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STD 101

STD 101. Kees Rietmeijer, MD, PhD Denver Prevention Training Center. Goal. Provide overview of the management of the most common STD syndromes: Vaginal discharge Male urethral discharge Genital ulcer disease. CDC STD Treatment Guidelines. New edition expected in 2014. Triage.

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STD 101

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  1. STD 101 Kees Rietmeijer, MD, PhD Denver Prevention Training Center

  2. Goal • Provide overview of the management of the most common STD syndromes: • Vaginal discharge • Male urethral discharge • Genital ulcer disease

  3. CDC STD Treatment Guidelines New edition expected in 2014

  4. Triage • Express Visit • Eligible • Asymptomatic • Low-risk • Testing • All • Chlamydia NAAT • Gonorrhea NAAT • HIV • Based on risk • Syphilis: RPR • Comprehensive Exam • Eligible • Symptomatic • High-risk • MSM • Partner of STI • Sex work • Testing • Based on symptoms • POCT • All • CT/GC NAAT • RPR • HIV

  5. Vaginal Discharge

  6. Case 1 • 31 year old woman • Complains of abnormal, malodorous vaginal discharge since 10 days • Over the counter medications have been ineffective • Last sexual contact 3 days ago with new partner • 2 partners in past 3 months • Otherwise no health problems

  7. Case 1 • What else do you want to know? • Only sex with men • Not aware of any partners’ symptoms • Inconsistent condom use • Previous STDs: • Chlamydia infection 2 years ago • No substance use or sex work • Never been tested for HIV

  8. Examination

  9. What Next?

  10. Vaginal Discharge

  11. Wet Prep (KOH)

  12. Gram Stain NUGENT Score 0 NUGENT Score 10

  13. Vaginal Discharge -Management • Yeast • Hyphae • Spores • Treatment • Azoles • Topical/5-7d • Oral/single dose • Partner management • Not recommended • BV • Amsell Criteria • Homogeneous, grey discharge • Whiff • Ph >4.5 • Clue cells • Treatment • Metronidazole/7d • Tinidazole/7d • Partner management • Not recommended • Trichomoniasis • Motile trichomonads • Treatment • Metronidazole/single dose • Tinidazole/single dose • Partner management • Yes

  14. Trichomonas Test Comparisons Briselden AM. J ClinMicrobiol. 1994; Demeo LR. Am J Obstet Gynecol. 1996; Huppert JS. J ClinMicrobiol. 2005; Nye MB. Am J Obstet Gynecol. 2009; Van DerPol B. J ClinMicrobiol. 2006. Van Der Pol; Schwebke; Taylor: Posters STI & AIDS, 2013 Courtesy: Charlotte Gaydos. ISSTDR, Vienna; 2013.

  15. What Other Tests Are Recommended? • Chlamydia and gonorrhea NAAT (e.g., APTIMA or ProbeTec) • Syphilis: • Traditional algorithm: • Non-trepenamal (RPR or VDRL) • If + followed by treponemal test (TPPA/TPHA/FTA) • Reverse algorithm: • Treponemal (EIA or rapid POC) • If + followed by non-treponemal (RPR or VDRL) • HIV

  16. Male Urethral Discharge

  17. Case 2 • 24 year-old MSM • Urethral discharge since 3 days • Known HIV+ • 10+ partners in past 3 months • Last sex 2 days ago in bath house • Pt is “versatile”; i.e., engaging in both insertive and recepetive anal inntercourse

  18. What Else Do You Want to Know? • Patient is in HIV care and had an undetectable viral load at last testing 2 months ago • Unprotected sex only with partners he knows are HIV+ as well • Has a history of multiple STDs, including syphilis and gonorrhea

  19. Clinical Exam

  20. What Next?

  21. Male Urethral DischargeClinical Presentation

  22. Urethral DischargeGram Stain • Gonococcal Urethritis • Treatment • Ceftriaxone + • Azithromycin or Doxycycline • Partners • <60 days • Evaluation and treatment • Expedited partner treatment (EPT) • Nongonococcal urethritis • Treatment • Azithromycin or Doxycycline • Partners • <60 days • Evaluation and treatment • EPT

  23. Cause of Urethritis Among MalesDenver Metro Health Clinic (N=7527)

  24. Cause of Nongonococcal UrethritisSeattle, 2007 - 2011 N = 606 Manhart et al. Clin Infect Dis 2013;56:934

  25. Treatment Results • C. trachomatis 86 90 • M. genitalium 40 30 • U. urealyticum 75 70 • Clinical Cure 80 76 Azithromycin Doxycycline % % Manhart et al. Clin Infect Dis 2013;56:934

  26. Gram Stain Diagnosis of NGU • Traditionally, clinical diagnosis established on basis of Gram-stained smear of urethral discharge at > 5 PMNs/HPF • However: • Cut-off determined in • pre-HAART era • Low-level infections may be accompanied by low-level inflammatory response (especially for chlamydia) • How does the Gram stain perform at different cut-off levels when using chlamydia NAAT as the gold standard?

  27. Gram Stain Diagnosis of NGU N = 11,422 Gram Stains Rietmeijer and Mettenbrink Sex Transm Dis 2012;39:18

  28. Case 3 • 29 year-old woman • Very painful vulvar lesions, increasing in severity for past 4 days • Monogamous relationship with new partner since 3 months • Used condoms initially, but unprotected vaginal and oral sex after both partners tested negative for STD • No history of STDs • Partner not aware of symptoms and also negative STD history

  29. What Next?

  30. Genital Ulcer Disease - Clinical

  31. Dark Field

  32. GUD - Differential • Syphilis • Point of care • History • MSM • Contact • Darkfield • RPR • Non-Point of care • Treponemal test • EIA • TPPA • FT-ABS • Treatment • 2.4 MU LAB • Partner Management • Genital Herpes • Point of care • History • Contact • Clinical presentation • (Tzanck) • Non-Point of care • Culture • (PCR) • Treatment • Acyclovir/Valacyclovir/ Famciclovir • Partner Management

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