Sexually Transmitted Infections - Gonorrhea and Syphilis Flashcards
What are the prevention options for STIs?
- Mechanical barriers
- Pre-Exposure Prophylaxis (PrEP )
- Post-Exposure Prophylaxis (PEP)
- Human Papillomavirus (HPV) vaccine
What are examples of mechanical barriers?
external condoms (male condoms)
internal condoms (female condoms)
condoms do NOT provide protection against STIs spread by skin-to-skin contact (genital herpes, HPV, syphilis)
What is pre-exposure prophylaxis (PrEP)?
FDA approved medications to prevent HIV in adults and adolescents weighing ≥77 lb (35 kg): truvada, descovy, apretude (IM injection)
What is post-exposure prophylaxis (PEP)?
People who are already using PrEP typically do not need PEP
substantial risk for HIV acquisition and </= 72 hours since exposure with source person known to have HIV –> PEP recommended
substantial risk for HIV acquisition and >/= 73 hours since exposure –> PEP NOT recommended
What are PEP regimens?
preferred: tenofovir disoproxil fumarate + emtricitabine AND raltegravir or dolutegravir for 28 days
alternative: tenofovir disoproxil fumurate + emtricitabine AND darunavir + ritonavir for 28 days
What is the HPV vaccine?
- CDC recommends HPV vaccination to protect against HPV infections that can cause some cancers
- HPV vaccine is recommended for routine vaccination at age 11 or 12 years (can be started at age 9)
- HPV vaccination prevents new HPV infections, but does not treat existing HPV infections or diseases
What is the etiologic agent for gonorrhea?
Neisseria gonorrhoeae
(gram-negative, diplococci bacteria)
What is the epidemiology of gonorrhea?
Second most common notifiable disease in the US
Associated with increased risk of HIV transmission
Major cause of pelvic inflammatory disease
What are the risk factors for gonorrhea?
low socioeconomic status, urban residence, unmarried, IV drug use, sex work, h/o gonorrheal infection
What are the clinical manifestations of gonorrhea - Uncomplicated genital infections in women?
Primary site – endocervix; Up to 80% of women are asymptomatic or mildly symptomatic; Symptoms: cervicitis and/or urethritis → increased vaginal discharge, dysuria, urinary frequency, intermenstrual bleeding, menorrhagia
What are the clinical manifestations of gonorrhea - Genital infections in men?
Predominant manifestation – acute urethritis; Symptoms – purulent urethral discharge and dysuria
What are the clinical manifestations of gonorrhea - anorectal infection?
Most patients are asymptomatic; If symptomatic – acute proctitis → anal pruritis, tenesmus, purulent discharge, rectal bleeding/discharge, rectal pain
What are the clinical manifestations of gonorrhea - pharyngeal infection?
Major risk factor – orogenital sexual exposure; Most are asymptomatic; may cause pharyngitis or cervical lymphadenitis
What are the clinical manifestations of gonorrhea - newborns?
Results from passage through the birth canal (may be transmitted in utero); Most common form – ophthalmia neonatorum; If not treated properly → corneal ulceration and blindness
What is the diagnosis of gonorrhea?
Gram stain of a male urethral specimen – gram-negative diplococci within PMNs
Nucleic acid amplification tests (NAAT) - standard of care
Culture – endocervical or urethral swab
Test for other STIs (chlamydia, syphilis, HIV) if diagnosed with gonorrhea
o If HIV negative, offer PrEP
What drugs are of concern for resistance in gonorrhea?
fluoroquinolones, cefixime, ceftriaxone, azithromycin
What is the treatment for uncomplicated gonorrhea of the cervix, urethra, and rectum?
weight < 150 kg: ceftriaxone 500 mg IM x 1 and if chlamydia not exlcuded - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
weight >/= 150 kg: ceftriaxone 1 gm IM x 1 and if chlamydia not excluded - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
What is the treatment for uncomplicated gonorrhea of the cervix, urethra, and rectum if ceftriaxone is not available?
gentamicin 240 mg IM x 1 PLUS azithromycin 2 gm x 1
OR
cefixime 800 mg x 1 –> chlamydia not excluded - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
What is the treatment for uncomplicated gonorrhea of the pharynx?
weight < 150 kg: ceftriaxone 500 mg IM x 1 and if chlamydia (+) - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
weight >/= 150 kg: ceftriaxone 1 gm IM x 1 and if chlamydia (+) - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
no reliable treatment alternatives for pharyngeal gonorrhea
What is patient education for gonorrhea?
Instruct patients to abstain from sexual activity for 7 days after treatment and until all sex partners are adequately treated
Treatment of sexual partner – expedited partner therapy (EPT) may be delivered by patient: cefixime 800 mg x 1 plus doxycycline 100 mg x 7 days if chlamydia not excluded OR azithromycin 1 gm x 1 if adherence a concern
What is the etiologic agent of syphilis?
Treponema pallidum
(spirochete)
What is the epidemiology of syphilis?
Strong association between syphilis and HIV
o All patients with syphilis should be tested for HIV; in areas with high prevalence of HIV, patients with primary syphilis should be re-tested for HIV after 3 months if first HIV test was negative
What is the clinical presentation of syphilis?
- Primary syphilis
- Secondary syphilis
- Latent syphilis
- Tertiary (late) syphilis
- Neurosyphilis
- Congenital syphilis
What is primary syphilis?
painless lesion (chancre) appears at site of entry
Chancre – usually single, dull red macule → papule that erodes and ulcerates
What is secondary syphilis?
- Develops 2-6 weeks after onset of primary stage
- Characterized by a variety of mucocutaneous eruptions → secondary to widespread hematogenous and lymphatic spread
- Lesions – anywhere on body including palms of hands and soles of feet
- Other symptoms – malaise, fever, pharyngitis, headache, anorexia, arthralgias, generalized lymphadenopathy
What is latent syphilis?
Patients have positive serologic tests but no other evidence of disease
Early latent – patient is potentially infectious; defined as 1 year from the onset of infections
Late latent – patient is considered non-infectious (exception – pregnancy)
What is tertiary syphilis?
Slowly progressing, inflammatory phase of the disease
Can affect any organ in the body
What is neurosyphilis?
- May occur at any stage of syphilis
- Headache, meningismus, increased CSF leukocyte count and protein
- VDRL-CSF – when reactive, diagnostic for neurosyphilis
What is congenital syphilis?
Early congenital syphilis – manifestations resemble secondary syphilis
May result in fetal death, prematurity, or congenital syphilis
What is the diagnosis for syphilis?
Microscopic examination of material from lesion:
* Primary syphilis – presence of T. pallidum on dark-field microscopy
* Secondary syphilis – spirochete may be found in cutaneous lesions and lymph nodes
* Direct fluorescent antibody test (DFA-TP)
What is the serologic testing used for diagnosis in syphilis?
use of only one type of serologic test is insufficient; presumptive diagnosis requires use of 2 tests
1. Nontreponemal tests – detect reagin (heterogeneous group of antibodies): Positive test indicates presence of any stage of syphilis; Negative in incubating syphilis and early primary syphilis
2. Treponemal tests (more sensitive than nontreponemal tests; confirmatory)
What is the treatment for syphilis?
Penicillin G – treatment of choice for all stages of syphilis (parenteral)
What is the treatment for primary and secondary syphilis?
benzathine pen G 2.4 million units IM x 1
if PCN allergy: doxycycline 100 mg x 14 days OR tetracycline 500 mg x 14 days OR azithromycin 2 g x 1 (*resistance to azithromycin with treatment failure has been documented)
What is the treatment for early latent syphilis?
Early latent syphilis (< 1 year duration): benzathine pen G 2.4 million units IM x 1
if PCN allergy: doxycycline 100 mg x 14 days OR tetracycline 500 mg x 14 days
What is the treatment for late latent syphilis?
Late latent (> 1 year duration) or unknown duration: benzathine pen G 2.4 million units IM once weekly x 3 weeks
if PCN allergy: doxycycline 100 mg x 28 days OR tetracycline 500 mg x 28 days
What is the treatment for tertiary syphilis?
benzathine pen G 2.4 million units IM once weekly x 3 weeks
if PCN allergy: doxycycline 100 mg x 28 days OR tetracycline 500 mg x 28 days
What is the treatment for neurosyphilis?
Aqueous crystalline penicillin G 3-4 million units x 10-14 days (or 18-24 million units per day as a continuous infusion) –> May administer benzathine penicillin 2.4 million units IM once weekly x 3 weeks after completion of IV therapy
OR
Procaine penicillin 2.4 million units IM daily + probenecid 500 mg x 10-14 days
if PCN allergy: ceftriaxone 2g IM or IV x 10-14 days
What is the treatment of syphilis in patients with HIV - primary and secondary syphilis?
primary and secondary syphilis: benzathine pen G 2.4 million units IM x 1
if PCN allergy: doxycycline 100 mg x 14 days OR tetracycline 500 mg x 14 days OR azithromycin 2 g x 1
What is the treatment of syphilis in patients with HIV - early latent?
benzathine pen G 2.4 million units IM x 1
What is the treatment of syphilis in patients with HIV - late latent or unknown duration?
benzathine pen G 2.4 million units IM once weekly x 3 weeks
What is the treatment of syphilis in patients with HIV - neurosyphilis?
same as non-HIV infected pt
What is the treatment of syphilis in pregnancy?
- Penicillin is only agent that reliably protects and treats the fetus
- If penicillin allergic → skin testing → desensitization → treat with penicillin regimen appropriate for their stage of infection
What are clinical pearls of syphilis treatment?
Jarisch-Herxheimer reaction: Acute febrile reaction characterized by flu-like symptoms, headache, fever, chills, malaise, arthralgia, myalgia, tachycardia, peripheral vasodilation, temporary exacerbation of pre-existing lesions
treat with antipyretics (APAP)
