Sexual Assault | Questions & Answers | 2010 Treatment Guidelines
Question 1: What is the best STD testing timeline for sexual assault survivors? Should there be a period of delay following a sexual assault (or other encounter) before STD screening?
Answer: For several reasons STD screening should occur as soon as the sexual assault is reported and a genital examination can be conducted. First, among sexually active adults and adolescents, an STD might have been acquired prior to the assault. Therefore, STD screening at the time of the initial examination would result in earlier treatment and avoid potential complications. Second, if there is concern that infectious agents acquired through assault might not have produced sufficient concentrations of organisms to result in positive test results at the initial examination, testing can be repeated after one week, if empiric treatment is not given rather than delayed. However, it is important to note that while collection of specimens at the time of initial examination for laboratory STD diagnosis gives the survivor and clinician the option to defer empiric prophylactic antimicrobial treatment and retest in one week, compliance with follow-up visits post-assault is traditionally low. As a result, routine preventive therapy after a sexual assault should be encouraged and will negate the potential harm that could occur as the result of a possible false negative STD test result due to specimen collection immediately post-assault. However, if prophylactic treatment after the examination is refused, a follow-up examination for repeat STD screening should be scheduled in one week. All clinicians should be knowledgeable with the test performance characteristics of each type of STD test used. For example, serological tests used for syphilis screening include nontreponemal tests (i.e., RPR and VDRL) as well as treponemal tests (ELISA, chemo-luminescence, etc). None of these tests detect incubating syphilis and so would not reliably detect a syphilis infection acquired during a sexual assault within the first 90 days after the assault. Likewise, serological tests used for HIV screening include rapid and traditional HIV ELISA tests. These tests are generally reliable four to six weeks after initial infection. Please refer to each specific STD section in the 2010 STD Treatment Guidelines to learn about the test performance characteristics.
Question 2: Is there any evidence that sexual assault victims might benefit from prophylaxis with an antiviral, such as acyclovir, to prevent herpes simplex virus (HSV) infection?
Answer: At this time, there is no evidence to support recommendations for the administration of acyclovir as post-exposure prophylaxis to prevent the acquisition of genital HSV infection after a sexual assault. There currently are no data to support recommendations it actually works, how long it should be given, and what dosage should be used. Further research is needed to determine the efficacy of an HSV antiviral treatment regimen provided within a specified time interval post assault (see 2010 STD Treatment Guidelines, page 91 for a complete discussion of STD prophylaxis after sexual assault).
Question 3: What are the recommended diagnostic tests for sexually assaulted children and what is the appropriate timeline for examination of the child?
Answer: A single exam might be sufficient if the child was abused for an extended period of time and a substantial period of time elapsed between the last suspected episode of abuse and the medical evaluation. If this is not the case, an initial examination and a follow-up examination two weeks later is recommended. Since it is not recommended that children routinely receive empiric antibiotic prophylaxis, the recommendations are the same for both the initial and follow-up examinations. During the initial examination and two-week follow-up examination the following should be performed (see 2010 STD Treatment Guidelines, pages 94–95 for a detailed explanation). Visual inspection of genital, perianal, and oral areas for genital discharge, odor, bleeding, irritation, warts, ulcerative lesions, and signs of trauma. Screening tests for gonorrhea and chlamydia from the vagina, urine, and rectum in girls and the urethra, urine, and rectum in boys. Culture and wet mount of a vaginal swab specimen for T. vaginalis infection and bacterial vaginosis in girls is recommended. Collection of sera samples can be used as a baseline for comparison with follow-up serologic tests. Sera should be tested for antibodies to T. pallidum, HIV, and hepatitis B virus. Examination of children for sexual assault or abuse should be conducted in a manner designed to minimize pain and trauma to the child. Cervical specimens are not recommended in the prepubescent girl. Vaginal samples are adequate as test specimens for gonorrhea and chlamydia infections in prepubescent girls. There is no need to use a vaginal speculum unless there is concern about trauma or retention of a foreign body. Cervical samples are needed as test specimens for gonorrhea and chlamydia infections in the post-pubescent female, and a vaginal speculum is needed to obtain these samples. The exception would be if nucleic acid amplification testing (NAAT) is used for the detection of gonorrhea and chlamydia. In this case, sensitivity is very high with use of a self-obtained or provider-obtained vaginal swab sample.
Question 4: We are using Suprax [cefixime] over Rocephin [ceftriaxone] for prophylactic treatment of gonorrhea in sexual assault victims. This is done to avoid the discomfort of an intramuscular injection. Would a preferred treatment be to give the patient Rocephin? We also treat assault victims with Zithromax [azithromycin].
Answer: The 2010 STD Treatment Guidelines list ceftriaxone 250 mg. injected in a single dose, OR cefixime 400 mg. orally in a single dose for the post-exposure prophylaxis of gonorrhea infection after sexual assault; PLUS metronidazole 2g. orally in a single dose, PLUS azithromycin 1 g. orally in a single dose, OR doxycycline 100 mg. orally twice a day for 7 days as prophylaxis for trichomonas and chlamydia. The 2010 Treatment Guidelines recommend ceftriaxone 250 mg. in a single dose OR, if not an option, cefixime 400 mg. orally in a single dose for the treatment of a confirmed case of gonorrhea. Even though the use of cefixime as an oral treatment post-assault is acceptable, it is important to note that ceftriaxone 250 mg. is more effective for the treatment of gonorrhea at all sites, especially in extragenital sites (pharynx and rectum) which are sites commonly exposed during sexual assault. It is also thought that ceftriaxone 250 mg. may provide a higher level of prophylaxis of an incubating syphilis infection compared to cefixime 400 mg. The use of lidocaine as the dilutent with the ceftriaxone 250 mg. will reduce discomfort associated with the injection. While the comfort of a patient who has been assaulted is an important consideration, a complication of gonorrhea as a result of treatment failure could result in a negative emotional experience for the patient and in unwanted medical sequelae. The patient can be reassured that the ceftriaxone injection is the best possible treatment of gonorrhea that could have been transmitted at any anatomical site and that the use of the lidocaine will minimize the discomfort. (See 2010 STD Treatment Guidelines pages 90–95 for a full discussion of sexual assault and STDs)
Question 5: In cases of sexual assault, why are extragenital nucleic acid amplification tests (NAATs) recommended for adults, but not children?
Answer: There is not enough data at this time to recommend the use of NAATs for gonorrhea and chlamydia screening of extragenital specimens (pharynx or rectum) in children. On a related note, be aware that even though CDC recommends using extra-genital NAATs on adults. The use of NAAT testing for the detection of N. gonorrhoeae and C. trachomatis of extragenital specimens (pharynx or rectum) is not FDA approved. Although commercially available NAATs have not been FDA-approved for pharyngeal or rectal specimens, an increasing number of public health and commercial laboratories are utilizing Clinical Laboratory Improvement Act (CLIA) guidelines and conducting verification studies for off-label use. A list of public health and commercial laboratories that offer non-culture testing of rectal and pharyngeal specimens for chlamydia and gonorrhea can be found on the NNPTC website.