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Diagnosis and Treatment of Sexually Transmitted InfectionsA Review

Educational Objective
To review recommended approaches to the diagnosis and treatment of sexually transmitted infections.

Importance  Approximately 1 in 5 adults in the US had a sexually transmitted infection (STI) in 2018. This review provides an update on the epidemiology, diagnosis, and treatment of gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, trichomoniasis, and genital herpes.

Observations  From 2015 to 2019, the rates of gonorrhea, chlamydia, and syphilis increased in the US; from 1999 to 2016, while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. Populations with higher rates of STIs include people younger than 25 years, sexual and gender minorities such as men and transgender women who have sex with men, and racial and ethnic minorities such as Black and Latinx people. Approximately 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms. STIs are associated with HIV acquisition and transmission and are the leading cause of tubal factor infertility in women. Nucleic acid amplification tests have high sensitivities (86.1%-100%) and specificities (97.1%-100%) for the diagnosis of gonorrhea, chlamydia, M genitalium, trichomoniasis, and symptomatic HSV-1 and HSV-2. Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal (antiphospholipid) antibodies. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles, such as metronidazole, are effective treatments for gonorrhea, chlamydia, syphilis, M genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and M genitalium. No cure is available for genital herpes. Effective STI prevention interventions include screening, contact tracing of sexual partners, and promoting effective barrier contraception.

Conclusions and Relevance  Approximately 1 in 5 adults in the US had an STI in 2018. Rates of gonorrhea, chlamydia, and syphilis in the US have increased, while rates of HSV-1 and HSV-2 have declined. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.

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Article Information

Corresponding Author: Khalil G. Ghanem, MD, PhD, Johns Hopkins University Bayview Medical Center, 5200 Eastern Ave, MFL Center Tower No. 378, Baltimore, MD 21224 (kghanem@jhmi.edu).

Accepted for Publication: December 10, 2021.

Author Contributions: Drs Tuddenham and Hamill contributed equally to this article.

Conflict of Interest Disclosures: Dr Tuddenham reported serving as a consultant for Luca Biologics, Roche Molecular Diagnostics, and Biofire; receiving royalties from UpToDate, and receiving speaker honoraria from Roche Molecular Diagnostics and Medscape. Drs Ghanem and Hamill reported receiving royalties from UpToDate. No other disclosures were reported.

Funding/Support: Dr Tuddenham is supported by grant K23-AI125715 from the National Institute of Allergy and Infectious Diseases.

Role of the Funder/Sponsor: The National Institute of Allergy and Infectious Diseases had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Barbara Wilgus, MSN, CRNP, at the Johns Hopkins University School of Medicine for her thoughtful comments, for which she received no compensation.

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