Sexually Transmitted Infections Treatment Guidelines, 2021
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Morbidity and Mortality Weekly Report Recommendations and Reports / Vol. 70 / No. 4 July 23, 2021 Sexually Transmitted Infections Treatment Guidelines, 2021 U.S. Department of Health and Human Services Centers for Disease Control and Prevention Recommendations and Reports CONTENTS Introduction ............................................................................................................1 Methods ....................................................................................................................1 Clinical Prevention Guidance ............................................................................2 STI Detection Among Special Populations ............................................... 11 HIV Infection ......................................................................................................... 24 Diseases Characterized by Genital, Anal, or Perianal Ulcers ............... 27 Syphilis ................................................................................................................... 39 Management of Persons Who Have a History of Penicillin Allergy .. 56 Diseases Characterized by Urethritis and Cervicitis ............................... 60 Chlamydial Infections ....................................................................................... 65 Gonococcal Infections ...................................................................................... 71 Mycoplasma genitalium .................................................................................... 80 Diseases Characterized by Vulvovaginal Itching, Burning, Irritation, Odor, or Discharge ........................................................................................... 82 Pelvic Inflammatory Disease .......................................................................... 94 Epididymitis .......................................................................................................... 98 Human Papillomavirus Infections ..............................................................100 Viral Hepatitis .....................................................................................................113 Proctitis, Proctocolitis, and Enteritis ..........................................................124 Ectoparasitic Infections ..................................................................................126 Sexual Assault and Abuse and STIs ............................................................128 References ...........................................................................................................135 The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30329-4027. Suggested citation: [Author names; first three, then et al., if more than six.] [Title]. MMWR Recomm Rep 2021;70(No. RR-#):[inclusive page numbers]. Centers for Disease Control and Prevention Rochelle P. Walensky, MD, MPH, Director Debra Houry, MD, MPH, Acting Principal Deputy Director Daniel B. Jernigan, MD, MPH, Acting Deputy Director for Public Health Science and Surveillance Rebecca Bunnell, PhD, MEd, Director, Office of Science Jennifer Layden, MD, PhD, Deputy Director, Office of Science Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services MMWR Editorial and Production Staff (Serials) Charlotte K. Kent, PhD, MPH, Editor in Chief Martha F. Boyd, Lead Visual Information Specialist Ian Branam, MA, Acting Lead Christine G. Casey, MD, Editor Alexander J. Gottardy, Maureen A. Leahy, Health Communication Specialist Mary Dott, MD, MPH, Online Editor Julia C. Martinroe, Stephen R. Spriggs, Tong Yang, Shelton Bartley, MPH, Terisa F. Rutledge, Managing Editor Visual Information Specialists Lowery Johnson, Amanda Ray, David C. Johnson, Lead Technical Writer-Editor Quang M. Doan, MBA, Phyllis H. King, Jacqueline N. Sanchez, MS, Marella Meadows, Project Editor Terraye M. Starr, Moua Yang, Health Communication Specialists Information Technology Specialists Will Yang, MA, Visual Information Specialist MMWR Editorial Board Timothy F. Jones, MD, Chairman Matthew L. Boulton, MD, MPH William E. Halperin, MD, DrPH, MPH Carlos Roig, MS, MA Carolyn Brooks, ScD, MA Jewel Mullen, MD, MPH, MPA William Schaffner, MD Jay C. Butler, MD Jeff Niederdeppe, PhD Nathaniel Smith, MD, MPH Virginia A. Caine, MD Celeste Philip, MD, MPH Morgan Bobb Swanson, BS Jonathan E. Fielding, MD, MPH, MBA Patricia Quinlisk, MD, MPH Abbigail Tumpey, MPH David W. Fleming, MD Patrick L. Remington, MD, MPH Recommendations and Reports Sexually Transmitted Infections Treatment Guidelines, 2021 Kimberly A. Workowski, MD1,2; Laura H. Bachmann, MD1; Philip A. Chan, MD1,3; Christine M. Johnston, MD1,4; Christina A. Muzny, MD1,5; Ina Park, MD1,6; Hilary Reno, MD1,7; Jonathan M. Zenilman, MD1,8; Gail A. Bolan, MD1 1Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia; 2Emory University, Atlanta, Georgia; 3Brown University, Providence, Rhode Island; 4University of Washington, Seattle, Washington; 5University of Alabama at Birmingham, Birmingham, Alabama; 6University of California San Francisco, San Francisco, California; 7Washington University, St. Louis, Missouri; 8Johns Hopkins University, Baltimore, Maryland Summary These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs. Introduction These STI treatment guidelines complement Recommendations for Providing Quality Sexually Transmitted Diseases Clinical The term “sexually transmitted infection” (STI) refers to Services, 2020 (2) regarding quality clinical services for STIs a pathogen that causes infection through sexual contact, in primary care and STD specialty care settings. This guidance whereas the term “sexually transmitted disease” (STD) refers specifies operational determinants of quality services in various to a recognizable disease state that has developed from an clinical settings, describes on-site treatment and partner infection. Physicians and other health care providers have a services, and indicates when STI-related conditions should be crucial role in preventing and treating STIs. These guidelines managed through consultation with or referral to a specialist. are intended to assist with that effort. Although the guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed. Methods This report updates Sexually Transmitted Diseases Treatment Guidelines, 2015 (1) and should be regarded as a source of These guidelines were developed by CDC staff who worked clinical guidance rather than prescriptive standards. Health care with subject matter experts with expertise in STI clinical providers should always consider the clinical circumstances of management from other federal agencies, nongovernmental each person in the context of local disease prevalence. These academic and research institutions, and professional medical guidelines are applicable to any patient care setting that serves organizations. CDC staff identified governmental and persons at risk for STIs, including family planning clinics, nongovernmental subject matter experts on the basis of their HIV care clinics, correctional health care settings, private expertise and assisted them in developing questions to guide physicians’ offices, Federally Qualified Health Centers, clinics individual literature reviews. CDC staff informed the subject for adolescent care, and other primary care facilities. These matter experts that they were being consulted to exchange guidelines are focused on treatment and counseling and do information and observations and to obtain their individual not address other community services and interventions that input. All subject matter experts disclosed potential conflicts are essential to STI and HIV prevention efforts. of interest. STI Treatment Guidelines, 2021, Work Group members are listed at the end of this report. In 2018, CDC staff identified key questions about treatment and clinical management to guide an update of the 2015 Corresponding preparer: Kimberly A. Workowski, MD, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD treatment guidelines (1). To answer these questions STD, and TB Prevention, CDC. Telephone: 404-639-1898; Email: and synthesize new information available since publication [email protected]. of the 2015