Should a patient who had unprotected sex with a sex worker be treated empirically for Sexually Transmitted Diseases (STDs)?

Empiric STD Treatment After Unprotected Sex with Sex Worker

Yes, empiric treatment for gonorrhea and chlamydia should be provided to patients who had unprotected sex with a sex worker, especially when there are concerns about follow-up compliance or when the patient is from a high-risk setting. 1

Rationale for Empiric Treatment

The CDC explicitly recommends presumptive antibiotic treatment for STDs in settings where:

• The likelihood of STD infection is high 1
• Prompt follow-up for subsequent treatment is in question 1
• Doubts exist about whether a patient will follow up for test results or adhere to recommendations to avoid sexual activity while potentially infected 1

Unprotected sex with a sex worker represents a high-risk exposure that meets these criteria for empiric treatment. 2 Sex workers are recognized as a population group at increased risk for STD transmission and play an important role in maintaining epidemic status of STDs. 3

Recommended Empiric Treatment Regimen

For asymptomatic patients after high-risk exposure, treat empirically with:

• Ceftriaxone 500 mg IM single dose (for gonorrhea coverage) 4
• PLUS Doxycycline 100 mg orally twice daily for 7 days (for chlamydia coverage) 5, 4

This dual therapy provides coverage for the two most common bacterial STDs. 5, 6

Alternative if Doxycycline Cannot Be Used:

• Azithromycin 1 g orally single dose can substitute for doxycycline 5, 7

Additional Testing and Management

While empiric treatment should be initiated immediately, laboratory testing should still be performed whenever possible to confirm the nature of infection: 1

• Test for Neisseria gonorrhoeae and Chlamydia trachomatis 5
• Obtain serologic test for syphilis 1
• Offer HIV testing and counseling 1
• Consider testing for other STDs including hepatitis B 1

Critical Counseling Points

Instruct the patient to:

• Abstain from sexual intercourse for 7 days after initiating therapy and until symptoms resolve (if present) 5
• Return for evaluation if symptoms develop or persist 5
• Understand that most STDs produce no symptoms, making screening crucial 1
• Recognize that other STDs facilitate HIV transmission 1

Follow-Up Recommendations

• Test-of-cure is not routinely needed for asymptomatic patients who received recommended treatment 5
• Consider repeat testing 3-6 months after treatment due to high rate of reinfection 5
• If symptoms develop or persist, return for re-evaluation 5

Common Pitfalls to Avoid

Do not delay treatment while waiting for test results in high-risk patients unlikely to return for follow-up. 1 The interval between testing and treatment provides opportunity for transmission, and patients with positive tests are often difficult to locate when results become available. 1

Do not rely solely on patient-reported absence of symptoms. Most STDs, particularly chlamydia, are asymptomatic. 1

Do not treat only for one organism if empiric therapy is indicated. Coverage should include both gonorrhea and chlamydia regardless of clinical presentation. 6

Special Considerations for Symptomatic Patients

If the patient has urethral discharge:

• Treat presumptively with antibiotics for both gonorrhea and chlamydia without waiting for confirmatory testing 1
• Document urethritis by presence of mucopurulent/purulent discharge, positive leukocyte esterase test, or ≥10 WBC per high-power field on first-void urine 5

If the patient has genital ulcers and is from a community with high syphilis rates:

• Add presumptive treatment for primary syphilis with penicillin G benzathine 2.4 million units IM single dose 1, 4