SEXUALLY TRANSMITTED DISEASE AND HUMAN …



STD

Table of Contents

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CLINICAL PROTOCOLS

STD Matrix 1

Requirements for STD Examinations 5

Treatment of Common Sexually Transmitted Diseases 6

Syphilis 6

Gonococcal Infections 10

Chlamydial Infections 14

Mucopurulent Cervicitis (MPC) 16

Nongonococcal Urethritis (NGU) 18

Epididymitis 19

Pelvic Inflammatory Disease (PID) 20

Bacterial Vaginosis (BV) 21

Trichomoniasis 22

Candidiasis 23

Human Papillomavirus (HPV) 24

STD Drugs in Pregnancy 27

CASE MANAGEMENT

STD Offices by Area Developmental Districts 29

STD MATRIX

| |STD VISIT |STD RE-VISIT |

| |(Primary reason for visit is due to symptoms, exposure, partner |Requirements of an STD Visit |

| |problem, positive test and/or high risk behavior) |Males and Females |

| |Males and Females | |

|REASON FOR VISIT |PRIMARY REASON: |Positive Test |

| |Positive Test |Symptoms – (list symptom and duration) |

| |Symptoms – ( for STD symptom and duration) |Results |

| |Symptomatic Partner |Follow-up appointment |

| |Exposure (list STD) |Other |

| |STD test only | |

| |HIV test only | |

| |Referral (list agency) | |

| |For all other clinical visits (i.e. Family planning, Adult/Child | |

| |Prevention, Cancer, etc.), lab testing for STD screening does not| |

| |require an STD physical exam unless STD symptoms are reported. | |

|MEDICAL |Significant illnesses; hospitalizations; chronic or acute medical|Identify any changes to the medical history obtained |

|HISTORY |conditions |during the prior visit including allergies, |

| |Allergies |prescriptions and/or antibiotics |

| |Current prescription medication and/or antibiotics w/in the last | |

| |month | |

| |HX of STD/HIV (list condition, date, and place of RX) | |

|SEXUAL & REPRODUCTIVE |Sex with males, females or both |Sexual exposure since last visit |

|HISTORY |Number of partners w/in 12 mos |Identify any changes to the sexual & reproductive |

| |Number of partners w/in 60 days |history obtained during the prior visit. |

| |Number of new partners w/in 60 days | |

| |Date of last sexual exposure (LSE) | |

| |Anatomical sites exposed during sexual activity | |

| | | |

| |Exposed Sites | |

| |< 60 days | |

| |< 12 months | |

| | | |

| |Vagina | |

| | | |

| | | |

| | | |

| |Anus | |

| | | |

| | | |

| | | |

| |Mouth | |

| | | |

| | | |

| | | |

| |Penis | |

| | | |

| | | |

| | | |

| | | |

| |Frequency of condom usage | |

| |FEMALES: Last menstrual period, obstetrical history, and | |

| |gynecological conditions, and current contraceptive use. | |

|RISK ASSESSMENT |Suggested Questions to Ask During The Sexual History | Identify any changes since last visit |

| | | |

| |When was the last time you had sex? | |

| |How many partners have you had sex with in the last 12 months? | |

| |How many new partners have you had sex with in the last 2 months?| |

| |When is the last time you had sex with a man? Woman? Both? | |

| |At what age did you become sexually active? | |

| |What are you doing to prevent pregnancy? | |

| |Did you use a barrier the last time you had sex? | |

| |How often do you use a barrier when you have sex? | |

| |When is the last time you engaged in oral, anal, or vaginal | |

| |intercourse? | |

| |Are you the insertive partner, the receptive partner, or both? | |

| |Was the sexual encounter consensual or nonconsensual? | |

| |Have you ever been paid for sex (exchanged sex for drugs or | |

| |exchanged sex for money)? | |

| |Have you ever been a resident in a correctional facility? | |

| |Do you have a history of sexually transmitted diseases? | |

| |Has your judgment ever been impaired by the use of alcohol or | |

| |drugs? | |

| |STD/HIV exposure | |

| |Substance abuse including IV drug use and alcohol | |

| |Multiple partners | |

| |Anonymous partners | |

| |Sex for money or drugs | |

| |Abuse or domestic violence | |

|PHYSICAL |ALL: |Repeat physical exam per medical/sexual history and risk|

|EXAM |Oral examination. |assessment |

| |Skin inspection over entire body, especially the lower abdomen, | |

| |inguinal areas, thighs, hands, palms, and forearms. | |

| |Inspection of the pubic hair for lice and nits. | |

| |Inspect external genitalia, perineum, and anus. | |

| |Palpate for lymphadenopathy, especially the inguinal and femoral | |

| |regions. | |

| | | |

| |FEMALES: | |

| |The examination for STDs should not be deferred for menses unless| |

| |bleeding is extremely heavy. Urine specimen can be collected for | |

| |CT/GC testing. | |

| | | |

| |A pregnant patient should be examined and tested in the same | |

| |manner as the non-pregnant patient with the exception of the | |

| |bimanual pelvic exam. If a pregnant patient is experiencing | |

| |vaginal bleeding she should be immediately referred to her | |

| |obstetrician or certified nurse midwife. | |

| |Examine the vagina and the cervix, using the appropriate | |

| |speculum. It is highly recommended that a specimen be obtained | |

| |from the vaginal vault for a wet mount. Obtain an endocervical | |

| |specimen for gonorrhea and Chlamydia utilizing an APTIMA test | |

| |kit. A urine specimen should be obtained from females without a | |

| |cervix. | |

| |Obtain specimens for gonorrhea from other exposure sites as | |

| |indicated i.e. throat, rectum | |

| |Perform a Bimanual pelvic examination. A bimanual exam is to be | |

| |performed on all females presenting for STD evaluation with the | |

| |exception of pregnancy and hysterectomy. | |

| |Recommend women complaining of rectal symptoms to have an | |

| |anoscopic exam at their primary care provider or an appropriate | |

| |specialist. | |

| | | |

| |MALES: | |

| |Inspect scrotum and palpate scrotal contents; inspect rectal area| |

| |(perineum & anus) if patient has had male-male sex. | |

| |Inspect and palpate penis, retract foreskin, and inspect urethra.| |

| |Using APTIMA Test Kits, obtain intraurethral specimens for | |

| |gonorrhea and Chlamydia testing and Gram staining if available. | |

| |If patient is asymptomatic and has not urinated for one hour, may| |

| |obtain first-catch urine specimen for gonorrhea and Chlamydia. | |

| |Obtain specimens for gonorrhea from other exposure sites as | |

| |indicated, i.e. throat, rectum. Recommend men complaining of | |

| |rectal symptoms to have an anoscopic exam at their primary care | |

| |provider or an appropriate specialist. | |

| |Note: |Repeat labs per medical/sexual history and risk |

|LABORATORY |Routine laboratory tests shall be obtained at each STD visit. An|assessment. |

| |STD visit is defined as a visit in which the patient presents | |

| |with new symptoms, new exposure, partner problem, positive test |(Note: Testing for Chlamydia less than 3 weeks from |

| |and/or high risk behavior. |date of treatment may result in a positive result which |

| | |may represent nonviable Chlamydia remnants from an |

| |Obtain blood specimens from all patients for Syphilis IGGE (if |earlier infection) |

| |using the Kentucky Division of Laboratory Services) or RPR (Rapid| |

| |Plasma Reagin) at each visit except for those patients who have | |

| |had a documented non-reactive Syphilis test within the past 30 | |

| |days. Patients presenting with symptoms suggestive of syphilis | |

| |or who are epidemiologically related to another person with | |

| |syphilis should have a syphilis test regardless of documentation | |

| |of testing within the last 30 days. For patients presenting with | |

| |lesion(s) suggestive of syphilis, a confirmatory test should be | |

| |requested if using a non-state laboratory. Confirmatory tests | |

| |for syphilis are IGG, TPPA and FTA. | |

| |Obtain specimen for Chlamydia (CT/GC APTIMA Test) | |

| |Except in pregnant women, a test of cure is not recommended for | |

| |persons treated with the recommended or alternative regimens, | |

| |unless therapeutic compliance is in question symptoms persist, or| |

| |re-infection is suspected. Testing in less than 3 weeks after | |

| |completion of therapy could yield a false positive result due to | |

| |the presence of dead CT organisms. | |

| |Obtain specimen for Gonorrhea (CT/GC APTIMA Test) | |

| |Test of cure is not recommended routinely for patients with | |

| |uncomplicated gonorrhea who have been treated with the | |

| |recommended regimens. Patients with persistent symptoms or whose| |

| |symptoms recur shortly after treatment should be reevaluated by | |

| |culture; positive isolates should undergo antimicrobial | |

| |susceptibility testing. | |

| |Obtain blood specimens for HIV testing from all patients seeking | |

| |STD services except for those patients who have a documented | |

| |negative HIV test within the past 90 days or if the patient | |

| |declines. | |

| | | |

| |Stat Testing (Dependent upon availability at the LHD) | |

| |Stat RPRs for syphilis, if available, should be ordered on | |

| |patients with ANY of the following: | |

| |Genital lesion(s) | |

| |Rash suggestive of syphilis | |

| |Epidemiological link to another person with syphilis | |

| |History of lesions or lymphadenopathy since last negative | |

| |serologic test for syphilis (STS). | |

| | | |

| |If stat RPR is not available and the patient has a lesion(s), | |

| |obtain a blood specimen for Syphilis IGGE (if using the Division | |

| |of Laboratory Services). If using a lab that does not use reverse| |

| |syphilis testing, order a VDRL or RPR plus request confirmatory | |

| |testing such as IGG, TPPA, or FTA. (A negative VDRL or RPR with | |

| |clinical symptoms suggestive of primary syphilis such as a | |

| |lesion(s) does not rule out syphilis). Repeat screening for | |

| |primary disease may require additional testing at 2-4 weeks but | |

| |should not impede empiric treatment if symptoms are highly | |

| |suggestive of syphilis. For specimens submitted to Kentucky’s | |

| |Division of Laboratory Services, reflexive confirmatory testing | |

| |will follow the current CDC Guidelines (VDRL and TPPA as | |

| |indicated for positive results). | |

| | | |

| |Gram stain for gonorrhea, if available, should be ordered on male| |

| |patients who present with ANY of the following: | |

| |Penile Discharge | |

| |Dysuria | |

|PROVIDE |Treatment as indicated in this guide or CDC Treatment Guidelines.|As assessed for individual patient needs. |

| |Recommendation/Referral for other health care needs or to a | |

| |higher level provider if needed. | |

| |Recommendation/Referral for social services (as needed) | |

| |Linkage for partner services (contact STD regional area to | |

| |initiate partner services if patient is diagnosed with syphilis | |

| |and/or HIV. | |

| |Follow up appointment (as needed) | |

| |Condoms | |

| | | |

| |Priority consideration in regards to patient flow should be given| |

| |to patients who are known to be infected with an STD or is an | |

| |epidemiological link to an individual known to be infected. | |

|COUNSELING |Counseling messages should include: |As assessed for individual patient needs. |

| |Take medication as directed. | |

| |Abstain from sex until the patient and patient’s sex partners | |

| |have completed treatment. Abstinence should be continued until 7| |

| |days after a single-dose regimen or after completion of a | |

| |multi-dose regimen. | |

| |Return for all follow-up appointments. | |

| |How to obtain test results. | |

| |Safe sex, risk reduction messages. | |

| |Pregnancy prevention. | |

| |Provide partner services to individuals diagnosed with Chlamydia,| |

| |gonorrhea, NGU or MPC. | |

| | | |

| |Educational materials can be located at: | |

| | | |

|REQUIREMENTS FOR STD EXAMINATIONS |

| |

|Assure that patients with positive Chlamydia and/or gonorrhea tests return for treatment within seven (7) days of receipt of laboratory |

|report. The STD Program goal is to provide treatment to 85% of infected patients within 14 days of specimen collection and to 90% within |

|30 days of specimen collection. |

|Provide face-to-face counseling/interviewing to public health clinic patients diagnosed with Chlamydia, gonorrhea, NGU or Mucopurulent |

|Cervicitis. Interviews should be achieved in a timely manner, with the goal of obtaining an average of at least one contact elicited per |

|case interviewed. This service should be available to privately diagnosed and treated patients upon request of their physician. Although|

|infected patients are under no legal obligation to participate in partner services, every effort should be made to motivate the patient to|

|engage in partner services to ensure that exposed partners are identified, notified and provided adequate exam and treatment services. |

|Assure that contacts to syphilis, HIV, Chlamydia, gonorrhea, NGU, Mucopurulent Cervicitis named in interviews with infected patients are |

|referred for medical evaluation in a timely manner. |

|Assure that DIS priority referrals are “fast tracked” within the LHD STD clinic. |

|Assure reporting of suspected sexual abuse to the Department for Community-Based Services. |

|Provide all patients with counseling and/or printed materials, and motivate patients to: |

|Increase patients’ awareness of signs and symptoms of STDs and prompt patient to seek medical care immediately should evidence of symptoms|

|occurs. |

|Increase the number of sexual partners referred for evaluation by STD patients. |

|Increase patients’ rate of compliance with prescribed medication regimens. |

|Increase the practice of preventive behaviors in the patient population (e.g. use of condoms, selection of partners, etc.). |

|Request area DIS for epidemiologic follow-up for 100% of suspected or diagnosed cases of priority STD (early syphilis and HIV infection). |

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES |

|CONDITION |

|PRIMARY (1º), SECONDARY (2º)|PRIMARY(1º): Indurated chancre |(For specimens submitted |BENZATHINE PENICILLIN G |(For penicillin allergic |Contact STD Supervisor within your |Complete EPID 200 and |

|OR |usually painless |to the Kentucky Division |2.4 million units (MU) IM |non-pregnant adult |regional area within 24 hours to |fax to State STD |

|EARLY LATENT ( 12 years of age. |Plus |

|Latent | |CSF Examination |of 2.4 MU |should be desensitized and | |Report suspected cases |

|(aged > 1 month) | | |Generally, RX for STDs found in a |then treated with | |of sexual abuse to the |

|See CDC Treatment Guidelines| | |pre-pubertal child should be |penicillin | |Dept of Community Based|

|for the management of | | |managed by the child’s physician. | | |Services |

|congenital syphilis | | |LHDs shall assure adequate RX. | | | |

|LATE LATENT (>1 YEAR) OR |None |(For specimens submitted |Benzathine penicillin G |(For penicillin allergic |Contact STD Supervisor within your |Complete EPID 200 and |

|LATENT OF UNKNOWN DURATION | |to the Kentucky Division |2.4 million units IM for 3 doses, |non-pregnant adult |regional area. |fax to State STD |

| | |of Laboratory Services) |1 week apart (total: 7.2 million |patients) | |Program. |

|Adults | |Syphilis IGGE |units) | | | |

| | |with reflex to | |DOXYCYCLINE 100 mg orally | | |

| | |VDRL or TPPA | |2 times a day for 28days | | |

| | | | |(for adults only) | | |

| | |(For specimens submitted | | | | |

| | |to labs not using reverse | | | | |

| | |syphilis testing) | | | | |

| | |VDRL/RPR | | | | |

| | |And confirmatory test if | | | | |

| | |needed such as:TPPA, FTA, | | | | |

| | |or MHA | | | | |

| | | | | | | |

| | |See CDC Treatment | | | | |

| | |Guidelines to determine if| | | | |

| | |CSF exam is needed | | | | |

|Children |Same as Adult |Same as Adult |Benzathine penicillin G 50,000 |Infants and children who |Contact STD Supervisor within your |Same as Adult |

|Late Latent or Latent of | |Plus |units/kg IM up to the adult dose |are allergic to penicillin |regional area > 12 years of age. |Plus |

|Unknown Duration | |CSF Examination |of 2.4 million units, administered|should be desensitized and | |Report suspected cases |

|(aged > 1 month) | | |for three doses at 1 week |then treated with | |of sexual abuse to the |

| | | |intervals |penicillin | |Dept of Community Based|

|See CDC Treatment Guidelines| | |(total 150,000 units/kg up to the | | |Services |

|for the management of | | |adult total dose of 7.2 million | | | |

|congenital syphilis | | |units) | | | |

| | | | | | | |

|Generally, RX for STDs found| | | | | | |

|in a pre-pubertal child | | | | | | |

|should be managed by the | | | | | | |

|child’s physician. LHDs | | | | | | |

|shall assure adequate RX. | | | | | | |

|NEUROSYPHILIS |Neurologic or ophthalmic |CSF Examination |Aqueous crystalline penicillin G |Procaine penicillin 2.4 |Contact STD Supervisor within your |Complete EPID 200 and |

| |abnormalities | |18-24 million units per day, |million units IM once daily|regional area. |fax to State STD |

| | | |administered as 3-4 million units |for 10-14 days plus | |Program. |

| | | |IV every 4 hours or continuous |probenecid 500 mg orally | | |

| | | |infusion, for 10-14 days |4 times a day for 10-14 | | |

| | | | |days | | |

|SYPHILIS WITH A CO-INFECTION|SEE ABOVE |SEE ABOVE |For 1º, 2º and early latent |The use of any alternative |Contact STD Supervisor within your |Notify HIV/AIDS |

|OF HIV | | |syphilis: Treat as above. |therapy in HIV infected |regional area if index patient is |surveillance if newly |

| | | |Additional doses of Benzathine |persons has not been well |co-infected w/HIV to initiate partner |diagnosed HIV case. |

| | | |penicillin G in early syphilis do |studied; therefore the use|services. | |

| | | |not enhance efficacy, regardless |of doxycycline and | | |

| | | |of HIV status. |ceftriaxone must be | | |

| | | |For late latent syphilis or latent|undertaken with caution | | |

| | | |syphilis of unknown duration: | | | |

| | | |Perform CSF exam to | | | |

| | | |rule-out neurosyphilis | | | |

|SYPHILIS AND PREGNANCY |SEE ABOVE |SEE ABOVE |Penicillin is the only recommended|N/A |Contact STD Supervisor within your |Complete EPID 200 and |

| | | |treatment for syphilis during | |regional area within 24 hours of |fax to State STD |

| | | |pregnancy. Women who are allergic | |laboratory receipt. |Program within 24 |

| | | |should be desensitized and then | | |hours. Indicate |

| | | |treated with penicillin. Dosages | | |pregnancy status on |

| | | |are the same as in non-pregnant | | |EPID 200. |

| | | |patients for each stage of | | | |

| | | |syphilis.2 | | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Syphilis (Pages 26-40)

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|GC - ADULTS |Females- |MALE & FEMALE: |Symptomatic men & women |Azithromycin 2gm orally in a |Sex partners exposed during the |Complete EPID 200 and fax or |

| |Often asymptomatic. |APTIMA CT/GC COMBO 2 |presenting for an STD visit |single dose |previous 60 days should be |mail to State STD Program |

| | |(NAAT) |shall be treated empirically for|OR |examined, tested and preventively |within 14 days. |

|Cervix, Urethra, Rectum|Cervical: |TEST |both GC and CT on their initial |Single-dose injectable |treated for gonorrhea and | |

| |Cervical discharge. | |visit. |cephalosporin1 regimens |Chlamydia on their initial visit. |EPID 200’s that do not |

| |Also-Increased vaginal |DLS offers this molecular | | |They shall also be screened for |contain treatment at time of |

| |discharge, bleeding between |test for rectal and |Ceftriaxone1 250 mg IM in a |PLUS |Chlamydia, syphilis and HIV. |initial report shall be |

| |periods and dysuria. |pharyngeal specimens. |single dose | | |updated with treatment |

| | | |OR |Adequate treatment for | |information and sent to state|

| |Males- | |Cefixime 400 mg orally in a |Chlamydia. | |STD office 7 days after RX |

| |May be asymptomatic. |Male: Gram stain (if test|single dose3 | | |administration |

| | |is available at LHD) of | |See 2010 CDC guidelines for | | |

| |Males & Females- |urethral discharge. |PLUS |discussion of | |85% of patients diagnosed |

| |Urethra: Discharge (white, | | |alternative regimens | |w/GC should be treated within|

| |yellow or green), Dysuria. | |Adequate treatment for |Quinolones4 should not be | |14 days from the date of lab |

| |Rectal: Pain, itching | |Chlamydia. |used for treatment of | |collection and 90% within |

| |discharge, bleeding; may be | | |gonorrhea | |30 days from the date of lab |

| |asymptomatic. | | | | |collection. |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|GC – PHARYNX |Sore throat, |APTIMA CT/GC COMBO 2 (NAAT) |Ceftriaxone1 250 mg IM in a single|Ciprofloxacin 4 500 mg orally in a |SEE ABOVE |SEE ABOVE |

| |pharyngeal exudate, |TEST |dose |single dose | | |

| |enlarged cervical | | | | | |

| |lymph nodes; often |DLS offers this molecular test |PLUS | | | |

| |asymptomatic. |for rectal and pharyngeal | |PLUS | | |

| | |specimens. |Adequate treatment for Chlamydial | | | |

| | | |infection. |Adequate treatment for Chlamydial | | |

| | |DLS does not perform GC | |infection. | | |

| | |cultures. | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | |(Individuals receiving alternative | | |

| | | | |regimens for pharyngeal GC shall have a| | |

| | | | |test of cure (NAAT) 3 weeks after | | |

| | | | |completion of therapy) | | |

|GC in CHILDREN |SEE GC SX IN ADULTS |DLS lab does not perform GC |Ceftriaxone1 125 mg IM once |N/A |SEE ABOVE if |Complete EPID 200 and |

|(45KG) | |cultures. |adults | |> 12 years of age. |fax or mail to State STD|

| | |Because of the legal | | | |Program within 14 days. |

|Generally, RX for STDs | |implications of a diagnosis of | | | | |

|found in a pre-pubertal | |N. gonorrhoeae infection in a | | | |Report suspected cases |

|child should be managed | |child, culture is the preferred| | | |of sexual abuse to the |

|by the child’s physician.| |method. NAATs, however, can be| | | |Dept of Community Based |

|LHDs shall assure | |used for vaginal or urine | | | |Services |

|adequate RX. | |specimens from girls (only). | | | | |

|GC - PREGNANCY |SEE GC SX IN ADULTS |SEE GC TESTS IN ADULTS |Ceftriaxone 1 250 mg IM once |Azithromycin 2 g orally in a single |Sex partners exposed during|Complete EPID 200 and |

| | | |OR |dose (sufficient to treat for both GC |the previous 60 days should|fax or mail to State STD|

| | | |Cefixime 400 mg orally in a |and CT) |be examined, tested and |Program within 14 days. |

| | | |single dose3 | |preventively treated for | |

| | | | | |gonorrhea and Chlamydia on | |

| | | |PLUS |PLUS |their initial visit. They |Indicate pregnancy |

| | | | | |shall also be screened for |status on EPID 200 form.|

| | | |Adequate treatment for Chlamydial |Adequate treatment for Chlamydial |Chlamydia, syphilis and | |

| | | |infection (for pregnant women). |infection (for pregnant women). |HIV. | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Gonococcal Infections (Pages 49-55)

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|CT - ADULT |Men- |MALE & FEMALE APTIMA CT/GC COMBO 2 |Symptomatic men and women, |Erythromycin base 500 mg |Sex partners exposed during |Complete EPID 200 and fax or |

| |Urethral discharge or |(NAAT) TEST |presenting for an STD visit,|orally 4 times a day for 7 |the previous 60 days should |mail to State STD Program within|

| |dysuria; often asymptomatic.| |shall be treated empirically|days |be examined, tested and |14 days. |

| | |DLS offers this molecular test for |for both CT and GC on their |OR |preventively treated for |EPID 200’s that do not contain |

| |Women- |rectal and pharyngeal specimens. |initial visit. |Erythromycin ethylsuccinate |Chlamydia on their initial |treatment at time of initial |

| |Vaginal/cervical discharge, | | |800 mg orally 4 times a day |visit. They shall also be |report shall be updated with |

| |dysuria; often asymptomatic.| |Azithromycin 1 g orally |for 7 days |screened for gonorrhea, |treatment information and sent |

| | |Retest men and women who have been |single dose |OR |syphilis and HIV. |to state STD office 7 days after|

| | |treated for Chlamydia whenever they|OR |Ofloxacin4 300 mg orally | |RX administration |

| | |seek medical care within 3–12 |Doxycycline 100 mg orally |2 times a day for 7 days OR | | |

| | |months following treatment. |2 times a day for 7 days |Levofloxacin4 500 mg orally | |85% and 90% of patients DX w/CT |

| | | | |once a day for 7 days | |should be treated within 14 and |

| | | | | | |30 days, respectively, from the |

| | | | | | |date of lab collection. |

|CT in CHILDREN |SEE CT SX IN ADULTS ABOVE |MALE & FEMALE APTIMA CT/GC COMBO 2 |Erythromycin base or |N/A |N/A |Complete EPID 200 and fax or |

|( 12 years of age. | |

|CT IN PREGNANCY |SEE ABOVE |SEE ABOVE |Azithromycin 1 g orally |Erythromycin base 500 mg |Sex partners exposed during |Complete EPID 200 and fax or |

| | | |single dose |orally 4 times a day for 7 |the previous 60 days should |mail to State STD Program within|

| | |Repeat testing (preferably by NAAT)|OR |days OR Erythromycin 250 mg |be examined, tested and |14 days. |

| | |3 weeks after completion of therapy|Amoxicillin 500 mg orally |orally 4 times a day for 14 |preventively treated for | |

| | |is recommended for all pregnant |3 times a day for 7 days |days OR |Chlamydia on their initial |Indicate pregnancy status on |

| | |women to ensure therapeutic cure. | |Erythromycin ethylsuccinate |visit. They shall also be |EPID 200 form. |

| | | | |800 mg orally 4 times a day |screened for gonorrhea, | |

| | | | |for |syphilis and HIV. | |

| | | | |7 days OR | | |

| | | | | | | |

| | | | |Erythromycin ethylsuccinate | | |

| | | | |400 mg 4 times a day for 14 | | |

| | | | |days | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Chlamydial Infections (Pages 44-49)

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|MPC |Endocervical discharge which |APTIMA CT/GC COMBO 2(NAAT)|Symptomatic women presenting for |Azithromycin 1 gm orally in a |Sex partners exposed during the |MPC is not a reportable |

|Mucopurulent |may appear green or yellow |TEST |an STD visit, shall receive |single dose* |previous 60 days should be |condition. However if the |

|Cervicitis |when viewed on a white cotton | |empirical treatment for both CT |OR |examined and tested for gonorrhea|Chlamydia or gonorrhea test is|

| |tipped swab. | |and GC during their initial |Erythromycin 500 mg orally |and chlamydia on their initial |positive, complete the EPID |

| |Easily induced cervical | |visit. |4 times a day for 7 days |visit. They shall also be |200 form and report to state |

| |bleeding (friability, i.e. | |MPC is a clinical assessment | |screened for syphilis and HIV. |STD program within 14 days. |

| |bleeding when the first swab | |based on all or some of the | | | |

| |is placed in the endocervix). | |symptoms listed. | |Asymptomatic sex partners should | |

| | | | | |be preventively treated on their | |

| | | |Azithromycin 1 g orally single |*Consider concurrent treatment |initial visit if the original | |

| | | |dose |for gonococcal infection if |patient’s lab result is pending | |

| | | |OR |prevalence of gonorrhea is high |or positive. | |

| | | |Doxycycline 100 mg orally 2 times|in the patient population under | | |

| | | |a day for 7 days |assessment. |Symptomatic sex partners should | |

| | | | | |be empirically treated on their | |

| | | |*Consider concurrent treatment | |initial visit. | |

| | | |for gonococcal infection if | | | |

| | | |prevalence of gonorrhea is high | | | |

| | | |in the patient population under | | | |

| | | |assessment. | | | |

|MPC in PREGNANCY |SEE ABOVE |SEE ABOVE |Azithromycin 1 g orally single |Azithromycin 1 gm orally in a |SEE ABOVE |SEE ABOVE |

| | | |dose |single dose * | | |

| | | |OR |OR | | |

| | | |Amoxicillin 500 mg orally 3 times|Erythromycin 500 mg orally 4 | | |

| | | |a day for 7 days |times a day for 7 days | | |

| | | | | | | |

| | | |*Consider concurrent treatment |*Consider concurrent treatment | | |

| | | |for gonococcal infection if |for gonococcal infection if | | |

| | | |prevalence of gonorrhea is high |prevalence of gonorrhea is high | | |

| | | |in the patient population under |in the patient population under | | |

| | | |assessment. |assessment. | | |

| | | | | | | |

| | | | | | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Cervicitis (Pages 43-44)

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|NON-GONOCOCCAL URETHRITIS |Urethral Discharge |NGU is a clinical |Symptomatic men shall receive |Erythromycin base8 500 mg |All persons sexually exposed |NGU is not a reportable |

|(NGU) |(Often early a.m.) And |assessment based on |empirical treatment for both |orally 4 times a day for 7 days|within the previous 60 days |condition. However if the|

|Men |Dysuria. |symptoms. |CT and GC during their initial|OR |should be tested and |Chlamydia or gonorrhea |

| | | |visit. |Erythromycin ethylsuccinate8 |preventively treated for |test is positive, complete|

|Inflammation of the |Discharge can be |It is best supported by | |800 mg orally 4 times a day for|chlamydia and gonorrhea on their|the EPID 200 form and |

|urethra not caused by |mucopurulent, purulent or |one type of lab. Such as |Azithromycin7 1 g orally |7 days OR |initial visit. Partners shall |report to state STD |

|gonorrhea. Chlamydia |clear. |a gram stain with five |single dose OR |Ofloxacin4 300 mg orally 2 |be screened for CT, GC, syphilis|program within 14 days. |

|trachomatis has been | |(5) or more PMNs per oil |Doxycycline 100 mg orally |times a day for 7 days OR |and HIV. | |

|implicated as the cause of| |immersion field with no |2 times a day for 7 days |Levofloxacin4 500 mg orally | | |

|NGU in 15% - 55% of cases.| |evidence of gonorrhea. | |once a day for 7 days | | |

| | | |PLUS | |Empiric treatment for partners | |

| | |Submit APTIMA CT/GC | |PLUS |with a drug regimen effective | |

| | |COMBO (NAATS) test |Adequate treatment for | |against chlamydia is recommended| |

| | | |gonorrhea if gram stain is not|Adequate treatment for |for women exposed to NGU | |

| | | |available. |gonorrhea if gram stain is not |regardless of whether a specific| |

| | | | |available. |etiology is identified in the | |

| | | | | |original patient. Empiric | |

| | | | | |partner treatment for gonorrhea | |

| | | | | |may be omitted if ruled out by | |

| | | | | |Gram Stain or | |

| | | | | |NAATS testing in the original | |

| | | | | |patient. | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Nongonococcal Urethritis (Pages 41-43).

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|Epididymitis9 |Acute pain (present for less |Submit CT/GC APTIMA test.|Ceftriaxone1 250 mg IM single |Ofloxacin4 300 mg orally |All persons sexually exposed |Epididymitis is not a |

| |than 7 days) and swelling in | |dose PLUS |twice daily for 10 days |within the previous 60 days |reportable condition. |

| |area of epididymis (may also | |Doxycycline 100 mg orally |OR |should be tested and preventively|However, if the Chlamydia |

| |involve testes). | |2 times a day for 10 days |Levofloxacin4 500 mg orally |treated for Chlamydia and |or gonorrhea test is |

| |Tender swelling, infrequently | |Consult Physician or refer if: |once a day for 10 days |gonorrhea on their initial visit.|positive, complete the EPID|

| |accompanied by redness, usually| |Any patient with No. 1 and No. | |Partners shall be screened for |200 form and report to |

| |unilateral noted in the | |2 listed under symptoms who is | |CT, GC, syphilis and HIV. |state STD program within 14|

| |posterior aspect of the | |40 yrs of age or older. | | |days. |

| |scrotum. | |History of symptoms present for| | | |

| |Accompanying urethral discharge| |longer than 30 days. | | | |

| |or dysuria. | |Consider testicular torsion in | | | |

| | | |adolescent without pyuria/white| | | |

| | | |cells on urethral smear with | | | |

| | | |acute onset pain. | | | |

| | | |Note: This is a surgical | | | |

| | | |emergency. | | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Epididymitis (Pages 67-69).

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|PELVIC INFLAMMATORY DISEASE|Low abdominal pain or |Submit CT/GC APTIMA test. |REGIMEN A |REGIMEN B |Sexual contacts within the |PID, alone, is not a |

|(PID)10 |painful intercourse by | |Ceftriaxone |Ceftriaxone |previous 60 days should be |reportable condition. |

|(outpatient management) |patient’s history. |Perform stat pregnancy |250 mg IM once |250 mg IM once |evaluated and treated for |However, if the Chlamydia|

| |Low abdominal tenderness on |test (Although PID is |PLUS |OR |GC and CT during their |or gonorrhea test is |

|These regimens to be used |bimanual exam. |uncommon in pregnancy, |Doxycycline 100 mg orally 2 times a |Cefoxitin 2 g IM once plus |initial visit. Partners |positive, complete EPID |

|with or without |Adnexal tenderness or |regimens appropriate for |day for 14 days (Doxycycline is |probenecid 1 g orally once |shall also be screened for |200 form and report to |

|metronidazole 500 mg orally|adnexal mass. |PID in pregnant women may |contraindicated in pregnancy – |OR |syphilis and HIV. |state STD program within |

|twice a day for 14 days |Cervical motion tenderness |be used after |Erythromycin 500 mg 4 x daily for 14 |Other third generation | |14 days. Mark “PID” box |

| |or pain. |physician/APRN evaluation |days is appropriate for pregnant |cephalosporin | |as well as the |

| |Fever and chills |and concurrence. Patients|women) |OR | |appropriate CT and/or GC |

| |Nausea and vomiting. |should be directed for | |2 g Azithromycin | |box. |

| | |admission to a hospital) |Assessment is made by identifying | | | |

| | | |symptoms No. 3 or No. 4 or both. |PLUS | | |

| | | |If symptoms No. 3, 4, 5, 6 and/or | | | |

| | | |abdominal rebound tenderness is |Doxycycline 100 mg orally | | |

| | | |identified, treat and refer to E.R. |2 times a day for 14 days | | |

| | | |Women w/PID should be re-evaluated in | | | |

| | | |3-4 days and 10-14 days after initial | | | |

| | | |visit to re-assess symptoms and RX | | | |

| | | |tolerance. Consult with an upper | | | |

| | | |level provider. If worse, direct the | | | |

| | | |patient to a hospital of her choice. | | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Pelvic Inflammatory Disease (Pages 63-67).

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|BACTERIAL VAGINOSIS |Mild to moderate amount of |Note character of vaginal |Metronidazole11 500 mg orally 2 times a day |Tinidazole 2 g orally once daily for 2 |N/A |N/A |

|(BV) |homogeneous chalky white or |discharge |for 7 days. |days | | |

| |grey-green discharge; patient |Ensure normal appearance of |OR | | | |

| |may complain of odor. |cervix with speculum exam |Metronidazole gel 0.75% intravaginally once a|OR | | |

| |Positive whiff test: fishy |Collect discharge from lateral |day for 5 days. | | | |

| |amine odor from vaginal fluids |wall of vagina |OR |Tinidazole 1 g orally once daily for 5 | | |

| |enhanced by mixing with 10% |Determine vaginal pH |Clindamycin cream12 2% intravaginally at |days | | |

| |KOH. |Perform microscopic exam of |bedtime for 7 days | | | |

| |pH of vaginal secretion > 4.5. |discharge with 10% KOH to | |OR | | |

| |Clue cells on saline wet mount |discharge |Assessment is made by identifying 3 out of | | | |

| |of vaginal discharge |Perform amine or whiff test after|the 4 symptoms listed. |Clindamycin 300 mg orally 2 times a day| | |

| | |application of 10% KOH to | |for 7 days | | |

| | |discharge | |OR | | |

| | | | |Clindamycin ovules 100 g intravaginally| | |

| | | | |at bedtime for 3 days | | |

|BV11 AND PREGNANCY |SEE ABOVE |SEE ABOVE |Metronidazole11 500 mg orally 2 times a day |Metronidazole11 250 mg orally 3 times |N/A |N/A |

| | | |for 7 days |a day for 7 days | | |

| | | |BV in pregnancy has been associated with |OR | | |

| | | |preterm delivery. Metronidazole can be |Clindamycin 300 mg orally 2 times a | | |

| | | |given during pregnancy, but avoid repeated |day for 7 days | | |

| | | |dosing. Consult and/or direct patient to an| | | |

| | | |upper level provider if BV is suspected. | | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Bacterial Vaginosis (Pages 56-58).

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|Trichomoniasis Females |Frothy grey or yellow-green |SEE ABOVE |Metronidazole11 2 g orally single dose |Metronidazole11 500 mg orally |Advise females to have |N/A |

| |vaginal discharge | |OR |2 times a day for 7 days |partners treated. Male | |

| |Pruritus/Itching | |Tinidazole13 2 g orally single dose (not | |partners shall be screened | |

| |Cervical petechiae | |recommended in pregnancy) | |for CT, GC, syphilis and HIV.| |

| |(“strawberry-cervix”) | | | |Men exposed to Trichomoniasis| |

| | | |Usual mode of assessment is made by observation| |should be treated on their | |

| | | |of motile trichomonas in saline wet mount. | |initial visit: | |

| | | | | |Metronidazole 2 g orally In a| |

| | | |Consult and/or direct patient to an upper level| |single dose | |

| | | |provider if Trichomoniasis is suspected. | |OR | |

| | | | | |Tinidazole14 2 g orally | |

| | | | | |single dose | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Trichomoniasis (Pages 58-61).

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|Candida (Yeast) |Thick white discharge of a |SEE ABOVE |Terazol 7, 0.4% vaginal cream, 1 application full|Femstat vaginal cream 2% - |N/A |N/A |

| |cottage cheese consistency | |H.S. for 7 days |one applicator full of cream| | |

| |Itching and burning of the | |OR |intravaginally, at bedtime, | | |

| |labia and vulva | |Clotrimazole vaginal cream 1% (over the counter) |for 3 days | | |

| |Painful intercourse | |– 5 g intravaginally for 7-14 days |OR | | |

| |Burning during urination | |OR |Fluconazole 150 mg PO for | | |

| |Pelvic exam reveals cheese | |Clotrimazole vaginal cream 2% (over the counter) |1 dose (contraindicated in | | |

| |discharge in labial folds and| |– 5 g intravaginally for 3 days |pregnancy) | | |

| |at vaginal opening with | | | | | |

| |patches adhering to vaginal | |Assessment is made by observing budding yeast | | | |

| |wall and cervix | |cells or pseudo hyphae on 10% KOH exam, wet mount| | | |

| | | |or Gram stain | | | |

| | | |OR | | | |

| | | |Clinical presentation and symptoms | | | |

| | | | | | | |

| | | |Consult and/or direct patient to a higher level | | | |

| | | |provider if candida is suspected | | | |

| | | | | | | |

| | | |(If pH is abnormally high (>4.5) consider | | | |

| | | |concurrent BV or Trichomoniasis) | | | |

Centers for Disease Control and Prevention. MMWR 2010; Vol. 59/No. RR-12: Vulvovaginal Candidiasis (Pages 61-63)

|PROTOCOLS FOR TREATMENT OF COMMON SEXUALLY TRANSMITTED DISEASES (continued) |

|CONDITION |

|HPV (Genital Warts) |Pedunculated, elongated, |Screening women or men with an|EXTERNAL GENITAL WARTS |EXTERNAL GENITAL WARTS |N/A |N/A |

| |raised fleshy lesions of |HPV test, outside of the | | | | |

| |the genitalia; pink to red |recommendations for cervical |PROVIDER –APPLIED Cryotherapy with liquid nitrogen or |PATIENT-APPLIED | | |

| |in color. Large lesions |cancer screening, is not |cryoprobe. Repeat application every 1-2 weeks. |(Available w/script) | | |

| |appear in cauliflower-like |recommended. |OR |Podofilox 0.5% solution or gel14. | | |

| |masses or clusters | |Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) |Apply 2 times a day for 3 days, | | |

| |Usually painless, unless |Assessment of genital warts is|80% -90%. Apply small amount only to warts. Allow to dry.|followed by 4 days of no therapy. | | |

| |there is irritation from |made by visual inspection. |Repeat weekly if necessary |This cycle can be repeated as | | |

| |friction or secondary |HPV may be confirmed by |OR |necessary for up to 4 times. Total | | |

| |infection |biopsy, but needed only under |Podophyllin resin 10%-25%14 in a compound tincture of |wart area should not exceed 10 cm2 | | |

| | |certain circumstances |benzoin. Allow to air dry. Limit application to ................
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