Sexually Transmitted Infections

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2 Causative pathogens of STD's characterized by urethritis and cervicitis

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Chlamydia trachomatis
Neisseria gonorrhoeae

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2 Diseases characterized by vaginal discharge

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Trichomoniasis vaginalis
Vulvovaginal Candidiasis

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3 causative pathogens of Pelvic inflammatory diseases (PID)

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C. trachomatis,
N. gonorrhoeae,
vaginal flora

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Genital warts are due to this pathogen (virus)

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Human Papillomavirus

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HSV1 more commonly found on what area of the body?

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oropharyngeal region (mouth)

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HSV2 more commonly found on what area of the body?

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genitalia

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Herpes Seroprevalence: in what population is there a larger % relative increase of this virus?

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whites (both men and women)

although the black population still experiences larger prevalence of this virus (esp. women)

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type:
HHV-1
HHV-2

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Herpes Simplex Virus 1
Herpes Simplex Virus 2

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This always occurs in genital herpes:

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shedding! (sx of herpes are present, but are so mild that often go unnoticed)

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when does detection of genital herpes become difficult?

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during virus intermittent periods

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2 types of infection of genital herpes

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1. first clinical episode
2. recurrent infection

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Despite being the most common STI, over ?% ...

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over 80% of people affected are unaware that they have the infection

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First episode or recurrent genital herpes?
multiple painful vesiculopustular lesions

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first episode

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1st or recurrent genital herpes?
sx more severe & prolonged in immunocompromized patients

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recurrent

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1st or recurrent genital herpes?
fewer lesions, shorter duration, milder symptoms

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recurrent

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1st or recurrent genital herpes?
severity F>M

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both

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First episode genital herpes; how long does shedding last?

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11-12 days for primary infection

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recurrent genital herpes; how long does shedding last?

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~4 days

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1st or recurrent genital herpes? minimally symptomatic

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first episode

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1st or recurrent genital herpes? prodrome in 50% pts

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recurrent

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about symptoms of first episode and recurrent genital herpes...

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MANY patients are asymptomatic!

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complications of genital herpes: (5)

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1. Secondary infection of lesions
2. Extragenital infection due to autoinoculation
3. Disseminated infection
(Particularly in immunocompomised patients)
4. Meningitis or encephalitis
5. Neonatal transmission

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Preferred treatment options for 1st clinical episode of genital herpes: (4 options)

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1. *Acyclovir 400 mg PO TID
2. *Acyclovir 200 mg PO Five times daily
3. Famciclovir 250 mg PO TID
4. Valacyclovir 1g PO BID

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treatment duration of 1st clinical episode of genital herpes with preferred agents:

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7-10 days

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Preferred treatment options for recurrent infection (EPISODIC therapy) [5]

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1. Acyclovir 400 mg PO TID
2. Acyclovir 800 mg PO BID
3. Famciclovir 125 mg PO BID
4. Valacyclovir 500 mg PO BID
5. Valacylovir 1g PO QD

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treatment duration of recurrent infection; episodic therapy

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5 days

exception: valacyclovir 500mg po BID 3-5 days

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Suppressive therapy for genital herpes infection

for pts who keep on having recurrent general herpes infections (up to 6 episodes per year)

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1. Acyclovir 400 mg PO BID
2. Famciclovir 250 mg PO BID
3. Valacyclovir 500 mg PO QD
4. Valacylovir 1g PO QD

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Suppressive therapy is not a scapegoat for what? why?

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unsafe sexual practices
b/c low level viral shedding still occurs

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duration of suppressive therapy?

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1 year - assess possible changes in intrinsic pattern of recurrence
some continue tx indefinitely

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can genital herpes be cured?

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no, Viruses have no true endpoint – can control growth, but cant really “kill” them
"evaluation of outcomes": palliative not curative
- continue tx indefinitely significantly reduces viral shedding, but transmission is still possible to uninfected partner

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Syphilis causative agent

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Treponema pallidum (spirochete)

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Transmission of syphillis occurs via:

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sexual contact!
kissing (via active lesions on lips/breasts/genitals(
congenital
blood transfusion (olden days)

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syphillis affects men or women more?

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MEN

whites more commonly affected

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Primary Syphilis time to onset

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10-90 days

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Secondary Syphilis time to onset

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2-8 weeks after infxn

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Latent Syphilis time to onset

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4-10 weeks after 2ndary stage

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Tertiary Syphilis time to onset

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10-30 years after initial infection

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Site of infection: primary syphilis

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genitalia, perianal, mouth/throat

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site of infection: secondary syphilis

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multisystem involvement

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site of infection: latent syphilis

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potentially multisystem (dormant)

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site of infection: tertiary syphilis

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CNS, heart, eyes, bones, joints

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signs and symptoms of primary syphilis

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lesions (chancre)
lymphadenopathy

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s/sx of secondary syphilis

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rash, mucocutaneous lesion, constitutional sx

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s/sx of latent syphilis

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asymptomatic

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s/sx of tertiary syphilis

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CV syphilis, neurosyphilis, gummatous lesions

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treatment of primary, secondary, and EARLY latent syphilis

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BENZATHINE penicillin G 2.4 million units IM x 1 dose

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Follow up serology after treatment of primary, secondary, and EARLY latent syphilis (same for PCN allergic pts)

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Primary/Secondary: Quantitative nontreponemal tests at 6 and 12 months

Early Latent: Quantitative nontreponemal tests at 6, 12, and 24 months

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treatment of LATE latent syphilis (>1year known duration)

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BENZATHINE penG 2.4. millino units IM x 1 dose/**week x 3 consecutive weeks**

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follow up serology after tx of late latent syphilis (after tx with regular or PCN allergic pt tx)

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Quantitative nontreponemal tests at 6, 12, and 24 months

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treatment of neurosyphilis

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Aqueous PROCAINE penG 2.4 million units IM qd + probenecid 500 mg PO QID, both x 10-14 days

Aqueous CRYSTALLINE pen G 18-24 million units IV (3-4 million units every 4 hours or by continuous infusion) for 10-14 days

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follow-up serology after treatment of neurosyphilis

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CSF exam q 6 mos until cell count normal

If cell count has not decreased at 6 months or not normal by 2 yrs – consider retreatment

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pt is PCN allergic -- what is are treatment options for syphilis (any stage)?

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doxycycline 100mg PO BID
tetracycline 500mg PO QID

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treatment duration for primary, secondary, and EARLY latent syphilis w/meds used for PCN allergic pts?

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2 weeks

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treatment duration for LATE latent syphilis w/meds used for PCN allergic pts?

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4 weeks

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causative agent for Chlamydia

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chlamydia trachomatis

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is chlamydia trachomatis gram + or gram -?

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gram (-)

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women or men more affected w/chlamydia?

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women

(blacks more commmonly affected)

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usual onset of chlamydia in days

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7-21 d in males and females

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most common site of infection of chlamydia in m and f

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m: urethra
f: endocervical canal

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symptoms of chlamydia in m and f

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m: dysuria/discharge
f: subclinical

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signs of chlamydia in m and f

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m: discharge
f: abnormal discharge or bleeding

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complications of chlamydia in m and f

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m: epididymitis, Reiter's syndrome
f: pelvic inflammatory disease, Reiter's syndrome
also: infertility, ectopic pregnancy

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clinical pearl on chlamydia

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Over 50% of male urethral/rectal infections and >66% cervical infections *asymptomatic*

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recommended treatment regimen for chlamydia

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Azithromycin 1g PO x 1
Doxycycline 100mg PO BID x 7d

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causative agent for gonorrhea

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Neisseria gonorrhoeae
gram (-) diplococci

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usual time to onset of gonorrhea (m and f)

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m: 2-8 days
f: 10 days

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most common site of gonorrhea

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m: urethra
f: endocervical canal

(same as chlamydia)

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symptoms of gonorrhea (m & f)

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m: dysuria, urinary frequency
f: dysuria, urinary frequency

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signs of gonorrhea (m&f)

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m: purulent discharge
f: abnormal discharge or bleeding

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Complications of gonorrhea (m&f)

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m: disseminated gonorrhea
f: PID, ectopic pregnancy, infretility

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Clinical Pearl: coinfection happens with these two disease states is documented in >50% of women and 20% of men; BOTH should be treated

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chlamydia + gonorrhea

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recommended treatment regimen for gonorrhea

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ceftriaxone 125mg IM once
cefixime 400mg PO once

PLUS --> treatment for presumptive C. trachomatis coinfection

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treatment of gonorrhea in pregnant patients

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ceftriaxone 125mg IM once

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Why arent fluoroquinolones used for the treatment of gonorrhea?

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levels of FQ resistance are too high