TCP Week 1 - Sexually Transmitted Infections

STI prevention and control: 5 primary strategies

1. Accurate risk assessment, education, and counseling to avoid high-risk behaviors and use prevention services; 2. Pre-exposure vaccination for vaccine-preventable STIs; 3. Identification of persons with asymptomatic infection or STI symptoms; 4. Diagnosis, treatment, counseling, and follow-up; 5. Evaluation, treatment, and follow-up for sex partners.

STI epidemiology: current trends

Syphilis and gonorrhea are on the rise; gonorrhea treatment options are limited due to antimicrobial resistance; people ages 15-24 account for 50% of new STI cases.

Why did STI progress reverse after the 2010s?

Barriers include mass incarceration, poverty, stigma, homophobia, deteriorating public health infrastructure, and lack of access to healthcare.

Populations at highest risk for STIs

Sexually active adolescents, people with multiple partners, inconsistent condom use, MSM, and people who exchange sex for money or drugs.

Additional STI risk groups

People with low income in urban settings, current/former inmates, military recruits, people with mental illness or disability, current/former injection drug users, and people with a history of sexual abuse.

General STI screening principle

Every person seeking evaluation and treatment for an STI should also be screened for HIV.

Follow-up screening after gonorrhea or chlamydia

All persons testing positive for gonorrhea or chlamydia should be rescreened 3 months after treatment.

Follow-up testing after syphilis diagnosis

All persons diagnosed with syphilis should undergo follow-up serologic syphilis testing.

MSM screening recommendation

MSM should be screened annually for oral and rectal gonorrhea and chlamydia, and as often as every 3-6 months depending on number of partners and partner risk.

USPSTF gonorrhea/chlamydia screening recommendation

Screen annually for chlamydia and gonorrhea in sexually active women age 24 years and younger and in older women at increased risk.

Why screen for gonorrhea and chlamydia?

Gonorrhea and chlamydia may be asymptomatic and are major causes of PID, which is associated with infertility, chronic pelvic pain, and ectopic pregnancy.

Pregnancy STI screening: gonorrhea

Screen all pregnant women younger than 25 or those at increased risk at the first visit.

Pregnancy risks of untreated gonorrhea

Miscarriage, premature birth, low birth weight, premature rupture of membranes, chorioamnionitis, and neonatal eye infections.

Pregnancy gonorrhea newborn prevention

Topical prophylaxis at delivery is used to reduce risk of newborn eye infection.

Pregnancy gonorrhea recommended regimen

Recommended cephalosporin-based combination therapy.

Pregnancy STI screening: chlamydia

Screen all pregnant women younger than 25 or those at increased risk at the first visit.

Pregnancy risks of untreated chlamydia

Preterm labor, low birth weight, premature rupture of membranes, and newborn eye or lung infections.

Chlamydia treatment warning in pregnancy

Do not use doxycycline in the second or third trimester.

Pregnancy chlamydia recommended regimen

Azithromycin is recommended; amoxicillin can be used as an alternative if severe intolerance or allergy to macrolides.

Pregnancy STI screening: HSV

No routine HSV-2 testing is recommended in asymptomatic pregnant women.

HSV pregnancy risk

Higher neonatal risk occurs if the mother develops her first outbreak during the third trimester.

HSV pregnancy delivery management

C-section is recommended if active genital lesions or early symptoms are present.

Pregnancy STI screening: syphilis

Screen all pregnant women at the initial visit.

Pregnancy risks of syphilis

Congenital syphilis, premature birth, stillbirth, and death after delivery.

Pregnancy STI screening: trichomoniasis

No routine testing is recommended in asymptomatic pregnant women.

Pregnancy STI screening: bacterial vaginosis

No routine testing is recommended in asymptomatic pregnant women.

Pregnancy STI screening: HPV

No pregnancy screening recommendation was listed in the presentation.

Pregnancy STI screening: HIV

Screen all pregnant women at the initial visit.

Pregnancy STI screening: HBV

Screen all pregnant women at the initial visit.

Pregnancy STI screening: HCV

Screen pregnant women at increased risk, such as past or current injection drug use.

Pregnancy risks of BV

Preterm delivery, low birth weight, premature rupture of membranes, and chorioamnionitis.

HBV/HCV pregnancy concern

Increased risk of mother-to-child transmission.

HBV newborn complication

Infected newborns have a high risk of becoming chronic carriers, approximately 90%.

Pregnancy candidiasis treatment

Uncomplicated vulvovaginal candidiasis should be treated with topical agents.

Gonorrhea organism

Neisseria gonorrhoeae.

Gonorrhea epidemiology

WHO estimated 82.4 million new infections worldwide among persons ages 15-49 in 2020.

Gonorrhea in men: clinical features

May be asymptomatic or cause dysuria, white/yellow/green penile discharge, painful urination, painful or swollen testicles, and rectal itching, discharge, pain, or bleeding.

Gonorrhea in women: clinical features

May be asymptomatic or cause dysuria, increased vaginal discharge, bleeding between periods, abdominal pain, frequent or painful urination, and rectal itching, discharge, pain, or bleeding.

Gonorrhea diagnostic test

Urine or swab testing; NAAT is the preferred method.

Gonorrhea NAAT specimen sites

Endocervical, vaginal, urethral, oropharyngeal, rectal swab, or first-catch urine.

Point-of-care NAAT

In 2021, FDA approved NAAT for point-of-care settings; female vaginal swabs and male urine specimens can detect chlamydia and gonorrhea with results in 30 minutes.

Gonorrhea treatment: first-line

Ceftriaxone 500 mg IM as one dose.

Gonorrhea treatment if chlamydia not excluded

Add doxycycline 100 mg PO twice daily for 7 days.

Gonorrhea antimicrobial resistance: causes

Unrestricted access to antimicrobials, inappropriate antibiotic selection and overuse, and genetic mutations within the organism.

Gonorrhea partner management

Treat sexual partners.

Gonorrhea complications

Five-fold increase in HIV transmission, infertility, chronic lower abdominal pain in women, ectopic pregnancy, maternal death, first-trimester spontaneous abortion, and severe neonatal eye infections that can lead to blindness.

Chlamydia organism

Chlamydia trachomatis.

Chlamydia association

Chlamydia is most frequently reported with gonorrhea.

Chlamydia in men: clinical features

May be asymptomatic; urethral discharge, dysuria, urethritis with acute severe dysuria, frequency, copious purulent discharge, and possible progression to epididymitis.

Chlamydia in women: clinical features

May be asymptomatic; vaginal discharge, post-coital bleeding or bleeding between periods, dysuria, lower abdominal pain, and deep dyspareunia.

Chlamydia female physical exam findings

Cervical motion tenderness, yellow mucopurulent exudate, contact bleeding, and cervical ectopy.

Cervical motion tenderness exam pearl

Cervical motion tenderness is strongly associated with PID and was emphasized as board-exam important.

Chlamydia diagnostic test

Urine or swab testing; NAAT is preferred.

Chlamydia NAAT advantage

NAAT has greater sensitivity and specificity.

Chlamydia specimen collection by anatomy

Vulvovaginal specimen in patients with a vagina, first-catch urine in patients with a penis, rectal swab in MSM or those who frequently receive anal sex, and oropharyngeal swab for oral infection.

Chlamydia first-line treatment

Doxycycline 100 mg PO twice daily for 7 days.

Chlamydia alternative treatment: azithromycin

Azithromycin 1 g PO single dose; useful if adherence is a concern and preferred in pregnancy.

Chlamydia alternative treatment: levofloxacin

Levofloxacin 500 mg PO daily for 7 days.

Chlamydia pregnancy contraindications

Doxycycline is contraindicated in the second and third trimesters; levofloxacin is contraindicated in pregnancy.

Chlamydia pregnancy treatment

Azithromycin is safe and effective; amoxicillin 500 mg three times daily for 7 days can be used if severe intolerance or known allergy to macrolides.

Chlamydia test of cure

Test of cure 3-4 weeks after therapy if treatment failure is suspected, adherence is doubted, symptoms persist, or reinfection is suspected.

Chlamydia retesting in pregnancy

Pregnant women diagnosed with chlamydia should be retested 3 months after treatment and rescreened in the third trimester.

Chlamydia neonatal complications

Transmission during delivery can lead to pneumonia and ophthalmia neonatorum, a cause of blindness.

Partner management for chlamydia and gonorrhea

Treat all sexual partners from the past 60 days.

Expedited Partner Therapy

EPT can be used if partners cannot be evaluated.

EPT legal status in Pennsylvania

EPT is legal and protected in Pennsylvania since 2023.

EPT provider responsibility

Providers may give treatment medications without an exam, but must include counseling and documentation; use "EPT" label if partner name is unknown.

Abstinence after STI treatment

Abstain from sex for 7 days after single-dose therapy or until completion of a 7-day regimen.

EPT urgent care warning

Seek urgent care if severe abdominal or pelvic pain, fever, vomiting, testicular pain or swelling, rash, or allergic reaction occurs.

EPT follow-up advice

Even after taking medication, patients should be tested for HIV, syphilis, and other STIs and retested in 3 months.

Bacterial vaginosis definition

BV is not sexually transmitted and is associated with altered vaginal flora and increased vaginal pH.

BV organisms

Gardnerella vaginalis and Atopobium vaginae are the most common etiologies.

Normal vaginal pH

Normal vaginal pH is less than 4.5.

BV pathophysiology

Vaginal pH rises above 4.5; hydrogen peroxide-producing lactobacilli are normally dominant, but when pH increases, anaerobic bacteria increase in concentration.

BV risk factors

Frequent vaginal douching, antibiotic use, poor hygiene, receptive oral sex, lack of condom use, multiple or new sex partner, smoking, presence of another STI, poorly controlled diabetes, and immune system disorders.

BV clinical features

Unpleasant fishy smell especially after vaginal intercourse; thin white discharge that may be grayish and frothy.

BV negative features

BV is not associated with soreness, itching, or irritation and rarely has signs of inflammation.

BV diagnosis: Amsel criteria

Thin white homogeneous discharge coating the vaginal wall, clue cells, vaginal pH greater than 4.5, and fishy odor after adding 10% KOH.

BV whiff test

Adding 10% potassium hydroxide to vaginal discharge releases a fishy odor if positive.

BV treatment: oral metronidazole

Metronidazole 500 mg PO twice daily for 7 days.

BV treatment: intravaginal options

Clindamycin vaginal cream 2%, 5 g at bedtime for 7 days, or metronidazole gel 0.75%, 5 g intravaginally for 5 days.

Syphilis organism

Treponema pallidum, a spirochete.

Syphilis transmission

Direct contact with an infectious chancre or vertical transmission during pregnancy.

Syphilis infectious stages

Can be transmitted at any stage of infection.

Primary syphilis

Average incubation is 21 days; painless chancre appears at infection site with regional lymphadenopathy.

Secondary syphilis

Develops 4-10 weeks after initial chancre; classic triad is rash, mucocutaneous lesions, and generalized lymphadenopathy.

Early latent syphilis

Disease becomes asymptomatic after spontaneous resolution of secondary syphilis, 3-12 weeks from onset.

Tertiary syphilis

Occurs 10-40 years after initial infection in 33% of untreated patients; causes many systemic complications and can be fatal.

Tertiary syphilis complications

Bone lesions, connective tissue disorders including cardiac disease, liver disease, and brain/CNS involvement.

Neurosyphilis

Can occur at any time; late neurosyphilis appears 10-30 years after primary disease and may cause progressive dementia, paralysis, optic involvement, and blindness.

Chancre pronunciation and meaning

Chancre is pronounced "shang-kr" and refers to the ulcer of primary syphilis.

Syphilis screening test

RPR, or rapid plasma reagin, is used for initial screening.

RPR significance

RPR is accurate for screening and confirming positive testing and is sensitive to treatment response.

Syphilis CSF test

VDRL is the only FDA-approved test for CSF specimens.

Syphilis treatment: primary, secondary, early latent

Benzathine penicillin G 2.4 million units IM once.

Syphilis treatment: late latent or unknown duration

Benzathine penicillin G total 7.2 million units, given as 2.4 million units IM weekly for 3 doses.

Syphilis treatment: tertiary non-neuro

Benzathine penicillin G total 7.2 million units, given as 2.4 million units IM weekly for 3 doses.

Chancroid organism

Haemophilus ducreyi.

Chancroid transmission

Sexual contact with an infected person.

Chancroid diagnostic criteria

One or more painful genital ulcers, regional lymphadenopathy, no evidence of Treponema pallidum, and negative HSV.