Sexually Transmitted Diseases and Treatment

chlamydia trachomatis

• obligate, intracellular parasite of eukaryotic cells

• cannot replicate extracellularly or synthesize ATP

• humans are the only known natural host

chlamydia trachomatis incubation for symptomatic infection

7-21 days (1-3 weeks)

chlamydia life cycle

• chlamydia infects host mucosal epithelial cells (may kill cells)

1. 0-6 hrs: elementary body (EB) (extracellular chlamydia) attaches and enters the host cell

   1. EBs are infectious

2. 6-12 hrs: EB becomes reticulate body (RB)

   1. RBs are non-infectious, but replicating form

3. 12-24 hrs: RB replication

4. 24-36 hrs: RBs reorganize back to EBs

5. 36-48 hrs

6. 48-72 hrs: lysis or extrusion occurs; RBs and EBs escape from cell

• if untreated, infection can become chronic

chronic chlamydia timeline

lasting months to 1 yr+ 

chlamydia overall transmission rate

~55%

chlamydia transmission rate per act of sex

~10%

chlamydia transmission - higher rate of transmission from ____ to _____ (genders)

higher rate of transmission from males to females

percentage of chlamydia transmitted perinatally

20-50%

diagnosis of Ct (chlamydia) and GC (gonorrhea)

• NAAT (Nucleic Acid Amplification Test) 

• urogenital 

  • urine (M/F)

  • vaginal swab (F)

  • urethral swab (M)

• rectal

  • swab (M/F)

• oropharyngeal

  • throat swab (M/F)

• swabs can be self-collected

Ct & GC screening for women

• annual screening 

• pregnancy 

• prn based on reported sexual activity 

Ct & GC screening for women - annual screening

annual screening:

• all sexually active women younger than 25 yo

  • highest incidence

  • asymptomatic 

  • severe health/reproductive complications if undiagnosed

• sexually active 25+ yo women, if at increased risk

  • new or multiple partners

  • not monogamous 

  • partner has STI

Ct & GC screening for women - pregnancy

• at first prenatal visit and in third trimester

• same criteria as annual screening:

  • all sexually active women younger than 25 yo

    • highest incidence

    • asymptomatic 

    • severe health/reproductive complications if undiagnosed

  • sexually active 25+ yo women, if at increased risk

    • new or multiple partners

    • not monogamous 

    • partner has STI

Ct & GC screening for women - prn based on reported sexual activity

rectal and oropharyngeal screening prn based on reported sexual activity

Ct & GC screening for men 

• men who have sex with women only 

• MSM (men who have sex with men) 

Ct & GC screening for men - men who have sex with women only

• no routine screening recommended

  • low risk 

  • no data to support

• increased risk should be considered

  • high chlamydia setting

  • correctional facilities

  • STD/sexual health clinics, etc. 

Ct & GC screening for men - MSM

• at least annual testing for all sexually active MSM 

  • rectal and urethral based on reported sexual activity 

  • routine oropharyngeal not recommended for chlamydia but can be picked up on GC NAAT if tested 

• more frequent testing based on risk 

chlamydia presentation in men - urethretis

• discharge - clear to mucopurulent; dysuria

• how it likely presents itself (scale of 1-3)

  • 1/3 chance symptomatic presentation

  • 3/3 chance asymptomatic presentation

chlamydia presentation in men - epididymitis

• scrotal and flank pain, inguinal flank, urethral discharge (any type of groin pain) 

• how it likely presents itself 

  • 3/3 chance symptomatically 

  • 1/3 chance asymptomatically 

chlamydia presentation in men - anorectal

• irritation, painful defecation, purulent discharge, pruritis, scant bleeding 

• how it likely presents itself 

  • 1/3 chance symptomatically 

  • 3/3 chance asymptomatically 

chlamydia presentation in men - oropharyngeal

• pharyngitis, tonsillitis, fever, cervical adenitis

• how it likely presents itself

  • 1/3 chance symptomatically (mild)

  • 3/3 chance asymptomatically

chlamydia presentation in women 

• cervicitis

• urethritis

• PID (Pelvic Inflammatory Disease) 

• anorectal 

• oropharyngeal

chlamydia presentation in women - cervicitis

• non-specific vaginal discharge, spotting/bleeding, abdominal discomfort 

• site of infection in 75-80% of women 

• how it likely presents: 

  • 1/3 chance symptomatically 

  • 3/3 chance asymptomatically 

chlamydia presentation in women - urethritis

• dysuria, urinary frequency

• how it likely presents:

  • 1/3 chance symptomatically

  • 3/3 chance asymptomatically

chlamydia presentation in women - PID

• lower abdominal pain, vaginal discharge, dyspareunia, intermenstrual bleeding, fever

• 20% infertile

• 30% develop chronic pain

• 1% experience ectopic pregnancy if they conceive

• likely presentation:

  • 3/3 chance symptomatic

  • 1/3 chance asymptomatic

chlamydia presentation in women - anorectal

• irritation, painful defecation, purulent discharge, pruritus, scant bleeding 

• may be due to sex or autoinoculation from vaginal secretions 

• likely presentation

  • 1/3 chance symptoms

  • 3/3 chance asymptomatic 

chlamydia presentation in women - oropharyngeal

• pharyngitis, tonsillitis, fever, cervical adenitis 

• likely presentation 

  • 1/3 chance symptomatic (mild) 

  • 3/3 chance asymptomatic 

PID

• fallopian tube is infected and swollen 

• infertility 

• adhesion

• vagina = path of ascension of chlamydia 

Chlamydia trachomatis conjunctivitis sx

redness, not much discharge tbh

treatment of urogenital, rectal, and pharyngeal chlamydia (general/nonpregnant)

• doxycycline 100mg po BID x 7 days

• alternative: 

  • azithromycin 1000mg po x 1 dose 

  • levaquin 500mg po q24h x 7 days

treatment of urogenital, rectal, and pharyngeal chlamydia (pregnancy)

azithromycin 1000mg po x 1 dose

urogenital/rectal/pharyngeal chlamydia follow-up for patient

• retesting for lack of CL of sx or for recurrence of sx 

• repeat testing @ 3 months

• routine test of cure @ 7-14 days is not recommended 

urogenital/rectal/pharyngeal chlamydia follow-up for partners

• evaluate and/or treat all partners within the last 60 days from onset or dx 

• last partner > 60 days = evaluate and treat 

• no sexual activity for 7 days after end of tx

Neisseria gonorrhoeae

• gram-negative diplococci

• resistance mechanisms

  • many carry a plasmid that produces TEM-1 type of beta-lactamase (penicillinase) 

    • PCN is no longer accepted as tx 

    • cephalosporins are stable to beta-lactamase 

  • FQ resistance increasing

    • third world countries = 30-60%

    • USA = 0-30%

N. gonorrhoeae transmission methods

• M to F (if male infected) 

• M to F (if female infected) 

• oropharyngeal 

• perinatally 

• anorectal? 

N. gonorrhoeae transmission rate of infection - M to F (if male infected)

50-70% per episode of sex

N. gonorrhoeae transmission - M to F (if female infected)

~20% per episode of sex

N. gonorrhoeae transmission rate - oropharyngeal

lower rates

N. gonorrhoeae transmission rate - anorectal

rates not quantified

N. gonorrhoeae transmission - perinatally

can be transmitted perinatally

GC presentation in men - sites

• urethritis 

• epididymitis

• anorectal 

• oropharyngeal

GC presentation in men - incubation & sx presentation (timeline)

• incubation = 1-14 days 

• sx = most sx present within 2-5 days

GC presentation in men - urethritis

• mucopurulent discharge, dysuria 

• likely presentation 

  • 3/3 sx

  • 1/3 asymptomatic 

GC presentation in men - epididymitis

• scrotal and/or inguinal and/or flank pain, urethral discharge 

• likely presentation 

  • 3/3 sx 

  • 1/3 asx

GC presentation in men - anorectal 

• irritation, painful defecation, purulent discharge, pruritis, scant bleeding 

• likely presentation 

  • 1/3 sx

  • 3/3 asx

GC presentation in men - oropharyngeal

• pharyngitis, tonsillitis, fever, cervical adenitis

• likely presentation 

  • 1/3 sx (mild) 

  • 3/3 asx

GC presentation in females - incubation and sx presentation (timeline)

• incubation = variable

• most sx present within 10 days

GC presentation in females - sites

• vaginitis/urethritis/cervicitis

• PID

• anorectal

• oropharyngeal

GC presentation in women - vaginitis/urethritis/cervicitis

• non-specific vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, dyspareunia

• likely presentation 

  • 1/3 sx

  • 3/3 asx

GC presentation in women - PID

• lower abdominal pain, vaginal discharge, dyspareunia, intermenstrual bleeding, fever

• long term can impact fertility and pregnancy

• likely presentation 

  • 3/3 sx

  • 1/3 asx

GC presentation in women - anorectal

• irritation, painful defecation, purulent discharge, pruritis, scant bleeding 

• may be due to sex or perineal contamination from cervical secretions 

• likely presentation

  • 1/3 sx

  • 3/3 asx

GC presentation in women - oropharyngeal

• pharyngitis, tonsillitis, fever, cervical adenitis

• likely presentation 

  • 1/3 sx (mild) 

  • 3/3 asx 

gonococcal conjunctivitis sx

redness

discharge

disseminated gonococci can lead to ___ and ___

rash 

arthritis 

tx of GC (general/non-pregnant)

• resistance issues with GC

• FQs 

• only give oral cefixime if ceftriaxone is unavailable in uncomplicated pt 

  • otherwise, it is no longer recommended

tx of GC alone (urogenital/rectal/pharyngeal) (and if they’re allergic)

• ceftriaxone 500mg IM x 1 dose 

  • if pt weighs more than 150kg, dose 1000mg IM 

• highly allergic alternative:

  • gentamicin/azithromycin

  • 240mg IM/2000mg po

tx of GC including chlamydia

• often with vaginal, cervical, urethral infections, there is a co-infection with chlamydia

• ^ must tx both organisms 

• ceftriaxone 500mg IM x 1 dose and doxycycline 100mg BID x 7 days

tx for disseminated GC

• ceftriaxone 1000mg IM or IV q24h

• cefotaxime 1000mg IV q8h

tx of GC only in pregnant pts

ceftriaxone 500mg IM x 1 dose

tx of GC with chlamydia in pregnant pts

ceftriaxone 500mg IM x 1 dose and azithromycin 1000mg po x 1 dose

GC f/u - urogenital or rectal

• repeat testing at 3 months

• retesting for lack of CL of sx or for recurrence of sx

GC f/u - pharyngeal

• test-of-cure recommended between 7-14 days 

• retesting for lack of CL of sx or for recurrence of sx

GC f/u - partners

• evaluate and/or treat all partners within last 60 days from onset or dx 

• last partner > 60 days = evaluate and tx 

• no sexual activity for 7 days after end of tx

syphilis bug name

Treponema pallidum

syphilis

Treponema pallidum; spirochete

syphilis transmission methods

• sexual transmission

• congenital syphilis (mother to child) 

syphilis transmission - sexual transmission

• contagious throughout primary/secondary stages

• contact with lesions or rash 

• enters through skin or mucous membranes

syphilis transmission - congenital syphilis

• mother to child

• generally occurs via transplacental passage of T. pallidum during maternal spirochetemia 

• may also be transmitted at birth if contact with genital lesions

T. pallidum stages

• play role in determining tx 

1. primary 

2. secondary 

3. latent 

   1. early (less than a year) 

   2. late (more than a year) 

   3. unknown 

4. tertiary

T. pallidum stages - primary syphilis

• incubation period: 10-90 days (average 21)

• chancre appears @ site of spirochete penetration 

  • painless and resolves spontaneously within 1-8 weeks 

  • highly infectious

T. pallidum stages - secondary syphilis

• develops 4-8 weeks (1-2 mo) after onset of primary 

• hematogenous or lymphatic spread of organism → results in rash (especially skin lesions; often on palms of hands and soles of feet) 

• spontaneously resolves in 4-6 weeks

• sx: 

  • lymphadenopathy 

  • malaise

  • fever

  • alopecia

  • rashes (body, palms, soles, penis, scrotum)

T. pallidum stages - latent syphilis

• individuals with positive serologic test

• no other signs of disease related to primary, secondary, or tertiary stages

• can remain asxtic for life or can develop tertiary disease

• less likely to transmit in this phase than others

T. pallidum stages - tertiary syphilis

• can affect any organ of the body 

• gummas 

• neurosyphilis

• CV

T. pallidum stages - tertiary syphilis → gummas

• granulomatous lesions 

• often affect bone, skin, upper respiratory tract 

• can involve any organ

T. pallidum stages - tertiary syphilis → neurosyphilis

• general paresis

• deafness

• optic atrophy 

• blindness

• dementia

• can actually occur @ any stage

T. pallidum stages - tertiary syphilis → CV

• aortic insufficiency 

• aortic aneurysms 

congenital syphilis

80% due to lack of screening or appt tx :(

situations in which outcomes of congenital syphilis are worse

• more likely worse outcomes in 1st/2nd trimester

  • outcomes less likely to be worse in 3rd trimester but still could present with issues post-nataly

• if conception occurs during early syphilis

• increased risk of fetal death with acute infection — mom/fetal inflammatory response? 

• untreated syphilis

does treatment entirely eliminate congenital syphilis?

no :(

early congenital syphilis manifestations (neonates/young children)

• early = less than 2 yo 

• small for gestational age

• liver issues

• spleen issues

• lymphadenopathy

• rash

• bone

• potential CV

• neurologic

• ophthalmic issues

late manifestations of congenital syphilis (neonates/young children)

• late = older than 2 yo

• orofacial issues

• bone

• ophthalmic

• deafness

syphilis screening tests

• non-specific screening

• specific screening

syphilis non-specific screening

• measure IgM/IgG antibodies NOT specific to T. pallidum, but to cellular breakdown products

• VDRL (venereal disease research laboratory)

• RPR (rapid plasma regain) - reactive or dilution (ex., 1:32)

specific syphilis screening

• measure antibody specific to T. pallidum

• FTA (fluorescent treponemal antibody) 

• TP-PA (T. pallidum particle agglutination) 

traditional syphilis screening algorithm

syphilis screening algorithm - reverse sequence algorithm

• EIA = Enzyme Immunoassay

• CIA = Chemiluminescent Immunoassay

when do you screen for syphilis in pregnancy?

• first prenatal visit

• third trimester/after 28 weeks

• @ delivery

how to screen for syphilis in pregnancy

“Follow-up reliable” just means:

👉 Can we trust that this patient will come back for follow-up labs and treatment if needed? / Will this person actually show up again?

primary, secondary, and early latent syphilis - timeline

12+ months

how to treat primary, secondary, and early latent syphilis

benzathine PCN G 2.4 MU IM x 1 dose

(MU = million units)

benzathine PCN G

• depot IM injection

• slow release

how to treat tertiary and late latent or unknown duration of latency syphilis

benzathine PCN G 2.4 MU IM qweek x 3

how to tx neurosyphilis

• aqueous PCN G 3-4 MU q4h

• continuous infusion if possible

how to treat syphilis in pregnancy

• PCN

• desensitize to PCN if allergic

Jarish-Herxheimer rxn

• not an allergy to PCN

• rxn seen soon after tx w/PCN for syphilis (usually a few to 24 hrs after the dose) in early stage

• due to high bacterial burden? 

Jarish-Herxheimer rxn sx

• fever

• malaise

• N/V

• rash or worsening rash 

• less often chills

• hypotension

treatment of Jarish-Herxheimer rxn

• self-limiting w/in 24 hrs

• supportive care

primary syphilis follow-up

• resolution of sx/signs

• check RPR at 6 and 12 months

• RPR titer should drop 4+ fold 

• if not seen, reassessment and retreatment may be necessary

secondary syphilis follow up

• resolution of sx/signs

• check RPR at 6 and 12 months

• RPR titer should drop 4+ fold 

• if not seen, reassessment and retreatment may be necessary

latent syphilis follow up

• resolution of sx/signs

• check RPR at 6, 12 and 24 months

• RPR titer should drop 4+ fold 

• if not seen, reassessment and retreatment may be necessary

primary syphilis - partners testing

• evaluate and tx all partners within last 90 days from onset or diagnosis 

• last partner > 90 = evaluate and tx if positive serology

• no sex for 7 days after end of tx