STD Part 2

Question 1

Which infection significantly increases risk of acquiring HIV?

Answer 1

Chlamydia

Question 2

Chlamydia signs and symptoms

Answer 2

Silent infection - most are asymptomatic

See cervicitis in women - mucupurulent endocervical discharge, easily induced endocervical bleeding; can lead to pelvic inflammatory disease

Urethritis in men and women (looks like UTI)

Conjunctivities (can also be transmitted to child during delivery)

Question 3

How to treat chlamydia?

Answer 3

Azithromycin 1 g PO single dose
or
Doxycycline 100 mg PO twice daily for 7 days

Note: Same as gonorrhea!

Question 4

Follow-up for chlamydia treatment?

Answer 4

Test of cure is NOT recommended unless the patient is pregnant, compliance to treatment is in question, symptoms persist, or reinfection is suspected

Wait at least 3 weeks before testing NAAT because it could lead to false positives. It tests for protein targets, not viable organisms, and these can take a while to clear out

Question 5

Describe bacterial vaginosis

Answer 5

Basically Lactobacillus sp replaces normal flora in the vagina and causes infection

Associated with having multiple sex partners, a new sex partner, douching, lack of condom use, and lack of vaginal lactobacilli

Question 6

Treatment for bacterial vaginosis?

Answer 6

Treat symptomatic women:
Metronidazole 500 mg BID for 7 days
Metronidazole gel, insert one applicatorful daily for 5 days
Clindamycin cream, insert one applicatorful at bedtime for 7 days

Question 7

Follow up for bacterial vaginosis treatment?

Answer 7

Not necessary if symptoms resolve; women should be advised to return for evaluation if symptoms return

Question 8

Describe trichomoniasis

Answer 8

Caused by trichomonas vaginalis, a flagellated/motile protozoan

Women infected are 3-5 times more likely to have gonorrhea than those who don’t have it

Question 9

Clinical presentation of trichomoniasis?

Answer 9

Taked 3-28 days for incubation
Site of infection in men is the urethra, in women it’s the endocervical canal. Other sites can be rectum, oropharynx, eye

Signs and symptoms: Men can be asymptomatic, may have discharge/dysuria
Women can be asymptomatic, some have discharge

Question 10

If trichomoniasis can be asymptomatic why do we care?

Answer 10

It can lead to pelvic inflammatory disease in women, male infertility, premature labor/low birth weight, cervical neoplasia (cancer)

Question 11

How to diagnose trichomoniasis?

Answer 11

Wet mount exam of vaginal discharge; look for pear shaped flagellated organisms

Also can check vaginal pH, if greater than 5 it usually indicates presence of T vaginalis or gardenerella vaginalis

Question 12

Treatment of Trichomoniasis?

Answer 12

Symptomatic and asymptomatic infections should be treated:
Metronidazole 2 g PO single dose (big doses = side effects)
Tinidazole 2 g PO in a single dose

Pregnancy: Metronidazole 2 g PO single dose

Question 13

Do we contact partners of women with bacterial vaginosis?

Answer 13

No

Question 14

Do we contact partners of women/men with trichomoniasis?

Answer 14

Yes they should be treated

Question 15

Follow up for trichomoniasis?

Answer 15

Rescreen at 3 months following initial infection in sexually active women

Question 16

Describe herpes infections

Answer 16

Type 1 is oropharyngeal, type 2 is genital

First episode primary: Initial genital infection in individuals lacking antibodies against HSV-1 or HSV-2

First episode non-primary: Initial genital infections with clinical or serologic evidence of prior HSV infection (usually type 1)

Recurrent: Appearance of genital lesions at some time following healing of first-episode infection

Question 17

Signs and symptoms of herpes?

Answer 17

Primary infection: most are asymptomatic or minimally symptomatic; multiple painful lesions on external genitalia developing over 7-10 days and taking 2-4 weeks to heal; flu like symptoms

Recurrent infections: Prodrome in 50%, associated with fewer lesions that are more localized, and shorter duration (heal in 7 days vs 2-4 weeks); symptoms are also milder

This is because we already have active antibodies against the virus in recurrent infections

Question 18

How to diagnose Herpes

Answer 18

Cell culture and PCR

Cell culture sensitivity is low; declines over time
PCR assays look for HSV DNA and are more sensitive

Negative cultures do NOT excluse HSV infections because viral shedding is intermittent

Question 19

How to treat first episode of herpes?

Answer 19

Acyclovir 400 mg TID or 200 mg 5 times daily for 7-10 days
Famciclovir 250 mg TID for 7-10 days
Valacyclovir 1 g once daily for 7-10 days ***

In severe disease use IV acyclovir followed by oral acyclovir

Question 20

How to treat recurrent herpes infections - active?

Answer 20

Valacyclovir 1 g daily for 5 days
or 500 mg BID for 3 days

NOTE: Must be within 24 hours of lesion onset or during the prodrome that precedes some outbreaks

Question 21

How to treat recurrent herpes infections - suppressive?

Answer 21

Valacyclovir 500 mg or 1000 mg PO daily

500 mg dose appears less effective than 1000 mg in patients with more than 10 recurrences per year

Question 22

What is the most common STD?

Answer 22

HPV

Question 23

What are the types of HPV

Answer 23

Oncogenic types (cancer) - cause cervical and anogenital cancers

Non-oncogenic types: PV types 6 and 11 cause genital warts and recurrent respiratory papillomatosis

Question 24

Describe clinical presentation of HPV

Answer 24

Asymptomatic is common and usually self-limited

Transmitted through oral, vaginal, or anal sex

Usually appear as a small bump or group of bumps in the genital area varying in shape and size; can appear weeks or months after contact with infected partner

If left untreated they could go away, get bigger, or increase in number

Question 25

How to treat genital warts caused by HPV?

Answer 25

Imiquimod 3.75% every night or 5% cream at bedtime 3x weekly for up to 16 weeks (but could weaken condoms or vaginal diaphragms!)

Podofilox 0.5% solution or gel applied twice daily for 3 days followed by 4 days of no therapy (cycle repeated as necessary for up to 4 cycles)

Sinecatechins 15% ointment - apply 3 times daily for up to 16 weeks; do not wash off after using

NOTE: PODOFILOX IS CONTRAINDICATED IN PREGNANCY

Question 26

How to prevent HPV?

Answer 26

Cervarix - women only (no protection against warts)

Gardasil 4 or Gardasil 9 - men and women

9 is the best

Question 27

Who is required to get the HPV vaccine?

Answer 27

Routine HPV vaccine at age 11 or 12 years, could begin series at 9

Also recommended for females age 13-26
Males age 13-21
Males 22-26 MAYBE
Men who have sex with men and immunocompromised persons through age 26 years if not vaccinated previously

Question 28

What are the 5 P’s?

Answer 28

Partners
Prevention of pregnancy
Protection from STD's
Practices
Past history of STDs

Question 29

Cervical diaphragms are good against most STD’s but does not include…

Answer 29

HIV

Question 30

Are topical microbicides and spermicides helpful?

Answer 30

No they provide no additional protection against HIV or other STI’s