Sexually Transmitted Diseases


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  • I just want everyone to know never to give up believing there is someone out there for you even though you have std! We are very happy with each other and that made it possible for us to find each other. Don't pass a good thing, you never know what it may evolve into.Good luck on your search and wish you the best:)
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  • Sexually Transmitted Diseases

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