Sexually transmitted infections (in women) Timothy Kremer, MD Assistant Professor, Department of Obstetrics and Gynecology University of North Texas Health Science Center Last official CDC guidelines: 2015 now available
none Disclosures
Objectives Review common and important aspects in the treatment of sexually transmitted diseases Highlight updates in the 2015 CDC Guidelines for the treatment of sexually transmitted diseases Identify relevant applicable Texas statutes regarding sexually transmitted infection reporting and testing
Syphilis 2013 (for Texas) 1475 cases (#13 ranking) [primary + secondary] Male rate: 10/100,000 Female rate: 0.9/100,000 75 cases of congenital syphilis (#3 ranking) Disproportionate rates by ethnicity
Syphilis tests Non-treponemal tests Rapid Plasma Reagin (RPR) Venereal Disease Research Laboratory (VDRL) Treponemal tests Fluorescent treponemal antibody absorption (FTA-ABS) T. pallidum particle agglutination assay (TP-PA) Microhemagglutination test for antibodies to T. pallidum (MHA- TP) Enzyme immunoassays (EIAs) Chemiluminescence immunoassays (CIAs) Darkfield microscopy
Syphilis testing algorithms Traditional Non-treponemal test, reflex to treponemal test if positive Newer algorithm Treponemal test (EIA or CIA), reflex to non-treponemal test if positive A positive treponemal and non-treponemal test needed to make a diagnosis (usually)
Syphilis treatment Penicillin G (not V) Special considerations: PCN allergy Pregnancy Late latent syphilis of unknown duration I always check the CDC website before I treat
Chlamydia The most frequently reported infectious disease in the United States Highest prevalence: <25 years old Usually asymptomatic Annual screening for chlamydia and gonorrhea recommended for sexually active women <25 years old and high risk populations
Gonorrhea 2009: reached historic low levels (98/100,000) Texas #12/50 Annual screening now recommended for women <25 years old and high risk women Antimicrobial resistance emerging MSM, Minneapolis, San Diego, Portland, Honolulu
Gonorrhea and Chlamydia: Screening and testing Chlamydia: NAAT (nucleic acid amplification tests) are preferred Endo-cervical specimen preferred over urine (more sensitive) Gonorrhea: Endocervical culture preferred NAAT acceptable Endo-cervical specimen preferred over urine
Gonorrhea and Chlamydia: Screening and testing Post-hysterectomy: Could be in the rectum or urethra, but not the vagina (assuming the cervix was removed) Sensitivity exceeds >90% for NAAT PPV may be <90% in low incidence populations Rectum and pharynx: culture Sexual assault/abuse legal cases: will probably require culture to be admissible
Chlamydia: Treatment considerations Azithromycin 1 g orally in a single dose (or Doxycycline 100 mg po BID x 7 days) Test of cure not recommended except in pregnant women Must wait 3 weeks before TOC Re-testing in recommended 3 months after treatment You don t have to remove an IUD, especially if the infection is asymptomatic
Gonorrhea: Treatment considerations Ceftriaxone 250mg IM + Azithromycin 1g PO Cephalosporin allergy: Gemifloxacin 320mg PO + Azithromycin 2 g PO Gentamicin 240mg IM + Azithromycin 2 g PO Quinolones no longer recommended Oral cephalosporins no longer recommended For true treatment failure: culture for ID and sensitivity + contact CDC (via the health department) You don t have to remove an IUD, especially if the infection is asymptomatic
Pelvic Inflammatory Disease Not all cases are associated with N. gonorrhoeae and C. trachomatis Can be asymptomatic and/or unrecognized Consider anaerobic coverage when treating Parenteral regimen (example): Cefoxitin 2 g IV q6h PLUS Doxycycline 100 mg po or IV q12h (until clinically improved) PLUS complete a 14 day course of Doxycyline Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg po bid x 14 days WITH or WITHOUT Metronidazole 500 mg po bid x 14 days
Trichomoniasis Wet prep is not sensitive (65%) NAATs are now recommended When the pap shows trich>assess risk and counsel Cultures can be obtained Nitroimidazoles allergy: may need to be desensitized
Trichomoniasis Topical therapy is NOT effective Most common cause of recurrent or persistent symptoms: Reinfection Incidence of decreased sensitivity for nitroimidazoles: 2-5% Protocols for suspected decreased sensitivity 500mg BID x 7 days (1 st attempt) 2grams QD x 5 days (2 nd attempt) Call CDC (3 rd attempt)
Molluscum Contagiosum Poxvirus Will usually resolve in 6-12 weeks Lesions Small and raised (2-5mm DIA) White, pink, or flesh-colored with a dimple or pit in the center. Spread by direct contact AND formites Therapy: cryotherapy, curettage
Condyloma accuminatum 90% of genital warts from HPV types 6&11 Gardisil covers 6&11; Cervarix does not When to biopsy and/or culture: Molluscom contagiosum, Lymphogranuloma venereum, Crohn s disease, vulvar dysplasia, vulvar cancer, herpes, donovanosis, hidradenitis supportiva, skin tags Treatment options include imiquimod 3.75% or 5% cream. (previously only 5% cream included) Podophyllin resin is no longer a recommended (Podofilox 0.5% solution or gel still acceptable)
HSV Culture is not sensitive, consider PCR test IgM is not helpful (because IgM tests are not type-specific and might be positive during recurrent genital or oral episodes of herpes) Most HSV-2 is sexually acquired Incidence of anogenital HSV-1 probably rising When should you initiate suppressive therapy? How long should it be continued?
Mycoplasma genitalium with urethritis and cervicitis Detected in 10-30% of cervicitis cases Emerging evidence suggests it may be a causative agent of PID May play a role in infertility NAAT preferred method of detection (difficult to culture) PID treatment regimens are not effective against M. genitalium Treatment considerations Moxifloxacin 400mg PO daily x 14 days Azithromycin 1g PO (resistance emerging) Doxycycline x 7 days (poor efficacy)
Chancroid Painful genital ulcer + inguinal lymphadenopathy H. ducreyi Treatment options: Azithromycin 1 g po OR Ceftriaxone 250 mg IM
HIV Universal testing recommended (15-65 years old) Testing in pregnancy Opt-out testing for all women Repeat testing in 3 rd trimester of high risk women (defined by incidence in the patient population) Out-out rapid testing for women in labor with unknown HIV status Texas law (Chapter 81.090 of the Texas Health and Safety Code)
Reporting requirements (for Texas) HIV and AIDS, Syphilis, Chlamydia, Gonorrhea, and Chancroid Reporting is exempt from HIPAA http://www.dshs.state.tx.us/hivstd/healthcare/reporting.sht m Failure to report a reportable disease is a Class B misdemeanor under the Texas Health and Safety Code, 81.049