Sexually Transmitted Diseases Flashcards
Gonococcal Infections (Essentials)
• Purulent and profuse urethral discharge, especially in men, with dysuria, yielding positive smear • In men – Epididymitis – Prostatitis – Periurethral inflammation – Proctitis – Pharyngeal infection • In women – Asymptomatic or cervicitis with purulent discharge – Vaginitis, salpingitis, proctitis also occur • Disseminated disease – Fever – Rash – Tenosynovitis – Septic arthritis • Gram-negative intracellular diplococci seen in a smear or cultured from any site, particularly the urethra, cervix, pharynx, and rectum
Gonococcal Infections (Treatment)
• For uncomplicated infections of cervix, urethra, or rectum
– Treatment of choice is either ceftriaxone (250 mg intramuscularly), plus either azithromycin (1000 mg orally as a single dose) or doxycycline (100 mg twice daily for 7 days)
– When an oral cephalosporin is the only option, cefixime, 400 mg orally as a single dose, can be combined with azithromycin or doxycycline as above but a “test of cure” culture or nuclear amplification test is recommend 1 week after treatment
• Pharyngeal gonorrhea also treated with ceftriaxone (250 mg intramuscularly) plus either azithromycin (1000 mg orally as a single dose) or doxycycline (100 mg twice daily for 7 days
• Pelvic inflammatory disease
– Cefoxitin, 2 g parenterally every 6 hours, or cefotetan, 2 g intravenously every 12 hours plus doxycycline 100 mg every 12 hours
– Clindamycin, 900 mg intravenously every 8 hours, plus gentamicin, administered intravenously as a 2-mg/kg loading dose followed by 1.5 mg/kg every 8 hours
– Ceftriaxone, 250 mg intramuscularly as a single dose (or cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally as a single dose,) plus doxycycline, 100 mg twice a day for 14 days, with or without metronidazole, 500 mg twice daily for 14 days, is an effective outpatient regimen
• Disseminated gonococcal infection
– Ceftriaxone, 1 g daily intravenously; 48 hours after improvement begins, therapy may be switched to cefixime, 400 mg daily orally to complete at least 1 week of therapy
– An oral fluoroquinolone (ciprofloxacin, 500 mg twice daily, or levofloxacin, 500 mg once daily) for 7 days also is effective, provided the isolate is susceptible
• Endocarditis
– Ceftriaxone, 2 g every 12 hours intravenously, for at least 3 weeks
Chlamydial Urethritis & Cervicitis (Essentials)
- Chlamydia trachomatis immunotypes D–K are isolated in about 50% of cases of nongonococcal urethritis and cervicitis by appropriate techniques
- Coinfection with gonococci is common
- Postgonococcal (ie, chlamydial) urethritis may persist after successful treatment of the gonococcus
Chlamydial Urethritis & Cervicitis (Treatment)
- Sexual partners of infected patients should also be treated
- Presumptively administered therapy still indicated in some cases
- A single oral 1-g dose of azithromycin is effective for uncomplicated urethritis and cervicitis and has the advantage of improved patient compliance and minimal toxicity
- Doxycycline, 100 mg twice daily for 7 days, or levofloxacin, 500 mg once daily for 7 days; however, both are contraindicated in pregnancy
Trichomoniasis (About and Findings)
• Caused by the protozoan Trichomonas vaginalis
• Often asymptomatic
• For women with symptomatic disease
– Vaginal discharge develops after an incubation period of 5 days to 4 weeks
▪ May be copious
▪ Usually not foul smelling
▪ Often frothy and yellow or green in color
– Vulvovaginal discomfort, pruritus, dysuria, dyspareunia, or abdominal pain may be present
– Inflammation of the vaginal walls and cervix with punctate hemorrhages are common
• Most men infected with T vaginalis are asymptomatic, but it can be isolated from about 10% of men with nongonococcal urethritis
• In men with trichomonal urethritis, the urethral discharge is generally more scanty than with other causes of urethritis
Trichomoniasis (Treatment)
- The treatment of choice is metronidazole or tinidazole, each as a 2 g single oral dose
- Tinidazole may be better tolerated and active against some resistant parasites
- If the large single dose cannot be tolerated, an alternative metronidazole dosage is 500 mg orally twice daily for 1 week
- All infected persons should be treated, even if asymptomatic, to prevent subsequent symptomatic disease and limit spread
- Treatment failure suggests reinfection
Herpesviruses 1 & 2, Oral and Genital (Treatment)
• For primary herpes labialis
– Oral acyclovir (200 mg orally five times a day or 400 mg orally three times a day for 7–10 days)
– Intravenous acyclovir, 5–10 mg/kg every 8 hours for 7–14 days, should be considered in immunosuppressed patients
• For recurrent herpes simplex labialis
– Topical 1% hydrocortisone cream in combination with 5% acyclovir cream
– Lesions heal faster with topical penciclovir than with topical acyclovir
– Docosanol cream offers modest benefit
• For primary genital infection
– Acyclovir, 200 mg orally five times a day or 400 mg orally three times a day for 7–10 days
– Valacyclovir, 1 g orally twice daily
– Famciclovir, 250 mg orally three times daily
• For recurrent genital disease
– Acyclovir, 800 mg orally three times daily for 2–5 days
– Valacyclovir, 500 mg orally twice daily for 3 days or 1 g once a day for 5 days
– Famciclovir, 1 g orally twice daily for 1 day or 500 mg initial dose followed by 250 mg twice daily for 2 days
– Patient-initiated therapy with a short course (1–2 day regimens) of antiviral agents at first symptoms of recurrence or prodrome is a frequently used approach
• Secondary prophylaxis for frequent recurrent genital infections
– Acyclovir, 400 mg twice a day
– Valacyclovir, 500–1000 mg once daily
– Famciclovir, 250 mg twice a day
• Secondary prophylaxis for herpes labialis: valacyclovir, 500 mg daily
Herpesviruses 1 & 2, Oral and Genital (About & Findings)
HSV-1 and HSV-2 disease
• Burning and stinging are principal symptoms
• Neuralgia may precede or accompany attacks
• Lesions consist of small, grouped vesicles on an erythematous base that can occur anywhere but that most often occur on the vermillion border of the lips, the penile shaft, the labia, the perianal skin, and the buttocks
• Any erosion in anogenital region can be due to HSV-2 (or HSV-1)
• Regional lymph nodes may be swollen and tender
• The lesions usually crust and heal in 1 week
HSV-1 disease
– Largely involves the mouth and oral cavity
– Occasionally, primary infections may be manifested as severe gingivostomatitis
– Digital lesions (whitlows) are an occupational hazard in medicine and dentistry
– Contact sports (eg, wrestling) are associated with outbreaks of skin infections
– Primary infection is usually more severe than recurrences but may be asymptomatic
– Recurrences often
▪ Involve fewer lesions
▪ Tend to be labial
▪ Heal faster
HSV-2 lesions
– Largely involve the genital tract, with the virus remaining latent in the presacral ganglia
– Lesions arising on the external genitalia are multiple, painful, small, grouped, and vesicular
– Occasionally, lesions arise in the perianal region or on the buttocks and upper thighs
– Dysuria, cervicitis, and urinary retention may occur in women
Syphilis (Findings; Primary, Secondary, Tertiary)
Primary
• Painless ulcer (chancre) on genitalia, perianal area, rectum, pharynx, tongue, lip, or elsewhere 2–6 weeks after exposure
• Nontender enlargement of regional lymph nodes
Secondary
• Generalized maculopapular skin rash
• Mucous membrane lesions, which can be found on the lips, mouth, throat, genitalia, and anus
• Weeping papules (condyloma lata) in moist skin areas
• Generalized nontender lymphadenopathy
• Fever
• Meningitis, hepatitis, osteitis, arthritis, iritis
Early latent
• No physical signs
Late latent
• No physical signs
Late (tertiary)
• Infiltrative tumors of skin, bones, liver (gummas)
• Aortitis, aneurysms, aortic regurgitation
• CNS disorders, including
– Meningovascular and degenerative changes
– Paresthesias
– Shooting pains
– Abnormal reflexes
– Dementia
– Psychosis
Early Primary, Secondary, or early latent Syphilis Treatment
Benzathine penicillin G 2.4 million units IM. Alternatives: Doxycycline 100 mg PO BID x 14 days, Tetracycline 500 mg PO QID X 14 days, Ceftriaxone 1 g IM/IV X 8-10 days
Late latent or uncertain duration, or tertiary without neurosyphilis Syphilis Treatment
Benzathine penicillin G 2.4 million units intramuscularly weekly for 3 weeks
Alternatives: Doxycycline 100 mg orally twice daily for 28 days
or
Tetracycline 500 mg orally four times a day for 28 days
Neurosyphilis
Aqueous penicillin G 18-24 million units intravenously daily, given every 3-4 hours or as continuous infusion for 10-14 days
Alternative: Procaine penicillin, 2.4 million units intramuscularly daily with probenecid 500 mg orally four times a day for 10–14 days
or
Ceftriaxone 2 g intramuscularly or intravenously daily for 10–14 days
Chancroid
• A sexually transmitted disease caused by the gram-negative bacillus Haemophilus ducreyi
• Culturing a swab of the lesion onto special medium
• A single dose of either azithromycin, 1 g orally, or ceftriaxone, 250 mg intramuscularly, is effective
• Effective multiple-dose regimens
– Erythromycin, 500 mg four times daily orally for 7 days
– Ciprofloxacin, 500 mg twice daily orally for 3 days
Granuloma Inuinale
• A chronic, relapsing granulomatous anogenital infection caused by Calymmatobacterium (Donovania) granulomatis
• Culture
– Doxycycline, 100 mg twice daily orally or
– Azithromycin, 1 g once weekly orally or
– Ciprofloxacin, 750 mg twice daily orally or
– Erythromycin, 500 mg four times daily orally
• Treatment duration is 3 weeks or until all lesions have healed
Lymphogranuloma Venereum
- An acute and chronic sexually transmitted disease
- Caused by Chlamydia trachomatis types L1–L3
- The complement fixation test may be positive (titers > 1:64), but cross-reaction with other chlamydiae occurs
- Nucleic acid detection tests are sensitive, but not FDA-approved for rectal specimens and cannot differentiate lymphogranuloma venereum (LGV) from non-LGV strains
- Doxycycline, 100 mg twice daily orally for 21 days
- Erythromycin, 500 mg four times daily orally for 21 days
- Trimethoprim-sulfamethoxazole, 160/800 mg twice daily orally for 21 days
