Sexually Transmitted Infections
Treating Patients with STIs
The prevention, treatment, and control of sexually transmitted infections (STI) involves many different aspects or health care. Individual physicians’ attitudes and actions can impact on an individual, on a core groups with high-risk behaviors, or the population as a whole. Older concepts such as primary and secondary prevention interventions are being retooled into schemes that recognize strategies that impact at many levels to reduce the ultimate burden of STI.
All primary care physicians should have access to a copy of the most recent Canadian STI Guidelines in their office. The 2006 Edition guidelines are available online through the Public Health Agency of Canada. This is a useful reference for managing patients with STIs as it includes information on most aspects of screening, testing and treating patients with STI. Special sections on managing the pregnant patient, sexual assault victims and persons with repeated STIs are also included.
The goals of treatment (7) for STIs are:
- Biological cure
- Amelioration of clinical symptoms
- Prevention of sequelae
- Prevention of transmission
- Community-based prevention
Of particular significance, the concept of “epidemiologic” treatment should be well accepted by physicians in all forms of primary care and consultant practice. This refers to the active treatment of a patient who presents having a history of contact with another individual with a known STI. Such patients should be administered treatment even in the absence of clinical signs or symptoms and laboratory evidence of infection. Failure to do so creates a missed opportunity for intervention and the high likelihood for subsequent transmission to other individuals and the development of disease in the index patient.
Physicians should also be aware of recent developments in common STIs that have had a major impact on treatment or management. Examples of these include:
- The use of one gram single-dose azithromycin (Zithromax™) for uncomplicated genital tract chlamydial infection. This is now the empiric treatment of choice for all patients presenting with urethritis or cervicitis given concurrently with single-dose therapy for gonococcal infection consisting of either cefixime (Suprax™) or a quinolone such as ciprofloxacin (Cipro™) or ofloxacin (Floxin™).
- Chronic suppressive antiviral therapy is now the preferred means of managing most patients with recurrent genital herpes. Acyclovir, valacylovir (Valtrex™) and famciclovir (Famvir™) have all been proven to be of equal efficacy in this clinical setting.
- The management of human papilloma virus infection has been improved with the increasing availability of viral typing in the clinical setting. This enables physicians to identify women who are infected with types(16, 18, 31) that are strongly associated with high-grade dysplasia and invasive cervical carcinoma. This then allows for more frequent Pap test screening of these women for cervical dysplasia. For those patients with symptomatic disease in the form of genital warts, a patient-applied topical therapy with a new agent, imiquimod (Aldara™), an immune modifier that stimulates local cytokines and other components of the host immune system, is now available. This offers an alternative to ablative methods that are often painful and require a provider-applied approach. Imiquimod has also been associated with a reduced frequency of recurrence in patients as compared with ablative techniques8.
All physicians have a role to play in the prevention and management of STIs. Thoughtful consideration of patient encounter-based opportunities to assess for and provide education on STIs are particularly important to family physicians and obstetrician/gynecologists in their daily practice. Current knowledge on important advances in treating patients with STIs and access to relevant up-to-date guidelines for STI management round out the clinician resources necessary to manage sexually transmitted infections in their patients.