STD and Infections Review Flashcards
Danger Signals: Acute HIV Infection Overview
Aka Acute Retroviral Syndrome
- ~10-60% of individuals w/ early HIV infection may be asymptomatic
- takes approx 2-4 wks to develop sx
- most people (97%) develop antibodies within 3 months after exposure
- Initial immune response may mimic mononucleosis (fever, headache, sore throat, lymphadenopathy, rash, joint ache, myalgia; may be accompanied w/ diarrhea and weight loss)
- may have painful ulcerative lesions in mouth d/t HIV for from coinfection w/ herpes simplex, sphyilis, or chancroid
- Very infectious d/t extremely high viral load (>100,000 copies/mL) in blood and genital secretions
- If acute HIV infection is strongly suspected → order HIV RNA polymerase chain reaction (PCR) test, which can detect infection 7-28 days after exposure
Danger Signals: Acquired Immunodeficiency Syndrome
- Without treatment, people w/ AIDS typically survive ~3 years
- Without antiretroviral therapy, HIV infection usually advances to AIDS within 10 years
AIDS = absolute CD4 cell count of <200 cells/mm3 + certain opportunistic infections and malignancies
- CD4 levels in health people range from 500-16,000 cells/mm3
S/Sx suggesting AIDS:
- caused by AIDS-defining opportunistic infections such as oral candidiasis, TB, pneumocystis jirovecii PNA, CNS toxoplasmosis, histoplasmosis, cryptosporidiosis, Kaposi’s sarcoma (purple-bluish-red bumps on skin
* P. jirovecii is infection causing most deaths in HIV pts
Danger Signals: Disseminated Gonococcal Infection
- Very small percentage (0.5-3.0%) of individuals w/ gonococcal infection may progress to disseminated gonococcal infection (DGI)
S/Sx
sexually active adult from high-risk population c/o:
- petechial or pustular skin lesions of hands/soles (acral lesions)
- tenosynovitis
- swollen, red, and tender joints
In young, healthy patients w/ new-onset:
- polyarthralgias
- polyarthritis
OR
- oligoarthritis (arthritis in one large joint such as knee) → DGI is one of the most common causes
* Look for characteristic skin lesions of DGI
- may be accompanied by signs of STD (e.g., cervicitis, urethritis)
If pharyngitis, will have severe sore throat w/ green purulent throat exudate that does NOT respond to usualy antibiotics used for strep throat
- Occasionally complicated by perihepatitis (Fitz-Hugh-Curtis syndrome)
- Endocarditis (rare)
- meningitis (rare)
► Refer to ID specialist
STD Screening Recommended by CDC (2020)
Complications of untreated STD/STI are:
- infertility
- ectopic pregnancy
- congenital infections
- cervical cancer
- chronic pelvic pain
- chronic hepatitis
- chronic syphilis
- HIV/AIDS
Some STDs (e.g., chlamydia, gonorrhea, and genital herpes) can be passed from mother to infant during vaginal delivery
- Others (HIV, herpes, syphilis, and hepatitis) can cause serious congenital infections in fetus)
- ~20 million new STD infections every year; almost half are in young people, age 15-24
- Routine annual screening of all sexually active females aged ≤25 for chlamydia trachomatis and gonorrhea → If infected, retest for chlamydia and gonorrhea 3 months after treatment (to check for reinfection, not for test-of-cure)
-Annual testing for syphilis, chlamydia, and gonorrhea in persons w/ HIV infection
- Minors do NOT need parental consent if clinic visit is r/t testing or treating STDs and birth control; NO state requires parental consent for STD care
- PE for STDs includes inspection of skin, pharynx, lymph nodes, anus, pelvic/genital area, and neurologic system
Men who have Sex with Men
- Annual screening of chlamydia & gonorrhea at sites of contact (urethra, rectum), regardless of condom use
- screen Q3-6 months if at increased risk
-annual screening recommended for pharyngeal gonorrhea (throat); screen Q3-6 months if at increased risk - Annual testing recommended for HIV, syphilis, hepatitis B surface antigen (HBsAg); retest for frequently if at risk
- If hx of anal-receptive intercourse, an anoscopy can be offered as part of STD care
STD: Pregnant Women
- Screen pregnant women for HIV, chlamydia, gonorrhea, syphilis, and HBsAg at first prenatal visit
- pregnant women treated for chlamydia/gonorrhea should have a test-of-cure within 3-4 weeks after treatment
- Retest at 3 months for chlamydia and gonorrhea (check for reinfection, not test-of-cure)
STD Risk Factors
- Younger ages (females aged 15-24); sex initiated at a younger age
- Multiple sex partners; new sex partner in past 60 days
- Inconsistent condom use; unmarried stats
- Hx of previous STD infection; illicit drug use
- Genital ulceration (↑ risk of HIV transmission)
- Use of alcohol or illicit drugs
- adolescents
Chlamydia Trachomatis
1. Definition/Etiology/Guidelines
2. Possible sites of infection & complications
3. Labs/Diagnostics
- an obligate intracellular bacteria (atypical bacteria)
- most chlamydial infections are asymptomatic
- highest prevalence: among persons ≤ 25 years
- MOST common STD in US
- Annual screening of all sexually active women <25 years if recommended as is screening of older women at ↑ risk of infection (e9g.,partners, or a sex partner w/ STI)
- During first prenatal visit, screen all pregnant women <25 years and older pregnant women at ↑ risk
- Rescreen younger women <25 years in 3rd trimester
- an obligate intracellular bacteria (atypical bacteria)
- Females: Cervicitis, endometritis, salpingitis (fallopian tubes), PID
- Males: epididymitis, prostatitis
- Both genders: Urethritis pharyngitis, proctitis (from receptive anal intercourse)
** Up to 20% of women w/ cervicitis d/t gonorrhea will develop PID!
- Females: Cervicitis, endometritis, salpingitis (fallopian tubes), PID
Complications:
- PID
- tubal scarring
- ectopic pregnancy
- infertility
- Reiter’s syndrome (males)
- Fitz-Hugh-Curtis syndrome
- NAATs are highly sensitive tests for both gonorrhea and chlamydia; be CAREFUL to use correct NAAT testing kit → Swab samples (vagina, cervix, urethra, rectum, pharynx) or urine specimen can be collected for both males and females
- Vaginal swab specimens can be collected by a provider or self-collected in a clinical setting; self-collected vaginal swab specimens are equivalent in sensitivity and specificity to those collected by clinician using NAAT
- Preferred diagnostic test for men: URINE SPECIMEN for NAAT → collect first part of urinary stream (15-20 mL) from the first void of the day
- For samples of pharynx or rectum, swab using NAAT test
- Another option for gonorrhea is to order gonorrheal culture (Thayer-Martin or chocolate agar), which takes 2-3 days
- Chlamydial cultures are NOT used in primary care (use NAAT test)
- Gram stain (symptomatic men): If pt shows urethritis sx, obtain Gram stain → Polymorphonuclear leukocytes w/ Gram- intracellular diplococci can be used for males w/ gonorrheal urethritis (considered diagnostic) → not commonly used in primary care
- NAATs are highly sensitive tests for both gonorrhea and chlamydia; be CAREFUL to use correct NAAT testing kit → Swab samples (vagina, cervix, urethra, rectum, pharynx) or urine specimen can be collected for both males and females
** NAAT can detect HIV infection in 7-28 days!
Chlamydia Trachomatis
4. Treatment Plan: Uncomplicated Infections
5. Treatment for Sexual Partners
6. Treatment for Pregnant women
- Chlamydia (Cervicitis, Urethritis [Nongonococcal Urethritis], Sexual Partners)
- No test-of-cure is necessary for azithromycin or doxycycline regimen
- FIRST LINE: Azithromycin 1 g PO x single dose (directly observed therapy preferred)
OR
- doxycycline 100 mg BID x 7 days
→ Swallow w/ large amount of water; doxycycline may cause esophagitis if tablet gets stuck in throat (difficulty and/or pain w/ swallowing, acute-onset heartburn, N/V)
→ Nausea, GI upset, photosensitivity (avoid sun/use sunscreen)
→ category D drug (stains growing tooth enamel)
→ Advise pt treated w/ 1 dose of azithromycin that it takes up to 7 days for treatment to become effective
*** If STD treated w/ azithromycin 1 g x 1 dose (chlamydia), instruct pt and partner to abstain from sex for at least 7 days
If cervicitis, perform bimanual exam to assess if infection ascended to upper genital tract (R/O PID)
- Administer azithromycin 1 g PO x single dose
- Patient and partner abstain from sex for 7 days
- Expedited partner therapy (EPT) is practice of treating sexual partner(s) of a patient diagnosed w/ STD w/out sexual partner being seen or evaluated by healthcare provider
- EPT is permissible in 45 states, District of Columbia, and Commonwealth or the Northern Mariana Islands
→ EPT is potentially allowable in 4 states, Puerto Rico, and Guam
→ EPT is likely prohibited in 1 state (NC)
- Administer azithromycin 1 g PO x single dose
→ Refer to CDC website to confirm if EPT is legal in your state
- Azithromycin 1 g PO x single dose OR
- Amoxicillin 500 mg PO TID x 7 days
* Test-of-cure recommended 3-4 weeks after treatment and retest again in 3rd trimester
- Azithromycin 1 g PO x single dose OR
Neisseria Gonorrhoeae
1. Definition/Etiology
2. Clinical Presentation
3. S/S (by site)
- Gram- infecting urinary and genital tracts , anorectum, pharynx, and conjunctiva (gonococcal ophthalmia neonatorum)
- unlike chlamydia, gonorrhea can become systemic or disseminated if left untreated
- ALWAYS cotreat for chlamydia when treating gonorrhea (even if negative chlamydial tests) d/t high rate of coinfection
- women more likely to be asymptomatic or present w/ PID
- males are more likely to present w/ urethritis
-During first prenatal visit, screen all pregnant women <25 years and older pregnant women at increased risk
- Rescreen again in 3rd trimester
- Gram- infecting urinary and genital tracts , anorectum, pharynx, and conjunctiva (gonococcal ophthalmia neonatorum)
- hx of new sexual partner <3 months or multiple partners w/ inconsistent or no condom use
- during speculum exam, cervix can appear normal or w/ purulent discharge
- may bleed easily (friable)
- Males w/ urethritis may have penile discharge and dysuria
- may report staining of underwear w/ green purulent discharge
* S/Sx depends on site infected
- hx of new sexual partner <3 months or multiple partners w/ inconsistent or no condom use
- Cervicitis → mucopurulent cervix, pain, mild bleeding after intercourse
- Urethritis → scant-copious purulent discharge, dysuria, frequency, urgency
- Proctitis → pruritis, rectal pain, tenesmus, urge to defecate even if rectum is empty, or avoidance of defecation d/t pain
- Pharyngitis → severe sore throat unresponsive to typical antibiotics, purulent green-colored discharge on posterior pharynx
- Bartholin’s gland abscess → cystic lump that is red and warm or has purulent discharge that is located on each side of introitus or vestibule
- Endometritis → menometrorrhagia, or heavy, prolonged menstrual bleeding
- Disseminated gonococcal infection → petechial or pustular skin lesions of hands/fingers, asymmetric polyarthralgia, tenosynovitis, oligoarticular septic arthritis (arthritis-dermatitis syndrome), or meningitis, or endocarditis
- PID (see note card “Complicated Gonorrheal Infections”)
- Epididymitis and prostatitis
- Cervicitis → mucopurulent cervix, pain, mild bleeding after intercourse
Neisseria Gonorrhoeae
4. Labs/Diagnostic
- see labs for C. trachomatis
- Another alternative is gonococcal culture (Thayer-Martin medium)
- Retesting is recommended at 3 months after tx for all pts d/t high rates of reinfection
- see labs for C. trachomatis
Syphilis
1. Definition/Etiology
2. Clinical Presentation
3. Stages
- screen for syphilis if HIV infection, men who have sex w/ men (MSM), presence of genital ulcer esp if painless chancre, previous STD, pregnancy, intravenous drug user, or high risk
- majority are males
- Treponema pallidum (spirochete) infection becomes syetemic if untreated
- screen for syphilis if HIV infection, men who have sex w/ men (MSM), presence of genital ulcer esp if painless chancre, previous STD, pregnancy, intravenous drug user, or high risk
- S/Sx
- Depends on stage (see below) - Stages:
Primary
- painless chancre (heals in 6-9 wks if not treated)
- chancre has clean base, well demarcated w/ indurated margins
Secondary (>2 years)
- Condyloma lata (infectious white papules that looks like white warts] in moist areas)
- maculopapular rash in palms and soles, not pruritic (may be generalized)
Latent stage
- Asymptomatic
Tertiary (3-10 years)
- neurosyphilis
- gumma (soft tissue tumors)
- aneurysms
- valvular damage
Condyloma Lata
infectious white papules that looks like white warts] in moist areas
gumma
soft tissue tumors
Syphilis
4. Labs/ Diagnostics
2 types of syphilis serologic tests:
- treponemal
- nontreponemal
→ required to diagnose syphilis
Step 1: Order screening test (nontreponemal test)
- Rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL).
- If reactive, order confirmatory test
Step 2: Order confirmatory test (treponemal test)
- Fluorescent treponemal antibody absorption (FTA-ABS), microhemagglutination test for antibodies to T. pallidum (MHA-TP), T. pallidum particle agglutination assay (TPPA), etc
- + darkfield microscopy (not commonly use anymore)
* If BOTH RPR and VDRL (nontreponemal test) and FTA-ABS (or other treponemal test) are REACTIVE → Diagnostic for syphilis
During tx, if initial test used is RPR, order sequential RPR to document tx response
- If initial test is VDRL, order sequential VDRL; use same laboratory to monitor*
- If RPR or VDRL shows a fourfold or higher (>1:4) ↓ in titers, pt is responding to tx
Syphilis
5. Treatment Plan (per stage)
- Tx for pregnancy
6. Follow-up
Primary Syphilis (chancre), Secondary Syphilis, or Early latent Syphilis (<1 year)
- Benzathine penicillin G (Bicillin L-A) 2.4 million units IM x 1 dose
Latent Syphilis (>1 year), Latent Unknown Duration, Tertiary w/out evidence of neurosyphilis
- Benzathine penicillin G 2.4 million units IMV once per week x 3 consecutive weeks
- PCN allergy → Doxycycline or tetracycline x 28 days
- If neurosyphilis → ceftriaxone
- Use therapies w/ close clinical and lab follow-up
→ Refer to specialist
Pregnancy
- Same treatment as nonpregnant
- For PCN allergy → refer to allergist of PCN desensitization
- Screen ALL pregnant women; repeat at 28 wks and at delivery
- Recheck RPR or VDRL at 6 & 12 mons after treatment (look for at least a fourfold ↓ in pretreatment and posttreatment titers)
- Treat sex partner(s) from previous 90 days before pt’s diagnosis even if their RPR or VDRL is negative
- Test pt and partner(s) for HIV and other STDs
- Refer to ID specialist for suspected neurosyphilis, poor response to treatment, PCN allergy, or if primary clinician is not familiar w/ syphilis management
- Recheck RPR or VDRL at 6 & 12 mons after treatment (look for at least a fourfold ↓ in pretreatment and posttreatment titers)
What are the screening tests for syphilis?
RPR and VDRL
If positive RPR and VDRL, what should you order next?
RPR and VDRL (nontreponemal tests)
Confirm w/ FTA-ABS (treponemal test)
If reactive RPR and reactive FTA-ABS, this is diagnostic for syphilis
What should you always cotreat when treating gonorrhea? With what medication(s)?
Chlamydia
Ceftriaxone 250 mg IM x 1 dose (for both uncomplicated and complicated cases) + cotreated w/ chlamydia
Condyloma acuminata vs condyloma lata
Condyloma acuminata = genital warts
Condyloma lata = secondary syphilis
What stage of HIV infection is very infectious?
acute retroviral syndrome (or primary HIV infection) w/ flu-like or mono-like infection is VERY infectious at this stage of HIV infection
- BEST if HIV is treated as early as possible
How long will NAAT remain positive for?
2-3 weeks after treatment d/t presence of nonviable organisms
What can cause an false-positive RPR?
- Pregnancy
- Lyme disease
- autoimmune diseases
- chronic/acute disease
When should you recheck syphilitic chancre after injfection?
3-7 days, should start healing
When should nontreponemal titers decline?
RPR or VDRL usually decline after treatment
- in some persons, nontreponemal antibodies can persist for a long time (serofast reaction)
- most pts w/ reactive nontreponemal tests will be reactive for the rest of their lives (low titers) but ~15-25% revert to being serologically nonreactive in 2-3 years
CDC-Recommended STD Treatment Regimens: Uncomplicated Gonorrheal Infections of the Cervix, Urethra, Rectum, and Pharynx + Tx of sexual partners
First line:
- Ceftriaxone (Rocephin) 250 mg IM X 1 dose + co treat for chlamydia
- Azithromycin 1 g PO x 1 dose OR doxycycline 100 mg PO x 7 days
- Test-of-cure (i.e., repeat testing 3-4 weeks after treatment) is not needed (except pregnant woman); if sx persist, obtain specimen for gonococcal C&S
Management of Sexual Partners:
- Treat male partners of women w/ PID if sexual contact during the 60 days preceding pt’s sx
- Avoid sex until both partners finish tx and no longer have sx
CDC-Recommended STD Treatment Regimens: Chlamydia trachomatis
1. Uncomplicated
2. Complicated
- Indications:
- Mucopurulent cervicitis
- Urethritis
- Sexual partner tx
Tx:
- Azithromycin 1 g x 1 dose OR
- doxycycline 100 mg BI x 7 days
Pregnancy: azithromycin 1 g x 1 dose
- Indications:
- PID
- salpingitis
- tubo-ovarian abscess
- epididymitis
- prostatitis
- males
Tx:
- Doxycycline 100 mg BID x 14 days
CDC-Recommended STD Treatment Regimens: Gonorrhea
1. Uncomplicated
2. Complicated
Neisseria gonorrhoeae
1. Indications:
- Mucopurulent cervicitis
- urethritis
- proctitis
- sexual partner treatment
Tx:
- Ceftriaxone 250 mg IV x 1 dose + azithromycin 1 g x 2 dose OR
- doxycycline 100 mg BID x 7 days
Pregnancy:
- Ceftriaxone 250 mg IM x 2 dose + azithromycin 1 g x 1 dose
- Indications:
- PID
- salpingitis
- tubo-ovarian abscess
- epididymitis
- orchitis
- prostatitis
- disseminated gonorrhea
- asymmetric arthritis and maculopapular rash
- males
Tx: Ceftriaxone 250 mg IM x 1 dose + doxycycline 100 mg BID x 14 days
** Use Ceftriaxone (Rocephin) 250 mg IM x 1 dose for BOTH uncomplicated and complicated gonorrheal infection
** ALWAYS cotreat for chlamydia if gonorrheal test is positive!! BUT inverse is NOT true; if chlamydia, do NOT give prophylaxis against gonorrhea unless indicated
