STI's Flashcards
STI Bacterial Infections
Gonorrhea – Neisseria gonorrhoeae Chlamydia – Chlamydia trachomatis Bacterial Vaginosis Syphilis – Treponema pallidum Chancroid - Haemophilus ducreyi Pelvic Inflammatory Disease***
Urethritis and Cervicitis
Frequent co-infection so use drug regimens effective against both gonorrhea and chlamydia unless diagnostic point-of-care testing
Organism(s): Neisseria gonorrhoeae
Gram negative diplococci
Organism(s): Neisseria gonorrhoeae
Clinical Presentation:
Often asymptomatic (especially in females) Dysuria Green or white discharge from urethra or cervix
Gonorrhea
Ceftriaxone 250 mg IM x 1 plus
azithromycin 1 g PO x 1
Administer on the same day & together
Disseminated Gonococcal Infection
Skin lesions (red or purple spot)
Asymmetric arthralgia or septic arthritis
Endocarditis (rare)
Meningitis (rare)
Disseminated Gonococcal Infection
Diagnosis
Nucleic Acid Amplification Tests (NAAT)
and/or cultures
Disseminated Gonococcal Infection
Treatment
Ceftriaxone 1 g IM/IV Q24H for at least 7 days
plus azithromycin 1 g PO x 1
Organism(s): Chlamydia trachomatis
Gram negative obligate intracellular parasite
Highest prevalence: age <24 years
Organism(s): Chlamydia trachomatis: Diagnosis
Nucleic Acid Amplification Tests (NAAT)
Organism(s): Chlamydia trachomatis: Treatment
Azithromycin 1 g PO x 1
Doxycycline 100 mg PO BID x 7 days
Bacterial Vaginosis: Organism(s):
Polymicrobial clinical syndrome
Result of normal flora being replaced by an overgrowth of anaerobes
Clinical Presentation:
Asymptomatic or malodorous discharge
Bacterial Vaginosis: Diagnosis
Amsel’s Criteria require 3 of following 4:
- ) Homogeneous, thin, white discharge
- ) Clue cells (vaginal skin cells with bacteria “stuck” to edges) on microscopy
- ) pH >4.5
- ) Whiff test positive (fishy odor to discharge before or after addition of 10% KOH)
Bacterial Vaginosis Treatment:
- ) Metronidazole 500 mg PO BID x 7 days
- ) Metronidazole gel 0.75%, 5 g intravaginally once daily x 5 days
- ) Clindamycin cream 2%, 5 g intravaginally at bedtime x 7 days
Syphilis Organism(s):
Treponema pallidum
Syphilis Diagnosis:
Darkfield microscopy
Visualization of spirochete is definitive diagnostic
Syphilis Diagnosis: Treponemal Tests
Used for confirmation
Less sensitive, but highly specific
Most patients remain reactive for rest of life
NOT used to assess treatment response
Syphilis Diagnosis: Nontreponemal Tests
Used for screening
Highly sensitive, but less specific
Venereal Disease Research Laboratory (VDRL)
Rapid Plasma Reagin (RPR)
Reported quantitatively as antibody titer
4-fold change in titer (e.g. 1:16 to 1:4) is considered clinically significant
Types of Syphilis
Primary Secondary Latent Early latent Late latent Tertiary Neurosyphilis
Primary Syphilis
Timing:
10-90 days after infection
Average = 21 days
Clinical Presentation: Single, painless ulcer or chancre Localized to where bacteria entered body External genitalia Vagina Anus Rectum Mouth
Secondary Syphilis
Timing:
2-8 weeks after initial infection
Occurs primarily in untreated individuals
Clinical Presentation: Systemic symptoms Skin rash (painless) Mucocutaneous lesions Lymphadenopathy Genital warts
Latent Syphilis Timing:
If occurred within 1 year, then early latent
If occurred >1 year ago or unknown, then late latent
Clinical Presentation:
Serologic activity without signs/symptoms of disease
Tertiary Syphilis Timing:
10-30 years after initial infection
May damage the brain, nerves, eyes, heart, blood vessels, liver, bones, or joints and lead to death
Clinical Presentation: Difficulty coordinating muscles or paralysis Numbness Gradual blindness Dementia Gumma = soft, inflammatory masses
Neurosyphilis Timing:
May occur during any stage
Clinical Presentation:
Early signs = cranial nerve dysfunction, meningitis, stroke, acutely altered mental status, auditory or visual abnormalities
Late signs = tabes dorsalis, muscle weakness
Syphilis Treatment
Primary, secondary, and early latent syphilis
Benzathine penicillin G 2.4 million units IM x 1
Syphilis Treatment
Tertiary, late latent syphilis, syphilis of unknown duration
Benzathine penicillin G 2.4 million units IM weekly x 3 doses
Syphilis Treatment
Neurosyphilis or Ocular Syphilis
Aqueous crystalline penicillin G 3-4 million units IV Q4H x 10-14 days
Aqueous crystalline penicillin G 18-24 million units IV continuous infusion x 10-14 days
Penicillin notes
T. pallidum can reside in sequestered sites (e.g., the CNS) that are poorly accessed by some forms of penicillin.
Oral penicillins are NOT appropriate for syphilis.
Combinations such as Bicillin C-R are NOT appropriate for syphilis.
Penicillin dosage forms
IV Formulation Penicillin G (Aqueous) IM Formulations Penicillin G Benzathine (Bicillin L-A) Penicillin G Procaine Penicillin G Benzathine and Penicillin G Procaine (Bicillin C-R) PO Formulation Penicillin V Potassium
Jarisch-Herxhelmer Reaction
As bacterial cells die, endotoxins are released more quickly than the body can process
Fever, headache, myalgia, tachycardia
May occur in first few hours after administration of penicillin for syphilis treatment
Manage with antipyretics, but do not change syphilis treatment regimen
Penicillin Allergy in pregnancy
Pregnant with any stage of syphilis: Penicillin desensitization
Neurosyphilis: Penicillin desensitization
Penicillin Allergy in Primary & secondary syphilis:
Doxycycline 100 mg PO BID x 14 days
Tetracycline 500 mg PO four times daily x 14 days
Ceftriaxone 1-2 g IM/IV daily x 10-14 days
Penicillin Allergy in Latent syphilis alternatives:
Doxycycline 100 mg PO BID x 28 days
Tetracycline 500 mg PO four times daily x 28 days
Syphilis follow-up:
Primary or secondary syphilis: 6 and 12 months
Early or late latent syphilis: 6, 12, and 24 months
Neurosyphilis: CSF exam every 6 months until CSF WBC count is normalized
Pregnancy and Syphilis
Only penicillin is currently recommended
Desensitization required for β-lactam allergic pregnant patients
Some experts recommend a second dose of benzathine PCN G 2.4 million units IM 1 week after the initial dose for primary, secondary, early latent syphilis in pregnancy
Chancroid Organism(s):
Haemophilus ducreyi
Gram negative coccobacillus
Chancroid Treatment:
Azithromycin 1 g PO x 1
Ceftriaxone 250 mg IM x 1
Ciprofloxacin 500 mg PO BID x 3 days
Follow Up: 3-7 days
HPV Genital warts Prevention:
Bivalent vaccine (Cervarix): -Types 16 & 18 Quadrivalent vaccine (Gardasil): -Types 6, 11, 16, & 18 9-Valent vaccine (Gardasil-9): -Types 6, 11, 16, 18, 31, 33, 45, 52, & 58
All are 3-dose series given over 6 months
Use same product for entire 3-dose series
Genital Herpes treatment:
1st episode
First Episode
Acyclovir 400 mg PO TID x 7-10 days
Valacyclovir 1 g PO BID x 7-10 days
Genital Herpes treatment:
suppresive therapy
Acyclovir 400 mg PO BID
Valacyclovir 1,000 mg PO daily
Famciclovir 250 mg PO BID
Genital Herpes treatment:
Episodic Therapy
Initiate within 1 day of onset or during prodrome
Regimens:
Acyclovir 400 mg PO TID x 5 days Acyclovir 800 mg PO BID x 5 days Acyclovir 800 mg PO TID x 2 days Valacyclovir 500 mg PO BID x 3 days Valacyclovir 1 g PO daily x 5 days Famciclovir 125 mg PO BID x 5 days Famciclovir 1 g PO BID x 1 day Famciclovir 500 mg x 1, 250 mg BID x 2 days
Organism(s): Trichomonas vaginalis
Clinical Presentation:
Males: urethritis, epididymitis, prostatitis
Females: diffuse, malodorous discharge
Complications: increased risk for HIV acquisition, preterm birth, PID
Organism(s): Trichomonas vaginalis
Diagnosis
Diagnosis:
NAAT
Culture
Wet mount microscopy
Organism(s): Trichomonas vaginalis
Treatment:
Treatment:
Metronidazole 2 g PO x 1
Tinidazole 2 g PO x 1
Follow Up: 3 months in women
Re-infection rate of 17% at 3 months
Vulvovaginal Candidiasis
Organism(s):
Candida spp.
Usually Candida albicans but may be other yeast
Clinical Presentation:
Pruritus, vaginal soreness, painful intercourse, dysuria, abnormal discharge
Classification of VVC
Uncomplicated VVC:
Sporadic or infrequent AND Mild to moderate AND Likely to be Candida albicans AND Non-immunocompromised women
Classification of VVC
Complicated VVC
Recurrent OR Severe OR Non-albicans Candida OR Women with DM, immunocompromised or debilitation
Uncomplicated VVC Diagnosis:
Signs/symptoms of vaginitis with:
1. Wet prep or Gram stain with yeast or hyphae
2. Culture positive for yeast species
Normal vaginal pH (<4.5)
Uncomplicated VVC Treatment:
OTC agents
- Clotrimazole cream
- Miconazole cream or vaginal suppository
- Tioconazole ointment
Rx agents
- Fluconazole 150 mg PO x 1
- Butoconazole cream
- Terconazole cream or vaginal suppository
Follow Up: Not required
Complicated VVC
Diagnosis:
Treatment:
Follow Up:
Diagnosis: Vaginal culture to confirm diagnosis and check for non-albicans species
Treatment: Topical therapy x 7-14 days
Fluconazole 150 mg PO Q72H x 2 doses
Follow-up: Not required
Risk assessment
Five P’s:
Partners, Practices, Pregnancy prevention, Protection, Past history
Prevention via Male Condoms
May reduce the risk of developing pelvic inflammatory disease (PID) in women
Pelvic Inflammatory Disease (PID)
Definition: Ascending infection of the female genital tract involving the fallopian tubes
Salpingitis:
type of PID, inflammation of the fallopian tube
Tubo-ovarian abscess:
Late complications of PID that can be life-threatening if the abscess ruptures and results in sepsis
Consists of an encapsulated or confined “pocket of pus” with defined boundaries during an infection of a fallopian tube and ovary
Should be managed inpatient initially
PID is:
spontaneous ascension of microbes from the cervix or vagina to the endometrium, fallopian tubes or adjacent structures
PID: Common Pathogens
N. gonorrhoeae C. trachomatis Anaerobes Gram-negative bacteria Streptococcus species
PID: Clinical Presentation
Tenderness in the lower abdomen, cervical motion, and adnexal area
Abnormal discharge and menorrhagia
Fever
Dysuria
Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
PID Complications:
Complications: Abscess formation, occlusion, fibrosis, ectopic pregnancy, infertility
Who can be treated outpatient?
Temp < 38oC WBC < 11,000/mm3 Minimal evidence of peritonitis Active bowel sounds Able to tolerate oral nourishment
PID Outpatient Treatment Options
Ceftriaxone 250 mg IM x 1, plus doxycycline 100 mg PO BID x 14 days
Cefoxitin 2 g IM x 1, plus probenecid 1 gram PO x 1, plus doxycycline 100 mg PO BID x 14 days
Metronidazole 500 mg PO BID x 14 days can be added for further anaerobic coverage
PID Inpatient Treatment Options
Beta-lactam regimens
- Cefotetan 2 g IV q12h + Doxycycline 100 mg IV/PO q12h
- Cefoxitin 2 g IV q6h + Doxycycline 100 mg IV/PO q12h
Beta-lactam free regimens
- Clindamycin 900 mg IV q8h + gentamicin IV/IM 2-mg/kg loading dose followed by 1.5 mg/kg q8h (or 3-5 mg/kg once-daily dosing)
PID Treatment Recommendations
IV to PO Switch
Patients can be switched from IV to PO therapy after the patient has been clinically stable for 24-48 hours
PID Treatment Recommendations
Treatment failure:
Check for Mycoplasma genitalium
Start Moxifloxacin 400 mg PO daily x 14 days
PID Treatment Recommendations
General considerations
Fluoroquinolones no longer recommended because of increasing resistance
DOT
CDC recommends 14 days of therapy regardless of administration route of therapy
