DECISION SUPPORT TOOL FOR RN SANES DISPENSING PROPHYLAXIS FOR SEXUALLY TRANSMITTED INFECTION AFTER SEXUAL ASSAULT

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1 BC WOMEN S SEXUAL ASSAULT SERVICE PURPOSE DECISION SUPPORT TOOL FOR RN SANES DISPENSING PROPHYLAXIS FOR SEXUALLY TRANSMITTED INFECTION AFTER SEXUAL ASSAULT This decision support tool (DST) and accompanying documents have been developed to assist Registered Nurses (RNs) working in hospital emergency departments as sexual assault nurse examiners (SANEs) to assess the sexual assault patient s risk of exposure to sexually transmitted infection (STI), in particular gonorrhea, chlamydia, and hepatitis, and to safely offer and dispense prophylactic medication when appropriate. RNs using this DST must meet the competencies established by BC Women s Sexual Assault Service (BCW SAS), Competencies For RN SANEs Dispensing Prophylactic Medications to Prevent STI and HIV After Sexual Assault. RN SANEs will refer to the emergency physician for patient-specific medication orders when the patient is pregnant or breastfeeding. See DST for RN SANEs Dispensing HIV PEP After Sexual Assault for risk assessment and prophylaxis for HIV. To be sure you have the most recent version of this DST please contact BCW SAS at (1) or visit our website bcwomens.ca/sexualassaultservice.

2 BC WOMEN S SEXUAL ASSAULT SERVICE DECISION SUPPORT TOOL FOR RN SANES DISPENSING PROPHYLAXIS FOR SEXUALLY TRANSMITTED INFECTION AFTER SEXUAL ASSAULT INDICATIONS FOR STI PROPHYLAXIS AFTER SEXUAL ASSAULT All sexual assault patients seen within seven days of the assault, who have experienced any form of genital/oral, genital/anal, or genital/genital contact, are offered antibiotic prophylaxis for gonorrhea and chlamydia. ASSESSMENT History Determine type of sexual contact that occurred during the sexual assault Determine possibility of pregnancy unrelated to the sexual assault o date of last menstrual period o use of contraception o vaginal intercourse within last month Perform pregnancy test as relevant Is patient breastfeeding? Determine any medication allergies Determine any medications the patient is currently taking Determine hepatitis B vaccination status All patients with unexplained lower abdominal pain should be referred to the emergency physician to be assessed for pre-existing pelvic inflammatory disease (PID). Any medications indicated for treatment of PID will be ordered by a physician. PROPHYLAXIS OF GONORRHEA & CHLAMYDIA Prophylactic Regimen of Choice 1. cefixime 800 mg po in a single dose and azithromycin 1 gram po in a single dose Potential Indications for Alternate Prophylactic Regimen 1. Patient has suspected history of allergy to antibiotics 2. Patient is pregnant or breastfeeding. Refer to emergency physician for patient-specific medication order. 2

3 Alternate Prophylactic Regimens for History of Allergy to Antibiotics 1. Patient has suspected history of allergy to penicillins or cephalosporins: azithromycin 2 gram po (associated with gastrointestinal side-effects) 2. Patient has a suspected history of allergy to azithromycin, or other macrolides: cefixime 800 mg po in a single dose plus doxycycline 100 mg po bid for 7 days Do not use doxycycline if patient is pregnant or breastfeeding. 3. Patient has suspected history of allergy to macrolides and tetracyclines: cefixime 800 mg po plus amoxicillin 500 mg po tid for 7 days 4. Patient has a suspected history of allergy to penicillins/cephalosporins and macrolides doxycycline 100 mg bid for 7 days (if no allergy to tetracycline) and Contact BCCDC in office hours ( ) to discuss potential use of spectinomycin or Contact physician or NP for patient specific order or alternate plan Do not use doxycycline if patient is pregnant or breastfeeding. Important Notes All listed medication dosages are for a complete course of prophylaxis Do not use cefixime if allergic to penicillins or cephalosporins. Do not use azithromycin if allergic to macrolides. Do not use doxycycline if allergic to tetracyclines. For further information on side-effects, cautions and contraindications for cefixime, azithromycin, doxycycline, or amoxicillin, please see: Spectinomycin: o treats vaginal/anal gonorrhea only 3

4 o does not treat oral gonorrhea. o does not treat chlamydia RECOMMENDATIONS FOR FOLLOW-UP Testing for chlamydia and gonorrhea is recommended in pregnancy at 3-4 weeks post sexual assault. Follow-up testing for chlamydia and gonorrhea is not required for nonpregnant patients who have taken appropriate prophylaxis, unless symptoms develop, including unusual discharge or lower abdominal pain. These treatments are not sufficient to cover syphilis. Testing for syphilis is recommended at one and three months for all patients. If patient declines prophylactic treatment, advise to have follow-up testing for chlamydia and gonorrhea in 7 to 14 days post sexual assault. PATIENT TEACHING Review and ensure the patient understands how to take the medication and is aware of the possible side effects. Offer take-home written materials. Discuss need to attend follow-up for further testing as above, or in the event of symptoms. Discuss options for follow-up. Discuss need to protect partners for one week following single dose prophylaxis or for the entire course of multi-dose prophylaxis. Answer any questions the patient may have. PROPHYLAXIS OF HEPATITIS B AFTER SEXUAL ASSAULT 4

5 HEPATITIS B VACCINE Indications All sexual assault patients who: have experienced any form of genital/genital contact, genital/anal contact, or have been potentially exposed through drug-facilitated sexual assault (where the nature of the exposure is unknown) should be offered Hepatitis B Vaccine. Route and Dosage Age 20 and over - Hepatitis B Vaccine 1 ml IM into the deltoid muscle Under 20 years of age Hepatitis B Vaccine 0.5 ml IM into the deltoid muscle Immunocompromised patients (e.g. HIV positive, chronic liver disease, liver transplant, chronic kidney disease, stem cell transplant) should receive double the regular dose of Hepatitis B Vaccine for their age (BC Centre for Disease Control 2009). Refer to physician for medication order in this case. Before administering Hepatitis B Vaccine, SANEs must ensure an emergency physician is available in the event of anaphylaxis, and that protocols and supplies are in place to manage anaphylaxis. Patients receiving Hepatitis B Vaccine should remain in the Emergency Department for a minimum of 15 minutes after vaccine administration to be monitored for possible anaphylactic reaction. Notes Regarding Hepatitis B Vaccination 1. Oral/genital contact is not considered a risk for hepatitis B. 2. Hepatitis B Vaccine is offered regardless of: the risk status of the assailant whether ejaculation took place whether the patient has completed the series of 3 Hepatitis B Vaccines. See number 3 below. 3. If the patient states that they have had hepatitis B disease or they have documented anti-hbs level greater than or equal to 10 IU/L on prior testing, then the Hepatitis B Vaccine is not indicated. 4. Long-term immunity to hepatitis B is gained through receiving a series of three Hepatitis B Vaccines over a six month period. The first is given as soon as possible after exposure, and the next is given one month later and the third is given six months after the initial dose was given. The seroprotective rate of this dosing schedule is 96% in healthy individuals (GlaxoSmithKline Inc. 2008). Patients who have completed their series prior to an assault, but are unsure of their immune status, are offered a booster and recommended to have follow-up testing at one and three months. 5

6 5. The Hepatitis B Vaccine series can be started or continued by the SANE in the emergency department. However if the patient declines the vaccine during sexual assault care, it can be given by other healthcare providers in the community. 6. Sexual assault patients on haemodialysis may require a different formula and should be referred to their dialysis facility for Hepatitis B Vaccine (BC Centre for Disease Control 2009). Contraindications History of anaphylactic reaction to a previous dose of any Hepatitis B Vaccine, to any component of the Hepatitis B Vaccine, or to latex. Adverse Events Fever ( 37.7 C) and mild short-term soreness at injection site. For further information on adverse events, cautions and contraindications for Hepatitis B Vaccine, please see: Follow-Up Teaching 1. Inform the patient that the injection site may be sore, reddened and slightly swollen for a few days. 2. Provide the patient with written information outlining when the second and/or third vaccinations should be given, and listing clinics where the subsequent vaccinations may be obtained. 3. Follow-up testing for hepatitis B may be done at one and three months after possible exposure. Provide the patient with information as to where this may be provided. HEPATITIS B IMMUNE GLOBULIN (HBIG) Indications All sexual assault patients who: 6

7 have experienced any form of genital/genital or genital/anal contact or have been potentially exposed through drug-facilitated sexual assault (where the nature of the exposure is unknown) and have had only one or no doses of Hepatitis B Vaccine should be offered Hepatitis B Immune Globulin (HBIG), as well as one dose of Hepatitis B vaccine. (Patients with a history of 2 or 3 doses of Hepatitis B Vaccine require only a dose of Hepatitis B Vaccine, as above). If the assailant is a known Hepatitis B carrier, HBIG should be considered for the patient regardless of completion of Hepatitis B Vaccine series and additional Hepatitis B Vaccine given at time of exam. For exceptions to these indications see Notes Regarding HBIG Administration. Route and Dosage Hepatitis B Immune Globulin 0.06 ml/kg of patient s body weight intramuscularly HBIG must be given at a separate anatomic site from Hepatitis B Vaccine. The ventrogluteal site is preferred. Due to the large volume of fluid, this is usually administered in two divided doses, one on each side. Before administering HBIG, SANEs must ensure an emergency physician is available in the event of anaphylaxis, and that protocols and supplies are in place to manage anaphylaxis. Patients receiving HBIG should remain in the Emergency Department for a minimum of 15 minutes after vaccine administration, to be monitored for possible anaphylactic reaction. Notes Regarding HBIG Administration 1. Oral/genital contact is not considered a risk for hepatitis B 2. If the patient states that they have had hepatitis B disease, or have documented anti-hbs level greater than or equal to 10 IU/L on prior testing, then neither HBIG nor hepatitis B Vaccine is indicated. 3. A special blood products patient consent form will need to be signed by the patient. Follow your agency protocol on the administration of blood products. 4. HBIG is most effective if given 48 hours or less after possible exposure, but can be given up to 14 days post-exposure. 5. HBIG vials are single dose; discard unused contents. Cautions 1. History of anaphylactic reaction following receipt of any human immunoglobulin product or a history of anaphylactic reaction to latex. Refer to emergency physician for patient-specific physician order and risk assessment. 7

8 2. Severe thrombocytopenia or coagulation disorders that contraindicate IM injections. Refer to emergency physician for patient-specific physician order and risk assessment. Adverse Events Local pain at injection site, itchiness and swelling may occur. For further information on adverse events, cautions and contraindications for HBIG please see: Follow-Up Teaching 1. Inform the patient that the site(s) may be sore, reddened and slightly swollen for a few days. 2. Provide the patient with written information. Patients receiving HBIG should be given a record to note they have received a blood product. 3. Follow-up testing for hepatitis B may be done at one and three months after possible exposure. Provide the patient with information as to where this may be provided. DEFINITIONS & ABBREVIATIONS BCW SAS - BC Women s Sexual Assault Service, part of Children s and Women s Health Centre of British Columbia Branch, an agency of the PHSA Cephalosporins - a frequently prescribed class of antibiotics closely related to the penicillins. Cefixime is one of many examples. 8

9 Chlamydia bacterial infection caused by the transmission of Chlamydia trachomatis during sexual contact in which body fluids are exchanged Decision Support Tool evidence-based document used by RNs to guide assessment, diagnosis and treatment of client-specific clinical problems. RNs may use DSTs to direct their practice but they should be used in conjunction with clinical judgement, available evidence, and following discussion with professional colleagues. Dispensing - the preparation and transfer of a medication to a client, taking steps to ensure its pharmaceutical and therapeutic suitability and its proper use. (CRNBC, 2010) DST Decision support tool Gonorrhea bacterial infection caused by the transmission of Neisseria gonorrhoeae during sexual contact, in which body fluids are exchanged Macrolides a class of antibiotics including azithromycin and erythromycin Prophylactic an agent used to prevent disease Prophylaxis measures taken to prevent disease; common term for chemoprophylaxis SANE - sexual assault nurse examiner Sexual assault - any form of sexual activity with another person without that person s consent Sexual assault nurse examiner - RN with special training in comprehensive care for sexual assault patients. SANE competencies include, but are not limited to, the provision of crisis counselling, advocacy and support, sexual assault health assessment and examination, preventative health care, forensic examination, collection of forensic samples, and documentation of injuries. Women-centred-care a model of care that recognizes that trauma is a central aspect of many girls and women s lives, and focuses on empowering women impacted by violence through respect and support of their decisions. (Cory & Dechief, 2007) REFERENCES BC Centre for Disease Control. (2009). Communicable Disease Control Immunization Program. 9

10 CRNBC. (2010). Practice Standard for Registered Nurses and Nurse Practitioners: Dispensing Medications. Cory, Jill & Dechief, Linda. (2007). SHE framework: Safety & Health Enhancement for women experiencing abuse: a toolkit for providers and planners. GlaxoSmithKline Inc., (2008). PRODUCT MONOGRAPH ENGERIX -B Public Health Agency of Canada. (2006). Canadian Guidelines on Sexually Transmitted Infections. (updated January 2008). Revised: March 4,