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Std ppt use this one 1.12.12

Std ppt use this one 1.12.12






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    Std ppt use this one 1.12.12 Std ppt use this one 1.12.12 Presentation Transcript

    • Sexually Transmitted Disease Update Dennis montoya, MD
    • Shands STD Dx Rates
      • 25% of STD’s in Duval County are Dx’d through Shands. 
      • Public Health Dept. initially thought we were only tx 75% of these infections. 
      • They were unaware of the prescriptions called in by the flex care attending.
    • Shands STD Dx’s Rates
      • Tawana Brown works behind the scenes following up on DNA probes that grow positive.
      • She contacts patients and gets prescriptions called in for them.
      • Looking back over 4 months of data we had treated 75% before they left the ED.
      • Looking at the 25% untreated, most were reachable and treated. 
      • In speaking to the DCHD all the numbers combined brought us to 85% treatment rate for the adult ED.
    • Chlamydia
      • Chlamydia trachomatis: obligate intracellular bacteria, lacks peptidoglycan, therefore not true G(-)
      • The most commonly reported bacterial STD in both men and women in the United States
      • Estimated 2.8 million infections occur each year
      • Most are asymptomatic, providing an ongoing reservoir for infection
      • The most frequent clinical manifestation in men is urethritis, in women is cervicitis
    • Chlamydia - Male Sx’s
    • Chlamydia - Speculum Exam
    • Untreated Chlamydia
      • In untreated women 10-15% risk of developing into PID
      • Can cause fallopian tube infection w/out any sx’s leading to permanent damage of the fallopian tubes & uterus
      • Damage can lead to chronic pelvic pain, infertility, and ectopic pregnancy
      • Complications among men are rare. Infection sometimes spreads to the epididymitis, causing pain, fever, and, rarely, sterility
    • Chlamydia Tx – Cervicitis
      • CDC recommends Azithromycin or Doxycycline as first-line therapy for the treatment of Chlamydial infection
      • When cost is not a factor, CDC prefers the use of Azithromycin 1 gram PO one time dose [preferred pregnancy]
      • If cost is an issue, then Doxycycline 100 mg q 12 hrs for 7 days [contraindicated in pregnancy]
    • Gonorrhea
      • Neisseria Gonorrhea: G(-) cocci
      • Can grow and multiply in the cervix, uterus, fallopian tubes in women, and in the urethra in women and men
      • Can also grow in the mouth, throat, eyes, and anus
      • CDC estimates that more than 700,000 persons in the U.S. get new gonorrheal infections each year
    • Gonorrhea Sx’s - Women
    • Gonorrhea Sx’s - Men
    • Untreated Gonorrhea
      • PID
      • Fallopian tube damage, infertility, increase the risk of ectopic pregnancy
      • In men, gonorrhea can cause epididymitis that may lead to infertility if left untreated
      • Gonorrhea can spread to the blood or joints
    • Gonorrhea Tx
      • Ceftriaxone 250 mg I.M. single dose
      • Cefixime 400mg PO single dose + (Azithromycin 1g PO or Doxycycline 100mg PO q 12 x 7 days)
      • Penicillin allergic patients :
      • Azithromycin (2g single dose) – requires test of cure secondary to increasing resistance
    • Test of Cure – GC / Chlmaydia
      • The CDC guidelines do not recommend "test of cure " for nonpregnant patients who have received the appropriate treatment for gonorrhea or Chlamydia unless symptoms persist or there is suspicion of reinfection or nonadherence
      • Per the CDC, a test of cure may be considered 3 weeks after completion of treatment
      • Testing sooner may lead to inappropriate false-positive results
    • Pelvic Inflammatory Disease
    • PID - Tx
      • Azithromycin 1 gram PO one time dose
      • Ceftriaxone 250 mg I.M. single dose
      • In addition to above add Doxycycline 100mg PO q 12hrs x 14 days
    • Trichomoniasis
      • Trichomoniasis is considered the most common curable STD
      • Estimated 3.7 million people have the infection, but only about 30% develop any symptoms
      • Vagina is the most common site of infection in women
      • Urethra is the most common site of infection in men
    • Trichomoniasis – Sx’s
      • Most men do not have si’s / sx’s; some may have temporary irritation inside the penis, mild discharge, or slight burning after urination or ejaculation
      • Women have a frothy, yellow-green vaginal discharge with a strong odor, discomfort during intercourse and urination, as well as irritation and itching of the genital area
      • Symptoms usually appear in women within 5 - 28 days of exposure
    • Trichomoniasis
    • Trichomoniasis - Tx
      • Metronidazole (Flagyl) 2g PO once!
    • Syphilis: Treponema Pallidum
    • Stages of Syphilis
      • Primary Syphilis : Ulcer @ site of infection develops into a chancre 3 weeks post exposure, heals spontaneously in 4-6 weeks
      • Secondary Syphilis ( highly infectious state ): appears 2-8 weeks after appearance of chancre. Skin lesions now include trunk, extremities, palms, soles, & face
        • Condylomata lata: mucosal warty erosions
    • Primary & Secondary Syphilis
    • Condyloma lata – Secondary Syphilis
    • Stages of Syphilis
      • Latent Syphilis : No clinical manifestations despite continued infection
      • Tertiary Syphilis : Typically occurs 15-20 yrs later
        • Neurosyphilis - cortical degeneration causing mental status changes from decreased memory to frank psychosis
        • Tabes Dorsalis – demyelination of posterior columns of spinal cord causing ataxia and a wide based gate
        • Cardiovascular syphilis – arteritis of aortic vasa vasorum degrading elastic fibers leading to aneurysm & dilatation of aorta & aorta valve ring
    • Syphilis Tx
      • Early Syphilis:
        • Benzathine penicillin G 2.4 million units IM in a single dose
      • Early Latent Syphilis:
        • Benzathine penicillin G 2.4 million units IM in a single dose
      • Late Latent Syphilis or Latent Syphilis of Unknown Duration:
        • Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals
    • Syphilis Tx – Possible Board Question
      • Jarisch-Herxheimer reaction  — During PCN therapy for syphilis, patients may develop an acute febrile reaction frequently accompanied by headache and myalgias within the first 24 hours of treatment
      • This reaction is most common among patients with early syphilis. Tx with Antipyretics
    • Chancroid (Haemophilus ducreyi)
      • H/P:
      • Common subtropics or immunocompromised
      • 2wk’s after contact small papule becomes PAIN ful ulcer with GRAYish base and FOUL odor
      • May also cause significant inguinal swelling
    • Chancroid (Haemophilus ducreyi)
    • Chancroid (Haemophilus ducreyi) -Tx
      • Azithromycin, 1 g PO in a single dose  
      • Ceftriaxone, 250 mg IM in a single dose  
      • Ciprofloxacin, 500 mg PO twice daily for 3 days  
      • Erythromycin, 500 mg PO 3 times daily for 7 days
    • Lymphogranuloma Venereum
      • Disease caused by L1, L2, or L3 serotypes of Chlamydia trachomatis
      • Common developing nations
      • H/P : Within 2 wk’s of contact malaise, HA, fever, formation of papule site that becomes pain LESS ulcer after a few days
      • After one month significant inguinal bubo's develop
      • Can progress to bubo ulceration, elephantiasis, fistula formation and abscess formation
    • Lymphogranuloma Venereum
    • Lymphogranuloma Venereum - Groove Sign
      • Striking tender lymphadenopathy is present at the femoral and inguinal lymph nodes separated by a groove made by the Poupart ligament (groove sign)
    • Groove Sign
    • Lymphogranuloma Venereum - Tx
      • Recommended: Doxycycline, 100 mg PO twice daily for 21 days
      • Alternative: Erythromycin, 500 mg PO 4 times daily for 21 days
        • or  Azithromycin, 1 g PO/week x 3 weeks
      • Sex partners in prior 30 days:
        • Doxycycline, 100 mg PO twice daily for 7 days
        • or Azithromycin, 1 g PO as a single dose
    • Grauloma Inguinale (Donovanosis)
      • Genital ulcerative disease caused by the intracellular G(-) Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis )
      • H/P: Papule on external genitalia forms several weeks after contact and rapidly becomes pain less ulcer with beefy red and irregular borders, mild lymphadenopathy may occur
    • Grauloma inguinale
    • Grauloma inguinale - Tx
      • First line: Doxycycline, 100 milligrams PO twice daily for at least 3 wk and until lesions completely healed
      • Alternative Tx:
        • Azithromycin, 1 gram PO every week for at least 3 wk and until lesions completely healed
        • Ciprofloxacin, 750 milligrams PO twice daily for at least 3 wk and until lesions completely healed
        • Erythromycin, 500 milligrams four times daily PO for at least 3 wk and until lesions completely healed
        • Trimethoprim/sulfamethoxazole DS, 1 tablet PO twice daily for at least 3 wk and until lesions completely healed
    • New D/C Hand Outs
    • Sources
      • Harwood-Nuss. Clinical Practice of Emergency Medicine . Philadelphia: Lippincott, 2005.
      • Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. McGraw Hill, 2010
      • Ryan KJ, Ray CG (2004). Sherris Medical Microbiology (4th ed.) . McGraw Hill, 2004
      • Sexually Transmitted Diseases (STDs). http://www.cdc.gov/std/general/
      • Van Kleunen. Step-up to USLME Step 2 (2nd Ed.) . Lippincott, 2008