STIs

Question 1

First-episode, primary HSV infection tx

Answer 1

Acyclovir 400mg TID
Famciclovir 250mg TID
Valacyclovir 1g BID

7-10 days

Question 2

Recurrent HSV infection

Answer 2

Tx is for HSV2

Start as soon as prodromal symptoms begin or within 1 day of lesion onset

Acyclovir, famciclovir, valacyclovir range from 2-5 days

Question 3

Daily suppressive therapy for HSV

Answer 3

Indicated if >= 6 episodes/year

Acyclovir 400mg BID
Famciclovir 250mg BID
Valacyclovir 500-1000mg daily

Question 4

HSV severe infection

Answer 4

Acyclovir IV 5-10mg/kg q8H x2-7 days, then PO for 10 days total therapy

Question 5

Herpes encephalitis

Answer 5

Nonspecific signs/symptoms (HA, fever, speech disorder, AMS, focal seizure)

Need lumbar puncture to analyze CSF

Acyclovir IV x21 days

Question 6

Jarish-Herxheimer reaction

Answer 6

May occur within 4-8 hours of receiving first antibiotic dose for syphilis

T. pallidum is a spirochete. When these breakdown from antibiotics, they release inflammatory cytokines

May include fever, chills, myalgias, flushing, dizziness, rash

Use antipyretics, IV fluids to treat (if needed)

Steroid/antipyretics pretreatment does not prevent

Question 7

Syphilis bug

Answer 7

Treponema pallindum

Question 8

Primary syphilis treatment

Answer 8

Primary = 10-90 days from exposure

Primary symptom: chancre (painless, round, firm sore)

Benazthine penicillin 2.4 million units IM. Single dose.

Question 9

Primary syphilis tx if PCN allergy

Answer 9

doxycycline 100mg BID x14 d
Tetracycline 500mg QID x14 d
Ceftriaxone 1g IM/IV x10 days

Pregnant: ceftriaxone or pcn desensitization

Question 10

Secondary/early latent syphilis

Answer 10

4-10 weeks after exposure

Skin lesions on palms, soles

Same treatment & alternatives as primary syphilis however if using doxy/tetra, use for 28 days

Question 11

Late latent syphilis

Answer 11

> 1 year in duration

Benzathine penicillin G 2.4 million units IM weekly x3 weeks

Question 12

Late latent syphilis if PCN allergy

Answer 12

Doxycycline 100mg BID x4 weeks
Tetracycline 500mg QID x4 weeks

Question 13

Tertiary syphilis treatment

Answer 13

Infectious granulomas and CV effects

Benzathin penicillin G 2.4 million units IM weekly x3 weeks

Question 14

Neurosyphilis treatment

Answer 14

aqueous crystalline penicillin G 3-4 million units IV q4H (or continuous) (total 18-24 million units/day) for 10-14 days

Question 15

Neurosyphilis alternative treatment

Answer 15

Procaine penicillin 2.4 million units/day IM plus probenecid 500mg QID x10-14 days

PCN allergy: ceftriaxone 2g/day IM/IV x10-14 days, or desensitization

Question 16

Treatment of sexual partners for syphilis

Answer 16

<90 days: presumptively treat
>90 days: test & monitor - or treat presumptively

Question 17

Chlamydia treatment

Answer 17

Doxycycline 100mg BID x7 days
Alt: azithromycin 1gm x1 (if pregnant)
Alt: levofloxacin 500mg daily x 7 days

Do not have sex for 7 days
Treat all partners within last 60 days

Question 18

Gonorrhea treatment

Answer 18

Ceftriaxone 500mg IM
If >150kg, then 1g

If chlamydia cannot be excluded, then treat with doxycycline 100mg BID x 7 days

Abstain from sex for 7 days
Treat all partners within last 60 days

Question 19

Gonorrhea symptoms compared to chlamydia

Answer 19

Chlamydia:
-Women: can lead to PID, ectopic pregnancy, infertility
-Men: more asymptomatic compared to gonorrhea

Gonorrhea:
-Women: asymptomatic (some vaginal discharge, dysuria) - can lead to PID
-Men: penile discharge and dysuria

Question 20

Urethritis

Answer 20

Treat for chlamydia and gonorrhea

Consider trichomonas if recurrent or persistent (metronidazole or tinidazole and azithromycin)

Treat all partners in past 60 days

Question 21

Pelvic Inflammatory Disease background

Answer 21

Infection of female genital tract involving fallopian tubes

If untreated can lead to abscess, infertility, ectopic pregnancies

usually sexually transmitted & caused by gonorrhea, chlamydia, anaerobes, gram negative facultative bacteria, strep

Question 22

PID treatment

Answer 22

Ceftriaxone 1g IV q24h + doxycycline 100mg PO or IV q12H + metronidazole 500mg PO or IV q12H

Cefotetan 2g IV q12H + doxycycline 100mg PO or IV q12H

Cefoxitin 2g IV q6H + doxycycline 100mg PO or IV q12H

Cefoxitin and cefotetan are second generation cephs with anaerobic activity

Parenteral therapy can be d/cd after 24-48 hours then PO for 14 days

If no improvement after 7-10 days, add on moxifloxacin 400mg daily x14 days

Sexual partners in past 60 days should be tested & treated

Question 23

Trichomoniasis treatment

Answer 23

Men (asymptomatic): metronidazole 2g once
Women (malodorous, yellow-green vaginal discharge): metronidazole 500mg BID x7 days

Alt: tinidazole 2g once

Treat all sexual partners

Desensitize metronidazole allergic patients

Question 24

Recurrent vulvovaginal candidiasis

Answer 24

> =3 episodes/year

Initial treatment for 7-14 days OR
fluconazole q3 days for 3 doses

Maintenance: fluconazole once weekly for 6 months

Question 25

Oteseconazole

Answer 25

FDA approved for postmenopausal or permanent infertility women for recurrent vulvovaginal candidiasis

HA/nausea

Question 26

DOC for pregnant women with vulvovaginal candidiasis

Answer 26

Topical azoles for 7 days

Question 27

Contraindication for testosterone therapy

Answer 27

Prostate cancer

Question 28

Testosterone monitoring for replacement

Answer 28

Monitor within 1-3 months of initiating
then 6-12 months

If no improvement after 3 months, discontinue

Question 29

Treatment of premature ejaculation

Answer 29

off label

SSRI (fluoxetine, paroxetine, sertraline)
TCA (clomipramine)
EMLA cream before intercourse