Sexually Transmitted Diseases Treatment and Management

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Sexually Transmitted DiseasesTreatment and
Management
Clinical correlations 3 Med Micro 2008

• November, 2008
• Divya Ahuja, MD
• Assistant Professor of Medicine

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Syndromic approach
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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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Clinical Manifestations- Male

• Symptoms of Acute anterior urethritis (gt95)
• Scant urethral discharge at onset
• discharge becomes more profuse purulent
• dysuria
• spontaneous resolution over several weeks if
  untreated
• 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
• Purulent exudate
• 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
• gt95 S S if overt exudate expressed
• Not sufficient for endocervical, pharyngeal or
  rectal specimens
• Culture, NAAT, Nucleic acid hybridization tests
• Only culture tests are approved for rectum,
  pharynx and abuse cases

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What is the diagnosis if this patient also had
penile discharge?
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Disseminated Gonococcal Infection (DGI)

• Arises from GC bacteremia
• Acute arthritis-dermatitis syndrome
• Asymmetrical arthritis usually involves wrist,
  fingers, toes, ankle knee joints
• classic skin lesion tender, necrotic pustule on
  an erythematous base
• Tenosynovitis
• Remember anorectal, and
  pharyngeal gonorrhea

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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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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
• 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
• peak occurrence females(ages 15 -19) males
  (ages 20 to 24)
• 70 to 80 of infected women are asymptomatic
• 50 of infected men are asymptomatic

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Chlamydia Clinical Manifestation-Male

• Urethritis
• Dysuria
• Mucopurulent 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
• Cytology
• Isolation in Tissue Culture
• 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

• ETIOLOGY
• 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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ETIOLOGY OF ACUTE EPIDIDYMITISBerger et al. N.
Engl J Med 1978298.301

• Men under 35 years of age
• C. trachomatis 16 (47)
• N. gonorrhoeae 9 (26)
• Gram-negative rods 1 (3)
• No pathogens 8 (24)
• Men 35 years of age or older
• Gram-negative rods 12 (75)
• No pathogens 3 (19)
• C. trachomatis 1 (6)
• N. gonorrhoeae 0

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Epididymitis

• If due to GC or CT
• Ceftriaxone 250 mg IM in a single dose, PLUS
• Doxycycline 100 mg po bid x 10 days
• If due to enteric organisms or age gt 35 or
  allergic to above therapies
• Ofloxacin 300 mg po bid x 10 days OR
• Levofloxacin 500 mg po daily x 10 days
• Revaluate if no improvement in 3 days
• REMEMBER Torsion of testes

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PID

• 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
• Sexually active woman, lower abdominal pain,
  adnexal OR cervical motion tenderness
• Specific Criteria
• Transvaginal sonography, Laparoscopy

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INDICATIONS FOR HOSPITALIZATION

• 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
• Clindamycin plus gentamicin
• 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 ORCefoxitin
  and Probenecid, PLUSDoxycycline 100 mg orally
  twice a day for 14 days   WITH OR WITHOUT
  Metronidazole 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
• 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
• 20 of adults 15 to 49 have genital HPV
• 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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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 Epidemiology

• HSV 2 - 50 million persons in US infected
• HSV-1 - several million in US infected
• All ages susceptible - highest in 25 -35 y/o
• Incubation period ranges from 2 to 28 days
• Transmitted
• asymptomatic persons
• direct contact
• perinatal transfer

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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
• Within first year of initial infection males will
  average 5 and females 4 outbreaks per year
• 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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Whats your diagnosis?
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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 ulceration on previous slide

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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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Condylomata lata
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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
• (-) 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
• Nodules that enlarge and ulcerate (painless)
• Treatment
• Tetracycline
• Trimethoprim/sulfa

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Lymphogranuloma venereum

• Endemic in Africa, South America
• Chlamydia trachomatis serovars L1, L2, L3
• Incubation 5-21 days
• Transient genital ulcer, buboes
• Diagnosis serology
• Treatment
• Doxycycline
• Azithromycin
• Lymph nodes fibrose

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Bacterial Vaginosis

• Arises from alteration of normal vaginal flora
• Overgrowth of Gardnerella vaginalis, Bacteroides,
  Mobilincus
• Grayish white vaginal discharge (fishy)
• Pruritus
• 50 are asymptomatic
• Diagnosis
• Increased pH and clue cells
• Treatment
• Metronidazole 500mg BID x 7 days
• Metronidazole gel 0.75 once daily x 5 days
• Clindamycin cream 2

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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