Prophylaxis After Sexual Assault

Patient Population:

Pediatric

This and other STI sections are not meant to be comprehensive references for all STI treatment but primarily focused on the most commonly used initial empiric antimicrobial therapy. Users should refer to linked resources (SFDPH City Clinic protocols, CDC guidelines) or other local resources to provide patients and their partners appropriate counseling and follow-up. For non-adolescent age patients, patients with STIs not addressed in these guidelines, or patients with contraindications to the listed therapies, we recommend referring to the linked resources, or Lexi-Comp for medication information, or consulting ID/ASP for individualized recommendations.  

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Sexual assault	Multiple possible exposures (including Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, HIV, Treponema pallidum, HBV)	For postpubertal adolescents: Ceftriaxone Weight> 45 kg and <150kg: 500 mg IM x 1 dose Weight>=150kg: 1000 mg IM x 1 dose AND Doxycycline 100 mg enterally bid x 7 days AND Metronidazole 500 mg enterally bid x 7 days Consider HIV post-exposure prophylaxis	Pregnancy not ruled out: Replace Doxycycline with Azithromycin 1000 mg enterally  x 1 dose Penicillin or cephalosporin allergy with higher risk for allergic reaction: Omit Ceftriaxone from regimen, monitor, test & treat for gonorrhea as clinically indicated	Refer to facility specific HIV post-exposure prophylaxis guidelines (BCH OAK) or to national guidelines Assistance can be obtained by calling the National Clinician’s PEP hotline Perform pregnancy testing and provide emergency contraception when appropriate Review hepatitis B and HPV vaccination status and need for repeat vaccination or HBIG

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Sexual assault

Multiple possible exposures (including Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, HIV, Treponema pallidum, HBV)

For postpubertal adolescents:

Ceftriaxone

Weight> 45 kg and <150kg:

500 mg IM x 1 dose

Weight>=150kg:

1000 mg IM x 1 dose

AND

Doxycycline
100 mg enterally bid x 7 days

AND

Metronidazole
500 mg enterally bid x 7 days

Consider HIV post-exposure prophylaxis

Pregnancy not ruled out:

Replace Doxycycline with Azithromycin 1000 mg enterally  x 1 dose

Penicillin or cephalosporin allergy with higher risk for allergic reaction:
Omit Ceftriaxone from regimen, monitor, test & treat for gonorrhea as clinically indicated

Refer to facility specific HIV post-exposure prophylaxis guidelines (BCH OAK) or to national guidelines

Assistance can be obtained by calling the National Clinician’s PEP hotline

Perform pregnancy testing and provide emergency contraception when appropriate

Review hepatitis B and HPV vaccination status and need for repeat vaccination or HBIG

References: 

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021. 

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

St. Cyr S, et al. Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916.

Sexually Transmitted Infections

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Trichomoniasis

Patient Population:

Pediatric

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Trichomoniasis	Trichomonas vaginalis	Metronidazole 500 mg enterally bid	Tinidazole is another option for patients with contraindications to metronidazole; refer to CDC guidelines linked below, or SFDPH City Clinic protocol linked in comments	Current partners should be evaluated and presumptively treated Duration: 7 days Refer to SFDPH City Clinic STI protocols section on trichomoniasis for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex for at least 7 days after patient and partner treatment, and avoid alcohol consumption during treatment), and follow up (including retesting in 3 months)

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Trichomoniasis

Trichomonas vaginalis

Metronidazole
500 mg enterally bid

Tinidazole is another option for patients with contraindications to metronidazole; refer to CDC guidelines linked below, or SFDPH City Clinic protocol linked in comments

Current partners should be evaluated and presumptively treated

Duration: 7 days

Refer to SFDPH City Clinic STI protocols section on trichomoniasis for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex for at least 7 days after patient and partner treatment, and avoid alcohol consumption during treatment), and follow up (including retesting in 3 months)

Reference:

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

Sexually Transmitted Infections

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Syphilis

Patient Population:

Pediatric

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Syphilis, adolescent treatment See separate Congenital Syphilis section	Treponema pallidum	Primary, secondary, or early latent:  Benzathine Penicillin G 50,000 units/kg (max 2.4 million units/dose) IM x 1 dose ------------------------ Late latent, or latent of unknown duration: Benzathine Penicillin G 50,000 units/kg/dose (max 2.4 million units/dose) IM qweek x 3 doses	Penicillin allergy with higher risk for allergic reaction, patient not pregnant: Doxycycline 100mg/dose enterally bid x 14 days Consult ID/ASP for other options if doxycycline contraindicated	Sexual partners should be notified and evaluated per linked SFDPH City Clinic guidelines below, following recommendations based on the patient’s stage of infection RPR titer should be checked on the day of treatment to provide baseline for follow-up serology monitoring Refer to SFDPH City Clinic STI protocols section on syphilis for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex during patient and partner treatment), and follow up (including retesting recommendations based on stage of infection) Patients who are receiving three doses of penicillin must restart their treatment if more than 10 days elapse since the last dose. They should also receive each dose no sooner than five days since the preceding one.

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Syphilis, adolescent treatment

See separate Congenital Syphilis section

Treponema pallidum

Primary, secondary, or early latent: 

Benzathine Penicillin G 50,000 units/kg (max 2.4 million units/dose) IM x 1 dose

------------------------

Late latent, or latent of unknown duration:

Benzathine Penicillin G 50,000 units/kg/dose (max 2.4 million units/dose) IM qweek x 3 doses

Penicillin allergy with higher risk for allergic reaction, patient not pregnant:

Doxycycline
100mg/dose enterally bid x 14 days

Consult ID/ASP for other options if doxycycline contraindicated

Sexual partners should be notified and evaluated per linked SFDPH City Clinic guidelines below, following recommendations based on the patient’s stage of infection

RPR titer should be checked on the day of treatment to provide baseline for follow-up serology monitoring

Refer to SFDPH City Clinic STI protocols section on syphilis for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex during patient and partner treatment), and follow up (including retesting recommendations based on stage of infection)

Patients who are receiving three doses of penicillin must restart their treatment if more than 10 days elapse since the last dose. They should also receive each dose no sooner than five days since the preceding one.

References:

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

Sexually Transmitted Infections

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Pelvic Inflammatory Disease

Patient Population:

Pediatric

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Pelvic inflammatory disease, inpatient therapy Need for inpatient therapy is based on clinical judgment and meeting any suggested criteria: Surgical emergencies (e.g., appendicitis) cannot be excluded Severe PID (vomiting, severe pain, high fever, overt peritonitis) Tubo-ovarian abscess Pregnancy Inability to follow or tolerate outpatient regimen Treatment failure on appropriate outpatient regimen	Often polymicrobial Chlamydia trachomatis Neisseria gonorrhoeae Enteric gram-negative and anaerobic bacteria	Cefoxitin 2000 mg IV q6h AND Doxycycline 100 mg enterally or IV q12h (enteral route preferred if tolerated) 24 hours after clinical improvement: Stop Cefoxitin, continue Doxycycline 100 mg enterally bid, and ADD Metronidazole 500 mg enterally bid to complete 14 day total course*	Penicillin or cephalosporin allergy with higher risk for allergic reaction: Clindamycin 900 mg IV q8h  AND  Gentamicin 2 mg/kg/dose IV x 1 dose, followed by 1.5 mg/kg/dose IV q8h  24 hours after clinical improvement: Stop Clindamycin and Gentamicin, start Doxycycline 100 mg enterally  bid and Metronidazole 500 mg enterally bid to complete 14 day total course	Refer to SFDPH City Clinic STI protocols section on PID for diagnostic criteria, recommended laboratory evaluation (including testing for other STIs), counseling (including abstinence from sex during treatment),  partner treatment, and follow up (including retesting in 3 months). *Metronidazole likely improves outcomes in all patients with PID, and is especially indicated if bacterial vaginosis or tubo-ovarian abscess cannot be ruled out
Pelvic inflammatory disease, outpatient therapy Outpatient treatment is standard in those patients with mild to moderate symptoms and able to return for frequent reassessment. All patients who begin outpatient treatment should be clinically re-evaluated within 72 hours and if not improved should start parenteral therapy and consider additional diagnostics	Same	Ceftriaxone Weight > 45 kg and <150kg: 500 mg IM x 1 dose Weight >=150kg: 1000 mg IM x 1 dose AND Doxycycline 100 mg enterally bid x 14 days AND  Metronidazole 500 mg enterally bid x 14 days*	Penicillin or cephalosporin allergy with higher risk for allergic reaction:  Consult ID/ASP If anticipate significant challenges to adherence: Consider replacing Doxycycline with: Azithromycin 1000 mg enterally qweek x 2 doses	Refer to SFDPH City Clinic STI protocols section on PID for diagnostic criteria, evaluation, counseling, and follow up recommendations *Metronidazole likely improves outcomes in all patients with PID, and is especially indicated if bacterial vaginosis or tubo-ovarian abscess cannot be ruled out

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Pelvic inflammatory disease, inpatient therapy

Need for inpatient therapy is based on clinical judgment and meeting any suggested criteria:

Surgical emergencies (e.g., appendicitis) cannot be excluded

Severe PID (vomiting, severe pain, high fever, overt peritonitis)

Tubo-ovarian abscess

Pregnancy

Inability to follow or tolerate outpatient regimen

Treatment failure on appropriate outpatient regimen

Often polymicrobial

Chlamydia trachomatis

Neisseria gonorrhoeae

Enteric gram-negative and anaerobic bacteria

Cefoxitin
2000 mg IV q6h

AND

Doxycycline
100 mg enterally or IV q12h (enteral route preferred if tolerated)

24 hours after clinical improvement:

Stop Cefoxitin, continue Doxycycline 100 mg enterally bid, and ADD Metronidazole 500 mg enterally bid to complete 14 day total course*

Penicillin or cephalosporin allergy with higher risk for allergic reaction:

Clindamycin
900 mg IV q8h 

AND 

Gentamicin
2 mg/kg/dose IV x 1 dose, followed by 1.5 mg/kg/dose IV q8h 

24 hours after clinical improvement:

Stop Clindamycin and Gentamicin, start Doxycycline 100 mg enterally  bid and Metronidazole 500 mg enterally bid to complete 14 day total course

Refer to SFDPH City Clinic STI protocols section on PID for diagnostic criteria, recommended laboratory evaluation (including testing for other STIs), counseling (including abstinence from sex during treatment),  partner treatment, and follow up (including retesting in 3 months).

*Metronidazole likely improves outcomes in all patients with PID, and is especially indicated if bacterial vaginosis or tubo-ovarian abscess cannot be ruled out

Pelvic inflammatory disease, outpatient therapy

Outpatient treatment is standard in those patients with mild to moderate symptoms and able to return for frequent reassessment. All patients who begin outpatient treatment should be clinically re-evaluated within 72 hours and if not improved should start parenteral therapy and consider additional diagnostics

Same

Ceftriaxone

Weight > 45 kg and <150kg: 500 mg IM x 1 dose

Weight >=150kg:
1000 mg IM x 1 dose

AND

Doxycycline
100 mg enterally bid x 14 days

AND 

Metronidazole
500 mg enterally bid x 14 days*

Penicillin or cephalosporin allergy with higher risk for allergic reaction: 

Consult ID/ASP

If anticipate significant challenges to adherence:

Consider replacing Doxycycline with:

Azithromycin
1000 mg enterally qweek x 2 doses

Refer to SFDPH City Clinic STI protocols section on PID for diagnostic criteria, evaluation, counseling, and follow up recommendations

*Metronidazole likely improves outcomes in all patients with PID, and is especially indicated if bacterial vaginosis or tubo-ovarian abscess cannot be ruled out

References:

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

Wiesenfeld, HC, et al.. (2020). A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis 2020;72;1181-1189.

St. Cyr S, et al. Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916.

Sexually Transmitted Infections

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Gonorrhea

Patient Population:

Pediatric

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Gonorrhea (uncomplicated infections of the cervix, urethra, rectum, or pharynx) See Pelvic Inflammatory Disease section for patients with consistent clinical findings	Neisseria gonorrhoeae	Ceftriaxone Weight >45 kg and <150kg: 500 mg IM x 1 dose Weight >=150kg: 1000 mg IM x 1 dose If chlamydia has not been excluded:  ADD Doxycycline 100 mg enterally bid x 7 days	If chlamydia hhas not been excluded, AND pregnancy has not been excluded, or anticipate significant challenges to adherence:  Replace Doxycycline with Azithromycin 1000 mg enterally x 1 dose Doxycycline is likely superior to azithromycin for treatment of chlamydia in all sites, and particularly for rectal and urethral chlamydia Penicillin or cephalosporin allergy with higher risk for allergic reaction*:  Consult ID/ASP	All sexual partners within preceding 60 days should be notified, tested, and treated; if not feasible then expedited partner therapy is recommended Refer to SFDPH City Clinic STI protocols section on gonorrhea for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex for at least 7 days following patient treatment and until partner treatment), and follow up (including retesting at 7-14 days for patients with pharyngeal gonorrhea and in 3 months for all patients)

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Gonorrhea (uncomplicated infections of the cervix, urethra, rectum, or pharynx)

See Pelvic Inflammatory Disease section for patients with consistent clinical findings

Neisseria gonorrhoeae

Ceftriaxone

Weight >45 kg and <150kg: 500 mg IM x 1 dose

Weight >=150kg:
1000 mg IM x 1 dose

If chlamydia has not been excluded: 

ADD Doxycycline
100 mg enterally bid x 7 days

If chlamydia hhas not been excluded, AND pregnancy has not been excluded, or anticipate significant challenges to adherence: 

Replace Doxycycline with Azithromycin 1000 mg enterally x 1 dose

*Doxycycline is likely superior to azithromycin for treatment of chlamydia in all sites, and particularly for rectal and urethral chlamydia

Penicillin or cephalosporin allergy with higher risk for allergic reaction: 

Consult ID/ASP

All sexual partners within preceding 60 days should be notified, tested, and treated; if not feasible then expedited partner therapy is recommended

Refer to SFDPH City Clinic STI protocols section on gonorrhea for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex for at least 7 days following patient treatment and until partner treatment), and follow up (including retesting at 7-14 days for patients with pharyngeal gonorrhea and in 3 months for all patients)

References:

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

San Francisco Department of Public Health City Clinic New Guidelines for Treatment of Gonococcal Infection, 12/2020

St. Cyr S, et al. Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916.

Sexually Transmitted Infections

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Chlamydia

Patient Population:

Pediatric

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Chlamydia (uncomplicated anogenital tract infection) See Pelvic Inflammatory Disease section for patients with consistent clinical findings	Chlamydia trachomatis	Doxycycline 100 mg enterally bid	If pregnancy has not been excluded, or anticipate significant challenges to adherence:  Azithromycin 1000 mg enterally x 1 dose* *Doxycycline is likely superior to azithromycin for treatment of chlamydia in all sites, and particularly for rectal and urethral chlamydia	All sexual partners within preceding 60 days should be notified, tested, and treated; if not feasible then expedited partner therapy is recommended Refer to SFDPH City Clinic STI protocols section on chlamydia for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex during patient and partner treatment), and follow up (including retesting in 3 months) Duration: 7 days for doxycycline, single dose for azithromycin

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Chlamydia (uncomplicated anogenital tract infection)

See Pelvic Inflammatory Disease section for patients with consistent clinical findings

Chlamydia trachomatis

Doxycycline
100 mg enterally bid

If pregnancy has not been excluded, or anticipate significant challenges to adherence: 

Azithromycin
1000 mg enterally x 1 dose*

*Doxycycline is likely superior to azithromycin for treatment of chlamydia in all sites, and particularly for rectal and urethral chlamydia

All sexual partners within preceding 60 days should be notified, tested, and treated; if not feasible then expedited partner therapy is recommended

Refer to SFDPH City Clinic STI protocols section on chlamydia for recommended laboratory evaluation (including testing for other STIs), and further recommendations on partner treatment, counseling (including abstinence from sex during patient and partner treatment), and follow up (including retesting in 3 months)

Duration: 7 days for doxycycline, single dose for azithromycin

References:

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

St. Cyr S, et al. Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916.

San Francisco Department of Public Health City Clinic New Guidelines for Treatment of Gonococcal Infection, 12/2020

Kong FYS, et al. Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. Clin Infect Dis 2014;59:193–205.

Dombrowski JC et al, Doxycycline versus azithromycin for the treatment of rectal chlamydia in men who have sex with men: a randomized controlled trial. Clin Infect Dis, 2021 (epub)

Dukers-Muijrers N, et al. Treatment effectiveness of azithromycin and doxycycline in uncomplicated rectal and vaginal Chlamydia trachomatis infections in women: a multicenter observational study (FemCure). Clin Infect Dis, 2019; 69: 1946-1954

Chandra NL, et al.  Detection of Chlamydia trachomatis in rectal specimens in women and its association with anal intercourse: a systematic review and meta-analysis. Sex Transm Infect 2018; 94:320–6.

Jensen JS, et al. Azithromycin treatment failure in Mycoplasma genitalium-positive patients with nongonococcal urethritis is associated with induced macrolide resistance. Clin Infect Dis. 2008;47:1546–53.

Bachmann LH, et al. Measured versus self-reported compliance with doxycycline therapy for chlamydia-associated syndromes: high therapeutic success rates despite poor compliance. Sex Transm Dis. 1999; 26:272-278.

Sexually Transmitted Infections

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Bacterial Vaginosis 

Patient Population:

Pediatric

Condition	Major Pathogens	First Choice Therapy	Alternative Therapy	Comments
Bacterial vaginosis, treatment in symptomatic patients	Anaerobic bacteria	Metronidazole 500 mg enterally bid x 7 days OR  Metronidazole gel 0.75% one applicator (5 g) intravaginally at bedtime daily	Other treatment options exist for patients with contraindications to metronidazole; refer to CDC guidelines linked below, or SFDPH City Clinic protocol linked in comments	Refer to SFDPH City Clinic STI protocols section on bacterial vaginosis for recommended evaluation, additional STI testing, counseling (including to avoid alcohol consumption during treatment), and follow up Duration: 7 days for systemic treatment (enteral), 5 days for intravaginal treatment

Condition

Major Pathogens

First Choice Therapy

Alternative Therapy

Comments

Bacterial vaginosis, treatment in symptomatic patients

Anaerobic bacteria

Metronidazole
500 mg enterally bid x 7 days

Metronidazole gel
0.75% one applicator (5 g) intravaginally at bedtime daily   

Other treatment options exist for patients with contraindications to metronidazole; refer to CDC guidelines linked below, or SFDPH City Clinic protocol linked in comments

Refer to SFDPH City Clinic STI protocols section on bacterial vaginosis for recommended evaluation, additional STI testing, counseling (including to avoid alcohol consumption during treatment), and follow up

Duration: 7 days for systemic treatment (enteral), 5 days for intravaginal treatment

Reference:

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

Sexually Transmitted Infections