Medical Treatment of Patient

Sexually Transmitted Infections

The Centers for Disease Control (CDC) and Prevention updated the sexually transmitted infection (STI) guidelines in 2021. For latest guidelines, see STI Treatment Guidelines.

Testing:

  • Nucleic acid amplification tests (NAATs) for Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) of sites of penetration or attempted/suspected penetration.
  • Wet prep, urine or vaginal NAAT for Trichomoniasis vaginalis.
  • Wet prep, vaginal pH, and potassium hydroxide (KOH) or bacterial vaginosis and candidiasis.
  • Serum samples for:
    • HIV,
    • Hepatitis, and
    • Syphilis.

Follow local protocols regarding weight or BMI for pregnancy prophylaxis and STI prophylaxis.

  • Adult Females (patients over 45 kg):
    • Ceftriaxone 500 mg IM in a single dose (1 g for persons weighing greater than 150 kg), plus
    • Doxycycline 100 mg two times per day orally for seven days, plus
    • Metronidazole 500 mg orally two times per day for seven days (females). Contraindicated if alcohol consumption. Consider providing a prescription.
  • Adult Males (patients over 45kg):
    • Ceftriaxone 500 mg IM in a single dose (1 g for persons weighing greater than 150 kg), plus
    • Doxycycline 100 mg two times per day orally for seven days.
  • Consider prophylaxis or treatment (patients over 45 kg):
    • Post-exposure hepatitis B vaccination without hepatitis B immune globulin (HBIG) “if hepatitis status of assailant is unknown and the survivor has not been previously vaccinated,” plus
    • Human papillomavirus (HPV) vaccination for all sexual assault patients 9–26 years of age who have not received vaccine previously or are incompletely vaccinated, plus
    • HIV PEP (refer to CDC, 2016, for current recommended treatment regimen).
  • Prophylaxis or treatment (patients under 45 kg):
    • “Presumptive treatment for children who have been sexually assaulted or abused is not recommended because the incidence of most STIs among children is low after abuse or assault, prepubertal girls appear to be lower risk for ascending infection than adolescent or adult women, and regular follow-up of children usually can be ensured” (CDC, 2021).Ceftriaxone 25–50 mg/kg IM in a single dose (not to exceed 250 mg), plusErythromycin 50 mg/kg/day PO divided into four doses/day for 14 days.
  • Consider treatment (patients under 45 kg):
    • Post-exposure hepatitis B vaccination without HBIG, plus
    • Human papillomavirus (HPV) vaccination for all sexual assault patients 9–26 years of age who have not received vaccine previously or are incompletely vaccinated, plus
    • HIV PEP (refer to CDC, 2016, for current recommended treatment regimen).

Pregnancy Prophylaxis

Emergency contraception is also referred to as “the morning after pill” or “emergency prophylaxis pill (ECP).” It may be taken within five days (120 hours) after sexual assault to reduce the risk of pregnancy. ECP works by temporarily stopping the ovary from releasing an egg or preventing fertilization of an egg (the uniting of sperm with the egg) or by preventing attachment (implantation) to the uterus (womb).

Ensure all female patients have informed consent on pregnancy prophylaxis. Catholic patients have the right to protect themselves from an unwanted pregnancy related to sexual assault. See Ethical and Religious Directives for Catholic Health Care Services Doctrine 36 (2016).

Emergency contraception is a method of birth control to be used occasionally in specific emergency situations, not as a primary form of birth control. Using emergency contraception should not be confused with taking medicine to induce an abortion. The “abortion pill” contains different medications.

Hormonal or intrauterine emergency contraception will not interfere with an existing pregnancy. Women who cannot use estrogen-containing hormonal birth control as their primary method of contraception (such as those with a history of heart attack, stroke, clotting disorders, migraine headaches or liver disease, or who are breastfeeding) can use emergency contraception because the hormones are taken for only one day.

Pregnancy Prophylaxis Treatment:

Regimen containing a form of the hormone progesterone called levonorgestrel:

  • Single-dose regimen is Plan B One-Step® 1.5 mg tablet (My Way, Next Choice One Dose) OR
  • Two-dose regimen is Plan B® (0.75 mg) tablets (Plan B® available OTC for everyone). Ulipristal (Ella®) is more effective in women with BMI >26.
  • Most effective if taken within 72 hours (3 days) but can be taken up to 5 days (120 hours).

Combination regimen containing forms of two hormones, progesterone and estrogen, is most effective when taken as soon as possible up to 120 hours (5 days) after sexual assault.

Ulipristal acetate (Ella®) is not a hormone. It is a synthetic compound that works by blocking progesterone receptors. This delays ovulation and/or prevents implantation.

  • Effective up to 120 hours (five days) after sexual assault, and evidence supports it is as effective on day five as it is day one.
  • Ella® is more effective than Plan B One-Step if taken more than 72 hours post unprotected vaginal-penile intercourse (Rosato, Farris, & Bastianelli, 2016).
  • If a patient is taking hormonal contraception and has not missed a dose, using Ella® might make their birth control less effective (i.e., giving Ella® “just in case” is contraindicated in these patients).

Pregnancy Prophylaxis in Women with Higher BMIs:

In women who weigh 165 pounds (75 kilograms) or more, or have a BMI >26, ulipristal acetate (Ella®) seems to be more effective than levonorgestrel. All forms of emergency contraceptive (including Ella® and others) may be less effective in women with BMI >26.

Side Effects of Pregnancy Prophylaxis:

  • Nausea and vomiting are the most common side effects of ECP. Follow facility protocol if the patient vomits within two hours of ECP ingestion.
  • Altered menstrual cycle, to include:
    • Menstrual cycle may be sooner, later, longer or shorter than patient’s normal cycle.
    • Educate patient that if she does not have her cycle within three or four weeks of taking emergency contraception, she should take a pregnancy test.
  • Other side effects include headache, fatigue, abdominal pain, dizziness and dysmenorrhea. Side effects are typically less common and milder with Ella® than other pregnancy prophylaxis.

HIV Non-Occupational Post-Exposure Prophylaxis (HIV nPEP)

While documented cases of HIV infection from sexual assault have not been widely published, there is still a risk of transmission (CDC, 2016) and individual cases have been documented. Therefore, it is important to assess the level of risk after a sexual assault has occurred. Providers should offer prophylactic treatment to reduce the risk of seroconversion as appropriate within 72 hours of contact (CDC, 2015).

Risk Assessment for Children within 72 Hours of Sexual Assault

HIV prophylaxis is a 28-day regimen of three classes of medications and requires baseline laboratory testing and follow-up to monitor adherence, side effects and HIV status. Patients may be required to pay up-front costs for medications and seek reimbursement through Crime Victims’ Compensation, if reporting the assault to law enforcement. Emergency medical care compensation may be available to cover costs for the emergency medical care a person who experiences sexual assault may incur during a sexual assault examination at a hospital. (Texas OAG).

Assess the risk for HIV infection in the assailant, if possible. Evaluate risk based on the circumstances of the assault as related to risk of possible transmission. Consult with an Infectious Disease specialist for medication and dosing recommendations if considering initiating PEP.

Discuss with the caregiver the risks and benefits of prophylactic treatment. Obtain a baseline HIV test of the child at the time of the medical forensic examination.

If PEP is initiated, also order a CBC and serum chemistry at the time of the medical forensic examination. Provide enough medication to last until the first follow-up visit, ideally 3–7 days. Infectious disease specialist will then assess tolerance to the medications.

HIV Follow-up Care

Referrals for follow-up care, testing and monitoring of laboratory values are critical in the sexual assault population. Therefore, all options (cost, side effects, benefits, and risks) should be discussed at discharge with the patient and/or caregivers to determine the best plan of care.