Therapeutics - STIs part 2 Flashcards
syphilis is caused by what organism
treponema pallidum - a gram (-) spirochete
syphilis is divided into stages based on what?
clinical findings
the stage of disease determines what treatment is given
most new cases of syphilis in the US are in which population?
MSM
how is syphilis acquired
by sexual contact with infected mucous membranes or skin lesions
how many stages of syphilis are there and what are they
primary - 21 days after initial infection
secondary - 4-8 weeks after primary infection. ulcer appearance
tertiary - 1-20 years after initial infection
latent - divided into early and late
early - first year after resolution of lesions
late - unknown duration or more than a year
the time period for primary syphilis is 21 days after initial infection. what are the symptoms?
painless ulcer in the mouth, genitals, rectum, or skin
time period for secondary syphilis is 4-8 weeks after the ulcer from the primary infection has appeared
what are the symptoms??
head to to body rash, headache, fever, fatiguw
differentiate between the symptoms of early latent syphilis (1 year after primary or secondary lesions have resolved) and late latent syphilis (unknown or greater than 1 year)
early - signs and symptoms usually have dissapeared
late - CV, neuro syphilis, meningitis
what is the preferred drug for treating ALL STAGES OF SYPHILIS
parenteral penicillin G
(the preparation/dose/duration depends on the stage)
preferred treatment for primary, secondary, and EARLY latent syphilis
benzathine penicillin G 2.4 million units IM x1
preferred treatment for tertiary syphilis WITHOUT neurologic involvement, and for late latent syphilis
benzathine penicillin G 2.4 million units IM ONCE A WEEK FOR 3 WEEKS!!!
not just 1 like for primary, secondary, and early latent
preferred treatment regimen for NEUROSYPHILIS
aqueous crystalline penicillin g 18-24 million units/day IV DIVIDED every 4 hours for 10-14 days
alternative:
procaine penicillin 2.4 million units/day IM + probenecid 500mg PO QID for 10-14 days
as mentioned, parenteral penicillin G is the preferred drug for ALL STAGES OF SYPHILIS
what if the patient has a penicillin allergy?
name 3 alternatives
confirm the allergy. pencillin is still preferred, even in cases of allergy, because it works so well for syphilis.
consider desensitizing the patient, especially if they are pregnant or have neurologic involvement
3 alternatives:
doxy 100mg PO Q12 for 28 days
tetracycline 500mg PO QID 28 days
ceftriaxone IM or IV daily 8-10 days (if MILD allergy only)
true or false
even in cases of penicillin allergy, penicillin is still the drug of choice for pregnant patients with syphilis
TRUE
it works so well. consider desensitizing if they have an allergy
what is the “syphilis Jarisch Herxheimer Reaction?”
what is it caused by?
when does it most often occur and why?
what is the treatment?
acute rxn – fever, headache, myalgia within the 1st 24 hrs after starting syphilis treatment
happens bc as we kill the organism, toxic components of T. pallidum are released
the reaction occurs most often in early syphilis because of the high amount of bacteria
the treatment is just supportive care. but imp to let patients know they may feel worse before they get better!!!
explain the follow up procedure for syphilis
-follow up testing every 3, 6, 9, 12, and 24 months after primary and secondary syphilis. 4-fold reduction in antibody titer
-should get HIV test
-ppl exposed to primary, 2ary, or early latent should be referred fro clinical evalutation
anyone (+) for syphilis should get what test
HIV test
pt is 39 with diffuse rash and generalized lymphadenopathy.
painless ulcer on penis that resolved on its own around 5 weeks ago.
diagnosed with syphilis and NKA
what therapy is appropriate?
resolved on its own 5 weeks ago, so this is SECONDARY SYPHILIS
benzathine penicillin G 2.4 million units IM as a single dose
true or false
genital herpes is a CHRONIC viral infection
TRUE
2 causes of genital herpes
HSV1 and HSV2
true or false
HSV1 causes most cases of recurrent genital herpes
what are the symptoms?
FALSE
HSV2
mild infections - can’t even be recognized - but intermittenly shed virus
most genital herpes infections are transmitted by what kind of people?
ppl that are unaware they are even infected
explain the 5 components of the genital herpes infection cycle
primary infection
ganglia infection
lifelong latency
periodic reactivation
recurrent infection
incubation of genital herpes
2-14 days
explain the clinical presentation in the 1ST EPISODE of a genital herpes infection
there will be severe, painful, pus lesions on the external genitalia. local discharge, itching, burning
pt will have flu like symptoms
as mentioned, in the 1st episode of genital herpes infection, there are severe painful pustular or ulcerative lesions on the external genitalia
this usually develops over a period of….
7-10 days
differentiate between the length of viral shedding in the 1st episode vs recurrent infection of genital herpes
1st - virus shedding lasts around 12 days
recurrent - virus shedding lasts around 4 days
true or false
MAJORITY of pts have RECURRENT genital herpes infections
true
explain the clinical presentation of recurrent genital herpes infection
(which comes first - prodrome or lesions)
PRODROME symptoms come BEFORE the lesions appear
pt may get mild burning or itching - this means they’re about to have an outbreak
which has MORE lesions - primary genital herpes infection or recurrent?
which lesions are there for longer?
primary has more lesions and also lasts longer
recurrences and asymptomatic shedding in genital herpes infection are more common in HSV1 or HSV2 infection
HSV2
GOAL for treating the initial episode of a genital herpes infection
to relieve the symptoms and shortern the duration
treatment for initial episode of genital herpes infection
acyclovir 400mg TID for 7-10 days
famciclovir 250mg TID 7-10 days
valcyclovir 1gm BID 7-10 days
ALL HAVE SAME OUTCOME, but val is only BID
explain the treatment for genital herpes infection, in which we are treating a RECURRENT INFECTION
we can either give suppressive therapy OR episodic therapy - 2 different ways of dealing with it
in suppressive, pt takes antiviral on continuous basis in hopes to reduce the number of recurrences and reduce trasnmitting to partners
in episodic, pt gets supply of drug and takes immediately when symptoms begin (PRODROME HAPPENS BEFORE LESIONS) with the goal to lessen and shorten the duration
differentiate between when suppressive vs episodic genital herpes therapy would be given to a patient
suppressive - given to patients who have more frequent outbreaks or have partners - want to prevent transmission
episodic - for patients with mild or infrequent recurrences
differentiate between the length of therapy/dosing for episodic vs suppressive recurrent genital herpes treatment
episodic - shorter durations but higher dosing
suppressive - DAILY dosing, but lower doses
important counseling points for patients with genital herpes
-counsel the infected person AND sex partner(s). let them know that even if they’re asymptomatic, they can still transmit HSV
should avoid sex with uninfected partner when the lesions or prodrome is present
can condoms eliminate the risk for transmitting genital herpes
NO
can reduce the risk, but not eliminate
name 3 STI’s that are characterized by vaginal discharge
bacterial vaginosis
trichomoniasis
vulvovaginal candidiasis
in baterial vaginosis, how does the infection happen?
the vaginal flora is replaced with anaerobic bacteria like ureaplasma, mycoplasma, G. vaginalis
what are some risk factors for getting BV (bacterial vaginosis)
multiple sex partners, not using comdoms, new sex partner, lack of vaginal lactobacilli
true or false
since bacterial vaginosis associated bacteria can be found in the male genitalia, treating a male sex partner can help to prevent the recurrence of bacterial vaginosis
FALSE
while BV-associated bacteria is found there, treating the male is not beneficial
true or false
BV treatment is only recommended for women with symptoms
TRUE
3 potential recommended regimens for patients with bacterial vaginosis
metronidazole 500mg BID for 7 days
OR
metro gel 0.75% 1 full applicator (5g) intravaginal QD for 5 days
OR
Clindamycin cream 2% 1 full apllicator (5g) intravaginal at bedtime x 7 days
counseling point for each of the 3 potential regimens for bacterial vaginosis
metro oral AND gel - NO ALCOHOL
clindamycin cream - it’s OIL BASED. can weaken latex condoms
FOR ALL — REFRAIN FROM SEX OR USE CONDOMS CONSISTENTLY AND CORRECTLY DURING TREATMENT
Trichomoniasis is caused by what bacteria
trichomonas vaginalis
true or false
most patients with a trichomoniasis infection have symptoms
FALSE
most have minimal-no symptoms, so it’s possible the infection can last months to years, and can easily be spread to partners EVEN IF ASYMPTOMATIC
true or false
while treating the male is NOT helpful in preventing bacterial vaginosis in women, treating the male IS beneficial in preventing trichomoniasis in women
TRUE
as mentioned, patients with trichomoniasis infections typically have minimal-no symptoms
do we still treat them with antibiotics?? why or why not
YES bc trichomoniasis infection is associated with 2-3x risk of getting HIV and having adverse pregnancy outcomes
goals of treating trichomoniasis
reduce the symptoms and signs of infection – and to reduce transmission
recommended regimen for trichomoniasis in:
-women
-men
-alternative for women and men
women - metro oral 500mg BID for 7 days
men - metro 2g orally x1
alternative for both men and women - tinidazole 2g oral x1
AVOID ALCOOHL FOR ALL! ALL ARE NITROIMIDAZOLES
Counseling points when giving trichomoniasis treatment
when should they be retested?
NO ALC
no sex until patient AND THE PARTNER are treated
retest within 3 months of initial tretment to ensure infection is gone
vulvovaginal candidiasis is most commonly caused by what?
candida albicans
vulvovaginal candidiasis can be classified as……
what is this based on?
complicated or uncomplicated
complicated - recurrent, severe, nonalbicans, or immunocompromised
uncomplicated - sporadic/infrequent, mild-moderate, caused by Candida albicans, nonimmunocomp
treatment for uncomplicated vulvovaginal candidiasis treatment
OTC regimens - antifungal creams
if they fail OTC - prescription antifungal creams (intravaginal) or fluconazole 150mg x1
when counseling a patient being treated for vulvovaginal candidiasis, how long should you tell them the symptoms will take to go away?
around 3 days after starting treatment
a patient’s symptoms are persisting after trying OTC treatment for vulvovaginal candidiasis OR has a recurrence of symptoms within 2 months after treatment
what is recommendation?
see provider. dont try another OTC - need prescription
important counseling point for patients with vulvovaginal candidiasis using creams and suppositories
they are oil-based - may wekaen latex condoms or diaphragms
