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Sobel: Clinical Aspects of STDs Flashcards

1
Q

EPIDEMIOLOGY OF STD’S (USA)

How many new infections every year?

Syphilis, Chlamydia, and African American population

A

19 million new infections each year (1/2 among 15-24 y)

Syphilis rates increased in 2007 driven by gay and bisexual males (65%) especially in HIV men

Chlamydia record numbers

Highest rates for chlamydia in black women age 15-19

Gonorrhea remains high~ 70% in AA

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2
Q

TRANSMISSION OF STI’S

What is enhanced transmission of HIV associated with?

HSV-2 responsible for what % of incident cases of HIV?

STI effect M vs F:

A

Enhanced transmission of HIV associated with:

  • ulcerative genital lesions [+ + + +]
  • inflammatory genital lesions (vaginitis) [+ +]
  • altered vaginal flora (?) [+]

HSV-2 responsible for ~25% incident cases of HIV

STI effect > in transmission from male to female
Reduced by condoms!!

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3
Q

(ADULT) MALE CIRCUMCISION

How much does it reduce HIV acquisition among heterosexual men?

Where is it recommended?

Benefit:

A

RCT –Circumcision ↓ risk of HIV acquisition among heterosexual men by 51-76%

WHO recommends where prevalence of HIV is high

Benefit –Dense concentration of CD4 + T-cells, macrophages, and Langerhans cells –dense concentrations in nonkeratinized inner mucosal cells of foreskin

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4
Q

(ADULT) MALE CIRCUMCISION

Effect on HSV-2 and HPV:
syphilis and trichomonas:
N. gonorrhoeae, C. Trachomatis:

Benefits for females:

A

Circumcision significantly ↓ incidence of HSV-2 infection and ↓ prevalence of HPV
↓ risk of syphilis, ↓ trichomonas
No Benefit –N. gonorrhoeae, C. Trachomatis in males
Benefits for females -↓ HSV, ↓BV, ↓ trichomonas

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5
Q

Why is there a dramatic decrease in STIs worldwide? (4)

A

Risk reduction related to HIV

AIDS therapy HAART

Syndromic treatment of STI’s in developing countries

Programs in sex workers

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6
Q

URETHRITIS

Types of inflammation:
Symptoms: (3)
Types of urethral discharge:

A

Urethral inflammation

  • infectious
  • non-infectious

Symptoms:

  • Asymptomatic
  • Urethral discharge (Purulent/Mucopurulent)
  • Dysuria/burning/pain, pruritus
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7
Q

URETHRITIS

Infectious causes:
commonest non-gonoccal:

A

Infectious causes:
-N. gonorrhoeae

Non-gonoccal

  • Chlamydia (commonest non-gonoccal)
  • Mycoplasma genitalium
  • Etc

Note: Pathogens frequently co-exist

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8
Q

GONORRHEA
EPIDEMIOLOGY

Industrialized world:
US:
Races:
Homo vs heterosexual:
I.P.:
A

Industrialized world ↓ 90% 240/100,000 .45/100,000

In US, 400,000 new cases annually

Incidence higher in Black, Hispanic ↓

Homosexual = Heterosexual

I.P. –1-14 days, (5-10 days cervical)
:-males within 5d
:-females within 10d

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9
Q

RISK FACTORS FOR GONOCOCCAL INFECTION

just read the list

A 
Adolescence/urban
Multiple sexual partners
Nonbarrier contraception
Incorrect use of condoms
Low socioeconomic status
Concomitant use of IV drugs/crack cocaine
Previous history of gonorrhea
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10
Q

Gonorrhea symptomatic in males?

A

Infection usually symptomatic in males

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11
Q

Gonorrhea symptoms (7)

% after a single exposure:

A

Urethritis -Urethral discharge, dysuria, epididymitis, orchitis
Mucopurulent cervicitis –vaginal discharge, dysuria
Pelvic Inflammatory Diseases (10-20%)
Disseminated gonococcal infection (DGI) -Septic Arthritis
Proctitis
Pharyngitis
Conjunctivitis -Adult/Neonatal

20% after a single exposure

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12
Q

Gonorrhea

How high is the transmission rate to females?

A

Transmission rate to females is high at 50%

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13
Q

Diagnosis of Gonorrhea
Culture

Media type:
Sensitivity:
When is culture preferred?

A

Modified Thayer-Martin Media

Sensitivity 80-95%

Culture preferred for pharynx and rectum

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14
Q

Diagnosis of Gonorrhea
Culture

Women:
Men:

A

Women:

  • Cervical culture 80-90%
  • Anal culture 35-50%
  • Post-hysterectomy-urethra
  • Pharynx 5-20%

Men:Urethral exudate

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15
Q

Diagnosis of Gonorrhea

Gram Stain

A

Gram negative diplococci within or associated with PMN’s

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16
Q

Gonorrhea

Natural course

A

Resolves over several weeks. 95% asymptomatic within six months. (Infertility in females)

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17
Q

Gonorrhea

Progression as a superbug

A

sulphonamides –> PCN,TCN –> Quinolones, Macrolides –> Cephalosporins

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18
Q

Gonorrhea Treatment

2010
2013

A 
2010
Ceftriaxone 250 mg IM 
or
Cefixime 400 mg (SD orally)
or
Cefpodoxime 400 mg (SD orally)

2013
Azithromycin 1g orally (You know there will be compliance)
or
Doxycyclin 7 days

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19
Q

Gonorrhea Screening

Who is screened?
Who is at the highest risk?

A

Because GC infection among women frequently asymptomatic, screen all sexually active women if at higher risk.
No screening for M+F at low risk

Highest risk: < 25 years

  • previous GC infection
  • other STD’s
  • new or multiple sexual partners
  • inconsistent condom use
  • drug use
  • commercial sex work
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20
Q

Chlamydia Epidemiology

%Teenagers
Increased prevalence where? What population?
Average prevalence:
Asymptomatic among:

A

~4-5% of teenagers acquire chlamydia/yeast

Increased prevalence inner city. African-Americans/Latino population lacking healthcare

Average prevalence 5% (1 in 20)

Asymptomatic infection common among men and women

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21
Q

Chlamydia Risk Factors for Infection in Women:

A 
Age <20 yrs.
Recent partner change
Non-white race
Multiple partner change
Single
Inconsistent use of a barrier contraceptive
Oral contraceptives
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22
Q

Chlamydia

What do most women with positive cervical culture have?

Positive immunity:

Second infection severity? %?

A

Most females with positive cervical cultures already have UNRECOGNIZED UPPER TRACT DISEASE!

No protective immunity

A second infection (reinfection) may be more severe

> 20% became reinfected

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23
Q

Chlamydia Infection Screening

Young women:
Older women:

A

Selecting for sexual behavior risk is NO LONGER RECOMMENDED in young women (<25 y)…TEST ALL ANNUALLY

Test older women with risk factors

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24
Q

Chlamydia Infection Screening

Where is the yield highest?
Screening of males:
Non-amplification tests pick-up what %?

A

Yield highest in youngest sexually active.

Routine screening of males -NO

Non-amplification tests pick-up 60-70% of cases

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25
Chlamydia | Clinical aspects: (6)
``` Urethritis (NGU) Cervicitis Epididymitis, orchitis P.I.D./Infertility Conjunctivitis Asymptomatic infection common ```
26
Chlamydia Cervicitis Cervical abnormalities: Typically: Cultures:
Cervical abnormalities: Normal exam-20-70% Hypertrophic cervicitis-19-32% Mucopurulent or purulent-30% Typically asymptomatic with 33% noting vaginal discharge Endocervical cultures/PCR/DNA
27
Chlamydia Diagnosis Women: Men:
Women: Urine or swab from endocervix or vagina Men: Urine or urethral swab, Rectal swab for receptive anal intercourse
28
Chlamydia Diagnosis Culture
Direct immunofluorescence EIA Nucleic acid hybridization NAATS
29
Chlamydia Therapy Rescreen when?
Azithromycin 1 g single dose or Doxycycline (100 mg bid x 7d) Rescreening/retesting to detect reinfection at 3 months –(GC + Chlamydia)
30
Chlamydia | Alternative Therapy
Levofloxacin 500 mg daily x 7d Ofloxacin 300 mg bid x 7 d Erythromycin base 500 qid x 7d Pregnancy –amoxicillin
31
NON-GONOCOCCAL URETHRITIS (NGU) Etiology (long list)
Mycoplasma genitalium (10-25%) Chlamydia trachomatis Ureaplasma urealyticum -pathogenicity controversial Mycoplasma hominis -pathogenicity controversial T. vaginalis H. simplex Adenovirus Enteric organisms Commensals -Hemophilus, N. meningitidis, Branhamella No identifiable pathogen
32
What is Mycoplasma Genitalium associated with?
- Non-gonococcal urethritis (NGU) - Endometritis - Cervicitis (mucopurulent) - PID - HIV shedding
33
Treatment of NGU What may happen with Doxycycline?
Azithromycin 1 g (single dose) or Doxycycline 100 mg bid for 7 d Unfortunately –M. genitalium often fails with doxycycline and ↑ resistance to Azithromycin
34
Treatment of NGU | Alternatives
Erythromycin base 500 mg qid for 7 d Ofloxacin 300 mg bid for 7 d Levofloxacin 500 mg once daily for 7d
35
PID How many women treated annually? Hospitalized? Surgical procedures?
~1 million women are treated annually for PID in the USA 250-300,000 women hospitalized each year for PID 150,000 surgical procedures are performed each year for its complications
36
Chancroid Caused by: Closely linked to: Asymptomatic carrier state: IP:
Hemophilus ducreyi Closely linked to drugs/prostitution (core group) Absence of asymptomatic carrier state ~4-5,000 cases annually (U.S.) IP 2-10 days
37
Chancroid Ulceration: Systemic Sx: Inguinal adenopathy:
Painful ulceration, no systemic Sx. Ulcers deep, tender, friable, edges ragged, purulent base Painful tender inguinal adenopathy (50-65%) Usually unilateral (chancroid bubo)
38
Syphilis | Incubation period:
Long incubation period (12-40 d)
39
Syphilis Primary Development and disappearance: Ulcer: Purulence:
Slow development and disappearance Primary painless ulcer (chancre) Lack of purulence
40
Syphilis Primary Lymphadenopathy: Bilateral? VDRL:
Painless inguinal lymphadenopathy (80%) Bilateral in 70% VDRL -30% negative
41
STAGES OF SYPHILITIC INFECTION Acquired Primary Secondary Latent Tertiary
Acquired Primary 10-90 (21 d) Chancre, regional lymphadenopathy Secondary 6 wks -6 mos. Multiple mucocutaneous, fever, alopecia, lymph-adenopathy, meningitis Latent Early 1 year Asymptomatic Tertiary (Late) Months/years CNS, CVS, Gummatous
42
Diagnosis of syphilis Identification of T. pallidum: Serology:
Identification of T. pallidum Dark field microscopy Fluorescent Mab/Histology Serology a. Nontreponemal……VDRL/RPR/WR i. Screening ii. Assessment of disease activity b. Treponemal - Confirmatory only: FTA-ABS, MHA-TP
43
Syphilis Time between inoculation and primary syphilis: Time between primary and secondary syphilis: Time between secondary and latent syphilis: Time between latent and tertiary syphilis:
14-21 Days 3-8 Weeks Lesions disappear spontaneously after 3-8 wks 2-20 years
44
Syphilis % relapse in first year:
Up to 25%
45
Treatment of syphilis | Early syphilis:
Benzathine PCN 2.4 m.u. IM
46
Treatment of syphilis | Latent syphilis:
Benzathine PCN 2.4 m.u. IM weekly x 3
47
Treatment of syphilis | Asymptomatic neurosyphilis:
Benzathine PCN 2.4 m.u. IM weekly x 3
48
Treatment of syphilis | Neurosyphilis:
IV Benzyl PCN x 10d (IV Ceftriaxone)
49
SEROLOGICAL CRITERIA FOR TREATMENT RESPONSE Early vs latent/late syphilis: Follow up for:
4 fold titer ↓ in 6 months in early syphilis, in 24 months in latent/late syphilis Close follow up for HIV positive
50
HPV What is likely to replace cervical cytology (PAP) as primary cervical cancer screening tool?
HPV –DNA testing likely to replace cervical cytology (PAP) as primary cervical cancer screening tool
51
HPV Vaccine
Routine in UK in girls (10-12)
52
Genital Herpes | HSV establishes a latent state followed by:
HSV establishes a latent state followed by viral reactivation and recurrent local disease
53
Genital Herpes ``` HSV types: % HSV2: IP: Population: 1 vs 2 Recurrence: ```
``` HSV-1 and 2 (HSV-1 increasing) 50-90% caused by HSV-2 IP 2-10 days (up to 21 days) High prevalence all populations Recurrence and subclinical shedding much less frequent for genital HSV-1 ``` Many patients lack typical high-risk STD profile History of exposure (often absent)/new partner
54
Genital Herpes % Sexually active young: % in STD clinics: Estimated office visits a year: # in US
20-30% of sexually active young adults in U.S. (Serology) infected with HSV-2 50% in STD Clinics positive for HSV-2 (serology) 10% in STD Clinics present with clinical genital herpes Estimated 4-500,000 office visits/year. Commonest cause of genital ulceration in U.S.A. 50,000,000
55
Genital Herpes Symptoms:
Multiple painful, shallow, tender genital ulcers Constitutional signs (first episode, F > M) Tender lymphadenopathy Cervicitis Urethritis
56
Genital Herpes Diagnosis Clinical diagnosis:
Clinical diagnosis –Insensitive + non-specific Since prognosis varies HSV-1 or 2, clinical diagnosis should be confirmed by laboratory testing
57
Genital Herpes LABORATORY DIAGNOSIS DFA: Culture:
DFA…Useful Culture–highly specific, not SENSITIVE (especially recurrent HSV) + healing lesions
58
Genital Herpes PCR: Lack of HSV detection :
PCR–highly sensitive, now commercially available Lack of HSV detection (culture/PCR) does not exclude HSV as viral shedding is intermittent
59
Genital Herpes What is type-specific HSV IgG serology based upon? Kits: Specificity:
Type-specific HSV IgG serology based upon HSV-specific glycoprotein -Both HerpeSelect-1TM and HerpeSelect-21TM: ELISA or Immublot by Focus Tech -Several Kits: BIOKIT HSV-2, SureVue HSV-2 Specificity >96%
60
Genital Herpes TYPE-SPECIFIC HSV SEROLOGICAL ASSAYS is useful when? (4)
TYPE-SPECIFIC HSV SEROLOGICAL ASSAYS -USEFUL Recurrent genital symptoms + negative HSV culture or Atypical symptoms + negative HSV culture A clinical diagnosis of genital herpes with no laboratory confirmation Partner with genital herpes
61
Genital Herpes | Treatment of first episode
Treat most (if not all) patients for 7-10 days Acyclovir 400 mg tid (200 mg 5 x/d) Famciclovir 250 mg tid Valacyclovir 1.0 g bid (500 mg bid probably adequate)
62
Genital Herpes Treatment of Recurrent Herpes Most effective when?
``` Acyclovir 400 mg tid Acyclovir 800 mg bid Famciclovir 125 mg bid Valacyclovir 500 mg bid for 3 days Valacyclovir 1.0 g once daily for 5 days ``` Effective if initiated at prodrome or within 24 hrs of onset.
63
SUPPRESSIVE THERAPY FOR RECURRENT GENITAL HERPES Goal: Treatment: (4) Efficacy:
Goal -↓ frequency of symptomatic recurrence Acyclovir 400 mg bid Famciclovir 250 mg bid Valacyclovir 500 mg qd Valacyclovir 1.0 g qd Efficacy:75-80% reduction Indications: Variable! >6 outbreaks >Severe Psychological
64
GENITAL HSV IN PREGNANCY What increases with recurrent HSV? When is suppression of recurrent HSV recommended? If active lesions at birth: What can perinatal transmission of HSV can lead to?
No ↑ in congenital abnormalities with recurrent HSV Suppression of recurrent GH near term recommended? C-section if active lesions present Perinatal transmission of HSV can lead to significant neonatal morbidity and mortality
65
Perinatal Herpes Infection What do most mothers of infants with neonatal herpes lack? Risk of transmission to neonate is highest when?
Most mothers of infants with neonatal herpes lack history of clinically evident genital herpes. Risk of transmission to neonate a) Extremely low (<3%) in women with recurrent HSV b) Highest in women with first episode genital herpes Note: Viral cultures during pregnancy do not predict viral shedding at time of delivery and not indicated.
66
Common Genital Ulcers: (3)
Common (Often clinically indistinguishable) - T. pallidum - Hemophilus ducreyi - HSV (Types 1&2)
67
Uncommon Genital Ulcers: (3)
- C. trachomatis(LGV) - Calymmatobacterium granulomatis - NB-multiple etiology cases (multiplex PCR)
68
VAGINAL TRICHOMONIASIS ``` Prevalence: Clinics in Africa: % Asymptomatic: Symptoms: Males: ```
High prevalence worldwide Prenatal clinics in Africa (20-50%) 50% asymptomatic -exclusively sexually acquired Symptoms-malodorous vaginal discharge, dyspareunia -Males -asymptomatic reservoir, uncommon cause of NGU
69
VAGINAL TRICHOMONIASIS | Complications: (3)
- prematurity - ↑ PID - ↑ transmission of HIV
70
VAGINAL TRICHOMONIASIS Diagnosis ``` pH: PMNs Motile Trichomonads: Culture: Tests ```
``` ↑ pH (> 4.5) ↑ PMNs Motile Trichomonads (50% sensitivity) Culture (Diamond’s, In-Pouch) OSM-antigen detection test PCR ```
71
VAGINAL TRICHOMONIASIS Treatment Drugs: Partner: How common is re-infection and resistance?
Nitroimidazole, e.g., metronidazole (Flagyl®), tinidazole (Tindamax) Concurrent treatment of partner Re-infection common Resistance uncommon

Micro Exam 2 (18 decks)

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