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Sexually Transmitted Diseases Treatment and Management

Sexually Transmitted Diseases Treatment and Management. October, 2009 Divya Ahuja , MD Associate Professor of Medicine. Syndromic approach. Case 1. 24 year male, sexually active Presents with 4 day history of dysuria and penile discharge. Gonorrhea. Agent: Neisseria gonorrhoeae

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Sexually Transmitted Diseases Treatment and Management

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  1. Sexually Transmitted DiseasesTreatment and Management October, 2009 DivyaAhuja, MD Associate Professor of Medicine

  2. Syndromic approach

  3. Case 1 • 24 year male, sexually active • Presents with 4 day history of dysuria and penile discharge

  4. Gonorrhea • Agent: Neisseriagonorrhoeae • 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

  5. Gonorrhea Gonorrhea — Rates by state: United States and outlying areas, 2003 Note: The total rate of gonorrhea for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 114.7 per 100,000 population. The Healthy People year 2010 objective is 19.0 per 100,000 population. Source: CDC/NCHSTP 2003 STD Surveillance Report

  6. Clinical Manifestations- Male • Symptoms of Acute anterior urethritis (>95%) • Scant urethral discharge at onset • discharge • dysuria • spontaneous resolution over several weeks • Complications • Epididymitis: relatively infrequent • Penile edema, urethral stricture, prostatitis • Disseminated gonococcal infection (DGI)

  7. Clinical Manifestations- Female • Muco-purulent cervicitis • 1/3rd of cervical infections are subclinical • Cervical abnormalities may include: • Discharge, erythema, mucosal bleeding • Adnexal tenderness Complications • Pelvic Inflammatory Disease (PID) • 10 to 20% of non-pregnant women with GC

  8. Diagnosis • Gram- Stained Smear • Positive smear is considered diagnostic in men ( >99% specificity) • In women however, a culture is needed as sensitivity of gram stain is 50 % • Only culture tests are approved for rectum, pharynx and abuse cases

  9. What is the diagnosis if this patient has a monoarthritis and penile discharge?

  10. Disseminated Gonococcal Infection (DGI) • Arises from Gonococcalbacteremia • Think of gonococcus in a monoarthritis • Acute arthritis-dermatitis syndrome • arthritis: usually involves wrist, fingers, toes, ankle & knee joints • tender, necrotic pustule • Tenosynovitis

  11. 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 • Cefixime400 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

  12. Increasing QuinoloneResistance • CDC Update,MMWR:April 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%

  13. MUCOPURULENTCERVICITIS (MPC) • Typical causes • Chlamydia trachomatis • N. gonorrhoeae • Rarely M. genitalium and BV • Remember douching, chemical irritants • In most instances an organism is not isolated

  14. Chlamydia • Epidemiology • most common bacterial STD in the US • annual incidence in US is estimated @ 3 million cases • 70 to 80 % of infected women are asymptomatic • ~ 50% of infected men are asymptomatic • Peri-natal transmission results in neonatal conjunctivitis in 30-50% of exposed babies

  15. Chlamydia Chlamydia — Rates by state: United States and outlying areas, 2003 Note: Includes states and outlying areas that reported chlamydia positivity data on at least 500 women aged 15-24 years screened during 2003. SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention Source: CDC/NCHSTP 2003 STD Surveillance Report

  16. Chlamydia: Clinical Manifestation-Male • Urethritis • Dysuria • Discharge • Proctitis • Only 1 of 8 infected men followed without Rx developed symptoms

  17. Chlamydia: Clinical Manifestation - Female • Mucopurulentcervicitis (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

  18. CHLAMYDIA - DIAGNOSIS • Leucorrhea > 10 WBC per high power field • Non-Amplified Antigen Tests • Enzyme Immunoassay, DNA Probe • Nucleic Acid Amplification Tests • PCR, PROBE-TEC, TMA, etc.

  19. 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 poqid x 7days OR • Ofloxacin 300 mg po bid x 7 days • Dual treatment (GC/Chlamydia) • Treat sex partners • Abstain from sex for 7 days

  20. URETHRITIS • Gonococcal (GC) • Neisseriagonorrhoeae • Nongonococcal (where GC is negative) • Chlamydia trachomatis • Mycoplasmagenitalium • Ureaplasmaurealyticum • Trichomonasvaginalis • Herpes simplex virus • Cause unknown

  21. Gonococcal Urethritis

  22. Nongonococcal Urethritis

  23. 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

  24. 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

  25. Pelvic Inflammatory Disease Pathogens • N. Gonorrhoeae, C. trachomatis • Anaerobes, Gardnerellavaginalis, mycoplasma • gram-negative rods, S. agalactiae • Spectrum of disorders • Salpingitis • Endometritis • Tuboovarian abscess • Peritonitis

  26. Pelvic Inflammatory Disease

  27. Clinical Criteria • Symptoms • Abnormal bleeding • Dyspareunia • Vaginal Discharge • Fever • Minimum Criteria lower abdominal pain, adnexal OR cervical motion tenderness • Specific Criteria Transvaginalsonography, Laparoscopy

  28. Indications for hospitalization in suspected PID • 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

  29. TREATMENT OF PID • PARENTERAL REGIMENS • Cefoxitin 2 g IV Q 6hrs ORCefotetan 2g IV Q 12 PLUS Doxycycline 100 mg PO/IV Q 12 hrs OR ORAL REGIMEN • Ceftriaxone 250 mg IM in a single dose PLUSDoxycycline 100 mg orally twice a day for 14 daysWITH OR WITHOUTMetronidazole 500 mg orally twice a day for 14 days

  30. PID • COMPLICATIONS Infertility Ectopic pregnancy : 80% have antibodies to Chlamydia Chronic pelvic Pain in 18% • INFERTILITY AFTER PID One episode – 10% Two episodes – 20% Three or more episodes – 40% Westrom et al. Sex TransmDis 1992:185-192

  31. 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 • Transmitted by direct sexual contact • Vaccines now approved and in clinical use

  32. Clinical Manifestations of Genital Warts Atlas fig 8.13 Page 297 Smooth papular warts Condylomata acuminata Flat cervical condylomata Keratotic flat wart

  33. CLINICAL PRESENTATION OF GENITAL WARTS: VULVA

  34. HPV and Cervical Cancer Perianal Wart Source: Cincinnati STD/HIV Prevention Training Center

  35. PATIENT APPLIED TREATMENT PROVIDER 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

  36. Case # 4

  37. Genital ulcer-Does it hurt? • Painful • Chancroid • Genital herpes simplex • Painless • Syphilis • Lymphogranuloma venereum • Granuloma inguinale

  38. What’s your diagnosis?

  39. 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

  40. Genital Herpes: Clinical Manifestations • Subclinical infection • May be asymptomatic • Primary • inguinal node tenderness/enlargement • vesicular, ulcerated lesions • headaches, malaise and fever • Recurrent Herpes • > 90% of patients with HSV-2 will have recurrence • progressively less severe over time

  41. Genital Herpes • DIAGNOSIS • Tissue culture • Cytology (Tzanck Smear) • Direct Fluorescent Antibody • Nucleic Acid Amplification • SEROLOGY TREATMENT • Initial Episode • Acyclovir (Zovirax) 400 mg potid x 7-10 days • Famciclovir250 mg potid 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

  42. Case # 3 • 28 year HIV positive male with CD4 of 250 • Fever, malaise and a rash • Sex with a number of male partners • Penile ulcer on following slide

  43. What’s your diagnosis?

  44. 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

  45. Secondary Syphilis • Secondary lesions appear 4-10 weeks after primary chancre • Rash in 80-90% • In 60% will involve palms and soles • Mucus patches • Condylomatalata • Heaped, moist wartlike papules • Myalgia , headache, fever

  46. Rash of Secondary Syphilis

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