Alberta Health Services STI Blue Book PDF

GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES GON...

GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES The Blue Book Standards GONORHEA CHLAMYDIA NGU MPC HIV HPV for the Management and SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS Evaluation of STI Clinic PUBIC LICE HERPES GONORHEA CHLAMYDIA Clients NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS TRICHOMONIASIS PUBIC LICE HERPES GONORHEA CHLAMYDIA NGU MPC HIV HPV SYPHILIS YEAST SCABIES BACTERIAL VAGINOSIS Last Revised: November 2022 1 TRICHOMONIASIS PUBIC LICE HERPES GONORHEA CHLAMYDIA NGU MPC HIV HPV YEAST pSYPHILIS YEAST Contents Acknowledgements......................................................................................................8 Members of the committee were:............................................................................................................................9 Committee Reports to:..................................................................................................................................................9 Summary of Changes (Updates/Revisions) since April 2019.............................. 11 Notification of Sexually Transmitted Infections (STI) and Treatment................. 13 Notifiable Disease Management Guidelines........................................................... 14 Consent....................................................................................................................... 15 Overview........................................................................................................................................................................... 15 Most Responsible Health Practitioner................................................................................................................ 16 Implied Consent............................................................................................................................................................ 16 Minors / Mature Minors.............................................................................................................................................. 16 Assessment of Mature Minors............................................................................................................................... 17 Documentation of Assessment............................................................................................................................. 18 Consent via an Interpreter / Telephone / Fax................................................................................................ 18 Blood and Blood Products: Consent Policy:................................................................................................... 18 I. History...................................................................................................................... 19 A. Chief Complaint....................................................................................................................................................... 19 B. Functional Inquiry................................................................................................................................................... 19 1. Male..............................................................................................................................................................................19 2. Female.........................................................................................................................................................................20 C. Drug/Other Allergy................................................................................................................................................. 20 D. Concomitant Medication..................................................................................................................................... 20 E. Past History............................................................................................................................................................... 20 F. Social History............................................................................................................................................................ 21 G. Sexual History......................................................................................................................................................... 22 H. Identifying Vulnerable or At Risk Clients.................................................................................................... 22 II. Physical Examination............................................................................................ 24 A. Environment and Equipment............................................................................................................................ 24 B. Psychological Assessment................................................................................................................................ 24 C. General Outline....................................................................................................................................................... 24 D. Specific Examination............................................................................................................................................ 25 1. Mouth and Throat.......................................................................................................................................................25 2. Skin and Pubic Hair..................................................................................................................................................25 3. Lymphadenopathy.....................................................................................................................................................25 4. Male....................................................................................................................................................................................25 5. Female..............................................................................................................................................................................26 6. Surgically Constructed Sex Organs (see section XV. Caring for the Trans, Non- Binary and Two-Spirit Client)....................................................................................................................................27 III. Routine STI Testing.............................................................................................. 28 A. Male............................................................................................................................................................................... 28 B. Female......................................................................................................................................................................... 29 C. Transgender Males and Females (see section XV Caring for the Trans, Non-Binary and Two-Spirit Client).......................................................................................................................................................... 31 2 IV. Laboratory Procedures (Specimen Collection)................................................ 32 A. Venous Blood Specimen.................................................................................................................................... 32 B. Urethral Specimen................................................................................................................................................. 32 1. Urethra of people with a penis for Gram Stain.........................................................................................32 2. Urethra for culture of Neisseria gonorrhea or herpes simplex virus PCR...............................33 3. Urine for NAAT testing of Neisseria gonorrhea and Chlamydia trachomatis (Aptima® Urine Specimen Collection Guide)........................................................................................................................34 C. Endocervix Specimen.......................................................................................................................................... 35 1. Endocervix for culture of Neisseria gonorrhea and herpes simplex virus PCR...................35 2. Endocervix for NAAT testing of Neisseria gonorrhea and Chlamydia trachomatis (Aptima® Swab Specimen Collection Guide).................................................................................................36 3. Endocervix for Cervical Cancer Screening (Papanicolaou) Test.................................................37 D. Vaginal Swab........................................................................................................................................................... 40 1. Vaginal swab for wet mount and/or gram stain.......................................................................................40 2. Vaginal swab for culture.........................................................................................................................................40 3. Vaginal swab for NAAT testing of Neisseria gonorrhea and Chlamydia trachomatis (Aptima® Multitest Swab Specimen Collection Guide)............................................................................41 4. Rectum for culture/NAAT of Neisseria gonorrhoea and Chlamydia trachomatis...............42 E. Throat for culture/NAAT of Neisseria gonorrhoea................................................................................. 43 F. Eyes for culture/NAAT of Neisseria gonorrhea, Chlamydia trachomatis, and herpes simplex virus................................................................................................................................................................... 44 G. Lesions........................................................................................................................................................................ 45 1. Direct testing for Herpes Simplex virus and Syphilis PCR testing...............................................45 2. Haemophilus ducreyi (Chancroid) PCR Testing.....................................................................................46 3. Lymphogranuloma Venereum (LGV) Specimen Collection for Laboratory Testing or Arranging confirmation of Chlamydia trachomatis L1-L3........................................................................46 H. Inoculation of Culture Media/Agar Plate for Neisseria gonorrhea................................................. 47 I. Urinalysis and Urine Culture & Sensitivity................................................................................................... 50 V. Microscopy............................................................................................................. 51 A. Kohler Illumination................................................................................................................................................. 51 B. Gram Stain................................................................................................................................................................. 52 C. Use of Oil Immersion Lens................................................................................................................................ 52 D. Wet Mount Preparation (Candida albicans, Clue Cells and Trichomonas vaginalis).......... 53 E. KOH Preparation and Whiff Test for Bacterial Vaginosis................................................................... 53 F. Darkfield Microscopy/Fluorescent Antibody (FA) for T. pallidum................................................... 54 VI. Genital Ulcer Disease - Approach to Assessment and Management............ 55 A. Differential Diagnosis........................................................................................................................................... 55 B. Introduction................................................................................................................................................................ 55 C. Clinical Assessment.............................................................................................................................................. 56 1. History...............................................................................................................................................................................56 D. Examination.............................................................................................................................................................. 56 1. Ulcer...................................................................................................................................................................................56 2. Lymph nodes................................................................................................................................................................56 3. Other clinical findings...............................................................................................................................................56 E. Testing......................................................................................................................................................................... 56 F. Diagnosis of Genital Ulcer Disease (see genital ulcer algorithm).................................................. 57 1. Syphilis.............................................................................................................................................................................57 2. Herpes Simplex Virus (HSV)...............................................................................................................................59 3  3. Chancroid (Haemophilus ducreyi)..................................................................................................................60 4. Lymphogranuloma venereum (LGV)..............................................................................................................60 G. Treatment of Genital Ulcer Disease............................................................................................................. 61 1. Syphilis.............................................................................................................................................................................61 2. Genital Herpes.............................................................................................................................................................64 3. Chancroid........................................................................................................................................................................65 4. Lymphogranuloma Venereum (LGV).............................................................................................................65 H. Client Follow –Up................................................................................................................................................... 66 1. Syphilis.............................................................................................................................................................................66 2. HSV.....................................................................................................................................................................................66 3. Chancroid........................................................................................................................................................................67 4. LGV.....................................................................................................................................................................................67 I. Contact Management............................................................................................................................................. 67 1. Syphilis.............................................................................................................................................................................67 2. HSV.....................................................................................................................................................................................68 3. Chancroid........................................................................................................................................................................68 4. LGV.....................................................................................................................................................................................68 J. Genital Ulcer Disease – Algorithm................................................................................................................. 69 VII. Urethritis............................................................................................................... 70 A. Introduction................................................................................................................................................................ 70 B. Clinical Assessment.............................................................................................................................................. 70 C. Testing (see Urethritis algorithm)................................................................................................................... 70 D. Diagnosis.................................................................................................................................................................... 71 1. Non-Gonococcal Urethritis...................................................................................................................................71 2. Chlamydia Urethritis.................................................................................................................................................71 3. Gonorrhea Urethritis.................................................................................................................................................71 E. Treatment................................................................................................................................................................... 72 1. Non-gonococcal Urethritis....................................................................................................................................72 2. Chlamydia.......................................................................................................................................................................74 3. Gonorrhea.......................................................................................................................................................................75 F. Non-gonococcal Urethritis (NGU) Treatment Failure.......................................................................... 77 G. Chlamydia Treatment Failure (urogenital, pharyngeal, rectum)..................................................... 78 H. Gonorrhea Treatment Failure (urogenital, pharyngeal, rectum)..................................................... 78 I. Client Follow-Up........................................................................................................................................................ 79 1. Non-Gonococcal Urethritis (NGU)...................................................................................................................79 2. Chlamydia Urethritis.................................................................................................................................................79 3. Gonorrhea Urethritis.................................................................................................................................................80 J. Contact Management............................................................................................................................................ 81 1. Non-Gonococcal Urethritis (NGU)...................................................................................................................81 2. Chlamydia.......................................................................................................................................................................81 3. Gonorrhea.......................................................................................................................................................................81 K. Urethritis – Algorithm............................................................................................................................................ 82 VIII. Epididymo-orchitis............................................................................................. 83 A. Introduction................................................................................................................................................................ 83 B. Clinical Assessment.............................................................................................................................................. 83 C. Testing......................................................................................................................................................................... 83 D. Diagnosis.................................................................................................................................................................... 83 E. Testicular Pain/Swelling – Algorithm............................................................................................................ 84 4 F. Treatment................................................................................................................................................................... 85 G. Client Follow-Up..................................................................................................................................................... 86 H. Contact Management........................................................................................................................................... 86 IX. Vaginal Discharge – Cervicitis and Vaginitis.................................................... 87 I. Cervicitis....................................................................................................................................................................... 87 A. Introduction....................................................................................................................................................................87 B. Clinical Assessment.................................................................................................................................................87 C. Testing.............................................................................................................................................................................87 D. Diagnosis (See Cervicitis algorithm).............................................................................................................88 E. Treatment.......................................................................................................................................................................90 F. Chlamydia Treatment Failure (Urogenital, pharyngeal, rectum)...................................................97 G. Gonorrhea Treatment Failure (Urogenital, pharyngeal, rectum).................................................98 H. Client Follow-Up.........................................................................................................................................................99 I. Contact Management............................................................................................................................................. 101 J. Cervicitis Algorithm................................................................................................................................................. 103 II. Vaginitis.................................................................................................................................................................... 104 A. Introduction................................................................................................................................................................. 104 B. Clinical Assessment.............................................................................................................................................. 104 C. Testing.......................................................................................................................................................................... 104 D. Diagnosis (see Vaginal Discharge algorithm)....................................................................................... 104 E. Treatment.................................................................................................................................................................... 105 F. Client Follow-Up...................................................................................................................................................... 109 G. Contact Management.......................................................................................................................................... 109 H. Vaginal Discharge - Algorithm........................................................................................................................ 110 X. Lumps and Bumps.............................................................................................. 111 A. Differential Diagnosis........................................................................................................................................ 111 B. Introduction............................................................................................................................................................. 111 C. Clinical Assessment........................................................................................................................................... 111 D. Testing...................................................................................................................................................................... 111 E. Diagnosis................................................................................................................................................................. 111 F. Treatment................................................................................................................................................................ 112 1. Visible EGW only (excluding vagina, cervix, intraurethral, or oral warts)............................. 112 2. Molluscum contagiosum..................................................................................................................................... 113 G. Counselling............................................................................................................................................................ 113 1. EGW/HPV.................................................................................................................................................................... 113 2. Molluscum contagiosum..................................................................................................................................... 115 H. Client Follow-up................................................................................................................................................... 116 1. EGW/HPV.................................................................................................................................................................... 116 2. Molluscum contagiosum..................................................................................................................................... 116 I. Contact Management.......................................................................................................................................... 116 1. EGW/HPV.................................................................................................................................................................... 116 2. Molluscum contagiosum..................................................................................................................................... 117 XI. Hepatitis............................................................................................................... 118 A. Introduction............................................................................................................................................................. 118 B. Clinical Assessment........................................................................................................................................... 118 C. Testing...................................................................................................................................................................... 118 1. Screening for Hepatitis A (anti-HAV IgG antibody)............................................................................ 118 2. Screening for Hepatitis B (HBsAb, HBsAg, Anti-HBc)..................................................................... 119 5  3. Screening for HCV (anti-HCV antibody)................................................................................................... 119 D. Client Follow-up................................................................................................................................................... 119 1. Hepatitis A (anti-HAV IgG antibody)............................................................................................................ 119 2. Hepatitis B (HBsAG, HBsAb, Anti-HBc).................................................................................................... 120 3. Hepatitis C (Anti-HCV antibody and HCV RNA).................................................................................. 121 E. Counselling............................................................................................................................................................. 121 F. Contact Management........................................................................................................................................ 121 XII. Human Immunodeficiency (HIV)...................................................................... 122 A. Introduction............................................................................................................................................................. 122 B. Clinical Assessment........................................................................................................................................... 122 C. Diagnosis/Further Management.................................................................................................................. 122 D. HIV diagnostic algorithm.................................................................................................................................. 123 E. Counselling............................................................................................................................................................. 124 1. Pre-test Counselling:............................................................................................................................................. 124 2. Post-test Counselling:.......................................................................................................................................... 124 F. Reporting................................................................................................................................................................. 126 G. Partner Notification............................................................................................................................................ 126 XIII. Infestations........................................................................................................ 127 A. Introduction............................................................................................................................................................. 127 B. Clinical Assessment........................................................................................................................................... 127 C. Testing...................................................................................................................................................................... 127 D. Diagnosis................................................................................................................................................................. 127 E. Treatment................................................................................................................................................................ 128 1. Pubic Lice.................................................................................................................................................................... 128 2. Scabies.......................................................................................................................................................................... 128 F. Client Follow-up.................................................................................................................................................... 129 G. Contact Management....................................................................................................................................... 129 1. Pubic Lice.................................................................................................................................................................... 129 2. Scabies.......................................................................................................................................................................... 129 XIV. Sexual Assault/Abuse...................................................................................... 130 A. Introduction............................................................................................................................................................. 130 B. Initial Management............................................................................................................................................. 130 1. Management of Sexual Assault/Abuse in Children (< 18 years)............................................... 130 2. Management of Sexual Assault/Abuse in Adults................................................................................. 131 C. Further Management of Sexual Assault/Abuse................................................................................... 132 1. History............................................................................................................................................................................ 132 2. Physical Examination............................................................................................................................................ 132 3. Laboratory Tests...................................................................................................................................................... 132 4. Treatment/Post-Exposure Prophylaxis (Non-Pregnant Adults).................................................. 132 5. Other Management................................................................................................................................................ 133 D. Follow-up................................................................................................................................................................. 133 E. Contact Tracing.................................................................................................................................................... 134 XV. Caring For the Transgender, Non-Binary and Two-Spirit Client................ 135 A. Introduction............................................................................................................................................................. 135 1. Inclusive Language and Communication................................................................................................. 135 2. Definitions.................................................................................................................................................................... 136 B. Clinical Assessment........................................................................................................................................... 137 6 C. Gender-affirming Surgeries............................................................................................................................ 137 Creating a vagina.......................................................................................................................................................... 137 Creating a penis............................................................................................................................................................. 138 D. Examination and Testing................................................................................................................................. 138 1. Men and non-binary persons with vaginas.............................................................................................. 139 2. Women and non-binary persons with penises...................................................................................... 139 3. Lab Requisitions...................................................................................................................................................... 139 4. Neovaginas................................................................................................................................................................. 140 5. Neopenises............................................................................................................................................................... 140 E. Treatment and Screening Guidelines....................................................................................................... 141 F. Counselling and Referrals............................................................................................................................... 141 XVI. Partner Notification.......................................................................................... 143 A. Types of Partner Notifications....................................................................................................................... 143 1. Health provider referral or active partner notification:....................................................................... 143 2. Combined or conditional referral:.................................................................................................................. 143 3. Client referral or passive contact tracing:................................................................................................. 143 B. Methods of Partner Notification.................................................................................................................... 144 1. Health Provider/active partner notification and conditional referral:........................................ 144 2. Client referral or passive partner notification......................................................................................... 144 C. Standardized Interview Periods For Obtaining Contact Information......................................... 145 XVII. Client Education/Counselling........................................................................ 146 A. The Information, Motivation, and Behavioural (IMB) Skills Model.............................................. 146 B. Common Counselling Topics........................................................................................................................ 147 C. STI Prevention/Safer Sex Counselling..................................................................................................... 148 XVIII. Accepted Abbreviations for Charting.......................................................... 149 XIX. Charting Guidelines......................................................................................... 150 A. Suggested Admission Information.............................................................................................................. 150 B. History....................................................................................................................................................................... 150 1. Chief complaint......................................................................................................................................................... 150 2. Functional Inquiry.................................................................................................................................................... 150 3. Sexual history............................................................................................................................................................ 150 4. Past history................................................................................................................................................................. 151 C. On Examination................................................................................................................................................... 151 D. Impression.............................................................................................................................................................. 151 E. Plan/Education...................................................................................................................................................... 152 F. Laboratory Examinations................................................................................................................................. 152 G. Treatment................................................................................................................................................................ 152 H. Sign-Off.................................................................................................................................................................... 152 I. Follow Up Visits...................................................................................................................................................... 152 Appendix 1: Nursing Guidelines............................................................................ 153 1. Liquid Nitrogen Cryotherapy for the Treatment of External Genital Warts and Molluscum Contagiosum....................................................................................................................................... 153 2. Vyloma (Imiquimod) 3.75% Cream for the Treatment of External Genital Warts................ 155 3. Emergency Contraceptive Pill (ECP)......................................................................................................... 157 4. Over the Counter Medication......................................................................................................................... 160 3. Patient Delivered Partner Therapy (PDPT)............................................................................................ 161 7 Appendix 2: Treatment Algorithms........................................................................ 163 1. Chlamydia Treatment Failure/Relapse..................................................................................................... 163 2. NGU/MPC or Contact to CT/NGU/MPC.............................................................................................. 164 3. NGU Treatment Failure/Relapse............................................................................................................ 165 4. Gonorrhea Positive or Contact to Gonorrhea................................................................................... 166 5. Gonorrhea Treatment Failure/Relapse................................................................................................ 167 6. Contact to PID or Epididymo-orchitis.................................................................................................... 168 8 Acknowledgements A committee of provincial sexually transmitted disease representatives convened by Alberta Health Services (AHS) prepared this manual. Thanks are extended to the members of the STI Blue Book Working Group and the staff of the Alberta Provincial Laboratory for Public Health for their expertise and time to provide input and feedback in the development of the document. Special thanks extended to Tammy Troute-Wood and Marni Panas for their expert review of the Caring For the Trans, Non-Binary and Two-Spirit Client chapter. Members of the committee were: Marla Dane (Chair) Clinical Instructor, Calgary STI Clinic, AHS Lindsay Rathjen Director, Provincial STI Programs, AHS Jennifer Gratrix Manager, STI Centralized Services, AHS Logan Chinski Manager, Calgary STI Clinic, AHS Alyshah Lalany/Kaitlin Trimble (Chair) Clinical Instructor, Edmonton STI Clinic, AHS Michelle Fudge STI Clinic RN, Fort McMurray STI Clinic, AHS Shannon Schreyer Associate Manager, Fort McMurray STI Clinic, AHS Garret Meyer Manager, Edmonton STI Clinic, AHS Dr. Angel Chu Medical Director, Calgary STI Clinic, AHS Dr. Petra Smyczek Medical Director, Provincial STI Services, AHS Committee Reports to: Cindy Dribnenki Director, Population, Public & Indigenous Health, AHS 9 Important Considerations for Users of this Manual This manual is intended solely for use by Registered Nurses (RN) working in the Alberta Health Services (AHS) Edmonton, Calgary and Fort McMurray Sexually Transmitted Infection (STI) clinics, with approval and supervision by the designated physician for each of these clinics. This manual may be used as a resource to others developing their own STI clinical practice guidelines. Practice guidelines need to be drafted and tailored to reflect the scope of practice of each unique clinical practice environment. The standards set out in this manual were developed by the Blue Book Working Group. In keeping with the College and Association of Registered Nurses of Alberta’s Medication Administration Guidelines, the development of this manual has been a collaborative process involving a multidisciplinary team. The goal of the working group is to draw on the expertise of STI physicians, STI managers and STI clinical nursing educators to develop an updated manual that reflects the emerging issues and incorporates current evidence-based practice. It also draws from the Canadian Guidelines on Sexually Transmitted Infections. Numerous updates to the Blue Book have been written since 1986 to set standards of practice for the STI clinics in Alberta. The manual includes the minimum history, physical exam and laboratory examination to be performed on clients at each clinic visit within the scope of the RN practicing in these STI clinics. Procedures for physical examination, obtaining the specimens, protocols for client management, treatment schedules and charting standards are included. This manual replaces all previously printed materials and treatment regimens and is current as of the publication date. Updates to this manual will be made as new evidence emerges. It is recommended that the users of this manual ensure that they are utilizing the most current version of this blue book (most recent version will be posted on the Alberta Health Services external website: https://www.albertahealthservices.ca/info/page1730.aspx ) We are disseminating this document to clinical and Public Health professionals for informational purposes only. Adoption of these standards outside of the scope of clinical practice of STI clinics highlighted here is the sole responsibility of the individual(s) using the manual and must be tailored to the specific clinical environment. 10 Summary of Changes (Updates/Revisions) since April 2019 Chapter: Title Subsection: Title Page Update/Revision III. Routine STI Added contraindications for speculum examination. B. Female 30 Testing IV. Laboratory Urinalysis and C&S lab procedure added 50 Procedures F. Diagnosis of Adjusted serology intervals for ruling out BFP Genital Ulcer Disease 1. Syphilis Instruct client to abstain from sexual contact for 7 days following treatment or until after treatment with 58, G. Treatment of doxycycline. VI. Genital Ulcer 61, Genital Ulcer Disease 63, Disease Fetal monitoring in pregnancy for Bicillin treatment over 65, 1. Syphilis 20 weeks gestation clarified. 67 Pregnant Adults Added abstinence guidelines. H. Client Follow-up 4. LGV Adjusted timing of TOC. Updated Managing Penicillin-Allergic Patients: Penicillin-allergic clients receiving treatment with cephalosporins must be counseled regarding the 6 months ago if deemed likely to return for follow up. Syphilis: Primary, Secondary, Early Latent (< 1 year duration): Recommended Regimen: Benzathine penicillin 2.4 mu IM as a single dose Alternate: (Penicillin anaphylactic clients) Doxycycline 100 mg PO BID for 14 days Late Latent (> 1 year or unknown duration or cardiovascular): *Clients with neurological and/or cardiovascular symptoms require consult with clinic physician. Recommended Regimen: Benzathine penicillin 2.4 mu IM weekly for 3 consecutive weeks Alternate: (Penicillin anaphylactic clients) Doxycycline 100 mg PO BID for 28 days Note: 10% of patients report a penicillin allergy however 20 weeks gestation, or gestational age uncertain must be managed in consultation with the clinic physician. The clinic physician may arrange for a detailed fetal ultrasound and manage the client together with a materno-fetal specialist. Routine obstetric ultrasound may be necessary prior to detailed ultrasound. Treatment of infectious syphilis in pregnancy may precipitate a Jarisch-Herxheimer reaction which may cause fetal distress or premature labour. Clients >20 weeks gestation may require fetal monitoring (arranged by the clinic physician) for 12-24 hours after administration of benzathine penicillin. In situations where fetal monitoring is unavailable and/or not deemed necessary by clinic physician, the client will be advised that if they experience any changes (cramping, bleeding, change in fetal movement) and/or labour following the injections, to proceed immediately to the hospital. There is no satisfactory alternative to penicillin in pregnancy, those with allergies should be considered for desensitization followed by treatment with benzathine penicillin. Doxycycline is not recommended for use during pregnancy. Primary, Secondary, Early Latent (1 year duration or unknown duration or cardiovascular): Recommended Regimen: Benzathine penicillin 2.4 mu IM weekly for 3 consecutive weeks 63 All Adults Neurosyphilis (treatment not provided by STI Clinics) Recommended Regimen: Crystalline penicillin G 4 mu IV q4h for 10-14 days Considerations: CSF examinations for cell count and differential, protein, glucose and VDRL is recommended to establish a diagnosis of neurosyphilis and is indicated in all clients with neurologic or eye/ear symptoms or signs, and clients meeting other criteria. 2. Genital Herpes Primary Episode: Recommended Regimen: Valacyclovir 1g PO BID for 10 days Alternate: Acyclovir 400 mg PO TID for 7-10 days OR Famcyclovir 250 mg PO TID for 5 days Note: Duration of therapy depends on severity of outbreak. Recurrent Lesions: Episodic Therapy: Recommended Regimen: Valacyclovir 500mg PO BID for 3 days OR Valacyclovir 1gm PO QD for 3 days Alternate: Acyclovir 800 mg po TID for 2 days OR Famciclovir 125 mg PO BID for 5 days 64 Suppressive Therapy: Non Pregnant: Recommended Regimen: Valacyclovir 500 mg PO QD (for clients with  9 recurrences per year) OR Valacyclovir 500 mg PO BID or 1 g PO QD (for clients with >9 recurrences per year) Alternate: Acyclovir 400 mg PO BID OR Famciclovir 250 mg PO BID Suppressive Therapy: Pregnant: Recommended Regimen: Valacyclovir 500 mg PO BID at 36 weeks with termination at parturition Alternate: Acyclovir 400 mg PO TID at 36 weeks with termination at parturition Note: Individual clinics will provide episodic and suppressive therapy as per their own protocols. Consult clinic physician on all pregnant clients presenting with apparent first episode. 3. Chancroid Recommended Regimen: Azithromycin 1 g PO single dose Alternate: Ceftriaxone 250 mg IM single dose OR Ciprofloxacin 500 mg PO bid x 3 days 4. Lymphogranuloma Venereum (LGV) Consult clinic physician prior to treatment. Recommended Regimen: Doxycycline 100 mg PO bid for 21 days Alternate: Azithromycin 1 g PO once weekly for 3 weeks Note: Advise client to abstain from sexual contact for duration of treatment regimen. 65 H. Client Follow –Up 1. Syphilis Primary, Secondary, Early Latent Syphilis ▪ Recall at 1, 3, 6, and 12 months for follow-up syphilis serology; this can be terminated if client seroreverts (i.e. – RPR non-reactive) ▪ If treated with oral therapy contact in two weeks to determine adherence to regimen. ▪ Test for HIV at 1 and 3 months Late Latent Syphilis ▪ Repeat syphilis serology will be based on physician recommendation. If not specified should be done at 12 and 24 months unless RPR non-reactive. ▪ If treated with oral therapy, contact in 4 weeks to determine adherence to regimen ▪ If drugs lost or did not adhere to treatment, additional or alternate therapies may be provided in consultation with clinic physician Presumptive (with non-reactive serology) ▪ If treated with benzathine penicillin, no follow-up needed HIV clients (any stage) ▪ Follow-up syphilis serology at 1, 3, 6, 12 and 24 months and yearly thereafter Neurosyphilis ▪ Follow-up as per clinic physician Adequate Serologic Response ▪ Primary: 4 fold drop at 6 months, 8-fold drop at 12 months, 16-fold drop at 24 months ▪ Secondary: 8-fold drop at 6 months and 16-fold drop at 12 months ▪ Early Latent: 4-fold drop at 12 months Note: A four-fold drop = 2-tube drop (e.g., change from 1:32 dilutions to 1:8 dilutions) 2. HSV ▪ Clinic physician should be consulted on immuno-compromised clients with HSV and pregnant clients with apparent first episode. ▪ Recall for speculum exam and additional STI testing if this was not possible at initial visit. ▪ Clients should be counselled that they are potentially infectious and that condoms do not provide 100% protection ▪ Clients should be counselled about asymptomatic viral shedding between outbreaks 66  ▪ Advise clients that antiviral therapy for recurrent episodes may shorten the duration of lesions and suppressive antiviral therapy can ameliorate or prevent recurrent outbreaks and reduce transmission to partners by 50%. 3. Chancroid ▪ Recall in 1 week for reassessment and re-interviewing. Ensure that lesion(s) and lymphadenopathy have resolved. 4. LGV ▪ Recall for TOC 3 weeks following completion of treatment for all sites. ▪ Note: TOC Test Type Recommendations: NAAT: all sites ▪ For non-genital sites, test of cure is done from site of positive infection (rectal, pharyngeal, eye). ▪ Re-screening of all individuals diagnosed with chlamydia is recommended after 6 months. ▪ If vomiting occurs > 1 hour post administration of azithromycin, a repeat dose is not required. ▪ If client does not return to clinic for TOC, efforts should be made to contact client to arrange for TOC to ensure adequate follow up. I. Contact Management 1. Syphilis Primary, Secondary, and Early Latent Syphilis ▪ Interview for contacts for 12 months prior to onset of symptoms or date of specimen collection if asymptomatic ▪ Contacts should be tested and treated presumptively ▪ If contact refuses treatment, repeat STS monthly until 3 months have elapsed following last contact with infected person. Late Latent Syphilis ▪ STS performed on sexual partners of long duration and on children of infected persons with a vagina. 67 Presumptive ▪ Clients treated presumptively or as contacts to confirmed infectious syphilis (Primary, Secondary, or Early latent) should be interviewed for contacts and follow up of contacts would only be initiated on confirmation of infectious syphilis. 2. HSV ▪ Client is counselled around informing sexual partners of their risk and encouraging them to seek counselling, assessment and treatment as needed. ▪ Client must be counselled that condoms may not be 100% protective and that asymptomatic viral shedding can occur between outbreaks. 3. Chancroid ▪ Contacts of clients with chancroid should be examined and treated for chancroid regardless of presence or absence of symptoms, if their contact was within 10 days of onset of symptoms in the infected person 4. LGV Definitive Diagnosis ▪ All contacts in last 2 months, regardless of symptoms or signs, must be located, examined, tested and treated. It may be necessary to extend this time period until a sexual contact is identified. Presumptive Diagnosis ▪ Obtain contact information as above and follow up with the contact only if laboratory test confirms infection. Recommended Regimen: Doxycycline 100 mg PO bid for 7 days OR Azithromycin 1 g PO in a single dose Note: Should test results confirm an LGV infection, treat as recommended for confirmed cases. 68 J. Genital Ulcer Disease – Algorithm Genital Ulcer Disease Vesicular, ulcerative, erosive, or pustular genital lesions +/- regional lyphadenopathy Minimum testing includes: Syphilis serology HIV serology Swab of lesion for both: -Herpes Simplex Virus (HSV) PCR -Syphilis PCR Darkfield/FA for T.Pallidum (if appropriate lesion) Negative HSV and Syphilis tests: HSV suspected and/or positive Syphilis suspected and/or HSV test: positive syphilis test(s): Repeat syphilis serology in 4 weeks See management of Herpes See Management of syphilis If lesion persists: -Consider testing for H.Ducreyi and/ or LGV -Consult with clinic physician 69 VII. Urethritis A. Introduction Urethritis consists of the clinical symptoms and signs associated with an inflammatory process in the urethra, including urethral discharge and/or dysuria. Urethritis must be distinguished clinically from cystitis (bladder infection), which is most often associated with urinary frequency and a sense of urgency to urinate. Conversely, a client may have urethral infection and have no associated symptoms, emphasizing the importance of screening for urethral infection in at-risk clients. Clients with untreated urethritis are at risk for the development of epididymo-orchitis. The microbiologic etiology of urethritis includes: ▪ Chlamydia trachomatis ▪ Neisseria gonorrhoea ▪ genital mycoplasmas, Ureaplasma urealyticum ▪ Trichomonas vaginalis ▪ herpes simplex virus B. Clinical Assessment In addition to the general STI assessment, clients with symptoms or suspicion for urethritis should have the following information collected: ▪ Presence and quality of urethral discharge ▪ Presence of regional (inguinal) lymphadenopathy ▪ Travel history ▪ Sexual contacts in period prior to onset of symptoms ▪ Associated features – rash, joint symptoms, conjunctivitis The clinical examination in a client with urethral symptoms, or who is suspected of having urethritis should include: ▪ Examination of the urethral meatus for evidence of inflammation or discharge. ▪ Examination of the shaft of the penis for lumps ▪ Examination of the inguinal area for lymph nodes ▪ Scrotal examination to exclude epididymal or testicular swelling and tenderness, suggestive of epididymo-orchitis or the presence of scrotal masses. C. Testing (see Urethritis algorithm) Testing of clients with suspicion of urethritis should include: ▪ Urethral smear ▪ Urethral swab for gonorrhea culture ▪ Urine sample for chlamydia and gonorrhea NAAT 70 D. Diagnosis 1. Non-Gonococcal Urethritis Definitive Diagnosis ▪ Urethral discharge +/- dysuria plus urethral smear with >5 polymorphonuclear leukocytes (PMN)/high power fields (HPF) in 5 or more fields, but no gram-negative intracellular diplococci seen 2. Chlamydia Urethritis Definitive Diagnosis ▪ Positive urine NAAT or urethral culture for chlamydia Presumptive Diagnosis ▪ Contacts of persons with positive chlamydia laboratory test ▪ Contacts of persons with mucopurulent cervicitis, PID, and/or NGU Note: To screen for reinfection it is recommended that all clients with a diagnosis of chlamydia are recommended to be retested for chlamydia in 6 months. 3. Gonorrhea Urethritis Definitive Diagnosis ▪ Gram negative intracellular diplococci on urethral smear ▪ Positive urethral culture or urine NAAT for gonorrhea Presumptive Diagnosis ▪ Sexual contact to client with laboratory confirmed gonorrhoea ▪ Sexual contact to persons with PID ▪ Sexual contact to MPC or NGU (where no gonorrhea result is available on index case) Note: To screen for reinfection it is recommended that all clients with a diagnosis of gonorrhea are recommended to be retested for gonorrhea in 6 months. 71 E. Treatment 1. Non-gonococcal Urethritis *Always perform swab(s) for GC culture prior to treatment MSM: Recommended Regimen: Azithromycin 1 gm PO as a single dose PLUS Ceftriaxone 250 mg IM as a single dose Alternate: Azithromycin 1 gm PO as a single dose PLUS Cefixime 800 mg PO as a single dose OR (not recommended in pregnancy) Azithromycin 2 gm PO as a single dose PLUS *Gentamicin 240mg IM in 2 separate 3ml injections OR (not recommended in pregnancy) Azithromycin 2 gm PO as a single dose PLUS Gemifloxacin 320 mg PO in a single dose (not yet available in Canada) Heterosexual: Recommended Regimen: Azithromycin 1 gm PO as a single dose PLUS Cefixime 800 mg PO as a single dose Alternate: Azithromycin 1 gm PO as a single dose PLUS Ceftriaxone 250 mg IM as a single dose OR Azithromycin 2 gm PO as a single dose PLUS *Gentamicin 240mg IM in 2 separate 3ml injections OR Azithromycin 2 gm PO as a single dose PLUS Gemifloxacin 320 mg PO in a single dose (not yet available in Canada) 72 Considerations: ▪ Advise client no sexual contact for 1 week following treatment is recommended. At a minimum, no unprotected sexual contact for 1 week following treatment is advised. ▪ Use of alternate medication regimens should be in consultation with clinic physician. ▪ *Due to concerns with renal and ototoxicity, physician should be consulted prior to all gentamicin treatments. ▪ Managing Penicillin-Allergic Clients: Note: 10% of patients report a penicillin allergy however