STDs

Question 1

Syphilis - cause

Answer 1

Trepoema pallidum

Question 2

Syphilis - stage

Answer 2

Stage:
1st = ulcer/chancre ( painless ulcer) at site of infection
2nd = systemic manifestations (hand and feet skin rash, malaise, lymphadenopathy )
Latent= suppresses infection (no symptom)
- Early < 1 yr.
- Late >1 yr.
3rd = within in 1-20yr of infection
- Lesions looks like a benign tumor
- CV: ascending aortic aneurysm, aortic insufficiency, coronary stenosis

Question 3

Syphilis - manifestation

Answer 3

Neurosyphilis: occur in any stage. Acute syphilitic meningitis with altered mental status.
Endarteritis present as a stroke-like symptoms with seizures
Congenital syphilis:
Infected mother increase risk of baby

Question 4

Syphilis - diagnosis

Answer 4

Pt history including sexual 
Physical exam of whole body 
Darkfield microscopy 
Nontrponemal test: VDRL,RPR
-	IgM & IgG 
-	Useful marker of disease severity
-	4X change indicated clinical significant 
-	RPR cannot be tested on CSF samples  
Treponemal test: FTA-ABS, EIA, immunoassays.  
-	Often reactive for life 
-	Not correlate with disease severity 
-	If + run a nontrponemal 
-	If – run another treponemal

Question 5

Syphilitic Treatment

Answer 5

Pen G IV for all stage
- The only effective therapy for pregnancy
1st, 2nd, early:
- Benzathine Pen G 2.4 MU IM X1; children 5万/kg IM
- Evaluation at 6 & 12 month;
- If retreat needed 3 week is recommended
3rd, Late, unknown:
- 2.4 MU IM weekly X 3
- Children above X 3
- Evaluation 6, 12, 24 month
If Penicillin ALL use Doxycycline 100mg PO BID 14/28 days accordingly
Neurosyphilis:
- Aqueous crystalline Pen G 4 MU IV q4hr or continuous infusion 24 U/day X 10-14 days
- ALL: desensitize Pt
Treat sexual partner:
- 3 month for 1st
- 6 month for 2nd
- 1 yr for early latent

Question 6

Jarisch- Herxheimer RXN

Answer 6

Abrupt onset fever, headache, myalgia, tachycardia, skin rash, mild hypotension

Question 7

Syphilis - medication alert

Answer 7

MEDICATION ALERT: There have been errors in treatment of syphilis due to confusion between formulations.
2.4 million Units of Bicillin L-A contains 2.4 million units of benzathine penicillin G as recommended for syphilis. BICILLIN C-R SHOULD NOT BE USED TO TREAT SYPHILIS.

Question 8

Chlamydia - cause

Answer 8

Chlamydia trachomatis

Question 9

Chlamydia - presentation

Answer 9

Mostly asymptomatic in both men and women.
Women: Vaginal discharge, dysuria
Men: dysuria, penile discharge, pain/ swelling of testicles

Annual screening of sexually active women 25 and under is recommended

Question 10

Chlamydia - Diagnosis

Answer 10

• Urine test
• Swans from endocervix or vagina
• Nucleic Acid amplification tests (NAATs)

Testing for other STD is recommended for diagnostic person
- Co-infection w/ gonococcal are common and should be treat simultaneously

Question 11

Chlamydia - treatment

Answer 11

1st line:
-	Azithromycin 1g PO X1 
-	Doxycycline 100mg PO BID  X 7 days 
Alternative 
-	Levoquine 500mg PO daily X 7 days 
Pregnancy: 
-	Azithromycin 1g X1 
-	Amoxicillin 500 mg PO TID X 7 days 

1st dose of Azithromycin should be directly observed for compliance issue

Pt need to be abstain sexual intercourse for 7 days

Question 12

EPT

Answer 12

Expedited Partner Therapy

- Treatment for sexual partners

Question 13

Gonorrhea - causes

Answer 13

Neisseria gonorrhoeae

Question 14

Gonorrhea - presentation

Answer 14

Most women do not produce recognizable symptoms

Men are symptomatic 90% of the time

• Urethritis, dysuria, epididymitis
• copious purulent/ mucopurulent penile discharge

Screening is only recommended for who are at risk.

Question 15

Gonorrhea - niagnosis

Answer 15

Diagnosis:
-	NAATs 
-	Commonly utilized test  
Men: NAATs 
Women: vaginal swab 

Urethral culture

Testing for other STD is recommended for diagnostic person

Question 16

Gonorrhea - treatment

Answer 16

Uncomplicated infective:

• Ceftriaxone 250 mg IM + Aziththromycin 1G X 1
• Doxycycline 100mg PO BID X7 days
• If ALL: do Azithro 2G PO X 1
• RX given on directly observation

Disseminated:

• Ceftriaxone 1g IM/IV q24 hr X 1 week or more
• Often presents w/ septic arthritis affecting multiple Joints

Endocarditis:
- Ceftriaxone 1-2g IV BID X 4weeks

Patients should be instructed to abstain from sexual intercourse until therapy is completed and until they and their sex partners no longer have symptoms

it is recommended for patients positive for gonorrhea to be treated for both gonococcal and chlamydial infections concurrently

Question 17

BV cause

Answer 17

Bacterial vaginosis

G. vaginalis

Question 18

BV presentation

Answer 18

Women - asymptomatic, vaginal white thin discharge and vaginal fishy odor

clue cells - wet mount

Question 19

Trichomoniasis - cause

Answer 19

protozoan parasite Trichamonas vaginalis

Question 20

Trichomoniasis - presentation

Answer 20

malodorous discharge
dyspareunia, burning, dysuria
Thin green-yellow discharge, vulvovsginal erythema
motile trichomonads

Question 21

BV - treatment

Answer 21

Metronidazole 500mg PO BID X 7 days

metronidazole 0.75% gel, intravaginally daily X 5days

Question 22

Trchomoniasis - treatment

Answer 22

Metronidazole 2g PO X1

Question 23

PID (pelvic inflammatory disease ) -causes

Answer 23

N. gonorrhoeae and C. trachomatis

Question 24

PID diagnosis

Answer 24

Lower abdominal pain is the cardinal symptom in women with PID.
the diagnosis of PID is usually based on clinical findings

at least one of the following criteria is present on pelvic examination: 1) cervical motion tenderness, 2) uterine tenderness, or 3) adnexal tenderness. Additional criteria can support the diagnosis of PID and include: oral temperature >101°F (>38.3°C), abnormal cervical or vaginal mucopurulent discharge, presence of abundant WBC in vaginal fluid, elevated CRP, elevated ESR, or laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis

Question 25

PID treatment

Answer 25

All women who have PID should be tested for both N. gonorrhoeae and C. trachomatis and should be screened for other STDs including HIV and syphilis.

Question 26

PID treatment

Answer 26

PID is a polymicrobial infection
Treatment should be initiated as soon as presumptive diagnosis has been made since prevention of long term complications is dependent on early administration of appropriate antibiotics.
Inpatient IV treatment is indicated in pregnancy, severe illness with nausea/vomiting and high fevers, tubo-ovarian abscess, or if oral therapy fails or cannot be tolerated

Question 27

PID treatment MIld

Answer 27

Regimen 1:
Ceftriaxone 250mg IM x 1 dose
PLUS
Doxycycline 100mg PO BID x 14 days
WITH or WITHOUT
Metronidazole 500mg PO BID x 14 days
Regimen 2:
Cefoxitin 2 gm IM x 1 dose + Probenecid 1g PO x 1 dose
PLUS
Doxycycline 100mg PO BID x 14 days

Question 28

PID treatment severe

Answer 28

Regimen 1:
Cefotetan 2 g IV q12h OR Cefoxitin 2g IV q6h (cephs with anaerobic activity) until 24 hrs after clinical improvement
PLUS
Doxycycline 100mg PO q12h for a total of 14 days

Regimen 2:
Gentamicin 5 mg/kg IV q24h until 24 hrs after clinical improvement
PLUS
Clindamycin 900mg IV q8h (then 450 mg PO QID when switched to PO) for a total of 14 days

Parenteral therapies can be discontinued 24 hours after clinical improvement, but oral therapy should continue to
complete a total of 14 days of therapy. For the second regimen, clindamycin should be continued at a dose of
450mg PO QID for a total of 14 days. If a tubo-ovarian abscess is present, clindamycin is preferred over doxycycline
for its anaerobic coverage.