Diagnosis and Treatment of Sexually Transmitted Infections in Urgent Care

Table of Contents

 

About This Course

Sexually transmitted infections are a growing public health threat that is often underrecognized by both patients and clinicians. Symptoms of STIs may overlap, and some STIs may be asymptomatic. Testing is most accurate if the appropriate sample collection method is used within the most likely window for detection by laboratory testing. Urgent care clinicians can play an important role in identification and management of STIs. In this issue, you will learn:

How to obtain a thorough but sensitive history in a patient with suspected STIs

The physical examination findings associated with chlamydia, gonorrhea, syphilis, bacterial vaginosis, donovanosis, lymphogranuloma venereum, genital herpes, human papillomavirus, and trichomoniasis

The window and incubation periods for common STIs, which can help to determine when to test

How to select the appropriate test type based on the suspected STI(s), test availability, patient presentation, and local disease prevalence

The updated treatment recommendations for STIs, including treatment for pregnant patients

When expedited partner therapy should be offered

CHARTING & CODING: How to select the appropriate level of service for urgent care encounters related to STIs

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
   1. Chlamydia trachomatis Infection
   2. Gonorrhea
   3. Syphilis
   4. Bacterial Vaginosis
   5. Donovanosis (Granuloma Inguinale)
   6. Lymphogranuloma Venereum
   7. Mycoplasma genitalium
   8. Genital Herpes
   9. Human Papillomavirus
   10. Trichomoniasis
6. Differential Diagnosis
7. Emergency Medical Services Transport
8. Urgent Care Evaluation
   1. History
   2. Physical Examination
      1. Physical Examination Findings in Chlamydia
      2. Physical Examination Findings in Gonorrhea
      3. Physical Examination Findings in Syphilis
      4. Physical Examination Findings in Bacterial Vaginosis
      5. Physical Examination Findings in Donovanosis
      6. Physical Examination Findings in Lymphogranuloma Venereum
      7. Physical Examination Findings in Genital Herpes
      8. Physical Examination Findings in Human Papillomavirus
      9. Physical Examination Findings in Trichomoniasis
9. Diagnostic Studies
   1. Chlamydia Testing
   2. Gonorrhea Testing
   3. Syphilis Testing
   4. Bacterial Vaginosis Testing
   5. Donovanosis Testing
   6. Lymphogranuloma Venereum Testing
   7. Mycoplasma genitalium Testing
   8. Genital Herpes Testing
   9. Human Papillomavirus Testing
   10. Trichomoniasis Testing
10. Treatment
    1. Chlamydia Treatment
    2. Gonorrhea Treatment
    3. Syphilis Treatment
    4. Bacterial Vaginosis Treatment
    5. Donovanosis Treatment
    6. Lymphogranuloma Venereum Treatment
    7. Mycoplasma genitalium Treatment
    8. Genital Herpes Treatment
    9. Human Papillomavirus Treatment
    10. Trichomoniasis Treatment
11. Special Populations
    1. Pregnant Patients
       1. Chlamydia
       2. Gonorrhea
       3. Syphilis
       4. Bacterial Vaginosis
       5. Genital Herpes
       6. Human Papillomavirus
       7. Trichomoniasis
    2. Persons in Correctional Facilities
12. Controversies and Cutting Edge
    1. Antimicrobial Resistance
    2. Ceftriaxone Administration Route for Treatment of Gonorrhea
    3. Strategies for Partner Therapies
       1. Syphilis
       2. Bacterial Vaginosis
       3. Trichomoniasis
       4. Genital Herpes
       5. Human Papillomavirus
    4. Zika Virus
    5. Mpox
13. Disposition
14. Summary
15. Risk Management Pitfalls in the Treatment of Sexually Transmitted Infections in Urgent Care
16. 5 Things That Will Change Your Practice
17. Case Conclusions
18. Charting & Coding: What You Need to Know
    1. Medical Decision Making
       1. Problems Addressed Category
       2. Complexity of Data Category
       3. Risk of Complications Category
       4. Asymptomatic Patients
19. Clinical Pathway for Management of Sexually Transmitted Infections in Urgent Care
20. References

Abstract

Sexually transmitted infections (STIs) continue to be a growing threat to public health. Because they may be asymptomatic or feature nonspecific signs and symptoms, STIs often go underrecognized by patients and healthcare workers. Frontline clinicians in particular must remain vigilant, playing a critical role in combatting the rising tide of infections by obtaining a thorough but sensitive history, conducting an appropriate physical examination, ordering relevant laboratory tests, and, when necessary, prescribing antimicrobial treatments. This issue reviews the CDC's 2021 updated guidelines for the diagnosis and treatment of STIs, focusing on efficient and safe strategies to promote health for all patients and their partners, regardless of their sex, gender, age, pregnancy status, or other demographic variables.

Case Presentations

A 32-year-old woman walks in reporting she has a urinary tract infection...

• Her vital signs are reassuring at triage: blood pressure, 120/63 mm Hg; heart rate, 71 beats/min; respiratory rate, 18 breaths/min; oxygen saturation,100% on room air; and temperature, 37°C (98.6°F).
• The intake note states: “Patient presents today with a 3-week history of dysuria, urinary frequency, and lower abdominal pain despite a full course of nitrofurantoin prescribed by another local urgent care clinic and a full course of ciprofloxacin prescribed by her primary care provider thereafter.”
• When you examine the patient, she advises she felt mild improvement in her symptoms 2 days prior, but now has persistent dysuria again.
• Her initial physical exam is positive only for mild suprapubic discomfort with palpation. Urinalysis shows small leukocyte esterase and negative nitrite. Her urine pregnancy test is negative.
• You wonder whether to prescribe a third antibiotic and send a urine culture, or if there is something else you should be considering…

A 50-year-old man and his wife present to clinic, clearly arguing with one another in hushed tones...

• While the man is being triaged, he says he has “bumps” on his penis. He reports that the lesions appeared 3 days ago and are itchy but not painful.
• He denies use of any new soaps, detergents, or other potential allergens. He states that he hasn’t noticed any bumps elsewhere and has never had a skin rash like this before.
• During the chaperoned physical exam, you note a small cluster of red bumps at the base of the penis. There is no drainage, crusting, or ulcerated tissue.
• As you consider the differential diagnosis for these bumps, you wonder how best to broach the possibility of genital herpes with this married couple, wishing to be both gentle but comprehensive in your evaluation...

A 19-year-old college student calls ahead, asking if any female providers are working that day...

• On arrival, the anxious but otherwise healthy young woman states that she was sexually assaulted at a party 2 nights ago. She does not know what happened but believes she was drugged by someone at the party and only remembers waking up in an empty hotel room.
• She does not want to go to the ED for a forensic exam but does ask to be treated for STIs.
• You recall that the CDC recently updated its guidelines for victims of sexual assault and return to your workstation to check the current recommendations…

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Clinical Pathway for Management of Sexually Transmitted Infections in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Are sex toys safe? National Health Service England. Updated January 5, 2023. Accessed February 10, 2023. (UK National Health Service informational webpage)

2. * Kessler R, Hinkle BT, Moyers A, et al. Adolescent sexual health: identity, risk, and screening for sexually transmitted infections. Prim Care. 2020;47(2):367-382. (Review) DOI: 10.1016/j.pop.2020.02.012

4. * Silverberg B, Moyers A, Hinkle BT, et al. 2021 CDC update: treatment and complications of sexually transmitted infections (STIs). Venereology. 2022;1(1):23-46. (Review of CDC recommendations) DOI: 10.3390/venereology1010004

5. New data suggest STDs continued to increase during first year of the COVID-19 pandemic. Centers for Disease Control and Prevention. News release. April 22, 2022. Accessed February 10, 2023. (Press release)

6. 2017 STD surveillance report. Centers for Disease Control and Prevention. Last reviewed September 25, 2018. Accessed February 10, 2023. (CDC guidelines)

7. * Torrone E, Papp J, Weinstock H. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years--United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838. (Expert guideline/systematic review)

10. * Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. (Expert guidelines/systematic review) DOI: 10.15585/mmwr.rr7004a1

12. Centers for Disease Control and Prevention, Division of STD Prevention. Sexually Transmitted Disease Surveillance 2017. 2018. Accessed February 10, 2023. (CDC report)

25. HPV infection. Centers for Disease Control and Prevention. Last reviewed July 23, 2021. Accessed February 10, 2023. (CDC website)

26. 1 in 5 people in the U.S. have a sexually transmitted infection. Centers for Disease Control and Prevention. News release. January 25, 2021. Accessed February 10, 2023. (Press release)

29. * A guide to taking a sexual history. Centers for Disease Control and Prevention. Last reviewed January 14, 2022. Accessed February 10, 2023. (CDC clinician guidance)

46. * Adamson PC, Loeffelholz MJ, Klausner JD. Point-of-care testing for sexually transmitted infections: a review of recent developments. Arch Pathol Lab Med. 2020;144(11):1344-1351. (Review) DOI: 10.5858/arpa.2020-0118-RA

47. FDA allows for first point-of-care chlamydia and gonorrhea test to be used in more near-patient care settings. News release. US Food and Drug Administration. March 30, 2021. Accessed February 10, 2023. (Press release)

61. Association of Public Health Laboratories. Laboratory diagnostic testing for Treponema pallidum: expert consultation meeting summary report. 2009. Accessed February 10, 2023. (Expert guidelines)

62. * Ghanem KG, Ram S, Rice PA. The modern epidemic of syphilis. N Engl J Med. 2020;382(9):845-854. (Review) DOI: 10.1056/NEJMra1901593

75. STI Treatment Guidelines, 2021: Chlamydial infection among adolescents and adults. Centers for Disease Control and Prevention. Last reviewed July 22, 2021. Accessed February 10, 2023. (CDC guidelines)

77. * The American College of Obstetricians and Gynecologists. Management of genital herpes in pregnancy: ACOG Practice Bulletin, Number 220. Obstet Gynecol. 2020;135(5):e193-e202. (Practice guidelines) DOI: 10.1097/AOG.0000000000003840

80. STI Treatment Guidelines, 2021: Gonococcal infections among adolescents and adults. Centers for Disease Control and Prevention. Last reviewed September 21, 2022. Accessed February 10, 2023. (CDC guidelines)

81. Syphilis – CDC detailed fact sheet. Centers for Disease Control and Prevention. Last reviewed April 12, 2022. Accessed February 10, 2023. (CDC fact sheet)

89. * Vodstrcil LA, Plummer EL, Doyle M, et al. Treating male partners of women with bacterial vaginosis (StepUp): a protocol for a randomised controlled trial to assess the clinical effectiveness of male partner treatment for reducing the risk of BV recurrence. BMC Infect Dis. 2020;20(1):834. (Randomized controlled trial; 342 couples) DOI: 10.1186/s12879-020-05563-w

92. World Health Organization. Recommendations for treatment of genital herpes simplex virus. In: WHO Guidelines for the Treatment of Genital Herpes Simplex Virus. 2016; chap 4. Accessed February 10. 2023. (Guidelines)

95. STI Treatment Guidelines, 2021: Trichomoniasis. Centers for Disease Control and Prevention. Last reviewed September 21, 2022. Accessed February 10, 2023. (CDC guidelines)

104. STI Treatment Guidelines, 2021: Reporting and confidentiality. Centers for Disease Control and Prevention. Last reviewed July 22, 2021. Accessed February 10, 2023. (Guideline)

108. Strick LB, Budak JZ. HIV and corrections. National HIV Curriculum. Updated August 26, 2020. Accessed February 10, 2023. (Review)

109. *European Centre for Disease Prevention and Control. Response plan to control and manage the threat of multi- and extensively drug-resistant gonorrhoea in Europe: 2019 update. 2019. Accessed February 10, 2023. (Technical report)

110. *Krupp K, Madhivanan P. Antibiotic resistance in prevalent bacterial and protozoan sexually transmitted infections. Indian J Sex Transm Dis AIDS. 2015;36(1):3-8. (Review) DOI: 10.4103/0253-7184.156680

111. Roche. ROCEPHIN® (ceftriaxone sodium) for injection. 2004. Accessed February 10, 2023. (Drug company package insert)

112. *Schillinger JA, Gorwitz R, Rietmeijer C, et al. The expedited partner therapy continuum: a conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 Suppl 1):S63-S75. (Systematic review; 42 articles) DOI: 10.1097/OLQ.0000000000000399

114. Expedited partner therapy. Centers for Disease Control and Prevention. Last reviewed April 19, 2021. Accessed February 10, 2023. (CDC website)

117. About Zika. Centers for Disease Control and Prevention. Last reviewed May 20, 2019. Accessed February 10, 2023. (Overview)

118. Monkeypox: past U.S. cases and outbreaks. Centers for Disease Control and Prevention. Last reviewed June 6, 2022. Accessed February 10, 2023. (CDC information)

119. CDC Health Alert Network. Updated case-finding guidance: monkeypox outbreak—United States, 2022. Centers for Disease Control and Prevention. Last reviewed June 14, 2022. Accessed February 10, 2023. (CDC public health update)

120. 2022 national notifiable infectious diseases (historical). Centers for Disease Control and Prevention. Accessed February 10, 2023. (CDC website)

122. *Owens DK, Davidson KW, Krist AH, et al. Screening for HIV infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(23):2326-2336. (Practice recommendation) DOI: 10.1001/jama.2019.6587

123. *Carter MW, Wu H, Cohen S, et al. Linkage and referral to HIV and other medical and social services: a focused literature review for sexually transmitted disease prevention and control programs. Sex Transm Dis. 2016;43(2 Suppl 1):S76-S82. (Systematic review; 33 studies) DOI: 10.1097/OLQ.0000000000000290

124. *Burns CM, Endres K, Farrow L, et al. Perceptions on HIV pre-exposure prophylaxis among urgent care clinicians in the southern United States. Curr HIV Res. 2022. (Cross-sectional survey; 82 urgent care clinicians) DOI: 10.2174/1570162X20666220426094920

126. * Human immunodeficiency virus (HIV) infection: screening. US Preventive Services Task Force. July 11, 2019. Accessed February 10, 2023. (Recommendation statement)

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Keywords: sexually transmitted infection, sexually transmitted disease, STI, STD, chlamydia, gonorrhea, syphilis, herpes, genital herpes, HIV, human papillomavirus, HPV, HSV, HSV-1, HSV-2, trichomonas, trichomoniasis, bacterial vaginosis, Donovanosis, lymphogranuloma venereum, Mycoplasma genitalium, chancre, condylomata lata, gumma, cervicitis, NAAT, VDRL, FTA-ABS, TP-PA, treponemal, window period, incubation period, EPT, expedited partner therapy, Zika virus, Mpox, Monkeypox