Sexually Transmitted Infections (STIs)

1. In a patient who is sexually active or considering sexual activity, take advantage of opportunities to advise her or him about prevention, screening, and complications of sexually transmitted diseases (STIs).

2. In a patient with symptoms that are atypical or non-specific for STIs (dysuria, recurrent vaginal infections):

   1. Consider STIs in the differential.

   2. Investigate appropriately.

3. In high-risk patients who are asymptomatic for STIs, screen and advise them about preventive measures.

4. In high-risk patients who are symptomatic for STIs, provide treatment before confirmation by laboratory results.

5. In a patient requesting STI testing:

   1. Identify the reasons for testing.

   2. Assess patient’s risk.

   3. Provide counseling appropriate to risk (i.e., human immunodeficiency virus [HIV] infection risk, non-HIV risk)

6. In a patient with a confirmed STI, initiate:

• • treatment of partner(s).

  • contact tracing through a public health or community agency.

7. Use appropriate techniques for collecting specimens.

8. Given a clinical scenario that is strongly suspicious for an STI and a negative test result, do not exclude the diagnosis of an STI (i.e., because of sensitivity and specificity problems or other test limitations).

General Overview

• Assess reason for consultation

• Ensure confidentiality

History

• Genital symptoms - discharge, dysuria, abdominal pain, testicular pain, skin changes

• Systemic symptoms - fever, weight loss, lymphadenopathy

• The Five Ps:

  • Partners (past year)

  • Practices (vaginal, oral, anal, other)

  • Prevention

    • STI - condom use, Hep A/B vaccination

  • Pregnancy/contraception

  • Previous STI testing

• IVDU

• Exchange money/drugs for sex

• LMP, Pap

• Risk factors (below)

STI Risk Factors

• • Previous STI

  • Sexual contact with person(s) known STI

  • Sexually active <25yo

  • New sexual partner

  • >2 sexual partners in last year or serial one-partner relationships

  • No barrier contraception use

  • IVDU

  • Homelessness

  • Substance use, especially if associated with sex

  • Sex workers

  • Sexual assault

Physical Examination

• Vitals, temperature

• Oropharynx: Mucocutaneous lesions

• Inguinal lymph nodes

• External genitalia - lesions, inflammation, discharge

• Perianal inspection

  • Anoscopy/DRE if receptive anal intercourse and rectal symptoms

• Scrotum - palpate testes, epididymis

• Pelvic exam

  • Bimanual for uterine/adnexal tenderness

  • Speculum

Appropriate screening/testing

• Gonorrhea/Chlamydia NAAT PCR (first catch urine, urethral, vaginal, cervical, pharynx, rectal)

  • If symptomatic, add Gonorrhea culture

    • All Gonorrhea should have culture prior to treatment due to increasing resistance

  • Swab all areas of sexual contact (except no need for chlamydia testing in pharynx)

• VDRL (Nontreponemal RPR or VDRL vs. Treponemal-specific EIA or FTA-ABS)

• HIV serum EIA (detected at 3w with new generation test, but may take up to 6mo with older tests), western blot to confirm

  • Post-exposure baseline

    • Prophylaxis (Truvada plus raltegravir 400mg PO BID x 28d) if known HIV (or high-risk, eg. sex worker, MSM, IVDU)

      • Re-test HIV 6w, 12w after exposure

• HBV (if no vaccine) - HBsAg, HBsAb, HBcAb

  • Post-exposure baseline serologies (ensure HBsAb immune)

    • Vaccinate

      • Immunoglobulin if contact known HepBsAg positive

    • Repeat serology 2 months after vaccine series

• HCV - HCV Ab (IVDU or MSM)

  • Post-exposure baseline HCV Ab

    • HCV RNA 3w after exposure (or HCV Ab 6 months after exposure)

Window period

• Repeat testing at 6w, 12w, 6mo in the case of sexual assault

  • 1w - Gonorrhea

  • 2w - Chlamydia

  • 12w - Syphilis, HIV, HBsAg /HCV Ab

Diagnosis and post-test counselling

• Organism/syndrome-specific advice

• Safe sex practices

• Treatment information - curable (bacterial) vs. manageable (virus)

• Motivational interviewing as above

Treatment

• Code K ( Patient), Code L (Partner)

  • Gonorrhea: Ceftriaxone 500mg IM x1 as per CDC 2020 guidelines (or alternative: Cefixime 800mg PO x1)

    • If weight ≥150kg (300lb), Ceftriaxone 1g IM is recommended

    • Treat concurrently for chlamydia if chlamydial coinfection not excluded

  • Chlamydia: Doxycycline 100mg PO BID x7d or Azithromycin 1g PO x1

    • Doxycycline PO preferred for rectal chlamydia

    • Azithromycin PO preferred in pregnancy

• Syphilis

  • Primary, secondary, and early latent syphilis:

    • Pen G 2.4 million units IM x1

  • Late latent (>1y from likely infection) or tertiary (gummatous or cardiovascular disease):

    • Pen G 2.4 million units IM once weekly x 3 weeks

  • Tertiary neurosyphilis

    • Pen G 3-4 million units IV q4h x 10-14d

• Trichomoniasis (green-yellow malodorous discharge, burning, dyspareunia)

  • Metronidazole 2g PO x1

  • Treat partner

• Bacterial STI or trichomonas should abstain from unprotected sex until 7d after treatment of both partners complete

• HSV1 (gingovostomatitis +/- pharyngitis, then recurrent herpes labialis)

  • Initial (within 72h or ongoing new lesions/pain): Acyclovir 400mg PO TID, Famciclovir 500mg PO TID , Valacyclovir 1000mg PO BID x 7-10d

    • If severe odynophagia, consider IV acyclovir

  • Recurrent episodic: Famciclovir 1500mg PO x 1 dose or Valacyclovir 2g PO BID x 1 day

  • Chronic: Acyclovir 400mg PO BID or Valacyclovir 500mg PO daily

• HSV2 (genital herpes simplex)

  • Initial (within 72h or ongoing new lesions/pain): Acyclovir 400mg PO TID, Famciclovir 250mg PO TID , Valacyclovir 1000mg PO BID x 7-10d

  • Recurrent episodic: Acyclovir 800mg PO TID x2d, Famciclovir 1000mg PO BID x 1 day, Valacyclovir 500mg PO BID x3d

  • Chronic suppressive: Valacyclovir 500-1000mg PO daily

• HPV

  • Imiquimod 5% cream qHS 3/week x 15w, wash off after 6-10h

  • Podofilox 0.5% solution BID x3d then none x4d, repeat PRN x4

  • Cryotherapy

• BV (white-grey malodorous discharge, no dyspareunia)

  • Metronidazole 500mg PO BID x7-14d or gel

• Candidiasis (pruritus, soreness, white clumpy- normal pH 4-4.5)

  • Fluconazole 150mg PO x1 or topical cream/intravaginal/suppository (clotrimazole, miconazole)

Reporting to public health and partner notification

• Explore barriers to partner notification (feared of abuse, losing partner, legal procedures, anonymity)

  • Traceback

    • Gono/chlam up to 60 days (or last partner if no sexual partners)

    • Longer if syphilis, Hep B, HIV

Following-up

• Presumptive treatment of partners within

  • 90d for syphilis (if >90d can test first)

  • 60d of symptoms (or most recent if >60d) for gono/chlam

  • Current sex partners for trichomoniasis

  • Notify HIV partners and PEP offered if within exposure within 72h

• Refrain from sexual activity for 7d post-treatment (and 7d post-treatment for all partners) and resolution of symptoms

• Managing comorbidity and associated risks

  • Consider Hep A/B vaccinations in MSM or high risk

• Resolution of symptoms

• Follow-up testing as indicated

  • Chlamydia (PCR >3w after treatment)

    • Persistent symptoms

    • Re-exposure

    • Pregnancy

    • Poor adherence

    • Alternate antibiotic use (eg. Azithromycin to treat rectal)

    • Chlamydia genotype L

  • All gonorrhea given increasing resistance (PCR >2w after treatment, or culture >3d after treatment)

  • Syphilis

    • Primary, secondary, early latent infection: Repeat serology at 1, 3, 6 and 12 months after treatment

    • Late latent: Repeat serology 12 and 24 months after treatment

• Follow-through on partner notification

Patient-centered education and counselling

• Access to condoms, how to use condoms, signs of STIs and how to get tested/treated

• Motivational interviewing for condom use

  • Scalify 1-10, how important is it to you to always use condoms?

    • Why X, and not lower?

  • Scalify 1-10, how confident are you that you (and your partner) could always use condoms?

    • Why X, and not lower?

  • What would it take for you to become more confident that you could always use condoms?

• Promote STI testing for patient and partners before cessation of condom use (particularly when prescribing OCP)

Pelvic inflammatory disease

• Suspect in sexually active women with pelvic/lower abdominal pain and one of: Adnexal, cervical motion, uterine tenderness

  • Additional criteria to increase specificity

    • Abnormal cervical or vaginal mucopurulent discharge or cervical friability

    • Positive Chlamydia/Gonorrhea

    • Oral T>38.3

    • Abundant WBC (>15 WBC per hpf) on saline microscopy of vaginal secretions

    • Elevated ESR/CRP (less specific)

  • Confirm with pelvic imaging (ultrasound, CT, MRI)

Treatment

• Mild-moderate with Ceftriaxone 250mg IM x1 + Doxycycline 100mg PO BID x 14d (+/- Metronidazole for T vaginalis or anaerobic coverage for recent instrumentation)

• Severe or complicated (eg. tubo-ovarian abscess) with Clindamycin 900mg IV q8h + Gentamicin 1.5mg/kg IV q8h x 14d (step down to Doxycycline)

  • Consider treating male partners if sexual contact 60d prior (or if >60d, most recent) to patient's onset of symptoms (eg. Ceftriaxone 250mg IM, PLUS Azithromycin 1g PO x1 or Doxycycline 100mg PO BID x 7d)

• Avoid sex until patient and partners adequately treated and asymptomatic

• Re-assess if need to remove IUD 3d post -treatment