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This document is being maintained for historical purposes, but is now out of date.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

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.

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