Therapeutics - STIs part 2

Question 1

syphilis is caused by what organism

Answer 1

treponema pallidum - a gram (-) spirochete

Question 2

syphilis is divided into stages based on what?

Answer 2

clinical findings

the stage of disease determines what treatment is given

Question 3

most new cases of syphilis in the US are in which population?

Answer 3

MSM

Question 4

how is syphilis acquired

Answer 4

by sexual contact with infected mucous membranes or skin lesions

Question 5

how many stages of syphilis are there and what are they

Answer 5

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

Question 6

the time period for primary syphilis is 21 days after initial infection. what are the symptoms?

Answer 6

painless ulcer in the mouth, genitals, rectum, or skin

Question 7

time period for secondary syphilis is 4-8 weeks after the ulcer from the primary infection has appeared

what are the symptoms??

Answer 7

head to to body rash, headache, fever, fatiguw

Question 8

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)

Answer 8

early - signs and symptoms usually have dissapeared

late - CV, neuro syphilis, meningitis

Question 9

what is the preferred drug for treating ALL STAGES OF SYPHILIS

Answer 9

parenteral penicillin G

(the preparation/dose/duration depends on the stage)

Question 10

preferred treatment for primary, secondary, and EARLY latent syphilis

Answer 10

benzathine penicillin G 2.4 million units IM x1

Question 11

preferred treatment for tertiary syphilis WITHOUT neurologic involvement, and for late latent syphilis

Answer 11

benzathine penicillin G 2.4 million units IM ONCE A WEEK FOR 3 WEEKS!!!

not just 1 like for primary, secondary, and early latent

Question 12

preferred treatment regimen for NEUROSYPHILIS

Answer 12

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

Question 13

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

Answer 13

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)

Question 14

true or false

even in cases of penicillin allergy, penicillin is still the drug of choice for pregnant patients with syphilis

Answer 14

TRUE

it works so well. consider desensitizing if they have an allergy

Question 15

what is the “syphilis Jarisch Herxheimer Reaction?”

what is it caused by?

when does it most often occur and why?

what is the treatment?

Answer 15

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!!!

Question 16

explain the follow up procedure for syphilis

Answer 16

-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

Question 17

anyone (+) for syphilis should get what test

Answer 17

HIV test

Question 18

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?

Answer 18

resolved on its own 5 weeks ago, so this is SECONDARY SYPHILIS

benzathine penicillin G 2.4 million units IM as a single dose

Question 19

true or false

genital herpes is a CHRONIC viral infection

Answer 19

TRUE

Question 20

2 causes of genital herpes

Answer 20

HSV1 and HSV2

Question 21

true or false

HSV1 causes most cases of recurrent genital herpes

what are the symptoms?

Answer 21

FALSE

HSV2

mild infections - can’t even be recognized - but intermittenly shed virus

Question 22

most genital herpes infections are transmitted by what kind of people?

Answer 22

ppl that are unaware they are even infected

Question 23

explain the 5 components of the genital herpes infection cycle

Answer 23

primary infection
ganglia infection
lifelong latency
periodic reactivation
recurrent infection

Question 24

incubation of genital herpes

Answer 24

2-14 days

Question 25

explain the clinical presentation in the 1ST EPISODE of a genital herpes infection

Answer 25

there will be severe, painful, pus lesions on the external genitalia. local discharge, itching, burning pt will have flu like symptoms

Question 26

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....

Answer 26

7-10 days

Question 27

differentiate between the length of viral shedding in the 1st episode vs recurrent infection of genital herpes

Answer 27

1st - virus shedding lasts around 12 days recurrent - virus shedding lasts around 4 days

Question 28

true or false MAJORITY of pts have RECURRENT genital herpes infections

Answer 28

true

Question 29

explain the clinical presentation of recurrent genital herpes infection (which comes first - prodrome or lesions)

Answer 29

PRODROME symptoms come BEFORE the lesions appear pt may get mild burning or itching - this means they're about to have an outbreak

Question 30

which has MORE lesions - primary genital herpes infection or recurrent? which lesions are there for longer?

Answer 30

primary has more lesions and also lasts longer

Question 31

recurrences and asymptomatic shedding in genital herpes infection are more common in HSV1 or HSV2 infection

Answer 31

HSV2

Question 32

GOAL for treating the initial episode of a genital herpes infection

Answer 32

to relieve the symptoms and shortern the duration

Question 33

treatment for initial episode of genital herpes infection

Answer 33

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

Question 34

explain the treatment for genital herpes infection, in which we are treating a RECURRENT INFECTION

Answer 34

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

Question 35

differentiate between when suppressive vs episodic genital herpes therapy would be given to a patient

Answer 35

suppressive - given to patients who have more frequent outbreaks or have partners - want to prevent transmission episodic - for patients with mild or infrequent recurrences

Question 36

differentiate between the length of therapy/dosing for episodic vs suppressive recurrent genital herpes treatment

Answer 36

episodic - shorter durations but higher dosing suppressive - DAILY dosing, but lower doses

Question 37

important counseling points for patients with genital herpes

Answer 37

-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

Question 38

can condoms eliminate the risk for transmitting genital herpes

Answer 38

NO can reduce the risk, but not eliminate

Question 39

name 3 STI's that are characterized by vaginal discharge

Answer 39

bacterial vaginosis trichomoniasis vulvovaginal candidiasis

Question 40

in baterial vaginosis, how does the infection happen?

Answer 40

the vaginal flora is replaced with anaerobic bacteria like ureaplasma, mycoplasma, G. vaginalis

Question 41

what are some risk factors for getting BV (bacterial vaginosis)

Answer 41

multiple sex partners, not using comdoms, new sex partner, lack of vaginal lactobacilli

Question 42

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

Answer 42

FALSE while BV-associated bacteria is found there, treating the male is not beneficial

Question 43

true or false BV treatment is only recommended for women with symptoms

Answer 43

TRUE

Question 44

3 potential recommended regimens for patients with bacterial vaginosis

Answer 44

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

Question 45

counseling point for each of the 3 potential regimens for bacterial vaginosis

Answer 45

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

Question 46

Trichomoniasis is caused by what bacteria

Answer 46

trichomonas vaginalis

Question 47

true or false most patients with a trichomoniasis infection have symptoms

Answer 47

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

Question 48

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

Answer 48

TRUE

Question 49

as mentioned, patients with trichomoniasis infections typically have minimal-no symptoms do we still treat them with antibiotics?? why or why not

Answer 49

YES bc trichomoniasis infection is associated with 2-3x risk of getting HIV and having adverse pregnancy outcomes

Question 50

goals of treating trichomoniasis

Answer 50

reduce the symptoms and signs of infection -- and to reduce transmission

Question 51

recommended regimen for trichomoniasis in: -women -men -alternative for women and men

Answer 51

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

Question 52

Counseling points when giving trichomoniasis treatment when should they be retested?

Answer 52

NO ALC no sex until patient AND THE PARTNER are treated retest within 3 months of initial tretment to ensure infection is gone

Question 53

vulvovaginal candidiasis is most commonly caused by what?

Answer 53

candida albicans

Question 54

vulvovaginal candidiasis can be classified as...... what is this based on?

Answer 54

complicated or uncomplicated complicated - recurrent, severe, nonalbicans, or immunocompromised uncomplicated - sporadic/infrequent, mild-moderate, caused by Candida albicans, nonimmunocomp

Question 55

treatment for uncomplicated vulvovaginal candidiasis treatment

Answer 55

OTC regimens - antifungal creams if they fail OTC - prescription antifungal creams (intravaginal) or fluconazole 150mg x1

Question 56

when counseling a patient being treated for vulvovaginal candidiasis, how long should you tell them the symptoms will take to go away?

Answer 56

around 3 days after starting treatment

Question 57

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?

Answer 57

see provider. dont try another OTC - need prescription

Question 58

important counseling point for patients with vulvovaginal candidiasis using creams and suppositories

Answer 58

they are oil-based - may wekaen latex condoms or diaphragms