Morbidity and Mortality Weekly Report www.cdc.gov/mmwr Recommendations and Reports December 17, 2010 / Vol. 59 / No. RR-12 Sexually Transmitted Diseases Treatment Guidelines, 2010 department of health and human services Centers for Disease Control and Prevention MMWR CONTENTS The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Introduction .............................................................................. 1 Disease Control and Prevention (CDC), U.S. Department of Health Methods ................................................................................... 1 and Human Services, Atlanta, GA 30333. Clinical Prevention Guidance ..................................................... 2 STD/HIV Prevention Counseling ............................................... 2 Suggested Citation: Centers for Disease Control and Prevention. [Title]. MMWR 2010;59(No. RR-#):[inclusive page numbers]. Prevention Methods ................................................................ 4 Partner Management .............................................................. 7 Centers for Disease Control and Prevention Reporting and Confidentiality .................................................. 8 Thomas R. Frieden, MD, MPH Special Populations ................................................................... 8 Director Pregnant Women ................................................................... 8 Harold W. Jaffe, MD, MA Adolescents .......................................................................... 10 Associate Director for Science Children .............................................................................. 11 James W. Stephens, PhD Persons in Correctional Facilities ............................................ 11 Office of the Associate Director for Science Men Who Have Sex with Men ............................................... 12 Stephen B. Thacker, MD, MSc Women Who Have Sex with Women .................................... 13 Deputy Director for HIV Infection: Detection, Counseling, and Referral ..................... 14 Surveillance, Epidemiology, and Laboratory Services Diseases Characterized by Genital, Anal, or Perianal Ulcers ...... 18 Stephanie Zaza, MD, MPH Chancroid............................................................................ 19 Director, Epidemiology and Analysis Program Office Genital HSV Infections .......................................................... 20 Granuloma Inguinale (Donovanosis) ...................................... 25 Editorial and Production Staff Lymphogranuloma Venereum ................................................ 26 Ronald L. Moolenaar, MD, MPH Syphilis ................................................................................ 26 Editor, MMWR Series Congenital Syphilis ............................................................ 36 Christine G. Casey, MD Management of Persons Who Have a History of Penicillin Allergy . 39 Deputy Editor, MMWR Series Diseases Characterized by Urethritis and Cervicitis .................... 40 Teresa F. Rutledge Urethritis ............................................................................. 40 Managing Editor, MMWR Series Nongonococcal Urethritis ..................................................... 41 David C. Johnson Cervicitis .............................................................................. 43 Lead Technical Writer-Editor Chlamydial Infections .............................................................. 44 Rachel J. Wilson Gonococcal Infections .............................................................. 49 Project Editor Diseases Characterized by Vaginal Discharge ........................... 56 Martha F. Boyd Bacterial Vaginosis ............................................................... 56 Lead Visual Information Specialist Trichomoniasis ..................................................................... 58 Malbea A. LaPete Vulvovaginal Candidiasis ...................................................... 61 Stephen R. Spriggs Pelvic Inflammatory Disease .................................................... 63 Terraye M. Starr Epididymitis ............................................................................ 67 Visual Information Specialists Human Papillomavirus (HPV) Infection ...................................... 69 Quang M. Doan, MBA Genital Warts ......................................................................... 70 Phyllis H. King Cervical Cancer Screening for Women Who Attend STD Clinics Information Technology Specialists or Have a History of STDs ....................................................... 74 Vaccine-Preventable STDs ........................................................ 78 Editorial Board Hepatitis A ........................................................................... 78 William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Hepatitis B ........................................................................... 80 Hepatitis C .............................................................................. 85 Virginia A. Caine, MD, Indianapolis, IN Proctitis, Proctocolitis, and Enteritis ........................................... 87 Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Ectoparasitic Infections ............................................................. 88 David W. Fleming, MD, Seattle, WA Pediculosis Pubis .................................................................. 88 William E. Halperin, MD, DrPH, MPH, Newark, NJ Scabies ................................................................................ 89 King K. Holmes, MD, PhD, Seattle, WA Sexual Assault and STDs .......................................................... 90 Deborah Holtzman, PhD, Atlanta, GA References .............................................................................. 96 John K. Iglehart, Bethesda, MD Terms and Abbreviations Used in This Report .......................... 109 Dennis G. Maki, MD, Madison, WI Patricia Quinlisk, MD, MPH, Des Moines, IA Patrick L. Remington, MD, MPH, Madison, WI Barbara K. Rimer, DrPH, Chapel Hill, NC John V. Rullan, MD, MPH, San Juan, PR William Schaffner, MD, Nashville, TN Anne Schuchat, MD, Atlanta, GA Dixie E. Snider, MD, MPH, Atlanta, GA John W. Ward, MD, Atlanta, GA Vol. 59 / RR-12 Recommendations and Reports 1 Sexually Transmitted Diseases Treatment Guidelines, 2010 Prepared by Kimberly A. Workowski, MD1,2 Stuart Berman, MD1 1Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 2Emory University, Atlanta, Georgia Summary These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 18–30, 2009. The information in this report updates the 2006 Guidelines for Treatment of Sexually Transmitted Diseases (MMWR 2006;55[No. RR–11]). Included in these updated guidelines is new information regarding 1) the expanded diagnostic evaluation for cervicitis and trichomoniasis; 2) new treatment recommendations for bacterial vaginosis and genital warts; 3) the clinical efficacy of azithromycin for chlamydial infections in pregnancy; 4) the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications; 5) lymphogranuloma venereum proctocolitis among men who have sex with men; 6) the criteria for spinal fluid examination to evaluate for neurosyphilis; 7) the emergence of azithromycin-resistant Treponema pallidum; 8) the increasing prevalence of antimicrobial-resistant Neisseria gonorrhoeae; 9) the sexual transmission of hepatitis C; 10) diagnostic evaluation after sexual assault; and 11) STD prevention approaches. Introduction Methods The term sexually transmitted diseases (STDs) is used to These guidelines were developed using a multistage refer to a variety of clinical syndromes caused by pathogens process. Beginning in 2008, CDC staff members and public that can be acquired and transmitted through sexual activity. and private sector experts knowledgeable in the field of STDs Physicians and other health-care providers play a critical role in systematically reviewed literature using an evidence-based preventing and treating STDs. These guidelines for the treat- approach (e.g., published abstracts and peer-reviewed journal ment of STDs are intended to assist with that effort. Although articles), focusing on the common STDs and information that these guidelines emphasize treatment, prevention strategies and had become available since publication of the 2006 Guidelines diagnostic recommendations also are discussed. for Treatment of Sexually Transmitted Diseases (1). CDC staff These recommendations should be regarded as a source of members and STD experts developed background papers and clinical guidance and not prescriptive standards; health-care tables of evidence that summarized the type of study (e.g., providers should always consider the clinical circumstances of randomized controlled trial or case series), study population each person in the context of local disease prevalence. They are and setting, treatments or other interventions, outcome applicable to various patient-care settings, including family- measures assessed, reported findings, and weaknesses and biases planning clinics, private physicians’ offices, managed care orga- in study design and analysis. CDC staff then developed