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Treatment of Sexually Transmitted Infections (STIs) or Genital Infections – Adult/Pediatric – Ambulatory [27]

Treatment of Sexually Transmitted Infections (STIs) or Genital Infections – Adult/Pediatric – Ambulatory [27] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 27

Delegation Protocol Title:
Treatment of Sexually Transmitted Infections (STIs) or Genital Infections – Adult/Pediatric - Ambulatory

Delegation Protocol Applies To:
UW Health Primary Care Clinics including General Pediatrics, Adolescent, Internal Medicine, Family Medicine,
Geriatrics and OB/Gyn

Target Patient Population:
Patients ages 12 years and older

Delegation Protocol Champion:
Paula Cody, MD - Department of Pediatrics
Nancy Fuller, MD - Department of Medicine – General Internal Medicine
Laura Sabo, MD - Department of Obstetrics/Gynecology
Katherine Porter, MD - Department of Family Medicine

Delegation Protocol Reviewers:
Shelly Key, BSN - Clinical Support, Staff Education
Tracey Crowley, MSN – Clinical Support, Staff Education

Responsible Department:
Department of Pediatrics
Department of Internal Medicine
Department of Obstetrics/Gynecology
Department of Family Medicine

Purpose Statement:
To delegate authority from the patient’s Primary Care or OB/GYN Provider to Registered Nurses (RNs), the
management of selected sexually transmitted infections according to Center for Disease Control and Prevention
(CDC) guidelines based on a positive test result for gonorrhea, chlamydia, bacterial vaginosis or trichomoniasis.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RN) trained in the use of this delegation protocol.

Guidelines for Implementation:
This protocol is initiated when a patient tests positive for gonorrhea, chlamydia, bacterial vaginosis or
trichomoniasis or reports a recurrence of previously diagnosed genital herpes. Registered nurses (RNs) will
initiate treatment of listed infections by following this protocol, using the STI RN Delegation Protocol Smart Set
to enter orders.

1. Review of Culture Results
1.1 STI culture results are reviewed daily by RN Staff until the final results are available.
1.2 Lab will call clinic with positive results for chlamydia and gonorrhea.
1.3 All persons found to have gonorrhea should be tested for other STIs, including chlamydia, syphilis, and
HIV. Chlamydia should be either ruled out or empirically treated due to high rates of co-infection with
gonorrhea.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

2. Inform Patient and Instructions
2.1 The RN will notify the patient by phone with all positive and negative results. When providing the results
the RN will ensure the patient is in an environment where they can talk freely and privately or the
patient may come to the clinic.
2.2 The RN will determine if the patient has developed any new or worsening symptoms. If they have, the
patient will be instructed to come to the clinic as soon as possible for evaluation and treatment. No
orders will be placed without further consultation with a provider.
2.3 The Department of Public Health will be notified of positive results for required diseases by the UW
Health Infection Control department. The Department of Public Health will contact patients with these
infections for follow-up and partner information. Obtain a phone number where the patient can be
contacted.
2.4 The RN will encourage participation in Expedited Partner Therapy (EPT) for gonorrhea, chlamydia, and
trichomoniasis. The RN may place orders for Expedited Partner Therapy.
2.5 The RN will instruct the patient to refrain from sexual activity for one week after all parties have been
treated for gonorrhea and chlamydia. The RN will reinforce the use of condoms.

3. Treatment – Prior to placing orders the RN will review the patient’s medical record, including medications,
allergies, and pregnancy status to determine the appropriate action. The treatment options are listed in
order of preference.
Consult provider prior to placing any orders for the following patients:
• Signs of complicated infection in women: (pelvic inflammatory disease): temperature >101 F, new or
worsening abdominal or pelvic pain
• Signs of complicated infection in men (epididymitis or orchitis): temperature >101 F, new or
worsening testicular pain, swelling, or tenderness
• HIV-positive
• Severe hepatic impairment (AST/ALT > 3 times upper limit of normal or history of liver disease, such
as cirrhosis)
• Treatment failure to all of the listed antibiotics for the organism being treated
• Allergies to all of the listed antibiotics for the organism being treated
• Immunosuppressed: large doses of steroids (prednisone >10 mg/day; dexamethasone >1.5 mg/day),
immunomodulators (for example, adalimumab (Humira), etanercept (Enbrel), tacroliumus (Prograf))
or chemotherapy
• If patient is taking warfarin and metronidazole is indicated (e.g., treatment of Trichomoniasis or
Bacterial Vaginosis)

3.1 Chlamydia infections of the genitalia
3.1.1 Non-pregnant patients:
3.1.1.1 Azithromycin 1 g orally once.
3.1.1.2 Allergies: If the patient has an allergy to azithromycin, clarithromycin, or erythromycin:
doxycycline 100 mg orally twice a day for 7 days
3.1.2 Pregnant patients:
3.1.2.1 Azithromycin 1 g orally once.
3.1.2.2 Allergies: The provider will be consulted prior to placing any orders
3.1.2.3 Repeat testing to confirm eradication is required 3 weeks after completing therapy.
Pregnant women diagnosed with chlamydial infection during the first trimester should
be retested again 3 months after treatment. Women aged < 25 years and those at
increased risk for chlamydia (i.e. women who have a new or more than one sex partner)
should be retested during the third trimester.
3.1.3 Expedited Partner Therapy: Azithromycin 1 g orally once


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

3.2 Gonococcal infection of the cervix, urethra, rectum or pharynx:
3.2.1 Non-pregnant patients:
3.2.1.1 Ceftriaxone 250 mg IM once plus azithromycin 1 g orally once
3.2.1.2 Allergies: If the patient has an allergy to azithromycin: ceftriaxone 250 mg IM once plus
doxycycline 100 mg orally twice a day for 7 days
3.2.2 Pregnant patients:
3.2.2.1 Ceftriaxone 250 mg IM once plus azithromycin 1 g orally once
3.2.2.2 Allergies: The provider will be consulted before placing any order orders
3.2.3 Expedited Partner Therapy: Cefixime 400 mg orally once plus azithromycin 1 g orally once
3.2.4 Due to high rates of co-infection, patients treated for gonorrhea should also be treated for
chlamydia (see 3.1) or have this infection ruled out.

3.3 Bacterial vaginosis
3.3.1 Non-pregnant patients:
3.3.1.1 Metronidazole 500 mg orally twice a day for 7 days. RN will instruct patient to avoid
alcohol consumption during treatment and for 24 hours after the treatment. If the patient
prefers a medication administered vaginally: Metronidazole gel (0.75%), one full applicator (5 g)
vaginally once daily for 5 days.
3.3.1.2 Allergies or unable to avoid alcohol: Clindamycin 300 mg orally twice daily for 7 days. If
the patient prefers medication administered vaginally: Clindamycin cream 2% one full applicator
(5 g) vaginally once daily for 5 days.
3.3.2 Pregnant patients:
3.3.2.1 Clindamycin 300 mg orally twice daily for 7 days. RN will instruct patient to avoid
alcohol consumption during treatment and for 24 hours after the treatment.
3.3.2.2 Allergies or unable to avoid alcohol consumption: They provider will be consulted prior
to placing any orders.

3.4 Trichomoniasis
3.4.1 Non-pregnant patients:
3.4.1.1 Metronidazole 2 gm orally as a single dose. RN will instruct patient to avoid alcohol
consumption for 24 hours after the treatment.
3.4.1.2 Allergies or unable to avoid alcohol consumption: The provider will be consulted prior to
placing any orders.
3.4.2 Pregnant patients:
3.4.2.1 Metronidazole 2 gm orally as a single dose. RN will instruct patient to avoid alcohol
consumption for 24 hours after the treatment.
3.4.2.2 Allergies or unable to avoid alcohol consumption: The provider will be consulted prior to
placing any orders.
3.4.3 Expedited Partner Therapy: metronidazole 2 gm orally once

3.5 Genital Herpes (HSV)
3.5.1 Non-pregnant patients:
3.5.1.1 Acyclovir 400 mg orally three times a day for 5 days
3.5.1.2 Allergies: The provider will be consulted prior to placing any orders
3.5.2 Pregnant patients:
3.5.2.1 Acyclovir 400 mg orally three times a day for 5 days
3.5.2.2 Allergies: The provider will be consulted prior to placing any orders

3.6 Yeast Infections
3.6.1 Yeast infections will be treated with over-the-counter medications (miconazole or clotrimazole).
3.6.2 If over-the-counter medications fail to treat the yeast infection, the provider will be consulted.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Order Mode: Cosign Required Protocol/Policy

References:
1. Workowski KA, Berman S: Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases
treatment guidelines. 2010 MMWR Recomm Rep. 2010 Dec 17; 59(RR-12):1-
114. http://www.cdc.gov/std/treatment/2010/default.htm. Accessed October 6, 2014.
2. ACOG. Gynecologic Herpes Simplex Virus Infections. ACOG Practice Bulletin No. 57. Nov. 2004
3. ACOG. Management of Herpes in Pregnancy. ACOG Practice Bulletin No 82. June 2007
4. Sobel, JD. Bacterial vaginosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Accessed on January
28, 2015.

Collateral Documents/Tools:
RN Delegation Protocol – Sexually Transmitted Infections (STI) – Smart Set [5264]

Approved By:
UW Health Ambulatory Protocol Committee: September 2012, Feburary 2015 Expedited Review
UW HC Antimicrobial Use Subcommittee: August 2012, March 2015 Expedited Review
UWHC Pharmacy and Therapeutics Committee: August 2012, April 2015 Expedited Review
UWHC Medical Board: August 2012, April 2015 Expedited Review
UW Health Chief Ambulatory Medical Officer: May 2015

Effective Date: May 2015

Scheduled for Review: May 2017
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org