Chapter 87: Sexually Transmitted Infections

INTRODUCTION

This chapter covers some of the major sexually transmitted infections that are commonly found in the United States, with the exception of human immunodeficiency virus (HIV), which is discussed in Chapter 92. Vaginitis and pelvic inflammatory disease (PID) are covered separately in Chapters 63 and 64.

GENERAL RECOMMENDATIONS

Sexually transmitted infections are a major public health problem, and emergency medicine providers are commonly called upon to identify, treat, and recommend appropriate follow-up for these conditions. Complications from such infections may contribute to infertility, cancer, or urogenital complications. Due to issues with compliance and the challenge of obtaining consistent follow-up care in some communities, single-dose antibiotic treatment regimens are recommended, when possible. Several of these infections frequently occur together, and providers should consider additional screening for coexisting infections such as HIV, syphilis, and hepatitis. Test for pregnancy, advise treatment of all recent sexual partners, and counsel patients about the appropriate time frame for resuming sexual contact. Treatment regimens listed here are for adult patients who are not pregnant. Updated treatment recommendations are available on the Centers for Disease Control and Prevention (CDC) website (www.cdc.gov) and include specific guidelines for the treatment of children and pregnant patients. The most recent full publication with treatment guidelines for sexually transmitted infections was issued by the CDC in 2010 and is available at https://www.cdc.gov/std/treatment/2010/default.htm.

CHLAMYDIAL INFECTIONS

Clinical Features

Chlamydia trachomatis infections in men present with urethritis, epididymitis, orchitis, proctitis, or Reiter's syndrome (nongonococcal urethritis, conjunctivitis, and rash). Women often have asymptomatic cervicitis, but may also present with vaginal discharge, spotting, or dysuria. Consider chlamydial infection in patients with sterile pyuria. Complications can include PID, ectopic pregnancy, and infertility.

Diagnosis and Differential

Diagnosis of chlamydia is best made with indirect detection methods such as enzyme-linked immunosorbent assay or DNA probes, which have a sensitivity of 75% to 90%. The CDC recommends a nucleic acid amplification test (NAAT) to be used as screening tests for Chlamydia. Optimal specimen types for NAAT are vaginal swabs from women and first-catch urine from men.

Emergency Department Care and Disposition

1. Azithromycin 1 g PO as a single dose or doxycycline 100 mg PO twice daily for 7 days is the treatment of choice for uncomplicated urethritis or cervicitis from chlamydia infection.

2. Alternatives include 7-day treatment with erythromycin base 500 mg PO four times daily, ofloxacin 300 mg PO twice daily, or levofloxacin 500 mg PO daily.

3. Recommend that patients avoid sexual contact for 7 days after completing antibiotic treatment and symptoms have resolved.

GONOCOCCAL INFECTIONS

Clinical Features

Neisseria gonorrhoeae causes urethritis, epididymitis, orchitis, and prostatitis in men and urethritis, cervicitis, PID, and infertility in women. Many ...