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STD 2012

STD 2012. Jonathan Vilasier Iralu, MD, FACP Indian Health Service Chief Clinical Consultant for Infectious Diseases. Ulcers, ulcers, ulcers!. Chancroid Donovanosis Herpes Syphilis. Chancroid epidemiology. Low prevalence in the US Seen in Africa and Caribbean

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STD 2012

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  1. STD 2012 Jonathan Vilasier Iralu, MD, FACP Indian Health Service Chief Clinical Consultant for Infectious Diseases

  2. Ulcers, ulcers, ulcers! • Chancroid • Donovanosis • Herpes • Syphilis

  3. Chancroid epidemiology • Low prevalence in the US • Seen in Africa and Caribbean • Increases risk for HIV transmission

  4. Chancroid Microbiology • Hemophilus ducreyi • Small coccobacillus • Grows on special medium not available with <80% sensitivity • No FDA approved PCR

  5. Chancroid ulcers

  6. Chancroid Presentation • Painful genital ulcers • often multiple • with sharply defined edges • exudative base • bleed when traumatized. • Inguinal lymph nodes • tender • suppurative • drain spontaneously

  7. Chancroid - ruptured node

  8. Chancroid diagnostic criteria • One or more painful ulcers • Typical ulcer and lymph node appearance • Negative darkfield or negative RPR at 7 days • Negative HSV test of exudate

  9. Chancroid Treatment • Azithromycin 1 gm po x 1 • Ceftriaxone 250 mg IM x 1 • Ciprofloxacin 500 mg po x 1 • Erythromycin 500 mg po tid x 7 days

  10. Chancroid follow-up • Symptomatically better at 3 days • Healing at 7 days • Gone at 14 days • Lymph nodes may need aspiration or I &D

  11. Chancroid Special consideration • Partner Care • Examination and empiric therapy (Epi treatment) if contact within 7 days • Pregnancy • Avoid Ciprofloxacin • HIV • Follow closely for treatment failure

  12. Granuloma Inguinale • Painless, slowly progressive ulceration • “Beefy red” • Bleed easily • No adenopathy • Pseudobuboes may be present

  13. Granuloma Inguinale • Epidemiologic ‘hot spots’ • Papua New Guinea • Kwa Zulu-Natal • India • Brasil • Caribbean • Australia in aboriginal communities

  14. Granuloma Inguinale • Etiology • Klebsiella granulomatis • Pleomorphic GNR • 99% phylogenetic homology with K. pneumoniae • Difficult to grow in culture

  15. Granuloma Inguinale • Diagnosis • Tissue crush prep with Geimsa stain • PCR (not FDA approved)

  16. Granuloma Inguinale • Preferred treatment: • Doxycycline 100 mg po bid for 3 weeks • Alternate Treatments: • Azithromycin 1 gm po weekly for 3 weeks • Ciprofloxacin 750 mg po bid for 3 weeks • Erythromycin 500 mg po quid for 3 weeks • TMP/Sulfa DS 1 po bid for 3 weeks

  17. Granuloma Inguinale • Partners (60 days): • Examine and treat if infected • Epi treatment is not established • Pregnant: • Erythromycin preferred • HIV • Treat as if negative but consider gentamicin

  18. Herpes simplex • 50 million Americans have genital herpes • The majority are caused by HSV-2 • More aggressive than HSV-1 • More likely to relapse than HSV-1 • Virus is shed intermittently in the absence of symptoms

  19. Herpes simplex • Diagnosis: • Lesions • PCR is the most sensitive becoming test of choice • Viral culture is less sensitive • Serology: • Order glycoprotein G2/G1 assay to differentiate 2 types • Uses: • Recurrent Ulcers with negative cultures • Clinical diagnosis with no lesion testing • Partner with HSV

  20. Herpes simplex • Treatment of Primary HSV: treat all cases • Acyclovir 400 mg po tid for 7-10 days • Acyclovir 200 mg po 5 x per day for 7-10 days • Famciclovir 250 mg po tid for 7-10 days • Valacyclvori 1 gm po bid for 7-10 days

  21. Herpes simplex • Recurrent HSV • Suppression: • Acyclovir 400 mg po bid • Famciclovir 250 mg po bid • Valacylovir 500 to 1000 mg po daily • Episodic Rx of relapses • Acylovir 40 mg po tid for 5 days • Famclovir125po bid for 5 days or 100 mg po bid 1 day • Valacyclovir 500 mg po bid for 3 days or 1 gm po daily for 5 days

  22. Herpes simplex • Patient Education • Asymptomatic shedding occurs • Remain abstinent during prodrome and lesions • Daily Valacyclovir decreases transmission • Latex condoms may be effective • HSV-2 seropositive person are at risk for HIV acquisiton

  23. Lymphogranuloma Venerium • Etiology: • Chlamydia trachomatis, serovars L1, L2, L3 • Seen in heterosexuals and MSM

  24. Lymphogranuloma Venerium • Clinical Presentation • Unilateral inguinal adenopathy • Self-limited papule or ulcer at inoculation site • MSM present with proctocolitis • mucoid or hemorrhagic discharge • Tenesmus • Constipation • Complications • Colorectural fistulas • Fissures

  25. Lymphogranuloma Venerium • Diagnosis • Ulcer/bubo specimens: • Culture • DFA • Nucleic Acid Amplification Test for Chlamydia • PCR genotyping • Chlamydia Serology

  26. Lymphogranuloma Venerium • Treatment of choice: • Doxycycline 100 mg po bid for 21 days • Alternate • Erythromycin 500 mg po qid for 21 days

  27. Lymphogranuloma Venerium • Follow-up: • Testing not required • Pregnancy • Use the erythromycin regimen • HIV • Prolonged therapy may be needed

  28. New syphilis developments • Diagnosis algorithm • When to do an LP in HIV positive patients

  29. Syphilis Diagnosis • Many labs nationally do an EIA first, then RPR • NM State Lab: no • Tricore: yes • Doing EIA first saves money • What to do if RPR is negative?

  30. Syphilis and HIV • LP is no longer indicated for early syphilis • Ignore the CD4 count (<350) • Ignore the RPR > 1:32 • Concentrate only on Hx and Neuro Exam • LP is no longer indicated for latent syphilis • Ignore CD4 and RPR titer • Concentrate only Hx and Neuro Exam

  31. Syphilis and the LP • LP indications regardless of HIV status: -Symptoms or exam suggesting neurosyphilis • Stroke • Dementia • AR pupils • Hearing loss • Treatment failure: • Failure for RPR to drop 4-fold at 6 months for early syphilis and 12 months for late syphilis

  32. Urethritis • Etiology • Chlamydia • Gonorrhea • Mycoplasma genitalium • Trichomonas • Diagnosis • Mucopurulent or purulent discharge • > 5 WBC per HPF on gram stain • + Leukocyte esterase/>10WBC/hpf first void urine

  33. Non-Gonococcal Urethritis • Clinical approach: • Test for GC and chlamydia • Treat with • azithromycin 1 gmpo x1 OR • doxycycline 100 mg po bid for 7 days • Treat treatment failures with • Metronidazole 2 gmpo x1 PLUS • Azithromycin 1 gmpo x 1

  34. Cervicitis • Diagnostic signs: • Purulent or mucupurulent exudate • Easy induced cervical bleeding • >10 WBC/hpf suggests GC or Chlamydia • Gram stain is not recommended

  35. Cervicitis • Clinical approach • Rule out BV and trichomonas • Test for GC and Chlamydia • Treatment (if GC prevalence <5%) • Azithromycin 1 gm po x 1 • Doxycycline 100 mg po bid

  36. Urethritis and Cervicitis F/U • Test of cure not indicated • Test for reinfection at 3-6 months • Treat sex partners from the last 60 days • No sex for 7 days

  37. Chlamydia notes • Screen sexually active women <25 • NAATs are the test of choice • Rectal NAATs can be ordered at Labcorp • Treat with the NGU regimen • If pregnant treat with Azithro or Amoxicillin

  38. Gonorrhea • Epidemiology • >300,000 cases per year in the US • #2 STD in America

  39. Gonorrhea Slang • Dose • Clap • Drip • Gleet • Morning Drip • Running Rage • Gonorilla

  40. Gonorrhea

  41. Gonorrhea • Clinical Manifestations: • Urethritis • Cervicitis • Pharyngitis • Proctocolitis • Septic Arthritis • Disseminated Gonococcal Infection • Petechial/pustular skin lesion • Assymetric Arthralgia/Tenosynovitis • Perihepatitis • Meningitis

  42. Gonorrhea • History of treatment • Urethral mercury injection syringe found on the Mary Rose in 1545 • Sulfa introduced in 1937 • PCN introduced in 1930, resistant in 1989 • Cefixime resistance noted in 2003 in Japan • Quinolones declared worthless in April 2007 • Ceftriaxone resistance seen 2009 in Kyoto

  43. GISP resistance data 2006-2011

  44. Gonorrhea • Mechanisms of Cephalosporin resistance • PenA mutation: PBP-2 • PenB mutation: outer membrane protein channel • mtrR mutation: repressor of pump • CDC update- August 10, 2012 • Cefixime Resistance 1.5% nationally and 3.2% in the West • Ceftriaxone Resistance stable at 0.4% • Azithromycin Resistance stable at 0.3% • Tetracycline Resistance stable at 21.6%

  45. Gonorrhea • Urethra/Cervix/Rectum Treatment • Recommended: Ceftriaxone dose 250 mg IM x 1 • plus Azithromycin 1 gmpo x 1 • Or doxycycline 100 mg po bid for 7 days • Alternate: Azithromycin 2 gmpo x 1 or Cefixime 400 mg + Azithro 1 gm PO x 1 **Test of cure required at 1 week for alternate Rx**

  46. Gonorrhea • Disseminated Gonorrhea • Ceftriaxone 1 gm IM or IV daily until 24-48 hours then consider switch to Cefixime 400 mg po daily.

  47. Gonorrhea • DON’T DO: • test of cure unless using alternate Rx • DO: • Test for reinfection at 3 months • DO: • test of cure if there is suspected resistance

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