NAATs can be used on urethral and endocervical swabs as well as urine samples. But they should not be used on oral or rectal samples. Some products test for both gonorrhea and chlamydia in a single specimen. A positive result could be due to either organism, however, requiring more specific testing.
The CDC believes that NAATs on urine samples are acceptable methods of screening for genital gonorrhea and chlamydia in both men and women, although for gonorrhea, cultures of urethral and endocervical swabs are preferred so that sensitivities can be obtained. Gonorrhea and chlamydia cultures are recommended for diagnosing oropharyngeal or anal infection.11
Treatment
Single-dose therapies
A variety of single-dose therapies for STDs are now available (Table 2). Single-dose therapies are convenient for patients, and they encourage quicker completion of therapy. If single-dose therapy is administered in the clinical setting, it is essentially directly observed therapy. Tests of cure can be avoided when common STDs are treated with recommended regimens and completion of treatment is assured.
A disadvantage often of single-dose therapy is its cost. However, when compared with the total costs of incomplete treatments—lower cure rates, return visits, increased infection of contacts—the price of a single-dose agent may seem more acceptable.
Many of the single-dose therapies for gonorrhea are quinolones, which should not be used to treat gonorrhea in (or acquired in) areas with high rates of quinolone resistance (Hawaii, parts of California). Consult your local or state health department to learn the local rates of resistance.
TABLE 2
Single-dose therapies available for common STDs
| Infection | Single-dose therapy |
|---|---|
| Chlamydia | Azithromycin 1 gm (oral) |
| Gonorrhea | Cefixime 400 mg (oral)*† |
| Ceftriaxone 125 mg (intramuscular) | |
| Ciprofloxacin 500 mg (oral) | |
| Ofloxacin 400 mg (oral)† | |
| Levofloxacin 250 mg (oral)† | |
| Nongonococcal urethritis | Azithromycin 1 gm (oral) |
| Syphilis (primary, secondary, early latent) | Benzathene penicillin 2.4 million units (intramuscular) |
| *Cefixime tablets are currently not being manufactured. | |
| †Not recommended for pharyngeal gonorrhea. | |
Management of sex partners
Treatment of patients with STDs is not complete until sex partners who have been exposed are also evaluated, tested, and treated. The common STDs discussed in this article are reportable to local and state health departments. However, in many jurisdictions, cost and staffing limitations prevent public health investigation and contact notification of gonorrhea or chlamydia infections. Family physicians in such locations need to advise their patients to notify sexual contacts of their exposure and recommend that they be examined and treated.
Confidentiality. When patients express concern about having their infections reported to the public health department, reassure them that these departments have a very good record of maintaining patient confidentiality and that public health information is usually afforded a greater degree of protection than information in an office medical record. When public health departments notify sexual contacts of their exposure, they do not reveal who exposed them, although in some instances the sexual contacts can figure this out.
Gonorrhea or chlamydia. The CDC recommends that when a patient is diagnosed with either gonorrhea or chlamydia, all their sex partners from the past 60 days should be evaluated and treated prophylactically.12 Patients and their sex partner(s) should avoid intercourse for 7 days after initiation of treatment and until symptoms resolve.
Syphilis. Syphilis is more complicated. Persons who were exposed to primary, secondary, and early latent syphilis within the 90 days prior to diagnosis should be treated prophylactically. Those exposed from 91 days to 6 months prior to diagnosis of secondary syphilis, or 91 days to 1 year prior to the diagnosis of early latent syphilis, should be treated prophylactically if serology testing is not available or if follow up is uncertain.
Other infections. Current sex partners of those with mucopurulent cervicitis or nongonococcal urethritis should also be evaluated and treated with the same regimen chosen for the index patient. Sex partners within the past 60 days of women with pelvic inflammatory disease should be evaluated and treated prophylactically for both gonorrhea and chlamydia while sex partners within the past 60 days of men with epididymitis should be evaluated but not necessarily treated prophylactically.
Sex and the Internet
As of May 2001,169 million Americans were regular users of the Internet.5 Internet sites created for the purpose of facilitating sexual contact have proliferated and include those for heterosexuals, gay men, lesbians, swingers, and those interested in group sex.6
Use of the Internet to meet sex partners has generated concern in public health circles because of the potential for increased risk of STDs, including HIV/AIDS, from anonymous sex. One case report describes an outbreak of syphilis among gay men who were participants in an Internet chat room for sexual networking.7 Each man with syphilis who was located reported an average of 12 recent sex partners (range of 2–47); a mean of 6 partners (range of 2–15) were located and examined. Four out of the 7 with syphilis were also positive for HIV.
Another study of users of HIVcounseling and testing services found that 16% had sought sex partners on the Internet and 65% of these reported having sex with someone they met on the Internet.8 Internet users reported more previous STDs,more partners, more HIV-positive partners,and more sex with gay men than did non-Internet users.
While much remains to be learned about this topic,these studies indicate that Internet-initiated sex may involve higher risk than sex initiated through other means, although anonymous sex and having multiple sex partners should be considered high-risk activities however they are initiated. Warn patients about these risks.