Table 1.

Population	Screening specifics	Guideline group, yr of recommendation
Population	Screening specifics	USPSTF, 2018	ACOG, 2016	ACS, 2020
Persons at average risk	Age to start screening	21 yrs	21 yrs	25 yrs
	Age to end screening	65 yrs	65 yrs	65 yrs
	Age to end screening	If three consecutive negative cytology tests or two negative cytology plus HPV tests or two negative HPV tests (ACS) with the most recent within the previous 5 yrs and no abnormal tests within the previous 10 yrs (ACS) and no CIN 2 or CIN 3 within the previous 25 yrs
	Screening test options and intervals	Aged 21–65 yrs: Cytology alone every 3 yrs or Aged 21–29 yrs: Cytology alone every 3 yrs Aged 30–65 yrs: Cytology plus HPV testing every 5 yrs or Aged 21–29 yrs: Cytology alone every 3 yrs Aged 30–65: HPV testing alone every 5 yrs*		HPV testing alone every 5 yrs or Cytology plus HPV testing every 5 yrs or Cytology alone every 3 yrs
	Preferred strategies	Cytology alone every 3 yrs and HPV testing alone every 5 yrs (equally preferred)	Cytology plus HPV testing every 5 yrs	HPV testing alone every 5 yrs
	Previous hysterectomy with removal of cervix	Screening not recommended after hysterectomy for benign indications Surveillance testing recommended for previous diagnosis of high-grade precancer, AIS, or cancer
Persons with an immunocompromising medical condition^† (e.g., HIV infection or solid organ transplantation)	Age to start screening	No specific recommendation	Within 1 yr of onset of sexual activity or, if already sexually active, within the first year after HIV or other immunocompromising medical condition diagnosis but no later than age 21 yrs
	Age to end screening		None; lifelong screening recommended
	Screening test options and intervals		Aged 21–65 yrs: Cytology every year; after three consecutive annual normal cytology test results, screening can be every 3 yrs or Aged 21–29 yrs: Cytology every year Aged 30–65 yrs: Cytology plus HPV testing every 3 yrs
	Previous hysterectomy with removal of cervix		Not specified
Persons with in utero exposure to diethylstilbestrol^§	Age to start screening	No specific recommendation	Not specified	No specific recommendation
	Age to end screening		Not specified
	Screening test options and intervals		Cytology alone annually
	Previous hysterectomy with removal of cervix		Not specified
Persons who have received HPV vaccination	No changes to the screening approaches above
Population	Screening specifics	ASCCP, 2019, and ACOG, 2020
Persons with a diagnosis of CIN 2 or CIN 3 (histologic HSIL^¶) within the previous 25 yrs	Age to start screening	Not applicable
	Age to end screening	May end at age 65 yrs if CIN diagnosis ≥25 yrs ago and criteria for ending screening met, otherwise continue screening past age 65 yrs Continued screening for ≥25 yrs after diagnosis is acceptable if patient is in good health
	Screening test options and intervals	Initial surveillance: HPV testing alone or cytology plus HPV testing at 6, 18, and 30 mos or Cytology at 6, 12, 18, 24, and 30 mos Long-term surveillance: HPV testing alone or cytology plus HPV testing every 3 yrs or Cytology alone annually Continue for ≥25 yrs from the initial CIN diagnosis, even if extends past age 65 yrs Routine screening can resume after the posttreatment surveillance period
	Previous hysterectomy with removal of cervix	HPV testing alone or cytology plus HPV testing every 3 yrs or Cytology alone annually Continue for ≥25 yrs from the initial CIN diagnosis, even if extends past age 65 yrs

TABLE 1. Cervical cancer screening and surveillance recommendations

Source: Perkins R, Guido R, Saraiya M, et al. Summary of current guidelines for cervical cancer screening and management of abnormal test results: 2016–2020. J Womens Health (Larchmt) 2021;30:5–13.
Abbreviations: ACS = American Cancer Society; ACOG = American College of Obstetricians and Gynecologists; AIS = adenocarcinoma in situ; ASCCP = American Society for Colposcopy and Cervical Pathology; CIN = cervical intraepithelial neoplasia; HPV = human papillomavirus; HSIL = high-grade squamous intraepithelial lesion; USPSTF = U.S. Preventive Services Task Force.
*Considered an alternative screening strategy by ACOG.
^†Panel for Opportunistic Infections, ACOG, 2016.
^§ACOG, 2016.
^¶Either by cytology or by histology; includes a persistent cytologic diagnosis of atypical squamous cells, cannot rule out HSIL.

Table 2.

Current HPV result	Current Pap test result	Previous result	Management by 2012 guidelines	Management by 2019 guidelines
Negative	ASC-US	Unknown or HPV negative*	Repeat Pap plus HPV testing in 3 yrs	Repeat HPV test with or without concurrent Pap test in 3 yrs
Negative	LSIL	Unknown or HPV negative*	Repeat Pap plus HPV testing in 1 yr preferred, colposcopy acceptable	Repeat HPV test with or without concurrent Pap test in 1 yr
Negative	ASC-H	Noncontributory	Colposcopy	Colposcopy
Noncontributory	AGC	Noncontributory	Colposcopy	Colposcopy
Positive	NILM	Unknown or HPV negative*	Repeat Pap plus HPV testing in 1 yr	Repeat HPV test with or without concurrent Pap test in 1 yr
Positive	NILM	HPV positive^†	Colposcopy	Colposcopy
Positive for genotype HPV 16, HPV 18, or both	NILM	Noncontributory	Colposcopy	Colposcopy
Positive for genotype HPV 16, HPV 18, or both	ASC-US or LSIL	Noncontributory	Not applicable, genotyping not recommended for ASC-US or LSIL in 2012	Colposcopy
Positive	ASC-US or LSIL	Unknown or HPV positive	Colposcopy	Colposcopy
Positive	ASC-US or LSIL	Negative screening results with HPV testing or HPV plus Pap testing within the previous 5 yrs	Colposcopy	Repeat HPV test with or without concurrent Pap test in 1 yr^§
Positive	ASC-US or LSIL	Colposcopy confirming the absence of high-grade lesion within the past yr	Colposcopy	Repeat HPV test with or without concurrent Pap test in 1 yr^§
Positive	ASC-H	Noncontributory	Colposcopy	Colposcopy or expedited treatment
Positive untyped, positive for genotype other than HPV 16, or negative	HSIL	Noncontributory	Colposcopy or expedited treatment	Colposcopy or expedited treatment
Positive for genotype HPV 16	HSIL	Noncontributory	Colposcopy or expedited treatment	Expedited treatment^¶

TABLE 2. Comparison of 2012 and 2019 consensus recommendations for management of common abnormalities — American Society for Colposcopy and Cervical Pathology

Sources: Massad LS, Einstein MH, Huh WK, et al.; 2012 ASCCP Consensus Guidelines Conference. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol 2013;121:829–46; Perkins RB, Guido RS, Castle PE, et al; 2019 ASCCP Risk-Based Management Consensus Guidelines Committee. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2020;24:102–31; Perkins R, Guido R, Saraiya M, et al. Summary of current guidelines for cervical cancer screening and management of abnormal test results: 2016–2020. J Womens Health (Larchmt) 2021;30:5–13.
Abbreviations: AGC = atypical glandular cells; AIS = adenocarcinoma in situ; ASC-H = atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion; ASC-US = atypical squamous cells of undetermined significance; CIN = cervical intraepithelial neoplasia; HPV = human papillomavirus; HSIL = high-grade squamous intraepithelial lesion; LSIL = low-grade squamous intraepithelial lesion; NILM = negative for intraepithelial lesion or malignancy; Pap = Papanicolaou.
*Colposcopy may be warranted for patients with a history of high-grade lesions (CIN 2 or CIN 3, histologic or cytologic HSIL, ASC-H, AGC, or AIS).
^†Previous Pap test results do not modify the recommendation; colposcopy is always recommended for two consecutive HPV-positive tests
^§Negative HPV test or cotest (HPV plus Pap test) results only reduce risk sufficiently to defer colposcopy if performed for screening purposes within the last 5 years. Colposcopy is still warranted if negative HPV test or cotest results occurred in the context of surveillance for a previous abnormal result.
^¶Expedited treatment is preferred for nonpregnant patients aged ≥25 years. Colposcopy with biopsy is an acceptable option if desired by patient after shared decision-making.

Table 3.

Vaccine	Trade name (manufacturer)	Age group (yrs)	Dose	Route	Schedule	Booster
Hep A inactivated (2 doses)	Havrix (GlaxoSmithKline)	1–18	0.5 mL (720 ELISA units inactivated HAV)	IM	0, 6–12 mos	None
Hep A inactivated (2 doses)	Havrix (GlaxoSmithKline)	≥19	1 mL (1,440 ELISA units inactivated HAV	IM	0, 6–12 mos	None
Hep A inactivated (2 doses)	Vaqta (Merck)	1–18	0.5 mL (25 units HAV antigen)	IM	0, 6–18 mos	None
Hep A inactivated (2 doses)	Vaqta (Merck)	≥19	1 mL (50 units HAV antigen)	IM	0, 6–18 mos	None
Combined Hep A and Hep B* (3 doses)	Twinrix (GlaxoSmithKline)	≥18 (primary)	1 mL (720 ELISA units inactivated plus 20 μg HBsAg	IM	0, 1, 6 mos	None
Combined Hep A and Hep B* (3 doses)	Twinrix (GlaxoSmithKline)	≥18 (accelerated)	1 mL (720 ELISA units inactivated plus 20 μg HBsAg	IM	0, 7, 21–30 days	12 mos

TABLE 3. Vaccines for preventing hepatitis A infection

Source: Nelson NP, Weng MK, Hofmeister MG, et al. Prevention of hepatitis A virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep 2020;69(No. RR-5).
Abbreviations: ELISA = enzyme-linked immunosorbent assay; HAV = hepatitis A virus; HBsAg = hepatitis B surface antigen; Hep A = hepatitis A; Hep B = hepatitis B; IM= intramuscular.
*Combined Hep A and Hep B vaccine (Twinrix) should not be used as postexposure prophylaxis.

Table 4.

Indication and age group	Risk category and health status	Hepatitis A vaccine	IG*
Postexposure prophylaxis
0–11 mos	Healthy	No	0.1 mL/kg body weight
12 mos to 40 yrs	Healthy	1 dose^†	None
>40 yrs	Healthy	1 dose^†	0.1 mL/kg body weight^§
≥12 mos	Immunocompromised or chronic liver disease	1 dose^†	0.1 mL/kg body weight^¶
≥12 mos	Vaccine contraindicated**	No	0.1 mL/kg body weight
Pre-exposure protection (e.g., travel)^††
<6 mos	Healthy	No	0.1–0.2 mL/kg body weight^§§
6–11 mos	Healthy	1 dose^¶¶	None
12 mos to 40 yrs	Healthy	1 dose***	None
>40 yrs	Healthy	1 dose***	0.1–0.2 mL/kg body weight^{§§,†††}
>6 mos	Immunocompromised or chronic liver disease	1 dose***	0.1–0.2 mL/kg body weight^{§§,†††}
>6 mos	Persons who elect not to receive vaccine or for whom vaccine is contraindicated**	No	0.1–0.2 mL/kg body weight^§§

TABLE 4. Recommendations for hepatitis A postexposure prophylaxis and pre-exposure protection, by age group and risk category — Advisory Committee on Immunization Practices, 2020

Source: Nelson NP, Weng MK, Hofmeister MG, et al. Prevention of hepatitis A virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep 2020;69(No. RR-5).
Abbreviations: HAV = hepatitis A virus; IG = immune globulin.
*Measles, mumps, and rubella vaccine should not be administered for ≥2 weeks before and 6 months after administration of IG.
^†A second dose of hepatitis A vaccine is not required for postexposure prophylaxis; however, for long-term immunity, the vaccination series should be completed with a second dose ≥6 months after the first dose.
^§The provider's risk assessment should determine the need for IG administration. If the provider's risk assessment determines that both vaccine and IG are warranted, hepatitis A vaccine and IG should be administered simultaneously at different anatomic sites (e.g., separate limbs).
^¶Vaccine and IG should be administered simultaneously at different anatomic sites (e.g., separate limbs).
**Life-threatening allergic reaction to a previous dose of hepatitis A vaccine or allergy to any vaccine component.
^††IG should be considered before travel for persons with special risk factors for either HAV infection or severe disease from HAV infection.
^§§0.1 mL/kg body weight for travel ≤1 month; 0.2 mL/kg body weight for travel ≤2 months; 0.2 mL/kg every 2 months for travel of ≥2 months' duration.
^¶¶This dose should not be counted toward the routine 2-dose series, which should be initiated at age 12 months.
***For persons not previously vaccinated with hepatitis A vaccine, administer dose as soon as travel is considered and complete the series according to routine schedule if the next dose is needed before travel.
^†††Can be administered on the basis of the provider's risk assessment.

Table 5.

Serologic marker				Interpretation
HBsAg	Total anti-HBc	IgM anti-HBc	Anti-HBs	Interpretation
-	-	-	-	Never infected
+^†	-	-	-	Early acute infection; transient (≤18 days) after vaccination
+	+	+	-	Acute infection
-	+	+	-	Acute resolving infection
-	+	-	+	Recovered from past infection and immune
+	+	-	-	Chronic infection
-	+	-	-	Past infection; low-level chronic infection^§; passive transfer to infant born to HBsAg-positive mother; false positive (no infection)
-	-	-	+	Immune if concentration is >10 mIU/mL after vaccination, passive transfer after HBIG administration

TABLE 5. Interpretation of serologic test results* for hepatitis B virus infection

Source: Adapted from Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(No. RR-1).
Abbreviations: anti-HBc = antibody to hepatitis B core antigen; anti-HBs = antibody to hepatitis B surface antigen; HBIG = hepatitis B immune globulin; HBsAg = hepatitis B surface antigen; IgM = immunoglobulin M.
*- = negative test result; + = positive test result.
^†To ensure that an HBsAg-positive test result is not false positive, samples with repeatedly reactive HBsAg results should be tested with a neutralizing confirmatory test cleared by the Food and Drug Administration.
^§Persons positive for only anti-HBc are unlikely to be infectious, except under unusual circumstances involving direct percutaneous exposure to large quantities of blood (e.g., blood transfusion or organ transplantation) or mutant HBsAg-related infection.

Table 6.

Age group (yrs)	Single-antigen vaccine						Combination vaccine
	Recombivax HB		Engerix-B		Heplisav-B*		Twinrix^†
	Dose (μg)^§	Volume (mL)	Dose (μg)^§	Volume (mL)	Dose (μg)^§	Volume (mL)	Dose (μg)^§	Volume (mL)
Infants (<1)	5	0.5	10	0.5	—^¶	—^¶	NA	NA
Children (1–10)	5	0.5	10	0.5	—^¶	—^¶	NA	NA
Adolescents (11–15)	10**	1.0	NA	NA	—^¶	—^¶	NA	NA
Adolescents (11–19)	5	0.5	10	0.5	—^¶	—^¶	NA	NA
Adults (≥18)	—^††	—^††	—^††	—^††	20*	0.5	20^†	1
Adults (≥20)	10	1	20	1	20^†	0.5	20^†	1
Hemodialysis patients and other immunocompromised persons (<20^§§)	5	0.5	10	0.5	20	0.5	NA	NA
Hemodialysis patients and other immunocompromised persons (≥20)	40^¶¶	1	40***	2.0	20	0.5	NA	NA

TABLE 6. Recommended doses of licensed formulations of hepatitis B vaccines

Source: Adapted from Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(No. RR-1).
Abbreviation: NA = not applicable.
*Administered on a 2-dose schedule.
^†Combined hepatitis A and B vaccines. This vaccine is recommended for persons aged ≥18 years who are at increased risk for both hepatitis B and hepatitis A virus infections.
^§Recombinant hepatitis B surface antigen protein dose.
^¶Heplisav-B should not be used for vaccination of infants, children, or adolescents because the safety and effectiveness of Heplisav-B has not been established in persons aged <8 years and is not approved for use in these populations.
**Adult formulation administered on a 2-dose schedule.
^††Engerix-B and Recombivax HB are approved for use in persons of all ages.
^§§Higher doses might be more immunogenic; however, no specific recommendations have been made.
^¶¶Dialysis formulation administered on a 3-dose schedule at 0, 1, and 6 months.
***Two 1.0-mL doses administered at one site, on a 4-dose schedule at 0, 1, 2, and 6 months.

Table 7.

Source of exposure	Unvaccinated person^§	Previously vaccinated person^¶
HBsAg-positive source Percutaneous (e.g., bite or needlestick) or mucosal exposure to HBsAg-positive blood or body fluids or Sex or needle-sharing contact with an HBsAg-positive person or Victim of sexual assault or abuse by an assailant who is HBsAg positive	Administer hepatitis B vaccine series and HBIG	Complete hepatitis B vaccine series and HBIG, if vaccine series not completed or Administer hepatitis B vaccine booster dose, if previous vaccination without testing**
Source with unknown HBsAg status Percutaneous (e.g., bite or needlestick) or mucosal exposure to potentially infectious blood or body fluids from a source with unknown HBsAg status or Sex or needle-sharing contact with person with unknown HBsAg status or Victim of sexual assault or abuse by a perpetrator with unknown HBsAg status	Administer hepatitis B vaccine series	Complete hepatitis B vaccine series

TABLE 7. Guidelines for postexposure prophylaxis* of persons with nonoccupational exposure† to blood or body fluids that contain blood, by exposure type and hepatitis B vaccination status

Sources: CDC. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013;62(No. RR-10); CDC. Postexposure prophylaxis to prevent hepatitis B virus infection. MMWR Recomm Rep 2006;55(No. RR-16).
Abbreviations: HBIG = hepatitis B immune globulin; HBsAg = hepatitis B surface antigen.
*When indicated, immunoprophylaxis should be initiated as soon as possible, preferably within 24 hours. Studies are limited regarding the maximum interval after exposure during which postexposure prophylaxis is effective, but the interval is unlikely to exceed 7 days for percutaneous exposures or 14 days for sexual exposures. The hepatitis B vaccine series should be completed. These guidelines apply to nonoccupational exposures.
^†These guidelines apply to nonoccupational exposures.
^§A person who is in the process of being vaccinated but who has not completed the vaccine series should complete the series and receive treatment for hepatitis B as indicated.
^¶A person who has written documentation of a complete hepatitis B vaccine series and who did not receive postvaccination testing.
**No booster dose is needed for persons who have written documentation of hepatitis B vaccine series with serologic response.

Table 8.

Infection	Evidence for sexual abuse	Recommended action
Gonorrhea*	Diagnostic	Report^†
Syphilis*	Diagnostic	Report^†
HIV^§	Diagnostic	Report^†
Chlamydia trachomatis*	Diagnostic	Report^†
Trichomonas vaginalis*	Diagnostic	Report^†
Anogenital herpes	Suspicious	Consider report^†,¶
Condylomata acuminata (anogenital warts)*	Suspicious	Consider report^†,¶,**
Anogenital molluscum contagiosum	Inconclusive	Medical follow-up
Bacterial vaginosis	Inconclusive	Medical follow-up

TABLE 8. Implications of commonly encountered sexually transmitted or sexually associated infections for diagnosis and reporting of sexual abuse among infants and prepubertal children

Sources: Adapted from Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of child abuse in children. Pediatrics 2005;16:506–12; Adams JA, Farst KJ, Kellogg ND. Interpretation of medical findings in suspected child abuse: an update for 2018. J Pediatr Adolesc Gynecol 2018;31:225–31.
*If unlikely to have been perinatally acquired and vertical transmission, which is rare, is excluded.
^†Reports should be made to the local or state agency mandated to receive reports of suspected child abuse or neglect.
^§If unlikely to have been acquired perinatally or through transfusion.
^¶Unless a clear history of autoinoculation exists.
**Report if evidence exists to suspect abuse, including history, physical examination, or other identified infections. Lesions appearing for the first time in a child aged >5 years are more likely to have been caused by sexual transmission.

Box 1.

1. Partners "Are you currently having sex of any kind?" "What is the gender(s) of your partner(s)?" 2. Practices "To understand any risks for sexually transmitted infections (STIs), I need to ask more specific questions about the kind of sex you have had recently." "What kind of sexual contact do you have or have you had?" "Do you have vaginal sex, meaning 'penis in vagina' sex?" "Do you have anal sex, meaning 'penis in rectum/anus' sex?" "Do you have oral sex, meaning 'mouth on penis/vagina'?" 3. Protection from STIs "Do you and your partner(s) discuss prevention of STIs and human immunodeficiency virus (HIV)?" "Do you and your partner(s) discuss getting tested?" For condoms: "What protection methods do you use? In what situations do you use condoms?" 4. Past history of STIs "Have you ever been tested for STIs and HIV?" "Have you ever been diagnosed with an STI in the past?" "Have any of your partners had an STI?" Additional questions for identifying HIV and viral hepatitis risk: "Have you or any of your partner(s) ever injected drugs?" "Is there anything about your sexual health that you have questions about?" 5. Pregnancy intention "Do you think you would like to have (more) children in the future?" "How important is it to you to prevent pregnancy (until then)?" "Are you or your partner using contraception or practicing any form of birth control?" "Would you like to talk about ways to prevent pregnancy?"

1. Partners

"Are you currently having sex of any kind?"
"What is the gender(s) of your partner(s)?"

2. Practices

"To understand any risks for sexually transmitted infections (STIs), I need to ask more specific questions about the kind of sex you have had recently."
"What kind of sexual contact do you have or have you had?"
- "Do you have vaginal sex, meaning 'penis in vagina' sex?"
- "Do you have anal sex, meaning 'penis in rectum/anus' sex?"
- "Do you have oral sex, meaning 'mouth on penis/vagina'?"

3. Protection from STIs

"Do you and your partner(s) discuss prevention of STIs and human immunodeficiency virus (HIV)?"
"Do you and your partner(s) discuss getting tested?"
For condoms:
- "What protection methods do you use? In what situations do you use condoms?"

4. Past history of STIs

"Have you ever been tested for STIs and HIV?"
"Have you ever been diagnosed with an STI in the past?"
"Have any of your partners had an STI?"

Additional questions for identifying HIV and viral hepatitis risk:

"Have you or any of your partner(s) ever injected drugs?"
"Is there anything about your sexual health that you have questions about?"

5. Pregnancy intention

"Do you think you would like to have (more) children in the future?"
"How important is it to you to prevent pregnancy (until then)?"
"Are you or your partner using contraception or practicing any form of birth control?"
"Would you like to talk about ways to prevent pregnancy?"

BOX 1. The Five P’s approach for health care providers obtaining sexual histories: partners, practices, protection from sexually transmitted infections, past history of sexually transmitted infections, and pregnancy intention

Box 2.

Gastrointestinal symptoms Headache Pruritis without rash Localized rash Delayed onset rash (>24 hours) Symptoms unknown Family history of penicillin or another drug allergy Patient denies allergy but it is on the medical record

Gastrointestinal symptoms
Headache
Pruritis without rash
Localized rash
Delayed onset rash (>24 hours)
Symptoms unknown
Family history of penicillin or another drug allergy
Patient denies allergy but it is on the medical record

BOX 2. Low-risk history in patients who report penicillin allergy

Box 3.

Major determinant Benzylpenicilloyl polylysine injection (Pre-Pen) (AllerQuest) (6 × 10⁻⁵M) Minor determinant precursors Benzylpenicillin G (10⁻²M, 3.3 mg/mL, 10,000 units/mL) Benzylpenicilloate (10⁻²M, 3.3 mg/mL) Benzylpenicilloate (or penicilloyl propylamine) (10⁻²M, 3.3 mg/mL) Aged penicillin is not an adequate source of minor determinants. Penicillin G should either be freshly prepared or come from a fresh-frozen source. Positive control Commercial histamine for scratch testing (1.0 mg/mL) Negative control Diluent (usually saline) or allergen diluent

Major determinant

Benzylpenicilloyl polylysine injection (Pre-Pen) (AllerQuest) (6 × 10⁻⁵M)

Minor determinant precursors

Benzylpenicillin G (10⁻²M, 3.3 mg/mL, 10,000 units/mL)
Benzylpenicilloate (10⁻²M, 3.3 mg/mL)
Benzylpenicilloate (or penicilloyl propylamine) (10⁻²M, 3.3 mg/mL)

Aged penicillin is not an adequate source of minor determinants. Penicillin G should either be freshly prepared or come from a fresh-frozen source.
Positive control

Commercial histamine for scratch testing (1.0 mg/mL)

Negative control

Diluent (usually saline) or allergen diluent

BOX 3. Skin test reagents for identifying persons at risk for adverse reactions to penicillin

Source: Adapted from Saxon A, Beall GN, Rohr AS, Adelman DC. Immediate hypersensitivity reactions to beta-lactam antibiotics. Ann Intern Med 1987;107:204–15.

Box 4.

Uncomplicated vulvovaginal candidiasis (VVC) Sporadic or infrequent VVC and Mild-to-moderate VVC and Likely to be Candida albicans and Nonimmunocompromised women Complicated VVC Recurrent VVC (three or more episodes of symptomatic VVC in <1 year) or Severe VVC or Non–albicans candidiasis or Women with diabetes, immunocompromising conditions (e.g., HIV infection), underlying immunodeficiency, or immunosuppressive therapy (e.g., corticosteroids)

Uncomplicated vulvovaginal candidiasis (VVC)

Sporadic or infrequent VVC

and

Mild-to-moderate VVC

and

Likely to be Candida albicans

and

Nonimmunocompromised women

Complicated VVC

Recurrent VVC (three or more episodes of symptomatic VVC in <1 year)

Severe VVC

Non–albicans candidiasis

Women with diabetes, immunocompromising conditions (e.g., HIV infection), underlying immunodeficiency, or immunosuppressive therapy (e.g., corticosteroids)

BOX 4. Classification of vulvovaginal candidiasis

Source: Sobel JD, Faro S, Force RW, et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol 1998;178:203–11.

Box 5.

Children All children aged 12–23 months Unvaccinated children and adolescents aged 2–18 years Persons at increased risk for hepatitis A virus (HAV) infection International travelers Men who have sex with men Persons who use injecting or noninjecting drugs (i.e., all those who use illegal drugs) Persons with occupational risk for exposure Persons who anticipate close personal contact with an international adoptee Persons experiencing homelessness Persons at increased risk for severe disease from HAV infection Persons with chronic liver disease Persons with HIV infection Other persons recommended for vaccination Pregnant women at risk for HAV infection or severe outcome from HAV infection Any persons who requests a vaccine Vaccination during outbreaks Unvaccinated persons in outbreak settings who are at risk for HAV infection or at risk for severe disease from HAV Implementation strategies for settings providing services to adults Persons in settings that provide services to adults where a high proportion of those persons have risk factors for HAV infection Hepatitis A vaccination is no longer recommended by the Advisory Committee on Immunization Practices Persons who receive blood products for clotting disorders (e.g., hemophilia)

Children

All children aged 12–23 months
Unvaccinated children and adolescents aged 2–18 years

Persons at increased risk for hepatitis A virus (HAV) infection

International travelers
Men who have sex with men
Persons who use injecting or noninjecting drugs (i.e., all those who use illegal drugs)
Persons with occupational risk for exposure
Persons who anticipate close personal contact with an international adoptee
Persons experiencing homelessness

Persons at increased risk for severe disease from HAV infection

Persons with chronic liver disease
Persons with HIV infection

Other persons recommended for vaccination

Pregnant women at risk for HAV infection or severe outcome from HAV infection
Any persons who requests a vaccine

Vaccination during outbreaks

Unvaccinated persons in outbreak settings who are at risk for HAV infection or at risk for severe disease from HAV

Implementation strategies for settings providing services to adults

Persons in settings that provide services to adults where a high proportion of those persons have risk factors for HAV infection

Hepatitis A vaccination is no longer recommended by the Advisory Committee on Immunization Practices

Persons who receive blood products for clotting disorders (e.g., hemophilia)

BOX 5. Populations recommended for hepatitis A vaccination — Advisory Committee on Immunization Practices, 2020

Source: Nelson NP, Weng MK, Hofmeister MG, et al. Prevention of hepatitis A virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep 2020;69(No. RR-5).

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Kreimer AR, Rodriguez AC, Hildesheim A, et al.; CVT Vaccine Group. Proof-of-principle evaluation of the efficacy of fewer than three doses of a bivalent HPV16/18 vaccine. J Natl Cancer Inst 2011;103:1444–51. PMID:21908768 https://doi.org/10.1093/jnci/djr319
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Kuhar DT, Henderson DK, Struble KA, et al.; US Public Health Service Working Group. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013;34:875–92. PMID:23917901 https://doi.org/10.1086/672271
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Loutfy MR, Macdonald S, Myhr T, et al. Prospective cohort study of HIV post-exposure prophylaxis for sexual assault survivors. Antivir Ther 2008;13:87–95. PMID:18389902
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Announcement: Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:458. PMID:27149423 https://doi.org/10.15585/mmwr.mm6517a5
Ford N, Venter F, Irvine C, Beanland RL, Shubber Z. Starter packs versus full prescription of antiretroviral drugs for postexposure prophylaxis: a systematic review. Clin Infect Dis 2015;60(Suppl 3):S182–6. PMID:25972501 https://doi.org/10.1093/cid/civ093
Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect; American Academy of Pediatrics. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics 2013;132:e558–67. PMID:23897912 https://doi.org/10.1542/peds.2013-1741
Girardet RG, Lahoti S, Howard LA, et al. Epidemiology of sexually transmitted infections in suspected child victims of sexual assault. Pediatrics 2009;124:79–86. PMID:19564286 https://doi.org/10.1542/peds.2008-2947
Black CM, Driebe EM, Howard LA, et al. Multicenter study of nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in children being evaluated for sexual abuse. Pediatr Infect Dis J 2009;28:608–13. PMID:19451856 https://doi.org/10.1097/INF.0b013e31819b592e
Trotman GE, Young-Anderson C, Deye KP. Acute sexual assault in the pediatric and adolescent population. J Pediatr Adolesc Gynecol 2016;29:518–26. PMID:26702774 https://doi.org/10.1016/j.jpag.2015.05.001
Schwandt A, Williams C, Beigi RH. Perinatal transmission of Trichomonas vaginalis: a case report. J Reprod Med 2008;53:59–61. PMID:18251366
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Adachi K, Nielsen-Saines K, Klausner JD. Chlamydia trachomatis infection in pregnancy: the global challenge of preventing adverse pregnancy and infant outcomes in sub-Saharan Africa and Asia. BioMed Res Int 2016;2016:9315757. PMID:27144177 https://doi.org/10.1155/2016/9315757
Schachter J, Grossman M, Sweet RL, Holt J, Jordan C, Bishop E. Prospective study of perinatal transmission of Chlamydia trachomatis. JAMA 1986;255:3374–7. PMID:3712696 https://doi.org/10.1001/jama.1986.03370240044034
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Sabeena S, Bhat P, Kamath V, Arunkumar G. Possible non-sexual modes of transmission of human papilloma virus. J Obstet Gynaecol Res 2017;43:429–35. PMID:28165175 https://doi.org/10.1111/jog.13248
Adams JA, Farst KJ, Kellogg ND. Interpretation of medical findings in suspected child sexual abuse: an update for 2018. J Pediatr Adolesc Gynecol 2018;31:225–31. PMID:29294380 https://doi.org/10.1016/j.jpag.2017.12.011
Kellogg ND, Melville JD, Lukefahr JL, Nienow SM, Russell EL. Genital and extragenital gonorrhea and chlamydia in children and adolescents evaluated for sexual abuse. Pediatr Emerg Care 2018;34:761–6. PMID:28072668 https://doi.org/10.1097/PEC.0000000000001014
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Bandea CI, Joseph K, Secor EW, et al. Development of PCR assays for detection of Trichomonas vaginalis in urine specimens. J Clin Microbiol 2013;51:1298–300. PMID:23390274 https://doi.org/10.1128/JCM.03101-12
Gallion HR, Dupree LJ, Scott TA, Arnold DH. Diagnosis of Trichomonas vaginalis in female children and adolescents evaluated for possible sexual abuse: a comparison of the InPouch TV culture method and wet mount microscopy. J Pediatr Adolesc Gynecol 2009;22:300–5. PMID:19576816 https://doi.org/10.1016/j.jpag.2008.12.006
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Girardet RG, Lemme S, Biason TA, Bolton K, Lahoti S. HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault. Child Abuse Negl 2009;33:173–8. PMID:19324415 https://doi.org/10.1016/j.chiabu.2008.05.010
Panel on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the use of antiretroviral agents in pediatric HIV infection. Washington, DC: US Department of Health and Human Services, National Institutes of Health, AIDSinfo; 2020. https://aidsinfo.nih.gov/contentfiles/lvguidelines/pediatricguidelines.pdf

CME / ABIM MOC / CE

Sexually Transmitted Infections Treatment Guidelines, 2021

Authors: Kimberly A. Workowski, MD; Laura H. Bachmann, MD; Philip A. Chan, MD; Christine M. Johnston, MD; Christina A. Muzny, MD; Ina Park, MD; Hilary Reno, MD, PhD; Jonathan M. Zenilman, MD; Gail A. Bolan, MD
CME / ABIM MOC / CE Released: 10/27/2021
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 10/27/2022

Start Activity

Target Audience and Goal Statement

This activity is intended for family medicine clinicians, internists, adolescent medicine clinicians, obstetricians/gynecologists, emergency medicine clinicians, infectious disease clinicians, and other clinicians caring for patients with or at risk for sexually transmitted infections (STIs).

The goal of this activity is to describe on-site STI treatment and partner services, operational determinants of quality services in various clinical settings, and indications for consultation with or referral to a specialist for patients with STI-related conditions, according to updated Centers for Disease Control and Prevention (CDC) guidelines.

Upon completion of this activity, participants will:

Describe treatment recommendations for sexually transmitted infections (STIs), according to updated Centers for Disease Control and Prevention (CDC) guidelines
Determine vaccine and other preventive strategy recommendations for STIs, according to updated CDC guidelines
Identify diagnostic and counseling recommendations for STIs, according to updated CDC guidelines

Disclosures

As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Faculty

Kimberly A. Workowski, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention (CDC)
Department of Medicine, Emory University
Atlanta, Georgia

Disclosures

Disclosure: Kimberly A. Workowski, MD, has disclosed no relevant financial relationships.

Laura H. Bachmann, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention (CDC)
Atlanta, Georgia

Disclosures

Disclosure: Laura H. Bachmann, MD, has disclosed no relevant financial relationships.

Philip A. Chan, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia
Brown University
Providence, Rhode Island

Disclosures

Disclosure: Philip A. Chan, MD, has disclosed no relevant financial relationships.

Christine M. Johnston, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia
University of Washington
Seattle, Washington

Disclosures

Disclosure: Christine M. Johnston, MD, has disclosed the following relevant financial relationships:
Serve(d) as advisor or consultant for: AbbVie, Inc.; Gilead Sciences, Inc.; MedPace, Inc.
Received grants for clinical research from: Bill and Melinda Gates Foundation
Other (Royalties for HSV sections): UpToDate

Christina A. Muzny, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia
University of Alabama at Birmingham

Disclosures

Disclosure: Christina A. Muzny, MD, has disclosed the following relevant financial relationships:
Serve(d) as advisor or consultant for: Abbott Laboratories; Becton, Dickinson and Co.; Cepheid; Lupin Pharmaceuticals, Inc.; PhagoMed Biopharma GmbH; Roche Diagnostics
Received grants for clinical research from: Lupin Pharmaceuticals, Inc.

Ina Park, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia
University of California San Francisc

Disclosures

Disclosure: Ina Park, MD, has disclosed no relevant financial relationships.

Hilary Reno, MD, PhD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia
Washington University
St Louis, Missouri

Disclosures

Disclosure: Hilary Reno, MD, PhD, has disclosed the following relevant financial relationships:
Received grants for clinical research from: Hologics, Inc.

Jonathan M. Zenilman, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia
Johns Hopkins University
Baltimore, Maryland
Participation by Dr. Jonathan M. Zenilman does not constitute or imply endorsement by the Johns Hopkins University or the Johns Hopkins Hospital and Health System.

Disclosures

Disclosure: Jonathan M. Zenilman, MD, has disclosed no relevant financial relationships.

Gail A. Bolan, MD

Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia

Disclosures

Disclosure: Gail A. Bolan, MD, has disclosed no relevant financial relationships.

CME Author

Laurie Barclay, MD

Freelance writer and reviewer
Medscape, LLC

Disclosures

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

Stephanie Corder, ND, RN, CHCP

Associate Director, Accreditation and Compliance
Medscape, LLC

Disclosures

Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

None of the nonfaculty planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.

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From Morbidity & Mortality Weekly Report

CME / ABIM MOC / CE

Sexually Transmitted Infections Treatment Guidelines, 2021

Authors: Kimberly A. Workowski, MD; Laura H. Bachmann, MD; Philip A. Chan, MD; Christine M. Johnston, MD; Christina A. Muzny, MD; Ina Park, MD; Hilary Reno, MD, PhD; Jonathan M. Zenilman, MD; Gail A. Bolan, MDFaculty and Disclosures

THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / ABIM MOC / CE Released: 10/27/2021

Valid for credit through: 10/27/2022

processing....

Summary

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Introduction

The term "sexually transmitted infection" (STI) refers to a pathogen that causes infection through sexual contact, whereas the term "sexually transmitted disease" (STD) refers to a recognizable disease state that has developed from an infection. Physicians and other health care providers have a crucial role in preventing and treating STIs. These guidelines are intended to assist with that effort. Although the guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed.

This report updates Sexually Transmitted Diseases Treatment Guidelines, 2015^[1] and should be regarded as a source of clinical guidance rather than prescriptive standards. Health care providers should always consider the clinical circumstances of each person in the context of local disease prevalence. These guidelines are applicable to any patient care setting that serves persons at risk for STIs, including family planning clinics, HIV care clinics, correctional health care settings, private physicians' offices, Federally Qualified Health Centers, clinics for adolescent care, and other primary care facilities. These guidelines are focused on treatment and counseling and do not address other community services and interventions that are essential to STI and HIV prevention efforts.

These STI treatment guidelines complement Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020^[2] regarding quality clinical services for STIs in primary care and STD specialty care settings. This guidance specifies operational determinants of quality services in various clinical settings, describes on-site treatment and partner services, and indicates when STI-related conditions should be managed through consultation with or referral to a specialist.

Page 1 of 20

Methods

CME / ABIM MOC / CE Information

References

References

Disclaimer

The educational activity presented above may involve simulated, case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient, whether living or deceased, is intended or should be inferred. The material presented here does not necessarily reflect the views of Medscape, LLC, or any individuals or commercial entities that support companies that support educational programming on medscape.org. These materials may include discussion of therapeutic products that have not been approved by the US Food and Drug Administration, off-label uses of approved products, or data that were presented in abstract form. These data should be considered preliminary until published in a peer-reviewed journal. Readers should verify all information and data before treating patients or employing any therapies described in this or any educational activity. A qualified healthcare professional should be consulted before using any therapeutic product discussed herein.

Medscape, LLC

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Box 1.

Box 2.

Box 3.

Box 4.

Box 5.

References

Faculty and Disclosures

Faculty

Kimberly A. Workowski, MD

Laura H. Bachmann, MD

Philip A. Chan, MD

Christine M. Johnston, MD

Christina A. Muzny, MD

Ina Park, MD

Hilary Reno, MD, PhD

Jonathan M. Zenilman, MD

Gail A. Bolan, MD

CME Author

Laurie Barclay, MD

CME Reviewer/Nurse Planner

Stephanie Corder, ND, RN, CHCP

CME / ABIM MOC / CE

Sexually Transmitted Infections Treatment Guidelines, 2021

Target Audience and Goal Statement

Disclosures

Faculty

Kimberly A. Workowski, MD

Laura H. Bachmann, MD

Philip A. Chan, MD

Christine M. Johnston, MD

Christina A. Muzny, MD

Ina Park, MD

Hilary Reno, MD, PhD

Jonathan M. Zenilman, MD

Gail A. Bolan, MD

CME Author

Laurie Barclay, MD

CME Reviewer/Nurse Planner

Stephanie Corder, ND, RN, CHCP

Accreditation Statements

For Physicians

For Nurses

For Pharmacists

Instructions for Participation and Credit

Sexually Transmitted Infections Treatment Guidelines, 2021

Summary

Introduction

Table of Contents