Lecture 7 Part 2 - Sexually Transmitted Infections

what causes chlamydia?

chlamydia trachomatis

symptoms of chlamydia

urethritis, cervicitis, pelvic inflammatory disease (PID, complication)

are symptoms typically present with chlamydia?

no, and this is important because of transmission risk

what is used to diagnose chlamydia?

first catch urine or swab specimen

NAAT for chlamydia

highly sensitive and specific chlamydia test in which a patient can self collect their urine for testing

what does NAAT detect?

urethritis

what is first line for chlamydia?

doxycycline 100 mg PO BID for 7 days

alternative option for chlamydia

azithromycin 1g PO once

pros of using azithromycin for chlamydia

one dose, safe in pregnancy

cons of using azithromycin for chlamydia

inferior to doxycycline

what is expedited partner therapy (EPT) for chlamydia

treatment for the partner of the diagnosed individual

what causes gonorrhea?

Neisseria gonorrhoeae

gonorrhea manifestations in men

urethritis and epididymitis

gonorrhea manifestations in women

urethritis and cervicitis

what are serious complications of gonorrhea?

pharyngitis, proctitis, disseminated infection

how do we diagnose gonorrhea?

culture ideal (preferred over NAAT)

why is a culture preferred for gonorrhea?

because every drug that has been used for gonorrhea has shown resistance eventually

treatment for uncomplicated gonorrhea

ceftriaxone 500 mg IM once (if < 150 kg)

alternative option for uncomplicated gonorrhea (cephalosporin allergy)

gentamicin IM once + azithromycin PO once

EPT for gonorrhea

cefixime 800 mg PO once (we try not to because of cross resistance with ceftriaxone)

what do we use for gonorrhea if chlamydia is not excluded by testing?

doxycycline 100 mg BID for 7 days

what do we use for gonorrhea if a pharyngeal infection has occurred?

test of cure recommended (a lot of failed therapies)

what do we use for serious complications of gonorrhea (gonorrheal arthritis, meningitis, endocarditis)?

ceftriaxone at HIGHER doses for LONGER time

duration of ceftriaxone therapy for gonorrheal arthritis and endocarditis

a -> >/= 7 days

e -> >/= 4 weeks

what is pelvic inflammatory disease a complication of?

C. Trachomatis and N. Gonorrhoeae, but can also be due to normal anaerobic flora

clinical presentation of PID

abnormal bleeding, dyspareunia, vaginal discharge

what does PID cause?

infertility, chronic pelvic pain, ectopic pregnancy

diagnosis of PID

hard to diagnose, based on clinical findings

who should empiric PID treatment be started in?

sexually active young women and other women at risk of STDs with pelvic/lower abdominal pain, findings on pelvic exam

treatment of PID

ceftriaxone IM once + doxycycline PO 14 days + metronidazole PO 14 days

what causes nongonococcal urethritis?

many different bacteria and unknown pathologies

what is the most common cause of nongonococcal urethritis?

C. Trachomatis

clinical presentation of nongonococcal urethritis

urethral discharge, irritation, dysuria

what is genital herpes?

chronic, life long viral infection that is often asymptomatic

how is genital herpes reactivated?

immunologic effects and stress (latent infection)

clinical presentation of genital herpes

multiple vesicular lesions (may cause more severe disease)

how is genital herpes diagnosed?

PCR (preferred over cultures as it is more sensitive for HSV DNA)

when are serologic tests used for genital herpes?

if recurrence of HSV, signs or partner diagnosed and PCR comes back negative

treatment for genital herpes

famciclovir and valacyclovir, acyclovir (not preferred) for 1-5 days depending on agent

how long is the first clinical episode of genital herpes treated vs recurrent episode?

first episode treated longer

what are the different ways of treating genital herpes?

episodic or suppressive/everyday

severe genital herpes

CNS complications, disseminated infection, pneumonitis, hepatitis

what does severe genital herpes require?

IV acyclovir followed by oral acyclovir to complete the therapy

what causes syphilis?

Treponema Pallidum

how is syphilis acquired?

organism penetrating intact mucous membranes or skin abrasions → immune response causes initial symptoms at site of infection (sometimes asymptomatic) → disseminates systemically

primary syphilis

single lesion that eventually heals 3-6 weeks later

what is secondary syphilis?

multisystem involvement secondary to hematogenous and lymphatic spread, resolving in 4-10 weeks

what does secondary syphilis look like?

rash (often on palms and soles)

latent syphilis or unknown duration syphilis

when there is a + test for syphilis but no evidence of disease, infection occurring within the past 12 months or unknown

are patients with latent syphilis or unknown duration syphilis infectious sexually?

no (except mother to fetus)

what can latent syphilis or unknown duration syphilis progress to?

tertiary or late neurosyphilis

how is syphilis diagnosed?

non treponema tests (NT, Lipoidal antigen tests)

syphilis NT test risk

may show false negatives in primary and secondary syphilis or false positive for other infections/pregnancy

what is a TT (treponemal test)?

highly specific test used to detect antibodies against treponemal-specific antigens

what does syphilis diagnosis require?

both NT and treponema tests (if NT test positive confirm with TT and vice vera)

what is used to treat syphilis?

penicillin G (safe during pregnancy as well)

dosing frequency for primary, secondary and early latent syphilis

benzathine penicillin G once IM (anything else = 3 times)

what is given for syphilis if someone has a PCN allergy?

doxycycline PO 14 days

what is given for late latent syphilis or unknown duration if PCN allergy?

doxycycline for 28 days

neurosyphilis treatment

penicillin G but much more than other types of syphilis

Jarisch Herxheimer Reaction

cytokine storm type reaction that occurs after penicillin G treatment of syphilis (6-8 hours after)

what does the Jarisch Herxheimer Reaction look like and how long does it last?

resembles bacterial sepsis and lasts 12-24 hrs

what is Jarisch Herxheimer Reaction most common with?

early syphilis (highest bacterial burden)

what is Jarisch Herxheimer Reaction prevented with?

aspirin q 4 hr for 24-48 hours

what is Doxy PEP for syphilis?

doxycycline 200 mg can be used