Sexually Transmitted Infections Flashcards
General treatment goal of STD
Eradicate infection within 5-7 days (curable infections only) Alleviate symptoms Prevent reinfection Prevent further STDs Prevent spread to partners Prevent complications Contraception discussion
What is Nucleic Acid Amplification Tests (NAATs)? What is it used for?
Considered the standard of care due to high sensitivity
Wide variety of FDA-cleared specimens types: endocervical, vaginal, urethral, and urine
Used for Chlamydia and Gonorrheal
Clinical presentation of Chlamydia
About 25% of men, and 30% of women will not have ANY symptoms.
More frequently, patients are asymptomatic
When symptoms are present, they tend to be less noticeable
Urethral discharge usually is less profuse, and more mucoid or watery than the urethral discharge associated with gonorrhea
Treatment for Chlamydia
Uncomplicated urethral, endocervical, or rectal infection in adults
Azithromycin 1g PO once
OR
Doxycycline 100mg PO BID x 7 days
More alternative in ppt
Treatment for Chlamydia
Urogenital infections during pregnancy
Azithromycin 1g PO once
Is Chlamydia curable?
YES
Follow-up for Chlamydia
Treatment is highly effective; post-treatment laboratory testing is not recommended unless:
_Adherence is in question
_Symptoms persist
_Reinfection is suspected
Must wait at least 3 weeks after therapy (presence of nonviable organisms that can lead to false-positive results)
If not treated, Chlamydia can lead to ….
Men: Epididymitis, Reiter’s syndrome
Women: Pelvic inflammatory disease and associated complications (i.e. ectopic pregnancy, infertility), Reiter’s syndrome
Reiter’s syndrome
Rare
Reactive arthritis that occurs following a type of bacteria in the body
Gonorrhea
Second most commonly reported communicable disease
Difficult to control due to rapid incubation period and large number of infected individuals
More easily transmitted male female
Clinical presentation of gonorrhea
May be symptomatic or asymptomatic
May be complicated or uncomplicated
May have infections involving several anatomical sites
Most symptomatic patients not treated become asymptomatic within 6 months
If pt have gonorrhea and other diseases were not ruled out, what should we think?
Estimated 46% of people with gonorrhea also have chlamydia
All patients with gonorrhea should be treated for Chlamydia, if Chlamydia cannot be ruled out
Treatment for Gonorrhea
Ceftriaxone 250mg IM once
PLUS
Azithromycin 1g PO once
Is gonorrhea curable?
YES
Follow-up for gonorrhea
Symptoms that persist after treatment should be evaluated by culture for N. gonorrhoeae (with or without simultaneous NAAT)
A high prevalence of infection has been observed among men and women previously treated for gonorrhea
Most of these are a result of reinfection rather than treatment failure
If not treated, gonorrhea can lead to ….
Men: Epididymitis, prostatitis, inguinal lymphadenopathy, urethral stricture/urethritis
Women: Pelvic inflammatory disease and associated complications (i.e. ectopic pregnancy, infertility), disseminated gonorrhea (three times more common than in men)
Infant: blindness
EPT pt needs treatments for Chlamydia and Gonorrhea
Symptomatic: 60 days before onset of symptoms, through the date of treatment
Asymptomatic: 60 days before date of specimen collection, through the date of treatment, if patient was not on treatment at time of specimen
What do we give EPT patients for Chlamydia? Gonorrhea?
Chlamydia:
Azithromycin 1 g PO once
Gonorrhea:
Cefixime 400mg PO once
AND
Azithromycin 1g PO once
Syphilis and HIV association
Highly contagious and, if left untreated, progresses to a chronic systemic illness that can be fatal
Strong association between syphilis and HIV
May increase the risk of acquiring HIV
Immunologic defects in HIV-infected persons can cause abnormal serologic response to syphilis
Compromised immune function could accelerate the progression of syphilis – particularly to neurosyphilis
How many stages of syphillis? What are they?
3 main stages: primary, secondary, and tertiary
2 more stages associated with syphillis: latent, neurosyphillis
Primary syphillis
Painless ulcer appears at the site of infection about 10-90 days after exposure
Heals without treatment in 3-6 weeks
Secondary syphillis
Begins 3-6 weeks after ulcer heals
A rash begins to develop
May also have fever, swollen lymph nodes, sore throat, weight loss, muscle aches, fatigue, alopecia,
Condylomata lata (confused as warts) Resolves without treatment
Latent syphillis / Tertiary syphillis
Latent:
– (+) serological tests; no other evidence
– develops 4-10 weeks after secondary stage
– No signs or symptoms
Tertiary Syphilis:
_ Develops 10-30 years after infection
_ Damage to internal organs, can lead to death
_ Signs and symptoms include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, dementia, gummatous lesions involving any organ or tissue
Neurosyphillis
Develops 10-30 years after infection
May occur at any stage of syphilis
Can be asymptomatic
Signs and symptoms include meningitis, general paresis, dementia, eighth cranial nerve deafness, blindness, ocular involvement
Diagnosis of syphillis require how many tests? Why?
At least 2 tests
Treponemal and Nontreponemal
Results in false negative results during primary syphilis
Results in false positive results in those without syphilis
What are nontreponemal tests? Include what tests?
Detect antibodies that are not specifically directed against the T. pallidum bacterium
_ Venereal Disease Research Laboratory (VDRL)
_ Rapid Plasma Reagin (RPR)
What are treponemal tests? Include what tests?
Detect antibodies that specifically target T. pallidum bacterium
_ Fluorescent treponemal antibody absorbed (FTA-ABS) test
_ T. Pallidum passive particle agglutination (TP-PA) assay
_ Various enzyme immunoassays (EIAs)
FYI: nontreponemal tests
Inexpensive, easily performed
Positive results indicate any stage of syphilis
Useful for screening, progression of disease, recovery after therapy, reinfection
Antibodies in adequately treated patient disappear after about 3 years
Results can vary in HIV positive patients
Chronic false-positive results are commonly associated with heroin addiction, aging, chronic infection, autoimmune disease, malignant disease
FYI: treponemal tests
Highly specific for syphilis – unlikely to have a false positive
Once infected, antibodies remain in blood for life
Positive screening must be followed by nontreponemal test to differentiate between an active infections vs one that occurred in the past and has been treated
Interpretation of Serologic Tests Results
look in ppt or add pic later
Treatment for syphillis (1st choice vs PCN allergy)
Primary, secondary, or early latent (<1 year duration)
Benzathine penicillin G 2.4 million units IM in a single dose
For PCN allergy: Doxycycline 100mg PO BID x 14 days OR Tetracycline 500mg PO 4x daily x 14 days OR Ceftriaxone 1g IM or IV daily x 10-14 days
Treatment for syphillis (1st choice vs PCN allergy) Late latent (> 1 year duration) or latent of unknown duration, or tertiary syphilis
Benzathine penicillin G 2.4 mil units IM once a week for 3 successive weeks (7.2 mil units total)
For PCN allergy:
Doxycycline 100mg PO BID for 28 days
OR
Tetracycline 500mg PO 4x daily x 28 days
Treatment for syphillis (1st choice vs PCN allergy)
Neurosyphillis
Aqueous crystalline penicillin G 18-24 mil units IV (3-4 mil units every 4 hours or by continuous infusion) for 10-14 day
For PCN allergy
Ceftriaxone 2g daily either IM or IV for 10-14 days
Is syphillis curable?
YES
Follow-up serology for primary, secondary, or early latent (<1 year duration)
Retreatment if needed
Clinical and quantitative nontreponemal tests at 6 and 12 months for primary and secondary
At 6, 12, and 24 months for early latent
Retreatment as needed with weekly injections of benzathine penicillin 2.4 mil units IM for 3 weeks
Follow-up serology for late latent (> 1 year duration) or latent of unknown duration or tertiary
Retreatment if needed
Clinical and quantitative nontreponemal tests at 6, 12, and 24 months
Retreatment with neurosyphillis
Follow-up serology for neurosyphillis
Retreatment if needed
CSF examination every 6 months until the cell count is normal; if it has not decreased at 6 months or is not normal by 2 years, retreatment should be considered
Retreatment as initial
Jarisch-Herxheimer Reaction
Self-limited reaction to anti-treponemal therapy
Headache, fever, myalgia, malaise, nausea/vomiting
Occurs within 24 hours after therapy
Not an allergic reaction to penicillin
May pre-treat with APAP or ibuprofen to prevent reaction
More frequent after treatment of early syphilis
Pregnant women should be informed of this possible reaction – may induce early labor
Indications for CSF Examination
Patients with syphilis who demonstrate any of the following criteria should have a CSF evaluation promptly:
_ Neurologic or ophthalmic signs or symptoms
_ Evidence of active tertiary syphilis (e.g. aortitis, gumma, and iritis)
_ Treatment failure
_ HIV infection with late latent syphilis or syphilis of unknown duration
Congenital syphillis
Can cross the placenta at any time during pregnancy
The greatest risk of fetal infection occurs during primary and secondary syphilis in mother
Complications include fetal demise, premature delivery, and deformities
All women screened during first pregnancy visit
Intercourse education after treatment of syphillis
No unprotected sex until lesion is healed or 5-7 days after treatment (whichever is longer)
Partner management
in ppt, mostly treat presumptively
What organism causes syphillis?
Spirochete
What organism causes Chlamydia?
Chlamydia trachomatis
An intracellular parasite that shares properties of both a virus and bacteria – maintains its cellular identity throughout development
Like viruses, chlamydiae require cellular material from host cells for replication
Although the cells lack a cell wall, its major outer membrane is similar to gram-negative bacteria
What organism causes gonorrhea?
Neisseria gonorrhea is gram-negative diplococcus
Trichomonas
Infection from inanimate objects and bath or toilet articles is possible – can survive on moist surface for 45 minutes
Coinfection with other STIs is common
Approximately 20% of men with gonococcal urethritis also have trichomoniasis
What causes Trichomonas?
Trichomonas vaginalis is flagellated, motile protozoan that attaches to vaginal or urethral mucosa
An inflammatory response is initiated that manifests as a discharge containing large amounts of PMNs
Clinical presentation for Trichomonas
More common for females to have symptoms than males. Painful urination Frequent urination Discharge – may be yellow or green Typically smells Painful urination Pain during sex “Strawberry” cervix
Treatment for trichomonas
Metronidazole 2g PO in a single dose
Metronidazole things to remember + ADR
Increase in GI complaints (e.g. anorexia, nausea, vomiting, and diarrhea) associated with 2g dose of either metronidazole or tinidazole
Patients intolerant to GI ADRs usually tolerate the alternate metronidazole multidose regimen
Alcohol should be avoided for 24 hours after completion of metronidazole and 72 hours after completion of tinidazole
Intercourse education following Trich treatment
No sexual activity until 1 week after treatment is completed!
Follow-up for Trichomonas treatment
High rate of reinfection for all sexually active women diagnosed need to be retested within 3 months following initial treatment regardless of whether they believe their sex partners were treated or not
Data insufficient to suggest retesting men
Recurrent treatment for Trichomonas
Treat with metronidazole 500mg PO BID x 7 days for patient and partner
Herpes
Most common cause of genital ulceration
Presence of genital herpes is associated with an increased risk of contracting HIV after exposure
HSV-1
Oral herpes
Most common cause of genital ulceration
More than 50 million Americans have genital herpes, and is increasing by at least 776,000 cases each year
Presence of genital herpes is associated with an increased risk of contracting HIV after exposure
HSV-2
Genital herpes
Lives in nerve cells in the lower back
Recurs in genital or anal areas
Spread through unprotected oral, anal, vaginal sex
Pathophysiology of HSV
Infection occurs in 5 stages: _ Primary mucocutaneous infection _ Infection of the ganglia _ Establishment of latency _ Reactivation _ Recurrent infection
Latency appears to be lifelong
Interrupted by reactivation of the viral infection
Unclear what factors are important in maintaining latency but appear to be affected by:
Immune responses
Emotional stressors
Physical stressors
Diagnosis of HSV using
Tissue culture, serologic test, PCR
Polymerase Chain Reaction (PCR) Assays
Detect HSV DNA, and can differentiate HSV-1 and 2
More sensitive than culture, diagnostic test of choice for suspected CNS infection (i.e. HSV encephalitis and HSV meningitis)
Not widely used to diagnose genital ulcers
Highly sensitive in detecting asymptomatic viral shedding
Treatment goal for HSV
Most achievable goals in the management of genital herpes are
Relieve symptoms and shorten the clinical course
Prevent complications and recurrences
Decrease disease transmission
Treatment for first clinical episode of genital herpes
Valacyclovir 1g PO BID for 7-10 days
Treatment for first recurrent infection (episodic)
Valacyclovir 1g PO once daily for 5 days
Treatment for recurrent infection (suppressive)
Valacyclovir 1g PO once daily
Is herpes curable?
NO
Suppressive Therapy
CDC recommends discontinuing at 1 year
Some clinicians will continue indefinitely or use “drug holidays”
Not clear if decreases transmission to partners, although markedly decreases asymptomatic viral shedding
Topical acyclovir for HSV treatment?
Not effective for treatment or prophylaxis.
DO NOT USE
Intercourse education after HSV treatment
Risk for spread of disease – viral shedding
No sexual activity during active outbreak
Clinical Presentation – Genital Warts
Anogenital warts are usually asymptomatic as well, but depending on size and anatomic location, they can be painful or pruritic
_ Condylomata, acuminata (Cauliflower-like appearance, skin-colored, pink, or hyperpigmented) _Smooth papules (dome-shape, skin-colored) _ Flat papules (Macular or slightly raised, skin-colored, smooth surface, most commonly found on internal structures (cervix) but can be on external genitalia) _Keratotic wart (Thick horny layer, can resemble common warts or seborrheic keratosis)
What diagnosis to use for HPV and cancer
Pap smear
Depends on the degree of abnormal cells
Colposcopy may be completed – small sample of tissue taken from cervix and examined under microscope
Cervical cell biopsy may be completed
What diagnosis to use for HPV and cancer
Pap smear
Depends on the degree of abnormal cells
Colposcopy may be completed – small sample of tissue taken from cervix and examined under microscope
Cervical cell biopsy may be completed
Goal of therapy for genital wart
Eliminate symptoms, and removal of wart(s)
Treatment for genital wart
Patient applied treatment
Podofilox 0.5% solution or gel (Condylox) OR Imiquimod 3.75% or 5% cream (Aldara) OR Sinecatechins 15% ointment (Veregen)
Podofilox
Apply to visible warts BID x 3 days, followed by 4 days of no therapy
Cycle may be repeated as needed up to 4 cycles
*May cause mild to moderate pain or local irritation
*Contraindicated in pregnancy
FYI: Imiquimod
Apply to visible warts QHS 3x/week up to 16 weeks
Treatment area should be washed with soap and water 6-10 hours after application
*May cause local inflammatory reactions, redness, irritation, induration, ulceration/erosions, and hypopigmentation
*Limited information in pregnancy, but animal data suggest low risk
FYI: Sinecatechins
Apply 0.5cm strand to each wart TID, up to 16 weeks
Must avoid sexual contact while ointment is on the skin
*May cause erythema, pruritus/ burning, pain, ulceration, edema, induration, and vesicular rash
*Avoid use in pregnant patients and patients with HIV or genital herpes
Treatment for genital wart
Provider applied treatments
Cryotherapy with liquid nitrogen or cryoprobe
OR
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% solution
OR
Surgical remove
More info in ppt
Screening Recommendations from the American Cancer Society for woman age 21-29? 30-65? >65?
Age 21-29: Pap smear every 3 years – HPV testing only if patient has an abnormal Pap smear
Age 30-65: Pap smear and HPV testing every 5 years – optional Pap smear only every 3 years
Age 65: If they have had any pre-cancers found, they need to continue screening every 3-5 years until it has been 20 years since the pre-cancer was found. If their screens have been normal, they may stop screening for cervical cancer.
What is HPV vaccine?
Gardasil 9
Bacterial Vaginosis
BV is a clinical syndrome resulting from replacement of the normal Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria
Cause of microbial alteration is not fully understood
Most prevalent cause of vaginal discharge or malodor
Bacterial Vaginosis Risk Factors
Having multiple male or female partners New sex partners Douching Lack of condom use Lack of vaginal lactobacilli
*women who have never been sexually active are rarely affected
Bacterial Vaginosis Clinical Presentation
Thin, white vaginal discharge
Malodorous – usually fishy smell present
Most women are asymptomatic
Bacterial Vaginosis Diagnosis
Diagnosis requires 3 of the following signs or symptoms:
_ Homogeneous, thin, white discharge that smoothly coats the vaginal walls
_ Presence of clue cells on microscopic examination
_ pH of vaginal fluid > 4.5
_ A fishy odor of vaginal discharge before or after addition of 10% KOH (i.e. the whiff test)
Therapy goal for BV
Relieve vaginal symptoms and signs of infection
Reduce risk of acquiring STIs
Treatment for BV
Metronidazole 500mg orally BID for 7 days
OR
Metronidazole gel 0.75% one applicator (5g) intravaginally, once daily for 5 days
More info in ppt
Things to know about BV treatment
Should be advised to refrain from sexual activity or use condoms, consistently and correctly during the treatment regimen
Avoid douching – can increase risk for relapse
No data support the use of douching for treatment or relief of symptoms
No data available supporting the use of lactobacillus formulations or probiotics as adjunctive therapy or replacement therapy
All women with BV diagnosis should be tested for HIV and other STIs
BV follow-up
Follow-up unnecessary if symptoms resolve
Since BV recurrence is common, women should be advised to return for evaluation if symptoms recur
Can reuse the previous tx or choose an alternate
Bacterial Vaginosis Recurrent Infections
For women with multiple recurrences after completion of a recommended regimen
Metronidazole 0.75% gel 2x/week for 4-6 months
shown to reduce recurrences; benefit is not persistent once suppressive therapy is stopped
What to do after a case of sexual assualt?
Presumptive Treatment
_ Ceftriaxone 250mg IM x 1
_ Metronidazole 2g PO x 1
_ Azithromycin 1g PO x 1
Emergency contraception may be offered Hep B vaccine HPV vaccine HIV test Anti-emetics
Some monitorings considered for pt
Prevent method
Talk w her BF so he can be treated
Need to treat partner (> or
