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Proctitis, Proctocolitis, and EnteritisSexually transmitted gastrointestinal syndromes include proctitis, proctocolitis, and enteritis. Evaluation for these syndromes should include appropriate diagnostic procedures (e.g., anoscopy or sigmoidoscopy, stool examination, and culture). Proctitis is inflammation limited to the rectum (the distal 10--12 cm) that may be associated with anorectal pain, tenesmus, or rectal discharge. N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV are the most common sexually transmitted pathogens involved. In patients coinfected with HIV, herpes proctitis may be especially severe. Proctitis occurs predominantly among persons who participate in receptive anal intercourse. Proctocolitis is associated with symptoms of proctitis plus diarrhea or abdominal cramps and inflammation of the colonic mucosa extending to 12 cm above the anus. Fecal leukocytes may be detected on stool examination depending on the pathogen. Pathogenic organisms include Campylobacter sp., Shigella sp., Entamoeba histolytica, and, rarely, LGV serovars of C. trachomatis. CMV or other opportunistic agents may be involved in immunosuppressed HIV-infected patients. Proctocolitis can be acquired by the oral route or by oral-fecal contact, depending on the pathogen. Enteritis usually results in diarrhea and abdominal cramping without signs of proctitis or proctocolitis; it occurs among persons whose sexual practices include oral-fecal contact. In otherwise healthy persons, Giardia lamblia is most frequently implicated. When outbreaks of gastrointestinal illness occur among social or sexual networks of MSM, clinicians should consider sexual transmission as a mode of spread and counsel accordingly. Among HIV-infected patients, gastrointestinal illness can be caused by other infections that usually are not sexually transmitted, including CMV, Mycobacterium avium-intracellulare, Salmonella sp., Campylobacter sp., Shigella sp., Cryptosporidium, Microsporidium, and Isospora. Multiple stool examinations may be necessary to detect Giardia, and special stool preparations are required to diagnose cryptosporidiosis and microsporidiosis. Additionally, enteritis may be directly caused by HIV infection. When laboratory diagnostic capabilities are available, treatment decisions should be based on the specific diagnosis. Diagnostic and treatment recommendations for all enteric infections are beyond the scope of these guidelines. TreatmentAcute proctitis of recent onset among persons who have recently practiced receptive anal intercourse is usually sexually acquired. Such patients should be examined by anoscopy and should be evaluated for infection with HSV, N. gonorrhoeae, C. trachomatis, and T. pallidum. If an anorectal exudate is found on examination, or if polymorphonuclear leukocytes are found on a Gram-stained smear of anorectal secretions, the following therapy may be prescribed pending results of additional laboratory tests.
NOTE: Patients with suspected or documented herpes proctitis should be managed in the same manner as those with genital herpes (see Management of HSV Infection). If painful perianal ulcers are present or mucosal ulcers are seen on anoscopy, presumptive therapy should include a regimen for treating genital herpes. Follow-UpFollow-up should be based on specific etiology and severity of clinical symptoms. Reinfection may be difficult to distinguish from treatment failure. Management of Sex PartnersPartners of patients with sexually transmitted enteric infections should be evaluated for any diseases diagnosed in the index patient. Ectoparasitic InfectionsPediculosis PubisPatients who have pediculosis pubis (i.e., pubic lice) usually seek medical attention because of pruritus or because they notice lice or nits on their pubic hair. Pediculosis pubis is usually transmitted by sexual contact.
Lindane toxicity, as indicated by seizure and aplastic anemia, has not been reported when treatment was limited to the recommended 4-minute period. Permethrin has less potential for toxicity than lindane. Other Management Considerations The recommended regimens should not be applied to the eyes. Pediculosis of the eyelashes should be treated by applying occlusive ophthalmic ointment to the eyelid margins twice a day for 10 days. Bedding and clothing should be decontaminated (i.e., machine-washed, machine-dried using the heat cycle, or dry-cleaned) or removed from body contact for at least 72 hours. Fumigation of living areas is not necessary. Patients with pediculosis pubis should be evaluated for other sexually transmitted diseases. Follow-Up Patients should be evaluated after 1 week if symptoms persist. Re-treatment may be necessary if lice are found or if eggs are observed at the hair-skin junction. Patients who do not respond to one of the recommended regimens should be re-treated with an alternative regimen. Management of Sex Partners Sex partners within the last month should be treated. Patients should avoid sexual contact with their sex partner(s) until patients and partners have been treated and reevaluated to rule out persistent disease. Special Considerations Pregnancy Pregnant and lactating women should be treated with either permethrin or pyrethrins with piperonyl butoxide; lindane is contraindicated in pregnancy. HIV Infection Patients who have pediculosis pubis and also are infected with HIV should receive the same treatment regimen as those who are HIV-negative. ScabiesThe predominant symptom of scabies is pruritus. Sensitization to Sarcoptes scabiei must occur before pruritus begins. The first time a person is infected with S. scabiei, sensitization takes up to several weeks to develop. However, pruritus might occur within 24 hours after a subsequent reinfestation. Scabies in adults often is sexually acquired, although scabies in children usually is not.
NOTE: Lindane should not be used immediately after a bath or shower, and it should not be used by persons who have extensive dermatitis, pregnant or lactating women, or children aged <2 years. Permethrin is effective and safe but costs more than lindane. Lindane is effective in most areas of the United States; however, lindane resistance has been reported in some areas of the world, including parts of the United States. Seizures have occurred when lindane was applied after a bath or used by patients who had extensive dermatitis. Aplastic anemia following lindane use also has been reported. One study has demonstrated increased mortality among elderly, debilitated persons who received ivermectin, but this observation has not been confirmed in subsequent reports. Other Management Considerations Bedding and clothing should be decontaminated (i.e., either machine-washed, machine-dried using the hot cycle, or dry-cleaned) or removed from body contact for at least 72 hours. Fumigation of living areas is unnecessary. Crusted Scabies Crusted scabies (i.e., Norwegian scabies) is an aggressive infestation that usually occurs in immunodeficient, debilitated, or malnourished persons. Patients who are receiving systemic or potent topical glucocorticoids, organ transplant recipients, mentally retarded or physically incapacitated persons, HIV-infected or human T-lymphotrophic virus-1 (HTLV-1)-infected persons, and persons with various hematologic malignancies are at risk for developing crusted scabies. Crusted scabies is associated with greater transmissibility than scabies. No controlled therapeutic studies for crusted scabies have been conducted, and the appropriate treatment remains unclear. Substantial treatment failure might occur with single topical scabicide or oral ivermectin treatment. Some specialists recommend combined treatment with a topical scabicide and oral ivermectin or repeated treatments with ivermectin. Lindane should be avoided because of risks of neurotoxicity with heavy applications and denuded skin. Patient's fingernails should be closely trimmed to reduce injury from excessive scratching. Follow-Up Patients should be informed that the rash and pruritus of scabies may persist for up to 2 weeks after treatment. Symptoms or signs that persist for >2 weeks can be attributed to several factors. Treatment failure may be caused by resistance to medication or by faulty application of topical scabicides. Patients with crusted scabies may have poor penetration into thick scaly skin and harbor mites in these difficult-to-penetrate layers. Particular attention must be given to the fingernails of these patients. Reinfection from family members or fomites may occur in the absence of appropriate contact treatment and washing of bedding and clothing. Even when treatment is successful and reinfection is avoided, symptoms may persist or worsen as a result of allergic dermatitis. Finally, household mites might cause symptoms to persist as a result of cross-reactivity between antigens. Some specialists recommend re-treatment after 1--2 weeks for patients who are still symptomatic; others recommend re-treatment only if live mites are observed. Patients who do not respond to the recommended treatment should be re-treated with an alternative regimen. Management of Sex Partners and Household Contacts Both sexual and close personal or household contacts within the preceding month should be examined and treated. Management of Outbreaks in Communities, Nursing Homes, and Other Institutional Settings Scabies epidemics often occur in nursing homes, hospitals, residential facilities, and communities. Control of an epidemic can only be achieved by treatment of the entire population at risk. Ivermectin can be considered in this setting, especially if treatment with topical scabicides fails. Epidemics should be managed in consultation with a specialist. Special Considerations Infants, Young Children, and Pregnant or Lactating Women Infants, young children, and pregnant or lactating women should not be treated with lindane. They can be treated with permethrin. Ivermectin is not recommended for pregnant or lactating patients. The safety of ivermectin in children who weigh <15 kg has not been determined. HIV Infection Patients who have uncomplicated scabies and also are infected with HIV should receive the same treatment regimens as those who are HIV-negative. HIV-infected patients and others who are immunosuppressed are at increased risk for crusted scabies. Such patients should be managed in consultation with a specialist. Sexual Assault and STDsAdults and AdolescentsThe recommendations in this report are limited to the identification, prophylaxis, and treatment of sexually transmitted infections and conditions commonly identified in the management of such infections. The documentation of findings, collection of non-microbiologic specimens for forensic purposes, and the management of potential pregnancy or physical and psychological trauma are beyond the scope of this report. Examinations of survivors of sexual assault should be conducted so as to minimize further trauma to the survivor and should be performed by an experienced clinician. The decision to obtain genital or other specimens for STD diagnosis should be made on an individual basis. Mechanisms to ensure continuity of care (including timely review of the results of any tests obtained) and to monitor compliance with and adverse reactions to any therapeutic or prophylactic regimens should be in place in any setting where survivors of sexual assault are examined. Laws in all 50 states strictly limit the evidentiary use of a survivor's prior sexual history, including evidence of previously acquired STDs, as part of an effort to undermine the credibility of the survivor's testimony. Evidentiary privilege against revealing any aspect of the examination or treatment is enforced in most states. In unanticipated, exceptional situations, STD diagnoses may later be accessed, and the survivor and clinician may opt to defer testing for this reason. However, collection of specimens at initial examination for laboratory STD diagnosis gives the survivor and clinician the option to defer empiric prophylactic antimicrobial treatment. Among sexually active adults, the identification of sexually transmitted infection after an assault is usually more important for the psychological and medical management of the patient than for legal purposes, because the infection could have been acquired before the assault. Trichomoniasis, BV, gonorrhea, and chlamydial infection are the most frequently diagnosed infections among women who have been sexually assaulted. Because the prevalence of these infections is high among sexually active women, their presence after an assault does not necessarily signify acquisition during the assault. A post-assault examination is, however, an opportunity to identify or prevent sexually transmitted infections, regardless of whether they were acquired during an assault. Chlamydial and gonococcal infections in women are of particular concern because of the possibility of ascending infection. In addition, post-assault evaluation can detect HBV infection, which may be prevented by postexposure administration of hepatitis B vaccine. Reproductive-aged female survivors should be evaluated for pregnancy, if appropriate. Evaluation for Sexually Transmitted InfectionsInitial Examination An initial examination should include the following procedures.
Follow-Up Examinations Although persons may have difficulty in complying with follow-up examinations several weeks following an assault, such examinations are essential because they provide an opportunity to a) detect new infections acquired during or after the assault; b) complete hepatitis B immunization, if indicated; and c) complete counseling and treatment for other STDs. Examination for STDs should be repeated within 1--2 weeks of the assault. Because infectious agents acquired through assault may not have produced sufficient concentrations of organisms to result in positive test results at the initial examination, a culture (or cultures), a wet mount, and other tests should be repeated at the follow-up visit unless prophylactic treatment was provided. If treatment was provided, testing should be done only if the survivor reports having symptoms. If treatment was not provided, follow-up examination should be conducted within a week to ensure that results of positive tests can be discussed promptly with the survivor and that treatment is provided. Serologic tests for syphilis and HIV infection should be repeated 6, 12, and 24 weeks after the assault if initial test results were negative and these infections are likely to be present in the assailant (see Risk of Acquiring HIV Infection). Prophylaxis Many specialists recommend routine preventive therapy after a sexual assault because follow-up of survivors of sexual assault can be difficult and because these persons may be reassured if offered treatment or prophylaxis for possible infection. The following prophylactic regimen is suggested as preventive therapy.
NOTE: For patients requiring alternative treatments, see the sections in this report that specifically address the appropriate agent. The efficacy of these regimens in preventing gonorrhea, trichomoniasis, BV, and C. trachomatis genitourinary infections after sexual assault has not been evaluated. Clinicians should counsel patients regarding the possible benefits, as well as the possible toxicity, associated with these treatment regimens; gastrointestinal side effects can occur with this combination. Providers may also consider anti-emetic medications if prophylaxis is administered, particularly if emergency contraception is also provided. Other Management Considerations At the initial examination and, if indicated, at follow-up examinations, patients should be counseled regarding the following:
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 a single episode of sexual assault is likely low. The overall probability of HIV transmission during a single act of intercourse from a person known to be HIV-infected, however, depends on many factors, and in specific circumstances could be high. These factors may include the type of sexual intercourse (i.e., oral, vaginal, or anal); presence of oral, vaginal, or anal trauma (including bleeding); site of exposure to ejaculate; viral load in ejaculate; and presence of an STD or genital lesions in assailant or survivor. Children may be at higher risk for transmission, because child sexual abuse is often associated with multiple episodes of assault and may result in mucosal trauma (see Sexual Assault or Abuse of Children). In certain circumstances, the potential of HIV transmission has been reduced by postexposure therapy for HIV with antiretroviral agents. Postexposure therapy with zidovudine has been associated with a reduced risk for HIV infection in a study of health-care workers who had percutaneous exposures to HIV-infected blood. On the basis of these results and the biologic plausibility of the effectiveness of antiretroviral agents in preventing infection, postexposure therapy has been recommended for health-care workers who have occupational exposures to HIV. The degree to which these findings can be extrapolated to other HIV-exposure situations, including sexual assault, is unknown. Although a definitive recommendation cannot be made regarding postexposure antiretroviral therapy after sexual exposure to HIV, such therapy should be considered in cases in which the risk for HIV exposure during the assault is likely high. Health-care providers who consider offering postexposure therapy should take into account the likelihood of exposure to HIV, the potential benefits and risks of such therapy, and the interval between the exposure and initiation of therapy. Timely determination of the HIV-infection status of the assailant is not possible in many sexual assaults. Therefore, the health-care provider should assess the local epidemiology of HIV/AIDS, the nature of the assault, and any available information about HIV-risk behaviors exhibited by the assailant(s) (e.g., high-risk sexual practices and injection-drug or crack cocaine use). When an assailant's HIV status is unknown, factors that should be considered in determining whether an increased risk of HIV transmission exists include a) whether oral, vaginal, or anal penetration occurred; b) whether ejaculation occurred on mucous membranes; c) whether multiple assailants were involved; d) whether mucosal lesions are present in assailant or survivor; and e) other characteristics of the assault, survivor, or assailant. If antiretroviral postexposure prophylaxis is offered, the following information should be discussed with the patient: a) the unknown efficacy and known toxicities of antiretrovirals; b) the close follow-up that is necessary; c) the importance of strict compliance with the recommended therapy; and d) the necessity of immediate initiation of treatment for maximal likelihood of effectiveness (as soon as possible after, and up to 72 hours following, the most recent assault). Providers should emphasize that although data are limited, postexposure antiretroviral therapy appears to be well tolerated in both adults and children, and severe adverse effects are rare. Personnel likely to examine survivors of sexual assault should consult with federal or state health departments or other professionals knowledgeable in STDs to develop algorithms and protocols for the determination of risk for exposure to HIV and management in their community. Clinical management of the patient should be implemented according to the following guidelines (107,108). If postexposure HIV prophylaxis is being considered, consultation with an HIV specialist is recommended. Recommendations for Postexposure Assessment of Adolescent and Adult Survivors within 72 hours of Sexual Assault§§§
§§§ Assistance with postexposure prophylaxis decisions can be obtained by calling the National HIV Telephone Consultation Service (tel: 800-933-3413). Sexual Assault or Abuse of ChildrenRecommendations in this report are limited to the identification and treatment of STDs. Management of the psychosocial aspects of the sexual assault or abuse of children is beyond the scope of these recommendations. The identification of sexually transmissible agents in children beyond the neonatal period suggests sexual abuse. The significance of the identification of a sexually transmitted agent in such children as evidence of possible child sexual abuse varies by pathogen. Postnatally acquired gonorrhea; syphilis; and non-transfusion, non-perinatally acquired HIV are usually diagnostic of sexual abuse. Sexual abuse should be suspected in the presence of genital herpes. The investigation of sexual abuse among children who possibly have a sexually transmitted infection should be conducted in compliance with recommendations by clinicians who have experience and training in all elements of the evaluation of child abuse, neglect, and assault (109--111). The social significance of each sexually transmitted infection and the recommended action regarding reporting of suspected child sexual abuse varies by STD (Table 5). In all cases in which a sexually transmitted infection has been diagnosed in a child, efforts should be made to detect evidence of sexual abuse, including conducting diagnostic testing for other commonly occurring sexually transmitted infections (109,110). The general rule that sexually transmissible infections beyond the neonatal period are evidence of sexual abuse has exceptions. For example, rectal or genital infection with C. trachomatis among young children may be the result of perinatally acquired infection and has, in some cases, persisted for as long as 2--3 years. Genital warts have been diagnosed in children who have been sexually abused, but also in children who have no other evidence of sexual abuse. BV has been diagnosed in children who have been abused, but its presence alone does not prove sexual abuse. Most HBV infections in children result from household exposure to persons who have chronic HBV infection. The possibility of sexual abuse should be strongly considered if no conclusive explanation for non-sexual transmission of a sexually transmitted infection can be identified. 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 considered carefully. TABLE 5. Implications of commonly encountered sexually transmitted (ST) or sexually associated (SA) infections for diagnosis and reporting of sexual abuse among infants and pre-pubertal children
Source: Adapted from American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children. Pediatrics 1999;103:186–91. Published correction Pediatrics 1999;103:149.
Evaluation for Sexually Transmitted Infections Examinations of children for sexual assault or abuse should be conducted so as to minimize pain and trauma to the child. Collection of vaginal specimens in prepubertal children can be very uncomfortable and should be performed by an experienced clinician to avoid psychological and physical trauma to the child. The decision to obtain genital or other specimens from a child to conduct an STD evaluation must be made on an individual basis. The following situations involve a high risk for STDs and constitute a strong indication for testing.
If a child has symptoms, signs, or evidence of an infection that might be sexually transmitted, the child should be tested for other common STDs before the initiation of any treatment that could interfere with the diagnosis of those other STDs. Because of the legal and psychosocial consequences of a false-positive diagnosis, only tests with high specificities should be used. The potential social benefit to the child of a reliable diagnosis of an STD justifies deferring presumptive treatment until specimens for highly specific tests are obtained by providers with experience in the evaluation of sexually abused and assaulted children. The scheduling of examination should depend on the history of assault or abuse. If the initial exposure was recent, the infectious agents acquired through the exposure may not have produced sufficient concentrations of organisms to result in positive test results. A follow-up visit approximately 2 weeks after the most recent sexual exposure may include a repeat physical examination and collection of additional specimens. To allow sufficient time for antibodies to develop, another follow-up visit approximately 12 weeks after most recent sexual exposure may be necessary to collect sera. A single examination may be sufficient if the child was abused for an extended time period and if the last suspected episode of abuse occurred well before the child received medical evaluation. The following recommendations for scheduling examinations serve as a general guide. The exact timing and nature of follow-up examinations should be determined on an individual basis and should be performed so as to minimize the possibility for psychological trauma and social stigma. Compliance with follow-up appointments might be improved when law enforcement personnel or child protective services are involved. Initial and 2-Week Follow-Up Examinations During the initial examination and 2-week follow-up examination (if indicated), the following should be performed.
HIV infection has been reported in children whose only known risk factor was sexual abuse. Serologic testing for HIV infection should be considered for abused children. The decision to test for HIV infection should be made on a case-by-case basis, depending on the likelihood of infection among assailant(s). Data are insufficient concerning the efficacy and safety of postexposure prophylaxis among both children and adults. However, antiretroviral treatment is well tolerated by infants and children with and without HIV infection; in addition, children who receive such treatment have a minimal risk for serious adverse reactions because of the short period of time recommended for prophylaxis (30,114). In those cases in which a child presents to a health-care provider shortly after a sexual exposure (i.e., within 72 hours), the assailant(s) are likely to be at risk for HIV infection, and likelihood of compliance with treatment regimens is high, the potential benefit of treating a sexually abused child should be weighed against the risk for adverse reactions. If antiretroviral postexposure prophylaxis is being considered, a professional specializing in HIV-infected children should be consulted. Recommendations for Postexposure Assessment of Children within 72 Hours of Sexual Assault
Examination 12 Weeks After Assault In circumstances in which transmission of syphilis, HIV, or hepatitis B is a concern but baseline tests are negative, an examination approximately 12 weeks after the last suspected sexual exposure is recommended to allow time for antibodies to infectious agents to develop. The prevalence of these infections differs substantially by community. In addition, results of HBsAg testing must be interpreted carefully, because HBV can be transmitted non-sexually. Decisions regarding which tests should be performed must be made on an individual basis. Presumptive Treatment The risk of a child acquiring an STD as a result of sexual abuse or assault has not been determined. Presumptive treatment for children who have been sexually assaulted or abused is not recommended because a) the prevalence of most STDs is low following abuse/assault, b) pre-pubertal girls appear to be at lower risk for ascending infection than adolescent or adult women, and c) regular follow-up of children usually can be ensured. However, some children or their parent(s) or guardian(s) may be concerned about the possibility of infection with an STD, even if the risk is perceived to be low by the health-care provider. Such concerns may be an appropriate indication for presumptive treatment in some settings and may be considered after all specimens for diagnostic tests relevant to the investigation have been collected. Reporting Every state and U.S. territory has laws that require the reporting of child abuse. Although the exact requirements differ by state, if a health-care provider has reasonable cause to suspect child abuse, a report must be made. Health-care providers should contact their state or local child-protection service agency about child-abuse reporting requirements in their areas. |
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