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Warning:
This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:
- STD Treatment Guidelines at http://www.cdc.gov/STD/treatment
1998 Guidelines for Treatment of Sexually Transmitted Disease
Date: 01/23/98
Source: 47(RR-1);1-118
SUGGESTED CITATION: Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1): {inclusive page numbers}.
The material in this report was prepared for publication by: National Center for HIV, STD and TB Prevention, Division of Sexually Transmitted Diseases Prevention
SPECIAL POPULATIONS
Pregnant Women
Intrauterine or perinatally transmitted STDs can have fatal or severely debilitating effects on a fetus. Pregnant women and their sex partners should be questioned about STDs and should be counseled about the possibility of perinatal infections.
Recommended Screening Tests
A serologic test for syphilis should be performed on all pregnant women at the first prenatal visit. In populations in which utilization of prenatal care is not optimal, rapid plasma reagin (RPR)-card test screening and treatment, if that test is reactive, should be performed at the time a pregnancy is diagnosed. For patients at high risk, screening should be repeated in the third trimester and again at delivery. Some states also mandate screening all women at delivery. No infant should be discharged from the hospital without the syphilis serologic status of its mother having been determined at least one time during pregnancy and, preferably, again at delivery. Any woman who delivers a stillborn infant should be tested for syphilis.
A serologic test for hepatitis B surface antigen (HBsAg) should be performed for all pregnant women at the first prenatal visit. HBsAg testing should be repeated late in the pregnancy for women who are HBsAg negative but who are at high risk for HBV infection (e.g., injecting-drug users and women who have concomitant STDs).
A test for Neisseria gonorrhoeae should be performed at the first prenatal visit for women at risk or for women living in an area in which the prevalence of N. gonorrhoeae is high. A repeat test should be performed during the third trimester for those at continued risk.
A test for Chlamydia trachomatis should be performed in the third trimester for women at increased risk (i.e., women aged less than 25 years and women who have a new or more than one sex partner or whose partner has other partners) to prevent maternal postnatal complications and chlamydial infection in the infant. Screening during the first trimester might enable prevention of adverse effects of chlamydia during pregnancy. However, evidence for adverse effects during pregnancy is minimal. If screening is performed only during the first trimester, a longer period exists for acquiring infection before delivery.
A test for HIV infection should be offered to all pregnant women at the first prenatal visit.
A test for bacterial vaginosis (BV) may be conducted early in the second trimester for asymptomatic patients who are at high risk for preterm labor (e.g., those who have a history of a previous preterm delivery). Current evidence does not support universal testing for BV.
A Papanicolaou (Pap) smear should be obtained at the first prenatal visit if none has been documented during the preceding year.
Other Concerns
Other STD-related concerns are to be considered as follows:
Pregnant women who have either primary genital herpes infection, HBV, primary cytomegalovirus (CMV) infection, or Group B streptococcal infection and women who have syphilis and who are allergic to penicillin may need to be referred to an expert for management.
HBsAg-positive pregnant women should be reported to the local and/or state health department to ensure that they are entered into a case-management system and appropriate prophylaxis is provided for their infants. In addition, household and sexual contacts of HBsAg-positive women should be vaccinated.
In the absence of lesions during the third trimester, routine serial cultures for herpes simplex virus (HSV) are not indicated for women who have a history of recurrent genital herpes. However, obtaining cultures from such women at the time of delivery may be useful in guiding neonatal management. Prophylactic cesarean section is not indicated for women who do not have active genital lesions at the time of delivery.
The presence of genital warts is not an indication for cesarean section.
For a more detailed discussion of these guidelines, as well as for infections not transmitted sexually, refer to Guidelines for Perinatal Care (6).
NOTE: The sources for these guidelines for screening of pregnant women include the Guide to Clinical Preventive Services (7), Guidelines for Perinatal Care (6), American College of Obstetricians and Gynecologists (ACOG) Technical Bulletin: Gonorrhea and Chlamydial Infections (8), "Recommendations for the Prevention and Management of Chlamydia trachomatis Infections" (9), and "Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States through Universal Childhood Vaccination -- Recommendations of the Immunization Practices Advisory Committee (ACIP)" (1). These sources are not entirely compatible in their recommendations. The Guide to Clinical Preventive Services recommends screening of patients at high risk for chlamydia, but indicates that the optimal timing for screening is uncertain. The Guidelines for Perinatal Care recommend that pregnant women at high risk for chlamydia be screened for the infection during the first prenatal-care visit and during the third trimester. Recommendations to screen pregnant women for STDs are based on disease severity and sequelae, prevalence in the population, costs, medicolegal considerations (e.g., state laws), and other factors. The screening recommendations in this report are more extensive (i.e., if followed, more women will be screened for more STDs than would be screened by following other recommendations) and are compatible with other CDC guidelines. Physicians should select a screening strategy that is compatible with the population and setting of their medical practices and that meets their goals for STD case detection and treatment.
Adolescents
Health-care providers who provide care for adolescents should be aware of several issues that relate specifically to these persons. The rates of many STDs are highest among adolescents (e.g., the rate of gonorrhea is highest among females aged 15-19 years). Clinic-based studies have demonstrated that the prevalence of chlamydial infections, and possibly of human papillomavirus (HPV) infections, also is highest among adolescents. In addition, surveillance data indicate that 9% of adolescents who have acute HBV infection either a) have had sexual contact with a chronically infected person or with multiple sex partners or b) gave their sexual preference as homosexual. As part of a comprehensive strategy to eliminate HBV transmission in the United States, ACIP has recommended that all children be administered hepatitis B vaccine.
Adolescents who are at high risk for STDs include male homosexuals, sexually active heterosexuals, clients in STD clinics, and injecting-drug users. Younger adolescents (i.e., persons aged less than 15 years) who are sexually active are at particular risk for infection. Adolescents are at greatest risk for STDs because they frequently have unprotected intercourse, are biologically more susceptible to infection, and face multiple obstacles to utilization of health care.
Several of these issues can be addressed by clinicians who provide services to adolescents. Clinicians can address the general lack of knowledge and awareness about the risks and consequences of STDs and offer guidance, constituting true primary prevention, to help adolescents develop healthy sexual behaviors and prevent the establishment of patterns of behavior that can undermine sexual health. With limited exceptions, all adolescents in the United States can consent to the confidential diagnosis and treatment of STDs. Medical care for STDs can be provided to adolescents without parental consent or knowledge. Furthermore, in many states adolescents can consent to HIV counseling and testing. Consent laws for vaccination of adolescents differ by state. Several states consider provision of vaccine similar to treatment of STDs and provide vaccination services without parental consent. Providers should appreciate how important confidentiality is to adolescents and should strive to follow policies that comply with state laws to ensure the confidentiality of STD-related services provided to adolescents.
The style and content of counseling and health education should be adapted for adolescents. Discussions should be appropriate for the patient's developmental level and should identify risky behaviors, such as sex and drug-use behaviors. Careful counseling and thorough discussions are especially important for adolescents who may not acknowledge engaging in high-risk behaviors. Care and counseling should be direct and nonjudgmental.
Children
Management of children who have STDs requires close cooperation between the clinician, laboratorians, and child-protection authorities. Investigations, when indicated, should be initiated promptly. Some diseases (e.g., gonorrhea, syphilis, and chlamydia), if acquired after the neonatal period, are almost 100% indicative of sexual contact. For other diseases, such as HPV infection and vaginitis, the association with sexual contact is not as clear (see Sexual Assault and STDs).
