Sexually Transmitted Infections

Indications for Testing

Urgency, frequency, dysuria in the absence of a documented UTI
Vaginal or penile discharge
Pelvic pain
Proctitis symptoms

Laboratory Testing

Refer to the following ARUP Consult topics for STI testing recommendations for the following
CDC – testing recommendations
STI testing methods (note: for optimal specimen types and collection instructions, refer to ARUP's Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests )
- Wet mount
  - Bacterial vaginosis
    - Presence of clue cells is diagnostic in appropriate clinical setting
- Nucleic acid amplification testing (NAAT)
  - Preferred for detecting C. trachomatis and N. gonorrhoeae in a variety of specimens (USPTFS, 2014; CDC, 2014)
  - Most sensitive test for T. vaginalis
  - Highly sensitive and specific
- Culture
  - C. trachomatis
    - Not recommended for routine detection
    - May be considered for anatomic locations for which amplified testing has not been validated
    - May be used in medicolegal settings and to assess suspected treatment failure
    - High specificity; less sensitive than NAAT
  - N. gonorrhoeae
    - Not recommended for routine detection
    - Recommended in combination with antimicrobial susceptibility testing in cases of suspected or documented treatment failure
    - May be considered for anatomic locations for which amplified testing has not been validated
    - Sensitivity dependent on transport time
      - N. gonorrhoeae is fastidious; viability declines rapidly during transport
  - T. vaginalis
    - Not recommended for routine detection
- DNA probes and DFA
  - Not recommended for routine detection
  - Lower sensitivity than NAAT

Differential Diagnosis

Urinary tract infection
Vaginitis/cervicitis
Vulvovaginal candidiasis
Malignancy – ovarian cancer, cervical cancer
Nephrolithiasis
Ectopic pregnancy
Diverticulitis
Inflammatory bowel disease
Appendicitis
Pregnancy
Ovarian cyst

For optimal specimen types and collection instructions for STI screening tests, refer to ARUP's Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests
STI screening recommendations for women

STI screening recommendations for sexually active nonpregnant women

STI Screening Recommendations for Sexually Active Nonpregnant Women
STI	USPSTF	CDC	AAFP	ACOG
Chlamydia	Annual screening – women <25 years and others at increased risk* Do not screen women >25 years and not at high risk	Annual screening – women <25 years and others at increased risk* Do not screen women >25 years and not at high risk	Screen women ≤25 years and others at increased risk*	Screen women ≤25 years and others at increased risk****
Gonorrhea	Screen women <25 years and others at increased risk* No recommendation for or against screening women not at risk and >25 years	Screen women <25 years and others at increased risk* No recommendation for or against screening women not at risk and >25 years	Screen women <25 years and others at increased risk*	Screen adolescents and others at increased risk****
Syphilis	Screen women at increased risk**	Screen women exposed to syphilis	Screen women at increased risk*	Screen women at increased risk****
HIV	Screen women at increased risk*	Screen all patients 13-64 years regardless of risk factors	Screen women at increased risk*	Screen women at increased risk****
Hepatitis B	Do not screen general population	Provide prevaccination screening for women at increased risk***	Do not screen general population	No specific recommendation
Hepatitis C	Do not screen general population; insufficient evidence to recommend for or against screening women at increased risk	Screen women at increased risk*** Do not screen general population	Do not screen general population; insufficient evidence to recommend for or against screening women at increased risk*	Screen women at increased risk****
HSV	Do not screen asymptomatic patients	Screening not recommended	Do not screen general population	Screen if sex partner has HSV
HPV	Insufficient evidence to use as primary screening test for cervical cancer	Screening not recommended until 25 yrs	Insufficient evidence to use as primary screening test for cervical cancer	Testing with a Pap smear is an option for women >30 years
Bacterial vaginosis	Screening not recommended	Screening not recommended	No specific recommendations	No specific recommendations
STI = sexually transmitted infection; USPSTF = U.S. Preventive Services Task Force; CDC = Centers for Disease Control and Prevention; AAFP = American Academy of Family Physicians; ACOG = American Congress of Obstetricians and Gynecologists; HIV = human immunodeficiency virus; HSV = herpes simplex virus; HPV = human papillomavirus; Pap = Papanicolaou * At risk = new or multiple partners; diagnosis of gonorrhea or chlamydia within the last 12 months; those not consistently using barrier methods; those having sex under the influence of drugs Commercial sex workers; persons who exchange sex for drugs; incarceration in adult correctional facility; multiple sex partners * Increased risk defined as <25 years with inconsistent condom use; history of other STIs; multiple sex partners or drug use **** High-risk factors = history of multiple sex partners or a sex partner with multiple contacts; sexual contact with individuals with a culture-proven STI; history of repeated episodes of STIs; attendance at clinics for STIs

STI screening recommendations for pregnant women

STI Screening Recommendations for Pregnant Women
STI	USPSTF	CDC	AAFP	ACOG
Chlamydia	Screen women <25 years and others at increased risk*	Screen all sexually active females ≤25 years and those >25 who are at risk**	Screen women ≤25 years and others at increased risk*	Screen women at increased risk***
Gonorrhea	Screen women <25 years and others at increased risk*	Screen women at increased risk**	Screen women at increased risk*	Screen women at increased risk***
Syphilis	Screen all	Screen all at first prenatal visit; retest in 3rd trimester for women at high risk	Screen all	Screen all
HIV	Screen all	Screen all at first prenatal visit; retest in 3rd trimester for women at high risk	Screen all	Screen all
Hepatitis B	Screen all	Screen all at first prenatal visit	Screen all	Screen all
Hepatitis C	No specific recommendation	Screen women at increased risk**	No specific recommendation	Screen women at increased risk***
HSV	Do not screen asymptomatic patients	No specific recommendation	Do not screen general population	No specific recommendation
HPV	No specific recommendation	No specific recommendation	No specific recommendation	No specific recommendation
Bacterial vaginosis	Do not screen for low-risk patients; insufficient evidence to recommend screening in patients at high risk for preterm delivery	No specific recommendation	Do not screen for low-risk patients; insufficient evidence to recommend screening in patients at high risk for preterm delivery	No specific recommendation
STI = sexually transmitted infection; USPSTF = U.S. Preventive Services Task Force; CDC = Centers for Disease Control and Prevention; AAFP = American Academy of Family Physicians; ACOG = American Congress of Obstetricians and Gynecologists; HIV = human immunodeficiency virus; HSV = herpes simplex virus; HPV = human papillomavirus; Pap = Papanicolaou * At risk = new or multiple partners; diagnosis of gonorrhea or chlamydia within the last 12 months; those not consistently using barrier methods; those having sex under the influence of drugs Increased risk = defined as <25 years with inconsistent condom use; history of other STIs; multiple sex partners or drug use * High-risk factors = history of multiple sex partners or a sex partner with multiple contacts; sexual contact with individuals with a culture-proven STI; history of repeated episodes of STIs; attendance at clinics for STIs

Guidelines

Cantor AG, Pappas M, Daeges M, Nelson HD. Screening for Syphilis: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;315(21):2328-2337.

Geisler WM. Management of uncomplicated Chlamydia trachomatis infections in adolescents and adults: evidence reviewed for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007; 44 Suppl 3: S77-83. PubMed

Meyers D, Wolff T, Gregory K, Marion L, Moyer V, Nelson H, Petitti D, Sawaya GF, USPSTF. USPSTF recommendations for STI screening. Am Fam Physician. 2008; 77(6): 819-24. PubMed

Newman LM, Moran JS, Workowski KA. Update on the management of gonorrhea in adults in the United States. Clin Infect Dis. 2007; 44 Suppl 3: S84-101. PubMed

Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae - 2014. Recommendations and Reports, Vol. 63, No. 2. Centers for Disease Control and Prevention. Atlanta, GA [Published Mar 2014; Accessed: Jan 2017]

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. June 5, 2015, 64(RR3);1-137. Centers for Disease Control and Prevention. Atlanta, GA [Last updated Jun 2015; Accessed: Aug 2017]

U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2007; 147(2): 128-34. PubMed

van Schalkwyk J, Yudin MH, Infectious Disease Committee, Yudin MH, Allen V, Bouchard C, Boucher M, Boucoiran I, Caddy S, Castillo E, Kennedy L, Money DM, Murphy K, Ogilvie G, Paquet C, van Schalkwy JK, Society of Obstetricians and Gynaecologists of Canada. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015; 37(3): 266-76. PubMed

Zakher B, Cantor AG, Pappas M, Daeges M, Nelson HD. Screening for gonorrhea and Chlamydia: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014; 161(12): 884-93. PubMed

General References

Beharry MS, Shafii T, Burstein GR. Diagnosis and treatment of chlamydia, gonorrhea, and trichomonas in adolescents. Pediatr Ann. 2013; 42(2): 26-33. PubMed

Copeland NK, Decker CF. Other sexually transmitted diseases chancroid and donovanosis Dis Mon. 2016; PubMed

de Vries HJ. Sexually transmitted infections in men who have sex with men. Clin Dermatol. 2014; 32(2): 181-8. PubMed

Frenkl TL, Potts J. Sexually transmitted infections. Urol Clin North Am. 2008; 35(1): 33-46; vi. PubMed

Garner AL, Schembri G, Cullen T, Lee V. Should we screen heterosexuals for extra-genital chlamydial and gonococcal infections? Int J STD AIDS. 2015; 26(7): 462-6. PubMed

Gaydos CA, Ferrero DV, Papp J. Laboratory aspects of screening men for Chlamydia trachomatis in the new millennium. Sex Transm Dis. 2008; 35(11 Suppl): S45-50. PubMed

Hobbs MM, Seña AC. Modern diagnosis of Trichomonas vaginalis infection. Sex Transm Infect. 2013; 89(6): 434-8. PubMed

Markle W, Conti T, Kad M. Sexually transmitted diseases. Prim Care. 2013; 40(3): 557-87. PubMed

Mishori R, McClaskey EL, WinklerPrins VJ. Chlamydia trachomatis infections: screening, diagnosis, and management. Am Fam Physician. 2012; 86(12): 1127-32. PubMed

Quan M. Vaginitis: diagnosis and management. Postgrad Med. 2010; 122(6): 117-27. PubMed

Verstraelen H, Verhelst R. Bacterial vaginosis: an update on diagnosis and treatment. Expert Rev Anti Infect Ther. 2009; 7(9): 1109-24. PubMed

Workowski K. In the clinic. Chlamydia and gonorrhea. Ann Intern Med. 2013; 158(3): ITC2-1. PubMed

Wright HR, Turner A, Taylor HR. Trachoma. Lancet. 2008; 371(9628): 1945-54. PubMed

Medical Reviewers

Fisher, Mark A., PhD, D(ABMM), Medical Director, Bacteriology and Antimicrobials at ARUP Laboratories; Assistant Professor of Clinical Pathology, University of Utah

Schlaberg, Robert, MD, MPH, Medical Director, Microbial Amplified Detection, Virology, and Fecal Chemistry; and Assistant Medical Director, Virology and Molecular Infectious Disease at ARUP Laboratories; Assistant Professor of Clinical Pathology, University of Utah

Cervical Cancer

Herpes Simplex Virus - HSV

HSV Infection During Pregnancy Testing Algorithm

Human Immunodeficiency Virus - HIV

Human Papillomavirus - HPV

Septic Arthritis

Treponema pallidum - Syphilis

Spotlight on Test Utilization: STD screening in MSM - Importance of testing extra-genital sites -- Robert Schlaberg, MD, MPH (5 min)

Last Update: October 2017

Sexually Transmitted Infections

Indications for Testing

Laboratory Testing

Differential Diagnosis

STI screening recommendations for sexually active nonpregnant women

STI screening recommendations for pregnant women

Epidemiology

Risk Factors

Clinical Presentation

Epidemiology

Risk Factors

Clinical Presentation

Epidemiology

Risk Factors

Clinical Presentation

Epidemiology

Risk Factors

Clinical Presentation

Guidelines

General References

Medical Reviewers

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	Sexually Transmitted Infections. ARUP Consult^©. Retrieved October 13, 2017, from: https://arupconsult.com/content/sexually-transmitted-infections

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Sexually Transmitted Infections

Indications for Testing

Laboratory Testing

Differential Diagnosis

STI screening recommendations for sexually active nonpregnant women

STI screening recommendations for pregnant women

Epidemiology

Risk Factors

Clinical Presentation

Epidemiology

Risk Factors

Clinical Presentation

Epidemiology

Risk Factors

Clinical Presentation

Epidemiology

Risk Factors

Clinical Presentation

Guidelines

General References

Medical Reviewers

Feedback