STDs Flashcards
Which are fluids?
GC
CT
Trich
HIV
Which are skin-skin?
HSV
HPV
Syphilis
Chancroid
Preexposure vaccines?
- Hep B- ALL sexually active persons
- Hep A- MSM
- HPV- ages 9-26, M & F
What can still get through lambskin condoms due to large pores?
HIV
Hep B
MSM screening
Annual STD screening:
HIV and syphilis serology
- NAAT for GC/CT- urine or discharges (also in W) - pharyngeal and rectal
HPV- pap smear
HBsAg
Hep C ab
Who should always be tested for HIV?
pregnant W
Sores
- Syphilis
- HSV
- Lymphogranuloma venereum
- Chancroid, &
- Granuloma inguinale
Drips
- Gonorrhea
- Chlamydia
- Mycoplasma genitalium
- Mucopurulent cervicitis
- Trichomonas vaginitis/ urethritis
- Candidiasis
Painful vs painless ulcers
Painful
- Chancroid
- Genital herpes simplex
Painless
- Syphilis
- Lymphogranuloma venereum
- Granuloma inguinale “
Herpes virus (HSV1/HSV2)- HSV1 vs HSV2
1-oral- cold sores/blisters
2-genital mucosa
Herpes virus (HSV1/HSV2)- transmission
asymptomatic viral shedding
Herpes virus (HSV1/HSV2)- description and duration
Multiple painful vesicles on erythematous base- painful ulcer surrounded by red halo
- Persists 7-10 days
Herpes virus (HSV1/HSV2)- primary vs recurrent signs and symptoms
Primary lesion:
- Fever and bilateral adenopathy
Recurrent:
- no fever or adenopathy
Herpes virus (HSV1/HSV2)- prodrome
tingling or burning 18-36 hours prior lesion
flu like symptoms
Herpes virus (HSV1/HSV2)- labs and diagnosis
Tzank smear (historic test)- lacks sensitivity- GOLD - (+) if presence of multinucleated giant cells
Serologies- many false + and -
Viral studies
- Cultures
- PCR= BEST
Herpes virus (HSV1/HSV2)- treatment 1st episode
- Acyclovir 400mg TID
- Famciclovir 250mg TID
- Valacyclovir 1000mg BID
7-10days any agent, within 72hrs is best
Herpes virus (HSV1/HSV2)- treatment episodic
same agents
- Acyclovir 400mg TID
- Famciclovir 250mg TID
- Valacyclovir 1000mg BID
For W- happens around menstrual cycle (decreased immunity)- can prescribe episodic if they are regular
Herpes virus (HSV1/HSV2)- treatment suppression
- Acyclovir 400mg BID
- Famciclovir 250mg BID
- Valacyclovir 500-1000mg daily
Herpes virus (HSV1/HSV2) treatment in pregnancy
acyclovir
- no increased risk of major birth defects (1st tri)
- risk of transmission to neonate is 30-50% if acquired HSV near delivery
Hep A vaccine
MSM
Illegal drug users
Chronic liver disease
Hep B and C infection
Hep B vaccine
- sex partners
- MSM
- illegal drug use
- household members
- hemodialysis
- occupational blood exposure
HIV co-infection with?
Hep C= blood borne- no vaccine
Syphilis- incidence increases in…
HIV + men
MSM
IV drug usage
Syphilis caused by
Treponema pallidum
Syphilis active infection classification
- Primary (ulcer)
- Secondary (skin rash, lymphadenopathy), neurologic (AMS, stroke, meningitis)
- Tertiary (cardiac or gummatous lesion)
Syphilis staging
Early latent: reactive testing within 1 yr of infection- no symptoms
Late: … greater than 1 yr after onset of infection or timing cannot be determined- no symptoms
Syphilis- chancre description and duration
- Early: macule/ papule- erodes/ulcerates
- Late: clean based, painless, indurated ulcer w smooth firm borders
- Resolves in 1-5wks
- HIGHLY infectious
Syphilis- diagnosis GOLD
Darkfield examination of exudates/tissue
Syphilis- labs and imaging
Serologic tests
- nontreponemal tests:
RPR, VDRL- reactivity fades over time
- treponemal tests:
Fluorescent treponemal ab (FT-AB)
T pallidum passive particle agglutination (TP-PA)- once +, usually stays +
Syphilis- what should you also test for?
Test for HIV in newly diagnosed syphilis
- run close together
Syphilis- treatment for primary, secondary and early latent
Benzathine Pen G-
- 4 million units IM x 1 dose - into glutes
- 6-12m follow-up for repeat RPR
Pen allergy
- Doxy or ceftriaxone
Syphilis- treatment for late latent
Benzathine Pen G-
2.4 million units IM x 1 dose weekly x 3 weeks
Syphilis- sex partners management
treat presumptively
Secondary Syphilis- what is it? when does it appear?
Represents hematogenous dissemination of sphirochetes
- 2-8 weeks after chancre appears
Secondary Syphilis- signs and symptoms
Rash- whole body includes palms and soles
Mucous patches
Condylomata lata- HIGHLY infectious
Cauliflower lesion in mouth
Resolve in 2-10 wks
Tertiary syphilis- what is it?
Gumma (soft tumor like growth of tissues) and cardiovascular syphilis
Tertiary syphilis- treatment
Pen G
2.4 million units IM q week x 3 weeks (Bicillin LA)
Neurosyphilis can cause
eye disease- uveitis, optic neuritis and AMS
Neurosyphilis- exam
CSF
Neurosyphilis treatment
Aqueous Pen G 18-24 million units/day for 10-14 days
Jarisch- Herxheimer Rxn
Acute febrile rnx w long treatments- not rnx to drug but to death of bacteria- release of toxins
In tertiary syphilis - 24 hr infusion of PCN
Jarisch- Herxheimer Rxn- what is it?
Acute febrile rnx w long treatments
-not rnx to drug but to death of bacteria- release of toxins
What reaction do you get with tertiary syphilis?
Jarisch- Herxheimer Rxn- 24 hour infusion of PCN
Jarisch- Herxheimer Rxn- signs and symptoms
HA
Myalgia
Fever
Jarisch- Herxheimer Rxn- treatment
Antipyretics but can be life threatening- can lead to anaphylaxis
Syphilis during pregnancy
- ALL W should be screened for syphilis at 1st prenatal visit
- Also at 28 wks & before delivery if high risk or high incidence location (Denver)
Syphilis during pregnancy- risk factors
- sex w multiple partners
- sex in conjunction w drug use or transactional sex
- late entry to prenatal care or no prenatal care
- meth or heroin use hx
- incarceration
- unstable housing/ homelessness
Syphilis during pregnancy- treatment
- Tx for the appropriate stage of syphilis
- Additional benzathine pen 2.4mu IM after the initial dose for primary, secondary, or early latent syphilis
Congenital syphilis- complications
Fetal demise
Nerve damage- vision and hearing
Chancroid is a risk factor for what?
HIV transmission
Chancroid is caused by?
Haemophilus ducreyi
Chancroid signs and symptoms
Painful
Vesicle or papule to pustule or ulcer, soft
Not indurated
Tender inguinal adenopathy
Chancroid- treatment
Azithro 1gm PO
Ceftriaxone 250mg IM- single dose
Cipro 500mg BID x 3 days
Erythro base 500mg TID x 7 days
- no cipro in pregnancy
Who needs a longer course of treatment for chancroid?
Uncircumcised men and people w HIV
Lymphogranuloma venereum- caused by
Chlamydia trachomatis
Lymphogranuloma venereum- signs and symptoms
Painless papule, vesicle or ulcer
Tender regional lymphadenopathy- usually unilateral
Lymphogranuloma venereum in females
genital elephantiasis
Lymphogranuloma venereum- treatment
Doxy 100mg BID x 21 days
Alternative:
Azithro 1g PO once weekly x 3 w
or
Erythro base 500mg 4x/d x 21 days
Granuloma inguinale- also called what ?
Also called donovanosis- because Donovan bodies are present in swab of ulcer exudate
Granuloma inguinale- caused by
Klebsiella (Calymmatobacterium) granulomatis
Granuloma inguinale- signs and symptoms
Painless papule that eventually ulcerates
No regional lymph nodes
Granuloma inguinale- treatment
Doxy 100mg BID x 3 wks
Azithro 1g once per week x 3 wks
Tri- sulfa 800mg/160mg BID
Minimum tx duration- 3 wks
Condyloma acuminatum- cause
Genital warts
HPV virus
Name alert- condylomata lata- lesions (grouping) in syphilis
Condyloma acuminatum- common in
pregnancy
Gonorrhea is MC in what population ?
MSM
Gonorrhea- testing and diagnosis
Gram stain- gram (-) diplococci intracellular= GOLD
NAAT= preferred
Gonorrhea- Bartholin’s abscess treatment
I&D for area to be treated
-small- hot compress & abx
Gonorrhea- treatment disseminated infection
Ceftriaxone 1gm IM or IV q 24 hrs
Gonorrhea- treatment of cervix, urethra, rectum, and pharynx
Ceftriaxone 500mg IM single dose (if weight >150kgs- 1g ceftriaxone)
Alternatives:
Gentamicin- 240mg IM x 1 dose + Azythro 2 g PO x 1 dose OR
Cefixime 800mg PO x 1 dose
Gonorrhea urethritis- signs and symptoms
- incubation1-14 d - usually 2-5d
- urethral inflammation
- Dysuria and urethral discharge
Gonorrhea cervicitis- signs and symptoms
- incubation- unlear, sx usually in 10 d
- majority asymp
- vaginal discharge (not as much as men)
- dysuria
- labial pain/swelling
- abd pain
Gonorrhea cervicitis- complications
- majority asymp so high rate of complications-
PID–> infertility
Neisseria gonorrhoeae- resistance to?
Antimicrobial resistance
No significant resistance to ceftriaxone
Fluoroquinolone resistance worldwide
Nongonococcal urethritis is caused by?
C. trachomatis
Genital mycoplasmas- Ureaplasma urealyticum, Mycoplasma genitalium
Occasionally-
Trichomonas vaginalis
HSV
Nongonococcal urethritis- signs and symptoms
Mild dysuria
Mucoid discharge- not as purulent as gono: clear- watery
Nongonococcal urethritis- labs and diagnosis
Urethral smear >/= 5 PMNs (usually >15)/ OI field
Urine microscopic >/=10 PMNs/ HPF
Leukocyte esterase +
Nongonococcal urethritis- treatment
Doxy- 100mg BID x 7 days
OR
Azithro 1gm in a single dose
Chlamydia trachomatis- Potential to transmit to newborn during pregnancy- causes what?
Potential to transmit to newborn during pregnancy- conjunctivitis, pneumonia
Chlamydia trachomatis- responsible for causing:
- Cervicitis
- Urethritis
- Proctitis
- Lymphogranuloma venereum
- Pelvic inflammatory disease
Chlamydia trachomatis- symptoms
Most asymptomatic
Chlamydia trachomatis- screening
- W =25, sexually active- annually
- W >25, sexually active, risk factors- annually
- Rescreen W 3-4m after tx- repeat infection
Chlamydia trachomatis- testing
Urine (NAAT) or cervical/urethral swabs
Nucleic acid hybridization (NA probe)- ex Gen-probe pace-2
- gono and chlamydia from one swab
Chlamydia trachomatis- treatment
Doxy 100mg BID x 7d
Azithro 1gm single dose
Chlamydia trachomatis- pregnancy
Pregnancy
- Azithro 1g orally
- Amox 500mg TID x 7days
- No doxy
Pelvic inflammatory disease (PID)- complications
- infertility
- ectopic pregnancy
- chronic pelvic pain
Pelvic inflammatory disease (PID)- signs and symptoms
- endocervical discharge
- fever
- lower abd pain
- cervical motion tenderness
- pain or bleeding w intercourse
Pelvic inflammatory disease (PID)- diagnosis criteria
Minimal:
- Uterine tenderness
- Adnexal tenderness (bimanual exam)
- Cervical motion tenderness
others:
- oral temp >101
- Cervical CT or GC
- WBCs/saline microscopy
- Elevated CRP
- Elevated ESR
- Cx discharge- culture shows gono
Pelvic inflammatory disease (PID)- when to hospitalize
- surgical emergencies not excluded
- pregnancy
- clinical failure of oral antimicrobials
- inability to follow or tolerate oral regimen
- severe illness, N/V, high fever
- tubo-ovarian abscess
Pelvic inflammatory disease (PID)- sex partners
treated for sexual contact 60 days preceding pts onset of symptoms
- tx empirically w regimens effective against CT and GC
Pelvic inflammatory disease (PID)- parenteral regimen
Ceftriaxone 1g IV q 24hrs +
Doxy 100mg PO or IV q 12hrs +
Metro 500mg PO or IV q 12 hrs
Pelvic inflammatory disease (PID)- oral regimen
Ceftriaxone 250mg IM in a single dose +
Doxy 100mg BID x 14 days +
Metro 500mg BID x 14 days
Pelvic inflammatory disease (PID) - what is it?
Inflammatory disorder of the upper GT
- caused by gono +/- chlamydia
Pelvic inflammatory disease (PID)- risk factors
<25 previous PID untreated STI multiple sex partners douches IUD
Epididymitis - cause
Sexually active men <35, most likely gono or chlamydia
>35- enteric organisms more likely E.coli
Epididymitis- signs and symptoms
Pain, swelling and inflammation
Unilateral testicular pain
Epididymitis- treatment
Scrotal elevation
Ceftriaxone 500mg IM x 1 +
Doxy 100mg BID x 10days (GC/chlamydia)
If enteric organism:
- Levo 500mg PO q day x 10 days
Epididymitis- treatment if men insertive anal sex
Ceft 500mg IM x 1 dose +
Levo 500mg PO x 10 days
Prostatitis- what is it?
Acute swelling and inflammation of the prostate gland usually due to infection
Same etiology as epididymitis- gono or chlamydia
Prostatitis- signs and symptoms
Dysuria Pain w erection Fever Chills Low back pain
Prostatitis- testing
UA/culture
- pre and post prostate exam
Prostatitis- treatment
Same as epididymitis but longer duration
Ceftriaxone
Doxy
If enteric organism:
- Levo
Bacterial vaginosis is most common during what?
menses- decreased immunity
Bacterial vaginosis is caused by
Alteration in vaginal flora- most caused by Gardnerella vaginosis
Bacterial vaginosis- risk factors
- new sex partners
- douching
- decrease in normal flora
- absence of barrier methods
- IUDs- copper
- partner is uncircumcised male
- WSW
Bacterial vaginosis- diagnosis criteria
At least 3 of the following:
- Homogenous, thin discharge, gray- white
- Wet prep- clue cells
- whiff test, fishy odor
- pH >4.5
NAAT test- higher sensitivity
Bacterial vaginosis- treatment
Metro 500mg BID x 7days
Metro gel 0.75%, 5g intravaginally once daily x 5 days- caution w alcohol
Clinda cream 5%, 5g intravaginally q hs x 7days
Bacterial vaginosis- treatment in pregnancy
screen & treat at first prenatal visit
- Metro 500mg PO BID x 7days
- Metro 250mg TID x 7days
- Clinda 300mg BID x 7days
Vulvo vaginitis caused by
bacterial vaginitis
candidiasis
trichomoniasis
Vulvo vaginitis- testing
pH
whiff test
KOH microscopy- yeast
saline wet prep
Vulvovaginal candidiasis- caused by
candida albicans
Vulvovaginal candidiasis - classification
Uncomplicated:
- sporadic or infrequent VVC
- mild to mod VVC
- likely to be C albicans
- non immunocompromised
Complicated:
- recurrent (>/=3 in 1 yr)
- severe VVC
- non albicans candida
- immunocompromised
Vulvovaginal candidiasis- signs and symptoms
Pruritis Vaginal soreness Dyspareunia External dysuria Abnormal vaginal discharge (white, curdy)- "cottage cheese" "no odor"
Vulvovaginal candidiasis- testing
KOH prep or culture- buddying yeast and pseudo hyphae- spaghetti and meatballs
Vulvovaginal candidiasis- treatment OTC
- Clotrimazole cream 5g intravaginally
- Miconazole cream 5g intravaginally or vaginal suppository
- Tioconazole cream 5g intravaginally
Vulvovaginal candidiasis - treatment prescription
- Butoconazole cream 5g intravaginally
- Terconazole cream 5g intravaginally or suppository
Oral:
- Fluconazole 150mg orally in a single dose
Vulvovaginal candidiasis - treatment recurrent
- Initial regimen of 7-14days topical therapy or fluconazole 150 mg (repeat 72 hr)
- Maintenance regimens: clotrimazole, ketoconazole, fluconazole, itraconazole
- non albicans: longer duration therapy w non-azole regimen
Vulvovaginal candidiasis - treatment sex partners
- not recommended
- M w balanitis may benefit
- Doesn’t reduce freq of recurrences in F
Vulvovaginal candidiasis - treatment in pregnancy
topical, 7 days
Trichomonas- associated w
risk of HIV
increased risk of PID
coexists with others like gono and chlamydia
Trichomonas- signs and symptoms
Diffuse malodorous yellow to green discharge- “frothy”
Itchiness and burning
Strawberry cervix- tichomoniasis
In men= asymptomatic
Trichomonas- testing
Wet prep= GOLD- motile pear-shaped flagellated trichomonas
NAAT = more sensitive
Trichomonas- treatment
W- Metronidazole 500mg PO x 7d OR
M- Metronidazole 2g orally in a single dose OR
Tinidazole 2g orally in a single dose (W or M)
metro also in pregnancy
Trichomonas- treatment if failure or reinfection
- metro 500mg BID x7d
- if repeat failure- metro or tini 2g PO x7d
- if repeat consider metro susceptibility testing (CDC)
Human Papillomavirus- associated with
Cervical cancer and other squamous cell cancers- anal, penile, vulvar, vaginal
Human Papillomavirus- high risk and low risk strands for cancer
High risk for cancer- 16 & 18, low 6 & 11 (warts)
Human Papillomavirus- testing
pap smear
Human Papillomavirus- treatment
Removal of symptomatic warts
- therapy may reduce but not eradicate infectivity
Human Papillomavirus vaccines
- ages 9-26, approved till age 45
- Gardasil quadrivalent- 6, 11, 16, and 18
- Gardasil 9 valent- 6, 11, 16, 18, 31, 33, 45, 52 & 58”
HPV- anogenital warts- strand types
6 & 11
HPV- anogenital warts- signs and symptoms
Asymptomatic
If large- obstructive symptoms
Looks like cauliflower
Condyloma acuminata- high risk for cancer
HPV- anogenital warts- patient applied treatment
Podofilox 0.5% solution or gel
Imiquimod 5% cream
Sinecatechins 15% ointment
HPV- anogenital warts provider administered treatment
Cryotherapy
Trichloroacetic or bichloroacetic acid 80-90%
Surgical removal
HPV- anogenital warts- what should not be used for treatment in pregnancy
- Imiquimod, podophyllin, podofilox & sinecatechins should not be used
Scabies- what is it?
Parasitic skin infection by the mite Sarcoptes scabiei
Scabies- signs and symptoms
intense itching
Scabies - treatment
Permethrin 5% cream to all areas of body
Ivermectin 200 ug/kg PO- repeat in 2 wks
Crusted scabies (Norwegian scabies)- infestation in what populations?
immunodeficient, debilitated, or malnourished, organ transplant, hematologic malignancies
Crusted scabies (Norwegian scabies) - treatment
Failure w topical scabicide or oral ivermectin
Combine or repeat w ivermectin
Pediculosis pubis- “crabs”- what is it?
Pruritus or lice or nits on pubic hair
Pediculosis pubis- “crabs”- treatment
Permethrin 1% cream
Pyrethrin w piperonyl butoxide
Both- Applied and washed off after 10 min
If failure- Malathion 0.5% lotion to affected area- washed off 8-12hrs or
Ivermectin 250 ug/kg PO- repeated in 7-14d
