Selected guidelines (*). (Featured CME Topic: Female Patient).

SCREENING FOR CERVICAL CANCER

American Geriatrics Society: Screening for cervical carcinoma in older women. J Am Geriatr Soc 2001; 49 (5) :655-657

The following recommendations are designed to help primary care physicians screen for cervical carcinoma in older women.

* Papanicolaou (Pap) smear screening in older women should be the responsibility of the primary care providers. Other health professionals, including gynecologists, geriatricians, internists, family practitioners, nurse practitioners, and physician assistants may provide cervical cancer screening.

* Regular Pap smear screening at one- to three-year intervals is considered reasonable until the age of 70.

* An older woman of any age who has never had a Pap smear should be screened until two negative Pap smears are conducted one year apart.

* Risk factors for cervical carcinoma (eg, race, users of pessaries, multiple sex partners, history of human papilloma virus, human immunodeficiency virus, cervical dysplasia, smoking, and immunosuppression) should be assessed on an ongoing basis. This information should be taken into account when determining how often and for how long older women should be screened.

* Individual circumstances, such as the patient's life expectancy, ability to undergo treatment if cancer is found, and the ability to cooperate with and tolerate the Pap smear procedure, may obviate the need for screening.

* Women who have had a hysterectomy and still have a cervix should be screened. If no cervical tissue remains, no further Pap smear is necessary, provided the hysterectomy was performed for benign disease and risk factors for developing cervical neoplasia are not present.

* Cervical sampling should be conducted by means of gentle scraping of the ectocervix with a curved spatula, followed by insertion and rotation of an endocervical brush.

* Further research on Pap smear screening in older women should be conducted. Areas of investigation should include defining high-risk subsets of older people; estimating the utility of screening residents of long-term institutions; and developing innovative approaches to enhance the participation of older people in screening programs.

U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. 2nd Ed. Baltimore, Williams & Wilkins, 1996

The main screening test for cervical cancer is the Papanicolaou (Pap) smear. Although it sometimes detects endometrial, vaginal, and other cancers, its use as a screening test is intended for the early detection of cervical dysplasia and cancer. The task force offers the following recommendations for clinical intervention:

* Regular Pap tests should be performed on all women who are or have been sexually active and have a cervix.

* Testing should begin at the age when a woman first engages in sexual intercourse.

* Adolescents whose sexual history is thought to be unreliable should be presumed to be sexually active at 18 years old.

* There is little evidence to recommend an annual screening over three-year screening.

* Pap tests should be conducted at least every three years.

* The interval for each patient should be recommended by the patient's physician based on risk factors (eg, early onset of sexual intercourse, history of multiple sexual partners, low socioeconomic status).

* Women with human immunodeficiency virus should be screened more frequently.

* There is insufficient evidence to recommend for or against an upper age limit for Pap testing.

* Regular screening may be discontinued after age 65 in women who have had regular normal previous screening.

* Pap testing is not recommended for women who have undergone a hysterectomy in which the cervix was removed, unless the hysterectomy was performed due to cervical cancer or its precursors.

* Patients at increased risk of cervical cancer because of unprotected sexual activity with multiple sexual partners should receive appropriate counseling about sexual practices.

* Specimens should be sent to laboratories that have adequate quality control measures in order to ensure optimal accuracy.

* A thorough follow-up of test results should be ensured, including repeat testing and referral for colposcopy.

* Clinicians should provide patients with a pamphlet or other written information on the meaning of abnormal smears to help ensure follow-up and minimize anxiety over false-positive results.

* There is insufficient evidence to recommend for or against routine cervicography or colposcopy screening for cervical cancer in asymptomatic women or for those with human papilloma virus infections.

SCREENING FOR OVARIAN CANCER

U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. 2nd Ed. Baltimore, Williams & Wilkins, 1996

Ovarian cancer is the fifth leading cause of cancer deaths in women in the United States and has the highest mortality of any of the gynecologic cancers. The overall five-year survival rate is at least 75% if the cancer is confined to the ovaries and decreases to 17% in women diagnosed with distant metastases. Symptoms usually do not become obvious until the tumor compresses or invades adjacent structures, ascites develops, or metastases become clinically evident. As a result, two thirds of women with ovarian cancer have advanced disease when diagnosed. The task force offers the following recommendations for clinical intervention:

* Screening asymptomatic women for ovarian cancer using ultrasound, measurement of serum tumor markers, or pelvic examination is not recommended.

* There is insufficient evidence to recommend for or against screening of asymptomatic women at increased risk of ovarian cancer.

* The National Institutes of Health Consensus Conference recommends that women with presumed hereditary cancer syndrome should have an annual pelvic examination, CA-125 measurements, and transvaginal ultrasound until childbearing is completed or at age 35, at which time prophylactic bilateral oophorectomy is recommended.

BREAST CANCER

Please refer to Southern Medical Journal, Special CME Feature on Primary Care, September 2001 issue.

OSTEOPOROSIS

Please refer to Southern Medical Journal, Special CME Feature on Osteoporosis, June 2001 issue.

DEMENTIA

Please refer to Southern Medical Journal, Special CME Feature on Dementia, July 2001 issue.

CHLAMYDIAL INFECTIONS

National Guideline for the Management of Chlamydia Trachomatis Genital Tract Infection. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Inf 1999; 75(Suppl 1):S4-S8

The following guidelines are designed to help clinicians recognize and treat the infection.

Clinical Features Include:

* No symptoms in 80% of women;

* Post coital or intermenstrual bleeding;

* Lower abdominal pain;

* Purulent vaginal discharge;

* Mucopurulent cervicitis and/or contact bleeding.

Risk Factors for Infection Include:

* Patients under the age of 25 years;

* Patients with a new sexual partner or more than one sexual partner in the recent past;

* A lack of barrier contraception;

* The use of oral contraceptive pill;

* Women undergoing termination of pregnancy.

Rectal Infections

These infections are usually asymptomatic, but may cause anal discharge and anorectal discomfort.

Pharyngeal Infections

These infections are asymptomatic.

Complications Include:

* Pelvic inflammatory disease;

* Fitz-Hugh-Curtis syndrome;

* Tubal damage (infertility, ectopic pregnancy);

* Chronic pelvic pain (adhesions);

* Transmission to neonate (conjunctivitis, pneumonia);

* Epididymo-orchitis;

* Adult conjunctivitis;

* Sexually acquired reactive arthritis/ Reiter's syndrome (more common in men).

Diagnosis

Advantages and disadvantages of tests:

Cell Culture

* has high specificity which is essential for medicolegal cases;

* requires expertise;

* is expensive and unsuitable for large numbers.

Direct Fluorescent Antibody (DIF)

* has high sensitivity;

* is labor intensive;

* is unsuitable for over 30 cases per day;

* is the method of choice for confirmation of other assays;

* accommodates all specimen types.

Enzyme Immunoassays (EIA)

* have high specificity when combined with confirmation assay;

* have variable sensitivity (assay dependent);

* are inexpensive and suitable for large numbers;

* are automatable.

Nucleic Acid Amplification Techniques (NAAT)

* have high specificity; have high sensitivity;

* are expensive in staff, space, and consumables compared with enzyme immunoassays;

* need particular care in laboratories to avoid contamination;

* have reduced sensitivity of the ligase chain reaction (LCR) on urine if transport delay is > 24 hours at room temperature;

* have possible enhanced sensitivity if urine is stored overnight at 4[degrees] C or freeze thawing is used;

* have the possibility of impairment of the LCR urine test due to pregnancy.

Recommendations

* The ideal diagnostic test sensitivity is >90% with specificity of >99%. The NAATs are recommended to reach these results.

* Only the better performing EIA should be used with sensitivities of >80%, and where sensitivity comparisons against NAAT techniques have been conducted.

* With EIAs, the technique of confirmation in the negative grey zone should be introduced in order to improve sensitivity by 5% - 30%.

* Quality control is recommended to validate the sensitivity and specificity of the assay used by individual laboratories. Both interlaboratory and intralaboratory control samples should be conducted using both strong positives, and negative and weakly reactive specimens.

Specimens (Antigen detection techniques - EIA and DIF)

* The cervical swab is the best specimen.

* Ten to 20 percent additional positives will be detected by assaying a urethral specimen. This can be combined with the cervical specimen for analysis.

* Urine specimens are not recommended because they perform significantly less with EIA than do cervical specimens.

NAAT Characteristics

* Cervical swabs consistently have sensitivities 80%.

* Urine has reported sensitivities of 44% to 94%.

* Vulvo-vaginal swabs have a sensitivity of -85%.

Menstrual Cycle and Testing

Data suggest that testing for C trachomatis may be more effective if conducted in the latter part of the menstrual cycle.

Quality of Specimens

* Samples must contain cellular material. Swabs should be inserted inside the cervical os and firmly rotated against the endocervix.

* Inadequate specimens reduce the sensitivity of all the diagnostic tests.

* There is no recommendation for taking a urethral swab in women.

* DIF is the only method that offers information concerning the quality of the sample.

Management

* Patients in whom C trachomatis is detected should be assessed for other sexually transmitted infections.

* Treatment should be effective, easy to take, have low side effects, and cause minimal interference with daily lifestyles.

Treatment of Uncomplicated Infection

Recommended Regimens

* Doxycycline, 100 mg twice a day for seven days, or Azithromycin, 1 g orally in a single dose.

* Both of these treatments have been shown to have equal efficacy in clinical studies.

* Azithromycin is more expensive than doxycycline.

* Azithromycin may be useful in patients who seek healthcare erratically.

Alternative Regimens

* The following medications may be prescribed:

* Erythromycin, 500 mg four times a day for seven days;

* Deteclo, 300 mg twice a day for seven days;

* Ofloxacin, 200 mg twice a day or 400 mg once a day for seven days (it is unknown which dosage is superior);

* Tetracycline, 500 mg four times a day for seven days.

* Ofloxacin has similar efficacy to doxycydine and better side effects than doxycydine, but is more expensive. Therefore, it is not recommended as a first-line treatment.

* Erythromycin is less effective than either azithromycin or doxycycline.

* Erythromycin taken four times a day may cause side effects sufficient enough to cause the patient to discontinue treatment.

* Limited data on erythromycin 500 mg twice daily has efficacy reported between 73%-95%. A two-week course seems to be more effective than a one-week course of 500 mg twice daily, with a cure rate 95%.

Other Tetracyclines 

* Deteclo is probably as effective as doxycyline; however, photosensitivity occurs more frequently.

* Tetracycline 500 mg is effective when taken four times a day for seven days; however, patient compliance is likely to be poor.

* Oxytetracycline 250 mg four times a day is effective, although the published evidence is limited.

Compliance With Therapy

Clinicians should discuss therapy with patients and provide clear written information on the following:

* The definition of chlamydia and how it is a sexually transmitted disease;

* If the infection is asymptomatic, it could persist for months or years;

* The infection can be isolated from the throat and eye without detectable infection in the lower genital tract, so it may not always be sexually acquired;

* Chlamydia is often asymptomatic;

* No test is absolutely accurate;

* The complications of untreated chlamydia;

* The side effects and the importance of complying fully with treatment and what to do if a dose is missed;

* The interaction between antibiotics and oral contraceptive pills;

* The importance of their sexual partner(s) being evaluated and treated;

* The importance of abstaining from sexual intercourse until therapy is completed and the partner is treated;

* Advice on safer sexual practices.

Pregnancy and Breast Feeding

* Doxycycline and ofloxacin are contraindicated.

* The safety of azithromycin in pregnancy and lactating mothers has not been fully assessed, although data suggest that it is effective.

* Erythromycin has a significant side effect profile and is < 95% effective.

* Amoxycillin has a similar cure rate to erythromycin in a meta-analysis and a much better side effect profile; however, in vitro it has been shown to induce latency and may not be reliable.

Recommended Regimens in Pregnancy and Breast Feeding

* The following medications may be prescribed:

* Erythromycin, 500 mg four times a day for seven days;

* Erythromycin, 500 mg twice a day for 14 days;

* Amoxycillin, 500 mg three times a day for seven days.

* Patients should have a test of cure three weeks following therapy.

Management of Sexual Partners

* All patients identified with C trachomatis should discuss partner notification.

* The method of partner notification should be documented.

* Partner notification outcomes should be ascertained and documented at subsequent follow-up visits.

* Partners at risk should be informed and asked to have an evaluation and epidemiological treatment even if tests are negative.

Follow-Up

* Follow-up care is necessary for:

* Following up partner notification, reinforcing health education;

* Providing reassurance;

* Assessing treatment efficacy/exclusion of re-infection.

* Patients do not need to be retested for C trachomatis after completing treatment with doxycycline or azithromycin unless symptoms persist or re-infection is suspected.

* A test of cure should be considered three weeks following treatment with erythromycin.

SCREENING FOR CHLAMYDIAL INFECTION

U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. 2nd Ed. Baltimore, Williams & Wilkins, 1996

C trachomatis is the most common bacterial sexually transmitted disease in the United States. The medical consequences and costs of infection are greatest in women, who may develop urethritis, cervicitis, or pelvic inflammatory disease. Up to 25% of men and 70% of women with chlamydial infections are asymptomatic. Some research suggests that chlamydial infections increase the risk of infertility and ectopic pregnancy because the symptoms of salpingitis may be mild or nonspecific. The task force offers the following recommendations for clinical intervention:

* Routine screening for asymptomatic infection with Chiamydia trachomatis is recommended during pelvic examination for all sexually active female adolescents and for other women at high risk for chlamydial infection.

* Characteristics of patients with a higher prevalence of infection include:

* A history of prior sexually transmitted disease;

* New or multiple sex partners;

* Patients under the age of 25;

* Inconsistent use of barrier contraceptives;

* Cervical ectopy;

* Unmarried status.

* Clinicians should consult local public health authorities for guidance in identifying highrisk populations within their community.

* Clinicians should refer to algorithms that identify high-risk women.

* Routine screening should be conducted in clinical settings where the prevalence of infection is known to be high (eg, some urban family planning clinics).

* Clinicians should remain alert for findings suggestive of chlamydial infection (eg, mucopurulent discharge, cervical erythema, or cervical friability) during pelvic examinations of women who are asymptomatic.

* Pregnant women at high risk of infection (including those under age 25) should be tested for chlamydia.

* There is insufficient evidence to recommend for or against screening all women during pregnancy or in high-risk men.

* Routine screening is not recommended in men or women who are considered low-risk.

* Endocervical specimens should be obtained for cell culture or nonculture assays.

* Verification of positive nonculture results could be necessary, depending on the underlying risk in the patient and potential adverse consequences of a false-positive result.

* The frequency of testing should be left up to clinicians.

* Routine ocular antibiotic prophylaxis with silver nitrate, erythromycin, or tetracycline is recommended for all newborn infants to prevent ophthalmia neonatorum due to gonorrhea.

* There is insufficient evidence to recommend for or against universal ocular prophylaxis of newborns solely for the prevention of chlamydial conjunctivitis.

GENITAL HERPES

National Guideline for the Management of Genital Herpes. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Inf 1999; 75(Suppl 1) :S24-S28

The following guidelines are designed to help clinicians diagnose, treat and manage genital herpes.

Clinical Features

* Genital herpes is frequently atypical.

* Only about 20% of patients with genital symptoms receive a correct diagnosis.

* The first symptoms are blistering and ulceration of the external genitalia resulting in pain, dysuria, vaginal or urethral discharge, and local lymphadenopathy.

Natural History

* The median recurrence rate after symptomatic first episode infection is 0.34 recurrences/month for herpes simplex virus (HSV)-2 and 0.08 recurrences/month for HSV-1.

* Prolonged first episode is associated with a more frequent subsequent recurrence; the risk of extragenital recurrences is 20%.

Diagnosis

Virus Detection and Characterization

* Laboratory diagnosis is based on direct detection of HSV from genital lesions that may be atypical.

* Since the quality of the samples is critical, specimens should be collected using swabs directly from the base of the lesion.

* Successful virus culture depends on maintaining the cool chain (4[degrees]C), rapidly transporting specimens to the laboratory, and avoiding freeze thaw cycles.

* Local factors (laboratory resources and distance) should be considered when deciding on the testing strategy.

* Virus culture and typing is considered the "gold standard" method; however, antigen detection can be valuable for samples taken late in an outbreak.

Serology 

* Most currently available commercial tests for HSV antibodies are not type specific and are of no value in the management of genital HSV.

* Full serological assessment of genital HSV in the United Kingdom requires access to both HSV-1 and HSV-2 type specific antibody assays.

* Tests should be fully evaluated for sensitivity, specificity, and reproducibility, using sera from culture confirmed cases and/or validated established tests (eg, Western blot).

* The value of these tests for patient management has not been fully assessed.

FIRST EPISODE GENITAL HERPES

Management

* Patients should be given oral antiviral drugs within five days of the start of the episode or while new lesions are still forming.

* Acyclovir, valaciclovir, and famciclovir should be used to reduce the severity and duration of episodes.

* There is no evidence to suggest that any antiviral therapy alters the natural history of the disease.

* Intravenous therapy should be considered only when the patient is unable to swallow or tolerate oral medication because of vomiting.

* Topical agents are considered less effective than oral ones.

* There is no evidence to support combining oral and topical treatment.

* Treatment regimens recommended for five days and include the following:

* Acyclovir, 200 mg five times daily;

* Famciclovir, 250 mg three times daily;

* Valaciclovir, 500 mg twice daily.

Supportive Measures

* Saline baths and analgesics are recommended;

* Anesthetic agents should be used with caution due to patient sensitivity.

Counseling

Counseling patients with first episode genital herpes should include the following:

* Possible source(s) of infection;

* Natural history including risk of subclinical viral shedding;

* Future treatment options;

* Risk of transmission by sexual and other means;

* Risks of transmission to the fetus during pregnancy;

* Advising the obstetrician/midwife;

* Sequelae of infected men infecting their uninfected partners during pregnancy;

* The possibility of partner notification.

HIV Positive Patients With First Episode Genital Herpes

Ten-day courses of treatment are recommended by some clinicians since there are no controlled trials on duration and dose of treatment.

Management of Complications

* Hospitalization may be required for urinary retention, meningism, and severe constitutional symptoms.

* If catheterization is required, suprapubic catheterization is recommended to prevent ascending infection, to reduce the pain associated with the procedure and to allow normal micturition to be restored without multiple removals and recatheterizations.

RECURRENT GENITAL HERPES

* Clinicians should determine how to manage clinical recurrences with the patient.

* Management strategies include supportive therapy only, episodic antiviral treatments, and suppressive antiviral therapy.

* The most effective strategy in managing a patient may vary over time according to recurrence frequency, symptom severity, and relationship status.

Supportive Measures

Saline bathing and Vaseline are recommended.

Episodic Antiviral Treatment

* Oral acyclovir, valaciclovir, and famciclovir are recommended to reduce the duration and severity of recurrent genital herpes.

* Valaciclovir is not considered more or less effective than acyclovir.

* Famciclovir has not been compared with acyclovir or valaciclovir.

* Famciclovir and valaciclovir have a twice-daily dose regimen that is easier to take than a five-times-daily regimen.

* Early treatment is recommended.

* The following medications are recommended:

* Acyclovir, 200 mg five times daily for five days;

* Valaciclovir, 500 mg twice daily for five days;

* Famciclovir, 125 mg twice daily for five days.

Supportive Measures

Saline bathing, Vaseline, and lignocaine gel are recommended.

Suppressive Therapy

* Patients with culture proved genital herpes who have a recurrence rate of six or more episodes annually should be given full information on the advantages and disadvantages of suppressive therapy.

* Experience with suppressive antiviral therapy is most extensive with acyclovir; the optimal daily dose is 800 mg.

* Twice daily valaciclovir (250 mg twice daily) has been proven as effective as twice daily acyclovir (400 mg twice daily).

* Acyclovir once daily is not recommended to suppress genital herpes recurrences.

* Therapy should be discontinued after a maximum of one year of continuous antiviral therapy to reassess recurrence frequency.

* The minimum period of assessment should include two recurrences. Treatment should be restarted in patients who continue to have unacceptably high rates of recurrence.

* Short courses of suppressive therapy to prevent clinical symptoms may be considered for some patients.

Viral Shedding

* Viral shedding is more likely to occur in patients with genital HSV-2 infection during the first year after infection or in patients with frequent symptomatic recurrences.

* The efficacy of antiviral drugs on the rate of sexual transmission has not been established.

Transmission Risk

* Patients should be advised to abstain from sexual contact during lesional recurrences, prodrome, or during viral shedding.

* The effectiveness of condoms to prevent sexual transmission has not been formally assessed.

* Earlier infection with HSV-1 reduces the HSV-2 seroconversion risk in serodiscordant couples.

Partner Not Notification

The following points should be stressed when counseling patients on partner notification:

* Asymptomatic shedding plays a major role in the transmission of HSV infection.

* Partner notification is an effective way of detecting individuals with unrecognized disease.

* Education on recognition of recurrences is essential.

* Partner awareness can prevent further onward transmission.

Management of Herpes in Pregnancy

First and Second Trimester Acquisition

* Management should be in line with the clinical condition and may involve either oral or intravenous acyclovir in standard doses.

* If delivery does not ensue, the pregnancy should be managed expectantly and vaginal delivery anticipated.

* Continuous acyclovir in the last four weeks of pregnancy may prevent recurrence at term and also the need for cesarean section.

Third Trimester Acquisition

* Cesarean sections should be considered for all women, especially those developing symptoms within six weeks of delivery since the risk of viral shedding in labor is very high.

* Acyclovir treatment of mother and child may be indicated if vaginal delivery is unavoidable.

Management of Pregnant Women With Recurrent Genital Herpes

* Sequential cultures during late gestation to predict viral shedding at term are not recommended.

* Cesarean section to prevent neonatal herpes should not be performed in women who do not have genital lesions at the time of delivery.

* Symptomatic recurrences of genital herpes during the third trimester will be brief; vaginal delivery is recommended if no lesions are present at delivery.

* There are no proven benefits of obtaining specimens for culture at delivery in order to identify women who are symptomatically shedding HSV.

Management of Women With Genital Lesions at Onset of Labor

* Cesarean sections are recommended in the United Kingdom.

* The risks of vaginal delivery for the fetus are small and should be considered against the risks to the mother of cesarean sections.

Prevention of Acquisition of Infection

* Strategies for preventing neonatal herpes should involve both parents.

* All women should be asked at their first antenatal visit if they or their partner have ever had genital herpes.

* Female partners of men with genital herpes, but without a history of genital herpes, should be advised not to have sex at the time of lesional recurrence.

* The use of condoms throughout pregnancy may diminish the risk of acquisition.

* Pregnant women should be advised of the risk of acquiring HSV-1 as a result of orogenital contact.

* Identifying susceptible women with type specific antibody testing has not been evaluated in terms of costs and benefits.

* All women should undergo a careful vulval inspection at the onset of labor to look for clinical signs of herpes infection.

* Mothers, staff, and other relatives/friends with active oral lesions should be counseled on the risk of postnatal transmission.

Management of Herpes in Immunocompromised Individuals

* Clinically refractory lesions due to genital HSV are a major problem in patients with severe immunodeficiency, including late stage HJV diseases.

* There is no evidence to suggest that immunocompromised patients on suppressive antiviral therapy for frequently recurring genital herpes need other than the standard regimen.

Auditable Outcome Measures

* Virological confirmation should be attempted in all of the patients.

* At least one of the viral isolates should be typed.

* Patients seen early in the course of the first episode of genital herpes should be offered antiviral therapy.

* Patients with a diagnosis of genital herpes should be offered counseling, support, and written information about the virus.

* Suppressive therapy should be offered to all patients with a recurrence rate of more than six per year.

* If suppressive therapy is begun, a clear plan of duration of treatment should be entered in the notes and the patient should be reviewed in accordance with this plan.

SCREENING FOR GENITAL HERPES SIMPLEX

U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. 2nd Ed. Baltimore, Williams & Wilkins, 1996

Primary genital herpes simplex virus (HSV) infection occurs in about 200,000 to 500,000 Americans each year, mostly in adolescents and young adults. Between 25 and 31 million people are chronically infected. Both HSV types 1 (HSV-1) and 2 (HSV-2) can infect the genitalia. HSV-2 causes the majority of primary and recurrent genital herpes infections. Most HSV-2 infections are asymptomatic and detected only by seroconversion. Sixteen percent of the adult population is HSV-2 seropositive. The task force offers the following recommendations for clinical intervention:

* Routine screening for genital herpes simplex is not recommended in asymptomatic people using culture, serology, or other tests.

* Routine screening for genital herpes simplex infection in asymptomatic pregnant women, by surveillance cultures or serology is not recommended.

* Physicians should take a complete sexual history on all adolescent and adult patients.

* Clinicians should consider asking all pregnant women at the first prenatal visit whether they or their sex partner(s) have had genital herpetic lesions.

* There is not enough evidence to recommend for or against routine counseling of women who have no history of genital herpes but whose partners do have a positive history.

* There is insufficient evidence to recommend for or against the examination of all pregnant women for signs of active genital HSV lesions during labor and cesarean delivery on those with lesions.

* There is insufficient evidence to recommend for or against the routine use of systemic acyclovir in pregnant women with recurrent herpes to prevent reactivations near term.

* The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Canadian Task Force on the Periodic Health Examination and the Infectious Disease Society of America recommend careful examination of all women at the time of delivery and culture of active lesions with cesarean delivery for women with positive findings on clinical examination.

ASYMPTOMATIG BACTERIURIA 

SCREENING FOR ASYMPTOMATIC BACTERIURIA

U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. 2nd Ed. Baltimore, Williams & Wilkins, 1996

Asymptomatic bacteriuria is classified as a significant bacterial count in the urine of a patient without symptoms. It may precede symptomatic urinary tract infection which is characterized by dysuria, frequency, pain, fever, etc, which accounts for over six million outpatient visits each year. The task force offers the following recommendations for clinical intervention:

* Screening for asymptomatic bacteriuria with a urine culture is recommended for pregnant women at 12-16 weeks of gestation.

* The frequency for subsequent periodic urine cultures during pregnancy is left to clinical discretion.

* The urine specimen should be obtained in a way that minimizes contamination.

* Routine screening for asymptomatic bacteriuria with leukocyte esterase of nitrite testing in pregnant women is not recommended.

* There is insufficient evidence to recommend for or against routine screening for asymptomatic bacteriuria with leukocyte esterase or nitrite testing in ambulatory elderly women, women with diabetes, asymptomatic school-aged girls, or adults.

* Screening with microscopy testing is not recommended.

RUBELLA 

SCREENING FOR RUBELLA

U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. 2nd Ed. Baltimore, Williams & Wilkins, 1996

Rubella is usually a mild illness. However, when contracted by pregnant women, especially those in the first 16 weeks of pregnancy, it often causes serious complications including miscarriage, abortion, stillbirth, and congenital rubella syndrome. The task force offers the following recommendations for clinical intervention:

* All susceptible nonpregnant women of childbearing age should be offered a vaccination.

* Susceptible pregnant women should be vaccinated in the immediate postpartum period.

* An alternative for nonpregnant women of childbearing age is vaccination against rubella without screening.

* Routine screening or vaccination of postmenopausal women is not recommended.

* The American College of Obstetricians and Gynecologists recommends vaccinating women in colleges, health care settings, and military who have no contraindications and who lack documented evidence of either rubella immunization on or after the first birthday or serologic evidence of immunity.

* The Canadian Task Force on the Periodic Health Examination recommends serologic screening of women of childbearing age, with vaccination of seronegative non-pregnant women immediately and seronegative pregnant women after delivery. They also recommend vaccination of women of childbearing age without screening as an alternative.

(*.) Abstracted by Elaine McClellan-Holm.