STDsValerie Robinson D.O.

Prevention• Abstinence• Risk reduction• Vaccines• Male or female condoms• Cervical diaphragm might protect against cervical GC,

CT, trichomonas• Male circumcision reduces transmission of herpes, HPV

and HIV in heterosexual men• Antiretroviral therapy in HIV-infected people

• Trichomoniasis, chlamydia, gonorrhea, and syphilis are curable

Screening

• Pregnant women should be screened for GC, CT, syphilis, HIV, hepatitis B. Not trich or hep C

• Adolescents: Discuss sexual behavior– Screen CT, GC in females <25– Discuss HIV screen with sexually active or IV drug-using

adolescents• MSM: annual screen for HIV, syphilis, oral, anal, and

penile gonorrhea and chlamydia• Anyone who has an STD should be screened for HIV

Chlamydia• Chlamydia trachomatis• The most commonly reported STD• CDC recommends yearly chlamydia testing of all sexually active women

age 25 or younger, women with risk factors, and all pregnant women.• Symptoms occur 1-3 weeks after exposure• May be transmitted to baby during vaginal delivery, causing conjunctivitis

or pneumonia, NOT transmitted through placenta• In pregnant women, there is some evidence that untreated chlamydial

infections can lead to premature delivery• Complications: PID, infertility, ectopic, Reiter's syndrome

– 10-15% of untreated women progress to PID– Reiter's syndrome : Rare. arthritis, uveitis, conjunctivitis, circinate balanitis urethritis, cervicitis, Achilles enthesitis,

Chlamydia - Symptoms

• Vaginal discharge, UTI• May cause lower abdominal pain, low back pain, nausea,

fever, pain during intercourse, or bleeding between menstrual periods, especially if it has progressed to PID.

• Men: penile discharge “the clap”, UTI, burning or itching around meatus. Rarely epididymitis: pain, fever, and, rarely, sterility

• Rectal: rectal pain, discharge, or bleeding• May be oral• May cause lymphogranuloma venereum

Chlamydia - Diagnosis

• Nucleic Acid Amplification Testing (NAAT) Urine• Vaginal swab culture• Infants: conjunctival swab - direct fluorescence

antibody [DFA] tests, ELISA, and NAAT

Chlamydia - Treatment

• Azithromycin 1 g orally in a single dose• Doxycycline 100 mg orally twice a day for 7 days• Erythromycin base 500 mg orally four times a day for 7 days• Levofloxacin 500 mg orally once daily for 7 days• Infant conjunctivitis OR pneumonia:

– Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days

• Lymphogranuloma venereum– Doxycycline 100 mg orally twice a day for 21 days– Erythromycin base 500 mg orally four times a day for 21 days

(Use this in pregnancy)

Gonorrhea• Very common• Often co-infection with chlamydia• Babies have ocular prophylaxis with erythromycin

ointment or silver nitrateOpthalmia neonatorum

• May cause PID, infertility, ectopic, epididymitis– PID: abdominal pain and fever. Can lead to internal abscesses

and chronic pelvic pain• Diagnosis: urine NAAT, vaginal, or urethral culture,

nucleic acid hybridization tests

Gonorrhea - Symptoms

• Women: dysuria, increased vaginal discharge, or vaginal bleeding between periods.

• Men: dysuria, or a white, yellow, or green penile discharge that usually appears 1 to 14 days after infection. Sometimes men with gonorrhea get painful or swollen testicles

• Rectal: discharge, anal itching, soreness, bleeding, or painful bowel movements OR asymptomatic

• Oral: sore throat, but usually asymptomatic• Disseminated Gonococcal Infection: petechial or pustular acral

skin lesions, asymmetrical arthralgia, tenosynovitis, or septic arthritis. The infection is complicated occasionally by perihepatitis and rarely by endocarditis or meningitis

Gonorrhea - Treatment• #1: combination therapy

– ceftriaxone 250 mg IM AND azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days

• CDC no longer recommends cefixime at any dose as a first-line d/t resistance

• Alternate: – azithromycin 2 g orally in a single dose– cefixime 400 mg orally AND azithromycin 1 g orally OR doxycycline 100 mg twice daily orally for 7 days

• DIG– Ceftriaxone 1 g IM or IV every 24 hours until 24 hours after improvement

THEN Oral therapy x 1 week• Children

– Uncomplicated: Ceftriaxone 125 mg IM in a single dose– Complicated: Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM or IV in a single

dose daily for 7 days

Syphilis

• Treponema pallidum• Can have vertical transmission – congenital

syphilis• Has 5 stages (primary, secondary, tertiary,

latent, and late)

Syphilis – Symptoms• Primary stage: Single or multiple painless chancres lasting 3-6 weeks.

May appear up to 3 months after initial infection.• Secondary stage: Rash, may appear on palms and soles

– fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.

• Tertiary stage: cardiac or gummatous lesions • Latent stage: may last for years without sx• Late stage:

– Occurs in about 15% of untreated people– May appear 10-20 years after initial infection– damage the internal organs, including the brain, nerves, eyes, heart, blood

vessels, liver, bones, and joints. Includes neurosyphilis. This damage may be serious enough to cause death.

Syphilis - Complications

• Pregnancy – can cause stillbirth• Congenital syphilis - developmental delay, seizures, or

death.• Neurosyphilis – can occur at any stage

– cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, loss of vibration sense, and auditory or neuroretinitis, optic neuritis

• Jarisch-Herxheimer reaction is an acute febrile reaction frequently accompanied by headache, myalgia, fever, and other symptoms that usually occur within the first 24 hours after the initiation of any therapy for syphilis

Syphilis - Diagnosis

• Dark field microscopy=definitive– Spirochetes

• Nontreponemal– VRDL (Venereal Disease Research Laboratory)– RPR (Rapid plasma reagin)– May have false positive d/t autoimmune dz

• Treponemal– Fluorescent Treponemal Antibody Absorbed test [FTA-ABS] – T. pallidum passive particle agglutination [TP-PA] assay– ELISA– chemiluminescence immunoassays

Syphilis - Treatment• Primary and Secondary and Early Latent

– Benzathine penicillin G 2.4 million units IM in a single dose– Infants and children: Benzathine penicillin G 50,000 units/kg

• Tertiary– Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units

IM each at 1-week intervals• Late Latent

– Benzathine penicillin G 7.2 million units total, administered as 3 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• Pregnancy: same as above• Congenital

– Aqueous crystalline penicillin G 100,000–150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days

– Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days– If diagnosed later in life: Aqueous crystalline penicillin G 200,000–300,000 units/kg/day IV,

administered as 50,000 units/kg every 4–6 hours for 10 days

HIV

• Course: brief acute retroviral syndrome that typically transitions to a multiyear chronic and clinically latent illness.

• Depletes CD4 lymphocytes• Progresses to AIDS estimated median time of

approximately 11 years. AIDS increases life-threatening opportunistic infections.

• Most in USA are HIV-1. HIV-2 West Africa, Portugal• They are highly contagious in the first stages of

infection.

HIV - Symptoms

• fever, malaise, lymphadenopathy, and skin rash Occur within a few weeks of infection

• Opportunistic infections.

HIV - Diagnosis

• Serologic screening for antibodies to HIV-1, HIV-2 Using ELISA

• Confirm Ab with Western Blot, or Indirect immunofluorescence assay (IFA) or virologic test

• Virologic testing looks for HIV antigens or RNA• HIV Ab is detected within 3 months of infection• In children <18m, use virology• CD4 T-lymphocyte count and viral load confirms AIDS• New OraQuick swab October 2012

HIV - Pregnancy

• 15%–25% of infants born to untreated HIV-infected mothers will become infected with HIV;

• an additional 12%–14% of infants born to infected mothers who breastfeed into the second year of life will become infected

• risk for perinatal HIV transmission can be reduced to <2% through the use of antiretroviral therapy and and elective cesarean section at 38 weeks of pregnancy and by avoiding breastfeeding

HIV - Treatment

• HAART– Zidovudine– Nevirapine

Hepatitis A• Incubation period of approximately 28 days.• Self-limited disease • Fecal-oral transmission• Symptoms compatible with acute viral hepatitis• 10%–15% of patients experience a relapse of symptoms during

the 6 months after acute illness• Antibody produced in response to HAV infection persists for life

and confers protection against reinfection.• Diagnosis: Serum HepA IgM• Tx: supportive care• Post-exposure prophylaxis in un-vaccinated persons: single-

antigen vaccine or IG (0.02 mL/kg)

Hepatitis B

• Incubation period 6 weeks-6months• Self-limited or chronic• Diagnosis: Serum IgM anti-HBc, HBs antigen• Treatment:– Acute: supportive care– Chronic: antiviral suppressive therapy

• Post-exposure prophylaxis– HepB vaccine, HBIG

Hepatitis C

• Mostly asymptomatic• Leads to cirrhosis• Diagnosis: – anti-HCV immunoassay, ELISA, or enhanced

chemiluminescence imunoassay – Reverse Transcriptase Polymerase Chain Reaction

(RT-PCR) Used for confirmation• Treatment: Combination therapy with

pegylated interferon and ribavirin

Pediculosis Pubis

• Symptoms: itching• Treatment– Permethrin 1% cream rinse applied to affected

areas and washed off after 10 minutes– Pyrethrins with piperonyl butoxide applied to the

affected area and washed off after 10 minutes– Ivermectin 250 μg/kg orally, repeated in 2 week

AKA pubic lice AKA “crabs”

Chancroid

• Hemophilus ducreyi• Symptoms: painful genital ulcer and tender

suppurative inguinal adenopathy • Diagnosis: culture, R/O syphilis, herpes

Chancroid - Treatment

• Azithromycin 1 g orally in a single dose• Ceftriaxone 250 mg intramuscularly (IM) in a single

dose• Ciprofloxacin* 500 mg orally twice a day for 3 days*• Erythromycin base 500 mg orally three times a day

for 7 days• * Ciprofloxacin is contraindicated for pregnant and

lactating women.

HPV• Most common STD• 40 HPV types that infect human mucosal surfaces• at least 50% of sexually active men and women get it at some point in their

lives.• In 90% of cases, the body’s immune system clears HPV naturally within two

years.• Genital warts, cervical cancer, cancers of the vulva, vagina, penis, anus, and

oropharynx • Gay and bisexual men are about 17 times more likely to develop anal cancer

than men who only have sex with women.• Warts don’t become cancer• Usually asymptomatic• Rarely vaginal to baby transmission during birth. HPV types 6 and 11 can

cause juvenile onset recurrent respiratory papillomatosis

HPV - Prevention

• Cervarix - 16 and 18, which cause 70% of cervical cancers• Gardasil - HPV 16 and 18, as well as HPV 6 and 11, which

cause 90% of genital warts • Recommended for girls and boys age 11-26, may begin at

age 9. • Series of 3 shots, given at T, T+2months, T+6months• HPV DNA test with Paps• May do anal paps in gay or bisexual men or HIV infected

persons• Vaccine should not be given to pregnant women d/t lack of

data

HPV - Treatment• Wart

– Podofilox 0.5% solution or gel (patient-applied)– Imiquimod 5% cream (patient-applied) – Sinecatechins 15% ointment (patient-applied)– Cryotherapy with liquid nitrogen or cryoprobe. Repeat every 1–2 weeks. – Podophyllin resin 10%–25% in a compound tincture of benzoin – Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90% – Surgical removal either by tangential scissor excision, tangential shave

excision, curettage, or electrosurgery. • Imiquimod, sinecatechins, podophyllin, and podofilox should not be

used during pregnancy• Treat cervical cancer as per guidelines• Vaccines do NOT treat existing HPV

Herpes

• Most genital herpes is caused by HSV-2• HSV-1 can cause genital herpes, but it more

commonly causes infections of the mouth and lips, so-called “fever blisters.

• May be transmitted whether or not there is an active outbreak

• Occurs in areas not covered by condoms

Herpes - Symptoms

• First episode may have fever and lymphadenopathy as well as sores

• blisters on or around the genitals or rectum. The blisters break, leaving tender ulcers

• Multiple outbreaks occurring weeks or months apart. Often 4-5 per year, decreasing in frequency

Herpes

• C/S is performed if a pregnant woman has active lesions at delivery

• Diagnosis: wound cx, PCR for DNA, blood antibodies, visual

• There is no cure, but suppressive therapy reduces the frequency of genital herpes recurrences by 70%–80% in patients who have frequent recurrences

Herpes - Treatment• First episode

– Acyclovir 400 mg orally three times a day for 7–10 days– Acyclovir 200 mg orally five times a day for 7–10 days– Famciclovir 250 mg orally three times a day for 7–10 days– Valacyclovir 1 g orally twice a day for 7–10 days– *Treatment can be extended if healing is incomplete after 10 days of therapy.

• Pregnancy – acyclovir seems to be okay and may be used• Suppression

– Acyclovir 400 mg orally twice a day– Famiciclovir 250 mg orally twice a day– Valacyclovir 500 mg orally once a day*– Valacyclovir 1 g orally once a day– * Valacyclovir 500 mg once a day might be less effective than other

valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e., ≥10 episodes per year).

Herpes - Treatment• Recurrent episodes

– Acyclovir 400 mg orally three times a day for 5 days– Acyclovir 800 mg orally twice a day for 5 days– Acyclovir 800 mg orally three times a day for 2 days– Famciclovir 125 mg orally twice daily for 5 days– Famciclovir 1000 mg orally twice daily for 1 day– Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days– Valacyclovir 500 mg orally twice a day for 3 days– Valacyclovir 1 g orally once a day for 5 days

• Severe disease with complications– Acyclovir 5–10 mg/kg IV Q8H x 2–7 days or until clinical improvement is

observed, followed by oral antiviral therapy to complete at least 10 days of total therapy.

• Neonatal herpes– Acyclovir 20 mg/kg IV every 8 hours for 21 days for disseminated or CNS – 14 days if only skin and mucous membranes are involved

Trichomonas

• Trichomonas vaginalis• About 70% of infected people do not have any

signs or symptoms. • Pregnancy Complications: low birth weight,

preterm delivery

Trichomonas - Symptoms

• May be asymptomatic• Symptoms may not appear until a month after

infection or may be intermittent. • Men with trichomoniasis may feel itching or irritation

inside the penis, burning after urination or ejaculation, or some discharge from the penis.

• Women with trichomoniasis may notice itching, burning, redness or soreness of the genitals, discomfort with urination, or a malodorous discharge that is white, yellowish, or greenish.

Trichomonas - Diagnosis

• Wetprep shows trichomonas organisms • OSOM Trichomonas Rapid Test: an

immunochromatographic capillary flow dipstick

• Affirm VP III: nucleic acid probe• Culture• NAAT

Trichomonas - Treatment

• Metronidazole 2 g orally in a single dose• Tinidazole 2 g orally in a single dose• Metronidazole 500 mg orally twice a day for 7

days

Always

• Treat the partner• Educate• Vaccinate – Hepatitis A, Hepatitis, B, HPV

References

• cdc.gov• “Update to CDC's Sexually Transmitted Diseases

Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections.” Morbidity and Mortality Weekly Report. August 10, 2012 / 61(31);590-594. www.cdc.gov/mmwr

• “Sexually Transmitted Diseases Treatment Guidelines, 2010.” Morbidity and Mortality Weekly Report. December 17, 2010 / Vol. 59 / No. RR-12. www.cdc.gov/mmwr