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STDs Flashcards

1
Q

List of STDs and infections of reproductive organs

A
  • Chlamydia
  • Gonorrhea
  • Syphilis
  • Pelvic inflammatory disease (PID)
  • Epididymitis
  • Human papillomavirus (HPV)
  • Herpes simplex virus (types 1 & 2)
  • Trichomonas vaginalis
  • Human immunodeficiency virus (HIV)
  • Hepatitis B and C
  • Lymphogranuloma venereum
  • Granuloma Inguinale (donovanosis)
  • Mycoplasma genitalium
  • Chancroid
  • Bacterial vaginosis
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2
Q

What is the most common notifiable disease in the U.S.?

A

Chlamydia Trachomatis

  • prevalence among females 14-24 years old is ~5%
  • Usually it’s asymptomatic: Screen is important.
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3
Q

Who should be screened for Chlamydia?

A

All sexually active women < 25 yr and women 25+ yr at increased risk for infection
1. Annual screening
2. Increased risk: new sex partner, more than one sex
partner, a sex partner w/ concurrent partners or
sexually transmitted infections
B. Pregnancy
1. First perinatal visit (for women < 25 yr, and those at
increased risk 25+ yr)
2. Retest in third trimester for those at increased risk
C. Sexually active men who have sex with men (MSM)1
1. Annual screening (at least)
2. Test genital and rectal sites
3. More frequent (every 3-6 months) for MSM with HIV
or increased risk (multiple partners)
D. Correctional facilities
1. Routine intake screening for all women < 35 yr and
men < 30 yr

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4
Q

First line treatment for Chlamydia?

A

Azithromycin 1 gram PO as single dose (pref if preg)
OR
Doxycycline 100 mg BID x 7 days

Alternatives include 7 days of: Erythromycin, Levaquin, Ofloxacin. If pregant, Amoxicillin is an option.

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5
Q

Do you need to test for cure with Chlamydia? What about repeat testing for reinfection?

A

Only if patient is pregnant: 3-4 weeks after completing treatment. Must culture. Nucleic acid amplification tests (NAAT’s) are not approved for testing for cure.

All patients should be tested for reinfection 3 months after diagnosis due to high risk of reinfection. Can use NAAT.

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6
Q

If you’re positive for Chlamydia, all sexual partners in the preceding ___ days should be referred.

A

60 Days

Most recent partner if this contact occurred > 60 days ago

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7
Q

Patients diagnosed with Chlamydia should abstain from sexual contact for __ days after treatment.

A

7 Days. Whether treated with azithromycin 1 gram x 1, or 7 days of doxy.

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8
Q

Clinical manifestations of Gonorrhea?

A

Females: asymptomatic 50%. Cervicitis/urethritis including vaginal discharge, bleeding, dysuria, abdominal pain, dyspareunia

Males: Urethritis (most commonly) with purulent or mucopurulent urethral discharge +/- dyuria. Sometimes asymptomatic.

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9
Q

Non-genital gonococcal clinical manifestations?

A

Pharyngeal infection
Ocular infection
Disseminated gonococcal infection
Proctitis or rectal infection

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10
Q

Gonorrhea Screening Recommendations

A

Same as chlamydia:

All sexually active women < 25 yr and women 25+ yr at increased risk for infection
1. Annual screening
2. Increased risk: new sex partner, more than one sex
partner, a sex partner w/ concurrent partners or
sexually transmitted infections
B. Pregnancy
1. First perinatal visit (for women < 25 yr, and those at
increased risk 25+ yr)
2. Retest in third trimester for those at increased risk
C. Sexually active men who have sex with men (MSM)1
1. Annual screening (at least)
2. Test genital and rectal sites
3. More frequent (every 3-6 months) for MSM with HIV
or increased risk (multiple partners)
D. Correctional facilities
1. Routine intake screening for all women < 35 yr and
men < 30 yr

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11
Q

Gonorrhea diagnosis

A

Very similar to chlamydia:

NAATs are recommended
B. In symptomatic males
1. Gram’s stain from urethral sample (>95% sensitivity with symptoms)
C. Preferred screening in asymptomatic patients
1. Vaginal swabs are preferred for females vs. urine
2. Urethral swab or first-catch urine specimen for males
D. N. gonorrhoeae NAATs FDA approved for:
1. Urine specimens from men and women
2. Urethral swabs in men and endocervical swabs in women
3. Some tests are approved for vaginal swabs
E. NAAT for pharyngeal and rectal specimens is now FDA approved

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12
Q

What is GISP?

A

Gonococcal Isolate Surveillance Project. Each month, N. gonorrhoeae isolates are collected from the first 25 men with gonococcal urethritis at participating sites. Established to monitor trends in antimicrobial susceptibilities of N. gonorrhoeae strains in the United States.

Important because NAAT testing does not yield live organisms, and thus antimicrobial susceptibility testing is not commonly performed.

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13
Q

What is the resistance profile of Gonorrhea?

A

25% are resistant to tetracyline
19% resistant to cipro
16% resistant to pcn

  1. 5% show reduced susceptibility to Azithromycin
  2. 8% show reduced susceptibility to Rocephin/Cefixime
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14
Q

What is the treatment of choice for Gonorrhea?

A

Azithromycin 1 gram PO once + Ceftriaxone 250 mg IM once is the only CDC rec’d regimen.

  • If conjunctivitis, increase rocephin to 1,000 mg.
  • Anaphylactic allergy? Gent 240 mg IM x 1 + Azith 2 grams PO once.
  • Unlikely a strain will be resistant to both
  • Reduces prevalence of resistant strains
  • Also treats Chlamydia (often a co-infection)
  • Cefixime can be used if Rocephin unavailable.

Treatment of Arthritis and arthritis-dermatitis syndrome:
Rocephin 1 gram IM/IV q24h for 7 days PLUS azithromycin 1 gram PO once

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15
Q

Should you test for cure of Gonorrhea?

A

If patient was not treated with ceftriaxone, yes, 14 days after treatment, using either culture or NAAT.
OR
If persistent symptoms

*If there was a treatment failure, must do culture and sensitivity. If failed cephalosporin therapy, must report the case to the CDC through state/local health agencies.

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16
Q

How transmissible is gonorrhea?

A

Very: Male to female transmission is 50-70%, and female to male is 20%, which is highly transmissible.

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17
Q

How long should a person abstain from sexual contact after being diagnosed with Gonorrhea?

A

7 days from starting therapy.

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18
Q

What is EPT as related to STDs?

A

Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner. Rec’d by CDC. Not allowed in every state.

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19
Q

If you are diagnosed with 1 STD what else should you test for?

A

Others: Syphilis, HIV, Chlamydia, Gonorrhea.

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20
Q

Why do we give newborns erythromycin ophth oint?

A

To prevent contraction of gonorrhea in the eye.

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21
Q

What organism causes Syphilis?

A

Treponema pallidum

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22
Q

The Stages of Syphilis:

A

Primary syphillis: Ulcers or chancre at infection site
Secondary: skin rash (palms/feet), mucocutaneous lesions, and lymphadenopathy
Teriary: Cardiac, gummatous lesions, tabes dorsalis, and general paresis
Latent syphilis: Lacking clinical manifestations and are detected by serologic testing
Late latent: acquired a year or more ago
*Neurosyphilis: can occur at any stage

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23
Q

Late Congenital Syphilis (mother to child) classic triad of signs:

A

Hutchison’s Teeth, interstitial keratitis, and eighth nerve deafness.

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24
Q

Syphilis screening recs:

A

Pregnant: Serological test at first prenatal visit. Repeat at 28 weeks and delivery if high risk.

Correctional Facilities: Universal based on local prevalence

Sexually Active MSM: Annual at least. More frequent if high risk behaviors or if partners have multiple partners.

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25
Q

Syphilis microbiology:

A

Treponema pallidum:

  • Very small and hard to see. Must use “dark-field” for definitive dx. Not commonly done
  • Corkscrew-shaped (usually described as gram negative - but lacks lipopolysaccharide cell wall).
  • Cannot be cultured unless inoculated into rabbits.
26
Q

Presumptive diagnosis of Syphilis requires what two diagnostic tests?

A

Nontreponemal test: Venereal disease research laboratory VDRL and/or Rapid Plasma Reagin RPR (many false positives)

Treponemal test: More specific, but can remain positive after treatment.

27
Q

Recommended Treatment of Syphilis?

A

Primary and secondary syphilis and early latent:
Benzathine penicillin G 2.4 mil units IM once

Tertiary syphilis, latent, or unknown duration, or after treatment failure (if CSF normal): Penicillin Benzathine 2.4 mil units q7d x 3 doses

Neurosyphilis and ocular syphilis: Aqueous Crystalline Penicillin G 18-24 million units per day (q4h or continuous) for 10-14 days.
-Alternative: Procaine PCN G 2.4 mil IM daily PLUS probenecid 500 mg PO QID, for 10-14 days.

28
Q

What about pregnant women who test positive for syphilis but have a penicillin allergy?

A

Skin testing and desensitization protocol is rec’d by CDC. Oral may be easier and safer. After desensitization, should maintain PCN levels for the duration of therapy. Desensitization = controlled anaphylaxis.

29
Q

Alternative Syphilis Therapy for non-pregnant patients allergic to PCN?

A

Primary/Secondary: Doxycycline 100 mg BID x 14 days
Latent: Doxycycline 100 mg BID for 28 days.

*Could use tetracycline, but doxy is better tolerated.
*Rocephin is a promising alternative
*Azithromycin has been used too, but
congenital Syphilis has been observed.

30
Q

What about the Jarisch-Herxheimer Reaction (JHR)?

A

-Is seen when treatment for any spirochete is initiated
(Syphilis is a spirochete).
-Acute reaction that includes fever, rigors, sweats,
hypotension, and worsening of skin rashes
-Typically in the first 2-5 hours of therapy, and usually resolves within 24 hours.
-Antipyretic agents (acetaminophen) can be used to
manage symptoms, but they have not been proven to
prevent this reaction
-JHR in pregnant women has been associated with
early spontaneous termination of pregnancy and
preterm labor. (Close monitoring)
-JHR should not indicate an adverse drug reaction and
patient should continue therapy— it is due to an
elevation in the level of cytokines in the body

31
Q

Monitoring Syphilis Treatment?

A

Serology: Nontreponemal test antibody titers

  • Use same test each time (VDLR vs RPR). Preferably same lab.
  • 4 fold decrease in titer is clinical response. E.g. 1:16 to
    1: 4
  • Clinical and serological evaluation should be performed 6 and 12 months after treatment.
32
Q

How is PID diagnosed?

A

No single diagnostic test. Clinical criteria used, however these vary and sometime asymptomatic.

a. Cervical motion tenderness
b. Uterine tenderness
c. Adnexal tenderness

33
Q

What is Fitz-Hugh-Curtis syndrome

A

A rare complication of PID. It results from ascending pelvic infection causing liver capsule inflammation. Perihepatitis is characterized by right upper quadrant pain, nausea, vomiting, and fever, which are generally accompanied by evidence of PID on physical examination

34
Q

What microbes are implicated in PID?

A

Neiseria gonorrhea, Chlamydia trachomatis, as well as vaginal flora (Anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae)

35
Q

Treatments of choice for severe PID?

A

Parenteral Abx.

Cefotetan 2 gram IV q12h or Cefoxitin 2 gram IV q6h PLUS doxycycline 100 mg BID.
OR
Clindamycin 900 mg IV q8h PLUS Gentamicin

Alternative: Unasyn + Doxy

*Pregant woman should be hospitalized and treated with IV abx.

36
Q

Treatment of choice for mild or moderate PID?

A

IM 3rd gen Cef (rocephin or (cefoxitin+probenecid)) PLUS doxy x 14 days (covers chlamydia) +/- Flagyl 14 days.

37
Q

If a woman has PID what else should you test for?

A

HIV, gonorrhea, chlamydia

38
Q

What is epididymitis and what are the most common offending organisms?

A

Inflammation of the epididymis (a tube at the back of the testicles that carries semen).

  • In sexually active men < 35, most common source is Neisseria Gonorrhea and Chlamyidia Trachomatis. For MSM who are anal inserters, enteric orgs.
  • Men >35, usually secondary to BPH and bacturia.
39
Q

Symptoms of Epididymitis

A

Posterior testicular pain that is gradual in onset, usually unilateral, occasionally radiates to lower abdomen. Pain, swelling, and inflammation < 6 weeks is acute. > weeks is chronic.

40
Q

Treatment for Epididymitis?

A

Based on presumptive cause:

NG and CT: Rocephin 250 mg IM x 1 plus Doxy 100 mg BID x 10 days. (Sexually active men < 35)

Men who practice insertive anal sex, cover enterics too: Rocephin 250 mg IM x 1 and Levaquin 500 mg q24h x 10 days (ofloxacin is another FQ option)

To cover only enterics (men > 35): Levaquin

41
Q

What is the most common STD in the US?

A

HPV. Over 40% aged 18-59 had it in 2013!

42
Q

Why should people get the HPV vaccine?

A

The 9 valent vaccine covers the 7 strains that cause 81% of cervical cancers. As well as HPV-6 and HPV-11, which cause 90% of genital warts.

43
Q

What are complications of HPV?

A

From asymptomatic (most common) to genital warts to cancer (cervical, penile, vaginal, vulvar, anal, and oropharyngeal).

44
Q

Recommended treatment for genital warts?

A

Most likely HPV.

At home: Imiquimod 3,75% cream QHS x 16 weeks, Imiquimod 5% cream TIW for 16 weeks, Podofilox 0.5% solution or gel BID x 3 days then 4 days with no therapy
Sinecatechins 15% oin TID until clearance (up to 16 weeks)

In office: Cryotherapy, surgical removal, or acid.

45
Q

HPV Vaccine recs?

A

Give 9 valent vaccine to males and females routinely. Start at 11-12 years old (as late as 26, early as 9)

From 27-45: Use shared clinical decision making.

9-14 years old: second dose 1-2 months after first.
>15 years: give a third dose 6 months after first.

46
Q

Genital Herpes is usually caused by which strain?

A

HSV-2. It is a chronic, lifelong vial infection. Recurrences and subclinical shedding are more common with HSV-2. Very common. ~50 million in US. Most are not diagnosed.

47
Q

HSV Screening Recs?

A

Consider serologic testing for people seeking STD evaluation. Outside of this, routine testing not advised, even for pregnant women.

48
Q

What tests are available for HSV?

A

NAAT
PCR (preferred for CNS infections)
HSV antibody testing - ABs develop in first several weeks of infxn and persist indefinitely.

*Positive PCR and negative ABs likely a new, primary infection.

49
Q

Treatment of first episode of HSV?

A

DOT = 7-10 days
Start right away regardless of severity if first episode suspected. Do not wait for confirmation. Biggest benefit if started within 72 hours of onset.

One of the following:

  • Acyclovir 400 mg PO TID or 200 mg 5x/day
  • Valacyclovir 1 g PO BID
  • Famciclovir 250 mg PO TID
50
Q

Treatment of Recurrent HSV?

A

Take at first sign of recurrence (prodrome)
-Shorter courses

One of the following:
-Acyclovir 400 mg TID or 800 mg BID x5d or
800 mg TID x2d
-Valacyclovir 500 mg BID x3d or 1 g QD x5d
-Famciclovir 125 mg BID x5d or 1 g BID x1d or
500 mg x1, then 250 mg BID x2d.

51
Q

Suppressive Therapy for HSV?

A

Acyclovir: 400 mg BID
Valacyclovir: 500-1000 mg daily (500 is less effective if
> 10 episodes per year).
Famciclovir: 250 mg BID (500 mg if HIV coinfection)

52
Q

Suppressive therapy for pregnant women?

A

Begin at 36 weeks:
Acyclovir 400 mg TID or
Valacyclovir 500 mg BID

53
Q

What change in RDR titer shows a response in therapy?

A

A four fold decrease in titer. E.g. 1:64 to 1:16 is a good response to therapy.

A four fold increase in titer shows

54
Q

If Syphillus follow-up shows treatment failure or re-infection, how do treat?

A

Confirm that it’s not neurosyphillis, and then give PCN benzathine 2.4 million units weekly for 3 weeks.

55
Q

Is Chlamydia a reportable disease?

A

Yes

56
Q

Is Gonorrhea a reportable disease?

A

Yes

57
Q

Who gets screened for Syphillis?

A

MSM (annually), inmates (possibly), first prenatal visit (required by law in most states).

58
Q

Urine vs swab for C&G screening?

A

Urine: okay for males
Swabs: okay for male and female. Urethral for men. Endocervical for women. (Sucks to be a woman).

59
Q

What if you’re allergic to cephalosporins and you need treatment for gonorrhea?

A

Azithromycin 2,000 mg (big dose!) and Gentamicin 240 mg IM x 1.

60
Q

What is the rec’d EPT for gonorrhea?

A

cefixime 400 mg + Azithromycin 1,000 mg Once

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