Sexually Transmitted Diseases Treatment and Management

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Sexually Transmitted DiseasesTreatment and
Management

• October, 2009
• Divya Ahuja, MD
• Associate Professor of Medicine

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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
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Case 1

• 24 year male, sexually active
• Presents with 4 day history of dysuria and penile
  discharge

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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

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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
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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)

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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

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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

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What is the diagnosis if this patient has a
monoarthritis and penile discharge?
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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

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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

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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

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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

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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

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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
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Chlamydia Clinical Manifestation-Male

• Urethritis
• Dysuria
• Discharge
• Proctitis
• Only 1 of 8 infected men followed without Rx
  developed symptoms

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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

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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.

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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

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URETHRITIS

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

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Gonococcal Urethritis
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Nongonococcal Urethritis
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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

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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

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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

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Pelvic Inflammatory Disease
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Clinical Criteria

• Symptoms
• Abnormal bleeding
• Dyspareunia
• Vaginal Discharge
• Fever
• Minimum Criteria
• lower abdominal pain, adnexal OR cervical motion
  tenderness
• Specific Criteria
• Transvaginal sonography, Laparoscopy

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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

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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

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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

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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

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Clinical Manifestations of Genital Warts
Atlas fig 8.13 Page 297
Smooth papular warts
Condylomata acuminata
Flat cervical condylomata
Keratotic flat wart
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CLINICAL PRESENTATION OF GENITAL WARTS VULVA
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Perianal Wart
HPV and Cervical Cancer
Source Cincinnati STD/HIV Prevention Training
Center
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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

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Case 4
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Genital ulcer-Does it hurt?

• Painful
• Chancroid
• Genital herpes simplex
• Painless
• Syphilis
• Lymphogranuloma venereum
• Granuloma inguinale

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Whats your diagnosis?
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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

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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

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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

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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

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Whats your diagnosis?
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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

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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

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Rash of Secondary Syphilis
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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

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Tertiary Syphilis

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

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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

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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)

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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

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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

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Granuloma inguinale (Donovanosis)

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

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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

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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

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What not to do