7: Sexually Transmitted Infections

patients with sexually transmitted infections often present with recognizable clinical _ rather than confirmed diagnoses

syndromes

common patterns of sti’s include

• _ discharge and _

• pelvic pain with _ motion tenderness

• painful _ or _ genital lesions

• painless genital _

• genital _ or abnormal _ screening results

mucopurulent and cervicitis

cervical

vesicular or ulcerative

ulcers

warts or cervical

clinical reasoning for sti’s begin with:

• identifying the dominant _ pattern

• narrowing the _ diagnosis

• selecting _ testing and treatment

symptom

differential

targeted

what is the most common bacterial STI?

chlamydia

clinical pattern of chlamydia:

• often _

• _ discharge

• _ pelvic discomfort

asymptomatic

mucopurulent

mild

chlamydia is frequently missed because of _ progession

silent

untreated chlamydia infection can lead to → _ → leading to _, _ pregnancy

PID→ infertility, ectopic pregnancy

clinical pattern of gonorrhea:

• _ discharge

• cervical inflammation (_)

• _

mucopurulent

friability

dysuria

key clinical point:

_ is frequently co-infected with chlamydia

gonorrhea

complications of gonorrhea:

• _

• rare _ infection (_, _)

PID

disseminated (arthritis, rash)

GC/CT diagnostic strategy preferred test?

NAAT

why is NAAT preferred?

• high _ and _

• detects infection _

• used for _ and _

sensitivity and specificity

early

screening/diagnosis

clinical application of GC/CT diagnostics is to

• test _ patients

• screen _ _-_ patients

symptomatic

asymptomatic high-risk

GC/CT treatment:

• _ 500 mg IM x 1 dose for uncomplicated gonorrhea

  • 1 g IM once if patient >/= 150 kg

• add _ 100 mg PO BID x 7 days if chlamydia not excluded

ceftriaxone

doxycycline

GC/CT partner management:

• treat all _ partners

• _ until treatment completed

sexual

abstain

in pregnancy, use _ instead of doxycycline for chlamydial infection

azithromycin

GC/CT Follow-up after treatment, most patient do NOT need a test of _.

• after recommended treatment, repeat testing is _ unless there is concern that the infection persists.

• patients do need _ testing in _ months

• the goal is to detect _, which is much more common than true treatment failure

Cure

unnecessary

repeat in 3 months

reinfection

when should you perform a test of cure?

• _

• _ symptoms

• _ _

pregnancy

persistent symptoms

pharyngeal gonorrhea

you should suspect pelvic inflammatory diseases when a sexually active patient has:

• _ or lower _ pain

• _ motion, _, or _ tenderness

• _ or _ cervical discharge may also be present

pelvic or lower abdominal

cervical motion, uterine, or adnexal

fever or mucopurulent

PID is a _ diagnosis

clinical

start _ treatment for PID when suspicion is high. Do not delay terapy while waiting for _ _

empiric

test results

most common cause of PID

• _ infection from _ or _

• increasingly, _ infection is recognized

ascending from chlamydia trachomatis or neisseria gonorrhoeae

polymicrobial

early treatment for PID matters because inflammation damages the _ _

• tubal inflammation leads to _, which can permanently impair normal reproductive function

fallopian tubes

scarring

long term consequences of PID:

• _ - scarring blocks _ transport

• _ pregnancy- damaged tubes increase _ outside the uterus

• _ pelvic pain - persistent inflamamtion and _

the risk of permanent damage increases with _ or _ treatment

infertility; ovum

ectopic; implantation

chronic; adhesions

recurrent or delayed

it is very important to recognize the _ of syphilis

stages

what are the stages of syphilis?

primary, secondary, latent/tertiary

primary disease of syphilis

• single _ chancre

• highly _

painless

infectious

secondary disease syphilis

• diffuse rash involving _ and _

• _ symptoms may occur

palms and soles

systemic

latent/tertiary disease of syphilis

• _ latent period

• late _ and _ complications if untreated

asymptomatic

cardiovascular and neurologic

pregnancy pearl for syphilis:

• _ screening at first prenatal visit

• repeat screening during _ in high risk patients

universal

pregnancy

most genital ulcers are caused by:

• _

• _

consider less common _ when presentation doesnt fit

HSV

syphilis

sti’s

a chancroid is a _, _ ulcer, with tender _ _, caused by _ _

painful, soft

inguinal nodes

haemophilus ducreyi

LGV (lymphogranuloma venereum) is a _, _ ulcer, with painful _ _, caused by _ _ (L1-L3)

small, transient

inguinal lymphadenopathy

chlamydia trachomatis

_ history, _, and _ factors become increasingly important when evaluating atypical genital ulcers

travel

epidemiology

risk

classic evolution of HSV:

• _ (burning or tingling)

• grouped _ that rupture into painful _

prodrome

vesicles

ulcers

the _ episode of HSV is usually the most severe, _ may be significant with _ or _

first

pain

fever/malaise

recurrent disease of HSV is usually _/_ and lesions often occur in same _

milder/shorter

location

HSV-treatment strategy:

• greatest benefit when started during the _ or within _ hours of lesion onset

prodrome

72 hours

to treat the first episode of HSV, you want a _ course (7-10 days), and you want to treat with _ 1g PO BID

longer

valacyclovir

for recurrent outbreaks of HSV

• _-course antiviral therapy

• start treatment as soon as _ begins

short

symptoms

suppressive therapy for HSV

• consider for patient with frequent _

• reduces _ and decreases _ risk

recurrences

outbreaks/transmission

most HPV infections clear _

persistent infections with _-_ types is what leads to cancer

spontaneously

high-risk

what types of HPV cause genital warts?

6 and 11

what types of HPV cause cervical precancer and cancer

16 and 18

what prevents most HPV related cancers? what detects precancer before cancer develops?

HPV vaccination

cervical screening

a negative HIV test is only meaningful when interpreted in the context of _ after exposure

timing

what are the three tests for HIV?

NAT, 4th generation Ag/Ab, antibody only

what is the typical window period for NAT?

10-33 days

what is the typical window period for 4th generation Ag/Ab?

18-45 days

what is the typical window period for antibody only?

23-90 days

does early testing for HIV exclude infection?

_ testing if performed during the window period

NO

repeat

to prevent HIV infection you can

• safer _ practices

• routine HIV _

• _: before exposure for patients at ongoing risk

• _: within _ hours after a potential exposure

sex

screening

PrEP

PEP/72

to prevent transmission of HIV:

• _ diagnosis and prompt _ therapy (ART)

• viral _ prevents sexual transmission (U=U/ undetectable=untransmittable)

early/ antiretroviral
suppression

common pitfalls in STI eval/management:

• dont let a negative _ fool you (many sti’s are asymptomatic)

• dont wait to treat suspected _ (treat clinically when criteria are met)

• dont forget the _(treatment is incomplete without partner management)

• dont over rely on one _(HIV window periods and STI testing have limitations)

• dont anchor on one _ (not every genital uncer is HSV)

history

PID

partner

test

diagnosis

• recognize the _ before naming the organism (clinical presentation guides the initial evaluation)

• asymptomatic does not mean _ (untreated infection can lead to PID< infertility, and ectopic pregnancy)

• dont wait to treat when the diagnosis is _ (early empiric therapy prevents long-term complications)

• use _ wisely (choose the right test and understand its limitations and timing)

• think beyond todays _ (partner management, prevention counseling, vaccination, and follow up are part of treatment )

syndrome

harmless

clinical

testing

visit