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: 2010 (2014 update coming soon)
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 recommended for sexually active women <25 years old and high risk populations
Gonorrhea 2009: reached historic low levels (98/100,000) Texas #12/50 Widespread screening of women only recommended in high risk groups 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 If PCN allergy: Azithromycin 2g PO + TOC 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 Strongly consider removing IUD, if present
Trichomoniasis Wet prep is not sensitive (65%) POC tests will increase sensitivity, but are still not great When the pap shows trich>assess risk and counsel Cultures can be obtained Treatment failure: consider tinidazole Nitroimidazoles allergy: may need to be desensitized
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 Poorly controlled HIV and pregnancy: times when treatment seems futile
HSV Culture is not sensitive, consider PCR test IgM is not helpful 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?
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, all pregnant women) Opt-out testing may be acceptable Confidential versus anonymous testing
cobas HPV test Detects 14 high risk HPV types, with specific genotyping of 16 and 18 FDA approved for first-line screening for cervical dysplasia in women >25 years old ATHENA trial If 16 or 18 positive: colposcopy If other high risk: reflex to pap
Gardisil-9 6, 11, 16, 18, 31, 33, 45, 52 and 58 Females: 6-26 years old Males: 6-15 years old Same administration regimen as Gardisil (0,2, and 6 months)
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