Screening

Complications of untreated sexually transmitted infections (STIs) include upper genital tract infections, infertility, chronic pelvic pain, cervical cancer, and chronic infection with hepatitis viruses and HIV.

Many patients have asymptomatic disease, which increases the risk of complications and sustained transmission in the community. Thus, screening is an important approach to identify and treat infected individuals, who would otherwise go undetected.

Routine screening for all potential STIs in all patients is cost-prohibitive [1]; screening for all STIs in all patients is not practical.

Targeted screening of asymptomatic patients in specified risk groups is more feasible. Thus, screening for STIs focuses on those who are at high risk. For some STIs, this is done by targeting specific risk groups that have a high prevalence for STIs (eg, females <25 years old, men who have sex with men [MSM], HIV-infected patients, and individuals entering into correctional facilities).

In other cases, screening is dependent on assessment of an individual's personal risk based on behavioral factors or the prevalence of infection in the local community.

HIV

Gonorrhea

Symptoms

1. Partners

  • "Are you currently sexually active?" "If no, have you ever been sexually active?"

  • "In recent months, how many sex partners have you had?"

  • "Are your sex partners men, women, or both?"

2. Prevention of pregnancy

  • "Are you currently trying to conceive or father a child?"

  • "Are you concerned about getting pregnant or getting your partner pregnant?"

  • "Are you using contraception or practicing any form of birth control?" "Do you need any information on birth control?"

3. Protection from STI

  • "Do you and your partner(s) use any protection against STI?" "If not, could you tell me the reason?"

  • "If so, what kind of protection do you use?"

  • "How often do you use this protection?" "If 'sometimes,' in what situations or with whom do you use protection?"

  • "Do you have any other questions, or are there other forms of protection from STI that you would like to discuss today?"

4. Practices

  • "What kind of sexual contact do you have or have you had? Genital (penis in the vagina)? Anal (penis in the anus)? Oral (mouth on penis, vagina, or anus)?"

5. Past history of STI

  • "Have you ever been diagnosed with an STI?" "When?" "How were you treated?"

  • "Have you had any recurring symptoms or diagnoses?"

  • "Have you ever been tested for HIV or other STI?" "Would you like to be tested?"

  • "Has your current partner or any former partners ever been diagnosed or treated for an STI?"

  • "Were you tested for the same STI(s)?" "If yes, when were you tested?" "What was the diagnosis?" "How was it treated?"

Abbreviation: HIV = human immunodeficiency virus.

 

Pelvic pain.

Signs

Perform a pregnancy test in all females of childbearing potential, because pregnancy can affect treatment options. As appropriate, have chaperones present whenever breast, genital, or rectal examinations are performed. In women, perform a vaginal speculum examination, bimanual examination, and rectal examination. In males, retract the foreskin in uncircumcised patients to fully examine the area. Examine the areas between skinfolds, particularly in obese patients. Obtain directed site test specimens, which may include urine, vaginal, rectal, and urethral samples.Vaginal discharge, urethral discharge, ulcerative genital disease, nonulcerative genital disease (?),

 

 

 

 

Content 9

 

  1. When an STI is suspected, especially for gonorrhea and chlamydia infection, treat the patient in the ED with single-dose antibiotic regimens.

  2. Obtain a pregnancy test and consult or refer promptly if the patient is pregnant.

  3. If one STI is suspected or diagnosed, screen for other STIs (HIV infection, syphilis, and hepatitis) in the ED or through follow-up.

  4. Report any notifiable infections such as Chlamydia trachomatis, gonorrhea, HIV infection, and syphilis. This is often based on final laboratory testing and can be automated.

  5. Counsel all patients with suspected STIs about prevention and co-infection risks (notably HIV and hepatitis) in the ED and ensure follow-up options. Although no method aside from abstinence is 100% effective for STI prevention, male latex condoms and female condoms are useful in preventing STIs.

  6. Advise that the partner(s) must seek treatment before any reengagement in sex.

  7. Arrange follow-up to ensure relief of symptoms, compliance, and STI cure.

Although the Centers for Disease Control and Prevention recommend that health care providers in all settings routinely screen for HIV infection in all patients aged 13 to 64 years, the ED remains an underused venue for HIV screening.6 Rapid HIV testing in the ED is not routine but is becoming more prevalent.7

Treatment of Sexually Transmitted Infections

Sexually Transmitted Infection First-Line Treatment Alternative(s) Pregnancy/Lactation
Bacterial vaginosis Metronidazole, 500 milligrams PO two times daily × 7 d Tinidazole, 2 grams PO daily × 3 d Metronidazole, 500 milligrams PO two times daily × 7 d
   or    or  
Metronidazole vaginal gel 0.75%, 5 grams intravaginally daily × 5 d Tinidazole, 1 gram PO daily × 5 d  
   or    or  
Clindamycin vaginal cream 2%, 5 grams intravaginally at bedtime × 7 d Clindamycin, 300 milligrams PO twice daily × 7 d  
     or  
  Clindamycin ovule, 100 milligrams intravaginally at bedtime × 3 d  
Chancroid Azithromycin, 1 gram PO single dose   Azithromycin, 1 gram PO single dose
   or      or
Ceftriaxone, 250 milligrams IM single dose*   Ceftriaxone, 250 milligrams IM single dose*
   or    
Ciprofloxacin, 500 milligrams PO, two times daily × 3 d    
   or    
Erythromycin base, 500 milligrams PO three times daily × 7 d    
Chlamydia (treat for Neisseria gonorrhoeae concurrently) Azithromycin, 1 gram PO single dose Erythromycin base, 500 milligrams PO four times daily × 7 d Azithromycin, 1 gram PO single dose
   or    or    or
Doxycycline, 100 milligrams PO two times daily × 7 d Erythromycin ethylsuccinate, 800 milligrams PO four times daily × 7 d Amoxicillin, 500 milligrams PO three times daily × 7 d
     or    or
  Levofloxacin, 500 milligrams PO once daily × 7 d Erythromycin base, 500 milligrams PO four times a day for 7 d
     or    or
  Ofloxacin, 300 milligrams PO twice daily × 7 d Erythromycin base, 250 milligrams PO four times a day for 14 d
       or
    Erythromycin ethylsuccinate, 800 mg orally four times a day for 7 d
       or
    Erythromycin ethylsuccinate, 400 mg orally four times a day for 14 d
Gonorrhea (treat for Chlamydia trachomatis concurrently) Ceftriaxone*, 250 milligrams IM single dose AND azithromycin, 1 gram PO single dose Cefixime, 400 milligrams PO single dose AND azithromycin, 1 gram PO single dose Ceftriaxone*, 250 milligrams IM single dose AND azithromycin, 1 gram PO single dose
   or    or    or
Ceftriaxone*, 250 milligrams IM single dose AND doxycycline, 100 milligrams PO twice a day for 7 d Cefixime, 400 milligrams PO single dose AND doxycycline, 100 milligrams PO twice a day for 7 d Cefixime, 400 milligrams PO single dose AND azithromycin, 1 gram PO single dose
     or    or
  Azithromycin, 2 grams PO single dose AND test-of-cure in 1 week Azithromycin, 2 grams PO single dose AND test-of-cure in 1 week
       or
    Spectinomycin 2 grams IM single dose
Granuloma inguinale (donovanosis) Doxycycline, 100 milligrams PO two times daily for at least 3 weeks until lesions completely healed Azithromycin, 1 gram PO weekly for at least 3 weeks until lesions completely healed Erythromycin base, 500 milligrams PO four times daily for at least 3 weeks until lesions completely healed
     or    or
Granuloma inguinale (donovanosis) (continued)   Ciprofloxacin, 750 milligrams PO two times daily for at least 3 weeks until lesions completely healed Azithromycin, 1 gram PO weekly for at least 3 weeks until lesions completely healed
     or    or
  Erythromycin base, 500 milligrams PO four times daily for at least 3 weeks until lesions completely healed Gentamicin 1 milligram/kg IV every 8 hours (if the above therapy is ineffective)
     or  
  Trimethoprim-sulfamethoxazole, double-strength (160/800 milligrams) PO two times daily for at least 3 weeks until lesions completely healed  

Herpes simplex

First episode

Acyclovir, 400 milligrams PO three times daily × 7–10 d   Acyclovir, 400 milligrams PO three times daily × 7–10 d
   or      or
Acyclovir, 200 milligrams PO five times daily × 7–10 d   Acyclovir, 200 milligrams PO five times daily × 7–10 d
   or      or
Famciclovir, 250 milligrams PO three times daily × 7–10 d   Valacyclovir, 1 gram PO two times daily × 7–10 d
   or    
Valacyclovir, 1 gram PO two times daily × 7–10 d    
Recurrent or suppressive therapy for patients without HIV Valacyclovir, 500 milligrams daily if >9 episodes/year   Acyclovir, 400 milligrams orally three times a day for 5 d
   or      or
Valacyclovir, 1 gram PO daily × 5 d   Valacyclovir 1 PO daily × 5d
Severe Acyclovir, 5–10 milligrams/kg IV every 8 h × 2–7 d then oral meds for total treatment time of 10 d   Acyclovir, 5–10 milligrams/kg IV every 8 h × 2–7 d then oral meds for total treatment time of 10 d
       or
    Valacyclovir, 500 milligrams PO once per day
Lymphogranuloma venereum Doxycycline, 100 milligrams PO two times daily × 21 d Erythromycin base, 500 milligrams PO four times daily × 21 d Erythromycin base, 500 milligrams PO four times daily × 21 d

Syphilis

Primary, secondary, and early latent

Benzathine penicillin G, 2.4 million units IM single dose Doxycycline, 100 milligrams PO two times daily × 14 d Benzathine penicillin G, 2.4 million units IM single dose
     or  
  Tetracycline, 500 milligrams PO four times daily × 28 d  
     or  
  Ceftriaxone, 250 milligrams IM or IV daily × 10–14 d (early syphilis)  
     or  
  Azithromycin, 1 gram PO single dose (early syphilis)  
Latent Benzathine penicillin G, 2.4 million units IM one time a week × 3 weeks Doxycycline, 100 milligrams PO two times daily × 28 d  
     or  
  Tetracycline, 500 milligrams PO four times daily × 28 d  
Trichomoniasis Metronidazole, 2 grams PO single dose Metronidazole, 500 milligrams PO two times daily × 7 d Metronidazole, 2 grams PO single dose (only if symptomatic)
   or      or
Tinidazole, 2 grams PO single dose   If asymptomatic, deferral of treatment until after 37 weeks
    Consider withholding breastfeeding until 12–24 h after last dose

*Ceftriaxone is painful IM and may be mixed with lidocaine 1% to decrease patient discomfort with administration.

 

Content 4

Content 3

Content 11

 

USMLE Reviewer (Subscription Required)