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STD Overview

STD Overview. Sam Brown-Parks, MD, MPH July 26, 2012. Overview/ Classifications. Lesions Chancroid Genital HSV Infections Granuloma Inguinale (Donovanosis) Lymphogranuloma Venereum Syphilis Urethritis/Cervicitis Chlamydia Gonorrhea Trichomonas Nongonococcal Urethritis. Bacterial

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STD Overview

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  1. STD Overview Sam Brown-Parks, MD, MPH July 26, 2012

  2. Overview/ Classifications Lesions Chancroid Genital HSV Infections Granuloma Inguinale (Donovanosis) Lymphogranuloma Venereum Syphilis Urethritis/Cervicitis Chlamydia Gonorrhea Trichomonas Nongonococcal Urethritis • Bacterial • Chlamydia • Gonorrhea • Syphilis • Viral • HSV • HPV (not discussed today) • HIV (not discussed today) • Parasitic • Trichomonas

  3. Chlamydia • Chlamydia Trachomatis • most common treatable bacterial STD • 2.8 Million Americans/ year • Cost at least $2.4B/ year for direct and indirect costs • Reportable in all 50 states

  4. Adolescents • Young Adults • Ethnicities • Detention centers

  5. Chlamydia • Transmission: vaginal, anal, oral, perinatal • Sexual transmission rate >50% • Perinatal transmission conjunctivitis in 30-50% • Perinatal transmission with pneumonia in 3-16% • Incubation period 7-21 days • “Silent” infection- no sx • 75% of women • 50% of men

  6. Risk Factors • Ectopy of Ectocervix • Adolescents, OCP users • New, multiple sex partners • Hx of STD infection • Presence of other STD • Lack of Barrier method

  7. Microbiology and Pathogenesis • C. Trachomatis • Trachomatis • Genital infections • Lymphogranuloma venerum (LGV) • Conjunctivitis • Pneumonia in infants • C. pneumoniae -pneumonia • C. Psittaci -pneumonia • Obligate intracellular bacteria • Life Cycle is 72 hrs-> replication kills host • Elemental Bodies released and free to attach to new cells

  8. WOMEN Increased Vag D/C (due to inflammation) +/- Urinary freq/ Dysuria Abdominal Pain Dyspaurenia Menstrual irregularity MEN Uncomplicated Urethritis-White to watery discharge dysuria Complicated Epididymitis Reiter’s Syndrome Chlamydia: Signs & Symptoms

  9. Chlamydia: Complications • PID • Infertility/ Ectopic Pregnancy • Chronic Pelvic Pain • Perihepatitis • Endometritis • Salpingitis • Epididymitis • Reiters Syndrome • Inflammation of eyes, joints, rash • Appendicitis?

  10. Wet Prep with increased WBCs & Bacteria with + physical findings Nucleic Acid Amplification Test (NAAT) Vaginal/ Urethral DNA probe (with GC) Urine testing Azithromycin 1gm* Rescreen positives in 3 months after treatment Pregnant Erythromycin estolate, doxycycline, ofloxacin, and levofloxacin are contraindicated during pregnancy. *+ Concomitant tx for GC Testing & Treatment Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days Erythromycin base 500 mg orally four times a day for 7 days OR Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days OR Levofloxacin 500 mg orally once daily for 7 days OR Azithromycin 1 g orally in a single dose OR Amoxicillin 500 mg orally three times a day for 7 days

  11. Lymphogranuloma venereum (LGV) • Caused by strains of C. trachomatis • Rare in the US • Some sporadic outbreaks in European and American groups of MSM • Multiple, enlarged, matted, tender inguinal LNs • Usually suppurative and bilateral • Fever, Chills, meningismus, myalgia • May have genital ulcer at site of inoculation

  12. Chlamydia Questions… • The reported rates of chlamydia are higher in women than in men because: • Men are less susceptible to C. trachomatis infection. • Men are less likely to exchange sex for drugs. • Women are screened for chlamydia more often than men. • The bacteria are increasing in drug resistance; hence, the disease is more difficult to treat.

  13. Chlamydia Q#2 All of the following statements are true of C. trachomatis except: • C. trachomatisare obligatory intracellular organisms. • C. trachomatissurvive by replication that results in death of the cell in which they have entered. • The life cycle of C. trachomatisis six hours. • The elementary body is the infectious particle of C. trachomatis.

  14. Chlamydia Q #3 Which of the following best describes the clinical signs/symptoms of chlamydial urethral infection in men? • Yellow discharge from penis • Dysuria • Scrotal pain • Most men screened are asymptomatic.

  15. Chlamydia Q#4 Which one of the following is true regarding chlamydial infection in men? • Epididymitis is a complication of untreated C. trachomatis infection. • Epididymitis is always the result of a sexually transmitted infection. • Men almost always experience symptoms. • Chlamydia urethritis (or NGU) can be reliably distinguished clinically from gonococcal urethritis by its association with a clear urethral discharge (in contrast to gonorrhea’s thicker yellow discharge).

  16. Chlamydia Q#5 Which of the following statements best describes the clinical signs/symptoms of chlamydial infection in women? • Most women complain of a discharge. • Most women complain of urinary symptoms. • Clinical signs/symptoms depend on the strain of chlamydia. • Most women are asymptomatic.

  17. Chlamydia Q#6 Which of the following is true for sex partners of a patient diagnosed with chlamydia? • Only the most recent sex partner needs to be referred for treatment. • All partners exposed in the last 60 days should be referred for treatment. • Only symptomatic partners need to be referred for treatment. • No partners need to be referred since chlamydia is not efficiently transmitted.

  18. Gonorrhea • Neisseria gonorrhoeae • >700,000 cases in US per year • Costs $56M/ year • Intracellular gm- diplococci • Infects mucus secreting epithelial cells • Transmission: vaginal, anal, oral, perinatal • Often asymptomatic • Incubation period 1-14 days. Most symptomatic @ 2-5

  19. Rates highest in the South • Higher in ethnicities • Higher in young adults/ adolescents

  20. Risk factors for acquiring gonorrhea include: • Multiple or new sex partners • Inconsistent condom use • Living in an urban area where gonorrhea prevalence is high • Being adolescent (especially female) • Having a lower socio-economic status • Using drugs including alcohol • Exchanging sex for drugs or money • African Americans

  21. WOMEN 50% asymptomatic Urethritis-Dysuria Cervicitis- Vaginal discharge Irregular bleeding Dyspaurenia MEN Uncomplicated Urethritis Dysuria White, yellow or green purulent or mucopurulent penile discharge Swollen, painful testicles Gonorrhea: Signs & Symptoms

  22. Gonorrhea: Complications • PID • Perihepatitis • Infertility • Ectopic Pregnancy • Accessory Gland Infection (Bartholin’s, Skene’s) • Epididymitis, balantitis, prostatis • Conjuncitivitis, pharyngitis • Disseminated Gonococcal Disease • Arthritis, dermatitis, endometritis, myocarditits • Increased spread of HIV (contraction and transmission)

  23. Wet Prep with increased WBCs (PMNs) & Bacteria with + physical findings Vaginal/ Urethral DNA probe (with Chlamydia) Urine testing Can also Culture sites Ceftriaxone 125mg IM* or Cefixime 400mg po* *Plus concomitant tx for Chlamydia Pregnant women who cannot tolerate a cephalosporin should be administered a single 2 g dose of spectinomycin IM or azithromycin 2 g PO. Pregnant women should not be treated with quinolones or tetracyclines. A repeat test should be performed during the third trimester for those at continued risk. Testing & Treatment

  24. Screening • Pregnancy - A test for N. gonorrhoeae should be performed at the first prenatal visit for women at risk or for women living in an area in which the prevalence of N. gonorrhoeae is high. A repeat test should be performed during the third trimester for those at continued risk. • The U.S. Preventive Service Task Force recommends that clinicians screen all sexually active women, for gonorrhea infection if they are at increased risk of infection. Women aged <25 years are at highest risk for gonorrhea infection. Other populations should be selected for screening based on local prevalence of gonorrhea and the patient's risk behaviors. • The CDC recommends screening of at-risk men who have sex with men at least annually for urethral and rectal gonorrhea and chlamydia, and for pharyngeal gonorrhea

  25. Gonorrhea Q#1 The region of the U.S. with the highest rates of gonorrhea is: • Western U.S. • Midwest U.S. • Southern U.S. • Northern U.S.

  26. GCQ#2 Which of the following statements best describes the clinical signs/symptoms of gonorrhea in men? • Most men complain of testicular pain. • Most men complain of urethral discharge. • It depends on the gonococcal strain. • Most men are asymptomatic.

  27. GCQ#3 Which of the following regimens is the best option in the case of a 17-year-old male with an uncomplicated gonococcal infection, and who has not been tested for chlamydia? • Ceftriaxone 125 mg IM in a single dose plus Azithromycin 1 g orally in a single dose • Azithromycin 1 g orally in a single dose • Cefixime 400 mg orally in a single dose

  28. Syphilis • Treponema pallidum • The “great imitator” • 37,000 cases in 2006 • Transmission: vaginal, anal, oral, perinatal • Increasing number of new cases • Fulton Co #5, DeKalb #11 (2006) • 64% cases involved MSM

  29. Higher in south • Higher in males • Higher in Ethnicities

  30. Syphilis: Microbiology • Treponema pallidum • corkscrew-shaped, motile microaerophilic bacterium that cannot be cultured in vitro • cannot be viewed by normal light microscopy. • enters the body via skin and mucous membranes through macroscopic and microscopic abrasions during sexual contact • also be transmitted transplacentally from mother to fetus during pregnancy • travels via the lymphatics to regional lymph nodes and then through blood stream. • Invasion of the central nervous system can occur during any stage of syphilis.

  31. Syphilis: Signs & Symptoms • Many are asymptomatic or unaware of lesions at time of transmission • Primary: firm, round, small painless chancre • Usually develop sx 10-90 d after infection (mean 21) • Lasts 3-6 weeks, resolves without treatment • Multiple chancres occur in 25% of cases • highly infectious • Regional lymphadenopathy is classically rubbery, painless, and bilateral

  32. Secondary Syphilis • can develop in weeks, months • 75%-100% of secondary syphilis cases • Rash: rough, reddish brown on palms/ soles • +/- fever, +LNs, sore throat, patchy hair loss, h/a,weight loss, muscle aches, and fatigue • Condylomata lata (10%-20%) moist, heaped, warty papules in warm intertriginous areas (gluteal folds, perineum, perianal); these lesions are very infectious. • Resolves without tx

  33. Syphilis: Signs & Symptoms • Tertiary (latent) Syphilis • Begins as soon as rash disappears • Sx may not develop for 10-20 years • 15% of untreated cases will develop Neurosyphilis • Ataxia, imbalance • Paralysis, numbness • Blindness • Dementia, death

  34. Primary w/ Chancre: Dark Field Examination + : definitive, immediate - :specialized scope, skills, confused with other spirochetes Secondary: Nontreponemal (RPR, VDRL) If +, EIA If +/- FTA-ABS Tertiary: CSF tested <2 years (early latent) Benzathine PCN x 1 Doxycycline if allergic >2 years (late latent) Procaine PCN q wk x3 Neuro findings: PCN IV q 4 hours x 2 wk Testing

  35. Treatment • Primary, secondary, and early latent syphilis without neurologic involvement: • Benzathine penicillin G, IM, 2.4 million units in a single doseIf penicillin allergic (one of the following):Doxycycline 100 mg orally twice daily for 2 weeksTetracycline 500 mg orally 4 times daily for 2 weeks • Late latent or latent syphilis of unknown duration without neurologic involvement: • Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals • If Allergic, Doxycycline 100 mg orally twice daily for 28 days or Tetracycline 500 mg orally 4 times daily for 28 days • Tertiary (late) syphilis without neurologic involvement: • Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals • Neurosyphilis: • Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion for 10-14 days IV Alternative regimen (if compliance can be ensured): Procaine penicillin 2.4 million units IM once daily PLUS Probenecid 500 mg orally 4 times a day, both for 10-14 days

  36. Syphilis Q#1 All of the following are true about syphilis in the U.S. except: • Recent syphilis outbreaks have occurred in MSM subpopulations. • P&S syphilis rates reached an all-time low in 2000. • P&S syphilis is widespread throughout the United States. • Syphilis disproportionately affects African Americans.

  37. Syphilis Q#2 Which of the following is not a sign of secondary syphilis? • Alopecia Chancre at the site of inoculation • Condyloma lata • Palmar/plantar rash • Papulosquamous rash

  38. Syphilis Q#3 A patient is referred to you by the plasma center because she has a "positive RPR." Which of the following are appropriate next steps? • Order a quantitative serologic nontreponemal test (e.g. RPR) and a confirmatory serologic treponemal test (e.g., FTA-ABS). • Obtain a detailed history and assess whether she has had syphilis before. • Contact your local health department STD program to see if they have additional information about the patient. • Perform a complete physical examination. • All of the above may be appropriate.

  39. Viral STDs

  40. Genital Herpes • Very prevalent STD: 20% in >12yo in US • Most due to HSV-2, occasionally HSV-1 • 1.6M new cases per year in US • At Least 50M cases in US • Transmitted by Genital-Genital contact or Genital-oral contact as well as through birth canal • Most genital herpes infections are transmitted by persons unaware that they have the infection or who are asymptomatic when transmission occurs.

  41. HSV Microbiology • HSV is a double-stranded DNA virus surrounded by an envelope of lipid glycoprotein • HSV penetrates susceptible mucosal surfaces or abraded cracks in the skin • All herpes viruses establish latent infection in specific target cells • Reactivation, is precipitated by multiple known (trauma, fever, ultra-violet light, stress, etc.) and unknown factors; and induces viral replication.

  42. Herpes: Signs & Symptoms • Most are asymptomatic • Primary Outbreak (within 2 wks of transmission) • Pruritic, Painful vesicles -> shallow ulceration • last an average of 11-12 days • Fever, malaise prodrome • Lymphadenopathy • Dysuria • Secondary Outbreaks • Less severe • Decrease in freq over time for most

  43. Herpes: Complications • Recurrent outbreaks with asymptomatic shedding greater with HSV2 than HSV1 • Dissemination with immunosuppression • Neonatal transmission • Rarely intrauterine infection (congenital herpes)

  44. Clinical DX Insensitive and nonspecific Lab Tests Viral Culture- gold standard 99% specific Antigen Testing Sensitive DFA distinguishes 1 & 2 PCR: highly sensitive and specific While serologic assays for HSV-2 should be available for persons who request them, screening for HSV-1 or HSV-2 infection in the general population is not indicated. Diagnosis

  45. Treatment • First Outbreak • Acyclovir 400 mg orally three times a day for 7-10 days, OR • Acyclovir 200 mg orally 5 times a day for 7-10 days, OR • Famciclovir 250 mg orally three times a day for 7-10 days, OR • Valacyclovir 1 g orally twice a day for 7-10 days • Recurrent Outbreaks • Acyclovir 400 mg orally 3 times a day for 5 days,OR • Acyclovir 800 mg orally twice a day for 5 days,OR • Acyclovir 800 mg orally 3 times a day for 2 days;OR • Famciclovir 125 mg orally twice a day for 5 days,OR • Famciclovir 1000 mg orally twice a day for 1 day,OR • Valacyclovir 500 mg orally twice a day for 3 days,OR • Valacyclovir 1 g orally once a day for 5 days. • Suppression • Acyclovir 400 mg orally twice a day,OR • Famciclovir 250 mg orally twice a day,OR • Valacyclovir 500 mg orally once a day,OR • Valacyclovir 1 g orally once a day

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