STIs Flashcards
Five P’s of sexual health
Partners (men, women, both? how many? do they have other partners?)
Practices (vaginal, oral, anal)
Prevention of pregnancy
Protection from STIs
Past history of STIs
chancroid
painful superficial non-indurated ulcers
often with regional lymphadenopathy
chancroid: pathogen
Hemophilus ducreyi, a gram-negative bacillus
chancroid: S/Sx
women: usually asymptomatic
men: single or multiple painful ulcers surrounded by an erythematous halo
Ulcers may be necrotic or severely erosive
Involves genitalia and unilateral bubo (swollen inguinal lymph node) or both
chancroid: Dx
Probable diagnosis is usually a matter of exclusion
T. palladium (syphilis) and HSV (by inspection or culture) ruled out
Definitive diagnosis of chancroid is made morphologically
chancroid: treatment
azithromycin 1g PO x1
OR
ceftriaxone 250mg IM x1
OR
ciprofloxacin 500mg PO BID x3 days
chlamydia: pathogen
chlamydia trichromatis
parasitic, resembles gram-negative bacteria
chlamydia: complications
females: PID, infertility, ectopic pregnancy
men: epididymitis, prostatits
most common cause of cervicitis and urethritis
chlamydia: cause
chlamydia trachomatis
chlamydia: S/Sx
Females: often asymptomatic
- dysuria
- intramenstrual spotting
- postcoital bleeding
- dyspareunia
- vaginal discharge
Males: often asymptomatic
- dysuria
- thick, cloudy penile discharge
- testicular pain
- rectal tenesmus
chlamydia: labs/Dx
NAAT to detect bacteria DNA or RNA (most specific & sensitive)
- women: vaginal or cervical swabs or first-void urine
- men: first-void urine or urethral swab
- women and men: detection by rectal swab (not first choice)
chlamydia: treatment
doxycycline 100mg PO BID x7 days
alternatives:
-azithromycin 1g PO x1 dose
-levofloxacin 500mg PO daily x7 days
gonorrhea
bacterial
gonorrhea: cause
neisseria gonorrhoeae, gram-negative diplococci
gonorrhea: complications if untreated
women: PID, fallopian tube damage, infertility or increased risk of ectopic pregnancy
men: may lead to epididymitis, infertility (rare)
gonorrhea: transmission
sexual
perinatally during childbirth
gonorrhea: S/Sx
Females: often asymptomatic
- dysuria
- urinary frequency
- mucopurulent vaginal discharge, green/yellow
- labial pain/swelling
- lower abdominal pain
- fever
- dysmenorrhea
- N/V
Males: often asymptomatic
- dysuria
- frequency
- white/yellow-green penile discharge
- testicular pain
gonorrhea: labs/Dx
NAAT urine sample
POC NAAT: GeneXpert (Cepheid)
culture: endocervical (female) or urethral (male)
gonorrhea: treatment
<150 kg: ceftriaxone 500mg IM x1
>150kg: ceftriaxone 1g IM x1
pregnant: ceftriaxone + azithromycin
if chlamydia not ruled out: ceftriaxone + doxycycline 100mg PO BID x7 days
herpes
viral
painful vesicles or ulcers
Herpes: transmission
direct contact with active lesions or by virus containing fluid (e.g. saliva or cervical secretions)
HSV-1: S/Sx
painful, sore blisters on lips and sometimes mouth/nose
HSV-1: triggers
stress, lack of sleep, too much exposure to sunlight, cold weather, hormonal changes (women)
HSV-2: S/Sx
headache
fever
body aches
malaise
joint pain
First outbreak is usually the worst; recur with additional outbreaks but less severe and shorter duration
HSV-2: triggers
other viral or bacterial infections
menstrual periods
stress
HSV lesions
group/cluster of painful, itching, burning blisters or ulcers
appear on the buttocks, anus or thighs, the vulva or vagina, or on the penis or scrotum
Prodrome often before the lesions appear: tingling or burning where the lesions will develop
Can be noticed during urination
Itching or discomfort in the genital area
Cannot tell the difference between the sores of HSV-1 and HSV-2 on physical exam (can have HSV-1 on genitals and HSV-2 in the mouth)
herpetic whitlow
translocation to fingertips
HSV-1: 60%
HSV-2: 40%
herpes: labs/Dx
gold standard: culture from a lesion
NAAT from a lesion
herpes: management
No cure
Symptomatic:
-docosanol (Abreva) for HSV-1 to shorten healing time
-1st line: Acyclovir for topical, oral, IV
-famciclovir
-valacyclovir: especially useful for reducing symptomatic viral shedding of HSV-2
Syphillis: pathogen
treponema pallidum, a spirochete
primary syphilis
3 weeks after exposure
Often missed
Lesions may be hidden on/around genitals, anus, mouth
Chancre indurated and painless
Regional lymphadenopathy
secondary syphilis
Occurs 2-8 weeks later
flu like symptoms
generalized lymphadenopathy
generalized maculopapular rash, especially on the palm and soles, also trunk, mouth, vagina, anus
early latent syphilis
<12 months
late latent syphilis
> 12 months
tertiary syphilis
10-30 years after exposure
leukoplakia (white patches in the mouth)
cardiac insufficiency: aortitis, aneurysms, aortic regurgitation
infiltrative tumors of skin, bones, liver
CNS involvement: meningitis, hemiparesis, hemiplegia
syphilis: serologic tests
Screening: non-treponema antibody tests: VDRL and/or rapid plasma reagin (RGR) (many clinics do a combination)
Confirmed with a treponemal test:
-treponema pallidum particle agglutination assay (TP-PA)
-fluorescent treponemal antibody absorption (FTA-ABS)
primary, secondary, early latent syphilis: treatment
benzathine penicillin G 2.4 million units IM x1 dose
late latent, indeterminate length, tertiary syphilis: treatment
benzathine penicillin G 2.4 million units IM weekly x3 weeks
neurosyphilis, ocular syphilis, otosyphilis: treatment
aqueous crystalline penicillin G 18-24 million units/day (3-4 million units IV Q4h or continuous infusion for 10-14 days)
early latent syphilis treatment if penicillin allergy
doxycycline 100mg PO BID x14 days
OR
tetracycline 500mg PO QID x14 days
late latent syphilis treatment if penicillin allergy
doxycycline 100mg PO BID x28 days
OR
tetracycline 500mg PO QID x28 days
vulvovaginitis
inflammation or infection of the vulva and vagina most commonly caused by bacteria, protozoa, and/or fungi
trichomoniasis s/sx
malodorous, frothy yellow-green discharge
pruritis
vaginal erythema
petechiae (“strawberry patches”) on cervix and vagina
dyspareunia
dysuria
bacterial vaginosis s/sx
watery, gray, fishy-smelling discharge
vaginal spotting
candidiasis: s/sx
thick, white, curd-like discharge
vulvovaginal erythema with pruritis
trichomoniasis: Dx
microscopic wet-prep; may use NAAT or vaginal culture
normal saline mixture shows motile trichomonas
bacterial vaginosis: Dx
microscopic wet-prep; may use NAAT or vaginal culture
normal saline mixture shows irregularly-shaped vaginal epithelial cells (I.e. clue cells)
candidiasis: Dx
microscopic wet-prep; may use NAAT or vaginal culture
KOH mixture shows pseudohyphae
trichomoniasis: management
metronidazole
- women: 500mg PO BID x7 days
- men: 2g PO x1
alternative: tinidazole 2g PO x1
bacterial vaginosis: management
Metronidazole 500mg PO BID x7 days
OR
metronidazole gel 0.75% 1 applicator intravaginally daily x5 days
OR
clindamycin cream 2% 1 applicator intravaginally at bedtime x7 days
candidasis: management
OTC intravaginal agents:
-clomitrazole
-miconazole
-tioconazole
Rx intravaginal agents:
-butoconazole
-terconazole
Oral:
-fluconazole (contraindicated in pregnancy)
Prophylaxis of opportunistic infections in HIV+ persons: CD4 <200
Pneumocystis jiroveci pneumonia: TMP-SMX double strength 1 tab daily or dapsone 100mg PO daily
Prophylaxis of opportunistic infections in HIV+ persons: CD4 <100
Toxoplasma gondii: TMP-SMX double strength 1 tab daily or dapsone 100mg PO daily
HSV testing for asymptomatic partners of persons with genital herpes
Counseling
Type-specific serologic testing for HSV infection
HIV: S/Sx
flu-like symptoms
earliest S/Sx: fever, night sweats, weight loss
When does AIDS occur?
When the CD4 count is <200 cells/mcl and/or an opportunistic infection is present in an HIV+ patient
HIV: labs/Dx (screening and monitoring)
Initial screening: HIV-1/HIV-2 antigen/antibody combination immunoassay
-if positive, HIV-1/-HIV-2 antibody differentiation immunoassay
Monitoring:
-absolute CD4 lymphocyte count
-viral load
normal CD4 count
500-1200 cells/mm3
HIV: management
Prevention of opportunistic infections
-bactrim for pneumocystis pneumonia and toxoplasmosis prevention
-azithromycin for mycobacterium avian complex
-monitor for CMV
Antiretroviral treatment
-combination therapy to start at the time of HIV+ diagnosis, regardless of CD4 count
Indications for PrEP
Anal or vaginal sex within the past 6 months and:
-a sexual partner with HIV
-not consistently used a condom
-been diagnosed with an STD in the past 6 months
People who inject drugs and:
-have an injection partner with HIV
-share needles or other equipment
People who have been prescribed nonoccupational post-exposure prophylaxis (PEP) and
-repeat continued risk behavior
-have used multiple courses of PEP
Agents with indications for PrEP
Truvada
-recommended to prevent HIV for all people at risk through sex or injection drug use
-can cause significant renal and bone density effects d/t increased plasma concentrations
Descovy
-recommended for people at risk through sex, except those who receive vaginal sex
-improved renal/bone safety
Apretude
-recommended for at-risk adults and adolescents
-injected every 2 months
most common cause of cervicitis and urethritis
chlamydia
AIDS transmission
blood
semen
vaginal secretions
breast milk
