Mastering Minor Care: Updated STI Guidelines
/+ Background
Rates of sexually transmitted infections (STI), including syphilis, gonorrhea, and chlamydia, have been increasing over the past 10 years [1,2]. Emergency department (ED) visits with an STI diagnosis increased 39% from the time period of 2008-2010 to 2011-2013. From 2011-2013 alone, that equals a total of 506,000 visits with STI diagnoses in the ED. EDs fill the gap in STI diagnosis and treatment, especially in the setting of closed STI clinics and difficulty in accessing primary care providers [1]. STIs are important to diagnose and manage early to avoid complications such as pelvic inflammatory disease (PID), infertility, sepsis, or even death.
In 2021 the CDC Treatment Guidelines for STIs were updated, which are the main source of information for treatment recommendations in the ED: these will be reviewed here.
New Antibiotic Guidelines
The biggest changes for the treatment of STIs in the CDC 2021 guidelines are the recommendations for Neisseria gonorrhea, Chlamydia trachomatis, Trichomonas vaginalis, and pelvic inflammatory disease (PID).
Gonococcal Infections: 500mg Intramuscular in a single dose for patients <150kg, 1g Intramuscular for patients >150kg
There was decreased susceptibility of Neisseria gonorrhea to ceftriaxone in some strains of urogenital or oropharyngeal infections [3].
Chlamydia: 100mg doxycycline oral twice daily x 7 days
Doxycycline has been shown to have better treatment thresholds than azithromycin.
Azithromycin, while still highly efficacious for use in women, is less successful for urogenital treatment of men or anorectal treatment.
This requires a conversation with patients on their likelihood of taking a week of antibiotics versus a one-time dose in the ED. A one-time dose of azithromycin is better than the inappropriate dosing of doxycycline [4].
Trichomonas: 500mg Twice Daily x 7 days for women, 2g orally once for men
While tinidazole is similarly or more effective compared to metronidazole, metronidazole is significantly less expensive and therefore is recommended over tinidazole [5].
In women, a 7-day course of oral treatment reduced the percentage of repeat positive tests one month after treatment compared to one time dose in the ED [5].
PID: Metronidazole was added to the regimen of ceftriaxone and doxycycline for better upper genital tract coverage [6].
Table 1. Adapted from the CDC STI guidelines for diagnosis and first-line recommended management of common STIs
For alternative treatment regimens and further recommendations about diagnosis, you can visit: https://www.cdc.gov/std/treatment-guidelines/toc.htm
Special Considerations
Sexual Assault: The guidelines for evaluation and management of sexual assault survivors are primarily limited to female survivors, however some can still be applied to males.
Examination should occur with an experienced clinician to maximize forensic evidence and minimize additional trauma to the patient.
Although determining what tests to obtain should be done on an individual basis with consent from the patient, samples that can be obtained include: NAATs for chlamydia and gonorrhea of penetrated sites, NAAT for trichomonas for females, and serum samples of HIV, hepatitis B, and syphilis [11].
The following management is recommended:
Antimicrobial regimen for chlamydia, gonorrhea, and trichomonas
Emergency contraception for women should be discussed
Post-exposure hepatitis B vaccination if patient not previously vaccinated and HBIG if assailant is known HBsAg positive
HPV vaccination for ages 9-26 if not already received
Discussion of HIV PEP
HIV Post-EXPOSURE PROPHYLAXIS:
Patients that carry a substantial risk for HIV acquisition and may be appropriate for PEP include:
Exposure of the vagina, rectum, eye, mouth, or other mucous membrane, non-intact skin, or percutaneous contact with blood, semen vaginal or rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood when the source is known to be HIV positive [12].
Preferred initial regimens for 28 days regimens for PEP [12]:
Adults + adolescents > 13 years: Emtricitabine/Tenofovir 300mg/200mg daily + Raltegravir 400mg BID OR Dolutegravir 50mg daily
Adults + adolescents > 13 years with renal dysfunction: Zidovudine + Lamivudine (adjusted to renal function) + Raltegravir 400mg BID OR Dolutegravir 50mg daily
Children 2-12 years: Tenofovir DF + Emtricitabine + Raltegravir each dosed to age/weight
EPIdidymitis: depending on risk factors and exposure, this can be caused by STIs or enteric organisms such as Escherichia coli [13].
Most likely caused by chlamydia/gonorrhea: Ceftriaxone 500mg IM once + Doxycycline 100mg PO BID x10 days
Most likely caused by chlamydia, gonorrhea or enteric organisms (men who have insertive anal sex): Ceftriaxone 500mg IM once + Levofloxacin 500mg PO daily x10 days
Most likely caused by enteric organisms only: Levofloxacin 500mg PO daily x10 days
Post by Melanie yates, MD
Dr. Yates is a PGY-2 in Emergency Medicine at the University of Cincinnati
Editing by bronwyn finney, MD & James Li, MD
Dr. Finney is a PGY-2 in Emergency Medicine at the University of Cincinnati.
Dr. Li is an EMS fellow in Emergency Medicine at the University of Cincinnati.
References
Cuffe KM, Coor A, Hogben M, Pearson WS. Health Care Access and service use among behavioral risk factor surveillance system respondents engaging in high-risk sexual behaviors, 2016. Sexually Transmitted Diseases. 2019;47(1):62-66. doi:10.1097/olq.0000000000001091
Pearson WS, Peterman TA, Gift TL. An increase in sexually transmitted infections seen in US emergency departments. Preventive Medicine. 2017;100:143-144. doi:10.1016/j.ypmed.2017.04.028
Gonococcal infections among adolescents and adults - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm. Published November 24, 2021. Accessed March 25, 2022.
Chlamydial infections - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/chlamydia.htm. Published July 22, 2021. Accessed March 25, 2022.
Trichomoniasis - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm. Published July 22, 2021. Accessed March 25, 2022.
Pelvic inflammatory disease (PID) - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/pid.htm. Published November 9, 2021. Accessed March 25, 2022.
P&S syphilis - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/p-and-s-syphilis.htm. Published July 22, 2021. Accessed March 25, 2022.
Herpes - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/herpes.htm. Published July 22, 2021. Accessed March 25, 2022.
Lymphogranuloma Venereum (LGV) - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/lgv.htm. Published July 22, 2021. Accessed March 25, 2022.
HIV - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/hiv.htm. Published July 22, 2021. Accessed March 25, 2022.
Sexual assault and abuse and STIs - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/sexual-assault-adults.htm. Published July 22, 2021. Accessed March 25, 2022.
Dominguez KL, Smith DK, Thomas K, et al. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV-united states, 2016. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/38856. Accessed March 25, 2022.
Epididymitis - STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm. Published July 22, 2021. Accessed March 25, 2022
