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1 Date: March 30, 2012 ATTN: Medical Health Officers and Branch Offices Public Health Nursing Administrators and Assistant Administrators Holders of Communicable Disease Control Manuals Re: Revisions to the Communicable Disease Control Manual Chapter 5 Sexually Transmitted Infections Please note the following changes to the Communicable Disease Control Manual Chapter 5 Sexually Transmitted infections: (1) CORRECTIONS TO ADMINISTRATIVE CIRCULAR 2012:02 Please note the following corrections to BCCDC Decision Support Tools (DSTs) released on February 7, 2012: Proctitis Decision Support Tool page 4 Under Treatment of Choice regarding note #7: For intramuscular injections (IM) of ceftriaxone or spectinomycin, the ventrogluteal site is preferred; spectinomycin has been removed from this note as this medication is not identified as a first or second treatment choice within the DST. Proctitis Decision Support Tool page 5 Under Treatment of Choice Men who have sex with men (MSM), two typos corrected under Second Choice now reads: cefixime 800 mg PO in a single dose and doxycycline 100 mg PO for 7 days Pelvic Inflammatory Disease Decision Support Tool page 5 Under Treatment of Choice regarding note #7: For intramuscular injections (IM) of ceftriaxone or spectinomycin, the ventrogluteal site is preferred; spectinomycin has been removed from this note as this medication is not identified as a first or second treatment choice within the DST. Pelvic Inflammatory Disease Decision Support Tool page 6 Under Treatment of Choice PID WITH Bacterial Vaginosis. Second Choice: error, ceftriaxone treatment option written twice. Treatment now reads: cefixime 800 mg PO in a single dose and azithromycin 1 gm PO in a single dose repeated in 1 week (2 doses of 1 gm PO each given 7 days apart) and metronidazole 500 mg PO bid for 10 days OR ceftriaxone 250 mg IM and azithromycin 1gm PO in a single dose repeated in 1 week (2 doses of 1 gm PO each given 7 days apart) and metronidazole 500 mg PO bid for 10 days. Administrative Circular 2012:05 1
2 (2) BCCDC VULVOVAGINAL CANDIDIASIS (VVC) DECISION SUPPORT TOOL - Updated Please note changes to pages 1-6 (discard & replace entire DST) page 1 - Predisposing Risk Factors Updated list to include HIV infection. Poorly controlled diabetes removed and replaced by diabetes. page 2 - Diagnostic Tests Introductory paragraph removed and redistributed to notes where applicable. If bacterial vaginosis (BV) is suspected in conjunction with VVC then refer also to the BV DST. page 2 - Diagnostic Tests - Section has been expanded to include various diagnostic tests used in different clinical settings for bacterial vaginosis, Trichomonas vaginalis, and vaginal yeast. T. vaginalis NAAT has been included to reflect current practice and recent changes in the STI Assessment DST. page 2 - Diagnostic Tests Addition to note with information regarding the safe use of 10% Potassium Hydroxide in STI Screening, and blind swab collection. page 2 - Clinical Evaluation Removed negative lab results do not rule out the diagnosis, replaced with treatment may be offered based on clinical findings. The latter statement supports nursing practice where immediate microscopy is not available (the majority of clinical settings for RN(c)). If the client is symptomatic treatment can be offered regardless of the availability of immediate results. page 3 Clinical Management for Vulvovaginal Symptoms - Flow diagram has been revised to support offering treatment when clinical findings are suggestive of VVC and onsite microscopy for diagnostic testing is not available. page 4 Treatment of Choice Treatment table updated with two tables separated into Vaginal Symptoms or Vulvar-external symptoms. page 4 Treatment of Choice Under Vaginal Symptoms - Treatment added fluconazole 150 mg PO in a single dose. Added note regarding medication reconciliation for fluconazole. page 4 Treatment of Choice Under Vulvar external symptoms - Notes, added information regarding medication reconciliation for miconazole and clotrimazole creams. page 5 Alternate Treatment Removal of fluconazole 150 mg tablet PO stat. This medication no longer requires a prescription to attain. Removal of butaconazole 2% cream as alternate treatment as Physician/NP prescribing preferences will vary for alternate treatment for recurrent VVC. 2
3 page 5 Alternate Treatment Referral recommendations to physician or NP for recurrent VVC has been added to this section. page 6 Consultation or Referral - Removal of last bullet, client is taking anticoagulants. Medication reconciliation is addressed under Treatment of Choice. (3) BCCDC GENITAL HERPES SIMPLEX VIRUS DECISION SUPPORT TOOL - Updated Please note changes to pages 1-9 (discard & replace entire DST) page 1 - Potential Causes Revised for clarity regarding transmission of HSV 1 and HSV 2. page 1 - Predisposing Risk Factors Removal of multiple sex partners. page 2 Sexual Health History Removed bullets: at least one sexual partner, and condoms may or may not have been used for sexual contact. page 3 Physical Assessment Revised to include information about alternate screening methods for women (urine testing) if infection includes extensive vulvar or cervical involvement. page 4 Diagnostic Tests HSV Culture section replaced with Swab: HSV Polymerase Chain Reaction (PCR), to reflect current diagnostics for HSV. page 4 Diagnostic Tests added Interpretation of HSV PCR results - Updated to reflect detection of varicella zoster virus (VZV) on PCR results and appropriate follow-up for herpes zoster (shingles). page 4 Serology Revised to include syphilis RPR as routine serology for clients with presumptive HSV (recommended in the Canadian Guidelines on Sexually Transmitted Infections referenced within the HSV DST). page 4 Serology Added Case Specific Serology section. Included to clarify indications for HSV antibody testing and/or HSV type specific serology. page 5 Type Specific Serology Information revised to clarify indications for type specific HSV serology and recommendations with regard to diagnostic testing and HSV infection window period. page 6 Treatment of Choice Introductory paragraph condensed for clarity. page 7 Potential Complications Revised for clarity regarding risks associated with neonatal HSV infection. 3
4 page 8 Client Education and Follow Up Revised to include current data regarding HSV prevalence within the population. page 8 Consultation or Referral Updated to reflect clients requiring prescription medication, herpes zoster on diagnostic testing (shingles), and extensive primary outbreaks. page 9 References References included to support change in diagnostics (HSV PCR) and current population prevalence of HSV. Please remove the following page from the Communicable Disease Control Manual, Chapter 5 Sexually Transmitted Infections, Section I STI: BCCDC Non-certified practice decision support tool Proctitis February 2012, pg. 4 BCCDC Non-certified practice decision support tool Proctitis February 2012, pg. 5 February 2012, p. 5 February 2012, p. 6 BCCDC Non-certified practice decision support tool VVC April 2010 (pg 1-6) BCCDC Non-certified practice decision support tool Genital HSV April 2010 (pg. 1-9) Please insert the following updates to the Communicable Disease Control Manual, Chapter 5 Sexually Transmitted Infections, Section I STI BCCDC Non-certified practice decision support tool Proctitis March 2012, pg. 4 BCCDC Non-certified practice decision support tool Proctitis March 2012, pg. 5 March 2012, p. 5 March 2012, p. 6 BCCDC Non-certified practice decision support tool VVC March 2012 (pg 1-8) BCCDC Non-certified practice decision support tool Genital HSV March 2012 (pg. 1-10) 4
5 If you have any questions regarding these practice changes, please contact Elizabeth Elliot, Director, Nursing & Manager, Professional Practice at telephone (604) , or Cheryl Prescott, Nurse Educator, Clinical Prevention Services at telephone (604) or by at Sincerely, Gina Ogilvie MD MSc CCFP FCFP Medical Director Clinical Prevention Services BC Centre for Disease Control pc: Ministry of Health Dr. Perry Kendall Provincial Health Officer Dr. Bob Fisk Medical Consultant Non-Communicable Disease Dr. Eric Young Deputy Provincial Health Officer Craig Thompson Director, CD Prevention Immunization Warren O Briain Executive Director Communicable Disease and Addiction Prevention 5
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