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Chapter 135 SEXUALLY TRANSMITTED INFECTIONS Sexually Transmitted Infections: Differential Diagnosis  Urethritis  Vaginal infections  STIs (related to cervicitis, PID, and other STIs)  Interstitial cystitis  Atrophic vaginitis  Sexually Transmitted Infections: Defini...

Chapter 135 SEXUALLY TRANSMITTED INFECTIONS Sexually Transmitted Infections: Differential Diagnosis  Urethritis  Vaginal infections  STIs (related to cervicitis, PID, and other STIs)  Interstitial cystitis  Atrophic vaginitis  Sexually Transmitted Infections: Definition  In the United States the most prevalent STIs are  Human papillomavirus (HPV), chlamydia, trichomoniasis, gonorrhea, genital herpes, syphilis, HIV, and hepatitis B  Transmitted by anal, oral, or vaginal sex with an infected individual  Transmitted through pregnancy, childbirth, and breastfeeding through infected blood/blood products  Symptoms are not always present, and knowing if sexual partners are infected can be challenging.  There are federally funded programs for chlamydia, gonorrhea, and syphilis.  Chlamydia continues to be the most commonly reported nationally notifiable disease.  Gonorrhea is the second most commonly reported disease in the US. Infections due to Neisseria gonorrhea are a major cause of PID in the US, resulting in serious outcomes in women including tubal infertility, ectopic pregnancy, and chronic pelvic pain. They also facilitate the transmission of HIV infection.  Syphilis is a genital ulcerative disease caused by Treponema pallidum. It can leave significant complications if left untreated and can facilitate the acquisition and transmission of HIV infection. Primary and secondary syphilis represent the earliest stages of syphilis and reflect symptomatic disease.  Race: Blacks are disproportionally affected by chlamydia, gonorrhea, and syphilis.  Factors that contribute to this disparity include poverty, lack of health care access, and high prevelance of STDs in the community. Sexually Transmitted Infections: Clinical Presentation  A significant number of persons with STIs have no apparent signs or symptoms.  More than one site may be infected simultaneously (e.g., cervix plus urethra).  Symptoms may overlap and involve more than one pathogen.  The CDC suggests talking with patients about the five Ps: partners, practices, protection from STDs, past history of STDs, and prevention of pregnancy.  An effective sexual history is crucial for diagnosis and for counseling individuals with regard to risk reduction behaviors.  Because STIs don’t always manifest with symptoms, determination of which patients are at risk necessitates a thorough sexual history.  Ages 15-24 acquire half all of new STDs  Prevalence rates for many STDs are highest among adolescents and young adults  Eliciting the history and physical exam for an STI needs to be routine, standardized, and guided by individual’s age. Sexually Transmitted Infections: Physical Exam and Diagnostics  Maintain sensitivity and open discussion with focused minimal clinical exam.  Void prior to exam for comfort  Obtain a first- void urine specimen to test for UTI, gonorrhea, or chlamydia.  Obtain sexual history.  Partners of persons with identified STIs are evaluated and treated on the basis of their last sexual encounter and the particular STI in question.  Urine can be tested for gonorrhea and chlamydia  Culture, nucleic acid hybridization tests, and nucleic acid amplification tests (NAATs) through a urine sample are critical tools used to diagnose gonorrhea and chlamydia. Sexually Transmitted Infections: Management  Treatment is individualized to the cause because there is a broad spectrum of sources with STDs.  A number of different organisms may be associated with different syndromes (Ex. Genital ulcers can result from herpes, cancroid or syphilis).  Major curable syndromes in adults include genital ulcers, urethritis vaginitis, cervicitis, and PID  Antimicrobial therapy is available for all bacterial STIs as well as for those caused by protozoa and ectoparasites.  In the US, treatments are frequently initiated against common pathogens causing the symptoms while lab results are pending.  Antimicrobial therapy is available for bacterial STDs.  Drugs for viral STIs are largely limited to symptom alleviation because they cannot eradicate the organism.  CDC standards have treatment regimens.  Expedited partner treatment (EPT) is a treatment where providers give prescriptions to the patient for STI treatment in their sexual partner.  Gonorrhea-Neisseria gonorrhoeae  Differential diagnosis: NGU, PID, Candidiasis, Bacterial vaginosis, endometriosis, pregnancy, salpingitis, orchitis, trichomoniasis, UTI, epididymitis  Bacterial gram negative STD caused by Neisseria gonorrhoeae  In men, characterized by purulent urethral discharge, but is asymptomatic in up to 80% of women. Lab confirmation of the presence of Neisseria gonorrhoeae is required for a diagnosis.  At risk: young, sexually active individuals, nonwhite urban poor, and individuals who engage in high risk behavior such as illicit drug use or prostitution.  Can be cultured from the GU tract, oropharynx, and rectum.  Produces urethritis in men and cervicitis in women.  Leading cause of infertility in women in the US  Female symptoms: develop within 10 days, can have thin, purulent, mildly odorous leukorrhea, dysuria, intermenstrual bleeding, dyspareunia (lower abdominal pain), pharyngitis. Can develop to PID in 10-20% of women, symptoms of PID include lower abdominal pain, vaginal discharge, urethral discharge, dysuria, cervical motion tenderness, adnexal tenderness/mass, menstrual bleeding, fever, chills, nausea, vomiting.  Male symptoms: develop within 2-5 days, cam have urethritis (burning on urination, serous penile progressing to copious purulent, blood tinged discharge, testicular pain, and nausea and vomiting.  Reportable diagnosis to the health department. Gonorrhea-Neisseria gonorrhoeae Gonorrhea-Neisseria gonorrhoeae  Clinical Presentation:  Purulent urethral discharge  Dysuria  Puritus  Anorectal burning  Skin lesions  Diagnosis:  NAAT’s –vaginal swab in women, first catch urine in men.  Culture (gram stain of discharge smear) that shows gram negative diplococci and WBCs. Gonorrhea-Neisseria gonorrhoeae  Complications:  Prostatitis  Epididymitis (painful testicle condition that can lead to infertility).  Cystitis  Major cause of PID, ectopic pregnancy, and chronic pelvic pain  Gonococcal conjunctivitis Gonorrhea-Neisseria gonorrhoeae  Treatment: Treat presumptively for chlamydia  Specimen testing for gonorrhea should occur before testing.  Partners are evaluated and treated.  Perform syphilis serology.  Offer HIV counseling and testing. Gonorrhea-Neisseria gonorrhoeae  Uncomplicated Gonococcal infections  Recommended Regimens:  Ceftriaxone 250mg IM in a single dose to treat gonorrhea PLUS Azithromycin 1 gram PO in a single dose to treat chlamydia.  Alternative: Doxycycline 100 mg PO twice daily for 7 days (azithromycin preferred)  Gonorrhea-Neisseria gonorrhoeae  Alternative Regimens  If Ceftriaxone NOT AVAILABLE:  Cefixime 400mg po in a single dose Plus Azithromycin 1 gram PO in a single dose  Alternative: Doxycycline 100mgPO twice daily for 7 days (azithromycin is preferred) Plus Test –of-cure in 1 week Gonorrhea-Neisseria gonorrhoeae  If patient has a Severe Cephalosporin Allergy:  Azithromycin 2 Grams PO in a single dose Plus Test-of Cure in 1 week  Uncomplicated Gonococcal infection of the Pharynx  Ceftriaxone 250 mg IM in a single dose  OR Doxycycline 100mg PO twice daily X 7 days (Azithromycin preferred)  Pregnant Women:  Ceftriaxone 250 mg IM in a single dose Plus Azithromycin 1 Gram in a single dose  Alternative Regimen for Pregnant Women:  Azithromycin 2 Grams in a single dose Gonorrhea-Neisseria gonorrhoeae  Education  Annual screening for gonorrhea is recommended for all sexually active women < 25 years. Chlamydia-Chlamydia trachomatis  Differential Diagnosis:  PID, gonorrhea, candidiasis, bacterial vaginosis, endometriosis, pregnancy, salpingitis, orchitis, epididymitis, trichomoniasis, UTI Chlamydia-Chlamydia trachomatis  Caused by bacteria called Chlamydia trachomatis  Most commonly reported and most common bacterial STD.  Clinical presentation:  Often asymptomatic  May infect the lungs and eyes  Female: Abnormal vaginal discharge (yellow or green), Vaginal bleeding, dysuria, cervical friability or edema. Chlamydia should be suspected in females with cervicitis on the basis of cervical discharge, easily induced bleeding, and edema in the area of ectopy.  Male: Dysuria, penile discharge, itching  Those having receptive –anal intercourse: Rectal pain, discharge, bleeding Chlamydia-Chlamydia trachomatis Chlamydia-Chlamydia trachomatis  Diagnosis:  NAAT’s- preferred method of testing for chlamydia.  Vaginal (endocervical) swab. Can be coupled with liquid based Pap smears at wellness visits (like gonorrhea).  First catch urine  Pharyngeal or rectal samples  Culture Chlamydia-Chlamydia trachomatis  Complications:  Reactive arthritis  Chronic conjunctivitis  Female:  PID, infertility, ectopic pregnancy, chronic pelvic pain  Male:  Epididymitis, orchitis, proctocolitis  Infant:  Conjunctivitis , pneumonia  Treated prophylactically in OR Erythromycin Chlamydia-Chlamydia trachomatis  Education  All sexually active women < 26 years and all pregnant women should be screened for chlamydia. Routine screening not currently recommended for men  Management  Collect specimen.  Treat presumptively in patients with PID, NGU, gonoccal infection, epididymitis in men less than 35 year old.  Perform syphilis serology  Offer HIV counseling and testing Chlamydia-Chlamydia trachomatis  Recommended Regimen:  Azithromycin 1 Gram PO in a in a single dose Or Doxycycline 100 mg twice daily x7days.  Alternative regimens:  Erythromycin base 500mg PO 4 X daily for 7 days, Or ofloxacin 300mg PO twice daily x 7 days, or  Levofloxacin 500mg PO once daily x 7 days.  Pregnant Women:  Azithromycin 1 Gram PO in a single dose Or Amoxicillin 500mg PO 3 x daily X 7 days. Nongonococcal Urethritis  C. trachomatis (23%-55% of cases)  Ureaplasma urealyticum (20%-40% of case)  Trichomonas vaginalis (25% of cases)  Urethritis is characterized by the discharge of mucoid or purulent material and burning upon urination.  Differential Diagnosis:  PID, gonorrhea, candidiasis, bacterial vaginosis, endometriosis, pregnancy, salpingitis, orchitis, epididymitis, trichomoniasis, UTI Nongonococcal Urethritis Nongonococcal Urethritis  NOT caused by an STD  Clinical Presentation:  Dysuria  Mucoid or purulent discharge  Pruritus  Hematuria  Frequency  Urgency  Endocervical exudate, friability Nongonococcal Urethritis  Diagnosis:  Gram Stain  Wet mount  Test for Gonorrhea and Chlamydia Nongonococcal Urethritis  Complications:  Epididymitis  Penial Edema  Reiter Syndrome  Tenosynovitis Nongonococcal Urethritis  Management:  If microscopic test results are not available, treat for both Gonorrhea and Chlamydia Nongonococcal Urethritis  Recommended Regimen:  Azithromycin 1Gram PO in a single dose OR Doxycycline 100mg PO twice daily X 7 days. Primary Syphilis-Treponema palidum  Caused by Treponema palidum  Differential Diagnosis:  Genital Herpes, chancroid, LGV; Balanitis, excoriation of nonulcerative lesions, squamous cell carcinoma  Clinical Presentation:  Painless firm round chancre sores at site of inoculation, lasts 3-6 weeks, Discrete enlarged painless regional lymph nodes.  May resolve spontaneously without treatment. The patient enters the latent stage, in which there are generally no clinical signs of symptoms and diagnosis is made off of serology  Incubation 10-90 days: average, 21 days. Primary Syphilis-Treponema pallidum Primary Syphilis-Treponema pallidum Primary Syphilis-Treponema pallidum  Diagnosis:  Darkfield microscopy and direct fluorescent antibody tests are the definitive methods for diagnosis of early syphilis, but not used in practice today because of their complexity.  Nontreponemal serology (RPR, VDRL) for screening but not used diagnostically due to give out false positives.  Confirm with treponemal serology (MHA-TP, FTA-ABS)  Sequential serology testing: use same testing method and laboratory Primary Syphilis-Treponema pallidum  Complications:  Secondary Syphilis  Meningitis  Cardiovascular or neurologic disease (blindness, dementia, loss of pain sensation)  Facilitates HIV transmission  Left untreated, can cause perinatal death or congenital syphilis in infants Primary Syphilis-Treponema pallidum  Management:  Systemic disease treatment: Chancre is unnoticed in 15%-39% of cases  Perform nontreponemal serology and clinical follow up at 6 and 12 months  Note fourfold drop in titer: evaluate for HIV infection  Treatment Failure: re-treatment and consultation with specialist are indicated. Patient may need lumbar puncture. Secondary Syphilis_T. pallidum  Differential Diagnosis:  All undiagnosed mucocutaneous skin eruptions (eg. drug eruption, pityriasis rosea, scabies) Secondary Syphilis_T. pallidum Secondary Syphilis T. pallidum  Clinical presentation:  Nonpruritic rash: rough, red, red-brown spots, sometimes very faint; may occur on mucus membranes, vagina, anus, palms , soles, trunk.  Appears 2-8 weeks after chancre, may be present while chancre is resolving  Generalized adenopathy  Fever  Sore throat  Patchy alopecia  Malaise, arthralgias, weight loss, oral mucous patches,  Condylomata lata  Hepatosplenomegaly  Increased incidence is associated with crack cocaine and illicit drug use Condyloma lata Secondary Syphilis_T. pallidum  Diagnosis:  Same as primary syphilis  Complications:  Same as primary syphilis Secondary Syphilis_T. pallidum  Management:  At 6 and 12 month follow up, assess for fourfold drop in titer.  A fourfold increase in titer at any time may indicate treatment failure of reinfection Latent Syphilis (Early Latent, Late Latent) T. pallidum  Clinical Presentation:  Occur after primary and secondary symptoms resolve  Difficulty coordination muscle movements  Paralysis  Numbness  Gradual Blindness  Dementia  Positive serology without evidence of clinical disease Latent Syphilis (Early Latent, Late Latent) T. pallidum Latent Syphilis (Early Latent, Late Latent) T. pallidum  Diagnosis:  Reactive VDRL or RPR  Reactive FTA-ABS or MHA-TP  Complications:  Progression of disease Latent Syphilis (Early Latent, Late Latent) T. pallidum  Management:  Latent syphilis is diagnosed as probable on the basis of documented seroconversion or a fourfold increase in titer of nontreponemal test  History of symptoms or exposure to partner during previous 12 months.  Evaluate for aortitis, neurosyphilis iritis. Chancroid- Haemophilus ducreyi  Differential Diagnosis:  Genital herpes; primary syphilis, LGV; infected or traumatic lesions  Clinical presentation:  One or more painful genital ulcers with tender inguinal adenopathy.  May have suppurative inguinal adenopathy and undermine ulcer boarders Chancroid- Haemophilus ducreyi Chancroid- Haemophilus ducreyi  Diagnosis:  Isolation of H-ducreyi  Most cases diagnosed on clinical grounds  Painful ulcers 4-7 days  Complications:  Successful treatment cures infection  In extensive cases, scaring despite successful therapy Chancroid- Haemophilus ducreyi  Management:  Topical clearing with gentle soaks.  Symptomatic treatment to reduce swelling  Antibiotic administration to patients with nonfluctuant buboes.  No need to drain lesions  Reexamine patients in 3 – 7 days.  Larger ulcers heal more slowly  No evidence of T. pallidum appears on darkfield examination or by serology  Culture is negative for Herpes simplex virus  Partner contact: examine and treat within 10 days perform syphilis serology,  Offer HIV counseling Chancroid  Recommended Regimen:  Azithromycin 1 Gram PO in a single dose Or Ceftriaxone 250mg IM in a single dose or Ciprofloxacin 500mg PO twice daily for 3 days or Erythromycin base 500 mg PO three times daily for 7 days. Treatment of Diseases Characterized by gential ulcers  Primary, Secondary, or Latent syphilis of less than 1 year duration  Recommended Regimens:  Benzathine Penicillin G 2.4 million units IM in a single dose  If allergic to PCN:  Doxycyline 100mg PO twice a day for 14 days  Or tetracycline 500mg PO four times a day X14 days Early Latent Syphilis  Recommended Regimen:  Benzathine Penicillin G 2.4 million units IM in a single dose Late Latent Syphilis of more than 1 years duration or unknown duration  Recommended regimen:  Benzathine Penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM at 1 week intervals. Genital Herpes (primary , recurrent) HSV-2 and HSV-1  Differential Diagnosis  Primary syphilis; Chancre; candiasis; hand foot and mouth disease, herpes zoster; fixed drug eruption; folliculitis Genital Herpes (primary , recurrent) HSV-2 and HSV-1 Genital Herpes (primary , recurrent) HSV-2 and HSV-1  Clinical presentation:  Primary- vesicular lesions on erythematous base  Male- penis shaft, glans, urethra, rectum  Female- vulva, vagina, anus, cervix  Painful lesions, malaise, fever, painful adenopathy, lesions ulcerative superficial ulcers  Recurrent- clinical prodrome- pain, itching, burning, tingling constitutional symptoms rare  Vesicles superficial ulcers Genital Herpes (primary , recurrent) HSV-2 and HSV-1  Diagnosis:  History and physical examination with confirmation with viral culture  Moist swab of unroofed or weeping vesicle from base of ulcer  Tzanck smear of scrapings from lesion looking for multinucleated giant cells  Testing for HSV routine in all atypical and all undiagnosed genital ulcers. Genital Herpes (primary , recurrent) HSV-2 and HSV-1  Complications:  Secondary infections  Ocular infections  Neonatal infection  Premature delivery  Spontaneous abortion  Intrauterine growth retardation  Fetal infection  Genital Herpes (primary , recurrent) HSV-2 and HSV-1  Management:  Treatment is symptomatic infection may recur  HSV may be transmitted to sex partners even when no lesion are present  Support groups are available  Many educational resources are available Genital Herpes-First clinical episode  Recommended regimen:  Acyclovir 400mg PO 3 x daily for 7-10 days  Or Acyclovir 200mg PO 5 x daily for 7-10 days  Or Famcyclovir 250 mg PO 3 x daily for 7-10 days  Or Valacyclovir 1Gram PO twice daily for 7-10 days Genital Herpes-Recurrent Episode  Recommended Regimen:  Acyclovir 400mg PO 3 x a day for 5 days  Or Acyclovir 800mg PO 3 times per day for 2 days  Or Acyclovir 800mg PO twice daily for 5 days  Or Famcyclovir 125mg PO twice daily for 5 days  Or Famcylclovir 100mg PO twice daily for 1 day  Or Famcyclovir 500mg PO once, followed by 250mg PO twice daily x 2 days  Or Valacyclovir 500mg PO twice daily for 3 days  Or Valocyclovir 1Gram PO once daily for 5 days. Lymphogranuloma Verereum- C. trachomatis  Differential Diagnosis:  Chancroid  Colitis  Granuloma Inguinale  Herpes simplex  Syphilis Lymphogranuloma Verereum- C. trachomatis Lymphogranuloma Verereum- C. trachomatis  Clinical Presentation:  Small, nonpainful, ulcerative, genital papule  Painful inguinal or femoral lymph nodes follow 2-6 weeks later  Proctocolitis in third stage Lymphogranuloma Verereum- C. trachomatis  Diagnosis:  Based on clinical suspicion, epidemiologic information and exclusion of other etiologies.  Complications:  Patients should be followed clinically until signs and symptoms are resolved.  Person who receive a LGV diagnosis should be tested for other STI’s especially HIV, Gonorrhea and syphilis  Management:  Drainage of infected buboes  Treat with antibiotics Lymphogranuloma Verereum- C. trachomati  Recommended Regimen:  Doxycycline 100mg PO twice daily for 21 days  Or Erythromycin base 500mg PO 4 times daily for 21 days. Granuloma Inguinale- Klebsiella granulomatis  Differential Diagnosis:  Chancroid  Herpes Simplex  LGV  Syphilis Granuloma Inguinale- Klebsiella granulomatis Granuloma Inguinale- Klebsiella granulomatis  Clinical Presentation:  Painless slowly progressive ulcerative lesions form the genital or perineum lymphadenopathy; subcutaneous granulomas (pseudobuboes) also might occur the lesion are highly vascular (ie beefy red appearance) and bleed.  Diagnosis:  Difficult to culture requires visualization of dark staining Granuloma Inguinale- Klebsiella granulomatis  Complications:  Relapse can occur 6-18 months after apparently effective therapy  Management:  Treatment has been shown to halt progression of lesions, and healing typically proceeds inward from the ulcers margins; prolonged therapy is usually required to permit granulation and re- epithelialization of the ulcers. Watch 60 seconds Script writng  https://www.youtube.com/watch?v=Zy4ypgvLX8o This will be useful for your worksheet Examples of scripts The End !