Morbidity and Mortality Weekly Report

Recommendations and Reports / Vol. 70 / No. 4 July 23, 2021

Sexually Transmitted Infections Treatment

Guidelines, 2021

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
 Recommendations and Reports

CONTENTS
Introduction.............................................................................................................1
Methods.....................................................................................................................1
Clinical Prevention Guidance.............................................................................2
STI Detection Among Special Populations................................................ 11
HIV Infection.......................................................................................................... 24
Diseases Characterized by Genital, Anal, or Perianal Ulcers................ 27
Syphilis.................................................................................................................... 39
Management of Persons Who Have a History of Penicillin Allergy... 56
Diseases Characterized by Urethritis and Cervicitis................................ 60
Chlamydial Infections........................................................................................ 65
Gonococcal Infections....................................................................................... 71
Mycoplasma genitalium..................................................................................... 80
Diseases Characterized by Vulvovaginal Itching, Burning, Irritation,
Odor, or Discharge............................................................................................ 82
Pelvic Inflammatory Disease........................................................................... 94
Epididymitis........................................................................................................... 98
Human Papillomavirus Infections...............................................................100
Viral Hepatitis......................................................................................................113
Proctitis, Proctocolitis, and Enteritis...........................................................124
Ectoparasitic Infections...................................................................................126
Sexual Assault and Abuse and STIs.............................................................128
References............................................................................................................135

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Centers for Disease Control and Prevention
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 Recommendations and Reports

Sexually Transmitted Infections Treatment Guidelines, 2021

Kimberly A. Workowski, MD1,2; Laura H. Bachmann, MD1; Philip A. Chan, MD1,3; Christine M. Johnston, MD1,4; Christina A. Muzny, MD1,5;
Ina Park, MD1,6; Hilary Reno, MD1,7; Jonathan M. Zenilman, MD1,8; Gail A. Bolan, MD1

1Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia; 2Emory University, Atlanta, Georgia;
3Brown University, Providence, Rhode Island; 4University of Washington, Seattle, Washington; 5University of Alabama at Birmingham, Birmingham, Alabama;
6University of California San Francisco, San Francisco, California; 7Washington University, St. Louis, Missouri; 8Johns Hopkins University, Baltimore, Maryland

Summary
These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by
CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019.
The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of
Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended
treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of
Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors
for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with
men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health
care providers can use these guidelines to assist in prevention and treatment of STIs.

Introduction These STI treatment guidelines complement Recommendations

for Providing Quality Sexually Transmitted Diseases Clinical
The term “sexually transmitted infection” (STI) refers to Services, 2020 (2) regarding quality clinical services for STIs
a pathogen that causes infection through sexual contact, in primary care and STD specialty care settings. This guidance
whereas the term “sexually transmitted disease” (STD) refers specifies operational determinants of quality services in various
to a recognizable disease state that has developed from an clinical settings, describes on-site treatment and partner
infection. Physicians and other health care providers have a services, and indicates when STI-related conditions should be
crucial role in preventing and treating STIs. These guidelines managed through consultation with or referral to a specialist.
are intended to assist with that effort. Although the guidelines
emphasize treatment, prevention strategies and diagnostic
recommendations also are discussed.
This report updates Sexually Transmitted Diseases Treatment
Methods
Guidelines, 2015 (1) and should be regarded as a source of These guidelines were developed by CDC staff who worked
clinical guidance rather than prescriptive standards. Health care with subject matter experts with expertise in STI clinical
providers should always consider the clinical circumstances of management from other federal agencies, nongovernmental
each person in the context of local disease prevalence. These academic and research institutions, and professional medical
guidelines are applicable to any patient care setting that serves organizations. CDC staff identified governmental and
persons at risk for STIs, including family planning clinics, nongovernmental subject matter experts on the basis of their
HIV care clinics, correctional health care settings, private expertise and assisted them in developing questions to guide
physicians’ offices, Federally Qualified Health Centers, clinics individual literature reviews. CDC staff informed the subject
for adolescent care, and other primary care facilities. These matter experts that they were being consulted to exchange
guidelines are focused on treatment and counseling and do information and observations and to obtain their individual
not address other community services and interventions that input. All subject matter experts disclosed potential conflicts
are essential to STI and HIV prevention efforts. of interest. STI Treatment Guidelines, 2021, Work Group
members are listed at the end of this report.
In 2018, CDC staff identified key questions about treatment
and clinical management to guide an update of the 2015
Corresponding preparer: Kimberly A. Workowski, MD, Division of
STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD treatment guidelines (1). To answer these questions
STD, and TB Prevention, CDC. Telephone: 404-639-1898; Email: and synthesize new information available since publication
[email protected]. of the 2015 guidelines, subject matter experts and CDC staff

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 1
 Recommendations and Reports

collaborated to conduct systematic literature reviews by using Management and Budget for influential scientific information.
an extensive MEDLINE database evidence-based approach for A public webinar was held to provide an overview of the draft
each section of the 2015 guidelines (e.g., using English-language recommendations and invite questions and comments on the
published abstracts and peer reviewed journal articles). These draft recommendations. The peer review comments, webinar,
systematic reviews were focused on four principal outcomes questions, and responses were considered by CDC staff in
of STI therapy for each disease or infection: 1) treatment developing the final recommendations for the updated STI
of infection on the basis of microbiologic eradication; treatment guidelines. Recommendations for HIV, hepatitis C,
2) alleviation of signs and symptoms; 3) prevention of sequelae; cervical cancer screening, STI screening in pregnancy, human
and 4) prevention of transmission, including advantages (e.g., papillomavirus (HPV) testing, and hepatitis A virus (HAV) and
cost-effectiveness, single-dose formulations, and directly hepatitis B virus (HBV) vaccination were developed after CDC
observed therapy) and disadvantages (e.g., adverse effects) staff reviewed existing published recommendations. The English-
of specific regimens. The outcome of the literature reviews language literature was searched periodically by CDC staff to
guided development of background materials, including tables identify subsequently published articles warranting consideration.
of evidence from peer-reviewed publications summarizing Throughout this report, the evidence used as the basis for
the type of study (e.g., randomized controlled trial or case specific recommendations is discussed briefly. Publication
series), study population and setting, treatments or other of comprehensive, annotated discussions of such evidence
interventions, outcome measures assessed, reported findings, is planned in a supplemental issue of the journal Clinical
and weaknesses and biases in study design and analysis. Infectious Diseases after publication of the treatment guidelines.
In June 2019, the subject matter experts presented their When more than one therapeutic regimen is recommended
assessments of the literature reviews at an in-person meeting and the listed regimens have similar efficacy and similar
of governmental and nongovernmental participants. Each rates of intolerance or toxicity, the recommendations are
key question was discussed and pertinent publications were listed alphabetically. If differences are specified, regimens are
reviewed in terms of strengths, weaknesses, and relevance. prioritized on the basis of these differences. Recommended
Participants evaluated the quality of evidence, provided their regimens should be used primarily; alternative regimens can be
input, and discussed findings in the context of the modified considered in instances of notable drug allergy or other medical
rating system used by the U.S. Preventive Services Task Force contraindications to the recommended regimens. Alternative
(USPSTF). The discussions were informal and not structured regimens are considered inferior to recommended regimens on
to reach consensus. CDC staff also reviewed the publications the basis of available evidence regarding the principal outcomes
from other professional organizations, including the American and disadvantages of the regimens.
College of Obstetricians and Gynecologists (ACOG), USPSTF,
the American Cancer Society (ACS), the American Society
for Colposcopy and Cervical Pathology (ASCCP), and the Clinical Prevention Guidance
Advisory Committee on Immunization Practices (ACIP). Prevention and control of STIs are based on the following
The discussion culminated in a list of participants’ opinions five major strategies (3):
on all the key STI topic areas for consideration by CDC. 1. Accurate risk assessment and education and counseling
(More detailed descriptions of the key questions, search terms, of persons at risk regarding ways to avoid STIs through
systematic search, evidence tables, and review process are changes in sexual behaviors and use of recommended
available at https://www.cdc.gov/std/treatment-guidelines/ prevention services
default.htm). 2. Pre-exposure vaccination for vaccine-preventable STIs
CDC staff then independently reviewed the tables of evidence 3. Identification of persons with an asymptomatic
prepared by the subject matter experts, individual comments infection and persons with symptoms associated with
from the participants and professional organizations, and existing an STI
guidelines from other organizations to determine whether 4. Effective diagnosis, treatment, counseling, and follow-
revisions to the 2015 STD treatment guidelines were warranted. up of persons who are infected with an STI
CDC staff ranked evidence as high, medium, and low on the 5. Evaluation, treatment, and counseling of sex partners
basis of each study’s strengths and weaknesses according to the of persons who are infected with an STI
USPSTF ratings (https://www.uspreventiveservicestaskforce.
org/uspstf/us-preventive-services-task-force-ratings). CDC staff
then developed draft recommendations that were peer reviewed
by public health and clinical experts as defined by the Office of

2 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

STI and HIV Infection Risk Assessment is it for you?”). The “Five P’s” approach to obtaining a sexual
history is one strategy for eliciting information about the key
Primary prevention of STIs includes assessment of behavioral
areas of interest (Box 1). In addition, health care professionals
risk (i.e., assessing the sexual behaviors that can place persons
can consider assessing sexual history by asking patients such
at risk for infection) and biologic risk (i.e., testing for risk
questions as, “Do you have any questions or concerns about
markers for STI and HIV acquisition or transmission). As part
your sexual health?” Additional information about gaining
of the clinical encounter, health care providers should routinely
cultural competency when working with certain populations
obtain sexual histories from their patients and address risk
(e.g., gay, bisexual, or other men who have sex with men
reduction as indicated in this report. Guidance for obtaining
[MSM]; women who have sex with women [WSW] or with
a sexual history is available at the Division of STD Prevention
women and men [WSWM]; or transgender men and women
resource page (https://www.cdc.gov/std/treatment/resources.
or adolescents) is available in sections of these guidelines related
htm) and in the curriculum provided by the National Network
to these populations.
of STD Clinical Prevention Training Centers (https://www.
In addition to obtaining a behavioral risk assessment, a
nnptc.org). Effective interviewing and counseling skills,
comprehensive STI and HIV risk assessment should include
characterized by respect, compassion, and a nonjudgmental
STI screening as recommended in these guidelines because
attitude toward all patients, are essential to obtaining a
STIs are biologic markers of risk, particularly for HIV
thorough sexual history and delivering effective prevention
acquisition and transmission among certain MSM. In most
messages. Effective techniques for facilitating rapport with
clinical settings, STI screening is an essential and underused
patients include using open-ended questions (e.g., “Tell me
component of an STI and HIV risk assessment. Persons
about any new sex partners you’ve had since your last visit” and
seeking treatment or evaluation for a particular STI should be
“What has your experience with using condoms been like?”);
screened for HIV and other STIs as indicated by community
understandable, nonjudgmental language (e.g., “What gender
prevalence and individual risk factors (see Chlamydial
are your sex partners?” and “Have you ever had a sore or scab
Infections; Gonococcal Infections; Syphilis). Persons should
on your penis?”); and normalizing language (e.g., “Some of my
be informed about all the tests for STIs they are receiving and
patients have difficulty using a condom with every sex act. How
notified about tests for common STIs (e.g., genital herpes,

BOX 1. The Five P’s approach for health care providers obtaining sexual histories: partners, practices, protection from sexually
transmitted infections, past history of sexually transmitted infections, and pregnancy intention

1. Partners 4. Past history of STIs

• “Are you currently having sex of any kind?” • “Have you ever been tested for STIs and HIV?”
• “What is the gender(s) of your partner(s)?” • “Have you ever been diagnosed with an STI in the past?”
2. Practices • “Have any of your partners had an STI?”
• “To understand any risks for sexually transmitted Additional questions for identifying HIV and viral
infections (STIs), I need to ask more specific questions hepatitis risk:
about the kind of sex you have had recently.” • “Have you or any of your partner(s) ever injected drugs?”
• “What kind of sexual contact do you have or have you had?” • “Is there anything about your sexual health that you
űű “Do you have vaginal sex, meaning ‘penis in vagina’ sex?” have questions about?”
űű “Do you have anal sex, meaning ‘penis in rectum/anus’
5. Pregnancy intention
sex?” • “Do you think you would like to have (more) children
űű “Do you have oral sex, meaning ‘mouth on penis/vagina’?”
in the future?”
3. Protection from STIs • “How important is it to you to prevent pregnancy
• “Do you and your partner(s) discuss prevention of STIs (until then)?”
and human immunodeficiency virus (HIV)?” • “Are you or your partner using contraception or
• “Do you and your partner(s) discuss getting tested?” practicing any form of birth control?”
• For condoms: • “Would you like to talk about ways to prevent
űű “What protection methods do you use? In what pregnancy?”
situations do you use condoms?”

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 3
 Recommendations and Reports

trichomoniasis, Mycoplasma genitalium, and HPV) that are the STD National Network of Prevention Training Centers
available but not being performed and reasons why they are (https://www.nnptc.org).
not always indicated. Persons should be informed of their test In addition to one-on-one STI and HIV prevention
results and recommendations for future testing. Efforts should counseling, videos and large group presentations can provide
be made to ensure that all persons receive STI care regardless explicit information concerning STIs and reducing disease
of personal circumstances (e.g., ability to pay, citizenship transmission (e.g., how to use condoms consistently and
or immigration status, gender identity, language spoken, or correctly and the importance of routine screening). Group-
specific sex practices). based strategies have been effective in reducing the occurrence
of STIs among persons at risk, including those attending STD
STI and HIV Infection clinics (9). Brief, online, electronic-learning modules for young
MSM have been reported to be effective in reducing incident
Prevention Counseling STIs and offer a convenient client platform for effective
After obtaining a sexual history from their patients, all interventions (10). Because the incidence of certain STIs,
providers should encourage risk reduction by offering most notably syphilis, is higher among persons with HIV
prevention counseling. Prevention counseling is most effective infection, use of client-centered STI counseling for persons
if provided in a nonjudgmental and empathetic manner with HIV continues to be encouraged by public health agencies
appropriate to the patient’s culture, language, sex and gender and other health organizations (https://www.cdc.gov/std/
identity, sexual orientation, age, and developmental level. statistics/2019/default.htm). A 2014 guideline from CDC,
Prevention counseling for STIs and HIV should be offered the Health Resources and Services Administration, and the
to all sexually active adolescents and to all adults who have National Institutes of Health recommends that clinical and
received an STI diagnosis, have had an STI during the nonclinical providers assess a person’s behavioral and biologic
previous year, or have had multiple sex partners. USPSTF risks for acquiring or transmitting STIs and HIV, including
recommends intensive behavioral counseling for all sexually having sex without condoms, having recent STIs, and having
active adolescents and for adults at increased risk for STIs and partners recently treated for STIs (https://stacks.cdc.gov/
HIV (4). Such interactive counseling, which can be resource view/cdc/44064). That federal guideline is for clinical and
intensive, is directed at a person’s risk, the situations in which nonclinical providers to offer or make referral for regular
risk occurs, and the use of personalized goal-setting strategies. screening for multiple STIs, on-site STI treatment when
One such approach, known as client-centered STI and HIV indicated, and risk-reduction interventions tailored to the
prevention counseling, involves tailoring a discussion of risk person’s risks. Brief risk-reduction counseling delivered by
reduction to the person’s situation. Although one large study in medical providers during HIV primary care visits, coupled
STI clinics (Project RESPECT) demonstrated that this approach with routine STI screening, has been reported to reduce STI
was associated with lower acquisition of curable STIs (e.g., incidence among persons with HIV infection (8). Other
trichomoniasis, chlamydia, gonorrhea, and syphilis) (5), another specific methods have been designed for the HIV care setting
study conducted 10 years later in the same settings but different (https://www.cdc.gov/hiv/effective-interventions/index.html).
contexts (Project AWARE) did not replicate this result (6).
With the challenges that intensive behavioral counseling poses,
health care professionals might find brief prevention messages
Primary Prevention Methods
and those delivered through video or in a group session to be Pre-Exposure Vaccination
more accessible for the client. A review of 11 studies evaluated Pre-exposure vaccination is one of the most effective methods
brief prevention messages delivered by providers and health for preventing transmission of HPV, HAV, and HBV, all
counselors and reported them to be feasible and to decrease of which can be sexually transmitted. HPV vaccination is
subsequent STIs in STD clinic settings (7) and HIV care recommended routinely for males and females aged 11 or
settings (8). Other approaches use motivational interviewing 12 years and can be administered beginning at age 9 years.
to move clients toward achievable risk-reduction goals. Client- HPV vaccination is recommended through age 26 years for
centered counseling and motivational interviewing can be used those not previously vaccinated (11). Sharing clinical decision-
effectively by clinicians and staff trained in these approaches. making about HPV vaccination is recommended for certain
CDC provides additional information on these and other adults aged 27–45 years who are not adequately vaccinated
effective behavioral interventions at https://www.cdc.gov/ in accordance with existing guidance (https://www.cdc.gov/
std/program/interventions.htm. Training in client-centered vaccines/hcp/acip-recs/vacc-specific/hpv.html).
counseling and motivational interviewing is available through

4 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Hepatitis B vaccination is recommended for all unvaccinated, on the box or individual package. Latex condoms should not
uninfected persons who are sexually active with more than be used beyond their expiration date or >5 years after the
one partner or are being evaluated or treated for an STI (12). manufacturing date. Condoms made of materials other than
In addition, hepatitis A and B vaccines are recommended for latex are available in the United States and can be classified
MSM, persons who inject drugs, persons with chronic liver into two general categories: 1) polyurethane, polyisoprene, or
disease, and persons with HIV or hepatitis C infections who other synthetic condoms and 2) natural membrane condoms.
have not had hepatitis A or hepatitis B (12). HAV vaccine is Polyurethane external condoms provide protection against
also recommended for persons who are homeless (13). Details STIs and HIV and pregnancy comparable to that of latex
regarding HAV and HBV vaccination, including routine condoms (20,31). These can be substituted for latex condoms
childhood vaccination, are available at https://www.cdc.gov/ by persons with latex sensitivity, are typically more resistant to
hepatitis and at the ACIP website (https://www.cdc.gov/ deterioration, and are compatible with use of both oil-based
vaccines/hcp/acip-recs/vacc-specific/index.html). and water-based lubricants. The effectiveness of other synthetic
external condoms to prevent STIs has not been extensively
Condoms studied, and FDA labeling restricts their recommended use
External Condoms to persons who are sensitive to or allergic to latex. Natural
membrane condoms (frequently called natural skin condoms
When used consistently and correctly, external latex
or [incorrectly] lambskin condoms) are made from lamb cecum
condoms, also known as male condoms, are effective in
and can have pores up to 1,500 nm in diameter. Although
preventing the sexual transmission of HIV infection (http://
these pores do not allow the passage of sperm, they are more
www.ashasexualhealth.org/pdfs/Male_and_Female_Condoms.
than 10 times the diameter of HIV and more than 25 times
pdf). In heterosexual HIV mixed-status relationships (i.e., those
that of HBV. Moreover, laboratory studies demonstrate that
involving one infected and one uninfected partner) in which
sexual transmission of viruses, including HBV, herpes simplex
condoms were used consistently, HIV-negative partners were
virus (HSV), and HIV, can occur with natural membrane
71%–80% less likely to become infected with HIV, compared
condoms (31). Therefore, natural membrane condoms are not
with persons in similar relationships in which condoms were
recommended for prevention of STIs and HIV.
not used (14,15). Two analyses of MSM mixed-status couple
Providers should advise that condoms must be used
studies estimated the protective effect of condom use to be 70%
consistently and correctly to be effective in preventing STIs and
and 91%, respectively (16,17). Moreover, studies demonstrate
HIV while noting that any condom use is better than no condom
that consistent condom use reduces the risk for other STIs,
use. Providing instructions about the correct use of condoms
including chlamydia, gonorrhea, hepatitis B, and trichomoniasis
can be useful. Communicating the following recommendations
(18–21). By limiting lower genital tract infections, condoms
can help ensure that patients use external condoms correctly:
also might reduce the risk for pelvic inflammatory disease
• Use a new condom with each sex act (i.e., oral, vaginal,
(PID) among women (22). In addition, consistent and correct
and anal).
use of latex condoms reduces the risk for HPV infection
• Carefully handle the condom to avoid damaging it with
and HPV-associated diseases, genital herpes, syphilis, and
fingernails, teeth, or other sharp objects.
chancroid when the infected area or site of potential exposure
• Put the condom on after the penis is erect and before any
is covered (23–27). Additional information is available at
genital, oral, or anal contact with the partner.
https://www.cdc.gov/condomeffectiveness/index.html and
• Use only water-based or silicone-based lubricants (e.g.,
www.factsaboutcondoms.com/professional.php. Condoms
K-Y Jelly, Astroglide, AquaLube, or glycerin) with latex
are regulated as medical devices and are subject to random
condoms. Oil-based lubricants (e.g., petroleum jelly,
sampling and testing by the Food and Drug Administration
shortening, mineral oil, massage oils, body lotions, or
(FDA). Each latex condom manufactured in the United States
cooking oil) can weaken latex and should not be used;
is tested electronically for holes before packaging. The rate of
however, oil-based lubricants typically can be used with
condom breakage during sexual intercourse and withdrawal in
polyurethane or other synthetic condoms.
the United States is approximately two broken condoms per
• Ensure adequate lubrication during vaginal and anal sex,
100 condoms. Rates of breakage and slippage might be slightly
which might require using exogenous water-based
higher during anal intercourse (28,29). The failure of condoms
lubricants.
to protect against STIs or unintended pregnancy usually results
• Hold the condom firmly against the base of the penis
from inconsistent or incorrect use rather than condom breakage
during withdrawal, and withdraw while the penis is still
(30). Users should check the expiration or manufacture date
erect to prevent the condom from slipping off.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 5
 Recommendations and Reports

Additional information about external condoms is available Topical Microbicides and Spermicides
at https://www.cdc.gov/condomeffectiveness. Nonspecific topical microbicides are ineffective for
Internal Condoms preventing HIV infection (40–45). Tenofovir gel has been
studied for prevention of herpes simplex virus 2 (HSV-2)
Condoms for internal vaginal use, also known as female
and HIV infections (46,47). Adherence can be low (48), and
condoms, are available worldwide (e.g., the FC2 Female
prevention of HIV infection, especially among women, has not
Condom, Reddy condom, Cupid female condom, and Woman’s
been demonstrated (47,49).Vaginal rings containing dapivirine
condom) (31,32). Use of internal condoms can provide
have provided some reduction in HIV infection (50,51). For
protection from acquisition and transmission of STIs, although
men and transgender women who have anal intercourse,
data are limited. Internal condoms are more costly compared
tenofovir gel appears safe when applied before and after anal
with external condoms; however, they offer the advantage of
sex (52). Spermicides containing nonoxynol-9 (N-9) might
being controlled by the receptive partner as an STI and HIV
disrupt genital or rectal epithelium and have been associated
prevention method, and the newer versions might be acceptable
with an increased risk for HIV infection. Condoms with N-9
to all persons. Although the internal condom also has been used
are no more effective than condoms without N-9; therefore,
during receptive anal intercourse, efficacy associated with this
N-9 alone or in a condom is not recommended for STI and
practice remains unknown (33). Additional information about
HIV prevention (40). N-9 use also has been associated with
the internal condom is available at http://www.ashasexualhealth.
an increased risk for bacterial urinary tract infections among
org/pdfs/Male_and_Female_Condoms.pdf.
women (53,54).
Cervical Diaphragms
Nonbarrier Contraception, Female Surgical
In observational studies, diaphragm use has been Sterilization, and Hysterectomy
demonstrated to protect against cervical gonorrhea, chlamydia,
and trichomoniasis (34). However, a trial examining the effect Contraceptive methods that are not mechanical barriers
of a diaphragm plus lubricant on HIV acquisition among offer no protection against HIV or other STIs. The ECHO
women in Africa reported no additional protective effect when study observed no differences in HIV incidence rates among
compared with the use of male condoms alone. Likewise, no women randomly assigned to DMPA, levonorgestrel implant,
difference by study arm in the rate of acquisition of chlamydia, or copper-containing IUD contraceptive methods (38). A
gonorrhea, or herpes occurred (35,36). Diaphragms should systematic review of epidemiologic evidence reported that the
not be relied on as the sole source of protection against HIV majority of studies demonstrated no association between use
and other STIs. of oral contraceptives and HIV acquisition among women
(55). Whether hormonal contraception alters a woman’s risk
Multipurpose Prevention Technologies for other STIs is uncertain (56,57).
Methods that combine STI and HIV prevention Sexually active women who use contraceptive methods
with pregnancy prevention are known as multipurpose other than condoms should be counseled about STI and HIV
prevention technologies (MPTs) (37) (https://www.who.int/ infection prevention measures. These include pre-exposure
reproductivehealth/topics/linkages/mpts/en). Internal and prophylaxis (PrEP) and postexposure prophylaxis (PEP),
external condoms are both examples of MPTs because they are limiting the number of sex partners, and correct and consistent
effective prevention measures when used correctly for STI and use of condoms.
HIV transmission or pregnancy prevention. The multicenter Emergency Contraception
Evidence for Contraception Options and HIV Outcomes
(ECHO) trial observed no statistically significant differences in Unprotected intercourse exposes women to risks for STIs
HIV incidence rates among women randomly assigned to one and unplanned pregnancy. Providers should offer counseling
of three contraceptive methods (depot medroxyprogesterone about the option of emergency contraception if pregnancy
acetate [DMPA], levonorgestrel implant, and copper- is not desired. Options for emergency contraception in the
containing intrauterine device [IUD]); however, rates of HIV United States include copper-containing IUDs and emergency
infection were high in all groups, indicating a need for MPTs contraceptive pills (ECPs) (58,59). More information is available
(38). Development of MPTs is complex and ongoing; products at https://www.acog.org/clinical/clinical-guidance/practice-
under study include microbicides with contraceptive devices bulletin/articles/2015/09/emergency-contraception?utm_
(e.g., tenofovir with a vaginal ring contraceptive delivery source=redirect&utm_medium=web&utm_campaign=otn.
package) and other innovative methods (39). ECPs are available in the following formulations: ulipristal

6 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

acetate in a single dose (30 mg) available by prescription, (https://www.afro.who.int/publications/voluntary-medical-male-

levonorgestrel in a single dose (1.5 mg) available over the circumcision-hiv-prevention). In the United States, the American
counter or by prescription, or a combined estrogen and Academy of Pediatrics (AAP) recommends that newborn male
progestin pill regimen. Insertion of a copper-containing circumcision be available to families that desire it because the
IUD ≤5 days after unprotected sex can reduce pregnancy risk benefits of the procedure, including prevention of penile cancers,
from a sex act by approximately 99% (60). ECPs are most urinary tract infections, GUD, and HIV infection, outweigh the
efficacious when initiated as soon as possible after unprotected risks. ACOG has also endorsed AAP’s policy statement. In light
sex. Ulipristal acetate is effective ≤5 days after unprotected sex, of these benefits, the American Urological Association states
and levonorgestrel is most effective ≤3 days after unprotected that male circumcision should be considered an option for risk
sex but has some efficacy at ≤5 days. ECPs are ineffective reduction, among other strategies (72). Additional information
(but not harmful) if the woman is already pregnant (61). A for providers counseling male patients and parents regarding
2019 Cochrane review summarized the efficacy, safety, and male circumcision for preventing HIV, STIs, and other adverse
convenience of different emergency contraception methods (61). health outcomes is available at https://www.cdc.gov/hiv/risk/
More information about emergency contraception is male-circumcision.html.
available in Contraceptive Technology, 21st Edition (31), in the No definitive data exist to determine whether male
2016 U.S. Selected Practice Recommendations (U.S. SPR) circumcision reduces HIV acquisition among MSM, although
for Contraceptive Use (emergency contraception) available one meta-analysis of 62 observational studies reported that
at https://www.cdc.gov/reproductivehealth/contraception/ circumcision was protective against HIV acquisition in low- to
mmwr/spr/emergency.html, and in the 2016 U.S. Medical middle-income countries but not in high-income countries
Eligibility Criteria (U.S. MEC) for Contraceptive Use (copper (73). Further studies are needed to confirm any potential
IUDs for emergency contraception) available at https:// benefit of male circumcision for this population.
www.cdc.gov/reproductivehealth/contraception/mmwr/mec/
appendixj.html. Pre-Exposure Prophylaxis for HIV
Providers should educate males and females about emergency Daily oral antiretroviral PrEP with a fixed-dose combination
contraception, especially if other methods of contraception of emtricitabine (FTC) and either tenofovir disoproxil fumarate
were used incorrectly or not at all and pregnancy is not desired (TDF) or tenofovir alafenamide (TAF) have demonstrated
(62). An advance supply of ECPs can be provided or prescribed safety (74) and a substantial reduction in the rate of HIV
so that ECPs will be available when needed (59). acquisition for MSM (75). TDF/FTC has demonstrated
safety and efficacy for mixed-status heterosexual couples (76)
Male Circumcision and heterosexual men and women recruited individually
Male circumcision reduces the risk for HIV infection and (77); however, no evidence is yet available regarding TAF/
certain STIs among heterosexual men. Three randomized, FTC among heterosexually active women. In addition, one
controlled trials performed in regions of sub-Saharan Africa, clinical trial involving persons who inject drugs (78) and one
where generalized HIV epidemics involving predominantly involving heterosexual mixed-status couples (76) demonstrated
heterosexual transmission were occurring, demonstrated that substantial efficacy and safety of daily oral PrEP with TDF
male circumcision reduces the risk for HIV acquisition among alone. High adherence to oral PrEP was strongly associated
men by 50%–60% (63–65). In those trials, circumcision with protection from HIV infection. Studies conducted with
also was protective against other STIs, including high-risk MSM have demonstrated that taking PrEP at specific times
genital HPV infection and genital herpes (66–68). Follow-up before and after sexual intercourse was effective in preventing
studies have demonstrated sustained benefit of circumcision HIV; however, less experience exits with this regimen, it is
for HIV prevention (69) and that the effect is not mediated not FDA cleared, and it has not been studied among other
solely through a reduction in HSV-2 infection or genital ulcer populations (79).
disease (GUD) (70). Comprehensive clinical practice guidelines are available
The World Health Organization (WHO) and the Joint for providers in prescribing PrEP to reduce the risk for HIV
United Nations Programme on HIV/AIDS (UNAIDS) infection (80). Among HIV-negative sexually active men
recommend that male circumcision efforts be scaled up as an and women, bacterial STIs are key indicators of risk for
effective intervention for preventing heterosexually acquired HIV HIV acquisition. Studies have documented the risk for HIV
infection (71) in countries with hyperendemic and generalized acquisition among MSM within 1 year after infection with
HIV epidemics within the context of ensuring universal access rectal gonorrhea or chlamydia (one in 15 men), primary
to comprehensive HIV prevention, treatment, care, and support or secondary syphilis (one in 18), and among men with no

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 7
 Recommendations and Reports

rectal STI or syphilis infection (one in 53) (81–83). Sexually chlamydia and syphilis by 70% and 73%, respectively, but no
active adults and adolescents should be screened for STIs effect on gonorrhea (93). Other studies are under way or in
(e.g., chlamydia, gonorrhea, and syphilis) in accordance with development regarding doxycycline prophylaxis for bacterial
recommendations, and persons with infection should be STIs (91). No long-term data are available regarding the impact
offered PrEP. The USPSTF recommends that persons at risk of STI PEP on antimicrobial resistance and the microbiome.
for HIV acquisition be offered PrEP (84). Persons at risk for Further studies are needed to determine whether STI PEP is
HIV acquisition include HIV-negative persons whose sexual an effective and beneficial strategy for STI prevention.
partner or partners have HIV infection (especially if viral load
is detectable or unknown), persons who have had gonorrhea HIV Treatment as Prevention: Antiretroviral
or syphilis during the previous 6 months, and injecting drug Treatment of Persons with HIV to Prevent HIV
users who share injection equipment (84). Clinical practice Among Partners
guidelines recommend STI screening for persons taking PrEP In 2011, the randomized controlled trial HPTN 052
(80) because increased rates of STI acquisition have been demonstrated that, among HIV mixed-status heterosexual
described (85–87). couples, HIV antiretroviral therapy (ART) for the infected
partner decreased the risk for transmission to the uninfected
Pre-Exposure Prophylaxis for STIs partner by 96% (94). Therefore, ART not only is beneficial to
Providing HSV treatment to persons with HIV and HSV the health of persons with HIV infection, it also reduces the
infection has not demonstrated benefit in reducing HIV risk for transmission. Additional studies of HIV mixed-status
acquisition among uninfected partners. A large randomized couples, heterosexual and MSM couples (PARTNER study),
controlled trial evaluated mixed-status heterosexual couples and MSM couples (Opposites Attract and PARTNERS2
among the partners with HIV infection who also were studies) reported that patients with HIV taking ART who
seropositive for HSV-2 (88). Use of acyclovir had no effect maintain an undetectable viral load demonstrate no risk for
on HIV transmission. These findings are consistent with a transmitting HIV to their HIV-negative sex partners (95–97).
previous trial that reported no benefit of acyclovir in preventing For those reasons, ART should be offered to all persons with
HIV acquisition among persons seropositive for HSV-2 (89). HIV infection to obtain viral suppression. Detailed guidance
Doxycycline prophylaxis has been examined for preventing regarding ART regimens is available in the U.S. Department of
bacterial STIs. In a pilot study, 30 MSM living with HIV with Health and Human Services’ HIV treatment guidelines (98).
previous syphilis (two or more episodes since HIV diagnosis)
were randomly assigned to doxycycline 100 mg for 48 weeks HIV Seroadaptive Strategies
versus a financial incentive–based behavioral intervention (90). Seroadaptive strategies for HIV prevention have largely
That study demonstrated a 73% reduction in any bacterial STI originated within communities of MSM. They are predicated
at any site, without substantial differences in sexual behavior. on knowledge of self and partner HIV status. One specific
Additional studies examining doxycycline prophylaxis are seroadaptive practice is serosorting, which includes limiting
under way or in development (91). anal sex without a condom to partners with the same HIV
status as their own or choosing to selectively use condoms
Postexposure Prophylaxis for HIV and STIs with HIV mixed-status partners. Another practice among
Guidelines for using PEP aimed at preventing HIV and other mixed-status couples is seropositioning, in which the
STIs as a result of sexual exposure are available at https://www. person with HIV infection is the receptive partner for anal
cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines. intercourse. Observational studies have consistently reported
pdf. Sexually active persons seeking HIV PEP should be that serosorting confers greater risk for HIV infection than
evaluated for PrEP after completing their PEP course and consistent condom use but has lower risk compared with anal
testing negative for HIV. HIV PEP is also discussed elsewhere intercourse without a condom and without serosorting (99–
in this report (see Sexual Assault and Abuse and STIs). Genital 101). Serosorting practices have been associated with increased
hygiene methods (e.g., vaginal washing and douching) after risk for STIs, including chlamydia and gonorrhea (102,103).
sexual exposure are ineffective in protecting against HIV and Serosorting is not recommended for the following reasons:
STIs and might increase the risk for bacterial vaginosis (BV), many MSM who have HIV infection do not know they
certain STIs, and HIV infection (92). have HIV because they have not been tested recently, men’s
STI PEP in the form of doxycycline 200 mg taken after assumptions about the HIV status of their partners might be
unprotected anal sex has been studied among MSM and wrong, and some men with HIV infection might not disclose or
transgender women; results demonstrated reduction in incident might misrepresent their HIV status. All of these factors increase

8 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

the risk that serosorting can lead to HIV infection. Serosorting trichomoniasis, or other STIs (105). Because STI diagnoses
has not been studied among heterosexually active persons. often can serve as risk markers for HIV acquisition (83), public
health services might include follow-up of MSM with an STI
Abstinence and Reduction of Number of to offer HIV PrEP. Public health services can also include HIV
Sex Partners and STI prevention interventions including HIV and STI
Abstinence from oral, vaginal, and anal sex and participating testing, linkage and relinkage of persons with HIV infection
in a long-term, mutually monogamous relationship with a to HIV care clinics, and referral of partners of persons with
partner known to be uninfected are prevention approaches to STIs or HIV infection to HIV PrEP, as indicated (106–109).
avoid transmission of STIs. For persons who are being treated Clinicians should familiarize themselves with public health
for an STI (or whose partners are undergoing treatment), practices in their area; however, in most instances, providers
counseling that encourages abstinence from sexual intercourse should understand that responsibility for discussing the
until completion of the entire course of medication is vital treatment of partners of persons with STIs rests with the
for preventing reinfection. A trial conducted among women diagnosing provider and the patient. State laws require a good
regarding the effectiveness of counseling messages when faith effort by the provider to inform partners, and providers
patients have cervicitis or vaginal discharge demonstrated should familiarize themselves with public health laws.
that women whose sex partners have used condoms might Clinicians who do not notify partners of patients directly
benefit from a hierarchical message that includes condoms can still provide partner services by counseling infected persons
but women without such experience might benefit more from and providing them with written information and medication
an abstinence-only message (104). A more comprehensive to give to their partners (if recommended and allowable by
discussion of abstinence and other sexual practices that can help state law), directly evaluating and treating sex partners, and
persons reduce their risk for STIs is available in Contraceptive cooperating with state and local health departments. Clinicians’
Technology, 21st Edition (31). efforts to ensure treatment of patients’ sex partners can reduce
the risk for reinfection and potentially diminish transmission
Partner Services of STIs (110). Therefore, clinicians should encourage all
persons with STIs to notify their sex partners and urge them
The term “partner services” refers to a continuum of clinical to seek medical evaluation and treatment. Exceptions to this
evaluation, counseling, diagnostic testing, and treatment practice include circumstances posing a risk for intimate
designed to increase the number of infected persons brought to partner violence (111). Available data are limited regarding
treatment and to reduce transmission among sexual networks. the rate of intimate partner violence directly attributable
This continuum includes efforts of health departments, to partner notification (112,113); however, because of the
medical providers, and patients themselves. The term “public reported prevalence of intimate partner violence in the general
health partner services” refers to efforts by public health population (114), providers should consider the potential
departments to identify the sex and needle-sharing partners risk before notifying partners of persons or encouraging
of infected persons to ensure their medical evaluation and partner notification. Time spent counseling patients about the
treatment. Health departments are increasingly incorporating importance of notifying partners is associated with improved
referral to additional services, as indicated, into the partner services notification outcomes (115). When possible, clinicians should
continuum. Aside from the general benefit to patients and partners, advise persons to bring their primary sex partner with them
service referrals and linkage can mitigate the circumstances that when returning for treatment and should concurrently treat
increase risk for future STI and HIV acquisition. both persons. Although this approach can be effective for a
The types and comprehensiveness of public health partner main partner (116,117), it might not be a feasible approach
services and the specific STIs for which they are offered vary for additional sex partners. Evidence indicates that providing
by public health agency, their resources, and the geographic patients with written information to share with sex partners
prevalence of STIs. In most areas of the United States, health can increase rates of partner treatment (110).
departments routinely attempt to provide partner services to Certain health departments now use technology (e.g.,
all persons with infectious syphilis (primary or secondary) email, texting, mobile applications, and social media outlets)
and persons with a new diagnosis of HIV infection. Health to facilitate partner services for locating and notifying the
departments should provide partner services for persons who sex partners of persons with STIs, including HIV (118,119).
might have cephalosporin-resistant gonorrhea. In contrast, Patients now have the option to use Internet sites to send
relatively few U.S. health departments routinely provide anonymous email or text messages advising partners of their
STI partner services to persons with gonorrhea, chlamydia, exposure to an STI (120); anonymous notification via the

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 9
 Recommendations and Reports

Internet is considered better than no notification at all. difference in the risk for reinfection or in the numbers of
However, because the extent to which these sites affect partner partners treated between persons offered EPT and those
notification and treatment is uncertain, patients should be advised to notify their sex partners (128). U.S. trials and a
encouraged to notify their partners in person or by telephone, meta-analysis of EPT revealed that the magnitude of reduction
email, or text message; alternatively, patients can authorize a in reinfection of index patients, compared with patient referral,
medical provider or public health professional to notify their differed according to the STI and the sex of the index patient
sex partners. (110,125–127). However, across trials, reductions in chlamydia
prevalence at follow-up were approximately 20%, and
Expedited Partner Therapy reductions in gonorrhea were approximately 50% at follow-up.
Expedited partner therapy (EPT) is a harm-reduction Existing data indicate that EPT also might have a role in
strategy and the clinical practice of treating the sex partners partner management for trichomoniasis; however, no partner
of persons with diagnosed chlamydia or gonorrhea, who are management intervention has been reported to be more
unable or unlikely to seek timely treatment, by providing effective than any other in reducing trichomoniasis reinfection
medications or prescriptions to the patient as allowable by law. rates (129,130). No data support use of EPT in the routine
Patients then provide partners with these therapies without management of patients with syphilis.
the health care provider having examined the partner (https:// Data are limited regarding use of EPT for gonococcal
www.cdc.gov/std/ept). Unless prohibited by law or other or chlamydial infections among MSM, compared with
regulations, medical providers should routinely offer EPT heterosexuals (131,132). Published studies, including recent
to patients with chlamydia when the provider cannot ensure data regarding extragenital testing, indicated that male partners
that all of a patient’s sex partners from the previous 60 days of MSM with diagnosed gonorrhea or chlamydia might have
will seek timely treatment. If the patient has not had sex other bacterial STIs (gonorrhea or syphilis) or HIV (133–135).
during the 60 days before diagnosis, providers should offer Studies have reported that 5% of MSM have a new diagnosis
EPT for the patient’s most recent sex partner. Because EPT of HIV when evaluated as partners of men with gonococcal
must be an oral regimen and current gonorrhea treatment or chlamydial infections (133,134); however, more recent data
involves an injection, EPT for gonorrhea should be offered indicate that, in certain settings, the frequency of HIV infection
to partners unlikely to access timely evaluation after linkage is much lower (135). Considering limited data and potential
is explored. EPT is legal in the majority of states but varies for other bacterial STIs among MSM partners, shared clinical
by chlamydial or gonococcal infection. Providers should visit decision-making regarding EPT is recommended. All persons
https://www.cdc.gov/std/ept to obtain updated information for who receive bacterial STI diagnoses and their sex partners,
their state. Providing patients with packaged oral medication particularly MSM, should be tested for HIV, and those at risk
is the preferred approach because the efficacy of EPT using for HIV infection should be offered HIV PrEP (https://www.
prescriptions has not been evaluated, obstacles to EPT can exist cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf ).
at the pharmacy level (121,122), and many persons (especially
adolescents) do not fill the prescriptions provided to them by
Reporting and Confidentiality
a sex partner (123,124). Medication or prescriptions provided
for EPT should be accompanied by educational materials for Accurate and timely reporting of STIs is integral to public
the partner, including treatment instructions, warnings about health efforts in assessing morbidity trends, allocating limited
taking medications (e.g., if the partner is pregnant or has an resources, and assisting local health authorities with partner
allergy to the medication), general health counseling, and a notification and treatment. STI and HIV/AIDS cases should
statement advising that partners seek medical evaluation as be reported in accordance with state and local statutory
soon as possible for HIV infection and any symptoms of STIs, requirements. Syphilis (including congenital syphilis),
particularly PID. gonorrhea, chlamydia, chancroid, and HIV are reportable
Evidence supporting EPT is based on three U.S. clinical diseases in every state. Because the requirements for reporting
trials involving heterosexual men and women with chlamydia other STIs differ by state, clinicians should be familiar with the
or gonorrhea (125–127). All three trials reported that more reporting requirements applicable within their jurisdictions.
partners were treated when patients were offered EPT. Two Reporting can be provider based, laboratory based, or
reported statistically significant decreases in the rate of both. Clinicians who are unsure of state and local reporting
reinfection, and one observed a lower risk for persistent or requirements should seek advice from state or local health
recurrent infection that was statistically nonsignificant. A department STI programs. STI and HIV reports are kept
fourth trial in the United Kingdom did not demonstrate a confidential. In most jurisdictions, such reports are protected

10 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

by statute or regulation. Before conducting a follow-up HIV through ART and obstetrical interventions. HIV testing
of a person with a positive STI test result, public health should be offered as part of the routine panel of prenatal tests
professionals should consult the patient’s health care provider, (i.e., opt-out testing). For women who decline HIV testing,
if possible, to inform them of the purpose of the public health providers should address their concerns and, when appropriate,
visit, verify the diagnosis, determine the treatments received, continue to encourage testing. Partners of pregnant patients
and ascertain the best approaches to patient follow-up. should be offered HIV testing if their status is unknown (139).
Retesting in the third trimester (preferably before 36 weeks’
Retesting After Treatment to Detect gestation) is recommended for women at high risk for
acquiring HIV infection. Examples of women at high risk
Repeat Infections include those who inject drugs, have STIs during pregnancy,
Retesting 3 months after diagnosis of chlamydia, gonorrhea, have multiple sex partners during pregnancy, have a new
or trichomoniasis can detect repeat infection and potentially sex partner during pregnancy, or have partners with HIV
can be used to enhance population-based prevention (136,137). infection; those who are receiving care in health care facilities
Any person who has a positive test for chlamydia or gonorrhea, in settings with HIV incidence ≥1 per 1,000 women per year;
along with women who have a positive test for trichomonas, those who are incarcerated; those who live in areas with high
should be rescreened 3 months after treatment. Any person rates of HIV infection; or those who have signs or symptoms
who receives a syphilis diagnosis should undergo follow-up of acute HIV infection (e.g., fever, lymphadenopathy, skin
serologic syphilis testing per current recommendations rash, myalgia, arthralgia, headache, oral ulcers, leukopenia,
and follow-up testing for HIV (see Syphilis). Additional thrombocytopenia, or transaminase elevation) (140).
information regarding retesting is available elsewhere in this Rapid HIV testing should be performed for any woman in labor
report (see Chlamydial Infections; Gonococcal Infections; who has not been tested for HIV during pregnancy or whose HIV
Syphilis; Trichomoniasis). status is unknown, unless she declines. If a rapid HIV test result
is positive, ART should be administered without waiting for the
results of confirmatory testing (https://clinicalinfo.hiv.gov/sites/
STI Detection Among Special default/files/inline-files/PerinatalGL.pdf).
Populations Syphilis
Pregnant Women During 2012–2019, congenital syphilis rates in the United
States increased from 8.4 to 48.5 cases per 100,000 births,
Intrauterine or perinatally transmitted STIs can have
a 477.4% increase (141). At least 45 states have a prenatal
debilitating effects on pregnant women, their fetuses, and their
syphilis testing requirement, with high variability among those
partners. All pregnant women and their sex partners should be
requirements (142). In the United States, all pregnant women
asked about STIs, counseled about the possibility of perinatal
should be screened for syphilis at the first prenatal visit, even
infections, and provided access to recommended screening and
if they have been tested previously (143). Prenatal screening
treatment, if needed.
for syphilis has been reported to be suboptimal in the United
Recommendations for screening pregnant women for
States (144,145). Testing in the third trimester and at delivery
STIs to detect asymptomatic infections are based on disease
can prevent congenital syphilis cases (146,147). Partners of
severity and sequelae, prevalence among the population, costs,
pregnant women with syphilis should be evaluated, tested,
medicolegal considerations (e.g., state laws), and other factors.
and treated.
The following screening recommendations for pregnant
When access to prenatal care is not optimal, a stat rapid
women summarize clinical guidelines from federal agencies
plasma reagin (RPR) card test and treatment, if that test is
and medical professional organizations.
reactive, should be administered at the time that a pregnancy
Screening Recommendations is confirmed or when the pregnancy test is performed, if
follow-up is uncertain. Pregnant women should be retested
HIV Infection for syphilis at 28 weeks’ gestation and at delivery if the mother
All pregnant women in the United States should be tested lives in a community with high syphilis rates or is at risk for
for HIV at the first prenatal visit, even if they have been syphilis acquisition during pregnancy (e.g., misuses drugs or
previously tested (138). Testing pregnant women for HIV has an STI during pregnancy, having multiple sex partners,
and prompt linkage to care of women with HIV infection are having a new sex partner, or having a sex partner with an STI).
vital for women’s health and reducing perinatal transmission of Neonates should not be discharged from the hospital unless

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 11
 Recommendations and Reports

the syphilis serologic status of the mother has been determined diagnosed with a chlamydial infection should be rescreened
at least once during pregnancy. Any woman who delivers a 3 months after treatment.
stillborn infant should be tested for syphilis.
Gonorrhea
Hepatitis B All pregnant women aged <25 years as well as women aged
All pregnant women should be routinely tested for hepatitis ≥25 years at increased risk for gonorrhea (e.g., those with other
B surface antigen (HBsAg) at the first prenatal visit even if they STIs during pregnancy or those with a new sex partner, more
have been previously vaccinated or tested (148). Women who than one sex partner, a sex partner with concurrent partners,
are HBsAg positive should be provided with, or referred for, or a sex partner who has an STI or is exchanging sex for money
counseling and medical management. Women who are HBsAg or drugs) should be screened for Neisseria gonorrhoeae at the
negative but at risk for HBV infection should be vaccinated. first prenatal visit (149). Pregnant women who remain at high
Women who were not screened prenatally, those who engage risk for gonococcal infection also should be retested during the
in behaviors that put them at high risk for infection (e.g., third trimester to prevent maternal postnatal complications and
having had more than one sex partner during the previous gonococcal infection in the neonate. Clinicians should consider
6 months, having been evaluated or treated for an STI, the communities they serve and might choose to consult local
having had recent or current injection drug use, or having an public health authorities for guidance on identifying groups
HBsAg-positive sex partner), and those with clinical hepatitis that are more vulnerable to gonorrhea acquisition on the basis
should be tested at the time of admission to the hospital of local disease prevalence. Gonococcal infection, in particular,
for delivery. To avoid misinterpreting a transient positive is concentrated among specific geographic locations and
HBsAg result during the 21 days after vaccination, HBsAg communities (https://www.cdc.gov/std/statistics/2019/default.
testing should be performed before vaccine administration. htm). Pregnant women identified as having gonorrhea should
All laboratories that conduct HBsAg tests should test initially be treated immediately. All persons diagnosed with gonorrhea
reactive specimens with a licensed neutralizing confirmatory should be rescreened 3 months after treatment.
test. When pregnant women are tested for HBsAg at the time
Hepatitis C Virus
of admission for delivery, shortened testing protocols can be
used, and initially reactive results should prompt expedited The rate of hepatitis C virus (HCV) infection has increased
administration of immunoprophylaxis to neonates (148). among pregnant women in recent years (150–153). HCV
Pregnant women who are HBsAg positive should be reported screening should be performed for all pregnant women
to the local or state health department to ensure that they during each pregnancy, except in settings where the HCV
are entered into a case-management system and that timely infection (HCV positivity) rate is <0.1% (154–156). The most
and age-appropriate prophylaxis is provided to their infants. important risk factor for HCV infection is past or current
Information concerning the pregnant woman’s HBsAg status injecting drug use (157). Additional risk factors include having
should be provided to the hospital where delivery is planned had a blood transfusion or organ transplantation before July
and to the health care provider who will care for the newborn. 1992, having received clotting factor concentrates produced
In addition, household and sexual contacts of women who are before 1987, having received an unregulated tattoo, having
HBsAg positive should be vaccinated. been on long-term hemodialysis, having other percutaneous
exposures, or having HIV infection. All women with HCV
Chlamydia infection should receive counseling, supportive care, and
All pregnant women aged <25 years as well as older women linkage to care (https://www.hcvguidelines.org). No vaccine
at increased risk for chlamydia (e.g., those aged ≥25 years who is available for preventing HCV transmission.
have a new sex partner, more than one sex partner, a sex partner
Cervical Cancer
with concurrent partners, or a sex partner who has an STI)
should be routinely screened for Chlamydia trachomatis at the first Pregnant women should undergo cervical cancer screening
prenatal visit (149). Pregnant women who remain at increased and at the same frequency as nonpregnant women; however,
risk for chlamydial infection also should be retested during the management differs slightly during pregnancy (158).
third trimester to prevent maternal postnatal complications and Colposcopy is recommended for the same indications during
chlamydial infection in the neonate. Pregnant women identified pregnancy as for nonpregnant women. However, biopsies
as having chlamydia should be treated immediately and have a may be deferred, and endocervical sampling should not
test of cure to document chlamydial eradication by a nucleic acid be performed. Treatment should not be performed during
amplification test (NAAT) 4 weeks after treatment. All persons pregnancy unless cancer is detected.

12 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Bacterial Vaginosis, Trichomoniasis, and Persons who initiate sex early in adolescence are at higher risk
Genital Herpes for STIs, as are adolescents living in detention facilities; those
Evidence does not support routine screening for BV among receiving services at STD clinics; those who are involved in
asymptomatic pregnant women at high risk for preterm commercial sex exploitation or survival sex and are exchanging
delivery (159). Symptomatic women should be evaluated sex for drugs, money, food, or housing; young males who
and treated (see Bacterial Vaginosis). Evidence does not have sex with males (YMSM); transgender youths; and youths
support routine screening for Trichomonas vaginalis among with disabilities, substance misuse, or mental health disorders.
asymptomatic pregnant women. Women who report symptoms Factors contributing to increased vulnerability to STIs during
should be evaluated and treated (see Trichomoniasis). In adolescence include having multiple sex partners, having
addition, evidence does not support routine HSV-2 serologic sequential sex partnerships of limited duration or concurrent
screening among asymptomatic pregnant women. However, partnerships, failing to use barrier protection consistently
type-specific serologic tests might be useful for identifying and correctly, having lower socioeconomic status, and facing
pregnant women at risk for HSV-2 infection and for guiding multiple obstacles to accessing health care (141,165).
counseling regarding the risk for acquiring genital herpes All 50 states and the District of Columbia explicitly allow
during pregnancy. Routine serial cultures for HSV are not minors to consent for their own STI services. No state requires
indicated for women in the third trimester who have a history parental consent for STI care, although the age at which a
of recurrent genital herpes. minor can provide consent for specified health care services
For more detailed discussions of STI screening and treatment (i.e., HPV vaccination and HIV testing and treatment) varies
among pregnant women, refer to the following references: among states. In 2019, a total of 18 states allowed but did not
Screening for HIV Infection: U.S. Preventive Services Task Force require physicians to notify parents of a minor’s receipt of STI
Recommendation Statement (138); Recommendations for the Use services, including states where minors can legally provide their
of Antiretroviral Drugs in Pregnant Women with HIV Infection own consent to the service (https://www.cdc.gov/hiv/policies/
and Interventions to Reduce Perinatal HIV Transmission in law/states/minors.html).
the United States (https://clinicalinfo.hiv.gov/sites/default/ Protecting confidentiality for STI care, particularly for
files/inline-files/PerinatalGL.pdf ); Guidelines for Perinatal adolescents enrolled in private health insurance plans, presents
Care (160); Prevention of Hepatitis B Virus Infection in the multiple problems. After a claim has been submitted, many
United States: Recommendations of the Advisory Committee states mandate that health plans provide a written statement
on Immunization Practices (12); Screening for Chlamydia and to the beneficiary indicating the service performed, the charges
Gonorrhea: U.S. Preventive Services Task Force Recommendation covered, what the insurer allows, and the amount for which the
Statement (149); Screening for Bacterial Vaginosis in Pregnant patient is responsible (i.e., explanation of benefits [EOB]) (166–
Persons to Prevent Preterm Delivery: U.S. Preventive Services 169). In addition, federal laws obligate notices to beneficiaries
Task Force Recommendation Statement (159); Screening for when claims are denied, including alerting beneficiaries who
Syphilis Infection in Pregnant Women: U.S. Preventive Services need to pay for care until the allowable deductible is reached.
Task Force Recommendation Statement (161); Serologic Screening For STI testing and treatment-related care, an EOB or
for Genital Herpes Infection: U.S. Preventive Services Task Force medical bill that is received by a parent might disclose services
Recommendation Statement (162); Screening for HIV Infection provided and list STI laboratory tests performed or treatment
in Pregnant Women: A Systematic Review for the U.S. Preventive administered. Some states have instituted mechanisms for
Services Task Force (163); Screening for Hepatitis B in Pregnant protecting adolescents’ confidentiality and limiting EOBs.
Women: Updated Evidence Report and Systematic Review Additional risks to confidentiality breaches can inadvertently
for the U.S. Preventive Services Task Force (164); and CDC occur through electronic health records, although technology
Recommendations for Hepatitis C Screening Among Adults — continues to evolve to assist with ensuring confidential care.
United States, 2020 (156). AAP and the Society for Adolescent Health and Medicine
(SAHM) have published guidance on strategies to address
emerging risks for confidentiality breaches associated with
Adolescents health information technology (169).
In the United States, prevalence rates of certain STIs are AAP and the SAHM recommend that providers have
highest among adolescents and young adults (141). For time alone with their adolescent patients that includes
example, reported rates of chlamydia and gonorrhea are highest assessment for sexual behavior. The AAP recommendations
among females during their adolescent and young adult years, are available at https://services.aap.org/en/news-room/
and many persons acquire HPV infection during that time. campaigns-and-toolkits/adolescent-health-care and the SAHM

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 13
 Recommendations and Reports

recommendations are available at https://www.adolescenthealth. authorities for guidance regarding identifying groups that are
org/My-SAHM/Login-or-Create-an-Account.aspx?returnurl= more vulnerable to gonorrhea acquisition on the basis of local
%2fResources%2fClinical-Care-Resources%2fConfidentiality. disease prevalence. Evidence is insufficient to recommend
aspx. Discussions concerning sexual behavior should be tailored routine screening, on the basis of efficacy and cost-effectiveness,
for the patient’s developmental level and be aimed at identifying for N. gonorrhoeae among asymptomatic sexually active young
risk behaviors (e.g., multiple partners; oral, anal, or vaginal males who have sex with females only. Screening for gonorrhea,
sex; or drug misuse behaviors). Careful, nonjudgmental, and including pharyngeal or rectal testing, should be offered to
thorough counseling is particularly vital for adolescents who YMSM at least annually (see Men Who Have Sex with Men).
might not feel comfortable acknowledging their engagement in Providers might consider opt-out chlamydia and gonorrhea
behaviors that make them more vulnerable to acquiring STIs. screening (i.e., the patient is notified that testing will be
performed unless the patient declines, regardless of reported
Screening Recommendations sexual activity) for adolescent and young adult females during
Recommendations for screening adolescents for STIs to clinical encounters. Cost-effectiveness analyses indicate that
detect asymptomatic infections are based on disease severity opt-out chlamydia screening among adolescent and young
and sequelae, prevalence among the population, costs, adult females might substantially increase screening, be cost-
medicolegal considerations (e.g., state laws), and other factors. saving (172), and identify infections among patients who do
Routine laboratory screening for common STIs is indicated not disclose sexual behavior (173).
for all sexually active adolescents. The following screening
recommendations summarize published clinical prevention HIV Infection
guidelines for sexually active adolescents from federal agencies HIV screening should be discussed and offered to all
and medical professional organizations. adolescents. Frequency of repeat screenings should be based on
the patient’s sexual behaviors and the local disease prevalence
Chlamydia (138). Persons with HIV infection should receive prevention
Routine screening for C. trachomatis infection on an annual counseling and linkage to care before leaving the testing site.
basis is recommended for all sexually active females aged
<25 years (149). Rectal chlamydial testing can be considered Cervical Cancer
for females on the basis of reported sexual behaviors and Guidelines from USPSTF and ACOG recommend that
exposure, through shared clinical decision-making between the cervical cancer screening begin at age 21 years (174,175). This
patient and the provider (170,171). Evidence is insufficient recommendation is based on the low incidence of cervical
to recommend routine screening for C. trachomatis among cancer and limited usefulness of screening for cervical cancer
sexually active young males, on the basis of efficacy and cost- among adolescents (176). In contrast, the 2020 ACS guidelines
effectiveness. However, screening of sexually active young males recommend that cervical cancer screening begin at age 25 years
should be considered in clinical settings serving populations with HPV testing. This change is recommended because the
of young men with a high prevalence of chlamydial infections incidence of invasive cervical cancer in women aged <25 years
(e.g., adolescent service clinics, correctional facilities, and STD is decreasing because of vaccination (177). Adolescents
clinics). Chlamydia screening, including pharyngeal or rectal with HIV infection who have initiated sexual intercourse
testing, should be offered to all YMSM at least annually on should have cervical screening cytology in accordance with
the basis of sexual behavior and anatomic site of exposure (see HIV/AIDS guidelines (https://clinicalinfo.hiv.gov/en/
Men Who Have Sex with Men). guidelines/adult-and-adolescent-opportunistic-infection/
human-papillomavirus-disease?view=full).
Gonorrhea
Routine screening for N. gonorrhoeae on an annual basis is Other Sexually Transmitted Infections
recommended for all sexually active females aged <25 years YMSM and pregnant females should be routinely screened
(149). Extragenital gonorrhea screening (pharyngeal or rectal) for syphilis (see Pregnant Women; Men Who Have Sex with
can be considered for females on the basis of reported sexual Men). Local disease prevalence can help guide decision-
behaviors and exposure, through shared clinical-decision making regarding screening for T. vaginalis, especially among
between the patient and the provider (170,171). Gonococcal adolescent females in certain areas. Routine screening of
infection is more prevalent among certain geographic adolescents and young adults who are asymptomatic for certain
locations and communities (141). Clinicians should consider STIs (e.g., syphilis, trichomoniasis, BV, HSV, HAV, and HBV)
the communities they serve and consult local public health is not typically recommended.

14 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Primary Prevention Recommendations Children

Primary prevention and anticipatory guidance for recognizing Management of children who have STIs requires close
symptoms and behaviors associated with STIs are strategies that cooperation among clinicians, laboratorians, and child-
should be incorporated into all types of health care visits for protection authorities. Official investigations, when indicated,
adolescents and young adults. The following recommendations should be initiated promptly. Certain diseases (e.g., gonorrhea,
for primary prevention of STIs (i.e., vaccination and syphilis, HIV, chlamydia, and trichomoniasis), if acquired after
counseling) are based on published clinical guidelines for the neonatal period, strongly indicate sexual contact. For other
sexually active adolescents and young adults from federal diseases (e.g., HSV, HPV and anogenital warts, and vaginitis),
agencies and medical professional organizations. the association with sexual contact is not as clear (see Sexual
• HPV vaccination is recommended through age 26 years Assault and Abuse and STIs).
for those not vaccinated previously at the routine age of
11 or 12 years (https://www.cdc.gov/vaccines/hcp/acip-
Men Who Have Sex with Men
recs/vacc-specific/hpv.html).
• The HBV vaccination series is recommended for all adolescents MSM comprise a diverse group in terms of behaviors,
and young adults who have not previously received the universal identities, and health care needs (179). The term “MSM” often
HBV vaccine series during childhood (12). is used clinically to refer to sexual behavior alone, regardless of
• The HAV vaccination series should be offered to sexual orientation (e.g., a person might identify as heterosexual
adolescents and young adults as well as those who have but still be classified as MSM). Sexual orientation is
not previously received the universal HAV vaccine series independent of gender identity. Classification of MSM can vary
during childhood (https://www.cdc.gov/vaccines/ in the inclusion of transgender men and women on the basis
schedules/hcp/imz/child-indications.html#note-hepa). of whether men are defined by sex at birth (i.e., transgender
• Information regarding HIV transmission, prevention, testing, women included) or current gender identity (i.e., transgender
and implications of infection should be regarded as an essential men included). Therefore, sexual orientation as well as gender
component of the anticipatory guidance provided to all identity of individual persons and their sex partners should be
adolescents and young adults as part of routine health care. obtained during health care visits. MSM might be at increased
• CDC and USPSTF recommend offering HIV PrEP to risk for HIV and other STIs because of their sexual network or
adolescents weighing ≥35 kg and adults who are HIV behavioral or biologic factors, including number of concurrent
negative and at substantial risk for HIV infection (80,178). partners, condomless sex, anal sex, or substance use (180–182).
YMSM should be offered PrEP in youth-friendly settings These factors, along with sexual network or higher community
with tailored adherence support (e.g., text messaging and disease prevalence, can increase the risk for STIs among MSM
visits per existing guidelines). Indications for PrEP, initial compared with other groups (183,184).
and follow-up prescribing guidance, and laboratory testing Performing a detailed and comprehensive sexual history is
recommendations are the same for adolescents and adults the first step in identifying vulnerability and providing tailored
(https://www.cdc.gov/hiv/risk/prep). counseling and care (3). Factors associated with increased
• Medical providers who care for adolescents and young vulnerability to STI acquisition among MSM include having
adults should integrate sexuality education into clinical multiple partners, anonymous partners, and concurrent
practice. Health care providers should counsel adolescents partners (185,186). Repeat syphilis infections are common and
about the sexual behaviors that are associated with risk for might be associated with HIV infection, substance use (e.g.,
acquiring STIs and should educate patients regarding methamphetamines), Black race, and multiple sex partners
evidence-based prevention strategies, which includes a (187). Similarly, gonorrhea incidence has increased among MSM
discussion about abstinence and other risk-reduction and might be more likely to display antimicrobial resistance
behaviors (e.g., consistent and correct condom use and compared with other groups (188,189). Gonococcal infection
reduction in the number of sex partners including among MSM has been associated with similar risk factors to
concurrent partners). Interactive counseling approaches syphilis, including having multiple anonymous partners and
(e.g., patient-centered counseling and motivational substance use, especially methamphetamines (190). Disparities
interviewing) are effective STI and HIV prevention in gonococcal infection are also more pronounced among certain
strategies and are recommended by USPSTF. Educational racial and ethnic groups of MSM (141).
materials (e.g., handouts, pamphlets, and videos) can
reinforce office-based educational efforts.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 15
 Recommendations and Reports

HIV Risk Among Men Who Have Sex with Men among patients with ongoing risk behaviors. MSM taking PrEP
MSM are disproportionately at risk for HIV infection. In might compensate for decreased HIV acquisition risk by using
the United States, the estimated lifetime risk for HIV infection condoms less frequently or modifying their behavior in other ways
among MSM is one in six, compared with heterosexual men at (202,203), although data regarding this behavior are inconsistent.
one in 524 and heterosexual women at one in 253 (191). These Studies have reported that MSM taking PrEP have high rates of
disparities are further exacerbated by race and ethnicity, with STIs, and frequent screening is warranted (204–206).
African American/Black and Hispanic/Latino MSM having a Importance of Rectal and Pharyngeal Testing
one in two and a one in four lifetime risk for HIV infection,
Rectal and pharyngeal testing by NAAT for gonorrhea
respectively. For HIV, transmission occurs much more readily
and chlamydia is recognized as an important sexual health
through receptive anal sex, compared with penile-vaginal sex
consideration for MSM. Rectal gonorrhea and chlamydia are
(192). Similar to other STIs, multiple partners, anonymous
associated with HIV infection (82,207), and men with repeat
partners, condomless sex, and substance use are all associated
rectal infections can be at substantially higher risk for HIV
with HIV infection (193–196). Importantly, other STIs
acquisition (208). Pharyngeal infections with gonorrhea or
also might significantly increase the risk for HIV infection
chlamydia might be a principal source of urethral infections
(197–199). An estimated 10% of new HIV infections were
(209–211). Studies have demonstrated that among MSM,
attributable to chlamydial or gonococcal infection (81). A
prevalence of rectal gonorrhea and chlamydia ranges from
substantial number of MSM remain unaware of their HIV
0.2% to 24% and 2.1% to 23%, respectively, and prevalence
diagnosis (200). Clinical care involving MSM, including
of pharyngeal gonorrhea and chlamydia ranges from 0.5% to
those who have HIV infection, should involve asking about
16.5% and 0% to 3.6%, respectively (171). Approximately
STI-related risk factors and routine STI testing. Clinicians
70% of gonococcal and chlamydial infections might be
should routinely ask MSM about their sexual behaviors and
missed if urogenital-only testing is performed among MSM
symptoms consistent with common STIs, including urethral
(212–216) because most pharyngeal and rectal infections are
discharge, dysuria, ulcers, rash, lymphadenopathy, and
asymptomatic. Self-collected swabs have been reported to be
anorectal symptoms that might be consistent with proctitis
an acceptable means of collection for pharyngeal and rectal
(e.g., discharge, rectal bleeding, pain on defecation, or pain
specimens (217–219), which can enhance patient comfort
during anal sex). However, certain STIs are asymptomatic,
and reduce clinical workloads.
especially at rectal and pharyngeal sites, and routine testing
A detailed sexual history should be taken for all MSM to
is recommended. In addition, clinicians should provide
identify anatomic locations exposed to infection for screening.
education and counseling regarding evidence-based safer-sex
Clinics that provide services for MSM at high risk should
approaches that have demonstrated effectiveness in reducing
consider implementing routine extragenital screening for
STI incidence (see HIV Infection, Detection, Counseling,
N. gonorrhoeae and C. trachomatis infections, and screening is
and Referral).
likely to be cost-effective (220).
Pre-Exposure Prophylaxis for HIV Prevention
Screening Recommendations
PrEP is the use of medications for preventing an infection
STI screening among MSM has been reported to be
before exposure. Studies have demonstrated that a daily oral
suboptimal. In a cross-sectional sample of MSM in the United
medication TDF/FTC is effective in preventing HIV acquisition,
States, approximately one third reported not having had an
and specifically among MSM (74,75,201). PrEP guidelines
STI test during the previous 3 years, and MSM with multiple
provide information regarding sexually active persons who are at
sex partners reported less frequent screening (221). MSM
substantial risk for acquiring HIV infection (having had anal or
living with HIV infection and engaged in care also experience
vaginal sex during the previous 6 months with either a partner
suboptimal rates of STI testing (222,223). Limited data exist
with HIV infection, a bacterial STI in the past 6 months, or
regarding the optimal frequency of screening for gonorrhea,
inconsistent or no condom use with a sex partner) or persons
chlamydia, and syphilis among MSM, with the majority of
who inject drugs (injecting partner with HIV infection or sharing
evidence derived from mathematical modeling. Models from
injection equipment) (80). Those guidelines provide information
Australia have demonstrated that increasing syphilis screening
regarding daily PrEP use for either TDF/FTC (men or women)
frequency from two times a year to four times a year resulted
or tenofovir alafenamide and emtricitabine for MSM. Screening
in a relative decrease of 84% from peak prevalence (224). In
for bacterial STIs should occur at least every 6 months for all
a compartmental model applied to different populations in
sexually active patients and every 3 months among MSM or
Canada, quarterly syphilis screening averted more than twice

16 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

the number of syphilis cases, compared with semiannual • A test for pharyngeal infection* with N. gonorrhoeae among
screening (225). Furthermore, MSM screening coverage men who have had receptive oral intercourse during the
needed for eliminating syphilis among a population is preceding year (pharyngeal NAAT is preferred).
substantially reduced from 62% with annual screening to 23% • Testing for C. trachomatis pharyngeal infection is not
with quarterly screening (226,227). In an MSM transmission recommended.
model that explored the impact of HIV PrEP use on STI Basing screening practices solely on history might be
prevalence, quarterly chlamydia and gonorrhea screening was suboptimal because providers might feel uncomfortable
associated with an 83% reduction in incidence (205). The only taking a detailed sexual history (229), men might also feel
empiric data available that examined the impact of screening uncomfortable sharing personal sexual information with
frequency come from an observational cohort of MSM using their provider, and rectal and pharyngeal infections can be
HIV PrEP in which quarterly screening identified more identified even in the absence of reported risk behaviors (171).
bacterial STIs, and semiannual screening would have resulted Furthermore, the role of saliva, kissing, and rimming (i.e.,
in delayed treatment of 35% of total identified STI infections oral-rectal contact) in the transmission of N. gonorrhoeae and
(206). In addition, quarterly screening was reported to have C. trachomatis has not been well studied (230–232).
prevented STI exposure in a median of three sex partners Rectal and pharyngeal testing (provider-collected or self-
per STI infection (206). On the basis of available evidence, collected specimens) should be performed for all MSM who
quarterly screening for gonorrhea, chlamydia, and syphilis for report exposure at these sites. Testing can be offered to MSM
certain sexually active MSM can improve case finding, which who do not report exposure at these sites after a detailed
can reduce the duration of infection at the population level, explanation, due to known underreporting of risk behaviors.
reduce ongoing transmission and, ultimately, prevalence among All MSM with HIV infection entering care should be screened
this population (228). for gonorrhea and chlamydia at appropriate anatomic sites of
Preventive screening for common STIs is indicated for all exposure as well as for syphilis.
MSM. The following screening recommendations summarize More frequent STI screening (i.e., for syphilis, gonorrhea,
published federal agency and USPSTF clinical prevention and chlamydia) at 3- to 6-month intervals is indicated for
guidelines for MSM and should be performed at least annually. MSM, including those taking PrEP and those with HIV
infection, if risk behaviors persist or if they or their sex partners
HIV Infection
have multiple partners. In addition, providers can consider
HIV serologic testing is indicated if HIV status is unknown the benefits of offering more frequent HIV screening (e.g.,
or if HIV negative and the patient or their sex partner has had every 3–6 months) to MSM at increased risk for acquiring
more than one sex partner since the most recent HIV test. HIV infection.
Syphilis Hepatitis B Virus
Syphilis serologic testing is indicated to establish whether All MSM should be screened with HBsAg, HBV core
persons with reactive tests have untreated syphilis, have partially antibody, and HBV surface antibody testing to detect HBV
treated syphilis, or are manifesting a slow or inadequate infection (233). Vaccination against both HAV and HBV
serologic response to recommended previous therapy. is recommended for all MSM for whom previous infection
Gonorrhea and Chlamydia or vaccination cannot be documented. Serologic testing can
be considered before vaccinating if the patient’s vaccination
The following testing is recommended for MSM: history is unknown; however, vaccination should not be
• A test for urethral infection* with N. gonorrhoeae and delayed. Vaccinating persons who have had previous infection
C. trachomatis among men who have had insertive or vaccination does not increase the risk for vaccine-related
intercourse during the preceding year (urine NAAT adverse events (see Hepatitis A Virus; Hepatitis B Virus).
is preferred).
• A test for rectal infection* with N. gonorrhoeae and Hepatitis C Virus
C. trachomatis among men who have had receptive anal CDC recommends HCV screening at least once for all
intercourse during the preceding year (rectal NAAT adults aged ≥18 years, except in settings where the prevalence
is preferred). of HCV infection (HCV RNA positivity) is <0.1% (156).
The American Association for the Study of Liver Diseases/
* Regardless of condom use during exposure.
Infectious Diseases Society of America guidelines recommend
all MSM with HIV infection be screened for HCV during the

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 17
 Recommendations and Reports

initial HIV evaluation and at least annually thereafter (https:// chlamydia, and syphilis among MSM (90). However, these
www.hcvguidelines.org). More frequent screening depends studies had limitations because of small sample size, short
on ongoing risk behaviors, high-risk sexual behavior, and duration of therapy, and concerns about antibiotic resistance,
concomitant ulcerative STIs or STI-related proctitis. Sexual specifically regarding N. gonorrhoeae (241). Further study is
transmission of HCV can occur and is most common among needed to determine the effectiveness of using antimicrobials
MSM with HIV infection (234–237). Screening for HCV in for STI PrEP or PEP.
this setting is cost-effective (238,239). Screening should be
performed by using HCV antibody assays followed by HCV Counseling and Education Approaches
RNA testing for those with a positive antibody test. Suspicion Different counseling and STI prevention strategies are
for acute HCV infection (e.g., clinical evidence of hepatitis and needed to effectively engage different groups of MSM.
risk behaviors) should prompt consideration for HCV RNA Outreach efforts should be guided by local surveillance efforts
testing, despite a negative antibody test. and community input. Engaging MSM at risk through social
media, specifically online hookup sites, is an important
Human Papillomavirus outreach effort to consider. Hookup sites are Internet sites
HPV infection and associated conditions (e.g., anogenital and mobile telephone applications that men might use for
warts and anal squamous intraepithelial lesions) are highly meeting other men for sex. Internet use might facilitate sexual
prevalent among MSM. The HPV vaccination is recommended encounters and STI transmission among MSM, and many
for all men, including MSM and transgender persons or men report using hookup sites to meet partners (242–245).
immunocompromised males, including those with HIV The ease and accessibility of meeting partners online might
infection, through age 26 years (11). More information is reduce stigma and barriers of meeting partners through
available at https://www.cdc.gov/hpv/downloads/9vhpv- other settings. Moreover, these sites offer an opportunity for
guidance.pdf. effective STI prevention messaging (246), although the cost
A digital anorectal examination (DARE) should be might be limiting (247). Different groups of MSM might use
performed to detect early anal cancer among persons with HIV different hookup sites, and efforts should be guided by local
and MSM without HIV but who have a history of receptive community input. Studies have demonstrated the acceptability
anal intercourse. Data are insufficient to recommend routine and feasibility of reaching MSM through these hookup sites
anal cancer screening with anal cytology in populations at risk to promote STI prevention efforts (248,249).
for anal cancer (see Anal Cancer). Health centers that initiate a
cytology-based screening program should only do so if referrals Enteric Infections Among Men Who Have Sex
to high-resolution anoscopy (HRA) and biopsy are available. with Men
The importance of sexual transmission of enteric pathogens
Herpes Simplex Virus-2
among MSM has been recognized since the 1970s, after the
Evaluation for HSV-2 infection with type-specific serologic first report of MSM-associated shigellosis was reported in
tests also can be considered if infection status is unknown San Francisco (250,251). Global increases in the incidence
among persons with previously undiagnosed genital tract of shigellosis among adult MSM have been more recently
infection (see Genital Herpes). observed (252–256). Sporadic outbreaks of Shigella sonnei
Postexposure Prophylaxis and Pre-Exposure and Shigella flexneri have been reported among MSM
(257–262). Transmission occurs through oral-anal contact
Prophylaxis for STI Prevention
or sexual contact, and transmission efficiency is enhanced by
Studies have reported that a benefit might be derived both biologic or host and behavioral factors. HIV without
from STI PEP and PrEP for STI prevention. One study viral suppression can be an independent risk factor that
demonstrated that monthly oral administration of a 1-g dose can contribute to transmission by increasing shedding of
of azithromycin reduced infection with N. gonorrhoeae and the enteric pathogen, increasing susceptibility of the host,
C. trachomatis but did not decrease the incidence of HIV or both (255,263). Surveillance data in England during
transmission (240). Among MSM, doxycycline taken as PEP in 2004–2015 demonstrated that 21% of nontravel-associated
a single oral dose ≤24 hours after sex decreased infection with Shigella diagnoses among MSM were among persons with
Treponema pallidum and C. trachomatis; however, no substantial HIV infection (255).
effect was observed for infection with N. gonorrhoeae (93). Other enteric organisms might also cause disease among
Doxycycline taken as STI PrEP as 100 mg orally once daily MSM through sexual activities leading to oral-anal contact,
also demonstrated a substantial reduction in gonorrhea, including bacteria such as Escherichia coli (264) and

18 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Campylobacter jejuni or Campylobacter coli (265,266); viruses Recent studies regarding STI rates among WSW and
such as HAV (267); and parasites such as Giardia lamblia or WSWM indicate that WSWM experience higher rates of STIs
Entamoeba histolytica (268,269). Behavioral characteristics than WSW, with rates comparable with women who have sex
associated with the sexual transmission of enteric infections with men (WSM) in all studies reviewed (279,285,286). These
are broadly similar to those associated with other STIs (e.g., studies indicate that WSW might experience STIs at lower
gonorrhea, syphilis, and lymphogranuloma venereum [LGV]). rates than WSWM and WSM, although still at significant
This includes multiple sex partners and online hookup sites rates (287). One study reported higher sexual-risk behaviors
that increase opportunities for sexual mixing, which might among adolescent WSWM and WSW than among adolescent
create dense sexual networks that facilitate STI transmission WSM (280). WSW report reduced knowledge of STI risks
among MSM (270). Specific behaviors associated with sexually (288), and both WSW and WSWM experience barriers to care,
transmitted enteric infections among MSM involve attendance especially Black WSW and WSWM (289,290). In addition, a
at sex parties and recreational drug use including chem sex continuum of sexual behaviors reported by WSW and WSWM
(i.e., using crystal methamphetamine, gamma-butyrolactone, indicates the need for providers to not assume lower risk for
or mephedrone before or during sex), which might facilitate WSW, highlighting the importance of an open discussion
condomless sex, group sex, fisting, use of sex toys, and scat play about sexual health.
(253,271). The growing number of sexually transmitted enteric Few data are available regarding the risk for STIs conferred
infections might be attributable in part to the emergence of by sex between women; however, transmission risk probably
antimicrobial resistance. This is well reported regarding Shigella varies by the specific STI and sexual practice (e.g., oral-genital
species, for which rapid intercontinental dissemination of a sex; vaginal or anal sex using hands, fingers, or penetrative
S. flexneri 3a lineage with high-level resistance to azithromycin sex items; and oral-anal sex) (291,292). Practices involving
through sexual transmission among MSM (272) and clusters digital-vaginal or digital-anal contact, particularly with shared
of multidrug resistant shigella cases among MSM have recently penetrative sex items, present a possible means for transmission
been reported (273). Multidrug-resistant Campylobacter species of infected cervicovaginal or anal secretions. This possibility
have also been documented (266,274). For MSM patients with is most directly supported by reports of shared trichomonas
diarrhea, clinicians should request laboratory examinations, infections (293,294) and by concordant drug-resistance
including stool culture; provide counseling about the risk for genotype testing and phylogenetic linkage analysis identifying
infection with enteric pathogens during sexual activity (oral- HIV transmitted sexually between women (295,296). The
anal, oral-genital, anal-genital, and digital-anal contact) that majority of WSW (53%–97%) have had sex with men in the
could expose them to enteric pathogens; and choose treatment, past and continue to do so, with 5%–28% of WSW reporting
when needed, according to antimicrobial drug susceptibility. male partners during the previous year (292,297–300).
HPV can be transmitted through skin-to-skin contact,
Women Who Have Sex with Women and and sexual transmission of HPV likely occurs between WSW
(301–303). HPV DNA has been detected through polymerase
Women Who Have Sex with chain reaction (PCR)–based methods from the cervix, vagina,
Women and Men and vulva among 13%–30% of WSW (301,302) and can
WSW and WSWM comprise diverse groups with variations persist on fomites, including sex toys (304). Among WSW
in sexual identity, practices, and risk behaviors. Studies who report no lifetime history of sex with men, 26% had
indicate that certain WSW, particularly adolescents, young antibodies to HPV-16, and 42% had antibodies to HPV-6
women, and WSWM, might be at increased risk for STIs (301). High-grade squamous intraepithelial lesions (HSIL) and
and HIV on the basis of reported risk behaviors (275–280). low-grade squamous intraepithelial lesions (LSIL) have been
Studies have highlighted the diversity of sexual practices and detected on Papanicolaou smears (Pap tests) among WSW
examined use of protective or risk-reduction strategies among who reported no previous sex with men (301,302). WSWM
WSW populations (281–283). Use of barrier protection with are at risk for acquiring HPV from both their female partners
female partners (e.g., gloves during digital-genital sex, external and male partners and thus are at risk for cervical cancer.
condoms with sex toys, and latex or plastic barriers [also known Therefore, routine cervical cancer screening should be offered
as dental dams for oral-genital sex]) was infrequent in all to all women, regardless of sexual orientation or practices,
studies. Although health organizations have online materials and young adult WSW and WSWM should be offered HPV
directed to patients, few comprehensive and reliable resources vaccination in accordance with recommendations (11) (https://
of sexual health information for WSW are available (284). www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html).

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 19
 Recommendations and Reports

Genital transmission of HSV-2 between female sex partners Gardnerella vaginalis, and Atopobium vaginae might have
is inefficient but can occur. A U.S. population-based survey substantial roles in development of incident BV (323). These
among women aged 18–59 years demonstrated an HSV-2 studies have continued to support, although have not proven,
seroprevalence of 30% among women reporting same-sex the hypothesis that sexual behaviors, specific BV-associated
partners during the previous year, 36% among women bacteria, and possibly exchange of vaginal or extravaginal
reporting same-sex partners in their lifetime, and 24% among microbiota (e.g., oral bacterial communities) between partners
women reporting no lifetime same-sex behavior (299). HSV-2 might be involved in the pathogenesis of BV among WSW.
seroprevalence among women self-identifying as homosexual Although BV is common among WSW, routine screening
or lesbian was 8%, similar to a previous clinic-based study of for asymptomatic BV is not recommended. Results of one
WSW (299,305) but was 26% among Black WSW in one randomized trial used a behavioral intervention to reduce
study (287). The relatively frequent practice of orogenital sex persistent BV among WSW through reduced sharing of vaginal
among WSW and WSWM might place them at higher risk fluid on hands or sex toys. Women randomly assigned to the
for genital infection with HSV-1, a hypothesis supported by intervention were 50% less likely to report receptive digital-
the recognized association between HSV-1 seropositivity and vaginal contact without gloves than control subjects, and they
previous number of female partners. Thus, sexual transmission reported sharing sex toys infrequently. However, these women
of HSV-1 and HSV-2 can occur between female sex partners. had no reduction in persistent BV at 1 month posttreatment
This information should be communicated to women as part and no reduction in incident episodes of recurrent BV (324).
of sexual health counseling. Trials have not been reported examining the benefits of treating
Trichomonas is a relatively common infection among WSW female partners of women with BV. Recurrent BV among
and WSWM, with prevalence rates higher than for chlamydia WSW is associated with having a same-sex partner and a lack of
or gonorrhea (306,307), and direct transmission of trichomonas condom use (325). Increasing awareness of signs and symptoms
between female partners has been demonstrated (293,294). of BV among women and encouraging healthy sexual practices
Limited information is available regarding transmission (e.g., avoiding shared sex toys, cleaning shared sex toys, and
of bacterial STIs between female partners. Transmission of using barriers) might benefit women and their partners.
syphilis between female sex partners, probably through oral Sexually active women are at risk for acquiring bacterial,
sex, has been reported. Although the rate of transmission of viral, and protozoal STIs from current and previous partners,
C. trachomatis or N. gonorrhoeae between women is unknown, both male and female. WSW should not be presumed to be at
infection also might be acquired from past or current male low or no risk for STIs on the basis of their sexual orientation.
partners. Data indicate that C. trachomatis infection among Report of same-sex behavior among women should not deter
WSW can occur (275,286,308,309). Data are limited providers from considering and performing screening for STIs
regarding gonorrhea rates among WSW and WSWM (170). and cervical cancer according to guidelines. Effective screening
Reports of same-sex behavior among women should not deter requires that care providers and their female patients engage in
providers from offering and providing screening for STIs, a comprehensive and open discussion of sexual and behavioral
including chlamydia, according to guidelines. risks that extends beyond sexual identity.
BV is common among women, and even more so among
women with female partners (310–312). Epidemiologic data Transgender and Gender Diverse Persons
strongly demonstrate that BV is sexually transmitted among
women with female partners. Evidence continues to support Transgender persons often experience high rates of stigma and
the association of such sexual behaviors as having a new partner, socioeconomic and structural barriers to care that negatively
having a partner with BV, having receptive oral sex, and having affect health care usage and increase susceptibility to HIV and
digital-vaginal and digital-anal sex with incident BV (313,314). STIs (326–332). Persons who are transgender have a gender
A study including monogamous couples demonstrated identity that differs from the sex that they were assigned at birth
that female sex partners frequently share identical genital (333,334). Transgender women (also known as trans women,
Lactobacillus strains (315). Within a community-based transfeminine persons, or women of transgender experience)
cohort of WSW, extravaginal (i.e., oral and rectal) reservoirs are women who were assigned male sex at birth (born with
of BV-associated bacteria were a risk factor for incident BV male anatomy). Transgender men (also known as trans men,
(316). Studies have examined the impact of specific sexual transmasculine persons, or men of transgender experience)
practices on the vaginal microflora (306,317–319) and on are men who were assigned female sex at birth (i.e., born with
recurrent (320) or incident (321,322) BV among WSW. A female anatomy). In addition, certain persons might identify
BV pathogenesis study in WSW reported that Prevotella bivia, outside the gender binary of male or female or move back and

20 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

forth between different gender identities and use such terms the United States is 14% among transgender women, with the
as “gender nonbinary,” “genderqueer,” or “gender fluid” to highest prevalence among Black (44%) and Hispanic (26%)
describe themselves. Persons who use terms such as “agender” transgender women (344). Data also demonstrate high rates of
or “null gender” do not identify with having any gender. The HIV infection among transgender women worldwide (345).
term “cisgender” is used to describe persons who identify with Bacterial STI prevalence varies among transgender women and
their assigned sex at birth. Prevalence studies of transgender is based largely on convenience samples. Despite limited data,
persons among the overall population have been limited and international and U.S. studies have indicated elevated incidence
often are based on small convenience samples. and prevalence of gonorrhea and chlamydia among transgender
Gender identity is independent of sexual orientation. Sexual women similar to rates among cisgender MSM (346–348). A
orientation identities among transgender persons are diverse. recent study using data from the STD Surveillance Network
Persons who are transgender or gender diverse might have sex revealed that the proportions of transgender women with
with cisgender men, cisgender women, or other transgender extragenital chlamydial or gonococcal infections were similar
or gender nonbinary persons. to those of cisgender MSM (349).
Providers caring for transgender women should have
Clinical Environment Assessment knowledge of their patients’ current anatomy and patterns
Providers should create welcoming environments that of sexual behavior before counseling them about STI and
facilitate disclosure of gender identity and sexual orientation. HIV prevention. The majority of transgender women have
Clinics should document gender identity and sex assigned not undergone genital-affirmation surgery and therefore
at birth for all patients to improve sexual health care for might retain a functional penis; in these instances, they
transgender and gender nonbinary persons. Assessment of might engage in insertive oral, vaginal, or anal sex as well as
gender identity and sex assigned at birth has been validated receptive oral or anal sex. In the U.S. Transgender Survey, 12%
among diverse populations, has been reported to be acceptable of transgender women had undergone vaginoplasty surgery,
(335,336), and might result in increased patients identifying and approximately 50% more were considering surgical
as transgender (337). intervention (350). Providers should have knowledge about
Lack of medical provider knowledge and other barriers to care the type of tissue used to construct the neovagina, which
(e.g., discrimination in health care settings or denial of services) can affect future STI and HIV preventive care and screening
often result in transgender and gender nonbinary persons recommendations. The majority of vaginoplasty surgeries
avoiding or delaying preventive care services (338–340) and conducted in the United States use penile and scrotal tissue
incurring missed opportunities for HIV and STI prevention to create the neovagina (351). Other surgical techniques
services. Gender-inclusive and trauma-guided health care use intestinal tissue (e.g., sigmoid colon graft) or split-skin
might increase the number of transgender patients who seek grafts (352). Although these surgeries involve penectomy and
sexual health services, including STI testing (341), because orchiectomy, the prostate remains intact. Transgender women
transgender persons are at high risk for sexual violence (342). who have had a vaginoplasty might engage in receptive vaginal,
Primary care providers should take a comprehensive sexual oral, or anal sex.
history, including a discussion of STI screening, HIV PrEP Neovaginal STIs have infrequently been reported in
and PEP, behavioral health, and social determinants of sexual the literature and include HSV and HPV/genital warts in
health. Clinicians can improve the experience of sexual health penile-inversion vaginoplasty, C. trachomatis in procedures
screening and counseling for transgender persons by asking for that involved penile skin and grafts with urethra mucosa or
their choice of terminology or modifying language (e.g., asking abdominal peritoneal lining (353), and N. gonorrhoeae in
patients their gender pronouns) to be used during clinic visits both penile-inversion and colovaginoplasty (354–359). If
and history taking and examination (343). Options for fertility the vaginoplasty used an intestinal graft, a risk also exists for
preservation, pregnancy potential, and contraception options bowel-related disease (e.g., adenocarcinoma, inflammatory
should also be discussed, if indicated. For transgender persons bowel disease, diversion colitis, and polyps) (360–362).
who retain a uterus and ovaries, ovulation might continue in
the presence of testosterone therapy, and pregnancy potential Transgender Men
exists (https://transcare.ucsf.edu). The few studies of HIV prevalence among transgender men
indicated that they have a lower prevalence of HIV infection
Transgender Women than transgender women. A recent estimate of HIV prevalence
A systematic review and meta-analysis of HIV infection among transgender men was 2% (344). However, transgender
among transgender women estimated that HIV prevalence in men who have sex with cisgender men might be at elevated

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 21
 Recommendations and Reports

risk for HIV infection (332,363,364). Data are limited • HIV screening should be discussed and offered to all
regarding STI prevalence among transgender men, and the transgender persons. Frequency of repeat screenings should
majority of studies have used clinic-based data or convenience be based on level of risk.
sampling. Recent data from the STD Surveillance Network • For transgender persons with HIV infection who have sex
demonstrated higher prevalence of gonorrhea and chlamydia with cisgender men and transgender women, STI
among transgender men, similar to rates reported among screening should be conducted at least annually, including
cisgender MSM (365). syphilis serology, HCV testing, and urogenital and
The U.S. Transgender Survey indicated that the proportion extragenital NAAT for gonorrhea and chlamydia.
of transgender men and gender diverse persons assigned • Transgender women who have had vaginoplasty surgery
female sex at birth who have undergone gender-affirmation should undergo routine STI screening for all exposed sites
genital surgery is low. Providers should consider the anatomic (e.g., oral, anal, or vaginal). No data are available regarding
diversity among transgender men because a person can undergo the optimal screening method (urine or vaginal swab) for
a metoidioplasty (a procedure to increase the length of the bacterial STIs of the neovagina. The usual techniques for
clitoris), with or without urethral lengthening, and might not creating a neovagina do not result in a cervix; therefore,
have a hysterectomy and oophorectomy and therefore be at risk no rationale exists for cervical cancer screening (368).
for bacterial STIs, HPV, HSV, HIV, and cervical cancer (366). • If transgender men have undergone metoidioplasty surgery
For transgender men using gender-affirming hormone therapy, with urethral lengthening and have not had a vaginectomy,
the decrease in estradiol levels caused by exogenous testosterone assessment of genital bacterial STIs should include a
can lead to vaginal atrophy (367,368) and is associated with a cervical swab because a urine specimen will be inadequate
high prevalence of unsatisfactory sample acquisition (369). The for detecting cervical infections.
impact of these hormonal changes on mucosal susceptibility • Cervical cancer screening for transgender men and
to HIV and STIs is unknown. nonbinary persons with a cervix should follow current
Transgender men who have not chosen to undergo screening guidelines (see Human Papillomavirus Infections).
hysterectomy with removal of the cervix remain at risk for
cervical cancer. These persons often avoid cervical cancer Persons in Correctional Facilities
screening because of multiple factors, including discomfort
with medical examinations and fear of discrimination Multiple studies have demonstrated that persons entering
(338,370). Providers should be aware that conducting a correctional facilities have a high prevalence of STIs, HIV, and
speculum examination can be technically difficult after viral hepatitis, especially those aged ≤35 years (141,372,373).
metoidioplasty surgery because of narrowing of the introitus. Risk behaviors for acquiring STIs (e.g., having condomless
In these situations, high-risk HPV testing using a swab can sex, having multiple sex partners, substance misuse, and
be considered; self-collected swabs for high-risk HPV testing engaging in commercial, survival, or coerced sex) are common
has been reported to be an acceptable option for transgender among incarcerated populations. Before their incarceration,
men (371). many persons have had limited access to medical care. Other
social determinants of health (e.g., insufficient social and
Screening Recommendations economic support or living in communities with high local
The following are screening recommendations for STI prevalence) are common. Addressing STIs in correctional
transgender and gender diverse persons: settings is vital for addressing the overall STI impact among
• Because of the diversity of transgender persons regarding affected populations.
surgical gender-affirming procedures, hormone use, and Growing evidence demonstrates the usefulness of expanded
their patterns of sexual behavior, providers should remain STI screening and treatment services in correctional settings,
aware of symptoms consistent with common STIs and including short-term facilities (jails), long-term institutions
screen for asymptomatic infections on the basis of the (prisons), and juvenile detention centers. For example, in
patient’s sexual practices and anatomy. jurisdictions with comprehensive, targeted jail screening, more
• Gender-based screening recommendations should be chlamydial infections among females (and males if screened)
adapted on the basis of anatomy (e.g., routine screening are detected and subsequently treated in the correctional setting
for C. trachomatis and N. gonorrhoeae) as recommended than in any other single reporting source (141,374) and might
for all sexually active females aged <25 years on an annual represent the majority of reported cases in certain jurisdictions
basis and should be extended to transgender men and (375). Screening in the jail setting has the potential to reach
nonbinary persons with a cervix among this age group.

22 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

substantially more persons at risk than screening among the Trichomonas

prison population alone. Females aged ≤35 years housed in correctional facilities
Both males and females aged ≤35 years in juvenile and adult should be screened for trichomonas. This screening should be
detention facilities have been reported to have higher rates of conducted at intake and offered as opt-out screening.
chlamydia and gonorrhea than nonincarcerated persons in
the community (141,374,376). Syphilis seroprevalence rates, Syphilis
which can indicate previously treated or current infection, are Opt-out screening for incarcerated persons should be
considerably higher among incarcerated adult men and women conducted on the basis of the local area and institutional
than among adolescents, which is consistent with the overall prevalence of early (primary, secondary, or early latent)
national syphilis trends (141,374). Detection and treatment infectious syphilis. Correctional facilities should stay apprised
of early syphilis in correctional facilities might affect rates of local syphilis prevalence. In short-term facilities, screening
of transmission among adults and prevention of congenital at entry might be indicated.
syphilis (377).
In jails, approximately half of entrants are released back Viral Hepatitis
into the community within 48 hours. As a result, treatment All persons housed in juvenile and adult correctional facilities
completion rates for those screened for STIs and who receive should be screened at entry for viral hepatitis, including HAV,
STI diagnoses in short-term facilities might not be optimal. HBV, and HCV, depending on local prevalence and the
However, because of the mobility of incarcerated populations person’s vaccination status. Vaccination for HAV and HBV
in and out of the community, the impact of screening in should be offered if the person is susceptible.
correctional facilities on the prevalence of infections among
Cervical Cancer
detainees and subsequent transmission in the community
after release might be considerable (378). Moreover, treatment Women and transgender men who are housed in correctional
completion rates of ≥95% in short-term facilities can be facilities should be screened for cervical cancer as for women
achieved by offering screening at or shortly after intake, who are not incarcerated (393,394) (see Cervical Cancer).
thus facilitating earlier receipt of test results and, if needed, HIV Infection
follow-up of untreated persons can be conducted through
public health outreach. All persons being housed in juvenile and adult correctional
Universal, opt-out screening for chlamydia and gonorrhea facilities should be screened at entry for HIV infection;
among females aged ≤35 years entering juvenile and adult screening should be offered as opt-out screening. For those
correctional facilities is recommended (379). Males aged identified as being at risk for HIV infection (e.g., with
<30 years entering juvenile and adult correctional facilities diagnosed gonorrhea or syphilis or persons who inject drugs)
should also be screened for chlamydia and gonorrhea (380). and being released into the community, starting HIV PrEP
Opt-out screening has the potential to substantially increase (or providing linkage to a community clinic for HIV PrEP)
the number tested and the number of chlamydia and gonorrhea for HIV prevention should be considered (395,396). Persons
infections detected (381–385). Point-of-care (POC) NAAT are likely to engage in high-risk activities immediately after
might also be considered if the tests have demonstrated release from incarceration (397). For those identified with
sufficient sensitivity and specificity. Studies have demonstrated HIV infection, treatment should be initiated. Those persons
high prevalence of trichomoniasis among incarcerated receiving PrEP or HIV treatment should have linkage to
females (386–392). care established before release. Correctional settings should
consider implementing other STI prevention approaches,
Screening Recommendations both during incarceration and upon release, which might
include educational and behavioral counseling interventions
Chlamydia and Gonorrhea
(398–401), vaccination (e.g., for HPV) (402,403), condom
Females aged ≤35 years and males aged <30 years housed distribution (404,405), EPT (125), and PrEP to prevent HIV
in correctional facilities should be screened for chlamydia and infection (see Primary Prevention Methods).
gonorrhea. This screening should be conducted at intake and
offered as opt-out screening.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 23
 Recommendations and Reports

HIV Infection • CDC and USPSTF recommend HIV screening at least

once for all persons aged 15–65 years (417).
Detection, Counseling, and Referral • Persons at higher risk for HIV acquisition, including
Infection with HIV causes an acute but brief and nonspecific sexually active gay, bisexual, and other MSM, should be
influenza-like retroviral syndrome that can include fever, screened for HIV at least annually. Providers can consider
malaise, lymphadenopathy, pharyngitis, arthritis, or skin the benefits of offering more frequent screening (e.g., every
rash. Most persons experience at least one symptom; however, 3–6 months) among MSM at increased risk for acquiring
some might be asymptomatic or have no recognition of illness HIV (418,419).
(406–409). Acute infection transitions to a multiyear, chronic • All pregnant women should be tested for HIV during the
illness that progressively depletes CD4+ T lymphocytes crucial first prenatal visit. A second test during the third trimester,
for maintenance of effective immune function. Ultimately, preferably at <36 weeks’ gestation, should be considered
persons with untreated HIV infection experience symptomatic, and is recommended for women who are at high risk for
life-threatening immunodeficiency (i.e., AIDS). acquiring HIV infection, women who receive health care
Effective ART that suppresses HIV replication to undetectable in jurisdictions with high rates of HIV, and women
levels reduces morbidity, provides a near-normal lifespan, and examined in clinical settings in which HIV incidence is
prevents sexual transmission of HIV to others (95–97,410– ≥1 per 1,000 women screened per year (138,140).
412). Early diagnosis of HIV and rapid linkage to care are • HIV screening should be voluntary and free from coercion.
essential for achieving these goals. Guidelines from both the Patients should not be tested without their knowledge.
U.S. Department of Health and Human Services and the • Opt-out HIV screening (notifying the patient that an HIV
International AIDS Society–USA Panel recommend that all test will be performed, unless the patient declines) is
persons with HIV infection be offered effective ART as soon recommended in all health care settings. CDC also
as possible, both to reduce morbidity and mortality and to recommends that consent for HIV screening be
prevent HIV transmission (413). incorporated into the general informed consent for
STD specialty or sexual health clinics are a vital partner in medical care in the same manner as other screening or
reducing HIV infections in the United States. These clinics diagnostic tests.
provide safety net services to vulnerable populations in need • Requirement of specific signed consent for HIV testing is
of HIV prevention services who are not served by the health not recommended. General informed consent for medical
care system and HIV partner service organizations. Diagnosis care is considered sufficient to encompass informed
of an STI is a biomarker for HIV acquisition, especially among consent for HIV testing.
persons with primary or secondary syphilis or, among MSM, • Providers should use a laboratory-based antigen/antibody
rectal gonorrhea or chlamydia (197). STD clinics perform only (Ag/Ab) combination assay as the first test for HIV, unless
approximately 20% of all federally funded HIV tests nationally persons are unlikely to follow up with a provider to receive
but identify approximately 30% of all new infections (414). their HIV test results; in those cases screening with a rapid
Among testing venues, STD clinics are high performing in POC test can be useful.
terms of linkage to HIV care within 90 days of diagnosis; • Preliminary positive screening tests for HIV should be
during 2013–2017, the percentage of persons with a new followed by supplemental testing to establish the diagnosis.
diagnosis in an STD clinic and linked to care within 90 days • Providing prevention counseling as part of HIV screening
increased from 55% to >90% (415,415). programs or in conjunction with HIV diagnostic testing is
not required (6). However, persons might be more likely to
Screening Recommendations think about HIV and consider their risk-related behavior
The following recommendations apply to testing for HIV: when undergoing an HIV test. HIV testing gives providers
• HIV testing is recommended for all persons seeking STI an opportunity to conduct STI and HIV prevention
evaluation who are not already known to have HIV infection. counseling and communicate risk-reduction messages.
Testing should be routine at the time of the STI evaluation, • Acute HIV infection can occur among persons who report
regardless of whether the patient reports any specific behavioral recent sexual or needle-sharing behavior or who have had
risks for HIV. Testing for HIV should be performed at the time an STI diagnosis.
of STI diagnosis and treatment if not performed at the initial • Providers should test for HIV RNA if initial testing according
STI evaluation and screening (82,195,416). to the HIV testing algorithm recommended by CDC is
negative or indeterminate when concerned about acute HIV
infection (https://stacks.cdc.gov/view/cdc/50872).

24 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

• Providers should not assume that a laboratory report of a Acute HIV Infection
negative HIV Ag/Ab or antibody test indicates that the requisite Providers serving persons at risk for STIs are in a position
HIV RNA testing for acute HIV infection has been conducted. to diagnose HIV infection during its acute phase. Diagnosing
They should consider explicitly requesting HIV RNA testing HIV infection during the acute phase is particularly important
when concerned about early acute HIV infection. because persons with acute HIV have highly infectious
• Providers should assess eligibility of all persons seeking disease due to the concentration of virus in plasma and
STI services for HIV PrEP and PEP. For persons with genital secretions, which is extremely elevated during that
substantial risk whose results are HIV negative, providers stage of infection (421,422) (https://clinicalinfo.hiv.gov/en/
should offer or provide referral for PrEP services, unless guidelines/adult-and-adolescent-arv/acute-and-recent-early-
the last potential HIV exposure occurred <72 hours, in hiv-infection?view=full). ART during acute HIV infection
which case PEP might be indicated. is recommended because it substantially reduces infection
Diagnostic Considerations transmission to others, improves laboratory markers of
disease, might decrease severity of acute disease, lowers viral
HIV infection can be diagnosed by HIV 1/2 Ag/Ab
setpoint, reduces the size of the viral reservoir, decreases
combination immunoassays. All FDA-cleared HIV tests are
the rate of viral mutation by suppressing replication, and
highly sensitive and specific. Available serologic tests can
preserves immune function (https://clinicalinfo.hiv.gov/en/
detect all known subtypes of HIV-1. The majority also detect
guidelines/adult-and-adolescent-arv/acute-and-recent-early-
HIV-2 and uncommon variants of HIV-1 (e.g., group O and
hiv-infection?view=full). Persons who receive an acute HIV
group N).
diagnosis should be referred immediately to an HIV clinical
According to an algorithm for HIV diagnosis, CDC
care provider, provided prevention counseling (e.g., advised to
recommends that HIV testing begin with a laboratory-
reduce the number of partners and to use condoms correctly
based HIV-1/HIV-2 Ag/Ab combination assay, which, if
and consistently), and screened for STIs. Information should be
repeatedly reactive, is followed by a laboratory-based assay
provided regarding availability of PEP for sexual and injecting
with a supplemental HIV-1/HIV-2 antibody differentiation
drug use partners not known to have HIV infection if the
assay (https://stacks.cdc.gov/view/cdc/50872). This algorithm
most recent contact was <72 hours preceding HIV diagnosis.
confers an additional advantage because it can detect HIV-2
When providers test by using the CDC algorithm, specimens
antibodies after the initial immunoassay. Although HIV-2 is
collected during acute infection might give indeterminate or
uncommon in the United States, accurate identification is
negative results because insufficient anti-HIV antibodies and
vital because monitoring and therapy for HIV-2 differs from
potentially insufficient antigen are present to be reactive on
that for HIV-1 (420). RNA testing should be performed
Ag/Ab combination assays and supplemental HIV-1/HIV-2
on all specimens with reactive immunoassay but negative
antibody differentiation assays. Whenever acute HIV infection
supplemental antibody test results to determine whether the
is suspected (e.g., initial testing according to the CDC algorithm
discordance represents acute HIV infection.
is negative or indeterminate after a possible sexual exposure to
Rapid POC HIV tests can enable clinicians to make a
HIV within the previous few days to weeks, especially if the
preliminary diagnosis of HIV infection in <20 minutes. The
person has symptoms or has primary or secondary syphilis,
majority of rapid antibody assays become reactive later in the
gonorrhea, or chlamydia), additional testing for HIV RNA
course of HIV infection than conventional laboratory-based
is recommended. If this additional testing for HIV RNA is
assays and thus can produce negative results among persons
also negative, repeat testing in a few weeks is recommended
recently infected (e.g., acutely infected persons). Furthermore,
to rule out very early acute infection when HIV RNA might
HIV home-test kits only detect HIV antibodies and therefore
not be detectable. A more detailed discussion of testing in
will not detect acute HIV infection. If early or acute infection
the context of acute HIV infection is available at https://
is suspected and a rapid HIV antibody assay is negative,
clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/
confirmatory testing with combined laboratory-based assays or
initiation-antiretroviral-therapy?view=full.
RNA testing should be performed. CDC recommends that all
persons with reactive rapid tests be assessed with a laboratory- Treatment
based Ag/Ab assay. Additional details about interpretation of ART should be initiated as soon as possible for all persons with
results by using the HIV testing algorithm recommended by HIV infection regardless of CD4+ T-cell count, both for individual
CDC are available at https://stacks.cdc.gov/view/cdc/48472. health and to prevent HIV transmission (https://clinicalinfo.hiv.
gov/sites/default/files/inline-files/AdultandAdolescentGL.pdf).

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 25
 Recommendations and Reports

Persons with HIV infection who achieve and maintain a viral load • Provide prevention counseling to persons with diagnosed
suppressed to <200 copies/mL with ART have effectively no risk HIV infection.
for sexually transmitting HIV (95–97,421). Early HIV diagnosis • Ensure all persons with HIV infection are informed that
and treatment is thus not only vital for individual health but also as if they achieve and maintain a suppressed viral load, they
a public health intervention to prevent new infections. Knowledge have effectively no risk for transmitting HIV. Stress that
of the prevention benefit of treatment can help reduce stigma and a suppressed viral load is not a substitute for condoms and
increase the person’s commitment to start and remain adherent behavioral modifications because ART does not protect
to ART (423). The importance of adherence should be stressed persons with HIV against other STIs.
as well as the fact that ART does not protect against other STIs • Provide additional counseling, either on-site or through
that can be prevented by using condoms. Interventions to assist referral, about the psychosocial and medical implications
persons to remain adherent to their prescribed HIV treatment, to of having HIV infection.
otherwise reduce the possibility of transmission to others, and to • Assess the need for immediate medical care and
protect themselves against STIs, have been developed for diverse psychosocial support.
populations at risk (424) (https://clinicalinfo.hiv.gov/sites/default/ • Link persons with diagnosed HIV infection to services
files/inline-files/AdultandAdolescentGL.pdf). provided by health care personnel experienced in managing
Comprehensive HIV treatment and care services might not HIV infection. Additional services that might be needed
be available in facilities focused primarily on STI treatment. include substance misuse counseling and treatment,
Providers in such settings should be knowledgeable about HIV treatment for mental health disorders or emotional distress,
treatment and care options available in their communities reproductive counseling, risk-reduction counseling, and
and promptly link persons who have newly diagnosed HIV case management. Providers should follow up to ensure
infection and any persons with HIV infection who are not that patients have received services for any identified needs.
engaged in ongoing effective care to a health care provider • Persons with HIV infection should be educated about the
or facility experienced in caring for persons living with HIV importance of ongoing medical care and what to expect
(https://clinicalinfo.hiv.gov/sites/default/files/inline-files/ from these services.
AdultandAdolescentGL.pdf ).
STI Screening of Persons with HIV Infection in HIV
Other HIV Management Considerations Care Settings
Behavioral and psychosocial services are integral to caring for At the initial HIV care visit, providers should screen all
persons with HIV infection. Providers should expect persons sexually active persons for syphilis, gonorrhea, and chlamydia,
to be distressed when first informed that they have HIV. They and perform screening for these infections at least annually
face multiple adaptive challenges, including coping with the during the course of HIV care (425). Specific testing
reactions of others to a stigmatizing illness, developing and includes syphilis serology and NAAT for N. gonorrhoeae and
adopting strategies to maintain physical and emotional health, C. trachomatis at the anatomic site of exposure. Women should
initiating changes in behavior to prevent HIV transmission to also be screened for trichomoniasis at the initial visit and
others, and reducing the risk for acquiring additional STIs. annually thereafter. Women should be screened for cervical
Many persons will require assistance gaining access to health cancer precursor lesions per existing guidelines (98).
care and other support services and coping with changes in More frequent screening for syphilis, gonorrhea, and
personal relationships. chlamydia (e.g., every 3 or 6 months) should be tailored
Persons with HIV infection might have additional needs to individual risk and the local prevalence of specific STIs.
(e.g., referral for substance use or mental health disorders). Certain STIs can be asymptomatic; their diagnosis might
Others require assistance to secure and maintain employment prompt referral for partner services, might identify sexual and
and housing. Persons capable of reproduction might require needle-sharing partners who can benefit from early diagnosis
family planning counseling, information about reproductive and treatment of HIV, and might prompt reengagement in
health choices, and referral for reproductive health care. care or HIV prevention services (e.g., PEP or PrEP) (8). More
The following recommendations apply to managing persons detailed information on screening, testing, and treatment is
with diagnosed HIV infection: provided in pathogen-specific sections of this report.
• Link persons with HIV infection to care and start them
on ART as soon as possible.
• Report cases (in accordance with local requirements) to
public health and initiate partner services.

26 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Partner Services and Reporting transmission of HIV), and encourage testing at subsequent
prenatal visits. Women who decline testing because they have
Partner notification is a key component in the evaluation
had a previous negative HIV test result should be informed
of persons with HIV infection. Early diagnosis and treatment
about the importance of retesting during each pregnancy.
of HIV among all potentially exposed sexual and injecting
Women with no prenatal care should be tested for HIV at the
drug sharing partners can improve their health and reduce
time of delivery.
new infections. For those partners without HIV infection,
Testing pregnant women is crucial because knowledge of
partner services also provide an opportunity for offering HIV
infection status can help maintain the woman’s health, and
prevention services, including PrEP or PEP (if exposure was
it enables receipt of interventions (i.e., ART or specialized
<72 hours previous) and STI testing and treatment.
obstetrical care) that can substantially reduce the risk for
Health care providers should inform persons with diagnosed
perinatal transmission of HIV. Pregnant women with
HIV infection about any legal obligations of providers to report
diagnosed HIV infection should be educated about the benefits
cases of HIV to public health; the local confidential processes
of ART for their own health and for reducing the risk for HIV
for managing partner services, including that a public health
transmission to their infant. In the absence of ART, a mother’s
department still might be in contact to follow up in their care
risk for transmitting HIV to her neonate is approximately
and partner services; and the benefits and risks of partner
30%; however, risk can be reduced to <2% through ART,
notification and services. Health care providers should also
obstetrical interventions (i.e., elective cesarean delivery at
encourage persons with a new HIV diagnosis to notify their
38 weeks’ pregnancy), and breastfeeding avoidance (https://
partners and provide them with referral information for their
clinicalinfo.hiv.gov/sites/default/files/inline-files/PerinatalGL.
partners about HIV testing. Partner notification for exposure
pdf ). Pregnant women with HIV infection should be linked
to HIV should be confidential. Health care providers can assist
to an HIV care provider experienced in managing HIV in
in the partner notification process, either directly or by referral
pregnancy and provided antenatal and postpartum treatment
to health department partner notification programs. Health
and advice. Detailed and regularly updated recommendations
department staff are trained to use public health investigation
for managing pregnant patients with HIV infection are
strategies for confidentially locating persons who can benefit
available at https://clinicalinfo.hiv.gov/sites/default/files/inline-
from HIV treatment, care, or prevention services. Guidance
files/PerinatalGL.pdf.
regarding spousal notification varies by jurisdiction. Detailed
recommendations for notification, evaluation, and treatment of HIV Infection Among Neonates, Infants, and Children
exposed partners are available in Recommendations for Partner Diagnosis of HIV infection in a pregnant woman indicates
Services Programs for HIV Infection, Syphilis, Gonorrhea, and the need for evaluating and managing the HIV-exposed
Chlamydial Infections (111). neonate and considering whether the woman’s other children,
Special Considerations if any, might be infected. Detailed recommendations regarding
diagnosis and management of HIV infection among neonates
Pregnancy and children of mothers with HIV are beyond the scope of
All pregnant women should be tested for HIV during the these guidelines but are available at https://clinicalinfo.hiv.
first prenatal visit. A second test during the third trimester, gov/en/guidelines. Exposed neonates and children with HIV
preferably at <36 weeks’ gestation, should be considered and infection should be referred to physicians with expertise in
is recommended for women who are at high risk for acquiring neonatal and pediatric HIV management.
HIV, women who receive health care in jurisdictions with high
rates of HIV infection, and women served in clinical settings
in which prenatal screening identifies ≥1 pregnant woman Diseases Characterized by Genital,
with HIV per 1,000 women screened (138). Diagnostic Anal, or Perianal Ulcers
algorithms for HIV for pregnant women do not differ from
those for nonpregnant women (see STI Detection Among In the United States, the majority of young, sexually active
Special Populations). Pregnant women should be informed patients who have genital, anal, or perianal ulcers have either
that HIV testing will be performed as part of the routine panel genital herpes or syphilis. The frequency of each condition
of prenatal tests (138); for women who decline HIV testing, differs by geographic area and population; however, genital
providers should address concerns that pose obstacles, discuss herpes is the most prevalent of these diseases. More than one
the benefits of testing (e.g., early HIV detection, treatment, and etiologic agent (e.g., herpes and syphilis) can be present in
care for improving health of the mother and reducing perinatal any genital, anal, or perianal ulcer. Less common infectious

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 27
 Recommendations and Reports

causes of genital, anal, or perianal ulcers include chancroid, among populations and communities and travel history). For
LGV, and granuloma inguinale (donovanosis). GUDs (e.g., example, syphilis is so common among MSM that any male
syphilis, herpes, and LGV) might also present as oral ulcers. who has sex with men presenting with a genital ulcer should be
Genital herpes, syphilis, chlamydia, gonorrhea, and chancroid presumptively treated for syphilis at the initial visit after syphilis
have been associated with an increased risk for HIV acquisition and HSV tests are performed. After a complete diagnostic
and transmission. Genital, anal, or perianal lesions can also be evaluation, >25% of patients who have genital ulcers might
associated with infectious and noninfectious conditions that not have a laboratory-confirmed diagnosis (426).
are not sexually transmitted (e.g., yeast, trauma, carcinoma,
aphthae or Behcet’s disease, fixed drug eruption, or psoriasis). Chancroid
A diagnosis based only on medical history and physical
examination frequently can be inaccurate. Therefore, all Chancroid prevalence has declined in the United States
persons who have genital, anal, or perianal ulcers should be (141). When infection does occur, it is usually associated
evaluated. Specific evaluation of genital, anal, or perianal ulcers with sporadic outbreaks. Worldwide, chancroid appears to
includes syphilis serology tests and darkfield examination have decreased as well, although infection might still occur in
from lesion exudate or tissue, or NAAT if available; NAAT certain Africa regions and the Caribbean. Chancroid is a risk
or culture for genital herpes type 1 or 2; and serologic testing factor in HIV transmission and acquisition (197).
for type-specific HSV antibody. In settings where chancroid is Diagnostic Considerations
prevalent, a NAAT or culture for Haemophilus ducreyi should
A definitive diagnosis of chancroid requires identifying
be performed.
H. ducreyi on special culture media that is not widely
No FDA-cleared NAAT for diagnosing syphilis is available
available from commercial sources; even when these media
in the United States; however, multiple FDA-cleared NAATs
are used, sensitivity is <80% (427). No FDA-cleared NAAT
are available for diagnosing HSV-1 and HSV-2 in genital
for H. ducreyi is available in the United States; however,
specimens. Certain clinical laboratories have developed their
such testing can be performed by clinical laboratories that
own syphilis and HSV NAATs and have conducted Clinical
have developed their own NAAT and have conducted CLIA
Laboratory Improvement Amendment (CLIA) verification
verification studies on genital specimens.
studies with genital specimens. Type-specific serology for
The combination of one or more deep and painful
HSV-2 might aid in identifying persons with genital herpes
genital ulcers and tender suppurative inguinal adenopathy
(see Genital Herpes). In addition, biopsy of ulcers with
indicates the chancroid diagnosis; inguinal lymphadenitis
immunohistochemistry can help identify the cause of ulcers
typically occurs in <50% of cases (428). For both clinical and
that are unusual or that do not respond to initial therapy. HIV
surveillance purposes, a probable diagnosis of chancroid can
testing should be performed on all persons not known to have
be made if all of the following four criteria are met: 1) the
HIV infection who present with genital, anal, or perianal ulcers
patient has one or more painful genital ulcers; 2) the clinical
(see Diagnostic Considerations in disease-specific sections).
presentation, appearance of genital ulcers and, if present,
NAAT testing at extragenital sites should be considered for
regional lymphadenopathy are typical for chancroid; 3) the
cases in which GUDs are suspected (e.g., oral manifestations
patient has no evidence of T. pallidum infection by darkfield
of syphilis, herpes, or LGV). Commercially available NAATs
examination or NAAT (i.e., ulcer exudate or serous fluid) or
have not been cleared by FDA for these indications; however,
by serologic tests for syphilis performed at least 7–14 days
they can be used by laboratories that have met regulatory
after onset of ulcers; and 4) HSV-1 or HSV-2 NAAT or HSV
requirements for an off-label procedure.
culture performed on the ulcer exudate or fluid are negative.
Because early syphilis treatment decreases transmission
possibility, public health standards require health care Treatment
providers to presumptively treat any patient with a suspected
Successful antimicrobial treatment for chancroid cures
case of infectious syphilis at the initial visit, even before test
the infection, resolves the clinical symptoms, and prevents
results are available. Presumptive treatment of a patient with a
transmission to others. In advanced cases, genital scarring and
suspected first episode of genital herpes also is recommended
rectal or urogenital fistulas from suppurative buboes can result
because HSV treatment benefits depend on prompt therapy
despite successful therapy.
initiation. The clinician should choose the presumptive
treatment on the basis of the clinical presentation (i.e., HSV
lesions begin as vesicles and primary syphilis as a papule) and
epidemiologic circumstances (e.g., high incidence of disease

28 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Recommended Regimens for Chancroid Special Considerations

Azithromycin 1 g orally in a single dose Pregnancy
or
Ceftriaxone 250 mg IM in a single dose Data indicate ciprofloxacin presents a low risk to the
or
Ciprofloxacin 500 mg orally 2 times/day for 3 days
fetus during pregnancy but has potential for toxicity during
or breastfeeding (431). Alternative drugs should be used if the
Erythromycin base 500 mg orally 3 times/day for 7 days patient is pregnant or lactating. No adverse effects of chancroid
on pregnancy outcome have been reported.
Azithromycin and ceftriaxone offer the advantage of
single-dose therapy (429). Worldwide, several isolates with HIV Infection
intermediate resistance to either ciprofloxacin or erythromycin Persons with HIV infection who have chancroid infection
have been reported. However, because cultures are not routinely should be monitored closely because they are more likely to
performed, and chancroid is uncommon, data are limited experience chancroid treatment failure and to have ulcers
regarding prevalence of H. ducreyi antimicrobial resistance. that heal slowly (430,432). Persons with HIV might require
repeated or longer courses of therapy, and treatment failures
Other Management Considerations can occur with any regimen. Data are limited concerning
Men who are uncircumcised and persons with HIV infection the therapeutic efficacy of the recommended single-dose
do not respond as well to treatment as persons who are azithromycin and ceftriaxone regimens among persons with
circumcised or are HIV negative (430). Patients should be HIV infection.
tested for HIV at the time chancroid is diagnosed. If the initial
HIV test results were negative, the provider can consider the Children
benefits of offering more frequent testing and HIV PrEP to Because sexual contact is the major primary transmission route
persons at increased risk for HIV infection. among U.S. patients, diagnosis of chancroid ulcers among infants
and children, especially in the genital or perineal region, is highly
Follow-Up suspicious of sexual abuse. However, H. ducreyi is recognized as a
Patients should be reexamined 3–7 days after therapy major cause of nonsexually transmitted cutaneous ulcers among
initiation. If treatment is successful, ulcers usually improve children in tropical regions and, specifically, countries where
symptomatically within 3 days and objectively within 7 days yaws is endemic (433–435). Acquisition of a lower-extremity
after therapy. If no clinical improvement is evident, the clinician ulcer attributable to H. ducreyi in a child without genital ulcers
should consider whether the diagnosis is correct, another STI and reported travel to a region where yaws is endemic should
is present, the patient has HIV infection, the treatment was not be considered evidence of sexual abuse.
not used as instructed, or the H. ducreyi strain causing the
infection is resistant to the prescribed antimicrobial. The time Genital Herpes
required for complete healing depends on the size of the ulcer;
large ulcers might require >2 weeks. In addition, healing can Genital herpes is a chronic, lifelong viral infection. Two types
be slower for uncircumcised men who have ulcers under the of HSV can cause genital herpes: HSV-1 and HSV-2. Most
foreskin. Clinical resolution of fluctuant lymphadenopathy is cases of recurrent genital herpes are caused by HSV-2, and
slower than that of ulcers and might require needle aspiration 11.9% of persons aged 14–49 years are estimated to be infected
or incision and drainage, despite otherwise successful therapy. in the United States (436). However, an increasing proportion
Although needle aspiration of buboes is a simpler procedure, of anogenital herpetic infections have been attributed to
incision and drainage might be preferred because of reduced HSV-1, which is especially prominent among young women
need for subsequent drainage procedures. and MSM (186,437,438).
The majority of persons infected with HSV-2 have not
Management of Sex Partners had the condition diagnosed, many of whom have mild or
Regardless of whether disease symptoms are present, sex unrecognized infections but shed virus intermittently in the
partners of patients with chancroid should be examined and anogenital area. Consequently, most genital herpes infections
treated if they had sexual contact with the patient during the are transmitted by persons unaware that they have the
10 days preceding the patient’s symptom onset. infection or who are asymptomatic when transmission occurs.
Management of genital HSV should address the chronic nature
of the infection rather than focusing solely on treating acute
episodes of genital lesions.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 29
 Recommendations and Reports

Diagnostic Considerations Type-Specific Serologic Tests

Clinical diagnosis of genital herpes can be difficult because the Both type-specific and type-common antibodies to HSV
self-limited, recurrent, painful, and vesicular or ulcerative lesions develop during the first weeks after infection and persist
classically associated with HSV are absent in many infected persons indefinitely. The majority of available, accurate type-
at the time of clinical evaluation. If genital lesions are present, specific HSV serologic assays are based on the HSV-specific
clinical diagnosis of genital herpes should be confirmed by type- glycoprotein G2 (gG2) (HSV-2) and glycoprotein G1 (gG1)
specific virologic testing from the lesion by NAAT or culture (186). (HSV-1). Type-common antibody tests do not distinguish
Recurrences and subclinical shedding are much more frequent for between HSV-1 and HSV-2 infection; therefore, type-specific
HSV-2 genital herpes infection than for HSV-1 genital herpes serologic assays should be requested (450–452).
(439,440). Therefore, prognosis and counseling depend on which Both laboratory-based assays and POC tests that provide
HSV type is present. Type-specific serologic tests can be used to results for HSV-2 antibodies from capillary blood or serum
aid in the diagnosis of HSV infection in the absence of genital during a clinic visit are available. The sensitivity of glycoprotein
lesions. Both type-specific virologic and type-specific serologic tests G type-specific tests for detecting HSV-2 antibody varies from
for HSV should be available in clinical settings that provide care 80% to 98%; false-negative results might be more frequent
to persons with or at risk for STIs. HSV-2 genital herpes infection at early stages of infection (451,453,454). Therefore, in
increases the risk for acquiring HIV twofold to threefold; therefore, cases of recent suspected HSV-2 acquisition, repeat type-
all persons with genital herpes should be tested for HIV (441). specific antibody testing 12 weeks after the presumed time
of acquisition is indicated. The most commonly used test,
Virologic Tests HerpeSelect HSV-2 enzyme immunoassay (EIA), often is
HSV NAAT assays are the most sensitive tests because falsely positive at low index values (1.1–3.0) (457–457). One
they detect HSV from genital ulcers or other mucocutaneous study reported an overall specificity of 57.4%, with a specificity
lesions; these tests are increasingly available (442–444). of 39.8% for index values of 1.1–2.9 (458). Because of the
Although multiple FDA-cleared assays exist for HSV detection, poor specificity of commercially available type-specific EIAs,
these tests vary in sensitivity from 90.9% to 100%; however, particularly with low index values (<3.0), a confirmatory test
they are considered highly specific (445–447). PCR is also (Biokit or Western blot) with a second method should be
the test of choice for diagnosing HSV infections affecting the performed before test interpretation. Use of confirmatory
central nervous system (CNS) and systemic infections (e.g., testing with the Biokit or the Western blot assays have been
meningitis, encephalitis, and neonatal herpes). HSV PCR reported to improve accuracy of HSV-2 serologic testing (459).
of the blood should not be performed to diagnose genital The HerpeSelect HSV-2 immunoblot should not be used for
herpes infection, except in cases in which concern exists for confirmation because it uses the same antigen as the HSV-2
disseminated infection (e.g., hepatitis). In certain settings, viral EIA. If confirmatory tests are unavailable, patients should be
culture is the only available virologic test. The sensitivity of viral counseled about the limitations of available testing before
culture is low, especially for recurrent lesions, and decreases obtaining serologic tests, and health care providers should be
rapidly as lesions begin to heal (443,448). Viral culture aware that false-positive results occur. Immunoglobulin M
isolates and PCR amplicons should be typed to determine (IgM) testing for HSV-1 or HSV-2 is not useful because
whether HSV-1 or HSV-2 is causing the infection. Failure to IgM tests are not type specific and might be positive during
detect HSV by NAAT or culture, especially in the presence recurrent genital or oral episodes of herpes (460). Therefore,
of older lesions or the absence of active lesions, does not HSV IgM testing is not recommended.
indicate an absence of HSV infection because viral shedding Because approximately all HSV-2 infections are sexually
is intermittent. Similarly, random or blind genital swabs in acquired, presence of type-specific HSV-2 antibody implies
the absence of lesions should not be used to diagnose genital anogenital infection. In this instance, education and counseling
HSV infection because sensitivity is low, and a negative result for persons with genital HSV infections should be provided.
does not exclude the presence of HSV infection. The presence of HSV-1 antibody alone is more difficult
Cytologic detection of cellular changes associated with HSV to interpret. HSV-1 serologic testing does not distinguish
infection is an insensitive and nonspecific method of diagnosing between oral and genital infection and typically should not
genital lesions (i.e., Tzanck preparation) and therefore should be performed for diagnosing genital HSV-1 infection. Persons
not be relied on. Although a direct immunofluorescence with HSV-1 antibodies often have oral HSV infection acquired
assay using fluorescein-labeled monoclonal antibodies is also during childhood, which might be asymptomatic. Lack of
available for detecting HSV antigen from genital specimens, symptoms in a person who is HSV-1 seropositive does not
this assay lacks sensitivity and is not recommended (449).

30 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

distinguish anogenital from orolabial or cutaneous infection, mild clinical manifestations initially can experience severe or
and, regardless of site of infection, these persons remain at risk prolonged symptoms during recurrent infection. Therefore,
for acquiring HSV-2. In addition, HSV-1 serologic testing all patients with first episodes of genital herpes should receive
has low sensitivity for detection of HSV-1 antibody (458). antiviral therapy.
However, acquisition of HSV-1 genital herpes is increasing,
Recommended Regimens for First Clinical Episode of Genital
and HSV-1 genital herpes also can be asymptomatic (437– Herpes*
439,461,462). Diagnosis of HSV-1 infection is confirmed by Acyclovir† 400 mg orally 3 times/day for 7–10 days
virologic tests from genital lesions. or
Type-specific HSV-2 serologic assays for diagnosing Famciclovir 250 mg orally 3 times/day for 7–10 days
or
HSV-2 are useful in the following scenarios: recurrent or Valacyclovir 1 g orally 2 times/day for 7–10 days
atypical genital symptoms or lesions with a negative HSV
* Treatment can be extended if healing is incomplete after 10 days of therapy.
PCR or culture result, clinical diagnosis of genital herpes † Acyclovir 200 mg orally 5 times/day is also effective but is not

without laboratory confirmation, and a patient’s partner has recommended because of the frequency of dosing.
genital herpes. HSV-2 serologic screening among the general
population is not recommended. Patients who are at higher
Recurrent HSV-2 Genital Herpes
risk for infection (e.g., those presenting for an STI evaluation,
especially for persons with ≥10 lifetime sex partners, and Almost all persons with symptomatic first-episode HSV-2
persons with HIV infection) might need to be assessed for a genital herpes subsequently experience recurrent episodes of
history of genital herpes symptoms, followed by type-specific genital lesions. Intermittent asymptomatic shedding occurs
HSV serologic assays to diagnose genital herpes for those with among persons with HSV-2 genital herpes infection, even
genital symptoms. those with longstanding clinically silent infection. Antiviral
therapy for recurrent genital herpes can be administered either
Genital Herpes Management as suppressive therapy to reduce the frequency of recurrences
Antiviral medication offers clinical benefits to symptomatic or episodically to ameliorate or shorten the duration of lesions.
patients and is the mainstay of management. The goals for Certain persons, including those with mild or infrequent
use of antiviral medications to treat genital herpes infection recurrent outbreaks, benefit from antiviral therapy; therefore,
are to treat or prevent symptomatic genital herpes recurrences options for treatment should be discussed. Many persons prefer
and improve quality of life and suppress the virus to prevent suppressive therapy, which has the additional advantage of
transmission to sexual partners. Counseling regarding the decreasing the risk for transmitting HSV-2 genital herpes to
natural history of genital herpes, risks for sexual and perinatal susceptible partners (472,473).
transmission, and methods for reducing transmission is also Suppressive Therapy for Recurrent HSV-2
integral to clinical management. Genital Herpes
Systemic antiviral drugs can partially control the signs and
symptoms of genital herpes when used to treat first clinical and Suppressive therapy reduces frequency of genital herpes
recurrent episodes or when used as daily suppressive therapy. recurrences by 70%–80% among patients who have frequent
However, these drugs neither eradicate latent virus nor affect recurrences (469–472). Persons receiving such therapy
the risk, frequency, or severity of recurrences after the drug often report having experienced no symptomatic outbreaks.
is discontinued. Randomized trials have indicated that three Suppressive therapy also is effective for patients with less
FDA-approved antiviral medications provide clinical benefit frequent recurrences. Long-term safety and efficacy have
for genital herpes: acyclovir, valacyclovir, and famciclovir been documented among patients receiving daily acyclovir,
(463–471). Valacyclovir is the valine ester of acyclovir and has valacyclovir, and famciclovir (474). Quality of life is improved
enhanced absorption after oral administration, allowing for for many patients with frequent recurrences who receive
less frequent dosing than acyclovir. Famciclovir also has high suppressive therapy rather than episodic treatment (475).
oral bioavailability. Topical therapy with antiviral drugs offers Providers should discuss with patients on an annual basis
minimal clinical benefit and is discouraged. whether they want to continue suppressive therapy because
frequency of genital HSV-2 recurrence diminishes over time
First Clinical Episode of Genital Herpes for many persons. However, neither treatment discontinuation
Newly acquired genital herpes can cause a prolonged nor laboratory monitoring is necessary because adverse events
clinical illness with severe genital ulcerations and neurologic and development of HSV antiviral resistance related to long-
involvement. Even persons with first-episode herpes who have term antiviral use are uncommon.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 31
 Recommendations and Reports

Treatment with valacyclovir 500 mg daily decreases the rate prodrome that precedes some outbreaks. The patient should
of HSV-2 transmission for discordant heterosexual couples be provided with a supply of drug or a prescription for the
in which a partner has a history of genital HSV-2 infection medication with instructions to initiate treatment immediately
(473). Such couples should be encouraged to consider when symptoms begin. Acyclovir, famciclovir, and valacyclovir
suppressive antiviral therapy as part of a strategy for preventing appear equally effective for episodic treatment of genital herpes
transmission, in addition to consistent condom use and (466–470).
avoidance of sexual activity during recurrences. Suppressive
Recommended Regimens for Episodic Therapy for Recurrent
antiviral therapy for persons with a history of symptomatic HSV-2 Genital Herpes*
genital herpes also is likely to reduce transmission when used Acyclovir 800 mg orally 2 times/day for 5 days
by those who have multiple partners. HSV-2 seropositive or
persons without a history of symptomatic genital herpes Acyclovir 800 mg orally 3 times/day for 2 days
or
have a 50% decreased risk for genital shedding, compared Famciclovir 1 g orally 2 times/day for 1 day
with those with symptomatic genital herpes (476). No data or
are available regarding efficacy of suppressive therapy for Famciclovir 500 mg orally once, followed by 250 mg 2 times/day for
2 days
preventing HSV-2 transmission among discordant couples in or
which a partner has a history of asymptomatic HSV-2 infection Famciclovir 125 mg orally 2 times/day for 5 days
or
identified by a positive HSV-2 serologic test. Among HSV-2 Valacyclovir 500 mg orally 2 times/day for 3 days
seropositive persons without HIV infection, oral TDF/FTC or
and intravaginal tenofovir are ineffective at reducing the risk Valacyclovir 1 g orally once daily for 5 days
for HSV-2 shedding or recurrences (477). * Acyclovir 400 mg orally 3 times/day for 5 days is also effective but is not
recommended because of frequency of dosing.
Recommended Regimens for Suppression of Recurrent HSV-2
Genital Herpes
Acyclovir 400 mg orally 2 times/day Severe Disease
or
Intravenous (IV) acyclovir therapy (5–10 mg/kg body weight
Valacyclovir 500 mg orally once a day*
or IV every 8 hours) should be provided for patients who have severe
Valacyclovir 1 g orally once a day HSV disease or complications that necessitate hospitalization
or
Famciclovir 250 mg orally 2 times/day
(e.g., disseminated infection, pneumonitis, or hepatitis) or
CNS complications (e.g., meningitis or encephalitis). HSV-2
* Valacyclovir 500 mg once a day might be less effective than other
valacyclovir or acyclovir dosing regimens for persons who have frequent meningitis is a rare complication of HSV-2 genital herpes
recurrences (i.e., ≥10 episodes/year). infection that affects women more than men (480). IV therapy
should be considered until clinical improvement followed by
Famciclovir appears somewhat less effective for suppression of oral antiviral therapy to complete >10 days of total therapy.
viral shedding (478). Ease of administration and cost also are Longer duration is recommended for CNS complications.
key considerations for prolonged treatment. HSV-2 meningitis is characterized clinically by signs of
headache, photophobia, fever, meningismus, and cerebrospinal
Recurrent HSV-1 Genital Herpes
fluid (CSF) lymphocytic pleocytosis, accompanied by mildly
Recurrences are less frequent after the first episode of HSV-1 elevated protein and normal glucose (481). Optimal therapies
genital herpes, compared with genital HSV-2 genital herpes, for HSV-2 meningitis have not been well studied (482);
and genital shedding rapidly decreases during the first year of however, acyclovir 5–10 mg/kg body weight IV every 8 hours
infection (479). No data are available regarding the efficacy until clinical improvement is observed, followed by high-dose
of suppressive therapy for preventing transmission among oral antiviral therapy (valacyclovir 1 g 3 times/day) to complete
persons with HSV-1 genital herpes infection. Because of a 10- to 14-day course of total therapy, is recommended.
the decreased risk for recurrences and shedding, suppressive For patients with previous episodes of documented HSV-2
therapy for HSV-1 genital herpes should be reserved for those meningitis, oral valacyclovir may be used for the entire
with frequent recurrences through shared clinical decision- course during episodes of recurrent HSV-2 meningitis. A
making between the patient and the provider. randomized clinical trial indicated that suppressive therapy
Episodic Therapy for Recurrent HSV-2 Genital Herpes (valacyclovir 500 mg 2 times/day) did not prevent recurrent
HSV-2 meningitis episodes; however, the dose might not
Episodic treatment of recurrent herpes is most effective if have been sufficient for CNS penetration (483). Valacyclovir
therapy is initiated within 1 day of lesion onset or during the

32 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

500 mg 2 times/day is not recommended for suppression of are taking TDF as part of their ART regimen (495). No data
HSV-2 meningitis; higher doses have not been studied in indicate that antivirals (acyclovir, valacyclovir, or famciclovir)
clinical trials. HSV meningitis should be distinguished from can be taken as PrEP by persons without HSV-2 to prevent
encephalitis, which requires a longer course (14–21 days) of its acquisition.
IV therapy. Impaired renal function warrants an adjustment
in acyclovir dosage. Counseling
Counseling of persons with genital herpes and their sex
Hepatitis partners is crucial for management. The goals of counseling
Hepatitis is a rare manifestation of disseminated HSV include helping patients cope with the infection and preventing
infection, often reported among pregnant women who sexual and perinatal transmission. Although initial counseling
acquire HSV during pregnancy (484). Pregnant women in can be provided at the first visit, patients often benefit from
any trimester can present with fever and hepatitis (markedly learning about the chronic aspects of the disease after the acute
elevated transaminases) but might not have any genital or skin illness subsides. Multiple resources, including Internet sites and
lesions. HSV hepatitis is associated with fulminant liver failure printed materials, are available to assist patients, their partners,
and high mortality (25%). Therefore, a high index of suspicion and clinicians who provide counseling (496,497) (https://www.
for HSV is necessary, with a confirmatory diagnosis by HSV ashasexualhealth.org and https://www.cdc.gov/std/herpes).
PCR from blood (485). Among pregnant women with fever Although the psychological effect of a serologic diagnosis of
and unexplained severe hepatitis, disseminated HSV infection HSV-2 infection in a person with asymptomatic or unrecognized
should be considered, and empiric IV acyclovir should be genital herpes appears minimal and transient (498,499), certain
initiated pending confirmation (484). persons with HSV infection might express anxiety concerning
genital herpes that does not reflect the actual clinical severity
Prevention of their disease; the psychological effect of HSV infection can
Consistent and correct condom use has been reported be substantial. Common concerns about genital herpes include
in multiple studies to decrease, but not eliminate, the risk the severity of initial clinical manifestations, recurrent episodes,
for HSV-2 transmission from men to women (486–488). sexual relationships and transmission to sex partners, and ability
Condoms are less effective for preventing transmission from to bear healthy children.
women to men (489). Two randomized clinical trials of
medical male circumcision (MMC) demonstrated a decreased Symptomatic HSV-2 Genital Herpes
risk for HSV-2 acquisition among men in Uganda and When counseling persons with symptomatic HSV-2 genital
South Africa (66,68). Results from a third trial conducted herpes infection, the provider should discuss the following:
in Kenya did not demonstrate a substantial difference in • The natural history of the disease, with emphasis on the
HSV-2 acquisition among men who received MMC (490). potential for recurrent episodes, asymptomatic viral
A systematic review indicated high consistency for decreased shedding, and the attendant risks for sexual transmission
risk for HSV-2 acquisition among women with a male partner of HSV to occur during asymptomatic periods
who underwent MMC (491). These data indicate that MMC (asymptomatic viral shedding is most frequent during the
can be associated with decreased risk for HSV-2 acquisition first 12 months after acquiring HSV-2).
among adult heterosexual men and with decreased risk for • The effectiveness of daily suppressive antiviral therapy for
HSV-2 transmission from male to female partners. preventing symptomatic recurrent episodes of genital
Randomized clinical trials have demonstrated that PrEP with herpes for persons experiencing a first episode or recurrent
daily oral TDF/FTC decreases the risk for HSV-2 acquisition genital herpes.
by 30% in heterosexual partnerships (492). Pericoital • The effectiveness of daily use of valacyclovir in reducing
intravaginal tenofovir 1% gel also decreases the risk for HSV-2 risk for transmission of HSV-2 among persons without
acquisition among heterosexual women (493). Among MSM HIV (473) and use of episodic therapy to shorten the
and transgender women, daily oral TDF/FTC decreases the duration of recurrent episodes.
risk for severe ulcers with symptomatic genital HSV-2 infection • The importance of informing current sex partners about
but not for HSV-2 acquisition (494). Insufficient evidence genital herpes and informing future partners before
exists that TDF/FTC use among those who are not at risk for initiating a sexual relationship.
HIV acquisition will prevent HSV-2 infection, and it should • The importance of abstaining from sexual activity with
not be used for that sole purpose. Oral TDF does not prevent uninfected partners when lesions or prodromal symptoms
HSV-2 acquisition among persons with HIV infection who are present.

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 Recommendations and Reports

• The effectiveness of male latex condoms, which when used • Because of the decreased risk for recurrences and shedding,
consistently and correctly can reduce, but not eliminate, suppressive therapy for HSV-1 genital herpes should be
the risk for genital herpes transmission (486–488). reserved for those with frequent recurrences.
• The type-specific serologic testing of partners of persons • For patients with frequently recurring HSV-1 genital
with symptomatic HSV-2 genital herpes to determine herpes, suppressive therapy might be considered.
whether such partners are already HSV seropositive or Suppressive therapy to prevent HSV-1 transmission to sex
whether risk for acquiring HSV exists. partners has not been studied.
• The low risk for neonatal HSV except when genital herpes For persons with symptomatic HSV-1 genital herpes or
is acquired late in pregnancy or if prodrome or lesions are asymptomatic HSV-2 genital herpes, suppressive therapy can
present at delivery. be considered for those who have substantial psychosocial
• The increased risk for HIV acquisition among HSV-2 distress caused by the diagnosis of genital herpes. For women
seropositive persons who are exposed to HIV (76,471). who have genital herpes, the providers who care for them
• The lack of effectiveness of episodic or suppressive therapy during pregnancy and those who will care for their newborn
among persons with HIV infection to reduce risk for infant should be informed of their infection (see Genital
transmission to partners who might be at risk for Herpes During Pregnancy).
HSV-2 acquisition.
Management of Sex Partners
Asymptomatic HSV-2 Genital Herpes The sex partners of persons who have symptomatic
When counseling persons with asymptomatic HSV-2 genital genital herpes can benefit from evaluation and counseling.
herpes infection, the provider should consider the following: Symptomatic sex partners should be evaluated and treated in
• Asymptomatic persons who receive a diagnosis of HSV-2 the same manner as patients who have symptomatic genital
by type-specific serologic testing (with confirmatory testing, herpes. Asymptomatic sex partners of patients who have
if needed) should receive education about the symptoms of symptomatic genital herpes should be asked about a history
genital herpes infection (see Diagnostic Considerations). of genital symptoms and offered type-specific serologic testing
• Episodic and suppressive antiviral therapies are used for HSV-2. For partners without genital herpes, no data are
predominantly to treat recurrences, prevent recurrences, available on which to base a recommendation for PEP or
and prevent transmission to sex partners of persons with PrEP with antiviral medications or that they would prevent
symptomatic HSV-2 infection. acquisition, and this should not be offered to patients as a
• For patients with serological evidence of HSV-2 (with prevention strategy.
combination testing if needed) without symptomatic
recurrences, neither episodic nor suppressive therapy is Special Considerations
indicated for prevention of recurrences (see Diagnostic Drug Allergy, Intolerance, or Adverse Reactions
Considerations).
Allergic and other adverse reactions to oral acyclovir,
• Among persons with asymptomatic infection, the efficacy
valacyclovir, and famciclovir are rare. Desensitization to
of suppressive therapy to prevent HSV-2 transmission to
acyclovir has been described (500).
sex partners has not been studied.
• Because of the decreased risk for shedding among those HIV Infection
with asymptomatic HSV-2 genital herpes, the benefit of Immunocompromised patients can have prolonged or severe
suppressive therapy for preventing transmission is episodes of genital, perianal, or oral herpes. Lesions caused by
unknown among this population. HSV are common among persons with HIV infection and
HSV-1 Genital Herpes might be severe, painful, and atypical (501). HSV shedding is
increased among persons with HIV infection (502). Whereas
When counseling persons with HSV-1 genital herpes
ART reduces the severity and frequency of symptomatic genital
infection, the provider should consider the following:
herpes, frequent subclinical shedding still occurs (503,504).
• Persons with virologic laboratory-documented
Clinical manifestations of genital herpes might worsen during
symptomatic HSV-1 genital herpes infection should be
immune reconstitution early after initiation of ART. HSV-2
educated that the risk for recurrent genital herpes and
type-specific serologic testing can be considered for persons
genital shedding is lower with HSV-1 infection, compared
with HIV infection during their initial evaluation, particularly
with HSV-2 infection.
among those with a history of genital symptoms indicative of
HSV infection.

34 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Recommended therapy for first-episode genital herpes is disease specialist consultation. Imiquimod 5% applied to the lesion
the same as for persons without HIV infection, although for 8 hours 3 times/week until clinical resolution is an alternative
treatment courses might need to be extended for lesion that has been reported to be effective (510,511). Topical cidofovir
resolution. Suppressive or episodic therapy with oral antiviral gel 1% can be applied to lesions 2–4 times daily; however, cidofovir
agents is effective in decreasing the clinical manifestations of must be compounded at a pharmacy (512).
HSV infection among persons with HIV (503,504). The risk Prevention of antiviral resistance remains challenging among
for GUD increases during the first 6 months after starting persons with HIV infection. Experience with another group
ART, especially among persons who have a CD4+ T-cell count of immunocompromised persons (e.g., hematopoietic stem-
<200 cell/mm3. Suppressive antiviral therapy reduces the risk cell recipients) demonstrated that persons receiving daily
for GUD among this population and can be continued for suppressive antiviral therapy were less likely to experience
6 months after ART initiation (504) when the risk for GUD acyclovir-resistant HSV infection compared with those who
returns to baseline levels. Suppressive antiviral therapy among received episodic therapy for outbreaks (513).
persons with HIV and HSV infection does not reduce the
Genital Herpes During Pregnancy
risk for either HIV transmission or HSV-2 transmission to
susceptible sex partners (88,505). Suppressive antiviral therapy Prevention of neonatal herpes depends both on preventing
does not delay HIV disease progression and is not associated acquisition of genital herpes during late pregnancy and
with decreased risk for HIV-related inflammation among avoiding exposure of the neonate to herpetic lesions and viral
persons taking ART (506). For severe HSV disease, initiating shedding during delivery. Mothers of newborns who acquire
therapy with acyclovir 5–10 mg/kg IV every 8 hours might neonatal herpes often lack histories of clinically evident genital
be necessary. herpes (514,515). The risk for transmission to the neonate from
an infected mother is high (30%–50%) among women who
Recommended Regimens for Daily Suppression of Genital acquire genital herpes near the time of delivery and low (<1%)
Herpes Among Persons with HIV Infection
among women with prenatal histories of recurrent herpes or
Acyclovir 400–800 mg orally 2–3 times/day
or who acquire genital herpes during the first half of pregnancy
Famciclovir 500 mg orally 2 times/day (516,517). Women who acquire HSV in the second half of
or pregnancy should be managed in consultation with maternal-
Valacyclovir 500 mg orally 2 times/day
fetal medicine and infectious disease specialists.
Recommended Regimens for Episodic Genital Herpes Infection
All pregnant women should be asked whether they have
Among Persons with HIV Infection a history of genital herpes or genital symptoms concerning
Acyclovir 400 mg orally 3 times/day for 5–10 days for HSV infection. At the onset of labor, all women should
or be questioned thoroughly about symptoms of genital herpes,
Famciclovir 500 mg orally 2 times/day for 5–10 days
or
including prodromal symptoms (e.g., pain or burning at site
Valacyclovir 1 g orally 2 times/day for 5–10 days before appearance of lesion), and all women should be examined
thoroughly for herpetic lesions. Women without symptoms or
signs of genital herpes or its prodrome can deliver vaginally.
Antiviral-Resistant HSV Infection Although cesarean delivery does not eliminate the risk for HSV
If lesions persist or recur in a patient receiving antiviral transmission to the neonate (517), women with recurrent genital
treatment, acyclovir resistance should be suspected and a viral herpetic lesions at the onset of labor should have a cesarean
culture obtained for phenotypic sensitivity testing (507). delivery to reduce the risk for neonatal HSV infection.
Molecular testing for acyclovir resistance is not available. Routine HSV-2 serologic screening of pregnant women is not
Such persons should be managed in consultation with an recommended. Women without known genital herpes should
infectious disease specialist, and alternative therapy should be be counseled to abstain from vaginal intercourse during the
administered. All acyclovir-resistant strains are also resistant third trimester with partners known to have or suspected of
to valacyclovir, and the majority are resistant to famciclovir. having genital herpes. In addition, to prevent HSV-1 genital
Foscarnet (40–80 mg/kg body weight IV every 8 hours until herpes, pregnant women without known orolabial herpes
clinical resolution is attained) is the treatment of choice for should be advised to abstain from receptive oral sex during the
acyclovir-resistant genital herpes (508,509). Intravenous third trimester with partners known to have or suspected to
cidofovir 5 mg/kg body weight once weekly might also be have orolabial herpes. Type-specific serologic tests can be useful
effective. Foscarnet and cidofovir are nephrotoxic medications for identifying pregnant women at risk for HSV infection and
that require intensive laboratory monitoring and infectious for guiding counseling regarding the risk for acquiring genital

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 35
 Recommendations and Reports

herpes during pregnancy. For example, such testing might be clinical signs of neonatal herpes to guide treatment initiation.
offered to a woman with no history of genital herpes whose In addition, administration of acyclovir might be considered
sex partner has HSV infection. Many fetuses are exposed to for neonates born to women who acquired HSV near term
acyclovir each year, and the medication is believed to be safe because the risk for neonatal herpes is high for these newborn
for use during all trimesters of pregnancy. A case-control study infants. All newborn infants who have neonatal herpes should
reported an increased risk for the rare neonatal outcome of be promptly evaluated and treated with systemic acyclovir.
gastroschisis among women who used antiviral medications The recommended regimen for infants treated for known or
between the month before conception and the third month of suspected neonatal herpes is acyclovir 20 mg/kg body weight
pregnancy (518). Acyclovir is also believed to be safe during IV every 8 hours for 14 days if disease is limited to the skin and
breastfeeding (431,519). Although data regarding prenatal mucous membranes, or for 21 days for disseminated disease
exposure to valacyclovir and famciclovir are limited, data from and disease involving the CNS.
animal trials indicate that these drugs also pose a low risk
among pregnant women (520). Acyclovir can be administered Granuloma Inguinale (Donovanosis)
orally to pregnant women with first-episode genital herpes or
recurrent herpes and should be administered IV to pregnant Granuloma inguinale (donovanosis) is a genital ulcerative
women with severe HSV (see Genital Herpes, Hepatitis). disease caused by the intracellular gram-negative bacterium
Suppressive acyclovir treatment starting at 36 weeks’ gestation Klebsiella granulomatis (formerly known as Calymmatobacterium
reduces the frequency of cesarean delivery among women who granulomatis). The disease occurs rarely in the United States;
have recurrent genital herpes by diminishing the frequency of however, sporadic cases have been described in India, South
recurrences at term (521–523). However, such treatment might Africa, and South America (526–535). Although granuloma
not protect against transmission to neonates in all cases (524). inguinale was previously endemic in Australia, it is now
No data support use of antiviral therapy among asymptomatic extremely rare (536,537). Clinically, the disease is characterized
HSV-seropositive women without a history of genital herpes. as painless, slowly progressive ulcerative lesions on the genitals
In addition, the effectiveness of antiviral therapy among sex or perineum without regional lymphadenopathy; subcutaneous
partners with a history of genital herpes to decrease the risk granulomas (pseudobuboes) also might occur. The lesions
for HSV transmission to a pregnant woman has not been are highly vascular (i.e., beefy red appearance) and can bleed.
studied. Additional information on the clinical management Extragenital infection can occur with infection extension to
of genital herpes in pregnancy is available through existing the pelvis, or it can disseminate to intra-abdominal organs,
guidelines (525). bones, or the mouth. The lesions also can develop secondary
bacterial infection and can coexist with other sexually
Recommended Regimen for Suppression of Recurrent Genital transmitted pathogens.
Herpes Among Pregnant Women*
Acyclovir 400 mg orally 3 times/day Diagnostic Considerations
or
Valacyclovir 500 mg orally 2 times/day
The causative organism of granuloma inguinale is difficult
to culture, and diagnosis requires visualization of dark-staining
* Treatment recommended starting at 36 weeks’ gestation.
Donovan bodies on tissue crush preparation or biopsy.
Although no FDA-cleared molecular tests for the detection of
Neonatal Herpes K. granulomatis DNA exist, molecular assays might be useful
Newborn infants exposed to HSV during birth, as for identifying the causative agent.
documented by virologic testing of maternal lesions at delivery Treatment
or presumed by observation of maternal lesions, should be
Multiple antimicrobial regimens have been effective;
followed clinically in consultation with a pediatric infectious
however, only a limited number of controlled trials have
disease specialist. Detailed guidance is available regarding
been published (538). Treatment has been reported to halt
management of neonates who are delivered vaginally in the
progression of lesions, and healing typically proceeds inward
presence of maternal genital herpes lesions and is beyond the
from the ulcer margins. Prolonged therapy is usually required to
scope of these guidelines; more information is available from
permit granulation and reepithelialization of the ulcers. Relapse
the AAP (https://redbook.solutions.aap.org). Surveillance
can occur 6–18 months after apparently effective therapy.
cultures or PCR of mucosal surfaces of the neonate to detect
HSV infection might be considered before the development of

36 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Recommended Regimen for Granuloma Inguinale (Donovanosis) Lymphogranuloma Venereum

Azithromycin 1 g orally once weekly or 500 mg daily for >3 weeks and LGV is caused by C. trachomatis serovars L1, L2, or L3
until all lesions have completely healed
(539,540). LGV can cause severe inflammation and invasive
infection, in contrast with C. trachomatis serovars A–K that
Alternative Regimens
cause mild or asymptomatic infection. Clinical manifestations
Doxycycline 100 mg orally 2 times/day for at least 3 weeks and until all
lesions have completely healed of LGV can include GUD, lymphadenopathy, or proctocolitis.
or Rectal exposure among MSM or women can result in
Erythromycin base 500 mg orally 4 times/day for >3 weeks and until all
lesions have completely healed
proctocolitis, which is the most common presentation of
or LGV infection (541), and can mimic inflammatory bowel
Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 disease with clinical findings of mucoid or hemorrhagic
mg) tablet orally 2 times/day for >3 weeks and until all lesions have
completely healed rectal discharge, anal pain, constipation, fever, or tenesmus
(542,543). Outbreaks of LGV proctocolitis have been
The addition of another antibiotic to these regimens can be reported among MSM with high rates of HIV infection
considered if improvement is not evident within the first few (544–547). LGV proctocolitis can be an invasive, systemic
days of therapy. infection and, if it is not treated early, can lead to chronic
colorectal fistulas and strictures; reactive arthropathy has also
Other Management Considerations been reported. However, reports indicate that rectal LGV can
Patients should be followed clinically until signs and also be asymptomatic (548). A common clinical manifestation
symptoms have resolved. All persons who receive a diagnosis of LGV among heterosexuals is tender inguinal or femoral
of granuloma inguinale should be tested for HIV. lymphadenopathy that is typically unilateral. A self-limited
genital ulcer or papule sometimes occurs at the site of inoculation.
Follow-Up However, by the time persons seek care, the lesions have often
Patients should be followed clinically until signs and disappeared. LGV-associated lymphadenopathy can be severe,
symptoms resolve. with bubo formation from fluctuant or suppurative inguinal or
femoral lymphadenopathy. Oral ulceration can occur and might
Management of Sex Partners be associated with cervical adenopathy (549–551). Persons with
Persons who have had sexual contact with a patient who has genital or colorectal LGV lesions can also experience secondary
granuloma inguinale within the 60 days before onset of the bacterial infection or can be infected with other sexually and
patient’s symptoms should be examined and offered therapy. nonsexually transmitted pathogens.
However, the value of empiric therapy in the absence of clinical
signs and symptoms has not been established. Diagnostic Considerations
A definitive LGV diagnosis can be made only with LGV-
Special Considerations specific molecular testing (e.g., PCR-based genotyping). These
Pregnancy tests can differentiate LGV from non–LGV C. trachomatis in
rectal specimens. However, these tests are not widely available,
Use of doxycycline in pregnancy might be associated
and results are not typically available in a time frame that
with discoloration of teeth; however, the risk is not well
would influence clinical management. Therefore, diagnosis is
defined. Doxycycline is compatible with breastfeeding (431).
based on clinical suspicion, epidemiologic information, and a
Sulfonamides can be associated with neonatal kernicterus
C. trachomatis NAAT at the symptomatic anatomic site, along
among those with glucose-6-phospate dehydrogenase
with exclusion of other etiologies for proctocolitis, inguinal
deficiency and should be avoided during the third trimester
lymphadenopathy, or genital, oral, or rectal ulcers (551,552).
and while breastfeeding (431). For these reasons, pregnant and
Genital or oral lesions, rectal specimens, and lymph node
lactating women with granuloma inguinale should be treated
specimens (i.e., lesion swab or bubo aspirate) can be tested
with a macrolide regimen (erythromycin or azithromycin).
for C. trachomatis by NAAT or culture. NAAT is the preferred
HIV Infection approach for testing because it can detect both LGV strains and
Persons with granuloma inguinale and HIV infection should non–LGV C. trachomatis strains (553). Therefore, all persons
receive the same regimens as those who do not have HIV. presenting with proctocolitis should be tested for chlamydia
with a NAAT performed on rectal specimens. Severe symptoms
of proctocolitis (e.g., bloody discharge, tenesmus, and rectal

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 37
 Recommendations and Reports

ulcers) indicate LGV. A rectal Gram stain with >10 white A small nonrandomized study from Spain involving patients
blood cells (WBCs) has also been associated with rectal LGV with rectal LGV demonstrated cure rates of 97% with a
(545,554,555). regimen of azithromycin 1 g once weekly for 3 weeks (560).
Chlamydia serology (complement fixation or Pharmacokinetic data support this dosing strategy (561);
microimmunofluorescence) should not be used routinely as a however, this regimen has not been validated. Fluoroquinolone-
diagnostic tool for LGV because the utility of these serologic based treatments also might be effective; however, the optimal
methods has not been established, interpretation has not been duration of treatment has not been evaluated. The clinical
standardized, and validation for clinical proctitis presentation significance of asymptomatic LGV is unknown, and it is
has not been done. It might support an LGV diagnosis in effectively treated with a 7-day course of doxycycline (562).
cases of isolated inguinal or femoral lymphadenopathy for
which diagnostic material for C. trachomatis NAAT cannot Other Management Considerations
be obtained. Patients should be followed clinically until signs and
symptoms have resolved. Persons who receive an LGV diagnosis
Treatment should be tested for other STIs, especially HIV, gonorrhea, and
At the time of the initial visit (before diagnostic NAATs syphilis. Those whose HIV test results are negative should be
for chlamydia are available), persons with a clinical syndrome offered HIV PrEP.
consistent with LGV should be presumptively treated.
Presumptive treatment for LGV is indicated among patients Follow-Up
with symptoms or signs of proctocolitis (e.g., bloody All persons who have been treated for LGV should be retested
discharge, tenesmus, or ulceration); in cases of severe inguinal for chlamydia approximately 3 months after treatment. If
lymphadenopathy with bubo formation, particularly if the retesting at 3 months is not possible, providers should retest
patient has a recent history of a genital ulcer; or in the presence at the patient’s next visit for medical care within the 12-month
of a genital ulcer if other etiologies have been ruled out. The period after initial treatment.
goal of treatment is to cure infection and prevent ongoing tissue
Management of Sex Partners
damage, although tissue reaction to the infection can result in
scarring. Buboes might require aspiration through intact skin Persons who have had sexual contact with a patient who
or incision and drainage to prevent formation of inguinal or has LGV within the 60 days before onset of the patient’s
femoral ulcerations. symptoms should be evaluated, examined, and tested for
chlamydial infection, depending on anatomic site of exposure.
Recommended Regimen for Lymphogranuloma Venereum Asymptomatic partners should be presumptively treated with
Doxycycline 100 mg orally 2 times/day for 21 days a chlamydia regimen (doxycycline 100 mg orally 2 times/day
for 7 days).
Alternative Regimens
Azithromycin 1 g orally once weekly for 3 weeks*
Special Considerations
or
Erythromycin base 500 mg orally 4 times/day for 21 days Pregnancy
* Because this regimen has not been validated, a test of cure with C. trachomatis Use of doxycycline in pregnancy might be associated with
NAAT 4 weeks after completion of treatment can be considered. discoloration of teeth; however, the risk is not well defined
(563). Doxycycline is compatible with breastfeeding (431).
The optimal treatment duration for symptomatic LGV has Azithromycin might prove useful for LGV treatment during
not been studied in clinical trials. The recommended 21-day pregnancy, at a presumptive dose of 1 g weekly for 3 weeks;
course of doxycycline is based on long-standing clinical practice no published data are available regarding an effective dose and
and is highly effective, with an estimated cure rate of >98.5% duration of treatment. Pregnant and lactating women with
(555,556). Shorter courses of doxycycline might be effective LGV can be treated with erythromycin, although this regimen
on the basis of a small retrospective study of MSM with rectal is associated with frequent gastrointestinal side effects. Pregnant
LGV, 50% of whom were symptomatic, who received a 7- to women treated for LGV should have a test of cure performed
14-day course of doxycycline and had a 97% cure rate (558). 4 weeks after the initial C. trachomatis NAAT-positive test.
Randomized prospective studies of shorter-course doxycycline
for treating LGV are needed. Longer courses of therapy might
be required in the setting of fistulas, buboes, and other forms
of severe disease (559).

38 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

HIV Infection Diagnostic Considerations

Persons with LGV and HIV infection should receive the Darkfield examinations and molecular tests for detecting
same regimens as those who do not have HIV. Prolonged T. pallidum directly from lesion exudate or tissue are
therapy might be required because a delay in resolution of the definitive methods for diagnosing early syphilis and
symptoms might occur. congenital syphilis (565). Although no T. pallidum direct-
detection molecular NAATs are commercially available,
certain laboratories provide locally developed and validated
Syphilis PCR tests for detecting T. pallidum DNA. A presumptive
Syphilis is a systemic disease caused by T. pallidum. The diagnosis of syphilis requires use of two laboratory serologic
disease has been divided into stages on the basis of clinical tests: a nontreponemal test (i.e., Venereal Disease Research
findings, which guide treatment and follow-up. Persons who Laboratory [VDRL] or rapid plasma reagin [RPR] test)
have syphilis might seek treatment for signs or symptoms. and a treponemal test (i.e., the T. pallidum passive particle
Primary syphilis classically presents as a single painless ulcer agglutination [TP-PA] assay, various EIAs, chemiluminescence
or chancre at the site of infection but can also present with immunoassays [CIAs] and immunoblots, or rapid treponemal
multiple, atypical, or painful lesions (564). Secondary syphilis assays) (566–568). At least 18 treponemal-specific tests are
manifestations can include skin rash, mucocutaneous lesions, cleared for use in the United States. Use of only one type of
and lymphadenopathy. Tertiary syphilis can present with serologic test (nontreponemal or treponemal) is insufficient
cardiac involvement, gummatous lesions, tabes dorsalis, and for diagnosis and can result in false-negative results among
general paresis. persons tested during primary syphilis and false-positive results
Latent infections (i.e., those lacking clinical manifestations) among persons without syphilis or previously treated syphilis.
are detected by serologic testing. Latent syphilis acquired
Nontreponemal Tests and Traditional Algorithm
within the preceding year is referred to as early latent syphilis;
all other cases of latent syphilis are classified as late latent False-positive nontreponemal test results can be associated
syphilis or latent syphilis of unknown duration. with multiple medical conditions and factors unrelated to
T. pallidum can infect the CNS, which can occur at any stage syphilis, including other infections (e.g., HIV), autoimmune
of syphilis and result in neurosyphilis. Early neurologic clinical conditions, vaccinations, injecting drug use, pregnancy,
manifestations or syphilitic meningitis (e.g., cranial nerve and older age (566,569). Therefore, persons with a reactive
dysfunction, meningitis, meningovascular syphilis, stroke, nontreponemal test should always receive a treponemal test
and acute altered mental status) are usually present within to confirm the syphilis diagnosis (i.e., traditional algorithm).
the first few months or years of infection. Late neurologic Nontreponemal test antibody titers might correlate with disease
manifestations (e.g., tabes dorsalis and general paresis) occur activity and are used for monitoring treatment response. Serum
10 to >30 years after infection. should be diluted to identify the highest titer, and results should
Infection of the visual system (ocular syphilis) or auditory be reported quantitatively. A fourfold change in titer, equivalent
system (otosyphilis) can occur at any stage of syphilis but is to a change of two dilutions (e.g., from 1:16 to 1:4 or from 1:8
commonly identified during the early stages and can present to 1:32), is considered necessary for demonstrating a clinically
with or without additional CNS involvement. Ocular syphilis significant difference between two nontreponemal test results
often presents as panuveitis but can involve structures in obtained by using the same serologic test, preferably from the
both the anterior and posterior segment of the eye, including same manufacturer to avoid variation in results. Sequential
conjunctivitis, anterior uveitis, posterior interstitial keratitis, serologic tests for a patient should be performed using the
optic neuropathy, and retinal vasculitis. Ocular syphilis can same testing method (VDRL or RPR), preferably by the same
result in permanent vision loss. Otosyphilis typically presents laboratory. VDRL and RPR are equally valid assays; however,
with cochleo-vestibular symptoms, including tinnitus, vertigo, quantitative results from the two tests cannot be compared
and sensorineural hearing loss. Hearing loss can be unilateral or directly with each other because the methods are different,
bilateral, have a sudden onset, and progress rapidly. Otosyphilis and RPR titers frequently are slightly higher than VDRL titers.
can result in permanent hearing loss. Nontreponemal test titers usually decrease after treatment
and might become nonreactive with time. However, for certain
persons, nontreponemal antibodies might decrease less than
fourfold after treatment (i.e., inadequate serologic response)
or might decline appropriately but fail to serorevert and

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 39
 Recommendations and Reports

persist for a long period. Atypical nontreponemal serologic risk and clinical probability for syphilis are low, further
test results (e.g., unusually high, unusually low, or fluctuating evaluation or treatment is not indicated.
titers) might occur regardless of HIV status. When serologic Multiple studies demonstrate that high quantitative index
tests do not correspond with clinical findings indicative of values or high signal-to-cutoff ratio from treponemal EIA
primary, secondary, or latent syphilis, presumptive treatment is or CIA tests correlate with TP-PA positivity, which might
recommended for persons with risk factors for syphilis, and use eliminate the need for additional confirmatory testing;
of other tests (e.g., biopsy for histology and immunostaining however, the range of index values varies among different
and PCR of lesion) should be considered. For the majority treponemal immunoassays, and the values that correspond to
of persons with HIV infection, serologic tests are accurate high levels of reactivity with confirmatory testing might differ
and reliable for diagnosing syphilis and evaluating response by immunoassay (567,575–582).
to treatment.
Cerebrospinal Fluid Evaluation
Treponemal Tests and Reverse Further testing with CSF evaluation is warranted for
Sequence Algorithm persons with clinical signs of neurosyphilis (e.g., cranial nerve
The majority of patients who have reactive treponemal tests dysfunction, meningitis, stroke, acute or chronic altered mental
will have reactive tests for the remainder of their lives, regardless status, or loss of vibration sense). All patients with ocular
of adequate treatment or disease activity. However, 15%–25% symptoms and reactive syphilis serology need a full ocular
of patients treated during the primary stage revert to being examination, including cranial nerve evaluation. If cranial nerve
serologically nonreactive after 2–3 years (570). Treponemal dysfunction is present, a CSF evaluation is needed. Among
antibody titers do not predict treatment response and therefore persons with isolated ocular symptoms (i.e., no cranial nerve
should not be used for this purpose. dysfunction or other neurologic abnormalities), confirmed
Clinical laboratories sometimes screen syphilis serologic ocular abnormalities on examination, and reactive syphilis
samples by using automated treponemal immunoassays, serology, a CSF examination is unnecessary before treatment.
typically by EIA or CIA (571–573). This reverse sequence CSF analysis can be helpful in evaluating persons with ocular
algorithm for syphilis testing can identify persons previously symptoms and reactive syphilis serology who do not have ocular
treated for syphilis, those with untreated or incompletely findings or cranial nerve dysfunction on examination. Among
treated syphilis, and those with false-positive results that can patients with isolated auditory abnormalities and reactive
occur with a low likelihood of infection (574). Persons with syphilis serology, CSF evaluation is likely to be normal and is
a positive treponemal screening test should have a standard unnecessary before treatment (583,584).
quantitative nontreponemal test with titer performed Laboratory testing is helpful in supporting the diagnosis of
reflexively by the laboratory to guide patient management neurosyphilis; however, no single test can be used to diagnose
decisions. If the nontreponemal test is negative, the laboratory neurosyphilis in all instances. Diagnosis of neurosyphilis
should perform a treponemal test different from the one used depends on a combination of CSF tests (e.g., CSF cell count,
for initial testing, preferably TP-PA or treponemal assay based protein, or reactive CSF-VDRL) in the presence of reactive
on different antigens than the original test, to adjudicate the serologic test (nontreponemal and treponemal) results and
results of the initial test. neurologic signs and symptoms. CSF laboratory abnormalities
If a second treponemal test is positive (e.g., EIA reactive, are common for persons with early syphilis and are of
RPR nonreactive, or TP-PA reactive), persons with a history unknown medical significance in the absence of neurologic
of previous treatment will require no further management signs or symptoms (585). CSF-VDRL is highly specific but
unless sexual history indicates a reexposure. In this instance, a insensitive. For a person with neurologic signs or symptoms, a
repeat nontreponemal test 2–4 weeks after a confirmed medical reactive CSF-VDRL (in the absence of blood contamination)
history and physical examination is recommended to evaluate is considered diagnostic of neurosyphilis.
for early infection. Those without a history of treatment for When CSF-VDRL is negative despite clinical signs of
syphilis should be offered treatment. Unless a medical history neurosyphilis, reactive serologic tests results, lymphocytic
or results of a physical examination indicate a recent infection, pleocytosis, or protein, neurosyphilis should be considered.
previously untreated persons should be treated for syphilis of In that instance, additional evaluation by using fluorescent
unknown duration or late latent syphilis. treponemal-antibody absorption (FTA-ABS) or TP-PA testing
If the second treponemal test is negative (e.g., EIA reactive, on CSF might be warranted. The CSF FTA-ABS test is less
RPR nonreactive, TP-PA nonreactive) and the epidemiologic specific for neurosyphilis than the CSF-VDRL but is highly
sensitive. Fewer data are available regarding CSF TP-PA;

40 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

however, the sensitivity and specificity appear similar to the Special Considerations
CSF FTA-ABS (586). Neurosyphilis is highly unlikely with
a negative CSF FTA-ABS or TP-PA test, especially among Pregnancy
persons with nonspecific neurologic signs and symptoms (587). Parenteral penicillin G is the only therapy with documented
Among persons with HIV infection, CSF leukocyte count efficacy for syphilis during pregnancy. Pregnant women with
can be elevated (>5 WBCs/mm3); the association with CSF syphilis at any stage who report penicillin allergy should be
leukocyte count and plasma HIV viral suppression has not been desensitized and treated with penicillin (see Management of
well characterized. Using a higher cutoff (>20 WBCs/mm3) Persons Who Have a History of Penicillin Allergy).
might improve the specificity of neurosyphilis diagnosis among
Jarisch-Herxheimer Reaction
this population (588).
The Jarisch-Herxheimer reaction is an acute febrile reaction
frequently accompanied by headache, myalgia, and fever that
Treatment can occur within the first 24 hours after the initiation of any
Penicillin G, administered parenterally, is the preferred drug syphilis therapy; it is a reaction to treatment and not an allergic
for treating patients in all stages of syphilis. The preparation reaction to penicillin. Patients should be informed about this
used (i.e., benzathine, aqueous procaine, or aqueous possible adverse reaction and how to manage it if it occurs. The
crystalline), dosage, and length of treatment depend on the Jarisch-Herxheimer reaction occurs most frequently among
stage and clinical manifestations of the disease. Treatment for persons who have early syphilis, presumably because bacterial
late latent syphilis (>1 years’ duration) and tertiary syphilis loads are higher during these stages. Antipyretics can be used
requires a longer duration of therapy because organisms to manage symptoms; however, they have not been proven to
theoretically might be dividing more slowly (the validity of this prevent this reaction. The Jarisch-Herxheimer reaction might
rationale has not been assessed). Longer treatment duration is induce early labor or cause fetal distress in pregnant women;
required for persons with latent syphilis of unknown duration however, this should not prevent or delay therapy (590) (see
to ensure that those who did not acquire syphilis within the Syphilis During Pregnancy).
preceding year are adequately treated.
Selection of the appropriate penicillin preparation is Management of Sex Partners
important because T. pallidum can reside in sequestered sites Sexual transmission of T. pallidum is thought to occur only
(e.g., the CNS and aqueous humor) that are poorly accessed when mucocutaneous syphilitic lesions are present. Such
by certain forms of penicillin. Combinations of benzathine manifestations are uncommon after the first year of infection.
penicillin, procaine penicillin, and oral penicillin preparations Persons exposed through sexual contact with a person who
are not considered appropriate for syphilis treatment. Reports has primary, secondary, or early latent syphilis should be
have indicated that practitioners have inadvertently prescribed evaluated clinically and serologically and treated according to
combination long- and short-acting benzathine-procaine the following recommendations:
penicillin (Bicillin C-R) instead of the standard benzathine • Persons who have had sexual contact with a person who
penicillin product (Bicillin L-A) recommended in the United receives a diagnosis of primary, secondary, or early latent
States for treating primary, secondary, and latent syphilis. syphilis <90 days before the diagnosis should be treated
Practitioners, pharmacists, and purchasing agents should be presumptively for early syphilis, even if serologic test results
aware of the similar names of these two products to avoid are negative.
using the incorrect combination therapy agent for treating • Persons who have had sexual contact with a person who
syphilis (589). receives a diagnosis of primary, secondary, or early latent
Penicillin’s effectiveness for treating syphilis was well syphilis >90 days before the diagnosis should be treated
established through clinical experience even before the value of presumptively for early syphilis if serologic test results are
randomized controlled clinical trials was recognized. Therefore, not immediately available and the opportunity for
approximately all recommendations for treating syphilis are follow-up is uncertain. If serologic tests are negative, no
based not only on clinical trials and observational studies, but treatment is needed. If serologic tests are positive,
on many decades of clinical experience. treatment should be based on clinical and serologic
evaluation and syphilis stage.
• In certain areas or among populations with high syphilis
infection rates, health departments recommend notification
and presumptive treatment of sex partners of persons with

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 41
 Recommendations and Reports

syphilis of unknown duration who have high nontreponemal Other Management Considerations
serologic test titers (i.e., >1:32) because high titers might All persons who have primary and secondary syphilis should
be indicative of early syphilis. These partners should be be tested for HIV at the time of diagnosis and treatment. Those
managed as if the index patient had early syphilis. persons whose HIV test results are negative should be offered
• Long-term sex partners of persons who have late latent HIV PrEP. In geographic areas in which HIV prevalence is
syphilis should be evaluated clinically and serologically for high, persons who have primary or secondary syphilis should
syphilis and treated on the basis of the evaluation’s findings. be offered PrEP and retested for HIV in 3 months if the initial
• The following sex partners of persons with syphilis are HIV test result was negative.
considered at risk for infection and should be confidentially Persons who have syphilis and symptoms or signs indicating
notified of the exposure and need for evaluation: partners neurologic disease (e.g., cranial nerve dysfunction, meningitis,
who have had sexual contact within 3 months plus the stroke, or altered mental state) should have an evaluation
duration of symptoms for persons who receive a diagnosis that includes CSF analysis. Persons with syphilis who have
of primary syphilis, within 6 months plus duration of symptoms or signs of ocular syphilis (e.g., uveitis, iritis,
symptoms for those with secondary syphilis, and within neuroretinitis, or optic neuritis) should have a thorough cranial
1 year for persons with early latent syphilis. nerve examination and ocular slit-lamp and ophthalmologic
examinations. CSF evaluation is not always needed for persons
Primary and Secondary Syphilis with ocular syphilis if no evidence of cranial nerves 2, 3, 4,
5, and 6 dysfunction or other evidence of neurologic disease
Treatment exists. If symptoms and signs of otic syphilis are present then
Parenteral penicillin G has been used effectively for achieving an otologic examination is needed; CSF evaluation in persons
clinical resolution (i.e., the healing of lesions and prevention of with otic syphilis does not aid in the clinical management
sexual transmission) and for preventing late sequelae. However, and therefore is not recommended (see Cerebrospinal Fluid
no comparative trials have been conducted to guide selection Evaluation). Treatment should be guided by the results of these
of an optimal penicillin regimen. Substantially fewer data are evaluations. Invasion of CSF by T. pallidum accompanied
available for nonpenicillin regimens. by CSF laboratory abnormalities is common among adults
who have primary or secondary syphilis but has unknown
Recommended Regimen for Primary and Secondary Syphilis*
Among Adults medical significance (585). In the absence of clinical
Benzathine penicillin G 2.4 million units IM in a single dose neurologic findings, no evidence supports variation from the
recommended treatment regimen for primary or secondary
* Recommendations for treating syphilis among persons with HIV infection
and pregnant women are discussed elsewhere in this report (see Syphilis syphilis. Symptomatic neurosyphilis after treatment with the
Among Persons with HIV Infection; Syphilis During Pregnancy). penicillin regimens recommended for primary and secondary
syphilis is rare. Therefore, unless clinical signs or symptoms of
Available data demonstrate that use of additional doses of neurologic or ophthalmic involvement are present, routine CSF
benzathine penicillin G, amoxicillin, or other antibiotics do analysis is not recommended for persons who have primary or
not enhance efficacy of this recommended regimen when used secondary syphilis.
to treat primary and secondary syphilis, regardless of HIV
status (591–593). Follow-Up
Clinical and serologic evaluation should be performed at
Recommended Regimen for Syphilis Among Infants and
Children 6 and 12 months after treatment; more frequent evaluation
Benzathine penicillin G 50,000 units/kg body weight IM, up to the adult
might be prudent if opportunity for follow-up is uncertain
dose of 2.4 million units in a single dose or if repeat infection is a clinical concern. Serologic response
(i.e., titer) should be compared with the titer at the time of
Infants and children aged ≥1 month who receive a syphilis treatment. However, assessing serologic response to treatment
diagnosis should have birth and maternal medical records can be difficult, and definitive criteria for cure or failure by
reviewed to assess whether they have congenital or acquired serologic criteria have not been well established. In addition,
syphilis (see Congenital Syphilis). Infants and children aged nontreponemal test titers might decrease more slowly for
≥1 month with primary and secondary syphilis should be persons previously treated for syphilis (594,595).
managed by a pediatric infectious disease specialist and Persons who have signs or symptoms that persist or recur
evaluated for sexual abuse (e.g., through consultation with child and those with at least a fourfold increase in nontreponemal
protective services) (see Sexual Assault or Abuse of Children).

42 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

test titer persisting for >2 weeks likely were reinfected or Management of Sex Partners
experienced treatment failure. Among persons who have See Syphilis, Management of Sex Partners.
neurologic findings or persons with no neurologic findings
without any reported sexual exposure during the previous Special Considerations
3–6 months indicating that treatment failure might be possible,
Penicillin Allergy
a CSF examination is recommended with treatment guided
by CSF findings. These persons should also be reevaluated for Data to support use of alternatives to penicillin in treating
HIV infection. primary and secondary syphilis are limited. However, multiple
Among persons with no neurologic findings after a thorough therapies might be effective for nonpregnant persons with
neurologic examination and who are sexually active, reinfection penicillin allergy who have primary or secondary syphilis.
is likely and repeat treatment for early syphilis is recommended. Doxycycline (100 mg orally 2 times/day for 14 days) (600,601)
These persons should also be reevaluated for HIV infection. and tetracycline (500 mg orally 4 times/day for 14 days) have
Failure of nontreponemal test titers to decrease fourfold been used for years and can be effective. Compliance is likely to
within 12 months after therapy for primary or secondary be better with doxycycline than tetracycline because tetracycline
syphilis (inadequate serologic response) might be indicative can cause more gastrointestinal side effects and requires more
of treatment failure. However, clinical trial data have frequent dosing. Limited clinical studies, along with biologic
demonstrated that 10%–20% of persons with primary and and pharmacologic evidence, indicate that ceftriaxone (1 g daily
secondary syphilis treated with the recommended therapy either IM or IV for 10 days) is effective for treating primary
will not achieve the fourfold decrease in nontreponemal titer and secondary syphilis; however, the optimal dose and duration
within 12 months after treatment (591,596,597). Serologic of ceftriaxone therapy have not been defined (602,603).
response to treatment appears to be associated with multiple Azithromycin as a single 2-g oral dose has been effective
factors, including the person’s syphilis stage (earlier stages are for treating primary and secondary syphilis among certain
more likely to decrease fourfold and become nonreactive), populations (602,604,605). However, because of T. pallidum
initial nontreponemal antibody titers (titers <1:8 are less likely chromosomal mutations associated with azithromycin and
to decline fourfold than higher titers), and age (titers among other macrolide resistance and documented treatment failures
older patients might be less likely to decrease fourfold than in multiple U.S. geographic areas, azithromycin should not be
those of younger patients) (596–598). Optimal management used as treatment for syphilis (606–608). Thorough clinical
of persons who have an inadequate serologic response after and serologic follow-up of persons receiving any alternative
syphilis treatment is unclear. At a minimum, these persons therapy is essential.
should receive additional neurologic examinations, clinical Persons with a penicillin allergy whose compliance with
and serologic follow-up annually, and reevaluation for HIV therapy or follow-up cannot be ensured should be desensitized
infection. If neurologic symptoms or signs are identified, and treated with benzathine penicillin G. Skin testing for
a CSF evaluation is recommended, with findings guiding penicillin allergy might be useful in circumstances in which
management. If additional follow-up cannot be ensured, the reagents and expertise are available for performing the test
retreatment is recommended. Because treatment failure might adequately (see Management of Persons Who Have a History
be the result of unrecognized CNS infection, CSF examination of Penicillin Allergy).
can be considered in situations in which follow-up is uncertain. Pregnancy
For retreatment, weekly injections of benzathine penicillin G
2.4 million units intramuscularly (IM) for 3 weeks is recommended, Pregnant women with primary or secondary syphilis who
unless CSF examination indicates that neurosyphilis is present are allergic to penicillin should be desensitized and treated
(see Neurosyphilis, Ocular Syphilis, and Otosyphilis). with penicillin G. Skin testing or oral graded penicillin dose
Serologic titers might not decrease, despite a negative CSF challenge might be helpful in identifying women at risk for
examination and a repeated 3-week therapy course (599). acute allergic reactions (see Management of Persons Who Have
In these circumstances, the benefit of additional therapy or a History of Penicillin Allergy; Syphilis During Pregnancy).
repeated CSF examinations is unclear, and it is not typically HIV Infection
recommended. Serologic and clinical monitoring at least
Persons with HIV infection who have primary or secondary
annually should continue to monitor for any sustained
syphilis should be treated similarly to those without HIV (see
increases in nontreponemal titer.
Syphilis Among Persons with HIV Infection).

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 43
 Recommendations and Reports

Latent Syphilis Infants and children aged ≥1 month with diagnosed latent
syphilis should be managed by a pediatric infectious disease
Latent syphilis is defined as syphilis characterized by
specialist and receive a CSF examination. In addition, birth
seroreactivity without other evidence of primary, secondary,
and maternal medical records should be reviewed to assess
or tertiary disease. Persons who have latent syphilis and who
whether these infants and children have congenital or acquired
acquired syphilis during the preceding year are classified as
syphilis. For those with congenital syphilis, treatment should
having early latent syphilis (early nonprimary, nonsecondary).
be undertaken as described (see Congenital Syphilis). Those
Persons can receive a diagnosis of early latent syphilis if, during
with acquired syphilis should be evaluated for sexual abuse
the year preceding the diagnosis, they had a documented
(e.g., through consultation with child protection services) (see
seroconversion or a sustained (>2 weeks) fourfold or greater
Sexual Assault or Abuse of Children). These regimens are for
increase in nontreponemal test titers in a previously treated
children who are not allergic to penicillin who have acquired
person; unequivocal symptoms of primary or secondary
syphilis and who have normal CSF examinations.
syphilis; or a sex partner documented to have primary,
secondary, or early latent syphilis. In addition, for persons Other Management Considerations
with reactive nontreponemal and treponemal tests whose only
All persons who have latent syphilis should be tested for HIV
possible exposure occurred during the previous 12 months,
at the time of diagnosis or treatment. Those persons whose
early latent syphilis can be assumed.
HIV test results are negative should be offered HIV PrEP. In
In the absence of these conditions associated with latent
geographic areas in which the prevalence of HIV infection is
syphilis, an asymptomatic person should be considered to
high or among populations vulnerable to HIV acquisition,
have latent syphilis of unknown duration or late latent syphilis
persons who have early latent or late latent syphilis should be
(>1 year’s duration). Nontreponemal serologic titers usually are
offered PrEP and retested for HIV in 3 months if the first HIV
higher early in the course of syphilis infection. However, early
test result was negative.
latent syphilis cannot be reliably diagnosed solely on the basis
Persons who receive a diagnosis of latent syphilis and have
of nontreponemal titers. All persons with latent syphilis should
neurologic or ocular signs and symptoms (e.g., cognitive
have careful examination of all accessible mucosal surfaces to
dysfunction, motor or sensory deficits, ophthalmic or auditory
evaluate for mucosal lesions (primary or secondary syphilis)
symptoms, cranial nerve palsies, or symptoms or signs of
before making a latent syphilis diagnosis. Physical examination
meningitis or stroke) should be evaluated for neurosyphilis, ocular
should include the oral cavity, perianal area, perineum, rectum,
syphilis, or otosyphilis according to their clinical presentation
and genitals (vagina and cervix for women; scrotum, penis, and
(see Neurosyphilis, Ocular Syphilis, and Otosyphilis).
underneath the foreskin for uncircumcised men).
If a person receives a delayed dose of penicillin in a course of
Treatment weekly therapy for late latent syphilis or syphilis of unknown
duration, the course of action that should be recommended
Because latent syphilis is not transmitted sexually, the
is unclear. Clinical experience indicates that an interval of
objective of treating persons in this disease stage is to prevent
10–14 days between doses of benzathine penicillin for latent
medical complications of syphilis. Latent syphilis can also be
syphilis might be acceptable before restarting the sequence of
vertically transmitted to a fetus; therefore, the goal of treating
injections (i.e., if dose 1 is administered on day 0, dose 2 is
a pregnant woman is to prevent congenital syphilis. Although
administered on days 10–14). Pharmacologic considerations
clinical experience supports the effectiveness of penicillin in
indicate that an interval of 7–9 days between doses, if feasible,
achieving this goal, limited evidence is available for guiding
might be preferred (610–612). Delayed doses are not optimal
choice of specific regimens or duration. Available data
for pregnant women receiving therapy for latent syphilis (613).
demonstrate that additional doses of benzathine penicillin G,
Pregnant women who have delays in any therapy dose >9 days
amoxicillin, or other antibiotics in early latent syphilis do not
between doses should repeat the full course of therapy.
enhance efficacy, regardless of HIV status (592,593,609).
Recommended Regimens for Latent Syphilis* Among Adults
Follow-Up
Early latent syphilis: Benzathine penicillin G 2.4 million units IM in a Quantitative nontreponemal serologic tests should be
single dose repeated at 6, 12, and 24 months. These serologic titers should
Late latent syphilis: Benzathine penicillin G 7.2 million units total, be compared with the titer at the time of treatment. Persons
administered as 3 doses of 2.4 million units IM each at 1-week intervals
with at least a fourfold sustained increase in nontreponemal
* Recommendations for treating syphilis in persons with HIV and pregnant test titer persisting for >2 weeks or who experienced signs
women are discussed elsewhere in this report (see Syphilis Among
Persons with HIV Infection; Syphilis During Pregnancy). or symptoms attributable to primary or secondary syphilis

44 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

were likely reinfected or experienced treatment failure. These each for 28 days. The efficacy of these alternative regimens
persons should be retreated and reevaluated for HIV infection. among persons with HIV infection has not been well studied.
Among persons who have neurologic findings after a thorough These therapies should be used only in conjunction with close
neurologic examination or among persons with no neurologic serologic and clinical follow-up, especially among persons
findings and no sexual exposure during the previous year, a CSF with HIV infection. On the basis of biologic plausibility and
examination is recommended. Treatment should be guided by pharmacologic properties, ceftriaxone might be effective for
CSF findings. Among persons with no neurologic findings after treating latent syphilis. However, the optimal dose and duration
neurologic examination and who are sexually active, treatment of ceftriaxone therapy have not been defined; treatment
with weekly injections of benzathine penicillin G 2.4 million decisions should be discussed in consultation with a specialist.
units IM for 3 weeks is recommended. Persons with a penicillin allergy whose compliance with
Optimal management of persons who have less than a therapy or follow-up cannot be ensured should be desensitized
fourfold decrease in titers 24 months after treatment (i.e., an and treated with benzathine penicillin G. Skin testing for
inadequate serologic response) is unclear, especially if the initial penicillin allergy might be useful in circumstances in which
titer was <1:8. At a minimum, these persons should receive the reagents and expertise are available for performing the test
additional clinical and serologic follow-up and be evaluated for adequately (see Management of Persons Who Have a History
HIV infection. If neurologic symptoms or signs are identified, of Penicillin Allergy).
a CSF evaluation is recommended, with the findings guiding
Pregnancy
management. If additional follow-up cannot be ensured or if
an initially high titer (>1:32) does not decrease at least fourfold Pregnant women who are allergic to penicillin should be
24 months after treatment, retreatment with weekly injections desensitized and treated with penicillin G. Skin testing for
of benzathine penicillin G 2.4 million units IM for 3 weeks is penicillin allergy might be useful in circumstances in which
recommended. Because treatment failure might be the result the reagents and expertise are available for performing the test
of unrecognized CNS infection, CSF examination can be adequately (see Management of Persons Who Have a History
considered in such situations where follow-up is uncertain or of Penicillin Allergy; Syphilis During Pregnancy).
initial high titers do not decrease after 24 months. HIV Infection
If the CSF examination is negative, repeat treatment for
latent syphilis is recommended. Serologic titers might not Persons with HIV infection who have latent syphilis should
decrease despite a negative CSF examination and a repeated be treated similarly to persons who do not have HIV (see
course of therapy, especially if the initial nontreponemal titer Syphilis Among Persons with HIV Infection).
is low (<1:8); in these circumstances, the need for additional
therapy or repeated CSF examinations is unclear but is usually Tertiary Syphilis
not recommended. Serologic and clinical monitoring at Tertiary syphilis refers to gummas, cardiovascular syphilis,
least annually should continue to monitor for any sustained psychiatric manifestations (e.g., memory loss or personality
increases in nontreponemal titer. changes), or late neurosyphilis. Guidelines for all forms of
Management of Sex Partners neurosyphilis (e.g., early or late neurosyphilis) are discussed
elsewhere in these recommendations (see Neurosyphilis,
See Syphilis, Management of Sex Partners. Ocular Syphilis, and Otosyphilis). Persons with gummas
Special Considerations and cardiovascular syphilis who are not allergic to penicillin
and have no evidence of neurosyphilis by clinical and CSF
Penicillin Allergy examination should be treated with the following regimen.
The effectiveness of alternatives to penicillin in treating
Recommended Regimen for Tertiary Syphilis Among Adults
latent syphilis has not been well documented. Nonpregnant
Tertiary syphilis with normal CSF examination: Benzathine
patients allergic to penicillin who have clearly defined early penicillin G 7.2 million units total, administered as 3 doses of 2.4 million
latent syphilis should respond to antibiotics recommended as units IM each at 1-week intervals
alternatives to penicillin for treating primary and secondary
syphilis (see Primary and Secondary Syphilis). The only
acceptable alternatives for treating late latent syphilis or Other Management Considerations
syphilis of unknown duration are doxycycline (100 mg orally All persons who have tertiary syphilis should receive a CSF
2 times/day) or tetracycline (500 mg orally 4 times/day), examination before therapy is initiated and have an HIV test.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 45
 Recommendations and Reports

Those persons whose HIV test results are negative should be syphilis serology need a full ocular examination, including
offered HIV PrEP. Persons with CSF abnormalities should be cranial nerve evaluation. If cranial nerve dysfunction is present,
treated with a neurosyphilis regimen. Certain providers treat all a CSF evaluation is needed. Among persons with isolated ocular
persons who have cardiovascular syphilis with a neurosyphilis symptoms (no cranial nerve dysfunction or other neurologic
regimen. These persons should be managed in consultation abnormalities), reactive syphilis serology, and confirmed ocular
with an infectious disease specialist. Limited information is abnormalities on examination, CSF examination is unnecessary
available concerning clinical response and follow-up of persons before treatment. CSF analysis might be helpful in evaluating
who have tertiary syphilis. persons with ocular symptoms and reactive syphilis serology
who do not have ocular findings on examination. If ocular
Management of Sex Partners syphilis is suspected, immediate referral to and management
See Syphilis, Management of Sex Partners. in collaboration with an ophthalmologist is crucial. Ocular
syphilis should be treated similarly to neurosyphilis, even if a
Special Considerations
CSF examination is normal.
Penicillin Allergy Hearing loss and other otologic symptoms can occur at any
Any person allergic to penicillin should be treated in stage of syphilis and can be isolated abnormalities or associated
consultation with an infectious disease specialist. with neurosyphilis, especially of cranial nerve 8. However,
among persons with isolated auditory symptoms, normal
Pregnancy neurologic examination, and reactive syphilis serology, CSF
Pregnant women who are allergic to penicillin should be examination is likely to be normal and is not recommended
desensitized and treated with penicillin G. Skin testing or oral before treatment. Otosyphilis should be managed in
graded penicillin dose challenge might be helpful in identifying collaboration with an otolaryngologist and treated by using
women at risk for acute allergic reactions (see Management the same regimen as for neurosyphilis.
of Persons Who Have a History of Penicillin Allergy; Syphilis Recommended Regimen for Neurosyphilis, Ocular Syphilis, or
During Pregnancy). Otosyphilis Among Adults
Aqueous crystalline penicillin G 18–24 million units per day,
HIV Infection administered as 3–4 million units IV every 4 hours or continuous
Persons with HIV infection who have tertiary syphilis should infusion for 10–14 days

be treated as described for persons without HIV (see Syphilis

Among Persons with HIV Infection). If compliance with therapy can be ensured, the following
alternative regimen might be considered.
Neurosyphilis, Ocular Syphilis, and Alternative Regimen
Otosyphilis Procaine penicillin G 2.4 million units IM once daily
plus
Probenecid 500 mg orally 4 times/day, both for 10–14 days
Treatment
CNS involvement can occur during any stage of syphilis, The durations of the recommended and alternative regimens
and CSF laboratory abnormalities are common among for neurosyphilis are shorter than the duration of the regimen
persons with early syphilis, even in the absence of clinical used for latent syphilis. Therefore, benzathine penicillin,
neurologic findings. No evidence exists to support variation 2.4 million units IM once per week for 1–3 weeks, can be
from recommended diagnosis and treatment for syphilis at considered after completion of these neurosyphilis treatment
any stage for persons without clinical neurologic findings, regimens to provide a comparable total duration of therapy.
except tertiary syphilis. If clinical evidence of neurologic
involvement is observed (e.g., cognitive dysfunction, motor or Other Management Considerations
sensory deficits, cranial nerve palsies, or symptoms or signs of The following are other considerations in the management
meningitis or stroke), a CSF examination should be performed of persons who have neurosyphilis:
before treatment. • All persons who have neurosyphilis, ocular syphilis, or
Syphilitic uveitis or other ocular syphilis manifestations otosyphilis should be tested for HIV at the time of
(e.g., neuroretinitis and optic neuritis) can occur at any stage diagnosis. Those whose HIV test results are negative
of syphilis and can be isolated abnormalities or associated with should be offered HIV PrEP.
neurosyphilis. All persons with ocular symptoms and reactive

46 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

• Although systemic steroids are used frequently as been observed among persons with HIV infection who have
adjunctive therapy for otosyphilis and for ocular syphilis, syphilis. The majority of reports have involved posttreatment
such drugs have not been proven to be beneficial. serologic titers that were higher than expected (i.e., high serofast)
or fluctuated, and false-negative serologic test results and delayed
Follow-Up appearance of seroreactivity have also been reported (622).
Data from two studies indicate that, among immunocompetent When clinical findings are indicative of syphilis, but serologic
persons and persons with HIV infection who are on effective tests are nonreactive or their interpretation is unclear, alternative
ART, normalization of the serum RPR titer predicts tests (e.g., biopsy of a lesion, darkfield examination, or PCR of
normalization of abnormal CSF parameters after neurosyphilis lesion material) might be useful for diagnosis. Neurosyphilis,
treatment (614,615). Therefore, repeated CSF examinations ocular syphilis, and otosyphilis should be considered in the
are unnecessary for persons without HIV infection or persons differential diagnosis of neurologic, ocular, and other signs
with HIV infection who are on ART and who exhibit serologic and symptoms among persons with HIV infection.
and clinical responses after treatment.
Treatment
Management of Sex Partners Persons with HIV infection who have early syphilis might
See Syphilis, Management of Sex Partners. be at increased risk for neurologic complications (623) and
might have higher rates of inadequate serologic response
Special Considerations
with recommended regimens. The magnitude of these risks is
Penicillin Allergy not defined precisely but is likely small. Although long-term
Limited data indicate that ceftriaxone 1–2 g daily either IM (>1 year) comparative data are lacking, no treatment regimens
or IV for 10–14 days can be used as an alternative treatment for syphilis have been demonstrated to be more effective in
for persons with neurosyphilis (603,616,617). Cross-sensitivity preventing neurosyphilis among persons with HIV infection
between ceftriaxone and penicillin can occur; however, the than the syphilis regimens recommended for persons without
risk for penicillin cross-reactivity between third-generation HIV (609). Careful follow-up after therapy is essential. Using
cephalosporins is negligible (618–621) (see Management of ART per current HIV guidelines might improve clinical
Persons Who Have a History of Penicillin Allergy). If concern outcomes among persons coinfected with HIV and syphilis;
exists regarding ceftriaxone safety for a patient with neurosyphilis, concerns regarding adequate treatment of syphilis among
skin testing should be performed to confirm penicillin allergy persons with HIV infection might not apply to those with
and, if necessary, penicillin desensitization in consultation with HIV virologic suppression (624,625).
a specialist is recommended. Other regimens have not been Primary and Secondary Syphilis Among Persons
adequately evaluated for treatment of neurosyphilis. with HIV Infection
Pregnancy Recommended Regimen for Primary and Secondary Syphilis
Pregnant women who are allergic to penicillin should be Among Persons with HIV Infection
desensitized and treated with penicillin G. Skin testing or oral Benzathine penicillin G 2.4 million units IM in a single dose
graded penicillin dose challenge might be helpful in identifying
women at risk for acute allergic reactions (see Management of Available data demonstrate that additional doses of
Persons Who Have a History of Penicillin Allergy). benzathine penicillin G, amoxicillin, or other antibiotics in
primary and secondary syphilis among persons with HIV
HIV Infection infection do not result in enhanced efficacy (592,593,609).
Persons with HIV infection who have neurosyphilis should
be treated as described for persons without HIV (see Syphilis Other Management Considerations
Among Persons with HIV Infection). The majority of persons with HIV infection respond
appropriately to the recommended benzathine penicillin G
Syphilis Among Persons with HIV Infection treatment regimen for primary and secondary syphilis (626).
CSF abnormalities (e.g., mononuclear pleocytosis and elevated
Diagnostic Considerations protein levels) can be common among persons with HIV, even
Interpretation of treponemal and nontreponemal serologic those without syphilis. The clinical and prognostic significance
tests for persons with HIV infection is the same as for persons of such CSF laboratory abnormalities among persons with
without HIV. Although rare, unusual serologic responses have primary and secondary syphilis who lack neurologic symptoms

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 47
 Recommendations and Reports

is unknown. Certain studies have demonstrated that among be desensitized and treated with penicillin G (see Management
persons with HIV infection and syphilis, CSF abnormalities of Persons Who Have a History of Penicillin Allergy). Using
are associated with a CD4+ T-cell count of ≤350 cells/mL or penicillin alternatives has not been well studied among persons
an RPR titer of ≥1:32 (614,627). However, CSF examination with HIV infection; azithromycin is not recommended for
followed by treatment for neurosyphilis on the basis of persons with HIV and primary or secondary syphilis infection.
laboratory abnormalities has not been associated with improved Alternative therapies should be used only in conjunction with
clinical outcomes in the absence of neurologic signs and close serologic and clinical follow-up. Persons with HIV and
symptoms. All persons with HIV infection and primary and latent syphilis should be treated similarly to persons who do
secondary syphilis should have a thorough neurologic, ocular, not have HIV (see Latent Syphilis).
and otic examination (614,622,625). CSF examination should
be reserved for those with an abnormal neurologic examination. Latent Syphilis Among Persons with HIV Infection
Recommended Regimen for Early Latent Syphilis Among
Follow-Up Persons with HIV Infection
Persons with HIV infection and primary or secondary Benzathine penicillin G 2.4 million units IM in a single dose
syphilis should be evaluated clinically and serologically for
possible treatment failure at 3, 6, 9, 12, and 24 months after Recommended Regimen for Late Latent Syphilis or Latent
therapy; those who meet the criteria for treatment failure Syphilis of Unknown Duration Among Persons with HIV
Infection
(i.e., signs or symptoms that persist or recur or a sustained
[>2 weeks] fourfold or greater increase in titer) should be Benzathine penicillin G 7.2 million units total, administered as 3 doses
of 2.4 million units IM at 1-week intervals
managed in the same manner as persons without HIV infection
(i.e., depending on history of sexual activity and on findings of
neurologic examination, either repeat treatment with weekly Other Management Considerations
injections of benzathine penicillin G 2.4 million units IM for All persons with HIV and latent syphilis infection should
3 weeks or CSF examination and repeat treatment guided by undergo a thorough neurologic, ocular, and otic examination;
CSF findings) (see Primary and Secondary Syphilis). those with neurologic symptoms or signs should undergo
In addition, CSF examination and retreatment can be immediate CSF examination. In the absence of neurologic
considered for persons whose nontreponemal test titers do symptoms or signs, CSF examination has not been associated
not decrease fourfold within 24 months of therapy. If CSF with improved clinical outcomes and therefore is not
examination is normal, treatment with benzathine penicillin G recommended. Those with ocular or otic symptoms or
administered as 2.4 million units IM at weekly intervals for signs should be evaluated for ocular syphilis and otosyphilis
3 weeks is recommended. Serologic titers might not decrease according to those clinical presentations (see Neurosyphilis,
despite a negative CSF examination and a repeated 3-week Ocular Syphilis, and Otosyphilis).
course of therapy (599). Especially if the initial nontreponemal
titer is low (<1:8) in these circumstances, the benefit of Follow-Up
additional therapy or repeated CSF examinations is unclear but Patients with HIV and latent syphilis infection should
is not usually recommended. Serologic and clinical monitoring be evaluated clinically and serologically at 6, 12, 18, and
at least annually should continue to monitor for any sustained 24 months after therapy. Those persons who meet the criteria
increases in nontreponemal titer. for treatment failure (i.e., signs or symptoms that persist or
recur or a sustained [>2 weeks] fourfold or greater increase
Management of Sex Partners
in titer) should be managed in the same manner as persons
See Syphilis, Management of Sex Partners. without HIV (i.e., depending on history of sexual activity and
Special Considerations on findings of neurologic examination, either repeat treatment
with weekly injections of benzathine penicillin G 2.4 million
Penicillin Allergy units IM for 3 weeks or CSF examination and repeat treatment
Persons with HIV infection who are allergic to penicillin guided by CSF findings) (see Latent Syphilis).
and have primary or secondary syphilis should be managed In addition, CSF examination and retreatment can be
according to the recommendations for persons without HIV considered for persons whose nontreponemal test titers do
who are allergic to penicillin (see Primary and Secondary not decrease fourfold within 24 months of therapy. If CSF
Syphilis). Persons with penicillin allergy whose compliance examination is normal, treatment with benzathine penicillin G
with alternative therapy or follow-up cannot be ensured should administered as 2.4 million units IM at weekly intervals for

48 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

3 weeks is recommended. Serologic titers might not decrease recommendations for persons without HIV infection with
despite a negative CSF examination and a repeated 3-week neurosyphilis who are allergic to penicillin (see Neurosyphilis,
course of therapy (599). Especially if the initial nontreponemal Ocular Syphilis, and Otosyphilis). Small observational studies
titer is low (<1:8) in these circumstances, the benefit of conducted among persons with HIV and neurosyphilis report
additional therapy or repeated CSF examinations is unclear but that ceftriaxone 1–2 g IV daily for 10–14 days might be
is not usually recommended. Serologic and clinical monitoring effective as an alternative agent (628–630). The possibility
at least annually should continue to ensure nontreponemal of cross-sensitivity between ceftriaxone and penicillin exists;
titers remain stable without any sustained titer increases. however, the risk for penicillin cross-reactivity between
third-generation cephalosporins is negligible (619–621,631)
Management of Sex Partners
(see Management of Persons Who Have a History of Penicillin
See Syphilis, Management of Sex Partners. Allergy). If concern exists regarding the safety of ceftriaxone
Special Considerations for a person with HIV and neurosyphilis, skin testing should
be performed to confirm penicillin allergy and, if necessary,
Penicillin Allergy penicillin desensitization in consultation with a specialist is
recommended. Other regimens have not been adequately
The efficacy of alternative nonpenicillin regimens for latent
evaluated for treatment of neurosyphilis.
syphilis for persons living with HIV infection has not been well
studied, and these therapies should be used only in conjunction
with close serologic and clinical follow-up. Patients with Syphilis During Pregnancy
penicillin allergy whose compliance with alternative therapy All women should be screened serologically for syphilis
or follow-up cannot be ensured should be desensitized and at the first prenatal care visit (174), which is mandated by
treated with penicillin G (see Management of Persons Who the majority of states (142). Among populations for whom
Have a History of Penicillin Allergy). receipt of prenatal care is not optimal, serologic screening and
treatment (if serologic test is reactive) should be performed at
Neurosyphilis, Ocular Syphilis, and Otic Syphilis
the time of pregnancy testing (632). Antepartum screening can
Among Persons with HIV Infection be performed by manual nontreponemal antibody testing (e.g.,
All persons with HIV and syphilis infection should receive a RPR) by using the traditional syphilis screening algorithm or
careful neurologic ocular and otic examination. Persons with by treponemal antibody testing (e.g., immunoassays) using the
HIV infection and neurosyphilis should be treated according reverse sequence algorithm.
to the recommendations for persons with neurosyphilis and Pregnant women with positive treponemal screening tests
without HIV infection (see Neurosyphilis, Ocular Syphilis, (e.g., EIA, CIA, or immunoblot) should have additional
and Otosyphilis). quantitative nontreponemal testing because titers are essential
Follow-Up for monitoring treatment response. Serologic testing should
also be performed twice during the third trimester: at 28 weeks’
Persons with HIV and neurosyphilis infection should be gestation and at delivery for pregnant women who live in
managed according to the recommendations for persons without communities with high rates of syphilis and for women who
HIV infection. Serum RPR can be followed for necessary have been at risk for syphilis acquisition during pregnancy.
treatment success rather than following CSF parameters (see Maternal risk factors for syphilis during pregnancy include
Neurosyphilis, Ocular Syphilis, and Otosyphilis). Limited data sex with multiple partners, sex in conjunction with drug
indicate that changes in CSF parameters might occur more use or transactional sex, late entry to prenatal care (i.e., first
slowly among persons with HIV infection, especially those visit during the second trimester or later) or no prenatal
with more advanced immunosuppression (588,624). care, methamphetamine or heroin use, incarceration of the
Management of Sex Partners woman or her partner, and unstable housing or homelessness
(174,633–636). Moreover, as part of the management of
See Syphilis, Management of Sex Partners.
pregnant women who have syphilis, providers should obtain
Special Considerations information concerning ongoing risk behaviors and treatment
of sex partners to assess the risk for reinfection.
Penicillin Allergy Any woman who has a fetal death after 20 weeks’ gestation
Persons with HIV who are allergic to penicillin and have should be tested for syphilis. No mother or neonate should
neurosyphilis infection should be managed according to the leave the hospital without maternal serologic status having been

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 Recommendations and Reports

documented at least once during pregnancy. Any woman who at treatment is necessary. If follow-up is not likely, women with an
the time of delivery has no prenatal care history or has been at isolated reactive treponemal test and without a history of treated
risk for syphilis acquisition during pregnancy (e.g., misuses drugs; syphilis should be treated according to the syphilis stage.
has had another STI during pregnancy; or has had multiple sex
partners, a new partner, or a partner with an STI) should have the Treatment
results of a syphilis serologic test documented before discharge. Penicillin G is the only known effective antimicrobial for
treating fetal infection and preventing congenital syphilis
Diagnostic Considerations (639). Evidence is insufficient to determine the optimal
Pregnant women seropositive for syphilis should be penicillin regimen during pregnancy (640).
considered infected unless an adequate treatment history is
Recommended Regimen for Syphilis During Pregnancy
clearly documented in the medical records and sequential
Pregnant women should be treated with the recommended penicillin
serologic antibody titers have decreased as recommended for regimen for their stage of infection
the syphilis stage. The risk for antepartum fetal infection or
congenital syphilis at delivery is related to the syphilis stage
during pregnancy, with the highest risk occurring during Other Management Considerations
the primary and secondary stages. Quantitative maternal The following recommendations should be considered for
nontreponemal titer, especially if >1:8, might be a marker of pregnant women with syphilis infection:
early infection and bacteremia. However, risk for fetal infection • Certain evidence indicates that additional therapy is
is still substantial among pregnant women with late latent beneficial for pregnant women to prevent congenital
syphilis and low titers. Pregnant women with stable, serofast syphilis. For women who have primary, secondary, or early
low nontreponemal titers who have previously been treated latent syphilis, a second dose of benzathine penicillin G
for syphilis might not require additional treatment; however, 2.4 million units IM can be administered 1 week after the
increasing or high antibody titers in a pregnant woman initial dose (641–643).
previously treated might indicate reinfection or treatment • When syphilis is diagnosed during the second half of
failure, and treatment should be offered. pregnancy, management should include a sonographic fetal
If an automated treponemal test (e.g., EIA or CIA) is used for evaluation for congenital syphilis. However, this evaluation
antepartum syphilis screening, all positive tests should be reflexed should not delay therapy. Sonographic signs of fetal or
to a quantitative nontreponemal test (e.g., RPR or VDRL). If placental syphilis (e.g., hepatomegaly, ascites, hydrops, fetal
the nontreponemal test is negative, the results are considered anemia, or a thickened placenta) indicate a greater risk for
discrepant and a second treponemal test (TP-PA is preferred) fetal treatment failure (644); cases accompanied by these
should be performed, preferably on the same specimen. signs should be managed in consultation with obstetric
If the second treponemal test is positive (e.g., EIA positive, specialists. A second dose of benzathine penicillin G
RPR negative, or TP-PA positive), current or previous syphilis 2.4 million units IM after the initial dose might be beneficial
infection can be confirmed. For women with a history of for fetal treatment in these situations.
adequately treated syphilis who do not have ongoing risk, no • Women treated for syphilis during the second half of
further treatment is necessary. Women without a history of pregnancy are at risk for premature labor or fetal distress
treatment should have the syphilis stage determined and should if the treatment precipitates the Jarisch-Herxheimer
be treated accordingly with a recommended penicillin regimen. reaction (590). These women should be advised to seek
If the second treponemal test is negative (e.g., EIA positive, obstetric attention after treatment if they notice any fever,
RPR negative, or TP-PA negative), the positive EIA or CIA is contractions, or decrease in fetal movements. Stillbirth is
more likely to represent a false-positive test result for women a rare complication of treatment; however, concern for
who are living in communities with low rates of syphilis, have this complication should not delay necessary treatment.
a partner who is uninfected, and have no history of treated No data are available to support that corticosteroid
syphilis (637,638). If the woman is at low risk for syphilis, treatment alters the risk for treatment-related complications
lacks signs or symptoms of primary syphilis, has a partner during pregnancy.
with no clinical or serologic evidence of syphilis, and is likely • Missed doses >9 days between doses are not acceptable for
to follow up with clinical care, repeat serologic testing within pregnant women receiving therapy for late latent syphilis
4 weeks can be considered to determine whether the EIA or CIA (613). An optimal interval between doses is 7 days for
remains positive or if the RPR, VDRL, or TP-PA result becomes pregnant women. If a pregnant woman does not return
positive. If both the RPR and TP-PA remain negative, no further for the next dose on day 7, every effort should be made

50 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

to contact her and link her to immediate treatment within for treatment of maternal infection and prevention of
2 days to avoid retreatment. Pregnant women who miss a congenital syphilis (646,647).
dose of therapy should repeat the full course of therapy.
HIV Infection
• All women who have syphilis should be offered testing for
HIV at the time of diagnosis. Placental inflammation from congenital syphilis infection
might increase the risk for perinatal transmission of HIV. All
Follow-Up women with HIV infection should be evaluated for syphilis and
Coordinated prenatal care and treatment are vital because receive a penicillin regimen appropriate for the syphilis stage.
providers should document that women are adequately Data are insufficient to recommend any alternative regimens
treated for the syphilis stage and ensure that the clinical and for pregnant women with syphilis and HIV infection (see
antibody responses are appropriate for the patient’s disease Syphilis Among Persons with HIV).
stage. If syphilis is diagnosed and treated at or before 24 weeks’
gestation, serologic titers should not be repeated before 8 weeks Congenital Syphilis
after treatment (e.g., at 32 weeks’ gestation) but should be
The rate of reported congenital syphilis in the United States
repeated again at delivery. Titers should be repeated sooner
has increased dramatically since 2012. During 2019, a total of
if reinfection or treatment failure is suspected. For syphilis
1,870 cases of congenital syphilis were reported, including 94
diagnosed and treated after 24 weeks’ gestation, serologic titers
stillbirths and 34 infant deaths (141). The 2019 national rate
should be repeated at delivery.
of 48.5 cases per 100,000 live births represents a 41% increase
A majority of women will not achieve a fourfold decrease
relative to 2018 (34.3 cases per 100,000 live births) and a 477%
in titers before delivery, although this does not indicate
increase relative to 2012 (8.4 cases per 100,000 live births).
treatment failure (645). However, a fourfold increase in titer
During 2015–2019, the rate of congenital syphilis increased
after treatment (e.g., from 1:8 to 1:32) that is sustained for
291.1% (12.4 to 48.5 per 100,000 live births), which mirrors
>2 weeks is concerning for reinfection or treatment failure.
increases in the rate of primary and secondary syphilis among
Nontreponemal titers can increase immediately after treatment,
females aged 15–44 years (a 171.9% increase, from 3.2 to 8.7
presumably related to the treatment response. Therefore, unless
per 100,000 females).
symptoms and signs exist of primary or secondary syphilis,
Effective prevention and detection of congenital syphilis
follow-up titer should not be repeated until approximately
depend on identifying syphilis among pregnant women and,
8 weeks after treatment. Inadequate maternal treatment is
therefore, on the routine serologic screening of pregnant
likely if delivery occurs within 30 days of therapy, clinical signs
women during the first prenatal visit and at 28 weeks’ gestation
of infection are present at delivery, or the maternal antibody
and at delivery for women who live in communities with high
titer at delivery is fourfold higher than the pretreatment titer.
rates of syphilis, women with HIV infection, or those who
Management of Sex Partners are at increased risk for syphilis acquisition. Certain states
See Syphilis, Management of Sex Partners. have recommended screening three times during pregnancy
for all women; clinicians should screen according to their
Special Considerations state’s guidelines.
Maternal risk factors for syphilis during pregnancy include
Penicillin Allergy
sex with multiple partners, sex in conjunction with drug
No proven alternatives to penicillin are available for use or transactional sex, late entry to prenatal care (i.e., first
treatment of syphilis during pregnancy. Pregnant women who visit during the second trimester or later) or no prenatal
have a history of penicillin allergy should be desensitized and care, methamphetamine or heroin use, incarceration of the
treated with penicillin G. Skin testing or oral graded penicillin woman or her partner, and unstable housing or homelessness
dose challenge might be helpful in identifying women at risk (174,633–636). Moreover, as part of the management of
for acute allergic reactions (see Management of Persons Who pregnant women who have syphilis, providers should obtain
Have a History of Penicillin Allergy). information concerning ongoing risk behaviors and treatment
Tetracycline and doxycycline are to be avoided in the second of sex partners to assess the risk for reinfection.
and third trimesters of pregnancy (431). Erythromycin and Routine screening of neonatal sera or umbilical cord blood
azithromycin should not be used because neither reliably cures is not recommended because diagnosis at that time does not
maternal infection nor treats an infected fetus (640). Data are prevent congenital syphilis in certain newborns. No mother
insufficient to recommend ceftriaxone or other cephalosporins or newborn infant should leave the hospital without maternal

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 Recommendations and Reports

serologic status having been documented at least once during a CLIA-validated test should be considered; direct fluorescence
pregnancy. Any woman who had no prenatal care before antibody (DFA-TP) reagents are unavailable (565). Darkfield
delivery or is considered at increased risk for syphilis acquisition microscopic examination or PCR testing of suspicious lesions
during pregnancy should have the results of a syphilis serologic or body fluids (e.g., bullous rash or nasal discharge) also should
test documented before she or her neonate is discharged. A be performed. In addition to these tests, for stillborn infants,
quantitative RPR is needed at the time of delivery to compare skeletal survey demonstrating typical osseous lesions might aid
with the neonate’s nontreponemal test result. If a stat RPR in the diagnosis of congenital syphilis because these
is unavailable and a rapid treponemal test is performed at abnormalities are not detected on fetal ultrasound.
delivery, the results should be confirmed by using standard The following scenarios describe the recommended
syphilis serologic laboratory tests (e.g., RPR and treponemal congenital syphilis evaluation and treatment of neonates born
test) and algorithms. to women who had reactive nontreponemal and treponemal
serologic tests for syphilis during pregnancy (e.g., RPR reactive,
Evaluation and Treatment of Neonates TP-PA reactive or EIA reactive, RPR reactive) and have a
Diagnosis of congenital syphilis can be difficult because reactive nontreponemal test at delivery (e.g., RPR reactive).
maternal nontreponemal and treponemal immunoglobulin G Maternal history of infection with T. pallidum and treatment
(IgG) antibodies can be transferred through the placenta to the for syphilis should be considered when evaluating and treating
fetus, complicating the interpretation of reactive serologic tests the neonate for congenital syphilis in most scenarios, except
for syphilis among neonates (infants aged <30 days). Therefore, when congenital syphilis is proven or highly probable.
treatment decisions frequently must be made on the basis of
identification of syphilis in the mother; adequacy of maternal Scenario 1: Confirmed Proven or Highly Probable
treatment; presence of clinical, laboratory, or radiographic Congenital Syphilis
evidence of syphilis in the neonate; and comparison of maternal Any neonate with
(at delivery) and neonatal nontreponemal serologic titers (e.g., • an abnormal physical examination that is consistent with
RPR or VDRL) by using the same test, preferably conducted congenital syphilis;
by the same laboratory. Any neonate at risk for congenital • a serum quantitative nontreponemal serologic titer that is
syphilis should receive a full evaluation and testing for HIV. fourfold§ (or greater) higher than the mother’s titer at
All neonates born to mothers who have reactive nontreponemal delivery (e.g., maternal titer = 1:2, neonatal titer ≥1:8 or
and treponemal test results should be evaluated with a maternal titer = 1:8, neonatal titer ≥1:32)¶; or
quantitative nontreponemal serologic test (RPR or VDRL) • a positive darkfield test or PCR of placenta, cord, lesions, or
performed on the neonate’s serum because umbilical cord blood body fluids or a positive silver stain of the placenta or cord.
can become contaminated with maternal blood and yield a
Recommended Evaluation
false-positive result, and Wharton’s jelly within the umbilical
cord can yield a false-negative result. The nontreponemal • CSF analysis for VDRL, cell count, and protein**
test performed on the neonate should be the same type of § One dilution is within the test performance of nontreponemal tests and is not
nontreponemal test performed on the mother. a significant change.
¶ The absence of a fourfold or greater titer for a neonate does not exclude
Conducting a treponemal test (e.g., TP-PA, immunoassay-
congenital syphilis.
EIA, CIA, or microbead immunoassay) on neonatal serum is ** Interpretation of CSF test results requires a nontraumatic lumbar puncture
not recommended because it is difficult to interpret, as passively (i.e., a CSF sample that is not contaminated with blood). CSF test results
transferred maternal antibodies can persist for >15 months. obtained during the neonatal period can be difficult to interpret; normal values
differ by gestational age and are higher among preterm infants. Studies indicate
Commercially available IgM tests are not recommended. that 95% of healthy neonates have values of ≤16–19 WBCs/mm3 or protein
All neonates born to women who have reactive nontreponemal levels of ≤115–118 mg/dL on CSF examination. During the second month
of life, 95% of healthy infants have ≤9–11 WBCs/mm3 or protein levels of
serologic tests for syphilis at delivery should be examined ≤89–91 mg/dL. Lower values (i.e., 5 WBCs/mm3 and protein level of 40 mg/dL)
thoroughly for evidence of congenital syphilis (e.g., nonimmune might be considered the upper limits of normal for older infants. Other causes
hydrops, conjugated or direct hyperbilirubinemia † or of elevated values should be considered when an infant is being evaluated for
congenital syphilis (Sources: Kestenbaum LA, Ebberson J, Zorc JJ, Hodinka
cholestatic jaundice or cholestasis, hepatosplenomegaly, RL, Shah SS. Defining cerebrospinal fluid white blood cell count reference
rhinitis, skin rash, or pseudoparalysis of an extremity). values in neonates and young infants. Pediatrics 2010;125:257–64; Shah SS,
Pathologic examination of the placenta or umbilical cord using Ebberson J, Kestenbaum LA, Hodinka RL, Zorc JJ. Age-specific reference
values for cerebrospinal fluid protein concentration in neonates and young
specific staining (e.g., silver) or a T. pallidum PCR test using infants. J Hosp Med 2011;6:22–7; Thomson J, Sucharew H, Cruz AT, et al.;
Pediatric Emergency Medicine Collaborative Research Committee [PEM
† Direct
hyperbilirubinemia is direct bilirubin level >2 mg/dL (34 umol/L) or CRC] HSV Study Group. Cerebrospinal fluid reference values for young
20% of the total bilirubin level. infants undergoing lumbar puncture. Pediatrics 2018;141:e20173405.)

52 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

• Complete blood count (CBC) and differential and Recommended Regimens, Possible Congenital Syphilis
platelet count Aqueous crystalline penicillin G 100,000–150,000 units/kg body
• Long-bone radiographs weight/day, administered as 50,000 units/kg body weight/dose IV every
• Other tests as clinically indicated (e.g., chest radiograph, 12 hours during the first 7 days of life and every 8 hours thereafter for a
total of 10 days
liver function tests, neuroimaging, ophthalmologic or
examination, and auditory brain stem response) Procaine penicillin G 50,000 units/kg body weight/dose IM in a single
daily dose for 10 days
Recommended Regimens, Confirmed or Highly Probable or
Benzathine penicillin G 50,000 units/kg body weight/dose IM in a
Congenital Syphilis
single dose
Aqueous crystalline penicillin G 100,000–150,000 units/kg body
weight/day, administered as 50,000 units/kg body weight/dose IV every
12 hours during the first 7 days of life and every 8 hours thereafter for a Before using the single-dose benzathine penicillin G regimen,
total of 10 days the recommended evaluation (i.e., CSF examination, long-
or
Procaine penicillin G 50,000 units/kg body weight/dose IM in a single bone radiographs, and CBC with platelets) should be normal,
daily dose for 10 days and follow-up should be certain. If any part of the neonate’s
evaluation is abnormal or not performed, if the CSF analysis
If >1 day of therapy is missed, the entire course should is uninterpretable because of contamination with blood, or
be restarted. Data are insufficient regarding use of other if follow-up is uncertain, a 10-day course of penicillin G
antimicrobial agents (e.g., ampicillin). When possible, a full is required.
10-day course of penicillin is preferred, even if ampicillin was If the neonate’s nontreponemal test is nonreactive and
initially provided for possible sepsis (648–650). Using agents the provider determines that the mother’s risk for untreated
other than penicillin requires close serologic follow-up for syphilis is low, treatment of the neonate with a single IM
assessing therapy adequacy. dose of benzathine penicillin G 50,000 units/kg body weight
for possible incubating syphilis can be considered without
Scenario 2: Possible Congenital Syphilis
an evaluation. Neonates born to mothers with untreated
Any neonate who has a normal physical examination and a early syphilis at the time of delivery are at increased risk for
serum quantitative nontreponemal serologic titer equal to or congenital syphilis, and the 10-day course of penicillin G
less than fourfold of the maternal titer at delivery (e.g., maternal should be considered even if the neonate’s nontreponemal
titer = 1:8, neonatal titer ≤1:16) and one of the following: test is nonreactive, the complete evaluation is normal, and
• The mother was not treated, was inadequately treated, or follow-up is certain.
has no documentation of having received treatment.
• The mother was treated with erythromycin or a regimen Scenario 3: Congenital Syphilis Less Likely
other than those recommended in these guidelines (i.e., a Any neonate who has a normal physical examination and a
nonpenicillin G regimen).†† serum quantitative nontreponemal serologic titer equal or less
• The mother received the recommended regimen but than fourfold of the maternal titer at delivery (e.g., maternal
treatment was initiated <30 days before delivery. titer = 1:8, neonatal titer ≤1:16) and both of the following
are true:
Recommended Evaluation
• The mother was treated during pregnancy, treatment was
• CSF analysis for VDRL, cell count, and protein** appropriate for the infection stage, and the treatment
• CBC, differential, and platelet count regimen was initiated ≥30 days before delivery.
• Long-bone radiographs • The mother has no evidence of reinfection or relapse.
This evaluation is not necessary if a 10-day course of
parenteral therapy is administered, although such evaluations Recommended Evaluation
might be useful. For instance, a lumbar puncture might No evaluation is recommended.
document CSF abnormalities that would prompt close
Recommended Regimen, Congenital Syphilis Less Likely
follow-up. Other tests (e.g., CBC, platelet count, and long-
bone radiographs) can be performed to further support a Benzathine penicillin G 50,000 units/kg body weight/dose IM in a
single dose*
diagnosis of congenital syphilis.
* Another approach involves not treating the newborn if follow-up is
certain but providing close serologic follow-up every 2–3 months for
†† A women treated with a regimen other than recommended in these guidelines 6 months for infants whose mothers’ nontreponemal titers decreased
should be considered untreated. at least fourfold after therapy for early syphilis or remained stable for
low-titer, latent syphilis (e.g., VDRL <1:2 or RPR <1:4).

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 Recommendations and Reports

Scenario 4: Congenital Syphilis Unlikely recommended for the neonate. If syphilis exposure is possible
Any neonate who has a normal physical examination and a or unknown in the mother or the mother desires further
serum quantitative nontreponemal serologic titer equal to or evaluation to definitively rule out syphilis, repeat serology
less than fourfold of the maternal titer at delivery§ and both within 4 weeks is recommended to evaluate for early infection
of the following are true: (see Syphilis During Pregnancy).
• The mother’s treatment was adequate before pregnancy. Isolated reactive maternal treponemal serology (e.g., rapid
• The mother’s nontreponemal serologic titer remained low treponemal test) at delivery. For mothers with late or no
and stable (i.e., serofast) before and during pregnancy and prenatal care with a reactive rapid treponemal test at delivery,
at delivery (e.g., VDRL ≤1:2 or RPR ≤1:4). confirmatory laboratory-based testing should be performed;
however, results should not delay evaluation and treatment
Recommended Evaluation of the neonate. These neonates should be evaluated and
No evaluation is recommended. treated with a 10-day course of penicillin as recommended in
Scenario 1, and consultation with a specialist is recommended.
Recommended Regimen, Congenital Syphilis Unlikely
No treatment is required. However, any neonate with reactive Follow-Up
nontreponemal tests should be followed serologically to ensure the
nontreponemal test returns to negative (see Follow-Up). Benzathine All neonates with reactive nontreponemal tests should receive
penicillin G 50,000 units/kg body weight as a single IM injection might thorough follow-up examinations and serologic testing (i.e., RPR
be considered, particularly if follow-up is uncertain and the neonate has
a reactive nontreponemal test.
or VDRL) every 2–3 months until the test becomes nonreactive.
For a neonate who was not treated because congenital syphilis
The following situations describe management of neonates was considered less likely or unlikely, nontreponemal antibody
born to women screened during pregnancy by using the reverse titers should decrease by age 3 months and be nonreactive
sequence algorithm with reactive treponemal serologic tests by age 6 months, indicating that the reactive test result was
and a nonreactive nontreponemal serologic test. caused by passive transfer of maternal IgG antibody. At age
Reactive maternal treponemal serologies with a 6 months, if the nontreponemal test is nonreactive, no further
nonreactive nontreponemal serology (e.g., EIA reactive, evaluation or treatment is needed; if the nontreponemal test is
RPR nonreactive, or TP-PA reactive) during pregnancy. still reactive, the infant is likely infected and should be treated.
Syphilis is highly unlikely for neonates born to mothers with Treated neonates who exhibit persistent nontreponemal test
a nonreactive nontreponemal test after adequate treatment titers by age 6–12 months should be reevaluated through CSF
for syphilis during pregnancy or documentation of adequate examination and managed in consultation with an expert.
treatment before pregnancy (with no evidence of reinfection Retreatment with a 10-day course of a penicillin G regimen
of relapse). If testing is performed again at delivery and 1) the might be indicated.
maternal nontreponemal test remains nonreactive and 2) the Neonates with a negative nontreponemal test at birth and
neonate has a normal physical examination and nonreactive whose mothers were seroreactive at delivery should be retested
nontreponemal test (e.g., RPR nonreactive), the provider at age 3 months to rule out serologically negative incubating
should consider managing similarly to Scenario 4 without congenital syphilis at the time of birth. Treponemal tests should
a laboratory evaluation and with no treatment required. not be used to evaluate treatment response because the results
Benzathine penicillin G 50,000 units/kg body weight as a are qualitative, and passive transfer of maternal IgG treponemal
single IM injection might be considered if syphilis exposure antibody might persist for >15 months.
is possible within 1 month of delivery and follow-up of the Neonates whose initial CSF evaluations are abnormal do
mother and infant is uncertain. not need repeat lumbar puncture unless they exhibit persistent
Isolated reactive maternal treponemal serology (e.g., nontreponemal serologic test titers at age 6–12 months.
EIA reactive, RPR nonreactive, or TP-PA nonreactive) Persistent nontreponemal titers and CSF abnormalities should
during pregnancy. Syphilis is unlikely for neonates born to be managed in consultation with an expert.
mothers screened with the reverse sequence algorithm with Special Considerations
isolated reactive maternal treponemal serology. Among low-
prevalence populations, these are likely false-positive results and Penicillin Allergy
might become nonreactive with repeat testing (638). If these Neonates who require treatment for congenital syphilis
neonates have a normal physical examination and the risk for but who have a history of penicillin allergy or develop an
syphilis is low in the mother, no evaluation and treatment are allergic reaction presumed secondary to penicillin should

54 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

be desensitized and then treated with penicillin G (see HIV Infection

Management of Persons Who Have a History of Penicillin Evidence is insufficient to determine whether neonates who
Allergy). Skin testing remains unavailable for neonates because have congenital syphilis and HIV infection or whose mothers
the procedure has not been standardized for this age group. have HIV require different therapy or clinical management
Data are insufficient regarding use of other antimicrobial agents than is recommended for all neonates. All neonates with
(e.g., ceftriaxone) for congenital syphilis among neonates. If congenital syphilis should be managed similarly, regardless of
a nonpenicillin G agent is used, close clinical and serologic HIV status.
follow-up is required in consultation with an expert. Repeat
CSF examination should be performed if the initial CSF Evaluation and Treatment of Infants and Children
examination was abnormal. with Congenital Syphilis
Penicillin Shortage Infants and children aged ≥1 month who are identified as
having reactive serologic tests for syphilis (e.g., RPR reactive,
During periods when the availability of aqueous crystalline
TP-PA reactive or EIA reactive, RPR reactive) should be
penicillin G is compromised, the following is recommended
examined thoroughly and have maternal serology and records
(https://www.cdc.gov/std/treatment/drug-notices.htm):
reviewed to assess whether they have congenital or acquired
• For neonates with clinical evidence of congenital syphilis
syphilis (see Primary and Secondary Syphilis; Latent Syphilis;
(see Scenario 1), check local sources for aqueous crystalline
Sexual Assault or Abuse of Children). In the case of extremely
penicillin G (potassium or sodium) and notify CDC and
early or incubating syphilis at the time of delivery, all maternal
FDA of limited supply. If IV penicillin G is limited,
serologic tests might have been negative; thus, infection might
substitute some or all daily doses with procaine penicillin G
be undetected until a diagnosis is made later in the infant or
(50,000 units/kg body weight/dose IM/day in a single
child. Any infant or child at risk for congenital syphilis should
daily dose for 10 days).
receive a full evaluation and testing for HIV infection.
• If aqueous or procaine penicillin G is unavailable,
International adoptee, immigrant, or refugee children from
ceftriaxone (50–75 mg/kg body weight/day IV every
countries where treponemal infections (e.g., yaws or pinta) are
24 hours) can be considered with thorough clinical and
endemic might have reactive nontreponemal and treponemal
serologic follow-up and in consultation with an expert
serologic tests, which cannot distinguish between syphilis and
because evidence is insufficient to support using ceftriaxone
other subspecies of T. pallidum (651). These children might
for treating congenital syphilis. Ceftriaxone should be used
also have syphilis (T. pallidum subspecies pallidum) and should
with caution in neonates with jaundice.
be evaluated for congenital syphilis.
• For neonates without any clinical evidence of congenital
syphilis (see Scenario 2 and Scenario 3), use Recommended Evaluation
űű procaine penicillin G 50,000 units/kg body weight/
The following evaluations should be performed:
dose/day IM in a single dose for 10 days, or • CSF analysis for VDRL, cell count, and protein
űű benzathine penicillin G 50,000 units/kg body weight
• CBC, differential, and platelet count
IM as a single dose. • Other tests as clinically indicated (e.g., long-bone
• If any part of the evaluation for congenital syphilis is radiographs, chest radiograph, liver function tests,
abnormal or was not performed, CSF examination is not abdominal ultrasound, ophthalmologic examination,
interpretable, or follow-up is uncertain, procaine neuroimaging, and auditory brain-stem response)
penicillin G is recommended. A single dose of ceftriaxone
is inadequate therapy. Recommended Regimen for Congenital Syphilis Among Infants
and Children
• For premature neonates who have no clinical evidence of
Aqueous crystalline penicillin G 200,000–300,000 units/kg body
congenital syphilis (see Scenario 2 and Scenario 3) and weight/day IV, administered as 50,000 units/kg body weight every
might not tolerate IM injections because of decreased 4–6 hours for 10 days
muscle mass, IV ceftriaxone can be considered with
thorough clinical and serologic follow-up and in If the infant or child has no clinical manifestations of
consultation with an expert. Ceftriaxone dosing should congenital syphilis and the evaluation (including the CSF
be adjusted according to birthweight. examination) is normal, treatment with <3 weekly doses of
benzathine penicillin G 50,000 units/kg body weight IM
can be considered. A single dose of benzathine penicillin G
50,000 units/kg body weight IM up to the adult dose of

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 55
 Recommendations and Reports

2.4 million units in a single dose can be considered after the • For infants and children with clinical evidence of
10-day course of IV aqueous penicillin G to provide more congenital syphilis, if IV penicillin is limited after checking
comparable duration for treatment in those who have no local sources and notifying CDC and FDA about limited
clinical manifestations and normal CSF. All of these treatment supplies, procaine penicillin G (50,000 units/kg body
regimens should also be adequate for children who might have weight/dose IM up to the adult dose of 2.4 million units
other treponemal infections. a day in a single daily dose for 10 days) is recommended.
• If procaine penicillin G is not available, ceftriaxone (in doses
Follow-Up
for age and weight) can be considered with thorough clinical
Thorough follow-up examinations and serologic testing (i.e., and serologic follow-up. Infants and children receiving
RPR or VDRL) of infants and children treated for congenital ceftriaxone should be managed in consultation with an expert
syphilis after the neonatal period (aged >30 days) should be because evidence is insufficient to support use of ceftriaxone
performed every 3 months until the test becomes nonreactive for treatment of congenital syphilis among infants or children.
or the titer has decreased fourfold. The serologic response For infants aged ≥30 days, use ceftriaxone 75 mg/kg body
after therapy might be slower for infants and children than weight/day IV or IM in a single daily dose for 10–14 days
neonates. If these titers increase at any point >2 weeks or do (dose adjustment might be necessary on the basis of current
not decrease fourfold after 12–18 months, the infant or child weight). For children, ceftriaxone 100 mg/kg body weight/
should be evaluated (e.g., CSF examination), treated with day in a single daily dose is recommended.
a 10-day course of parenteral penicillin G, and managed in • For infants and children without any clinical evidence of
consultation with an expert. Treponemal tests (e.g., EIA, CIA, infection (see Scenario 2 and Scenario 3), use
or TP-PA) should not be used to evaluate treatment response űű procaine penicillin G 50,000 units/kg body weight/dose
because the results are qualitative and persist after treatment, IM up to the adult dose of 2.4 million units a day in a
and passive transfer of maternal IgG treponemal antibody single dose for 10 days, or
might persist for >15 months after delivery. Infants or children űű benzathine penicillin G 50,000 units/kg body weight
whose initial CSF evaluations are abnormal do not need repeat IM up to the adult dose of 2.4 million units as a
lumbar puncture unless their serologic titers do not decrease single dose.
fourfold after 12–18 months. After 18 months of follow-up, • If any part of the evaluation for congenital syphilis is
abnormal CSF indices that persist and cannot be attributed to abnormal or not performed, CSF examination is not
other ongoing illness indicate that retreatment is needed for interpretable, or follow-up is uncertain, procaine
possible neurosyphilis and should be managed in consultation penicillin G is recommended. In these scenarios, a single
with an expert. dose of ceftriaxone is inadequate therapy.
Special Considerations HIV Infection
Penicillin Allergy Evidence is insufficient to determine whether infants and
Infants and children who require treatment for congenital children who have congenital syphilis and HIV infection or
syphilis but who have a history of penicillin allergy or develop whose mothers have HIV require different therapy or clinical
an allergic reaction presumed secondary to penicillin should be management than what is recommended for all infants and
desensitized and treated with penicillin G (see Management children. All infants and children with congenital syphilis
of Persons Who Have a History of Penicillin Allergy). Skin should be managed similarly, regardless of HIV status.
testing remains unavailable for infants and children because the
procedure has not been standardized for this age group. Data
are insufficient regarding use of other antimicrobial agents (e.g., Management of Persons Who Have a
ceftriaxone) for congenital syphilis among infants and children. History of Penicillin Allergy
If a nonpenicillin G agent is used, close clinical, serologic, and Penicillin and other ß-lactam antibiotics have a crucial
CSF follow-up is required in consultation with an expert. role in treating STIs. Penicillin is recommended for all
Penicillin Shortage clinical stages of syphilis, and no proven alternatives exist for
treating neurosyphilis, congenital syphilis, or syphilis during
During periods when availability of penicillin G is
pregnancy. Ceftriaxone, a third-generation cephalosporin, is
compromised, management options are similar to options
recommended for gonorrhea treatment. For extragenital site
for the neonate (see Evaluation and Treatment of Neonates).
infections, especially pharyngeal, failure rates of nonceftriaxone

56 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

regimens can be substantial. In most clinical settings, patients of patients could receive ß-lactams. In hospitalized patients
who report a penicillin allergy are not treated with ß-lactam and other populations with comorbidities, the typical rates of
antimicrobials. For patients with a diagnosis of gonorrhea and validated penicillin allergy among patients who report a history
a concomitant reported allergy to penicillin, ceftriaxone is often of penicillin allergy are 2.5%–9.0% (670–673).
avoided, even though the cross-reactivity between penicillin
allergy and third-generation cephalosporins is low (652–654). Cross-Reactivity with Cephalosporins
Prevalence of reported allergy to penicillin is approximately
10% among the U.S. population and higher among hospital Penicillin and cephalosporins both contain a ß-lactam ring.
inpatients and residents in health care–related facilities (655– This structural similarity has led to considerable confusion
658). One large study in an STI clinic revealed that 8.3% of regarding cross-reactivity of these drugs and the risks for
patients reported penicillin or another ß-lactam antibiotic allergic reactions from cephalosporins among penicillin-
allergy (659). Penicillin allergy is often overreported, with the allergic patients. In most clinical settings, patients with
majority of patients who report penicillin allergy able to tolerate reported penicillin allergy are precluded from treatment
the medication (660). The prevalence of reported penicillin with such cephalosporin antibiotics as ceftriaxone. Third-
allergy in low-income countries is unknown; however, limited generation cephalosporins (e.g., ceftriaxone and cefixime) have
data indicate that penicillin is one of the most frequently lower cross-reactivity with IgE-mediated penicillin-allergic
reported antibiotic allergies (661). patients (<1%) compared with first- and second-generation
Patients often are incorrectly labeled as allergic to penicillin cephalosporins (range: 1%–8%). Moreover, anaphylaxis
and are therefore denied the benefit of a ß-lactam therapy. secondary to cephalosporins is extremely rare among persons
The presence of a penicillin allergy label considerably reduces who report a penicillin allergy and is estimated to occur at a rate
prescribing options for affected patients. Moreover, penicillin of one per 52,000 persons (652). Data from the Kaiser health
allergy labels lead to the use of more expensive and less effective care system reported that among 3,313 patients with self-
drugs and can result in adverse consequences, including longer reported cephalosporin allergy who received a cephalosporin
length of hospital stay and increased risk for infection. Multiple (mostly first generation), no cases of anaphylaxis were reported
studies have described that persons with reported penicillin or (652). Use of third- and fourth-generation cephalosporins
another ß-lactam antibiotic allergy have higher rates of surgical- and carbapenems is safe for patients without a history of any
site infections, methicillin-resistant Staphylococcus aureus IgE-mediated symptoms (e.g., anaphylaxis or urticaria) from
infections, and higher medical care usage (653,662–664). penicillin during the preceding 10 years.
The overreported prevalence of penicillin allergy is
secondary to imprecise use of the term “allergy” by families Validating Penicillin or Another ß-Lactam
and clinicians and lack of clarity to differentiate between Antibiotic Allergy
immunoglobulin E (IgE)-mediated hypersensitivity reactions,
Evaluating a patient who reports a penicillin or another
drug intolerances, and other idiosyncratic reactions that can
ß-lactam antibiotic allergy involves three steps: 1) obtaining
occur days after exposure. Approximately 80% of patients
a thorough medical history, including previous exposures to
with a true IgE-mediated allergic reaction to penicillin have
penicillin or other ß-lactam antibiotics (658); 2) performing
lost the sensitivity after 10 years (658). Thus, patients with
a skin test evaluation by using the penicillin major and minor
recent reactions are more likely to be allergic than patients
determinants; and 3) among those who have a negative
with remote reactions, and patients who had allergic reactions
penicillin skin test, performing an observed oral challenge with
in the distant past might no longer be reactive.
250 mg amoxicillin before proceeding directly to treatment
In a Baltimore, Maryland, STI clinic study, only 7.1% of
with the indicated ß-lactam therapy (667,675).
the patients who reported allergy to penicillin or to another
For persons who have a positive skin test reactive to penicillin
ß-lactam antibiotic had an objective positive test for penicillin
(either to the major or minor determinants), treatment with a
allergy (659). Moreover, in studies that have incorporated
ß-lactam antibiotic is not usually advised, and other effective
penicillin skin testing and graded oral challenge among persons
antimicrobials should be used (656,658). For persons among
with reported penicillin allergy, the true rates of allergy are low,
whom the only therapy option is a penicillin antibiotic (e.g., a
ranging from 1.5% to 6.1% (665–667). Studies in preoperative
patient with neurosyphilis or a pregnant woman with syphilis)
surgical patients with reported penicillin allergy, evaluated
and among whom a penicillin skin test is positive, induction
for cardiovascular surgery (668) or orthopedics (669), have
of penicillin tolerance (also referred to as desensitization) is
rates of skin test positivity <8.5%. However, when patients
required (675). Desensitization protocols to penicillin should
with high-risk penicillin allergy histories are excluded, 99%

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 Recommendations and Reports

be performed by allergists, and they require a monitored In a time of increasing antimicrobial resistance, following
inpatient environment. recommended use of antibiotic treatments is crucial. STI
programs and clinicians should promote increased access to
Penicillin Skin Testing penicillin allergy testing. Allergy testing is being provided
Penicillin skin testing with a major determinant by clinicians in primary care and hospital settings. If
analog (penicilloyl-polylysine) and minor determinants appropriate, STI programs and ambulatory settings should
(benzylpenicilloate, benzylpenilloate, or benzylpenicillin consider developing expanded access to penicillin or ß-lactam
isomers of penicillin) are used for skin test evaluation for allergy assessment.
IgE-dependent penicillin allergy and can reliably identify Persons with high-risk symptom histories (e.g., anaphylaxis
persons at high risk for IgE-mediated reactions to penicillin within the previous 10 years) should not be administered
(658,660,676). Until recently, penicillin skin testing in the penicillin or a ß-lactam antibiotic in an ambulatory setting.
United States only included the major determinant benzyl Furthermore, these persons with high-risk symptoms should
penicillin poly-L-lysine (Pre-Pen) in addition to penicillin G. not receive penicillin skin testing or amoxicillin oral challenge
This test identifies approximately 90%–99% of the IgE- in an ambulatory STI setting and should be referred to an
mediated penicillin-allergic patients. Because the remaining allergist for further evaluation.
1%–10% of penicillin-allergic patients who are not captured High-risk symptom histories include development of
by this penicillin skin test are due to minor determinants IgE the following after penicillin or ß-lactam administration:
antibodies, the standard practice is to follow skin testing with anaphylaxis within 6 hours or severe adverse cutaneous reaction
an observed oral challenge of amoxicillin 250 mg with 1 hour (e.g., eosinophilia and systemic symptoms, Stevens-Johnson
of observation. If the skin test and oral challenge are both syndrome, toxic epidermal necrolysis, or acute generalized
negative, the risk for IgE-mediated anaphylaxis approaches zero exanthematous pustulosis) and other severe non–IgE-mediated
and is equivalent to that of a person who has never reported reactions (e.g., kidney or hepatic injury, hemolytic anemia, or
an allergy to penicillin. thrombocytopenia).
A revised version of the penicillin skin test kit, which includes
the major determinant reagent Pre-Pen, minor determinants, Direct Treatment Approach for Ceftriaxone
and amoxicillin, is being evaluated by FDA. This penicillin Among persons with confirmed IgE-mediated penicillin
skin test kit has been evaluated among 455 patients (677) allergy, the level of cross-reactivity with third-generation
with previous allergy history and has a negative predictive cephalosporins is low (652,680,681). If a patient has a low-
value of 98%. If approved, this kit might eliminate the need risk history for an IgE-mediated penicillin allergy, ambulatory
for oral challenge. settings often treat with third-generation cephalosporins
Penicillin skin testing has become a clinically significant without further testing. Low-risk history includes one
element in antibiotic stewardship programs, and the nonspecific symptom (e.g., gastrointestinal intolerance,
procedure has been increasingly used by hospital-based headache, fatigue, or nonurticarial rash) (Box 2). In addition,
pharmacists, hospitalists, and infectious disease physicians a family history of penicillin or ß-lactam allergy alone is not a
(670,672,673,678,679) as part of overall antibiotic stewardship contraindication for treatment with ß-lactam antibiotics. This
interventions. When integrated into stewardship, the rates of practice is increasingly being used in ambulatory settings and
ß-lactam antibiotic use increased substantially (670). for preoperative prophylaxis (658,663,680,682–684).
Recommendations BOX 2. Low-risk history in patients who report penicillin allergy
Persons with a history of severe adverse cutaneous Gastrointestinal symptoms
reaction (e.g., Stevens-Johnson syndrome or toxic epidermal
necrolysis) and other severe non–IgE-mediated reactions (e.g., Headache
interstitial nephritis or hemolytic anemia) are not candidates Pruritis without rash
for penicillin skin testing or challenge. Penicillin and any Localized rash
other ß-lactam antibiotics should be avoided indefinitely
among these patients, who should be referred to an allergy Delayed onset rash (>24 hours)
center for further evaluation. Similarly, patients who deny Symptoms unknown
penicillin allergy, but who report previous IgE-type reactions Family history of penicillin or another drug allergy
to cephalosporins, should be referred to an allergist for specific
cephalosporin testing. Patient denies allergy but it is on the medical record

58 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Patients at Low Risk for Oral Challenge Penicillin skin testing during pregnancy is considered safe.
If the patient gives only a low-risk history of IgE-mediated For pregnant persons who report a penicillin or ß-lactam
penicillin allergy that includes symptoms such gastrointestinal allergy, penicillin allergy is an important consideration in
intolerance, headache, fatigue, or nonspecific pruritus, or gives treating syphilis during pregnancy and the potential for group
a family history only, an oral challenge can be administered B streptococcal infection and preoperative prophylaxis if a
to document the absence of allergy (Box 2). If the reaction cesarean delivery is required. However, oral challenges should
occurred in the distant past (>10 years), the likelihood is not be performed unless in a setting where additional support
reduced even further (653,658,663,682,683,685,686). The services are available.
risk for severe amoxicillin-mediated anaphylaxis has decreased Managing Persons Being Tested
over time and is rare. In the United Kingdom during 1972–
Patients who have a positive skin test should not receive
2007, one fatal case of amoxicillin-medicated anaphylaxis was
ß-lactam drugs in the ambulatory setting and should be
reported (684).
referred to an allergist or penicillin allergy expert for further
evaluation. The allergy testing results should be documented
Skin Testing for Penicillin Allergy in the medical record. Patients who test negative should be
Skin testing for penicillin allergy should be performed if informed that their risk for anaphylaxis is extremely low and is
any indication exists that the symptoms were secondary to an equivalent to a person who does not report an allergy history. If
IgE-mediated hypersensitivity. Testing is also indicated as a treatment with penicillin or ceftriaxone is indicated, it can be
potential diagnostic procedure to definitively rule out penicillin administered safely. Documentation of testing results should
allergy and document a negative allergy status in the medical be provided to the patient.
record (i.e., delabeling). Because penicillin allergy testing
does not test for multiple minor determinants, a person with
Desensitization
a negative skin test should follow up with an oral challenge to Desensitization is required for persons who have a
confirm the negative status. documented penicillin allergy and for whom no therapeutic
Persons with negative results of a penicillin skin test, followed by alternatives exist (e.g., syphilis during pregnancy and persons
an amoxicillin oral challenge, can receive conventional penicillin with neurosyphilis). Modified protocols might be considered
therapy safely if needed. Persons with positive skin test results and BOX 3. Skin test reagents for identifying persons at risk for
for whom no other clinical options exist (e.g., neurosyphilis and adverse reactions to penicillin
syphilis in a pregnant woman) should be referred to an allergist
and desensitized before initiating treatment. Major determinant
• Benzylpenicilloyl polylysine injection (Pre-Pen)
Testing Procedures (AllerQuest) (6 × 10-5M)
Penicillin skin testing includes use of skin test reagents for Minor determinant precursors
identifying persons at risk for adverse reactions (Box 3), followed • Benzylpenicillin G (10-2M, 3.3 mg/mL, 10,000 units/mL)
by initial pinprick screening with penicillin major determinants • Benzylpenicilloate (10-2M, 3.3 mg/mL)
(Pre-Pen) and penicillin G, followed by intradermal testing if • Benzylpenicilloate (or penicilloyl propylamine)
pinprick results are negative. Penicillin testing procedures are (10-2M, 3.3 mg/mL)
performed in accordance with the Pre-Pen test kit instructions
(https://penallergytest.com/wp-content/uploads/PRE-PEN- Aged penicillin is not an adequate source of minor
Package-Insert.pdf ). Saline negative controls and histamine determinants. Penicillin G should either be freshly
positive controls are an integral part of the procedure. Penicillin prepared or come from a fresh-frozen source.
skin testing should not be performed for patients who have Positive control
taken antihistamines within the past 7 days. • Commercial histamine for scratch testing (1.0 mg/mL)
Skin testing can be safely performed by trained Negative control
nonallergists and has been implemented as an antimicrobial • Diluent (usually saline) or allergen diluent
stewardship intervention by internal medicine physicians,
Source: Adapted from Saxon A, Beall GN, Rohr AS, Adelman DC. Immediate
pharmacists, hospitalists, and infectious disease physicians hypersensitivity reactions to beta-lactam antibiotics. Ann Intern Med
(670,673,678,679). Patients tested should also receive 1987;107:204−15.
documentation of status, and the results should be entered in
the medical record.

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 Recommendations and Reports

on the basis of the clinical syndrome, drug of choice, and route prevalence varies by age group, with a lower proportion of
of administration (687–690). Patients might require referral disease occurring among older men (699). Documentation of
to a specialty center where desensitization can be performed. chlamydial infection as NGU etiology is essential because of the
need for partner referral for evaluation and treatment to prevent
Allergy Referral Resources complications of chlamydia, especially for female partners.
With increased access to skin testing kits and the need to Complications of C. trachomatis–associated NGU among
better target therapy for gonorrhea and syphilis, programs males include epididymitis, prostatitis, and reactive arthritis.
should identify local allergy consultant resources. M. genitalium is associated with symptoms of urethritis and
urethral inflammation and accounts for 15%–25% of NGU
cases in the United States (691–693,696,697,700). Among
Diseases Characterized by Urethritis men with symptoms of urethritis, M. genitalium was detected
and Cervicitis in 11% of those with urethritis in Australia (701), 12%–15%
in the United Kingdom (702–704), 15% in South Africa (696),
Urethritis 19% in China (705), 21% in Korea, 22% in Japan (706), and
Urethritis, as characterized by urethral inflammation, can 28.7% in the United States (range: 20.4%–38.8%) (697). Data
result from either infectious or noninfectious conditions. are inconsistent regarding other Mycoplasma and Ureaplasma
Symptoms, if present, include dysuria, urethral pruritis, and species as etiologic agents of urethritis (707). The majority
mucoid, mucopurulent, or purulent discharge. Signs of urethral of men with Ureaplasma infections do not have overt disease
discharge on examination can also be present among persons unless a high organism load is present.
without symptoms. Although N. gonorrhoeae and C. trachomatis T. vaginalis can cause urethritis among heterosexual
are well established as clinically important infectious causes of men; however, the prevalence varies substantially by U.S.
urethritis, M. genitalium has been strongly associated with geographic region, age, and sexual behavior and within specific
urethritis and, less commonly, prostatitis (691–697). If POC populations. Studies among men with and without overt
diagnostic tools (e.g., Gram, methylene blue [MB], or gentian urethritis in developed countries document relatively low
violet [GV] stain microscopy) are unavailable, drug regimens rates of T. vaginalis in the Netherlands (0.5%) (708), Japan
effective against both gonorrhea and chlamydia should be (1.3%) (706,709), the United States (2.4%) (710), and the
administered. Further testing to determine the specific etiology United Kingdom (3.6%) (703). Studies in other countries
is recommended for preventing complications, reinfection, have documented higher rates, such as in Croatia (8.2%)
and transmission because a specific diagnosis might improve (711) and Zimbabwe (8.4%) (712), particularly among
treatment compliance, delivery of risk-reduction interventions, symptomatic patients.
and partner services. Both chlamydia and gonorrhea are Neisseria meningitidis can colonize mucosal surfaces and
reportable to health departments. NAATs are preferred for cause urethritis (713). Urogenital N. meningitidis rates
detecting C. trachomatis and N. gonorrhoeae, and urine is the and duration of carriage, prevalence of asymptomatic and
preferred specimen for males (553). NAAT-based tests for symptomatic infection, and modes of transmission have
diagnosing T. vaginalis among men with urethritis have not not been systematically described; however, studies indicate
been cleared by FDA; however, laboratories have performed that N. meningitidis can be transmitted through oral-
the CLIA-compliant validation studies (698) needed to provide penile contact (i.e., fellatio) (714–716). N. meningitidis
such testing. has similar colony morphology appearance on culture and
cannot be distinguished from N. gonorrhoeae on Gram stain.
Etiology Identification of N. meningitidis as the etiologic agent with
Multiple organisms can cause infectious urethritis. The presumed gonococcal urethritis on the basis of Gram stain
presence of gram-negative intracellular diplococci (GNID) but negative NAAT for gonorrhea requires a confirmation
or purple intracellular diplococci (MB or GV) on urethral by culture. Meningococcal urethritis is treated with the same
smear is indicative of presumed gonococcal infection, antimicrobial regimens as gonococcal urethritis. Although
which is frequently accompanied by chlamydial infection. evidence is limited regarding the risk for sexual transmission or
Nongonococcal urethritis (NGU), which is diagnosed when recurrent infections with meningococcal urethritis, treatment
microscopy of urethral secretions indicate inflammation of sex partners of patients with meningococcal urethritis with
without GNID or MB or GV purple intracellular diplococci, the same antimicrobial regimens as for exposure to gonococcal
is caused by C. trachomatis in 15%–40% of cases; however, infection can be considered. No indication exists for treating

60 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

persons with N. meningitidis identified in their oropharynx Diagnostic Considerations

when not also associated with symptomatic urethritis. Clinicians should attempt to obtain objective evidence of
In other instances, NGU can be caused by HSV, Epstein- urethral inflammation. If POC diagnostic tests (e.g., Gram
Barr virus, and adenovirus (699) acquired by fellatio (i.e., oral- stain or MB or GV microscopy) are unavailable, urethritis
penile contact). In a retrospective review of 80 cases of HSV can be documented on the basis of any of the following signs
urethritis in Australia (717), the majority of infections were or laboratory tests:
associated with HSV-1 with clinical findings of meatitis (62%), • Mucoid, mucopurulent, or purulent discharge on examination.
genital ulceration (37%), and dysuria (20%). Adenovirus can • Gram stain is a POC diagnostic test for evaluating
present with dysuria, meatal inflammation, and conjunctivitis urethritis that is highly sensitive and specific for
(718). Enteric bacteria have been identified as an uncommon documenting both urethritis and the presence or absence
cause of NGU and might be associated with insertive anal of gonococcal infection; MB or GV stain of urethral
intercourse (699). secretions is an alternative POC diagnostic test with
Other bacterial pathogens have been implicated as potential performance characteristics similar to Gram stain; thus,
causes of clinical urethritis, either in clustered case series or as the cutoff number for WBCs per oil immersion field
sporadic cases such as Haemophilus influenzae and Haemophilus should be the same (737).
parainfluenzae (719–723). Haemophilus was identified in 12.6% űű Presumed gonococcal infection is established by
of cases among 413 men (mostly MSM reporting insertive oral documenting the presence of WBCs containing GNID
sex) (724), and high rates of azithromycin resistance (39.5%) in Gram stain or intracellular purple diplococci in MB
were identified among Haemophilus urethritis patients (725). or GV smears; men should be tested for C. trachomatis
Individual case reports have linked NGU to multiple bacterial and N. gonorrhoeae by NAATs and presumptively treated
species, including Corynebacterium propinquum (726), Kurthia and managed accordingly for gonococcal infection (see
gibsonii (727), Corynebacterium glucuronolyticum (728,729), Gonococcal Infections).
Corynebacterium striatrium (730), Aerococcus urinae (731), űű If no intracellular gram-negative or purple diplococci
and Neisseria elongata (732). Diagnostic testing and treatment are present, men should receive NAATs for C. trachomatis
for less-common organisms are reserved for situations in and N. gonorrhoeae and can be managed for NGU as
which these infections are suspected (e.g., sexual partner with recommended (see Nongonococcal Urethritis).
trichomoniasis, urethral lesions, or severe dysuria and meatitis) űű Gram stain of urethral secretions exist that demonstrate
or when NGU is not responsive to recommended therapy. ≥2 WBCs per oil immersion field (738). The microscopy
Even in settings that provide comprehensive diagnostic diagnostic cutoff might vary, depending on background
testing, etiology can remain obscure in half of cases. Idiopathic prevalence (≥2 WBCs/high power field [HPF] in high-
NGU was reported in 772 (59%) of 1,295 first presentations prevalence settings [STI clinics] or ≥5 WBCs/HPF in
of NGU among men seeking sexual health services in Australia lower-prevalence settings).§§
(701). In a case-control study of 211 men with NGU
symptoms in Denmark, no identifiable pathogen was identified §§ For urethral microscopy, the cutoff for diagnosing urethritis is ≥2 WBCs/HPF
in 24% of acute cases and 33% of chronic cases (733). NGU’s (Sources: Rietmeijer CA, Mettenbrink CJ. Recalibrating the Gram stain
diagnosis of male urethritis in the era of nucleic acid amplification testing. Sex
importance if not caused by a defined pathogen is uncertain; Transm Dis 2012;39:18–20; Rietmeijer CA, Mettenbrink CJ. The diagnosis
neither complications (e.g., urethral stricture or epididymitis) of nongonococcal urethritis in men: can there be a universal standard? Sex
nor adverse outcomes among sex partners have been identified Transm Dis 2017;44:195–6). An additional evaluation supported this cutoff
by demonstrating NGU sensitivity of 92.6% for cutoff of ≥2 versus 55.6%
in these cases. sensitivity for cutoff of ≥5 (Source: Sarier M, Sepin N, Duman I, et al.
Associations between NGU and insertive anal and oral Microscopy of Gram-stained urethral smear in the diagnosis of urethritis: which
exposure have been reported (734), as have higher rates threshold value should be selected? Andrologia 2018;50:e13143). Diagnostic
cutoffs for 369 symptomatic and asymptomatic heterosexual men seeking STI
of BV-associated Leptotrichia or Sneathia species among care in Seattle revealed a maximal sensitivity and specificity achieved with a
heterosexual men with urethritis (735). These studies increase cutoff of ≥5 WBCs/HPF. Using a lower cutoff of ≥2 WBCs/HPF would miss
13% of C. trachomatis and M. genitalium and overtreat 45% of persons who
concern for possible undetected infectious rectal or vaginal have negative tests (Source: Leipertz G, Chambers L, Lowens S, et al. P796
pathogens, or alternatively, a transient reactive dysbiosis after Reassessing the Gram stain smear [GSS] polymorphonuclear leukocyte [PMN]
exposure to a new microbiome or even a noninfectious reactive cutoff for diagnosing non-gonococcal urethritis [NGU]. Sex Transm Infect
2019;95[Suppl 1]:A339). Another study discussed that the WBC/HPF cutoff
etiology (736). value should discriminate on the basis of the prevalence of chlamydia,
mycoplasma, and gonorrhea among a clinic population (Source: Moi H,
Hartgill U, Skullerud KH, Reponen EJ, Syvertsen L, Moghaddam A.
Microscopy of stained urethral smear in male urethritis: which cutoff should
be used? Sex Transm Dis 2017;44:189–94).

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 61
 Recommendations and Reports

• Positive leukocyte esterase test on first-void urine or urine demonstrating ≥10 WBCs/HPF has a high negative
microscopic examination of sediment from a spun first- predictive value.
void urine demonstrating ≥10 WBCs/HPF. All men who have suspected or confirmed NGU should
Men evaluated in settings in which Gram stain or MB or be tested for chlamydia and gonorrhea by using NAATs.
GV smear is unavailable who meet at least one criterion for A specific diagnosis can potentially reduce complications,
urethritis (i.e., urethral discharge, positive leukocyte esterase reinfection, and transmission. M. genitalium testing should be
test on first void urine, or microscopic examination of first- performed for men who have persistent or recurrent symptoms
void urine sediment with ≥10 WBCs/HPF) should be tested after initial empiric treatment. Testing for T. vaginalis should
for C. trachomatis and N. gonorrhoeae by NAATs and treated be considered in areas or among populations with high
with regimens effective against gonorrhea and chlamydia. prevalence, in cases where a partner is known to be infected,
If symptoms are present but no evidence of urethral or for men who have persistent or recurrent symptoms after
inflammation is present, NAATs for C. trachomatis and initial empiric treatment.
N. gonorrhoeae might identify infections (739). Persons
with chlamydia or gonorrhea should receive recommended Treatment
treatment, and sex partners should be referred for evaluation Ideally, treatment should be pathogen based; however,
and treatment. If none of these clinical criteria are present, diagnostic information might not be immediately available.
empiric treatment of men with symptoms of urethritis is Presumptive treatment should be initiated at NGU diagnosis.
recommended only for those at high risk for infection who are Doxycycline is highly effective for chlamydial urethral
unlikely to return for a follow-up evaluation or test results. Such infections and is also effective for chlamydial infections of
men should be treated with drug regimens effective against the rectum; it also has some activity against M. genitalium.
gonorrhea and chlamydia. In contrast, reports have increased of azithromycin treatment
failures for chlamydial infection (748,749), and the incidence
of macrolide resistance in M. genitalium also has been rapidly
Nongonococcal Urethritis
rising (697,702,705,750,751). Pharmacokinetic data indicate
NGU is a nonspecific diagnosis that can have various that changing azithromycin dosing from a single-dose strategy
infectious etiologies. C. trachomatis has been well established to a multiday strategy might protect against inducing resistance
as an NGU etiology; however, prevalence varies across in M. genitalium infections (745,752) (see Mycoplasma
populations and accounts for <50% of overall cases (712,740– genitalium).
742). M. genitalium is estimated to account for 10%–25% of
cases (696,697,701,703,704,706,733,743), and T. vaginalis Recommended Regimen for Nongonococcal Urethritis
for 1%–8% of cases depending on population and location Doxycycline 100 mg orally 2 times/day for 7 days
(703,706,708,710,712). Other etiologies include different
bacteria, such as Haemophilus species (724,725), N. meningitidis Alternative Regimens
(713,716), HSV (706,717), and adenovirus (744). However, Azithromycin 1 g orally in a single dose
or
even when extensive testing is performed, no pathogens are Azithromycin 500 mg orally in a single dose; then 250 mg orally daily
identified in approximately half of cases (701,733). for 4 days

Diagnostic Considerations To maximize compliance with recommended therapies,

Clinical presentation can include urethral discharge, medications should be dispensed on-site at the clinic, and,
irritation, dysuria, or meatal pruritus (697,743,745). NGU is regardless of the number of doses involved in the regimen,
confirmed for symptomatic men when diagnostic evaluation of the first dose should be directly observed. Erythromycin is no
urethral secretions indicates inflammation, without evidence longer recommended for NGU because of its gastrointestinal
of diplococci by Gram, MB, or GV smear on microscopy side effects and dosing frequency. Levofloxacin is no longer
(712,746,747). Visible discharge or secretions can be collected recommended for NGU because of its inferior efficacy,
by a swab without inserting it into the urethra; if no visible especially for M. genitalium.
secretions, the swab can be inserted into the urethral meatus
and rotated, making contact with the urethral wall before Management Considerations
removal. If microscopy is unavailable, urine testing for To minimize transmission and reinfections, men treated for
leukocyte esterase can be performed on first-void urine, and NGU should be instructed to abstain from sexual intercourse
microscopic examination of sediment from a spun first-void until they and their partners have been treated (i.e., until

62 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

completion of a 7-day regimen and symptoms have resolved or achieve clinical cure (i.e., resolution of symptoms) but can
for 7 days after single-dose therapy). Men with NGU should still have detectable M. genitalium in urethral specimens (758).
be tested for HIV and syphilis. The initial step in recurrent urethritis is assessing compliance
with treatment or potential reexposure to an untreated sex
Follow-Up partner (697,743). If the patient did not comply with the
Men should be provided their testing results obtained as treatment regimen or was reexposed to an untreated partner,
part of the NGU evaluation. Those with a specific diagnosis retreatment with the initial regimen can be considered. If
of chlamydia, gonorrhea, or trichomoniasis should be therapy was appropriately completed and no reexposure
offered partner services and instructed to return 3 months occurred, therapy is dependent on the initial treatment
after treatment for repeat testing because of high rates of regimen. Ideally, diagnostic testing among men with recurrent
reinfection, regardless of whether their sex partners were treated or persistent symptoms, including those with gonorrhea,
(136,137,753,754) (see Chlamydial Infections; Gonococcal chlamydia, M. genitalium, and trichomoniasis, can be used to
Infections; Trichomoniasis). guide further management decisions.
If symptoms persist or recur after therapy completion, men T. vaginalis is also known to cause urethritis among men who
should be instructed to return for reevaluation and should be have sex with women. In areas where T. vaginalis is prevalent,
tested for M. genitalium and T. vaginalis. Symptoms alone, men who have sex with women with persistent or recurrent
without documentation of signs or laboratory evidence of urethritis should be tested for T. vaginalis and presumptively
urethral inflammation, are insufficient basis for retreatment. treated with metronidazole 2 g orally in a single dose or
Providers should be alert to the possible diagnosis of chronic tinidazole 2 g orally in a single dose; their partners should be
prostatitis or chronic pelvic pain syndrome in men experiencing referred for evaluation and treatment, if needed.
persistent perineal, penile, or pelvic pain or discomfort; If T. vaginalis is unlikely (MSM with NGU or negative
voiding symptoms; pain during or after ejaculation; or new- T. vaginalis NAAT), men with recurrent NGU should be tested
onset premature ejaculation lasting for >3 months. Men with for M. genitalium by using an FDA-cleared NAAT. Treatment
persistent pain should be referred to a urologist with expertise for M. genitalium includes a two-stage approach, ideally using
in pelvic pain disorders. resistance-guided therapy. If M. genitalium resistance testing is
available it should be performed, and the results should be used
Management of Sex Partners
to guide therapy (see Mycoplasma genitalium). If M. genitalium
All sex partners of men with NGU within the preceding resistance testing is not available, doxycycline 100 mg orally
60 days should be referred for evaluation and testing and 2 times/day for 7 days followed by moxifloxacin 400 mg orally
presumptive treatment with a drug regimen effective against once daily for 7 days should be used. The rationale for this
chlamydia. All partners should be evaluated and treated approach is that although not curative, doxycycline decreases
according to the management section for their respective the M. genitalium bacterial load, thereby increasing likelihood
pathogen; EPT could be an alternate approach if a partner is of moxifloxacin success (759). Higher doses of azithromycin
unable to access timely care. To avoid reinfection, sex partners have not been effective for M. genitalium after azithromycin
should abstain from sexual intercourse until they and their treatment failures. Men with persistent or recurrent NGU after
partners are treated. treatment for M. genitalium or T. vaginalis should be referred
to an infectious disease or urology specialist.
Persistent or Recurrent Nongonococcal Urethritis
The objective diagnosis of persistent or recurrent NGU Special Considerations
should be made before considering additional antimicrobial
HIV Infection
therapy. Symptomatic recurrent or persistent urethritis might
be caused by treatment failure or reinfection after successful NGU might facilitate HIV transmission (760). Persons with
treatment. Among men who have persistent symptoms after NGU and HIV infection should receive the same treatment
treatment without objective signs of urethral inflammation, the regimen as those who do not have HIV.
value of extending the duration of antimicrobials has not been
demonstrated. Treatment failure for chlamydial urethritis has Cervicitis
been estimated at 6%–12% (755). The most common cause Two major diagnostic signs characterize cervicitis: 1) a
of persistent or recurrent NGU is M. genitalium, especially purulent or mucopurulent endocervical exudate visible in
after doxycycline therapy (756,757). Treatment failure for the endocervical canal or on an endocervical swab specimen
M. genitalium is harder to determine because certain men (commonly referred to as mucopurulent cervicitis), and

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 63
 Recommendations and Reports

2) sustained endocervical bleeding easily induced by gentle microscopy for trichomonads should receive further testing
passage of a cotton swab through the cervical os. Either or both (i.e., NAAT, culture, or other FDA-cleared diagnostic test)
signs might be present. Cervicitis frequently is asymptomatic; (see Trichomoniasis). Testing for M. genitalium with the FDA-
however, certain women might report an abnormal vaginal cleared NAAT can be considered. Although HSV-2 infection
discharge and intermenstrual vaginal bleeding (e.g., especially has been associated with cervicitis, the utility of specific testing
after sexual intercourse). The criterion of using an increased (i.e., PCR or culture) for HSV-2 is unknown. Testing for
number of WBCs on endocervical Gram stain in the diagnosis U. parvum, U. urealyticum, Mycoplasma hominis, or genital
of cervicitis has not been standardized; it is not sensitive, culture for group B streptococcus is not recommended.
has a low positive predictive value for C. trachomatis and
N. gonorrhoeae infections, and is not available in most clinical Treatment
settings (297,761). Leukorrhea, defined as >10 WBCs/HPF on Multiple factors should affect the decision to provide
microscopic examination of vaginal fluid, might be a sensitive presumptive therapy for cervicitis. Presumptive treatment with
indicator of cervical inflammation with a high negative antimicrobials for C. trachomatis and N. gonorrhoeae should
predictive value (i.e., cervicitis is unlikely in the absence of be provided for women at increased risk (e.g., those aged
leukorrhea) (762,763). Finally, although the presence of gram- <25 years and women with a new sex partner, a sex partner
negative intracellular diplococci on Gram stain of endocervical with concurrent partners, or a sex partner who has an STI), if
exudate might be specific for diagnosing gonococcal cervical follow-up cannot be ensured, or if testing with NAAT is not
infection when evaluated by an experienced laboratorian, it is possible. Trichomoniasis and BV should be treated if detected
not a sensitive indicator of infection (764). (see Bacterial Vaginosis; Trichomoniasis). For women at lower
risk for STIs, deferring treatment until results of diagnostic
Etiology tests are available is an option. If treatment is deferred and
C. trachomatis or N. gonorrhoeae is the most common etiology C. trachomatis and N. gonorrhoeae NAATs are negative, a
of cervicitis defined by diagnostic testing. Trichomoniasis, follow-up visit to determine whether the cervicitis has resolved
genital herpes (especially primary HSV-2 infection), or can be considered.
M. genitalium (761,765–768) also have been associated
with cervicitis. However, in many cases of cervicitis, no Recommended Regimen for Cervicitis*
organism is isolated, especially among women at relatively Doxycycline 100 mg orally 2 times/day for 7 days

low risk for recent acquisition of these STIs (e.g., women aged * Consider concurrent treatment for gonococcal infection if the patient is
at risk for gonorrhea or lives in a community where the prevalence of
>30 years) (769). Limited data indicate that BV and frequent gonorrhea is high (see Gonococcal Infections).
douching might cause cervicitis (770–772). The majority
of persistent cases of cervicitis are not caused by reinfection Alternative Regimen
with C. trachomatis or N. gonorrhoeae; other factors might Azithromycin 1 g orally in a single dose
be involved (e.g., persistent abnormality of vaginal flora,
M. genitalium, douching or exposure to other types of chemical
irritants, dysplasia, or idiopathic inflammation in the zone of Other Management Considerations
ectopy). Available data do not indicate an association between To minimize transmission and reinfection, women treated
group B streptococcus colonization and cervicitis (773,774). for cervicitis should be instructed to abstain from sexual
No specific evidence exists for a role for Ureaplasma parvum or intercourse until they and their partners have been treated
Ureaplasma urealyticum in cervicitis (707,761,765,775,776). (i.e., until completion of a 7-day regimen or for 7 days after
Diagnostic Considerations single-dose therapy) and symptoms have resolved. Women
who receive a cervicitis diagnosis should be tested for syphilis
Because cervicitis might be a sign of upper genital tract and HIV in addition to other recommended diagnostic tests.
infection (e.g., endometritis), women should be assessed for
signs of PID and tested for C. trachomatis and N. gonorrhoeae Follow-Up
with NAAT on vaginal, cervical, or urine samples (553) (see Women receiving treatment should return to their provider
Chlamydial Infections; Gonococcal Infections). Women for a follow-up visit to determine whether cervicitis has
with cervicitis also should be evaluated for concomitant BV resolved. For women who are untreated, a follow-up visit gives
and trichomoniasis. Because sensitivity of microscopy for providers an opportunity to communicate test results obtained
detecting T. vaginalis is relatively low (approximately 50%), as part of the cervicitis evaluation. Providers should treat on
symptomatic women with cervicitis and negative wet-mount the basis of any positive test results and determine whether

64 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

cervicitis has resolved. Women with a specific diagnosis of Pregnancy

chlamydia, gonorrhea, or trichomoniasis should be offered Diagnosis and treatment of cervicitis for pregnant women
partner services and instructed to return in 3 months after does not differ from that for women who are not pregnant (see
treatment for repeat testing because of high rates of reinfection, Diagnostic Considerations; Treatment).
regardless of whether their sex partners were treated (753). If
symptoms persist or recur, women should be instructed to Contraceptive Management
return for reevaluation. According to U.S. Medical Eligibility Criteria for Contraceptive
Use, 2016, leaving an IUD in place during treatment for
Management of Sex Partners
cervicitis is advisable (58). However, current recommendations
Management of sex partners of women treated for cervicitis specify that an IUD should not be placed if active cervicitis
should be tailored for the specific infection identified or is diagnosed (59).
suspected. All sex partners during the previous 60 days should
be referred for evaluation, testing, and presumptive treatment
if chlamydia, gonorrhea, or trichomoniasis was identified. EPT Chlamydial Infections
and other effective partner referral strategies are alternative
approaches for treating male partners of women who have Chlamydial Infection Among
chlamydial or gonococcal infection (125–127) (see Partner Adolescents and Adults
Services). To avoid reinfection, sex partners should abstain
Chlamydial infection is the most frequently reported
from sexual intercourse until they and their partners are treated.
bacterial infectious disease in the United States, and prevalence
Persistent or Recurrent Cervicitis is highest among persons aged ≤24 years (141,784). Multiple
Women with persistent or recurrent cervicitis despite sequelae can result from C. trachomatis infection among
antimicrobial therapy should be reevaluated for possible women, the most serious of which include PID, ectopic
reexposure or treatment failure. If relapse or reinfection with pregnancy, and infertility. Certain women who receive a
a specific infection has been excluded, BV is not present, and diagnosis of uncomplicated cervical infection already have
sex partners have been evaluated and treated, management subclinical upper genital tract infection.
options for persistent cervicitis are undefined. In addition, Asymptomatic infection is common among both men and
the usefulness of repeated or prolonged administration of women. To detect chlamydial infection, health care providers
antimicrobial therapy for persistent symptomatic cervicitis frequently rely on screening tests. Annual screening of all
remains unknown. The etiology of persistent cervicitis, sexually active women aged <25 years is recommended, as is
including the potential role of M. genitalium (777), is unclear. screening of older women at increased risk for infection (e.g.,
M. genitalium might be considered for cases of cervicitis that women aged ≥25 years who have a new sex partner, more
persist after azithromycin or doxycycline therapy in which than one sex partner, a sex partner with concurrent partners,
reexposure to an infected partner or medical nonadherence is or a sex partner who has an STI) (149). In a community-
unlikely. Among women with persistent cervicitis who were based cohort of female college students, incident chlamydial
previously treated with doxycycline or azithromycin, testing infection was also associated with BV and high-risk HPV
for M. genitalium can be considered and treatment initiated on infection (785). Although chlamydia incidence might be higher
the basis of results of diagnostic testing (318) (see Mycoplasma among certain women aged ≥25 years in certain communities,
genitalium). For women with persistent symptoms that are overall, the largest proportion of infection is among women
clearly attributable to cervicitis, referral to a gynecologic aged <25 years (141).
specialist can be considered for evaluation of noninfectious Chlamydia screening programs have been demonstrated
causes (e.g., cervical dysplasia or polyps) (778). to reduce PID rates among women (786,787). Although
evidence is insufficient to recommend routine screening for
Special Considerations C. trachomatis among sexually active young men because of
certain factors (i.e., feasibility, efficacy, and cost-effectiveness),
HIV Infection
screening of sexually active young men should be considered
Women with cervicitis and HIV infection should receive in clinical settings with a high prevalence of chlamydia (e.g.,
the same treatment regimen as those who do not have HIV. adolescent clinics, correctional facilities, or STD specialty
Cervicitis can increase cervical HIV shedding, and treatment clinics) or for populations with a high burden of infection
reduces HIV shedding from the cervix and thereby might (e.g., MSM) (149,788). Among women, the primary focus of
reduce HIV transmission to susceptible sex partners (779–783).

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 Recommendations and Reports

chlamydia screening should be to detect and treat chlamydia, screening by NAAT, especially when clinicians are not available
prevent complications, and test and treat their partners, or when self-collection is preferred over clinician collection.
whereas targeted chlamydia screening for men should be Annual screening for rectal C. trachomatis infection should
considered only when resources permit, prevalence is high, and be performed among men who report sexual activity at the
such screening does not hinder chlamydia screening efforts for rectal site. Extragenital chlamydial testing at the rectal site
women (789–791). More frequent screening than annual for can be considered for females on the basis of reported sexual
certain women (e.g., adolescents) or certain men (e.g., MSM) behaviors and exposure through shared clinical decision-
might be indicated on the basis of risk behaviors. making by the patient and the provider. The majority of
persons with C. trachomatis detected at oropharyngeal sites do
Diagnostic Considerations not have oropharyngeal symptoms. The clinical significance of
For women, C. trachomatis urogenital infection can be oropharyngeal C. trachomatis infection is unclear, and prevalence
diagnosed by vaginal or cervical swabs or first-void urine. For is low, even among populations at high risk. However, when
men, C. trachomatis urethral infection can be diagnosed by gonorrhea testing is performed at the oropharyngeal site,
testing first-void urine or a urethral swab. NAATs are the most chlamydia test results might be reported because certain NAATs
sensitive tests for these specimens and are the recommended detect both bacteria from a single specimen.
test for detecting C. trachomatis infection (553). NAATs that POC tests for C. trachomatis among asymptomatic persons
are FDA cleared for use with vaginal swab specimens can be can expedite treatment of infected persons and their sex
collected by a clinician or patient in a clinical setting. Patient- partners. Among symptomatic patients, POC tests for
collected vaginal swab specimens are equivalent in sensitivity C. trachomatis can optimize treatment by limiting unnecessary
and specificity to those collected by a clinician using NAATs presumptive treatment at the time of clinical decision-making
(792,793), and this screening strategy is highly acceptable and improve antimicrobial stewardship. Thus, using a POC
among women (794,795). Optimal urogenital specimen test will likely be a cost-effective diagnostic strategy for
types for chlamydia screening by using NAAT include first- C. trachomatis infection (807). Newer NAAT-based POC tests
catch urine (for men) and vaginal swabs (for women) (553). have promising performance and are becoming commercially
Recent studies have demonstrated that among men, NAAT available (807–809).
performance on self-collected meatal swabs is comparable
to patient-collected urine or provider-collected urethral Treatment
swabs (796–798). Patient collection of a meatal swab for Treating persons with C. trachomatis prevents adverse
C. trachomatis testing might be a reasonable approach for men reproductive health complications and continued sexual
who are either unable to provide urine or prefer to collect their transmission. Furthermore, treating their sex partners
own meatal swab over providing urine. Previous evidence can prevent reinfection and infection of other partners.
indicates that the liquid-based cytology specimens collected for Treating pregnant women usually prevents transmission of
Pap smears might be acceptable specimens for NAAT, although C. trachomatis to neonates during birth. Treatment should be
test sensitivity using these specimens might be lower than that provided promptly for all persons with chlamydial infection;
associated with use of cervical or vaginal swab specimens (799); treatment delays have been associated with complications (e.g.,
regardless, certain NAATs have been cleared by FDA for use PID) in a limited proportion of women (810).
on liquid-based cytology specimens.
Recommended Regimen for Chlamydial Infection Among
Rectal and oropharyngeal C. trachomatis infection among Adolescents and Adults
persons engaging in receptive anal or oral intercourse can be Doxycycline 100 mg orally 2 times/day for 7 days
diagnosed by testing at the anatomic exposure site. NAATs
have been demonstrated to have improved sensitivity and Alternative Regimens
specificity, compared with culture, for detecting C. trachomatis Azithromycin 1 g orally in a single dose
at rectal and oropharyngeal sites (553,800–804), and certain or
NAAT platforms have been cleared by FDA for these Levofloxacin 500 mg orally once daily for 7 days
anatomic sites (805). Data indicate that NAAT performance
on self-collected rectal swabs is comparable to clinician- A meta-analysis and a Cochrane systematic review evaluated
collected rectal swabs, and this specimen collection strategy data from randomized clinical trials of azithromycin versus
for rectal C. trachomatis screening is highly acceptable among doxycycline for treating urogenital chlamydial infection
men (217,806). Self-collected rectal swabs are a reasonable determined that microbiologic treatment failure among men
alternative to clinician-collected rectal swabs for C. trachomatis was higher for azithromycin than for doxycycline (748,749).

66 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Observational studies have also demonstrated that doxycycline maximize adherence with recommended therapies, on-site,
is more efficacious for rectal C. trachomatis infection for men directly observed single-dose therapy with azithromycin should
and women than azithromycin (748,811). A randomized trial always be available for persons for whom adherence with
for the treatment of rectal chlamydia infection among MSM multiday dosing is a considerable concern.
reported microbiologic cure was 100% with doxycycline and
74% with azithromycin (812). A published review reported Other Management Considerations
that C. trachomatis was detected at the anorectal site among To minimize disease transmission to sex partners, persons
33%–83% of women who had urogenital C. trachomatis treated for chlamydia should be instructed to abstain from
infection, and its detection was not associated with report of sexual intercourse for 7 days after single-dose therapy or until
receptive anorectal sexual activity (813). completion of a 7-day regimen and resolution of symptoms if
Although the clinical significance of oropharyngeal present. To minimize risk for reinfection, patients also should
C. trachomatis infection is unclear and routine oropharyngeal be instructed to abstain from sexual intercourse until all of their
screening is not recommended, oropharyngeal C. trachomatis sex partners have been treated. Persons who receive a diagnosis
can be sexually transmitted to genital sites (211,814); therefore, of chlamydia should be tested for HIV, gonorrhea, and syphilis.
if C. trachomatis is identified from an oropharyngeal specimen MSM who are HIV negative with a rectal chlamydia diagnosis
while screening for pharyngeal gonorrhea, it should be treated. should be offered HIV PrEP.
Evidence is limited regarding the efficacy of antimicrobial
Follow-Up
regimens for oropharyngeal chlamydia; however, a recently
published observational study indicates doxycycline might Test of cure to detect therapeutic failure (i.e., repeat testing
be more efficacious than azithromycin for oropharyngeal 4 weeks after completing therapy) is not advised for nonpregnant
chlamydia (815). persons treated with the recommended or alternative regimens,
Available evidence supports that doxycycline is efficacious unless therapeutic adherence is in question, symptoms persist,
for C. trachomatis infections of urogenital, rectal, and or reinfection is suspected. Moreover, using chlamydial NAATs
oropharyngeal sites. Although azithromycin maintains high at <4 weeks after completion of therapy is not recommended
efficacy for urogenital C. trachomatis infection among women, because the continued presence of nonviable organisms
concern exists regarding effectiveness of azithromycin for (553,818,819) can lead to false-positive results.
concomitant rectal C. trachomatis infection, which can occur A high prevalence of C. trachomatis infection has been
commonly among women and cannot be predicted by reported observed among women and men who were treated
sexual activity. Inadequately treated rectal C. trachomatis for chlamydial infection during the preceding months
infection among women who have urogenital chlamydia (753,755,820–822). The majority of posttreatment infections
can increase the risk for transmission and place women at do not result from treatment failure but rather from reinfection
risk for repeat urogenital C. trachomatis infection through caused by failure of sex partners to receive treatment or
autoinoculation from the anorectal site (816). Doxycycline is initiation of sexual activity with a new infected partner (823),
also available in a delayed-release 200-mg tablet formulation, indicating a need for improved education and treatment of
which requires once-daily dosing for 7 days and is as effective sex partners. Repeat infections confer an elevated risk for PID
as doxycycline 100 mg twice daily for 7 days for treating and other complications among women. Men and women
urogenital C. trachomatis infection in men and women. It is who have been treated for chlamydia should be retested
more costly but also has lower frequency of gastrointestinal approximately 3 months after treatment, regardless of whether
side effects (817). Levofloxacin is an effective treatment they believe their sex partners were treated; scheduling the
alternative but is more expensive. Erythromycin is no longer follow-up visit at the time of treatment is encouraged (753).
recommended because of the frequency of gastrointestinal side If retesting at 3 months is not possible, clinicians should retest
effects, which can result in nonadherence. When nonadherence whenever persons next seek medical care <12 months after
to doxycycline regimen is a substantial concern, azithromycin initial treatment.
1 g regimen is an alternative treatment option but might
Management of Sex Partners
require posttreatment evaluation and testing because it has
demonstrated lower treatment efficacy among persons with Sex partners should be referred for evaluation, testing, and
rectal infection. presumptive treatment if they had sexual contact with the
Among persons receiving multidose regimens, medication partner during the 60 days preceding the patient’s onset of
should be dispensed with all doses involved, on-site and in symptoms or chlamydia diagnosis. Although the exposure
the clinic, and the first dose should be directly observed. To intervals defining identification of sex partners at risk are

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 Recommendations and Reports

based on limited data, the most recent sex partner should be breastfeeding; however, data from animal studies increase
evaluated and treated, even if the time of the last sexual contact concerns regarding cartilage damage to neonates (431).
was >60 days before symptom onset or diagnosis. Test of cure (i.e., repeat testing after completion of therapy)
If health department partner management strategies (e.g., to document chlamydial eradication, preferably by NAAT,
disease intervention specialists) are impractical or unavailable at approximately 4 weeks after therapy completion during
for persons with chlamydia, and if a provider is concerned pregnancy is recommended because severe sequelae can occur
that sex partners are unable to promptly access evaluation and among mothers and neonates if the infection persists. In
treatment services, EPT should be considered as permitted by addition, all pregnant women who have chlamydial infection
law (see Partner Services). Compared with standard patient diagnosed should be retested 3 months after treatment.
referral of partners, this approach to therapy, which involves Detection of C. trachomatis infection during the third semester
delivering the medication itself or a prescription by the is not uncommon among adolescent and young adult women,
patient or collaborating pharmacy, has been associated with including those without C. trachomatis detected at the time of
decreased rates of persistent or recurrent chlamydia among initial prenatal screening (827). Women aged <25 years and
women (125–127). Providers should provide patients with those at increased risk for chlamydia (i.e., those who have a
written educational materials to give to their partners about new sex partner, more than one sex partner, a sex partner with
chlamydia, which should include notification that partners concurrent partners, or a sex partner who has an STI) should
have been exposed and information about the importance be screened at the first prenatal visit and rescreened during the
of treatment. These materials also should inform partners third trimester to prevent maternal postnatal complications
about potential therapy-related allergies and adverse effects, and chlamydial infection in the infant (149).
along with symptoms indicative of complications (e.g.,
Recommended Regimen for Chlamydial Infection During
testicular pain among men and pelvic or abdominal pain Pregnancy
among women). Educational materials for female partners Azithromycin 1 g orally in a single dose
should include information about the importance of seeking
medical evaluation, especially if PID symptoms are present; Alternative Regimen
undertreatment of PID among female partners and missed Amoxicillin 500 mg orally 3 times/day for 7 days
opportunities for diagnosing other STIs among women
are concerning. MSM with chlamydia have a high risk for Because of concerns regarding chlamydia persistence
coexisting infections, especially undiagnosed HIV, among after exposure to penicillin-class antibiotics that has been
their partners and might have partners without HIV who demonstrated in animal and in vitro studies, amoxicillin is
could benefit from HIV PrEP. Data are also limited regarding listed as an alternative therapy for C. trachomatis for pregnant
effectiveness of EPT in reducing persistent or recurrent women (828,829). Erythromycin is no longer recommended
chlamydia among MSM (123,133,134); thus, shared clinical because of the frequency of gastrointestinal side effects that can
decision-making regarding EPT for MSM is recommended. result in therapy nonadherence. In addition, systematic reviews
Having partners accompany patients when they return for and meta-analyses have noted an association with macrolide
treatment is another strategy that has been used successfully antimicrobials, especially erythromycin, during pregnancy and
for ensuring partner treatment (see Partner Services). To avoid adverse child outcomes, indicating cautious use in pregnancy
reinfection, sex partners should be instructed to abstain from (830–831).
condomless sexual intercourse until they and their sex partners
have been treated (i.e., after completion of a 7-day regimen) HIV Infection
and any symptoms have resolved. Persons who have chlamydia and HIV infection should
Special Considerations receive the same treatment regimen as those who do not
have HIV.
Pregnancy
Clinical experience and published studies indicate that Chlamydial Infection Among Neonates
azithromycin is safe and effective during pregnancy (824–826). Prenatal screening and treatment of pregnant women is
Doxycycline is contraindicated during the second and third the best method for preventing chlamydial infection among
trimesters of pregnancy because of risk for tooth discoloration. neonates. C. trachomatis infection of neonates results from
Human data reveal that levofloxacin presents a low risk to the perinatal exposure to the mother’s infected cervix. Initial
fetus during pregnancy but has potential for toxicity during C. trachomatis neonatal infection involves the mucous

68 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

membranes of the eye, oropharynx, urogenital tract, and sex partner, a sex partner with concurrent partners, or a
rectum, although infection might be asymptomatic in these sex partner who has an STI); and
locations. Instead, C. trachomatis infection among neonates • screening at delivery those pregnant women who were not
is most frequently recognized by conjunctivitis that develops screened for C. trachomatis during pregnancy if at risk or
5–12 days after birth. C. trachomatis also can cause a subacute, who had no prenatal care; physicians and others caring
afebrile pneumonia with onset at ages 1–3 months. Although for the mother and the newborn should communicate to
C. trachomatis has been the most frequent identifiable ensure follow-up on the results of laboratory tests
infectious cause of ophthalmia neonatorum, neonatal performed at delivery, and if positive, prompt and age-
chlamydial infections, including ophthalmia and pneumonia, appropriate treatment for the newborn and the mother.
have occurred less frequently since institution of widespread Neonates born to mothers for whom prenatal chlamydia
prenatal screening and treatment of pregnant women. Neonates screening has been confirmed and the results are negative are
born to mothers at high risk for chlamydial infection, with not at high risk for infection.
untreated chlamydia, or with no or unconfirmed prenatal care,
Diagnostic Considerations
are at high risk for infection. However, presumptive treatment
of the neonate is not indicated because the efficacy of such Sensitive and specific methods for diagnosing chlamydial
treatment is unknown. Infants should be monitored to ensure ophthalmia in the neonate include both tissue culture and
prompt and age-appropriate treatment if symptoms develop. nonculture tests (e.g., DFA tests and NAATs). DFA is the
Processes should be in place to ensure communication between only nonculture FDA-cleared test for detecting chlamydia
physicians and others caring for the mother and the newborn from conjunctival swabs. NAATs are not cleared by FDA for
to ensure thorough monitoring of the newborn after birth. detecting chlamydia from conjunctival swabs, and clinical
laboratories should verify the procedure according to CLIA
Ophthalmia Neonatorum Caused by regulations. Specimens for culture isolation and nonculture
C. trachomatis tests should be obtained from the everted eyelid by using a
A chlamydial etiology should be considered for all infants aged Dacron (DuPont)-tipped swab or the swab specified by the
≤30 days who experience conjunctivitis, especially if the mother manufacturer’s test kit; for culture and DFA, specimens must
has a history of chlamydial infection. These infants should receive contain conjunctival cells, not exudate alone. Ocular specimens
evaluation and age-appropriate care and treatment. from neonates being evaluated for chlamydial conjunctivitis
also should be tested for N. gonorrhoeae (see Ophthalmia
Preventing Ophthalmia Neonatorum Caused by Neonatorum Caused by N. gonorrhoeae).
C. trachomatis
Treatment
Neonatal ocular prophylaxis with erythromycin, the only
agent available in the United States for this purpose, is Recommended Regimen for Chlamydial Infection Among
ineffective against chlamydial ophthalmia neonatorum (or Neonates
pneumonia) (833). As an alternative, prevention efforts should Erythromycin base or ethyl succinate 50 mg/kg body weight/day
orally, divided into 4 doses daily for 14 days*
focus on prenatal screening for C. trachomatis, including
• screening pregnant women at risk for C. trachomatis * An association between oral erythromycin and azithromycin and infantile
hypertrophic pyloric stenosis (IHPS) has been reported among infants
infection at the first prenatal visit (e.g., women aged aged <6 weeks. Infants treated with either of these antimicrobials should
<25 years and those aged ≥25 years who have a new sex be followed for IHPS signs and symptoms.
partner, more than one sex partner, a sex partner with
concurrent partners, or a sex partner who has an STI); Although data regarding use of azithromycin for treating
• treating all pregnant women with C. trachomatis during neonatal chlamydial infection are limited, available data
pregnancy and performing a test of cure 4 weeks after demonstrate that a short therapy course might be effective
treatment to verify chlamydial eradication; these women (834). Topical antibiotic therapy alone is inadequate for
should also be retested 3 months after treatment and again treating ophthalmia neonatorum caused by chlamydia and is
in the third trimester or at time of delivery, and their unnecessary when systemic treatment is administered.
partners should also be tested and treated;
Follow-Up
• retesting pregnant women during the third trimester who
initially tested negative but remained at increased risk for Because the efficacy of erythromycin treatment for
acquiring infection (e.g., women aged <25 years and those ophthalmia neonatorum is approximately 80%, a second
aged ≥25 years who have a new sex partner, more than one course of therapy might be required (834,835). Data regarding

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 Recommendations and Reports

the efficacy of azithromycin for ophthalmia neonatorum are an STI). In the absence of laboratory results in a situation
limited. Therefore, follow-up of infants is recommended to with a high degree of suspicion of chlamydial infection and
determine whether the initial treatment was effective. The the mother is unlikely to return with the infant for follow-up,
possibility of concomitant chlamydial pneumonia should be exposed infants can be presumptively treated with the shorter-
considered (see Infant Pneumonia Caused by C. trachomatis). course regimen of azithromycin 20 mg/kg body weight/day
orally, 1 dose daily for 3 days.
Management of Mothers and Their Sex Partners
Mothers of infants who have ophthalmia caused by chlamydia Recommended Regimen for Chlamydial Pneumonia Among
Infants
and the sex partners of these women should be evaluated and
Erythromycin base or ethyl succinate 50 mg/kg body weight/day orally
presumptively treated for chlamydia (see Chlamydial Infection divided into 4 doses daily for 14 days
Among Adolescents and Adults).
Alternative Regimen
Infant Pneumonia Caused by C. trachomatis
Azithromycin suspension 20 mg/kg body weight/day orally, 1 dose
Chlamydial pneumonia among infants typically occurs at age daily for 3 days
1–3 months and is a subacute pneumonia. Characteristic signs
of chlamydial pneumonia among infants include a repetitive
staccato cough with tachypnea and hyperinflation and bilateral Follow-Up
diffuse infiltrates on a chest radiograph. In addition, peripheral Because erythromycin effectiveness in treating pneumonia
eosinophilia (≥400 cells/mm3) occurs frequently. Because caused by C. trachomatis is approximately 80%, a second
clinical presentations differ, all infants aged 1–3 months course of therapy might be required (836). Data regarding
suspected of having pneumonia, especially those whose effectiveness of azithromycin in treating chlamydial pneumonia
mothers have a history of, are at risk for (e.g., aged <25 years are limited. Follow-up of infants is recommended to determine
and those aged ≥25 years who have a new sex partner, more whether the pneumonia has resolved, although certain infants
than one sex partner, a sex partner with concurrent partners, with chlamydial pneumonia continue to have abnormal
or a sex partner who has an STI), or suspected of having a pulmonary function tests later during childhood.
chlamydial infection should be tested for C. trachomatis and
Management of Mothers and Their Sex Partners
treated if infected.
Mothers of infants who have chlamydial pneumonia and the
Diagnostic Considerations sex partners of these women should be evaluated, tested, and
Specimens for chlamydial testing should be collected from presumptively treated for chlamydia (see Chlamydial Infection
the nasopharynx. Tissue culture is the definitive standard Among Adolescents and Adults).
diagnostic test for chlamydial pneumonia. Nonculture
tests (e.g., DFA and NAAT) can be used. DFA is the only Chlamydial Infection Among Infants and
nonculture FDA-cleared test for detecting C. trachomatis from
Children
nasopharyngeal specimens; however, DFA of nasopharyngeal
specimens has a lower sensitivity and specificity than culture. Sexual abuse should be considered a cause of chlamydial
NAATs are not cleared by FDA for detecting chlamydia from infection among infants and children. However, perinatally
nasopharyngeal specimens, and clinical laboratories should transmitted C. trachomatis infection of the nasopharynx,
verify the procedure according to CLIA regulations (553). urogenital tract, and rectum can persist for 2–3 years (see
Tracheal aspirates and lung biopsy specimens, if collected, Sexual Assault or Abuse of Children).
should be tested for C. trachomatis. Diagnostic Considerations
Treatment NAATs can be used to test vaginal and urine specimens
Because test results for chlamydia often are unavailable at the from girls and urine in boys (see Sexual Assault or Abuse
time initial treatment decisions are being made, treatment for of Children). Data are lacking regarding use of NAATs for
C. trachomatis pneumonia frequently is based on clinical and specimens from extragenital sites (rectum and pharynx) among
radiologic findings, age of the infant (i.e., 1–3 months), and boys and girls (553); other nonculture tests (e.g., DFA) are
risk for chlamydia in the mother (i.e., aged <25 years, history not recommended because of specificity concerns. Although
of chlamydial infection, multiple sex partners, a sex partner data regarding NAATs for specimens from extragenital sites for
with a concurrent partner, or a sex partner with a history of children are more limited and performance is test dependent
(553), no evidence supports that NAAT performance

70 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

for detecting C. trachomatis for extragenital sites among inconsistent condom use among persons who are not in
children would differ from that among adults. Because of mutually monogamous relationships, previous or coexisting
the implications of a diagnosis of C. trachomatis infection in STIs, and exchanging sex for money or drugs. Clinicians
a child, only CLIA-validated, FDA-cleared NAAT should be should consider the communities they serve and consult local
used for extragenital site specimens (837). public health authorities for guidance regarding identifying
groups at increased risk. Gonococcal infection, in particular, is
Recommended Regimens for Chlamydial Infection Among concentrated in specific geographic locations and communities.
Infants and Children MSM at high risk for gonococcal infection (e.g., those with
For infants and children weighing <45 kg: Erythromycin base or ethyl multiple anonymous partners or substance abuse) or those at
succinate 50 mg/kg body weight/day orally divided into 4 doses daily
for 14 days
risk for HIV acquisition should be screened at all anatomic
Data are limited regarding the effectiveness and optimal dose of
sites of exposure every 3–6 months (see Men Who Have Sex
azithromycin for treating chlamydial infection among infants and with Men). At least annual screening is recommended for all
children weighing <45 kg. MSM. Screening for gonorrhea among heterosexual men and
For children weighing ≥45 kg but aged <8 years: Azithromycin 1 g women aged >25 years who are at low risk for infection is
orally in a single dose
not recommended (149). A recent travel history with sexual
For children aged ≥8 years: Azithromycin 1 g orally in a single dose contacts outside the United States should be part of any
or
Doxycycline 100 mg orally 2 times/day for 7 days gonorrhea evaluation.
Diagnostic Considerations
Other Management Considerations Specific microbiologic diagnosis of N. gonorrhoeae infection
See Sexual Assault or Abuse of Children. should be performed for all persons at risk for or suspected of
having gonorrhea; a specific diagnosis can potentially reduce
Follow-Up complications, reinfections, and transmission. Culture, NAAT,
A test of cure to detect therapeutic failure ensures treatment and POC NAAT, such as GeneXpert (Cepheid), are available
effectiveness and should be obtained at a follow-up visit for detecting genitourinary infection with N. gonorrhoeae
approximately 4 weeks after treatment is completed. (149); culture requires endocervical (women) or urethral
(men) swab specimens. Culture is also available for detecting
rectal, oropharyngeal, and conjunctival gonococcal infection.
Gonococcal Infections NAATs and POC NAATs) allow for the widest variety of
FDA-cleared specimen types, including endocervical and
Gonococcal Infection Among vaginal swabs and urine for women, urethral swabs and urine
Adolescents and Adults for men, and rectal swabs and pharyngeal swabs for men and
women (www.accessdata.fda.gov/cdrh_docs/reviews/K121710.
In the United States, an estimated 1,568,000 new
pdf ). However, product inserts for each NAAT manufacturer
N. gonorrhoeae infections occur each year (141,838), and
should be consulted carefully because collection methods
gonorrhea is the second most commonly reported bacterial
and specimen types vary. Certain NAATs that have been
communicable disease. Urethral infections caused by
demonstrated to detect commensal Neisseria species might
N. gonorrhoeae can produce symptoms among men that cause
have comparable low specificity when testing oropharyngeal
them to seek curative treatment soon enough to prevent
specimens for N. gonorrhoeae (553). NAAT sensitivity for
sequelae, but often not soon enough to prevent transmission
detecting N. gonorrhoeae from urogenital and nongenital
to others. Among women, gonococcal infections are commonly
anatomic sites is superior to culture but varies by NAAT type
asymptomatic or might not produce recognizable symptoms
(553,800–803). For urogenital infections, optimal specimen
until complications (e.g., PID) have occurred. PID can result in
types for gonorrhea screening using NAATs include first-void
tubal scarring that can lead to infertility or ectopic pregnancy.
urine for men and vaginal swab specimens for women (553).
Annual screening for N. gonorrhoeae infection is recommended
Patient-collected samples can be used in place of provider-
for all sexually active women aged <25 years and for older
collected samples in clinical settings when testing by NAAT
women at increased risk for infection (e.g., those aged ≥25 years
for urine (men and women), vaginal swabs, rectal swabs, and
who have a new sex partner, more than one sex partner, a sex
oropharyngeal swabs after patient instructions have been
partner with concurrent partners, or a sex partner who has
provided (209,806,839–842). Patient-collected specimens
an STI) (149). Additional risk factors for gonorrhea include

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 Recommendations and Reports

are reasonable alternatives to provider-collected swabs for cefixime needed to inhibit in vitro growth of the N. gonorrhoeae
gonorrhea screening by NAAT. strains circulating in the United States and other countries
In cases of suspected or documented treatment failure, increased, demonstrating that cefixime effectiveness might be
clinicians should perform both culture and antimicrobial waning (851). In addition, treatment failures with cefixime or
susceptibility testing because NAATs cannot provide other oral cephalosporins were reported in Asia (852–855),
antimicrobial susceptibility results. Because N. gonorrhoeae Europe (856–860), South Africa (861), and Canada (862,863).
has demanding nutritional and environmental growth During that time, case reports of ceftriaxone treatment failures
requirements, optimal recovery rates are achieved when for pharyngeal infections reported in Australia (864,865),
specimens are inoculated directly and when the growth Japan (866), and Europe were concerning (856,867).
medium is promptly incubated in an increased carbon dioxide Consequently, CDC no longer recommends cefixime as a
(CO2) environment (553). Nonnutritive swab transport first-line regimen for gonorrhea treatment in the United
systems are available that might maintain gonococcal viability States (868). Since 2013, the proportion of GISP isolates
for <48 hours in ambient temperatures (843–845). that demonstrate reduced susceptibility (minimal inhibitory
Because of its high specificity (>99%) and sensitivity concentration [MIC] ≥2.0 µg/mL) to azithromycin has
(>95%), a Gram stain of urethral discharge or secretions that increased almost tenfold, to 5.1% in 2019 (141). Unlike the
demonstrate polymorphonuclear leukocytes with intracellular appearance of ciprofloxacin resistance in the early 2000s, and
gram-negative diplococci can be considered diagnostic for cefixime reduced-susceptibility isolates during 2010–2011,
infection with N. gonorrhoeae among symptomatic men. emergence of azithromycin resistance is not concentrated
However, because of lower sensitivity, a negative Gram stain among certain populations (e.g., MSM in the western United
should not be considered sufficient for ruling out infection States). Azithromycin has unique pharmacokinetic properties
among asymptomatic men. Infection detection by using that might predispose to resistance due to its prolonged half-life
Gram stain of endocervical, pharyngeal, and rectal specimens (869,870). With the exception of a small cluster of gonorrhea
also is insensitive and is not recommended. MB or GV stain strains with azithromycin resistance and reduced susceptibility
of urethral secretions is an alternative POC diagnostic test to cefixime and ceftriaxone among seven patients during 2016,
with performance characteristics similar to Gram stain. all gonorrhea strains identified by GISP are susceptible to
Gonococcal infection is diagnosed among symptomatic men by either or both azithromycin and ceftriaxone or cefixime. In
documenting the presence of a WBC-containing intracellular addition, since 2013, antimicrobial stewardship has become
purple diplococci in MB or GV smears. an urgent public health concern in the United States as
described in Antimicrobial Resistant Threats in the United States
Antimicrobial-Resistant N. gonorrhoeae (871). Emergence of azithromycin resistance is not isolated to
Gonorrhea treatment is complicated by the ability of N. gonorrhoeae; it has also been demonstrated in M. genitalium
N. gonorrhoeae to develop resistance to antimicrobials and such enteric pathogens as Shigella and Campylobacter (see
(846–848). In 1986, the Gonococcal Isolate Surveillance Mycoplasma genitalium; Proctitis, Proctocolitis, and Enteritis).
Project (GISP), a national sentinel surveillance system, was Finally, concern exists regarding azithromycin treatment
established to monitor trends in antimicrobial susceptibilities efficacy for chlamydia (see Chlamydial Infections).
of urethral N. gonorrhoeae strains in the United States Dual therapy for gonococcal infection with ceftriaxone and
(849). The epidemiology of antimicrobial resistance guides azithromycin recommended in previous guidance might have
decisions about gonococcal treatment recommendations mitigated emergence of reduced susceptibility to ceftriaxone in
and has evolved because of shifts in antimicrobial resistance N. gonorrhoeae; however, concerns regarding potential harm to
patterns. During 2007, emergence of fluoroquinolone- the microbiome and the effect on other pathogens diminishes
resistant N. gonorrhoeae in the United States prompted CDC the benefits of maintaining dual therapy. Consequently, only
to cease recommending fluoroquinolones for gonorrhea ceftriaxone is recommended for treating gonorrhea in the
treatment, leaving cephalosporins as the only remaining United States (872). Clinicians remaining vigilant for treatment
class of antimicrobials available for gonorrhea treatment in failures is paramount, and CDC plans to continue to monitor
the United States (850). Reflecting concern about emerging for changing ceftriaxone MICs until additional antimicrobials
gonococcal resistance, CDC’s 2010 STD treatment guidelines or a vaccine is available. In cases in which chlamydial
recommended dual therapy for gonorrhea with a cephalosporin infection has not been excluded, patients should also receive
plus either azithromycin or doxycycline, even if NAAT for antichlamydial therapy. CDC and state health departments
C. trachomatis was negative at the time of treatment (851). participate in CDC-supported gonorrhea surveillance activities
However, during 2006–2011, the minimum concentrations of

72 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

(https://www.cdc.gov/std/gisp) and can provide the most N. gonorrhoeae when manufacturer instructions are followed. Disc
current information regarding gonococcal susceptibility. diffusion only provides qualitative susceptibility results.
Criteria for resistance to cefixime and ceftriaxone have not
been defined by the Clinical and Laboratory Standards Institute Uncomplicated Gonococcal Infection of the
(CLSI). However, isolates with cefixime or ceftriaxone MICs Cervix, Urethra, or Rectum
≥0.5 µg/mL are considered to have decreased susceptibility Recommended Regimen for Uncomplicated Gonococcal
(873). In the United States, the proportion of isolates in Infection of the Cervix, Urethra, or Rectum Among Adults and
GISP demonstrating decreased susceptibility to ceftriaxone Adolescents
or cefixime has remained low; during 2019, <0.1% of isolates Ceftriaxone 500 mg* IM in a single dose for persons weighing <150 kg
with decreased susceptibility (MIC ≥0.5 µg/mL) to ceftriaxone If chlamydial infection has not been excluded, treat for chlamydia with
doxycycline 100 mg orally 2 times/day for 7 days.
or cefixime were identified (141). Because increasing MICs
might predict resistance emergence, GISP established lower * For persons weighing ≥150 kg, 1 g ceftriaxone should be administered.
cephalosporin MIC threshold values that are lower than the
susceptibility breakpoints set by CLSI to provide greater Although clinical data confirm that a single injection
sensitivity in detecting decreasing gonococcal susceptibility of ceftriaxone 250 mg is >99% (95% confidence interval
for surveillance purposes. The percentage of isolates with [CI]: 97.6%–99.7%) effective in curing anogenital gonorrhea
cefixime MICs ≥0.25 µg/mL increased from 0.1% during of circulating isolates (MIC = 0.03 µg/mL), a higher dose is
2006 to 1.4% during 2011 (851,874) and declined to 0.3% likely necessary for isolates with elevated MICs (880,881).
during 2019 (141). The percentage of isolates with ceftriaxone Effective treatment of uncomplicated urogenital gonorrhea with
MICs ≥0.125 µg/mL increased from <0.1% in 2006 to ceftriaxone requires concentrations higher than the strain MIC
0.4% in 2011 and decreased to 0.1% in 2019 (141). Isolates for approximately 24 hours; although individual variability
with high-level cefixime and ceftriaxone MICs (MICs = exists in the pharmacokinetics of ceftriaxone, a 500-mg dose
1.5–8.0 µg/mL and MICs = 1.5–4.0 µg/mL, respectively) of ceftriaxone is expected to achieve in approximately 50 hours
have been identified in Japan (866), France (867,875), Spain MIC >0.03 µg/mL (880,881). The pharmacokinetics of
(876,877), the United Kingdom, and Australia (878,879). ceftriaxone might be different in the pharynx with longer times
Decreased susceptibility of N. gonorrhoeae to cephalosporins higher than the strain MIC likely needed to prevent selection
and other antimicrobials is expected to continue; state and of mutant strains in the pharynx (882).
local surveillance for antimicrobial resistance is crucial for Single-dose injectable cephalosporin regimens, other than
guiding local therapy recommendations (846,847). Although ceftriaxone, that are safe and have been effective against
approximately 3% of all U.S. men who have gonococcal uncomplicated urogenital and anorectal gonococcal infections
infections are sampled through GISP, surveillance by clinicians in the past include ceftizoxime (500 mg IM), cefoxitin (2 g IM
also is crucial. Clinicians who diagnose N. gonorrhoeae infection with probenecid 1 g orally), and cefotaxime (500 mg IM).
in a person with suspected cephalosporin treatment failure None of these injectable cephalosporins offer any advantage
should perform culture and AST of relevant clinical specimens, over ceftriaxone 250 mg for urogenital infection, and efficacy
consult an infectious disease specialist or an STD clinical for pharyngeal infection is less certain (883,884). Because the
expert (https://www.stdccn.org/render/Public) for guidance ceftriaxone dose has been increased and the pharmacokinetics
in clinical management, and report the case to CDC through of other cephalosporins have not been evaluated, these dosing
state and local public health authorities within 24 hours. regimens might be at a disadvantage over ceftriaxone 500 mg.
Isolates should be saved and sent to CDC through local and Alternative Regimens if Ceftriaxone Is Not Available
state public health laboratory mechanisms. Health departments
Gentamicin 240 mg IM in a single dose
should prioritize notification and culture evaluation for sexual plus
partners of persons with N. gonorrhoeae infection thought Azithromycin 2 g orally in a single dose
or
to be associated with cephalosporin treatment failure or Cefixime* 800 mg orally in a single dose
persons whose isolates demonstrate decreased susceptibility
* If chlamydial infection has not been excluded, providers should treat for
to cephalosporin. Agar dilution is the reference standard chlamydia with doxycycline 100 mg orally 2 times/day for 7 days.
and preferred method of antimicrobial susceptibility testing
with N. gonorrhoeae. Antibiotic gradient strips, such as Etest In one clinical trial, dual treatment with single doses of
(bioMérieux), can be used and are considered an acceptable IM gentamicin 240 mg plus oral azithromycin 2 g cured
alternative for quantitative antimicrobial susceptibility testing with 100% of cases (lower one-sided 95% CI bound: 98.5%) and

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 73
 Recommendations and Reports

can be considered an alternative to ceftriaxone for persons Spectinomycin is effective (98.2% in curing uncomplicated
with cephalosporin allergy (885). This trial was not powered urogenital and anorectal gonococcal infections) but has poor
enough to provide reliable estimates of the efficacy of these efficacy for pharyngeal infections (883,887). It is unavailable
regimens for treatment of rectal or pharyngeal infection; in the United States, and the gentamicin alternative regimen
however, this regimen cured the few extragenital infections has replaced the need for spectinomycin, if a cephalosporin
among study participants. Notably, gastrointestinal adverse allergy exists, in the United States.
events, primarily vomiting <1 hour after dosing, occurred
among 3%–4% of persons treated with gentamicin plus Uncomplicated Gonococcal Infection of
azithromycin, necessitating retreatment with ceftriaxone the Pharynx
and azithromycin. A similar trial that studied gentamicin The majority of gonococcal infections of the pharynx are
240 mg plus azithromycin 1 g determined lower cure rates at asymptomatic and can be relatively common among certain
extragenital sites; 80% (95% CI: 72%–88%) of pharyngeal populations (800,801,888–890). Although these infections
and 90% (95% CI: 84%–95%) of rectal infections were cured rarely cause complications, they have been reported to be a
with this regimen (886). Gemifloxacin plus azithromycin has major source of community transmission and might be a driver
been studied and is no longer recommended as an alternative of antimicrobial resistance (891,892). Gonococcal infections
regimen because of limited availability, cost, and antimicrobial of the pharynx are more difficult to eradicate than infections
stewardship concerns (885). at urogenital and anorectal sites (862). Few antimicrobial
An 800-mg oral dose of cefixime should be considered only regimens reliably cure >90% of gonococcal pharyngeal
as an alternative cephalosporin regimen because it does not infections (883,884). Providers should ask their patients with
provide as high, nor as sustained, bactericidal blood levels as a urogenital or rectal gonorrhea about oral sexual exposure; if
500-mg IM dose of ceftriaxone. Furthermore, it demonstrates reported, pharyngeal testing should be performed.
limited efficacy for treatment of pharyngeal gonorrhea (92.3%
Recommended Regimen for Uncomplicated Gonococcal
cure; 95% CI: 74.9%–99.1%); in older clinical studies, Infection of the Pharynx Among Adolescents and Adults
cefixime cured 97.5% of uncomplicated urogenital and Ceftriaxone 500 mg* IM in a single dose for persons weighing <150 kg
anorectal gonococcal infections (95% CI: 95.4%–99.8%)
* For persons weighing ≥150 kg, 1 g ceftriaxone should be administered.
(883,884). The increase in the prevalence of isolates obtained
through GISP with elevated cefixime MICs might indicate
If chlamydial infection is identified when pharyngeal
early stages of development of clinically significant gonococcal
gonorrhea testing is performed, treat for chlamydia with
resistance to cephalosporins. Changes in cefixime MICs can
doxycycline 100 mg orally 2 times/day for 7 days. No reliable
result in decreasing effectiveness of cefixime for treating
alternative treatments are available for pharyngeal gonorrhea.
urogenital gonorrhea. Furthermore, as cefixime becomes
For persons with an anaphylactic or other severe reaction
less effective, continued used of cefixime might hasten the
(e.g., Stevens Johnson syndrome) to ceftriaxone, consult
development of resistance to ceftriaxone, a safe, well-tolerated,
an infectious disease specialist for an alternative treatment
injectable cephalosporin and the last antimicrobial known to
recommendation.
be highly effective in a single dose for treatment of gonorrhea
at all anatomic infection sites. Other oral cephalosporins (e.g., Other Management Considerations
cefpodoxime and cefuroxime) are not recommended because of To maximize adherence with recommended therapies
inferior efficacy and less favorable pharmacodynamics (883). and reduce complications and transmission, medication
Monotherapy with azithromycin 2 g orally as a single for gonococcal infection should be provided on-site and
dose has been demonstrated to be 99.2% effective against directly observed. If medications are unavailable when
uncomplicated urogenital gonorrhea (95% CI: 97.3%–99.9%) treatment is indicated, linkage to an STI treatment facility
(883). However, monotherapy is not recommended because should be provided for same-day treatment. To minimize
of concerns about the ease with which N. gonorrhoeae can disease transmission, persons treated for gonorrhea should
develop resistance to macrolides, the high proportion of isolates be instructed to abstain from sexual activity for 7 days after
with azithromycin decreased susceptibility, and documented treatment and until all sex partners are treated (7 days after
azithromycin treatment failures (859). Strains of N. gonorrhoeae receiving treatment and resolution of symptoms, if present).
circulating in the United States are not adequately susceptible All persons who receive a diagnosis of gonorrhea should be
to penicillin, tetracycline, and older macrolides (e.g., tested for other STIs, including chlamydia, syphilis, and HIV.
erythromycin), and thus use of these antimicrobials cannot
be recommended.

74 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Those persons whose HIV test results are negative should be been documented, the partner may be treated with a single
offered HIV PrEP. dose of oral cefixime 800 mg plus oral doxycycline 100 mg
2 times/day for 7 days. If adherence with multiday dosing is
Follow-Up
a considerable concern, azithromycin 1 g can be considered
A test of cure (i.e., repeat testing after completion of but has lower treatment efficacy among persons with rectal
therapy) is unnecessary for persons who receive a diagnosis of chlamydia (see Chlamydial Infections). Provision of medication
uncomplicated urogenital or rectal gonorrhea who are treated by EPT should be accompanied by written materials (125,127)
with any of the recommended or alternative regimens. Any for educating partners about gonorrhea, their exposure to
person with pharyngeal gonorrhea should return 7–14 days gonorrhea, and the importance of therapy. These materials
after initial treatment for a test of cure by using either culture or should also educate partners about seeking clinical evaluation
NAAT; however, testing at 7 days might result in an increased for adverse reactions or complications and general follow-up
likelihood of false-positive tests. If the NAAT is positive, effort when able. Educational materials for female partners should
should be made to perform a confirmatory culture before include information about the importance of seeking medical
retreatment, especially if a culture was not already collected. All evaluation for PID, especially if symptomatic; undertreatment
positive cultures for test of cure should undergo antimicrobial of PID among female partners and missed opportunities for
susceptibility testing. Symptoms that persist after treatment diagnosing other STIs among women are of concern. MSM
should be evaluated by culture for N. gonorrhoeae (with or with gonorrhea have a high risk for coexisting infections
without simultaneous NAAT) and antimicrobial susceptibility. (especially undiagnosed HIV) among their partners, and they
Persistent urethritis, cervicitis, or proctitis also might be caused might have partners without HIV who could benefit from
by other organisms (see Urethritis; Cervicitis; Proctitis). PrEP. Data are also limited regarding the effectiveness of EPT
A high prevalence of N. gonorrhoeae infection has been in reducing persistent or recurrent gonorrhea among MSM
observed among men and women previously treated for (133,135); thus, shared clinical decision-making regarding
gonorrhea (137,753,754,893). The majority of these infections EPT for MSM is recommended (see Partner Services). To avoid
result from reinfection caused by failure of sex partners to reinfection, sex partners should be instructed to abstain from
receive treatment or the initiation of sexual activity with a condomless sexual intercourse for 7 days after they and their
new infected partner, indicating a need for improved patient sex partners have completed treatment and after resolution of
education and treatment of sex partners. Men or women who symptoms, if present.
have been treated for gonorrhea should be retested 3 months
after treatment regardless of whether they believe their sex Suspected Cephalosporin Treatment Failure
partners were treated; scheduling the follow-up visit at the Cephalosporin treatment failure is the persistence of
time of treatment is encouraged. If retesting at 3 months is not N. gonorrhoeae infection despite recommended cephalosporin
possible, clinicians should retest whenever persons next seek treatment; such failure is indicative of infection with
medical care <12 months after initial treatment. cephalosporin-resistant gonorrhea among persons whose
partners were treated and whose risk for reinfection is
Management of Sex Partners
low. Suspected treatment failure has been reported among
Recent sex partners (i.e., persons having sexual contact with persons receiving oral and injectable cephalosporins (852–
the infected patient <60 days preceding onset of symptoms or 855,857,859,861,863,864,867,875,894). Treatment failure
gonorrhea diagnosis) should be referred for evaluation, testing, should be considered for persons whose symptoms do not
and presumptive treatment. If the patient’s last potential sexual resolve within 3–5 days after recommended treatment and
exposure was >60 days before onset of symptoms or diagnosis, report no sexual contact during the posttreatment follow-up
the most recent sex partner should be treated. period and persons with a positive test of cure (i.e., positive
If health department partner-management strategies (e.g., culture >72 hours or positive NAAT >7 days after receiving
disease intervention specialists) are impractical or unavailable recommended treatment) when no sexual contact is reported
for persons with gonorrhea and partners’ access to prompt during the posttreatment follow-up period (874). Treatment
clinical evaluation and treatment is limited, EPT can be failure should also be considered for persons who have a
delivered to the partner by the patient or a collaborating positive culture on test of cure, if obtained, if evidence exists
pharmacy as permitted by law (see Partner Services). Treatment of decreased susceptibility to cephalosporins on antimicrobial
of the sexual partner with cefixime 800 mg as a single dose susceptibility testing, regardless of whether sexual contact is
is recommended, provided that concurrent chlamydial reported during the posttreatment follow-up period.
infection has been excluded. If a chlamydia test result has not

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 75
 Recommendations and Reports

The majority of suspected treatment failures in the United and presumptively treated by using the same regimen used
States are likely to be reinfections rather than actual treatment for the patients.
failures (137,753,754,894). However, in cases in which
reinfection is unlikely and treatment failure is suspected, Special Considerations
before retreatment, relevant clinical specimens should be Drug Allergy, Intolerance, and Adverse Reactions
obtained for culture (preferably with simultaneous NAAT)
The risk for penicillin cross-reactivity is highest with
and antimicrobial susceptibility testing if N. gonorrhoeae is
first-generation cephalosporins but is rare (<1%) with
isolated. Phenotypic antimicrobial susceptibility testing should
third-generation cephalosporins (e.g., ceftriaxone and
be performed by using Etest or agar dilution. All isolates
cefixime) (631,680,896). Clinicians should first thoroughly
of suspected treatment failures should be sent to CDC for
assess a patient’s allergy history, including type of reaction,
antimicrobial susceptibility testing by agar dilution; local
associated medications, and previous prescription records.
laboratories should store isolates for possible further testing if
If IgE-mediated penicillin allergy is strongly suspected, dual
needed. Testing or storage of specimens or isolates should be
treatment with single doses of IM gentamicin 240 mg plus oral
facilitated by the state or local health department according to
azithromycin 2 g can be administered (885,886). If a patient
local public health protocol. Instructions for shipping isolates
is asymptomatic and the treating facility is able to perform
to CDC are available at https://www.cdc.gov/std/gonorrhea/
gyrase A (gyrA) testing to identify ciprofloxacin susceptibility
arg/specimen_shipping_instructions1-29-08.pdf.
(wild type), oral ciprofloxacin 500 mg in a single dose can be
For persons with suspected cephalosporin treatment failure,
administered. Providers treating persons with IgE-mediated
the treating clinician should consult an infectious disease
cephalosporin or penicillin allergy should refer to the section
specialist, the National Network of STD Clinical Prevention
of these guidelines regarding evaluation (see Management of
Training Center clinical consultation line (https://www.stdccn.
Persons Who Have a History of Penicillin Allergy).
org/render/Public), the local or state health department STI
program, or CDC (telephone: 800-232-4636) for advice about Pregnancy
obtaining cultures, antimicrobial susceptibility testing and Pregnant women infected with N. gonorrhoeae should be
treatment. Suspected treatment failure should be reported to treated with ceftriaxone 500 mg in a single IM dose plus
CDC through the local or state health department <24 hours treatment for chlamydia if infection has not been excluded.
after diagnosis. When cephalosporin allergy or other considerations preclude
Patients with suspected treatment failures should first be treatment with this regimen, consultation with an infectious
retreated routinely with the initial regimen used (ceftriaxone disease specialist or an STD clinical expert is recommended.
500 mg IM), with the addition of doxycycline if chlamydia Gentamicin use is cautioned during pregnancy because of risk
infection exists, because reinfections are more likely than for neonatal birth defects, nephrotoxicity, or ototoxicity (897)
actual treatment failures. However, in situations with a higher (https://www.stdccn.org/render/Public).
likelihood of treatment failure than reinfection, relevant
clinical specimens should be obtained for culture (preferably HIV Infection
with simultaneous NAAT) and antimicrobial susceptibility Persons who have gonorrhea and HIV infection should
testing before retreatment. Dual treatment with single doses receive the same treatment regimen as those who do not
of IM gentamicin 240 mg plus oral azithromycin 2 g can be have HIV.
considered, particularly when isolates are identified as having
elevated cephalosporin MICs (885,886,895). Persons with Gonococcal Conjunctivitis
suspected treatment failure after treatment with the alternative In the only published study of the treatment regarding
regimen (cefixime or gentamicin) should be treated with gonococcal conjunctivitis among adults, all 12 study
ceftriaxone 500 mg as a single IM dose or as a single dose with participants responded to a single 1-g IM injection of
or without an antichlamydial agent on the basis of chlamydia ceftriaxone (898). Because gonococcal conjunctivitis is
infection status. A test of cure at relevant clinical sites should uncommon and data regarding treatment of gonococcal
be obtained 7–14 days after retreatment; culture is the conjunctivitis among adults are limited, consultation with an
recommended test, preferably with simultaneous NAAT, and infectious disease specialist should be considered.
antimicrobial susceptibility testing of N. gonorrhoeae if isolated.
Clinicians should ensure that the patients’ sex partners from
the preceding 60 days are evaluated promptly with culture

76 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Recommended Regimen for Gonococcal Conjunctivitis Among Alternative Regimens

Adolescents and Adults Cefotaxime 1 g IV every 8 hours
Ceftriaxone 1 g IM in a single dose or
Ceftizoxime 1 g every 8 hours
Providers should consider one-time lavage of the infected eye with
saline solution. If chlamydial infection has not been excluded, providers should treat for
chlamydia with doxycycline 100 mg orally 2 times/day for 7 days.

Management of Sex Partners When treating for the arthritis-dermatitis syndrome, the
Patients should be instructed to refer their sex partners provider can switch to an oral agent guided by antimicrobial
for evaluation and treatment (see Gonococcal Infections, susceptibility testing 24–48 hours after substantial clinical
Management of Sex Partners). improvement, for a total treatment course of >7 days.

Disseminated Gonococcal Infection Treatment of Gonococcal Meningitis and Endocarditis

Infrequently, N. gonorrhoeae can cause disseminated Recommended Regimen for Gonococcal Meningitis and
infection. Disseminated gonococcal infection (DGI) frequently Endocarditis
results in petechial or pustular acral skin lesions, asymmetric Ceftriaxone 1–2 g IV every 24 hours
polyarthralgia, tenosynovitis, or oligoarticular septic arthritis If chlamydial infection has not been excluded, providers should treat for
(899–901). Rarely, DGI is complicated by perihepatitis chlamydia with doxycycline 100 mg orally 2 times/day for 7 days.

associated with gonococcal PID, endocarditis, or meningitis.

Certain strains of N. gonorrhoeae that cause DGI can cause No recent studies have been published regarding treatment
minimal genital inflammation, and urogenital or anorectal of DGI involving the CNS or cardiovascular system. The
infections are often asymptomatic among DGI patients. duration of treatment for DGI in these situations has not been
If DGI is suspected, NAATs or culture specimens from all systematically studied and should be determined in consultation
exposed urogenital and extragenital sites should be collected with an infectious disease specialist. Treatment for DGI should
and processed, in addition to disseminated sites of infection be guided by the results of antimicrobial susceptibility testing.
(e.g., skin, synovial fluid, blood, or CSF). All N. gonorrhoeae Length of treatment should be determined based on clinical
isolates should be tested for antimicrobial susceptibility. presentation. Therapy for meningitis should be continued with
Risk factors for dissemination have included female sex, recommended parenteral therapy for 10–14 days. Parenteral
menstruation, pregnancy, and terminal complement deficiency antimicrobial therapy for endocarditis should be administered
(899); however, reports are increasing among men (900,901). for >4 weeks. Treatment of gonococcal perihepatitis should be
Persons receiving eculizumab, a monoclonal antibody that managed in accordance with the recommendations for PID
inhibits terminal complement activation, also might be at in these guidelines.
higher risk for DGI (902). Management of Sex Partners
Hospitalization and consultation with an infectious disease
specialist are recommended for initial therapy, especially Gonococcal infection frequently is asymptomatic among sex
for persons who might not comply with treatment, have an partners of persons who have DGI. Providers should instruct
uncertain diagnosis, or have purulent synovial effusions or patients to refer partners with whom they have had sexual
other complications. Examination for clinical evidence of contact during the previous 60 days for evaluation, testing,
endocarditis and meningitis should be performed. and presumptive treatment (see Gonococcal Infections,
Management of Sex Partners).
Treatment of Arthritis and Arthritis-Dermatitis
Syndrome Gonococcal Infection Among Neonates
Recommended Regimen for Gonococcal-Related Arthritis and Prenatal screening and treatment of pregnant women for
Arthritis-Dermatitis Syndrome
gonorrhea is the best method for preventing N. gonorrhoeae
Ceftriaxone 1 g IM or IV every 24 hours infection among neonates. Gonococcal infection among
If chlamydial infection has not been excluded, providers should treat for neonates results from perinatal exposure to the mother’s infected
chlamydia with doxycycline 100 mg orally 2 times/day for 7 days.
cervix. It is usually an acute illness that manifests 2–5 days after
birth. Prevalence of infection among neonates depends on the
prevalence of infection among pregnant women and whether
pregnant women are screened and treated for gonorrhea during

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 77
 Recommendations and Reports

pregnancy. The most severe manifestations of N. gonorrhoeae in a community with high rates of gonorrhea) or received
infection among neonates are ophthalmia neonatorum and no prenatal care; providers caring for the mother and the
sepsis, which can include arthritis and meningitis. Less severe newborn should communicate to ensure follow-up on the
manifestations include rhinitis, vaginitis, urethritis, and scalp results of laboratory tests performed at delivery, and if
infection at sites of previous fetal monitoring. positive, prompt appropriate treatment of the newborn
and mother.
Preventing Ophthalmia Neonatorum Caused by Erythromycin is the only ophthalmic ointment recommended
N. gonorrhoeae for use among neonates. Silver nitrate and tetracycline
Ocular prophylaxis and preventive gonorrhea screening ophthalmic ointments are no longer manufactured in the
and treatment of infected pregnant women are especially United States, bacitracin is ineffective, and povidone iodine
important because ophthalmia neonatorum can result in has not been studied adequately (905,906). Gentamicin
perforation of the globe of the eye and blindness (903). ophthalmic ointment has been associated with severe ocular
Ocular prophylaxis for gonococcal ophthalmia neonatorum reactions (907,908). If erythromycin ointment is unavailable,
has a long history of preventing sight-threatening gonococcal infants at risk for exposure to N. gonorrhoeae, especially those
ocular infections. Cases in the United States are uncommon, born to a mother at risk for gonococcal infection or with no
which is likely attributable to gonorrhea screening programs prenatal care, can be administered ceftriaxone 25–50 mg/kg
for women, including pregnant women, that have contributed body weight IV or IM, not to exceed 250 mg in a single dose.
substantially to reduction in ophthalmia neonatorum (904).
Recommended Regimen to Prevent Ophthalmia Neonatorum
Neonatal ocular prophylaxis with erythromycin, the only agent Caused by N. gonorrhoeae
available in the United States, is required by law in most states Erythromycin 0.5% ophthalmic ointment in each eye in a single
and is recommended because of safety, low cost, and ease of application at birth
administration. It can contribute to preventing gonococcal
blindness because not all pregnant women are screened for Erythromycin ophthalmic ointment should be instilled
gonorrhea. The USPSTF recommends ocular prophylaxis into both eyes of neonates as soon as possible after delivery,
with erythromycin ointment for all newborns <24 hours regardless of whether they are delivered vaginally or by
after birth (903). In addition to continuing routine ocular cesarean delivery. Ideally, ointment should be applied by using
prophylaxis, prevention should focus on prenatal screening single-use tubes or ampules rather than multiple-use tubes. If
for N. gonorrhoeae, including prophylaxis is delayed (i.e., not administered in the delivery
• screening pregnant women at risk (e.g., women aged room), a monitoring system should be established to ensure
<25 years and those aged ≥25 years who have a new sex that all newborns receive prophylaxis <24 hours after delivery.
partner, more than one sex partner, a sex partner with
concurrent partners, a sex partner who has an STI, or live Diagnostic Considerations
in a community with high rates of gonorrhea) for Newborns at increased risk for gonococcal ophthalmia
N. gonorrhoeae infection at the first prenatal visit; include those who did not receive ophthalmic prophylaxis
• treating all pregnant women with N. gonorrhoeae infection and whose mothers had no prenatal care, have a history
during pregnancy and retesting in 3 months, in the third of STIs during pregnancy, or have a history of substance
trimester or at time of delivery (sex partners should be misuse. Gonococcal ophthalmia is strongly suspected when
tested and treated); intracellular gram-negative diplococci are identified on Gram
• retesting pregnant women in the third trimester who stain of conjunctival exudate, justifying presumptive treatment
initially tested negative but remained at increased risk for for gonorrhea after appropriate cultures and antimicrobial
acquiring infection (e.g., women aged <25 years and those susceptibility testing for N. gonorrhoeae are performed.
aged ≥25 years who have a new sex partner, more than one Presumptive treatment for N. gonorrhoeae might be indicated
sex partner, a sex partner with concurrent partners, a sex for newborns at increased risk for gonococcal ophthalmia who
partner who has an STI, or live in a community with high have increased WBCs (no GNID) in a Gram-stained smear
rates of gonorrhea); and of conjunctival exudate. Nongonococcal causes of neonatal
• screening for gonorrhea at delivery for women not tested ophthalmia include Moraxella catarrhalis and other Neisseria
during pregnancy and at risk for infection (e.g., women species, which are organisms that are indistinguishable from
aged <25 years and those aged ≥25 years who have a new N. gonorrhoeae on Gram-stained smear but can be differentiated
sex partner, more than one sex partner, a sex partner with in the microbiology laboratory.
concurrent partners, a sex partner who has an STI, or live

78 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Treatment of Gonococcal Ophthalmia Neonatorum Treatment

Recommended Regimen for Gonococcal Ophthalmia Recommended Regimens for Disseminated Gonococcal
Neonatorum Infection Among Neonates
Ceftriaxone 25–50 mg/kg body weight IV or IM in a single dose, not to Ceftriaxone 25–50 mg/kg body weight/day IV or IM in a single
exceed 250 mg daily dose for 7 days, with a duration of 10–14 days if meningitis is
documented
or
One dose of ceftriaxone is adequate therapy for gonococcal Cefotaxime 25 mg/kg body weight/day IV or IM every 12 hours for
ophthalmia. Ceftriaxone should be administered cautiously 7 days, with a duration of 10–14 days if meningitis is documented
to neonates with hyperbilirubinemia, especially those born
prematurely. Cefotaxime 100 mg/kg body weight IV or IM as Ceftriaxone should be administered cautiously to neonates
a single dose can be administered for those neonates unable to with hyperbilirubinemia, especially those born prematurely.
receive ceftriaxone because of simultaneous administration of Cefotaxime 100 mg/kg body weight IV or IM as a single
IV calcium. Topical antibiotic therapy alone is inadequate and dose can be administered for those neonates unable to
unnecessary if systemic treatment is administered. receive ceftriaxone because of simultaneous administration
of IV calcium.
Other Management Considerations
Chlamydial testing should be performed simultaneously from Other Management Considerations
the inverted eyelid specimen (see Ophthalmia Neonatorum Chlamydial testing should be performed simultaneously
Caused by C. trachomatis). Newborns who have gonococcal among neonates with gonococcal infection (see Chlamydial
ophthalmia should be evaluated for signs of disseminated Infection Among Neonates). Neonates who have DGI should
infection (e.g., sepsis, arthritis, and meningitis). Newborns be managed in consultation with an infectious disease specialist.
who have gonococcal ophthalmia should be managed in
consultation with an infectious disease specialist. Management of Mothers and Their Sex Partners
Mothers of newborns who have DGI or scalp abscesses caused
Management of Mothers and Their Sex Partners by N. gonorrhoeae should be evaluated, tested, and presumptively
Mothers of newborns with ophthalmia neonatorum caused by treated for gonorrhea, along with their sex partners (see
N. gonorrhoeae should be evaluated, tested, and presumptively Gonococcal Infection Among Adolescents and Adults).
treated for gonorrhea, along with their sex partners (see
Gonococcal Infection Among Adolescents and Adults). Neonates Born to Mothers Who Have Gonococcal
Infection
Disseminated Gonococcal Infection and
Neonates born to mothers who have untreated gonorrhea
Gonococcal Scalp Abscesses Among Neonates are at high risk for infection. Neonates should be tested for
DGI might present as sepsis, arthritis, or meningitis and gonorrhea at exposed sites (e.g., conjunctiva, vagina, rectum,
is a rare complication of neonatal gonococcal infection. and oropharynx) and treated presumptively for gonorrhea.
Localized gonococcal infection of the scalp can result
from fetal monitoring through scalp electrodes. Detecting Treatment in the Absence of Signs of Gonococcal
gonococcal infection among neonates who have sepsis, arthritis, Infection
meningitis, or scalp abscesses requires cultures of blood, CSF,
Recommended Regimen for Neonates Without Signs of
or joint aspirate. Specimens obtained from the conjunctiva, Gonococcal Infection
vagina, oropharynx, and rectum are useful for identifying the Ceftriaxone 20–50 mg/kg body weight IV or IM in a single dose, not to
primary site or sites of infection. Antimicrobial susceptibility exceed 250 mg
testing of all isolates should be performed. Positive Gram-
stained smears of abscess exudate, CSF, or joint aspirate provide
a presumptive basis for initiating treatment for N. gonorrhoeae. Other Management Considerations
Ceftriaxone should be administered cautiously to neonates
with hyperbilirubinemia, especially those born prematurely.
Cefotaxime 100 mg/kg body weight IV or IM as a single
dose can be administered for those neonates unable to
receive ceftriaxone because of simultaneous administration
of IV calcium. Age-appropriate chlamydial testing should be

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 79
 Recommendations and Reports

performed simultaneously among neonates with gonococcal Recommended Regimen for Uncomplicated Gonococcal
infection (see Chlamydial Infection Among Neonates). Vulvovaginitis, Cervicitis, Urethritis, Pharyngitis, or Proctitis
Follow-up examination is not required. Among Children Weighing >45 kg
Treat with the regimen recommended for adults
Management of Mothers and Their Sex Partners (see Gonococcal Infections)

Mothers who have gonorrhea and their sex partners should

Recommended Regimen for Bacteremia or Arthritis Among
be evaluated, tested, and presumptively treated for gonorrhea Children Weighing ≤45 kg
(see Gonococcal Infection Among Adolescents and Adults).
Ceftriaxone 50 mg/kg body weight (maximum dose: 2 g) IM or IV in a
single dose daily every 24 hours for 7 days
Gonococcal Infection Among
Recommended Regimen for Bacteremia or Arthritis Among
Infants and Children Children Weighing >45 kg
Sexual abuse is the most frequent cause of gonococcal Ceftriaxone 1 g IM or IV in a single dose daily every 24 hours for 7 days
infection among infants and children (see Sexual Assault or
Abuse of Children). For preadolescent girls, vaginitis is the most
common manifestation of this infection; gonococcal-associated Other Management Considerations
PID after vaginal infection can be less common among Follow-up cultures are unnecessary. Only parenteral
preadolescents than adults. Among sexually abused children, cephalosporins (i.e., ceftriaxone) are recommended for use
anorectal and pharyngeal infections with N. gonorrhoeae are among children. All children identified as having gonococcal
frequently asymptomatic. infections should be tested for C. trachomatis, syphilis, and
HIV (see Sexual Assault or Abuse of Children).
Diagnostic Considerations
Culture can be used to test urogenital and extragenital sites for
girls and boys. NAAT can be used to test for N. gonorrhoeae from Mycoplasma genitalium
vaginal and urine specimens from girls and urine for boys (see
M. genitalium causes symptomatic and asymptomatic
Sexual Assault or Abuse of Children). Although data regarding
urethritis among men and is the etiology of approximately
NAAT from extragenital sites (rectum and pharynx) among
15%–20% of NGU, 20%–25% of nonchlamydial NGU,
children are more limited, and performance is test dependent,
and 40% of persistent or recurrent urethritis (697,909,910).
no evidence supports that performance of NAAT for detection
Infection with C. trachomatis is common in selected geographic
of N. gonorrhoeae among children differs from that among adults
areas (911–913), although M. genitalium is often the sole
(553). Because of the implications of a N. gonorrhoeae diagnosis
pathogen. Data are insufficient to implicate M. genitalium
in a child, only validated FDA-cleared NAAT assays should be
infection with chronic complications among men (e.g.,
used with extragenital specimens. Consultation with an expert
epididymitis, prostatitis, or infertility). The consequences
is necessary before using NAAT to minimize the possibility of
of asymptomatic infection with M. genitalium among men
cross-reaction with nongonococcal Neisseria species and other
are unknown.
commensals (e.g., N. meningitidis, Neisseria sicca, Neisseria
Among women, M. genitalium has been associated with
lactamica, Neisseria cinerea, or M. catarrhalis) and to ensure
cervicitis, PID, preterm delivery, spontaneous abortion, and
correct interpretation of results.
infertility, with an approximately twofold increase in the risk
Gram stains are inadequate for evaluating prepubertal children
for these outcomes among women infected with M. genitalium
for gonorrhea and should not be used to diagnose or exclude
(766). M. genitalium infections among women are also
gonorrhea. If evidence of DGI exists, gonorrhea culture and
frequently asymptomatic, and the consequences associated
antimicrobial susceptibility testing should be obtained from
with asymptomatic M. genitalium infection are unknown.
relevant clinical sites (see Disseminated Gonococcal Infection).
M. genitalium can be detected among 10%–30% of women
Recommended Regimen for Uncomplicated Gonococcal with clinical cervicitis (767,770,772,914–916). The existing
Vulvovaginitis, Cervicitis, Urethritis, Pharyngitis, or Proctitis evidence between M. genitalium and cervicitis is mostly
Among Infants and Children Weighing ≤45 kg supportive of a causal association. Elevated proinflammatory
Ceftriaxone 25–50 mg/kg body weight IV or IM in a single dose, not to cytokines have been demonstrated among women with
exceed 250 mg IM
M. genitalium, with return to baseline levels after clearance of
the pathogen (917).

80 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

M. genitalium is identified in the cervix or endometrium Antimicrobial Resistance

of women with PID more often than in women without PID
Resistance to azithromycin has been rapidly increasing
(918–924). Prevalence of M. genitalium among women with
and has been confirmed in multiple studies. Prevalence of
PID ranges from 4% to 22% (925,926) and was reported
molecular markers for macrolide resistance, which highly
as 60% in one study of women with postabortal PID (918).
correlates with treatment failure, ranges from 44% to 90%
The association with PID is supported by early studies among
in the United States, Canada, Western Europe, and Australia
nonhuman primates that determined that endosalpingitis
(697,702,945–953). Treatment with azithromycin alone
develops after inoculation with M. genitalium (927). Recent
has been reported to select for resistance (705,954,955),
studies evaluating the lower and upper genital tract using
with treatment of macrolide-susceptible infections with a
highly sensitive M. genitalium NAAT assays or the role of
1-g dose of azithromycin resulting in selection of resistant-
M. genitalium in histologically defined endometritis have
strain populations in 10%–12% of cases. The prevalence of
reported significantly elevated risk for PID (928). However,
quinolone resistance markers is much lower (697,956–959).
most studies of M. genitalium and PID, even those that
The first clinical treatment failures after moxifloxacin were
controlled extensively for other infections and behavioral and
associated specifically with the S83I mutation in the parC gene
biologic risk, are cross-sectional. The few prospective studies
(954,960). Prevalence of the S83I mutation in the United
that have evaluated the role of M. genitalium in establishing
States ranges from 0% to 15% (947); however, correlation
subsequent PID demonstrated increased PID risk; however,
with fluoroquinolone treatment failure is less consistent than
these were not statistically significant associations, often
that with mutations associated with macrolide resistance
because of a lack of statistical power. No clinical trial data are
(953,961,962). Clinically relevant quinolone resistance often
available that demonstrate that treating M. genitalium cervical
is associated with coexistent macrolide resistance (954).
infection prevents development of PID or endometritis.
Although data regarding the benefits of testing women with
PID for M. genitalium and the importance of directing Diagnostic Considerations
treatment against this organism are limited, the associations of M. genitalium is an extremely slow-growing organism. Culture
M. genitalium with cervicitis and PID in cross-sectional studies can take up to 6 months, and technical laboratory capacity is
using NAAT testing are consistent (928). limited to research settings. NAAT for M. genitalium is FDA
Data from case-control serologic studies (929–931) cleared for use with urine and urethral, penile meatal, endocervical,
and a meta-analysis of clinical studies (766) indicate a and vaginal swab samples (https://www.hologic.com/package-
potential role in causing infertility. However, seroassays are inserts/diagnostic-products/aptima-mycoplasma-genitalium-
suboptimal and inconclusive. Similarly, evidence for a role for assay). Molecular tests for macrolide (i.e., azithromycin) or
M. genitalium infection during pregnancy as a cause of perinatal quinolone (i.e., moxifloxacin) resistance markers are not
complications, including preterm delivery, spontaneous commercially available in the United States. However, molecular
abortion, or low birthweight, are conflicting because evidence is assays that incorporate detection of mutations associated with
insufficient to attribute cause (766,932–934). Data are limited macrolide resistance are under evaluation.
regarding ectopic pregnancy and neonatal M. genitalium Men with recurrent NGU should be tested for M. genitalium
infection (935,936). using an FDA-cleared NAAT. If resistance testing is available,
Rectal infection with M. genitalium has been reported among it should be performed and the results used to guide therapy.
1%–26% of MSM (937–940) and among 3% of women Women with recurrent cervicitis should be tested for
(941). Rectal infections often are asymptomatic, although M. genitalium, and testing should be considered among women
higher prevalence of M. genitalium has been reported among with PID. Testing should be accompanied with resistance
men with rectal symptoms. Similarly, although asymptomatic testing, if available. Screening of asymptomatic M. genitalium
M. genitalium has been detected in the pharynx, no evidence infection among women and men or extragenital testing
exists of it causing oropharyngeal symptoms or systemic disease. for M. genitalium is not recommended. In clinical practice,
Urogenital M. genitalium infection is associated with HIV if testing is unavailable, M. genitalium should be suspected
among both men and women (942–944); however, the data in cases of persistent or recurrent urethritis or cervicitis and
are from case-control and cross-sectional studies. Risk for HIV considered for PID.
infection is increased among women with M. genitalium, and
evidence indicates that HIV shedding occurs more often among
persons with M. genitalium and HIV infection who are not taking
ART than among persons without M. genitalium (942,944).

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 81
 Recommendations and Reports

Treatment M. genitalium is detected, a regimen of moxifloxacin 400 mg

orally once daily for 14 days has been effective in eradicating the
M. genitalium lacks a cell wall, and thus antibiotics targeting
organism. Nevertheless, no data have been published that assess
cell-wall biosynthesis (e.g., ß-lactams including penicillins and
the benefits of testing women with PID for M. genitalium, and
cephalosporins) are ineffective against this organism. Because
the importance of directing treatment against this organism
of the high rates of macrolide resistance with treatment failures
is unknown.
(707) and efficient selection of additional resistance, a 1-g dose
of azithromycin should not be used.
Two-stage therapy approaches, ideally using resistance- Follow-Up
guided therapy, are recommended for treatment. Resistance- Test of cure is not recommended for asymptomatic persons
guided therapy has demonstrated cure rates of >90% and who received treatment with a recommended regimen. In
should be used whenever possible (759,963); however, it settings in which M. genitalium testing is available, persons
requires access to macrolide-resistance testing. As part of this with persistent urethritis, cervicitis, or PID accompanied by
approach, doxycycline is provided as initial empiric therapy, detection of M. genitalium should be treated with moxifloxacin.
which reduces the organism load and facilitates organism
clearance, followed by macrolide-sensitive M. genitalium
infections treated with high-dose azithromycin; macrolide-
Management of Sex Partners
resistant infections are treated with moxifloxacin (964,965). Recent studies report a high concordance of M. genitalium
among partners of males, females, and MSM; however, no
Recommended Regimens if M. genitalium Resistance Testing Is studies have determined whether reinfection is reduced with
Available
partner treatment (940,967,968). Sex partners of patients
If macrolide sensitive: Doxycycline 100 mg orally 2 times/day for
7 days, followed by azithromycin 1 g orally initial dose, followed by
with symptomatic M. genitalium infection can be tested, and
500 mg orally once daily for 3 additional days (2.5 g total) those with a positive test can be treated to possibly reduce the
If macrolide resistant: Doxycycline 100 mg orally 2 times/day for 7 days risk for reinfection. If testing the partner is not possible, the
followed by moxifloxacin 400 mg orally once daily for 7 days antimicrobial regimen that was provided to the patient can
be provided.
Recommended Regimen if M. genitalium Resistance Testing Is
Not Available
If M. genitalium is detected by an FDA-cleared NAAT: Doxycycline Special Considerations
100 mg orally 2 times/day for 7 days, followed by moxifloxacin 400 mg
orally once daily for 7 days HIV Infection
Persons who have M. genitalium and HIV infection should
Although the majority of M. genitalium strains are sensitive receive the same treatment regimen as those persons without HIV.
to moxifloxacin, resistance has been reported, and adverse
side effects and cost should be considered with this regimen.
In settings without access to resistance testing and when Diseases Characterized by
moxifloxacin cannot be used, an alternative regimen can be
considered, based on limited data: doxycycline 100 mg orally Vulvovaginal Itching, Burning,
2 times/day for 7 days, followed by azithromycin (1 g orally Irritation, Odor, or Discharge
on day 1 followed by 500 mg once daily for 3 days) and a test The majority of women will have a vaginal infection,
of cure 21 days after completion of therapy (963). Because of characterized by discharge, itching, burning, or odor, during
the high prevalence of macrolide resistance and high likelihood their lifetime. With the availability of complementary and
of treatment failure, this regimen should be used only when alternative therapies and over-the-counter medications for
a test of cure is possible, and no other alternatives exist. If candidiasis, symptomatic women often seek these products
symptomatic treatment failure or a positive test of cure occurs before or in addition to an evaluation by a medical provider.
after this regimen, expert consultation is recommended. Obtaining a medical history alone has been reported to
Data are limited regarding use of minocycline in instances of be insufficient for accurate diagnosis of vaginitis and can
treatment failure (966). lead to inappropriate administration of medication (969).
Recommended PID treatment regimens are not effective Therefore, a careful history, examination, and laboratory
against M. genitalium. Initial empiric therapy for PID, which testing to determine the etiology of any vaginal symptoms
includes doxycycline 100 mg orally 2 times/day for 14 days, are warranted. Information regarding sexual behaviors and
should be provided at the time of presentation for care. If

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 Recommendations and Reports

practices, sex of sex partners, menses, vaginal hygiene practices other noninfectious causes of vulvovaginal signs or symptoms.
(e.g., douching), and self-treatment with oral and intravaginal For women with persistent symptoms and no clear etiology,
medications or other products should be elicited. The referral to a specialist should be considered.
infections most frequently associated with vaginal symptoms
are BV (i.e., replacement of the vaginal flora by an overgrowth Bacterial Vaginosis
of anaerobic bacteria including G. vaginalis, Prevotella bivia,
A. vaginae, Megasphaera type 1, and numerous other fastidious BV is a vaginal dysbiosis resulting from replacement of normal
or uncultivated anaerobes), trichomoniasis, and vulvovaginal hydrogen peroxide and lactic-acid–producing Lactobacillus
candidiasis (VVC). Cervicitis can also cause an abnormal species in the vagina with high concentrations of anaerobic
vaginal discharge. Although VVC is usually not sexually bacteria, including G. vaginalis, Prevotella species, Mobiluncus
transmitted, it is included in this section because it is frequently species, A. vaginae, and other BV-associated bacteria. A notable
diagnosed among women who have vaginal symptoms or are feature is the appearance of a polymicrobial biofilm on vaginal
being evaluated for an STI. epithelial cells (970). Certain women experience transient
Multiple diagnostic methods are available for identifying the vaginal microbial changes, whereas others experience them for
etiology of vaginal symptoms. Clinical laboratory testing can longer intervals (971). BV is a highly prevalent condition and
identify the vaginitis cause in the majority of women and is the most common cause of vaginal discharge worldwide (972).
discussed in detail in the sections of this report dedicated to However, in a nationally representative survey, the majority of
each condition. In the clinician’s office, the cause of vaginal women with BV were asymptomatic (310).
symptoms can often be determined by pH, a potassium BV is associated with having multiple male sex partners,
hydroxide (KOH) test, and microscopic examination of a wet female partners, sexual relationships with more than one person
mount of fresh samples of vaginal discharge. The pH of the (973), a new sex partner, lack of condom use (974), douching
vaginal secretions can be measured by pH paper; an elevated (975,976), and HSV-2 seropositivity (977). Male circumcision
pH (i.e., >4.5) is common with BV or trichomoniasis (although reduces the risk for BV among women (978). In addition, BV
trichomoniasis can also be present with a normal vaginal pH). prevalence increases during menses (979,980). Women who
Because pH testing is not highly specific, vaginal discharge have never been sexually active are rarely affected (981). The
should be further examined microscopically by first diluting cause of the microbial alteration that precipitates BV is not
one sample in 1 or 2 drops of 0.9% normal saline solution on fully understood, and whether BV results from acquisition
one slide and a second sample in 10% KOH solution (samples of a single sexually transmitted pathogen is unknown. BV
that emit an amine odor immediately upon application of prevalence has been reported to increase among women with
KOH suggest BV or trichomoniasis). Coverslips are then copper-containing IUDs (972,982). Hormonal contraception
placed on the slides, and they are examined under a microscope does not increase risk for BV (983) and might protect against
at low and high power. The saline-solution specimen might BV development (983,984). Vitamin D deficiency has not
display motile trichomonads or clue cells (i.e., epithelial cells been reported to be a risk factor for BV (985).
with borders obscured by small anaerobic bacteria), which Women with BV are at increased risk for STI acquisition,
are characteristic of BV. The KOH specimen typically is used such as HIV, N. gonorrhoeae, C. trachomatis, T. vaginalis
to identify hyphae or blastospores observed with candidiasis. (977), M. genitalium (986), HPV (987), and HSV-2 (988);
However, absence of trichomonads in saline or fungal elements complications after gynecologic surgery; complications of
in KOH samples does not rule out these infections because the pregnancy; and recurrence of BV (971,989–991). BV also
sensitivity of microscopy is approximately 50% compared with increases HIV infection acquisition (992) because specific
NAAT (trichomoniasis) or culture (yeast) (670). Presence of BV-associated bacteria can increase susceptibility to HIV
WBCs without evidence of trichomonads or yeast might also (993,994) and the risk for HIV transmission to male
indicate cervicitis (see Cervicitis). sex partners (187). Evaluation of short-term valacyclovir
In settings where pH paper, KOH, and microscopy suppression among women with HSV-2 did not decrease the
are unavailable, a broad range of clinical laboratory tests, risk for BV, despite effective suppression of HSV-2 (995).
described in the diagnosis section for each disease, can be Although BV-associated bacteria can be identified on male
used. Presence of objective signs of vulvovaginal inflammation genitalia (996,997), treatment of male sex partners has not been
in the absence of vaginal pathogens after laboratory testing beneficial in preventing the recurrence of BV (998). Among
indicates the possibility of mechanical, chemical, allergic, or WSW, a high level of BV concordance occurs between sex
partners (292); however, no studies have evaluated treatment
of female sex partners of WSW to prevent BV recurrence.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 83
 Recommendations and Reports

Diagnostic Considerations Lactobacillus crispatus, Lactobacillus jensenii, and Lactobacillus

BV can be diagnosed by using clinical criteria (i.e., gasseri). They can be performed on either clinician- or self-
Amsel’s diagnostic criteria) (999) or by determining the collected vaginal specimens with results available in <24 hours,
Nugent score from a vaginal Gram stain (1000). Vaginal depending on the availability of the molecular diagnostic
Gram stain, considered the reference standard laboratory platform (1002). Five quantitative multiplex PCR assays are
method for diagnosing BV, is used to determine the relative available: Max Vaginal Panel (Becton Dickinson) (1007),
concentration of lactobacilli (i.e., long gram-positive rods), Aptima BV (Hologic), NuSwab VG (LabCorp) (1008),
small gram-negative and gram-variable rods (i.e., G. vaginalis or OneSwab BV Panel PCR with Lactobacillus Profiling by qPCR
Bacteroides), and curved gram-negative rods (i.e., Mobiluncus) (Medical Diagnostic Laboratories) (1009), and SureSwab BV
characteristic of BV. A Nugent score of 0–3 is consistent with (Quest Diagnostics). Two of these assays are FDA cleared (BD
a Lactobacillus-predominant vaginal microbiota, 4–6 with Max Vaginal Panel and Aptima BV), and the other three are
intermediate microbiota (emergence of G. vaginalis), and 7–10 laboratory-developed tests.
with BV. Clinical diagnosis of BV by Amsel criteria requires at The Max Vaginal Panel provides results by an algorithmic
least three of the following four symptoms or signs: analysis of molecular DNA detection of Lactobacillus species
• Homogeneous, thin discharge (milklike consistency) that (L. crispatus and L. jensenii) in addition to G. vaginalis,
smoothly coats the vaginal walls A. vaginae, BVAB2, and Megasphaera type 1. This test has
• Clue cells (e.g., vaginal epithelial cells studded with 90.5% sensitivity and 85.8% specificity for BV diagnosis,
adherent bacteria) on microscopic examination compared with Amsel criteria and Nugent score. It also provides
• pH of vaginal fluid >4.5 results for Candida species and T. vaginalis. The Aptima BV
• A fishy odor of vaginal discharge before or after addition detects G. vaginalis, A. vaginae, and certain Lactobacillus species
of 10% KOH (i.e., the whiff test) including L. crispatus, L. jensenii, and L. gasseri, with sensitivity
Detection of at least three Amsel criteria has been correlated and specificity ranging from 95.0% to 97.3% and 85.8% to
with results by Gram stain (1001). The sensitivity and 89.6%, respectively (using either clinician- or patient-collected
specificity of the Amsel criteria are 37%–70% and 94%–99%, vaginal swabs). The three laboratory-developed tests (NuSwab
respectively, compared with the Nugent score (1002). VG, OneSwab BV Panel PCR with Lactobacillus Profiling by
In addition to the Amsel criteria, multiple POC tests are qPCR, and SureSwab BV) have to be internally validated before
available for BV diagnosis. The Osom BV Blue test (Sekisui use for patient care yet have good sensitivity and specificity,
Diagnostics) detects vaginal sialidase activity (1003,1004). similar to FDA-cleared assays. BV NAATs should be used
The Affirm VP III (Becton Dickinson) is an oligonucleotide among symptomatic women only (e.g., women with vaginal
probe test that detects high concentrations of G. vaginalis discharge, odor, or itch) because their accuracy is not well
nucleic acids (>5 x 105 CFU of G. vaginalis/mL of vaginal defined for asymptomatic women. Despite the availability of
fluid) for diagnosing BV, Candida species, and T. vaginalis. BV NAATs, traditional methods of BV diagnosis, including
This test has been reported to be most useful for symptomatic the Amsel criteria, Nugent score, and the Affirm VP III assay,
women in conjunction with vaginal pH measurement and remain useful for diagnosing symptomatic BV because of their
presence of amine odor (sensitivity of 97%); specificity is lower cost and ability to provide a rapid diagnosis. Culture of
81% compared with Nugent. Finally, the FemExam Test G. vaginalis is not recommended as a diagnostic tool because
Card (Cooper Surgical) measures vaginal pH, presence of it is not specific. Cervical Pap tests have no clinical utility for
trimethylamine (a metabolic by-product of G. vaginalis), diagnosing BV because of their low sensitivity and specificity.
and proline aminopeptidase (1005). Sensitivity is 91% and Treatment
specificity is 61%, compared with Nugent. This test has
Treatment for BV is recommended for women with
primarily been studied in resource-poor settings (1005), and
symptoms. Established benefits of therapy among nonpregnant
although it has been reported to be beneficial compared with
women are to relieve vaginal symptoms and signs of infection.
syndromic management, it is not a preferred diagnostic method
Other potential benefits of treatment include reduction
for BV diagnosis.
in the risk for acquiring C. trachomatis, N. gonorrhoeae,
Multiple BV NAATs are available for BV diagnosis among
T. vaginalis, M. genitalium, HIV, HPV, and HSV-2 (971,986–
symptomatic women (1002). These tests are based on detection
988,990,1010). No data are available that directly compare
of specific bacterial nucleic acids and have high sensitivity
the efficacy of oral and topical medications for treating BV.
and specificity for BV (i.e., G. vaginalis, A. vaginae, BVAB2,
or Megasphaera type 1) (1006) and certain lactobacilli (i.e.,

84 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Recommended Regimens for Bacterial Vaginosis arm compared with 19% in the placebo arm (p<0.001)
Metronidazole 500 mg orally 2 times/day for 7 days
(1013). Secnidazole is listed as an alternative regimen, due
or to its higher cost and lack of long-term outcomes compared
Metronidazole gel 0.75% one full applicator (5 g) intravaginally, once with recommended BV treatments. A patient savings card
daily for 5 days
or for secnidazole is available at https://www.solosec.com/
Clindamycin cream 2% one full applicator (5 g) intravaginally at savings-card.
bedtime for 7 days
Additional BV treatment regimens include metronidazole
1.3% vaginal gel in a single dose (1017,1018) and clindamycin
A review regarding alcohol consumption during phosphate (Clindesse) 2% vaginal cream in a single dose
metronidazole treatment reported no in vitro studies, animal (1019). In a phase 3 clinical trial of metronidazole 1.3% vaginal
models, reports of adverse effects, or clinical studies providing gel versus placebo, BV clinical cure rates at day 21 were 37.2%
convincing evidence of a disulfiram-like interaction between in the metronidazole 1.3% vaginal gel arm, compared with
alcohol and metronidazole (1011). The previous warning 26.6% in the placebo arm (p = 0.01) (1018). A patient savings
against simultaneous use of alcohol and metronidazole was card for metronidazole 1.3% vaginal gel is available at https://
based on laboratory experiments and individual case histories nuvessa.com/nuvessa_files/19_Nuvessa_WEB_Card_032819.
in which the reported reactions were equally likely to have been pdf. In a multicenter, randomized, single-blind, parallel-
caused by alcohol alone or by adverse effects of metronidazole. group study of Clindesse 2% vaginal cream single dose versus
Metronidazole does not inhibit acetaldehyde dehydrogenase, clindamycin 2% vaginal cream at bedtime for 7 days among
as occurs with disulfiram. Ethanol alone or ethanol- 540 women with BV, no statistically significant difference
independent side effects of metronidazole might explain the existed between groups in clinical cure at days 21–30 (64.3%
suspicion of disulfiram-like effects. Thus, refraining from versus 63.2%; p = 0.95) (1019); however, this study had
alcohol use while taking metronidazole (or tinidazole) is methodologic problems. A patient savings card for Clindesse
unnecessary. Clindamycin cream is oil based and might weaken 2% vaginal cream is available at https://www.clindesse.com/
latex condoms and diaphragms for 5 days after use (refer to pdf/CLINDESSE_SavingsCard.pdf.
clindamycin product labeling for additional information). BV biofilm disrupting agents (i.e., TOL-463) (1020) are
Women should be advised to refrain from sexual activity being investigated to determine their role in enhancing the
or to use condoms consistently and correctly during the BV likelihood of BV cure relative to approved therapies. Studies
treatment regimen. Douching might increase the risk for have evaluated the clinical and microbiologic efficacy of
relapse, and no data support use of douching for treatment intravaginal Lactobacillus and other probiotic formulations to
or symptom relief. treat BV and restore normal vaginal microbiota (1021–1025);
Alternative Regimens overall, no studies support these products as an adjunctive or
Clindamycin 300 mg orally 2 times/day for 7 days replacement therapy for women with BV.
or
Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days* Other Management Considerations
or All women with BV should be tested for HIV and other STIs.
Secnidazole 2 g oral granules in a single dose†
or
Tinidazole 2 g orally once daily for 2 days Follow-Up
or Follow-up visits are unnecessary if symptoms resolve. Because
Tinidazole 1 g orally once daily for 5 days
persistent or recurrent BV is common, women should be advised
* Clindamycin ovules use an oleaginous base that might weaken latex or
rubber products (e.g., condoms and diaphragms). Use of such products
to return for evaluation if symptoms recur. Limited data are
within 72 hours after treatment with clindamycin ovules is not available regarding optimal management strategies for women
recommended. with persistent or recurrent BV. Using a different recommended
† Oral granules should be sprinkled onto unsweetened applesauce, yogurt,
or pudding before ingestion. A glass of water can be taken after treatment regimen can be considered for women who have a
administration to aid in swallowing. recurrence; however, retreatment with the same recommended
regimen is an acceptable approach for treating persistent or
Alternative regimens include secnidazole oral granules recurrent BV after the first occurrence (1026). For women
(1012–1014), multiple oral tinidazole regimens (1015), or with multiple recurrences after completion of a recommended
clindamycin (oral or intravaginal) (1016). In a phase 3 clinical regimen, either 0.75% metronidazole gel or 750 mg metronidazole
trial of secnidazole 2 g oral granules versus placebo, BV vaginal suppository twice weekly for >3 months has been
clinical cure rates at days 21–30 were 53% in the secnidazole reported to reduce recurrences, although this benefit does not

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 85
 Recommendations and Reports

persist when suppressive therapy is discontinued (1027,1028). Special Considerations

Limited data indicate that for women with multiple recurrences,
an oral nitroimidazole (metronidazole or tinidazole 500 mg Drug Allergy, Intolerance, or Adverse Reactions
2 times/day for 7 days), followed by intravaginal boric acid Intravaginal clindamycin cream is preferred in case of allergy
600 mg daily for 21 days and suppressive 0.75% metronidazole or intolerance to metronidazole or tinidazole. Intravaginal
gel twice weekly for 4–6 months, might be an option for women metronidazole gel can be considered for women who are not
with recurrent BV (1029). Monthly oral metronidazole 2 g allergic to metronidazole but do not tolerate oral metronidazole.
administered with fluconazole 150 mg has also been evaluated
Pregnancy
as suppressive therapy; this regimen reduced the BV incidence
and promoted colonization with normal vaginal microbiota BV treatment is recommended for all symptomatic pregnant
(1030). A randomized controlled trial of a dendrimer-based women because symptomatic BV has been associated with
microbicide 1% vaginal gel (Astodrimer) also reported favorable adverse pregnancy outcomes, including premature rupture
results in prolonging the time to BV recurrence, compared with of membranes, preterm birth, intra-amniotic infection, and
placebo (1031). In addition, a clinical trial of L. crispatus CTV-05 postpartum endometritis (989,991,1036). Studies have been
(Lactin-V), administered vaginally in 4 consecutive daily doses undertaken to determine the efficacy of BV treatment among
for 4 days in week 1 followed by twice weekly doses for 10 weeks this population, including two trials demonstrating that oral
(after initial treatment with 5 days of 0.75% vaginal metronidazole metronidazole was efficacious during pregnancy by using
gel), reported a substantially lower incidence of BV recurrence at the 250 mg 3 times/day regimen (1037,1038); however, oral
12 weeks in the Lactin-V arm, compared with placebo (1032); metronidazole administered as a 500 mg 2 times/day regimen
however this medication is not yet FDA cleared or commercially can also be used. One trial involving a limited number of
available. High-dose Vitamin D supplementation has not been participants revealed treatment with oral metronidazole
determined to decrease BV recurrence in randomized controlled 500 mg 2 times/day for 7 days to be equally effective as
trials (1033) and is not recommended. metronidazole gel 0.75% for 5 days, with cure rates of 70%
by using Amsel criteria to define cure (1039). Another trial
Management of Sex Partners demonstrated a cure rate of 85% by using Gram-stain criteria
Data from earlier clinical trials indicate that a woman’s after treatment with oral clindamycin 300 mg 2 times/day for
response to therapy and the likelihood of relapse or recurrence 7 days (1040–1043).
are not affected by treatment of her sex partner (998). Therefore, Although older studies indicated a possible link between
routine treatment of sex partners is not recommended. using vaginal clindamycin during pregnancy and adverse
However, a pilot study reported that male partner treatment outcomes for the newborn, newer data demonstrate that
(i.e., metronidazole 400 mg orally 2 times/day in conjunction this treatment approach is safe for pregnant women (1044).
with 2% clindamycin cream applied topically to the penile Although metronidazole crosses the placenta, no evidence of
skin 2 times/day for 7 days) of women with recurrent BV teratogenicity or mutagenic effects among infants has been
had an immediate and sustained effect on the composition of reported in multiple cross-sectional, case-control, and cohort
the vaginal microbiota, with an overall decrease in bacterial studies of pregnant women (1041–1043). These data indicate
diversity at day 28 (1034). Male partner treatment also had an that metronidazole therapy poses low risk during pregnancy.
immediate effect on the composition of the penile microbiota; Data from human studies are limited regarding the use of
however, this was not as pronounced at day 28, compared tinidazole in pregnancy; however, animal data demonstrate
with that among women. A phase 3 multicenter randomized that such therapy poses moderate risk. Thus, tinidazole should
double-blinded trial evaluating the efficacy of a 7-day oral be avoided during pregnancy (431). Data are insufficient
metronidazole regimen versus placebo for treatment of male regarding efficacy and adverse effects of secnidazole, Clindesse
sex partners of women with recurrent BV did not find that 2% vaginal cream, metronidazole 1.3% vaginal gel, and
male partner treatment reduced BV recurrence in female 750-mg vaginal metronidazole tablets during pregnancy; thus,
partners, although women whose male partners adhered their use should be avoided.
to multidose metronidazole were less likely to experience Oral therapy has not been reported to be superior to topical
treatment failure (1035). therapy for treating symptomatic BV in effecting cure or
preventing adverse outcomes of pregnancy. Pregnant women
can be treated with any of the recommended regimens for
nonpregnant women, in addition to the alternative regimens
of oral clindamycin and clindamycin ovules.

86 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

Treatment of asymptomatic BV among pregnant women rates are as high among women aged >24 years as they are
at high risk for preterm delivery (i.e., those with a previous for women aged <24 years (1057). Among persons attending
preterm birth or late miscarriage) has been evaluated by nine geographically diverse STD clinics, the trichomonas
multiple studies, which have yielded mixed results. Seven prevalence was 14.6% among women (1059), and a study
trials have evaluated treatment of pregnant women with of STD clinic attendees in Birmingham, Alabama, identified
asymptomatic BV at high risk for preterm delivery: one revealed a prevalence of 27% among women and 9.8% among men
harm (1045), two reported no benefit (1046,1047), and four (1060). Symptomatic women have a four times higher rate of
demonstrated benefit (1037,1038,1048,1049). infection than asymptomatic women (26% versus 6.5%) (1061).
Treatment of asymptomatic BV among pregnant women Rates are also high among incarcerated persons of both sexes at
at low risk for preterm delivery has not been reported to 9%–32% of incarcerated women (386,387,391,392,1062) and
reduce adverse outcomes of pregnancy in a large multicenter 3.2%–8% of incarcerated men (388). Women with a history of
randomized controlled trial (1050). Therefore, routine incarceration are two to five times more likely to have T. vaginalis
screening for BV among asymptomatic pregnant women at (387,388,1063,1064). Other risk factors for T. vaginalis include
high or low risk for preterm delivery for preventing preterm having two or more sex partners during the previous year, having
birth is not recommended. less than a high school education, and living below the national
Metronidazole is secreted in breast milk. With maternal poverty level (1065). Women with BV are at higher risk for
oral therapy, breastfed infants receive metronidazole in doses T. vaginalis (1066). Male partners of women with trichomoniasis
that are less than those used to treat infections among infants, are likely to have infection (1067), although the prevalence of
although the active metabolite adds to the total infant exposure. trichomoniasis among MSM is low (179,1068).
Plasma levels of the drug and metabolite are measurable but The majority of persons who have trichomoniasis
remain less than maternal plasma levels (https://www.ncbi. (70%–85%) either have minimal or no genital symptoms,
nlm.nih.gov/books/NBK501922/?report=classic). Although and untreated infections might last from months to years
multiple reported case series identified no evidence of (137,1069,1070). Men with trichomoniasis sometimes have
metronidazole-associated adverse effects for breastfed infants, symptoms of urethritis, epididymitis, or prostatitis, and women
certain clinicians recommend deferring breastfeeding for with trichomoniasis sometimes have vaginal discharge, which
12–24 hours after maternal treatment with a single 2-g dose can be diffuse, malodorous, or yellow-green with or without
of metronidazole (1051). Lower doses produce a lower vulvar irritation, and might have a strawberry-appearing cervix,
concentration in breast milk and are considered compatible which is observed more often on colposcopy than on physical
with breastfeeding (1052,1053). examination (1071). Although many persons might be unaware
of their infection, it is readily passed between sex partners
HIV Infection
during penile-vaginal sex (1072) or through transmission of
BV appears to recur with higher frequency among women infected vaginal fluids or fomites among women who have sex
who have HIV infection (1054). Women with HIV infection with women (275,294).
and BV should receive the same treatment regimen as those Among persons who are sexually active, the best way to
who do not have HIV. prevent genital trichomoniasis is through consistent and correct
use of condoms (external or internal) (18). Partners of men
Trichomoniasis who have been circumcised might have a somewhat reduced
risk for T. vaginalis infection (1072,1073). Douching is not
Trichomoniasis is estimated to be the most prevalent nonviral
recommended because it might increase the risk for vaginal
STI worldwide, affecting approximately 3.7 million persons
infections, including trichomoniasis (1074).
in the United States (838,1055). Because trichomoniasis is
T. vaginalis causes reproductive morbidity and has been
not a reportable disease (1056), and no recommendations are
reported to be associated with a 1.4-times greater likelihood
available for general screening for T. vaginalis, the epidemiology
of preterm birth, premature rupture of membranes, and
of trichomoniasis has largely come from population-based and
infants who are small for gestational age (1075). T. vaginalis
clinic-based surveillance studies. The U.S. population-based
was also determined to be associated with a 2.1-fold increased
T. vaginalis prevalence is 2.1% among females and 0.5% among
risk for cervical cancer in a meta-analysis (1076). Another
males, with the highest rates among Black females (9.6%)
meta-analysis of six studies reported a slightly elevated but
and Black males (3.6%), compared with non-Hispanic White
not statistically significant association between T. vaginalis and
women (0.8%) and Hispanic women (1.4%) (1057,1058).
prostate cancer (1077).
Unlike chlamydia and gonorrhea, T. vaginalis prevalence

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 87
 Recommendations and Reports

T. vaginalis infection is associated with a 1.5-fold increased risk clinician-collected endocervical swabs, clinician-collected
for HIV acquisition and is associated with an increase in HIV vaginal swabs, female urine specimens, and liquid Pap
vaginal shedding, which is reduced with T. vaginalis treatment smear specimens collected in PreservCyt Solution (Hologic)
among women without viral suppression (1078,1079). Among (698,1088). This assay detects RNA by transcription-
women with HIV infection, T. vaginalis infection is associated mediated amplification with a sensitivity of 95.3%–100%
with increased risk for PID (1080–1082). and specificity of 95.2%–100%, compared with wet mount
Diagnostic testing for T. vaginalis should be performed for and culture (1088,1089). Among women, vaginal swabs and
women seeking care for vaginal discharge. Annual screening urine specimens have <100% concordance (1084). This assay
might be considered for persons receiving care in high- has not been FDA cleared for use among men and should be
prevalence settings (e.g., STD clinics and correctional facilities) internally validated in accordance with CLIA regulations before
and for asymptomatic women at high risk for infection (e.g., use with urine or urethral swabs from men. The Probe Tec TV
multiple sex partners, transactional sex, drug misuse, or a Qx Amplified DNA Assay (Becton Dickinson) is FDA cleared
history of STIs or incarceration). However, data are lacking for detection of T. vaginalis from vaginal (patient-collected
regarding whether screening and treatment for asymptomatic or clinician-collected) swabs, endocervical swabs, or urine
trichomoniasis in high-prevalence settings for women at high specimens from women and has sensitivity of 98.3% and
risk can reduce any adverse health events and health disparities specificity of 99.6%, compared with wet mount and culture
or reduce community infection burden. Decisions about (1090). Similar to the Aptima T. vaginalis assay, this test is only
screening can be guided by local epidemiology of T. vaginalis FDA cleared for use among women and should be internally
infection. Routine annual screening for T. vaginalis among validated for use with men. The Max CTGCTV2 assay (Becton
asymptomatic women with HIV infection is recommended Dickinson) is also FDA cleared for detection of T. vaginalis in
because of these adverse events associated with trichomoniasis patient-collected or clinician-collected vaginal swab specimens
and HIV infection. and male and female urine specimens, with sensitivity and
Extragenital T. vaginalis is possible but highly uncommon specificity of 96.2%–100% and 99.1%–100%, respectively,
compared with genital infections. A study of 500 men in San depending on the specimen type, compared with wet mount
Francisco, California, reported a 0.6% rate of rectal T. vaginalis and culture (1091). GeneXpert TV (Cepheid) is a moderately
(1083); however, this might reflect deposition of T. vaginalis complex rapid test that can be performed in ≤1 hour and can be
DNA and not necessarily active infection. Few studies of used at the POC (1092). It has been FDA cleared for use with
extragenital T. vaginalis among women have been published. female urine specimens, endocervical swabs, patient-collected
The efficacy, benefit, and cost-effectiveness of extragenital or clinician-collected vaginal specimens, and male urine
screening are unknown, and no tests are FDA cleared for specimens, with sensitivity and specificity of 99.5%–100%
extragenital testing; therefore, rectal and oral testing for and 99.4%–99.9% (1007), respectively, compared with wet
T. vaginalis is not recommended. mount and culture.
Multiple FDA-cleared rapid tests are available for detecting
Diagnostic Considerations T. vaginalis with improved sensitivities and specificities,
Wet-mount microscopy traditionally has been used as compared with wet mount. The Osom trichomonas rapid
the preferred diagnostic test for T. vaginalis among women test (Sekisui Diagnostics) is an antigen-detection test that uses
because it is inexpensive and can be performed at the POC; immunochromatographic capillary flow dipstick technology
however, it has low sensitivity (44%–68%) compared with that can be performed at the POC by using clinician-obtained
culture (1084–1086). To improve detection, clinicians using vaginal specimens. Results are available in approximately
wet mounts should attempt to evaluate slides immediately 10–15 minutes, with sensitivities of 82%–95% and specificity
after specimen collection because sensitivity decreases quickly of 97%–100%, compared with wet mount, culture, and
to 20% within 1 hour after collection (1087). More highly transcription-mediated amplification (1089,1093,1094). A
sensitive and specific molecular diagnostic options are available, study of 209 women aged 14–22 years reported that >99%
which should be used in conjunction with a negative wet could correctly perform and interpret a vaginal self-test by
mount when possible. using the Osom assay, with a high correlation with clinician
NAATs are highly sensitive, detecting more T. vaginalis interpretation (96% agreement; κ = 0.87) (1094). The Osom
infections than wet-mount microscopy among women test should not be used with men because of low sensitivity
(1060). The Aptima T. vaginalis assay (Beckton Dickinson) is (38% compared with Aptima) (1095). The Solana trichomonas
FDA cleared for detection of T. vaginalis from symptomatic assay (Quidel) is another rapid test for the qualitative detection
or asymptomatic women. Reliable samples include of T. vaginalis DNA and can yield results <40 minutes after

88 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Recommendations and Reports

specimen collection. This assay is FDA cleared for diagnosing Alternative Regimen for Women and Men
T. vaginalis from female vaginal and urine specimens from Tinidazole 2 g orally in a single dose
asymptomatic and symptomatic women with sensitivity >98%,
compared with NAAT for vaginal specimens, and >92% for The nitroimidazoles are the only class of medications with
urine specimens (1096). The Amplivue trichomonas assay clinically demonstrated efficacy against T. vaginalis infections.
(Quidel) is another rapid test providing qualitative detection Tinidazole is usually more expensive, reaches higher levels in
of T. vaginalis that has been FDA cleared for vaginal specimens serum and the genitourinary tract, has a longer half-life than
from symptomatic and asymptomatic women, with sensitivity metronidazole (12.5 hours versus 7.3 hours), and has fewer
of 90.7% and specificity of 98.9%, compared with NAAT gastrointestinal side effects (1106,1107). In randomized
(1097). Neither the Osom assay nor the Affirm VP III test is clinical trials, recommended metronidazole regimens have
FDA cleared for use with specimens from men. resulted in cure rates of approximately 84%–98% (1108),
Culture, such as the InPouch system (BioMed Diagnostics), and the recommended tinidazole regimen has resulted in cure
was considered the most sensitive method for diagnosing rates of approximately 92%–100% (1108–1112). Randomized
T. vaginalis infection before molecular detection methods controlled trials comparing single 2-g doses of metronidazole
became available. Culture has sensitivity of 44%–75% and and tinidazole indicated that tinidazole is equivalent or superior
specificity of <100% (698,1086,1098). For women, vaginal to metronidazole in achieving parasitologic cure and symptom
secretions are the preferred specimen type for culture because resolution (1110,1113,1114).
urine culture is less sensitive (698,1099,1100). For men, Metronidazole gel does not reach therapeutic levels in the
culture specimens require a urethral swab, urine sediment, urethra and perivaginal glands. Because it is less efficacious
or semen. To improve diagnostic yield, multiple specimens than oral metronidazole, it is not recommended.
from men can be used to inoculate a single culture. Cultures
require an incubator and are necessary for T. vaginalis drug Other Management Considerations
susceptibility testing. The InPouch specimen should be Providers should advise persons with T. vaginalis infections
examined daily for 5 days over a 7-day period to reduce the to abstain from sex until they and their sex partners are treated
possibility of false negatives (1101). (i.e., when therapy has been completed and any symptoms
Although T. vaginalis might be an incidental finding on a have resolved). Testing for other STIs, including HIV, syphilis,
Pap test, neither conventional nor liquid-based Pap smears gonorrhea, and chlamydia, should be performed for persons
are considered diagnostic tests for trichomoniasis; however, with T. vaginalis.
women with T. vaginalis identified on a Pap smear should be
retested with sensitive diagnostic tests and treated if infection Follow-Up
is confirmed (1102,1103). Because of the high rate of reinfection among women treated
for trichomoniasis, retesting for T. vaginalis is recommended
Treatment
for all sexually active women <3 months after initial treatment
Treatment reduces symptoms and signs of T. vaginalis regardless of whether they believe their sex partners were
infection and might reduce transmission. Treatment treated (137,1115). If retesting at 3 months is not possible,
recommendations for women are based on a meta-analysis clinicians should retest whenever persons next seek medical
(1104) and a multicenter, randomized trial of mostly care <12 months after initial treatment. Data are insufficient
symptomatic women without HIV infection (1105). The to support retesting men after treatment.
study demonstrated that multidose metronidazole (500 mg
orally 2 times/day for 7 days) reduced the proportion of Management of Sex Partners
women retesting positive at a 1-month test of cure visit by half, Concurrent treatment of all sex partners is vital for
compared with women who received the 2-g single dose. No preventing reinfections. Current partners should be referred
published randomized trials are available that compare these for presumptive therapy. Partners also should be advised to
doses among men. abstain from intercourse until they and their sex partners
Recommended Regimen for Trichomoniasis Among Women
have been treated and any symptoms have resolved. EPT
might have a role in partner management for trichomoniasis
Metronidazole 500 mg orally 2 times/day for 7 days
(129,1116) and can be used in states where permissible by law
Recommended Regimen for Trichomoniasis Among Men
(https://www.cdc.gov/std/ept/legal/default.htm); however, no
partner management intervention has been demonstrated to
Metronidazole 2 g orally in a single dose
be superior in reducing reinfection rates (129,130). Although

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 89
 Recommendations and Reports

no definitive data exist to guide treatment for partners of can include metronidazole or tinidazole 2 g daily for 7 days.
persons with persistent or recurrent trichomoniasis among If a patient has treatment failure after the 7-day regimen of
whom nonadherence and reinfection are unlikely, partners high-dose oral metronidazole or tinidazole, two additional
might benefit from being evaluated and receiving treatment treatment options have been determined to have successful
(see Recurrent Trichomoniasis). results for women. The first is high-dose oral tinidazole
2 g daily plus intravaginal tinidazole 500 mg 2 times/day for
Recurrent Trichomoniasis 14 days (1121). If this regimen fails, high-dose oral tinidazole
A recurrent infection can result from treatment failure (1 g 3 times/day) plus intravaginal paromomycin (4 g of 6.25%
(antimicrobial-resistant T. vaginalis or host-related problems), intravaginal paromomycin cream nightly) for 14 days should
lack of adherence, or reinfection from an untreated sex partner. be considered (1122).
In the case of a recurrent infection, the origin of the repeat Alternative regimens might be effective but have not been
infection should be assessed because most recurrent infections systemically evaluated; therefore, consultation with an infectious
likely result from reinfection. Retesting can be considered in disease specialist is recommended. Clinical improvement has
cases of persistent or recurrent trichomoniasis with culture, the been reported with intravaginal boric acid (1123,1124) but
preferred test. If NAAT is used, it should not be conducted before not with nitazoxanide (1123–1125). The following topically
3 weeks after treatment completion because of possible detection applied agents have minimal success (<50%) and are not
of residual nucleic acid that is not clinically relevant (1117). recommended: intravaginal betadine (povidone-iodine),
The nitroimidazoles are the only class of antimicrobials clotrimazole, acetic acid, furazolidone, GV, nonoxynol-9, and
known to be effective against trichomonas infection. potassium permanganate (1126). No other topical microbicide
Metronidazole resistance occurs in 4%–10% of cases of has been reported to be effective against trichomoniasis.
vaginal trichomoniasis (1116,1118). Tinidazole resistance
is less well studied but was present in 1% of infections in Special Considerations
one study (1116). Overall, more T. vaginalis isolates have Drug Allergy, Intolerance, and Adverse Reactions
reported susceptibility to tinidazole than metronidazole (1119).
Metronidazole and tinidazole are both nitroimidazoles.
Multidose oral metronidazole is more effective than single-dose
Patients with an IgE-mediated-type hypersensitivity reaction
treatment, particularly for women who are symptomatic or
to 5-nitroimidazole antimicrobials should be managed by
have a history of T. vaginalis (1120).
metronidazole desensitization according to published regimens
Nitroimidazole-resistant trichomoniasis is concerning
(1127,1128) and in consultation with an allergy specialist. The
because few alternatives to standard therapy exist. If treatment
optimal treatment for patients with T. vaginalis who are unable
failure occurs in a woman after completing a regimen of
to be desensitized has not been systematically investigated and is
metronidazole 500 mg 2 times/day for 7 days and she has
based on case reports, some of which report using paromomycin
been reexposed to an untreated partner, a repeat course of the
or boric acid for treating T. vaginalis (1123,1129).
same regimen is recommended. If no reexposure has occurred,
she should be treated with metronidazole or tinidazole 2 g Pregnancy
once daily for 7 days. If a man has persistent T. vaginalis after T. vaginalis infection among pregnant women is associated
a single 2-g dose of metronidazole and has been reexposed with adverse pregnancy outcomes, particularly premature
to an untreated partner, he should be retreated with a single rupture of membranes, preterm delivery, and delivery of infants
2-g dose of metronidazole. If he has not been reexposed, he who are small for gestational age (1075). One randomized
should be administered a course of metronidazole 500 mg trial of pregnant women with asymptomatic trichomoniasis
2 times/day for 7 days. reported no substantial difference in preterm birth after
For persons who are experiencing persistent infection treatment with 2 g of metronidazole 48 hours apart during
not attributable to reexposure, clinicians should request a 16–23 and 24–29 weeks’ gestation, compared with placebo
kit from CDC to perform drug-resistance testing (https:// (1130). However, that trial had multiple limitations, including
www.cdc.gov/laboratory/specimen-submission/detail. use of an atypical metronidazole regimen. Another multicenter
html?CDCTestCode=CDC-10239). CDC is experienced with observational study of asymptomatic pregnant women in sub-
susceptibility testing for nitroimidazole-resistant T. vaginalis Sahara African, the majority with HIV infection, reported
and can provide guidance regarding treatment in cases of neither trichomoniasis nor its treatment appeared to influence
drug resistance. On the basis of drug resistance testing, an the risk for preterm birth or a low-birthweight infant (1131).
alternative treatment regimen might be recommended.
Treatments for infections demonstrating in vitro resistance

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 Recommendations and Reports

Although metronidazole crosses the placenta, data indicate for adverse reproductive health, poor birth outcomes, and
that it poses a low risk to the developing fetus (1040,1042,1132). possibly amplified HIV transmission, routine screening and
No evidence of teratogenicity or mutagenic effects among prompt treatment are recommended for all women with HIV
infants has been found in multiple cross-sectional and cohort infection; screening should occur at entry to care and then at
studies among pregnant women examining single-dose (2 g) least annually thereafter.
and multidose metronidazole regimens (1040,1131–1135). A randomized clinical trial involving women with HIV
Symptomatic pregnant women, regardless of pregnancy stage, and T. vaginalis infection demonstrated that a single dose
should be tested and treated. Treatment of T. vaginalis infection of metronidazole 2 g orally was less effective than 500 mg
can relieve symptoms of vaginal discharge for pregnant women 2 times/day for 7 days (1105). Factors that might interfere
and reduce sexual transmission to partners. Although perinatal with standard single-dose treatment for trichomoniasis among
transmission of trichomoniasis is uncommon, treatment women with HIV include high rates of asymptomatic BV
might also prevent respiratory or genital infection in the infection, ART use, changes in vaginal ecology, and impaired
newborn (1136,1137). Clinicians should counsel symptomatic immunity (1141). Thus, to improve cure rates, women with
pregnant women with trichomoniasis about the potential HIV who receive a diagnosis of T. vaginalis infection should
risks and benefits of treatment and about the importance of be treated with metronidazole 500 mg orally 2 times/day
partner treatment and condom use in the prevention of sexual for 7 days. For pregnant women with HIV, screening at
transmission. The benefit of routine screening for T. vaginalis the first prenatal visit and prompt treatment, as needed, are
in asymptomatic pregnant women has not been established. recommended because T. vaginalis infection is a risk factor for
Metronidazole is secreted in breast milk. With maternal oral vertical transmission of HIV (1142).
therapy, breastfed infants receive metronidazole in doses that
are lower than those used to treat infections among infants, Treatment
although the active metabolite adds to the total infant exposure. Treatment reduces symptoms and signs of T. vaginalis
Plasma levels of the drug and metabolite are measurable but infection, cures infection, and might reduce transmission.
remain less than maternal plasma levels (https://www.ncbi.nlm. Likelihood of adverse outcomes among women with HIV
nih.gov/books/NBK501922). Although multiple reported case infection is also reduced with T. vaginalis therapy.
series studies demonstrated no evidence of adverse effects among
Recommended Regimen for Trichomonas and HIV Infection
infants exposed to metronidazole in breast milk, clinicians Among Women
sometimes advise deferring breastfeeding for 12–24 hours after Metronidazole 500 mg orally 2 times/day for 7 days
maternal treatment with metronidazole (1051). In one study,
maternal treatment with metronidazole (400 mg 3 times/day If a woman with HIV infection experiences treatment failure, the
for 7 days) produced a lower concentration in breast milk and protocol outlined is recommended (see Recurrent Trichomonas).
was considered compatible with breastfeeding over longer Other management considerations, follow-up, and management
periods (1052). of sex partners should be performed as for women without HIV
Data from studies involving human subjects are limited infection. Treatment of men with HIV infection should follow
regarding tinidazole use during pregnancy; however, animal data the same guidelines as for men without HIV.
indicate this drug poses moderate risk. Thus, tinidazole should For women with HIV who receive a diagnosis of T. vaginalis
be avoided for pregnant women, and breastfeeding should be infection, retesting is recommended 3 months after treatment;
deferred for 72 hours after a single 2-g oral dose of tinidazole NAAT is encouraged because of higher sensitivity of these
(https://www.ncbi.nlm.nih.gov/books/NBK501922). tests. Data are insufficient to support retesting of men with
HIV Infection trichomonas and HIV infection.
Up to 53% of women with HIV have T. vaginalis infection
(1115,1138). T. vaginalis infection among these women is Vulvovaginal Candidiasis
substantially associated with pelvic inflammatory disease VVC usually is caused by Candida albicans but can
(1082). Among women who are not virally suppressed, occasionally be caused by other Candida species or yeasts.
treatment of trichomoniasis is associated with decreases in Typical symptoms of VVC include pruritus, vaginal soreness,
genital tract HIV viral load and viral shedding (1079,1139); dyspareunia, external dysuria, and abnormal vaginal discharge.
however, no difference might occur among women who are None of these symptoms is specific for VVC. An estimated
virally suppressed (1140). Because of the high prevalence 75% of women will have at least one episode of VVC, and
of T. vaginalis among women with HIV and the potential 40%–45% will have two or more episodes. On the basis of

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 Recommendations and Reports

clinical presentation, microbiology, host factors, and response symptoms or signs of VVC, and women with a positive result
to therapy, VVC can be classified as either uncomplicated or should be treated. For those with negative wet mounts but
complicated (Box 4). Approximately 10%–20% of women existing signs or symptoms, vaginal cultures for Candida should
will have complicated VVC, requiring special diagnostic and be considered. If Candida cultures cannot be performed for
therapeutic considerations. these women, empiric treatment can be considered. Identifying
Candida by culture in the absence of symptoms or signs is not
Uncomplicated Vulvovaginal Candidiasis an indication for treatment because approximately 10%–20%
Diagnostic Considerations of women harbor Candida species and other yeasts in the
vagina. The majority of PCR tests for yeast are not FDA
A diagnosis of Candida vaginitis is clinically indicated by the
cleared, and providers who use these tests should be familiar
presence of external dysuria and vulvar pruritus, pain, swelling,
with the performance characteristics of the specific test used.
and redness. Signs include vulvar edema, fissures, excoriations,
Yeast culture, which can identify a broad group of pathogenic
and thick curdy vaginal discharge. Most healthy women with
yeasts, remains the reference standard for diagnosis.
uncomplicated VVC have no identifiable precipitating factors.
The diagnosis can be made in a woman who has signs and Treatment
symptoms of vaginitis when either a wet preparation (saline, Short-course topical formulations (i.e., single dose and
10% KOH) of vaginal discharge demonstrates budding regimens of 1–3 days) effectively treat uncomplicated VVC.
yeasts, hyphae, or pseudohyphae, or a culture or other test Treatment with azoles results in relief of symptoms and negative
yields a positive result for a yeast species. Candida vaginitis is cultures in 80%–90% of patients who complete therapy.
associated with normal vaginal pH (<4.5). Use of 10% KOH
in wet preparations improves the visualization of yeast and Recommended Regimens for Vulvovaginal Candidiasis
mycelia by disrupting cellular material that might obscure Over-the-Counter Intravaginal Agents
the yeast or pseudohyphae. Examination of a wet mount with Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days
or
KOH preparation should be performed for all women with Clotrimazole 2% cream 5 g intravaginally daily for 3 days
or
BOX 4. Classification of vulvovaginal candidiasis Miconazole 2% cream 5 g intravaginally daily for 7 days
or
Miconazole 4% cream 5 g intravaginally daily for 3 days
Uncomplicated vulvovaginal candidiasis (VVC) or
• Sporadic or infrequent VVC Miconazole 100 mg vaginal suppository one suppository daily for 7 days
and or
Miconazole 200 mg vaginal suppository one suppository for 3 days
• Mild-to-moderate VVC or
and Miconazole 1,200 mg vaginal suppository one suppository for 1 day
or
• Likely to be Candida albicans Tioconazole 6.5% ointment 5 g intravaginally in a single application
and
Prescription Intravaginal Agents
• Nonimmunocompromised women Butoconazole 2% cream (single-dose bioadhesive product) 5 g
intravaginally in a single application
Complicated VVC or
• Recurrent VVC (three or more episodes of Terconazole 0.4% cream 5 g intravaginally daily for 7 days
symptomatic VVC in <1 year) or
Terconazole 0.8% cream 5 g intravaginally daily for 3 days
or or
• Severe VVC Terconazole 80 mg vaginal suppository one suppository daily for 3 days
or Oral Agent
• Non–albicans candidiasis Fluconazole 150 mg orally in a single dose
or
• Women with diabetes, immunocompromising The creams and suppositories in these regimens are oil
conditions (e.g., HIV infection), underlying based and might weaken latex condoms and diaphragms.
immunodeficiency, or immunosuppressive therapy Patients should refer to condom product labeling for further
(e.g., corticosteroids) information. Even women who have previously received a
diagnosis of VVC by a clinician are not necessarily more
Source: Sobel JD, Faro S, Force RW, et al. Vulvovaginal candidiasis: likely to be able to diagnose themselves; therefore, any woman
epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol
1998;178:203–11. whose symptoms persist after using an over-the-counter
preparation or who has a recurrence of symptoms <2 months

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 Recommendations and Reports

after treatment for VVC should be evaluated clinically and predisposing or underlying conditions. C. glabrata and other
tested. Unnecessary or unapproved use of over-the-counter non–albicans Candida species are observed in 10%–20%
preparations is common and can lead to a delay in treatment of women with recurrent VVC. Conventional antimycotic
of other vulvovaginitis etiologies, which can result in adverse therapies are not as effective against these non–albicans yeasts
outcomes. No substantial evidence exists to support using as against C. albicans.
probiotics or homeopathic medications for treating VVC.
Treatment
Follow-Up Most episodes of recurrent VVC caused by C. albicans
Follow-up typically is not required. However, women with respond well to short-duration oral or topical azole therapy.
persistent or recurrent symptoms after treatment should be However, to maintain clinical and mycologic control, a longer
instructed to return for follow-up visits. duration of initial therapy (e.g., 7–14 days of topical therapy
or a 100-mg, 150-mg, or 200-mg oral dose of fluconazole
Management of Sex Partners
every third day for a total of 3 doses [days 1, 4, and 7])
Uncomplicated VVC is not usually acquired through sexual is recommended, to attempt mycologic remission, before
intercourse, and data do not support treatment of sex partners. initiating a maintenance antifungal regimen.
A minority of male sex partners have balanitis, characterized Oral fluconazole (i.e., a 100-mg, 150-mg, or 200-mg dose)
by erythematous areas on the glans of the penis in conjunction weekly for 6 months is the indicated maintenance regimen.
with pruritus or irritation. These men benefit from treatment If this regimen is not feasible, topical treatments used
with topical antifungal agents to relieve symptoms. intermittently can also be considered. Suppressive maintenance
Special Considerations therapies are effective at controlling recurrent VVC but are
rarely curative long-term (1147). Because C. albicans azole
Drug Allergy, Intolerance, and Adverse Reactions resistance is becoming more common, susceptibility tests, if
Topical agents usually cause no systemic side effects, although available, should be obtained among symptomatic patients who
local burning or irritation might occur. Oral azoles occasionally remain culture positive despite maintenance therapy. These
cause nausea, abdominal pain, and headache. Therapy with the women should be managed in consultation with a specialist.
oral azoles has rarely been associated with abnormal elevations Severe Vulvovaginal Candidiasis
of liver enzymes. Clinically important interactions can occur
when oral azoles are administered with other drugs (1141). Severe VVC (i.e., extensive vulvar erythema, edema,
excoriation, and fissure formation) is associated with lower
Complicated Vulvovaginal Candidiasis clinical response rates among patients treated with short courses
of topical or oral therapy. Either 7–14 days of topical azole or
Diagnostic Considerations
150 mg of fluconazole in two sequential oral doses (second dose
Vaginal culture or PCR should be obtained from women 72 hours after initial dose) is recommended.
with complicated VVC to confirm clinical diagnosis and
identify non–albicans Candida. Candida glabrata does not Non–albicans Vulvovaginal Candidiasis
form pseudohyphae or hyphae and is not easily recognized Because approximately 50% of women with a positive culture
on microscopy. C. albicans azole resistance is becoming more for non–albicans Candida might be minimally symptomatic or
common in vaginal isolates (1144,1145), and non–albicans have no symptoms, and because successful treatment is often
Candida is intrinsically resistant to azoles; therefore, culture difficult, clinicians should make every effort to exclude other
and susceptibility testing should be considered for patients causes of vaginal symptoms for women with non–albicans
who remain symptomatic. yeast (1148). The optimal treatment of non–albicans VVC
remains unknown; however, a longer duration of therapy
Recurrent Vulvovaginal Candidiasis
(7–14 days) with a nonfluconazole azole regimen (oral or
Recurrent VVC, usually defined as three or more episodes topical) is recommended. If recurrence occurs, 600 mg of boric
of symptomatic VVC in <1 year, affects <5% of women but acid in a gelatin capsule administered vaginally once daily for
carries a substantial economic burden (1146). Recurrent VVC 3 weeks is indicated. This regimen has clinical and mycologic
can be either idiopathic or secondary (related to frequent eradication rates of approximately 70% (1149). If symptoms
antibiotic use, diabetes, or other underlying host factors). The recur, referral to a specialist is advised.
pathogenesis of recurrent VVC is poorly understood, and the
majority of women with recurrent VVC have no apparent

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