An STI upsurge requires a nimble approach to care
Being fluent in new guidelines helps you meet the challenges of changing disease prevalence, rising antibiotic resistance, and evolving social patterns.
PRACTICE RECOMMENDATIONS
› Focus efforts to prevent sexually transmitted infections (STIs) on patients ages 15 to 24 years—because half of new STIs in the United States occur in this age group. A
› Screen for other STIs, including HIV infection, if a person tests positive for a single STI. A
› Treat STIs by following updated (2021) guidelines developed by the Centers for Disease Control and Prevention. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
HSV can become disseminated, particularly in immunosuppressed people, and can manifest as encephalitis, hepatitis, and pneumonitis. Beyond its significant burden on health, HSV carries significant psychosocial consequences.9
Diagnosis. Clinical diagnosis can be challenging if classic lesions are absent at evaluation. If genital lesions are present, HSV can be identified by NAAT or culture of a specimen of those lesions. False-negative antibody results might be more frequent in early stages of infection; repeating antibody testing 12 weeks after presumed time of acquisition might therefore be indicated, based on clinical judgment. HSV-2 antibody positivity implies anogenital infection because almost all HSV-2 infections are sexually acquired.
HSV-1 antibody positivity alone is more difficult to interpret because this finding does not distinguish between oral and genital lesions, and most HSV-1 seropositivity is acquired during childhood.36 HSV polymerase chain reaction (PCR) testing of blood should not be performed to diagnose genital herpes infection, except in settings in which there is concern about disseminated infection.
Treatment. Management should address the acute episode and the chronic nature of genital herpes. Antivirals will not eradicate latent
- attenuate current infection
- prevent recurrence
- improve quality of life
- suppress the virus to prevent transmission to sexual partners.
All patients experiencing an initial episode of genital herpes should be treated, regardless of symptoms, due to the potential for prolonged or severe symptoms during recurrent episodes.9 Three drugs—acyclovir, valacyclovir, and famciclovir—are approved by the US Food and Drug Administration (FDA) to treat genital herpes and appear equally effective (TABLE 214).
Antiviral therapy for recurrent genital HSV infection can be administered either as suppressive therapy to reduce the frequency of recurrences or episodically to shorten the duration of lesions:
- Suppressive therapy reduces the frequency of recurrence by 70% to 80% among patients with frequent outbreaks. Long-term safety and efficacy are well established.
- Episodic therapy is most effective if started within 1 day after onset of lesions or during the prodrome.36
There is no specific recommendation for when to choose suppressive over episodic therapy; most patients prefer suppressive therapy because it improves quality of life. Use shared clinical decision-making to determine the best option for an individual patient.
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