Reportable in all states Chlamydia Gonorrhea Syphilis Chancroid Hepatitis B AIDS

Transcription

1 SEXUAL TRANSMITED DISEASES

2 Current Overview of Sexually Transmitted Diseases (STDs) Linda Creegan, FNP California STD/HIV Prevention Training Center

3 Common STDs Bacterial diseases Chlamydia (CT) Gonorrhea (GC) Syphilis Trichomoniasis (Trich) Viral diseases Human Papillomavirus (HPV) Genital herpes (HSV-2 or HSV-1) Hepatitis B

4 Reportable STDs Regulations vary from state to state Reportable in all states Chlamydia Gonorrhea Syphilis Chancroid Hepatitis B AIDS Generally not reportable Human Papillomavirus Genital herpes Trichomoniasis

5 Chlamydia Infection Incidence is highest among sexually active adolescents and young adults Most infections are asymptomatic Leading cause of preventable infertility in women

6 Chlamydia Infections in Women, Men, and Neonates Genitals Cervicitis PID Urethritis Eye (Conjunctivitis) Throat (Pharyngitis) Rectum (Proctitis) Genitals (Urethritis) (Epididymitis) Rectum(Proctitis) Throat (Pharyngitis) Eye(Conjunctivitis) Systemic (Reiter s Syndrome) Eye (conjunctivitis) Lungs (pneumonia) 70-80% ASYMPTOMATIC >50% ASYMPTOMATIC

7 Genital Chlamydia in Women: Complications Untreated genital CT infection 20-50% Acute PID Silent PID 9% 18% Ectopic pregnancy Chronic pelvic pain 14-20% Infertility

8 Chlamydia Infection Clinical Manifestations

9 Cervical Ectopy Ectopy SCJ Minimal ectopy STD Atlas, 1997

10 What IS Screening????? Screening testing Looking for disease which gives no symptoms Most effective when done for a common disease with bad consequences using a highly accurate, non-invasive, inexpensive test Diagnostic testing Looking for the cause of abnormal signs, symptoms, etc

11 Chlamydia Screening & Treatment Decreases community prevalence Prevents pelvic inflammatory disease Scholes et al., NEJM, 1996; 334: Cost effective CDC estimates that for every dollar spent on chlamydia screening, we could save $12 Opportunity to increase awareness and provide risk reduction counseling

12 What about chlamydia screening among men? Obvious source of transmission Urine-based testing advantage Unpublished cost effectiveness analysis demonstrate community and future partner benefits Limited data on prevalence & outcomes No guidelines available

13 Chlamydia Screening Recommendations CDC, NCQA HEDIS, USPSTF, ACOG and others are similar All sexually active women under 26 yoa Initial screen Repeat annually Consider repeat with new or multiple sex partners Repeat 2-3 months after an infection All pregnant women under 26 yoa Men, and women 26 and older, consider with New or multiple sex partners, Inconsistent condom use

14 Urine-Based CT Tests Highly accurate Non-invasive collection High patient acceptability Only test appropriate for screening asymptomatic males Screening in non-clinical settings Community settings Home testing

15 Chlamydia Partner Management Transmissibility: male to female: 45-55% 55% (culture) to 70% (PCR) female to male: 28-42% (culture) to 68% (PCR) Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated

16 Patient-Delivered Partner Therapy Repeat CT infections place women at greater risk for PID and infertility than first infection Most important risk factor for re-infection is an untreated partner Multi-center CDC trial demonstrated 20% decrease in re-infection with PDT Single-dose azithromycin has very few adverse reactions Authorized by law in California

17 Chlamydia: KEY POINTS Most common bacterial (curable) STD Most cases in women and men give no symptoms Leading cause of PID and infertility in women All sexually active women 25 y.o.a. and younger should be tested at least annually

18 Gonorrhea Infection Caused by Neisseria gonorrhoeae Overall rates falling, but incidence in certain groups remains high Most common in young adults and adolescents CT co-infection of GC cases remains at about 40% Resistance to medication is an spreading problem

19 Gonorrhea Infections in Men, Women and Neonoates Men are usually symptomatic (urethra), women are commonly asymptomatic Men: urethral infection, epididymitis Usually gives pain with urination and heavy, thick penile discharge; few may be asymptomatic carriers Women: cervical infection, PID ~50% women asymptomatic, others have pain with urination, vaginal discharge or bleeding Other sites of infection: throat, rectum, eye Neonates: eye and skin infections

20 Gonorrhea Infections Clinical Manifestations

21 GC Partner Management Transmissibility: Male to female: 50-90% Female to male: 20-80% Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated If no sex partners in previous 60 days, treat the most recent partner

22 Increasing Medication Resistance Almost all GC isolates testing in Asia are resistant to fluoroquinolones (Cipro and related medications) Resistant GC is spreading to the U.S. About 9% of isolates in Hawaii, 2002 More than 10% of isolates in California, 2002

23 Gonorrhea Infection Screening Considerations Screening is probably not warranted when GC prevalence is under 1% Accuracy of screening is dependent on: Prevalence of disease in the population Sensitivity and specificity of test used Screening a low-prevalence population can result in more false-positives than true-positives

24 Syphilis Incidence had been steadily declining in the U.S. since U.S. counties account for 50% of the reported cases In 1999, the CDC initiated a nation-wide Syphilis Elimination Effort, targeting these areas Recently, local outbreaks centered in urban areas among MSM

25 Syphilis Distribution of the Organism STD Atlas, 1997

26 Primary Syphilis Photos: Dr. Joseph Engelman, San Francisco City Clinic

27 Rash of Secondary Syphilis STD Atlas, 1997 Photo: Dr. Joseph Engelman, San Francisco City Clinic

28 Secondary Syphilis Other Symptoms Comdyloma lata DOIA Website, 2000 Photo: Dr. Joseph Engelman San Francisco City Clinic STD Atlas, 1997

29 Syphilis New Therapies Penicillin G (an injectable) remains the first line treatment Limited data support the use of Azithromycin (in a one-time oral dose) as an alternative regimen Azithromycin 2 gm orally in a single dose as treatment for early syphilis Azithromycin 1 gm orally in a single dose as prophylactic treatment for contacts to infectious syphilis Has not been well-studied in HIV + patients; larger trials ongoing Cefrtiaxone almost certainly effective, but best dose/duration has not been established

30 Syphilis: KEY POINTS Serious systemic infection Strong connection with HIV transmission Yearly testing of all HIV-positive patients is recommended

31 Genital Herpes: Overview Caused by Herpes Simplex Viruses HSV 1: orolabial herpes HSV 2: genital herpes Both symptomatic & asymptomatic infections are common Can cause serious complications Asymptomatic shedding is well documented

32 υ Genital Herpes Infection Epidemiology Estimated annual incidence: 600,000 to 1 million cases NHANES data provided new view of HSV-2 prevalence in the U.S. Twenty-two two percent of adults estimated to be infected with HSV-2 Rates are higher in HIV infected persons, African Americans and adults of lower socioeconomic status Most infections are unrecognized because of mild symptoms or absence of symptoms

33 Genital Herpes Transmission υ Major routes: sexual & mother-to-infant υ Most sexual transmission probably occurs when index case is asymptomatic υ Efficiency of transmission is greater from men to women than women to men υ Mertz, et al: 144 serodiscordant couples υ Almost 17% man-to-woman transmission υ Almost 4% woman-to-man transmission

34 Initial infection Genital Herpes Natural History Virus enters through microscopic breaks in skin Establishes chronic infection Virus becomes latent in nerves cells along spinal cord Infection persists despite host immune response Virus may remain latent indefinitely or can reactivate Virus can reactivate Precipitating factors: trauma, fever, UVL, stress Virus reproduces and moves along nerve axon to skin or mucosa, and recurrent lesions can occur Reactivation (shedding) can also be asymptomatic

35 Genital Herpes Educating to Recognize Symptoms 62 HSV-2 seropositive women denying history of genital symptoms were intensively educated 77% then presented with culture-+ lesions 53 seropositive asymptomatic men and women with education 87% with subsequent symptoms Landenberg, 1989 & Wald, 2000

36 Genital Herpes Patient s Perception of Etiology Women Yeast infection Vaginitis UTI Menstrual complaint Hemorrhoids Allergies (condoms, sperm, spermicide, pantyhose Rash from sex, shaving, bike seat Men Folliculitis Jock itch Normal itch Zipper burns Hemorrhoids Allergy to condom Irritation from tight jeans, sex, bike seat Insect bite Koutsky, NEJM, 1992

37 Genital Herpes Asymptomatic Shedding Multiple studies have documented asymptomatic shedding with culture and DNA amplification techniques Occurs in up to 90% of patients with HSV-2 Most common in first two years after infection (5-10% of days), less common thereafter (2% of days) Shedding may occur from cervix, vulva, urethra, rectum, penis Asymptomatic shedding reduced by antiviral suppression

38 Neonatal Herpes Infection υ Neonatal infection occurs υ Clinical disease manifests at days of age υ Skin, eye or mucous membrane: low mortality, but recurrences possible CNS: 30% mortality, 50% serious sequelae Disseminated: 80% mortality, 10% serious sequelae υ Overall mortality ~ 20%

39 Herpes Transmission in Pregnancy υ Most transmission occurs at time of delivery, rarely in utero υ Risk factors: primary infection, new infection, scalp electrodes υ Over half of infants with neonatal infection are born to mothers with no history of genital herpes

40 Blood Tests for Herpes Older blood tests did not distinguish HSV-1 from HSV-2 antibody Newer blood tests accurately distinguish type-specific glycoproteins gg1 and gg2

41 HSV Serology Testing Potential Uses, Diagnostic Testing Confirm diagnosis Recurrent undiagnosed GUD Atypical presentations (e.g. urinary symptoms) Note: positive test does not necessarily correlate with symptoms Note: Can help differentiate between Primary & non-primary infections Newly-acquired and older infections

42 HSV Serology Testing Benefits and Limitations of Screening May be useful to patients for informing partners May be helpful for pregnant couples or for planning pregnancy Does not tell How long infected If person has had or will have symptoms How likely a person is to shed asymptomatically

43 HSV Serology Testing Potential Uses, Screening Not recommended for routine screening May be useful in certain at-risk populations and individuals Patients with other STDs HIV infected persons and contacts Contacts to HSV Certain prenatal patients

44 Genital Herpes Treatment Options Treatment of symptomatic outbreaks Suppression of symptoms by daily medication Daily medication to lessen chance of transmission

45 Genital Herpes Psychological Impact A diagnosis of herpes can cause significant psychological distress Depression Anger Fear of rejection/discord in relationship Fear of passing infection to sex partners or infants Frustration regarding lack of a cure Uncertainty about asymptomatic shedding

46 Genital Herpes Counseling about Transmission Encourage patients to inform their sex partners of the herpes diagnosis Advise patients to abstain from sexual activity when lesions are present Discuss possibility of asymptomatic shedding Discuss treatment options Encourage condom use with new or uninfected partners

47 Perinatal Herpes Infection Prevention Emphasize preventing acquisition of genital HSV during late pregnancy υ Counsel susceptible pregnant women whose partners have oral or genital HSV to avoid unprotected genital & oral sexual contact in late pregnancy Examine women in labor for genital herpes Abdominal delivery is recommended with prodrome or active lesions at onset of labor Suppressive therapy near term to reduce number of C-sections in women with recurrent herpes is under investigation

48 Genital Herpes Condom Effectiveness Latex condoms, when used consistently and correctly, are highly effective for: HIV And can reduce the risk of: GC, CT, and Trichomonas Genital herpes, syphilis, chancroid, and HPV, only when the infected areas are covered by the condom CDC, 2002

49 Genital Herpes Vaccine Development SmithKline Beecham Biologicals Two multicenter, double-blind, blind, randomized placebo- controlled trials Participants had no history of genital herpes and a regular sex partner with HSV-2 73% reduction in symptomatic cases in women who were also HSV-1 negative Protects against symptoms of genital herpes, although not against acquisition of HSV-2 virus No protective effect found in men

50 Genital Human Papillomavirus (HPV) Two disease processes caused by different viral types Precancer and cancer of the genital tissues (abnormal Paps and anal carcinoma) Skin growths in the anogenital area (genital warts)

51 > 80 HPV Types Genital HPVs sexual contact (>30 types) Dermal HPVs nonsexual contact (>50 types) High-risk Low-risk Common types 16,18, types Warts 31,33,35,39, 45,51,52,56,58 6,11,42,43,44 (e.g., hands/feet) low grade cervical abnormalities cancer precursors genital cancers low grade cervical abnormalities genital warts respiratory papillomatosis

52 What happens once people get infected with HPV? For most people, nothing will happen The body s immune system usually eliminates HPV infection After HPV is found on the cervix, it becomes undetectable within 2 years in at least 90% of women Some people who get low-risk types will develop: Visible genital warts Low-grade Pap smear abnormalities that usually go away on their own

53 What happens once people get infected with HPV? Some women who get high-risk types will develop: Low or high grade Pap smear abnormalities Cervical cancer (rarely) Persistent infection with high-risk HPV types is associated with the development of pre- cancerous and cancerous cervical changes The course of penile infection in men has not been well studied

54 DOIA Website, 2000 Typical Genital Warts

55 Do Condoms Prevent HPV? Effectiveness of condoms to prevent HPV infection has not been determined A few studies in women show no protective effect However, these studies were not designed to assess condom effectiveness No prospective studies have evaluated the effectiveness of condom use to protect men from genital HPV infection Condoms work only if they cover infected areas HPV often infects genital areas not covered by condoms

56 The New Kind of Pap Thin-Layer Paps vs Conventional Paps Generally compare favorably Simple collection procedure for the clinician Provides a better sample Can be read more accurately in the lab More expensive Conventional Pap ThinPrep Pap Test

57 The New Test for HPV HPV DNA Tests Hybrid Capture Test (Digene) detects high-risk HPV by typing nucleic acids Results are reported as positive or negative for the most common cancer-associated associated HPV types(16,18,31,33,35 etc) Can be performed on same specimen collected for thin- layer Pap

58 HPV DNA Tests: Possible Uses NOT recommended for screening NOT recommended for diagnostic purposes with external genital warts Can be useful in management of certain abnormal Paps

59 ASCUS Paps: Proposed Algorithm Routine Pap smear, including specimen collection for HPV Normal Routine Pap schedule HPV (-) ASCUS Conduct HPV test on stored specimen HPV (+) SIL Usual follow-up and treatment Repeat Pap 6-12 mo Colposcopy

60 Cervical Disease Management of HIV Infected Women Dysplasia more common Progression of dysplasia is more likely if untreated Risk dependent on CD4 count and viral load Sensitivity of Pap probably equal Colposcopic exam may be warranted if follow-up is uncertain (ASC-US or higher) Recommend semi-annual Pap and careful follow- up

61 HPV, Anal Ca and MSM High prevalence of anal HPV infection Incidence of anal carcinoma 35/100,000 MSM Anal cancer x higher in AIDS patients Small studies and models demonstrate that routine anal Pap screening may be beneficial No current guidelines given uncertain natural history, laboratory issues, and treatment outcomes Goldie et al. JAMA 1999; 281: Prevention of Genital HPV Infection and Sequelae DHHS, Atlanta: CDC, 1999

62 HPV: KEY POINTS Extremely common virus Some types cause genital warts Other types cause cervical and anal cancer HPV tests can help in managing female patients with abnormal Paps Best approach to anal dysplasia is unclear

63 Trichomoniasis: KEY POINTS Caused by Trichomonas vaginalis,, flagellated anaerobic protozoa In women, causes malodorous yellow-grey discharge with irritation and vulvar itching In men, usually gives no symptoms but can cause urethritis Resistance to common treatment (metronidazole) does occur

64 The Ends

65 STD Prevention and Control Education and counseling to reduce risk of STD acquisition Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation Effective diagnosis and treatment Evaluation, treatment, and counseling of sexual partners Preexposure vaccination--hepatitis A, B

66 Prevention Messages Prevention messages tailored to the client s personal risk; interactive counseling approaches are effective Despite adolescents greater risk of STDs, providers often fail to inquire about sexual behavior, assess risk, counsel about risk reduction, screen for asx infection Specific actions necessary to avoid acquisition or transmission of STDs Clients seeking evaluation or treatment for STDs should be informed which specific tests will be performed

67 Prevention Methods Male Condoms Consistent/correct use of latex condoms are effective in preventing sexual transmission of HIV infection and can reduce risk of other STDs Likely to be more effective in prevention of infections transmitted by fluids from mucosal surfaces (GC,CT, trichomonas, HIV) than those transmitted by skin-skin contact (HSV,HPV, syphilis, chancroid)

68 Prevention Methods Spermicides N-9 vaginal spermicides are not effective in preventing CT, GC, or HIV infection Frequent use of spermicides/n-9 have been associated with genital lesions Spermicides alone are not recommended for STD/HIV prevention N-9 should not be used a microbicide or lubricant during anal intercourse

69 Early HIV Infection Initial Evaluation Medical/sexual history, previous STD Pex, pelvic (pap, wet mount), GC, CT Syphilis serology CD4 count, HIV viral load CBC, blood chemistry PPD, urinalysis, CXR Hepatitis A, B, C serology

70 Genital Ulcer Evaluation Diagnosis based on medical history and physical examination often inaccurate Serologic test for syphilis Culture/antigen test for herpes simplex Haemophilus ducreyi culture in settings where chancroid is prevalent Biopsy may be useful

71 HSV Serologic Tests Type-Specific HSV-specific glycoprotein G2 for HSV 2 infection and glycoprotein G1 for HSV 1 Available gg type-specific assays- POCkit HSV-2, HerpeSelect HSV1/2 IgG ELISA and HerpeSelect 1/2 immunoblot IgG Sensitivity 80-98%, Specificity > 96% Confirmatory testing may be indicated in some settings

72 Genital Herpes First Clinical Episode Acyclovir 400 mg tid or Famciclovir 250 mg tid or Valacyclovir 1000 mg bid Duration of Therapy 7-10 days

73 Genital Herpes Episodic Therapy Acyclovir 400 mg three times daily x 5 days or Acyclovir 800 mg twice daily x 5 days or Famciclovir 125 mg twice daily x 5 days or Valacyclovir 500 mg twice daily x 3-5 days or Valacyclovir 1 gm orally daily x 5 days

74 Genital Herpes Daily Suppression Acyclovir 400 mg bid or Famciclovir 250 mg bid or Valacyclovir mg daily

75 Genital Herpes HIV Infection May have prolonged or severe episodes with extensive genital or perianal disease Episodic or suppressive antiviral therapy often beneficial For severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary

76 Genital Herpes HIV Infection/Episodic Therapy Acyclovir 400 mg three times daily or Famciclovir 500 mg twice daily or Valacyclovir 1 gm twice daily Duration of Therapy 5-10 days

77 Genital Herpes HIV Infection/Daily Suppression Acyclovir mg twice to three times daily or Famciclovir 500 mg twice daily or Valacyclovir 500 mg twice daily

78 Genital Herpes Antiviral Resistance Persistent or recurrent lesions on antivirals Obtain viral isolate for viral susceptability 5% immunocomprised patients Acyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovir Alternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days)

79 Genital Herpes Treatment in Pregnancy Available data do not indicate an increased risk of major birth defects (first trimester) Limited experience on pregnancy outcomes with prenatal exposure to valacyclovir or famciclovir Acyclovir may be used with first episode or severe recurrent disease Risk of transmission to the neonate is 30-50% among women who acquire HSV near delivery

80 Genital Herpes Counseling Natural history of infection, recurrences, asymptomatic shedding, transmission risk Individualize use of episodic or suppressive therapy Abstain from sexual activity when lesions or prodromal symptoms present Risk of neonatal infection

81 Syphilis Primary, Secondary, Early Latent Recommended regimen Benzathine Penicillin G, 2.4 million units IM Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies) or Azithromycin 2 gm single oral dose (preliminary data) *Use in HIV-infection has not been studied

82 Primary/Secondary Syphilis Response to Treatment No definitive criteria for cure or failure are established Re-examine examine clinically and serologically at 6 and 12 months Consider treatment failure if signs/symptoms persist or sustained 4x increase in nontreponemal test Treatment failure: HIV test, CSF analysis; administer benzathine pcn weekly x 3 wks Additional therapy not warranted in instances when titers don t decline despite nl CSF and repeat therapy

83 Primary/Secondary Syphilis Response to Therapy/HIV Infection Most respond appropriately to benzathine penicillin 2.4 million units IM Some experts recommend CSF exam before therapy and additional tx (wkly benz pen IM x 3) Clinical/serologic evaluation at 3, 6, 9, 12, 24 mo; some perform CSF exam at 6 mo Tx/serologic failure (6-12 mo after tx)- CSF exam, retreat with benz penicillin 2.4 mu wkly x 3

84 Recommended regimen Syphilis Latent Syphilis Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses Penicillin allergy* Doxycycline 100 mg orally twice daily or Tetracycline 500 mg orally four times daily Duration of therapy 28 days; close clinical and serologic follow-up; data to support alternatives to pcn are limited

85 Latent Syphilis Management Considerations Clinical evaluation of tertiary disease (aorititis, gumma, iritis) 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 >1:32 Pharmacologic considerations suggest an interval of days between benz pen doses may be acceptable before restarting treatment course in nonpregnant patients

86 Latent Syphilis Response to Treatment Limited data available to guide evaluation Repeat quantitative nontreponemal tests at 6, 12, 24 months Perform CSF exam and re-treat for latent syphilis: 4x increase in titer, initial nontreponemal titer >1:32 fails to decline mo after tx, or signs/sx

87 Latent Syphilis Response to Therapy/HIV Infection CSF exam before treatment Normal CSF exam-benzathine penicillin 2.4 million units IM wkly x 3 weeks Clinical/serologic evaluation at 6, 12, 18, 24 months Development of sx or 4x titer rise-repeat repeat CSF exam and treat Repeat CSF exam and treatment if nontreponemal titer does not decline in months

88 Syphilis Management of Sex Partners At risk- 3 mo + sx for primary, 6 mo + sx for secondary, one yr for early latent Exposure to primary, secondary, or early latent within 90 days, tx presumptively Exposure to primary, secondary, or early latent > 90 days, tx presumptively if serology not available Exposure to latent syphilis who have high nontreponemal titers > 1:32, consider presumptive tx for early syphilis

89 Recommended regimen Neurosyphilis Aqueous crystalline penicillin G, million units administered 3-4 million units IV every 4 hours for days Alternative regimen Procaine penicillin 2.4 million units IM daily plus probenecid 500 mg orally four times daily for days Some experts administer benzathine penicillin 2.4 million units IM wkly x 3 after completion of these regimens to provide comparable duration of treatment with latent syphilis

90 Neurosyphilis Penicillin Allergy Ceftriaxone 2 gm daily IM/IV for days Consideration of cross-reactivityreactivity Pregnant patients should undergo penicillin desensitization Other regimens have not been evaluated

91 Neurosyphilis Response to Treatment Initial CSF pleocytosis--repeat CSF exam every 6 months until cell count normal CSF VDRL and protein decline slowly Consider re-treatment if cell count has not decreased by 6 months or if CSF is not normal by 2 years

92 Syphilis Treatment in Pregnancy Screen for syphilis at first prenatal visit; repeat RPR third trimester/delivery for those at high risk or high prevalence areas Treat for the appropriate stage of syphilis Some experts recommend additional benzathine penicillin 2.4 mu IM after the initial dose for primary, secondary, or early latent syphilis Management and counseling may be facilitated by sonographic fetal evaluation for congenital syphilis in the second half of pregnancy

93 Congenital Syphilis Infants with Seroreactive Mothers Nontreponemal test on infant serum Examination (nonimmune hydrops, jaundice, HSM, rhinitis, rash) Pathologic exam of placenta or umbilical cord (fluorescent antitreponemal antibody) Darkfield or DFA of suspicious lesions or body fluids

94 Congenital Syphilis Proven/highly probable disease Abnormal physical exam consistent with congenital syphilis Nontreponemal titer 4X > maternal titer or + DFA or darkfield Evaluation: CSF exam, CBC; other tests as clinically indicated--long bone films, LFTs, cranial US, eye exam, auditory brain stem response

95 Congenital Syphilis Proven/highly probable disease Aqueous crystalline penicillin G 100, ,000150,000 units/kg/day, administered as 50,000 units/kg/dose IV q 12 hours during the first 7 days and thereafter q 8 hours for 10 days or Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days

96 Congenital Syphilis Normal exam/rpr < 4X maternal titer Mother inadequately treated; treated with nonpenicillin regimen; received tx < 4 wks before delivery; or mother has early syphilis with serologic response Evaluation: CSF analysis, CBC/plt, long bone xray

97 Congenital Syphilis Normal Exam/RPR < 4X maternal titer Aqueous penicillin G 100, ,000150,000 units/kg/day as 50,000 units/kg/dose IV every 12 hours for first 7 d then q 8 hours for total of 10 d or Procaine penicillin G 50,000 units/kg/dose IM in single daily dose for 10 d or Benzathine penicillin G 50,000 units/kg/dose IM in single dose

98 Congenital Syphilis Normal exam/rpr < 4X maternal titer Mother treated appropriately > 4 wks before delivery; maternal RPR titers decreased 4X; no relapse or reinfection No evaluation required Benzathine pcn G 50,000 units/kg/dose IM

99 Congenital Syphilis Normal exam/rpr < 4X maternal titer Mother received adequate tx before pregnancy; maternal RPR remained low and stable during pregnancy and delivery No evaluation necessary No treatment required; some specialists would tx with single dose of benz pen G

100 Congenital Syphilis Subsequent Evaluation Clinical/serologic evaluation q 2-3 mo RPR should decline by 3 mo, nonreactive at 6 mo Stable or increasing titers after 6-12 mo-- --CSF analysis/parenteral pcn X 10 d Reactive treponemal/rpr after 18 mo re-evaluate evaluate and treat for congenital syphilis

101 Congenital Syphilis Older Infants and Children Review records and maternal serology- congenital vs acquired Evaluation- CSF analysis, CBC/pts; +/- long bone films, auditory brain stem response Treatment- Aqueous pcn G 50,000 units/kg q 4-6 hours for 10 days

102 Chancroid Azithromycin 1 gm orally or Ceftriaxone 250 mg IM in a single dose or Ciprofloxacin 500 mg twice daily x 3 days or Erythromycin base 500 mg tid x 7 days

103 Chancroid Management Considerations Re-examination examination 3-7 days after treatment Time required for complete healing related to ulcer size Lack of improvement: incorrect diagnosis, co- infection, non-compliance, antimicrobial resistance Resolution of lymphadenopathy may require drainage

104 Chancroid Management of Sex Partners Examine and treat partner whether symptomatic or not if partner contact < 10 days prior to onset

105 Lymphogranuloma Venereum Recommended regimen Doxycycline 100 mg twice daily for 21 days Alternative regimen Erythromycin base 500 mg four times daily for 21 days

106 Granuloma Inguinale Doxycycline 100 mg twice daily or Trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily Minimum treatment duration three weeks

107 Granuloma Inguinale Alternative regimens Ciprofloxacin 750 mg twice daily or Erythromycin base 500 mg four times daily or Azithromycin 1 gm orally weekly Minimum treatment duration three weeks

108 Urethritis Mucopurulent or purulent discharge Gram stain of urethral secretions > 5 WBC per oil immersion field Positive leukocyte esterase on first void urine or >10 WBC per high power field Empiric treatment in those with high risk who are unlikely to return

109 Nongonococcal Urethritis Azithromycin 1 gm in a single dose or Doxycycline 100 mg bid x 7 days

110 Nongonococcal Urethritis Alternative regimens Erythromycin base 500 mg qid for 7 days or Erythromycin ethylsuccinate 800 mg qid for 7 days or Ofloxacin 300 mg twice daily for 7 days or Levofloxacin 500 mg daily for 7 days

111 Recurrent/Persistent Urethritis Objective signs of urethritis Re-treat with initial regimen if non-compliant or re-exposure exposure occurs Intraurethral culture for trichomonas Effective regimens not identified in those with persistent symptoms without signs

112 Recurrent/Persistent Urethritis Metronidazole 2 gm single dose PLUS Erythromycin base 500 mg qid x 7d or Erythromycin ethylsuccinate 800 mg qid x 7d

113 Chlamydia trachomatis Annual screening of sexually active women < 25 yrs Annual screening of sexually active women > 25 yrs with risk factors Sexual risk assessment may indicate more frequent screening for some women Rescreen women 3-4 months after treatment due to high prevalence of repeat infection

114 Chlamydia trachomatis Azithromycin 1 gm single dose or Doxycycline 100 mg bid x 7d

115 Chlamydia trachomatis Alternative regimens Erythromycin base 500 mg qid for 7 days or Erythromycin ethylsuccinate 800 mg qid for 7 days or Ofloxacin 300 mg twice daily for 7 days or Levofloxacin 500 mg for 7 days

116 Chlamydia trachomatis Treatment in Pregnancy Recommended regimens Erythromycin base 500 mg qid for 7 days or Amoxicillin 500 mg three times daily for 7 days Alternative regimens Erythromycin base 250 mg qid for 14 days or Erythromycin ethylsuccinate 800 mg qid for 14 days or Erythromycin ethylsuccinate 400 mg qid for 14 days or Azithromycin 1 gm in a single dose

117 Neisseria gonorrhoeae Cervix, Urethra, Rectum Cefixime 400 mg or Ceftriaxone 125 IM or Ciprofloxacin 500 mg or Ofloxacin 400 mg/levofloxacin 250 mg PLUS Chlamydial therapy if infection not ruled out

118 Neisseria gonorrhoeae Cervix, Urethra, Rectum Alternative regimens Spectinomycin 2 grams IM in a single dose or Single dose cephalosporin (cefotaxime 500 mg) or Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg) PLUS Chlamydial therapy if infection not ruled out

119 Neisseria gonorrhoeae Pharynx Ceftriaxone 125 IM in a single dose or Ciprofloxacin 500 mg in a single dose PLUS Chlamydial therapy if infection not ruled out

120 Cephalosporin regimen Neisseria gonorrhoeae Treatment in Pregnancy Women who can t tolerate cephalosporin regimen may receive 2 g spectinomycin IM No quinolone or tetracycline regimen Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection

121 Disseminated Gonococcal Infection Recommended regimen Ceftriaxone 1 gm IM or IV q 24 hr Alternative regimens Cefotaxime or Ceftizoxime 1 gm IV q8 hr or Ciprofloxacin 400 mg IV q 12 or Ofloxacin 400 mg IV q 12 or Levofloxacin 250 mg IV daily

122 Neisseria gonorrhoeae Antimicrobial Resistance Geographic variation in resistance to penicillin and tetracycline No significant resistance to ceftriaxone Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California Surveillance is crucial for guiding therapy recommendations

123 Uncomplicated Sporadic, infrequent Mild-to-moderate Likely C albicans Non-immunocomprised Candida Vaginitis Classification Complicated Recurrent Severe Non-albicans Diabetes, pregnancy, immunosuppression

124 Candida Vulvovaginitis Intravaginal regimens Butoconazole, clotrimazole, miconazole, nystatin, tioconazole, terconazole Oral regimen Fluconazole 150 mg in a single dose

125 Recurrent VVC Four or more symptomatic episodes/year Vaginal culture useful to confirm diagnosis and identify unusual species Initial regimen of 7-14 days topical therapy or fluconazole 150 mg (repeat 72 hr) Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole Non-albicans VVC- longer duration of therapy with non-azole regimen

126 Vulvovaginal Candidiasis Management of Sex Partners Treatment not recommended Treatment of male partners does not reduce frequency of recurrences in the female Male partners with balanitis may benefit from treatment

127 Vulvovaginal Candidiasis Treatment in Pregnancy Only topical intravaginal regimens recommended Most specialists recommend 7 days of therapy

128 Trichomoniasis Recommended regimen Metronidazole 2 gm orally in a single dose Alternative regimen Metronidazole 500 mg twice a day for 7 days Pregnancy Metronidazole 2 gm orally in a single dose

129 Trichomoniasis Treatment Failure Re-treat with metronidazole 500 mg twice daily for 7 days If repeated failure occurs, treat with metronidazole 2 gm single dose for 3-5 days If repeated failure, consider metronidazole susceptibility testing through the CDC

130 Trichomoniasis Management of Sex Partners Sex partners should be treated Avoid intercourse until therapy is completed and patient and partner are asymptomatic

131 Bacterial Vaginosis Metronidazole 500 mg twice daily for 7 days or Metronidazole gel 0.75%, 5 g intravaginally once daily for 5 days or Clindamycin cream 5%, 5 g intravaginally qhs for 7 days

132 Bacterial Vaginosis Alternative regimens Metronidazole 2 gm in a single dose or Clindamycin 300 mg twice daily for 7 days or Clindamycin ovules 100 g intravaginally qhs for 3 days

133 Bacterial Vaginosis Treatment in Pregnancy Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes Existing data do not support use of topical agents in pregnancy Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatal visit; optimal regimen not established

134 Bacterial Vaginosis Treatment in Pregnancy Metronidazole 250 mg three times daily for 7 days or Clindamycin 300 mg twice daily for 7 days

135 Bacterial Vaginosis Management of Sex Partners Woman s response to therapy and the likelihood of relapse or recurrence not affected by treatment of sex partner

136 Pelvic Inflammatory Disease Minimum Diagnostic Criteria Uterine/adnexal tenderness or cervical motion tenderness Additional Diagnostic Criteria Oral temperature >38.3 C Cervical CT or GC WBCs/saline microscopy Elevated ESR Elevated CRP Cx discharge

137 Pelvic Inflammatory Disease Definitive Diagnostic Criteria Endometrial biopsy with histopathologic evidence of endometritis Transvaginal sonography or MRI showing thick fluid- filled tubes Laparoscopic abnormalities consistent with PID

138 Pelvic Inflammatory Disease Hospitalization Surgical emergencies not excluded Pregnancy Clinical failure of oral antimicrobials Inability to follow or tolerate oral regimen Severe illness, nausea/vomiting, high fever Tubo-ovarian ovarian abscess

139 Pelvic Inflammatory Disease No efficacy data compare parenteral with oral regimens Clinical experience should guide decisions regarding transition to oral therapy Until regimens that do not adequately cover anaerobes have been demonstrated to prevent sequelae as successfully as regimens active against these microbes, regimens should provide anaerobic coverage

140 Pelvic Inflammatory Disease Parenteral Regimen A Cefotetan 2 g IV q 12 hours or Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg orally/iv q 12 hrs

141 Pelvic Inflammatory Disease Parenteral Regimen B Clindamycin 900 mg IV q 8 hours PLUS Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.

142 Pelvic Inflammatory Disease Alternative Parenteral Regimens Ofloxacin 400 mg IV q 12 hours or Levofloxacin 500 mg IV once daily WITH OR WITHOUT Metronidazole 500 mg IV q 8 hours or Ampicillin/Sulbactam 3 g IV q 6 hrs PLUS Doxycycline 100 mg orally/iv q 12 hrs

143 Pelvic Inflammatory Disease Oral Regimen A Ofloxacin 400 mg twice daily for 14 days or Levofloxacin 500 mg once daily for 14 days WITH OR WITHOUT Metronidazole 500 mg twice daily for 14 days

144 Pelvic Inflammatory Disease Oral Regimen B Ceftriaxone 250 mg IM in a single dose or Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently PLUS Doxycycline 100 mg twice daily for 14 days WITH or WITHOUT Metronidazole 500 mg twice daily for 14 days

145 Pelvic Inflammatory Disease Management of Sex Partners Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt s onset of symptoms Sex partners should be treated empirically with regimens effective against CT and GC

146 Epididymitis Diagnostic Considerations Gram stain smear of urethral exudate for diagnosis of urethritis Intraurethral culture or nucleic acid amplification test for GC and CT Examination of first void uncentrifuged urine for WBCs if urethral gram stain negative

147 Epididymitis Infection likely due to GC or CT Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg twice daily for 10 days Infection likely due to enteric organisms or age > 35 Ofloxacin 300 mg twice daily for 10 days or Levofloxacin 500 mg once daily for 10 days

148 Papillomavirus Treatment Primary goal for treatment of visible warts is the removal of symptomatic warts Therapy may reduce but probably does not eradicate infectivity Difficult to determine if treatment reduces transmission No laboratory marker of infectivity Variable results utilizing viral DNA

149 Papillomavirus Source of therapy guided by preference of patient, experience of provider, resources No evidence that any regimen is superior Locally developed/monitored treatment algorithms associated with improved clinical outcomes Acceptable alternative may be to observe; possible regression/uncertain transmission

150 Papillomavirus Patient-appliedapplied Podofilox 0.5% solution or gel or Imiquimod 5% cream Provider-administered Cryotherapy or Podophyllin resin 10-25% or Trichloroacetic or Bichloroacetic acid 80-90% or Surgical removal

151 Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80-90% Urethral meatal warts Cryotherapy or podophyllin 10-25% Anal warts Cryotherapy or TCA/BCA 80-90%

152 Papillomavirus Treatment in Pregnancy Imiquimod, podophyllin, podofilox should not be used in pregnancy Many specialists advocate wart removal due to possible proliferation and friability HPV types 6 and 11 can cause respiratory papillomatosis in infants and children Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction

153 Cervical Cancer Screening Women with History of STDs Women with STD hx may be at increased risk of cervical cancer Clinics that offer pap screening without colposcopic f/u should arrange for referral Management of abnormal pap provided per Interim Guidelines for Management of Abnormal Cervical Cytology (NCI Consensus Panel) Emerging data support HPV testing for the triage of women with ASCUS Pap tests

154 Proctitis Anoscopic examination for HSV, GC, CT, syphilis Painful perianal or mucosal ulceration on anoscopy- presumptive therapy for HSV Recommended regimen Cefriaxone 125 mg IM PLUS Doxycycline 100 mg twice daily for 10 days

155 Pediculosis Pubis Pruritus or lice or nits on pubic hair Decontaminate bedding and clothing Recommended regimens Permethrin 1% Lindane 1% shampoo Pyrethrins with piperonyl butoxide Re-treatment may be necessary if sx persist Treatment of sex partners within the last month

156 Scabies Predominant symptom is pruritus Recommended regimen Permethrin cream 5% Alternative regimen Lindane 1% or Invermectin 200 ug/kg, repeat in 2 wks Sex partners and household contacts within the preceding month should be treated

157 Scabies Persistent Symptoms Rash and pruritus may persist for 2 wks Persistence > 2 wks: tx failure, resistance, reinfection, drug allergy, cross reactivity with household mites Attention to fingernails of infected patients Treat close contacts empirically Wash linens, bedding, clothing

158 Ophthalmia Neonatorum Prophylaxis Silver nitrate 1% aqueous solution in a single application or Erythromycin 0.5% ophthalmic ointment in a single application or Tetracycline ophthalmic ointment 1% in a single application

159 THE END 02STDRx. Rx.ppt