January 2010

Update

Section II:Primary Care and Sexually Transmitted Infections

Primary Care and Sexually Transmitted Infections

18,19

In Table 5. Partner notification reference chart, the column heading “Track-back period” now has an asterisk with the following note placed below the table:

* Trace-back period refers to the time period prior to symptom onset or date of specimen collection (if asymptomatic).

- The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

January 2010

Update

Section III: Laboratory Diagnosis of Sexually Transmitted Infections

Collection and Transportation of Specimens

2

2. Lesions (vesicles or ulcers)
b) Ulcers

Add the highlighted text to 5th bullet:

For the detection of T. pallidum, contact the laboratory to determine the availability of dark-field microscopy or direct/indirect fluorescent antibody (DFA/IFA) or NAAT (e.g., PCR) testing.

January 2010

Update

Section III:
Laboratory Diagnosis of Sexually Transmitted Infections

Laboratory Diagnosis of Specific Infections

8

Under 5. Treponema pallidum (syphilis), add as a 4th bullet:

- Direct/indirect fluorescent antibody (DFA/IFA) tests are not reliable for oral/rectal lesions, as there may be cross-reaction with non-pathogenic treponemes in oral and anal specimens. NAAT (e.g., PCR) testing may be an option for such specimens.

January 2010

Update

Section III: Laboratory Diagnosis of Sexually Transmitted Infections

Laboratory Diagnosis of Specific Infections

8

Under 5. Treponema pallidum (syphilis), add the highlighted text to the 6th bullet:

The introduction of treponemal tests for IgG/IgM antibodies, such as the treponemal enzyme immunoassay (EIA), may provide a more sensitive screening test for syphilis. Although EIA is highly sensitive, the test can lack specificity therefore if the treponemal-specific EIA is positive, confirmation by a second treponemal-specific test is recommended (e.g., TP-PA, MHA-TP, FTA-ABS, INNO-LIA™). See Syphilis chapter for more information.

January 2010

Update

Section III: Laboratory Diagnosis

Laboratory Diagnosis of Specific Infections

8

Under 5. Treponema pallidum (syphilis), add the highlighted text to the 8th bullet:

Treponemal tests (e.g., FTA-ABS, MHA-TP, EIA and INNO-LIA™) usually remain reactive for life regardless of the treatment, although 15-25% will serorevert if the patient is treated during the primary stage.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Syndromic Management of Sexually Transmitted Infections

2

In Table 1. Syndromic approach to the management of sexually transmitted infections, Column 6, Row 2, under “Next steps/special considerations”, replace current text with:

Window period for detection of early syphilis is 2-6 weeks depending on the screening test used.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Syndromic Management of Sexually Transmitted Infections

5

In Table 1. Syndromic approach to the management of sexually transmitted infections (continued), replace Column 4, Row 2, under “Specimens and testing,” with:

Syphilis serology should include a non-treponemal test (e.g., RPR,VDRL) or treponemal-specific enzyme immunoassay (EIA)

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Syndromic Management of Sexually Transmitted Infections

5

In Table 1. Syndromic approach to the management of sexually transmitted infections (continued), add the highlighted text to last column, row 2 as the second point:

If the initial serologic testing is negative and syphilis is suspected, serological testing should be repeated in 2-4 weeks

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Genital Ulcer Disease (GUD)

6

For T. pallidum, under “Identification”, add the highlighted text to the first bullet:

- Dark-field examination or direct/indirect fluorescent antibody (DFA/IFA) or NAAT (e.g., PCR) test on swabs from ulcers. Contact your local laboratory regarding these tests, as they are not widely available.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Genital Ulcer Disease (GUD)

6

For T. pallidum, add the following text as 2nd point under “Identification”:

- Dark-field microscopy and direct/indirect fluorescent antibody (DFA/IFA) tests are not reliable for rectal lesions, as there may be cross-reaction with non-pathogenic treponemes in anal specimens. NAAT (e.g., PCR) testing may be an option for such specimens.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Genital Ulcer Disease (GUD)

6

For T. pallidum, under “Serology”, add the highlighted text to the 1st point:

Although EIA is highly sensitive, the test can lack specificity therefore if the treponemal-specific EIA is positive, confirmation by a second treponemal-specific test is recommended (e.g. TP-PA, MHA-TP, FTA-ABS or INNO-LIA™). See Syphilis chapter for more information.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Genital Ulcer Disease (GUD)

6

For T. pallidum, under “Serology”, add the highlighted text to the 2nd point:

If non-treponemal syphilis serology is found to be positive, confirmation by treponemal-specific testing (e.g. Treponema pallidum particle agglutination [TP-PA], microhemagglutination for Treponema pallidum [MHA-TP], fluorescent treponemal antibody absorption [FTA-ABS] or INNO-LIA™) should be performed if not already ordered (see Syphilis chapter).

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Genital Ulcer Disease (GUD)

6

For T. pallidum, under “Serology” replace 3rd point with:

- If the initial serologic test is negative and syphilis is suspected, serological testing should be repeated in 2-4 weeks.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Genital Ulcer Disease (GUD)

6

For T. pallidum, under “Serology”, remove 4th point as it is repetition of the text under “Identification”.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Genital Ulcer Disease (GUD)

7

Under Management, replace current text:

If results are available for RPR, VDRL, TP-PA, MHA-TP/
dark-field examination/fluorescent antibody test

• Positive (motile corkscrew spirochetes present): treat for syphilis (see Syphilis chapter).

Etc.

With the following:

If the serologic test results for syphilis are negative  and:

• Dark-field examination is positive (motile corkscrew spirochetes present): treat for syphilis (see Syphilis chapter).
• Direct/indirect fluorescent antibody tests (DFA/IFA) or NAAT (e.g., PCR) are positive: treat for syphilis (see Syphilis chapter).

• Dark-field examination, DFA/IFA or NAAT tests for syphilis and tests for HSV infection and H. ducreyi are negative or not performed: treat for syphilis if there is a recent history of contact with infectious syphilis or clinical suspicion is strong and follow-up cannot be ensured.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Pelvic Inflammatory Disease (PID)

7

In Table 5. Recommended outpatient treatment regimens, add the highlighted text to the top of the first row, second column:

For each of the three treatment options listed below, many experts recommend the addition of metronidazole 500 mg PO bid for 14 days to this regimen for the additional anaerobic coverage and the treatment of bacterial vaginosis‡ [B-III].

(Delete 4th bullet in this cell due to repetition).

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Pelvic Inflammatory Disease (PID)

8

Under Reporting and Partner Notification, replace 3rd bullet with highlighted text:

Sexual partners should be traced 60 days prior to symptom onset or date of specimen collection (if asymptomatic).

(To be added as a sub-bullet, under the 3rd bullet)

• The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Sexually Transmitted Intestinal and Enteric Infections

5

In Table 3B: Recommended treatment regimens according to suspected or proven diagnosis, add the highlighted text to the 2nd bullet in Row 2, Column 2:

- Treat according to syphilis treatment recommendations for other suspected stages of syphilis or in HIV-infected individuals or in pregnant women (see Syphilis chapter)

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Sexually Transmitted Intestinal and Enteric Infections

6

Under Reporting and Partner Notification, replace 2nd bullet with:

When treatment for proctitis is indicated, sexual partners should be traced 60 days prior to symptom onset or date of specimen collection (if asymptomatic).

(To be added as a sub-bullet, under the 2nd bullet)

• The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

To be added as a 3rd bullet:

Partners should be located, clinically evaluated and treated with the same regimen as the index case regardless of clinical findings and without waiting for test results.

January 2010

Update

Section IV: Management and Treatment of Specific Syndromes

Urethritis

3

Under Reporting and Partner Notification, replace 2nd bullet with highlighted text:

Sexual partners should be traced 60 days prior to symptom onset or date of specimen collection (if asymptomatic).

(To be added as a sub-bullet, under the 2nd bullet)

• The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

To be added as a 3rd bullet:

Partners should be tested and treatment considered (see Figure 1 in this chapter).

January 2010

Update

Section V: Management and Treatment of Specific Infections

Chancroid

2

Under Diagnosis, add the highlighted text to the 2nd point under the 1st bullet:

Other causes of GUD should be ruled out by performing either a dark-field analysis, direct/indirect fluorescent antibody (DFA/IFA) or nucleic acid amplification testing (NAAT, e.g., PCR) for T. pallidum for primary syphilis and a culture for HSV.

January 2010

Update

Section V: Management and Treatment of Specific Infections

Chancroid

3

Under Reporting and Partner Notification, add the following as a 2nd bullet, under the current text:

The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

January 2010

Update

Section V: Management and Treatment of Specific Infections

Chlamydial Infections

8

Under Reporting and Partner Notification, add highlighted text to 2nd bullet:

All partners who have had sexual contact with the index case within 60 days prior to symptom onset or date of specimen collection (if asymptomatic) should be tested and empirically treated regardless of clinical findings and without waiting for test results.

(To be added as sub-bullet, under the 2nd bullet)

• The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

January 2010

Update

Section V: Management and Treatment of Specific Infections

Gonococcal Infections

13

Under Reporting and Partner Notification, add highlighted text to 4th bullet:

All partners who have had sexual contact with the index case within 60 days prior to symptom onset or date of specimen collection (if asymptomatic) should be tested and empirically treated regardless of clinical findings and without waiting for test results.

(To be added as sub-bullet, under the 4th bullet)

The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

Move down to be the 5th bullet:

Parents of neonates (i.e., mother and her sexual partner) should be located, clinically evaluated and empirically treated regardless of clinical findings and without waiting for test results.

January 2010

Update

Section V: Management and Treatment of Specific Infections

Lymphogranuloma Venereum (LGV)

7

Under Reporting and Partner Notification, replace 2nd bullet (under Table 5. Case definitions) with:

All partners who have had sexual contact with the index case within 60 days prior to symptom onset or date of specimen collection (if asymptomatic) should be tested and empirically treated regardless of clinical findings and without waiting for test results (see Treatment section).

(To be added as sub-bullet, under the 2nd bullet)
 

• The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

January 2010

Update

Section VI: Specific Populations

Pregnancy

4

Under Syphilis, within 1st paragraph, add the highlighted sentence:

Untreated primary or secondary syphilis carries a transmission risk of up to 100%, while early latent infection has a 40% transmission risk.¹⁹ Untreated late latent syphilis has a transmission rate of less than 10%. Treated syphilis has a transmission rate of 1.8%.²⁰

January 2010 Update

Section VI: Specific Populations

Pregnancy

4

Under Syphilis, within 4th paragraph, add the highlighted text:

Although EIA is highly sensitive, the test can lack specificity therefore if the treponemal-specific EIA is positive, confirmation by a second treponemal-specific test is recommended (e.g., FTA-ABS, MHA-TP, TP-PA or INNO-LIA™).

January 2010 Update

Section VI: Specific Populations

Pregnancy

4

Under Syphilis, 5th paragraph, add the  highlighted text:

Where initial screening is done using NTT only and serology is positive, treponemal-specific testing is required to confirm the diagnosis (e.g., FTA-ABS, MHA-TP, TP-PA, or INNO-LIA™).

January 2010 Update

Section VI: Specific Populations

Pregnancy

5

Under Treatment, 1st paragraph, add the highlighted sentence:

Pregnant women who have a history of significant penicillin allergy should be desensitized and then treated with penicillin.
See Syphilis chapter for information on penicillin desensitization including an oral desensitization protocol.

January 2010 Update

Section VI: Specific Populations

Pregnancy

5

Table 3. Treatment for syphilis during pregnancy†, now has a symbol attached, and the following notes are to be added below the table:

Note:  Benzathine penicillin G is commercially available in Canada and it is no longer necessary to access it through Health Canada's Special Access Program.

† Refer to Table 3 in the Syphilis chapter for additional information.

January 2010

Update

Section VI: Specific Populations

Sexual Abuse in Peripubertal and Prepubertal Children

5, 6

Table 1: Initial Visit: Prepubertal Children

Footnote to be added below Table 1 on pages 5 and 6:

* A recently published study evaluated the use of NAAT from urine and genital specimens and showed equivalence. When compared with culture, the use of NAAT testing resulted in a 33% increase in children with a positive diagnosis for both gonorrhea and Chlamydia.²⁴

Add an asterisk after the following words (under the “Specimen type by gender” column heading):
Boys and Girls* (page 5)
Girls* (page 5)
Boys* (page 6)

Add an asterisk after NAAT* in the following locations (under the “Condition or organism to be detected” column heading):

• First row, first bullet, first mention of NAAT
• Second row, second bullet
• Third row (page 6), second bullet

Please note: The addition of reference #24 affects all subsequent reference numbers in this chapter. As well, the footnote belonging to the first bullet in column one, row two has been changed to a double asterisk ** to accommodate this addition.

January 2010

Update

Section VI: Specific Populations

Sexual Abuse in Peripubertal and Prepubertal Children

6

In Table 1: Initial Visit: Prepubertal Children (continued), last row (Genital Ulcers), second column, replace the 2nd bullet with the highlighted text:

Direct or indirect fluorescent antibody (DFA/IFA) or NAAT (e.g., PCR) test should be taken for Treponema pallidum(see Syphilis chapter for details)

January 2010

Update

Section VI: Specific Populations

Sexual Assault in Postpubertal Adolescents and Adults

5

In Table 1: Initial Visit: Postpubertal children/adolescences/adults (continued), second row (Syphilis), second column, replace the 1st bullet with the highlighted text:

A screening test for syphilis should be performed (e.g.,. EIA or RPR) – see Syphilis chapter for details

January 2010

Update

Section VI: Specific Populations

Sex Workers

1

Under Epidemiology, make the following change to the first sentence in the 2nd paragraph:

Because of high rates of partner change, sex workers play an important role in the transmission of STIs (delete rest of sentence). Studies from developed and developing countries…