01Approach to the Critical Patient/attcp62

Immediate threats and stabilization

›Time-critical threats

›Septic shock from pelvic inflammatory disease or tubo-ovarian abscess

›Hypotension or lactate elevation

›Broad-spectrum IV antibiotics and source control pathway

›Disseminated gonococcal infection with meningitis or endocarditis

›Altered mental status or meningismus

›New murmur or heart failure signs

›Necrotizing soft tissue infection of genital or perineal region

›Pain out of proportion

›Crepitus or rapidly progressive erythema

›Ocular syphilis with vision loss

›Acute visual symptoms

›Emergent ophthalmology and IV therapy pathway

›Pregnancy with suspected ectopic or septic abortion in concurrent STI context

›Hemodynamic instability

›Obstetrics escalation

›Stabilization actions

›Airway or breathing support for altered mental status

›Target oxygenation

›Avoid delay of antibiotics in shock

›Circulation support

›Large-bore IV access

›Crystalloid bolus for hypotension

›Monitoring

›Continuous pulse oximetry and cardiac monitoring for toxic appearance

›Frequent blood pressure reassessment

›Early consult triggers

02History/hx62

Presenting syndrome and timing

›Symptom pattern and timeline

›Urogenital symptoms

›Dysuria

›Urethral discharge

›Vaginal discharge

›Postcoital bleeding

›Pelvic and abdominal symptoms

›Pelvic pain

›Dyspareunia

›Right upper quadrant pain consistent with perihepatitis

›Rectal symptoms

›Rectal pain

›Rectal bleeding

›Tenesmus

›Pharyngeal symptoms

›Sore throat

›Odynophagia

›Ulcer or rash symptoms

›Genital ulcer onset and pain quality

›Palmar or plantar rash

›Condyloma lata symptoms

›Systemic symptoms

›Fever

›Arthralgias or migratory joint pain

›Exposure window

›Sexual contacts in past 60 days for gonorrhea and chlamydia tracing

›Number of partners

03Physical Exam/exam47

Focused exam by syndrome

›Vital sign pattern

›Fever

›Pelvic inflammatory disease concern

›Disseminated infection concern

›Hypotension or tachycardia

›Sepsis physiology

›Pregnancy complications pathway

›Genital exam findings

›Urethral discharge

›Purulent discharge pattern

›Meatal erythema

›Cervical findings

›Mucopurulent cervicitis

›Cervical friability

›Pelvic tenderness pattern

›Cervical motion tenderness

›Uterine tenderness

›Adnexal tenderness

›Ulcer characteristics

›Single painless indurated ulcer consistent with primary syphilis

›Multiple painful vesicles or ulcers suggesting herpes rather than syphilis

›Extragenital findings

›Skin and mucous membranes

›Diffuse maculopapular rash

›Palmar or plantar involvement

›Mucous patches

›Lymph nodes

04Differential Diagnosis/ddx50

Life-threatening and high-risk alternatives

›High-risk pelvic and abdominal causes

›Ectopic pregnancy ICD-10 O00

›Positive pregnancy test

›Unilateral pain or bleeding

›Appendicitis ICD-10 K35

›Right lower quadrant tenderness

›Leukocytosis with peritoneal signs

›Ovarian torsion ICD-10 N83.5

›Sudden severe unilateral pain

›Adnexal mass risk

›Tubo-ovarian abscess ICD-10 N70.93

›Fever and adnexal mass

›Elevated inflammatory markers

›Invasive infection mimics

›Urinary tract infection ICD-10 N39.0

›Nitrite or leukocyte esterase positivity

›No genital discharge

›Pyelonephritis ICD-10 N10

›Flank pain

›Fever and systemic toxicity

›Fournier gangrene ICD-10 N49.3

›Severe perineal pain

›Crepitus or skin necrosis

›Ulcer disease differentials

›Genital herpes simplex ICD-10 A60

›Painful vesicular lesions

›Recurrence history

05Laboratory Tests/lt56

Core STI testing bundle

›First-line tests

›NAAT for Neisseria gonorrhoeae by site

›Urine or urethral swab

›Vaginal or cervical swab

›Rectal swab when exposure

›Pharyngeal swab when exposure

›NAAT for Chlamydia trachomatis by site

›Same site strategy as gonorrhea

›Rectal testing in receptive anal exposure

›Syphilis serology

›Nontreponemal test

›Treponemal test

›Co-infection testing

›HIV antigen and antibody testing

›Baseline status

›Linkage pathway for positive

›Hepatitis B testing when risk

›Surface antigen

›Surface antibody

›Hepatitis C testing when risk

›Antibody with reflex RNA where available

›Linkage pathway for positive

Syndrome-directed labs

›Pelvic inflammatory disease or systemic illness

›Pregnancy test

›Ectopic exclusion pathway

›Medication safety

06Diagnostic Tests/dt77

Scoring Systems

›Pelvic inflammatory disease clinical criteria

›Minimum criteria for empiric treatment

›Cervical motion tenderness

›Uterine tenderness

›Adnexal tenderness

›Supportive criteria

›Temperature elevation

›Mucopurulent discharge

›Abundant WBC on wet mount

›Elevated CRP or ESR

›Laboratory documentation of gonorrhea or chlamydia

›Syphilis staging framework

›Primary syphilis pattern

›Painless chancre

›Regional lymphadenopathy

›Secondary syphilis pattern

›Rash including palms or soles

›Mucous patches

›Condyloma lata

›Latent syphilis pattern

›No symptoms

›Serologic evidence only

›Neurosyphilis or ocular syphilis triggers

›Neurologic symptoms

›Visual or auditory symptoms

MRI

›MRI indications in STI complications

07Disposition/dispo28

Outpatient versus inpatient pathway

›Outpatient management criteria

›Uncomplicated urethritis or cervicitis

›No systemic toxicity

›Reliable follow-up

›Early syphilis without neurologic or ocular symptoms

›Stable vitals

›Ability to complete treatment and follow-up titers

›Inpatient management criteria

›Pelvic inflammatory disease requiring admission

›Pregnancy

›Severe illness or high fever

›Intractable vomiting or dehydration

›Tubo-ovarian abscess

›No clinical response to oral therapy within 72 hours

›Disseminated gonococcal infection

›Septic arthritis

›Meningitis or endocarditis concern

›Neurosyphilis or ocular syphilis

›IV penicillin therapy requirement

›Specialist-guided evaluation

›Public health and reporting

›Reportable infection workflow

›Gonorrhea report

›Chlamydia report

›Syphilis report

›Partner notification support

›Public health contact tracing

08Treatment/t135

Empiric syndromic management

›Empiric coverage triggers

›Symptomatic urethritis or cervicitis with high STI risk

›Same-day treatment when follow-up uncertain

›Co-treatment for chlamydia if not excluded

›Pelvic inflammatory disease with minimum criteria

›Low threshold for empiric therapy

›Delay increases sequelae risk

›Suspected syphilis with compatible lesion

›Stage-based treatment while awaiting confirmation when follow-up uncertain

›Baseline nontreponemal titer preferred before first dose

›Allergy and contraindication guardrails

›Severe cephalosporin allergy

›Avoid ceftriaxone

›Alternative gonorrhea regimen

›Pregnancy and lactation constraints

›Avoid doxycycline in pregnancy

›Penicillin required for syphilis in pregnancy

Gonorrhea regimens

›Uncomplicated urogenital or rectal gonorrhea

›Ceftriaxone IM single dose

›500 mg IM single dose for body weight under 150 kg

›Observe for immediate hypersensitivity

›Injection site counseling

›1 g IM single dose for body weight 150 kg or higher

›Same monitoring

›Consider antiemetic support if nausea

›Chlamydia not excluded

›Doxycycline 100 mg PO twice daily for 7 days

›Avoid in pregnancy

›Photosensitivity counseling

›Pharyngeal gonorrhea

›Ceftriaxone IM single dose

›Same weight-based dosing as uncomplicated infection

›Test of cure recommended

›Test of cure timing

›NAAT at 7 to 14 days

›Culture preferred when available for persistent symptoms

›Alternative regimens when ceftriaxone not feasible

›Cefixime PO single dose

›800 mg PO single dose

›Lower efficacy for pharyngeal infection

›Test of cure recommended

›Chlamydia not excluded

›Doxycycline 100 mg PO twice daily for 7 days

›Azithromycin 1 g PO single dose in pregnancy

›Cephalosporin allergy alternative

›Gentamicin plus azithromycin

›Gentamicin 240 mg IM single dose

›Nephrotoxicity risk counseling

›Avoid in significant renal impairment when alternatives exist

›Azithromycin 2 g PO single dose

›Nausea and vomiting risk

›QT prolongation risk review

Chlamydia regimens

›Uncomplicated urogenital or rectal chlamydia

›Preferred regimen

›Doxycycline 100 mg PO twice daily for 7 days

›Higher effectiveness for rectal infection

›Avoid in pregnancy

›Alternative regimens

›Azithromycin 1 g PO single dose

›Use in pregnancy

›Consider lower effectiveness for rectal infection

›Levofloxacin 500 mg PO daily for 7 days

›Tendinopathy risk counseling

›Avoid in pregnancy

›Lymphogranuloma venereum suspected or confirmed

›Doxycycline 100 mg PO twice daily for 21 days

›Proctocolitis symptoms

›Inguinal buboes management

›Specialist follow-up

›Test of cure planning

›Co-infection evaluation

Syphilis regimens

›Primary secondary or early latent syphilis

›Benzathine penicillin G IM

›2.4 million units IM single dose

›Administer as two injections at different sites when formulation requires

›Monitor for immediate allergy

›Penicillin allergy and nonpregnant

›Doxycycline 100 mg PO twice daily for 14 days

›Adherence critical

›Avoid in pregnancy

›Late latent or unknown duration syphilis

›Benzathine penicillin G IM weekly

›2.4 million units IM weekly for 3 doses

›Total 7.2 million units

›Avoid missed dose intervals beyond 10 to 14 days when possible

›Penicillin allergy and nonpregnant

›Doxycycline 100 mg PO twice daily for 28 days

›Lower evidence certainty than penicillin

›Strict follow-up titers

›Neurosyphilis ocular syphilis or otosyphilis

›Aqueous crystalline penicillin G IV

›18 to 24 million units per day for 10 to 14 days

›3 to 4 million units IV every 4 hours option

›Continuous infusion option

›Alternative regimen when adherence and monitoring feasible

›Procaine penicillin G IM plus probenecid

›Procaine penicillin G 2.4 million units IM daily for 10 to 14 days

›Monitor for allergy

›Ensure reliable daily dosing

›Probenecid 500 mg PO four times daily for 10 to 14 days

›Drug interaction review

›Renal dosing consideration

›Jarisch-Herxheimer reaction counseling

›Expected within 24 hours after therapy for early syphilis

›Fever and myalgias

›Supportive care

›Pregnancy risk

›Possible uterine contractions

›Obstetrics notification

Partner management and follow-up

›Partner treatment

›Gonorrhea and chlamydia partner window

›Sexual partners in past 60 days

›Most recent partner if no partners in 60 days

›Syphilis partner window

›Primary syphilis partners within 3 months plus symptom duration

›Secondary syphilis partners within 6 months plus symptom duration

›Early latent partners within 12 months

›Expedited partner therapy where permitted

›Indications

›Heterosexual partner of gonorrhea or chlamydia patient

›Barriers to timely partner evaluation

›Limitations

›Not recommended for syphilis

›Limited evidence for pharyngeal gonorrhea partner management without evaluation

›Retesting and test of cure

›Gonorrhea retest

›Retest at 3 months for reinfection

›Earlier if symptoms recur

›Chlamydia retest

›Retest at 3 months for reinfection

›Test of cure in pregnancy at about 4 weeks after therapy

›Syphilis serologic follow-up

›Nontreponemal titer at 6 and 12 months for early syphilis

›Longer follow-up for late latent

›Fourfold titer decline expectation with successful response in many early infections

09Special Populations/sp63

Pregnancy

›Pregnancy-specific risks

›Adverse outcomes

›Preterm birth association

›Neonatal infection risk

›Syphilis vertical transmission

›Congenital syphilis risk at any stage

›Urgent treatment priority

›Pregnancy-safe regimens

›Gonorrhea

›Ceftriaxone IM single dose using weight-based dosing

›Avoid gentamicin when safer alternatives exist

›Chlamydia

›Azithromycin 1 g PO single dose

›Amoxicillin 500 mg PO three times daily for 7 days alternative

›Syphilis

›Penicillin required

›Penicillin allergy desensitization pathway

›Follow-up in pregnancy

›Chlamydia test of cure

›NAAT about 4 weeks after treatment

›Retest later in pregnancy if ongoing risk

›Syphilis titers

›Repeat titers after treatment per obstetric protocol

›Fetal surveillance when indicated

Geriatric

›Older adult considerations

›Enteric organism epididymitis risk

10Background/b57

Epidemiology

›Burden patterns

›High prevalence in adolescents and young adults

›Highest incidence in sexually active ages under 25 years

›Screening focus in higher-risk groups

›Co-infection frequency

›Gonorrhea and chlamydia co-infection common

›HIV and syphilis co-occurrence in higher-risk networks

›Asymptomatic infection frequency

›Chlamydia often asymptomatic

›Up to about 70 percent asymptomatic in people with cervix in some studies

›Up to about 50 percent asymptomatic in people with penis in some studies

›Gonorrhea often asymptomatic in cervix and pharynx

›Cervical infection can lack symptoms

›Pharyngeal infection often asymptomatic

Pathophysiology

›Gonorrhea mechanisms

›Mucosal infection with local inflammation

›Urethritis and cervicitis

›Ascending infection risk

›Dissemination via bloodstream in susceptible hosts

›Arthritis dermatitis syndrome

›Septic arthritis

›Rare endocarditis or meningitis

›Chlamydia mechanisms

›Intracellular infection with subacute inflammation

›Cervicitis and urethritis

›Ascending infection causing PID

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Discharge counseling packet

›Sexual activity precautions

›No sex for 7 days after single-dose therapy

›No sex until 7 days after completion of multi-day therapy

›No sex until all partners treated

›Partner notification

›Notify partners from past 60 days for gonorrhea and chlamydia

›Public health support options

›Medication adherence

›Complete full doxycycline course

›Avoid missed doses

›Side effects to expect

›GI upset possible with antibiotics

›Photosensitivity with doxycycline

›Return to emergency care now

›Severe pelvic or abdominal pain

›Fever or chills

›Fainting or severe dizziness

›New rash with swelling of lips or trouble breathing

›Eye pain or vision changes

›Severe testicular pain or swelling

›Follow-up plan

›Results review plan

›Retesting at 3 months for gonorrhea or chlamydia

›Syphilis blood test follow-up schedule if treated

›Pregnancy considerations

›Pregnancy test if pregnancy possible

12References/r19

Clinical guidelines and decision support sources

›Guideline sources

›CDC Sexually Transmitted Infections Treatment Guidelines

›Gonorrhea treatment guidance

›Chlamydia treatment guidance

›Syphilis treatment guidance

›Public Health Agency of Canada Canadian Guidelines on Sexually Transmitted Infections

›Gonorrhea guide

›Chlamydia and LGV guide

›Syphilis guide

›US Preventive Services Task Force recommendations

›Chlamydia and gonorrhea screening Grade B for sexually active people with cervix at increased risk

›Syphilis screening recommendations for higher-risk groups where applicable in USPSTF topics

›Evidence-based references

›Syndromic management evidence base

›Empiric treatment thresholds in cervicitis and PID

›Partner management and reinfection reduction outcomes

›Diagnostic accuracy references

›NAAT high sensitivity for gonorrhea and chlamydia by site with variation

›Serologic testing algorithms for syphilis including treponemal and nontreponemal tests

Evidence & Review

Evidence & Review