STIs Flashcards
clinical presentation, diagnosis, treatment
What is the treatment duration for nPEP?
nonoccupational post-exposure prophylaxis
28 days
both regimens include 3 drugs
What is the preferred regimen for nPEP?
tenofovir disoproxil fumarate + emtricitabine + raltegravir or dolutegravir
How does gonorrhea present?
gram-negative
- typically asymptomatic as female genital infection, anorectal infection, or pharyngeal infection
- male genital infection –> purulent urethral discharge and dysuria
- newborns –> opthalmia neonatorum
newborn infection results from passage through birth canal – if not treated properly –> corneal ulceration and blindness
How is gonorrhea diagnosed?
- NAAT is standard of care
- endocervical or urethral swab culture
nucleic acid amplification tests (urine, rectum, throat)
What are the treatment considerations when picking a regimen for uncomplicated gonorrhea of the cervix, urethra, and rectum?
- Is ceftriaxone available?
- Do they weigh less or more than 150 kg?
- Has chlamydia been ruled out?
- If chlamydia hasn’t been rule out, consider if they are pregnant or not.
What are the treatment options for patients with uncomplicated gonorrhea of the cervix, urethra, and rectum?
- If chlamydia has been ruled out and they weigh less than 150 kg –> ceftriaxone 500 mg IM x 1
- If chlamydia has been ruled out and they weigh more than 150 kg –> ceftriaxone 1 gm IM x 1
- If chlamydia has not been ruled out and they are not pregnant –> add doxycycline 100 mg PO BID x 7 days to their weight based ceftriaxone
- If chlamydia has not been ruled out and they are pregnant –> add azithromycin 1 gm PO x 1 to their weight-based ceftriaxone
What are the treatment options for patients with uncomplicated gonorrhea of the cervix, urethra, or rectum is ceftriaxone is not available?
- If chlamydia has been ruled out –> gentamicin + azithromycin
- If chlamydia has not been ruled out –> cefixime 800 mg x 1 + doxy (or azithromycin if pregnant)
What are the treatment options for uncomplicated gonorrhea of the pharynx?
- Same as cervix, urethra, rectum regimens EXCEPT the doxy or azithromycin is only added if they are positive for chlamydia
- There are no reliable tx alternative for pharyngeal gonorrhea
Test-of-cure recommended 7-14 days after initial tx, regardless of tx regimen
What are the different forms of syphilis?
spirochete
- primary syphilis
- secondary syphilis
- latent syphilis
- tertiary (late) syphilis
- neurosyphilis
- congenital syphilis
How does primary syphilis present?
- highly infectious, painless chancre will appear at the site of entry after about 3 weeks
- will spontaneously disappear on it’s own
chancre - usually single, dull red macule that turns into papule that erodes and ulcerates; round or oval; indurated and well-marginated
How does secondary syphilis present?
- develops 2-6 weeks after primary
- mucocutaneous eruptions
- lesions anywhere including on hands and feet
- fever, pharyngitis, headache
- signs disappear in 4-10 weeks
How does latent syphilis present?
- positive serologic test, but no other evidence of disease
- early latent (w/in 1 year from onset) potentially infectious
- late latent –> considered non-infectious
- 30% progress to tertiary syphilis
How does tertiary (late) syphilis present?
- slowly progressing, inflammatory phase of the disease
- can affect any organ in the body
When does neurosyphilis occur and how does it present?
- neurosyphilis can occur at any stage of syphilis
- headache, meningismus, increased CSF leukocyte count and protein
How is neurosyphilis diagnosed?
If VDRL-CSF is reactive, it is diagnostic for neurosyphilis.
How does congenital syphilis present?
- resembles secondary syphilis
- may result in fetal death
How is syphilis diagnosed?
Two kinds of serologic testing is mainstay of diagnosis – must use both.
- nontreponemal tests – positive indicates presence of any stage of syphilis.
- treponemal tests – more sensitive and are confirmatory
Nontreponemal: VDRL, RPR, USR, TRUST
Treponemal: FTA-ABS, TPHA, TP-PA, EIAs
What is the treatment of choice for all stages of syphilis (parenteral)?
Penicillin G
What are the treatment options for primary syphilis, secondar syphilis, and early latent syphilis?
no pcn allergy
- benzathine penicillin G 2.4 million units IM x 1 dose
What are the treatment options for primary syphilis, secondary syphilis, and early latent syphilis for patients with penicillin allergy?
- doxycycline 100 mg PO BID x 14 days or
- tetracycline 500 mg PO QID x 14 days
Azithromycin 2 g PO x 1 dose is an option for primary and secondary, but resistance and failure has been documented.
What are the treatment options for late latent syphilis and tertiary syphilis?
- benzathine penicillin G 2.4 million units IM once weekly x 3 weeks
- If pcn allergy –> doxycycline 100 mg PO BID x 28 days or
- If pcn allergy –> tetracycline 500 mg PO QID x 28 days
What are the treatment options for neurosyphilis?
- aqueous crystalline pen G IV x 10-14 days followed by benzathine pcn IM x 3 weeks after completion of therapy
- procaine penicillin IM QD + probenecid PO QID x 10-14 days
- if pcn allergy –> ceftriaxone 2 g IM or IV QD x 10-14 days
How does syphilis treatment change if the patient is HIV+?
It doesn’t
How should syphilis be treated in a pregnancy?
- Penicillin is the only agent that reliably protects and treats the fetus, so use the appropriate treatment regimen according to their syphilis stage
- If pcn allergy –> desensitize –> treat with pcn
After starting a patient on penicillin for their syphilis, they developed flu-like symptoms, headache, fever, redness, and exacerbation of their lesions. What is this and what do we do?
- This is the Jarisch-Herxheimer reaction (NOT a pcn allergy)
- continue treatment
- treat with antipyretics
How does chlamydia present clinically?
gram-negative, anaerobic
- males: dysuria, urethral discharge, or asymptomatic
- females: mainly asymptomatic, endocervicitis with purulent discharge
- infants: neonatal eye infection, interstitial pneumonia
How is chlamydia diagnosed?
- nucleic acid amplification testing (NAAT) - detection of chlamydia antigen in urine
How is chlamydia treated for adolescents and adults?
doxycycline 100 mg PO BID x 7 days
Alt agents:
- azithromycin 1 gm PO x 1 dose (more tx failure)
- levofloxacin 500 mg PO QD x 7 days
What are the treatment options for chlamydia in pregnancy?
- standard: azithromycin 500 mg PO x 1 dose
- alternative: amoxicillin 500 mg PO TID x 7 days
How does mycoplasma genitalium present clinically?
- same as chlamydia
- frequently asymptomatic
How is mycoplasma genitalium diagnosed?
It is a slow growing organism that takes up to 6 months for positive culture, so NAAT is preferred
Urine, urethral, vaginal, cervical swabs
What does the course of treatment for mycoplasma genitalium depend on?
- macrolide resistance testing
What is the treatment for macrolide-susceptible mycoplasma genitalium?
- doxycycline 100 mg PO BID x 7 days followed by
- azithromycin 1 gram PO x 1 followed by 500 mg PO QD x 3 days
What is the treatment for macrolide-resistant mycoplasma genitalium?
- doxycycline 100 mg PO BID x 7 days followed by
- moxifloxacin 400 mg PO QD x 7 days
This is also the regimen if testing is not available
What is the treatment option for mycoplasma genitalium when resistance testing is not available?
- same as macrolide-resistant regimen
How does genital herpes simplex virus (HSV) present?
- flu-like symptoms
- pustular or ulcerative lesions on external genitalia
- itching
- vaginal or urethral discharge
What are the treatment options for an initial HSV infection?
- acyclovir 400 mg PO TID or
- famciclovir 250 mg PO TID or
- valacyclovir 1 g PO BID
- all options equivalent
- duration: 7-10 days
How does HSV treatment differ for a recurrent episode?
- shorter treatment duration
- 1-5 day regimens
What is the treatment regimen for severe disease HSV?
- acyclovir 5-10 mg/kg/dose IV q8h for 2-7 days or until clinical improvement
- followed by oral therapy to complete at least 10 days
What are the suppressive treatment options for HSV?
- acyclovir 400 mg PO BID
- famciclovir 250 mg PO BID
- valacyclovir 500 mg PO daily
- valacyclovir 1 g PO daily
Daily suppressive therapy reduces frequency of recurrences by 80% in patients who have more than 6 recurrences a year.
How does treating recurrent HSV infections differ in patients with HIV?
- longer duration (5-10 days)
What are the HSV suppressive therapy options for a pregnant patient and when should they start?
- start suppressive therapy at 36 weeks gestation
- acyclovir 400 mg PO TID
- valacyclovir 500 mg PO BID
What is the only drug class with documented clinical efficacy for trichomoniasis?
nitroimidazoles: metronidazole, tinidazole
Gel is not an option!
If allergy to metronidazole, desensitize and use it anyways
What are the treatment options for trichomoniasis?
- If female –> metronidazole 500 mg BID x 7 days
- If male –> metronidazole 2 g PO x 1 dose
- If HIV+ –> metronidazole 500 mg PO BID x 7 days
alternative for HIV(-) –> tinidazole 2 g PO x 1 dose for males and females
What reaction happens with metronidazole and alcohol?
- disulfiram reaction
- avoid alcohol with metronidazole for 24 hours
72 hours for tinidazole
What is the standard regimen for pelvic inflammatory disease (PID)?
- ceftriaxone 1 g IV Q24H plus
- doxycycline 100 mg IV or PO q12h plus
- metronidazole 500 mg IV or PO Q12H
- duration: 14 days
