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    Std Handout Std Handout Document Transcript

    • Sexually Transmitted Infections in Primary Care Eric Meininger, M.D. Community-University Health Care Center Page 1 of 4 Bacterial STDs Treatment Gonorrhea Preferred Alternates Cefixime 400mg po x1 (only available as liquid in US) or Ciprofloxacin 500mg po x1 Ceftriaxone 125 mg IM with lidocaine or Spectinomycin 2g IM for patients with cephalosporin or quinolone Avoid in pregnancy allergy or Levofloxacin 250mg po x 1 Increased resistance in MSM. CDC recommends use of alternative drug as of 2004 for MSM Also treat for chlamydia unless it has been ruled out by laboratory testing Chlamydia Preferred Alternates Doxycycline 100mg po bid x 7d or Azithromycin 1000mg po x1 Erythromycin base 500mg po qid x 7d Ureaplasma Urealyticum Preferred Alternates Doxycycline 100mg po bid x 7d or Erythromycin base 500mg po qid x 7d Trichomonas Preferred Alternates Metronidazole 2g po x 1 dose Metronidazole 500mg po bid x 7 days Treponema pallidum - Syphilis Treatment Followup Repeat serologies at 6, 12 and 24 months Benzathine penicillin 2.4 million units Retreat if Chancre present less than 1 year – single IM dose High titers (>1:32) fail to fall in 12-24 months or Unknown duration or tertiary symptoms – 3 doses IM 7-13 days apart Titers increase four-fold or Restart course of antibiotics if more than 14 days from last dose new symptoms develop Or, for non pregnant, penicillin allergic patients: Doxycycline 100mg po bid Chancre present less than 1 year – 2 weeks Unknown duration or tertiary symptoms – 4 weeks NSAIDS with first dose of antibiotics to prevent Jarisch-Herxheimer reaction Pelvic Inflammatory Disease Required Criterion (need one) Supporting Criterion Fever Uterine tenderness Elevated ESR Adnexal tenderness Elevated CRP Cervical motion tenderness Documented cervical infection with GC or Chlamydia Preferred Treatment Alternate Treatments Ofloxacin 400mg po bid or Levofloxacin 500mg po qd x 14d Ceftriaxone 250mg IM plus with or without Metronidazole 500mg po bid x 14d Doxycycline 100mg po bid x 14d with or without Metronidazole 500mg po bid x 14d Hospitalize when pregnant, acute abdomen cannot be ruled out, tubo-ovarian abscess, severe illness, or when there is no substantial improvement within 3 days of initiation of oral treatment. Recommend abstinence from intercourse until 7 days after treatment is initiated • Patients should be re-evaluated if symptoms persist or recur after completion of therapy • Partners should be referred for evaluation and treatment if sexual contact within the preceding 60 days and should be treated • empirically after collecting specimens, even if asymptomatic Ciprofloxacin contraindicated for pregnant and lactating women and persons <18 years • Safety of Azithromycin in pregnant and lactating women is not established, but it is commonly used • Twin Cities Adolescent Medicine Seminar – February 16, 2006
    • Sexually Transmitted Infections in Primary Care Eric Meininger, M.D. Community-University Health Care Center Page 2 of 4 Special Cases STD Pharyngitis Recommend treatment for both gonococcal and chlamydial infections Treatment failures should be evaluated by culture and sensitivities STD Conjunctivitis Consider gonococcal if history of recent STD Treat with Ceftriaxone 1g IM x1 dose and saline lavage infected eye. Disseminated Gonococcal infection Treat presumptively for concurrent chlamydia unless testing excludes this diagnosis Treat with Ceftriaxone 1g IM/IV q24 x 1-2 days then Cefixime 400mg po bid or Ciprofloxacin 500mg po bid to complete a week. Consider hospitalization if • Diagnosis is uncertain • Patient is not deemed reliable to comply with therapy • Clinical evidence of myocarditis or meningitis Painful testicle Treatment of epididymitis most likely caused by gonorrhea or chlamydia Ceftriaxone 250mg IM x1 and Doxycycline 100mg po bid x 10d or Ofloxacin 300mg po bid x 10d Scrotal elevation with jock strap Analgesics Followup Failure to improve within 3 days requires more extensive workup Exophytic STDs (vaccine currently being tested) Genital Warts (Condyloma accuminatum) Human Papilloma Virus Treatment Followup Podofilox 0.5% solution or gel May need multiple treatments until warts are cleared May be applied by patient x 3d followed by 4d of no therapy Regular cytologic screening for women (PAP and colposcopy) up to 4 cycles antimitotic (unknown safety in pregnancy) Podophyllin resin 10-25% Hurts 12 hours later x 2-3 days (unknown safety in pregnancy) Trichloroacetic acid 80-90% Hurts immediately x 5 minutes. Can repeat weekly 5% Florouricil Can burn normal skin Imiquimod 5% cream May be applied by patient qhs 3x week up to 16 weeks Wash area 6-10h after application Immune enhancer (unknown safety in pregnancy) Cryotherapy Surgical excision Twin Cities Adolescent Medicine Seminar – February 16, 2006
    • Sexually Transmitted Infections in Primary Care Eric Meininger, M.D. Community-University Health Care Center Page 3 of 4 Genital Ulcer Disease (vaccine currently being tested) Herpes Type Treatment Acyclovir 200mg po 5x day or 400mg po tid x 7-10 days or Primary Famciclovir 250mg po tid x 7-10d or Valacyclovir 1g po bid x 7-10d Topical therapy substantially less effective and not recommended Treatment may be extended if healing is incomplete after 10d Acyclovir 200mg po 5x day or 400mg po tid or 800mg po bid x 5d or Recurrent Famciclovir 125mg po bid x 5d or Valacyclovir 500mg po bid or 1 g po qd x 5d Have drug at home and begin at first symptom Acyclovir 400mg po bid x 1 year or Suppressive Therapy Documented safe & efficacious up to 6 years After more than 6 recurrences in 1 year Famciclovir 250mg po bid x 1 year or Valacyclovir 500mg po qd or 1 g po qd x 1 year For more than 10 recurrences / year, 1000mg po qd is more effective Discuss discontinuing prophylaxis after one year because frequency of recurrences decreases over time Suppressive therapy reduces but does not eliminate asymptomatic viral shedding Syphilis – Treponema pallidum See bacterial STDs Chancroid - Haemophilus ducreyi Treatment Azithromycin 1g po x 1 or Ceftriaxone 250 mg IM x 1 or Ciprofloxacin 500 mg po bid x 3 d or some resistance worldwide Erythromycin base 500 mg po qid x 7d some resistance worldwide Granuloma inguinale (Donovanosis Treatment Followup Trimethoprim Sulfamethoxazole DS po bid x 21 d or Follow clinically until all signs and symptoms have resolved Doxycycline 100mg po bid x 21 d Continue treatment until all lesions have healed completely Lymphogranuloma venereum Increased number of cases reported in Netherlands amongst MSM in Invasive Chlamydia Trachomatis serovars L1, L2, L3 2004. Treatment Followup Doxycycline 100mg po bid x 21 d or Follow clinically until all signs and symptoms have resolved Erythromycin base 500 mg po qid x 21 d Partners should be examined and tested for urethral or cervical chlamydia. Treat partners regardless if they have had sexual contact within 30 days preceding onset of symptoms in patient Reference: Centers for Disease Control and Prevention. “Sexually transmitted diseases treatment guidelines 2002.” Morbidity and Mortality Weekly Report 2002; 51(No. RR-6). Available online at http://www.cdc.gov/std/treatment/ Twin Cities Adolescent Medicine Seminar – February 16, 2006
    • Sexually Transmitted Infections in Primary Care Eric Meininger, M.D. Community-University Health Care Center Page 4 of 4 Vaginitis Treatment Diagnosis Cause KOH Prep Wet Prep Discharge Odor Butoconazole 2% cream (OTC) 5g intravaginally qhs x 3d or Yeast Candida Budding yeast, Creamy, curd-like, white Musty pseudohyphae Butoconazole 2% cream sustained release 5g intravaginally qhs x 1 or Clotrimazole 1% cream (OTC) 5g intravaginally qhs x 7 – 14 d or Clotrimazole vaginal tablet 100mg 2 tablets intravaginally qhs x 3d or Clotrimazole vaginal tablet 500mg 1 tablet intravaginally qhs x 1 or Miconazole 2% cream 5g intravaginally qhs x 7d or Miconazole vaginal suppository 200mg intravaginally x 3d or 100mg intravaginally x 7d or Fluconazole 150mg po x 1 dose Concern for developing resistance plus potential for toxicity plus many others . . . Torulopsis Long yeast, no buds Donʼt treat on culture unless symptomatic Trichomonas Unicellular flagellated Frothy, carbonated, white to Foul smelling Metronidazole 2g po x 1 dose protozoan (moving), yellow-green, malodorous many WBC with vulvar irritation Metronidazole 500mg po bid x 7d or Bacterial Vaginosis Clue cells (epithelial Gray-white, thin discharge Fishy Gardnerella plus cells coated with smoothly coats vaginal Clindamycin 2% cream intravaginally qhs x 7d or anaerobic species bacteria) walls, +whiff test, pH >4.5 Metronidazole 0.75% gel intravaginally bid x 7d or Metronidazole 2g po x 1 dose Lower efficacy Better for compliance Foreign body Foul smelling Remove foreign body, treat for presumptive PID Physiologic Clear, mucoid discharge No odor Caution! Creams and suppositories are oil based and may weaken latex condoms and diaphragms Vaccine Preventable STDs Type Treatment Vaccine recommended for sexually active adolescent and adult males who have sex Hepatitis A with males and illegal drug uses (injection and non-injection) Now required for school in Minnesota Hepatitis B Routine immunization Combined Hepatitis A & B vaccine available for adults on 0, 1, 6 month schedule Reference: Centers for Disease Control and Prevention. “Sexually transmitted diseases treatment guidelines 2002.” Morbidity and Mortality Weekly Report 2002; 51(No. RR-6). Available online at http://www.cdc.gov/std/treatment/ Twin Cities Adolescent Medicine Seminar – February 16, 2006