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This document is being maintained for historical purposes, but is now out of date.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

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

SEXUAL ASSAULT AND STDs

Adults and Adolescents
     
     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
specimens for forensic purposes and the management of potential
pregnancy or physical and psychological trauma are beyond the scope
of these recommendations. Among sexually active adults, the
identification of sexually transmitted infections following assault
is usually more important for the psychological and medical
management of the patient than for legal purposes, if the infection
could have been acquired before the assault.

     Trichomoniasis, chlamydia, gonorrhea, and BV appear to be the
infections most commonly diagnosed among women following sexual
assault. Since the prevalence of these conditions is substantial
among sexually active women, their presence (post-assault) does not
necessarily signify acquisition during the assault. Chlamydial and
gonococcal infection among females are of special concern because
of the possibility of ascending infection.

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 for
chlamydia are an acceptable substitute, although false-negative
test results are more common with nonculture tests and
false-positive test results may occur. If a nonculture test is
used, a positive test result should be verified with a second test
based on a different diagnostic principle or with a blocking
antibody or competitive probe procedure.

--   Wet mount and culture of a vaginal swab specimen for T.
     vaginalis infection. If vaginal discharge or malodor is evident,
     the wet mount should also be examined for evidence of BV and yeast
     infection.

--   Collection of a serum sample to be preserved for subsequent
     analysis if follow-up serologic tests are positive (see Follow-up
     Examination 12 Weeks After Assault).

Follow-Up Examination 2 Weeks After Assault
     Examination for sexually transmitted infections 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 tests at the
initial examination, culture and wet mount tests should be repeated
at the 2-week visit unless prophylactic treatment has already been
provided.

Follow-Up Examination 12 Weeks After Assault
     Serologic tests for syphilis and HIV infection should be
performed 12 weeks after the assault. If positive, testing of the
sera collected at the initial examination will assist in
determining whether the infection antedated the assault.

Prophylaxis
     Although not all experts agree, most patients probably benefit
from prophylaxis because a) follow-up of patients who have been
sexually assaulted can be difficult, and b) patients may be
reassured if offered treatment or prophylaxis for possible
infection. The following prophylactic measures address the more
common microorganisms:

--   HBV vaccination (see HEPATITIS B).

--   Antimicrobial therapy: empiric regimen for chlamydial,
     gonococcal, and trichomonal infections and for BV.

Recommended Regimen -
     Ceftriaxone 125 mg IM in a single dose
                      PLUS
     Metronidazole 2 g orally in a single dose
                      PLUS
     Doxycycline 100 mg orally 2 times a day for 7 days.

NOTE: For patients requiring alternative treatments, see the
appropriate sections of this report addressing those agents.

Other Management Considerations
     At the initial examination and, as 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

--   Use of condoms for 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 minimal in most instances. Although the overall rate of
transmission of HIV from an HIV-infected person during a single act
of heterosexual intercourse is thought to be low ( less than 1%),
this risk depends on many factors. Prophylactic treatment for HIV
is not known to be effective and is not generally recommended in
this situation. However, all persons should be offered HIV
counseling and testing after the assault.

     Raising the issue of the potential for HIV infection during
the initial medical evaluation may add to the acute psychological
stress the patient may be experiencing because of the assault. An
alternative is to address the issue at the 2-week follow-up
appointment when the patient may be better able to receive this
information and give informed consent for HIV testing. All persons
electing to be tested for HIV should receive pretest and posttest
counseling.

Sexual Assault or Abuse of Children
     
     Recommendations in this report are limited to the
identification and treatment of sexually transmitted infections.
Management of the psychosocial and legal aspects of the sexual
assault or abuse of children are important, but are beyond the
scope of these recommendations.

     The identification of sexually transmissible agents among
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, BV and genital mycoplasmas have been identified
among children who have been abused and among those who have not
been abused. A finding of genital warts, although suggestive of
assault, is not specific for sexual abuse without other evidence.
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 carefully
considered.

Evaluation for Sexually Transmitted Infections
     Examinations of children for sexual assault or abuse should be
conducted so as to minimize 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., multiple partners or past history of STD),

--   The child has symptoms or signs of an STD,

--   There is a high STD prevalence in the community.

     Obtaining the indicated specimens requires skill to avoid
psychological and physical trauma to the child. The clinical
manifestations of some sexually transmitted infections are
different among children when compared with adults. Examinations
and specimen collection 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. Additional cost and time are justified to obtain such
tests.

     The scheduling of examinations should depend on the history of
assault or abuse. If initial exposure is recent, infectious agents
acquired through the exposure may not have produced sufficient
concentrations of organisms to result in positive tests. A
follow-up visit approximately 2 weeks after the last sexual
exposure should include a repeat physical examination and
collection of additional specimens. To allow sufficient time for
antibody to develop, another follow-up visit approximately 12 weeks
after the last sexual exposure also is necessary to collect sera.
A single examination may be sufficient if the child was abused for
an extended period of time, or if the last suspected episode of
abuse took place some time 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 patient'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 Examinations
     During the initial examination and 2-week follow-up
examination (if indicated), the following should be performed:

--   Cultures for N. gonorrhoeae specimens collected from the
     pharynx and anus in both sexes, 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 sexes 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.

--   Culture and wet mount of a vaginal swab specimen for T.
     vaginalis infection. The presence of clue cells in the wet mount
     suggests BV among children with 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
     not clear.

--   Collection of a serum sample to be preserved for subsequent
     analysis if follow-up serologic tests are positive. If the last
     sexual exposure occurred greater than 8 weeks before the initial
     examination, sera should be tested immediately for antibody to
     sexually transmitted agents. Agents for which suitable tests are
     available include T. pallidum, HIV, and HBV. The choice of agents
     for serologic tests should be made on a case-by-case basis (see
     Examination 12 Weeks After Assault).

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. Serologic tests for the agents listed
below should be considered:

--   T. pallidum,

--   HIV,

--   HBV.

     The prevalence of these infections varies greatly among
communities, and depends upon whether risk factors are known to be
present in the abuser or assailant. Also, results of HBV tests must
be interpreted carefully, because HBV may be transmitted by
nonsexual modes as well as sexually. The choice of tests must be
made on a case-by-case basis.

Presumptive Treatment
     There are few data upon which to establish the risk of a
child's acquiring a sexually transmitted infection as a result of
sexual abuse. 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 can usually be assured. However,
some children or their parents or guardians may be very concerned
about the possibility of contracting an STD, even if the risk is
perceived by the health-care practitioner to be low. Addressing
patient concerns may be an appropriate indication for presumptive
treatment in some settings.

Reporting
     Every state, the District of Columbia, Puerto Rico, Guam, the
Virgin Islands, and American Samoa have laws that require the
reporting of child abuse. The exact requirements vary from state to
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 protective service agency about child
abuse reporting requirements in their areas.

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