Sexually Transmitted Infections

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Introduction

We have high rates of Sexually Transmitted Infections (STIs) in the Delta region and Alaska typically ranks number one or two in the nation for Chlamydia infections (CT) and Gonorrhea (GC). Due to high levels of STIs, it is recommended that we aggressively screen everyone over the age of 12 years old.

When screening for STIs, please confirm and document patient's phone number in your note as this is very helpful for the STI designated Provider to contact the patient if they have a positive result.

When someone asks for a STI check, please do urine, self-vaginal or cervical swab, anal and Oral GC/CT swab, RPR, and HIV tests. If a person specifically requests STI screening, inquire if they have gotten a social media notice or text from a partner notifying them of being a STI contact. Let them know many have NO symptoms with Chlamydia. Ask if they are interested in Hep B, C and Herpes (HSV1/HSV2) testing as well (FYI: HSV testing generally not offered unless specifically requested or herpetic lesion concern). When doing the urine STI test, it needs to be done with dirty urine without wiping beforehand. Use the AMB STI or the Village Reproductive PowerPlan which has all testing, treatments, etc. (Vaginal self swab preferred for any female over age 14, and not heavily menstruating).

A daily report generated of any +CT or +GC is sent to the Infectious Disease Advanced Practice Provide (IDAPP) who will complete the required AK State Epidemiology report form and follow-up with the patient regarding treatment. The provider should order any required medications and send a message to the IDAPP. We use Expedited Partner Therapy for anyone who is positive for GC or CT screening. The EPT kits can be given out at the hospital or the village clinic.

Please direct all reactive treponemal and HIV results to IDAPP by forwarding results. Any person who has a Reactive Syphilis or HIV test will have a State of AK Epidemiology report form filled out by the IDAPP to be sure a person is tracked and confirmatory testing completed. If a person is truly positive (confirmatory testing is positive) for Syphilis or HIV, the IDAPP will coordinate needed follow up care and initiation of medications.

Ideally, a Partner Notification Sheet is filled out so public health knows who was treated, but the patient does not need to provide the names of partners. The IDAPP is usually able to elicit the partner’s names, even if you are not.

Treatment Recommendations

As of July 15, 2021, STI treatment has been modified (see the table below):

STI treatment.PNG

Comments:

  1. While the CDC recommends Doxycycline if chlamydia cannot be ruled out, the STI team believes there is high risk for treatment failure with a 7-day course of medication and that one dose of azithromycin is a better choice. If a person has a +Anal/+Oral GC/CT result, they should be retested in 1month to be sure it is cleared, and appropriate medications to clear infection in Anal/Oral area should be prescribed.
  2. There is no effective therapy for pharyngeal gonorrhea beside ceftriaxone, thus we recommend you contact HROB, IDAPP, or an ID specialist. Contacting the experts in Seattle for a recommendation for therapy is highly recommended.
  3. The recommended medications are on formulary at all of the village clinics and SRCs. They are also in the Pyxis in the ED, Outpatient Clinic, Inpatient and OB.

Treatment of chlamydia Workflow in the outpatient clinic (OPC)

  1. Patient is seen with a positive chlamydia. (This could be during a visit, a return visit, or the nurse only clinic.)
  2. The provider orders the azithromycin 250 mg oral tablet CLINIC STOCK (1000 mg, Oral, Form: Tab, Once) or use the AMB STI PowerPlan and select the correct order for azithromycin. (unit dose tablets for the PATIENT are found in the small pyxis machines near the nurses stations.)
  3. The nurse pulls the medication from the Pyxis and gives the patient the medicine as direct observed therapy. They then document per standard clinic nursing practice.
  4. Patient should be asked the number of partners in the last 3 months. This is usually done by the STI/HIV case manager. The patient should be asked if they are willing to take treatment doses to their partners.
  5. The nurse will pull a prepackaged dose from the Pyxis for every partner the patient lists by number. (The prepacked bottles for the PARTNERS are found in the large pyxis that is located in the storage room. There will not be an order placed in Powerchart for the partners, so these will have to be pulled under the patient’s name using the override function. They are listed as "Partner Pack Azithromycin 1,000mg" in the pyxis and you can pull as many as you need for your patient to give to their partners. They DO NOT need to give the Partner's name for this process.)
  6. The nurse will provide these doses in separate bags for each dose with the patient education for partners being treated for a chlamydia contact.

Frequently Asked Questions

  1. What if the patient is allergic to a recommended antibiotic choice?
    • Be absolutely sure that the patient is truly allergic. If they are TRULY allergic to all penicillins and cephalosporins, give Azithromycin 2gm orally. It is very important to treat with 2 drugs if possible. If you are not sure, consult IDAPP or ID specialist.
  2. What if the patient is only a contact?
    • Get the appropriate testing for STIs. Do a pharyngeal, genital, and anal test as needed. Treat for the appropriate STI as a contact. DO NOT treat their partners.
  3. Has the patient been previously treated? How can I tell?
    • Please check the MAR, medications and notes for evidence of treatment. Make sure that you set the filter on your medications for All Medications All Statuses. Make sure that you set the MAR dates to include the dates in questions.
    • When looking under lab results, “change search criteria” and back date, to find other +STI results.
  4. When do you recommend an HIV or RPR?
    • If the patient has a negative HIV and RPR within the past 6 months they do not need a repeat. We want to strongly encourage those without a recent test to get tested.
  5. What if the patient answers yes to anal or oral sex? Do I change the treatment?
    • If the patient answers yes to having anal or oral sex, perform the extra-genital swab as appropriate or find a provider to help. Treat per Sexually Transmitted Infection YKHC Clinical Guideline. Wait for a positive test to treat with different medications. (Anal/Oral +STI results will not clear unless correct RX is prescribed and taken)
  6. Are you asking the 5 P’s: Partners (who and how many and gender); Practices (This includes behavior making them at risk for HIV, such as ETOH/Drugs); Protection for STI (Condom use with all routes of sex); Past Hx of +STI; Prevention of Pregnancy.

Resources/References


Please direct any comments or questions to the IDAPP or STI designated Provider via email or TigerText.