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Sexually Transmitted Diseases Treatment and Management

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Title: Sexually Transmitted Diseases Treatment and Management


1
Sexually Transmitted DiseasesTreatment and
Management
  • October, 2009
  • Divya Ahuja, MD
  • Associate Professor of Medicine

2
Syndromic approach
Genital Ulcer disease Syphilis Genital Herpes Chancroid Donovanosis LGV Urethritis/cervicitis Gonorrhea NGU/MPC( C. trachomatis, U. urealyticum, M. genitalium) Vaginal discharge Trichomoniasis Bacterial vaginosis Candidiasis
3
Case 1
  • 24 year male, sexually active
  • Presents with 4 day history of dysuria and penile
    discharge

4
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5
Gonorrhea
  • Agent Neisseria gonorrhoeae
  • Epidemiology
  • highest rates in Southeastern States
  • females and males between 15 to 34 represent
    80 of the cases
  • 400,000 new reported infections per year in US
  • 20 to 50 transmission risk per exposure
  • female-to-male transmission 20 per episode,
    rising to 60-80 after 4 or more exposures

6
Gonorrhea Rates by state United States and
outlying areas, 2003
Gonorrhea
Note The total rate of gonorrhea for the United
States and outlying areas (including Guam, Puerto
Rico and Virgin Islands) was 114.7 per 100,000
population. The Healthy People year 2010
objective is 19.0 per 100,000 population.
Source CDC/NCHSTP 2003 STD Surveillance Report
7
Clinical Manifestations- Male
  • Symptoms of Acute anterior urethritis (gt95)
  • Scant urethral discharge at onset
  • discharge
  • dysuria
  • spontaneous resolution over several weeks
  • Complications
  • Epididymitis relatively infrequent
  • Penile edema, urethral stricture, prostatitis
  • Disseminated gonococcal infection (DGI)

8
Clinical Manifestations- Female
  • Muco-purulent cervicitis
  • 1/3rd of cervical infections are subclinical
  • Cervical abnormalities may include
  • Discharge, erythema, mucosal bleeding
  • Adnexal tenderness
  • Complications
  • Pelvic Inflammatory Disease (PID)
  • 10 to 20 of non-pregnant women with GC

9
Diagnosis
  • Gram- Stained Smear
  • Positive smear is considered diagnostic in men
    ( gt99 specificity)
  • In women however, a culture is needed as
    sensitivity of gram stain is 50
  • Only culture tests are approved for rectum,
    pharynx and abuse cases

10
What is the diagnosis if this patient has a
monoarthritis and penile discharge?
11
Disseminated Gonococcal Infection (DGI)
  • Arises from Gonococcal bacteremia
  • Think of gonococcus in a monoarthritis
  • Acute arthritis-dermatitis syndrome
  • arthritis usually involves wrist, fingers, toes,
    ankle knee joints
  • tender, necrotic pustule
  • Tenosynovitis

12
Tx of Uncomplicated Infection of Cervix, Urethra
Rectum
  • Ceftriaxone 125 mg IM in a single dose OR
  • Cefoxitin 2 gm IM with Probenecid 1gm PO
  • Cefixime 400 mg by suspension OR
  • If PCN allergy
  • Spectinomycin 2gm IM X 1
  • Azithromycin 2 gm PO X 1
  • Plus if Chlamydia is not Ruled Out
  • Azithromycin 1 g po in a single dose or
  • Doxycycline 100 mg po bid x 7 days

13
Increasing Quinolone Resistance
  • CDC Update,MMWRApril 2007/56(14)332-336
  • Data from GISP (1986-ongoing)
  • 2000 Quinolone Resistance in Asia and Hawaii
  • 2002 California
  • 2004 MSM
  • 2007 Now not recommended for any gonococcal
    infection, heterosexuals or PID
  • The resistance rate in MSM is upto 38.3
  • In Heterosexual males about 6.7

14
MUCOPURULENTCERVICITIS (MPC)
  • Typical causes
  • Chlamydia trachomatis
  • N. gonorrhoeae
  • Rarely M. genitalium and BV
  • Remember douching, chemical irritants
  • In most instances an organism is not isolated

15
Chlamydia
  • Epidemiology
  • most common bacterial STD in the US
  • annual incidence in US is estimated _at_ 3 million
    cases
  • 70 to 80 of infected women are asymptomatic
  • 50 of infected men are asymptomatic
  • Peri-natal transmission results in neonatal
    conjunctivitis in 30-50 of exposed babies

16
Chlamydia Rates by state United States and
outlying areas, 2003
Chlamydia
Note Includes states and outlying areas that
reported chlamydia positivity data on at least
500 women aged 15-24 years screened during 2003.
SOURCE Regional Infertility Prevention Projects
Office of Population Affairs Local and State STD
Control Programs Centers for Disease Control and
Prevention Source CDC/NCHSTP 2003 STD
Surveillance Report
17
Chlamydia Clinical Manifestation-Male
  • Urethritis
  • Dysuria
  • Discharge
  • Proctitis
  • Only 1 of 8 infected men followed without Rx
    developed symptoms

18
Chlamydia Clinical Manifestation - Female
  • Mucopurulent cervicitis (MPC)
  • PID/ Infertility/ Ectopic pregnancy
  • Antibodies to C. trachomatis present in 75 of
    women who are infertile due to tubal obstruction
    vs. 25 of controls
  • Upto 40 of females with untreated Chlamydia will
    develop PID
  • Urethritis
  • Endometritis

19
CHLAMYDIA - DIAGNOSIS
  • Leucorrhea gt 10 WBC per high power field
  • Non-Amplified Antigen Tests
  • Enzyme Immunoassay, DNA Probe
  • Nucleic Acid Amplification Tests
  • PCR, PROBE-TEC, TMA, etc.

20
Chlamydia Treatment
  • Azithromycin 1.0 Gm PO in a single dose
  • OR
  • Doxycycline 100 mg orally bid x 7 days
  • Alternative regimen
  • Erythromycin base 500 mg po qid x 7days OR
  • Ofloxacin 300 mg po bid x 7 days
  • Dual treatment (GC/Chlamydia)
  • Treat sex partners
  • Abstain from sex for 7 days

21
URETHRITIS
  • Gonococcal (GC)
  • Neisseria gonorrhoeae
  • Nongonococcal (where GC is negative)
  • Chlamydia trachomatis
  • Mycoplasma genitalium
  • Ureaplasma urealyticum
  • Trichomonas vaginalis
  • Herpes simplex virus
  • Cause unknown

22
Gonococcal Urethritis
23
Nongonococcal Urethritis
24
DIAGNOSIS OF URETHRITIS
  • Visibly abnormal discharge
  • OR
  • Gram Stain - abnormal number of leukocytes
  • Urethral Gram stain (5 or more WBC/OIF)
  • First-void urine
  • 10 or more WBC/HPF
  • Positive leukocyte esterase test

25
Nongonococcal Urethritis- Treatment
  • Recommended Regimens
  • Azithromycin 1 g po in a single dose or
  • Doxycycline 100 mg po bid x 7 days
  • Alternative Regimens
  • Erythromycin base 500 mg po qid x 7 days
  • Erythromycin ethylsuccinate 800 mg po qid x 7days
  • Ofloxacin 300 mg po bid x 7 days
  • Levofloxacin 500 mg po daily x 7 days

26
Pelvic Inflammatory Disease
  • Pathogens
  • N. Gonorrhoeae, C. trachomatis
  • Anaerobes, Gardnerella vaginalis, mycoplasma
  • gram-negative rods, S. agalactiae
  • Spectrum of disorders
  • Salpingitis
  • Endometritis
  • Tuboovarian abscess
  • Peritonitis

27
Pelvic Inflammatory Disease
28
Clinical Criteria
  • Symptoms
  • Abnormal bleeding
  • Dyspareunia
  • Vaginal Discharge
  • Fever
  • Minimum Criteria
  • lower abdominal pain, adnexal OR cervical motion
    tenderness
  • Specific Criteria
  • Transvaginal sonography, Laparoscopy

29
Indications for hospitalization in suspected PID
  • Surgical emergencies cannot be ruled out
  • Pregnancy
  • Severe illness, nausea/vomiting, high fever
  • Tubo-ovarian abscess
  • Cannot tolerate oral regimen
  • Does not respond to out-patient Rx

30
TREATMENT OF PID
  • PARENTERAL REGIMENS
  • Cefoxitin 2 g IV Q 6hrs OR Cefotetan 2g IV Q 12
  • PLUS Doxycycline 100 mg PO/IV Q 12
    hrs OR
  • ORAL REGIMEN
  • Ceftriaxone 250 mg IM in a single
    dose PLUSDoxycycline 100 mg orally twice a day
    for 14 days   WITH OR WITHOUTMetronidazole 500
    mg orally twice a day for 14 days

31
PID
  • COMPLICATIONS
  • Infertility
  • Ectopic pregnancy 80 have antibodies to
    Chlamydia
  • Chronic pelvic Pain in 18
  • INFERTILITY AFTER PID
  • One episode 10
  • Two episodes 20
  • Three or more episodes 40
  • Westrom et al. Sex Transm Dis 1992185-192

32
HPV EPIDEMILOGY
  • Mostly (over 90) asymptomatic
  • Over 35 genital types
  • External genital warts
  • Types 6, 11, 42, 43, 44, 58
  • Cervical cancer
  • Types 16, 18, 31, 33, 39
  • Most common viral STD
  • Transmitted by direct sexual contact
  • Vaccines now approved and in clinical use

33
Clinical Manifestations of Genital Warts
Atlas fig 8.13 Page 297
Smooth papular warts
Condylomata acuminata
Flat cervical condylomata
Keratotic flat wart
34
CLINICAL PRESENTATION OF GENITAL WARTS VULVA
35
Perianal Wart
HPV and Cervical Cancer
Source Cincinnati STD/HIV Prevention Training
Center
36
PROVIDER applied TREATMENT
PATIENT APPLIED TREATMENT
  • Cryotherapy
  • Liquid nitrogen or cryoprobe. Every 1-2 weeks
  • Podophyllin resin
  • Repeat weekly as needed
  • Trichloroacetic acid
  • Repeat weekly is needed
  • Surgical removal
  • Podofilox (Condylox) 0.5 solution or gel
  • Apply bid for 3 days followed by 4 days of no
    therapy. Repeat three cycles if needed
  • Imiquimod (Aldara) 5 cream
  • Apply at bedtime three times a week. Upto 16 weeks

37
Case 4
38
Genital ulcer-Does it hurt?
  • Painful
  • Chancroid
  • Genital herpes simplex
  • Painless
  • Syphilis
  • Lymphogranuloma venereum
  • Granuloma inguinale

39
Whats your diagnosis?
40
Genital herpes
  • 90 - HSV-2, 10 - HSV-1
  • Estimated 400,000 episodes of primary infection
    and 20 million or more recurrent infections each
    year
  • Seropositivity is 20 between 15 and 40
  • Maternal-infant transmission
  • 50 mortality to newborn

41
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42
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43
Genital Herpes Clinical Manifestations
  • Subclinical infection
  • May be asymptomatic
  • Primary
  • inguinal node tenderness/enlargement
  • vesicular, ulcerated lesions
  • headaches, malaise and fever
  • Recurrent Herpes
  • gt 90 of patients with HSV-2 will have recurrence
  • progressively less severe over time

44
Genital Herpes
  • DIAGNOSIS
  • Tissue culture
  • Cytology (Tzanck Smear)
  • Direct Fluorescent Antibody
  • Nucleic Acid Amplification
  • SEROLOGY
  • TREATMENT
  • Initial Episode
  • Acyclovir (Zovirax) 400 mg po tid x 7-10 days
  • Famciclovir 250 mg po tid x 7 to 10 days
  • Valacyclovir (Valtrex) 1 g po bid x 7-10 days
  • Extend RX if healing is incomplete after 10 days
    of therapy

45
Case 3
  • 28 year HIV positive male with CD4 of 250
  • Fever, malaise and a rash
  • Sex with a number of male partners
  • Penile ulcer on following slide

46
Whats your diagnosis?
47
Syphilis
  • Pathogen T. pallidum
  • Primary Syphilis
  • Painless, indurated chancre
  • Appears 9-90 days after infection
  • 25 are multiple lesions
  • Regional lymphadenopathy, rubbery, painless
  • Neurosyphilis
  • Can coexist with early, secondary or tertiary
    syphilis
  • Ranges from asymptomatic to General paresis

48
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49
Secondary Syphilis
  • Secondary lesions appear 4-10 weeks after primary
    chancre
  • Rash in 80-90
  • In 60 will involve palms and soles
  • Mucus patches
  • Condylomata lata
  • Heaped, moist wartlike papules
  • Myalgia , headache, fever

50
Rash of Secondary Syphilis
51
Latent Syphilis and Neurosyphilis
  • Latent
  • No clinical manifestations
  • Evidence is positive serology
  • Early- lt 1 year, Late- gt 1 year
  • CSF analysis
  • neurologic or ophthalmic signs/sx, active
    tertiary disease, tx failure, HIV infection
  • Some experts recommend CSF exam in those with
    nontreponemal titer of gt132

52
Tertiary Syphilis
  • Tertiary
  • Late benign syphilis
  • Cardiovascular
  • Obliterative endarteritis of aortic vasovasorum
  • Average duration is 15 years
  • CNS (paresis,
  • dementia, tabes)

53
Diagnosis
  • A positive darkfield is diagnostic
  • Serology
  • Nontreponemal RPR, VDRL
  • False positive in lupus etc.
  • Monitor titers for cure/relapse
  • Treponemal tests- used for confirmation of a
    positive RPR
  • FTA-Abs, MHATP
  • RPR (VDRL) is positive in 70 of primary, 99 of
    secondary, and 56 of late (tertiary) patients
    with syphilis
  • A Lumbar puncture is needed to determine
    neurosyphilis

54
Treatment
  • Primary and Secondary syphilis
  • Preferred Benzathine PenicillinG , 2.4 million
    units IM in a single dose
  • Alternative (PCN allergy) Doxycycline 100mg PO
    BID X14 days
  • Latent Syphilis
  • Early Benzathine PCN 2.4 million units IM X1
  • Late latent or syphilis of unknown duration
    Benzathine penicillin G 2.4 million units IM X 3
    doses (one dose a week)

55
Treatment
  • Neurosyphilis
  • Aqueous crystalline penicillin G, 18- 24 million
    units IV in divided doses a day for 10-14 days
  • Procaine penicillin, 2.4 million units IM a day
    PLUS Probenecid 500 mg PO, 4 times a day, both
    for 10-14 days
  • Alternative Ceftriaxone 2 gm IV/IM X 10- 14 days
  • Pregnancy
  • Penicillin is the only recommended therapy
  • Desensitize if necessary
  • Advise patient about Jarisch- Herxheimer reaction

56
Chancroid
  • Etiology Haemophilus ducreyi
  • Incubation 4-10 days
  • Diagnosis
  • gt 1 painful ulcer and regional lymphadenopathy
  • Negative tests for syphilis and HSV
  • Poor sensitivity of lab tests so clinical
    diagnosis
  • Ceftriaxone 250 mg IM X 1

57
Granuloma inguinale (Donovanosis)
  • Common in developing countries
  • Etiology Calymmatobacterium granulomatis
  • Incubation 2-3 weeks
  • Painless nodules that enlarge and ulcerate
  • Treatment
  • Tetracycline
  • Trimethoprim/sulfa

58
Lymphogranuloma venereum
  • Endemic in Africa, South America
  • Chlamydia trachomatis serovars L1, L2, L3
  • Transient genital ulcer, buboes
  • Diagnosis serology
  • Treatment
  • Doxycycline
  • Azithromycin
  • Lymph nodes fibrose

59
Trichomonas vaginalis
  • Flagellated protozoan
  • Causes intense pruritus, discharge
  • Diagnosis is with Wet mount, culture and antigen
    testing
  • Treatment
  • Metronidazole 2 gm x 1 dose
  • Tinidazole 2 gm x 1 dose

60
What not to do
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