Sexually Transmitted Infections - Chlamydia, Mycoplasma Genitalium, Herpes, Trichomoniasis, Pelvic Inflammatory Disease Flashcards
What is the etiologic agent of chlamydia?
Chlamydia trachomatis
(gram-negative, anerobic bacteria)
What is the epidemiology of chlamydia?
In the US, chlamydial genital infection is the most common notifiable infectious disease
What is the clinical presentation of chalmydia in males?
Most common symptoms – dysuria, urinary frequency, mucoid urethral discharge
≈ 50% are asymptomatic
Rectal infections occur in homosexual men; usually asymptomatic
What is the clinical presentation of chlamydia in females?
Majority are asymptomatic; dysuria and frequency are uncommon
If symptomatic – endocervicitis with a mucopurulent discharge
What is the clinical presentation of chlamydia in infants?
Transmitted via contact with cervicovaginal secretions (70%)
Most common cause of neonatal eye infection and of afebrile interstitial pneumonia
What is the diagnosis of chlamydia?
- Nucleic acid amplification testing (NAAT) – detection of chlamydia antigen in urine
- Giemsa stain of cell scrapings from the endocervix or urethra
- Direct immunofluorescence
- Cell culture - 100% specific
What is the treatment of chlamydia?
recommended: doxycycline 100 mg x 7 days
alternative: azithromycin 1 g x 1 dose or levofloxacin 500 mg x 7 days
What is the treatment of chlamydia in pregnant patients?
standard: azithromycin 500 mg x 1 dose
alternative: amoxicillin 500 mg x 7 days
What is patient education for chlamydia?
- Instruct patients to abstain from sex for 7 days after the completion of therapy and until all sex partners are treated
- Offer PrEP for patients at risk for HIV
What is mycoplasma genitalium?
motile flask-shaped bacteria, no cell wall
What is the epidemiology of mycoplasma genitalium?
Recognized as a cause of male urethritis
May be sole pathogen or coinfection with C. trachomatis
What is the clinical presentation of mycoplasma genitalium?
Same as C. trachomatis (chlamydia); frequently asymptomatic
What is the diagnosis of mycoplasma genitalium?
- Slow growing organism (no cell wall) – takes up to 6 months for positive culture
- Nucleic acid amplification testing (NAAT) – preferred
What is the treatment for mycoplasma genitalium - macrolide-susceptible?
doxycycline 100 mg x 7 days followed by azithromycin 1 g x 1 followed by 500 mg daily x 3 additional days
What is the treatment for mycoplasma genitalium - macrolide-resistant?
doxycycline 100 mg x 7 days followed by moxifloxacin 400 mg x 7 days
What is the treatment for mycoplasma genitalium - testing not available?
doxycycline 100 mg x 7 days followed by moxifloxacin 400 mg x 7 days
What are the etiologic agents of genital herpes?
Herpes simplex virus type 1 (HSV-1)
Herpes simplex virus type 2 (HSV-2)
What is the epidemiology of herpes?
Chronic, life-long viral infection
Increases risk of becoming infected with HIV – major role in heterosexual spread
What is the clinical presentation of herpes in primary infections?
First-episode primary infections - characterized by a prolonged duration of symptoms: Flu-like symptoms - fever, headache, malaise, myalgias; Local symptoms - pustular or ulcerative lesions on external genitalia (painful), itching, vaginal or urethral discharge, inguinal adenopathy
First-episode nonprimary genital herpes: milder than true primary infections
What is the clinical presentation of herpes in recurrent infections?
- ≈ 50% of patients experience a prodrome prior to appearance of recurrent lesions
- Symptoms more severe in women and immunocompromised patients
What is the clinical presentation of herpes in special populations?
Effect of herpes on neonates exposed during pregnancy – high mortality and significant morbidity
What is the diagnosis of herpes?
Viral culture – preferred virologic test
HSV NAAT (nucleic acid amplification test) – most sensitive for detection
Serologic tests –detect antibodies to HSV
What is the initial treatment for herpes?
first clinical episode of genital herpes: acyclovir 400 mg OR famciclovir 250 mg OR valacyclovir 1 g
treat for 7-10 days
What is the recurrent treatment for herpes?
Recurrent infections – benefit if started in prodrome or within 1 day after onset of lesions:
acyclovir 800 mg BID x 5 days OR acyclovir 800 mg TID x 2 days
famciclovir 125 mg BID x 5 days OR famciclovir 1 g BID x 1 day
valacyclovir 500 mg BID x 3 days OR valacyclovir 1 g daily x 5 days
What is additional treatment for severe disease in herpes?
Acyclovir 5-10 mg/kg/dose IV q8h for 2-7 days followed by oral therapy to complete at least 10 days
What is suppressive treatment in herpes?
daily suppressive therapy: Reduces frequency of recurrences by 70-80% in patients who have frequent recurrences (≥ 6/year)
acyclovir 400 mg BID
famciclovir 250 mg BID
valacyclovir 500 mg daily (less effective)
valacyclovir 1 g daily
What is the treatment of herpes in HIV pts?
Regimens for episodic infections – treat x 5-10 days
o Acyclovir 400 mg TID
o Famciclovir 500 mg BID
o Valacyclovir 1 g BID
Regimens for daily suppressive therapy
o Acyclovir 400-800 mg BID to TID
o Famciclovir 500 mg BID
o Valacyclovir 500 mg BID
What is the treatment of herpes is resistance is present?
If acyclovir resistant HSV → foscarnet 40-80 mg/kg/dose IV q8h or cidofovir 5 mg/kg IV once weekly
What is the treatment of herpes in pregnant patients?
Start suppressive therapy at 36 weeks gestation
o Acyclovir 400 mg TID
o Valacyclovir 500 mg BID
What are the etiologic agents of trichomoniasis?
Trichomonas vaginalis
(flagellated, motile protozoan!)
What is the clinical presentation of trichomoniasis in women?
Asymptomatic in up to 50%
Symptoms (non-specific):
o Vaginal discharge (malodorous, foamy, greenish-yellow)
o Vulvar pruritis
o Dysuria
o Symptoms may worsen during menstruation
What is the clinical presentation of trichomoniasis in men?
Majority are asymptomatic
Symptoms – urethral discharge, pruritis, dysuria
Trichomoniasis – a cause of treatment failure in patients with presumed NGU treated with tetracyclines or erythromycin
What is the diagnosis of trichomoniasis?
Wet mount examination of the discharge – characteristic pear-shaped, flagellating organisms
NAAT
culture – highly specific and more sensitive than wet mount
What is the only drug class that treats trichomoniasis?
Nitroimidazoles are only drug class with documented clinical efficacy
Metronidazole gel is not recommended (does not reach therapeutic concentrations in urethra and perivaginal glands)
If allergy to metronidazole must use desensitization
What is the treatment for trichomoniasis?
women: metronidazole 500 mg BID x 7 days; alternative - tinidazole 2 g x 1 dose
men: metronidazole 2 g x 1 dose; alternative - tinidazole 2 g x 1 dose
HIV+: metronidazole 500 mg BID x 7 days
What are the clinical pearls of trichomoniasis?
- Retest all sexually active women <3 months of initial treatment
- Avoid alcohol with metronidazole (24 hours) and tinidazole (72 hours)
- Excreted in breast milk – may defer breastfeeding for 12-24 hours after end of maternal treatment
- Treat the sexual partner
What are the etiologic agents of pelvic inflammatory disease?
- N. gonorrhoeae
- C. trachomatis
- Vaginal flora (anaerobes, Gardnerella vaginalis, gram-negative bacilli, S. agalactiae)
- Mycoplasma hominis, Mycoplasma genitalium
- Ureaplasma urealyticum
What is the etiology of pelvic inflammatory disease?
Spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
What is the diagnosis/symptoms of pelvic inflammatory disease?
- Pelvic or lower abdominal pain, Adnexal or uterine tenderness, Cervical motion tenderness, Dyspareunia, Temperature > 101°F, Abnormal cervical or vaginal mucopurulent discharge
- Increased ESR and/or CRP
- Laboratory documentation of N. gonorrhoeae or C. trachomatis
What is the treatment of pelvic inflammatory disease - standard?
ceftriaxone 1 g + doxycycline 100 mg q12h + metronidazole 500 mg q12h x 14 days
What is the treatment of pelvic inflammatory disease - alternative parenteral regimen?
ampicillin/sulbactam 3 g q6h + doxycycline 100 mg q12h x 14 days
severe allergy: clindamycin 900 mg q8h + gentamicin 2mg/kg loading dose then 1.5mg/kg q8h x 14 days
What is the treatment of pelvic inflammatory disease - IM/Oral regimen?
ceftriaxone 500 mg IM x 1 dose + doxycycline 100 mg PO q12h + metronidazole 500 mg PO q12h x 14 days
