"Sexually Transmitted Disease Confidential Case Report Form" - Rhode Island

Sexually Transmitted Disease Confidential Case Report Form is a legal document that was released by the Rhode Island Department of Health - a government authority operating within Rhode Island.

Form Details:

  • Released on March 7, 2016;
  • The latest edition currently provided by the Rhode Island Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download "Sexually Transmitted Disease Confidential Case Report Form" - Rhode Island

744 times
Rate (4.3 / 5) 37 votes
SEXUALLY TRANSMITTED DISEASE CONFIDENTIAL CASE REPORT FORM
RHODE ISLAND DEPARTMENT OF HEALTH
CENTER FOR HIV, HEPATITIS, STDs, and TB
3 Capitol Hill, Room 106, Providence, RI 02908
PHONE: (401) 222-2577 | FAX: (401) 222-1105
Mail or fax report form within 4 days of diagnosis.
I. PATIENT INFORMATION:
Last Name
First (full) Name
MI
Date of Birth
Age
Street
Apt #
City/Town
State
Zip
Phone Number :
______ /______ /
(_ _ _) _ _ _ - _ _ _ _
_________
Sex:  Male  Female
Transgender:  M to F
 F to M
 Other
 Yes  No
Is this patient pregnant?
 Asian
Ethnic Origin:
Race (check all that apply):
 Hispanic or Latino
 American Indian or Alaskan Native
 White
 Not Hispanic or Latino
 Black or African American
 Native Hawaiian or Pacific Islander
Sex/Gender of partner(s) (Check all that apply):  Refused  Male  Female Transgender:  M to F  F to M Other
Number of partners: ______
II. FACILITY INFORMATION:
Physician or Facility Name
Facility Street Address, City, State, Zip Code
Facility Contact Person for STD Reporting
Phone Number: (_ _ _) _ _ _ - _ _ _ _
Fax Number: (_ _ _) _ _ _ - _ _ _ _
III. HIV TESTING STATUS
Was the patient tested for HIV at this visit?  Yes
 No
IV. STD INFORMATION
1. GONORRHEA
Clinical Information
Site / Specimen
(check all that apply):
(check all that apply):
Date of Test: __ __ / __ __/ __ __ __ __
Cervix
 Asymptomatic
Pharynx
 Symptomatic
Date of Treatment: __ __ / __ __/ __ __ __ __
Rectum
 Pelvic Inflammatory Disease
Urethra
Treatment:
 Referred by partner
 Ceftriaxone - 250 mg IM in a single dose
Urine
 Other: _________________
Vagina
PLUS Azithromycin - 1 gram as a single dose
 Other Med + Dose: __________________
Other: ______________
2. CHLAMYDIA
Clinical Information
Site / Specimen
(check all that apply):
Date of Test: __ __ / __ __/ __ __ __ __
(check all that apply):
Cervix
 Asymptomatic
Pharynx
Date of Treatment: __ __ / __ __/ __ __ __ __
 Symptomatic
Rectum
 Pelvic Inflammatory Disease
Treatment:
Urethra
 Referred by partner
 Azithromycin – 1 gram as a single dose
Urine
 Other: _________________
 Doxycycline – 100 mg 2x/day for 7 days
Vagina
 Other Med + Dose: __________________
Other: ______________
EXPEDITED PARTNER THERAPY (EPT):
Was EPT offered to the patient?  Yes  No
Was medication prescribed to the patient for their partner (partner does not need to be examined)?  Yes  No
3. SYPHILIS
Clinical Information
(check all that apply):
_________
Date _ _/_ _/_ _ _ _
RPR Titers:
 Asymptomatic
 Neurosyphilis
_________
Date _ _/_ _/_ _ _ _
 Rash
 Congenital (infant)
 Chancre (sore/lesion)
 Referred by partner
_________
Date _ _/_ _/_ _ _ _
FTA Result:
 Condyloma lata
 Other: ______________
_________
Date _ _/_ _/_ _ _ _
 Alopecia
Last negative syphilis test
(if
Date of Treatment: __ __ / __ __/ __ __ __ __
known):
Medication & Dose:
Date of Test: __ __ / __ __/ __ __ __ __
__ __ / __ __/ __ __ __ __
______________________________________
4. OTHER STDs
 Chancroid  Granuloma Inguinale  PID (Non-Chlamydial / Non-Gonococcal)  Lymphogranuloma - Venereum (LGV)
The CDC 2015 STD Treatment Guidelines can be viewed at
http://www.cdc.gov/std/tg2015/toc.htm
Updated March 7, 2016
SEXUALLY TRANSMITTED DISEASE CONFIDENTIAL CASE REPORT FORM
RHODE ISLAND DEPARTMENT OF HEALTH
CENTER FOR HIV, HEPATITIS, STDs, and TB
3 Capitol Hill, Room 106, Providence, RI 02908
PHONE: (401) 222-2577 | FAX: (401) 222-1105
Mail or fax report form within 4 days of diagnosis.
I. PATIENT INFORMATION:
Last Name
First (full) Name
MI
Date of Birth
Age
Street
Apt #
City/Town
State
Zip
Phone Number :
______ /______ /
(_ _ _) _ _ _ - _ _ _ _
_________
Sex:  Male  Female
Transgender:  M to F
 F to M
 Other
 Yes  No
Is this patient pregnant?
 Asian
Ethnic Origin:
Race (check all that apply):
 Hispanic or Latino
 American Indian or Alaskan Native
 White
 Not Hispanic or Latino
 Black or African American
 Native Hawaiian or Pacific Islander
Sex/Gender of partner(s) (Check all that apply):  Refused  Male  Female Transgender:  M to F  F to M Other
Number of partners: ______
II. FACILITY INFORMATION:
Physician or Facility Name
Facility Street Address, City, State, Zip Code
Facility Contact Person for STD Reporting
Phone Number: (_ _ _) _ _ _ - _ _ _ _
Fax Number: (_ _ _) _ _ _ - _ _ _ _
III. HIV TESTING STATUS
Was the patient tested for HIV at this visit?  Yes
 No
IV. STD INFORMATION
1. GONORRHEA
Clinical Information
Site / Specimen
(check all that apply):
(check all that apply):
Date of Test: __ __ / __ __/ __ __ __ __
Cervix
 Asymptomatic
Pharynx
 Symptomatic
Date of Treatment: __ __ / __ __/ __ __ __ __
Rectum
 Pelvic Inflammatory Disease
Urethra
Treatment:
 Referred by partner
 Ceftriaxone - 250 mg IM in a single dose
Urine
 Other: _________________
Vagina
PLUS Azithromycin - 1 gram as a single dose
 Other Med + Dose: __________________
Other: ______________
2. CHLAMYDIA
Clinical Information
Site / Specimen
(check all that apply):
Date of Test: __ __ / __ __/ __ __ __ __
(check all that apply):
Cervix
 Asymptomatic
Pharynx
Date of Treatment: __ __ / __ __/ __ __ __ __
 Symptomatic
Rectum
 Pelvic Inflammatory Disease
Treatment:
Urethra
 Referred by partner
 Azithromycin – 1 gram as a single dose
Urine
 Other: _________________
 Doxycycline – 100 mg 2x/day for 7 days
Vagina
 Other Med + Dose: __________________
Other: ______________
EXPEDITED PARTNER THERAPY (EPT):
Was EPT offered to the patient?  Yes  No
Was medication prescribed to the patient for their partner (partner does not need to be examined)?  Yes  No
3. SYPHILIS
Clinical Information
(check all that apply):
_________
Date _ _/_ _/_ _ _ _
RPR Titers:
 Asymptomatic
 Neurosyphilis
_________
Date _ _/_ _/_ _ _ _
 Rash
 Congenital (infant)
 Chancre (sore/lesion)
 Referred by partner
_________
Date _ _/_ _/_ _ _ _
FTA Result:
 Condyloma lata
 Other: ______________
_________
Date _ _/_ _/_ _ _ _
 Alopecia
Last negative syphilis test
(if
Date of Treatment: __ __ / __ __/ __ __ __ __
known):
Medication & Dose:
Date of Test: __ __ / __ __/ __ __ __ __
__ __ / __ __/ __ __ __ __
______________________________________
4. OTHER STDs
 Chancroid  Granuloma Inguinale  PID (Non-Chlamydial / Non-Gonococcal)  Lymphogranuloma - Venereum (LGV)
The CDC 2015 STD Treatment Guidelines can be viewed at
http://www.cdc.gov/std/tg2015/toc.htm
Updated March 7, 2016
2015 CDC SEXUALLY TRANSMITTED DISEASES (STD) TREATMENT SUMMARY GUIDELINES
RHODE ISLAND DEPARTMENT OF HEALTH
These guidelines for treatment of STDs reflect recommendations of the CDC STD Treatment Guidelines. The focus is on STDs encountered in outpatient settings and is not an
exhaustive
list
of
effective
treatments.
Please
refer
to
the
complete
document
for
more
information,
or
call
the
STD
Program,
or
see
http://health.ri.gov/diseases/sexuallytransmitted/for/providers/. Sexual partner services (identification, notification, risk counseling and referral) for gonorrhea, syphilis and HIV/AIDS will be
provided by public health personnel when a case is reported. Contact information for Partner Services and to Report Cases: (401) 222-2577. FAX (401) 222-1105. STD Program,
Rhode Island Department of Health, Room 106, 3 Capitol Hill, Providence, RI 02908.
DISEASE
RECOMMENDED TREATMENT
ALTERNATIVES
(use only if recommended regimens contraindicated)
SYPHILIS
 Benzathine penicillin G 2.4 million units IM once
ADULTS
(For penicillin-allergic non-pregnant patients only)
 Doxycycline 100 mg orally 2 times a day for 14 days OR
P
, S
E
L
(<1 Y
)
RIMARY
ECONDARY OR
ARLY
ATENT
EAR
 Tetracycline 500 mg orally 4 times a day for 14 days
 Benzathine penicillin G 2.4 million units IM for 3 doses at 1 week
ADULTS
(For penicillin-allergic non-pregnant patients only)
 Doxycycline 100 mg orally 2 times a day for 28 days OR
L
L
(>1 Y
)
L
O
U
D
intervals (total 7.2 million units)
ATE
ATENT
EAR
OR
ATENT
F
NKNOWN
URATION
 Tetracycline 500 mg orally 4 times a day for 28 days
All Suspect Syphilis Cases:
 Aqueous crystalline penicillin G 18-24 million units per day,
 Procaine penicillin G 2.4 million units IM once daily PLUS
NEUROSYPHILIS
Call the STD Registry at
including
administered as 3-4 million units IV every 4 hours or continuous
probenecid 500 mg orally 4 times a day, both for 10-14 days
(401) 222-2577 for past titers and
1
OCULAR SYPHILIS
infusion, for 10-14 days
treatment.
 Benzathine penicillin G 50,000 units/kg IM once, up to adult dose
CHILDREN
No specific alternative regimens exist.
P
, S
E
L
(<1 Y
)
RIMARY
ECONDARY OR
ARLY
ATENT
EAR
of 2.4 million units
 Benzathine penicillin G 50,000 units/kg IM (up to adult dose of 2.4
CHILDREN
L
L
(>1 Y
)
L
O
U
D
ATE
ATENT
EAR
OR
ATENT
F
NKNOWN
URATION
million units) for 3 doses at 1 week intervals (up to total adult dose
of 7.2 million units)
CONGENITAL SYPHILIS
See complete CDC guidelines.
HIV INFECTION
Same stage-specific recommendations as for HIV-negative persons.
PREGNANCY
Penicillin is the only recommended treatment for syphilis during pregnancy. Women who are allergic should be desensitized and treated with
2
penicillin. Treatment is the same as in non-pregnant patients for each stage of syphilis.
GONOCOCCAL INFECTIONS
 Ceftriaxone 250 mg IM once PLUS
3
ADULTS, ADOLESCENTS
CHILDREN >45
Note: Use of an alternative regimen for pharyngeal gonorrhea should be followed
AND
KG
 Azithromycin 1 g orally once
4
by a test-of-cure 14 days after treatment.
P
, U
, R
HARYNGEAL
ROGENITAL
ECTAL
For urogenital or rectal infections ONLY, and ONLY if ceftriaxone is not available:
 Cefixime 400mg orally once
3
PLUS
 Azithromycin 1 g orally once
OR in case of azithromycin allergy
 Doxycycline 100 mg orally 2 times a day for 7 days
Partner Management: Empiric treatment of all sexual
For azithromycin allergy:
contacts during the 60 days preceding symptom onset or,
 Ceftriaxone 250 mg IM once PLUS
3
if asymptomatic, date of diagnosis.
 Doxycycline 100 mg orally 2 times a day for 7 days
For cephalosporin allergy or IgE-mediated penicillin allergy:
 Gemifloxacin 320 mg orally once OR
 Gentamicin 240 mg IM once
3
PLUS
 Azithromycin 2 g orally once
 Ceftriaxone 1 g IM once PLUS
3
ADULTS
ADOLESCENTS
AND
 Azithromycin 1 g orally once, plus consider lavage
C
ONJUNCTIVAL
of infected eye with saline solution once
CHILDREN ≤45
 Ceftriaxone 25-50 mg/kg IV or IM once (max 250
KG
No specific alternative regimens exist.
mg)
 Ceftriaxone 25-50 mg/kg IV or IM once (max 250
NEONATES
O
N
mg)
PHTHALMIA
EONATORUM
I
B
T
I
M
NFANTS
ORN
O
NFECTED
OTHERS
CHLAMYDIAL INFECTIONS
 Azithromycin 1 g orally once OR
 Erythromycin base 500 mg orally 4 times a day for 7 days
6
ADULTS
CHILDREN
>8
AND
AGED
YEARS
OR
 Doxycycline
 Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days
5
6
100 mg orally 2 times a day for 7
OR
 Levofloxacin
7
days
500 mg orally once a day for 7 days OR
 Ofloxacin
7
300 mg orally 2 times a day for 7 days
CHILDREN ≥45 KG
 Azithromycin 1 g orally once
<8 YEARS
No specific alternative regimens exist.
BUT AGED
 Erythromycin base or ethylsuccinate 50 mg/kg/day
CHILDREN <45
NEONATES
For ophthalmia neonatorum:
KG AND
 Azithromycin 20 mg/kg/day orally once a day for 3 days
8
9
Partner Management: Expedited partner
orally divided into four doses daily for 14 days
 Azithromycin 1 g orally once
 Amoxicillin 500 mg orally 3 times a day for 7 days OR
therapy (EPT) is allowed in Rhode Island for
PREGNANCY
treatment of partners of patients infected with
 Erythromycin base 500 mg orally 4 times a day for 7 days (or 250 mg orally 4
chlamydia. For more information, go to
times a day for 14 days) OR
www.health.ri.gov/diseases/sexuallytransmitted/
 Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days (or 400 mg
for/providers/.
orally 4 times a day for 14 days)
NONGONOCOCCAL URETHRITIS
 Azithromycin 1 g orally once
 Erythromycin base 500 mg orally 4 times a day for 7 days
10
6
ADULT MALES
OR
OR
 Doxycycline
 Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days
5
6
100 mg orally 2 times a day for 7
OR
 Levofloxacin
7
days
500 mg orally once a day for 7 days OR
 Ofloxacin
7
300 mg orally 2 times a day for 7 days
11
EPIDIDYMITIS
 Ceftriaxone 250 mg IM once PLUS
L
D
T
C
G
IKELY
UE
O
HLAMYDIA AND
ONORRHEA
No specific alternative regimens exist.
 Doxycycline
5
100 mg orally 2 times a day for 10 days
 Ceftriaxone 250 mg IM once PLUS
L
D
T
C
G
E
IKELY
UE
O
HLAMYDIA AND
ONORRHEA AND
NTERIC
 Levofloxacin
7
O
RGANISMS
500 mg orally once a day for 10 days OR
No specific alternative regimens exist.
 Ofloxacin
(M
W
P
I
A
S
)
7
EN
HO
RACTICE
NSERTIVE
NAL
EX
300 mg orally twice a day for 10 days
PELVIC INFLAMMATORY DISEASE (outpatient management)
 Ceftriaxone 250 mg IM once OR
ADULT FEMALES
 Cefoxitin 2 g IM once plus probenecid 1 g orally once OR
 Other parenteral third generation cephalosporin (e.g., ceftizoxime
or cefotaxime)
See complete CDC guidelines for alternatives.
PLUS
 Doxycycline
5
100 mg orally 2 times a day for 14 days
WITH OR WITHOUT
 Metronidazole
12
500 mg orally twice a day for 14 days
♦ Indicates revision from previous STD Treatment Guidelines
1
Some specialists recommend benzathine penicillin G 2.4 million units IM weekly for up to 3 weeks after completion of neurosyphilis (including ocular syphilis) treatment.
2
Tetracycline/doxycycline contraindicated; erythromycin not recommended because it does not reliably cure an infected fetus; data insufficient to recommend azithromycin or ceftriaxone.
3
Dual therapy for gonococcal infection recommended for all patients with gonorrhea regardless of chlamydia test results.
4
Test of cure no longer necessary in cases of uncomplicated urogenital or rectal gonorrhea treated with recommended or alternative regimens. Test-of-cure for gonorrhea should be performed with culture or with nucleic acid amplification (NAAT) if culture not
available. If NAAT positive, confirmatory culture recommended. If treatment failure suspected: culture, perform antimicrobial susceptibility testing, notify and consult with the state health department, and/or consult with an infectious disease specialist, an
STD/HIV Prevention Training Center (www.nnptc.org), or CDC.
5
Doxycycline not recommended during pregnancy, lactation, or for children <8 years of age.
6
If patient cannot tolerate high dose erythromycin schedules, change to lower dose for longer (see under pregnancy alternatives).
7
Quinolones not recommended for use in patients <18 years of age, and contraindicated in pregnant women.
8
Efficacy of treating neonatal chlamydial conjunctivitis and pneumonia is about 80%. A second course of therapy may be required. An association between oral erythromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported in infants aged <6
weeks. See complete CDC guidelines for more information.
9
Data on efficacy of azithromycin for ophthalmia neonatorum limited, so follow-up recommended to assess response. An association between oral azithromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported in infants aged < 6 weeks. See
complete CDC guidelines for more information.
10
Infections with M. genitalium may respond better to azithromycin, although azithromycin efficacy may be declining.
11
Given increase in quinolone resistant gonorrhea, use of ofloxacin or levofloxacin alone recommended only if infection more likely caused only by enteric gram-negative organisms and gonorrhea has been ruled out.
12
Consuming alcohol should be avoided during treatment with metronidazole and for 24 hours thereafter. Multiple studies and meta-analyses have not demonstrated an association between metronidazole use during pregnancy and teratogenic or mutagenic
effects in newborns.
In lactating women administered metronidazole, withholding breastfeeding during treatment and for 12–24 hours after last dose will reduce exposure of infant to metronidazole.
Page of 2