STD QCS Questions and Answers

The questions contained on this web page were submitted by participants during the Recommendations for Providing Quality STD Clinical Services Webinar, which was hosted on January 28, 2020.

The Recommendations for Providing Quality STD Clinical Services (STD QCS) complement CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2015 (STD Treatment Guidelines). STD QCS provides guidance on clinical operations and the types of services that should or could be available for STD care. Therefore, the responses here primarily address STD QCS-related questions. For questions related to the 2015 STD Treatment Guidelines, resources are provided.

General

Question: When and how will the new treatment guidelines be released? What updates are expected?

In 2020, CDC expects to publish updated STI Treatment Guidelines based on the latest available science. After publication, the guidelines will be available on CDC’s STD website.  For notification when the guidelines are released, sign up for the Morbidity and Mortality Weekly Report (MMWR).

 

Question: What is considered timely detection and treatment.  Is there an actual time frame to attempt to achieve?

In general, timely detection means following screening guidance, offering partner services and providing same-day onsite testing.  Timely treatment means reducing the interval between testing and return visits, same-day treatments and expedited partner therapy (EPT).  Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020 outlines quality services relevant to timely detection and treatment that clinical settings providing STD care should or could have available such as screening, partner services, prevention, laboratory and treatment. Specific guidance regarding screening schedules, partner services management and EPT is available in the 2015 STD Treatment Guidelines.

Resources

Question: Where can I go for resources about caring for adolescents?

CDC offers the following resources on caring for adolescents:

CDC Division of Adolescent and School Health

CDC Division of STD Prevention

 

Question: Where can I go for resources for low-resource clinics?

The STD QCS implementation guide (expected to be released in 2020) can help clinics better identify resource gaps. The National Network of STD Clinical Prevention Training Centers (NNPTC) are CDC-funded regional training centersexternal icon which work to build clinician skills, knowledge and experience to address and prevent STDs. In addition to technical assistance, the NNPTCs provide in-person trainings, webinars, expert consultation and free or low-cost Continuing Medical Education (CME) or Certified Nurse Educator (CNE) courses from the National STD Curriculum’s online modules and question bankexternal icon.

CDC also funds the NNPTC STD Clinical Consultation Networkexternal icon (STDCCN) which provides treatment guidance for health care professionals and STD program staff.

CDC’s STD website has a number of free resources. The National Coalition for STD Directorsexternal icon provides free resources for health care providers and STD programs.

 

Question: Where can I go for more STI resources for patients?

CDC’s STD website has patient resources organized by disease:

 

Question: Where can I find more information on Quality Family Planning services?

The Quality Family Planning Services recommendations are available on CDC’s reproductive health website: https://www.cdc.gov/reproductivehealth/contraception/qfp.htm.

 

Question: Where can I find resources on sexual history taking?

Please see CDC’s Taking a Sexual History Guidepdf icon. This 2015 guide is being updated.

Prevention

Question: Why are hepatitis A virus (HAV) antibody testing and HAV vaccine for those that are negative not a recommendation for primary care clinics [human papilloma virus (HPV) and hepatitis B virus (HBV) are recommended but not HAV]?

CDC developed these recommendations after consultation with a wide range of experts and stakeholders. CDC also reviewed existing national guidelines, recommendations and current practice in the U.S.

STD QCS recommends the following:

1) on-site hepatitis B vaccination should be available as a basic STD care service in primary care settings; 2) on-site hepatitis A vaccination could be available as a basic STD care service in primary care settings; 3) serologic tests for hepatitis A, B, and C should be available through a clinical laboratory as basic STD care services.

Current guidance on hepatitis A screening and vaccination recommendations is available on CDC’s hepatitis website.

 

Question: HPV still seems to be the most common STD/STI. Are there new recommendations on reducing this virus aside from the vaccine?

STD QCS focuses on the optimal services that should or could be available to individuals seeking STD care in primary care or STD specialty clinical settings. You can find more information about prevention strategies in the HPV infection section of the 2015 STD Treatment Guidelines. You can find more information in the HPV vaccine recommendations MMWR.

Screening

Question: Does a person who has never been sexually active need to have blood drawn for syphilis?

Sexual historiespdf icon and risk assessments are foundational to providing quality STD care services. A sexual history helps clinicians identify those individuals at risk for STDs and determine the appropriate testing and treatment management.

STD QCS recommends that syphilis screening should be available in primary care settings providing STD care, as well as STD specialty settings. You can find screening recommendations for syphilis summarized on CDC’s STD website.

 

Question: Is it recommended to routinely test for hepatitis B? If a client presents for STD screening, should a hepatitis B surface antigen (HBsAg) test be done if the client has completed the hepatitis B vaccine series?

Hepatitis B screening and assessment should be available in primary care settings providing STD care and STD specialty settings. The Viral Hepatitis chapter of the 2015 STD Treatment Guidelines describes recommendations on HBV (under the sections on pre-exposure vaccination, pre-vaccination serologic testing, and post-vaccination serologic testing). You can find the screening recommendations summarized on CDC’s STD website.

 

Question: What are the recommendations for HPV testing in men?

You can find general information on HPV testing in the HPV and Men fact sheet on CDC’s STD website.

 

Question: What is the best way to do rectal pap?

STD QCS recommends that anal cancer screening and assessment could be available as a specialized STD care service. The anal cancer section of the 2015 STD Treatment Guidelines includes information regarding screening and assessment.  Additional resources are available at the following links:

University of California, San Francisco: https://analcancerinfo.ucsf.edu/obtaining-specimen-anal-cytologyexternal icon

University of Washington, Seattle:  https://www.uwhealth.org/healthfacts/diagnostic-tests/7056.pdfpdf iconexternal icon

Northwest AETC https://www.youtube.com/watch?v=olNphfWcO1g

Partner Services

Question: Thoughts on expedited partner therapy (EPT) for STDs? What is the recommendation for EPT for gonorrhea? Do you recommend EPT for trichomoniasis?

EPT (where legal and where local or state jurisdictions do not prohibit by regulation) should be available in primary care settings providing STD care and STD specialty care settings as a partner service. EPT medications for gonorrhea and chlamydia should be available onsite as a specialized STD care service and should be available by prescription as a basic STD care service. Information on EPT, including recommendations for gonorrhea, chlamydia and trichomoniasis, is available in the Clinical Prevention Guidance chapter of the 2015 STD Treatment Guidelines.

Laboratory

Question: For post-treated chlamydia, how soon should full STI testing be done, 30 days or 3 months? How long does it take chlamydia, gonorrhea, and trichomonas to clear urine testing? Could you briefly state the testing time frame after exposure to STDs?

Recommendations on retesting after treatment for chlamydia, gonorrhea or trichomoniasis are discussed in the follow-up section of the corresponding chapters in the 2015 STD Treatment Guidelines.

 

Question: Are you recommending gonorrhea culture in addition to nucleic acid amplification testing (NAAT)? In recommending “gonorrhea culture”, does that mean on-site Thayer Martin media and a candle jar or sending a gonorrhea culture to a lab?

The diagnostic considerations section of the 2015 STD Treatment Guidelines Gonorrhea chapter describes the various tests available for diagnosing gonorrhea. STD QCS outlines the quality laboratory tests that should or could be available at the time of the patient visit or in a clinical laboratory by clinical setting. Urogenital and extragenital NAAT testing for gonorrhea should be available at the time of the patient visit. Gonorrhea culture should be available through a clinical laboratory as a specialized STD care service. As basic STD care services, urogenital and extragenital NAAT testing for gonorrhea should be available through a clinical laboratory while gonorrhea culture could be through a clinical laboratory.

 

Question: What are the thoughts on laboratories using automated rapid plasma reagin (RPR) tests (rather than automated treponemal tests) as the initial test for syphilis screening. Do you have a recommendation regarding Reverse Algorithm Testing for Syphilis?  In using the reverse algorithm for syphilis, do you recommend using Treponema pallidum particle agglutination assay (TPPA) as the final confirmatory?

The syphilis diagnostic considerations section of the 2015 STD Treatment Guidelines provides direction on syphilis serologic testing algorithms.  CDC syphilis laboratory guidelines are in development.

 

Question: What is the status of rapid syphilis testing at the clinic level?  We’ve been told that current tests are not very accurate (not as sensitive nor selective as needed to be reliable).  Is there any particular test product you recommend? The challenge is that after rapid HIV testing, the patients often do not want to do the syphilis test because it’s a blood draw that’s sent out.

In the United States, the Food and Drug Administration, or FDA, has approved one rapid syphilis test. While the testing is being used in both the clinic and outreach settings, it is important to understand its limitations before embarking on a rapid syphilis testing program. The syphilis diagnostic considerations section of the 2015 STD Treatment Guidelines provides direction on syphilis serologic testing algorithms. CDC syphilis laboratory guidelines are in development.

 

Question: On slide 39, a suggestion was made for trichomoniasis testing in clinic. We already test for females. Are you suggesting testing for males on demand?

STD QCS focuses on quality laboratory tests that should or could be available at the time of the patient visit or in a clinical laboratory by clinical setting. Trichomoniasis screening guidance is outlined in the 2015 STD Treatment Guidelines.

 

Question: Please describe a situation where it is very useful to do Gram stain in the office when I have very good lab availability.

Urethral Gram stain results can document the presence of urethritis and distinguish between gonococcal and nongonococcal urethritis in men.  The availability of this test at the point-of-care can help to direct appropriate antibiotic therapy and decrease unnecessary antibiotic exposure in men presenting with urethral symptoms.  STD QCS recommends that Gram stain could be available through a clinical laboratory as a basic STD care service. As a specialized STD care service, Gram stain should be available at the time of the patient visit.  

Treatment

Question: Thoughts on same-day treatment while laboratories are pending and the issue of antibiotic resistance? Especially with gonorrhea on the Urgent Threat list for antimicrobial resistance? Have there been many cases of resistant chlamydia?

The Gonococcal Infections chapter of the 2015 STD Treatment Guidelines provides recommendations for gonorrhea regimens, including antimicrobial-resistant N. gonorrhoeae. Chlamydial resistance is thought to be rare though the issue is complicated by the lack of standardized testing methodology. To date, only a few cases of clinically significant chlamydia resistance in humans have been identified.

 

Question: When a client has antibiotic-resistant pharyngeal gonorrhea, is treated with ceftriaxone and azithromycin, returns to clinic for test-of-cure and states no sexual contact since treatment, does the client need to wait a few more weeks (thinking that gonorrhea takes longer to clear in throat) to retest, or is this considered a treatment failure and client needs to be retreated?

The Gonococcal Infections chapter of the 2015 STD Treatment Guidelines provides guidance on managing  suspected cephalosporin treatment failure.  In addition, the NNPTC’s STDCCNexternal icon is a resource for health care professionals and STD program staff to receive guidance on specific clinical case management.

 

Question: If I don’t have ceftriaxone available, can I treat gonorrhea with 2 grams of azithromycin?

Azithromycin monotherapy is not a recommended or alternative regimen for the treatment of gonococcal infection.  The Gonococcal Infections chapter of the 2015 STD Treatment Guidelines provides recommendations for gonorrhea regimens. The NNPTC’s STDCCNexternal icon is a resource for health care professionals and STD program staff to receive guidance on specific clinical case management.  Local STD programs also may be a resource for partnering on STD services.

 

Question: Does the CDC recommend empirical treatment if a patient is symptomatic or only after a positive result?

Sexual historiespdf icon, risk assessments and physical examinations are foundational to providing quality STD care services. A sexual history and risk assessment allow clinicians to learn about an individual’s sexual practices, partners, prevention, and past sexual history and to determine risk factors.  A physical examination allows clinicians the opportunity to identify any signs of STDs, including those not identified by the patient. Information from a sexual history, risk assessment, and physical examination can help clinicians identify those at risk for STDs and determine appropriate testing and treatment management including presumptive treatment.

 

Question: If an individual has RPR 1:2 but no confirmatory, should I treat without waiting for a confirmatory result?

The 2015 STD Treatment Guidelines describe diagnostic considerations for syphilis.

 

Question: What is the suggestion for someone with recurrent monthly bacterial vaginosis (BV)?

The 2015 STD Treatment Guidelines outline recommendations on managing recurrent BV.

Mycoplasma genitalium (M. genitalium)/Ureaplasma: Testing & Treatment

Question: What are the recommendations for testing and treating M. genitalium and Ureaplasma? How should sex partners of individuals with M. genitalium be managed?

The CDC does not recommend routine screening for Ureaplasma or M. genitalium.  The 2015 STD Treatment Guidelines include guidance on managing M. genitalium, as well as sex partners.

Referral to or Consultation with a Specialist

Question: Why is cephalosporin or IgE-mediated penicillin allergy considered a reason to refer to a specialist for complex chlamydia infections?

The recommendation is intended to include referral of patients who are diagnosed with chlamydia-related pelvic inflammatory disease and have an antimicrobial allergy.

 

Question: Is a patient who is living with HIV and has persistent elevation of syphilis titers after treatment considered a complex case needing referral to an infectious disease specialist?

The 2015 STD Treatment Guidelines outline recommendations on management and follow-up of syphilis in people with HIV. The NNPTC’s STDCCNexternal icon is a resource for health care professionals and STD program staff to receive guidance on specific clinical case management. Local STD programs also may be a resource for partnering on STD services.