Sexually Transmitted Infection Assessment and Management ...



Canberra Hospital and Health ServicesClinical ProcedureSexually Transmitted Infection Assessment and Management at Canberra Hospital and Health ServicesContents TOC \o "1-2" \h \z \u Contents PAGEREF _Toc418168599 \h 1Purpose PAGEREF _Toc418168600 \h 3Scope PAGEREF _Toc418168601 \h 3Section 1 – Patient Assessment PAGEREF _Toc418168602 \h 31.1 Sexual History Taking PAGEREF _Toc418168603 \h 3Procedure PAGEREF _Toc418168604 \h 31.2 Sexually Transmitted Infection (STI) and Blood Borne Virus (BBV) Screening in Asymptomatic Women and Men PAGEREF _Toc418168605 \h 5Procedure PAGEREF _Toc418168606 \h 61.3 Anogenital Examination of Females and Males PAGEREF _Toc418168607 \h 8Section 2 – Management of Sexually Transmitted Infections PAGEREF _Toc418168608 \h 112.1 Bacterial Vaginosis (BV) PAGEREF _Toc418168609 \h 112.2 Chlamydia PAGEREF _Toc418168610 \h 132.3 Epididymo-orchitis PAGEREF _Toc418168611 \h 142.4 Gonorrhoea PAGEREF _Toc418168612 \h 152.5 Herpes Simplex Virus (HSV) PAGEREF _Toc418168613 \h 172.6 Pelvic Inflammatory Disease (PID) PAGEREF _Toc418168614 \h 182.7 Proctitis PAGEREF _Toc418168615 \h 192.8 Syphilis PAGEREF _Toc418168616 \h 21Section 3 – Contact Tracing for Sexually Transmitted Infections and Human Immunodeficiency Virus (HIV) PAGEREF _Toc418168617 \h 223.1 Notifiable STIs and BBVs in the ACT PAGEREF _Toc418168618 \h 223.2 Contact Tracing Points PAGEREF _Toc418168619 \h 233.3 HIV Contact Tracing PAGEREF _Toc418168620 \h 24Procedure PAGEREF _Toc418168621 \h 24Implementation PAGEREF _Toc418168622 \h 25Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc418168623 \h 25Policies PAGEREF _Toc418168624 \h 25Procedures PAGEREF _Toc418168625 \h 25Guidelines PAGEREF _Toc418168626 \h 26Legislation PAGEREF _Toc418168627 \h 26References PAGEREF _Toc418168628 \h 26Definition of Terms and abbreviations PAGEREF _Toc418168629 \h 26Search Terms PAGEREF _Toc418168630 \h 27Attachments PAGEREF _Toc418168631 \h 27Attachment 1: HIV Contact Tracing Script Example PAGEREF _Toc418168632 \h 28PurposeTo outline the processes involved in assessing and managing sexually transmitted infections (STIs) in patients at Canberra Hospital and Health Services (CHHS) ScopeThis document is applicable to all clinicians who provide a service to adult and adolescent patients at CHHS who require STI assessment and/or management:All Medical OfficersAll nurses who are working within their scope of practiceSection 1 – Patient AssessmentSexual History TakingProcedureEnsure privacy;Document if support person, partner or other clinician or student is present;Introduce topic of taking a sexual and risk assessment history; andSexual histories need to be tailored to the patient and their reason for presentation. The following points allow for comprehensive sexual history taking and may be adapted according to clinical assessment. Presenting HistoryAscertain reason for visitIf asymptomatic, enquire about the reasons for the patient’s request for screeningIn females exclude: pelvic pain, deep dyspareunia, abnormal vaginal discharge, inter-menstrual bleeding, post coital bleeding, menstrual change, anal symptoms if history of anal sexIn males exclude: scrotal pain, anal symptoms if history of anal sexIf the patient is symptomatic, ascertain duration and nature of symptoms Medical, Surgical and Dermatological HistoryPrevious or existing medical conditionsPrevious or proposed surgical procedures or operationsPrevious or existing mental health conditions Previous or existing dermatological conditionsPrevious or existing oral or genital herpes simplex infection (cold sores)MedicationsCurrent treatment for any condition including non-prescription medication, topical medications and natural therapiesRecent antibiotic useAllergiesKnown allergiesGynaecological and Reproductive historyAge at menarcheAge at coitarcheDate of last normal menstrual periodCycle regularity, length Obstetric history – number of pregnancies, miscarriages, terminationsCervical screening historyContraceptive historyCurrent methodLevel of satisfaction, problems, side effectsSexually Transmitted Infection (STI) and Blood Borne Virus (BBV) HistoryType of previous STI or BBV diagnosisDate of previous STI or BBV diagnosisTreatment and follow up received for previous diagnosesPrevious STI/BBV testingVaccination HistoryHepatitis A (for men who have sex with men) – previous exposure or vaccinationHepatitis B - previous exposure or vaccinationHuman papillomavirus vaccinationSexual History/Risk AssessmentGender of sexual contactsSexual contact with a partner from overseas – country, date, nature of sexCurrent regular partnerTotal number of partners in past 3 and 6 monthsLast unprotected vaginal intercourseLast unprotected oral sexLast unprotected anal intercourse – whether receptive or insertive partnerLast vaginal or anal contact without a condom (eg nudging)Problems with condom useSex industry work – client or workerSexual assault history/ history of unwanted sexTime assault occurredAssess need for counselling or support Note: If a patient reports risk exposure to HIV, advice should be sought with an Infectious Diseases or Sexual Health Physician regarding HIV post exposure prophylaxis (PEP). This pertains in particular to men who have sex with men (MSM) and to all patients whose partners have HIV. Note: Consider offering Emergency Contraception (EC) in women who are at risk of pregnancy from recent unprotected sexual contactDrug and Alcohol HistoryTobacco– current and previous use, number per day, assess intention to quitAlcohol – days per week, standard drinks per sessionOther recreational drug use in the prior 12 months (cannabis, ecstasy, amphetamines, cocaine, heroin) – type, frequency, most recent useBlood Borne Virus Risk in addition to sexual historySignificant risk exposures includeHistory of Injecting Drug Use (IDU)Last exposure – shared needle or injecting equipmentTattoosContext - professional studio, non professional, overseasBody piercing or acupunctureContext - professional studio, non professional, overseasRecipient of blood transfusion or productsYear and location receivedBlood or body fluid exposureType of exposure and dateTime in custody Location, sharing implements that may pose riskOverseas travel and BBV riskEnsure history taking documentation in patients medical record is complete1.2 Sexually Transmitted Infection (STI) and Blood Borne Virus (BBV) Screening in Asymptomatic Women and MenEquipment Swab specific for chlamydia and gonorrhoea PCR (polymerase chain reaction) testing (PCR swab) Urine collection container if urine PCR requiredTongue depressor if throat swab requiredVenepuncture equipment Personal Protective Equipment (PPE) including gloves and gogglesAttend hand hygiene before touching the patient by hand washing or using alcohol hand rub 1.2.1 Screening Asymptomatic WomenProcedureHistory TakingAscertain reason for visitUndertake a medical and sexual health history (see Section 1.1)Note: Canberra Sexual Health Centre (CSHC) - if the patient is found to be symptomatic, consultation with a MO (Medical Officer) or Nurse Practitioner (NP) is required Determine need for genital examination. Genital examination required if:Symptoms consistent with an STI elicited by history taking The woman requires a Pap test Determine screening tests to be offered to the womanChlamydia PCREndocervical specimen preferable if patient examinedSelf collected vaginal specimen preferred over urine if patient not examinedFirst void urine (FVU means the first flow of urine NOT the first urine of the day)HIV antigen/antibody Syphilis enzyme immunoassay (EIA)Hepatitis B surface antibody, surface antigen, core antibody if no evidence of hepatitis B immunity. Hepatitis C antibody if at risk blood exposure (see section1.1 Blood Borne Virus Risk)Add ano-rectal PCR for chlamydia if history of anal sexPharyngeal PCR for gonorrhoea if sex industry workerDiscuss infections to be tested: natural history, transmission, treatment, preventionDiscuss contact tracing if positive results. See Section 3 for further details.Obtain consent for testingDiscuss methods of obtaining results with patientIf genital examination not required then self-collected vaginal swab or urine are appropriateSpecimen CollectionPrior to collection, specimens should be labelled with 3 patient identifiers and specimen site. Chlamydia Specimen collectionVaginal swabSelf-collected: Provide the woman with a PCR swab and instruct her to insert the swab approximately 3-4cm into the vaginal canal and rotate, then remove the swab and place it into the media tube fastening the lid securelyClinician collected: No need for direct visualisation of the cervix unless clinically indicated. Insert the swab approximately 3-4cm into the vaginal canal and rotate, then remove the swab and place it into the media tube fastening the lid securelyEndocervical swab (if undertaking examination and direct visualisation of the cervix) gently collect secretions from the os, then remove the swab and place it into the media tube fastening the lid securelyFirst Void Urine (FVU) It is preferable for the woman to not have passed urine for 20 minsProvide the woman with a urine specimen container and instruct her to collect the first pass urine when the stream commences, filling the container to 20mlsBBV Specimen collectionVenepuncture for BBV screen 1.2.2 Screening Asymptomatic MenAscertain reason for visitUndertake a medical and sexual health history Note: Canberra Sexual Health Centre - if the patient is found to be symptomatic, consultation with a MO or NP is required Determine screening tests to be offered to the man:Heterosexual sex onlyFirst void urine PCR for chlamydia HIV antibodySyphilis EIAHepatitis B surface antibody, surface antigen, core antibody if no evidence of hepatitis B immunity Hepatitis C if at risk blood exposure see Section 1.1 Blood Borne Virus RiskMen who have Sex with MenFirst void urine PCR for chlamydia Pharyngeal PCR for chlamydia and gonorrhoea Ano-rectal PCR for chlamydia and gonorrhoeaHIV antigen/antibodySyphilis EIAHepatitis A antibody, if no evidence of immunity Hepatitis B surface antibody, surface antigen, core antibody if no evidence of hepatitis B immunity Hepatitis C if at risk blood exposure see Section 1.1 Blood Borne Virus RiskDiscuss infections to be tested: natural history, transmission, treatment, preventionA specific discussion regarding notifiable infections and contact tracing procedures should be completed. See Section 3 for further details.Obtain consent for testing Discuss methods of obtaining results with patientSpecimen CollectionPrior to collection, specimens should be labelled with the patient’s coded sticker and specimen site clearly written on the labelIf genital examination not required then urine and self-collected ano-rectal swabs are appropriateDemonstrate use of PCR test kit when taking throat swab - patients may prefer to collect their own throat swabs Chlamydia / gonorrhoea specimen collectionFirst Void Urine (FVU): It is preferable for the patient to not have passed urine for 20 mins but failure to do this does not preclude specimen collectionProvide the patient with a urine specimen container and instruct him to collect the first pass urine when the stream commences, filling the container to 20mlsAno-rectal swab, self-collected:May be completed in the clinic room or toiletAdvise the patient that the swab may be moistened with water prior to use to facilitate insertionProvide the man with a PCR swab and instruct him to insert the swab approximately 3-4cm into the anal canal and rotate, then remove the swab and place it into the media tube fastening the lid securely.BBV Specimen collectionVenepuncture for BBV screen Ensure documentation in patients medical record is complete1.3 Anogenital Examination of Females and MalesEquipmentExamination bed, appropriate protective sheeting, pillow and drape sheetAdjustable light sourceSpeculumLubricantSwabs for specimen collection as determined by history and in consultation with patientGlovesFemale ExaminationProcedureDetermine need for a chaperone and/or offer chaperoneProvide the patient with the opportunity to empty her bladder prior to examination Explain procedure Demonstrate procedure with use of pelvic model as necessaryObtain verbal consentEnsure privacy, request woman removes clothing from waist down and inform her about how to position herself on the bed, provide drape Wash hands and don glovesEnsure the bed height is appropriate and adequate lighting is achievedNote: Canberra Sexual Health Centre male practitioners conducting vaginal examination must ensure a female clinician is present as chaperone. In all other CHHS departments refer to CHHS Intimate Care Policy.Inspection of external genitaliaPalpate inguinal lymph nodesExamine skin and pubic hairInspect the vulva, introitus, perineum and perianal area for irregularitiesVaginal Examination A small amount of water-based lubricant can be used to aid insertion of the speculumAdvise the patient to relax her pelvic floor muscles before speculum insertionUse the thumb and forefinger to part labia minora and insert closed speculum into the vagina guided by the posterior vaginal wall Gently open the blades to locate and visualise the cervixNote: if the cervix is difficult to locate remove the speculum. With the patient’s permission, insert one finger into the vagina to feel for the position of the cervix. Reinsert the speculum in the direction of the located cervixWhen the cervix is visualised with the speculum blades positioned in the anterior and posterior fornices secure the speculum ratchet to self-retain the speculum in the vaginaInspect the cervix and vaginal walls and noteInflammationDischarge BleedingLesionsPolypsColumnar epitheliumCollect specimens as clinically indicatedRemove the speculum by releasing the ratchet and withdraw slightly and gently from the fornices to avoid catching the cervix, then close the blades and completely remove the speculum using slight downward tractionBimanual examinationExplain procedure to patient and seek consentWash hands and don glovesApply lubricant to the gloved fingers that will be palpating the vaginaUse the thumb and forefinger of the other hand to part the labiaGently insert the lubricated forefinger and middle finger into the vagina and follow the posterior vaginal wall until the cervix is palpable Turn your vaginal hand, palm upwards and palpate the cervix, noting position, size and consistency of the cervix and cervical osCheck for cervical pain or tenderness through displacing the cervix laterally by placing a finger each side and rocking gently Place your other hand mid-position above the symphysis pubis and press down to stabilise the pelvic organs. With the fingers of the vaginal hand elevate the cervix and palpate the uterus to assess size and for tendernessPalpate the adnexae by moving the external hand and vaginal fingers to the relevant lateral fornix and palpate the area by gentle pressure between your fingers. Note and assess any masses or tendernessWith fingers in the posterior fornix, palpate the Pouch of Douglas for masses or tendernessRemove fingers from the vaginaAssist woman to sit up, offer tissues to wipe residual lubricant and allow to redressExplain and document findings in medical recordPerianal ExaminationWith patient’s permission, inspect perianal region by separating buttocksCollect rectal specimens as clinically indicated and agreed with patientAsk patient to wash their hands using the wash basin or offer alcohol based hand rubExplain and document findings in medical recordMale ExaminationDetermine need for a chaperone When possible, genital examination should be carried out prior to collection of urineEnsure privacyExplain procedure and obtain consentWash hands and don glovesInstruct the man to lay supine with lower abdomen and genitals exposed and provide drapeEnsure the bed height is appropriate and adequate lighting is achievedExamination of genitalia and anogenital regionInspect inguinal region and palpate lymph nodes Inspect pubic areaInspect and palpate scrotal skinPalpate scrotal contents Palpate testis, noting presence of pain, swelling, lumps, hardened areasPalpate epididymides, noting lumps, tendernessNote: Scrotal examination may be more accurate with man in standing position – if abnormalities are suggested by history or examination, consider examination when standing after completion of initial anogenital examination Inspect penis from base to tip, noting dorsal and ventral aspectsAsk patient to retract the foreskin if present and inspect the sub-preputial areaInspect external urinary meatusTo detect presence of urethral discharge, urethra should be ‘milked’ gently by the patientCollect urethral specimens as clinically indicated and agreed with patientPerianal ExaminationWith patient’s permission, inspect perianal region by separating buttocksCollect rectal specimens as clinically indicated and agreed with patientAssist patient to sit up, allow to dressAsk patient to wash their hands using the wash basin or offer alcohol based hand rubExplain and document findingsNote: If the patient has an erection during the examination, use the drape sheet to cover the genital area. Explain that erections are not uncommon in clinical situations. Ask the patient if they wish you to complete the examination immediately or would prefer to wait until the erection has subsided. Back to Table of ContentsSection 2 – Management of Sexually Transmitted InfectionsMost sexually transmitted infections are asymptomatic and testing for all sexually transmissible infections should be considered if the presence of any STI is suspected.Contact tracing should be undertaken for any patient with a positive STI result.Current treatment guidelines can be accessed: Bacterial Vaginosis (BV)Equipment Examination bed, appropriate protective sheeting, pillow and drape sheetAdjustable light sourceSpeculumLubricantGlovespH Indicator sticksPotassium hydroxidePipetteMicroscopy, culture and sensitivity (M/C+S) swabChlamydia and Gonorrhoea PCR swabLarge cotton swabSuperfrost slide and slide coverDiagnosisBV is currently diagnosed by one of two methods:The Amsel method requires 3 or more of the following criteria to be presentClinician observed homogenous white adherent vaginal discharge Vaginal pH of >4.5Positive amine test (whiff test) The presence of “clue cells” on a gram stain or wet prep from a high vaginal swabThe Nugent method grades vaginal bacterial morphotypes visible on a Gram stain0-3: normal flora4-5: intermediate flora7-10: BVIndications for TreatmentDiagnosis based on laboratory or clinical findings for symptomatic women or asymptomatic women undergoing invasive gynaecological proceduresTreatment in pregnancy is recommended for all womenTreatment Refer toAustralian STI Management Guidelines for Use in Primary CareAustralian Therapeutic GuidelinesNote:Exclude pelvic inflammatory disease (PID) in all female patients with BVClindamycin cream is oil based and can weaken condoms. Metronidazole can cause nausea and the patient should be advised to have her medication with food and to avoid drinking any alcohol whilst on treatmentPatient InformationProvide CSHC Bacterial Vaginosis pamphletManagement of sexual contactsScreening of female partners of women with BV recommendedNo treatment for male contacts2.2 Chlamydia Equipment Dependant on test:Chlamydia PCR swabUrine specimen jarImportant PointsChlamydia is a notifiable infection in the ACTNote:Patients diagnosed with chlamydia should be encouraged to have BBV and syphilis testingIndications for TreatmentChlamydia positive PCR testClinical diagnosis based on history and examination findingsPatients who present as sexual contacts of chlamydiaNote:Exclude pelvic inflammatory disease (PID) in all female patients with chlamydia Exclude epididymo-orchititis in all male patients with chlamydiaExclude proctitis in all patients with rectal chlamydiaIf the patient has symptoms of PID, epididymo-orchitis or proctitis, management should be based on assessment of the individual case Treatment Refer toAustralian STI Management Guidelines for Use in Primary Care Australian Therapeutic Guidelines Management of indeterminate chlamydia resultsRe-test with PCR swab from appropriate site as soon as possibleOffer patient presumptive treatment after discussion regarding the uncertain nature of the resultIf the patient tests positive for chlamydia at another site, treat and report the indeterminate result as a positive result Patient InformationNo sex for 7 daysProvide CSHC Chlamydia pamphlet3 month test of reinfection – all relevant sites retestedIf symptomatic 2 weeks post treatment return for reviewTest of cure in 4/52 in pregnant womenContact tracingFor chlamydia, a trace back period of at least 6 months is recommended Each patient needs individualised assessment and encouragement to identify all possible contacts based on their sexual historyAim to notify at least 2 contacts for each patient; public health modelling suggests there is particular value in trying to notify and treat casual contactsDetermine if contact tracing will be patient or clinician directed for each contactComplete contact tracing formManagement of sexual contactsClinical history to assess for complications of chlamydiaScreen all relevant sites by PCROffer and encourage empiric treatment for either asymptomatic infection or symptomatic disease 2.3 Epididymo-orchitisEquipment Dependant on test:Chlamydia and Gonorrhoea PCR swabUrine specimen jarImportant PointsNote:Testicular torsion, a surgical emergency, should be considered in the differential diagnosis of epididymo-orchitisInvestigationsChlamydia and gonorrhoea PCR. If urethral discharge is present, urethral swab for Gram stain and MC &S for N.?gonorrhoeaeMicroscopy, culture and sensitivity (MC &S) of midstream urine testing, as required for urinary tract pathogensIndications for TreatmentClinical diagnosis based on examination findingsConfirmed diagnosis based on positive laboratory investigationsTreatment Refer toAustralian STI Management Guidelines for Use in Primary CareAustralian Therapeutic GuidelinesPatient InformationNo sex for duration of treatmentBed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsidedSigns and symptoms of acute epididymo-orchitis that do not subside within 3 days requires re-evaluation of the diagnosis and therapyContact tracingEncourage partner screening for all patients where a sexually transmitted infection is thought to be a likely cause of epididymo-orchitis, even if a pathogen is not identified Management of sexual contactsOffer asymptomatic partners empiric treatment as per Australian STI Management Guidelines for Use in Primary Care2.4 GonorrhoeaEquipment Dependant on test:Gonorrhoea PCR swabM/C+S swab for all symptomatic patients, asymptomatic patients with positive gonorrhoea PCR and sexual contacts of people diagnosed with gonorrhoea prior to antibiotic treatmentUrine specimen jarImportant PointsGonorrhoea is a notifiable infection in the ACTFalse positive results have occurred with some polymerase chain reaction (PCR) assays. Interpret unexpected positive or indeterminate results with caution in low-risk patients and attempt to confirm these with repeat PCR and cultureThere are many regional differences in antibiotic susceptibility of N.?gonorrhoea and recommended treatment. Culture and susceptibility testing is necessary to ensure that changing antibiotic susceptibility patterns are closely monitored, particularly in infections acquired overseasNote: Prior to treatment ensure bacterial culture swab is collected from affected site. In the case of contacts wanting empiric treatment, culture from all relevant sites prior to treatment Note:Patients diagnosed with gonorrhoea should be encouraged to have blood borne virus and syphilis testingIndications for TreatmentClinical diagnosis based on history and examination findingsGram stain, positive PCR or bacterial culture and sensitivity Patients who present as sexual contacts of gonorrhoeaNote:Exclude pelvic inflammatory disease (PID) in all female patients with gonorrhoea. Exclude epididymo-orchitis in all male patients with gonorrhoeaIf the patient has symptoms of PID or epididymo-orchitis management should be based on assessment of the individual caseTreatment Refer toAustralian STI Management Guidelines for Use in Primary CareAustralian Therapeutic GuidelinesNote: Patients with hypersensitivity to penicillin requiring treatment must not be administered penicillin, a cephalosporin or a carbapenem. An alternative antibiotic must be administered according to sensitivities or consider desensitisation.Management of Indeterminate Gonorrhoea ResultsRe-test with PCR and bacterial culture swab at appropriate sites as soon as possibleOffer patient presumptive treatment after discussion regarding the uncertain nature of the resultIf the patient tests positive for gonorrhoea at another site, treat and report the indeterminate result as a positive resultCeftriaxone Sodium preparation and administrationReconstitute 1g ceftriaxone sodium with 3.6ml lignocaine 1%Resultant concentration is 250mg/mLReconstituted solution is stable for 6 hours at room temperature and 24 hours under refrigeration Administer 500mg (2mL) by deep injection into gluteal musclePatient should remain in clinic for 15 minutes post administrationPatient InformationNo sex for 7 daysProvide “CSHC Gonorrhoea” pamphlet If symptomatic 1 week post treatment return for reviewInformation on test of cure or test of reinfection as belowTest of Cure ProceduresTest of cure (TOC) at 2 weeks, with PCR and culture of all affected sites, for the following patients Persisting symptoms or signsPharyngeal infection Anal infectionCervical infectionTreatment with anything other than the first-line recommendationsNote: patients who only have urethral infection only do not need TOC in 2/52 if treated with first line recommendations and symptoms have fully resolvedInfection identified after treatment may well be due to reinfectionEnsure all potential treatment failures are discussed with the Director of CSHC or their delegate3 month test of reinfection (TORI) for all patients. Contact tracingFor gonorrhoea, a trace back period of at least 2 months is recommended Each patient needs individualised assessment and encouragement to identify all possible contacts based on their sexual historyDetermine if contact tracing will be patient or clinician directed for each contactComplete contact tracing formManagement of sexual contactsClinical history to assess for complications of gonorrhoeaScreen all relevant sites by PCR and bacterial cultureOffer and encourage empiric treatment for either asymptomatic infection or symptomatic disease 2.5 Herpes Simplex Virus (HSV)DiagnosisClinical diagnosis based on examination findingsViral swab (green top) for HSV PCRSerology should not be used in screening and only ordered when there are clear clinical indications. Where possible, the practitioner who ordered the test should give the resultImportant PointPrimary HSV infection may present with the following serious complications:Neurological involvement, transverse myelitis, encephalitis and meningitisUrinary retentionSevere constipationDisseminated infectionSecondary infectionIf any of these complications are present or the HSV infection is widespread consider hospitalisationNote:Patients diagnosed with Herpes Simplex Virus should be encouraged to have sexually transmitted infection and blood borne virus testingTreatmentRefer toAustralian STI Management Guidelines for Use in Primary CareAustralian Therapeutic GuidelinesPatient InformationNo sex whilst symptomaticProvide “CSHC Herpes Simplex Virus” pamphletAssess need to discuss HSV transmission with current partnersDue to the possibility of psychosexual morbidity often associated with a genital herpes diagnosis, patients should be given adequate education, information and the opportunity to discuss concerns. Refer for counselling as required. 2.6 Pelvic Inflammatory Disease (PID)Equipment Examination bed, appropriate protective sheeting, pillow and drape sheetAdjustable light sourceSpeculumLubricantGlovespH Indicator sticksPotassium hydroxidePipetteM/C+S swabChlamydia and Gonorrhoea PCR swabLarge cotton swabSuperfrost slide and slide coverImportant PointsPID is an important cause of reproductive failure. It includes endometritis, salpingitis, tubo-ovarian abscess, pelvic cellulitis and pelvic peritonitisPID is usually polymicrobial and due to sexually acquired pathogens, endogenous vaginal flora or exogenous organisms following mechanical disruption of the normal cervical barrierRepeated episodes of PID are associated with an increased risk of permanent tubal damageClinicians should have a high index of suspicion and low threshold for treatment for PID Specialist opinion should be sought if a patient with PID has an intrauterine device (IUD) in situ. Note:Ectopic pregnancy and appendicitis must be excluded as an alternative cause of symptomsInvestigationsendocervical or vaginal swab for chlamydia and gonorrhoea PCRendocervical or vaginal swab for bacterial culture, microscopy & sensitivityonsite investigations (if available) including gram stain, KOH test, pH pregnancy testconsideration should be given to FBC, ESR and CRPIndications for TreatmentDiagnosis based on clinical history and examination findings and test resultsTreatment Refer toAustralian STI Management Guidelines for Use in Primary Care Australian Therapeutic GuidelinesCeftriaxone preparation and administrationReconstitute 1g ceftriaxone sodium with 3.6ml lignocaine 1%Resultant concentration is 250mg/mLReconstituted solution is stable for 6 hours at room temperature and 24 hours under refrigeration Administer 500mg (2mL) by deep injection into gluteal musclePatient should remain in clinic for 15 minutes post administrationFollow up careAdvise patient to call the clinic for results in 7 days, and call same day if symptoms worsen or unable to tolerate medicationsAdvise review in clinic in 3 days for patients with worsening symptomsRoutine review of all patients with PID in 2-4 weeks, to review symptom resolution, check understanding of potential sequelae of PID, and encourage condom use with new/untested partners to reduce risk of reinfectionPatient InformationNo sex for 14 days (ie for full duration of treatment) and until partners are also treated Provide CSHC PID pamphlet and PID information cardContact tracingEncourage partner screening for all patients where a sexually transmitted infection is thought to be a likely cause of PID, even if a pathogen is not identified Management of sexual contactsCurrent sexual partners should be treated to cover chlamydia (and gonorrhoea if likely) immediately, irrespective of test results. Refer to Australian STI Management Guidelines for Use in Primary Care2.7 ProctitisEquipmentExamination bed, appropriate protective sheeting, pillow and drape sheetAdjustable light sourceProctoscope LubricantGlovesM/C+S swabChlamydia and Gonorrhoea PCR swabViral PCR swabPCR swab for Lymphogranuloma Venereum (LGV) if suspectedImportant PointsMucopurulent rectal discharge, rectal bleeding, tenesmus and rectal pain suggest moderate to severe proctitis In MSM or women who practise anal sex symptoms are likely to be due to a sexually transmitted infectionLymphogranuloma venereum can present as proctitis, especially in HIV+ MSMIndications for TreatmentClinical diagnosis based on examination findings Consider proctoscopy to identify localised infection Confirmed diagnosis based on positive laboratory investigationsInvestigationsSwabs for chlamydia and gonorrhoea PCRSwab for herpes simplex virus PCR or syphilis PCR depending on clinical appearanceStool culture if diarrhoea is presentNote:Consider LGV PCR testing in MSM with proctitis and a positive chlamydia PCRTreatment Refer toAustralian STI Management Guidelines for Use in Primary Care Australian Therapeutic GuidelinesNote: Patients with hypersensitivity to penicillin requiring treatment must not be administered penicillin, a cephalosporin or a carbapenem. An alternative antibiotic must be administered according to sensitivities or consider desensitisationCeftriaxone Sodium preparation and administrationReconstitute 1g ceftriaxone sodium with 3.6ml lignocaine 1%Resultant concentration is 250mg/mLReconstituted solution is stable for 6 hours at room temperature and 24 hours under refrigeration Administer 500mg (2mL) by deep injection into gluteal musclePatient should remain in clinic for 15 minutes post administrationPatient InformationNo sex for 7 daysIf symptomatic 1 week post treatment to return for reviewContact tracingEncourage partner screening for all patients where a sexually transmitted infection is thought to be a likely cause of proctitis, even if a pathogen is not identified 2.8 SyphilisImportant PointsSyphilis is a notifiable infection in the ACTSyphilis is categorised into early (<2 years duration), late (>2 years duration) and tertiaryInterpretation of syphilis results requires a thorough history including previous syphilis testing, previous positive results and treatmentAssess for neurosyphilis in early as well as late syphilis: headache, visual or auditory changesNote:Patients diagnosed with syphilis should be encouraged to have blood borne virus and other STI screeningDiagnosisDemonstration of spirochaetes in chancres or mucosal lesions by dark field microscopy Flocked swab (orange top) for PCR testing from a chancre or mucosal lesion positive T.pallidum-specific antibody test +/- positive Rapid Plasma Reagin (RPR) and confirmatory tests False positive nontreponemal tests can occurT.?pallidum-specific tests usually remain positive after successful treatmentTests may be negative in very early infection and following treatment may remain negative even when syphilis is confirmed by other means such as PCR RPR is often negative in late or tertiary syphilisIndications for TreatmentSyphilis positive serology, microscopy or PCR testingClinical diagnosis based on history and examination findingsPatients who present as sexual contacts of syphilisTreatment Refer toAustralian STI Management Guidelines for Use in Primary CareAustralian Therapeutic GuidelinesNote:Non-penicillin treatment regimens have not been thoroughly evaluated and should be used only when penicillin is contraindicatedContacts of syphilisOffer immediate presumptive treatment as per treatment of early syphilis. Further treatment if syphilis serology is positive according to duration of infection as defined above.ReviewRPR titre should be repeated on the day of treatment then at 3, 6 and 12 months until RPR is non-reactive. Ongoing syphilis screening will be required according to risk group recommendations eg men who have sex with men, PLWHIV. As T. pallidum-specific antibody tests remain positive for life, follow-up screening should include RPR and provide brief history of syphilis treatment for laboratory staff If the RPR titre falls following treatment and becomes non-reactive only to increase again, this usually signifies re-infectionWhere the RPR titre fails to fall fourfold within 6 months of treatment of early syphilis, treatment failure and CSF examination should be considered eg RPR on day of treatment 32 should fall to 4 or less.Patient InformationPatients being treated for syphilis should be warned of the possibility of the Jarisch Herxheimer reaction which may occur several hours after the first injection of penicillin. Patients should be reassured that it is usually transient and self limiting. Paracetamol and oral fluids can help with symptomsThis reaction rarely occurs and presents as a flu like illness with symptoms including fever aches and pains. This occurs due to the bacteria responding to the pen and is not a side effect or allergic reaction.No sex for 7 days after completion of treatment and any clinical signs of syphilis have resolvedProvide “CSHC Syphilis” pamphletBack to Table of Contents Section 3 – Contact Tracing for Sexually Transmitted Infections and Human Immunodeficiency Virus (HIV)Advice with regard to contact tracing may be sought from clinicians at CSHC.3.1 Notifiable STIs and BBVs in the ACTAIDSChlamydiaDonovanosisGonorrhoeaHepatitis AHepatitis BHepatitis CHIVSyphilis3.2 Contact Tracing PointsInclude contact tracing into pre-test discussion at initial clinic visitIndicate that clinicians will support client with this processProvide detailed information to patients who present as contacts of an STIAfter receiving a confirmed diagnosis discuss the aims and reasons for contact tracing with the patient:Interrupt the ongoing transmission of infectionIdentify people with an infection who may benefit from treatment in order to minimise complicationsPrevent re-infection from an untreated partner To help limit the prevalence of infection in the populationEstablish ‘trace back’ period according to the positive diagnosisRefer to: Australasian Society of HIV Medicine Contact Tracing Guidelines Review the sexual history taken at the initial visit to identify partners that require contactingEstablish whether contact tracing is to be undertaken by the patient or providerCall CSHC, through the Canberra Hospital Switch (6244 2222) for advice or assistance with contact tracingPatient initiatedDiscuss the information they will provide to their contacts:STI diagnosedAsymptomatic nature of STIsPossible sequelae of untreated infectionTreatment regimenWhere to access testing and treatmentProvide specific STI information – websites to assist with contact tracing including:.authedramadownunderinfo (for MSM)Discuss how a partner might react and problem solve with the patientAdvise that partners can be contacted by telephone, SMS, email or letterIf letter chosen as the preferred contact provide appropriate letter(s) to be given to contacts; see .au for templatesObtain patients permission for a follow up phone call to determine if the patient was able to inform their partners. If patient has not been able to contact partners offer further assistance with thisProvider initiatedObtain verbal consent from the patient to notify partnersObtain partners contact details and record name, phone number, state and approximate time of sexual contactMake contact with partners as soon as possible and try at least 3 times with a variety of communication methodsDiscuss relevant information with partners to assist with accessing testing and treatment (see above)Refer to other agency to assist with contact tracing if necessary, e.g. other sexual health service, public health unit, health department contact tracerAdvise patient to attend for test of re-infection in 3-6 monthsReview contact tracing process at this visit3.3 HIV Contact TracingNote: Due to the seriousness of HIV, it is recommended that an experienced HIV Partner Notification Officer undertake contact tracing. Referral to Canberra Sexual Health Centre for contact tracing is preferable. ProcedureDiscuss the goals of contact tracing with the index patient:to interrupt the ongoing transmission of infectionto identify those with an infection who may benefit from medication management in order to minimise complicationsto limit the prevalence of infection in the populationestablish ‘trace back’ period start with recent sexual or injecting partners, with an outer limit being the onset of risk behaviour or last known negative HIV testaim to obtain at least a first name and approximate date of sexual contact or injecting drug use for each individual. Try and get a contact phone number or other contact details; and the contacts state of residence review sexual history taken at the initial consult (if available) to match with number of contacts identified above, explore any discrepanciesFor each contact establish whether contact tracing is to be undertaken by the patient or provider or a combination of both, and document accordingly.Patient initiated contact tracingDiscuss the information the patient will provide to their contacts:the infection is HIV – not just a sexually transmissible infection (STI)that HIV usually has no symptomsthe possible sequelae of HIV infectionwhere to access testing Discuss how a partner might react and problem solve with the patientAdvise patients that they will receive a follow up phone call or review at next clinic visit to determine if the patient was able to inform each partnerIf patient has not been able to contact partners offer further assistance with this at follow-up.Provider initiated contact tracingObtain verbal consent from the index patient to notify partners and then document this in the notes.Ensure the patient is aware that whilst we do not disclose a patient’s name or other details, notifying partners of HIV risk may make them suspect that the patient is the source of infection. If patient is concerned about this, the clinician will inform partners that they have come in contact with a STI and need STI screening including blood tests (HIV not specifically mentioned).Make contact with partners as soon as possible, this may be done with an initial (introduction) SMS then follow up phone call or just by phone call.During each phone call, the following information should be given:introduce self as Sexual Health Nurse, Public Health Nurse or MO and reason for call HIV to be specifically mentioned (unless agreed not to) with advice to also get screened for all STIsdo not specify an exact time point at which the person may have been exposed as this may identify the index. If pressed, give a broad timeframe that has been calculated prior to making the call location/s of nearest testing facility, and try to ascertain where they might attendif individual nominates CSHC, explore when they may wish to attend, advise of walk-in clinic times, or if they prefer, offer to call them back with an appointment. for script example see Attachment 1If contact becomes verbally aggressive, the clinician can advise what organisation (eg “Sexual Health Centre”) they work for and then arrange for their supervisor to take the call or call them back. Back to Table of Contents Implementation This guideline will be circulated to the following for implementation to all relevant staff:Medical ExecutiveStrategic ExecutiveNursing ExecutiveBack to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesACT Health, Consent to Treatment PolicyACT Health, Nursing and Midwifery Continuing Competence PolicyACT Health, Five Step Correct Patient, Correct Site, Correct Procedure PolicyACT Health, Patient Identification and Pathology Specimen Labelling PolicyProceduresCHHS Intimate Body CareCHHS Blood Borne Virus Testing in Adult Patients CHHS15/061ACT Health, Infection Prevention and Control ManualGuidelines Australian STI Management Guidelines Australian Therapeutic Guidelines LegislationACT Government, Public Health Act 1997ACT Government Occupational Health and Safety Act 1989ACT Children and Young People Act 2008Back to Table of ContentsReferencesAustralasian Sexual Health Alliance (2014). Australian STI Management Guidelines for Use in Primary Care (2014). Retrieved November 2014 from Society for Sexual Health Medicine (2010). Australasian contact tracing manual (4th eds). Sydney: Australian Society for Sexual Health MedicineChan, R. (2011). Taking a Sexual History and the Sexual Health Examination. In Russell, Bradford, and Fairley (eds) Sexual health medicine (p51-69). IP Communications,MelbourneFamily Planning Australia. (2012). Reproductive and sexual health: an Australian clinical practice handbook. Sydney: Family Planning NSWNSW Sexually Transmitted Infections Programs Unit (2009). NSW Health Sexual Health Services Standard Operating Procedures Manual 2009. Retrieved April 20, 2011 from stipu..auBack to Table of ContentsDefinition of Terms and abbreviations BHCG: Beat-Human Chorionic GonadotrophinBBV:Blood borne virusBV:Bacterial vaginosis CRP: c - reactive proteinCoitarche: first coitus, or sexual intercourseCSF: Cerebrospinal fluidESR: Erythrocyte sedimentation rateEIA: Enzyme ImmunoassayFBC: Full blood countFVU: First Void urine (FVU means the first flow of urine NOT first urine of the day)KOH: Potassium Hydroxide ‘whiff’ testMenarche: Age of first menstrual periodMSM: Men who have sex with men. Do not always identify as gay menNudging: Penile-anal external contact without insertionPCR: polymerase chain reaction testPost Exposure Prophylaxis: a course of anti-HIV drugs to prevent acquisition of HIVSTI:Sexually Transmitted Infection T. pallidum: bacteria that causes syphilisIndex Patient:Is first person diagnosed with a infection.Back to Table of ContentsSearch Terms ChlamydiaProctitisMolluscum contagiosumGonorrhoeaHerpes Simplex VirusGenital examination SyphilisPelvic Inflammatory DiseaseVaginal dischargeEpididymo-orchitisPIDUrethral dischargeBacterial VaginosisHuman papillomavirusSTIBBVHIVPregnancy TestingHepatitis AHepatitis BSex workerMSMGayScreenExaminationChaperoneSexual HistoryCSHCCanberra Sexual Health CentreBack to Table of ContentsAttachmentsAttachment 1: HIV Contact Tracing Script ExampleDisclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Attachment 1: HIV Contact Tracing Script ExampleAs far as possible, make calls in the morning so contacts can access testing that day If Index has given permission to state specifically that contacts may have been exposed to HIV “My name is ……….. and I am a sexual health nurse/public health nurse/MO. I’m calling to discuss an important health matter with you. Are you somewhere where we can talk? My job is to phone people that may have come in contact with a sexually transmitted infection or HIV. I am calling you because you have been named as a possible contact of someone who has been diagnosed with HIV. I realise this call is probably unexpected. We phone so that people who are contacts are able to get tested for HIV, as well as other STIs.”Await response and questions…“If you can tell me where you live, I can recommend a clinic where you can access free testing and information, or you might prefer to see your GP”. If the contact lives in Canberra, and nominates to attend CSHC, advise them of walk-in clinic times and if preferred, offer to call them back with an appointment for testing. “Thank you for taking this call” If Index has NOT given permission to state specifically that contacts may have been exposed to HIV “My name is ……….. and I am a sexual health nurse/public health nurse/MO. I’m calling to discuss an important health matter with you. Are you somewhere where we can talk? My job is to phone people that may have come in contact with a sexually transmitted infection. I am calling you because you have been named as a possible contact of someone with a sexually transmitted infection. I realise this call is probably unexpected. We phone so that people who are contacts are able to get tested, with both swab or urine and blood tests.” Await response and questions…“If you can tell me where you live, I can recommend a clinic where you can access free testing and information, or you might prefer to see your GP”. If the contact lives in Canberra, and nominates to attend CSHC, advise them of walk-in clinic times and if preferred, offer to call them back with an appointment for testing. If the person does not intend to come to CSHC, remind them again that they need both swab or urine tests and a blood test. “Thank you for taking this call. Please remember that you need full testing including blood tests.” If the person questions the veracity of the call, or becomes verbally aggressive or threatening, offer the name of the organisation you are from and supervisors details”I understand this phone call is unexpected. To help you verify the information I am giving you, my name is …………… and I work at a Sexual Health Centre. My supervisor’s name is …………….. If you hold the line I can check if my supervisor is available to talk to you directly or call you back”. ................
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