CM/PHARM - STI & Vaginitis

Vulvovaginal Candidiasis (Yeast Infection)

• Caused by candida albicans
• Risk factors: recent antibiotic use, immunocompromise, diabetes, medications like SGLT2 and contraceptives, and pregnancy
• Symptoms: pruritis, burning pain, thick, curd-like vaginal discharge
• Diagnosis: clinical history, findings, and wet mount with KOH
• Treatment: fluconazole (single dose or 150mg every 72 hours for 3 doses) or topical azole medication (short course of 1-3 days)

Trichomoniasis

• Caused by a single-celled flagellated protozoan
• Often presents with bacterial vaginosis
• Symptoms: vaginal irritation, malodorous, froth, yellow/green discharge
• Key cervical finding: punctate hemorrhages on vaginal and cervix
• Diagnosis: gold standard is Nucleic Acid Amplification Test (NAAT) using Genprobe, initial test is wet mount showing motile, flagellated organisms
• Treatment: metronidazole (500mg twice a day for 7 days for women, 2g single dose for men)
• Partner treatment and abstinence from sex for 2 weeks post-treatment are necessary

Bacterial Vaginosis (BV)

• Caused by Gardnerella vaginalis
• Not a sexually transmitted infection (STI)
• Risk factors: being sexually active with a new partner or multiple partners, women who have sex with women, douching, and smoking
• Symptoms: thin white/gray vaginal discharge with a fishy odor
• Diagnosis: Amsel's Criteria (at least 3 of the following: gray/white discharge, clue cells on wet mount, vaginal fluid pH > 4.5, positive whiff/amine test)
• Treatment: metronidazole or clindamycin cream
• Male partners do not need treatment
• Asymptomatic patients do not need treatment

Chlamydia

• Highest reported STI in the United States
• Risk factors: young age, new or multiple sex partners, history of STIs, and/or inconsistent condom use
• Symptoms: cervicitis, cervical discharge, lower abdominal pain, fever, chills, and adnexal tenderness in women; urethritis, penile discharge, and dysuria in men
• Diagnosis: gold standard is Nucleic Acid Amplification Test (NAAT) using Genprobe
• Treatment: doxycycline (100mg twice a day for 7 days) or Azithromycin (1g single dose)
• Partner treatment and testing for cure in 3 months are necessary

Human Papillomavirus (HPV)

• Group of nonenveloped, icosahedral viruses classified within the family Papillomaviridae
• Composed of double-stranded DNA and divided into two major functional regions: early (E) and late (L) regions
• Highly species-specific, infecting humans exclusively
• Transmitted primarily through skin-to-skin contact
• Can persist in the host for varying durations, cleared by the immune system in most cases
• Clinical presentation varies depending on the affected site and type of virus
• Associated with various forms of cancer (anal, cervical, vulvar, vaginal, and oropharyngeal)
• Laboratory studies: detection using molecular techniques like polymerase chain reaction (PCR)
• Prevention strategies: promoting safe sexual practices, improving hygiene, and encouraging vaccination

Gonorrhea

• Found with a co-infection of chlamydia in 50% of cases
• Recommended routine screening annually for patients 25 years of age and younger
• Caused by Neisseria Gonorrhea, a gram-negative diplococci
• Presents exactly the same as Chlamydia
• Diagnostic gold standard: NAAT Genprobe
• Treatment: ceftriaxone (500mg IM injection single dose) or azithromycin (1g single dose)
• Partner treatment and abstinence from sex for 2 weeks post-treatment are necessary

Syphilis

• Caused by Treponema pallidum
• Transmitted through direct contact with an infected lesion
• Symptoms: painless papules that ulcerate into a 1-2 cm chancre with raised indurated margins
• Secondary syphilis: diffuse, symmetric maculopapular eruption involving the entire trunk and extremities
• Diagnosis: non-treponemal test (first test to screen for the bacteria), treponemal test (to confirm the diagnosis by finding syphilis antibodies)
• Treatment: penicillin (IM injection), even if an allergy is present
• Late (tertiary) syphilis: patient often presents with neurological deficits, blindness, and dementia, and internal organ damage

Human Immunodeficiency Virus (HIV)

• Retrovirus that targets and infects key components of the human immune system
• Three stages: asymptomatic HIV infection, clinical latency, and AIDS
• Stages can progress from initial infection to advanced disease
• Symptoms: may not experience any symptoms, may appear healthy, but can still transmit the virus
• Diagnosis: NAAT Genprobe
• Treatment: antiretroviral therapy (ART)

Lymphogranuloma Venereum (LGV)

• Subtype of Chlamydia trachomatis
• Presents in three stages: primary, secondary, and late
• Primary: genital ulcer or mucosal inflammation reaction at the site of inoculation
• Secondary: local direct extension of the infection to the regional lymph nodes, called "buboes"
• Late: fibrosis and strictures in the anogenital tract
• Diagnosis: NAAT
• Treatment: doxycycline (100mg twice a day for 21 days)

Pelvic Inflammatory Disease (PID)

• Ascending acute infection of the upper genital tract
• Caused by untreated Gonorrhea and Chlamydia
• Symptoms: lower abdominal pain, vaginal discharge, cervical discharge, fever, dyspareunia
• Diagnosis: presumptive clinical diagnosis using history and physical exam findings
• Treatment: ceftriaxone (500mg IM for one dose), doxycycline (100mg twice a day for 14 days), and metronidazole (500mg twice a day for 14 days)
• Complications: infertility, increased risk of ectopic pregnancies, and Fitz-Hugh-Curtis Syndrome

Non-Gonococcal Urethritis (NGU)

• Inflammation of the urethra that is not caused by Neisseria gonorrhea

• Diagnosis: urinalysis, microscopic examination of first-void urine sediment, urethral swabs, and culture testing

• Causes: Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, Ureaplasma urealyticum, Haemophilus vaginalis, and Herpes simplex virus

• Treatment: azithromycin or doxycycline are commonly prescribed for Chlamydia trachomitis infections

• CDC recommends considering M.genitalium infection in cases of persistent or recurrent urethritis### Genital Herpes (Herpes Simplex)

• Caused by strains HSV1 and/or HSV2

• Highly common disease that can present with latency

• HSV can remain latent in the nerve root ganglion and be reactivated by changes in the immune system

• Patients tend to report a prodrome of burning, tingling, and itching, followed by an outbreak of painful vesicles on an erythematous base

• Most outbreaks resolve spontaneously after 10-19 days

Diagnosis and Treatment

• Diagnosed in the clinical setting with viral cultures or PCR swabs if the patient has active lesions
• A Tzanck smear finding of “multi nucleated giant cells” is a key diagnostic finding in HSV
• Primary outbreaks should be treated for 7-10 days with antivirals
• Recurrent outbreaks should be treated for 1-5 days with antivirals
• Antivirals used for HSV include Acyclovir, Valacyclovir, and Famicilovir
• Patients with recurrent HSV infection or pregnant patients can take a daily dose of antivirals to suppress the virus and decrease the risk of spreading the disease to partners

Transmission and Prevention

• Can be transmitted from mother to infant before, during, and after delivery
• Prophylaxis is recommended to be started at 36 weeks gestation in known cases of HSV
• A c-section is preferred if a pregnant woman has an active infection of HSV at time of delivery
• Neonatal HSV can cause localized skin, eye mouth disease (SEM), CNS disease, and/or disseminated disease

Human Papilloma Virus (HPV)

• Most prevalent STI, with at least 50% of sexually active people contracting the virus in their lifetime
• Most patients will clear an HPV infection within 2 years
• Can present as a cutaneous viral infection with flat, common, and plantar warts
• Can present as a mucocutaneous viral infection with genital warts, squamous intraepithelial lesions, or carcinomas of the vagina, vulva, cervix, anus, or penis
• Can impact the oral and respiratory mucosa
• Most patients with HPV are asymptomatic
• Visible anogenital warts present as “soft, flesh colored single or multiple flat, cauliflower-like lesions”
• HPV 16 and 18 account for 70% of cervical cancers
• Gardasil 9 vaccine can be given as a 2 dose series, 6 months apart, if started between ages 9 to 14