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## Complete Summary

#### GUIDELINE TITLE

Sexual assault and STDs. Sexually transmitted diseases treatment
guidelines 2006.

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention, Workowski KA, Berman SM.
Sexual assault and STDs. Sexually transmitted diseases treatment
guidelines 2006. MMWR Morb Mortal Wkly Rep 2006 Aug 4;55(RR-11):80-6.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Centers for Disease Control
and Prevention. Sexual assault and STDs. Sexually transmitted diseases
treatment guidelines. MMWR Recomm Rep 2002 May 10;51(RR-6):69-74.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [September 11, 2007, Rocephin (ceftriaxone
    sodium)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Rocephin):
    Roche informed healthcare professionals about revisions made to the
    prescribing information for Rocephin to clarify the potential risk
    associated with concomitant use of Rocephin with calcium or
    calcium-containing solutions or products.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Sexually transmitted diseases (STDs) following sexual assault or sexual
abuse

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Infectious Diseases\
Internal Medicine\
Obstetrics and Gynecology\
Pediatrics\
Preventive Medicine\
Urology

#### INTENDED USERS

Health Care Providers\
Managed Care Organizations\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

-   To update the Sexually Transmitted Diseases Treatment Guidelines
    2002 (*MMWR 2002;51\[No. RR-6\]*)

-   To assist physicians and other health-care providers in preventing
    and treating sexually transmitted diseases (STDs)

#### TARGET POPULATION

Adolescents, adults, and children who have been sexually assaulted or
abused

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Management of Sexual Assault in Adults and Adolescents**

1.  Testing for *Neisseria gonorrhoeae* and *Chlamydia trachomatis* from
    specimens of sites of penetration or attempted penetration

2.  Culture of Food and Drug Administration (FDA)-approved nucleic
    amplification tests

3.  Wet mount and culture of a vaginal swab specimen for *Trichomonas
    vaginalis*

4.  Collection of a serum sample for evaluation for HIV, hepatitis B,
    and syphilis

5.  Follow-up examination with repetition of STD examination and testing
    (e.g., culture, wet mount, and other tests) within 1-2 weeks of
    assault

6.  Repetition of serological tests for syphilis and HIV 6weeks, 3
    months, and 6 months after the assault

7.  Postexposure hepatitis B vaccination without hepatitis B
    immunoglobulin

8.  Empiric antimicrobial regimens for chlamydia, gonorrhea,
    trichomonas, and bacterial vaginosis, including ceftriaxone,
    metronidazole, and azithromycin, or doxycycline

9.  Patient counseling on the symptoms of STDs and the need for
    immediate examination if symptoms occur and abstention from sexual
    intercourse until any STD prophylaxis is completed

10. Post-exposure therapy and management for HIV with antiretroviral
    agents, such as zidovudine

**Management of Sexual Assault or Abuse in Children**

1.  Initial and 2-week follow-up examinations to include the following:

    -   Visual inspection of the genital, perianal, and oral areas

    -   Specimen collection from all vesicular or ulcerative genital or
        perianal lesions

    -   Specimen collection for culture for *Neisseria gonorrhoeae* and
        *Chlamydia trachomatis*

    -   Use of standard culture systems for isolation of *C.
        trachomatis*, with isolation confirmed by microscopic
        identification of inclusions by staining with
        fluorescein-conjugated monoclonal antibody specific for *C.
        trachomatis*

    -   Preservation of isolates for repeat testing

    -   Nonculture tests for *C. trachomatis*, such as nucleic acid
        amplification

    -   Culture and wet mount of a vaginal swab specimen for
        *Trichomonas vaginalis* infection and bacterial vaginosis

    -   Collection of a serum sample and testing for *Treponema
        pallidum*, HIV, and hepatitis B

2.  Postexposure assessment with 72 hours of sexual assault to include
    the following:

    -   Assessing risk for HIV infection in the assailant

    -   Evaluating circumstances in assault that may affect risk for HIV
        transmission

    -   Consulting with specialists in treating HIV-infected children if
        postexposure prophylaxis is considered

    -   Discussing HIV prophylaxis with caregiver(s)

    -   Providing antiretroviral medication with reevaluation 3-7 days
        later

    -   Performing HIV antibody testing at original assessment, 6 weeks,
        3 months, and 6 months

3.  Examination 6 weeks, 3 months, and 6 months after assault and
    testing for syphilis, HIV, and hepatitis B, if initial tests are
    negative

4.  Presumptive treatment for STDs

5.  Reporting of child abuse to state or local child-protection services

#### MAJOR OUTCOMES CONSIDERED

-   Microbiologic cure

-   Alleviation of signs and symptoms

-   Prevention of sequelae

-   Prevention of transmission

-   Prevalence of and risk for sexually transmitted diseases (STDs) in
    assault and abuse cases

-   Sensitivity and specificity of diagnostic tests

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Subjective Review

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Beginning in 2004, the Centers for Disease Control and Prevention (CDC)
personnel and professionals knowledgeable in the field of sexually
transmitted diseases (STDs) systematically reviewed evidence (including
published abstracts and peer-reviewed journal articles) concerning each
of the major STDs, focusing on information that had become available
since publication of the *Sexually Transmitted Diseases Treatment
Guidelines, 2002*. Background papers were written and tables of evidence
constructed summarizing the type of study (e.g., randomized controlled
trial or case series), study population and setting, treatments or other
interventions, outcome measures assessed, reported findings, and
weaknesses and biases in study design and analysis. A draft document was
developed on the basis of the reviews.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Consensus Development Conference)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

In April 2005, the Centers for Disease Control and Prevention (CDC)
staff members and invited consultants assembled in Atlanta, Georgia, for
a 3-day meeting to present the key questions regarding sexually
transmitted disease (STD) treatment that emerged from the evidence-based
reviews and the information available to answer those questions. When
relevant, the questions focused on four principal outcomes of STD
therapy for each individual disease: 1) microbiologic cure, 2)
alleviation of signs and symptoms, 3) prevention of sequelae, and 4)
prevention of transmission. Cost-effectiveness and other advantages
(e.g., single-dose formulations and directly observed therapy of
specific regimens) also were discussed. The consultants then assessed
whether the questions identified were relevant, ranked them in order of
priority, and attempted to arrive at answers using the available
evidence. In addition, the consultants evaluated the quality of evidence
supporting the answers on the basis of the number, type, and quality of
the studies.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse and the Centers for
Disease Control and Prevention**: When more than one therapeutic regimen
is recommended, the sequence is alphabetized unless the choices for
therapy are prioritized based on efficacy, convenience, or cost. For
sexually transmitted diseases (STDs) with more than one recommended
regimen, almost all regimens have similar efficacy and similar rates of
intolerance or toxicity unless otherwise specified.

**Adults and Adolescents**

The recommendations in this report are limited to the identification,
prophylaxis, and treatment of sexually transmitted infections and
conditions commonly identified in the management of such infections. The
documentation of findings, collection of nonmicrobiologic specimens for
forensic purposes, and the management of potential pregnancy or physical
and psychological trauma are beyond the scope of this report.
Examinations of survivors of sexual assault should be conducted by an
experienced clinician in a way that minimizes further trauma to the
survivor. The decision to obtain genital or other specimens for sexually
transmitted diseases (STD) diagnosis should be made on an individual
basis. Care systems for survivors should be designed to ensure
continuity (including timely review of test results), support adherence,
and monitor for adverse reactions to any therapeutic or prophylactic
regimens prescribed at initial examination. Laws in all 50 states
strictly limit the evidentiary use of a survivor\'s previous sexual
history, including evidence of previously acquired STDs, as part of an
effort to undermine the credibility of the survivor\'s testimony.
Evidentiary privilege against revealing any aspect of the examination or
treatment is enforced in the majority of states. In unanticipated,
exceptional situations, STD diagnoses may later be accessed, and the
survivor and clinician may opt to defer testing for this reason.
However, collection of specimens at initial examination for laboratory
STD diagnosis gives the survivor and clinician the option to defer
empiric prophylactic antimicrobial treatment. Among sexually active
adults, the identification of sexually transmitted infection after an
assault might be more important for the psychological and medical
management of the patient than for legal purposes because the infection
could have been acquired before the assault.

Trichomoniasis, bacterial vaginosis (BV), gonorrhea, and chlamydial
infection are the most frequently diagnosed infections among women who
have been sexually assaulted. Because the prevalence of these infections
is high among sexually active women, their presence after an assault
does not necessarily signify acquisition during the assault. A
post-assault examination is, however, an opportunity to identify or
prevent sexually transmitted infections, regardless of whether they were
acquired during an assault. Chlamydial and gonococcal infections in
women are of particular concern because of the possibility of ascending
infection. In addition, hepatitis B virus (HBV) infection might be
prevented by postexposure administration of hepatitis B vaccine.
Reproductive-aged female survivors should be evaluated for pregnancy, if
appropriate.

**Evaluation for Sexually Transmitted Infections**

***Initial Examination***

An initial examination should include the following procedures:

-   Testing for *Neisseria gonorrhoeae* and *Chlamydia trachomatis* from
    specimens collected from any sites of penetration or attempted
    penetration.

-   Culture or Food and Drug Administration (FDA)-cleared nucleic acid
    amplification tests (NAAT) for either *N. gonorrhoeae* or *C.
    trachomatis*. NAAT offer the advantage of increased sensitivity in
    detection of *C. trachomatis*.

-   Wet mount and culture of a vaginal swab specimen for *Trichomonas
    vaginalis* infection. If vaginal discharge, malodor, or itching is
    evident, the wet mount also should be examined for evidence of BV
    and candidiasis.

-   Collection of a serum sample for immediate evaluation for human
    immunodeficiency virus (HIV), hepatitis B, and syphilis (see
    sections Prophylaxis, Risk for Acquiring HIV Infection, and
    Follow-Up Examination After Assault below).

***Follow-Up Examinations***

After the initial post-assault examination, follow-up examinations
provide an opportunity to 1) detect new infections acquired during or
after the assault; 2) complete hepatitis B immunization, if indicated;
3) complete counseling and treatment for other STDs; and 4) monitor side
effects and adherence to postexposure prophylactic medication, if
prescribed.

Examination for STDs should be repeated within 1-2 weeks of the assault.
Because infectious agents acquired through assault might not have
produced sufficient concentrations of organisms to result in positive
test results at the initial examination, testing should be repeated
during the follow-up visit, unless prophylactic treatment was provided.
If treatment was provided, testing should be conducted only if the
survivor reports having symptoms. If treatment was not provided,
follow-up examination should be conducted within 1 week to ensure that
results of positive tests can be discussed promptly with the survivor
and that treatment is provided. Serologic tests for syphilis and HIV
infection should be repeated 6 weeks, 3 months, and 6 months after the
assault if initial test results were negative and infection in the
assailant could not be ruled out (see Sexual Assaults, Risk for
Acquiring HIV Infection, below).

**Prophylaxis**

Many specialists recommend routine preventive therapy after a sexual
assault because follow-up of survivors of sexual assault can be
difficult. The following prophylactic regimen is suggested as preventive
therapy:

-   Postexposure hepatitis B vaccination, without hepatitis B immune
    globulin (HBIG), should adequately protect against HBV infection.
    Hepatitis B vaccination should be administered to sexual assault
    victims at the time of the initial examination if they have not been
    previously vaccinated. Follow-up doses of vaccine should be
    administered 1-2 and 4-6 months after the first dose.

-   An empiric antimicrobial regimen for chlamydia, gonorrhea,
    trichomonas, and BV.

-   Emergency contraception should be offered if the post-assault could
    result in pregnancy in the survivor.

***Recommended Regimens***

-   **Ceftriaxone** 125 mg intramuscularly (IM) in a single dose

> ***PLUS***

-   **Metronidazole** 2 g orally in a single dose

> ***PLUS***

-   **Azithromycin** 1 g orally in a single dose

> **OR**

-   **Doxycycline** 100 mg orally twice a day for 7 days

For patients requiring alternative treatments, refer to the sections in
this report relevant to the specific agent. The efficacy of these
regimens in preventing infections after sexual assault has not been
evaluated. Clinicians should counsel patients regarding the possible
benefits and toxicities associated with these treatment regimens;
gastrointestinal side effects can occur with this combination. Providers
might also consider anti-emetic medications, particularly if emergency
contraception also is provided.

**Other Management Considerations**

At the initial examination and, if indicated, at follow-up examinations,
patients should be counseled regarding 1) symptoms of STDs and the need
for immediate examination if symptoms occur and 2) abstinence from
sexual intercourse until STD prophylactic treatment is completed.

***Risk for Acquiring HIV Infection***

HIV seroconversion has occurred in persons whose only known risk factor
was sexual assault or sexual abuse, but the frequency of this occurrence
is probably low. In consensual sex, the risk for HIV transmission from
vaginal intercourse is 0.1%-0.2% and for receptive rectal intercourse,
0.5%-3%. The risk for HIV transmission from oral sex is substantially
lower. Specific circumstances of an assault might increase risk for HIV
transmission (e.g., trauma, including bleeding) with vaginal, anal, or
oral penetration; site of exposure to ejaculate; viral load in
ejaculate; and the presence of an STD or genital lesions in the
assailant or survivor.

Children might be at higher risk for transmission because child sexual
abuse is frequently associated with multiple episodes of assault and
might result in mucosal trauma (see Sexual Assault or Abuse of Children
below).

Postexposure therapy with zidovudine was associated with a reduced risk
for acquiring HIV in a study of health-care workers who had percutaneous
exposures to HIV-infected blood. On the basis of these results and the
results of animal studies, postexposure prophylaxis (PEP) has been
recommended for health-care workers who have occupational exposures to
HIV. These findings have been extrapolated to other types of HIV
exposure, including sexual assault. If HIV exposure has occurred,
initiation of PEP as soon as possible after the exposure likely
increases benefit. Although a definitive statement of benefit cannot be
made regarding PEP after sexual assault, the possibility of HIV exposure
from the assault should be assessed at the time of the post-assault
examination. The possible benefit of PEP in preventing HIV infection
also should be discussed with the assault survivor if risk exists for
HIV exposure from the assault.

The likelihood of the assailant having HIV, any exposure characteristics
that might increase the risk for HIV transmission, the time elapsed
after the event, as well as potential benefits and risks the PEP are all
factors that will impact the medical recommendation for PEP and impact
the assault survivor\'s acceptance of that recommendation. Determination
of assailant\'s HIV status at the time of the assault examination will
usually be impossible. Therefore, the health-care provider should assess
any available information concerning HIV-risk behaviors of the
assailant(s) (e.g., a man who has sex with other men and injecting-drug
or crack cocaine use), local epidemiology of HIV/AIDS, and exposure
characteristics of the assault. When an assailant\'s HIV status is
unknown, factors that should be considered in determining whether an
increased risk for HIV transmission exists include 1) whether vaginal or
anal penetration occurred; 2) whether ejaculation occurred on mucous
membranes; 3) whether multiple assailants were involved; 4) whether
mucosal lesions are present in the assailant or survivor; and 5) other
characteristics of the assault, survivor, or assailant that might
increase risk for HIV transmission.

If PEP is offered, the following information should be discussed with
the patient: 1) the unproven benefit and known toxicities of
antiretrovirals; 2) the close follow-up that will be necessary; 3) the
benefit of adherence to recommended dosing; and 4) the necessity of
early initiation of PEP to optimize potential benefits (as soon as
possible after and up to 72 hours after the assault). Providers should
emphasize that PEP appears to be well-tolerated in both adults and
children and that severe adverse effects are rare. Clinical management
of the survivor should be implemented according to the following
guidelines. Specialist consultation on PEP regimens is recommended if
HIV exposure during the assault was possible and if PEP is being
considered. The sooner PEP is initiated after the exposure, the higher
the likelihood that it will prevent HIV transmission, if HIV exposure
occurred; however, distress after an assault also might prevent the
survivor from accurately weighing exposure risks and benefits of PEP and
making an informed decision to start PEP. If use of PEP is judged to be
warranted, the survivor should be offered a 3- to 5-day supply of PEP
with a follow-up visit scheduled for additional counseling after several
days.

***Recommendations for Postexposure Assessment of Adolescent and Adult
Survivors Within 72 hours of Sexual Assault\****

-   Assess risk for HIV infection in the assailant.

-   Evaluate characteristics of the assault event that might increase
    risk for HIV transmission.

-   Consult with a specialist in HIV treatment, if PEP is being
    considered.

-   If the survivor appears to be at risk for HIV transmission from the
    assault, discuss antiretroviral prophylaxis, including toxicity and
    lack of proven benefit.

-   If the survivor chooses to start antiretroviral PEP, provide enough
    medication to last until the next return visit; reevaluate the
    survivor 3-7 days after initial assessment and assess tolerance of
    medications.

-   If PEP is started, perform a complete blood count and serum
    chemistry at baseline (initiation of PEP should not be delayed,
    pending results).

-   Perform HIV antibody test at original assessment; repeat at 6 weeks,
    3 months, and 6 months.

**\*Note**: Assistance with PEP decisions can be obtained by calling the
National Clinician\'s Post-Exposure Prophylaxis Hotline (PEPLine),
telephone: 888-448-4911.

**Sexual Assault or Abuse of Children**

Recommendations in this report are limited to the identification and
treatment of STDs. Management of the psychosocial aspects of the sexual
assault or abuse of children is beyond the scope of these
recommendations.

The identification of sexually transmissible agents in children beyond
the neonatal period suggests sexual abuse. The significance of the
identification of a sexually transmitted agent in such children as
evidence of possible child sexual abuse varies by pathogen. Postnatally
acquired gonorrhea; syphilis; and nontransfusion, non-perinatally
acquired HIV are usually diagnostic of sexual abuse. Sexual abuse should
be suspected when genital herpes is diagnosed. The investigation of
sexual abuse among children who possibly have an infection that might
have been sexually transmitted should be conducted in compliance with
recommendations by clinicians who have experience and training in all
elements of the evaluation of child abuse, neglect, and assault. The
social importance of infection that might have been acquired sexually
and the recommended action regarding reporting of suspected child sexual
abuse varies by the specific organism (see Table 6 of the original
guideline document). In all cases in which a sexually transmitted
infection has been diagnosed in a child, efforts should be made to
detect evidence of sexual abuse, including conducting diagnostic testing
for other commonly occurring sexually transmitted infections.

The general rule that sexually transmissible infections beyond the
neonatal period are evidence of sexual abuse has exceptions. For
example, rectal or genital infection with *C. trachomatis* among young
children might be the result of perinatally acquired infection and has,
in some cases, persisted for as long as 2-3 years. Genital warts have
been diagnosed in children who have been sexually abused, but also in
children who have no other evidence of sexual abuse. BV has been
diagnosed in children who have been abused, but its presence alone does
not prove sexual abuse. The majority of HBV infections in children
result from household exposure to persons who have chronic HBV
infection.

The possibility of sexual abuse should be strongly considered if no
conclusive explanation for nonsexual transmission of a sexually
transmitted infection can be identified. When the only evidence of
sexual abuse is the isolation of an organism or the detection of
antibodies to a sexually transmissible agent, findings should be
confirmed and the implications considered carefully.

**Evaluation for Sexually Transmitted Infections**

Examinations of children for sexual assault or abuse should be conducted
in a manner designed to minimize pain and trauma to the child.
Collection of vaginal specimens in prepubertal children can be very
uncomfortable and should be performed by an experienced clinician to
avoid psychological and physical trauma to the child. The decision to
obtain genital or other specimens from a child to conduct an STD
evaluation must be made on an individual basis. The following situations
involve a high risk for STDs and constitute a strong indication for
testing:

-   The child has or has had symptoms or signs of an STD or of an
    infection that can be sexually transmitted, even in the absence of
    suspicion of sexual abuse. Among the signs that are associated with
    a confirmed STD diagnosis are vaginal discharge or pain, genital
    itching or odor, urinary symptoms, and genital ulcers or lesions.

-   A suspected assailant is known to have an STD or to be at high risk
    for STDs (e.g., has multiple sex partners or a history of STDs).

-   A sibling or another child or adult in the household or child\'s
    immediate environment has an STD.

-   The patient or parent requests testing.

-   Evidence of genital, oral, or anal penetration or ejaculation is
    present.

If a child has symptoms, signs, or evidence of an infection that might
be sexually transmitted, the child should be tested for other common
STDs before the initiation of any treatment that could interfere with
the diagnosis of those other STDs. Because of the legal and psychosocial
consequences of a false-positive diagnosis, only tests with high
specificities should be used. The potential benefit to the child of a
reliable diagnosis of an STD justifies deferring presumptive treatment
until specimens for highly specific tests are obtained by providers with
experience in the evaluation of sexually abused and assaulted children.

The scheduling of an examination should depend on the history of assault
or abuse. If the initial exposure was recent, the infectious agents
acquired through the exposure might not have produced sufficient
concentrations of organisms to result in positive test results. A
follow-up visit approximately 2 weeks after the most recent sexual
exposure may include a repeat physical examination and collection of
additional specimens. To allow sufficient time for antibodies to
develop, another follow-up visit approximately 12 weeks after the most
recent sexual exposure might be necessary to collect sera. A single
examination might be sufficient if the child was abused for an extended
period and if the last suspected episode of abuse occurred substantially
before the child received medical evaluation.

The following recommendations for scheduling examinations serve as a
general guide. The exact timing and nature of follow-up examinations
should be determined on an individual basis and should be performed to
minimize the possibility for psychological trauma and social stigma.
Compliance with follow-up appointments might be improved when law
enforcement personnel or child protective services are involved.

**Initial and 2-Week Follow-Up Examinations**

During the initial examination and 2-week follow-up examination (if
indicated), the following should be performed:

-   Visual inspection of the genital, perianal, and oral areas for
    genital discharge, odor, bleeding, irritation, warts, and ulcerative
    lesions. The clinical manifestations of some STDs are different in
    children than in adults. For example, typical vesicular lesions
    might not be present in the presence of herpes simplex virus (HSV)
    infection. Because this infection is suspicious for sexual abuse,
    specimens should be obtained from all vesicular or ulcerative
    genital or perianal lesions compatible with genital herpes and then
    sent for viral culture.

-   Specimen collection for culture for *N. gonorrhoeae* from the
    pharynx and anus in both boys and girls, the vagina in girls, and
    the urethra in boys. Cervical specimens are not recommended for
    prepubertal girls. For boys with a urethral discharge, a meatal
    specimen discharge is an adequate substitute for an intraurethral
    swab specimen. Only standard culture systems for the isolation of
    *N. gonorrhoeae* should be used. All presumptive isolates of *N.
    gonorrhoeae* should be confirmed by at least two tests that involve
    different principles (i.e., biochemical, enzyme substrate,
    serologic, or nucleic acid hybridization test methods). Isolates and
    specimens should be retained or preserved in case additional or
    repeated testing is needed. Gram stains are inadequate to evaluate
    prepubertal children for gonorrhea and should not be used to
    diagnose or exclude gonorrhea.

-   Cultures for *C. trachomatis* from specimens collected from the anus
    in both boys and girls and from the vagina in girls. Some data
    suggest that the likelihood of recovering *C. trachomatis* from the
    urethra of prepubertal boys is too low to justify the trauma
    involved in obtaining an intraurethral specimen. However, a meatal
    specimen should be obtained if urethral discharge is present.
    Pharyngeal specimens for *C. trachomatis* are not recommended for
    children of either sex because the yield is low, perinatally
    acquired infection might persist beyond infancy, and culture systems
    in some laboratories do not distinguish between *C. trachomatis* and
    *C. pneumoniae*. Only standard culture systems for the isolation of
    *C. trachomatis* should be used. The isolation of *C. trachomatis*
    should be confirmed by microscopic identification of inclusions by
    staining with fluorescein-conjugated monoclonal antibody specific
    for *C. trachomatis*; enzyme immunoassays (EIAs) are not acceptable
    confirmatory methods. Isolates should be preserved. Nonculture tests
    for chlamydia (e.g., nonamplified probes, EIAs, and direct
    fluorescent antibody \[DFA\]) are not sufficiently specific for use
    in circumstances involving possible child abuse or assault. Data are
    insufficient to adequately assess the utility of NAAT in the
    evaluation of children who might have been sexually abused, but
    these tests might be an alternative if confirmation is available and
    culture systems for *C. trachomatis* are unavailable. Confirmation
    tests should consist of a second FDA-cleared NAAT that targets a
    different sequence from the initial test.

-   Culture and wet mount of a vaginal swab specimen for *T. vaginalis*
    infection and BV.

-   Collection of serum samples to be evaluated immediately, preserved
    for subsequent analysis, and used as a baseline for comparison with
    follow-up serologic tests. Sera should be tested immediately for
    antibodies to sexually transmitted agents. Agents for which suitable
    tests are available include *T. pallidum*, HIV, and HBV. Decisions
    regarding which agents to use for serologic tests should be made on
    a case-by-case basis (see Follow-up Examination after Assault
    below).

HIV infection has been reported in children whose only known risk factor
was sexual abuse. Serologic testing for HIV infection should be
considered for abused children. The decision to test for HIV infection
should be made on a case-by-case basis, depending on the likelihood of
infection among assailant(s). Data are insufficient concerning the
efficacy and safety of PEP among both children and adults. However,
antiretroviral treatment is well-tolerated by infants and children with
and without HIV infection. In addition, children who receive such
treatment have a minimal risk for serious adverse reactions because of
the short period recommended for prophylaxis. In considering whether to
offer antiretroviral PEP, health-care providers should consider whether
the child can be treated soon after the sexual exposure (i.e., within 72
hours), the likelihood that the assailant is at risk for HIV infection,
and the likelihood of high compliance with the prophylactic regimen. The
potential benefit of treating a sexually abused child should be weighed
against the risk for adverse reactions. If antiretroviral PEP is being
considered, a professional specializing in HIV-infected children should
be consulted.

***Recommendations for HIV-Related Postexposure Assessment of Children
within 72 Hours of Sexual Assault***

-   Review HIV/AIDS local epidemiology and assess risk for HIV infection
    in the assailant.

-   Evaluate circumstances of assault that might affect risk for HIV
    transmission.

-   Consult with a specialist in treating HIV-infected children if PEP
    is considered.

-   If the child appears to be at risk for HIV transmission from the
    assault, discuss PEP with the caregiver(s), including its toxicity
    and unknown efficacy.

-   If caregivers choose for the child to receive antiretroviral PEP,
    provide enough medication to last until the return visit at 3-7 days
    after the initial assessment, at which time the child should be
    reevaluated and tolerance of medication should be assessed; dosages
    should not exceed those for adults.

-   Perform HIV antibody test at original assessment, 6 weeks, 3 months,
    and 6 months.

**Follow-Up Examination After Assault**

In circumstances in which transmission of syphilis, HIV, or hepatitis B
is a concern but baseline tests are negative, an examination
approximately 6 weeks, 3 months, and 6 months after the last suspected
sexual exposure is recommended to allow time for antibodies to
infectious agents to develop. In addition, results of HBsAg testing must
be interpreted carefully, because HBV can be transmitted nonsexually.
Decisions regarding which tests should be performed must be made on an
individual basis.

**Presumptive Treatment**

The risk of a child acquiring an STD as a result of sexual abuse or
assault has not been well studied. Presumptive treatment for children
who have been sexually assaulted or abused is not recommended because 1)
the incidence of the majority of STDs in children is low after
abuse/assault, 2) prepubertal girls appear to be at lower risk for
ascending infection than adolescent or adult women, and 3) regular
follow-up of children usually can be ensured. However, some children or
their parent(s) or guardian(s) might be concerned about the possibility
of infection with an STD, even if the risk is perceived to be low by the
health-care provider. Such concerns might be an appropriate indication
for presumptive treatment in some settings and may be considered after
all specimens for diagnostic tests relevant to the investigation have
been collected.

**Reporting**

U.S. states and territories have laws that require the reporting of
child abuse. Although the exact requirements differ by state, if a
health-care provider has reasonable cause to suspect child abuse, a
report must be made. Health-care providers should contact their state or
local child-protection service agency regarding child-abuse reporting
requirements in their states.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

Throughout the 2006 guideline document, the evidence used as the basis
for specific recommendations is discussed briefly. More comprehensive,
annotated discussions of such evidence will appear in background papers
that will be published in a supplement issue of the journal *Clinical
Infectious Diseases*.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate diagnosis, treatment, and management of sexually
    transmitted diseases in victims of sexual assault or abuse.

-   Possibility of preventing sexually transmitted diseases, such as,
    hepatitis B, chlamydia, gonorrhea, trichomonas, bacterial vaginosis,
    and HIV with prophylaxis treatment in victims of sexual assault or
    abuse.

#### POTENTIAL HARMS

There are possible toxicities associated with the antimicrobial regimens
prescribed for prophylaxis of chlamydia, gonorrhea, trichomonas, and
bacterial vaginosis; gastrointestinal side effects can occur with the
combination treatment.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These recommendations were developed in consultation with public-
    and private-sector professionals knowledgeable in the treatment of
    patients with sexually transmitted diseases (STDs). The
    recommendations are applicable to various patient-care settings,
    including family planning clinics, private physicians\' offices,
    managed care organizations, and other primary-care facilities.

-   These recommendations are meant to serve as a source of clinical
    guidance: health-care providers should always consider the
    individual clinical circumstances of each person in the context of
    local disease prevalence. These guidelines focus on the treatment
    and counseling of individual patients and do not address other
    community services and interventions that are important in STD/human
    immunodeficiency virus (HIV) prevention.

-   The recommendations in this report are limited to the
    identification, prophylaxis, and treatment of sexually transmitted
    infections and conditions commonly identified in the management of
    such infections. The documentation of findings, collection of
    non-microbiologic specimens for forensic purposes, and the
    management of potential pregnancy or physical and psychological
    trauma are beyond the scope of this report.

-   Management of the psychosocial aspects of the sexual assault or
    abuse of children is beyond the scope of these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention, Workowski KA, Berman SM.
Sexual assault and STDs. Sexually transmitted diseases treatment
guidelines 2006. MMWR Morb Mortal Wkly Rep 2006 Aug 4;55(RR-11):80-6.

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1993 (revised 2006 Aug 4)

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### GUIDELINE DEVELOPER COMMENT

These guidelines for the treatment of persons who have sexually
transmitted diseases (STDs) were developed by CDC after consultation
with a group of professionals knowledgeable in the field of STDs who met
in Atlanta, Georgia, during April 19--21, 2005.

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Chairpersons*: David Atkins, MD, Agency for Healthcare Research and
Quality, Rockville, Maryland; Kimberly A. Workowski, MD, National Center
for HIV, STD, and TB Prevention, CDC, and Emory University, Atlanta, GA

*Presenters*: Heidi Bauer, MD, California Sexually Transmitted Disease
Control Branch, Oakland, California; Emily J. Erbelding, MD, Johns
Hopkins University School of Medicine, Baltimore, Maryland; William M.
Geisler, MD, Department of Medicine, University of Alabama, Birmingham,
Alabama; Margaret Hammerschlag, MD, State University of New York,
Downstate Medical Center, Brooklyn, New York; Peter Leone, MD,
University of North Carolina School of Medicine, Chapel Hill, North
Carolina; Jenne Marrazzo, MD, University of Washington, Harborview
Medical Center, Seattle, Washington; Kenneth Hugh Mayer, MD, Brown
University Medical School, Providence, Rhode Island; Pablo Sanchez, MD,
University of Texas Southwestern Medical Center, Dallas, Texas; Bradley
Stoner, MD, PhD, Washington University, St. Louis, Missouri; Anna Wald,
MD, University of Washington, Harborview Medical Center, Seattle,
Washington; George Wendel, MD, University of Texas Southwestern Medical
School, Dallas, Texas; Karen Wendel, MD, University of Oklahoma Health
Science Center, Oklahoma City, Oklahoma; Harold C. Wiesenfeld, MD,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

*Moderators*: Willard Cates, Jr., MD, Family Health International,
Durham, North Carolina; King K. Holmes, MD, PhD, University of
Washington, Harborview Medical Center, Seattle, Washington; David
Martin, MD, Louisiana State University Medical Center, New Orleans,
Louisiana

*Rapporteurs*: Hunter Handsfield, MD, National Center for HIV, STD, and
TB Prevention, CDC, Atlanta, Georgia, University of Washington, Seattle,
Washington; William McCormack, MD, State University of New York Health
Science Center, Brooklyn, New York; Anne Rompalo, MD, Johns Hopkins
School of Medicine, Baltimore, Maryland

*Consultants*: Michael Augenbraun, MD, State University of New York
Health Science Center, Brooklyn, New York; Gail Bolan, MD, California
Department of Health, Oakland, California; Carolyn Deal, PhD, National
Institute of Allergy and Infectious Diseases, National Institutes of
Health, Bethesda, Maryland; Kenneth H. Fife, MD, PhD, Indiana University
School of Medicine, Indianapolis, Indiana; J. Dennis Fortenberry, MD,
Indiana University School of Medicine, Indianapolis, Indiana; Edward
Hook, III, MD, Department of Medicine, University of Alabama,
Birmingham, Alabama; Franklyn Judson, MD, University of Colorado
Department of Medicine and Preventive Medicine, Denver, Colorado; Alice
A. Kraman, PharmD; Emory Healthcare, Atlanta, Georgia; Roberta B. Ness,
MD, University of Pittsburgh Department of Medicine, Pittsburgh,
Pennsylvania; Paul Nyirjesy, MD, Drexel University College of Medicine,
Philadelphia, Pennsylvania; Jeffrey Peipert, MD, Women and Infants
Hospital, Providence, Rhode Island; Jane R. Schwebke, MD, Department of
Medicine, University of Alabama, Birmingham, Alabama; Mary Ann Shafer,
MD, University of California, San Francisco Department of Medicine, San
Francisco, California; David Soper, MD, Medical University of South
Carolina, Charleston, South Carolina; Lawrence Stanberry, MD, PhD,
University of Texas Medical Branch, Galveston, Texas; Heather Watts, MD,
National Institute of Child Health and Development, National Institutes
of Health, Bethesda, Maryland; Jonathan M. Zenilman, MD, Johns Hopkins
Bayview Medical Center, Baltimore, Maryland

*Liaison Participants*: Joanne Armstrong, MD, Women\'s Health, Aetna,
Sugar Land, Texas; James R. Allen, MD, American Social Health
Association, Durham, North Carolina; Margaret J. Blythe, MD, American
Academy of Pediatrics, Indianapolis, Indiana; Sherry R. Crump, MD,
American College of Preventive Medicine, Atlanta, GA; Carolyn D. Deal,
PhD, National Institutes of Health, Bethesda, Maryland; Jordon
Dimitrakov, MD, PhD, American Urological Association, Boston,
Massachusetts; Mark FitzGerald, MD, British Association for Sexual
Health and HIV, Southampton, United Kingdom; Edward Harrison, National
Commission on Correctional Health Care, Chicago, Illinois; Edward W.
Hook, III, MD, Infectious Disease Society of America, Birmingham,
Alabama; Michel Janier, MD, PhD, International Union Against Sexually
Transmitted Infections Europe, Paris, France; Abe Macher, MD, HIV/AIDS
Bureau, Rockville, Maryland; Francis J. Ndowa, MD, World Health
Organization, Geneva, Switzerland; Jeffrey F. Peipert, MD, American
College of Obstetricians and Gynecologists, Providence, Rhode Island;
Kees A. Rietmeijer, MD, PhD, Denver Public Health Department, Denver,
Colorado; Richard Rothman, MD, American College of Emergency Physicians,
Baltimore, Maryland; David Soper, MD, Infectious Diseases Society for
Obstetrics and Gynecology, Charleston, South Carolina; Litjen Tan, PhD,
American Medical Association, Chicago, Illinois; Bruce Trigg, MD,
National Coalition for Sexually Transmitted Disease Directors,
Albuquerque, New Mexico; Julia Valderrama, MD, Pan American Health
Organization, Washington, DC; Tom Wong, MD, Public Health Agency of
Canada, Ottawa, Ontario, Canada; Miriam Zieman, MD, Association of
Reproductive Health Professionals, Atlanta, Georgia

*CDC, Division of Sexually Transmitted Disease Prevention Treatment
Guidelines 2006 Project. Coordinator*: Kimberly A. Workowski, MD,
National Center for HIV, STD, and TB Prevention, CDC, and Emory
University, Atlanta, GA

*Project Manager*: Donald F. Dowda, ORISE, Oakridge, Tennessee; Richard
Voigt, National Center for HIV, STD, and TB Prevention, CDC, Atlanta,
Georgia

*Co-Moderators*: Lyn Finelli, Ph.D., DSTDP; Robert Johnson, M.D., DSTDP;
Lauri Markowitz, M.D., DSTDP

*CDC Presenters*: Joanna Buffington, MD, National Center for Infectious
Diseases; Eileen Dunne, MD, National Center for HIV, STD, and TB
Prevention, CDC, Atlanta, Georgia; Matthew Hogben, PhD, National Center
for HIV, STD, and TB Prevention, CDC, Atlanta, Georgia; Emily Koumans,
MD, National Center for HIV, STD, and TB Prevention, CDC, Atlanta,
Georgia; Hershel Lawson, MD, National Center for Chronic Disease
Prevention and Health Promotion, Atlanta, Georgia; Catherine McLean, MD,
National Center for HIV, STD, and TB Prevention, Atlanta, Georgia;
Juliette Morgan, MD, National Center for Infectious Diseases, CDC,
Atlanta, Georgia; Lori Newman, MD, National Center for HIV, STD, and TB
Prevention, CDC, Atlanta, Georgia; Madeline Sutton, MD, National Center
for HIV, STD, and TB Prevention, CDC, Atlanta, Georgia

*CDC Consultants*: Sevgi O. Aral, PhD, Stuart M. Berman, MD, John
Douglas, MD, Susan J. DeLisle, Kathleen Ethier, PhD, National Center for
HIV, STD, and TB Prevention, CDC, Atlanta, Georgia; Kevin Fenton, MD,
National Center for HIV, Hepatitis, Sexually Transmitted Diseases and
Tuberculosis Prevention, CDC, Atlanta, Georgia; John Moran, MD, National
Immunization Program, CDC, Atlanta, Georgia; Julia Schillinger, MD,
National Center for HIV, STD, and TB Prevention, CDC, Atlanta, Georgia

*Support Staff*: Valerie Barner, Winda Graves, Garrett Mallory, Deborah
McElroy, National Center for HIV, STD, and TB Prevention, CDC, Atlanta,
Georgia; Eboney Walker, NAI Personnel, Washington, DC

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Centers for Disease Control
and Prevention. Sexual assault and STDs. Sexually transmitted diseases
treatment guidelines. MMWR Recomm Rep 2002 May 10;51(RR-6):69-74.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML Format](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm)

-   [Portable Document Format
    (PDF)](http://www.cdc.gov/mmwr/PDF/rr/rr5511.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Workowski KA, Levine WC, Wasserheit JN. U.S. Centers for Disease
    Control and Prevention guidelines for the treatment of sexually
    transmitted diseases: an opportunity to unify clinical and public
    health practice. Ann Intern Med. 2002 Aug 20;137(4):255-62.
    Electronic copies: Available through [Annals of Internal Medicine
    Online](http://www.annals.org/issues/v137n4/full/200208200-00010.html).

-   A pocket guide to adult HIV/AIDS treatment: companion to *A guide to
    primary care of people with HIV/AIDS*. August 2004 Edition. Fairfax
    (VA): Health Resources and Services Administration. 2004 Aug. 48 p.
    Available from the [AIDS Education and Training Centers National
    Resource Center Web
    site](http://aidsetc.org/pdf/tools/hrsa_adult_card-04.pdf). See the
    related QualityTool summary on the [Health Care Innovations Exchange
    Web site](http://innovations.ahrq.gov/content.aspx?id=1337).

-   The CDC Sexually Transmitted Diseases Treatment Guidelines 2004 for
    PDA or Palm OS. Available from the [CDC National Prevention
    Information Network (NPIN) Web
    site](http://www.cdcnpin.org/scripts/std/pda.asp).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on September 5, 2002. This summary
was updated by ECRI on October 19, 2006. This summary was updated by
ECRI Institute on October 3, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Rocephin (ceftriaxone sodium).

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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Date Modified: 11/3/2008