STI Flashcards
- Organism Type: Gram-Negative bacterium
- Scientific name: Chlamydia trachomatis
Chlamydia
Predisposing factors for chlamydia
- Women age 14-24
- Increased # of lifetime sexual partners
- History of chlamydia/gonorrhea infections
- Unprotected sex
- MSM
How is chlamydia transmitted
- Direct sexual contact
- Mother to child during birth
Incubation period for chlamydia
Poorly defined, but typically 5-10 days. Given the
relatively slow replication cycle of the organism, symptoms may not appear until several weeks.
- Known as a ‘silent’ infection because most infected people are asymptomatic & lack abnormal physical examination findings.
- Estimated that ~ 10% of men and 5-30% of women with laboratory confirmed chlamydial infection develop symptoms.
Chlamydia
Chlamydia frequency screening recommendations
- All sexually active women <25 y/o should be tested for GC/chlamydia annually.
- Women > 25 y/o with risk factors (new or multiple sex partners or a sex partner with STD) should be tested for gonorrhea and chlamydia every year
Female presentation:
(1) Urethritis
(a) Dysuria
(b) Pyuria
(c) Increased urinary frequency
(2) Cervicitis (most frequent clinical manifestation in female)
(a) Increased vaginal discharge
(b) Intermenstrual vaginal bleeding
(c) Dyspareunia
Chlamydia
Male presentation:
(1) Urethritis (most frequent clinical manifestation in males)
(a) Mucoid or clear watery discharge.
(b) Dysuria is most common complaint.
(c) Scant discharge on underwear usually presents in the
morning.
(2) Epididymitis
(a) Unilateral testicular pain and tenderness with palpable
swelling of epididymis.
(3) Prostatitis
(a) Pelvic pain
(b) Pain with ejaculation
(c) Dysuria
(4) Proctitis – Men who have sex with men (MSM)
(a) Anorectal pain
(b) Discharge
(c) Rectal bleeding
Chlamydia
Labs for chlamydia
- Gold standard for laboratory diagnosis is nucleic acid amplification testing (NAAT).
- Usually obtained via UA, vaginal, or urethral discharge
- Females: Endocervical swab specimen as part of annual screening or if symptomatic
Treatment of chlamydia
- Preferred treatment: Doxycycline 100mg PO BID for 7 days
- Alternative treatment: Azithromycin 1g single dose (must observe patient taking med).
- Can treat with ceftriaxone if concerned for coinfection.
How long should patients being treated for chlamydia abstain from sexual activity
should abstain from sexual activity for 7 days
after single dose antibiotics or until completion of a 7-day course of antibiotics, to prevent spreading the infection to partners
In women, untreated chlamydia can cause
- Pelvic inflammatory disease (PID).
- Subclinical inflammation of the upper genital tract
“subclinical PID”. - Both acute & subclinical PID can cause permanent damage to the fallopian tubes, uterus, and surrounding tissues, leading to chronic pelvic pain, tubal factor infertility, and potentially
fatal ectopic pregnancy.
Untreated chlamydia in pregnant women is associated with
Pre-term delivery
What is Reiter’s syndrome
Reactive arthritis can occur in men and women following symptomatic or asymptomatic chlamydial infection, sometimes as part of a triad of
symptoms (with urethritis and conjunctivitis)
When should patients with with laboratory-confirmed chlamydia be retested
~ 3 months after treatment of an initial infection, regardless of whether they believe that their sex partners were successfully treated.
- Organism Type: Gram-negative diplococci bacteria.
- Scientific name: Neisseria gonorrhoeae
Gonorrhea
Predisposing factors for Gonorrhea
- People between 20-39 years of age
- Increased # of lifetime sexual partners
- History of chlamydia/gonorrhea infections
- Unprotected sex
- MSM
How is gonorrhea transmitted
Direct sexual contact; mother to child during birth
Incubation period of gonorrhea
1 – 14 days, however, can be as short as 2-4 days.
Male presentation:
- Dysuria
- White/yellow/green urethral discharge
- Epididymitis, manifesting as testicular or scrotal pain
- Discharge, anal itching, bleeding, or painful bowel
movements or may be asymptomatic
- A sore throat, but typically asymptomatic
Gonorrhea
Female presentation:
- Dysuria, increased vaginal discharge, or vaginal bleeding between periods.
- Lower abdominal discomfort may be present.
- Dyspareunia may be present.
- Discharge, anal itching, bleeding, or painful bowel
movements or may be asymptomatic.
- a sore throat, but typically asymptomatic
Gonorrhea
Who is more likely to be symptomatic and asymptomatic between men and women for gonorrhea
Men: Symptomatic
Women: Asymptomatic
Dx of Gonorrhea
- GC/NAAT
What percentage of gonorrhea are resistant to at least one antibiotic
50%
Treatment of gonorrhea
(a) Ceftriaxone 500 mg IM in a single dose AND
(b) Doxycycline 100mg PO BID x 7 days.
(c) Alternative to Doxycycline: Azithromycin 1g orally in a single dose.
What STIs do we screen for
- Gonorrhea (at genital, rectal, and pharyngeal sites, according to exposure)
- Chlamydia (at genital and rectal sites, according to exposure)
- HIV
- RPR for syphilis
- HPV vaccination counseling
- Organism Type: Spirochete bacterium
- Scientific name: Treponema pallidum
Syphilis
Subtypes of syphilis
T. pallidum (causes syphilis), T. p. endemicum (causes
bejel), T. p. pertenue (causes yaws), T. carateum (causes pinta).
Predisposing factors for syphilis
- People between 20-39 years of age
- Increased # of lifetime sexual partners
- History of chlamydia/gonorrhea infections
- Unprotected sex
- MSM.
How is syphilis transmitted
Direct skin-to-skin contact with someone with active
primary or secondary lesions, mother to child (congenital).
Incubation period of syphilis
10 – 90 days; average is 21 days
What is syphilis historically called
“The Great Pretender”
Stages of syphilis
Early stage:
(a) Primary Syphilis
(b) Secondary Syphilis
Latent Stage
(c) Tertiary Syphilis
Which stage of syphilis is the following:
- Begins as a painless papule that proceeds to ulcerate into a 1- 2cm painless ulcer with raised margins. This is called a chancre.
- Lymphadenopathy is typically appreciated in the inguinal lymph nodes.
- Chancre lasts 3 to 6 weeks and heals regardless of whether a person is treated or not, however, active lesions are infectious.
- Patients often don’t report primary syphilis because it is painless, and the chancre resolves relatively quickly.
Primary syphilis
Which stage of syphilis is the following:
- Skin rashes and/or mucous membrane lesions (sores in the mouth, vagina, or anus) mark the second stage of symptoms.
- Syphilitic rash is characterized by diffuse non-pruritic maculopapular eruption on the trunk and extremities that includes the palms and soles.
- Additional symptoms may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.
Secondary syphilis
What is the latent stage of syphilis
- The latent stage is a period of no visible signs or symptoms of syphilis.
- Without treatment, the patient will continue to be infected but will not realize it.
Stages of latent syphilis
(a) Early latent syphilis
1) Latent syphilis where infection occurred within the past 12 months.
(b) Late latent syphilis
1) Latent syphilis where infection occurred more than 12 months ago. Latent syphilis can last for years.
Which stage of syphilis:
- rare and develops in a subset of untreated syphilis
infections that appear 10–30 years after infection and can be fatal.
- Symptoms vary depending on the organ system affected
- Dilated ascending aorta leads to aortic valve
regurgitation which can lead to heart failure
- General paresis
- Tabes dorsalis – Sensory ataxia and sudden bouts of
brief stabbing pain that can affect the limbs, back and
face. May also have abnormal pupillary responses
(Argyll-Robertson pupil)
Tertiary Syphilis
Labs for syphilis
- Nontreponemal tests (RPR) – based on serum reactivity to cardiolipincholesterol lecithin antigen.
(a) Nonspecific therefore not definitive.
(b) Can be falsely positive (Lupus, mononucleosis, pregnancy).
(c) Need to be confirmed with treponemal test. - Treponemal test (FTA-ABS)
(a) More complex and expensive to perform therefore usually used to confirm syphilis.
Treatment of Primary and secondary syphilis
(a) Penicillin G benzathine 2.4 million U IM once.
(b) PCN allergy: Doxycycline 100mg PO BID x 14 days
Treatment of Tertiary Syphilis
(a) Penicillin G benzathine 2.4 million U IM once weekly for 3 weeks
(b) Doxycycline 100mg PO BID x 4 weeks
What is:
- An acute febrile reaction frequently accompanied by
headache, myalgia, fever, rigors, diaphoresis, hypotension, and worsening rash if initially present. This can occur within 24 hours after initiation of therapy for syphilis.
- Reaction occurs most frequently among persons who have early syphilis, presumably because bacterial burdens are higher during these stages.
- There is no way to prevent this reaction. Inform patient of these possible signs & symptoms, and to contact you if a severe reaction occurs.
- Typically resolves in 12-24hrs. NSAIDS or antipyretics can help reduce symptom severity.
Jarisch-Herxheimer reaction
Transmission of syphilis is thought to occur only when what is present
Syphilitic lesions (chancres) are present. Such manifestations are uncommon after the first year of infection.
Should sexual contacts of syphilis be treated
- Sexual contacts of any seropositive primary/secondary, or early latent syphilis should be evaluated clinically/serologically and treated.
- Contacts treated presumptively for early syphilis, even if serologic test results are negative.
(1) Organism Type: Anaerobic, flagellated protozoan parasite
(2) Scientific name: Trichomonas vaginalis
Trichomoniasis
What is the most common protozoan STI
Trichomoniasis
Predisposing factors for Trichomoniasis
-People between 20-39 years of age
- Females,
- Increased # of lifetime sexual partners
- History of chlamydia/gonorrhea infections
- Unprotected sex.
Incubation period of Trichomonas
5 – 28 days
What percentage of patients have minimal or no sx
70-85%
Female presentation:
(a) Range from acute, severe disease to asymptomatic carrier.
(b) HPI: Purulent, malodorous discharge, burning, pruritis, dysuria, dyspareunia.
(c) Physical exam: Erythematous vulva, petechiae cervix “strawberry cervix”, green-yellow malodorous frothy discharge.
Trichomonas
Male presentation:
(a) Upwards of 75% of infected males are asymptomatic and can serve as carriers.
(b) HPI: Urethritis, clear or mucopurulent urethral discharge, dysuria.
(c) Some males may have symptoms of urethritis, epididymitis, or prostatitis.
Trichomonas
Labs for Trichomonas
- Wet mount preparation of genital secretion; convenient and relatively low cost.
- Unfortunately, the sensitivity of wet mount is low (51%–65%) in vaginal specimens
- NAAT is recommended due to high sensitivity/specificity; detecting three to five times more T. vaginalis infections than wet-mount
microscopy. - Testing for other STDs including HIV should be performed in persons infected with T vaginalis.
Treatment of Trichomoniasis
Metronidazole 2 g orally in a single dose, or Metronidazole 500 mg orally twice a day for 7 days.
Patient education for Trichomoniasis
- No alcohol consumption during treatment to reduce the possibility of a disulfiram-like reaction and for 24 hours after completion of metronidazole
- Abstain from sex until they and their sex partners have been treated and asymptomatic for 7 days.
- Counseling on safe sex practices.
When should patients with trichomonas be retested
3 months following initial treatment regardless of whether they believe their sex partners were treated
(1) Organism Type: Double-stranded DNA virus
(2) Scientific name: Human alphaherpesvirus 1 & Human alphaherpesvirus 2
HSV
Predisposing factors for HSV
- People between 20-39 years of age
- Increased # of lifetime sexual partners
- A history of chlamydia/gonorrhea infections
- Unprotected sex.
How is HSV transmitted
Direct sexual contact or vaginal secretions
Incubation period for HSV
2 - 12 days; average is 4 days.
Presentation:
- Severe, painful genital ulcers
- Dysuria
- Fever
- Local inguinal lymphadenopathy
- Unilateral small vesicular lesions on erythematous base or ulcerative lesions.
- May have mild tingling or shooting pains in buttocks and legs prior to recurrent episode.
HSV
Labs for HSV
- Cell culture and PCR
HSV - Primary Infection Treatment
(a) Acyclovir 400 mg orally TID for 7–10 days
(b) Acyclovir 200 mg orally five times a day for 7–10 days
(c) Valacyclovir 1 g orally BID for 7–10 days
(d) Famciclovir 250 mg orally TID for 7–10 days
HSV - Recurrent Infection TX
- Effective episodic treatment requires initiation of therapy within 1 day
of lesion onset or during the prodromal period.
(a) Acyclovir 800 mg orally twice a day for 5 days
(b) Valacyclovir 1 g orally once a day for 5 days
What can cause reactivation of HSV
stress, menstruation, anxiety etc
HSV – Complications
- Aseptic meningitis
- extragenital lesions may occur during infection
- 2-4x increase in risk of acquiring HIV, if individuals with genital herpes infection are genitally exposed to HIV
Low risk sub types of HPV
Types 6 & 11 are low risk subtypes, but the most common strains causing anogenital warts (condyloma acuminata
High risk sub types of HPV
Types 16 & 18 are high-risk subtypes for developing
malignancy such as cervical cancer.
Most common viral STI
HPV
Predisposing factors for HPV
- 20-39 years of age
- Increased # of lifetime sexual partners
- History of chlamydia/gonorrhea infections
- Smoking,
- HIV infection.
Incubation period of HPV
2 weeks to 1 year.
Presentation:
- Lesions are generally found in multiples & can coalesce into a larger lesion. However, solitary lesions are also possible.
- Oral Condyloma acuminata lesions are typically present on the tongue and lip.
- Anogenital lesions may be found on the penis, vulva, vagina, cervix, perineum, and the anal region.
HPV
HPV - General Treatment
(a) Topical therapies, cryotherapy, and surgical excision are common treatment modalities.
(b) A formal treatment algorithm does not exist, and treatment depends on lesion location, morphology, and patient preference.
HPV Treatment can be delayed in
Children, adolescents, and young, healthy adults, as lesions often resolve spontaneously over months to years.
HPV Treatment should be pursued with
Lesions that persist for more than two years if the lesions are symptomatic, or for cosmetic purposes.
HPV - Topical Therapies
(1) Imiquimod cream 5%:
(a) Applied 3x per week every other day.
(b) Resolution typically seen in sixteen weeks.
(2) Podophyllotoxin Solution (0.5% & 0.15%)
(a) Used to treat the fleshy papules. Applied BID x 3 days with a 4-day break.
(b) Lesions can resolve after four weeks.
Clinician Applied Therapy for HPV
- Cryotherapy (Dermatology)
- Surgical excision (Dermatology):
Vaccine that prevents HPV
Gardasil
Who should get the Gardasil?
- All females and males 11 – 26 years of age
- Unvaccinated adults aged 27-45 can request HPV vaccine
Complications of HPV
(a) (F) Cervix, vagina, vulva
(b) (M) Penis
(c) (M/F) Anus, base of tongue and oropharynx
