2. • Chancroid
• Chlamydia trachomatis, genital site
• Gonorrhea (include susceptibility profile)
• (URGENT) Acute Hepatitis (A-E)
• Chronic Hepatitis (B-D)
• Hepatitis B Surface Antigen + with each pregnancy
• HIV and AIDS Clinical Diagnosis and positive test results*
• Lymphogranuloma Venereum
• (URGENT) Syphilis (congenital, primary, secondary,
latent, tertiary, positive test
3. • The US ranks first among developed nations in the rate
of STI’s
• In addition to teen pregnancies
• 24% of adolescent females (14-19) have lab evidence of
at least 1/5 STI’s
• HPV (18%)
• Chlamydia (4%)
• Trichomonas (3%)
• HSV 2 (2%)
• Gonorrhea
• Repeated STI infection is a recognized risk factor for
development of HIV infection
• 3X higher in students with h/o multiple gonorrhea infections vs. no
infections
4. • FACT: 19 million new infections occur every year in the US
• FACT: STI’s cost the US HealthCare System $17 billion yearly
• FACT: Untreated STI’s cause 24,000 women in the US to
become infertile yearly
• FACT: While young people only represent 25% of the sexually
experienced population in the US, they account for almost
50% of newly diagnosed STI infections
• FACT: ~20% of adolescents fail to fill Rx for STI treatment
5. Risk Factors
• Behavioral
• Time elapsed since first
intercourse
• Multiple or new partners
• Inconsistent use of condoms
• Alcohol/drug use*
• Biologic
• Cervical ectopy/immaturity
• Low levels of sIgA
Unique Issues
• Self-consent for Dx and
Tx
• Concerns about privacy
and confidentiality
• Pregnancy/fear of
pregnancy
• Self-treatment
• Preference to notify
partners themselves
6. • Approach where partners who test positive for certain
STI’s are given RX without previous medical evaluation
• Recommended use from CDC since 2006
• Previously recommended for Gonorrhea and Chlamydia;
however Gonorrhea recs have changed
• Difficult to give due to new recommendations for ceftriaxone
injection only!
• EPT is permissible in SC and NC
• Visit www.cdc.gov/std/ept/legal/default.htm
8. • Chlamydia is the most common bacterial STI in men and
women
• Cervicitis (not vaginitis) with menometrorrhagia
• Dysuria-Pyuria Syndrome
• PID
• Perihepatitis
• Proctitis
• Men: See Urethritis, Prostatitis, Proctitis, Epididymitis, Reactive
Arthritis (1%)
• Gonorrhea
• Similar to above, but also can see higher incidence of pharyngitis
(1-12%)
• While mucoprulent discharge common, asymptomatic cases also
occur (50% in women vs 10-15% in men)
9. • Gonorrhea:
• Ceftriaxone 250mg IM x 1 PLUS Azithromycin 1g po x 1 OR
Doxycycline 100mg po BID x 7 days
• Other:
• ceftizoxime 500 mg intramuscularly/ cefotaxime 500 mg
intramuscularly/cefoxitin 2 g intramuscularly PLUS Azithro or Doxy
• Oral Cefixime 400mg x 1 dose PLUS Azithro OR Doxy
• Azithromycin Monotherapy with 2g x 1 dose
• Chlamydia:
• Azithromycin 1g po x 1 dose
• Doxycycline 100mg po BID x 7 days
• Other:
• Ofloxacin 300 mg orally twice daily for seven days
• Levofloxacin 500 mg orally once daily for seven days
• Erythromycin/PCN if pregnant and intolerant to Azithro
10. • “Rescreen all adolescents infected with chlamydia or
gonorrhea 3 months after treatment, regardless of
whether they believe that their sex partners were
treated.”
11. • Bacterial Vaginosis:
• Most common cause of vaginal discharge in women of
childbearing age (40-50%); abnormal alteration of vaginal flora
• Tx: Metronidazole 500mg po BID x 7 days OR Metronidazole
Gel 0.75% qday x 5 days OR Clindamycin 2% cream qhs x 7
days
• Other
• Clindamycin 300mg po x 7 days; Clindamycin Ovule;
Tinidazole
• Candidiasis:
• Common in healthy reproductive age women; less likely sexual
transmission; often clinical diagnosis
• Tx: Recommended: Fluconazole 150mg po x 1 dose or if
severe/complicated, 150mg po every 72h x 2-3 doses.
12. • Causes Non-Gonococcal Urethritis in men and emerging
cause of cervicitis and PID in women
• 15-25% of cases of NGU in men
• 18-46% of cases of NCNGU in men
• Role in women not fully established
• Co-infections with other STI-causing organisms is highly
reported
• Clinical:
• Men: usually symptomatic (as high as 70%) with discharge, balantitis,
or posthitis
• Women: usually asymptomatic or occur with symptoms of PID
• Treatment:
• Empiric: Azithromycin OR Doxycycline
• Targeted: Same as above; Moxifloxicin if persistent
infection/symptoms
13. • An 18-year-old woman has a 3-day history of fever, headache,
and painful sores in the genital area. The patient has no
previous history of genital lesions. Medical history is
unremarkable, and her only medication is an oral
contraceptive agent. She does not use condoms. On physical
examination, temperature is 38.1 °C (100.6 °F); other vital
signs are normal. There are no signs of meningismus. Tender
ulcerative lesions with a yellow crusted roof cover the labia
bilaterally and the vaginal introitus.
• A.) Chancroid
• B.) Genital Herpes Simplex Virus Infection
• C.) Primary Syphilis
• D.) Vulvovaginal Candidiasis
14. • An 18-year-old woman has a 3-day history of fever, headache,
and painful sores in the genital area. The patient has no
previous history of genital lesions. Medical history is
unremarkable, and her only medication is an oral
contraceptive agent. She does not use condoms. On physical
examination, temperature is 38.1 °C (100.6 °F); other vital
signs are normal. There are no signs of meningismus. Tender
ulcerative lesions with a yellow crusted roof cover the labia
bilaterally and the vaginal introitus.
• A.) Chancroid
• B.) Genital Herpes Simplex Virus Infection
• C.) Primary Syphilis
• D.) Vulvovaginal Candidiasis
15. • Belongs to the Genital Ulcer Syndromes
• HSV, T. pallidum, and H. ducreyi
• HSV2 is predominant, with increasing HSV1
genital occurrence in females
• Lesions begin as vesicles, which then rupture to
form painful ulcers
• Usually occurring as clusters
• Occurs as a Primary Outbreak, Recurrent
Outbreak, and Latent Infection
• Primary outbreak last 2-3 weeks and often associated
with systemic symptoms (fever, malaise, dysuria)
• Recurrent Outbreaks usually are shorter, 7-12 days
• HSV has a high infectivity and high recurrence
rate
• Infectivity 75-80% with active infection
• HSV1 Recurrence: 60%; HSV2 Recurrence: 90%
16. • Treatment differs based on type of infection
• Primary:
• Acyclovir 400mg po TID or 200mg po 5x/d x
7-10 days
• Famciclovir 250mg TID x 7-10 days
• Valacyclovir 1g BID x 7-10 days
• Recurrent:
• Acyclovir 800mg TID x 2 days or BID x 5
days
• Famciclovir 1g BID x 1 day or 125mg BID x 5
days
• Valacyclovir 500mg BID x 3 days
• Suppression:
• Valacyclovir 1g po qday (can be 500mg daily
if <9 recurrences/year)
• 500mg BID if immunoompromised
17.
18. • After incubation, a
ulcerating, painless
papule occurs at site of
inoculation; heal 3-6
weeks later
• Usually singular, but
can be multiple in
setting of HIV
• Associated with regional
mild-moderate bilateral
LAN
• Secondary Syphilis can
occur weeks to months
later
19. • Primary, Secondary,
or Latent <1 year
• PCN G Benzathine 2.4
million units IM x 1
• Doxycycline 100mg po
BID x 7 days
• Jarish-Herxheimer
Reaction
• Acute febrile reaction
with HA and myalgias in
first 24 hours of
treatment
20. • Chancroid
• Haemophilus ducreyi, very uncommon in the US
• Papule pustule PAINFUL ulcers with fluctuant buboes (lymph
nodes can spontaneously rupture)
• Tx: Azithromycin 1g po x 1 OR Ceftriaxone 250mg IM x 1
• Lymphogranuloma Venereum
• L1, L2, and L3 serovars of Chlamydia; tropical and subtropical areas
of the world
• Spontaneously healing PAINLESS genital ulcer extension to
regional lymph nodes (groove sign) fibrosis and stricture of
anogenital tract
• Tx: Doxycycline 100mg po BID x 21 days OR
Erythromycin/Azithromycin
• Granuloma Inguinale (Donovanosis)
• Uncommon, caused by Klebsiella granulomatis (PAINLESS
ULCER[S])
• Tx: Doxycycline, Azithromycin, Cipro, Erythromycin, or Bactrim x
21.
22. • Acute infection of the upper genital tract of women
• Chlamydia, Gonorrhea, or Vaginal Flora organisms (Anaerobes and
GNR)
• RF for subsequent ectopic pregnancy and infertility
• Clinical Diagnosis of PID is often imprecise; need evaluation of
risk factors
• Lower Quadrant Abdominal Pain, acute in nature
• Abnormal uterine bleeding (1/3 of patients)
• New onset discharge, urethritis, Proctitis, fever (non-specific)
• Empiric Treatment often initiated if 1 out of three clinical
findings present (in the setting of abdominal pain):
• Cervical Motion Tenderness
• Uterine Tenderness
• Adnexal Tenderness
23. Indications for
Hospitalization
• Pregnancy
• Nonresponse/tolerance to po
medications
• Noncompliance
• Inability to take oral
medications
• Severe clinical illness (high
fever, nausea, vomiting, severe
abdominal pain)
• Complicated PID with pelvic
abscess
• Possible need for surgical
intervention or diagnostic
exploration for alternative
etiology (e.g., appendicitis)
Outpatient vs Inpatient
• Outpatient:
• Ceftriaxone 250mg IM x 1
PLUS Doxy 100mg po BID x
14 days
• Cefoxitin 2mg IM with
Probenecid 1g po x 1 PLUS
Doxy 100mg po BID x 14 days
• Inpatient:
• Cefoxitin (2g IV q6) OR
Cefotetan (2g IV q12) PLUS
Doxy100mg po q12
• Clindamycin 900mg IV q8
PLUS Gentamicin (Load:
2mg/kg; Maint: 1.5mg/kg q8)
24. • Condyloma Accuminata, caused by Human Papilloma Virus
• >70 different subtypes; High risk associated with cancers (16, 18) and low risk
associated with genital warts (6, 11)
• Incubation is 3w-8m and most infections are cleared within 2 years
• Risk Factors
• Sexual activity (more partners increases the risk in Men and Women)
• Concomitant/history of recurrent STI’s
• Individuals who are HIV positive
• Clinical
• Ranges from asymptomatic (M and F) to problematic, depending on the size
of warts
• Can see Pruritus, pain, bleeding, tenderness, or vaginal discharge
• Differential Diagnosis
• Condyloma Lata
• Micropapillomatosis
• Pearly Penile Papules
• Squamous Cell Carcinoma
25. • Multiple Modalities of Treatment
• Spontaneous Remission (20-30% of cases)
• Chemical Agents
• Podophyllin: Teratogenic, risk of chemical burns
• Trichloroacetic Acid: can be used internally, but highly caustic
• 5-Fluorouracil Epinephrine Gel: Injected Intralesionally
• Immune Modulation
• Imiquimod: Complete clearance rates of 40-70% with few
recurrence
• Interferon Alfa: side effects of interferon
• Sinecatechins: botanical
• Surgery
• Cryotherapy, Laser, Excisional
• HPV Vaccination: highly effective
26.
27.
28. • 0.5-3% of those infected with Nisseria gonorrheae (M>F 3X)
• Certain Risk Factors Exist
• Recent menstruation, Pregnancy/immediate post-partum,
complement deficiencies, or SLE
• Clinical Findings:
• Triad: Tenosynovitis, dermatitis, polyarthralgias without purulent
arthritis
• Acute Fever, chills, malaise is heralding
• Lesions often painless, pustular or vesiculopustular
• Purulent arthritis without skin lesions
• Asymmetric, usually knees/wrists/ankles
• Treatment:
• Ceftriaxone 1g q24 hours initially PLUS Azithromycin 1g po x 1 OR
Doxycycline 100mg po BID x 7 days
• Duration: 7-14 days; step down therapy controversial
29.
30. • Crab Louse, transmitted through sex or sometimes
Fomites
• Clinical:
• Itching
• Maculae Cerulae: pale blue macules (0.5-1cm) from the
anticoagulant present in saliva of parasite, prolonged infestation
• Sometimes LAN
• Treatment:
• Permethrin 1% cream applied and washed off after 10 minutes
• Pyrethrins with piperonyl butoxide, same as above
• Alternative
• Malathion 0.5% lotion applied and washed off after 8-12 hours
• Ivermectin 250mcg/kg orally x 1, repeated in 1-2 weeks
• Lindane not recommended
31.
32. • Test: HIV Ag/Ab Combo
• CDC Recommendations:
• Opt-Out HIV testing for all patients 13-64 years old
• AAP Recommendations:
• Routine HIV testing to be offered at least once to all adolescents
(despite report of sexual activity) by 16-18yo in clinic settings
where HIV prevalence is >0.1%
• Prevalence <0.1%: HIV testing for all sexually active adolescents
and those with other risk factors
Editor's Notes
*and many labs related to the HIV diagnosis, such as CD4 results, subtype/genotype/phenotype, viral load, receptor assays
-Gonorrhea acquisition decreased slightly among adolescent females in 2011-2012
-In an observational study in adolescent females, ~25% were diagnosed with an STD within 1 year of first intercourse, particularly for HPV
-Inconsistent condom use particularly a concern when partners become established
-Alcohol/drugs may not be an independent risk factor, as this can track with poor contraceptive use or multiple partners
-2011 Youth Risk Behavior Survey (high school students): 47% ever had intercourse, 34% currently sexually active, 15% intercourse with >4 partners in lifetime, 60% reported condom use at last intercourse
-Columnar Epithelium is thought to be more susceptible than squamous epithelium to STI organisms
-Adolescent females with slightly lower IgA levels than adult women in one small study
-Self treatment reported by as much as 25% of adolescents with STD’s. Topical meds, Abx, or douching. Take about females 10 days on avg to seek care vs 6 days for males
-Not all genital ulcers are STI’s; Non-sexually transmitted ulcers (Lipschutz Ulcers, Virginal Ulcers, Aphthous Ulcers) can be seen with vital illness, Bechet’s disease, Crohn’s Disease, or other Vasculidities
Pharyngitis depends on women vs men, and if MSM; can also be colonization
-Menometrorrhagia: prolonged/excessive uterine bleeding occurring irregularly and with increased frequency
-Cervicitis: inflammation of the cervix
-Vaginitis: inflammation of the vagina (more associated with Candidiasis, Trichomonas, and BV)
-Strawberry Cervix with Trichomonas from capillary dilatation, not cervicitis
-Coinfection of Gonorrhea with Chlamydia as high as 46% in men and women
-Note: increased resistance to Doxycycline reserves its use for only Azithro-intolerant patients
-Test of Cure (Gonorrhea) needed ~1 week after treatment if Azithro monotherapy or Oral cephalosporin therapy used; Chlamydia only needs TOC if pregnant or has persistent symptoms.
-With Chlamydia and signs of Proctitis or Epididymitis, also treat for Gonorrhea; Pharyngeal suspicion needs a positive culture
Providers should consider rescreening females previously diagnosed with trichomoniasis 3 months after treatment. If retesting at 3 months is not possible, retest whenever patients next present for health care services in the 12 months after initial treatment.
BV: reduction in lactobacillus (H2O2 producing prevents bacterial overgrowth), The major bacteria detected are Gardnerella vaginalis (normal flora) and detection is increased in sexually active young women
-Sex activity is a risk factor for BV, and most believe it does not occur in those who have never had sex
-Condoms and estrogen-containing contraceptives appear to be protective
-Thin fishy discharge, 50-75% asymptomatic
Candida: Recurrent Infection is 4 or more times in 1 year, culture needs to be obtained; can be seen in HIV but not an indication for screening
-10-20% of women are asymptomatic and don’t need treatment
-Many treatments available
-Other causes of Vaginitis: Peptostreptococcus, Bacteroides
-can also see causing persistent/recurring cases of urethritis in men
-Dx only through NAAT (not widespread available)
Chancroid: Haemophilus ducreyi. Painful ulcer with irregular borders. Epidemics associated with prostitution and drug use. More in underdeveloped countries.
-Primary infection is most often symptomatic, but can be asymptomatic in some patients
-Viral culture of the lesion is diagnostic test of choice; serum PCR studies are also available.
-Triggers of recurrent infections can include fever, menstruation, stress, or friction
-Aim to start treatment within 72 hours of the lesion occurrence to decrease duration and potential for complications
Side Effects: GI symptoms, HA with acyclovir/Valtrex
Other Suppression: Acyclovir 400mg po BID, Famciclovir 250mg BID
-High Risk Populations: Sex Workers, Cocaine Users, and MSM
-Secondary Syphilis: may no be associated with a primary chancre, constellation of symptoms including palmar/sole rash, fever/malaise/HA/sore throat, LAN (post cervical, axillary, inguinal, and femoral regions), “moth eaten” alopecia, hepatitis, GI/MSK/Renal abnormalities, neurosyphilis
-LGV has a high association with HIV infection
Factors that potentially facilitate PID include:
Previous episode of PID
Sex during menses
Vaginal douching
Bacterial Vaginosis
Intrauterine device
The most specific criteria for diagnosing PID include:
endometrial biopsy with histopathologic evidence of endometritis;
transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia); or
laparoscopic abnormalities consistent with PID.
Lab tests: Pregnancy Test, CBC, Vaginal discharge GS and micro, GC/Chlamydia, U/A, CRP, HIV, Hepatitis B profile, RPR
Alternative IP: Unasyn + Doxy, Azithro only, Azithro + Flagyl, Azithro + beta lactam
Alternative OP: use recommended with or without flagyl, can use azithromycin instead of Doxy
-Duration is usually 14 days
-Probenecid is synergistic with Cefoxitin, improves efficacy
-Can also be transmitted by fomites, but this is not the predominate mode of transmission
Other: Topical Cidofovir, Bacillus Calmette-Guerin, Infrared Coagulation
Overall recurrence rates of 30-70% within 6 months, depending on the form used
-Imiquimod can not be used internally
-Overlap exists between the two stages
-Some suggest step down to cefixime, Cipro, Amox, or Doxy to finish course (only if sensitivities have been established)
-If recurrent episodes, screen for complement deficiency
-No resistance has been seen or noted in past, sexual contacts need to be treated, household contacts who are asymptomatic do not need to be treated.
-Permethrin = Elimite, Acticin, NIX
-Pyrethrins = RID, Pronto, Licide
-Malathion = Ovide
-Ivermectin = Sklice
-Lindane = associated with hypersensitivity, neurologic toxicity, not a first choice agent
-Opt-Out: informing the patient, orally or in writing, that HIV testing will be performed unless he/she declines
-Annual HIV testing for high risk adolescents (IV Drug Use, Sex for Money, Multiple Partners, MSM)
-Testing for other STD’s = test for HIV