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This document is being maintained for historical purposes, but is now out of date.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

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV 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 neonatal infections.

Recommended Screening Tests
     The following screening tests are recommended for pregnant
women:

--  A serologic test for syphilis

     All women should be screened serologically for syphilis during
the early stages of pregnancy. 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 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 once during pregnancy and, preferably, again at delivery.
Any woman who delivers a stillborn infant after 20 weeks gestation
should be tested for syphilis.

--   A serologic test for hepatitis B surface antigen (HBsAg)

--   A test for Neisseria gonorrhoeae

--   A test for Chlamydia trachomatis

     Pregnant women at increased risk ( less than 25 years of age,
or with a new or more than one partner) should be tested and
treated, if necessary, during the third trimester to prevent
maternal postnatal complications and chlamydial infection among
infants. Screening during the first trimester might permit
prevention of adverse effects of chlamydia during pregnancy.
However, the 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

     Patients with risk factors for HIV or with a high-risk sex
partner should be tested for HIV infection. Some authorities
recommend offering HIV tests to all pregnant women, particularly in
areas of high HIV seroprevalence. Appropriate counseling should be
provided, and informed consent for HIV testing should be obtained.

Other Issues
     Other STD-related issues to be considered are as follows:

--   Pregnant women with primary genital herpes, HBV, primary
     cytomegalovirus (CMV) infection, 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.

--   In the absence of lesions during the third trimester, routine
     serial cultures for herpes simplex virus (HSV) are not indicated
     for women with 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" caesarean
     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 considered an indication
     for caesarean section.

For a more detailed discussion of these issues, as well as for
infections not transmitted sexually, refer to Guidelines for
Perinatal Care (3).

     NOTE: The sources for these guidelines for screening of
pregnant women include Guide to Clinical Preventive Services (4),
Guidelines for Perinatal Care (3), and Recommendations for the
Prevention and Management of Chlamydia trachomatis Infections, 1993
(5). These sources are not entirely consistent in their
recommendations. The Guide to Clinical Preventive Services
recommends routine testing for gonorrhea at the first prenatal
visit, with repeat testing for those at increased risk, and
selective screening for chlamydia at the first prenatal visit. The
Guidelines for Perinatal Care does not specifically recommend
screening for either gonorrhea or chlamydia, but recommends
screening for STDs in the third trimester for women at risk. The
Recommendations for the Prevention and Management of Chlamydia
trachomatis Infections, 1993 recommend screening for chlamydia
during the third trimester for all pregnant women less than 25
years of age or for any woman with a new sex partner or multiple
partners. Recommendations to screen pregnant women for STDs are
based on disease severity and sequelae, prevalence in the
population, costs, medical/legal considerations (including state
laws), and other factors. The screening recommendations in this
report are more comprehensive (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 compatible with their
practice population and setting.

Adolescents
     
     Health-care providers who provide care for patients with
sexually transmitted infections should be aware of several issues
that relate specifically to adolescents. The rates of many STDs are
highest among adolescents; e.g., the rate of gonorrhea is highest
among persons 15-19 years of age. Clinic-based studies have
demonstrated that the prevalence of chlamydial infections, and
possibly of HPV infections, also is highest among adolescents.

     All adolescents in the United States can consent to the
confidential diagnosis and treatment of STDs. Medical care for
these conditions can be provided to adolescents without parental
consent or knowledge. Furthermore, in many states adolescents can
consent to HIV counseling and testing.

     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. Care
and counseling should be direct and nonjudgmental.

Children
     
     Management of children with STDs requires close cooperation
between the clinician, laboratory, and child-protection
authorities. Investigations, when indicated, should be initiated
promptly. Some diseases, such as 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).

Persons with HIV Infection
     
     The management of patients infected with HIV and patients
infected with both HIV and other STDs presents complex clinical and
behavioral issues. For that reason, these issues are addressed
throughout this report (see HIV Infection and Early Intervention
and specific disease sections). Because of its effects on the
immune system, HIV infection may alter the natural histories of
many STDs and the effect of antimicrobial therapy. Such effects are
likely to occur as the degree of immunosuppression advances;
frequent or severe episodes of some STDs or failure to respond
appropriately to therapy should lead the health-care provider to
consider HIV infection as a cause. Close clinical follow-up of
patients infected with both HIV and STDs is imperative.

     STD infection among patients with or without HIV is a sentinel
event, often indicating unprotected sexual activity. Further
patient counseling is needed in such situations.

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