STIs (Flemming)

What age range is at risk for STI?

15-24

What are some risk factors for STIs?

• sexual behavior

• age, gender, race

• sociocultural (illicit drug use, prostitution)

• sexual preference

• economic factors

What is the most common bacterial cause of STIs in U.S.?

Chlamydia trachomatis

Obligate intracellular gram-negative bacteria

Prevalence for chlamydia is highest in those ____< years

25

True or false: with chlamydia, asymptomatic infections are common

true

Clinical presentation of chlamydia in women

• mucopurulent discharge from cervix

• hypertrophic cervical ectopy

• abnormal vaginal bleeding (less common)

Clinical presentation of chlamydia in men

• mucopurulent discharge from urethra

• dysuria

• urethral pruritus

What are the screening recommendations for chlamydia/gonorrhea?

• Annually for:

  • sexually active women </= 25 yo

  • old women with risk factors

  • MSM

How is chlamydia diagnosed?

• urine

• swabs of site of infection

• culture

• Gram stain, nonamplified DNA probe

• NAATs

What infection is commonly to co-occur with chalmydia?

N. gonorrhea

True or false: when empirically treating for chlamydia, you should also empirically treat for N. gonorrhea as well

true

What are goals of treatment for chlamydia?

• cure

• symptomatic relief

Recommended treatment for uncomplicated genital infections

• Doxycycline 100 mg PO BID X7 days

Alternative regimens for uncomplicated genital infections

• Azithromycin 1gm PO X 1 dose

• Levofloxacin 500mg PO Q24h X 7 days

• Tetracycline 500mg PO QID X 7 days

What are the recommended therapies in genital infections for those who are pregnant?

• Azithromycin 1 gm PO X 1 dose

• Amoxicillin 500mg PO TID X 7 days

Dose of doxycycline for PEP

200mg within 72 hours of sexual encounter

What should be monitored since doxycycline is a 1st line recommendation for genital infections?

resistance patterns over time

Describe gonorrhea organism

• Non-motile

• non-spore forming

• Gram-negative intracellular diplococcus

• Infects mucosal epithelium

• Penetration within 24-48 hours

Clinical presentation for uncomplicated gonorrhea in women

• 10-day incubation period

• Many are asymptomatic

• Increased vaginal discharge, dysuria, intermenstrual bleeding

• Abdominal or pelvic pain

• purulent cervical exudate

Clinical presentation for uncomplicated gonorrhea in men

• 2-5 day incubation period

• Acute urethritis (urethral discharge)

• Acute epididymitis (localized complication)

What is disseminated gonococcal infection (DGI)?

A complication of untreated genital or pharyngeal gonococcal infection - bacteremia dissemination

• Local infection to blood to other parts of body

What are some risk factors for DGI?

• female

• mensuration

• pharyngeal infection

• pregnancy

What are some clinical manifestation of DGI?

• septic arthritis

• dermatitis

• perihepatitis

What test is most often used in diagnosing N. gonorrhea?

NAATs

Due to resistance, what is the mainstay therapy of gonorrhea?

Ceftriaxone 500mg IM X 1 dose

For patients >150kg, what dose of ceftriaxone is recommended?

1gm

For treatment of uncomplicated gonococcal infections where chlamydia is not excluded, the patient should also receive which therapies ?

Doxy or azithro in combination with gonococcal-directed therapy

Treatment for uncomplicated gonococcal infections includes:

• Ceftriaxone 500mg IV X 1 dose

• Alternative regimens:

  • Gentamicin 240mg IM X 1 PLUS Azithromycin 2gm PO X 1 dose

  • Cefixime 800mg PO X 1dose

Treatment of DGI

• Ceftriaxone 1gm IM or IV Q24h

• Alternative regimens:

  • Cefotaxime 1g IV Q8hr

  • Ciprofloxacin 400mg IV Q12hr

  • Levofloxacin 750 IV Q24hr

With treatment of DGI, FQs (should/should not) be used without known susceptibility tests?

should not

Duration of therapy in treatment of DGI

At least 7 days

Describe syphilis organism

• Treponema pallidum

• gram-negative spirochete

• slender, unicellular, helical cells

• “stealth” organism

How is syphilis differentiated?

By progressive stages and/or latency

Which STI is the leading cause of neurologic and CVD (beginning of 20th century)?

Syphilis

Clinical presentation of primary syphilis

• single, sometimes multiple, painless papules

• at site of infection

• self-healing within 1-6 weeks (even if untreated)

Clinical presentation of secondary syphilis

• most florid stage of infection

• begin 2-8 weeks following appearance of chancre

• manifestations include but not limited to:

  • skin lesions

  • mucocutaneous lesions

  • lymphadenopathy

In which stage of syphilis do we see multiplication and wide dissemination of spurochetes?

secondary

What is the difference between early latent and late latent syphilis?

Early is acquired in previous 1 year

Late is acquired > 1 year ago or of unknown acquisition time

What defines latent syphilis?

Positive serologic test without other evidence of disease

True or false: vertical transmission can still occur in pregnant patients with latent disease

true

True or false: because the is no way to predict which patients will have disease progression, all patients with late syphilis should be treated

true

Does early or late latent syphilis considered infectious?

early

Late syphilis with CV or gummatous clinical manifestations is considered “_______ syphilis”

tertiary

What are some neurosyphilis symptoms?

• meningitis

• seizure

• general paresis

• motor or sensory deficits

• uveitis/ocular manifestations

True or false: congential syphilis crosses the placenta in the primary stage?

false; in ANY stage of infection

• Highest risk with primary and secondary

What microscopic examinations help to diagnose syphilis?

• darkfield examinations

• direct fluorescent antibody tests (FDA-TP)

What serologic tests help diagnose syphilis?

• nontreponemal tests

• Treponemal tests

Treatment for primary, secondary, and early latent syphilis

Benzathine penicillin G 2.4 mu IM X 1 dose

Treatment for late latent or latent syphilis of unknown duration or tertiary

Benzathine penicillin G 2.4 mu IM X 3 doses at 1-week intervals

(7.2 mu total)

True or false: benzathine and procaine PCN is interchangeable

false

What are some non-PCN options for primary, secondary, and early latent syphilis?

• doxy 100mg PO BID X14 days

• Ceftriaxone 1-2 gm IV/IM X 10-14 days

• Azithromycin 2gm PO X 1

What are some non-PCN options for late latent or unknown duration syphilis?

• doxy 100mg PO BID X28 days

• Ceftriaxone 1-2 gm IV/IM

What alternative regimens for syphilis are available in pregnancy?

• Desensitization to PCN (PCN is DOC)

• Primary, secondary, or early:

  • erythromycin 500mg QID X 14 days

  • ceftriaxone 1-2gm IM X 14 days

  • azithromycin 2gm PO X 1

• Late:

  • Erythromycin 500 mg QID X 30

Treatment for neurosyphilis (ocular and otic)

Aqueous crystalline penicillin G 18-24 mu/day

Given as 3-4 mg IV Q4h or continuous infusion X 10-14 days

Which STI is a chronic, life-long viral infection?

genital herpes

How is HSV transmitted?

Infected secretions onto mucosal surfaces or abraded skin

True or false: with HSV, transmission can occur even when asymptomatic

true

What are s/s of HSV?

• Multiple painful pustular or ulcerative lesions

• heal within 2-4 weeks

• flu-like symptoms

• more severe in immunocompromised patients

• lessened in recurrent episodes

How is HSV diagnosed?

• Presence of painful vesicular or ulcerative lesions

• Virologic tests

• Serologic tests

Recommended regimens for (initial episode) HSV include:

• Acyclovir 400mg PO TID X 7-10 days OR 200mg PO 5 times daily X 7-10 days

• Famciclovir 250mg TID X 7-10 days

• Valacyclovir 1 gm PO BID X 7-10 days

How are HSV regimens categorized?

• initial episode

• recurrence

• suppressive (chronic daily)

• severe disease (necessitating hospitalization —> CNS involvement)

True or false: acyclovir is believed to be safe in all 3 trimesters

true

When do you use IV acyclovir?

sever infection

What is bacterial vaginosis?

When normal vaginal flora (Lactobacillus) is replaced by an overgrowth of anaerobic and other bacteria

What are some risk factors for bacterial vaginosis?

• new or multiple partners

• lack of condom use

• douching

• lack of vaginal lactobacillus

True or false: women who are NOT sexually active can NOT have bacterial vaginosis

false

Patients with BV are at increased risk of acquiring _______?

STIs

What is the treatment for BV?

Metronidazole 500mg PO BID X 7 days

What is Trichomoniasis?

Caused by infection with the protozoan trichomonas vaginalis

Risk factors for trichomoniasis

• new or multiple partners

• HX of STIs

• lack of condom use

• IVDU

Clinical presentation of trichomoniasis

Women: profuse, malodorous, yellow-green-grey discharge, relatively asymptomatic w/ mild symptoms

Men: asymptomatic or have urethritis