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Guideline Summary
Guideline Title
Sexual assault and STDs. In: Sexually transmitted diseases treatment guidelines, 2010.
Bibliographic Source(s)
Centers for Disease Control and Prevention (CDC). Sexual assault and STDs. In: Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010 Dec 17;59(RR-12):90-5.
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 2006 Aug 4;55(RR-11):80-6.

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
Advanced Practice Nurses
Health Care Providers
Managed Care Organizations
Nurses
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)
  • To update the Sexually Transmitted Diseases Treatment Guidelines 2006
  • To assist physicians and other health-care providers in preventing and treating sexually transmitted diseases (STDs)
Target Population

Adults, adolescents, and children who have been sexually assaulted or abused

Interventions and Practices Considered

Management of Sexual Assault in Adults and Adolescents

  1. Nucleic acid amplification tests (NAATs) for Neisseria gonorrhoeae and Chlamydia trachomatis
  2. Wet mount and culture or point-of-care testing of a vaginal swab specimen for Trichomonas vaginalis
  3. Wet mount of a vaginal swab specimen for evidence of bacterial vaginosis (BV) and candidiasis
  4. Collection of a serum sample for evaluation for human immunodeficiency virus (HIV), hepatitis B, and syphilis
  5. Follow-up examination with repetition of sexually transmitted disease (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 6 weeks, 3 months, and 6 months after the assault
  7. Postexposure hepatitis B vaccination without hepatitis B immunoglobulin (HBIG)
  8. Empiric antimicrobial regimens for chlamydia, gonorrhea, and trichomonas, including ceftriaxone or cefixime plus metronidazole, plus azithromycin or doxycycline
  9. Emergency contraception
  10. 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
  11. Post-exposure therapy and management for HIV with antiretroviral agents, such as zidovudine, followed by reevaluation and appropriate testing

Management of Sexual Assault or Abuse in Children

  1. Reporting of child abuse to state or local child-protection services
  2. 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 test (NAAT)
    • 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
    • Use of NAAT as an alternative to culture for detection of N. gonorrhoeae when appropriate
  3. 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
  4. Examination 6 weeks, 3 months, and 6 months after assault and testing for syphilis, HIV, and hepatitis B, if initial tests are negative
  5. Presumptive treatment for STDs
Major Outcomes Considered
  • Microbiologic cure
  • Presence of signs and symptoms
  • Occurrence of sequelae
  • Rate 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 the 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
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Beginning in 2008, Centers for Disease Control and Prevention (CDC) staff members and public- and private-sector experts knowledgeable in the field of sexually transmitted diseases (STDs) systematically reviewed literature using an evidence-based approach (e.g., published abstracts and peer-reviewed journal articles), focusing on the common STDs and information that had become available since publication of the 2006 Guidelines for Treatment of Sexually Transmitted Diseases. CDC staff members and STD experts developed background papers and tables of evidence that summarized 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. CDC staff then developed a draft document on the basis of this evidence-based review.

Methods Used to Formulate the Recommendations
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

Centers for Disease Control and Prevention (CDC) staff members and invited consultants (including public- and private-sector professionals knowledgeable in the treatment of patients with sexually transmitted diseases [STDs]) assembled in Atlanta, Georgia, in April 2009 for a meeting where all evidence from the literature reviews pertaining to STD management was discussed.

Specifically, participants identified key questions regarding STD treatment that emerged from the literature reviews and discussed the information available to answer those questions. Discussion focused on four principal outcomes of STD therapy for each individual disease: 1) treatment of infection based on microbiologic eradication, 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 [DOT] of specific regimens) also were discussed. The consultants then assessed whether the questions identified were relevant, ranked them in order of priority, and answered the questions 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 (NGC) and the Centers for Disease Control and Prevention (CDC): 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 diseases (STDs) 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 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 also is enforced in most states. Although it rarely occurs, STD diagnoses may later be accessed, and the survivor and clinician may opt to defer testing for this reason. While collection of specimens at initial examination for laboratory STD diagnosis gives the survivor and clinician the option to defer empiric prophylactic antimicrobial treatment, compliance with follow up visits is traditionally poor. Among sexually active adults, the identification of an STD might represent an infection acquired prior to the assault, and therefore, might be more important for the psychological and medical management of the patient than for legal purposes.

Trichomoniasis, bacterial vaginosis (BV), gonorrhea, and chlamydial infection are the most frequently diagnosed infections among women who have been sexually assaulted. Such conditions are relatively prevalent, and the presence after an assault does not necessarily imply acquisition during the assault. However, a post-assault examination presents an important opportunity to identify or prevent STDs. Chlamydial and gonococcal infections in women are of particular concern because of the possibility of ascending infection. In addition, hepatitis B virus (HBV) infection can be prevented by postexposure administration of hepatitis B vaccine. Reproductive-aged female survivors should be evaluated for pregnancy, if appropriate.

Evaluating Adults and Adolescents for Sexually Transmitted Diseases

Initial Examination

An initial examination might include the following procedures:

  • Nucleic acid amplification tests (NAATs) for Chlamydia trachomatis and Neisseria gonorrhoeae. These tests are preferred for the diagnostic evaluation of sexual assault victims, regardless of the sites of penetration or attempted penetration.
  • Wet mount and culture or point-of-care testing of a vaginal swab specimen for Trichomonas vaginalis infection. The wet mount also should be examined for evidence of BV and candidiasis, especially if vaginal discharge, malodor, or itching is evident.
  • A serum sample for immediate evaluation for human immunodeficiency virus (HIV) infection, hepatitis B, and syphilis. Decisions to perform these tests should be made on an individual basis.

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 vaccination, 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 can 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 can 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 can 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 section Risk for Acquiring HIV Infection below).

Prophylaxis

Compliance with follow-up visits is poor among survivors of sexual assault. As a result, routine preventive therapy after a sexual assault should be encouraged. The following prophylactic regimen is suggested as preventive therapy:

  • Postexposure hepatitis B vaccination, without hepatitis B immune globulin (HBIG). This vaccine should be administered to sexual assault survivors 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, and trichomonas.
  • Emergency contraception. (This measure is necessary only when the assault could result in pregnancy in the survivor).

Recommended Regimens

  • Ceftriaxone 250 mg intramuscularly (IM) in a single dose

    OR

  • Cefixime 400 mg orally 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 those requiring alternative treatments, refer to the specific sections in the original guideline document 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.

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 (e.g., bleeding, which often accompanies trauma) might increase risk for HIV transmission in cases involving 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 also might increase the risk for HIV.

Children might be at higher risk for transmission because the sexual abuse of children 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 the assault poses a risk for HIV exposure.

Several factors impact the medical recommendation for PEP and affect the assault survivor's acceptance of that recommendation, including 1) the likelihood of the assailant having HIV, 2) any exposure characteristics that might increase the risk for HIV transmission, 3) the time elapsed after the event, and 4) the potential benefits and risks associated with the PEP. Determination of the assailant's HIV status at the time of the assault examination usually in not possible. Therefore, the health-care provider should assess any available information concerning 1) characteristics and HIV risk behaviors of the assailant(s) (e.g., a man who has sex with other men and persons who use injection drugs or crack cocaine), 2) local epidemiology of HIV/acquired immune deficiency syndrome (AIDS), and 3) 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) any 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 importance of close follow-up; 3) the benefit of adherence to recommended dosing; and 4) the necessity of early initiation of PEP to optimize potential benefits (i.e., 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 such therapy. If use of PEP is judged to be warranted, the survivor should be offered a 3- to 5-day supply of PEP, and a follow-up visit should be scheduled several days later to allow for additional counseling.

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 (CBC) 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-related decisions can be obtained by calling the National Clinician's Post-Exposure Prophylaxis Hotline (PEP Line), 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 have an infection that could have been transmitted sexually 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 significance of infection that might have been acquired sexually and the recommended action regarding reporting of suspected child sexual abuse varies by the specific organism, as do the recommendations regarding reporting of suspected child sexual abuse (see Table 6 of the original guideline document). In all cases in which an STD has been diagnosed in a child, efforts should be made to detect evidence of sexual abuse, including conducting diagnostic testing for other commonly occurring STDs.

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. In addition, most 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 an STD can be identified.

Reporting

All 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.

Evaluating Children for Sexually Transmitted Diseases

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 place children at 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 can 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 a substantial amount of time elapsed between the last suspected episode of abuse and the 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 can be indicative of 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 N. gonorrhoeae culture 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. Because of the legal implications of a diagnosis of N. gonorrhoeae infection in a child, if culture for the isolation of N. gonorrhoeae is done, only standard culture procedures should be performed. Gram stains are inadequate to evaluate prepubertal children for gonorrhea and should not be used to diagnose or exclude gonorrhea. Specimens from the vagina, urethra, pharynx, or rectum should be streaked onto selective media for isolation of N. gonorrhoeae, and all presumptive isolates of N. gonorrhoeae should be identified definitively by at least two tests that involve different principles (i.e., biochemical, enzyme substrate, or serologic). Isolates should be preserved to enable additional or repeated testing.
  • Cultures for C. trachomatis from specimens collected from the anus in both boys and girls and from the vagina in girls. 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. NAATs can be used for detection of C. trachomatis in vaginal specimens or urine from girls. All specimens should be retained for additional testing if necessary. No data are available regarding the use of NAATs in boys or for extragenital specimens (e.g., those obtained from the rectum) in boys and girls. Culture remains the preferred method for extragenital sites.
  • 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 the agents for which to perform serologic tests should be made on a case-by-case basis.

Data on use of NAATs for detection of N. gonorrhoeae in children are limited, and performance is test dependent. Consultation with an expert is necessary before using NAATs in this context to minimize the possibility of cross-reaction with nongonococcal Neisseria species and other commensals (e.g., N. meningitidis, N. sicca, N. lactamica, N. cinerea, and Moraxella catarrhalis). NAATs can be used as an alternative to culture with vaginal specimens or urine from girls, whereas culture remains the preferred method for urethral specimens or urine from boys and for extragenital specimens (pharynx and rectum) from all children. All positive specimens should be retained for additional testing.

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). Although data are insufficient concerning the efficacy and safety of PEP among both children and adults, treatment is well-tolerated by infants and children (with and without HIV infection), and children 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 infected with HIV, 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 evaluating or treating 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 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 hepatitis B surface antigen (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 most 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.

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 this 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 human immunodeficiency virus (HIV) infection 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, and trichomonas; gastrointestinal side effects can occur with the combination treatment.

Qualifying Statements

Qualifying Statements
  • These recommendations should be regarded as a source of clinical guidance and not prescriptive standards; health-care providers should always consider the clinical circumstances of each person in the context of local disease prevalence. 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 guidelines focus on the treatment and counseling of individual patients and do not address other community services and interventions that are essential in sexually transmitted disease (STD)/human immunodeficiency virus (HIV) prevention efforts.
  • The recommendations in this report are limited to the identification, prophylaxis, and treatment of sexually transmitted diseases (STDs) 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
Mobile Device Resources
Resources
Slide Presentation
Staff Training/Competency Material
For information about 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 (CDC). Sexual assault and STDs. In: Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010 Dec 17;59(RR-12):90-5.
Adaptation

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

Date Released
1993 (revised 2010 Dec 17)
Guideline Developer(s)
Centers for Disease Control and Prevention - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Chairperson: Kimberly A. Workowski, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), CDC and Emory University, Atlanta, Georgia

Presenters: Heidi Bauer, MD, California Sexually Transmitted Disease Control Branch, Oakland, California; Laura Bachman, MD, Wake Forest University; Gale Burstein, MD, MPH, Erie County Department of Health; Linda Eckert, MD, University of Washington; William M. Geisler, MD, University of Alabama, Birmingham, Alabama; Khalil Ghanem, MD, Johns Hopkins University; Matt Golden, MD, MPH, University of Washington; Linda Gorgos, MD, New Mexico Department of Health; Margaret Hammerschlag, MD, State University of New York, Downstate Medical Center, Brooklyn, New York; Lisa Hollier, MD, University of Texas at Houston; Peter Leone, MD, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Jeanne Marrazzo, MD, University of Washington, Seattle, Washington; Kenneth Hugh Mayer, MD, Brown University Medical School, Providence, Rhode Island; Paul Nyirjesy, MD, Drexel University College of Medicine, Philadelphia, Pennsylvania; Anne Rompalo, MD, Johns Hopkins School of Medicine, Baltimore, Maryland; 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, Seattle, Washington; George Wendel, MD, University of Texas Southwestern Medical School, Dallas, Texas; Harold C. Wiesenfeld, MD, University of Pittsburgh, Pittsburgh, Pennsylvania

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

Rapporteurs: Hunter Handsfield, MD, University of Washington, Seattle, Washington; William McCormack, MD, State University of New York Health Science Center, Brooklyn, New York; William M. Geisler, MD, University of Alabama, Birmingham, Alabama

Consultants: N. Franklin Adkinson, MD, Johns Hopkins University; William Andrews, MD, PhD, University of Alabama, Birmingham; Michael Augenbraun, MD, State University of New York Health Science Center, Brooklyn, New York; Bryon Batteiger, MD, University of Indiana; Gail Bolan, MD, California Department of Health, Oakland, California; Bruce Coles, DO, New York Department of Health; Carolyn Deal, PhD, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland; J. Dennis Fortenberry, MD, Indiana University School of Medicine, Indianapolis, Indiana; Edward Hook, III, MD, University of Alabama, Birmingham, Alabama; Jane R. Schwebke, MD, University of Alabama, Birmingham, Alabama; Joann Schulte, DO, National Institutes of Health, Bethesda, Maryland; David Soper, MD, Medical University of South Carolina, Charleston, South Carolina; Lawrence Stanberry, MD, PhD, University of Texas Medical Branch, Galveston, Texas; Bruce Trigg, MD, New Mexico Department of Health; Yolanda Wimberly, MD, Morehouse School of Medicine; Jonathan M. Zenilman, MD, Johns Hopkins Bayview Medical Center, Baltimore, Maryland

Liaison Participants: Kaytura Aaron, MD, HRSA; Laura Bachman, MD, HIV Association of America; Lynn Barclay, MD, American Social Health Association; Margaret J. Blythe, MD, American Academy of Pediatrics; Carolyn D. Deal, PhD, National Institutes of Health; Jordon Dimitrakov, MD, PhD, American Urological Association; Mark FitzGerald, MD, British Association for Sexual Health and HIV, Southampton, United Kingdom; Dennis Fortenberry, MD, Society of Adolescent Medicine; Edward W. Hook, III, MD, Infectious Disease Society of America; Noreen Jack, MD, Pan American Health Association; Peter Kerndt, MD, National Coalition of STD Directors; Jeanne Marrazzo, MD, American Sexually Transmitted Diseases Association; Francis J. Ndowa, MD, World Health Organization, Geneva, Switzerland; Michael Parkinson, MD, American College of Preventative Medicine; Jeffrey Piepert, MD, American College of Obstetrics and Gynecology; Patricia Reams, MD, National Commission on Correctional Health Care; Bisan Salhi, MD, American College of Emergency Physicians; Karen Shea, MSN, Planned Parenthood Federation of America; David Soper, MD, Infectious Diseases Society for Obstetrics and Gynecology; Bradley Stoner, MD, PhD, CDC STD Prevention Training Centers; Amy Swann, Association of Reproductive Health Professionals; Litjen Tan, PhD, American Medical Association; Tom Wong, MD, Public Health Agency of Canada, Ottawa, Ontario, Canada

CDC, Division of Sexually Transmitted Disease Prevention Treatment Guidelines 2010 Project Coordinator: Kimberly A. Workowski, MD, NCHHSTP, CDC and Emory University, Atlanta, GA

Project Manager: Richard Voigt, NCHHSTP, CDC, Atlanta, Georgia

NCHHSTP/CDC Presenters: Deblina Datta, MD; Eileen Dunne, MD; Matthew Hogben, PhD; Scott Holmberg, MD; Emily Koumans, MD; Lori Newman, MD

CDC Consultants: Sevgi O. Aral, PhD; Ronald Ballard, PhD; Bernard Branson, MD; John Brooks, MD, MPH; John Douglas, MD; Alison Friedman; Dale Hu, MD; Peter Kilmarx, MD; John Papp, PhD; Phil Spradling, MD

Support Staff: Brenda Kelley, Valerie Barner, and Deborah McElroy, NCHHSTP, CDC, Atlanta, Georgia

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 2006 Aug 4;55(RR-11):80-6.

Guideline Availability

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

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:

  • The Centers for Disease Control and Prevention (CDC) sexually transmitted diseases (STD) treatment guidelines, 2010. eBook for iPad, iPhone, and iPod Touch. Available from the CDC Web site External Web Site Policy.
  • 2010 STD treatment guidelines webinar: an overview by CDC and the National Network of STD/HIV Prevention Training Centers (NNPTC), including continuing medical education (CME) activity. Available from the CDC Web site External Web Site Policy. Slides from the webinar are also available from the CDC Web site External Web Site Policy.
  • Sexually transmitted diseases treatment guidelines, 2010. Pod cast. Available from the CDC Web site External Web Site Policy.
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). This summary was updated by ECRI Institute on May 5, 2009, following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This NGC summary was updated by ECRI Institute on September 14, 2011.

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