Abuse, Sexual, Suspected — STI Prophylaxis — Clinical Pathway: Emergency Department

Sexual Abuse Clinical Pathway — Emergency Department

STI Prophylaxis

Indications for STI Treatment

Pre-pubertal
  • Risk for STI after sexual assault/abuse is not well studied, but the incidence is low
  • Prepubertal girls are at low risk for ascending infection
  • Survivors may be at risk for future unsafe sex practices
    • ACIP recommends HPV vaccine for age ≥ 9 yrs
  • History, PE findings guide treatment decision
  • Use shared decision-making with the family
  • Treatment is indicated:
    • Symptoms suggest presence of STI
    • Oral, genital, anal injury
    • Visible evidence of ejaculation
    • Confirmed STI in perpetrator
    • Concern for sex trafficking
Postpubertal Treat all patients

Empiric Treatment for Children/Adolescent Sexual Assault Survivors

Treat with all of the following and use single dose when possible, as compliance is low.

If alternative treatment required, refer to STI Pathway, CDC Sexually Transmitted Infections Treatment Guidelines, 2021   and CHOP Formulary.

Adolescent Assault Survivors ≥ 13 yrs or ≥ 45 kg, Gonorrhea, Chlamydia
and Trichomoniasis

Ceftriaxone
  • 500 mg IV or IM as single dose
  • ≥ 150 kg
    • 1,000 mg IV or IM as single dose
Azithromycin or Doxycycline
  • Azithromycin
    • 1,000 mg PO as a single dose
  • Doxycycline
    • Rectal penetration
    • Doxycycline replaces azithromycin
    • Doxycycline 100 mg PO 2x daily for 7 days
Tinidazole 2,000 mg PO as single dose

Prepubertal Assault Survivors < 45 kg, Gonorrhea, Chlamydia and Trichomoniasis

Ceftriaxone
  • 50 mg/kg IV or IM as single dose
  • Max 250 mg
Erythromycin or Doxycycline
  • Erythromycin tablet or
  • ethylsuccinate base, liquid
  • 12.5 mg/kg/dose PO QID for 14 days
  • Max 500 mg/dose
  • Doxycycline PO ≥ 8 yrs
    • Rectal penetration
    • Doxycycline replaces erythromycin
    • 2.2 mg/kg/dose PO BID for 7 days
    • Max 100 mg/dose
Metronidazole or Tinidazole
  • < 40 kg, metronidazole PO
  • 10 mg/kg/dose BID for 7 days
  • 40-45 kg, tinidazole PO
    • 2,000 mg as single dose

Syphilis Primary and Secondary — Consult ID

Treatment Special Considerations
  • Benzathine penicillin G, IM
  • 2.4 million units as a single dose
  • Pediatric dosing
  • 50,000 units/kg IM, max 2.4 mil units
  • No symptoms and no prior RPR in last year; consult local health dept.
  • 3-dose treatment for late latent syphilis may be required
  • Neurologic symptoms or findings on examination
  • Consult ID to discuss the need for LP and neurosyphilis treatment

Vaccinations

Human Papillomavirus Vaccination (HPV)
  • Gardasil 9-valent IM injection
  • Indicated for age ≥ 9 yrs who have not received their first dose
  • Contraindicated if hypersensitivity to HPV vaccine or allergic reaction to yeast
Hepatitis B Vaccination
  • Provide Hepatitis B vaccine if:
    • Victim unvaccinated and perpetrator is known to be HBsAg positive:
      • Provide Hepatitis B vaccine and HBIG
    • Victim unvaccinated and hepatitis B status of assailant is unknown:
      • Provide Hepatitis B vaccine
  • Follow-up Doses
    • 1-2 and 4-6 mos