Management of STI Flashcards
What type of bacterias are chlamydia + gonorrhea?
Gram-positive/negative
Intracellular/extracellular
Both Chlamydia and Gonorrhea are GRAM-NEGATIVE bacteria
- Chlamydia: obligate intracellular gram-negative
- Gonorrhea: usually intracellular
How is chlymadia process similar and different to a virus?
The elementary body enters into cell, forms reticulate body, and bursts out the cell
Similar to a virus, but does NOT take over host cell DNA machinery
How do both chlamydia + gonorrhea spread? (3)
What is the least likely spread.
Through infected secretions:
1. Sexual (oral, vaginal, anal)
2. Vertical (intrapartum, through birth)
Less likely:
- Autoinoculation (masturbation followed by touching the eye)
- Sex toys
T/F Receptive partner at greater risk than insertive partner with transmission
True
What is the average incubation period for chlamydia and gonorrhea
Chlamydia: 2-6 weeks
- difficult to tell who was responsible
Gonorrhea: 2-7 days
What are the type of symptoms associated with STI (3) What do present as?
Urogenital infection
- urethral or vaginal discharge
- dysuria (pain urination)
- Abnormal vaginal bleeding
- Lower abdo pain
Rectal infection
- Tenesmus (feeling of needing to poop)
- Rectal pain
- Rectal bleeding
- Mucus discharge
Pharyngeal infection
- sore throat
- pharyngeal exudate
- Cervical lymphadenopathy
Which STI are usually more asymptomatic? Which gender is more likely to have symptoms
Chlamydia
- more likely in women to have symptoms
Which STI infection is more symptomatic?
Which gender is more likely to have symptoms?
Gonorrhea
- most men will have symptoms
What are complications for both STIs (7)
- Increased risk of HIV (having and transmitting)
- Conjunctivitis (through auto inoculation)
- Reactive arthritis
- Disseminated gonococcal infection
- Epididymitis
- Pelvic inflammatory disease (PID)
- Ophthalmia neonatorum (child becomes blind)
Which STI is more likely to cause reactive arthritis? Where is the swelling likely to be in the body?
Chlamydia
- lower extremities
How does disseminated gonococcal infection present? (3)
- Tenosynovitis (tendon inflammation)
- Dermatitis (eczema)
- Polyarthralgia (joint pain)
How can epididymitis present? (4) What can it result in if serious? (2)
Swollen scrotum
Unilateral testicular pain
Dysuria
Urinary frequency
Result in
- infertility
- Chronic pain
How can pelvic inflammatory disease present? (6)
What can it result in if serious? (3)
Fever
Abdo/pelvic pain
vaginal discharge/bleeding
dyspareunia (painful sex)
Dysuria
Urinary frequency
Result in
- infertility,
- ectopic pregnancy
- preterm premature rupture of membranes (PPROM)
Which STI does the Nucleic Acid Amplification test?
Chalmydia + Gonorrhea together
Which STI is culture testing used? Why?
Gonorrhea only (since more resistance exists, we run cultures for it)
Allows for better targeted therapy for gonorrhea
How can someone collect a NAAT? Who collects it?
What is preferred method for each gender?
Urine or swab
- Patient-collected swabs, from urethra, cervix, vagina, rectum or pharynx
Men: urine sample preferred
Women: Swab - vaginal/cervical preferred
How can someone collect a culture
Who collects it?
From where? (5)
PHYSICIAN-collected swab from
- penile discharge
- cervix
- vagina
- rectum
- pharynx
When should NAAT be performed?
Turn around time?
- Request screening
- Have risk factors for STI
- Have symptoms of STI
- During 1st trimester of pregnancy (or all trimesters if high risk)
Recommended ANNUALLY for all sexually active people under 30
turnaround: 3 days
When should culture testing be added on to NAAT patients (2)
Turn around time?
Men: with penile discharge
Women: With suspected pelvic inflammatory disease (PID) (cervical culture)
turnaround: 5 days
Are screening rectum and pharynx routinely done?
No, depends on sexual history
What are indications for treatment of chlamydia (4)
- Positive NAAT
- Partner has chlamydia
- Suspected infection
- Positive gonorrhea (in partner or self)
What is the preferred treatment of chlyamdia (2)?
Which treatment has higher efficacy if adhered to?
Azithromycin 1g PO x 1 dose
OR
Doxycycline 100mg PO BID x 7 days
- has 100% efficacy if adherence is guaranteed
If patient had a RECTAL chlamydia infection, what is the more efficacious treatment
Doxycycline 100mg PO BID x 7 days
What is an alternative treatment to chlamydia?
Levofloxacin 500mg PO daily for 7 days
What are the treatments of chlamydia in pregnant and lactating people (2)
Azithromycin 1g PO x 1 dose
OR
Amoxicillin 500mg PO TID x 7 days
T/F Azithromycin is associated with more side effects than doxycycline
False
What is the most common to least common side effect associated with Azithromycin
- Diarrhea
- Nausea
- Vomiting
What is the rational of using double-coverage for Gonorrhea?
- May delay the emergence of resistance
- Increases the odds of actually killing the pathogen
- May improve effectiveness in pharyngeal infections (cephalosporins have poor penetration there, Azith helps)
What is the preferred treatment of gonorrhea?
Ceftriaxone 250mg IM + Azithromycin 1g PO at the same visit
When are you able to give alternate treatments for gonorrhea (2)
- If first-line is not possible
- Must have a test of cure
What are the 3 alternate therapies of gonorrhea?
Which is least preferred?
- Cefixime 400mg PO + Azith 1g PO
- Gentamicin 240mg IM (2 injections) + Azithromycin 2g PO
- Azithromycin 2g PO monotherapy
(least preferred)
What is ceftriaxone IM diluted with?
1% lidocaine w/o epi
(not water)
Why is Cefixime not preferred?
- Associated with treatment failures in ON due to inc MIC
- gbMSM have the increased MIC
- Poor penetration into pharynx
- Concern that lower concentrations of cephalosporins might create resistant strains
Why is Gentamicin not preferred
Poor evidence. heterogenous evidence based
(resistance is low tho)
What to do if gonorrhea patient is allergic to azithromycin?
What requirement would they have to meet?
Replace with doxycycline
- only use this for confirmed chlamydia ONLY
- OR susceptible gonorrhoea results
What to do if preferred treatment failed for gonorrhea?
Increase the dose of preferred treatment
Ceftriaxone 1g IM + Azithromycin 2g PO
What is the treatment for gonorrhea if a patient has a type 1 allergy to penicillin
Can still give ceftriaxone or any cephalosporin with a different side chain
+ Azithromycin 1g PO
What are the treatment options for gonorrhea if patient has a cephalosporin allergy?
Gentamicin 240mg IM 2 separate injections + Azithromycin 2g PO
OR
Azithromycin 2g PO monotherapy
What if a patient had a type 2,3,4 allergy to cephalosporin with gonorrhea
Gentamicin 240mg IM 2 separate injections + Azithromycin 2g PO
OR
Azithromycin 2g PO monotherapy
What % cut off is tolerated for antimicrobial resistance
5%
What is the follow up test of cure for chlamydia?
When to take it?
When is it recommended? (4)
NAAT test at least 3 weeks after Rx
Recommended only if:
- Pregnancy patient
- Unresolved symptoms
- Alternative regimen used
- Bad adherence (known or suspected)
What is the follow up test of cure for gonorrhea?
When to take it?
When is it recommended? (4)
Culture test 3-7 days after Rx (preffered)
or NAAT
Recommended for ALL, especially:
* Pregnant
* Pharyngeal infection
* Unresolved symptoms
* Alternative (non first line) regimen used
* Treatment failure in partner
* Bad adherence (known or suspected)
* Strain with reduced cephalosporin susceptibility (like from travel sex- new Asia strain)
What are reasons for treatment failure? (4)
- Re-infection
- Non-adherence
- Alternative diagnosis (other STI, UTI)
- Drug resistance: more likely in Gonorrhea
(unlikely in chlamydia)
When should we rescreen all patients after test of cure?
In 6 months
How long should patients abstain from intercourse after treatment?
Requirements?
7 days if single dose or completing the 7-day therapy
AND
Asympotamitc
Do we need to test partners or can we treat empirically
Treat partners
Which group of people is doxycycline prophylactic effective in?
Dose?
- Gay, bisexual men + transgender women who had bacterial STI in the last year
Dose: Doxycycline 200mg po within 72 hours after condomless sex
Is HSV (herpes simplex virus) Curable or manageable? Explain its pathophysiology
Virus enters through epidermis -> remains dormant in sensory ganglion until reactivation
- Remains there for LIFE (HSV is manageable, not curable)
How is HSV spread? When do most transmission occur?
Through direct contact with virus in Wet environment
- Lesions
- mucosal surfaces
- oral or genital secretions
Most transmission occurs during asymptomatic shedding
T/F Pre-existing HSV-1 infection protects against HSV-2
True
How does primary genital HSV present
Onset? How long does it last?
Presentation, systemic symptoms (5)?
Atypical symptoms (3)
Onset:
- Occurs 6-8 days after infection
- whole thing lasts 10-14 days, re-epithelialization can take 21 days
Presentation:
papules -> vesicles -> pustules rupture to ulcer -> crust -> heal without scarring
Systemic:
- May also involve swollen inguinal lymph nodes (lymphadenopathy),
- malaise
- fever
- myalgia
- headache
Atypical symptoms:
- genital pain
- urethritis
- cervicitis
How does presence of preexisting HSV-1 antibodies result if you get genital herpes HSV-2
Shorter duration
Less likely to have systemic symptoms
T/F HSV-1 recurrences are common than HSV-2
False
Differentiate between primary and recurrent episodes of genital herpes (3)
- Shorter duration (5-10 days)
- Unilateral lesions, fewer in number
- Systemic features less likely
What do prodromal symptoms look like (4)
Burning
itching
tingling
irritation
What are complications of genital herpes
Increased HIV risk
Primary infection risks:
- Meningitis
- Extragenital lesions
- Urinary retention
How are genital herpes diagnosed?
Usually a clinical diagnosis (story is enough)
What requirement do you need if you want to perform a NAAT or viral culture?
Active lesion
- allows for differentiation type
What would be the reasoning of getting a serological testing for antibodies against HSV?
How long does it take to be dectatable?
Used commonly for serodiscordant couples (one has HSV and one doesn’t) who want to know if they should use protection
(if they both have antibodies, no need for protection)
Provides evidence of past infection
- may take up to 6 months to be dectatable
When should treatment for primary infections of HSV be started within?
For recurrent infections?
Primary infection:
- within 7 days of symptoms
Recurrences:
- within 12-24 hours of symptoms
- Start ASAP - ideally in prodromal period (pt may need meds on hand)
What are benefits of treatment for PRIMARY HSV infection (2)
- decreased time-to-healing (TTH) and symptom duration by 2-4 days
- Decreased duration of viral shedding by ≤1 week
What are the benefits of treatment for recurrent HSV infection (3)
- decreased time-to-healing (TTH) and symptom duration by 1-2 days
- Decreased duration of viral shedding by 1 day
- More likely to have “aborted” episode (prodrome never turns into lesion - if antiviral started early enough)
T/F Topical antiviral therapy is useful in HSV therapy
False
What are the 3 treatment options for primary and recurrent episodes? Duration? Frequency
Acyclovir
- Primary: 400mg TID for 7-10 days
- Recurrent: 400mg TID for 5 days
Famiciclovir
- Primary: 250mg TID for 10 days
- Recurrent: 125mg po BID 5 days
Valacyclovir:
- 1000mg BID for 10 days
- Recurrent: 1000mg DAILY for 5 days
Benefits of chronic suppressive therapy (3)
- To prevent recurrences:
- evidence shows fewer SYMPTOMS, longer TIME BETWEEN recurrences, less asymptomatic shedding (evidence is for ≥1 year of use) - To prevent transmission to seronegative partners (3.6% -> 1.9%):
- should be continued indefinitely unless partner develops HSV (theoretically) - To prevent transmission to infant at time of delivery:
- 50% risk if primary infection during 3rd trimester -> reduced to 2-5% risk if lesion present and <0.05% risk if asymptomatic
- If mother has active lesions or prodromal symptoms upon delivery: C-section indicated
Which therapy is the only one studied to prevent transmission to partners
Valacyclovir
What bug is syphilis caused by? What is its appearance?
Treponema pallidum
- Thin, tightly coiled spirochete
How is syphilis transmitted?
Sexual
- oral, vaginal, anal sex toys
Vertically transferred (through placenta)
Less often transmitted through blood/contact/rash
Who is affected most by syphilis (2)
Indigenous people
gbMSM
T/F Syphilis is curable
True
- with early treatment
How does primary syphilis form? Incubation period?
How long does it take to resolve spontaneously?
upon contact, spirochete penetrates mucous membrane/broken skin to cause primary syphilis
Incubation period: 3 weeks (3-90 days)
Will resolve spontaneously in 3-6 weeks
How does primary syphilis present
Main presentation?
Description?
Location?
Main presentation: Chancre sore, regional lymphadenopathy (swollen lymph nodes)
Description
- round, painless, firm, sore
Location:
- Usually on or inside the genitals, around anus, inside rectum or on oropharyngeal mucosa
How does secondary syphilis form?
if primary untreated, spirochetes spread through bloodstream
How does secondary syphilis present as? (6)
The “great mimicker” - due to diverse/non-specific symptoms (can be confused with other conditions
Presentation
* Fever, Malaise, Headache, Myalgia/Arthralgia, diffuse lymphadenopathy
* Lesions on palms of hands/soles of feet
* Condyloma latum (wart-like lesion on genitals, inner thighs, axillae, umbilicus or in mouth)
* Alopecia
* Headache
* Maculopapular rash, Hepatosplenomegaly (enlargement of spleen and liver)
How does the latent stage of syphilis form?
if secondary untreated, pathogen will become dormant (latent stage)
- asymptomatic
How does latent syphilis present?
Asymptomatic
How long can a patient transmit syphilis for after initial infection even during latent phase
1 year
T/F Secondary syphilis does not resolve spontaneously
False
How does tertiary syphilis present?
Complications (3)
Permanent neurological and/or cardiac damage
- Heart: aortic aneurysm, regurgitation, coronary artery stenosis
- Brain (neurosyphilis): headache, vertigo, ataxia, dementia, personality changes
- Tissue: gummas - soft, tumour-like growths with tissue destruction (commonly on liver, skin, bones)
How can we lab diagnose syphilis?
Which type of syphilis is this possible in?
Who should it be done for? (2)
Only possible during PRIMARY and SECONDARY syphilis
How: Serological antibody tests
Screening: should be done for
* Patients with multiple sexual partners: Every 3-6 months
Pregnant patients: during first trimester (repeat based on risk factors)
T/F Syphilis cannot be cultured
True
What are complications of syphilis in pregnancy
- Miscarriage, still birth
- Congenital syphilis (asymptomatic at birth, symptoms develop weeks-months later). Signs include:
○ Rash, Jaundice, Skeletal abnormalities
○ Hepatomegaly, Lymphadenopathy
○ Snuffles - rhinitis with white/blood-tinged discharge - Late symptoms (>2 years of age): vision loss, hearing loss, intellectual disability
- Increased risk of acquiring/transmitting HIV
What is the treatment of choice for syphilis
Penicillin high conc
Benzathine penicillin G IM
What is the preferred treatment for early syphilis (primary, secondary, early latent)
Alternate duration? (2)
Benzathine penicillin G IM x 1 dose
Alt:
- Doxycycline for 14 days
- Ceftriaxone 1-2g IM/IV daily for 10-14 days
What is the preferred treatment for late syphilis (late latent, tertiary)?
Alternate duration? (2)
Benzathine penicillin G IM weekly x 3 weeks
Alt
- Doxycycline 4 weeks
- Ceftriaxone 2g IM/IV daily 10-14 days
What is the preferred treatment for late syphilis neurosyphilis?
Alternate duration? (1)
Penicillin G sodium IV q4h 10-14 days
Alternate
- Ceftriaxone 2g IV daily for 10-14 days
When would you consider penicillin desensitization (3)
- late syphilis
- neurosyphilis
- Pregnancy
How is the test of cure performed in syphilis
With serological testing to confirm resolution of the infection
Why type of syphilis do JHR reactions most commonly occur in
Secondary syphilis
What is JHR (Jarisch-Herxheimer Reaction). What is it caused by?
Onset?
Resolution time?
acute, self-limiting febrile (FEVER) reaction in first 24 hours after the START OF THERAPY
- Resolves alone after 24 hours
Onset: 2hrs after antimicrobial therapy
Caused by:
Thought to be due to a massive release of toxins/cytokines from killed spirochetes
What symptoms can JHR present with
Cyclic fluctuations in temperature, fever, chills, rigors, sweating
May include:
- malaise
- headache
- pharyngitis
- worsening of syphilitic symptoms (rash),
- nausea, vomiting
- flushing
- myalgias
How do the vital signs look like in JHR
- Vasoconstriction leading to HYPERtension, hyperventilation THEN –>
- Vasodilation leading to HYPOtension and tachycardia
What is the management of JHR (2)
Fever/pain: NSAID or acetaminophen
Hypotension: may need IV fluids until hemodynamics stabilize
