywasfoundtohaveaurogenitalandrectalcurerateof96.6%(95%CI
=93.9%),buttheefficacyofcefpodoxime400mgorallyatthepharyngealsitewaspoor(70.3%,95%CI=53.0%)(Hall,
unpublisheddata,2010).GonococcalstrainswithdecreasedsusceptibilitytooralcephalosporinshavebeenreportedintheUnited
States(308).Withacurerateof96.5%(95%CI=93.6%98.3%)forurogenitalandrectalinfection,cefpodoximeproxetil200mg
orallymeetsthecriteriaforanalternativeregimenhowever,itsuseisnotadvisedbecauseofconcernsaboutthe
pharmacodynamicsofcefpodoximeusingthisdose.Efficacyintreatingpharyngealinfectionwithcefpodoxime200mgis
unsatisfactory(78.9%95%CI=54.5%94%),aswithcefpodoximeatthe400mgdose.
Treatmentwithcefuroximeaxetil1gorallymeetsthecriteriaforminimumefficacyasanalternativeregimenforurogenitaland
rectalinfection(95.9%95%CI=94.3%97.2%),butthepharmacodynamicsofcefuroximeaxetil1gorallyarelessfavorablethan
thoseofcefpodoxime400mg,cefixime400mg,orceftriaxone125mg(309).Theefficacyofcefuroximeaxetil1gorallyintreating
pharyngealinfectionispoor(56.9%95%CI=42.2%70.7%).

Spectinomycin,whichisusefulinpersonswhocannottoleratecephalosporins,isexpensive,mustbeinjected,andisnotavailablein
theUnitedStates(updatesavailableat:www.cdc.gov/std/treatment)(310).However,ithasbeeneffectiveinpublishedclinical
trials,curing98.2%ofuncomplicatedurogenitalandanorectalgonococcalinfections.Spectinomycinhaspoorefficacyagainst
pharyngealinfection(51.8%95%CI=38.7%64.9%)(306).
Azithromycin2gorallyiseffectiveagainstuncomplicatedgonococcalinfection(99.2%95%CI=97.3%99.9%),butconcernsover
theeasewithwhichN.gonorrhoeaecandevelopresistancetomacrolidesshouldrestrictitsusetolimitedcircumstances.Although
azithromycin1gmeetsalternativeregimencriteria(97.6%95%CI=95.7%98.9%),itisnotrecommendedbecauseseveralstudies
havedocumentedtreatmentfailures,andconcernsaboutpossiblerapidemergenceofantimicrobialresistancewiththe1gdoseof
azithromycinareevengreaterthanwiththe2gdose(311313).N.gonorrhoeaeintheUnitedStatesisnotadequatelysusceptible
topenicillins,tetracyclines,andoldermacrolides(e.g.,erythromycin)fortheseantimicrobialstoberecommended.

UncomplicatedGonococcalInfectionsofthePharynx
Mostgonococcalinfectionsofthepharynxareasymptomaticandcanberelativelycommoninsomepopulations(103,278,279,314).
Gonococcalinfectionsofthepharynxaremoredifficulttoeradicatethaninfectionsaturogenitalandanorectalsites(315).Few
antimicrobialregimens,includingthoseinvolvingoralcephalosporins,canreliablycure>90%ofgonococcalpharyngealinfections
(306,307).Providersshouldasktheirpatientsaboutoralsexualexposureifreported,patientsshouldbetreatedwitharegimen
withacceptableefficacyagainstpharyngealinfection.Chlamydialcoinfectionofthepharynxisunusualhowever,because
coinfectionatgenitalsitessometimesoccurs,treatmentforbothgonorrheaandchlamydiaisrecommended.
RecommendedRegimens
Ceftriaxone250mgIMinasingledose
PLUS
Azithromycin1gorallyinasingledose
OR
Doxycycline100mgadayfor7days

FollowUp
Patientsdiagnosedwithuncomplicatedgonorrheawhoaretreatedwithanyoftherecommendedoralternativeregimensdonot
needatestofcure(i.e.,repeattesting34weeksaftercompletingtherapy).Patientswhohavesymptomsthatpersistafter
treatmentshouldbeevaluatedbycultureforN.gonorrhoeae,andanygonococciisolatedshouldbetestedforantimicrobial
susceptibility.Persistenturethritis,cervicitis,orproctitisalsomightbecausedbyC.trachomatisorotherorganisms.
N.gonorrhoeaeinfectionisprevalentamongpatientswhohavebeendiagnosedwithandtreatedforgonorrheainthepreceding
severalmonths(64,251,252,267).Mostinfectionsresultfromreinfectionratherthantreatmentfailure,indicatinganeedfor
improvedpatienteducationandreferralofsexpartners.Cliniciansshouldadvisepatientswithgonorrheatoberetested3months
aftertreatment.Ifpatientsdonotseekmedicalcareforretestingin3months,providersareencouragedtotestthesepatients
whenevertheynextseekmedicalcarewithinthefollowing12months,regardlessofwhetherthepatientsbelievethattheirsex
partnersweretreated.Retestingisdistinctfromtestofcuretodetecttherapeuticfailure,whichisnotrecommended.

ManagementofSexPartners
EffectiveclinicalmanagementofpatientswithtreatableSTDsrequirestreatmentofthepatients'recentsexpartnerstoprevent
reinfectionandcurtailfurthertransmission.Patientsshouldbeinstructedtorefertheirsexpartnersforevaluationandtreatment.
SexpartnersofpatientswithN.gonorrhoeaeinfectionwhoselastsexualcontactwiththepatientwaswithin60daysbeforeonsetof
symptomsordiagnosisofinfectioninthepatientshouldbeevaluatedandtreatedforN.gonorrhoeaeandC.trachomatisinfections.
Ifapatient'slastsexualintercoursewas>60daysbeforeonsetofsymptomsordiagnosis,thepatient'smostrecentsexpartner
shouldbetreated.Patientsshouldbeinstructedtoabstainfromsexualintercourseuntiltherapyiscompletedanduntiltheyand
theirsexpartnersnolongerhavesymptoms.
Forheterosexualpatientswithgonorrheawhosepartners'treatmentcannotbeensuredorisunlikely,deliveryofantibiotictherapy
forgonorrhea(aswellasforchlamydia)bythepatientstotheirpartnerscanbeconsidered(seePartnerManagement).Useofthis
approach(68,71)shouldalwaysbeaccompaniedbyeffortstoeducatepartnersaboutsymptomsandtoencouragepartnerstoseek
clinicalevaluation.Formalepatientsinformingfemalepartners,educationalmaterialsshouldincludeinformationaboutthe
importanceofseekingmedicalevaluationforPID(especiallyifsymptomatic).PossibleundertreatmentofPIDinfemalepartners
andpossiblemissedopportunitiestodiagnoseotherSTDsareofconcernandhavenotbeenevaluatedincomparisonwithpatient
deliveredtherapyandpartnerreferral.ThisapproachshouldnotbeconsideredaroutinepartnermanagementstrategyinMSM
becauseofthehighriskforcoexistingundiagnosedSTDsorHIVinfection.

SpecialConsiderations
Allergy,Intolerance,andAdverseReactions
Reactionstofirstgenerationcephalosporinsoccurinapproximately5%10%ofpersonswithahistoryofpenicillinallergyand
occurlessfrequentlywiththirdgenerationcephalosporins(239).Inthosepersonswithahistoryofpenicillinallergy,theuseof

cephalosporinsshouldbecontraindicatedonlyinthosewithahistoryofaseverereactiontopenicillin(e.g.,anaphylaxis,Stevens
Johnsonsyndrome,andtoxicepidermalnecrolysis)(316).
Becausedataarelimitedregardingalternativeregimensfortreatinggonorrheaamongpersonswhohaveseverecephalosporin
allergy,providerstreatingsuchpatientsshouldconsultinfectiousdiseasespecialists.Azithromycin2gorallyiseffectiveagainst
uncomplicatedgonococcalinfection,butbecauseofconcernsoveremergingantimicrobialresistancetomacrolides,itsuseshouldbe
limited.Cephalosporintreatmentfollowingdesensitizationisimpracticalinmostclinicalsettings.
Pregnancy
Aswithotherpatients,pregnantwomeninfectedwithN.gonorrhoeaeshouldbetreatedwitharecommendedoralternate
cephalosporin.BecausespectinomycinisnotavailableintheUnitedStates,azithromycin2gorallycanbeconsideredforwomen
whocannottolerateacephalosporin.Eitherazithromycinoramoxicillinisrecommendedfortreatmentofpresumptiveordiagnosed
C.trachomatisinfectionduringpregnancy(seeChlamydialInfections).
HIVInfection
PatientswhohavegonococcalinfectionandalsoareinfectedwithHIVshouldreceivethesametreatmentregimenasthosewhoare
HIVnegative.
SuspectedCephalosporinTreatmentFailureorResistance
Suspectedtreatmentfailurehasbeenreportedamongpersonsreceivingoralandinjectablecephalosporins(300304).Therefore,
cliniciansofpatientswithsuspectedtreatmentfailureorpersonsinfectedwithastrainfoundtodemonstrateinvitroresistance
shouldconsultaninfectiousdiseasespecialist,conductcultureandsusceptibilitytestingofrelevantclinicalspecimens,retreatwith
atleast250mgofceftriaxoneIMorIV,ensurepartnertreatment,andreportthesituationtoCDCthroughstateandlocalpublic
healthauthorities.
GonococcalConjunctivitis
IntheonlypublishedstudyofthetreatmentofgonococcalconjunctivitisamongU.S.adults,all12studyparticipantsrespondedtoa
single1gIMinjectionofceftriaxone(317).
RecommendedRegimen
Ceftriaxone1gIMinasingledose
Considerlavageoftheinfectedeyewithsalinesolutiononce.Personstreatedforgonococcalconjunctivitisshouldbetreated
presumptivelyforconcurrentC.trachomatisinfection.
ManagementofSexPartners
Patientsshouldbeinstructedtorefertheirsexpartnersforevaluationandtreatment(seeGonococcalInfections,Managementof
SexPartners).

DisseminatedGonococcalInfection(DGI)
DGIfrequentlyresultsinpetechialorpustularacralskinlesions,asymmetricalarthralgia,tenosynovitis,orsepticarthritis.The
infectioniscomplicatedoccasionallybyperihepatitisandrarelybyendocarditisormeningitis.SomestrainsofN.gonorrhoeaethat
causeDGIcancauseminimalgenitalinflammation.NorecentstudieshavebeenpublishedonthetreatmentofDGI.
Treatment
Hospitalizationisrecommendedforinitialtherapy,especiallyforpatientswhomightnotcomplywithtreatment,forthoseinwhom
diagnosisisuncertain,andforthosewhohavepurulentsynovialeffusionsorothercomplications.Examinationforclinicalevidence
ofendocarditisandmeningitisshouldbeperformed.PersonstreatedforDGIshouldbetreatedpresumptivelyforconcurrentC.
trachomatisinfection.
RecommendedRegimen
Ceftriaxone1gIMorIVevery24hours
AlternativeRegimens
Cefotaxime1gIVevery8hours
OR
Ceftizoxime1gIVevery8hours
Alloftheprecedingregimensshouldbecontinuedfor2448hoursafterimprovementbegins,atwhichtimetherapycanbe
switchedtocefixime400mgorallytwicedailytocompleteatleast1weekofantimicrobialtherapy.Notreatmentfailureshavebeen

reportedwiththerecommendedregimens.
ManagementofSexPartners
GonococcalinfectionfrequentlyisasymptomaticinsexpartnersofpatientswhohaveDGI.Aswithuncomplicatedgonococcal
infections,patientsshouldbeinstructedtorefertheirsexpartnersforevaluationandtreatment(seeGonococcalInfection,
ManagementofSexPartners).

GonococcalMeningitisandEndocarditis
RecommendedRegimen
Ceftriaxone12gIVevery12hours
Therapyformeningitisshouldbecontinuedfor1014daystherapyforendocarditisshouldbecontinuedforatleast4weeks.
TreatmentofcomplicatedDGIshouldbeundertakeninconsultationwithaninfectiousdiseasespecialist.
ManagementofSexPartners
Patientsshouldbeinstructedtorefertheirsexpartnersforevaluationandtreatment(seeGonococcalInfection,ManagementofSex
Partners).

GonococcalInfectionsAmongInfants
Gonococcalinfectionamonginfantsusuallyiscausedbyexposuretoinfectedcervicalexudateatbirth.Itisusuallyanacuteillness
thatmanifests25daysafterbirth.Theprevalenceofinfectionamonginfantsdependsontheprevalenceofinfectionamong
pregnantwomen,whetherpregnantwomenarescreenedforgonorrhea,andwhethernewbornsreceiveophthalmiaprophylaxis.
ThemostseveremanifestationsofN.gonorrhoeaeinfectioninnewbornsareophthalmianeonatorumandsepsis,whichcaninclude
arthritisandmeningitis.Lessseveremanifestationsincluderhinitis,vaginitis,urethritis,andreinfectionatsitesoffetalmonitoring.

OphthalmiaNeonatorumCausedbyN.gonorrhoeae
AlthoughN.gonorrhoeaecausesophthalmianeonatorumrelativelyinfrequentlyintheUnitedStates,identifyingandtreatingthis
infectionisespeciallyimportantbecauseophthalmianeonatorumcanresultinperforationoftheglobeoftheeyeandblindness.
DiagnosticConsiderations
Infantsatincreasedriskforgonococcalophthalmiaarethosewhodonotreceiveophthalmiaprophylaxisandthosewhosemothers
havehadnoprenatalcareorwhosemothershaveahistoryofSTDsorsubstanceabuse.Gonococcalophthalmiaisstrongly
suspectedwhenintracellulargramnegativediplococciareidentifiedinconjunctivalexudate,justifyingpresumptivetreatmentfor
gonorrheaafterappropriateculturesforN.gonorrhoeaeareobtained.Appropriatechlamydialtestingshouldbedone
simultaneously.PresumptivetreatmentforN.gonorrhoeaemightbeindicatedfornewbornswhoareatincreasedriskfor
gonococcalophthalmiaandwhohaveincreasedWBCs(butnotgonococci)inaGramstainedsmearofconjunctivalexudate.
Inallcasesofneonatalconjunctivitis,conjunctivalexudatesshouldbeculturedforN.gonorrhoeaeandtestedforantibiotic
susceptibilitybeforeadefinitivediagnosisismade.Adefinitivediagnosisisvitalbecauseofthepublichealthandsocial
consequencesofadiagnosisofgonorrhea.NongonococcalcausesofneonatalophthalmiaincludeMoraxellacatarrhalisandother
Neisseriaspecies,organismsthatareindistinguishablefromN.gonorrhoeaeonGramstainedsmearbutcanbedifferentiatedin
themicrobiologylaboratory.
RecommendedRegimen
Ceftriaxone2550mg/kgIVorIMinasingledose,nottoexceed125mg
Topicalantibiotictherapyaloneisinadequateandisunnecessaryifsystemictreatmentisadministered.
OtherManagementConsiderations
SimultaneousinfectionwithC.trachomatisshouldbeconsideredwhenapatientdoesnotimproveaftertreatment.Bothmother
andinfantshouldbetestedforchlamydialinfectionatthesametimethatgonorrheatestingisconducted(seeOphthalmia
NeonatorumCausedbyC.trachomatis).Ceftriaxoneshouldbeadministeredcautiouslytohyperbilirubinemicinfants,especially
thosebornprematurely.
FollowUp
Infantswhohavegonococcalophthalmiashouldbehospitalizedandevaluatedforsignsofdisseminatedinfection(e.g.,sepsis,
arthritis,andmeningitis).Onedoseofceftriaxoneisadequatetherapyforgonococcalconjunctivitis.

ManagementofMothersandTheirSexPartners
Themothersofinfantswhohavegonococcalinfectionandthemothers'sexpartnersshouldbeevaluatedandtreatedaccordingto
therecommendationsfortreatinggonococcalinfectionsinadults(seeGonococcalInfectionsinAdolescentsandAdults).

DGIandGonococcalScalpAbscessesinNewborns

Sepsis,arthritis,andmeningitis(oranycombinationoftheseconditions)arerarecomplicationsofneonatalgonococcalinfection.
Localizedgonococcalinfectionofthescalpcanresultfromfetalmonitoringthroughscalpelectrodes.Detectionofgonococcal
infectioninneonateswhohavesepsis,arthritis,meningitis,orscalpabscessesrequiresculturesofblood,CSF,andjointaspirateon
chocolateagar.Specimensobtainedfromtheconjunctiva,vagina,oropharynx,andrectumthatareculturedongonococcalselective
mediumareusefulforidentifyingtheprimarysite(s)ofinfection,especiallyifinflammationispresent.PositiveGramstained
smearsofexudate,CSF,orjointaspirateprovideapresumptivebasisforinitiatingtreatmentforN.gonorrhoeae.Diagnosesbased
onGramstainedsmearsorpresumptiveidentificationofculturesshouldbeconfirmedwithdefinitivetestsoncultureisolates.
RecommendedRegimens
Ceftriaxone2550mg/kg/dayIVorIMinasingledailydosefor7days,withadurationof1014days,ifmeningitisis
documented
OR
Cefotaxime25mg/kgIVorIMevery12hoursfor7days,withadurationof1014days,ifmeningitisisdocumented

ProphylacticTreatmentforInfantsWhoseMothersHaveGonococcalInfection
Infantsborntomotherswhohaveuntreatedgonorrheaareathighriskforinfection.
RecommendedRegimenintheAbsenceofSignsofGonococcalInfection
Ceftriaxone2550mg/kgIVorIM,nottoexceed125mg,inasingledose

OtherManagementConsiderations
Bothmotherandinfantshouldbetestedforchlamydialinfection.

FollowUp
Followupexaminationisnotrequired.

ManagementofMothersandTheirSexPartners
Themothersofinfantswhohavegonococcalinfectionandthemothers'sexpartnersshouldbeevaluatedandtreatedaccordingto
therecommendationsfortreatmentofgonococcalinfectionsinadults(seeGonococcalInfections).

GonococcalInfectionsAmongChildren
Sexualabuseisthemostfrequentcauseofgonococcalinfectioninpreadolescentchildren(seeSexualAssaultorAbuseofChildren).
Forpreadolescentgirls,vaginitisisthemostcommonmanifestationofthisinfectiongonococcalassociatedPIDaftervaginal
infectionislikelylesscommoninpreadolescentsthanadults.Amongsexuallyabusedchildren,anorectalandpharyngealinfections
withN.gonorrhoeaearecommonandfrequentlyasymptomatic.

DiagnosticConsiderations
BecauseofthelegalimplicationsofadiagnosisofN.gonorrhoeaeinfectioninachild,cultureremainsthepreferredmethodfor
diagnosis.Gramstainsareinadequateforevaluatingprepubertalchildrenforgonorrheaandshouldnotbeusedtodiagnoseor
exludegonorrhea.NAATsforthedetectionofN.gonorrhoeaecanbeusedundercertaincircumstances(seeSexualAssaultorAbuse
ofChildren)
RecommendedRegimenforChildrenWhoWeigh>45kg
Treatwithoneoftheregimensrecommendedforadults(seeGonococcalInfections)
RecommendedRegimenforChildrenWhoWeigh45kgandWhoHaveUncomplicatedGonococcal
Vulvovaginitis,Cervicitis,Urethritis,Pharyngitis,orProctitis
Ceftriaxone125mgIMinasingledose
RecommendedRegimenforChildrenWhoWeigh45kgandWhoHaveBacteremiaorArthritis
Ceftriaxone50mg/kg(maximumdose:1g)IMorIVinasingledosedailyfor7days
RecommendedRegimenforChildrenWhoWeigh>45kgandWhoHaveBacteremiaorArthritis
Ceftriaxone50mg/kgIMorIVinasingledosedailyfor7days

FollowUp
Followupculturesareunnecessaryifceftriaxoneisused.

OtherManagementConsiderations
Onlyparenteralcephalosporins(i.e.,ceftriaxone)arerecommendedforuseinchildrencefotaximeisapprovedforgonococcal
ophthalmiaonly.Nodataareavailableregardingtheuseoforalcefiximetotreatgonococcalinfectionsinchildren.
AllchildrenfoundtohavegonococcalinfectionsshouldbeevaluatedforcoinfectionwithsyphilisandC.trachomatis.(Fora
discussionofconcernsregardingsexualassault,seeSexualAssaultorAbuseofChildren.)

OphthalmiaNeonatorumProphylaxis
Topreventgonococcalophthalmianeonatorum,aprophylacticagentshouldbeinstilledintotheeyesofallnewborninfantsthis
procedureisrequiredbylawinmoststates.Alloftherecommendedprophylacticregimensinthissectionpreventgonococcal
ophthalmia.However,theefficacyofthesepreparationsinpreventingchlamydialophthalmiaislessclear,andtheydonoteliminate
nasopharyngealcolonizationbyC.trachomatis.Thediagnosisandtreatmentofgonococcalandchlamydialinfectionsinpregnant
womenisthebestmethodforpreventingneonatalgonococcalandchlamydialdisease.Notallwomen,however,receiveprenatal
care,andthereforegountreated.Ocularprophylaxisiswarrantedforneonates,becauseitcanpreventsightthreateninggonococcal
ophthalmiaandbecauseitissafe,easytoadminister,andinexpensive.
RecommendedRegimen
Erythromycin(0.5%)ophthalmicointmentineacheyeinasingleapplication
Thispreparationshouldbeinstilledintobotheyesofeveryneonateassoonaspossibleafterdelivery.Ideally,ointmentshouldbe
appliedusingsingleusetubesorampulesratherthanmultipleusetubes.Ifprophylaxisisdelayed(i.e.,notadministeredinthe
deliveryroom),amonitoringsystemshouldbeestablishedtoensurethatallinfantsreceiveprophylaxis.Allinfantsshouldbe
administeredocularprophylaxis,regardlessofwhethertheyaredeliveredvaginallyorbycesareansection.
Erythromycinistheonlyantibioticointmentrecommendedforuseinneonates.Silvernitrateandtetracyclineophthalmicointment
arenolongermanufacturedintheUnitedStates,bacitracinisnoteffective,andpovidoneiodinehasnotbeenstudiedadequately.If
erythromycinointmentisnotavailable,infantsatriskforexposuretoN.gonorrhoeae(especiallythoseborntoamotherwith
untreatedgonococcalinfectionorwhohasreceivednoprenatalcare)canbeadministeredceftriaxone2550mg/kgIVorIM,notto
exceed125mginasingledose.

DiseasesCharacterizedbyVaginalDischarge
Mostwomenwillhaveavaginalinfection,characterizedbydischarge,itching,orodor,duringtheirlifetime.Withtheavailabilityof
complementaryandalternativetherapiesandoverthecountermedicationsforcandidiasis,manysymptomaticwomenseekthese
productsbeforeorinadditiontoanevaluationbyamedicalprovider.
Obtainingamedicalhistoryalonehasbeenshowntobeinsufficientforaccuratediagnosisofvaginitisandcanleadtothe
inappropriateadministrationofmedication.Therefore,acarefulhistory,examination,andlaboratorytestingtodeterminethe
etiologyofvaginalcomplaintsarewarranted.Informationonsexualbehaviorsandpractices,genderofsexpartners,menses,
vaginalhygienepractices(suchasdouching),andothermedicationsshouldbeelicited.Thethreediseasesmostfrequently
associatedwithvaginaldischargeareBV(causedbythereplacementofthevaginalflorabyanovergrowthofanaerobicbacteria
includingPrevotellasp.,Mobiluncussp.,G.vaginalis,Ureaplasma,Mycoplasma,andnumerousfastidiousoruncultivated
anaerobes)trichomoniasis(causedbyT.vaginalis),andcandidiasis(usuallycausedbyCandidaalbicans).Cervicitisalsocan
sometimescauseavaginaldischarge.Althoughvulvovaginalcandidiasis(VVC)usuallyisnottransmittedsexually,itisincludedin
thissectionbecauseitisfrequentlydiagnosedinwomenwhohavevaginalcomplaintsorwhoarebeingevaluatedforSTDs.
Variousdiagnosticmethodsareavailabletoidentifytheetiologyofanabnormalvaginaldischarge.Clinicallaboratorytestingcan
identifythecauseofvaginitisinmostwomenandisdiscussedindetailinthesectionsofthisreportdedicatedtoeachcondition.In
theclinician'soffice,thecauseofvaginalsymptomsmightbedeterminedbypH,apotassiumhydroxide(KOH)test,and
microscopicexaminationoffreshsamplesofthedischarge.ThepHofthevaginalsecretionscanbedeterminedbynarrowrangepH
paperanelevatedpH(i.e.,>4.5)iscommonwithBVortrichomoniasis.BecausepHtestingisnothighlyspecific,dischargeshould
befurtherexaminedmicroscopicallybyfirstdilutingonesampleinonetotwodropsof0.9%normalsalinesolutionononeslideand
asecondsamplein10%KOHsolution(samplesthatemitanamineodorimmediatelyuponapplicationofKOHsuggestBVor
trichomoniasisinfection).Coverslipsarethenplacedontheslides,andtheyareexaminedunderamicroscopeatlowandhigh
power.
ThesalinesolutionspecimenmightyieldmotileT.vaginalis,orcluecells(i.e.,epithelialcellswithbordersobscuredbysmall
bacteria),whicharecharacteristicofBV,whereasthepresenceofWBCswithoutevidenceoftrichomonadsoryeastinthissolution
issuggestiveofcervicitis(seeCervicitis).TheKOHspecimentypicallyisusedtoidentifytheyeastorpseudohyphaeofCandida
species.However,theabsenceoftrichomonadsorpseudohyphaeinKOHsamplesdoesnotruleouttheseinfections,becausethe
sensitivityofmicroscropyisapproximately50%comparedwithNAAT(trichomoniasis)orculture(yeast).
InsettingswherepHpaper,KOH,andmicroscopyarenotavailable,alternativecommerciallyavailablepointofcaretestsorclinical
laboratorytestingcanbeusedtodiagnosevaginitis.Thepresenceofobjectivesignsofvulvarinflammationintheabsenceofvaginal
pathogensafterlaboratorytesting,alongwithaminimalamountofdischarge,suggeststhepossibilityofmechanical,chemical,
allergic,orothernoninfectiousirritationofthevulva.

BacterialVaginosis
BVisapolymicrobialclinicalsyndromeresultingfromreplacementofthenormalhydrogenperoxideproducingLactobacillussp.in
thevaginawithhighconcentrationsofanaerobicbacteria(e.g.,Prevotellasp.andMobiluncussp.),G.vaginalis,Ureaplasma,
Mycoplasma,andnumerousfastidiousoruncultivatedanaerobes.Somewomenexperiencetransientvaginalmicrobialchanges,
whereasothersexperiencethemforalongerintervalsoftime.Amongwomenpresentingforcare,BVisthemostprevalentcauseof
vaginaldischargeormalodorhowever,inanationallyrepresentativesurvey,mostwomenwithBVwereasymptomatic(318).
BVisassociatedwithhavingmultiplemaleorfemalepartners,anewsexpartner,douching,lackofcondomuse,andlackofvaginal
lactobacilliwomenwhohaveneverbeensexuallyactivecanalsobeaffected.Thecauseofthemicrobialalterationthatcharacterizes
BVisnotfullyunderstood,noriswhetherBVresultsfromacquisitionofasexuallytransmittedpathogen.Nonetheless,womenwith
BVareatincreasedriskfortheacquisitionofsomeSTDs(e.g.,HIV,N.gonorrhoeae,C.trachomatis,andHSV2),complications
aftergynecologicsurgery,complicationsofpregnancy,andrecurrenceofBV.Treatmentofmalesexpartnershasnotbeenbeneficial
inpreventingtherecurrenceofBV.

DiagnosticConsiderations
BVcanbediagnosedbytheuseofclinicalcriteria(i.e.,Amsel'sDiagnosticCriteria)(319)orGramstain.AGramstain(considered
thegoldstandardlaboratorymethodfordiagnosingBV)isusedtodeterminetherelativeconcentrationoflactobacilli(i.e.,long
Grampositiverods),GramnegativeandGramvariablerodsandcocci(i.e.,G.vaginalis,Prevotella,Porphyromonas,and
peptostreptococci),andcurvedGramnegativerods(i.e.,Mobiluncus)characteristicofBV.IfaGramstainisnotavailable,clinical
criteriacanbeusedandrequirethreeofthefollowingsymptomsorsigns:
homogeneous,thin,whitedischargethatsmoothlycoatsthevaginalwalls
presenceofcluecellsonmicroscopicexamination
pHofvaginalfluid>4.5or
afishyodorofvaginaldischargebeforeorafteradditionof10%KOH(i.e.,thewhifftest).
DetectionofthreeofthesecriteriahasbeencorrelatedwithresultsbyGramstain(320).Othertests,includingaDNAprobebased
testforhighconcentrationsofG.vaginalis(AffirmVPIII,BectonDickinson,Sparks,Maryland),aprolineaminopeptidasetestcard
(PipActivityTestCard,Quidel,SanDiego,California),andtheOSOMBVBluetesthaveacceptableperformancecharacteristics
comparedwithGramstain.AlthoughacardtestisavailableforthedetectionofelevatedpHandtrimethylamine,ithaslow
sensitivityandspecificityandthereforeisnotrecommended.PCRalsohasbeenusedinresearchsettingsforthedetectionofa
varietyoforganismsassociatedwithBV,butevaluationofitsclinicalutilityisuncertain.Detectionofoneorganismorgroupof
organismsmightbepredictiveofBVbyGramstain(321).However,additionalevaluationsareneededtoconfirmtheseassociations.
CultureofG.vaginalisisnotrecommendedasadiagnostictoolbecauseitisnotspecific.CervicalPaptestshavenoclinicalutility
forthediagnosisofBVbecauseoftheirlowsensitivity.

Treatment
Treatmentisrecommendedforwomenwithsymptoms.Theestablishedbenefitsoftherapyinnonpregnantwomenaretorelieve
vaginalsymptomsandsignsofinfection.OtherpotentialbenefitstotreatmentincludereductionintheriskforacquiringC.
trachomatisorN.gonorrhoeae(322),HIV,andotherviralSTDs.
RecommendedRegimens
Metronidazole500mgorallytwiceadayfor7days*
OR
Metronidazolegel0.75%,onefullapplicator(5g)intravaginally,onceadayfor5days
OR
Clindamycincream2%,onefullapplicator(5g)intravaginallyatbedtimefor7days
*Consumingalcoholshouldbeavoidedduringtreatmentandfor24hoursthereafter.
Clindamycincreamisoilbasedandmightweakenlatexcondomsanddiaphragmsfor5daysafteruse(refertoclindamycin
productlabelingforadditionalinformation).
Providersshouldconsiderpatientpreference,possiblesideeffects,druginteractions,andothercoinfectionswhenselectinga
regimen.Womenshouldbeadvisedtorefrainfromintercourseortousecondomsconsistentlyandcorrectlyduringthetreatment
regimen.Douchingmightincreasetheriskforrelapse,andnodatasupporttheuseofdouchingfortreatmentorreliefofsymptoms.
AlternativeRegimens
Tinidazole2gorallyoncedailyfor3days

OR
Tinidazole1gorallyoncedailyfor5days
OR
Clindamycin300mgorallytwicedailyfor7days
OR
Clindamycinovules100mgintravaginallyonceatbedtimefor3days
Alternativeregimensincludeseveraltinidazoleregimens(323)orclindamycin(oralorintravaginal)(324).Additionalregimens
includemetronidazole(750mgextendedreleasetabletsoncedailyfor7days),orasingledoseofclindamycinintravaginalcream,
althoughdataontheperformanceofthesealternativeregimensarelimited.
SeveralstudieshaveevaluatedtheclinicalandmicrobiologicefficacyofusingintravaginallactobacillusformulationstotreatBVand
restorenormalflora(325327).FurtherresearcheffortstodeterminetheroleoftheseregimensinBVtreatmentandpreventionare
ongoing.

FollowUp
Followupvisitsareunnecessaryifsymptomsresolve.BecauserecurrenceofBViscommon,womenshouldbeadvisedtoreturnfor
evaluationifsymptomsrecur.DetectionofcertainBVassociatedorganismshavebeenassociatedwithantimicrobialresistanceand
mightdetermineriskforsubsequenttreatmentfailure(328333).Limiteddataareavailableregardingoptimalmanagement
strategiesforwomenwithearlytreatmentfailure.Usingadifferenttreatmentregimenmightbeanoptioninpatientswhohavea
recurrencehowever,retreatmentwiththesametopicalregimenisanotheracceptableapproachfortreatingrecurrentBVduring
theearlystagesofinfection(334).Forwomenwithmultiplerecurrencesaftercompletionofarecommendedregimen,
metronidazolegeltwiceweeklyfor46monthshasbeenshowntoreducerecurrences,althoughthisbenefitmightnotpersistwhen
suppressivetherapyisdiscontinued(335).Limiteddatasuggestthatoralnitroimidazolefollowedbyintravaginalboricacidand
suppressivemetronidazolegelforthosewomeninremissionmightbeanoptioninwomenwithrecurrentBV(336).Monthlyoral
metronidazoleadministeredwithfluconazolehasalsobeenevaluatedassuppressivetherapy(337).

ManagementofSexPartners
Theresultsofclinicaltrialsindicatethatawoman'sresponsetotherapyandthelikelihoodofrelapseorrecurrencearenotaffected
bytreatmentofhersexpartner(s).Therefore,routinetreatmentofsexpartnersisnotrecommended.

SpecialConsiderations
AllergyorIntolerancetotheRecommendedTherapy
Intravaginalclindamycincreamispreferredincaseofallergyorintolerancetometronidazoleortinidazole.Intravaginal
metronidazolegelcanbeconsideredforwomenwhodonottoleratesystemicmetronidazole.Intravaginalmetronidazoleshouldnot
beadministeredtowomenallergictometronidazole.
Pregnancy
Treatmentisrecommendedforallpregnantwomenwithsymptoms.AlthoughBVisassociatedwithadversepregnancyoutcomes,
includingprematureruptureofmembranes,pretermlabor,pretermbirth,intraamnioticinfection,andpostpartumendometritis,
theonlyestablishedbenefitoftherapyforBVinpregnantwomenisthereductionofsymptomsandsignsofvaginalinfection.
AdditionalpotentialbenefitsincludereducingtheriskforinfectiouscomplicationsassociatedwithBVduringpregnancyand
reducingtheriskforotherinfections(otherSTDsorHIV).
SeveraltrialshavebeenundertakentodeterminetheefficacyofBVtreatmentamongpregnantwomen.Twotrialsdemonstrated
thatmetronidazolewasefficaciousduringpregnancyusingthe250mgregimen(338,339)however,metronidazoleadministeredat
500mgtwicedailycanbeused.Onetrialinvolvingalimitednumberofparticipantsrevealedthattreatmentwithoral
metronidazole500mgtwicedailywasequallyeffectiveasmetronidazolegel,withcureratesof70%usingAmselcriteriatodefine
cure(340),andarecenttrialdemonstratedacurerateof85%usingGramstaincriteriaafter4weekswithoralclindamycin(341).
Multiplestudiesandmetaanalyseshavenotdemonstratedanassociationbetweenmetronidazoleuseduringpregnancyand
teratogenicormutageniceffectsinnewborns(342,343).Regardlessoftheantimicrobialagentusedtotreatpregnantwomen,oral
therapyispreferredbecauseofthepossibilityofsubclinicaluppergenitaltractinfection.
RecommendedRegimensforPregnantWomen
Metronidazole500mgorallytwiceadayfor7days
OR
Metronidazole250mgorallythreetimesadayfor7days
OR

Clindamycin300mgorallytwiceadayfor7days
TreatmentofasymptomaticBVamongpregnantwomenwhoareathighriskforpretermdelivery(i.e.,thosewithaprevious
pretermbirth)hasbeenevaluatedbyseveralstudies,whichhaveyieldedmixedresults.Seventrialshaveevaluatedtreatmentof
pregnantwomenwithasymptomaticBVathighriskforpretermdeliveryoneshowedharm(344),twoshowednobenefit
(345,346),andfourdemonstratedbenefit(338,339,347,348).Therefore,evidenceisinsufficienttoassesstheimpactofscreening
forBVinpregnantwomenathighriskforpretermdelivery(85).
Similarly,dataareinconsistentregardingwhetherthetreatmentofasymptomaticpregnantwomenwithBVwhoareatlowriskfor
pretermdeliveryreducesadverseoutcomesofpregnancy.AlthoughUSPSTFrecommendsagainstscreeningthesewomen(85),one
trialdemonstrateda40%reductioninspontaneouspretermbirthamongwomenusingoralclindamycinduringweeks1322of
gestation(348).Severaladditionaltrialshaveshownthatintravaginalclindamycingivenatanaveragegestationoflaterthan20
weeksdidnotreducepretermbirth,andinthreeofthesetrials,intravaginalclindamycincreamadministeredat1632weeks'
gestationwasassociatedwithanincreaseinadverseevents(e.g.,lowbirthweightandneonatalinfections)innewborns(346,349
351).Providersshouldbeawarethatintravaginalclindamycincreammightbeassociatedwithadverseoutcomesifusedinthe
latterhalfofpregnancy.
HIVInfection
BVappearstorecurwithhigherfrequencyinHIVpositivewomen(352).PatientswhohaveBVandalsoareinfectedwithHIV
shouldreceivethesametreatmentregimenasthosewhoareHIVnegative.

Trichomoniasis
TrichomoniasisiscausedbytheprotozoanT.vaginalis.SomemenwhoareinfectedwithT.vaginalismightnothavesymptoms
othershaveNGU.Somewomenhavesymptomscharacterizedbyadiffuse,malodorous,yellowgreenvaginaldischargewithvulvar
irritation.However,manywomenhaveminimalornosymptoms.Becauseofthehighprevalenceoftrichomoniasisinclinicaland
nonclinicalsettings(64,92,353,354),testingforT.vaginalisshouldbeperformedinwomenseekingcareforvaginaldischarge.
ScreeningforT.vaginalisinwomencanbeconsideredinthoseathighriskforinfection(i.e.,womenwhohavenewormultiple
partners,haveahistoryofSTDs,exchangesexforpayment,anduseinjectiondrugs).
Diagnosisofvaginaltrichomoniasisisusuallyperformedbymicroscopyofvaginalsecretions,butthismethodhasasensitivityof
onlyapproximately60%70%andrequiresimmediateevaluationofwetpreparationslideforoptimalresults.FDAclearedtestsfor
trichomoniasisinwomenincludeOSOMTrichomonasRapidTest(GenzymeDiagnostics,Cambridge,Massachusetts),an
immunochromatographiccapillaryflowdipsticktechnology,andtheAffirmVPIII(BectonDickenson,SanJose,California),a
nucleicacidprobetestthatevaluatesforT.vaginalis,G.vaginalis,andC.albicans.Eachofthesetests,whichareperformedon
vaginalsecretions,haveasensitivityof>83%andaspecificityof>97%.Bothtestsareconsideredpointofcarediagnostics.The
resultsoftheOSOMTrichomonasRapidTestareavailableinapproximately10minutes,whereasresultsoftheAffirmVPIIIare
availablewithin45minutes.Althoughtheseteststendtobemoresensitivethanthoserequiringvaginalwetpreparation,false
positivesmightoccur,especiallyinpopulationswithalowprevalenceofdisease.
Cultureisanothersensitiveandhighlyspecificcommerciallyavailablemethodofdiagnosis.Amongwomeninwhomtrichomoniasis
issuspectedbutnotconfirmedbymicroscopy,vaginalsecretionsshouldbeculturedforT.vaginalis.WhilethesensitivityofaPap
testforT.vaginalisdiagnosisispoor,useofaliquidbasedtestinghasdemonstratedenhancedsensitivityhowever,falsepositive
testscanoccur,andconfirmatorytestingmightbeneededinsomecircumstances(355).AnFDAclearedPCRassayfordetectionof
gonorrheaandchlamydialinfection(Amplicor,manufacturedbyRocheDiagnosticCorp.)hasbeenmodifiedforT.vaginalis
detectioninvaginalorendocervicalswabsandinurinefromwomenandmensensitivityrangesfrom88%97%andspecificity
from98%99%(356).APTIMAT.vaginalisAnalyteSpecificReagents(ASRmanufacturedbyGenProbe,Inc.)alsocandetectT.
vaginalisRNAbytranscriptionmediatedamplificationusingthesameinstrumentationplatformsavailablefortheFDAcleared
APTIMACombo2assayfordiagnosisofgonorrheaandchlamydialinfectionpublishedvalidationstudiesofT.vaginalisASRfound
sensitivityrangingfrom74%98%andspecificityof87%98%(357359).LaboratoriesthatusetheGenProbeAPTIMACombo2
testfordetectionofN.gonorrhoeaeandC.trachomatiscanconsideraddingtheT.vaginalisASRtotheirtestingarmentarium,as
longasthenecessaryCLIAverificationstudieshavebeenconducted.
Inmen,wetpreparationisnotasensitivetest,andnoapprovedpointofcaretestsareavailable.Culturetestingofurethralswab,
urine,orsemenisonediagnosticoptionhowever,NAATs(i.e.,PCRortranscriptionmediatedamplification[TMA])havesuperior
sensitivityforT.vaginalisdiagnosisinmen(356,359).T.vaginalishasnotbeenfoundtoinfectoralsites,andrectalprevalence
appearslowinMSM(360).Therefore,oralandrectaltestingforT.vaginalisisnotrecommended.
RecommendedRegimens
Metronidazole2gorallyinasingledose
OR
Tinidazole2gorallyinasingledose
AlternativeRegimen

Metronidazole500mgorallytwiceadayfor7days*
*Patientsshouldbeadvisedtoavoidconsumingalcoholduringtreatmentwithmetronidazoleortinidazole.Abstinencefrom
alcoholuseshouldcontinuefor24hoursaftercompletionofmetronidazoleor72hoursaftercompletionoftinidazole.
Thenitroimidazolescomprisetheonlyclassofdrugsusefulfortheoralorparenteraltherapyoftrichomoniasis.Ofthesedrugs,
metronidazoleandtinidazoleareavailableintheUnitedStatesandareclearedbytheFDAforthetreatmentoftrichomoniasis.In
randomizedclinicaltrials,therecommendedmetronidazoleregimenshaveresultedincureratesofapproximately90%95%,and
therecommendedtinidazoleregimenhasresultedincureratesofapproximately86%100%.Theappropriatetreatmentofsex
partnersmightincreasethesereportedrates.Randomizedcontrolledtrialscomparingsingle2gdosesofmetronidazoleand
tinidazolesuggestthattinidazoleisequivalentorsuperiortometronidazoleinachievingparasitologiccureandresolutionof
symptoms(361).Treatmentofpatientsandsexpartnersresultsinreliefofsymptoms,microbiologiccure,andreductionof
transmission.
Metronidazolegelisconsiderablylessefficaciousforthetreatmentoftrichomoniasis(<50%)thanoralpreparationsof
metronidazole.Topicallyappliedantimicrobials(e.g.,metronidazolegel)areunlikelytoachievetherapeuticlevelsintheurethraor
perivaginalglandstherefore,useofthisgelisnotrecommended.Severalothertopicallyappliedantimicrobialsoccasionallyhave
beenusedfortreatmentoftrichomoniasishowever,thesepreparationslikelyarenomoreeffectivethanmetronidazolegel.

FollowUp
Becauseofthehighrateofreinfectionamongpatientsinwhomtrichomoniasiswasdiagnosed(17%werereinfectedwithin3months
inonestudy),rescreeningforT.vaginalisat3monthsfollowinginitialinfectioncanbeconsideredforsexuallyactivewomenwith
trichomoniasisthebenefitofthisapproach,however,hasnotbeenfullyevaluated(64).Nodatasupportrescreeninginmen
diagnosedwithT.vaginalis.WhilemostrecurrentT.vaginalisinfectionsarethoughttoresultfromhavingsexwithanuntreated
partner(i.e.,reinfection),somerecurrentcasescanbeattributedtodiminishedsusceptibilitytometronidazole.Lowlevel
metronidazoleresistancehasbeenidentifiedin2%5%ofcasesofvaginaltrichomoniasis(362,363),buthighlevelresistanceonly
rarelyoccurs.Fortunately,infectionscausedbymostoftheseorganismsrespondtotinidazoleorhigherdosesofmetronidazole.
Tinidazolehasalongerserumhalflifeandreacheshigherlevelsingenitourinarytissuesthanmetronidazole.Inaddition,manyT.
vaginalisisolateshavelowerminimallethalconcentrations(MLCs)totinidazolethanmetronidazole.
Iftreatmentfailureoccurswithmetronidazole2gsingledoseandreinfectionisexcluded,thepatientcanbetreatedwith
metronidazole500mgorallytwicedailyfor7days.Forpatientsfailingthisregimen,treatmentwithtinidazoleormetronidazoleat2
gorallyfor5daysshouldbeconsidered.Ifthesetherapiesarenoteffective,furthermanagementshouldbediscussedwitha
specialist.TheconsultationshouldideallyincludedeterminationofthesusceptibilityofT.vaginalistometronidazoleand
tinidazole.ConsultationandT.vaginalissusceptibilitytestingisavailablefromCDC(telephone:4047184141website:
http://www.cdc.gov/std).

ManagementofSexPartners
SexpartnersofpatientswithT.vaginalisshouldbetreated.Patientsshouldbeinstructedtoabstainfromsexuntiltheyandtheir
sexpartnersarecured(i.e.,whentherapyhasbeencompletedandpatientandpartner[s]areasymptomatic).Existingdatasuggest
thatpatientdeliveredpartnertherapymighthavearoleinpartnermanagementfortrichomoniasishowever,noonepartner
managementinterventionhasshownsuperiorityoveranotherinreducingreinfectionrates(72,73).Althoughnodataareavailable
toguidetreatmentofthemalepartnersofwomenwithnitroimidazoletreatmentfailure,onthebasisofexpertopinion,male
partnersshouldbeevaluatedandtreatedwitheithertinidazoleinasingledoseof2gorallyormetronidazoletwiceadayat500mg
orallyfor7days.

SpecialConsiderations
Allergy,Intolerance,andAdverseReactions
Metronidazoleandtinidazolearebothnitroimidazoles.Patientswithanimmediatetypeallergytoanitroimidazolecanbemanaged
bymetronidazoledesensitizationinconsultationwithaspecialist(364366).Topicaltherapywithdrugsotherthannitroimidazoles
canbeattempted,butcureratesarelow(<50%).
Pregnancy
Vaginaltrichomoniasishasbeenassociatedwithadversepregnancyoutcomes,particularlyprematureruptureofmembranes,
pretermdelivery,andlowbirthweight.However,metronidazoletreatmenthasnotbeenshowntoreduceperinatalmorbidity.
Althoughsometrialssuggestthepossibilityofincreasedprematurityorlowbirthweightaftermetronidazoletreatment,limitations
ofthestudiespreventdefinitiveconclusionsregardingrisksfortreatment(367,368).TreatmentofT.vaginalismightrelieve
symptomsofvaginaldischargeinpregnantwomenandmightpreventrespiratoryorgenitalinfectionofthenewbornandfurther
sexualtransmission.Cliniciansshouldcounselpatientsregardingthepotentialrisksandbenefitsoftreatmentandcommunicatethe
optionoftherapydeferralinasymptomaticpregnantwomenuntilafter37weeks'gestation.Allsymptomaticpregnantwomen
shouldnotonlybeconsideredfortreatmentregardlessofpregnancystage,butbeprovidedcarefulcounselingregardingcondom
useandthecontinuedriskofsexualtransmission.
Womencanbetreatedwith2gmetronidazoleinasingledoseatanystageofpregnancy.Multiplestudiesandmetaanalyseshave
notdemonstratedanassociationbetweenmetronidazoleuseduringpregnancyandteratogenicormutageniceffectsininfants

(342,343,369).Thesafetyoftinidazoleinpregnantwomen,however,hasnotbeenwellevaluated.
Inlactatingwomenwhoareadministeredmetronidazole,withholdingbreastfeedingduringtreatmentandfor1224hoursafterthe
lastdosewillreducetheexposureoftheinfanttometronidazole.Forwomentreatedwithtinidazole,interruptionofbreastfeedingis
recommendedduringtreatmentandfor3daysafterthelastdose.
HIVInfection
ThereisincreasingevidenceforepidemiologicandbiologicinteractionbetweenHIVandT.vaginalis(370375).T.vaginalis
infectioninHIVinfectedwomenmightenhanceHIVtransmissionbyincreasinggenitalsheddingofthevirus(376,377),and
treatmentforT.vaginalishasbeenshowntoreduceHIVshedding(376,377).ForsexuallyactivewomenwhoareHIVpositive,
screeningfortrichomoniasisatentryintocarewithsubsequentscreeningperformedatleastannuallyisrecommendedbasedonthe
reportedprevalenceofT.vaginalis,theeffectoftreatmentatreducingvaginalHIVshedding,andthepotentialcomplicationsof
uppergenitaltractinfectionsamongwomenwhoareleftuntreated(130,370375).Rescreening3monthsaftercompletionof
therapyshouldbeconsideredamongHIVpositivewomenwithtrichomoniasis,arecommendationbasedonthehighproportionof
recurrentorpersistentinfectionandtheassociationbetweenHIVandT.vaginalisinfection(64,374,378).
ArecentrandomizedclinicaltrialinvolvingwomencoinfectedwithtrichomoniasisandHIVdemonstratedthatasingledoseof
metronidazole2gmorallywasnotaseffectiveas500mgtwicedailyfor7days(379).Therefore,amultidosetreatmentregimenfor
T.vaginaliscanbeconsideredinHIVinfectedwomen.

VulvovaginalCandidiasis
VVCusuallyiscausedbyC.albicans,butoccasionallyiscausedbyotherCandidasp.oryeasts.TypicalsymptomsofVVCinclude
pruritus,vaginalsoreness,dyspareunia,externaldysuria,andabnormalvaginaldischarge.Noneofthesesymptomsisspecificfor
VVC.Anestimated75%ofwomenwillhaveatleastoneepisodeofVVC,and40%45%willhavetwoormoreepisodeswithintheir
lifetime.Onthebasisofclinicalpresentation,microbiology,hostfactors,andresponsetotherapy,VVCcanbeclassifiedaseither
uncomplicatedorcomplicated(Box3).Approximately10%20%ofwomenwillhavecomplicatedVVCthatnecessitatesdiagnostic
andtherapeuticconsiderations.

UncomplicatedVVC
DiagnosticConsiderations
AdiagnosisofCandidavaginitisissuggestedclinicallybythepresenceofexternaldysuriaandvulvarpruritus,pain,swelling,and
redness.Signsincludevulvaredema,fissures,excoriations,orthick,curdyvaginaldischarge.Thediagnosiscanbemadeinawoman
whohassignsandsymptomsofvaginitiswheneither1)awetpreparation(saline,10%KOH)orGramstainofvaginaldischarge
demonstratesyeasts,hyphae,orpseudohyphaeor2)acultureorothertestyieldsayeastspecies.Candidavaginitisisassociated
withanormalvaginalpH(<4.5),andtherefore,pHtestingisnotausefuldiagnostictool.Useof10%KOHinwetpreparations
improvesthevisualizationofyeastandmyceliabydisruptingcellularmaterialthatmightobscuretheyeastorpseudohyphae.
ExaminationofawetmountwithKOHpreparationshouldbeperformedforallwomenwithsymptomsorsignsofVVC,andwomen
withapositiveresultshouldreceivetreatment.Forwomenwithnegativewetmountswhoaresymptomatic,vaginalculturesfor
Candidashouldbeconsidered.IfthewetmountisnegativeandCandidaculturescannotbedone,empirictreatmentcanbe
consideredforsymptomaticwomenwithanysignofVVConexamination.IdentifyingCandidabycultureintheabsenceof
symptomsorsignsisnotanindicationfortreatment,becauseapproximately10%20%ofwomenharborCandidasp.andother
yeastsinthevagina.VVCcanoccurconcomitantlywithSTDs.MosthealthywomenwithuncomplicatedVVChavenoidentifiable
precipitatingfactors.
Treatment
Shortcoursetopicalformulations(i.e.,singledoseandregimensof13days)effectivelytreatuncomplicatedVVC.Thetopically
appliedazoledrugsaremoreeffectivethannystatin.Treatmentwithazolesresultsinreliefofsymptomsandnegativeculturesin
80%90%ofpatientswhocompletetherapy.
RecommendedRegimens
OvertheCounterIntravaginalAgents:
Butoconazole2%cream5gintravaginallyfor3days
OR
Clotrimazole1%cream5gintravaginallyfor714days
OR
Clotrimazole2%cream5gintravaginallyfor3days
OR
Miconazole2%cream5gintravaginallyfor7days

OR
Miconazole4%cream5gintravaginallyfor3days
OR
Miconazole100mgvaginalsuppository,onesuppositoryfor7days
OR
Miconazole200mgvaginalsuppository,onesuppositoryfor3days
OR
Miconazole1,200mgvaginalsuppository,onesuppositoryfor1day
OR
Tioconazole6.5%ointment5gintravaginallyinasingleapplication
PrescriptionIntravaginalAgents:
Butoconazole2%cream(singledosebioadhesiveproduct),5gintravaginallyfor1day
OR
Nystatin100,000unitvaginaltablet,onetabletfor14days
OR
Terconazole0.4%cream5gintravaginallyfor7days
OR
Terconazole0.8%cream5gintravaginallyfor3days
OR
Terconazole80mgvaginalsuppository,onesuppositoryfor3days
OralAgent:
Fluconazole150mgoraltablet,onetabletinsingledose
Thecreamsandsuppositoriesinthisregimenareoilbasedandmightweakenlatexcondomsanddiaphragms.Patientsand
providersshouldrefertocondomproductlabelingforfurtherinformation.
Intravaginalpreparationsofbutaconazole,clotrimazole,miconazole,andtioconazoleareavailableoverthecounter(OTC).Women
whoseconditionhaspreviouslybeendiagnosedwithVVCarenotnecessarilymorecapableofdiagnosingthemselvestherefore,any
womanwhosesymptomspersistafterusinganOTCpreparationorwhohasarecurrenceofsymptomswithin2monthsshouldbe
evaluatedwithofficebasedtesting.UnnecessaryorinappropriateuseofOTCpreparationsiscommonandcanleadtoadelayinthe
treatmentofothervulvovaginitisetiologies,whichcanresultinadverseclinicaloutcomes.
FollowUp
Patientsshouldbeinstructedtoreturnforfollowupvisitsonlyifsymptomspersistorrecurwithin2monthsofonsetoftheinitial
symptoms.
ManagementofSexPartners
VVCisnotusuallyacquiredthroughsexualintercoursenodatasupportthetreatmentofsexpartners.Aminorityofmalesex
partnersmighthavebalanitis,whichischaracterizedbyerythematousareasontheglansofthepenisinconjunctionwithpruritusor
irritation.Thesemenbenefitfromtreatmentwithtopicalantifungalagentstorelievesymptoms.
SpecialConsiderations
Allergy,Intolerance,andAdverseReactions
Topicalagentsusuallycausenosystemicsideeffects,althoughlocalburningorirritationmightoccur.Oralagentsoccasionally
causenausea,abdominalpain,andheadache.Therapywiththeoralazoleshasbeenassociatedrarelywithabnormalelevationsof
liverenzymes.Clinicallyimportantinteractionscanoccurwhentheseoralagentsareadministeredwithotherdrugs,including
astemizole,calciumchannelantagonists,cisapride,cyclosporinA,oralhypoglycemicagents,phenytoin,proteaseinhibitors,
tacrolimus,terfenadine,theophylline,trimetrexate,rifampin,andwarfarin.

ComplicatedVVC

RecurrentVulvovaginalCandidiasis(RVVC)
RVVC,usuallydefinedasfourormoreepisodesofsymptomaticVVCin1year,affectsasmallpercentageofwomen(<5%).The
pathogenesisofRVVCispoorlyunderstood,andmostwomenwithRVVChavenoapparentpredisposingorunderlyingconditions.
VaginalculturesshouldbeobtainedfrompatientswithRVVCtoconfirmtheclinicaldiagnosisandtoidentifyunusualspecies
(includingnonalbicansspecies),particularlyCandidaglabrata.AlthoughC.glabrataandothernonalbicansCandidiaspeciesare
observedin10%20%ofpatientswithRVVC,C.glabratadoesnotformpseudohyphaeorhyphaeandisnoteasilyrecognizedon
microscopy.ConventionalantimycotictherapiesarenotaseffectiveagainstthesespeciesastheyareagainstC.albicans.
Treatment
EachindividualepisodeofRVVCcausedbyC.albicansrespondswelltoshortdurationoralortopicalazoletherapy.However,to
maintainclinicalandmycologiccontrol,somespecialistsrecommendalongerdurationofinitialtherapy(e.g.,714daysoftopical
therapyora100mg,150mg,or200mgoraldoseoffluconazoleeverythirddayforatotalof3doses[day1,4,and7])toattempt
mycologicremissionbeforeinitiatingamaintenanceantifungalregimen.
MaintenanceRegimens
Oralfluconazole(i.e.,100mg,150mg,or200mgdose)weeklyfor6monthsisthefirstlineoftreatment.Ifthisregimenisnot
feasible,topicaltreatmentsusedintermittentlyasamaintenanceregimencanbeconsidered.
SuppressivemaintenanceantifungaltherapiesareeffectiveinreducingRVVC.However,30%50%ofwomenwillhaverecurrent
diseaseaftermaintenancetherapyisdiscontinued.Routinetreatmentofsexpartnersiscontroversial.C.albicansazoleresistanceis
rareinvaginalisolates,andsusceptibilitytestingisusuallynotwarrantedforindividualtreatmentguidance.
SevereVVC
Severevulvovaginitis(i.e.,extensivevulvarerythema,edema,excoriation,andfissureformation)isassociatedwithlowerclinical
responseratesinpatientstreatedwithshortcoursesoftopicalororaltherapy.Either714daysoftopicalazoleor150mgof
fluconazoleintwosequentialdoses(seconddose72hoursafterinitialdose)isrecommended.
NonalbicansVVC
TheoptimaltreatmentofnonalbicansVVCremainsunknown.Optionsincludelongerdurationoftherapy(714days)witha
nonfluconazoleazoledrug(oralortopical)asfirstlinetherapy.Ifrecurrenceoccurs,600mgofboricacidinagelatincapsuleis
recommended,administeredvaginallyoncedailyfor2weeks.Thisregimenhasclinicalandmycologiceradicationratesof
approximately70%(380).Ifsymptomsrecur,referraltoaspecialistisadvised.

SpecialConsiderations
CompromisedHost
Womenwithunderlyingdebilitatingmedicalconditions(e.g.,thosewithuncontrolleddiabetesorthosereceivingcorticosteroid
treatment)donotrespondaswelltoshorttermtherapies.Effortstocorrectmodifiableconditionsshouldbemade,andmore
prolonged(i.e.,714days)conventionalantimycotictreatmentisnecessary.
Pregnancy
VVCfrequentlyoccursduringpregnancy.Onlytopicalazoletherapies,appliedfor7days,arerecommendedforuseamongpregnant
women.
HIVInfection
TheincidenceofVVCinHIVinfectedwomenisunknown.VaginalCandidacolonizationratesamongHIVinfectedwomenare
higherthanamongthoseforseronegativewomenwithsimilardemographiccharacteristicsandhighriskbehaviors,andthe
colonizationratescorrelatewithincreasingseverityofimmunosuppression.SymptomaticVVCismorefrequentinseropositive
womenandsimilarlycorrelateswithseverityofimmunodeficiency.Inaddition,amongHIVinfectedwomen,systemicazole
exposureisassociatedwiththeisolationofnonalbicansCandidaspeciesfromthevagina.
Onthebasisofavailabledata,therapyforVVCinHIVinfectedwomenshouldnotdifferfromthatforseronegativewomen.
Althoughlongtermprophylactictherapywithfluconazoleatadoseof200mgweeklyhasbeeneffectiveinreducingC.albicans
colonizationandsymptomaticVVC(381),thisregimenisnotrecommendedforroutineprimaryprophylaxisinHIVinfectedwomen
intheabsenceofrecurrentVVC(129).GiventhefrequencyatwhichRVVCoccursintheimmmunocompetenthealthypopulation,
theoccurrenceofRVVCshouldnotbeconsideredanindicationforHIVtestingamongwomenpreviouslytestingHIVnegative.
AlthoughVVCisassociatedwithincreasedHIVseroconversioninHIVnegativewomenandincreasedHIVcervicovaginallevelsin
HIVpositivewomen,theeffectoftreatmentforVVConHIVacquisitionandtransmissionremainsunknown.

PelvicInflammatoryDisease
PIDcomprisesaspectrumofinflammatorydisordersoftheupperfemalegenitaltract,includinganycombinationofendometritis,
salpingitis,tuboovarianabscess,andpelvicperitonitis(382).Sexuallytransmittedorganisms,especiallyN.gonorrhoeaeandC.
trachomatis,areimplicatedinmanycaseshowever,microorganismsthatcomprisethevaginalflora(e.g.,anaerobes,G.vaginalis,

Haemophilusinfluenzae,entericGramnegativerods,andStreptococcusagalactiae)alsohavebeenassociatedwithPID(383).In
addition,cytomegalovirus(CMV),M.hominis,U.urealyticum,andM.genitaliummightbeassociatedwithsomecasesofPID
(263,384386).AllwomenwhohaveacutePIDshouldbetestedforN.gonorrhoeaeandC.trachomatisandshouldbescreenedfor
HIVinfection.

DiagnosticConsiderations
AcutePIDisdifficulttodiagnosebecauseofthewidevariationinthesymptomsandsigns.ManywomenwithPIDhavesubtleor
mildsymptoms.Delayindiagnosisandtreatmentprobablycontributestoinflammatorysequelaeintheupperreproductivetract.
Laparoscopycanbeusedtoobtainamoreaccuratediagnosisofsalpingitisandamorecompletebacteriologicdiagnosis.However,
thisdiagnostictoolfrequentlyisnotreadilyavailable,anditsuseisnoteasytojustifywhensymptomsaremildorvague.Moreover,
laparoscopywillnotdetectendometritisandmightnotdetectsubtleinflammationofthefallopiantubes.Consequently,adiagnosis
ofPIDusuallyisbasedonclinicalfindings.
TheclinicaldiagnosisofacutePIDisimprecise(387,388).DataindicatethataclinicaldiagnosisofsymptomaticPIDhasapositive
predictivevalue(PPV)forsalpingitisof65%90%comparedwithlaparoscopy.ThePPVofaclinicaldiagnosisofacutePIDdepends
ontheepidemiologiccharacteristicsofthepopulation,withhigherPPVsamongsexuallyactiveyoungwomen(particularly
adolescents),patientsattendingSTDclinics,andthosewholiveinothersettingswheretheratesofgonorrheaorchlamydiaare
high.RegardlesssofPPV,however,inallsettings,nosinglehistorical,physical,orlaboratoryfindingisbothsensitiveandspecific
forthediagnosisofacutePID.Combinationsofdiagnosticfindingsthatimproveeithersensitivity(i.e.,detectmorewomenwho
havePID)orspecificity(i.e.,excludemorewomenwhodonothavePID)dosoonlyattheexpenseoftheother.Forexample,
requiringtwoormorefindingsexcludesmorewomenwhodonothavePIDbutalsoreducesthenumberofwomenwithPIDwho
areidentified.
ManyepisodesofPIDgounrecognized.Althoughsomecasesareasymptomatic,othersarenotdiagnosedbecausethepatientorthe
healthcareproviderfailstorecognizetheimplicationsofmildornonspecificsymptomsorsigns(e.g.,abnormalbleeding,
dyspareunia,andvaginaldischarge).Becauseofthedifficultyofdiagnosisandthepotentialfordamagetothereproductivehealthof
women(evenbyapparentlymildorsubclinicalPID),healthcareprovidersshouldmaintainalowthresholdforthediagnosisofPID
(382).
TheoptimaltreatmentregimenandlongtermoutcomeofearlytreatmentofwomenwithasymptomaticorsubclinicalPIDare
unknown.ThefollowingrecommendationsfordiagnosingPIDareintendedtohelphealthcareprovidersrecognizewhenPID
shouldbesuspectedandwhentheyneedtoobtainadditionalinformationtoincreasediagnosticcertainty.Diagnosisand
managementofothercommoncausesoflowerabdominalpain(e.g.,ectopicpregnancy,acuteappendicitis,andfunctionalpain)are
unlikelytobeimpairedbyinitiatingempiricantimicrobialtherapyforPID.
EmpirictreatmentforPIDshouldbeinitiatedinsexuallyactiveyoungwomenandotherwomenatriskforSTDsiftheyare
experiencingpelvicorlowerabdominalpain,ifnocausefortheillnessotherthanPIDcanbeidentified,andifoneormoreofthe
followingminimumcriteriaarepresentonpelvicexamination:
cervicalmotiontenderness
or
uterinetenderness
or
adnexaltenderness.
Therequirementthatallthreeminimumcriteriabepresentbeforetheinitiationofempirictreatmentcouldresultininsufficient
sensitivityforthediagnosisofPID.Thepresenceofsignsoflowergenitaltractinflammation(predominanceofleukocytesin
vaginalsecretions,cervicalexudates,orcervicalfriability),inadditiontooneofthethreeminimumcriteria,increasesthespecificity
ofthediagnosis.Upondecidingwhethertoinitiateempirictreatment,cliniciansshouldalsoconsidertheriskprofileofthepatient
forSTDs.
MoreelaboratediagnosticevaluationfrequentlyisneededbecauseincorrectdiagnosisandmanagementofPIDmightcause
unnecessarymorbidity.Oneormoreofthefollowingadditionalcriteriacanbeusedtoenhancethespecificityoftheminimum
criteriaandsupportadiagnosisofPID:
oraltemperature>101F(>38.3C)
abnormalcervicalorvaginalmucopurulentdischarge
presenceofabundantnumbersofWBConsalinemicroscopyofvaginalfluid
elevatederythrocytesedimentationrate
elevatedCreactiveproteinand
laboratorydocumentationofcervicalinfectionwithN.gonorrhoeaeorC.trachomatis.
MostwomenwithPIDhaveeithermucopurulentcervicaldischargeorevidenceofWBCsonamicroscopicevaluationofasaline

preparationofvaginalfluid(i.e.,wetprep).IfthecervicaldischargeappearsnormalandnoWBCsareobservedonthewetprepof
vaginalfluid,thediagnosisofPIDisunlikely,andalternativecausesofpainshouldbeconsidered.Awetprepofvaginalfluidoffers
theabilitytodetectthepresenceofconcomitantinfections(e.g.,BVandtrichomoniasis).
ThemostspecificcriteriafordiagnosingPIDinclude:
endometrialbiopsywithhistopathologicevidenceofendometritis
transvaginalsonographyormagneticresonanceimagingtechniquesshowingthickened,fluidfilledtubeswithorwithoutfree
pelvicfluidortuboovariancomplex,orDopplerstudiessuggestingpelvicinfection(e.g.,tubalhyperemia)or
laparoscopicabnormalitiesconsistentwithPID.
Adiagnosticevaluationthatincludessomeofthesemoreextensiveproceduresmightbewarrantedinsomecases.Endometrial
biopsyiswarrantedinwomenundergoinglaparoscopywhodonothavevisualevidenceofsalpingitis,becauseendometritisisthe
onlysignofPIDforsomewomen.

Treatment
PIDtreatmentregimensmustprovideempiric,broadspectrumcoverageoflikelypathogens.Severalantimicrobialregimenshave
beeneffectiveinachievingclinicalandmicrobiologiccureinrandomizedclinicaltrialswithshorttermfollowup.However,onlya
limitednumberofinvestigationshaveassessedandcomparedtheseregimenswithregardtoeliminationofinfectioninthe
endometriumandfallopiantubesordeterminedtheincidenceoflongtermcomplications(e.g.,tubalinfertilityandectopic
pregnancy)afterantimicrobialregimens(389391).
AllregimensusedtotreatPIDshouldalsobeeffectiveagainstN.gonorrhoeaeandC.trachomatisbecausenegativeendocervical
screeningfortheseorganismsdoesnotruleoutupperreproductivetractinfection.Theneedtoeradicateanaerobesfromwomen
whohavePIDhasnotbeendetermineddefinitively.Anaerobicbacteriahavebeenisolatedfromtheupperreproductivetractof
womenwhohavePID,anddatafrominvitrostudieshaverevealedthatsomeanaerobes(e.g.,Bacteroidesfragilis)cancausetubal
andepithelialdestruction.BValsoispresentinmanywomenwhohavePID(383,391).Untiltreatmentregimensthatdonot
adequatelycoverthesemicrobeshavebeendemonstratedtopreventlongtermsequelae(e.g.,infertilityandectopicpregnancy)as
successfullyastheregimensthatareeffectiveagainstthesemicrobes,theuseofregimenswithanaerobicactivityshouldbe
considered.Treatmentshouldbeinitiatedassoonasthepresumptivediagnosishasbeenmadebecausepreventionoflongterm
sequelaeisdependentonearlyadministrationofappropriateantibiotics.Whenselectingatreatmentregimen,healthcareproviders
shouldconsideravailability,cost,patientacceptance,andantimicrobialsusceptibility(392).
InwomenwithPIDofmildormoderateclinicalseverity,outpatienttherapyyieldsshortandlongtermclinicaloutcomessimilarto
inpatienttherapy.Thedecisionofwhetherhospitalizationisnecessaryshouldbebasedonthejudgmentoftheproviderand
whetherthepatientmeetsanyofthefollowingsuggestedcriteria:
surgicalemergencies(e.g.,appendicitis)cannotbeexcluded
thepatientispregnant
thepatientdoesnotrespondclinicallytooralantimicrobialtherapy
thepatientisunabletofollowortolerateanoutpatientoralregimen
thepatienthassevereillness,nauseaandvomiting,orhighfeveror
thepatienthasatuboovarianabscess.
NoevidenceisavailabletosuggestthatadolescentsbenefitfromhospitalizationfortreatmentofPID.Thedecisiontohospitalize
adolescentswithacutePIDshouldbebasedonthesamecriteriausedforolderwomen.Youngerwomenwithmildtomoderate
acutePIDhavesimilaroutcomeswitheitheroutpatientorinpatienttherapy,andclinicalresponsetooutpatienttreatmentissimilar
amongyoungerandolderwomen.

ParenteralTreatment
ForwomenwithPIDofmildormoderateseverity,parenteralandoraltherapiesappeartohavesimilarclinicalefficacy.Many
randomizedtrialshavedemonstratedtheefficacyofbothparenteralandoralregimens(390,391,393).Clinicalexperienceshould
guidedecisionsregardingtransitiontooraltherapy,whichusuallycanbeinitiatedwithin2448hoursofclinicalimprovement.In
womenwithtuboovarianabscesses,atleast24hoursofdirectinpatientobservationisrecommended.
RecommendedParenteralRegimenA
Cefotetan2gIVevery12hours
OR
Cefoxitin2gIVevery6hours

PLUS
Doxycycline100mgorallyorIVevery12hours
Becauseofthepainassociatedwithintravenousinfusion,doxycyclineshouldbeadministeredorallywhenpossible.OralandIV
administrationofdoxycyclineprovidesimilarbioavailability.
Parenteraltherapycanbediscontinued24hoursafterclinicalimprovement,butoraltherapywithdoxycycline(100mgtwiceaday)
shouldcontinuetocomplete14daysoftherapy.Whentuboovarianabscessispresent,clindamycinormetronidazolewith
doxycyclinecanbeusedforcontinuedtherapyratherthandoxycyclinealonebecausethisregimenprovidesmoreeffectiveanaerobic
coverage.
Limiteddataareavailabletosupporttheuseofothersecondorthirdgenerationcephalosporins(e.g.,ceftizoxime,cefotaxime,and
ceftriaxone),whichalsomightbeeffectivetherapyforPIDandcouldpotentiallyreplacecefotetanorcefoxitin.However,these
cephalosporinsarelessactivethancefotetanorcefoxitinagainstanaerobicbacteria.
RecommendedParenteralRegimenB
Clindamycin900mgIVevery8hours
PLUS
GentamicinloadingdoseIVorIM(2mg/kgofbodyweight),followedbyamaintenancedose(1.5mg/kg)every8hours.Single
dailydosing(35mg/kg)canbesubstituted.
AlthoughuseofasingledailydoseofgentamicinhasnotbeenevaluatedforthetreatmentofPID,itisefficaciousinanalogous
situations.Parenteraltherapycanbediscontinued24hoursafterclinicalimprovementongoingoraltherapyshouldconsistof
doxycycline100mgorallytwiceaday,orclindamycin450mgorallyfourtimesadaytocompleteatotalof14daysoftherapy.When
tuboovarianabscessispresent,clindamycinshouldbecontinuedratherthandoxycycline,becauseclindamycinprovidesmore
effectiveanaerobiccoverage.
AlternativeParenteralRegimens
Limiteddataareavailabletosupporttheuseofotherparenteralregimens.Thefollowingregimenhasbeeninvestigatedinatleast
oneclinicaltrialandhasbroadspectrumcoverage(394).
AlternativeParenteralRegimens
Ampicillin/Sulbactam3gIVevery6hours
PLUS
Doxycycline100mgorallyorIVevery12hours
Ampicillin/sulbactamplusdoxycyclineiseffectiveagainstC.trachomatis,N.gonorrhoeae,andanaerobesinwomenwithtubo
ovarianabscess.Onetrialdemonstratedhighshorttermclinicalcurerateswithazithromycin,eitherasmonotherapyfor1week
(500mgIVfor1or2dosesfollowedby250mgorallyfor56days)orcombinedwitha12daycourseofmetronidazole(395).

OralTreatment
Outpatient,oraltherapycanbeconsideredforwomenwithmildtomoderatelysevereacutePID,becausetheclinicaloutcomes
amongwomentreatedwithoraltherapyaresimilartothosetreatedwithparenteraltherapy(390).Thefollowingregimensprovide
coverageagainstthefrequentetiologicagentsofPID.Patientswhodonotrespondtooraltherapywithin72hoursshouldbe
reevaluatedtoconfirmthediagnosisandshouldbeadministeredparenteraltherapyoneitheranoutpatientorinpatientbasis.
RecommendedRegimen
Ceftriaxone250mgIMinasingledose
PLUS
Doxycycline100mgorallytwiceadayfor14days
WITHorWITHOUT
Metronidazole500mgorallytwiceadayfor14days
OR
Cefoxitin2gIMinasingledoseandProbenecid,1gorallyadministeredconcurrentlyinasingledose
PLUS
Doxycycline100mgorallytwiceadayfor14days

WITHorWITHOUT
Metronidazole500mgorallytwiceadayfor14days
OR
Otherparenteralthirdgenerationcephalosporin(e.g.,ceftizoximeorcefotaxime)
PLUS
Doxycycline100mgorallytwiceadayfor14days
WITHorWITHOUT
Metronidazole500mgorallytwiceadayfor14days
Theoptimalchoiceofacephalosporinisunclearalthoughcefoxitinhasbetteranaerobiccoverage,ceftriaxonehasbettercoverage
againstN.gonorrhoeae.AsingledoseofcefoxitiniseffectiveinobtainingshorttermclinicalresponseinwomenwhohavePID.
However,thetheoreticallimitationsincoverageofanaerobesbyrecommendedcephalosporinantimicrobialsmightrequirethe
additionofmetronidazoletothetreatmentregimen(393).AddingmetronidazolealsowilleffectivelytreatBV,whichisfrequently
associatedwithPID.NodatahavebeenpublishedregardingtheuseoforalcephalosporinsforthetreatmentofPID.
AlternativeOralRegimens
Althoughinformationregardingotheroutpatientregimensislimited,otherregimenshaveundergoneatleastoneclinicaltrialand
havedemonstratedbroadspectrumcoverage.Inasingleclinicaltrial,amoxicillin/clavulanicacidanddoxycyclinewereeffective
togetherinobtainingshorttermclinicalresponse(394)however,gastrointestinalsymptomsmightlimitcompliancewiththis
regimen.Azithromycinhasdemonstratedshorttermeffectivenessinonerandomizedtrial(395),andinanotherstudy,itwas
effectivewhenusedcombinationwithceftriaxone250mgIMsingledoseandazithromycin1gorallyonceaweekfor2weeks(396).
Whenconsideringalternativeregimens,theadditionofmetronidazoleshouldbeconsideredbecauseanaerobicorganismsare
suspectedintheetiologyofPIDandmetronidazolewillalsotreatBV.
AsaresultoftheemergenceofquinoloneresistantNeisseriagonorrhoeae,regimensthatincludeaquinoloneagentarenolonger
recommendedforthetreatmentofPID.Ifparenteralcephalosporintherapyisnotfeasible,useoffluoroquinolones(levofloxacin
500mgorallyoncedailyorofloxacin400mgtwicedailyfor14days)withorwithoutmetronidazole(500mgorallytwicedailyfor
14days)canbeconsideredifthecommunityprevalenceandindividualriskforgonorrheaarelow.Diagnostictestsforgonorrhea
mustbeperformedbeforeinstitutingtherapyandthepatientmanagedasfollowsifthetestispositive.
Ifthecultureforgonorrheaispositive,treatmentshouldbebasedonresultsofantimicrobialsusceptibility.
IftheisolateisdeterminedtobequinoloneresistantN.gonorrhoeae(QRNG)orifantimicrobialsusceptibilitycannotbe
assessed(e.g.,ifonlyNAATtestingisavailable),parenteralcephalosporinisrecommended.However,ifcephalosporintherapy
isnotfeasible,theadditionofazithromycin2gorallyasasingledosetoaquinolonebasedPIDregimenisrecommended.

FollowUp
Patientsshoulddemonstratesubstantialclinicalimprovement(e.g.,defervescencereductionindirectorreboundabdominal
tendernessandreductioninuterine,adnexal,andcervicalmotiontenderness)within3daysafterinitiationoftherapy.Patients
whodonotimprovewithinthisperiodusuallyrequirehospitalization,additionaldiagnostictests,andsurgicalintervention.
Ifnoclinicalimprovementhasoccurredwithin72hoursafteroutpatientoralorparenteraltherapy,furtherassessmentshouldbe
performed.Subsequenthospitalizationandanassessmentoftheantimicrobialregimenanddiagnostics(includingtheconsideration
ofdiagnosticlaparoscopyforalternativediagnoses)arerecommendedinwomenwithoutclinicalimprovement.Womenwith
documentedchlamydialorgonococcalinfectionshaveahighrateofreinfectionwithin6monthsoftreatment.Repeattestingofall
womenwhohavebeendiagnosedwithchlamydiaorgonorrheaisrecommended36monthsaftertreatment,regardlessofwhether
theirsexpartnersweretreated(267).AllwomendiagnosedwithacutePIDshouldbeofferedHIVtesting.

ManagementofSexPartners
MalesexpartnersofwomenwithPIDshouldbeexaminedandtreatediftheyhadsexualcontactwiththepatientduringthe60days
precedingthepatient'sonsetofsymptoms.Ifapatient'slastsexualintercoursewas>60daysbeforeonsetofsymptomsor
diagnosis,thepatient'smostrecentsexpartnershouldbetreated.Patientsshouldbeinstructedtoabstainfromsexualintercourse
untiltherapyiscompletedanduntiltheyandtheirsexpartnersnolongerhavesymptoms.Evaluationandtreatmentareimperative
becauseoftheriskforreinfectionofthepatientandthestronglikelihoodofurethralgonococcalorchlamydialinfectioninthesex
partner.MalepartnersofwomenwhohavePIDcausedbyC.trachomatisand/orN.gonorrhoeaefrequentlyareasymptomatic.
Sexpartnersshouldbetreatedempiricallywithregimenseffectiveagainstbothoftheseinfections,regardlessoftheetiologyofPID
orpathogensisolatedfromtheinfectedwoman.Eveninclinicalsettingsinwhichonlywomenaretreated,arrangementsshouldbe
madetoprovidecareorappropriatereferralformalesexpartnersofwomenwhohavePID(seePartnerManagement).Expedited
partnertreatmentandenhancedpatientreferral(seePartnerManagement)arealternativeapproachestotreatingmalepartnersof
womenwhohavechlamydiaorgonococcalinfections(68,69).

Prevention
ScreeningandtreatingsexuallyactivewomenforchlamydiareducestheirriskforPID(272).AlthoughBVisassociatedwithPID,
whethertheincidenceofPIDcanbereducedbyidentifyingandtreatingwomenwithBVisunclear(383,391).

SpecialConsiderations
Pregnancy
Becauseofthehighriskformaternalmorbidityandpretermdelivery,pregnantwomenwhohavesuspectedPIDshouldbe
hospitalizedandtreatedwithparenteralantibiotics.

HIVInfection
DifferencesintheclinicalmanifestationsofPIDbetweenHIVinfectedwomenandHIVnegativewomenhavenotbeenwell
delineated.Inpreviousobservationalstudies,HIVinfectedwomenwithPIDweremorelikelytorequiresurgicalinterventionmore
comprehensiveobservationalandcontrolledstudiesnowhavedemonstratedthatHIVinfectedwomenwithPIDhavesimilar
symptomswhencomparedwithuninfectedcontrols(397399),excepttheyweremorelikelytohaveatuboovarianabscessboth
groupsofwomenrespondedequallywelltostandardparenteralandoralantibioticregimens.ThemicrobiologicfindingsforHIV
positiveandHIVnegativewomenweresimilar,exceptHIVinfectedwomenhadhigherratesofconcomitantM.hominis,candida,
streptococcal,andHPVinfectionsandHPVrelatedcytologicabnormalities.Regardlesssofthesedata,whetherthemanagementof
immunodeficientHIVinfectedwomenwithPIDrequiresmoreaggressiveinterventions(e.g.,hospitalizationorparenteral
antimicrobialregimens)hasnotbeendetermined.

IntrauterineContraceptiveDevices
IUDsarepopularcontraceptivechoicesforwomen.BothlevonorgestrelandcoppercontainingdevicesaremarketedintheUnited
States.TheriskforPIDassociatedwithIUDuseisprimarilyconfinedtothefirst3weeksafterinsertionandisuncommon
thereafter(400,401).GiventhepopularityofIUDs,practitionersmightencounterPIDinIUDusers.Evidenceisinsufficientto
recommendthattheremovalofIUDsinwomendiagnosedwithacutePID.However,cautionshouldbeexercisediftheIUDremains
inplace,andcloseclinicalfollowupismandatory.TherateoftreatmentfailureandrecurrentPIDinwomencontinuingtousean
IUDisunknown,andnodatahavebeencollectedregardingtreatmentoutcomesbytypeofIUD(e.g.,copperorlevonorgestrel).

Epididymitis
Acuteepididymitisisaclinicalsyndromeconsistingofpain,swelling,andinflammationoftheepididymisthatlasts<6weeks(402).
Chronicepididymitisischaracterizedbya6weekhistoryofsymptomsofdiscomfortand/orpaininthescrotum,testicle,or
epididymis.Inmostcasesofacuteepididymitis,thetestisisalsoinvolvedintheprocessaconditionreferredtoasepididymo
orchitis.Chronicepididymitishasbeensubcategorizedintoinflammatorychronicepididymitis,obstructivechronicepididymitis,
andchronicepididymalgia(403).
Amongsexuallyactivemenaged<35years,acuteepididymitisismostfrequentlycausedbyC.trachomatisorN.gonorrhoeae.
Acuteepididymitiscausedbysexuallytransmittedentericorganisms(e.g.,EscherichiacoliandPseudomonasspp.)alsooccurs
amongmenwhoaretheinsertivepartnerduringanalintercourse.Sexuallytransmittedacuteepididymitisusuallyisaccompanied
byurethritis,whichfrequentlyisasymptomatic.Inmenaged>35years,sexuallytransmittedepididymitisisuncommon,whereas
bacteriuriasecondarytoobstructiveurinarydisease(e.g.,benignprostatichyperplasia)ismorecommon.Inthisolderpopulation,
nonsexuallytransmittedepididymitisisassociatedwithurinarytractinstrumentationorsurgery,systemicdisease,and
immunosuppression.
ChronicinfectiousepididymitisismostfrequentlyseeninconditionsassociatedwithgranulomatousreactionMycobacterium
tuberculosis(TB)isthemostcommongranulomatousdiseaseaffectingtheepididymis.Upto25%ofpatientscanhavebilateral
disease,withultrasounddemonstratinganenlargedhyperemicepididymiswithmultiplecystsandcalcifications.Tuberculous
epididymitisshouldbesuspectedinallpatientswithaknownhistoryoforrecentexposuretoTBorinpatientswhoseclinicalstatus
worsensdespiteappropriateantibiotictreatment.

DiagnosticConsiderations
Menwhohaveacuteepididymitistypicallyhaveunilateraltesticularpainandtendernesshydroceleandpalpableswellingofthe
epididymisusuallyarepresent.Althoughtheinflammationandswellingusuallybegininthetailoftheepididymis,theycanspread
toinvolvetherestoftheepididymisandtesticle.Thespermaticcordisusuallytenderandswollen.Testiculartorsion,asurgical
emergency,shouldbeconsideredinallcases,butitoccursmorefrequentlyamongadolescentsandinmenwithoutevidenceof
inflammationorinfection.Emergencytestingfortorsionmightbeindicatedwhentheonsetofpainissudden,painissevere,orthe
testresultsavailableduringtheinitialexaminationdonotsupportadiagnosisofurethritisorurinarytractinfection.Ifthe
diagnosisisquestionable,aurologistshouldbeconsultedimmediatelybecausetesticularviabilitymightbecompromised.
Radionuclidescanningofthescrotumisthemostaccurateradiologicmethodofdiagnosis,butitisnotroutinelyavailable.Although
ultrasoundisprimarilyusedforrulingouttorsionofthespermaticcordincasesofacutescrotumswelling,itwilloftendemonstrate
epididymalhyperemiaandswellinginmenwithepididymitis.However,differentiationbetweentesticulartorsionandepididymitis
mustbemadeonthebasisofclinicalevaluation,becausepartialspermaticcordtorsioncanmimicepididymitisonscrotal
ultrasound.Ultrasoundprovidesminimalutilityformenwithaclinicalpresentationconsistentwithepididymitisanegative
ultrasounddoesnotalterphysicianmanagementofclinicalepididymitis.Ultrasound,therefore,shouldbereservedforpatientswith
scrotalpainwhocannotbediagnosedaccuratelybyphysicalexamination,history,andobjectivelaboratoryfindings.

Theevaluationofmenforepididymitisshouldincludeoneofthefollowing:
Gramstainofurethralsecretionsdemonstrating5WBCperoilimmersionfield.Gramstainisthepreferredrapiddiagnostic
testforevaluatingurethritisbecauseitishighlysensitiveandspecificfordocumentingbothurethritisandthepresenceor
absenceofgonococcalinfection.GonococcalinfectionisestablishedbydocumentingthepresenceofWBCcontaining
intracellularGramnegativediplococcionurethralGramstain.
Positiveleukocyteesterasetestonfirstvoidurineormicroscopicexaminationoffirstvoidurinesedimentdemonstrating10
WBCperhighpowerfield.
Culture,nucleicacidhybridizationtests,andNAATsareavailableforthedetectionofbothN.gonorrhoeaeandC.trachomatis.
Cultureandnucleicacidhybridizationtestsrequireurethralswabspecimens,whereasamplificationtestscanbeperformedonurine
orurethralspecimens.Becauseoftheirhighersensitivity,amplificationtestsarepreferredforthedetectionofC.trachomatis.
Dependingontherisk,patientswhoseconditionsareassociatedwithacquiringanSTDshouldreceivetestingforotherSTDs.

Treatment
Empirictherapyisindicatedbeforelaboratorytestresultsareavailable.ThegoalsoftreatmentofacuteepididymitiscausedbyC.
trachomatisorN.gonorrhoeaeare1)microbiologiccureofinfection,2)improvementofsignsandsymptoms,3)preventionof
transmissiontoothers,and4)adecreaseinpotentialcomplications(e.g.,infertilityorchronicpain).Asanadjuncttotherapy,bed
rest,scrotalelevation,andanalgesicsarerecommendeduntilfeverandlocalinflammationhavesubsided.Becauseempirictherapy
isofteninitiatedbeforelaboratorytestsareavailable,allpatientsshouldreceiveceftriaxoneplusdoxycyclinefortheinitialtherapy
ofepididymitis.Additionaltherapycanincludeafluoroquinoloneifacuteepididymitisisnotfoundtobecausedbygonorrheaby
NAAToriftheinfectionismostlikelycausedbyentericorganisms.Formenwhoareatriskforbothsexuallytransmittedand
entericorganisms(e.g.,MSMwhoreportinsertiveanalintercourse),ceftriaxonewithafluoroquinolonearerecommended.
RecommendedRegimens
Ceftriaxone250mgIMinasingledose
PLUS
Doxycycline100mgorallytwiceadayfor10days
Foracuteepididymitismostlikelycausedbyentericorganisms
Levofloxacin500mgorallyoncedailyfor10days
OR
Ofloxacin300mgorallytwiceadayfor10days
Althoughmostpatientscanbetreatedonanoutpatientbasis,hospitalizationshouldbeconsideredwhenseverepainsuggestsother
diagnoses(e.g.,torsion,testicularinfarction,orabscess)orwhenpatientsareunableorunlikelytocomplywithanantimicrobial
regimen.Becausehighfeverisuncommonandindicatesacomplicatedinfection,thesepatientsshouldbeadmittedforfurther
evaluation.

FollowUp
Patientsshouldbeinstructedtoreturntotheirhealthcareprovidersiftheirsymptomsfailtoimprovewithin48hoursofthe
initiationoftreatment.Signsandsymptomsofepididymitisthatdonotsubsidewithin3daysrequiresreevaluationofthediagnosis
andtherapy.Swellingandtendernessthatpersistaftercompletionofantimicrobialtherapyshouldbeevaluatedcomprehensively.
Differentialdiagnosesincludetumor,abscess,infarction,testicularcancer,TB,andfungalepididymitis.

ManagementofSexPartners
PatientswhohaveacuteepididymitisthatisconfirmedorsuspectedtobecausedbyN.gonorrhoeaeorC.trachomatisshouldbe
instructedtorefersexpartnersforevaluationandtreatmentiftheircontactwiththeindexpatientwaswithinthe60dayspreceding
onsetoftheirownsymptoms.
Patientsshouldbeinstructedtoabstainfromsexualintercourseuntiltheyandtheirsexpartnershavebeenadequatelytreated(i.e.,
untiltherapyiscompletedandpatientandpartnersnolongerhavesymptoms).

SpecialConsiderations
HIVInfection
PatientswhohaveuncomplicatedacuteepididymitisandalsoareinfectedwithHIVshouldreceivethesametreatmentregimenas
thosewhoareHIVnegative.OtheretiologicagentshavebeenimplicatedinacuteepididymitisinHIVinfectionincludingCMV,
salmonella,toxoplasmosis,Ureaplasmaurealyticum,Corynebacteriumsp.,Mycoplasmasp.,andMimapolymorpha.Fungiand
mycobacteriaarealsomorelikelytocauseacuteepididymitisinimmunosuppressedmenthaninimmunocompetentmen.

HumanPapillomavirus(HPV)Infection

Morethan100typesofHPVexist,morethan40ofwhichcaninfectthegenitalarea.MostHPVinfectionsareasymptomatic,
unrecognized,orsubclinical.Oncogenic,orhighriskHPVtypes(e.g.,HPVtypes16and18),arethecauseofcervicalcancers.These
HPVtypesarealsoassociatedwithotheranogenitalcancersinmenandwomen,includingpenile,vulvar,vaginal,andanalcancer,
aswellasubsetoforopharyngealcancers(404).Nononcogenic,orlowriskHPVtypes(e.g.,HPVtypes6and11),arethecauseof
genitalwartsandrecurrentrespiratorypapillomatosis.AsymptomaticgenitalHPVinfectioniscommonandusuallyselflimitedit
isestimatedthatmorethan50%ofsexuallyactivepersonsbecomeinfectedatleastonceintheirlifetime(405).Persistentoncogenic
HPVinfectionisthestrongestriskfactorfordevelopmentofprecancersandcancers.

HPVTests
HPVtestsareavailableforwomenaged>30yearsundergoingcervicalcancerscreening.Thesetestsshouldnotbeusedformen,for
women<20yearsofage,orasageneraltestforSTDs.TheseHPVtestsdetectviralnucleicacid(i.e.,DNAorRNA)orcapsid
protein.FourtestshavebeenapprovedbytheFDAforuseintheUnitedStates:theHCIIHighRiskHPVtest(Qiagen),HCIILow
RiskHPVtest(Qiagen),CervistaHPV16/18test,andCervistaHPVHighRisktest(Hologics).

Treatment
Treatmentisdirectedtothemacroscopic(i.e.,genitalwarts)orpathologic(i.e,precancerous)lesionscausedbyinfection.
SubclinicalgenitalHPVinfectiontypicallyclearsspontaneously,andthereforespecificantiviraltherapyisnotrecommendedto
eradicateHPVinfection.Intheabsenceoflesions,treatmentisnotrecommendedforsubclinicalgenitalHPVinfectionwhetheritis
diagnosedbycolposcopy,aceticacidapplication,orbylaboratorytestsforHPVDNA.Treatmentalsoisnotrecommendedfor
cervicalintraepithelialneoplasia1(CIN1).

Prevention
TwoHPVvaccinesarelicensedintheUnitedStates:abivalentvaccine(Cervarix)containingHPVtypes16and18anda
quadrivalentvaccine(Gardasil)vaccinecontainingHPVtypes6,11,16,and18.BothvaccinesofferprotectionagainsttheHPVtypes
thatcause70%ofcervicalcancers(i.e.,types16and18),andthequadrivalentHPVvaccinealsoprotectsagainstthetypesthatcause
90%ofgenitalwarts(i.e.,types6and11).Eithervaccinecanbeadministeredtogirlsaged1112yearsandcanbeadministeredto
thoseasyoungas9yearsofage(15,16)girlsandwomenages1326yearswhohavenotstartedorcompletedthevaccineseriesalso
shouldreceivethevaccine.HPVvaccineisindicatedforgirlsinthisagegroup,becausebenefitisgreatestifitisadministeredbefore
theonsetofsexualactivity.Thequadrivalent(Gardasil)HPVvaccinecanalsobeusedinmalesaged926yearstopreventgenital
warts(17).Administeringthevaccinetoboysbeforetheonsetofsexualactivityisoptimal.BothHPVvaccinesareadministeredasa
3doseseriesofIMinjectionsovera6monthperiod,withthesecondandthirddosesgiven12andthen6monthsafterthefirst
dose.Ideally,thesamevaccineproductshouldbeusedfortheentire3doseseries.HPVvaccineisavailableforeligiblechildrenand
adolescentsaged<19yearsthroughtheVaccinesforChildren(VFC)program(availablebycallingCDCINFO[8002324636]).
WomenwhohavereceivedHPVvaccineshouldcontinueroutinecervicalcancerscreeningbecause30%ofcervicalcancersare
causedbyHPVtypesotherthan16or18.IntheUnitedStates,thevaccinesarenotlicensedorrecommendedforuseinwomen>26
yearsofage.Nopublisheddataareavailableontheeffectiveness,programmaticrequirements,orcosteffectivenessof
administeringtheHPVvaccineinSTDclinicsettings.

GenitalWarts
Ofgenitalwarts,90%arecausedbyHPV6or11.HPVtypes6or11arecommonlyfoundbefore,oratthetimeof,detectionof
genitalwarts(406).HPVtypes16,18,31,33,and35arefoundoccasionallyinvisiblegenitalwarts(usuallyascoinfectionswithHPV
6or11)andcanbeassociatedwithfociofhighgradeintraepithelialneoplasia,particularlyinpersonswhoareinfectedwithHIV
infection.Inadditiontowartsongenitalareas,HPVtypes6and11havebeenassociatedwithconjunctival,nasal,oral,andlaryngeal
warts.
Genitalwartsareusuallyasymptomatic,butdependingonthesizeandanatomiclocation,theycanbepainfulorpruritic.Genital
wartsareusuallyflat,papular,orpedunculatedgrowthsonthegenitalmucosa.Genitalwartsoccurcommonlyatcertainanatomic
sites,includingaroundtheintroitusinwomen,undertheforeskinoftheuncircumcisedpenis,andontheshaftofthecircumcised
penis.Genitalwartscanalsooccuratmultiplesitesintheanogenitalepitheliumorwithintheanogenitaltract(e.g.,cervix,vagina,
urethra,perineum,perianalskin,andscrotum).Intraanalwartsareobservedpredominantlyinpersonswhohavehadreceptive
analintercourse,buttheycanalsooccurinmenandwomenwhodonothaveahistoryofanalsexualcontact.
Diagnosisofgenitalwartsisusuallyclinical,madebyvisualinspection.Genitalwartscanbeconfirmedbybiopsy,whichmightbe
indicatedif1)thediagnosisisuncertain2)thelesionsdonotrespondtostandardtherapy3)thediseaseworsensduringtherapy
4)thelesionisatypical5)thepatienthascomprisedimmunityor6)thewartsarepigmented,indurated,fixed,bleeding,or
ulcerated.Genitalwartsareusuallyasymptomatic,butdependingonthesizeandanatomiclocation,theymightbepainfulor
pruritic.TheuseofHPVDNAtestingforgenitalwartdiagnosisisnotrecommended,becausetestresultswouldnotalterclinical
managementofthecondition.
Theapplicationof3%5%aceticacid,whichcausesskincolortoturnwhite,hasbeenusedbysomeproviderstodetectHPV
infectedgenitalmucosa.However,aceticacidapplicationisnotaspecifictestforHPVinfection.Therefore,theroutineuseofthis
procedureforscreeningtodetectmucosalchangesattributedtoHPVinfectionisnotrecommended.

Treatment
Theprimaryreasonfortreatinggenitalwartsistheameliorationofsymptoms(includingrelievingcosmeticconcerns)and

ultimately,removalofthewarts.Inmostpatients,treatmentcaninducewartfreeperiods.Ifleftuntreated,visiblegenitalwartscan
resolveontheirown,remainunchanged,orincreaseinsizeornumber.Availabletherapiesforgenitalwartslikelyreduce,but
probablydonoteradicate,HPVinfectivity.WhetherthereductioninHPVviralDNAresultingfromtreatmentreducesfuture
transmissionremainsunclear.Noevidenceindicatesthatthepresenceofgenitalwartsortheirtreatmentisassociatedwiththe
developmentofcervicalcancer.

Regimens
Treatmentofgenitalwartsshouldbeguidedbythepreferenceofthepatient,availableresources,andtheexperienceofthehealth
careprovider.Nodefinitiveevidencesuggeststhatanyoftheavailabletreatmentsaresuperiortoanyother,andnosingletreatment
isidealforallpatientsorallwarts.Theuseoflocallydevelopedandmonitoredtreatmentalgorithmshasbeenassociatedwith
improvedclinicaloutcomesandshouldbeencouraged.Becauseofuncertaintyregardingtheeffectoftreatmentonfuture
transmissionofHPVandthepossibilityofspontaneousresolution,anacceptablealternativeforsomepersonsistoforegotreatment
andwaitforspontaneousresolution.
Factorsthatinfluenceselectionoftreatmentincludewartsize,wartnumber,anatomicsiteofthewart,wartmorphology,patient
preference,costoftreatment,convenience,adverseeffects,andproviderexperience.Factorsthatmightaffectresponsetotherapy
includethepresenceofimmunosuppressionandcompliancewiththerapy,whichcanconsistofeitherasingletreatmentor
completecourseoftreatment.Ingeneral,wartslocatedonmoistsurfacesorinintertriginousareasrespondbesttotopical
treatment.Thetreatmentmodalityshouldbechangedifapatienthasnotimprovedsubstantiallyafteracompletecourseof
treatmentorifsideeffectsaresevere.Mostgenitalwartsrespondwithin3monthsoftherapy.Theresponsetotreatmentandany
sideeffectsshouldbeevaluatedthroughoutthecourseoftherapy.
Complicationsoccurrarelywhentreatmentisadministeredproperly.Patientsshouldbewarnedthatpersistenthypopigmentation
orhyperpigmentationoccurscommonlywithablativemodalitiesandhasalsobeendescribedwithimmunemodulatingtherapies
(imiquimod).Depressedorhypertrophicscarsareuncommonbutcanoccur,especiallyifthepatienthashadinsufficienttimeto
healbetweentreatments.Rarely,treatmentcanresultindisablingchronicpainsyndromes(e.g.,vulvodyniaandhyperesthesiaof
thetreatmentsite)or,inthecaseofanalwarts,painfuldefecationorfistulas.Alimitednumberofcasereportsofseveresystemic
effectsresultingfromtreatmentwithpodophyllinresinandinterferonhavebeendocumented.
Treatmentregimensareclassifiedintopatientappliedandproviderappliedmodalities.Patientappliedmodalitiesarepreferredby
somepatientsbecausetheycanbeadministeredintheprivacyofthepatient'shome.Toensurethatpatientappliedmodalitiesare
effective,patientsmustcomplywiththetreatmentregimenandmustbecapableofidentifyingandreachingallgenitalwarts.
Followupvisitsarenotrequiredforpersonsusingpatientappliedtherapy.However,followupvisitsafterseveralweeksoftherapy
enableproviderstoansweranyquestionspatientsmighthaveabouttheuseofthemedicationandanysideeffectstheyhave
experiencedfollowupvisitsalsofacilitatetheassessmentofapatient'sresponsetotreatment.
RecommendedRegimensforExternalGenitalWarts
PatientApplied:
Podofilox0.5%solutionorgel
OR
Imiquimod5%cream
OR
Sinecatechins15%ointment
ProviderAdministered:
Cryotherapywithliquidnitrogenorcryoprobe.Repeatapplicationsevery12weeks.
OR
Podophyllinresin10%25%inacompoundtinctureofbenzoin
OR
Trichloroaceticacid(TCA)orBichloroaceticacid(BCA)80%90%
OR
Surgicalremovaleitherbytangentialscissorexcision,tangentialshaveexcision,curettage,orelectrosurgery.
Podofiloxisanantimitoticdrugthatdestroyswarts,isrelativelyinexpensive,easytouse,safe,andselfapplied.Podofiloxsolution
shouldbeappliedwithacottonswab,orpodofiloxgelwithafinger,tovisiblegenitalwartstwiceadayfor3days,followedby4days
ofnotherapy.Thiscyclecanberepeated,asnecessary,foruptofourcycles.Thetotalwartareatreatedshouldnotexceed10cm2,
andthetotalvolumeofpodofiloxshouldbelimitedto0.5mLperday.Ifpossible,thehealthcareprovidershouldapplytheinitial

treatmenttodemonstratetheproperapplicationtechniqueandidentifywhichwartsshouldbetreated.Mildtomoderatepainor
localirritationmightdevelopaftertreatment.Thesafetyofpodofiloxduringpregnancyhasnotbeenestablished.
Imiquimodisatopicallyactiveimmuneenhancerthatstimulatesproductionofinterferonandothercytokines.Imiquimodcream
shouldbeappliedoncedailyatbedtime,threetimesaweekforupto16weeks(407).Thetreatmentareashouldbewashedwith
soapandwater610hoursaftertheapplication.Localinflammatoryreactions,includingredness,irritation,induration,
ulceration/erosions,andvesicles,arecommonwiththeuseofimiquimod,andhypopigmentationhasalsobeendescribed(408).
Imiquimodmightweakencondomsandvaginaldiaphragms.Thesafetyofimiquimodduringpregnancyhasnotbeenestablished.
Sinecatechinointment,agreenteaextractwithanactiveproduct(catechins),shouldbeappliedthreetimesdaily(0.5cmstrandof
ointmenttoeachwart)usingafingertoensurecoveragewithathinlayerofointmentuntilcompleteclearanceofwarts.This
productshouldnotbecontinuedforlongerthan16weeks(409411).Themedicationshouldnotbewashedoffafteruse.Sexual
(i.e.,genital,anal,ororal)contactshouldbeavoidedwhiletheointmentisontheskin.Themostcommonsideeffectsof
sinecatechins15%areerythema,pruritis/burning,pain,ulceration,edema,induration,andvesicularrash.Thismedicationmay
weakencondomsanddiaphragms.Noclinicaldataareavailableregardingtheefficacyorsafetyofsinecatechinscomparedwith
otheravailableanogenitalwarttreatmentmodalities.ThemedicationisnotrecommendedforHIVinfectedpersons,
immunocompromisedpersons,orpersonswithclinicalgenitalherpesbecausethesafetyandefficacyoftherapyinthesesettingshas
notbeenestablished.Thesafetyofsinecatechinsduringpregnancyalsoisunknown.
Cryotherapydestroyswartsbythermalinducedcytolysis.Healthcareprovidersmustbetrainedontheproperuseofthistherapy
becauseoverandundertreatmentcanresultincomplicationsorlowefficacy.Painafterapplicationoftheliquidnitrogen,followed
bynecrosisandsometimesblistering,iscommon.Localanesthesia(topicalorinjected)mightfacilitatetherapyifwartsarepresent
inmanyareasoriftheareaofwartsislarge.
Pedophyllinresin10%25%shouldbeappliedtoeachwartandallowedtoairdrybeforethetreatedareacomesintocontactwith
clothingoverapplicationorfailuretoairdrycanresultinlocalirritationcausedbyspreadofthecompoundtoadjacentareas.The
treatmentcanberepeatedweekly,ifnecessary.Toavoidthepossibilityofcomplicationsassociatedwithsystemicabsorptionand
toxicity,twoguidelinesshouldbefollowed:1)applicationshouldbelimitedto<0.5mLofpodophyllinoranareaof<10cm2of
wartspersessionand2)theareatowhichtreatmentisadministeredshouldnotcontainanyopenlesionsorwounds.The
preparationshouldbethoroughlywashedoff14hoursafterapplicationtoreducelocalirritation.Thesafetyofpodophyllinduring
pregnancyhasnotbeenestablished.Podophyllinresinpreparationsdifferintheconcentrationofactivecomponentsand
contaminants.Theshelflifeandstabilityofpodophyllinpreparationsareunknown.
BothTCAandBCAarecausticagentsthatdestroywartsbychemicalcoagulationofproteins.Althoughthesepreparationsarewidely
used,theyhavenotbeeninvestigatedthoroughly.TCAsolutionshavealowviscositycomparablewiththatofwaterandcanspread
rapidlyifappliedexcessivelytherefore,theycandamageadjacenttissues.Asmallamountshouldbeappliedonlytothewartsand
allowedtodrybeforethepatientsitsorstands,atwhichtimeawhitefrostingdevelops.Ifpainisintense,theacidcanbeneutralized
withsoaporsodiumbicarbonate.Ifanexcessamountofacidisapplied,thetreatedareashouldbepowderedwithtalc,sodium
bicarbonate(i.e.,bakingsoda),orliquidsoappreparationstoremoveunreactedacid.Thistreatmentcanberepeatedweekly,if
necessary.
Surgicaltherapyhastheadvantageofusuallyeliminatingwartsatasinglevisit.However,suchtherapyrequiressubstantialclinical
training,additionalequipment,andalongerofficevisit.Afterlocalanesthesiaisapplied,thevisiblegenitalwartscanbephysically
destroyedbyelectrocautery,inwhichcasenoadditionalhemostasisisrequired.Caremustbetakentocontrolthedepthof
electrocauterytopreventscarring.Alternatively,thewartscanberemovedeitherbytangentialexcisionwithapairoffinescissorsor
ascalpel,bylaser,orbycurettage.Becausemostwartsareexophytic,thisprocedurecanbeaccomplishedwitharesultingwound
thatonlyextendsintotheupperdermis.Hemostasiscanbeachievedwithanelectrocauteryunitorachemicalstyptic(e.g.,an
aluminumchloridesolution).Suturingisneitherrequirednorindicatedinmostcasesifsurgicalremovalisperformedproperly.
Surgicaltherapyismostbeneficialforpatientswhohavealargenumberorareaofgenitalwarts.Bothcarbondioxidelaserand
surgerymightbeusefulinthemanagementofextensivewartsorintraurethralwarts,particularlyforthosepersonswhohavenot
respondedtoothertreatments.
Becauseallavailabletreatmentshaveshortcomings,someclinicsemploycombinationtherapy(simultaneoususeoftwoormore
modalitiesonthesamewartatthesametime).Dataarelimitedregardingtheefficacyorriskofcomplicationsassociatedwithuseof
suchcombinations.

AlternativeRegimens
Alternativeregimensincludetreatmentoptionsthatmightbeassociatedwithmoresideeffectsand/orlessdataonefficacy.
Alternativeregimensincludeintralesionalinterferon,photodynamictherapy,andtopicalcidofovir.
RecommendedRegimenforCervicalWarts
Forwomenwhohaveexophyticcervicalwarts,abiopsyevaluationtoexcludehighgradeSILmustbeperformedbeforetreatment
isinitiated.Managementofexophyticcervicalwartsshouldincludeconsultationwithaspecialist.
RecommendedRegimensforVaginalWarts
Cryotherapywithliquidnitrogen.Theuseofacryoprobeinthevaginaisnotrecommendedbecauseoftheriskforvaginal

perforationandfistulaformation.
OR
TCAorBCA80%90%appliedtowarts.Asmallamountshouldbeappliedonlytowartsandallowedtodry,atwhichtimea
whitefrostingdevelops.Ifanexcessamountofacidisapplied,thetreatedareashouldbepowderedwithtalc,sodiumbicarbonate,
orliquidsoappreparationstoremoveunreactedacid.Thistreatmentcanberepeatedweekly,ifnecessary.
RecommendedRegimensforUrethralMeatusWarts
Cryotherapywithliquidnitrogen
OR
Podophyllin10%25%incompoundtinctureofbenzoin.Thetreatmentareaandadjacentnormalskinmustbedrybefore
contactwithpodophyllin.Thistreatmentcanberepeatedweekly,ifnecessary.Thesafetyofpodophyllinduringpregnancyhasnot
beenestablished.Dataarelimitedontheuseofpodofiloxandimiquimodfortreatmentofdistalmeatalwarts.
RecommendedRegimensforAnalWarts
Cryotherapywithliquidnitrogen
OR
TCAorBCA80%90%appliedtowarts.Asmallamountshouldbeappliedonlytowartsandallowedtodry,atwhichtimea
whitefrostingdevelops.Ifanexcessamountofacidisapplied,thetreatedareashouldbepowderedwithtalc,sodiumbicarbonate,
orliquidsoappreparationstoremoveunreactedacid.Thistreatmentcanberepeatedweekly,ifnecessary.
OR
Surgicalremoval
Intraanalwartsshouldbemanagedinconsultationwithaspecialist.Manypersonswithwartsontheanalmucosaalsohavewarts
ontherectalmucosa,sopersonswithanaland/orintraanalwartsmightbenefitfromaninspectionoftherectalmucosabydigital
examination,standardanoscopy,orhighresolutionanoscopy.

Counseling
ThefollowingkeycounselingmessagesshouldbeconveyedtoallpatientsdiagnosedwithHPVinfection:
GenitalHPVinfectionisverycommon.ManytypesofHPVarepassedonthroughgenitalcontact,mostoftenduringvaginal
andanalsexualcontact.HPVcanalsobespreadbyoralsexualcontact.
MostsexuallyactiveadultswillgetHPVatsomepointintheirlives,thoughmostwillneverknowitbecauseHPVinfection
usuallyhasnosignsorsymptoms.
Inmostcases,HPVinfectionclearsspontaneously,withoutcausinganyhealthproblems.Nevertheless,someinfectionsdo
progresstogenitalwarts,precancers,andcancers.
ThetypesofHPVthatcausegenitalwartsaredifferentfromthetypesthatcancauseanogenitalcancers.
Withinanongoingsexualrelationship,bothpartnersareusuallyinfectedatthetimeonepersonisdiagnosedwithHPV
infection,eventhoughsignsofinfectionmightnotbeapparent.
AdiagnosisofHPVinonesexpartnerisnotindicativeofsexualinfidelityintheotherpartner.
TreatmentsareavailablefortheconditionscausedbyHPV(e.g.,genitalwarts),butnotforthevirusitself.
HPVdoesnotaffectawoman'sfertilityorabilitytocarryapregnancytoterm.
CorrectandconsistentmalecondomusemightlowerthechancesofgivingorgettinggenitalHPV,butsuchuseisnotfully
protective,becauseHPVcaninfectareasthatarenotcoveredbyacondom.
SexuallyactivepersonscanlowertheirchancesofgettingHPVbylimitingtheirnumberofpartners.However,HPViscommon
andoftengoesunrecognizedpersonswithonlyonelifetimesexpartnercanhavetheinfection.Forthisreason,theonly
definitivemethodtoavoidgivingandgettingHPVinfectionandgenitalwartsistoabstainfromsexualactivity.
TestsforHPVarenowavailabletohelpprovidersscreenforcervicalcancerincertainwomen.Thesetestsarenotusefulfor
screeningadolescentfemalesforcervicalcancer,noraretheyusefulforscreeningforotherHPVrelatedcancersorgenital
wartsinmenorwomen.HPVtestsshouldnotbeusedtoscreen:
men
partnersofwomenwithHPV
adolescentfemalesor
forhealthconditionsotherthancervicalcancer.
TwoHPVvaccinesareavailable,bothofwhichofferprotectionagainsttheHPVtypesthatcause70%ofcervicalcancers(i.e.,
types16and18)thequadrivalentvaccine(Gardasil)alsoprotectsagainstthetypesthatcause90%ofgenitalwarts(i.e.,types6

and11).Thesevaccinesaremosteffectivewhenalldosesareadministeredbeforesexualcontact.Eithervaccineis
recommendedfor11and12yearoldgirlsandforfemalesaged1326yearswhodidnotreceiveorcompletethevaccineseries
whentheywereyounger.ThequadrivalentHPVvaccinecanbeusedinmalesaged926yearstopreventgenitalwarts.
Thefollowingarespecificcounselingmessagesforthosepersonsdiagnosedwithgenitalwartsandtheirpartners:
Genitalwartsarenotlifethreatening.Ifleftuntreated,genitalwartsmightgoaway,staythesame,orgrowinsizeornumber.
Exceptinveryrareandunusualcases,genitalwartswillnotturnintocancer.
ItisdifficulttodeterminehoworwhenapersonbecameinfectedwithHPVgenitalwartscanbetransmittedtootherseven
whennovisiblesignsofwartsarepresent,evenafterwartsaretreated.
Itisnotknownhowlongapersonremainscontagiousafterwartsaretreated.Itisalsounclearwhetherinformingsubsequent
sexpartnersaboutapastdiagnosisofgenitalwartsisbeneficialtothehealthofthosepartners.
Genitalwartscommonlyrecuraftertreatment,especiallyinthefirst3months.
WomenshouldgetregularPaptestsasrecommended,regardlessofvaccinationorgenitalwarthistory.Womenwithgenital
wartsdonotneedtogetPaptestsmoreoftenthanrecommended.
HPVtestingisunnecessaryinsexualpartnersofpersonswithgenitalwarts.
Ifonesexpartnerhasgenitalwarts,bothsexpartnersbenefitfromgettingscreenedforotherSTDs.
Personswithgenitalwartsshouldinformcurrentsexpartner(s)becausethewartscanbetransmittedtootherpartners.In
addition,theyshouldrefrainfromsexualactivityuntilthewartsaregoneorremoved.
Correctandconsistentmalecondomusecanlowerthechancesofgivingorgettinggenitalwarts,butsuchuseisnotfully
protectivebecauseHPVcaninfectareasthatarenotcoveredbyacondom.
TheGardasilvaccine,whichhasbeenapprovedforuseinmalesandfemalesaged926years,protectsagainsttheHPVtypes
thatcause90%ofgenitalwarts(i.e.,types6and11).

SpecialConsiderations
Pregnancy
Imiquimod,sinecatechins,podophyllin,andpodofiloxshouldnotbeusedduringpregnancy.Genitalwartscanproliferateand
becomefriableduringpregnancy.Althoughremovalofwartsduringpregnancycanbeconsidered,resolutionmightbeincomplete
orpooruntilpregnancyiscomplete.Rarely,HPVtypes6and11cancauserespiratorypapillomatosisininfantsandchildren,
althoughtherouteoftransmission(i.e.,transplacental,perinatal,orpostnatal)isnotcompletelyunderstood.Whethercesarean
sectionpreventsrespiratorypapillomatosisininfantsandchildrenalsoisunclear(412)therefore,cesareandeliveryshouldnotbe
performedsolelytopreventtransmissionofHPVinfectiontothenewborn.Cesareandeliveryisindicatedforwomenwithgenital
wartsifthepelvicoutletisobstructedorifvaginaldeliverywouldresultinexcessivebleeding.Pregnantwomenwithgenitalwarts
shouldbecounseledconcerningthelowriskforwartsonthelarynx(recurrentrespiratorypapillomatosis)intheirinfantsor
children.

HIVInfection
PersonswhoareHIVinfectedaremorelikelytodevelopgenitalwartsthenpersonswhoarenotHIVinfected(413)moreover,
lesionsaremorerecalcitranttotreatmentduetodepressedcellmediatedimmunity.Nodatasuggestthattreatmentmodalitiesfor
externalgenitalwartsshouldbedifferentforHIVinfectedpersons.However,personswhoareimmunosuppressedbecauseofHIV
orotherreasonsmighthavelargerormorenumerouswarts,mightnotrespondaswellasimmunocompetentpersonstotherapyfor
genitalwarts,andmighthavemorefrequentrecurrencesaftertreatment(414416).Squamouscellcarcinomasarisinginor
resemblinggenitalwartsmightoccurmorefrequentlyamongimmunosuppressedpersons,thereforerequiringbiopsyfor
confirmationofdiagnosisforsuspiciouscases.BecauseoftheincreasedincidenceofanalcancerinHIVinfectedMSM,screening
foranalintraepithelialneoplasiabycytologycanbeconsidered(417).However,evidenceislimitedconcerningthenaturalhistoryof
analintraepithelialneoplasias,thereliabilityofscreeningmethods,thesafetyandresponsetotreatments,andtheprogrammatic
considerationsthatwouldsupportthisscreeningapproach.

SquamousCellCarcinomainSitu
Personsinwhomsquamouscellcarcinomainsituofthegenitaliaisdiagnosedshouldbereferredtoaspecialistfortreatment.
Ablativemodalitiesusuallyareeffective,butcarefulfollowupisessentialforpatientmanagement.

CervicalCancerScreeningforWomenWhoAttendSTDClinicsorHaveaHistoryofSTDs
WomenattendingSTDclinicsforthetreatmentofgenitalinfectionwithhighrisktypesofHumanPapillomavirus(HRHPV)might
beatincreasedriskforcervicalcancerpersistenceofHRHPVcancausecervicalcanceranditsprecancerouslesions.Onestudy
demonstratedanHRHPVprevalenceof27%amongwomenreceivingtreatmentinanSTDclinicsettingprevalencewashighest
amongpersonsaged1419anddecreasedwithincreasingage(418).InanevaluationofwomenattendingSTDclinics,overhalfof
womenwereatincreasedriskforcervicalcancerasaresultofHPVinfection,cervicaldisease,orhistoryofcervicaldisease
comparedwithwomenwithoutthesecharacteristics(419).
Cervicalcytology(i.e.,aPaptest)isaneffective,lowcostscreeningtestforpreventinginvasivecervicalcancer.Ina2004survey,

49%ofallSTDclinicsintheUnitedStatesreportedprovidingcervicalscreeningservices,and20%reporteduseofHPVDNAtesting
(419).
CurrentguidelinesfromUSPSTFandACOGrecommendthatcervicalscreeningbeginatage21years(96,97).Thisrecommendation
isbasedonthelowincidenceofcervicalcancerandlimitedutilityofscreeninginyoungerwomen(98).ACSrecommendsthat
womenstartcervicalscreeningwithPaptestsafter3yearsofinitiatingsexualactivitybutbynolaterthanage21years(98).
Recommendedscreeningintervals(http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf )shouldcontinuethrough65years
accordingtoUSPSTF(http://www.ahrq.gov/clinic/uspstf/uspscerv.htm)or70yearsaccordingtoACS
(http://cancer.org/docroot/ped/content/ped_2_3x_acs_cancerdetection_guidelines_36.asp ).

ScreeningRecommendations
STDclinicsthatprovideroutinecervicalscreeningservicesshouldfollowtheavailableguidelines.However,toensuretheprovision
ofadequatecare,followupandreferralsourcesmustbeinplace.Cervicalscreeningshouldbeperformedusingeitherconventional
orliquidbasedcytologictests(i.e.,Paptests)andcanincludeHRHPVDNAtestsinspecificcircumstances(420).For
cythopathologicandHPV/DNAtesting,STDclinicsshoulduseCLIAcertifiedlaboratories(421)andthosethatreportcytopathology
findingsaccordingtothefollowingBethesda2001terminology(422):atypicalsquamouscells(ASC),lowgradesquamous
intraepitheliallesions(LSIL),andhighgradeintraepitheliallesions(HSIL).TheASCcategoryissubdividedintoatypicalsquamous
cellsofundeterminedsignificance(ASCUS)andatypicalsquamouscellscannotexcludeHSIL(ASCH).
DuringappointmentsinwhichapelvicexaminationforSTDscreeningisperformed,thehealthcareprovidershouldinquireabout
theresultofthepatient'smostrecentPaptestanddiscussthefollowinginformationwiththepatient:
thepurposeandimportanceofaPaptest
theneedforregularlyscheduledPaptestsbetween2165yearsofage
whetheraPaptestwillbeobtainedduringthisclinicvisitand
ifaPaptestwillnotbeobtainedduringthisexamination,thenamesoflocalprovidersorreferralclinicsthatcanperformPap
testsandadequatelyfollowupresults.
IfawomanhasnothadaPaptestduringtheprevious12months(2yearintervalsforwomenaged2129yearsand3yearintervals
forwomenaged30yearswithahistoryofthreenormalPaptests)andcervicalscreeningisindicated,aPaptestshouldbe
obtainedaspartoftheroutinepelvicexamination.Healthcareprovidersshouldbeawarethatmanywomenfrequentlyequate
havingapelvicexaminationwithhavingaPaptesttheyerroneouslybelievethatasampleforPaptestingwastaken,wheninreality,
onlyapelvicexaminationwasperformed.BecauseselfreportsofPaptestsoftenarenotaccurate,STDclinicsshouldhavea
protocolforconductingcervicalcancerscreeningandobtainingaPaptestduringtheroutineclinicalevaluationofwomenwhodo
nothaveclinicalrecorddocumentationofanormalPaptestwithinthepreceding12monthsanddonothaveanotherproviderfor
screeningservices.

HPVTests
HPVtestsareavailableforclinicaluseandarerecommendedforthetriageofwomenaged21yearswhohaveabnormalPaptest
results(ASCUS).Additionally,thesetestscanbeusedinconjunctionwithaPaptest(adjuncttesting)forcervicalcancerscreening
ofwomenaged30years.Thesetestsshouldnotbeusedforwomenaged<20yearsforscreeningormanagementofabnormalPap
testsorforSTDscreening.CurrentFDAapprovedHPVtestsdetectviralnucleicacid(DNA).SeveralFDAapprovedtestsforhigh
riskHPVtestingareavailableforuseintheUnitedStates.TheHybridCapture2HighRiskHPVDNAtest(Qiagen,Gaithersburg,
Maryland)andtheCervistaHPVHighRisktest(Hologics,Beford,Massachusetts)detectanyof1314highriskHPVtypes,
whereastheCervistaHPV16/18testdetectstypespecificinfectionwithHPVtypes16and18.TheDigeneHC2HPVDNAtest
(Qiagen,Gaithersburg,Maryland)detectsanyof13highriskorfivelowriskHPVtypes,althoughuseofthistestisnotindicatedin
theSTDclinicsetting(i.e.,onlyhighriskHPVDNAtestingisnecessary)(423).
HighriskHPVDNAtestsarerecommendedforthetriageofwomenaged21yearswhohaveASCUScytologyresults.Inaddition,
thesetestsarerecommendedforroutineadjunctivetesting(alongwithcervicalcytology)usedtoscreenwomenaged30years
(424).
HPVDNAtesting(includingHRHPVandHPV16/18tests)isnotrecommendedforthefollowingsituations(425427):
decidingwhethertovaccinateforHPV
conductingSTDscreeningforHPV
triagingLSIL
testingadolescentsaged<21yearsand
screeningforprimarycervicalcancerasastandalonetest(i.e.,withoutaPaptest).
Womenmightbenefitfromreceivingprintedinformationaboutthevalueofandindicationforcervicalcancerscreening(i.e.,Pap
testing),andtheyshouldbeprovidedaclinicvisitreportthatstateswhetheraPaptestwasobtainedduringtheclinicvisit.When

available,acopyofthePaptestresultshouldbeprovided.Womenwithabnormalscreeningordiagnostictestsshouldbereferredto
clinicsettingsthatemployproviderswhoareexperiencedinmanagingthesecases(seeFollowUp).Cervicalscreeningprograms
shouldscreenwomenwhohavereceivedHPVvaccinationinthesamemannerasunvaccinatedwomen.

FollowUp
Amongwomenaged30yearswithnormalPaptestsandnegativetestsforHRHPV,thescreeningintervalcanbeincreasedto3
years.Atthattime,routinetestingwitheitheraPaptestoraPapandHRHPVtestingcanresume(428).
IftheresultsofthePaptestareabnormal,followupcareshouldbeprovidedaccordingtotheASCCP2006ConsensusGuidelines
forManagementofAbnormalCervicalCytology(429)(informationregardingmanagementandfollowupcareisavailableat
http://www.asccp.org ).IfresourcesinSTDclinicsdonotallowforfollowupofwomenwithabnormalresults,protocolsfor
referralforfollowupandcasemanagementshouldbeinplace.
AccordingtoAmericanSocietyforColposcopyandCervicalPathology(ASCCP)guidelines,womenwithPaptestsresults
indicatingASCH,loworhighgradesquamousintraepitheliallesionshouldbereferredtoaclinicianwhocanperforma
colposcopicexaminationofthelowergenitaltractand,ifindicated,conductacolposcopicallydirectedbiopsy.Forwomenaged
<21years,referraltocolposcopyforASCUSandLSILisnotrecommended,becauseratesofspontaneousclearancearehighin
thispopulationrepeatPaptestingat12and24monthsisrecommendedforthesewomen.
Forwomenaged21yearswithaPaptestreportofASCUS,threeoptionsareavailableforfollowupmanagement:1)prompt
colposcopy,2)repeatPaptestsat6and12months,and3)ahighriskHRHPVDNAtest.Colposcopyisappropriateifthe
providerhasconcernsaboutadherencewithrecommendedfollowuporconcernsaboutotherclinicalindications.Highgrade
histologicalchanges(i.e.,CIN2orhigher)aftercolposcopicevaluationforASCUSPaptestreportsistypicallydetectedin
<12%ofcases.IfrepeatPaptestsareused(insteadofpromptcolposcopy)tofollowASCUSresults,testsshouldbeperformed
at6and12monthintervalsuntiltwoconsecutivenegativeresultsarenoted,atwhichtimecervicalcancerscreeningata
normalintervalforagecanberesumed.IfsubsequentPaptestsdemonstrateASCoramoreseriouscondition,followupshould
beconductedaccordingtoASCCP2006ConsensusGuidelines(424).AthirdstrategyformanagingpatientswithASCUSPap
testresultsinvolvestestingforhighriskHPVDNA(423,424,430,431).WhereasconductinghighriskHPVtestingmightnotbe
possibleinsomeSTDclinicsbecauseofresourcelimitations,suchtestingmightbeappropriateinotherpublichealthclinic
settings.HPVteststhatdetectlowriskHPVtypesarenotrecommendedforuseinSTDclinics,becausetheyarenotbeneficial
inthissetting.
Ifindicated,highriskHPVDNAtestingcanbeperformedby1)collectingaspecimenforPaptestandHPVDNAonthesame
swab,2)usingasuppliedswabatthetimeofthePaptest,ifconventionalcytologyisused,3)reflextesting(ifliquidbased
cytologyisusedandenoughresidualmaterialisavailableinthecytologytestvial),or4)schedulingaseparatefollowup
appointmentwhenthePaptestreportresultsareknown.IfthehighriskHPVDNAtestisnegative,arepeatPaptestshouldbe
performedat12months.Ifthetestispositive,thepatientshouldbereferredimmediatelyforcolposcopy,andifindicated,
directedcervicalbiopsy.
Becausemanypublichealthclinics(includingmostSTDclinics)cannotprovideclinicalfollowupofabnormalPaptests,women
withPaptestsdemonstratingloworhighgradeSILorASCUSusuallyneedareferraltootherlocalhealthcareprovidersorclinics
forcolposcopyandbiopsy.Clinicsandhealthcareproviderswhooffercervicalscreeningservicesbutcannotprovideappropriate
colposcopicfollowupofabnormalPaptestsshouldarrangereferraltohealthcarefacilitiesthatwillpromptlyevaluateandtreat
patientsandreportevaluationresultstothereferringclinicorhealthcareprovider.Clinicsandhealthcareprovidersshould
developprotocolsthatidentifywomenwhomissfollowupappointmentssothatthesewomencanbelocatedandscheduledfor
neededstudiesandmanagement,andtheyshouldreevaluatetheseprotocolsroutinely.Paptestresults,typeandlocationoffollow
upappointments,andresultsoffollowupappointmentshouldbeclearlydocumentedintheclinicrecord.Theestablishmentof
colposcopyandbiopsyservicesinlocalhealthdepartments,especiallyincircumstancesinwhichreferralsaredifficultandfollowup
isunlikely,shouldbeconsideredifresourcesareavailable.

OtherManagementConsiderations
ThefollowingadditionalconsiderationsareassociatedwithperformingPaptests:
ThePaptestshouldnotbeconsideredascreeningtestforSTDs.
AllwomenreceivingcareinanSTDclinicsettingshouldbeconsideredforcervicalcancerscreening,regardlessofsexual
orientation(i.e.,heterosexualwomenandthosewhoidentifythemselvesaslesbianorbisexual).
Ifawomanismenstruating,aconventionalcytologyPaptestshouldbepostponed,andthewomanshouldbeadvisedtohavea
Paptestattheearliestopportunity.
IfspecificinfectionsotherthanHPVareidentified,thepatientmightneedtohavearepeatPaptestafterappropriatetreatment
forthoseinfections.However,inmostinstances(eveninthepresenceofsomesevereinfections),Paptestswillbereportedas
satisfactoryforevaluation,andreliablefinalreportscanbeproducedwithouttheneedtorepeatthePaptestaftertreatmentis
received.
WhenitisnecessarytorepeatthePaptestbecausethereportwasinterpretedasunsatisfactory,therepeattestmustbe
determinedbythelaboratorytobesatisfactoryandnegativebeforescreeningcanberesumedatregularlyscheduledintervals.
ThepresenceofamucopurulentdischargeshouldnotdelaythePaptest.Thetestcanbeperformedaftercarefulremovalofthe
dischargewithasalinesoakedcottonswab.
Intheabsenceofotherindications,womenwhohaveexternalgenitalwartsdonotneedPaptestsmorefrequentlythanwomen

whodonothavewarts.
ThesequenceofPaptestinginrelationtocollectionofothercervicovaginalspecimenshasnotbeenshowntoinfluencePaptest
resultsortheirinterpretation(432).
WomenwhohavehadatotalhysterectomydonotrequirearoutinePaptestunlessthehysterectomywasperformedbecauseof
cervicalcanceroritsprecursorlesions.AsrecommendedbyACOG,forwomenwithhysterectomyresultingfromCIN2or
higher,cervicalorvaginalcuffscreeningcanbediscontinuedoncethreenormalPaptestshavebeendocumented.Inthese
situations,womenshouldbeadvisedtocontinuefollowupwiththephysician(s)whoprovidedhealthcareatthetimeofthe
hysterectomy,ifpossible.Inwomenwhosecervixremainsintactafterahysterectomy,regularlyscheduledPaptestsshouldbe
performedasindicated(433435).
HealthcareproviderswhoreceivebasicretrainingonPaptestcollectionandclinicsthatusesimplequalityassurance
measuresaremorelikelytoobtainsatisfactorytestresultsasdeterminedbythelaboratory.Theuseofcytobrushesandbrooms
alsoimprovesthenumberofsatisfactoryPaptests.
AlthoughevidencesupportstheoptionofHPVtestingforthetriageofwomenwithASCUSPaptestresults,thisoptionmight
notbefeasibleinanSTDclinicbecauseoflimitedresources.
iquidbasedcytologyisanacceptablealternativetoconventionalPaptests,asithassimilartestperformancecharacteristics.

SpecialConsiderations
Pregnancy
Pregnantwomenshouldbescreenedatthesamefrequencyasnonpregnantwomenhowever,recommendationsformanagement
differinthispopulation(83,84,424).AswabandanAyre'sspatulacanbeusedforobtainingPaptestsinpregnantwomen,but
cytobrushesarenotrecommended.

HIVInfection
SeveralstudieshavedocumentedanincreasedprevalenceofSILinHIVinfectedwomen(416,436).Thefollowingrecommendations
forPaptestscreeningamongHIVinfectedwomenareconsistentwithmostoftheguidelinespublishedbytheU.S.Departmentof
HealthandHumanServices(HHS)(129)andarebasedpartiallyontheopinionsofprofessionalsknowledgeableaboutthecareand
managementofcervicalcancerandHIVinfectioninwomen.
HIVpositivewomenshouldbeprovidedcervicalcytologyscreeningtwice(every6months)withinthefirstyearafterinitialHIV
diagnosisand,ifbothtestsarenormal,annualscreeningcanberesumedthereafter.HIVpositivewomenwithASCH,LSIL,or
HSILoncytologicscreeningshouldundergocolposcopicevaluation.RecommendationsformanagementofHIVpositivewomen
withASCUSvary.HHSrecommendsamoreconservativemanagementapproach(i.e.,immediatecolposcopy),whereasASCCP
recommendsthatthesewomenbemanagedlikeHIVnegativewomenwithASCUS(i.e.,testedforHRHPVDNA)(424,429).

Adolescents
PrevalenceofHRHPVishighamongadolescentsaged<21years(425).Infectionsinadolescentpatientstendtoclearrapidly,and
lesionscausedbytheseinfectionsalsohavehighratesofregressiontonormal.Therefore,ASCCPandACOGrecommendthat
adolescentswithASCUSorlowgradeSILbemanagedwithrepeatcytologictestingat12monthsand24months.Onlythosewith
HSILateitherfollowupvisitorpersistenceofASCUSorLSILat24monthsshouldbereferredforcolposcopicevaluation.

CounselingMessagesforWomenReceivingCervicalCancerScreeningandHPVTesting
Whenawomanreceivesabnormalcervicalcytologytestresults,shemightexperienceconsiderableanxiety,distress,fear,and
confusion,whichcanserveasbarrierstofollowupcare.Furthermore,apositiveHPVDNAtestresultmightexacerbatethese
feelingsandmightalsoelicitpartnerconcerns,worryaboutdisclosure,andfeelingsofguilt,anger,andstigmatization.
HealthcareprovidersarethemosttrustedsourceofinformationaboutHPVandabnormalcervicalcytologytestresults.Therefore,
theyhaveanimportantroletoplayineducatingwomenabouthighriskHPVandmoderatingthepsychosocialimpactofthe
diagnosis.
STDclinicprovidersshouldofferpatientscounselingandinformationbothverballyandinprintwhendeliveringHPVandPaptest
results.Printmaterialsareavailableatseveralwebsites(http://www.cdc.gov/std/hpv/common/
http://www.ashastd.org/hpv/hpv_publications.cfm ).Themannerinwhichthisinformationiscommunicatedtopatientscan
influencethepsychologicaleffectofthisdiagnosis,aswellasawoman'slikelihoodoffollowingupwithnecessarytestingor
treatment.ProvidersshouldframehighriskHPVinaneutral,nonstigmatizingcontextandemphasizeitscommon,asymptomatic,
andtransientnature.Also,theprovidershouldemphasizethatHPVisoftensharedbetweenpartnersandcanliedormantformany
yearshavingHPVdoesnotimplyinfidelity,norshoulditnecessarilyraiseconcernsaboutapartner'shealth.
IncounselingwomenwithhighriskHPVinfectionsaboutpartnermanagement,messagesshouldbetailoredtotheindividual
woman'scircumstances.Whilenoevidencesupportseitherpartnernotification(PN)orclinicalevaluationreferralforpartnersof
patientswithhighriskHPV,somewomenmightbenefitfromhavinganinformeddiscussionabouttheirdiagnosiswiththeir
partners.Thistypeofcommunicationcanfosterpartnersupportandensurethesharingofinformationthatcaninformdecision
making(e.g.,decisionsregardingcondomuse).
Thefollowingspecifickeymessagesshouldbecommunicatedtopatientsreceivingcervicalscreening:

Thepurposeofregular,lifelongcervicalcancerscreeningistoidentifycervicalcancerprecursors,whichcanbetreatedbefore
progressiontocervicalcancer.
ApositivehighriskHPVDNAtestoranabnormalcervicalcytologytestisnotindicativeofcervicalcancer.Appropriatefollow
upisnecessarytoensurethatcervicalabnormalitiesdonotprogress.
SomewomenmighthaveanormalPaptestandapositivehighriskHPVtest.ApositivehighriskHPVDNAtestindicatesa
HPVinfectionofthecervix,butdoesnotindicatecervicalcancer.Anormalcervicalcytologytestindicatesthatnocellular
abnormalitiesweredetectedatthetimeoftesting,butwomenwhohaveHPVinfectionofthecervixhaveahigherlikelihoodof
developingcellchanges,whichcouldleadtocervicalcancerovertime.Followupevaluationisessentialtomonitorcervical
cytology.
APaptestthatrevealsASCUSindicatessomeabnormalareasonthecervixthatmayrequireclosefollowuportreatmentso
thattheydonotprogress.Additionaltestingmightberequiredtoconfirmtheseresults.Itisessentialthatpatientsreturnforall
followupappointmentsandrecommendedtests.
DiscussionconcerningdisclosureofapositivehighriskHPVtesttosexpartnersmightbeappropriateandcanincludethefollowing
information:
HPVisverycommon.Itcaninfectthegenitalareasofbothmenandwomen.Itusuallyhasnosignsorsymptoms.
MostsexuallyactivepersonsgetHPVatsometimeintheirlives,thoughmostwillneverknowit.Evenpersonswithonlyone
lifetimesexpartnercangetHPViftheirpartnerwasinfected.
WhiletheimmunesystemclearsHPVinfectionmostofthetime,insomepersons,HPVinfectiondoesnotresolve.
NoclinicallyvalidatedtestexistsformentodetermineiftheyhaveHPVinfection.ThemostcommonmanifestationofHPV
infectioninmenisgenitalwarts.HighriskHPVtypesseldomcausegenitalwarts.
PartnerswhoareinalongtermrelationshiptendtoshareHPV.SexualpartnersofHPVinfectedpatientsalsolikelyhaveHPV,
eventhoughtheymighthavenosignsorsymptomsofinfection.
DetectionofhighriskHPVinfectioninawomandoesnotmeanthatthewomanorherpartnerisengaginginsexualactivity
outsideofarelationship.HPVinfectioncanbepresentformanyyearsbeforeitisdetected,andnomethodcanaccurately
confirmwhenHPVinfectionwasacquired.
Preventionmeasuresforcurrentandsubsequentsexpartnersandriskreductionshouldbediscussed.Providersshouldcounsel
womenaboutcondomusedependingontheircurrentcircumstances.Consistentcondomusebymalepartnersofsexuallyactive
womencanreducetheriskforcervicalandvulvovaginalHPVinfection(25),andcondomusebycouplesinlongtermpartnerships
mightdecreasethetimerequiredtoclearHPVintheinfectedwoman.SkinnotcoveredbyacondomremainsvulnerabletoHPV
infection.HPVvaccinesareavailableandrecommendedforgirlsandyoungwomenaged926years,eventhosewhohavebeen
diagnosedwithHPVinfection.Malepartnerscanbevaccinatedwiththequadrivalentvaccine(Gardasil)topreventgenitalwarts.

VaccinePreventableSTDs
SeveralSTDscanbeeffectivelypreventedthroughpreexposurevaccinationwithwidelyavailablevaccines,includingHAV,HBV,
andHPV.VaccinesforotherSTDs(e.g.,HIVandHSV)areunderdevelopmentorareundergoingclinicaltrials.Thisguidance
focuseslargelyonintegratingtheuseofavailablevaccinesintoSTDpreventionandtreatmentactivities.
EverypersonbeingevaluatedortreatedforanSTDshouldreceivehepatitisBvaccinationunlessalreadyvaccinated.Inaddition,
somepersons(e.g.,MSMandIDUs)shouldreceivehepatitisAvaccination.

HepatitisA
HepatitisA,causedbyinfectionwithHAV,hasanincubationperiodofapproximately28days(range:1550days).HAVreplicates
intheliverandisshedinhighconcentrationsinfecesfrom2weeksbeforeto1weekaftertheonsetofclinicalillness.HAVinfection
producesaselflimiteddiseasethatdoesnotresultinchronicinfectionorchronicliverdisease(CLD).However,10%15%of
patientsexperiencearelapseofsymptomsduringthe6monthsafteracuteillness.AcuteliverfailurefromhepatitisAisrare(overall
casefatalityrate:0.5%).Theriskforsymptomaticinfectionisdirectlyrelatedtoage,with>80%ofadultshavingsymptoms
compatiblewithacuteviralhepatitisandmostchildrenhavingeitherasymptomaticorunrecognizedinfection.Antibodyproduced
inresponsetoHAVinfectionpersistsforlifeandconfersprotectionagainstreinfection.
HAVinfectionisprimarilytransmittedbythefecaloralroute,byeitherpersontopersoncontactorthroughconsumptionof
contaminatedfoodorwater.Althoughviremiaoccursearlyininfectionandcanpersistforseveralweeksafteronsetofsymptoms,
bloodbornetransmissionofHAVisuncommon.HAVoccasionallyisdetectedinsalivainexperimentallyinfectedanimals,but
transmissionbysalivahasnotbeendemonstrated.
IntheUnitedStates,almosthalfofallpersonswithhepatitisAreporthavingnoriskfactorforthedisease.Amongadultswith
identifiedriskfactors,mostcasesoccuramonginternationaltravelers,householdorsexualcontacts,nonhouseholdcontacts(e.g.,
thoseencounteredthroughplayanddaycare),andIDUs(437).BecausetransmissionofHAVduringsexualactivityprobablyresults
fromfecaloralcontact,measurestypicallyusedtopreventthetransmissionofotherSTDs(e.g.,useofcondoms)donotprevent
HAVtransmission.Inaddition,effortstopromotegoodpersonalhygienehavenotbeensuccessfulininterruptingoutbreaksof
hepatitisA.VaccinationisthemosteffectivemeansofpreventingHAVtransmissionamongpersonsatriskforinfection(e.g.,MSM,

illegaldrugusers,andpersonswithCLD),manyofwhommightseekservicesinSTDclinics.

Diagnosis
ThediagnosisofhepatitisAcannotbemadeonclinicalgroundsaloneserologictestingalsoisrequired.ThepresenceofIgM
antibodytoHAVisdiagnosticofacuteHAVinfection.ApositivetestfortotalantiHAVindicatesimmunitytoHAVinfectionbut
doesnotdifferentiatecurrentfrompreviousHAVinfection.Althoughusuallynotsensitiveenoughtodetectthelowlevelof
protectiveantibodyaftervaccination,antiHAVtestsalsomightbepositiveafterhepatitisAvaccination.

Treatment
PatientswithacutehepatitisAusuallyrequireonlysupportivecare,withnorestrictionsindietoractivity.Hospitalizationmightbe
necessaryforpatientswhobecomedehydratedbecauseofnauseaandvomitingandiscriticalforpatientswithsignsorsymptomsof
acuteliverfailure.Medicationsthatmightcauseliverdamageoraremetabolizedbythelivershouldbeusedwithcautionamong
personswithhepatitisA.

Prevention
TwoproductsareavailableforthepreventionofHAVinfection:hepatitisAvaccine(Table2)andimmuneglobulin(IG)forIM
administration.HepatitisAvaccinesarepreparedfromformalininactivated,cellculturederivedHAVandhavebeenavailablein
theUnitedStatessince1995,initiallyforpersonsaged2years.In2005,thevaccineswereapprovedbyFDAforpersonsaged12
months,andthevaccineisavailableforeligiblechildrenandadolescentsaged<19yearsthroughtheVFCprogram(telephone:800
2324636).
AdministeredIMina2doseseriesat0and612months,thesevaccinesinduceprotectiveantibodylevelsinvirtuallyalladults.By
1monthafterthefirstdose,94%100%ofadultshaveprotectiveantibodylevels100%ofadultsdevelopprotectiveantibodyaftera
seconddose.Inrandomizedcontrolledtrials,theequivalentof1doseofhepatitisAvaccineadministeredbeforeexposurehasbeen
94%100%effectiveinpreventingclinicalhepatitisA(2).Kineticmodelsofantibodydeclineindicatethatprotectivelevelsof
antibodypersistforatleast20years.
IGisasterilesolutionofconcentratedimmunoglobulinspreparedfrompooledhumanplasmaprocessedbycoldethanol
fractionation.IntheUnitedStates,IGisproducedonlyfromplasmathathastestednegativeforhepatitisBsurfaceantigen,
antibodiestoHIVandHCV,andHCVRNA.Inaddition,theprocessusedtomanufactureIGinactivatesviruses(e.g.,HBV,HCV,
andHIV).WhenadministeredIMbeforeorwithin2weeksafterexposuretoHAV,IGis>85%effectiveinpreventingHAV
infections.
AcombinedhepatitisAandhepatitisBvaccinehasbeendevelopedandlicensedforuseasa3doseseriesinadultsaged18years
(Table3).WhenadministeredIMona0,1,and6monthschedule,thevaccinehasequivalentimmunogenicitytothatofthe
monovalentvaccines.
PreexposureVaccination
PersonsinthefollowinggroupswhoarelikelytobetreatedinSTDclinicsettingsshouldbeofferedhepatitisAvaccine:1)allMSM
2)illegaldrugusers(ofbothinjectionandnoninjectiondrugs)and3)personswithCLD,includingpersonswithchronicHBVand
HCVinfectionwhohaveevidenceofCLD.
PrevaccinationSerologicTestingforSusceptibility
ApproximatelyonethirdoftheU.S.populationhasserologicevidenceofpreviousHAVinfection,whichincreaseswithageand
reaches75%amongpersonsaged>70years.ScreeningforHAVinfectionmightbecosteffectiveinpopulationswherethe
prevalenceofinfectionislikelytobehigh(e.g.,personsaged>40yearsandpersonsborninareasofhighHAVendemicity).The
potentialcostsavingsoftestingshouldbeweighedagainstthecostandthelikelihoodthattestingwillinterferewithinitiating
vaccination.Vaccinationofapersonwhoisalreadyimmuneisnotharmful.
PostvaccinationSerologicTesting
Postvaccinationserologictestingisnotindicatedbecausemostpersonsrespondtothevaccine.Inaddition,thecommercially
availableserologictestisnotsensitiveenoughtodetectthelow,butprotective,levelsofantibodyproducedbyvaccination.
PostexposureProphylaxis
PersonswhorecentlyhavebeenexposedtoHAVandwhopreviouslyhavenotreceivedhepatitisAvaccineshouldbeadministereda
singledoseofsingleantigenvaccineorIG(0.02mL/kg)assoonaspossible.Informationabouttherelativeefficacyofvaccine
comparedwithIGpostexposureislimited,andnodataareavailableforpersonsaged>40yearsorthosewithunderlyingmedical
conditions.Therefore,decisionstousevaccineorIGshouldtakeintoaccountpatientcharacteristicsassociatedwithmoresevere
manifestationsofhepatitisA,includingolderageandCLD.
Forhealthypersonsaged12monthsto40years,singleantigenhepatitisAvaccineattheageappropriatedoseispreferredoverIG
becauseofvaccineadvantages,includinglongtermprotectionandeaseofadministration.Forpersonsaged>40years,IGis
preferredbecauseoftheabsenceofinformationregardingvaccineperformanceandthemoreseveremanifestationsofhepatitisAin
thisagegroupvaccinecanbeusedifIGcannotbeobtained.ThemagnitudeoftheriskforHAVtransmissionfromtheexposure
shouldbeconsideredindecisionstouseIGorvaccine.IGshouldbeusedforchildrenaged<12months,immunocompromised

persons,personswhohavehaddiagnosedCLD,andpersonsforwhomvaccineiscontraindicated.
IfIGisadministeredtopersonsforwhomhepatitisAvaccinealsoisrecommended,adoseofvaccineshouldbeprovided
simultaneouslywithIG.Thesecondvaccinedoseshouldbeadministeredaccordingtothelicensedscheduletocompletetheseries.
TheefficacyofIGorvaccinewhenadministered>2weeksafterexposurehasnotbeenestablished(438).

SpecialConsiderations
LimiteddataindicatethatvaccinationofpersonswithCLDandofpersonswithadvancedHIVinfectionresultsinlower
seroprotectionratesandantibodyconcentrations(4).InHIVinfectedpersons,antibodyresponsemightbedirectlyrelatedtoCD4+
levels.

HepatitisB
HepatitisBiscausedbyinfectionwiththehepatitisBvirus(HBV).Theincubationperiodfromthetimeofexposuretoonsetof
symptomsis6weeksto6months.ThehighestconcentrationsofHBVarefoundinblood,withlowerconcentrationsfoundinother
bodyfluidsincludingwoundexudates,semen,vaginalsecretions,andsaliva(439,440).HBVismoreinfectiousandrelativelymore
stableintheenvironmentthanotherbloodbornepathogenslikeHCVandHIV.
HBVinfectioncanbeselflimitedorchronic.Inadults,onlyapproximatelyhalfofnewlyacquiredHBVinfectionsaresymptomatic,
andapproximately1%ofreportedcasesresultinacuteliverfailureanddeath.Riskforchronicinfectionisinverselyrelatedtoageat
acquisitionapproximately90%ofinfectedinfantsand30%ofinfectedchildrenaged<5yearsbecomechronicallyinfected,
comparedwith2%6%ofpersonswhobecomeinfectedasadults.AmongpersonswithchronicHBVinfection,theriskfor
prematuredeathfromcirrhosisorhepatocellularcarcinoma(HCC)is15%25%.
HBVisefficientlytransmittedbypercutaneousormucousmembraneexposuretobloodorbodyfluidsthatcontainblood.The
primaryriskfactorsassociatedwithinfectionamongadolescentsandadultsareunprotectedsexwithaninfectedpartner,
unprotectedsexwithmorethanonepartner,MSM,historyofotherSTDs,andillegalinjectiondruguse.Inaddition,severalstudies
havedemonstratedthehorizontaltransmissionofHBV,includingthroughpremastication,asalesscommonsourceoftransmission
(441,442).
CDC'snationalstrategytoeliminatetransmissionofHBVinfectionincludes1)preventionofperinatalinfectionthroughroutine
screeningofallpregnantwomenforHBsAgandimmunoprophylaxisofinfantsborntoHBsAgpositivemothersormotherswhose
HBsAgstatusisunknown,2)routineinfantvaccination,3)vaccinationofpreviouslyunvaccinatedchildrenandadolescentsthrough
age18years,and4)vaccinationofpreviouslyunvaccinatedadultsatincreasedriskforinfection(3,4).Highvaccinationcoverage
rates,withsubsequentdeclinesinacutehepatitisBincidence,havebeenachievedamonginfantsandadolescents(4,437,443).In
contrast,vaccinationcoverageamongmosthighriskadultgroups(e.g.,personswithmorethanonesexpartnerintheprevious6
months,MSM,andIDUs)hasremainedlow,andmostnewinfectionsoccurinthesehighriskgroups(3,108,444446).STDclinics
andothersettingsthatprovideservicestohighriskadultsareidealsitesinwhichtoprovidehepatitisBvaccinationtoadultsatrisk
forHBVinfection.AllunvaccinatedadultsseekingservicesinthesesettingsshouldbeassumedtobeatriskforhepatitisBand
shouldbeofferedhepatitisBvaccination.

Diagnosis
DiagnosisofacuteorchronicHBVinfectionrequiresserologictesting(Table4).BecauseHBsAgispresentinbothacuteandchronic
infection,thepresenceofIgMantibodytohepatitisBcoreantigen(IgMantiHBc)isdiagnosticofacuteorrecentlyacquiredHBV
infection.AntibodytoHBsAg(antiHBs)isproducedafteraresolvedinfectionandistheonlyHBVantibodymarkerpresentafter
vaccination.ThepresenceofHBsAgandtotalantiHBc,withanegativetestforIgMantiHBc,indicateschronicHBVinfection.The
presenceofantiHBcalonemightindicateafalsepositiveresultoracute,resolved,orchronicinfection.

Treatment
NospecifictherapyisavailableforpersonswithacutehepatitisBtreatmentissupportive.PersonswithchronicHBVinfection
shouldbereferredforevaluationtoaphysicianexperiencedinthemanagementofCLD.TherapeuticagentsclearedbyFDAfor
treatmentofchronichepatitisBcanachievesustainedsuppressionofHBVreplicationandremissionofliverdiseaseinsome
persons.Inaddition,patientswithchronichepatitisBmightbenefitfromscreeningtodetectHCCatanearlystage.

Prevention
TwoproductshavebeenapprovedforhepatitisBprevention:hepatitisBimmuneglobulin(HBIG)andhepatitisBvaccine(3,4).
HBIGprovidestemporary(i.e.,36months)protectionfromHBVinfectionandistypicallyusedasPEPeitherasanadjunctto
hepatitisBvaccinationinpreviouslyunvaccinatedpersonsoraloneinpersonswhohavenotrespondedtovaccination.HBIGis
preparedfromplasmaknowntocontainhighconcentrationsofantiHBs.TherecommendeddoseofHBIGis0.06mL/kg.
HepatitisBvaccinecontainsHBsAgproducedinyeastbyrecombinantDNAtechnologyandprovidesprotectionfromHBVinfection
whenusedforbothpreexposurevaccinationandPEP.ThetwoavailablemonovalenthepatitisBvaccinesforuseinadolescentsand
adultsareRecombivaxHB(MerckandCo.,Inc.,WhitehouseStation,NewJersey)andEngerixB(GlaxoSmithKlineBiologicals,
Pittsburgh,Pennsylvania).Acombinationvaccine(hepatitisAandhepatitisB)foruseinadults,Twinrix(GlaxoSmithKline
Biologicals,Pittsburgh,Pennsylvania),alsoisavailable.TherecommendedHBVdosevariesbyproductandageofrecipient(Table
3).
WhenselectingahepatitisBvaccinationschedule,thehealthcareprovidershouldconsidertheneedtoachievecompletionofthe

vaccineseries.ApprovedadolescentandadultschedulesforbothmonovalenthepatitisBvaccine(i.e.,EngerixBandRecombivax
HB)includethefollowing:0,1,and6months0,1,and4monthsand0,2,and4months.A4dosescheduleofEngerixBat0,1,2,
and12monthsislicensedforallagegroups.A2dosescheduleofRecombivaxHBadultformulation(10g)islicensedfor
adolescentsaged1115years.Whenscheduledtoreceivetheseconddose,adolescentsaged>15yearsshouldbeswitchedtoa3
doseseries,withdosestwoandthreeconsistingofthepediatricformulation(5g)administeredonanappropriateschedule.
Twinrixcanbeadministeredtopersonsaged18yearsatriskforbothHAVandHBVinfectionsat0,1,and6months.
HepatitisBvaccineshouldbeadministeredIMinthedeltoidmuscleandcanbeadministeredsimultaneouslywithothervaccines.
Foradolescentsandadults,theneedlelengthshouldbe12inches,dependingontherecipient'sweight(1inchforfemalesweighing
<70kg,1.5inchesformalesweighing<120kg,and2inchesformalesandfemalesweighing>120kgand>100kg,respectively).A
22to25gaugeneedleisrecommended.Ifthevaccineseriesisinterruptedafterthefirstorseconddoseofvaccine,themisseddose
shouldbeadministeredassoonaspossible.Theseriesdoesnotneedtoberestartedafteramisseddose.
Inadolescentsandhealthyadultsaged<40years,approximately30%55%acquireaprotectiveantibodyresponse(antiHBs10
mIU/mL)afterthefirstvaccinedose,75%afterthesecond,and>90%afterthethird.Vaccineinducedimmunememoryhasbeen
demonstratedtopersistforatleast1520years.Periodictestingtodetermineantibodylevelsafterroutinevaccinationin
immunocompetentpersonsisnotnecessary,andboosterdosesofvaccinearenotcurrentlyrecommended.
HepatitisBvaccinationisgenerallywelltoleratedbymostrecipients.Painattheinjectionsiteandlowgradefeverarereportedbya
minorityofrecipients.Forchildrenandadolescents,acausalassociationexistsbetweenreceiptofhepatitisBvaccinationand
anaphylaxis:foreach1.1milliondosesofvaccineadministered,approximatelyonevaccineewillexperiencethistypeofreaction.No
deathshavebeenreportedinthesepatients(3,4,447).Vaccineiscontraindicatedinpersonswithahistoryofanaphylaxisaftera
previousdoseofhepatitisBvaccineandinpersonswithaknownanaphylacticreactiontoanyvaccinecomponent.Noevidencefora
causalassociationhasbeendemonstratedforotheradverseeventsafteradministrationofhepatitisBvaccine.
PreexposureVaccination
HepatitisBvaccinationisrecommendedforallunvaccinatedadolescents,allunvaccinatedadultsatriskforHBVinfection,andall
adultsseekingprotectionfromHBVinfection.Foradults,acknowledgementofaspecificriskfactorisnotarequirementfor
vaccination.
HepatitisBvaccineshouldberoutinelyofferedtoallunvaccinatedpersonsattendingSTDclinicsandtoallunvaccinatedpersons
seekingtreatmentforSTDsinothersettings.Othersettingswhereallunvaccinatedadultsshouldbeassumedtobeatriskfor
hepatitisBandshouldreceivehepatitisBvaccinationincludecorrectionalfacilities,facilitiesprovidingdrugabusetreatmentand
preventionservices,healthcaresettingsservingMSM,andHIVtestingandtreatmentfacilities.Allpersonswhoreceiveclinical
servicesinthesesettingsshouldbeofferedhepatitisBvaccineunlesstheyhaveareliablevaccinationhistory(i.e.,awritten,dated
recordofeachdoseofacompleteseries).Inallsettings,vaccinationshouldbeinitiatedevenwhencompletionofthevaccineseries
cannotbeensured.
PrevaccinationAntibodyScreening
Prevaccinationserologictestingforsusceptibilitymightbeconsideredtoreducethecostofvaccinatingadultpopulationsthathave
anexpectedhighprevalence(20%30%)ofHBVinfection(e.g.,IDUsandMSM,especiallythoseinolderagegroups).Inaddition,
prevaccinationtestingforsusceptibilityisrecommendedforunvaccinatedhousehold,sexual,andneedlesharingcontactsof
HBsAgpositivepersons(108).
AntiHBcisthetestofchoiceforprevaccinationtestingpersonswhoareantiHBcpositiveshouldbetestedforHBsAg.Ifpersons
aredeterminedtobeHBsAgnegative,nofurtheractionisrequired.IfpersonsaredeterminedtobeHBsAgpositive,theperson
shouldbereferredformedicalfollowuptoincludecounselingandevaluationforantiviraltreatment(seeManagementofHBsAg
PositivePersons).Inaddition,allhouseholdmembers,sexpartners,andneedlesharingpartnersofHBsAgpositivepersonsshould
bevaccinated.
Serologictestingshouldnotbeabarriertovaccinationofsusceptiblepersons,especiallyinpopulationsthataredifficulttoaccess.
Inmostcases,thefirstvaccinedoseshouldbeadministeredimmediatelyaftercollectionofthebloodsampleforserologictesting.
VaccinationofpersonswhoareimmunetoHBVinfectionbecauseofcurrentorpreviousinfectionorvaccinationdoesnotincrease
theriskforadverseevents.
PostvaccinationTestingforSerologicResponse
Serologictestingforimmunityisnotnecessaryafterroutinevaccinationofadolescentsoradults.However,suchtestingis
recommendedforpersonswhosesubsequentclinicalmanagementdependsonknowledgeoftheirimmunestatus(e.g.,healthcare
workersorpublicsafetyworkersathighriskforcontinuedpercutaneousormucosalexposuretobloodorbodyfluids).Inaddition,
postvaccinationtestingisrecommendedfor1)HIVinfectedpersonsandotherimmunocompromisedpersonstodeterminetheneed
forrevaccinationandthetypeoffollowuptestingand2)sexandneedlesharingpartnersofHBsAgpositivepersonstodetermine
theneedforrevaccinationandforothermethodstoprotectthemselvesfromHBVinfection.
Ifindicated,testingshouldbeperformed12monthsafteradministrationofthelastdoseofthevaccineseriesbyusingamethod
thatallowsdeterminationofaprotectivelevelofantiHBs(i.e.,10mIU/mL).PersonsdeterminedtohaveantiHBslevelsof<10
mIU/mLaftertheprimaryvaccineseriesshouldberevaccinatedwitha3doseseriesandprovidedwithantiHBstesting12

monthsafterthethirddose.PersonswhodonotrespondtorevaccinationshouldbetestedforHBsAg.IfHBsAgpositive,theperson
shouldreceiveappropriatemanagement(seeManagementofHBsAgPositivePersons)ifHBsAgnegative,thepersonshouldbe
consideredsusceptibletoHBVinfectionandcounseledconcerningprecautionstopreventHBVinfectionandtheneedforHBIG
PEPforanyknownexposure(seePostexposureProphylaxis).
PostexposureProphylaxis
BothpassiveactivePEP(theadministrationofHBIGandhepatitisBvaccineatseparatesites)andactivePEP(theadministrationof
hepatitisBvaccinationalone)havebeendemonstratedtobehighlyeffectiveinpreventingtransmissionafterexposuretoHBV(4).
HBIGalonealsohasbeendemonstratedtobeeffectiveinpreventingHBVtransmission,butwiththeavailabilityofhepatitisB
vaccine,HBIGtypicallyisusedasanadjuncttovaccination.
ExposuretoHBsAgPositiveSource
UnvaccinatedpersonsorpersonsknownnottohaverespondedtoacompletehepatitisBvaccineseriesshouldreceivebothHBIG
andhepatitisvaccineassoonaspossible(preferably24hours)afteradiscrete,identifiableexposuretobloodorbodyfluidsthat
containbloodfromanHBsAgpositivesource(Table5).HepatitisBvaccineshouldbeadministeredsimultaneouslywithHBIGata
separateinjectionsite,andthevaccineseriesshouldbecompletedbyusingtheageappropriatevaccinedoseandschedule(Table
3).Exposedpersonswhoareintheprocessofbeingvaccinatedbutwhohavenotcompletedthevaccineseriesshouldreceivethe
appropriatedoseofHBIG(i.e.,0.06mL/kg)andshouldcompletethevaccineseries.Exposedpersonswhoareknowntohave
respondedtovaccinationareconsideredprotectedtherefore,theyneednoadditionaldosesofvaccine.Personswhohavewritten
documentationofacompletehepatitisBvaccineserieswhodidnotreceivepostvaccinationtestingshouldreceiveasinglevaccine
boosterdose.Alternatively,thesepersonscanbemanagedaccordingtoguidelinesformanagementofpersonswithoccupational
exposuretobloodorbodyfluidsthatcontainblood(446).
ExposuretoSourcewithUnknownHBsAgStatus
Unvaccinatedpersonswhohaveadiscrete,identifiableexposuretobloodorbodyfluidscontainingbloodfromasourcewith
unknownHBsAgstatusshouldreceivethehepatitisBvaccineseries,withthefirstdoseinitiatedassoonaspossibleafterexposure
(preferablywithin24hours)andtheseriescompletedbyusingtheageappropriatedoseandschedule.Exposedpersonswhoarenot
fullyvaccinatedshouldcompletethevaccineseries.ExposedpersonswithwrittendocumentationofacompletehepatitisBvaccine
seriesrequirenofurthertreatment.

SpecialConsiderations
Pregnancy
AllpregnantwomenreceivingSTDservicesshouldbetestedforHBsAg,regardlessofwhethertheyhavebeenpreviouslytestedor
vaccinated.AllHBsAgpositivepregnantwomenshouldbereportedtostateandlocalperinatalhepatitisBpreventionprograms.
HBsAgnegativepregnantwomenseekingSTDtreatmentwhohavenotbeenpreviouslyvaccinatedshouldreceivehepatitisB
vaccination.AdditionalinformationregardingmanagementofHBsAgpositivepregnantwomenandtheirinfantsisavailableat
http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf .
HIVInfection
HIVinfectioncanimpairtheresponsetohepatitisBvaccination.HIVinfectedpersonsshouldbetestedforantiHBs12months
afterthethirdvaccinedose(seePostvaccinationTestingforSerologicResponse).Modifieddosingregimens,includingadoublingof
thestandardantigendoseandadministrationofadditionaldoses,mightincreasetheresponserate(130).
ManagementofHBsAgPositivePersons
ThissectionprovidesrecommendationsformanagementofallHBsAgpositivepersons.Additionalrecommendationsfor
managementofHBsAgpositivepersonswhoarecoinfectedwithHIVareavailable(130).
AllpersonswithHBsAgpositivelaboratoryresultsshouldbereportedtothestateorlocalhealthdepartment.
ToverifythepresenceofchronicHBVinfection,HBsAgpositivepersonsshouldberetested.TheabsenceofIgMantiHBcor
thepersistenceofHBsAgfor6monthsindicateschronicHBVinfection.
PersonswithchronicHBVinfectionshouldbereferredforevaluationtoaphysicianexperiencedinthemanagementofCLD.
SomepatientswithchronichepatitisBwillbenefitfromearlyinterventionwithantiviraltreatmentorscreeningtodetectHCC
atanearlystage.
Household,sexual,andneedlesharingcontactsofchronicallyinfectedpersonsshouldbeidentified.Unvaccinatedsexpartners
andhouseholdandneedlesharingcontactsshouldbetestedforsusceptibilitytoHBVinfection(seePrevaccinationAntibody
Screening)andshouldreceivethefirstdoseofhepatitisBvaccineimmediatelyaftercollectionofthebloodsampleforserologic
testing.Susceptiblepersonsshouldcompletethevaccineseriesbyusinganageappropriatevaccinedoseandschedule.
SexpartnersofHBsAgpositivepersonsshouldbecounseledtouselatexcondoms(448)toprotectthemselvesfromsexual
exposuretoinfectiousbodyfluids(e.g.,semenandvaginalsecretions),unlesstheyhavebeendemonstratedtobeimmuneafter
vaccination(antiHBs10mIU/mL)orpreviouslyinfected(antiHBcpositive).
Topreventorreducetheriskfortransmissiontoothers,HBsAgpositivepersonsshouldbeadvisedabouttheriskfor
transmissiontohousehold,sexual,andneedlesharingcontactsandtheneedforsuchcontactstoreceivehepatitisB

vaccination.HBsAgpositivepersonsalsoshouldbeadvisedto:
usemethods(e.g.,condoms)toprotectnonimmunesexpartnersfromacquiringHBVinfectionfromsexualactivityuntilthe
partnercanbevaccinatedandimmunitydocumented
covercutsandskinlesionstopreventspreadbyinfectioussecretionsorblood
refrainfromdonatingblood,plasma,bodyorgans,othertissue,orsemenan
refrainfromsharinghouseholdarticles(e.g.,toothbrushes,razors,orpersonalinjectionequipment)thatcouldbecome
contaminatedwithblood.Inaddition,HBsAgpositivepersonsshouldrefrainfrompremasticatingfoodprovidedtosusceptible
persons.
Toprotecttheliverfromfurtherharm,HBsAgpositivepersonsshouldbeadvisedto:
avoidorlimitalcoholconsumptionbecauseoftheeffectsofalcoholontheliver
refrainfromstartinganynewmedicines,includingOTCandherbalmedicines,withoutcheckingwiththeirhealthcare
providerand
obtainvaccinationagainsthepatitisAifliverdiseaseisdeterminedtobepresent.
Whenseekingmedicalordentalcare,HBsAgpositivepersonsshouldbeadvisedtoinformtheirhealthcareprovidersoftheir
HBsAgstatussothattheycanbeappropriatelyevaluatedandmanaged.Thefollowingcounselingmessagesshouldbeconsidered
forHBsAgpositivepersons:
HBVisnotusuallyspreadbyhugging,coughing,foodorwater,sharingeatingutensilsordrinkingglasses,orcasualcontact.
Personsshouldnotbeexcludedfromwork,school,play,childcare,orothersettingsbecausetheyareinfectedwithHBV.
InvolvementwithasupportgroupmighthelppatientscopewithchronicHBVinfection.

HepatitisC
HepatitisCvirus(HCV)infectionisthemostcommonchronicbloodborneinfectionintheUnitedStatesanestimated3.2million
personsarechronicallyinfected(449).AlthoughHCVisnotefficientlytransmittedsexually,personsatriskforinfectionthrough
injectiondrugusemightseekcareinSTDtreatmentfacilities,HIVcounselingandtestingfacilities,correctionalfacilities,drug
treatmentfacilities,andotherpublichealthsettingswhereSTDandHIVpreventionandcontrolservicesareavailable.
PersonsnewlyinfectedwithHCVtypicallyareeitherasymptomaticorhaveamildclinicalillness.HCVRNAcanbedetectedin
bloodwithin13weeksafterexposure.TheaveragetimefromexposuretoantibodytoHCV(antiHCV)seroconversionis89
weeks,andantiHCVcanbedetectedin>97%ofpersonsby6monthsafterexposure.ChronicHCVinfectiondevelopsin70%85%
ofHCVinfectedpersons60%70%ofchronicallyinfectedpersonsdevelopevidenceofactiveliverdisease.Mostinfectedpersons
remainunawareoftheirinfectionbecausetheyarenotclinicallyill.However,infectedpersonsserveasasourceoftransmissionto
othersandareatriskforCLDandotherHCVrelatedchronicdiseasesfordecadesafterinfection.
HCVistransmittedthroughparenteralexposurestocontaminatedblood,usuallythroughuseofinjectiondrugs(sharingofneedles
orworks)andtoalesserextentthroughexposuresinhealthcaresettingsasaconsequenceofinadequateinfectioncontrol
practices.Transmissionrarelyfollowsreceiptofblood,tissues,andorgansfromHCVinfecteddonorswhowerenotidentified
duringroutinescreeningactivities,whichhavebeenmandatedintheUnitedStatessince1992.Occupationalandperinatal
exposures,althoughlessefficient,alsocanresultintransmissionofHCV.
SexualtransmissionofHCVhadbeenconsideredtooccurrarely.However,recentdataindicatethatsexualtransmissionofHCVcan
occur,especiallyamongHIVinfectedpersons.CDCsurveillancedatademonstratethat10%ofpersonswithacuteHCVinfection
reportcontactwithaknownHCVinfectedsexpartnerastheironlyriskforinfection(437).SpecificstudiesofHCVtransmission
betweenheterosexualorhomosexualcoupleshaveyieldedmixedresults,butgenerallyhavefoundlowbutincreasedratesofHCV
infectioninpartnersofpersonswithHCVinfectioncomparedwiththosewhosepartnersarenotHCVinfected(450455).Several
studieshaverevealedthatriskincreasescommensuratewithincreasingnumbersofsexpartnersamongheterosexualpersons
(450,451,456458)andMSM(459462),especiallyifthosepartnersarecoinfectedwithHIV(459465).
ApparentsexualtransmissionofHCVhasrecentlybeenreportedamongHIVinfectedMSMinmultipleEuropeancities(464,465)
andNewYorkCity(466).Commonpracticesassociatedwiththeseclustersofinfectionincludeserosorting(i.e.,HIVinfectedmen
havingsexwithoneanother),groupsex,andtheuseofcocaineandothernonintravenousdrugsduringsex.
AllpersonswithHIVinfectionshouldundergoserologictestingforHCVatinitialevaluation(130,131).HIVinfectedMSMcanalso
acquireHCVafterinitialscreening.Liverfunctiontestsshouldbeseriallymonitoredforabnormalitiesthatcouldbecausedbyacute
viralhepatitisormedicationtoxicity.HIVinfectedpersonswithnewandunexplainedincreasesinALTshouldbetestedforacute
HCVinfection.ToensurethedetectionofacuteHCVinfectionamongHIVinfectedMSMwithhighrisksexualbehaviorsor
concomitantulcerativeSTDs,routineHCVtestingofHIVinfectedMSMshouldbeconsidered.AcutehepatitisCisareportable
conditionin49states,andmatchingviralhepatitisandHIVsurveillanceregistriescanfacilitateearlydetectionofsocialnetworksof
HCVtransmissionamongHIVinfectedMSM.Suspectedclustersofacuteinfectionshouldbereportedtotheappropriatepublic
healthauthorities.UnprotectedsexualcontactbetweenHIVinfectedpartnerscanfacilitatespreadofHCV,astheviruscanbe
recoveredfromthesemenofmencoinfectedwithHIV(467).Specificpreventionpractices(e.g.,barrierprecautionsthatlimit
contactwithbodyfluidsduringsexualcontactwithotherMSM)shouldbediscussedwithpatients.

DiagnosisandTreatment
AntiHCVtestingisrecommendedforroutinescreeningofasymptomaticpersonsbasedontheirriskforinfectionorbasedona

recognizedexposure(seeHepatitisC,Prevention).Forsuchpersons,testingforHCVinfectionshouldincludetheuseofanFDA
clearedtestforantibodytoHCV(i.e.,immunoassay,EIA,orenhancedchemiluminescenceimunoassayand,ifrecommended,a
supplementalantibodytest)(468).
PersonscounseledandtestedforHCVinfectionanddeterminedtobeantiHCVpositiveshouldbeevaluated(byreferralor
consultation,ifappropriate)forthepresenceofactiveinfection,presenceordevelopmentofCLD,andpossibletreatment.Nucleic
acidtesting,includingreversetranscriptasepolymerasechainreaction(RTPCR)todetectHCVRNA,isnecessarytoconfirmthe
diagnosisofcurrentHCVinfection,andanelevatedALTlevelisbiochemicalevidenceofCLD.Combinationtherapywithpegylated
interferonandribavirinisthetreatmentofchoiceforpatientswithchronichepatitisC.Providersshouldconsultwithspecialists
knowledgeableaboutmanagementofhepatitisCinfectionbecausetheseexpertsremaincognizantofthelatestadvancesinthefield
ofantiviraltherapyforacuteandchronichepatitisC.

Prevention
NovaccineforhepatitisCisavailable,andprophylaxiswithimmuneglobulinisnoteffectiveinpreventingHCVinfectionafter
exposure.ReducingtheburdenofHCVinfectionanddiseaseintheUnitedStatesrequiresimplementationofbothprimaryand
secondarypreventionactivities.PrimarypreventionreducesoreliminatesHCVtransmission,whereassecondaryprevention
activitiesareaimedatreducingCLDandotherchronicdiseasesinHCVinfectedpersonsbyfirstidentifyingthemandthen
providingmedicalmanagementandantiviraltherapy,ifappropriate.
MostscientificevidencedemonstratesthatalthoughHCVcanbetransmittedsexually,suchtransmissionhappensrarely.Because
incidentHCVhasnotbeendemonstratedtooccurinheterosexualpartnerpairsfollowedovertime(452454),condomusemight
notbenecessaryinsuchcircumstances.However,heterosexualandhomosexualpersons,especiallythosewithconcurrentHIV
infectionorwithmorethanonepartner,shouldprotectthemselvesandtheirpartnersagainsttransmissionofHCV,HBV,HIV,and
otherpathogensbyuseofmalelatexcondoms.CondomuseisespeciallyimportantforHIVinfectedmen,whomightspreadHCVto
othermenthoughunprotectedsexualactivity(464466).
ProvidersinSTDclinicsandotherprimarycaresettingsshouldidentifythosepersonswhoshouldbeofferedHCVcounselingand
testing.InSTDclinicsandothersettingsthatservelargenumbersofpersonsathighriskforbloodborneinfections(e.g.,
correctionalsettings),themajorriskfactornecessitatingscreeningforHCVinfectionispastorcurrentinjectionofillegaldrugs.
BecausebothHCVandHIVaretransmittedthroughinjectiondruguse,aboutonefourthofallHIVpatientsarealsocoinfectedwith
HCV.Forthisreason,allpersonswithHIVinfectionshouldbeofferedHCVcounselingandtesting.Otherriskfactorsforwhich
routineHCVtestingisrecommendedinclude:
havinghadabloodtransfusionorsolidorgantransplantbeforeJuly1992
havingreceivedclottingfactorconcentratesproducedbefore1987
havingbeenonlongtermdialysisand
havingsignsandsymptomsofliverdisease(e.g.,abnormalALT).
PersonswhotestnegativeforantiHCVwhohadanexposurepreviouslyshouldbereassuredthattheyarenotinfected.Thosewho
testpositiveforantiHCV(seeDiagnosisandTreatment)shouldbeprovidedinformationregardinghowtoprotecttheirliverfrom
furtherharmforinstance,HCVpositivepersonsshouldbeadvisedtoavoiddrinkingalcoholandtakinganynewmedicines
(includingOTCandherbals)withoutcheckingwiththeirclinician.
Toreducetheriskfortransmissiontoothers,HCVpositivepersonsshouldbeadvisedto1)notdonateblood,bodyorgans,other
tissue,orsemen2)notshareanypersonalitemsthatmighthavebloodonthem(e.g.,toothbrushesandrazors)and3)covercuts
andsoresontheskintokeepthevirusfromspreadingbybloodorsecretions.HCVpositivepersonswithonelongterm,steadysex
partnerdonotneedtochangetheirsexualpractices.Theyshoulddiscussthelowbutpresentriskfortransmissionwiththeir
partneranddiscusstheneedforcounselingandtesting.HCVpositivewomendonotneedtoavoidpregnancyorbreastfeeding.
HCVpositivepersonsshouldbeevaluated(byreferralorconsultation,ifappropriate)todetectactiveHCVinfectionandthe
presenceofCLD.Evaluationshouldinvolvetestingforliverfunction,additionalassessmentoftheseverityofliverdisease,possible
treatment,andthedeterminationfortheneedofhepatitisAandBvaccination.
Regardlessoftestresults,personswhouseorinjectillegaldrugsshouldbecounseledtostopusingandinjectingdrugsandtoenter
andcompletesubstanceabusetreatment(includingrelapseprevention).Personswhocontinuetoinjectdrugsdespitecounseling
shouldbeencouragedtotakethefollowingstepstoreducepersonalandpublichealthrisks:
neverreuseorsharesyringes,water,ordrugpreparationequipment
onlyusesyringesobtainedfromareliablesource(e.g.,pharmacies)
useanew,sterilesyringetoprepareandinjectdrugs
ifpossible,usesterilewatertopreparedrugsotherwise,usecleanwaterfromareliablesource(e.g.,freshtapwater)
useanewordisinfectedcontainer(i.e.,cooker)andanewfilter(i.e.,cotton)topreparedrugs
cleantheinjectionsitebeforeinjectionwithanewalcoholswab

safelydisposeofsyringesafteroneuse
getvaccinatedforhepatitisAandBifnonimmuneand
gettestedforHIVinfection.

PostexposureFollowUp
NoPEPhasbeendemonstratedtobeeffectiveagainstHCV.TestingtodeterminewhetherHCVinfectionhasdevelopedis
recommendedforhealthcareworkersafterpercutaneousorpermucosalexposurestoHCVpositiveblood.ChildrenborntoHCV
positivewomenalsoshouldbetestedforHCV.Promptidentificationofacuteinfectionisimportant,becauseoutcomesare
improvedwhentreatmentisinitiatedearlierinthecourseofillness.

SpecialConsiderations
Pregnancy
RoutinetestingforHCVinfectionisnotrecommendedforallpregnantwomen.PregnantwomenwithaknownriskfactorforHCV
infectionshouldbeofferedcounselingandtesting.Patientsshouldbeadvisedthatapproximatelysixofevery100infantsbornto
HCVinfectedwomanbecomeinfectedthisinfectionoccurspredominantlyduringorneardelivery,andnotreatmentordelivery
methodsuchascaesariansectionhasbeendemonstratedtodecreasethisrisk.Theriskisincreased,however,bythepresenceof
maternalHCVviremiaatdeliveryandalsoisgreater(23times)ifthewomaniscoinfectedwithHIV.HCVhasnotbeenshownto
betransmittedthroughbreastmilk,althoughHCVpositivemothersshouldconsiderabstainingfrombreastfeedingiftheirnipples
arecrackedorbleeding.InfantsborntoHCVpositivemothersshouldbetestedforHCVinfectionand,ifpositive,evaluatedforthe
presenceofCLD.

HIVInfection
BecauseofthehighprevalenceofHIV/HCVcoinfectionandbecauseofcriticalclinicalmanagementissuesforcoinfectedpersons,
allpersonswithHIVinfectionshouldundergoserologictestingforHCV.ProvidersshouldbeawareofthelikelihoodthatHIV
infectedMSMwillacquireHCVafterinitialscreening.Liverfunctiontestsshouldbeseriallymonitored,andthosepersonswithnew
andunexplainedincreasesinALTshouldbetestedforacuteHCVinfection.TodetectacuteHCVinfectionamongHIVinfected
MSMwithhighrisksexualbehaviorsorconcomitantulcerativeSTDs,routineHCVtestingofHIVinfectedMSMshouldbe
considered.BecauseasmallpercentageofcoinfectedpersonsfailtoacquireHCVantibodies,HCVRNAshouldbetestedinHIV
positivepersonswithunexplainedliverdiseasewhoareantiHCVnegative.ThecourseofliverdiseaseismorerapidinHIV/HCV
coinfectedpersons,andtheriskforcirrhosisisnearlytwicethatofpersonswithHCVinfectionalone.Coinfectedpersonsreceiving
HIVantiviralregimensarenowbeingtreatedforHCVaftertheirCD4+cellcountsincrease,optimizingtheirimmuneresponse.

Proctitis,Proctocolitis,andEnteritis
Sexuallytransmittedgastrointestinalsyndromesincludeproctitis,proctocolitis,andenteritis.Evaluationforthesesyndromes
shouldincludeappropriatediagnosticprocedures(e.g.,anoscopyorsigmoidoscopy,stoolexamination,andculture).
Proctitisisinflammationoftherectum(i.e.,thedistal1012cm)thatcanbeassociatedwithanorectalpain,tenesmus,orrectal
discharge.N.gonorrhoeae,C.trachomatis(includingLGVserovars),T.pallidum,andHSVarethemostcommonsexually
transmittedpathogensinvolved.InpatientscoinfectedwithHIV,herpesproctitiscanbeespeciallysevere.Proctitisoccurs
predominantlyamongpersonswhoparticipateinreceptiveanalintercourse.
Proctocolitisisassociatedwithsymptomsofproctitis,diarrheaorabdominalcramps,andinflammationofthecolonicmucosa
extendingto12cmabovetheanus.Fecalleukocytesmightbedetectedonstoolexamination,dependingonthepathogen.
PathogenicorganismsincludeCampylobactersp.,Shigellasp.,Entamoebahistolytica,andLGVserovarsofC.trachomatis.CMV
orotheropportunisticagentscanbeinvolvedinimmunosuppressedHIVinfectedpatients.Proctocolitiscanbeacquiredbytheoral
routeorbyoralanalcontact,dependingonthepathogen.
Enteritisusuallyresultsindiarrheaandabdominalcrampingwithoutsignsofproctitisorproctocolitisitoccursamongpersons
whosesexualpracticesincludeoralanalcontact.Inotherwisehealthypersons,Giardialambliaismostfrequentlyimplicated.
WhenoutbreaksofgastrointestinalillnessoccuramongsocialorsexualnetworksofMSM,cliniciansshouldconsidersexual
transmissionasamodeofspreadandprovidecounselingaccordingly.AmongHIVinfectedpatients,gastrointestinalillnesscanbe
causedbyotherinfectionsthatusuallyarenotsexuallytransmitted,includingCMV,Mycobacteriumaviumintracellulare,
Salmonellasp.,Campylobactersp.,Shigellasp.,Cryptosporidium,Microsporidium,andIsospora.Multiplestoolexaminations
mightbenecessarytodetectGiardia,andspecialstoolpreparationsarerequiredtodiagnosecryptosporidiosisand
microsporidiosis.Inaddition,enteritiscanbedirectlycausedbyHIVinfection.
Whenlaboratorydiagnosticcapabilitiesareavailable,treatmentdecisionsshouldbebasedonthespecificdiagnosis.Diagnosticand
treatmentrecommendationsforallentericinfectionsarebeyondthescopeoftheseguidelines.

TreatmentforProctitis
Acuteproctitisofrecentonsetamongpersonswhohaverecentlypracticedreceptiveanalintercourseisusuallysexuallyacquired
(469,470).SuchpatientsshouldbeexaminedbyanoscopyandshouldbeevaluatedforinfectionwithHSV,N.gonorrhoeae,C.
trachomatis,andT.pallidum.Ifananorectalexudateisdetectedonexaminationorifpolymorphonuclearleukocytesaredetected
onaGramstainedsmearofanorectalsecretions,thefollowingtherapyshouldbeprescribedwhileawaitingadditionallaboratory

tests.
RecommendedRegimen
Ceftriaxone250mgIM
PLUS
Doxycycline100mgorallytwiceadayfor7days
Patientswithsuspectedordocumentedherpesproctitisshouldbemanagedinthesamemannerasthosewithgenitalherpes(see
GenitalHSVInfections).Ifpainfulperianalulcersarepresentormucosalulcersaredetectedonanoscopy,presumptivetherapy
shouldincludearegimenforgenitalherpesandLGV.AppropriatediagnostictestingforLGVshouldbeconductedinaccordance
withstateorfederalguidelines,anddoxycyclinetherapyshouldbeadministered100mgorallytwicedailyfor3weeks.
ForMSM,treatmentforLGVproctitis/proctocolitiswith3weeksofdoxycyclineinthosewithanorectalchlamydiaandeither1)
proctitis(asdetectedbyproctoscopicexaminationandthepresenceof>10whitebloodcellsuponhighpowerfieldexaminationof
ananorectalsmearspecimen)or2)HIVinfectioncanbeconsidered.

FollowUp
Followupshouldbebasedonspecificetiologyandseverityofclinicalsymptoms.Reinfectionmightbedifficulttodistinguishfrom
treatmentfailure.

ManagementofSexPartners
Partnersofpersonswithsexuallytransmittedentericinfectionsshouldbeevaluatedforanydiseasesdiagnosedintheindexpatient.

EctoparasiticInfections
PediculosisPubis
Personswhohavepediculosispubis(i.e.,pubiclice)usuallyseekmedicalattentionbecauseofpruritusorbecausetheynoticeliceor
nitsontheirpubichair.Pediculosispubisisusuallytransmittedbysexualcontact.
RecommendedRegimens
Permethrin1%creamrinseappliedtoaffectedareasandwashedoffafter10minutes
OR
Pyrethrinswithpiperonylbutoxideappliedtotheaffectedareaandwashedoffafter10minutes
AlternativeRegimens
Malathion0.5%lotionappliedfor812hoursandwashedoff
OR
Ivermectin250g/kgorally,repeatedin2weeks
Reportedresistancetopediculicideshasbeenincreasingandiswidespread(471473).Malathioncanbeusedwhentreatment
failureisbelievedtohaveresultedfromdrugresistance.Theodorandlongdurationofapplicationformalathionmakeitaless
attractivealternativethantherecommendedpediculcides.Ivermectinhasbeensuccessfullyusedtotreatlice,butithasonlybeen
evaluatedinstudiesinvolvingalimitednumberofparticipants.

OtherManagementConsiderations
Therecommendedregimensshouldnotbeappliedtotheeyes.Pediculosisoftheeyelashesshouldbetreatedbyapplyingocclusive
ophthalmicointmenttotheeyelidmarginstwiceadayfor10days.Beddingandclothingshouldbedecontaminated(i.e.,eitherdry
cleanedormachinewashedanddriedusingtheheatcycle)orremovedfrombodycontactforatleast72hours.Fumigationofliving
areasisnotnecessary.
PatientswithpediculosispubisshouldbeevaluatedforotherSTDs.

FollowUp
Patientsshouldbeevaluatedafter1weekifsymptomspersist.Retreatmentmightbenecessaryiflicearefoundorifeggsare
observedatthehairskinjunction.Patientswhodonotrespondtooneoftherecommendedregimensshouldberetreatedwithan
alternativeregimen.

ManagementofSexPartners
Sexpartnersthathavehadsexualcontactwiththepatientwithinthepreviousmonthshouldbetreated.Patientsshouldabstain
fromsexualcontactwiththeirsexpartner(s)untilpatientsandpartnershavebeentreatedandreevaluatedtoruleoutpersistent

disease.

SpecialConsiderations
Pregnancy
Pregnantandlactatingwomenshouldbetreatedwitheitherpermethrinorpyrethrinswithpiperonylbutoxidelindaneand
ivermectinarecontraindicatedinpregnancyandlactatingwomen.
HIVInfection
PatientswhohavepediculosispubisandalsoareinfectedwithHIVshouldreceivethesametreatmentregimenasthosewhoare
HIVnegative.

Scabies
Thepredominantsymptomofscabiesispruritus,butsensitizationtoSarcoptesscabieioccursbeforepruritusbegins.Thefirsttime
apersonisinfestedwithS.scabiei,sensitizationcantakeseveralweekstodevelop.However,pruritusmightoccurwithin24hours
afterasubsequentreinfestation.Scabiesinadultsfrequentlyissexuallyacquired,althoughscabiesinchildrenusuallyisnot.
RecommendedRegimens
Permethrincream(5%)appliedtoallareasofthebodyfromtheneckdownandwashedoffafter814hours
OR
Ivermectin200ug/kgorally,repeatedin2weeks
AlternativeRegimen
Lindane(1%)1oz.oflotion(or30gofcream)appliedinathinlayertoallareasofthebodyfromtheneckdownandthoroughly
washedoffafter8hours
Lindaneisnotrecommendedasfirstlinetherapybecauseoftoxicity(471).Itshouldonlybeusedasanalternativeifthepatient
cannottolerateothertherapiesorifothertherapieshavefailed.
Lindaneshouldnotbeusedimmediatelyafterabathorshower,anditshouldnotbeusedbypersonswhohaveextensivedermatitis,
womenwhoarepregnantorlactating,orchildrenaged<2years.Lindaneresistancehasbeenreportedinsomeareasoftheworld,
includingpartsoftheUnitedStates(474).Seizureshaveoccurredwhenlindanewasappliedafterabathorusedbypatientswho
hadextensivedermatitis.Aplasticanemiaafterlindaneusealsohasbeenreported(471,474).
Permethriniseffectiveandsafeandlessexpensivethanivermectin(471,474).Onestudydemonstratedincreasedmortalityamong
elderly,debilitatedpersonswhoreceivedivermectin,butthisobservationhasnotbeenconfirmedinsubsequentstudies(475).

OtherManagementConsiderations
Beddingandclothingshouldbedecontaminated(i.e.,eitherdrycleanedormachinewashedanddriedusingthehotcycle)or
removedfrombodycontactforatleast72hours.Fumigationoflivingareasisunnecessary.

CrustedScabies
Crustedscabies(i.e.,Norwegianscabies)isanaggressiveinfestationthatusuallyoccursinimmunodeficient,debilitated,or
malnourishedpersons(476).Patientswhoarereceivingsystemicorpotenttopicalglucocorticoids,organtransplantrecipients,
mentallyretardedorphysicallyincapacitatedpersons,HIVinfectedorhumanTlymphotrophicvirus1infectedpersons,and
personswithvarioushematologicmalignanciesareatriskfordevelopingcrustedscabies.Crustedscabiesisassociatedwithgreater
transmissibilitythanscabies.Nocontrolledtherapeuticstudiesforcrustedscabieshavebeenconducted,andtheappropriate
treatmentremainsunclear.Substantialriskfortreatmentfailuremightexistwithasingletopicalscabicideorwithoralivermectin
treatment.Combinedtreatmentwithatopicalscabicideandrepeatedtreatmentwithoralivermectin200g/kgondays1,2,8,9,
and15aresuggested.Additionaltreatmentondays22and29mightberequiredforseverecases.Ivermectinshouldbecombined
withtheapplicationofeither5%topicalbenzylbenzoateor5%topicalpermethrin(fullbodyapplicationtoberepeateddailyfor7
daysthen2timesweeklyuntilreleasefromcareorcure).Lindaneshouldbeavoidedbecauseoftherisksforneurotoxicity
associatedwithbothheavyapplicationsanddenudedskin.Fingernailsshouldbecloselytrimmedtoreduceinjuryfromexcessive
scratching.

FollowUp
Patientsshouldbeinformedthattherashandpruritusofscabiesmightpersistforupto2weeksaftertreatment.Symptomsorsigns
thatpersistfor>2weekscanbeattributedtoseveralfactors.Treatmentfailurecanbecausedbyresistancetomedication,although
faultyapplicationoftopicalscabicidesalsocancontributetopersistencepatientswithcrustedscabiesmighthavepoor
penetrationintothickscalyskinandharbormitesinthesedifficulttopenetratelayers.Particularattentionmustbegiventothe
fingernailsofthesepatients.Reinfectionfromfamilymembersorfomitescanoccurintheabsenceofappropriatecontacttreatment
andwashingofbeddingandclothing.Evenwhentreatmentissuccessfulandreinfectionisavoided,symptomscanpersistorworsen
asaresultofallergicdermatitis.Finally,thepresenceofhouseholdmitescancausesymptomstopersistasaresultofcross

reactivitybetweenantigens.Retreatmentcanbeconsideredafter12weeksforpatientswhoarestillsymptomaticoriflivemites
arepresent.Treatmentwithanalternativeregimenisrecommendedforpersonswhodonotrespondtotherecommended
treatment.

ManagementofSexPartnersandHouseholdContacts
Sexualcontactsandthosethathavehadclosepersonalorhouseholdcontactwiththepatientwithintheprecedingmonthshouldbe
examinedandtreated.

ManagementofOutbreaksinCommunities,NursingHomes,andOtherInstitutionalSettings
Scabiesoutbreaksfrequentlyoccurinnursinghomes,hospitals,residentialfacilities,andothercommunities.Controlofanepidemic
canonlybeachievedbytreatmentoftheentirepopulationatrisk.Ivermectincanbeconsideredinthissetting,especiallyif
treatmentwithtopicalscabicidesfails.Epidemicsshouldbemanagedinconsultationwithaninfectiousdiseasespecialist.

SpecialConsiderations
Infants,YoungChildren,andPregnantorLactatingWomen
Infants,youngchildren,andpregnantorlactatingwomenshouldnotbetreatedwithlindanehowever,theycanbetreatedwith
permethrin.Ivermectinisnotrecommendedforpregnantorlactatingpatients,andthesafetyofivermectininchildrenwhoweigh
<15kghasnotbeendetermined.
HIVInfection
PatientswhohaveuncomplicatedscabiesandalsoareinfectedwithHIVshouldreceivethesametreatmentregimensasthosewho
areHIVnegative.HIVinfectedpatientsandotherswhoareimmunosuppressedareatincreasedriskforcrustedscabies,forwhich
ivermectinhasbeenreportedtobeeffectiveinnoncontrolledstudiesinvolvingonlyalimitednumberofparticipants.HIVinfected
patientswithcrustedscabiesshouldbemanagedinconsultationwithaninfectiousdiseasespecialist.

SexualAssaultandSTDs
AdultsandAdolescents
Therecommendationsinthisreportarelimitedtotheidentification,prophylaxis,andtreatmentofSTDsandconditionscommonly
identifiedinthemanagementofsuchinfections.Thedocumentationoffindings,collectionofnonmicrobiologicspecimensfor
forensicpurposes,andmanagementofpotentialpregnancyorphysicalandpsychologicaltraumaarebeyondthescopeofthis
report.
Examinationsofsurvivorsofsexualassaultshouldbeconductedbyanexperiencedclinicianinawaythatminimizesfurthertrauma
tothesurvivor.ThedecisiontoobtaingenitalorotherspecimensforSTDdiagnosisshouldbemadeonanindividualbasis.Care
systemsforsurvivorsshouldbedesignedtoensurecontinuity(includingtimelyreviewoftestresults),supportadherence,and
monitorforadversereactionstoanytherapeuticorprophylacticregimensprescribedatinitialexamination.Lawsinall50states
strictlylimittheevidentiaryuseofasurvivor'sprevioussexualhistory,includingevidenceofpreviouslyacquiredSTDs,aspartofan
efforttounderminethecredibilityofthesurvivor'stestimony.Evidentiaryprivilegeagainstrevealinganyaspectoftheexamination
ortreatmentalsoisenforcedinmoststates.Althoughitrarelyoccurs,STDdiagnosesmightlaterbeaccessed,andthesurvivorand
clinicianmightopttodefertestingforthisreason.WhilecollectionofspecimensatinitialexaminationforlaboratorySTDdiagnosis
givesthesurvivorandcliniciantheoptiontodeferempiricprophylacticantimicrobialtreatment,compliancewithfollowupvisitsis
traditionallypoor(477,478).Amongsexuallyactiveadults,theidentificationofanSTDmightrepresentaninfectionacquiredprior
totheassault,andthereforemightbemoreimportantforthepsychologicalandmedicalmanagementofthepatientthanforlegal
purposes.
Trichomoniasis,BV,gonorrhea,andchlamydialinfectionarethemostfrequentlydiagnosedinfectionsamongwomenwhohave
beensexuallyassaulted.Suchconditionsarerelativelyprevalent,andthepresenceafteranassaultdoesnotnecessarilyimply
acquisitionduringtheassault.However,apostassaultexaminationpresentsanimportantopportunitytoidentifyorpreventSTDs.
Chlamydialandgonococcalinfectionsinwomenareofparticularconcernbecauseofthepossibilityofascendinginfection.In
addition,HBVinfectioncanbepreventedbypostexposureadministrationofhepatitisBvaccine.Reproductiveagedfemale
survivorsshouldbeevaluatedforpregnancy,ifappropriate.

EvaluatingAdultsandAdolescentsforSexuallyTransmittedDiseases
InitialExamination
Aninitialexaminationmightincludethefollowingprocedures:
NAATsforC.trachomatisandN.gonorrhoeae.Thesetestsarepreferredforthediagnosticevaluationofsexualassaultvictims,
regardlessofthesitesofpenetrationorattemptedpenetration(197).
WetmountandcultureorpointofcaretestingofavaginalswabspecimenforT.vaginalisinfection.Thewetmountalso
shouldbeexaminedforevidenceofBVandcandidiasis,especiallyifvaginaldischarge,malodor,oritchingisevident.
AserumsampleforimmediateevaluationforHIVinfection,hepatitisB,andsyphilis.Decisionstoperformthesetestsshould
bemadeonanindividualbasis.

FollowUpExaminations
Aftertheinitialpostassaultexamination,followupexaminationsprovideanopportunityto1)detectnewinfectionsacquiredduring
oraftertheassault2)completehepatitisBvaccination,ifindicated3)completecounselingandtreatmentforotherSTDsand4)
monitorsideeffectsandadherencetopostexposureprophylacticmedication,ifprescribed.
ExaminationforSTDscanberepeatedwithin12weeksoftheassault.Becauseinfectiousagentsacquiredthroughassaultmight
nothaveproducedsufficientconcentrationsoforganismstoresultinpositivetestresultsattheinitialexamination,testingcanbe
repeatedduringthefollowupvisit,unlessprophylactictreatmentwasprovided.Iftreatmentwasprovided,testingshouldbe
conductedonlyifthesurvivorreportshavingsymptoms.Iftreatmentwasnotprovided,followupexaminationshouldbeconducted
within1weektoensurethatresultsofpositivetestscanbediscussedpromptlywiththesurvivorandthattreatmentisprovided.
SerologictestsforsyphilisandHIVinfectioncanberepeated6weeks,3months,and6monthsaftertheassaultifinitialtestresults
werenegativeandinfectionintheassailantcouldnotberuledout(seeSexualAssaultandSTDs,RiskforAcquiringHIVInfection).

Prophylaxis
Compliancewithfollowupvisitsispooramongsurvivorsofsexualassault(477,478).Asaresult,routinepreventivetherapyaftera
sexualassaultshouldbeencouraged.Thefollowingprophylacticregimenissuggestedaspreventivetherapy:
PostexposurehepatitisBvaccination,withoutHBIG.Thisvaccineshouldbeadministeredtosexualassaultsurvivorsatthe
timeoftheinitialexaminationiftheyhavenotbeenpreviouslyvaccinated.Followupdosesofvaccineshouldbeadministered
12and46monthsafterthefirstdose.
Anempiricantimicrobialregimenforchlamydia,gonorrhea,andtrichomonas.
Emergencycontraception.(Thismeasureisnecessaryonlywhentheassaultcouldresultinpregnancyinthesurvivor.)
RecommendedRegimens
Ceftriaxone250mgIMinasingledose
OR
Cefixime400mgorallyinasingledose
PLUS
Metronidazole2gorallyinasingledose
PLUS
Azithromycin1gorallyinasingledoseORDoxycycline100mgorallytwiceadayfor7days
Forthoserequiringalternativetreatments,refertothespecificsectionsinthisreportrelevanttothespecificagent.Theefficacyof
theseregimensinpreventinginfectionsaftersexualassaulthasnotbeenevaluated.Cliniciansshouldcounselpatientsregardingthe
possiblebenefitsandtoxicitiesassociatedwiththesetreatmentregimensgastrointestinalsideeffectscanoccurwiththis
combination.

OtherManagementConsiderations
Attheinitialexaminationand,ifindicated,atfollowupexaminations,patientsshouldbecounseledregarding1)symptomsofSTDs
andtheneedforimmediateexaminationifsymptomsoccurand2)abstinencefromsexualintercourseuntilSTDprophylactic
treatmentiscompleted.
RiskforAcquiringHIVInfection
HIVseroconversionhasoccurredinpersonswhoseonlyknownriskfactorwassexualassaultorsexualabuse,butthefrequencyof
thisoccurrenceisprobablylow.Inconsensualsex,theriskforHIVtransmissionfromvaginalintercourseis0.1%0.2%andfor
receptiverectalintercourse,0.5%3%(479).TheriskforHIVtransmissionfromoralsexissubstantiallylower.Specific
circumstancesofanassault(e.g.,bleeding,whichoftenaccompaniestrauma)mightincreaseriskforHIVtransmissionincases
involvingvaginal,anal,ororalpenetration.Siteofexposuretoejaculate,viralloadinejaculate,andthepresenceofanSTDor
genitallesionsintheassailantorsurvivoralsomightincreasetheriskforHIV.
Childrenmightbeathigherriskfortransmission,becausethesexualabuseofchildrenisfrequentlyassociatedwithmultiple
episodesofassaultandmightresultinmucosaltrauma(seeSexualAssaultorAbuseofChildren).
PostexposuretherapywithzidovudinewasassociatedwithareducedriskforacquiringHIVinastudyofhealthcareworkerswho
hadpercutaneousexposurestoHIVinfectedblood(480).Onthebasisoftheseresultsandtheresultsofanimalstudies,PEPhas
beenrecommendedforhealthcareworkerswhohaveoccupationalexposurestoHIV(446).Thesefindingshavebeenextrapolated
toothertypesofHIVexposure,includingsexualassault(78).IfHIVexposurehasoccurred,initiationofPEPassoonaspossible
aftertheexposurelikelyincreasesbenefit.AlthoughadefinitivestatementofbenefitcannotbemaderegardingPEPaftersexual
assault,thepossibilityofHIVexposurefromtheassaultshouldbeassessedatthetimeofthepostassaultexamination.Thepossible

benefitofPEPinpreventingHIVinfectionalsoshouldbediscussedwiththeassaultsurvivoriftheassaultposesariskforHIV
exposure.
SeveralfactorsimpactthemedicalrecommendationforPEPandaffecttheassaultsurvivor'sacceptanceofthatrecommendation,
including1)thelikelihoodoftheassailanthavingHIV,2)anyexposurecharacteristicsthatmightincreasetheriskforHIV
transmission,3)thetimeelapsedaftertheevent,and4)thepotentialbenefitsandrisksassociatedwiththePEP(78).Determination
oftheassailant'sHIVstatusatthetimeoftheassaultexaminationusuallyinnotpossible.Therefore,thehealthcareprovider
shouldassessanyavailableinformationconcerning1)characteristicsandHIVriskbehaviorsoftheassailant(s)(e.g.,amanwhohas
sexwithothermenandpersonswhouseinjectiondrugsorcrackcocaine),2)localepidemiologyofHIV/AIDS,and3)exposure
characteristicsoftheassault.Whenanassailant'sHIVstatusisunknown,factorsthatshouldbeconsideredindeterminingwhether
anincreasedriskforHIVtransmissionexistsinclude1)whethervaginaloranalpenetrationoccurred2)whetherejaculation
occurredonmucousmembranes3)whethermultipleassailantswereinvolved4)whethermucosallesionsarepresentinthe
assailantorsurvivorand5)anyothercharacteristicsoftheassault,survivor,orassailantthatmightincreaseriskforHIV
transmission.
IfPEPisoffered,thefollowinginformationshouldbediscussedwiththepatient:1)theunprovenbenefitandknowntoxicitiesof
antiretrovirals2)theimportanceofclosefollowup3)thebenefitofadherencetorecommendeddosingand4)thenecessityof
earlyinitiationofPEPtooptimizepotentialbenefits(i.e.,assoonaspossibleafterandupto72hoursaftertheassault).Providers
shouldemphasizethatPEPappearstobewelltoleratedinbothadultsandchildrenandthatsevereadverseeffectsarerare(481
483).Clinicalmanagementofthesurvivorshouldbeimplementedaccordingtothefollowingguidelines(78).Specialist
consultationonPEPregimensisrecommendedifHIVexposureduringtheassaultwaspossibleandifPEPisbeingconsidered.The
soonerPEPisinitiatedaftertheexposure,thehigherthelikelihoodthatitwillpreventHIVtransmissionifHIVexposureoccurred
however,distressafteranassaultalsomightpreventthesurvivorfromaccuratelyweighingexposurerisksandbenefitsofPEPand
frommakinganinformeddecisiontostartsuchtherapy.IfuseofPEPisjudgedtobewarranted,thesurvivorshouldbeoffereda3
5daysupplyofPEP,andafollowupvisitshouldbescheduledseveraldayslatertoallowforadditionalcounseling.
RecommendationsforPostexposureAssessmentofAdolescentandAdultSurvivorsWithin72HoursofSexual
Assault
AssessriskforHIVinfectionintheassailant.
EvaluatecharacteristicsoftheassaulteventthatmightincreaseriskforHIVtransmission.
ConsultwithaspecialistinHIVtreatment,ifPEPisbeingconsidered.
IfthesurvivorappearstobeatriskforHIVtransmissionfromtheassault,discussantiretroviralprophylaxis,includingtoxicity
andlackofprovenbenefit.
IfthesurvivorchoosestostartantiretroviralPEP(78),provideenoughmedicationtolastuntilthenextreturnvisitreevaluate
thesurvivor37daysafterinitialassessmentandassesstoleranceofmedications.
IfPEPisstarted,performCBCandserumchemistryatbaseline(initiationofPEPshouldnotbedelayed,pendingresults).
PerformHIVantibodytestatoriginalassessmentrepeatat6weeks,3months,and6months.

SexualAssaultorAbuseofChildren
RecommendationsinthisreportarelimitedtotheidentificationandtreatmentofSTDs.Managementofthepsychosocialaspectsof
thesexualassaultorabuseofchildrenisbeyondthescopeoftheserecommendations.
Theidentificationofsexuallytransmissibleagentsinchildrenbeyondtheneonatalperiodsuggestssexualabuse.Thesignificanceof
theidentificationofasexuallytransmittedagentinsuchchildrenasevidenceofpossiblechildsexualabusevariesbypathogen.
Postnatallyacquiredgonorrheasyphilisandnontransfusion,nonperinatallyacquiredHIVareusuallydiagnosticofsexualabuse.
Sexualabuseshouldbesuspectedwhengenitalherpesisdiagnosed.Theinvestigationofsexualabuseamongchildrenwhohavean
infectionthatcouldhavebeentransmittedsexuallyshouldbeconductedincompliancewithrecommendationsbyclinicianswho
haveexperienceandtraininginallelementsoftheevaluationofchildabuse,neglect,andassault.Thesocialsignificanceofan
infectionthatmighthavebeenacquiredsexuallyandtherecommendedactionregardingreportingofsuspectedchildsexualabuse
variesbythespecificorganism,asdotherecommendationsregardingreportingofsuspectedchildsexualabuse(Table6).Inall
casesinwhichanSTDhasbeendiagnosedinachild,effortsshouldbemadetodetectevidenceofsexualabuse,including
conductingdiagnostictestingforothercommonlyoccurringSTDs(484486).
Thegeneralrulethatsexuallytransmissibleinfectionsbeyondtheneonatalperiodareevidenceofsexualabusehasexceptions.For
example,rectalorgenitalinfectionwithC.trachomatisamongyoungchildrenmightbetheresultofperinatallyacquiredinfection
andhas,insomecases,persistedforaslongas23years.Genitalwartshavebeendiagnosedinchildrenwhohavebeensexually
abused,butalsoinchildrenwhohavenootherevidenceofsexualabuse(487,488).BVhasbeendiagnosedinchildrenwhohave
beenabused,butitspresencealonedoesnotprovesexualabuse.Inaddition,mostHBVinfectionsinchildrenresultfromhousehold
exposuretopersonswhohavechronicHBVinfection.
ThepossibilityofsexualabuseshouldbestronglyconsideredifnoconclusiveexplanationfornonsexualtransmissionofanSTDcan
beidentified.

Reporting
AllU.S.statesandterritorieshavelawsthatrequirethereportingofchildabuse.Althoughtheexactrequirementsdifferbystate,ifa
healthcareproviderhasreasonablecausetosuspectchildabuse,areportmustbemade.Healthcareprovidersshouldcontacttheir
stateorlocalchildprotectionserviceagencyregardingchildabusereportingrequirementsintheirstates.

EvaluatingChildrenforSexuallyTransmittedDiseases
Examinationsofchildrenforsexualassaultorabuseshouldbeconductedinamannerdesignedtominimizepainandtraumatothe
child.Collectionofvaginalspecimensinprepubertalchildrencanbeveryuncomfortableandshouldbeperformedbyan
experiencedcliniciantoavoidpsychologicalandphysicaltraumatothechild.Thedecisiontoobtaingenitalorotherspecimensfrom
achildtoconductanSTDevaluationmustbemadeonanindividualbasis.Thefollowingsituationsplacechildrenathighriskfor
STDsandconstituteastrongindicationfortesting.
ThechildhasorhashadsymptomsorsignsofanSTDorofaninfectionthatcanbesexuallytransmitted,evenintheabsenceof
suspicionofsexualabuse.AmongthesignsthatareassociatedwithaconfirmedSTDdiagnosisarevaginaldischargeorpain,
genitalitchingorodor,urinarysymptoms,andgenitalulcersorlesions.
AsuspectedassailantisknowntohaveanSTDortobeathighriskforSTDs(e.g.,hasmultiplesexpartnersorahistoryof
STDs).
Asiblingoranotherchildoradultinthehouseholdorchild'simmediateenvironmenthasanSTD.
Thepatientorparentrequeststesting.
Evidenceofgenital,oral,oranalpenetrationorejaculationispresent.
Ifachildhassymptoms,signs,orevidenceofaninfectionthatmightbesexuallytransmitted,thechildshouldbetestedforother
commonSTDsbeforetheinitiationofanytreatmentthatcouldinterferewiththediagnosisofthoseotherSTDs.Becauseofthelegal
andpsychosocialconsequencesofafalsepositivediagnosis,onlytestswithhighspecificitiesshouldbeused.Thepotentialbenefitto
thechildofareliablediagnosisofanSTDjustifiesdeferringpresumptivetreatmentuntilspecimensforhighlyspecifictestsare
obtainedbyproviderswithexperienceintheevaluationofsexuallyabusedandassaultedchildren.
Theschedulingofanexaminationshoulddependonthehistoryofassaultorabuse.Iftheinitialexposurewasrecent,theinfectious
agentsacquiredthroughtheexposuremightnothaveproducedsufficientconcentrationsoforganismstoresultinpositivetest
results.Afollowupvisitapproximately2weeksafterthemostrecentsexualexposurecanincludearepeatphysicalexaminationand
collectionofadditionalspecimens.Toallowsufficienttimeforantibodiestodevelop,anotherfollowupvisitapproximately12weeks
afterthemostrecentsexualexposuremightbenecessarytocollectsera.Asingleexaminationmightbesufficientifthechildwas
abusedforanextendedperiodandifasubstantialamountoftimeelapsedbetweenthelastsuspectedepisodeofabuseandthe
medicalevaluation.
Thefollowingrecommendationsforschedulingexaminationsserveasageneralguide.Theexacttimingandnatureoffollowup
examinationsshouldbedeterminedonanindividualbasisandshouldbeperformedtominimizethepossibilityforpsychological
traumaandsocialstigma.Compliancewithfollowupappointmentsmightbeimprovedwhenlawenforcementpersonnelorchild
protectiveservicesareinvolved.
Initialand2WeekFollowUpExaminations
Duringtheinitialexaminationand2weekfollowupexamination(ifindicated),thefollowingshouldbeperformed.
Visualinspectionofthegenital,perianal,andoralareasforgenitaldischarge,odor,bleeding,irritation,warts,andulcerative
lesions.TheclinicalmanifestationsofsomeSTDsaredifferentinchildrenthaninadults.Forexample,typicalvesicularlesions
mightnotbepresentinthepresenceofHSVinfection.Becausethisinfectioncanbeindicativeofsexualabuse,specimens
shouldbeobtainedfromallvesicularorulcerativegenitalorperianallesionscompatiblewithgenitalherpesandthensentfor
viralculture.
SpecimencollectionforN.gonorrhoeaeculturefromthepharynxandanusinboysandgirls,thevaginaingirls,andthe
urethrainboys.Cervicalspecimensarenotrecommendedforprepubertalgirls.Forboyswithaurethraldischarge,ameatal
specimendischargeisanadequatesubstituteforanintraurethralswabspecimen.Becauseofthelegalimplicationsofa
diagnosisofN.gonorrhoeaeinfectioninachild,ifculturefortheisolationofN.gonorrhoeaeisdone,onlystandardculture
proceduresshouldbeperformed.Gramstainsareinadequatetoevaluateprepubertalchildrenforgonorrheaandshouldnotbe
usedtodiagnoseorexcludegonorrhea.Specimensfromthevagina,urethra,pharynx,orrectumshouldbestreakedonto
selectivemediaforisolationofN.gonorrhoeae,andallpresumptiveisolatesofN.gonorrhoeaeshouldbeidentifieddefinitively
byatleasttwoteststhatinvolvedifferentprinciples(e.g.,biochemical,enzymesubstrate,orserologic).Isolatesshouldbe
preservedtoenableadditionalorrepeatedtesting.
CulturesforC.trachomatisfromspecimenscollectedfromtheanusinbothboysandgirlsandfromthevaginaingirls.The
likelihoodofrecoveringC.trachomatisfromtheurethraofprepubertalboysistoolowtojustifythetraumainvolvedin
obtaininganintraurethralspecimen.However,ameatalspecimenshouldbeobtainedifurethraldischargeispresent.
PharyngealspecimensforC.trachomatisarenotrecommendedforchildrenofeithersexbecausetheyieldislow,perinatally
acquiredinfectionmightpersistbeyondinfancy,andculturesystemsinsomelaboratoriesdonotdistinguishbetweenC.
trachomatisandC.pneumoniae.OnlystandardculturesystemsfortheisolationofC.trachomatisshouldbeused.The
isolationofC.trachomatisshouldbeconfirmedbymicroscopicidentificationofinclusionsbystainingwithfluorescein
conjugatedmonoclonalantibodyspecificforC.trachomatisEIAsarenotacceptableconfirmatorymethods.Isolatesshouldbe

preserved.Nonculturetestsforchlamydia(e.g.,nonamplifiedprobes,EIAs,andDFA)arenotsufficientlyspecificforusein
circumstancesinvolvingpossiblechildabuseorassault.NAATscanbeusedfordetectionofC.trachomatisinvaginal
specimensorurinefromgirls.Allspecimensshouldberetainedforadditionaltestingifnecessary.Nodataareavailable
regardingtheuseofNAATsinboysorforextragenitalspecimens(e.g.,thoseobtainedfromtherectum)inboysandgirls.
Cultureremainsthepreferredmethodforextragenitalsites.
CultureandwetmountofavaginalswabspecimenforT.vaginalisinfectionandBV.
Collectionofserumsamplestobeevaluatedimmediately,preservedforsubsequentanalysis,andusedasabaselinefor
comparisonwithfollowupserologictests.Serashouldbetestedimmediatelyforantibodiestosexuallytransmittedagents.
AgentsforwhichsuitabletestsareavailableincludeT.pallidum,HIV,andHBV.Decisionsregardingtheagentsforwhichto
performserologictestsshouldbemadeonacasebycasebasis.
DataonuseofNAATsfordetectionofN.gonorrhoeaeinchildrenarelimited,andperformanceistestdependent(197,486).
ConsultationwithanexpertisnecessarybeforeusingNAATsinthiscontexttominimizethepossibilityofcrossreactionwith
nongonococcalNeisseriaspeciesandothercommensals(e.g.,N.meningitidis,N.sicca,N.lactamica,N.cinerea,andMoraxella
catarrhalis).NAATscanbeusedasanalternativetoculturewithvaginalspecimensorurinefromgirls,whereascultureremainsthe
preferredmethodforurethralspecimensorurinefromboysandforextragenitalspecimens(pharynxandrectum)fromallchildren.
Allpositivespecimensshouldberetainedforadditionaltesting.
HIVinfectionhasbeenreportedinchildrenwhoseonlyknownriskfactorwassexualabuse.SerologictestingforHIVinfection
shouldbeconsideredforabusedchildren.ThedecisiontotestforHIVinfectionshouldbemadeonacasebycasebasis,depending
onthelikelihoodofinfectionamongassailant(s).AlthoughdataareinsufficientconcerningtheefficacyandsafetyofPEPamong
bothchildrenandadults,treatmentiswelltoleratedbyinfantsandchildren(withandwithoutHIVinfection),andchildrenhavea
minimalriskforseriousadversereactionsbecauseoftheshortperiodrecommendedforprohylaxis.(78,138).Inconsidering
whethertoofferantiretroviralPEP,healthcareprovidersshouldconsiderwhetherthechildcanbetreatedsoonafterthesexual
exposure(i.e.,within72hours),thelikelihoodthattheassailantisinfectedwithHIV,andthelikelihoodofhighcompliancewiththe
prophylacticregimen.Thepotentialbenefitoftreatingasexuallyabusedchildshouldbeweighedagainsttheriskforadverse
reactions.IfantiretroviralPEPisbeingconsidered,aproviderspecializinginevaluatingortreatingHIVinfectedchildrenshouldbe
consulted.
RecommendationsforHIVRelatedPostexposureAssessmentofChildrenwithin72HoursofSexualAssault
ReviewHIV/AIDSlocalepidemiologyandassessriskforHIVinfectionintheassailant.
EvaluatecircumstancesofassaultthatmightaffectriskforHIVtransmission.
ConsultwithaspecialistintreatingHIVinfectedchildrenifPEPisconsidered.
IfthechildappearstobeatriskforHIVtransmissionfromtheassault,discussPEPwiththecaregiver(s),includingitstoxicity
andunknownefficacy.
IfcaregiverschooseforthechildtoreceiveantiretroviralPEP(78,142,489),provideenoughmedicationtolastuntilthereturn
visitat37daysaftertheinitialassessment,atwhichtimethechildshouldbereevaluatedandtoleranceofmedication
assesseddosagesshouldnotexceedthoseforadults.
PerformHIVantibodytestatoriginalassessment,6weeks,3months,and6months.

FollowUpExaminationAfterAssault
Incircumstancesinwhichtransmissionofsyphilis,HIV,orhepatitisBisaconcernbutbaselinetestsarenegative,anexamination
approximately6weeks,3months,and6monthsafterthelastsuspectedsexualexposureisrecommendedtoallowtimefor
antibodiestoinfectiousagentstodevelop.Inaddition,resultsofHBsAgtestingmustbeinterpretedcarefully,becauseHBVcanbe
transmittednonsexually.Decisionsregardingwhichtestsshouldbeperformedmustbemadeonanindividualbasis.

PresumptiveTreatment
TheriskofachildacquiringanSTDasaresultofsexualabuseorassaulthasnotbeenwellstudied.Presumptivetreatmentfor
childrenwhohavebeensexuallyassaultedorabusedisnotrecommendedbecause1)theincidenceofmostSTDsinchildrenislow
afterabuse/assault,2)prepubertalgirlsappeartobeatlowerriskforascendinginfectionthanadolescentoradultwomen,and3)
regularfollowupofchildrenusuallycanbeensured.However,somechildrenortheirparent(s)orguardian(s)mightbeconcerned
aboutthepossibilityofinfectionwithanSTD,eveniftheriskisperceivedtobelowbythehealthcareprovider.Suchconcerns
mightbeanappropriateindicationforpresumptivetreatmentinsomesettingsandmightbeconsideredafterallspecimensfor
diagnostictestsrelevanttotheinvestigationhavebeencollected.

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*STIisthetermusedbyUSPSTFtodescribethesyndromescausedbyvariouspathogensthatcanbeacquiredandtransmitted
throughsexualactivity.
Regardlessofhistoryofcondomuseduringexposure.
CommerciallyavailableNAATSarenotFDAclearedfortheseindications,buttheycanbeusedbylaboratoriesthathavemetall
regulatoryrequirementsforanofflabelprocedure.
Theabsenceofafourfoldorgreatertiterforaninfantdoesnotexcludecongenitalsyphilis.
**CSFtestresultsobtainedduringtheneonatalperiodcanbedifficulttointerpretnormalvaluesdifferbygestationalageandare
higherinpreterminfants.Valuesashighas25whitebloodcells(WBCs)/mm3and/orproteinof150mg/dLmightoccuramong
normalneonatessomespecialists,however,recommendthatlowervalues(i.e.,5WBCs/mm3andproteinof40mg/dL)be
consideredtheupperlimitsofnormal.Othercausesofelevatedvaluesshouldbeconsideredwhenaninfantisbeingevaluatedfor
congenitalsyphilis.
Awomantreatedwitharegimenotherthanthoserecommendedintheseguidelinesfortreatmentshouldbeconsidered
untreated.
Iftheinfant'snontreponemaltestisnonreactiveandtheproviderdeterminesthatthemother'sriskforuntreatedsyphilisislow,
treatmentoftheinfant(singleIMdoseofbenzathinepenicillinG50,000units/kgforpossibleincubatingsyphilis)withoutan
evaluationcanbeconsidered.
AssistancewithPEPrelateddecisionscanbeobtainedbycallingtheNationalClinician'sPostExposureProphylaxisHotline
(PEPLine)(telephone:8884484911).

TermsandAbbreviationsUsedinThisReport
AIDSAcquiredimmunodeficiencysyndrome
ALTAlanineaminotransferase
antiHBcAntibodytohepatitisBcoreantigen
antiHCVHepatitisCantibodies
ASCUSAtypicalsquamouscellsofundeterminedsignificance
BCABichloroaceticacid
BVBacterialvaginosis
CBCCompletebloodcount
CIConfidenceinterval
CINCervicalintraepithelialneoplasia
CLDChronicliverdisease

CLIAClinicalLaboratoryImprovementAmendments
CNSCentralnervoussystem
CSFCerebrospinalfluid
DFADirectfluorescentantibody
DGIDisseminatedgonococcalinfection
dLDeciliter
DNADeoxyribonucleicacid
ECEmergencycontraception
EIAEnzymeimmunoassay
ELISAEnzymelinkedimmunosorbentassay
EPTExpeditedpartnertherapy
FDAFoodandDrugAdministration
FTAABSFluorescenttreponemalantibodyabsorbed
gGGlycoproteinG
GNIDGramnegativeintracellulardiplococci
HAARTHighlyactiveantiretroviraltherapy
HAVHepatitisAvirus
HBIGHepatitisBimmuneglobulin
HBsAgHepatitisBsurfaceantigen
HBVHepatitisBvirus
HCChepatocellularcarcinoma
HCVHepatitisCvirus
HIVHumanimmunodeficiencyvirus
HPVHumanpapillomavirus
HSVHerpessimplexvirus
IFAImmunofluorescenceassay
IgEImmunoglobulinE
IgImmuneglobulin
IgGImmunoglobulinG
IgMImmunoglobulinM
IMIntramuscularly
IUDIntrauterinedevice
IVIntravenousorintravenously
KOHPotassiumhydroxide
LGVLymphogranulomavenereum
MACMycobacteriumaviumcomplex
MICMinimuminhibitoryconcentration
MSMMenwhohavesexwithmen
N9Nonoxynol9
NAATNucleicacidamplificationtest

NGUNongonococcalurethritis
PapPapanicolaou
PCRPolymerasechainreaction
PEPPostexposureprophylaxis
PIDPelvicinflammatorydisease
POBymouth
PPVPositivepredictivevalue
QRNGQuinoloneresistantNeisseriagonorrhoeae
RNARibonucleicacid
RPRRapidplasmareagin
RTPCRReversetranscriptasepolymerasechainreaction
RVVCRecurrentvulvovaginalcandidiasis
SILSquamousintraepitheliallesion
STDSexuallytransmitteddisease
TCATrichloroaceticacid
TEToxoplasmicencephalitis
TPPATreponemapallidumparticleagglutation
VDRLVenerealDiseaseResearchLaboratory
VVCVulvovaginalcandidiasis
WBWesternblot
WBCWhitebloodcount
WSWWomenwhohavesexwithwomen
Box1.TheFiveP's:Partners,PreventionofPregnancy,ProtectionfromSTDs,Practices,andPastHistoryof
STDs
1.Partners
"Doyouhavesexwithmen,women,orboth?"
"Inthepast2months,howmanypartnershaveyouhadsexwith?"
"Inthepast12months,howmanypartnershaveyouhadsexwith?"
"Isitpossiblethatanyofyoursexpartnersinthepast12monthshadsexwithsomeoneelsewhiletheywerestillinasexual
relationshipwithyou?"
2.Preventionofpregnancy
"Whatareyoudoingtopreventpregnancy?"
3.ProtectionfromSTDs
"WhatdoyoudotoprotectyourselffromSTDsandHIV?"
4.Practices
"TounderstandyourrisksforSTDs,Ineedtounderstandthekindofsexyouhavehadrecently."
"Haveyouhadvaginalsex,meaning'penisinvaginasex'?"Ifyes,"Doyouusecondoms:never,sometimes,oralways?"
"Haveyouhadanalsex,meaning'penisinrectum/anussex'?"Ifyes,"Doyouusecondoms:never,sometimes,oralways?"

Haveyouhadoralsex,meaning'mouthonpenis/vagina'?"
Forcondomanswers:
If"never:""Whydon'tyouusecondoms?"
If"sometimes:""Inwhatsituations(orwithwhom)doyounotusecondoms?"
5.PasthistoryofSTDs
"HaveyoueverhadanSTD?"
"HaveanyofyourpartnershadanSTD?"
AdditionalquestionstoidentifyHIVandviralhepatitisriskinclude:
"Haveyouoranyofyourpartnerseverinjecteddrugs?"
"Haveanyofyourpartnersexchangedmoneyordrugsforsex?"
"IsthereanythingelseaboutyoursexualpracticesthatIneedtoknowabout?"

Box2.Skintestreagentsforidentifyingpersonsatriskforadversereactionstopenicillin*
MajorDeterminant
BenzylpenicilloylpolyLlysine(PrePen)(AllerQuest,PlainvilleConnecticut)(6x105M).
MinorDeterminantPrecursors
BenzylpenicillinG(102M,3.3mg/mL,10,000units/mL)
Benzylpenicilloate(102M,3.3mg/mL)
Benzylpenicilloate(orpenicilloylpropylamine)(102M,3.3mg/mL)
PositiveControl
Commercialhistamineforintradermalskintesting(1.0mg/mL)
NegativeControl
Diluent(usuallysaline)orallergendiluent
*AdaptedfromSaxonA,BeallGN,RohrAS,AdelmanDC.Immediatehypersensitivityreactionstobetalactamantibiotics.Ann
InternMed1987107:20415.ReprintedwithpermissionfromG.N.BeallandAnnalsofInternalMedicine.
Agedpenicillinisnotanadequatesourceofminordeterminants.PenicillinGshouldbefreshlypreparedorshouldcomefroma
freshfrozensource.
TABLE1.Oraldesensitizationprotocolforpatientswithapositiveskintest*
PenicillinVsuspensiondose

Amount(units/mL)

mL Units

Cumulativedose(units)

1,000

0.1

100

100

1,000

0.2

200

300

1,000

0.4

400

700

1,000

0.8

800

1,500

1,000

1.6

1,600

3,100

1,000

3.2

3,200

6,300

1,000

6.4

6,400

12,700

10,000

1.2

12,000

24,700

10,000

2.4

24,000

48,700

10

10,000

4.8

48,000

96,700

11

80,000

1.0

80,000

176,700

12

80,000

2.0

160,000

336,700

13

80,000

4.0

320,000

656,700

14

80,000

8.0

640,000

1,296,700

Note:Observationperiodwas30minutesbeforeparenteraladministrationofpenicillin.
*ReprintedwithpermissionfromtheNewEnglandJournalofMedicine(WendelGO,Jr,StarkBJ,JamisonRB,MelinaRD,
SullivanTJ.Penicillinallergyanddesensitizationinseriousinfectionsduringpregnancy.NEnglJMed1985312:122932.).
Intervalbetweendoses,1530minuteselapsedtime,48hourscumulativedose,1.3millionunits.
Thespecificamountofdrugwasdilutedinapproximately30mLofwaterandthenadministeredorally.
Box3.Classificationofvulvovaginalcandidiasis(VVC)
UncomplicatedVVC
Sporadicorinfrequentvulvovaginalcandidiasis
OR
Mildtomoderatevulvovaginalcandidiasis
OR
LikelytobeC.albicans
OR
Nonimmunocompromisedwomen
ComplicatedVVC
Recurrentvulvovaginalcandidiasis
OR
Severevulvovaginalcandidiasis
OR
Nonalbicanscandidiasis
OR
Womenwithuncontrolleddiabetes,debilitation,orimmunosuppression

TABLE2.Recommendedregimens:doseandscheduleforhepatitisAvaccines
Vaccine
HAVRIX

VAQTA

Age(yrs)

Dose

Volume(mL)

Twodoseschedule(months)*

118

720(EL.U.)

0.5

0(612)

>18

1,440(EL.U.)

1.0

0(612)

118

25(U)

0.5

0(618)

>18

50(U)

1.0

0(618)

Source:CDC.PreventionofhepatitisAthroughactiveorpassiveimmunization:recommendationsoftheAdvisoryCommitteeon
ImmunizationPractices(ACIP).MMWR200655(No.RR7).
Abbreviations:EL.U=Enzymelinkedimmunosorbentassay(ELISA)unitsU=units.
*0monthsrepresentstimingoftheinitialdosesubsequentnumbersrepresentmonthsaftertheinitialdose.
HepatitisAvaccine,inactivated,GlaxoSmithKlineBiologicalsthisvaccineisalsolicensedfora3doseseriesinchildrenaged2
18years,with360EL.U,0.5mLdosesat0,1,and612months.
HepatitisAvaccine,inactivated,Merck&Co.,Inc.
TABLE3.RecommendeddosesofcurrentlylicensedformulationsofadolescentandadulthepatitisBvaccines
Singleantigenvaccine

Combination
vaccine

RecombivaxHB

EngerixB

Twinrix*

Dose
(g)

Volume
(mL)

Dose
(g)

Volume
(mL)

Dose
(g)

Volume
(mL)

Adolescentsaged1119years

0.5

10

0.5

NA

NA

Adolescentsaged1115years

10

1.0

NA

NA

NA

NA

Adults(aged20years)

10

1.0

20

1.0

20

1.0

Hemodialysispatientsandotherimmunocompromised
personsaged<20years

0.5

10

0.5

NA

NA

Hemodialysispatientsandotherimmunocompromised
personsaged20years

40**

1.0

40

2.0

NA

NA

Group

Sources:CDC.AcomprehensiveimmunizationstrategytoeliminatetransmissionofhepatitisBvirusinfectionintheUnited
States:recommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP)Part1:immunizationofinfants,children,
andadolescents.MMWR200554(No.RR16).CDC.Acomprehensiveimmunizationstrategytoeliminatetransmissionof
hepatitisBvirusinfectionintheUnitedStates:recommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP)
PartII:immunizationofadults.MMWR200655(No.RR16).
*CombinedhepatitisAandhepatitisBvaccine.Thisvaccineisrecommendedforpersonsaged18yearswhoareatincreasedrisk
forbothhepatitisBandhepatitisAvirusinfections.
RecombinanthepatitisBsurfaceantigenproteindose,inmicrograms.
Pediatricformulationadministeredona3doseschedulehigherdosesmightbemoreimmunogenic,butnospecific
recommendationshavebeenmade.
Adultformulationadministeredona2doseschedule.
**Dialysisformulationadministeredona3dosescheduleat0,1,and6months.
Two1.0mLdosesoftheadultformulationadministeredatonesiteona4dosescheduleat0,1,2,and6months.

TABLE4.Interpretationofserologictestresults*forHBVinfection

Serologicmarker
HBsAg

Total
IgM
Anti Interpretation
antiHBc antiHBc HBs**

Neverinfected

Earlyacuteinfectiontransient(upto18days)aftervaccination

Acuteinfection

Acuteresolvinginfection

Recoveredfrompastinfectionandimmune

Chronicinfection

Falsepositive(i.e.,susceptible)pastinfection"lowlevel"chronicinfectionpassive
transfertoinfantborntoHBsAgpositivemother

Immuneifconcentrationis>10mIU/mL,passivetransferafterHBIGadministration

*Symbolfornegativetestresult,""symbolforpositivetestresult,"+".
HepatitisBsurfaceantigen.
AntibodytohepatitisBcoreantigen.
ImmunoglobulinM.
**AntibodytoHBsAg.
ToensurethatanHBsAgpositivetestresultisnotafalsepositive,sampleswithrepeatedlyreactiveHBsAgresultsshouldbe
testedwithanFDAcleared(and,ifappropriate,neutralizingconfirmatory)test.
PersonspositiveforonlyantiHBcareunlikelytobeinfectiousexceptunderunusualcircumstancesinvolvingdirect
percutaneousexposuretolargequantitiesofblood(e.g.,bloodtransfusionandorgantransplantation).
MilliInternationalUnitspermilliliter.
TABLE5.Guidelinesforpostexposureimmunoprophylaxisofunvaccinatedpersonswhohaveanidentifiable
exposuretobloodorbodyfluidsthatcontainblood
Cause

Action

ExposuretoanHBsAg*positivesource
Percutaneous(e.g.,biteorneedlestick)ormucosalexposuretoHBsAgpositivebloodorbodyfluids
thatcontainblood

AdministerhepatitisB
vaccine&HBIG

SexualorneedlesharingcontactofanHBsAgpositiveperson

AdministerhepatitisB
vaccine&HBIG

Victimofsexualassault/abusebyaperpetratorwhoisHBsAgpositive

AdministerhepatitisB
vaccine&HBIG

ExposuretoasourcewithunknownHBsAgstatus
Victimofsexualassault/abusebyaperpetratorwithunknownHBsAgstatus

AdministerhepatitisB
vaccine

Percutaneous(e.g.,biteorneedlestick)ormucosalexposuretobloodorbodyfluidsthatcontainblood AdministerhepatitisB
fromasourcewithunknownHBsAgstatus
vaccine
*HepatitisBsurfaceantigen.
Immunoprophylaxisshouldbeadministeredassoonaspossible,preferably24hours.Studiesarelimitedonthemaximum
intervalafterexposureduringwhichpostexposureprophylaxisiseffective,buttheintervalisunlikelytoexceed7daysfor
percutaneousexposuresand14daysforsexualexposures.Thecomplete,3dosehepatitisBvaccineseriesshouldbeadministered.

TABLE6.Implicationsofcommonlyencounteredsexuallytransmitted(ST)orsexuallyassociated(SA)
infectionsfordiagnosisandreportingofsexualabuseamonginfantsandprepubertalchildren
ST/SAconfirmed

Evidenceforsexualabuse

Suggestedaction

Gonorrhea*

Diagnostic

Report

Syphilis*

Diagnostic

Report

Humanimmunodeficiencyvirus

Diagnostic

Report

Chlamydiatrachomatis*

Diagnostic

Report

Trichomonasvaginalis

Highlysuspicious

Report

Condylomataacuminata(anogenitalwarts)*

Suspicious

Report

Genitalherpes*

Suspicious

Report

Bacterialvaginosis

Inconclusive

Medicalfollowup

Source:AdaptedfromKelloggN,AmericanAcademyofPediatricsCommitteeonChildAbuseandNeglect.Theevaluationofchild
abuseinchildren.Pediatrics2005116(2):50612.
*Ifnotlikelytobeperinatallyacquiredandrarenonsexual,verticaltransmissionisexcluded.
Reportsshouldbemadetotheagencyinthecommunitymandatedtoreceivereportsofsuspectedchildabuseorneglect.
Ifnotlikelytobeacquiredperinatallyorthroughtransfusion.
Unlessthereisaclearhistoryofautoinoculation.

SexuallyTransmittedDiseasesTreatmentGuidelines,2010
Consultants
Chairperson:KimberlyA.Workowski,MD,NationalCenterforHIV/AIDS,ViralHepatitis,STD,andTBPrevention(NCHHSTP),CDCandEmory
University,Atlanta,Georgia.
Presenters:HeidiBauer,MD,CaliforniaSexuallyTransmittedDiseaseControlBranch,Oakland,CaliforniaLauraBachman,MD,WakeForestUniversity
GaleBurstein,MD,MPH,ErieCountyDepartmentofHealthLindaEckert,MD,UniversityofWashingtonWilliamM.Geisler,MD,UniversityofAlabama,
Birmingham,AlabamaKhalilGhanem,MD,JohnsHopkinsUniversityMattGolden,MD,MPH,UniversityofWashingtonLindaGorgos,MD,NewMexico
DepartmentofHealthMargaretHammerschlag,MD,StateUniversityofNewYork,DownstateMedicalCenter,Brooklyn,NewYorkLisaHollier,MD,
UniversityofTexasatHoustonPeterLeone,MD,UniversityofNorthCarolinaSchoolofMedicine,ChapelHill,NorthCarolinaJeanneMarrazzo,MD,
UniversityofWashington,Seattle,WashingtonKennethHughMayer,MD,BrownUniversityMedicalSchool,Providence,RhodeIslandPaulNyirjesy,MD,
DrexelUniversityCollegeofMedicine,Philadelphia,PennsylvaniaAnneRompalo,MD,JohnsHopkinsSchoolofMedicine,Baltimore,MarylandPablo
Sanchez,MD,UniversityofTexasSouthwesternMedicalCenter,Dallas,TexasBradleyStoner,MD,PhD,WashingtonUniversity,St.Louis,MissouriAnna
Wald,MD,UniversityofWashington,Seattle,WashingtonGeorgeWendel,MD,UniversityofTexasSouthwesternMedicalSchool,Dallas,TexasHaroldC.
Wiesenfeld,MD,UniversityofPittsburgh,Pittsburgh,Pennsylvania.
Moderators:WillardCates,Jr.,MD,MPH,FamilyHealthInternational,Durham,NorthCarolinaKingK.Holmes,MD,PhD,UniversityofWashington,
Seattle,WashingtonDavidMartin,MD,LouisianaStateUniversityMedicalCenter,NewOrleans,Louisiana.
Rapporteurs:HunterHandsfield,MD,UniversityofWashington,Seattle,WashingtonWilliamMcCormack,MD,StateUniversityofNewYorkHealth
ScienceCenter,Brooklyn,NewYorkWilliamM.Geisler,MD,UniversityofAlabama,Birmingham,Alabama.
Consultants:N.FranklinAdkinson,MD,JohnsHopkinsUniversityWilliamAndrews,MD,PhD,UniversityofAlabama,BirminghamMichael
Augenbraun,MD,StateUniversityofNewYorkHealthScienceCenter,Brooklyn,NewYorkBryonBatteiger,MD,UniversityofIndianaGailBolan,MD,
CaliforniaDepartmentofHealth,Oakland,CaliforniaBruceColes,DO,NewYorkDepartmentofHealthCarolynDeal,PhD,NationalInstituteofAllergyand
InfectiousDiseases,NationalInstitutesofHealth,Bethesda,MarylandJ.DennisFortenberry,MD,IndianaUniversitySchoolofMedicine,Indianapolis,
IndianaEdwardHook,III,MD,UniversityofAlabama,Birmingham,AlabamaJaneR.Schwebke,MD,UniversityofAlabama,Birmingham,Alabama
JoannSchulte,DO,NationalInstitutesofHealth,Bethesda,MarylandDavidSoper,MD,MedicalUniversityofSouthCarolina,Charleston,SouthCarolina
LawrenceStanberry,MD,PhD,UniversityofTexasMedicalBranch,Galveston,TexasBruceTrigg,MD,NewMexicoDepartmentofHealthYolanda
Wimberly,MD,MorehouseSchoolofMedicineJonathanM.Zenilman,MD,JohnsHopkinsBayviewMedicalCenter,Baltimore,Maryland.
LiaisonParticipants:KayturaAaronMD,HRSALauraBachman,MD,HIVAssociationofAmericaLynnBarclay,MD,AmericanSocialHealth
AssociationMargaretJ.Blythe,MD,AmericanAcademyofPediatricsCarolynD.Deal,PhD,NationalInstitutesofHealthJordonDimitrakov,MD,PhD,
AmericanUrologicalAssociationMarkFitzGerald,MD,BritishAssociationforSexualHealthandHIV,Southampton,UnitedKingdomDennisFortenberry,
MD,SocietyofAdolescentMedicineEdwardW.Hook,III,MD,InfectiousDiseaseSocietyofAmericaNoreenJack,MD,PanAmericanHealthAssociation
PeterKerndt,MD,NationalCoalitionofSTDDirectorsJeanneMarrazzo,MD,AmericanSexuallyTransmittedDiseasesAssociationFrancisJ.Ndowa,MD,
WorldHealthOrganization,Geneva,SwitzerlandMichaelParkinson,MD,AmericanCollegeofPreventativeMedicineJeffreyPiepert,MD,AmericanCollege
ofObstetricsandGynecologyPatriciaReams,MD,NationalCommissiononCorrectionalHealthCareBisanSalhi,MD,AmericanCollegeofEmergency
PhysiciansKarenShea,MSN,PlannedParenthoodFederationofAmericaDavidSoper,MD,InfectiousDiseasesSocietyforObstetricsandGynecology
BradleyStoner,MD,PhD,CDCSTDPreventionTrainingCentersAmySwann,AssoicationofReproductiveHealthProfessionalsLitjenTan,PhD,American

MedicalAssociationTomWong,MD,PublicHealthAgencyofCanada,Ottawa,Ontario,Canada.
CDC,DivisionofSexuallyTransmittedDiseasePreventionTreatmentGuidelines2010ProjectCoordinator:KimberlyA.Workowski,MD,
NCHHSTP,CDCandEmoryUniversity,Atlanta,Georgia.
ProjectManager:RichardVoigt,NCHHSTP,CDC,Atlanta,Georgia.
NCHHSTP/CDCPresenters:DeblinaDatta,MDEileenDunne,MDMatthewHogben,PhDScottHolmberg,MDEmilyKoumans,MDLoriNewman,
MD.
CDCConsultants:SevgiO.Aral,PhDRonaldBallard,PhDBernardBranson,MDJohnBrooks,MD,MPHJohnDouglas,MDAlisonFriedmanDaleHu,
MDPeterKilmarx,MDJohnPapp,PhDPhilSpradling,MD.
SupportStaff:BrendaKelley,ValerieBarner,andDeborahMcElroy,NCHHSTP,CDC,Atlanta,Georgia.

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Pagelastreviewed:December17,2010
Pagelastupdated:December17,2010
Contentsource:CentersforDiseaseControlandPrevention

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