Symptomatic Sexually Transmitted Infection Screening

SymptomaticSymptomatic Sexually Sexually Transmitted Transmitted Infection Infection Screening Screening

SYMPTOMATIC

Clinical and Therapeutic Symptoms Recommended Diagnostic Testing Considerations

Female • Vaginal itching Vaginal examination: Promptly begin empiric Symptomatic• Vaginal Sexuallydischarge Transmitted1. Observe vaginal Infection anatomy Screeningtreatment of Chlamydia and • Painful urination 2. Gram stain for bacterial Gonorrhea before lab results • Increased urinary vaginosis return SYMPTOMATIC urgency 3. Vaginal swabs for PCR assay: • Pelvic pain • Gonorrhea Clinical Vaginaland Therapeutic exam will allow Symptoms Recommended Diagnostic Testing • Pain with sexual • Chlamydia Considerationsvisualization of vaginal intercourse 4. Vaginal swabs for Affirm DNA anatomy Female • Vaginal itching Vaginal examination: Promptly begin empiric •• Vaginal discharge bleeding 1. Observe vaginal• Trichomoniasis anatomy treatment of Chlamydia and •• GenitalPainful urination warts 2. Gram5. HIV stain test for bacterial Gonorrhea Vaginalbefore lab or results cervical swab may •• GenitalIncreased lesion/ulcer urinary vaginosis6. Syphilis (RPR screen/ titer) return be necessary for specific test • Pharyngitisurgency 3. Vaginal7. Urinalysis swabs for PCR assay: kits • Pelvic pain 8. • PregnancyGonorrhea Test Vaginal exam will allow Pain with sexual Chlamydia visualization of vaginal • 9. • Oropharyngeal (OP) Culture intercourse 4. Vaginal swabs for Affirm DNA anatomy • Vaginal bleeding • swabTrichomoniasis for GC when indicated • Genital warts 5. HIV test Vaginal or cervical swab may • Genital lesion/ulcer 6. SyphilisUnable (RPR to perform screen/ titer) vaginal be necessaryPromptly for specific begin test empiric • Pharyngitis 7. Urinalysisexamination: kits treatment of Chlamydia and 8. Pregnancy1. Urinalysis Test Gonorrhea before lab results 9. Oropharyngeal2. Urine for (OP)PCR Cultureassay: return swab for GC• Gonorrheawhen indicated Unable to perform• Chlamydia vaginal Promptly begin empiric examination:3. HIV test treatment of Chlamydia and 1. Urinalysis4. Syphilis (RPR screen/titer) Gonorrhea before lab results 2. Urine5. Pregnancy for PCR assay: Test return • Gonorrhea 6. OP Culture for GC when • Chlamydia 3. HIV testindicated 4. Syphilis (RPR screen/titer) Male • Penile discharge 5. Pregnancy1. Urinalysis Test Promptly begin empiric • Painful urination 6. OP2. CultureUrine for for GC PCR whenassay: treatment of Chlamydia and • Increased urgency indicated• Gonorrhea Gonorrhea before lab results • Pelvic pain • Chlamydia return Male • Penile discharge 1. Urinalysis Promptly begin empiric •• Swollen/tenderPainful urination 2. Urine3. HIV for PCRtestassay: treatment of Chlamydia and • testiclesIncreased urgency 4. • SyphilisGonorrhea (RPR screen/ titer) Gonorrhea before lab results •• PainPelvic withpain sexual 5. • OPChlamydia Culture Swab or Rectal return • intercourseSwollen/tender 3. HIV testculture swab for GC when • Genitaltesticles warts 4. Syphilisindicated (RPR screen/ titer) • Pain with sexual 5. OP Culture Swab or Rectal • Genitalintercourse lesion/ulcer culture swab for GC when •• PharyngitisGenital warts indicated • Genital lesion/ulcer • PharyngitisTREATMENT (DISCUSS TREATMENT OF PREGNANT WOMEN WITH ID AND OB/GYN)

Gonorrhea TREATMENTCeftriaxone(DISCUSS TREATMENT 250 OFmgPREGNANT IM ANDWOMENAzithromycinWITH ID AND OB/GYN) 1 gm PO x 1 dose Chlamydia OR doxycycline 100 mg PO Q12H for 7 days Gonorrhea Ceftriaxone 250 mg IM AND Azithromycin 1 gm PO x 1 dose Chlamydia OR doxycycline 100 mg PO Q12H for 7 days Penicillin Allergy (anaphylaxis): Consult ID Penicillin Allergy (anaphylaxis): Consult ID HIV or Syphilis Consult Infectious Diseases HIV or Syphilis Consult Infectious Diseases Bacterial vaginosis Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at Bacterial vaginosis Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at bedtimebedtime for 5 for days 5 days

Alternatives:Alternatives: Metronidazole Metronidazole 500 mg 500PO Q12H mg POOR Q12HclindamycinOR clindamycin 300 mg PO Q12H 300 mg PO Q12H forfor 7 days 7 days

TrichomonasTrichomonasvaginalisvaginalis MetronidazoleMetronidazole 2 gm 2PO gm x 1 PO dose x 1OR dosemetronidazole OR metronidazole500 mg PO Q12H500 mg for PO7 days Q12H for 7 days DNA= deoxyribonucleic acid; GC= gonococcus; H= hours; HIV= human immunodeficiency virus; ID= infectious diseases; IM= intramuscular; DNAOB/GYN== deoxyribonucleic obstetrics/gynecology; acid; GC= OP= gonococcus Oropharyngeal;; H= PCR=hours; Polymerase HIV= human chain reaction;immunodeficiency PO= by mouth virus; Q=; every; ID= infectious RPR= rapid diseases;plasma reagin IM=; intramuscular; OB/GYN=STI= sexually obstetrics/gynecology; transmitted infection. OP= Oropharyngeal; PCR= Polymerase chain reaction; PO= by mouth; Q= every; RPR= rapid plasma reagin; STI= sexually transmitted infection. PAGE 18 AsymptomaticAsymptomatic Sexually Sexually Transmitted Transmitted Infection Infection Screening Screening

ASYMPTOMATIC Screening Clinical and Therapeutic Population Frequency Recommendations Considerations

Female Age ≤ 25 Urine PCR for Chlamydia Annually Cervical screening should be performed 3 years after Urine PCR for Gonorrhea Annually initiating sexual activity or no HIV test At least once later than age 21 Cervical Screening No later than age 21 Age > 25 No routine screening for Consider minimum of annual STIs screening if high risk* patient Screen according to risk

Pregnant Urine PCR for Chlamydia First trimester Repeat Screening (all pathogens) in 3rd trimester Urine PCR for Gonorrhea First trimester and at birth if patient is high HIV test First trimester risk* Hepatitis B S Ag, S Ab, C Ab First trimester Hepatitis C Ab First trimester Syphilis RPR/titer First trimester

HIV-positive Urine PCR for Chlamydia Annually *Consider rectal and pharyngeal culture swabs for Urine PCR for Gonorrhea* Annually GC if exposed Syphilis RPR/titer Annually May repeat screening every Trichomoniasis Annually 3-6 months, as indicated by Hepatitis B S Ag, S Ab, C Ab Baseline risk Hepatitis C Ab Yearly if high risk*

EPT= expedited partner treatment; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Antibody; HIV= human immunodeficiency virus; MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma reagin; STI= sexually transmitted infection Test of Cure/ Retest Post Diagnosis and Treatment of Gonorrhea or Chlamydia - Retest all patients after 3 months for reinfection (if 3 months not possible, within 1 year). - Retest all pregnant patients a minimum of >/=3 weeks after completion of therapy. - If suspect treatment failure, reinfection , or failure due to alternative regimen then repeat testing at a minimum of >/= 3weeks after completion of therapy. - For pharyngeal gonorrhea– get test of cure on all patients after 14 days. Culture and susceptibilities preferred.

Note: Gonnorrhea/Chlamydial PCR <3 weeks from completion of therapy are not recommended due to presence of non-viable organisms and false-positive results.

STIs: Partner Treatment -Any recent sexual partner who has had contact with the infected patient within 60 days of their diagnosis should be considered for treatment. -Discuss treatment of partners or questions regarding Expedited Partner Treatment (EPT) with the Infectious Disease Service. -EPT should not be employed with MSMs (these patients should be referred for comprehensive STI testing first).

*Definition of High Risk Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

PAGE 19 Asymptomatic Sexually Transmitted Infection Screening

AsymptomaticAsymptomatic Sexually Sexually Transmitted TransmittedASYMPTOMATIC Infection Infection Screening Screening Screening Clinical and Therapeutic Population ASYMPTOMATIC Frequency Recommendations Considerations Screening Clinical and Therapeutic Male HeterosexualPopulation No routine screening Frequencyfor STIs. Screen according to *risk. men Note:Recommendations All ‘Babyboomers’ (Patients born from 1945 throughConsiderations 1965) should be Male Heterosexual No routine screening forscreened STIs. Screen for HCVaccording to *risk. men Note: All ‘Babyboomers’ (Patients born from 1945 through 1965) should be Men who have Urine PCR for Chlamydia Annually Consider GC/Chl culture, sex with men screened for HCVrectal and pharyngeal swabs (MSM) Urine PCR for Gonorrhea Annually Men who have Urine PCR for Chlamydia Annually Consider GC/Chl culture, ORsex with men HIV test Annually Highrectal risk and defined pharyngeal as: swabs *high risk Urine PCR for Gonorrhea Annually - New or multiple sex (MSM) Hepatitis B S Ag, S Ab, C Ab Baseline heterosexualOR men HIV test Annually Highpartners risk defined as: Hepatitis C Ab Annually *high risk - InconsistentNew or multiple condom sex use Hepatitis B S Ag, S Ab, C Ab Baseline heterosexual men Syphilis (RPR screen/ titer) Annually - Commercialpartners sex work Hepatitis C Ab Annually - DrugInconsistent use condom use Syphilis (RPR screen/ titer) Annually - Commercial sex work May- Drug repeat usescreening every 3-6 months, as indicated by riskMay repeat screening every 3-6 months, as indicated by HIV-positive men Urine PCR for Chlamydia Annually Consider GC/Chl culture, rectalrisk and pharyngeal swabs Urine PCR for Gonorrhea Annually HIV-positive men Urine PCR for Chlamydia Annually Consider GC/Chl culture, Syphilis (RPR screen/ titer) Annually Mayrectal repeat and pharyngealscreening everyswabs Urine PCR for Gonorrhea Annually 3-6 months, as indicated by Hepatitis B S Ag, S Ab, C Ab Baseline Syphilis (RPR screen/ titer) Annually riskMay repeat screening every Hepatitis C Ab Annually 3-6 months, as indicated by Hepatitis B S Ag, S Ab, C Ab Baseline risk GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B SurfaceHepatitis Antigen; Hepatitis C Ab C Ab= Hepatitis C CoreAnnually Antibody; HIV= human immunodeficiency virus; MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection. GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus; MSM=*Definition Men who of Highhave sexRisk with men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection. Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent*Definition sex contact of High outside Risk the US. Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

References: 1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. 2.References:"Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department 1. of"Sexually Health, Transmitted 2011. URL: httpDiseases://www.health.ri.gov/data/diseases/Syphilis.pdf Treatment Guidelines, 2015." Centers for Disease. Control and Prevention. Department of Health and Human 3. “CaliforniaServices, 17 Sexually Dec. 2010. Transmitted URL: http Disease://www.cdc.gov/std/treatment/2010/STD (STD) Screening Recommendations-Treatment 2010”. California-2010-RR5912.pdf Department. Of Public Health, June. 2011. URL: 2. http"Primary,://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA Secondary, and Early Latent Syphilis Surveillance 2007--STD2011."-Screening Division-Recommendations.pdf of Infectious Disease & Epidemiology. Rhode Island Department of Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf. 3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL: http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf PAGE 20 Asymptomatic Sexually Transmitted Infection Screening Asymptomatic Sexually Transmitted Infection Screening Asymptomatic Sexually TransmittedHIV testing Infection Screening Population Frequency HIV testing Special Considerations Consider frequent testing if high PopulationAll women age 13-64 FrequencyBaseline Special Considerations risk* Consider frequent testing if high All women age 13-64 Baseline risk*Consider PREP if HIV+ partner All women who seek STI screening At time of STI (Consult ID) Consider PREP if HIV+ partner All women who seek STI screening At time of STI (ConsultThird trimester ID) and at birth if high All pregnant women First Trimester risk Third trimester and at birth if high All pregnant women First Trimester riskConsider frequent testing if high All men age 13-64 Baseline risk* Consider frequent testing if high All men age 13-64 Baseline risk*Q3-6 months if higher risk activity MSM Annually (minimum) (Consider PREP and consult ID) Q3-6 months if higher risk activity MSM Annually (minimum) (ConsiderConsider PREP PREP if and HIV+ consult partner ID) All men who seek STI screening At time of STI (consult ID) Consider PREP if HIV+ partner All men who seek STI screening At time of STI HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP=(consult pre-exposure ID) prophylaxis; Q= every; RPR= rapid plasma regain; STI= sexually transmitted infection. HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP= pre-exposure prophylaxis; Q= every; *RPR=Definition rapid plasma of High regain; Risk STI= sexually transmitted infection. Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , *inconsistentDefinition of condom High Risk use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, Thoserecent whosex contact have a newoutside sex thepartner, US. >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

References: 1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human References:Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. 1.2. "Sexually"Primary, TransmittedSecondary, andDiseases Early LatentTreatment Syphilis Guidelines, Surveillance 2015." 2007 Centers-2011." for Division Disease of Control Infectious and DiseasePrevention. & Epidemiology. Department Rhodeof Health Isla andnd Department Human Services,of Health, 17 2011. Dec. URL: 2010. http URL::// www.health.ri.gov/data/diseases/Syphilis.pdfhttp://www.cdc.gov/std/treatment/2010/STD.-Treatment-2010-RR5912.pdf. 2.3. "“CaliforniaPrimary, Secondary, Sexually Transmitted and Early Latent Disease Syphilis (STD) SurveillanceScreening Recommendations 2007-2011." Division 2010”. of Infectious California DiseaseDepartment & Epidemiology. Of Public Health, Rhode June. Island20 Department11. URL: ofhttp Health,://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf-STD-Screening. -Recommendations.pdf 3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL: http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf PAGE 21