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Introduction 

Preface

In the last few decades, the spectrum and epidemiology of sexually transmitted diseases (STDs) has changed dramatically. This has created frequent diagnostic dilemmas for clinicians, since STDs enter into the differential diagnosis of many conditions. While treatments of some common STDs have remained static, others have undergone major change related to rising rates of antimicrobial resistance that continue to pose impressive challenges to practitioners and public health advocates.

The purpose of this manual is to assist practitioners in primary health care, ambulatory medicine, and other specialties in the optimal management of patients with STD and their sex partners. The manual is organized by disease syndrome (for example, vaginitis or urethritis) rather than by microorganism, since this more closely approximates how patients present in clinical practice. Because most patients with STD have few or no symptoms or have simultaneous infections involving more than one site, appropriate screening is also emphasized. Algorithms are used, whenever feasible, as a step-by-step guide to diagnosis and treatment. Tables and appendices summarize the chief clinical features, laboratory tests, and treatment of the more common STDs.

Acknowledgements

This project was made possible by a cooperative agreement with the Centers for Disease Control and Prevention, grant number 1 U62 PS003298.

In addition, contractual funding provided to the Seattle STD/HIV Prevention Training Center by the CDC helped to support the development of many teaching materials that were instrumental in preparing the hand­book. In particular, we would like to acknowledge the late Dr. Walter Stamm (1945-2009), who originated the first edition and remains one of the greatest pioneers in the diagnosis and management of STD.

We also acknowledge the following for their contributions in previous editions: Drs. T.M. Hooton, David Eschenbach, Anna Wald, David Spach and Negusse Ocbamichael, PA-C, who reviewed chapters; H. Hunter Handsfield, MD, Former Director, Sexually Transmitted Disease Control Program, Seattle-King County; and the many physicians and clinicians who serve as faculty of the Seattle STD/HIV Prevention Training Center. We would also like to thank Susan M. Kaetz, MPH, Maryann B. Beirne, MS, and Jill A. Ashman, MS, who were involved in the first edition of the handbook; Cynthia Fennell, MS, MT(ASCP) and Edie Wilch, MEd, who were involved in the second edition, Anne Meegan who was involved in the third and fourth editions, as well as Barbara Macfadden, Mi­chèle Savelle, David Wolbrecht, and the production staff at the University of Washington Health Sciences Academic Services and Facilities. All algorithms are reproduced with the permission of the Sylvie Ratelle STD/HIV Prevention Training Center of New England.

  • Jeanne Marrazzo, MD, MPH
    Devika Singh, MD, MPH
    Amy Radford, MSW

STD SYNDROMES

Once a routine screening history and physical examination are obtained, it should be possible to tentatively classify patients according to their signs and symptoms into one of several clinical syndromes (Table i). For those patients who are asymptomatic and have a normal exam and are not known to be a sexual contact to a person with treatable STD, it is generally necessary to wait for results from the laboratory in order to direct treatment.

Table i
Clinical Syndromes - Female Clinical Syndromes - Male
Vaginitis Urethritis
Cervicitis Epididymitis
Urethritis/UTI Genital ulcers (inguinal adenopathy)
Lower abdominal pain (PID) Non-ulcerative genital skin lesions
Genital ulcers (inguinal adenopathy) Proctocolitis/Enteritis
Non-ulcerative genital skin lesions Acute arthritis
Proctocolitis/Enteritis  
Acute arthritis  

Identifying a tentative clinical syndrome helps narrow the number of possible pathogens that could cause the infection. The next step is to establish the specific cause of the patient's symptoms. The recommendations for empiric management outlined in the algorithms should be followed while waiting for laboratory confirmation of a diagnosis. They may also suggest that additional historical data or laboratory tests are necessary.

Each patient presenting with a possible STD should have a clearly-stated clinical assessment that summarizes both the clinician's interpretation of the patient's subjective information and the clinician's objective information. A management plan should be formulated for each patient, including a specific listing of diagnostic tests and therapeutic interventions. The management plan should clearly state which drugs and exact doses have been prescribed, and when the patient should return for follow-up. A specific management plan for the patient's sexual partners should also be listed.

Treatment of Specific STD

The STD treatment regimens recommended by the Centers for Disease Control and Prevention are included in the discussion of each syndrome. For a more detailed discussion of these regimens and other treatment considerations, please refer to http://www.cdc.gov/std/treatment/.

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