Sexually Transmitted Diseases

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  • 1. Sexually Transmitted Diseases Capital Conference, June 2007 Gregory Perron, MD
  • 2. Introduction
    • Diseases Covered
      • Genital Ulcer Disease
        • HSV, syphilis, others
      • Urethritis/Cervicitis
        • GC, Chlamydia
      • Vaginal Discharge
        • BV, vulvovaginal candidiasis, trichomonas
      • HPV
    • Not Covered
      • HIV, PID
    • Future Trends
  • 3. Useful Resources
    • CDC: Center for Disease Control
    • Sexually Transmitted Diseases Treatment Guidelines, 2002
    • http://www.cdc.gov/std/treatment/TOC2002TG.htm
    • Also a good source of patient handouts, statistical information, MMWR bulletins
    • American Family Physician – article series on STD’s
  • 4.  
  • 5. Genital Ulcer Diseases
    • Differential includes:
      • HSV-1 vs HSV-2 : most common in US
      • Primary Syphilis
      • Chancroid - rare
      • LGV-- lymphogranuloma venereum - rare
      • Granuloma Inguinale - rare
  • 6. Herpes Simplex Virus
    • Recurrent, incurable viral disease
    • HSV-1 and HSV-2: Over 50 million affected patients in US; ~1 million new cases/year
    • Most HSV-2 infections undiagnosed
    • Most transmission from undiagnosed or asymptomatic pts
    • Diagnose by clinical suspicion and type-specific testing (e.g. culture or DFA)- not Tzank
  • 7. HSV, Primary Infection
    • 5-30% due to HSV1
    • HSV-2 mostly anogenital
    • Patient Education:
    • a. Natural history of disease
    • b. Sexual & perinatal transmission c. Methods to reduce risk of transmission
  • 8. Primary HSV, female patient Primary infection in pregnancy: highest risk of fetal transmission
  • 9. Medical Treatment First Clinical Episode
    • Recommended Regimens Acyclovir 400 mg po tid x 7-10 days, OR Acyclovir 200 mg po 5x/day for 7-10 days, OR Famciclovir 250 mg po tid x 7-10 days, OR Valacyclovir 1 gm po bid x 7-10 days.
  • 10. HSV – Recurrent Episodes
    • HSV-2 significant more likely to recur
    • Recurrent episodes less severe than initial
    • Episodic Treatment:
      • Acyclovir 400 TID or 200 5X/Day or 800 BID X 5days
      • Famvir 125 BID X 5 days
      • Valacyclovir 500 BID X 3-5 days
  • 11. HSV Suppression
    • Suppression in pregnancy not routinely suggested by ACOG or CDC
    • Reduces frequency of clinical flares by 70-80%, significantly reduces shedding
      • Acyclovir 400 BID
      • Famvir 250 BID
      • Valacyclovir 500mg-1000mg QD
      • Start at 36 wks in pregnancy, or if recurrent episodes
  • 12. Syphilis - Treponema pallidum
    • Systemic disease caused by T. pallidum
    • Stage of infection
      • Primary
      • Secondary
      • Tertiary
      • Latent
  • 13. Primary syphilis-chancre Hallmark: PAINLESS!
  • 14. Secondary syphilis -skin rash; mucocutaneous lesions, regional lymphadenopathy characteristic
  • 15. Secondary syphilis - condyloma lata
  • 16. Syphilis Stages cont
    • Tertiary - cardiac, neurologic, ophthalmic, auditory, gummatous lesions
    • Latent - active infection diagnosed by serology without clinical signs of infection
      • Early Latent - infection acquired within preceding year
      • Late Latent - infection acquired >1 yr ago
      • Syphilis of Unknown Duration - self explanatory
  • 17. Syphilis- Diagnostic Considerations
    • Treponemal Tests
      • Darkfield exam
      • Direct Fluorescent Antibody Tests
    • Nontreponemal Tests
      • Venereal Disease Research Laboratory (VDRL)
      • RPR
  • 18. Nontreponemal Tests
    • Titers may wax & wane as course of disease changes
    • 4 fold change in titer considered clinically significant
    • Should (but not always) become undetectable with treatment
    • Multiple etiologies for false positives
  • 19. Treponemal Tests
    • Fluorescent Treponemal Antibody Absorbed (FTA-ABS)
      • CSF FTA-ABS highly sensitive for neurosyphilis (i.e. if negative it excludes neurosyphilis)
    • Microhemagglutination Assay for Antibody to T. pallidum (MHA-TP)
      • Most patients positive for remainder of their lives
      • Poor marker for disease activity
  • 20. Syphilis Diagnosis
    • No single test reliable enough to diagnose
    • Need combination of treponemal & non-treponemal tests and associated clinical picture
  • 21. Syphilis Treatment
    • Primary, Secondary, Early Latent
      • No PCN allergy: Penicillin G 2.4 MU IM X1
      • PCN allergy
        • Pregnant: desensitize and give penicillin
        • Others: Doxycycline 100mg BID X 14 days
        • - or- TCN 500 QID X 14 days
  • 22. Syphilis Treatment
    • Late Latent, Unknown Duration, Tertiary
      • No PCN allergy
        • penicillin G 2.4 MU IM Qweek X 3
      • PCN allergy
        • Pregnant: Desensitize and treat with PCN
        • Nonpregnant: Doxy 100 BID X 28 days, TCN 500 QID X 28 days
  • 23. Primary & Secondary cont
    • No definitive criteria for cure or failure
    • Follow-up VDRL/RPR at 1,3,6,12 months
    • Think failure if titer fails to fall fourfold, or if titers rise
  • 24. Primary & Secondary cont
    • If symptoms persist, recur, or sustained titers=failure or reinfection
    • Retest for HIV, perform LP, and retreat x3 weekly doses unless CSF studies show neurosyphilis present
  • 25. Neurosyphilis
    • Non PCN Allergic Adults
    • Aqueous crystalline penicillin G 3-4 million units IV every 4 hours for 10-14 days
    • Procaine penicillin 2.4 million units IM a day, PLUS Probenecid 500 mg orally four times a day, both for 10-14 days
  • 26. Neurosyphilis cont
    • Follow-Up:
    • If CSF pleocytosis present initially, CSF examination every 6 months until the cell count is normal
    • If the cell count has not decreased after 6 months, or if the CSF is not entirely normal after 2 years, re-treatment should be considered
  • 27. Chancroid ulcers
    • Diagnose by culture for H. ducreyi (rarely available)
    • Clinical Diagnosis:
      • painful genital ulcer
      • negative test for syphilis, HSV
      • suggestive clinical picture: endemic area; exposure; regional lymphadenopathy, risk factors such as HIV.
    • Treatment: Azithromycin 1gm OR ceftriaxone 250mg IM OR cipro 500 BID X 3D OR erythromycin 500 TID X7D
  • 28. Granuloma inguinale, male
    • Rare in US
    • Painless, progressive ulcers without LAN
    • May need biopsy to diagnose- donovan bodies
    • RX: doxycycline 100 BID –or- Bactrim DS BID, 3+ weeks
  • 29. Urethritis/Cervicitis Diseases
    • Chlamydia
    • GC
    • MPC
    • NGU
  • 30. Chlamydia
    • 467 per 100,000 population in 2003
      • Up from 79/100,000 in 1987
    • Asymptomatic infection common in women, less common in men
    • Complications: infertility, PID, ectopic pregnancy
  • 31. Chlamydia Diagnosis
    • Culture- rarely recommended
    • DNA amplification testing
      • PCR, Ligase Chain Reaction – urine or swab
    • Antigen detection with EIA acceptable
    • Annual Screening for all women <25
    • Some data supports Q6mo screening for women < 18, female military recruits
  • 32. Chlamydia Treatment
    • Direct Observed Therapy Is Best!
      • Azithromycin 1gm po X 1
    • Doxycycline 100mg BID X 7 days
    • Alternatives:
      • Erythromycin 500 QID X 7D
      • EES 800 QID X 7D
      • Ofloxacin 300BID X 7D
      • Levofloxacin 500 QD X 7D
    • ALL: Treat sexual partner; screen for other STDs
    • counsel patients to abstain from sex until 7 days after patient and partner treated
  • 33. Chlamydia in Pregnancy
    • Screen all women in 1 st trimester, selective screening in 3 rd trimester
    • Treat with
      • Azithryomycin 1gm X single dose
      • erythromycin 500 QID X 7D
      • amoxicillin 500 TID X 7d
      • Treat partners; abstain from sex until 7 days after treatment & partner treated
    • Test of Cure in 3 weeks recommended!
  • 34. Chlamydia Followup
    • Test of Cure: recommended if doxy/azithro not used, or in pregnancy
    • Test for REINFECTION-– test 3-4 months later, definitely by 12 months after diagnosis
      • urine chlamydia testing ideal
  • 35. Gonorrhea
    • 300,000 cases reported; estimated total 700,000
    • Men typically symptomatic
    • Women often asymptomatic
    • Complications: epididymitis, PID, infertility, ectopic pregnancy
    ick
  • 36. Gonococcal cervicitis
    • Diagnose with DNA probe or culture
      • CO2-rich environment for culture
    • Cannot diagnose women with gram stain
  • 37. Gonorrhea - gram stain of urethral discharge Diagnosis by gram stain– MEN only
  • 38. Gonorrhea Infection in the Eye Diagnosis is by clinical suspicion and culture- need selective media in CO2-enriched environment Treatment: ceftriazone 1gm IM; consider saline lavage
  • 39. GC Treatment
    • Ceftriaxone 125mg IM; ALWAYS presume chlamydia and treat
    • Fluoroquinolones are OUT: no longer recommended due to resistance .
    • (cefixime 400mg PO)
  • 40. MPC, NGU
    • MPC- mucopurulent cervicitis
    • Dx: mucopurulent discharge from os or on endocervical swab.
    • ? Value of increased PMN’s on endocervical gram stain
    • Test for GC, Chlamydia
    • Consider empiric Rx
    • NGU- nongonococcal urethritis
    • Dx: urethral smear w/ >5WBC/hpf; no GNID; clinical hx of discharge
    • RX: 1gm azithro or doxy 100 BID X 7d
    • Test for GC ,Chlamdyia
  • 41. Diseases Characterized by Vaginal Discharge
    • Vulvovaginal Candidiasis
    • Bacterial Vaginosis
    • Trichomonas vaginitis
    • Recommend targeted history, exam, KOH, wet prep, vaginal pH. Consider GC/Chlamdyia testing
  • 42. Vulvovaginal Candidiasis
    • pH <4 (yellow)
    • KOH, Wet Prep
    • Candida albicans most common
      • ( C. glabrata, C. tropicalis, C. parapsilosis are next most common)
      • Diagnosis is by:
        • Characteristic discharge
        • Appropriate pH
        • Budding yeast or pseudohyphae
        • Culture + for yeast
  • 43. VVC, Cont’d
    • Uncomplicated VVC
    • Sporadic/infrequent episodes
    • Mild-to-moderate VVC
    • Likely C. albicans
    • Non-immunocompromised patient
    • Complicated VVC
    • Recurrent VVC
    • Severe VVC disease
    • Non-albicans candidiasis
    • Patient factors: immunocompromised, uncontrolled DM, debilitated patients, pregnancy
  • 44. Treatment of VVC
    • Topical agents vs. Oral Agents?
    • Why pick one over others?
    • Treatment with two agents?
      • Diflucan 150mg PO X 1 dose
      • Terazol 7: 0.4% IVA X 7 days
      • Monistat 1,3,7 (OTC)
      • etc
  • 45. Trichomonas
    • -motile, pear-shaped, 10 µm by 7 µm, organisms with visible flagella. Wet prep ~60-70% sensitive
    • + whiff test; WBC’s on wet prep; vaginal pH >4.5
    • Diffuse, yellow-green, malodorous discharge
    • Treat with metronidazole 2gm PO; or 500 BID X 7D
    • Treat sexual partner
  • 46. Bacterial Vaginosis
    • Diagnostic Criteria for Bacterial Vaginosis
    • Homogeneous vaginal discharge (color and amount may vary)
    • Presence of clue cells (greater than 20%)
    • Amine (fishy) odor when potassium hydroxide solution is added to vaginal secretions (&quot;whiff test&quot;)
    • Vaginal pH greater than 4.5
    • Absence of the normal vaginal lactobacilli
    • 3+ above criteria for diagnosis.
    Vagin osis – not Vagin itis
  • 47. Bacterial Vaginosis Treatment
    • Treatment Regimens:
      • Metronidazole 500 BID PO X 7D
      • Metronidazole 2gm PO X 1 dose
      • Metronidazole gel 0.75% IVA BID X 5D
      • Clindamycin 300mg PO BID X 7D
      • Clindamycin 2% cream 5GM IVA QHS X7D
    • Recurrence is common
    • Treatment of sexual partners not suggested
  • 48. Human Papilloma Virus
    • HPV: > 40 types in anogenital infection
    • Visible warts: 6/11
    • Cervical dysplasia: especially 16/18
    • Diagnosis: clinical exam
  • 49. HPV Factoids
    • Most common STD (6.2 million PER YR!)
      • Risk correlated to # of lifetime sexual partners
    • Most infections self-limited
    • Asymptomatic/Subclinical disease is common
    • Visible warts don’t typically cause dysplasia
  • 50. HPV Counselling
    • Once you’ve got it, you’ve got it – clearance questionable.
    • Counsel re: link to dysplasia; transmissibility; routine pap testing
    • No role for HPV typing or routine colposcopy for visible warts
  • 51. HPV- Treatment
    • Patient-applied
      • Podophilox 0.5% BID X 3 days, off 4 days, repeat up to 4 cycles.
      • Inimiquod 5% cream QHS, 3X/wk, 16wks max, wash off 6-10 hrs later
    • Provider-applied
      • LN2 Q 1-2 wks
      • Podophyllin resin 10-25%
      • TCA 80-90%, weekly
      • Laser therapy
    • Suggest referral for meatal warts, laryngeal warts
  • 52. HPV Vaccine - Gardisil
    • Approved for use in women only, 9-26
      • Recommended at ages 11-12
      • Catch-up older patients
      • 3 vaccine series (0,2,6 mo)
    • Efficacy varies, outcomes studied vary
      • But efficacy in the 90+ percentile for reduction of type-specific dysplasia
    • Targets HPV 6/11,16/18
      • Based on primary capsid proteins
  • 53. Other Vaccines for STDs
    • Hepatitis A: MSM (men who have sex with men); illicit drug users, patients with chronic liver disease
    • Hepatitis B: as per hepA, plus all teenagers; all treated for an STD; household contacts of chronic hep B patients
  • 54. HPV, HSV Vaccines
    • Won’t be on Boards tests
    • HPV
      • Merk’s Gardisil approved by FDA panel
      • GSK’s Cervarix in Phase 3 testing
    • HSV vaccines still in testing phase
  • 55. Questions?