SUGGESTED CITATION: Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1): {inclusive page numbers}.
The material in this report was prepared for publication by: National Center for HIV, STD and TB Prevention, Division of Sexually Transmitted Diseases Prevention
The 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 nonmicrobiologic specimens for forensic purposes and the management of potential pregnancy or physical and psychological trauma are not included. Among sexually active adults, the identification of sexually transmitted infections 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, chlamydia, and gonorrhea are the most frequently diagnosed infections among women who have been sexually assaulted. Because the prevalence of these STDs is substantial among sexually active women, the presence of these infections after an assault does not necessarily signify acquisition during the assault. Chlamydial and gonococcal infections in women are of special concern because of the possibility of ascending infection. In addition, HBV infection, if transmitted to a woman during an assault, can be prevented by postexposure administration of hepatitis B vaccine.
An initial examination should include the following procedures:
Although it is often difficult for persons to comply with follow-up examinations weeks after an assault, such examinations are essential a) to detect new infections acquired during or after the assault; b) to complete hepatitis B immunization, if indicated; and c) to complete counseling and treatment for other STDs. For these reasons, it is recommended that assault victims be reevaluated at follow-up examinations.
Examination for STDs 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 test results at the initial examination, a culture (or cultures), a wet mount, and other tests should be repeated at the 2-week follow-up visit unless prophylactic treatment has already been 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.
Many experts recommend routine preventive therapy after a sexual assault. Most patients probably benefit from prophylaxis because the follow-up of patients who have been sexually assaulted can be difficult, and they may be reassured if offered treatment or prophylaxis for possible infection. The following prophylactic regimen is suggested as preventive therapy:
Recommended Regimen
Ceftriaxone 125 mg IM in a single dose,
PLUS
Metronidazole 2 g orally in a single dose,
PLUS
Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice a day for 7 days.
NOTE: For patients requiring alternative treatments, see the sections in this report that specifically address those agents.
The efficacy of these regimens in preventing gonorrhea, BV, or C. trachomatis genitourinary infections after sexual assault has not been evaluated. The clinician might consider counseling the patient regarding the possible benefits, as well as the possibility of toxicity, associated with these treatment regimens, because of possible gastrointestinal side effects with this combination.
At the initial examination and, if indicated, at follow-up examinations, patients should be counseled regarding the following:
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 low. The overall probability of HIV transmission from an HIV-infected person during a single act of intercourse depends on many factors. These factors may include the type of sexual intercourse (i.e., oral, vaginal, or anal); presence of oral, vaginal or anal trauma; site of exposure to ejaculate; viral load in ejaculate; and presence of an STD.
In certain circumstances, the likelihood of HIV transmission also may be affected 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 percutaneous exposures to HIV. However, whether these findings can be extrapolated to other HIV-exposure situations, including sexual assault, is unknown. A recommendation cannot be made, on the basis of available information, regarding the appropriateness of postexposure antiretroviral therapy after sexual exposure to HIV.
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. Because timely determination of the HIV-infection status of the assailant is not possible in many sexual assaults, the health-care provider should assess the nature of the assault, any available information about HIV-risk behaviors exhibited by persons who are sexual assailants (e.g., high-risk sexual practices and injecting-drug or crack cocaine use), and the local epidemiology of HIV/AIDS. 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 critical need for frequent dosing of medications, c) the close follow-up that is necessary, d) the importance of strict compliance with the recommended therapy, and e) the necessity of immediate initiation of treatment for maximal likelihood of effectiveness. If the patient decides to take postexposure therapy, clinical management of the patient should be implemented according to the guidelines for occupational mucous membrane exposure.
Recommendations 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 important but is not included in these recommendations.
The identification of sexually transmissible agents in children beyond the neonatal period suggests sexual abuse. However, there are exceptions; for example, rectal or genital infection with C. trachomatis among young children may be the result of perinatally acquired infection and may persist for as long as 3 years. In addition, genital warts, BV, and genital mycoplasmas have been diagnosed in children who have been abused and in those not abused. There are several modes by which HBV is transmitted to children; the most common of these is household exposure to persons who have chronic HBV infection.
The possibility of sexual abuse should be considered if no obvious risk factor for 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. The evaluation for determining whether sexual abuse has occurred among children who have infections that can be sexually transmitted should be conducted in compliance with expert recommendations by practitioners who have experience and training in the evaluation of abused or assaulted children (29).
Examinations of children for sexual assault or abuse should be conducted so as to minimize pain and trauma to the child. The decision to evaluate the child for STDs must be made on an individual basis. Situations involving a high risk for STDs and a strong indication for testing include the following:
A principal purpose of the examination is to obtain evidence of an infection that is likely to have been sexually transmitted. However, because of the legal and psychosocial consequences of a false-positive diagnosis, only tests with high specificities should be used. The additional cost of such tests and the time required to conduct them are justified.
The scheduling of examinations 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 should 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 the 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 or if the last suspected episode of abuse occurred well before the child received the medical evaluation.
The following recommendation for scheduling examinations is a general guide. The exact timing and nature of follow-up contacts should be determined on an individual basis and should be considerate of the child's psychological and social needs. Compliance with follow-up appointments may be improved when law enforcement personnel or child protective services are involved.
During the initial examination and 2-week follow-up examination (if indicated), the following should be performed:
Only standard culture systems for the isolation of C. trachomatis should be used. The isolation of C. trachomatis should be confirmed by microscopic identification of inclusions by staining with fluorescein-conjugated monoclonal antibody specific for C. trachomatis. Isolates should be preserved. Nonculture tests for chlamydia are not sufficiently specific for use in circumstances involving possible child abuse or assault. Data are insufficient to adequately assess the utility of nucleic acid amplification tests in the evaluation of children who might have been sexually abused, but expert opinion suggests these tests may be an alternative if confirmation is available but culture systems for C. trachomatis are unavailable.
An examination approximately 12 weeks after the last suspected sexual exposure is recommended to allow time for antibodies to infectious agents to develop if baseline tests are negative. Serologic tests for T. pallidum, HIV, and HBsAg should be considered. The prevalence of these infections differs substantially by community, and serologic testing depends on whether risk factors are known to be present in the abuser or assailant. In addition, results of HBsAg testing must be interpreted carefully, because HBV also can be transmitted nonsexually. The choice of tests must be made on an individual basis.
The risk for a child's acquiring an STD as a result of sexual abuse has not been determined. The risk is believed to be low in most circumstances, although documentation to support this position is inadequate.
Presumptive treatment for children who have been sexually assaulted or abused is not widely recommended because girls appear to be at lower risk for ascending infection than adolescent or adult women, and regular follow-up 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 by the health-care provider to be low. Patient or parental/guardian concerns may be an appropriate indication for presumptive treatment in some settings (i.e., after all specimens relevant to the investigation have been collected).
Every state, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and American Samoa have laws that require the reporting of child abuse. The exact requirements differ by state, but, generally, if there is reasonable cause to suspect child abuse, it must be reported. Health-care providers should contact their state or local child-protection service agency about child abuse reporting requirements in their areas.