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Warning:
This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:
- STD Treatment Guidelines at http://www.cdc.gov/STD/treatment
1998 Guidelines for Treatment of Sexually Transmitted Disease
Date: 01/23/98
Source: 47(RR-1);1-118
SUGGESTED CITATION: Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1): {inclusive page numbers}.
The material in this report was prepared for publication by: National Center for HIV, STD and TB Prevention, Division of Sexually Transmitted Diseases Prevention
SEXUAL ASSAULT AND STDs
Adults and Adolescents
The recommendations in this report are limited to the identification and treatment of sexually transmitted infections and conditions commonly identified in the management of such infections. The documentation of findings and collection of nonmicrobiologic specimens for forensic purposes and the management of potential pregnancy or physical and psychological trauma are not included. Among sexually active adults, the identification of sexually transmitted infections after an assault is usually more important for the psychological and medical management of the patient than for legal purposes, because the infection could have been acquired before the assault.
Trichomoniasis, BV, chlamydia, and gonorrhea are the most frequently diagnosed infections among women who have been sexually assaulted. Because the prevalence of these STDs is substantial among sexually active women, the presence of these infections after an assault does not necessarily signify acquisition during the assault. Chlamydial and gonococcal infections in women are of special concern because of the possibility of ascending infection. In addition, HBV infection, if transmitted to a woman during an assault, can be prevented by postexposure administration of hepatitis B vaccine.
Evaluation for Sexually Transmitted Infections
Initial Examination
An initial examination should include the following procedures:
Cultures for N. gonorrhoeae and C. trachomatis from specimens collected from any sites of penetration or attempted penetration.
If chlamydial culture is not available, nonculture tests, particularly the nucleic acid amplification tests, are an acceptable substitute. Nucleic acid amplification tests offer advantages of increased sensitivity if confirmation is available. If a nonculture test is used, a positive test result should be verified with a second test based on a different diagnostic principle. EIA and direct fluorescent antibody are not acceptable alternatives, because false-negative test results occur more often with these nonculture tests, and false-positive test results may occur.
Wet mount and culture of a vaginal swab specimen for T. vaginalis infection. If vaginal discharge or malodor is evident, the wet mount also should be examined for evidence of BV and yeast infection.
Collection of a serum sample for immediate evaluation for HIV, hepatitis B, and syphilis (see Prophylaxis, Risk for Acquiring HIV Infection and Follow-Up Examination 12 Weeks After Assault).
Follow-Up Examinations
Although it is often difficult for persons to comply with follow-up examinations weeks after an assault, such examinations are essential a) to detect new infections acquired during or after the assault; b) to complete hepatitis B immunization, if indicated; and c) to complete counseling and treatment for other STDs. For these reasons, it is recommended that assault victims be reevaluated at follow-up examinations.
Follow-Up Examination After Assault
Examination for STDs should be repeated 2 weeks after the assault. Because infectious agents acquired through assault may not have produced sufficient concentrations of organisms to result in positive test results at the initial examination, a culture (or cultures), a wet mount, and other tests should be repeated at the 2-week follow-up visit unless prophylactic treatment has already been provided.
Serologic tests for syphilis and HIV infection should be repeated 6, 12, and 24 weeks after the assault if initial test results were negative.
Prophylaxis
Many experts recommend routine preventive therapy after a sexual assault. Most patients probably benefit from prophylaxis because the follow-up of patients who have been sexually assaulted can be difficult, and they may be reassured if offered treatment or prophylaxis for possible infection. The following prophylactic regimen is suggested as preventive therapy:
Postexposure hepatitis B vaccination (without HBIG) should adequately protect against HBV. Hepatitis B vaccine should be administered to victims of sexual assault at the time of the initial examination. Follow-up doses of vaccine should be administered 1-2 and 4-6 months after the first dose.
An empiric antimicrobial regimen for chlamydia, gonorrhea, trichomonas, and BV should be administered.
Recommended Regimen
Ceftriaxone 125 mg IM in a single dose,
PLUS
Metronidazole 2 g orally in a single dose,
PLUS
Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice a day for 7 days.
NOTE: For patients requiring alternative treatments, see the sections in this report that specifically address those agents.
The efficacy of these regimens in preventing gonorrhea, BV, or C. trachomatis genitourinary infections after sexual assault has not been evaluated. The clinician might consider counseling the patient regarding the possible benefits, as well as the possibility of toxicity, associated with these treatment regimens, because of possible gastrointestinal side effects with this combination.
Other Management Considerations
At the initial examination and, if indicated, at follow-up examinations, patients should be counseled regarding the following:
Symptoms of STDs and the need for immediate examination if symptoms occur, and
Abstinence from sexual intercourse until STD prophylactic treatment is completed.
Risk for Acquiring HIV Infection
Although HIV-antibody seroconversion has been reported among persons whose only known risk factor was sexual assault or sexual abuse, the risk for acquiring HIV infection through sexual assault is low. The overall probability of HIV transmission from an HIV-infected person during a single act of intercourse depends on many factors. These factors may include the type of sexual intercourse (i.e., oral, vaginal, or anal); presence of oral, vaginal or anal trauma; site of exposure to ejaculate; viral load in ejaculate; and presence of an STD.
In certain circumstances, the likelihood of HIV transmission also may be affected by postexposure therapy for HIV with antiretroviral agents. Postexposure therapy with zidovudine has been associated with a reduced risk for HIV infection in a study of health-care workers who had percutaneous exposures to HIV-infected blood. On the basis of these results and the biologic plausibility of the effectiveness of antiretroviral agents in preventing infection, postexposure therapy has been recommended for health-care workers who have percutaneous exposures to HIV. However, whether these findings can be extrapolated to other HIV-exposure situations, including sexual assault, is unknown. A recommendation cannot be made, on the basis of available information, regarding the appropriateness of postexposure antiretroviral therapy after sexual exposure to HIV.
Health-care providers who consider offering postexposure therapy should take into account the likelihood of exposure to HIV, the potential benefits and risks of such therapy, and the interval between the exposure and initiation of therapy. Because timely determination of the HIV-infection status of the assailant is not possible in many sexual assaults, the health-care provider should assess the nature of the assault, any available information about HIV-risk behaviors exhibited by persons who are sexual assailants (e.g., high-risk sexual practices and injecting-drug or crack cocaine use), and the local epidemiology of HIV/AIDS. If antiretroviral postexposure prophylaxis is offered, the following information should be discussed with the patient: a) the unknown efficacy and known toxicities of antiretrovirals, b) the critical need for frequent dosing of medications, c) the close follow-up that is necessary, d) the importance of strict compliance with the recommended therapy, and e) the necessity of immediate initiation of treatment for maximal likelihood of effectiveness. If the patient decides to take postexposure therapy, clinical management of the patient should be implemented according to the guidelines for occupational mucous membrane exposure.
Sexual Assault or Abuse of Children
Recommendations in this report are limited to the identification and treatment of STDs. Management of the psychosocial aspects of the sexual assault or abuse of children is important but is not included in these recommendations.
The identification of sexually transmissible agents in children beyond the neonatal period suggests sexual abuse. However, there are exceptions; for example, rectal or genital infection with C. trachomatis among young children may be the result of perinatally acquired infection and may persist for as long as 3 years. In addition, genital warts, BV, and genital mycoplasmas have been diagnosed in children who have been abused and in those not abused. There are several modes by which HBV is transmitted to children; the most common of these is household exposure to persons who have chronic HBV infection.
The possibility of sexual abuse should be considered if no obvious risk factor for infection can be identified. When the only evidence of sexual abuse is the isolation of an organism or the detection of antibodies to a sexually transmissible agent, findings should be confirmed and the implications considered carefully. The evaluation for determining whether sexual abuse has occurred among children who have infections that can be sexually transmitted should be conducted in compliance with expert recommendations by practitioners who have experience and training in the evaluation of abused or assaulted children (29).
Evaluation for Sexually Transmitted Infections
Examinations of children for sexual assault or abuse should be conducted so as to minimize pain and trauma to the child. The decision to evaluate the child for STDs must be made on an individual basis. Situations involving a high risk for STDs and a strong indication for testing include the following:
A suspected offender is known to have an STD or to be at high risk for STDs (e.g., has multiple sex partners or a history of STD).
The child has symptoms or signs of an STD or of an infection that can be sexually transmitted.
The prevalence of STDs in the community is high. Other indications recommended by experts include a) evidence of genital or oral penetration or ejaculation or b) STDs in siblings or other children or adults in the household. If a child has symptoms, signs, or evidence of an infection that might be sexually transmitted, the child should be tested for other common STDs. Obtaining the indicated specimens requires skill to avoid psychological and physical trauma to the child. The clinical manifestations of some STDs are different among children in comparison with adults. Examinations and specimen collections should be conducted by practitioners who have experience and training in the evaluation of abused or assaulted children.
A principal purpose of the examination is to obtain evidence of an infection that is likely to have been sexually transmitted. However, because of the legal and psychosocial consequences of a false-positive diagnosis, only tests with high specificities should be used. The additional cost of such tests and the time required to conduct them are justified.
The scheduling of examinations should depend on the history of assault or abuse. If the initial exposure was recent, the infectious agents acquired through the exposure may not have produced sufficient concentrations of organisms to result in positive test results. A follow-up visit approximately 2 weeks after the most recent sexual exposure should include a repeat physical examination and collection of additional specimens. To allow sufficient time for antibodies to develop, another follow-up visit approximately 12 weeks after the most recent sexual exposure may be necessary to collect sera. A single examination may be sufficient if the child was abused for an extended time period or if the last suspected episode of abuse occurred well before the child received the medical evaluation.
The following recommendation for scheduling examinations is a general guide. The exact timing and nature of follow-up contacts should be determined on an individual basis and should be considerate of the child's psychological and social needs. Compliance with follow-up appointments may be improved when law enforcement personnel or child protective services are involved.
Initial and 2-Week Follow-Up Examinations
During the initial examination and 2-week follow-up examination (if indicated), the following should be performed:
Visual inspection of the genital, perianal, and oral areas for genital warts and ulcerative lesions.
Cultures for N. gonorrhoeae specimens collected from the pharynx and anus in both boys and girls, the vagina in girls, and the urethra in boys. Cervical specimens are not recommended for prepubertal girls. For boys, a meatal specimen of urethral discharge is an adequate substitute for an intraurethral swab specimen when discharge is present. Only standard culture systems for the isolation of N. gonorrhoeae should be used. All presumptive isolates of N. gonorrhoeae should be confirmed by at least two tests that involve different principles (e.g., biochemical, enzyme substrate, or serologic methods). Isolates should be preserved in case additional or repeated testing is needed.
Cultures for C. trachomatis from specimens collected from the anus in both boys and girls and from the vagina in girls. Limited information suggests that the likelihood of recovering Chlamydia from the urethra of prepubertal boys is too low to justify the trauma involved in obtaining an intraurethral specimen. A urethral specimen should be obtained if urethral discharge is present. Pharyngeal specimens for C. trachomatis also are not recommended for either sex because the yield is low, perinatally acquired infection may persist beyond infancy, and culture systems in some laboratories do not distinguish between C. trachomatis and C. pneumoniae.
Only standard culture systems for the isolation of C. trachomatis should be used. The isolation of C. trachomatis should be confirmed by microscopic identification of inclusions by staining with fluorescein-conjugated monoclonal antibody specific for C. trachomatis. Isolates should be preserved. Nonculture tests for chlamydia are not sufficiently specific for use in circumstances involving possible child abuse or assault. Data are insufficient to adequately assess the utility of nucleic acid amplification tests in the evaluation of children who might have been sexually abused, but expert opinion suggests these tests may be an alternative if confirmation is available but culture systems for C. trachomatis are unavailable.
Culture and wet mount of a vaginal swab specimen for T. vaginalis infection. The presence of clue cells in the wet mount or other signs, such as a positive whiff test, suggests BV in girls who have vaginal discharge. The significance of clue cells or other indicators of BV as an indicator of sexual exposure is unclear. The clinical significance of clue cells or other indicators of BV in the absence of vaginal discharge also is unclear.
Collection of a serum sample to be evaluated immediately, preserved for subsequent analysis, and used as a baseline for comparison with follow-up serologic tests. Sera should be tested immediately for antibodies to sexually transmitted agents. Agents for which suitable tests are available include T. pallidum, HIV, and HBsAg. The choice of agents for serologic tests should be made on a case-by-case basis (see Examination 12 Weeks After Assault). HIV antibodies have been reported in children whose only known risk factor was sexual abuse. Serologic testing for HIV infection should be considered for abused children. The decision to test for HIV infection should be made on a case-by-case basis, depending on likelihood of infection among assailant(s). Data are insufficient concerning the efficacy and safety of postexposure prophylaxis among children. Vaccination for HBV should be recommended if the medical history or serologic testing suggests that it has not been received (see Hepatitis B).
Examination 12 Weeks After Assault
An examination approximately 12 weeks after the last suspected sexual exposure is recommended to allow time for antibodies to infectious agents to develop if baseline tests are negative. Serologic tests for T. pallidum, HIV, and HBsAg should be considered. The prevalence of these infections differs substantially by community, and serologic testing depends on whether risk factors are known to be present in the abuser or assailant. In addition, results of HBsAg testing must be interpreted carefully, because HBV also can be transmitted nonsexually. The choice of tests must be made on an individual basis.
Presumptive Treatment
The risk for a child's acquiring an STD as a result of sexual abuse has not been determined. The risk is believed to be low in most circumstances, although documentation to support this position is inadequate.
Presumptive treatment for children who have been sexually assaulted or abused is not widely recommended because girls appear to be at lower risk for ascending infection than adolescent or adult women, and regular follow-up usually can be ensured. However, some children -- or their parent(s) or guardian(s) -- may be concerned about the possibility of infection with an STD, even if the risk is perceived by the health-care provider to be low. Patient or parental/guardian concerns may be an appropriate indication for presumptive treatment in some settings (i.e., after all specimens relevant to the investigation have been collected).
Reporting
Every state, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and American Samoa have laws that require the reporting of child abuse. The exact requirements differ by state, but, generally, if there is reasonable cause to suspect child abuse, it must be reported. Health-care providers should contact their state or local child-protection service agency about child abuse reporting requirements in their areas.
