Sexually Transmitted Infections - Chlamydia, Mycoplasma Genitalium, Herpes, Trichomoniasis, Pelvic Inflammatory Disease

Question 1

What is the etiologic agent of chlamydia?

Answer 1

Chlamydia trachomatis
(gram-negative, anerobic bacteria)

Question 2

What is the epidemiology of chlamydia?

Answer 2

In the US, chlamydial genital infection is the most common notifiable infectious disease

Question 3

What is the clinical presentation of chalmydia in males?

Answer 3

Most common symptoms – dysuria, urinary frequency, mucoid urethral discharge
≈ 50% are asymptomatic
Rectal infections occur in homosexual men; usually asymptomatic

Question 4

What is the clinical presentation of chlamydia in females?

Answer 4

Majority are asymptomatic; dysuria and frequency are uncommon
If symptomatic – endocervicitis with a mucopurulent discharge

Question 5

What is the clinical presentation of chlamydia in infants?

Answer 5

Transmitted via contact with cervicovaginal secretions (70%)
Most common cause of neonatal eye infection and of afebrile interstitial pneumonia

Question 6

What is the diagnosis of chlamydia?

Answer 6

• 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

Question 7

What is the treatment of chlamydia?

Answer 7

recommended: doxycycline 100 mg x 7 days
alternative: azithromycin 1 g x 1 dose or levofloxacin 500 mg x 7 days

Question 8

What is the treatment of chlamydia in pregnant patients?

Answer 8

standard: azithromycin 500 mg x 1 dose
alternative: amoxicillin 500 mg x 7 days

Question 9

What is patient education for chlamydia?

Answer 9

• 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

Question 10

What is mycoplasma genitalium?

Answer 10

motile flask-shaped bacteria, no cell wall

Question 11

What is the epidemiology of mycoplasma genitalium?

Answer 11

Recognized as a cause of male urethritis
May be sole pathogen or coinfection with C. trachomatis

Question 12

What is the clinical presentation of mycoplasma genitalium?

Answer 12

Same as C. trachomatis (chlamydia); frequently asymptomatic

Question 13

What is the diagnosis of mycoplasma genitalium?

Answer 13

• Slow growing organism (no cell wall) – takes up to 6 months for positive culture
• Nucleic acid amplification testing (NAAT) – preferred

Question 14

What is the treatment for mycoplasma genitalium - macrolide-susceptible?

Answer 14

doxycycline 100 mg x 7 days followed by azithromycin 1 g x 1 followed by 500 mg daily x 3 additional days

Question 15

What is the treatment for mycoplasma genitalium - macrolide-resistant?

Answer 15

doxycycline 100 mg x 7 days followed by moxifloxacin 400 mg x 7 days

Question 16

What is the treatment for mycoplasma genitalium - testing not available?

Answer 16

doxycycline 100 mg x 7 days followed by moxifloxacin 400 mg x 7 days

Question 17

What are the etiologic agents of genital herpes?

Answer 17

Herpes simplex virus type 1 (HSV-1)
Herpes simplex virus type 2 (HSV-2)

Question 18

What is the epidemiology of herpes?

Answer 18

Chronic, life-long viral infection
Increases risk of becoming infected with HIV – major role in heterosexual spread

Question 19

What is the clinical presentation of herpes in primary infections?

Answer 19

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

Question 20

What is the clinical presentation of herpes in recurrent infections?

Answer 20

• ≈ 50% of patients experience a prodrome prior to appearance of recurrent lesions
• Symptoms more severe in women and immunocompromised patients

Question 21

What is the clinical presentation of herpes in special populations?

Answer 21

Effect of herpes on neonates exposed during pregnancy – high mortality and significant morbidity

Question 22

What is the diagnosis of herpes?

Answer 22

Viral culture – preferred virologic test
HSV NAAT (nucleic acid amplification test) – most sensitive for detection
Serologic tests –detect antibodies to HSV

Question 23

What is the initial treatment for herpes?

Answer 23

first clinical episode of genital herpes: acyclovir 400 mg OR famciclovir 250 mg OR valacyclovir 1 g
treat for 7-10 days

Question 24

What is the recurrent treatment for herpes?

Answer 24

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

Question 25

What is additional treatment for severe disease in herpes?

Answer 25

Acyclovir 5-10 mg/kg/dose IV q8h for 2-7 days followed by oral therapy to complete at least 10 days

Question 26

What is suppressive treatment in herpes?

Answer 26

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

Question 27

What is the treatment of herpes in HIV pts?

Answer 27

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

Question 28

What is the treatment of herpes is resistance is present?

Answer 28

If acyclovir resistant HSV → foscarnet 40-80 mg/kg/dose IV q8h or cidofovir 5 mg/kg IV once weekly

Question 29

What is the treatment of herpes in pregnant patients?

Answer 29

Start suppressive therapy at 36 weeks gestation o Acyclovir 400 mg TID o Valacyclovir 500 mg BID

Question 30

What are the etiologic agents of trichomoniasis?

Answer 30

Trichomonas vaginalis (flagellated, motile protozoan!)

Question 31

What is the clinical presentation of trichomoniasis in women?

Answer 31

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

Question 32

What is the clinical presentation of trichomoniasis in men?

Answer 32

Majority are asymptomatic Symptoms – urethral discharge, pruritis, dysuria Trichomoniasis – a cause of treatment failure in patients with presumed NGU treated with tetracyclines or erythromycin

Question 33

What is the diagnosis of trichomoniasis?

Answer 33

Wet mount examination of the discharge – characteristic pear-shaped, flagellating organisms NAAT culture – highly specific and more sensitive than wet mount

Question 34

What is the only drug class that treats trichomoniasis?

Answer 34

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

Question 35

What is the treatment for trichomoniasis?

Answer 35

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

Question 36

What are the clinical pearls of trichomoniasis?

Answer 36

* 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

Question 37

What are the etiologic agents of pelvic inflammatory disease?

Answer 37

* N. gonorrhoeae * C. trachomatis * Vaginal flora (anaerobes, Gardnerella vaginalis, gram-negative bacilli, S. agalactiae) * Mycoplasma hominis, Mycoplasma genitalium * Ureaplasma urealyticum

Question 38

What is the etiology of pelvic inflammatory disease?

Answer 38

Spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis

Question 39

What is the diagnosis/symptoms of pelvic inflammatory disease?

Answer 39

* 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

Question 40

What is the treatment of pelvic inflammatory disease - standard?

Answer 40

ceftriaxone 1 g + doxycycline 100 mg q12h + metronidazole 500 mg q12h x 14 days

Question 41

What is the treatment of pelvic inflammatory disease - alternative parenteral regimen?

Answer 41

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

Question 42

What is the treatment of pelvic inflammatory disease - IM/Oral regimen?

Answer 42

ceftriaxone 500 mg IM x 1 dose + doxycycline 100 mg PO q12h + metronidazole 500 mg PO q12h x 14 days