Source: Market Information
From: Medical Realm
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Sexually transmitted infections (STIs) impose a significant global burden, with over 30 known pathogens, including bacteria, viruses, and parasites. A recent assessment by the World Health Organization (WHO) of data up to 2020 globally revealed that there are 374 million cases of curable STIs among individuals aged 15-49, including 156.3 million cases of trichomoniasis, 128.5 million cases of chlamydia, 82.4 million cases of gonorrhea, and 7.1 million cases of syphilis, approximately 1 million new cases of curable STIs are reported daily.
Given the current severity of STIs, to achieve the “Global Health Sector Strategy on STIs,” WHO has issued treatment recommendations for the five common STIs, providing new treatment regimens for trichomoniasis, Chlamydia, Candidiasis, Bacterial Vaginosis, and Human Papillomavirus (HPV).
Figure 1 Literature screenshot
Trichomoniasis
Trichomoniasis infection is the most common non-viral STI globally. Trichomoniasis can be transmitted during sexual intercourse, with humans being the only known hosts.
In females, trichomoniasis infection can lead to vaginitis and may result in cervicitis and pelvic inflammatory disease. Infection with trichomoniasis during pregnancy is associated with an increased risk of preterm birth, premature rupture of membranes, and low birth weight infants. Moreover, trichomoniasis infection also increases the risk of HIV infection, with an increased shedding of HIV in the semen of male patients infected with trichomoniasis.
1. WHO recommends (conditionally recommended, evidence certainty moderate): Metronidazole 400mg or 500mg orally twice daily for 7 days for adult and adolescent individuals infected with trichomoniasis (including pregnant women).
2. If there are severe issues with continued administration, WHO recommends one of the following alternatives:
1. Metronidazole 2g orally once.
2. Tinidazole 2g orally once (excluding during pregnancy).
Note: If metronidazole or tinidazole is not available, a single dose of secnidazole 2g orally (excluding during pregnancy) or a single dose of ornidazole 1.5g orally (excluding during pregnancy) can be used as alternatives.
Chlamydia
Chlamydia, due to the lack of a rigid cell wall, exhibits resistance to beta-lactam antibiotics acting on the bacterial cell wall, such as penicillin, cephalosporins, and carbapenems.
Chlamydia is commonly found in the human genitourinary tract. Population-based studies have shown a higher prevalence of chlamydia among sexually active males and females, with rates as high as 20% in key populations (such as males having sex with males and sex workers).
1. WHO recommends that the treatment selection for chlamydia infection should be guided by individual resistance profiles, monitoring data, or the suspected resistance based on typical prescription practices for other infections (using antibiotics) (good practice statement).
2. In environments with high or suspected high resistance to macrolides or where testing indicates macrolide resistance in chlamydia, WHO recommends:
Doxycycline 100mg orally twice daily for 7 days followed by moxifloxacin 400mg orally twice daily for 7 days to reduce the bacterial load.
3. In environments with low or suspected low resistance to macrolides or where testing indicates chlamydia sensitivity to macrolides, WHO recommends:
Doxycycline 100mg orally twice daily for 7 days followed by azithromycin 1g orally once (initial dose), with azithromycin switching to 500mg orally once daily for 3 days starting from the second day.
If azithromycin or moxifloxacin is not available, or if there is confirmed or suspected high resistance to both, WHO recommends one of the following:
1. Minocycline 100mg orally twice daily for 14 days.
2. Ciprofloxacin 200mg orally once daily for 7 days.
3. Pristinamycin 1g orally four times a day for 10 days.
Note: 1. If suspected chlamydia-infected patients have been treated (with doxycycline 100mg orally twice daily for 7 days), there is no need for reducing the bacterial load with doxycycline before using either moxifloxacin or azithromycin.
2. When individual resistance profiles or monitoring data are not available, the possibility of resistance may be based on typical prescription practices (using antibiotics). For instance, in regions where azithromycin is primarily used to treat infections, resistance to azithromycin and other macrolides is more likely.
3. Doxycycline, moxifloxacin, minocycline, and ciprofloxacin should not be used during pregnancy and lactation, only pristinamycin should be used.
Candidiasis
Vulvovaginal candidiasis (VVC) is one of the most common causes of vulvovaginitis, with about 70-75% of women affected. In approximately 90% of cases, VVC is caused by Candida species.
1. For adult and adolescent individuals infected with Candidiasis, WHO recommends one of the following (conditionally recommended, evidence certainty low):
1. Fluconazole 150-200mg orally as a single dose.
2. Clotrimazole 500mg or 200mg intravaginally once daily for 3 days or a 10% cream administered intravaginally as a single dose.
3. Miconazole 1200mg or 400mg intravaginally once daily for 7 days.
4. Econazole 150mg intravaginally.
5. Nystatin 100,000 units intravaginally twice daily for 15 days.
2. For pregnant women, WHO recommends one of the following:
1. Clotrimazole 100mg intravaginally once daily for 7 days or a 1% cream intravaginally once daily for 7 days.
2. Nystatin 100,000 units intravaginally twice daily for 15 days.
Bacterial Vaginosis
Bacterial vaginosis arises from an imbalance in the vaginal microbiota. BV is associated with an increased risk of obstetric complications, including preterm birth, miscarriage, and an increased risk of HIV and other STIs.
1. For adult and adolescent individuals with BV (including pregnant women), WHO recommends (conditionally recommended, metronidazole efficacy evidence certainty moderate, clindamycin and secnidazole efficacy evidence certainty low, tinidazole efficacy evidence certainty very low):
Metronidazole 400mg or 500mg orally twice daily for 7 days.
2. If oral metronidazole is not feasible, continued administration is a serious problem, or vaginal cream is preferred, WHO recommends one of the following treatment regimens:
1. 0.75% metronidazole gel intravaginally for 7 days.
2. Tinidazole 2g orally once.
3. Clindamycin 300mg orally twice daily for 7 days.
4. 2% clindamycin cream (5g) intravaginally once daily for 7 days.
5. Secnidazole 2g orally once.
HPV
HPV 6 and HPV 11 account for approximately 90% of HPV cases. Recurrent warts often necessitate repeated treatment procedures. In countries where HPV vaccination (covering both HPV 6 and HPV 11 types) has been implemented, the incidence of genital warts has significantly decreased.
1. For adult and adolescent individuals with simple anogenital warts, WHO recommends the use of one of the following (conditionally recommended, evidence certainty moderate):
1. 0.5% podophyllotoxin solution or 0.5%-1.5% podophyllotoxin cream applied twice daily for 3 days followed by a 4-day treatment interruption (this cycle can be repeated 4 times) (except during pregnancy).
2. 3.75% or 5% imiquimod cream applied thrice weekly for 16 weeks (except during pregnancy).
2. In case of treatment failure, based on available resources, WHO recommends the following:
1. Electrocautery/cryotherapy.
2. Carbon dioxide laser therapy.
3. 80% trichloroacetic acid (except during pregnancy).
4. Cryotherapy.
Note: 1. The choice of treatment method should be guided by factors such as the thickness, size, and anatomical location of anogenital warts.
2. Responses to treatment may vary, hence close monitoring is necessary. Additionally, while podophyllotoxin (10%-25%, to be applied by healthcare workers, rinsed off 2-4 hours later, repeated weekly if necessary) may be less effective than other treatment methods, it can serve as an alternative when no other options are available, but close monitoring is necessary.
3. Podophyllotoxin solution or cream, imiquimod cream, trichloroacetic acid, and podophyllotoxin are contraindicated in pregnant women. If necessary, cryotherapy is the safest choice during pregnancy.
References:
[1] https://www.who.int/publications/i/item/9789240096370
