management of sexually transmitted diseases

1. SEXUALLY TRANSMITTED
DISEASES: APPLIED
THERAPEUTICS
BY- DR UTSAV
SHINGHAL
JR-II
PHARMACOLOGY

2. REFERENCES
• Goad JA, Hess KM, Bech AT. Sexually
Transmitted Diseases. In: Zeind CS, Carvalho
MG, ed. Applied Therapeutics : The Clinical Use
of Drugs. 11th ed. Philadelphia: Wolters Kluwer
Health; 2018:1505-33.
• CDC Official Webpage on STD treatment
guidelines 2021. Accessed on May 19th 2022.
https://www.cdc.gov/std/treatment-
guidelines/STI-Guidelines-2021.pdf

3. • Rashid RM, Janjua SA, Khachemoune A.
Granuloma inguinale: A case report. Dermatology
online journal, 2006; 12(7). doi:10.5070/D387q57161
• Samies N, James SH. Prevention and treatment
of neonatal herpes simplex virus infection.
Antiviral Res, 2020 Apr; 176:104721.
doi: 10.1016/j.antiviral.2020.104721

4. • American Academy of Dermatology Webpage on
Genital Herpes.
https://www.aad.org/public/diseases/a-z/genital-
herpes-symptoms.
Accessed on May 22nd 2022.
• Syphilis-CDC Fact Sheet.
https://www.cdc.gov/std/syphilis/stdfact-
syphilis.htm
Accessed on May 22nd 2022.

5. OUTLINE
• Chancroid
• Donovanosis
• Lymphogranuloma venerum
• Syphilis
• Genital herpes
• Gonorrhea
With clinical
cases

6. DISEASES CHARACTERIZED BY GENITAL
ULCERS

7. Chancroid Granuloma
inguinale
(Donovanosis)
Lymphogranulom
a venerum
Incubation period
(time interval
between sexual
exposure and
onset of
symptoms)
3-10 days 2 weeks- 6
months
3-30 days
Causative agent Haemophilus
ducreyi
Klebsiella
granulomatis
(formerly known as
Calymmatobacteri
um
granulomatosis)
Chlamydia
trachomatis
Clinical
presentation
≥1 painful
genital ulcers
with tender
suppurative
inguinal
lymphadenopat
hy
Painless slowly
progressive
genital ulcers
without regional
lymphadenopath
y
Stage 1: A painless shallow
genital ulcer which heals
rapidly and leaves no scar;
often goes unnoticed by the
individual
Stage 2: Manifests as inguinal
syndrome (acutely painful,
tender, suppurative, unilateral
inguinal/ femoral
lymphadenopathy) or
anogenitorectal syndrome
(proctocolitis with symptoms
of anal pain, constipation,
tenesmus,
mucopurulent/bloody rectal
discharge; and hyperplasia of
intestinal and perirectal
lymphatic tissue). Both
syndromes are accompanied
by fever, chills, malaise,
myalgia, arthralgia, anorexia.
Treatmen
t
Ceftriaxone 250 mg IM
single dose or
Azithromycin 1 gm oral
single dose or
Ciprofloxacin 500 mg 2
times/day for 3 days or
Erythromycin 500 mg 3
times/day for 7 days.
Recommended regimen:
Azithromycin 1 gm orally
once a week or 500 mg
daily for ≥21 days and
until all lesions have
completely healed.
Alternative regimens:
Erythromycin 500 mg 4
times/day or
Doxycycline 100 mg 2
times/day or
Trimethoprim-
Sulfamethoxazole 160/800
mg tablet 2 times/day.
Any of the above 3 for
≥21 days and until all
lesions have completely
healed.
Recommended
regimen:
Doxycycline 100 mg
2 times/day for 21
days
Alternative
regimens:
Azithromycin 1 gm
orally once a week
for 21 days or
Erythromycin 500
mg 4 times/day for
21 days

8. Case: A.D., a 31 year old uncircumcised
sexually active male, presents to the STD
clinic with complains of tender lesions on
the penis and inguinal regions. He noticed
the penile lesions on the external surface
of the prepuce 2 days before his visit. The
ulcer was covered with yellowish-gray
purulent exudate. Right inguinal
lymphadenitis was present and extremely
painful on palpation. What will be your
provisional diagnosis? How will you treat
the patient?

9. CASE : S.K., a 48-year-old sexually active man presented with 3-
month history of a few painless ulcerated lesions on the penis,
pubic area, and scrotum. The patient reported painless nodules
that slowly evolved to red ulcerated lesions over 1 month. There
was a history of unprotected intercourse with a CSW about 2
months prior to the eruption. Physical examination revealed
multiple beefy-red nontender round ulcers of various sizes on
the shaft of the penis, the pubic area, and the scrotum. The
ulcers had clean bases. Inguinal lymph nodes were not
palpable. The man was circumcised but he had a below-
average-to-poor standard of hygiene. What will be your
provisional diagnosis? How will you treat the patient?

11. CASE: A.K., a 32 year old male who reports of having
unprotected sex, presents to the STD clinic with chief
complaints of pain and swelling in the groin. He reports the
appearance of a small ulcer on his penis about 2 weeks ago,
which resolved rapidly on its own. On examination he has
bubo with surrounding erythema on his right side. He also
has fever, myalgia, anorexia and arthralgia. What will be
your provisional diagnosis? How will you treat the patient?

12. SYPHILIS
CLINICAL COURSE WITH TREATMENT:
Primary stage:
• A primary lesion develops 3 weeks after
exposure in the form of painless papule which
subsequently becomes ulcerated and indurated.
• Regardless of whether patient receives the
treatment, the primary chancre heals
spontaneously in 3-6 weeks.
• Regional lymph nodes are enlarged and non-
tender.
• Treatment: Benzathine penicillin G 2.4 million

13. Second stage:
• Skin rash mark the second stage of syphilis.
• Macular lesions, round-oval in shape and rose-
pink in color, appear on trunk.
• As lesions mature, become papular and nodular
with scaling (papulosquamous rash).
• Palms and soles are characteristically involved.
• Condyloma lata, greyish lesions develop in the
warm and moist regions like perineum, are the
most infectious lesions.

14. • The other symptoms which may be present in
second stage are generalized lymphadenopathy,
sore throat, patchy hair loss, fever, fatigue,
weight loss, headache, myalgia.
• The symptoms of second stage also go away
regardless of whether patient receives the
treatment.
• Treatment: Benzathine penicillin G 2.4 million
units IM single dose.

15. Latent stage:
• In this stage no visible signs and symptoms of
disease are present.
Early latent
syphilis:
When infection
was acquired
within last 12
months.
Treatment:
Benzathine
penicillin G 2.4
million units IM
single dose.
Late latent syphilis:
When infection was
acquired more
than12 months ago.
Latent syphilis of
unknown duration:
When there is no
enough evidence
to confirm that
infection was
acquired within
last 12 months.
Treatment: Benzathine penicillin G 7.2 million
units total, administered as 3 doses of 2.4
million units IM at 1-weekly intervals.

16. Alternative therapy for patients with
primary/secondary/ early latent syphilis are:
• Doxycycline 100 mg 2 times/day for 14 days or
• Tetracycline 500 mg 4 times/day for 14 days or
• Ceftriaxone 1 gm IM/IV once daily for 10 days.
Alternative therapy for patients with late latent
syphilis/ latent syphilis of unknown duration are:
• Doxycycline 100 mg 2 times/day for 28 days or
• Tetracycline 500 mg 4 times/day for 28 days or

17. Tertiary syphilis:
• Occurs in a subset of untreated patients after 10-
30 years of initial infection.
• It may affect multiple organ systems (like brain
neuro-syphilis, heart, liver, eyes ocular
syphilis, ears otosyphilis, neurons, blood
vessels, bones, joints) and can be fatal.
• Treatment for tertiary syphilis except
neurosyphilis/ocular syphilis/otosyphilis is:
Benzathine penicillin G 7.2 million units total,
administered as 3 doses of 2.4 million units IM at
1-weekly intervals.

18. Neurosyphilis
Early neurosyphilis Late neurosyphilis
# Syphilitic meningitis # Meningovascular
syphilis
hemiplegia/hemiparesis
aphasia
seizures
# General paresis
P: Personality
disturbances
A: Affect disorders
R: ReflexesHyperactive
E: EyesArgyll Robertson
pupil
S: Altered Sensorium
I: Intellectual disturabnces
# Tabes dorsalis
Wide-based gait/Foot-
slap gait
bladder disturbances
impotence
paresthesias

19. Otosyphilis presents with tinnitus, dizziness,
vertigo, hearing loss.
Ocular syphilis presents with red eye, ocular pain,
sensitivity to light, blurred vision, floaters (floating
spots in field of vision), even blindness may occur.

20. Treatment for neurosyphilis/ocular
syphilis/otosyphilis is:
Recommended regimen:
Aqueous crystalline penicillin G 18-24 million
units/day, administered as 3-4 million units IV
every 4 hours or by continuous infusion for 10-14
days.
Alternative regimen:
Procaine penicillin G 2.4 million units IM once daily
with
Probenecid 500 mg orally 4 times/day for 10-14
days.
In patients with penicillin allergy:

21. Congenital syphilis
Confirmed/Proven/Highly
probable congenital
syphilis:
Aqueous crystalline
penicillin G 1-1.5 lakh
units/kg body
weight/day, administered
as 50000 units/kg body
weight every 12 hours for
first 7 days and every 8
hours thereafter for total
duration of 10 days. OR
Procaine penicillin G
50000 units/kg body
weight IM once daily for
10 days
Possible congenital syphilis:
Aqueous crystalline penicillin
G 1-1.5 lakh units/kg body
weight/day, administered as
50000 units/kg body weight
every 12 hours for first 7
days and every 8 hours
thereafter for total duration
of 10 days. OR
Procaine penicillin G 50000
units/kg body weight IM
once daily for 10 days OR
Benzathine penicillin G
50000 units/kg bogy weight
IM single dose
Congenital
syphilis less
likely:
Benzathine
penicillin G
50000 units/kg
bogy weight IM
single dose
Congenital syphilis
unlikely:
Treatment not
needed.

22. CASE: D.M., a 27-year-old sexually active man,
presents to the STD clinic with complaints of
malaise, headache, and fever of 4 days duration. He
also reveals that he had a sore on his penis about 8
weeks ago, but it has since resolved. Upon
examination, he is afebrile and has a widespread
maculopapular skin rash that involves the soles of
his feet; general lymphadenopathy also is
appreciated. What is your provisional diagnosis and
how will you treat the patient?

23. GENITAL HERPES
• Caused by Herpes Simplex virus (HSV).
HSV-1 HSV-2
Herpes labialis (Gingivostomatitis) Genital herpes
Herpes keratitis
Herpes encephalitis
Genital herpes
2
serotypes

24. • Up to 50% of all reported primary genital herpes cases
are caused by HSV-1.
• Most cases of recurrent genital herpes are caused by
HSV-2.
Clinical course:
• Symptoms start about a week after initial exposure.
• Prodromal stage: flu-like symptoms, and pain, itching,
tingling and burning sensation in the genitals.
• Followed by the appearance of numerous vesicles in the
genital area which break open leaving painful ulcers and
tender inguinal lymphadenopathy.

25. Recommended regimens for the treatment of first
episode of genital herpes:
• Acyclovir 400 mg orally 3 times/day for 7-10
days or
• Famciclovir 250 mg orally 3 times/day for 7-10
days or
• Valacyclovir 1 gm orally 2 times/day for 7-10
days.

26. Suppressive therapy for recurrent genital herpes:
• Reduces the frequency of recurrences by 70-80%.
• In addition, it also reduces the risk of HSV-2
transmission by decreasing asymptomatic viral
shedding.
Recommended suppressive regimens:
• Acyclovir 400 mg orally 2 times/day or
• Famciclovir 250 mg orally 2 times/day or
• Valacyclovir 1 gm orally once a day or
• Valacyclovir 500 mg orally once a day.
Valacyclovir 500 mg OD is less effective than other
regimens for patients who have frequent recurrences
(≥10 recurrences/year).

27. Episodic therapy for recurrent genital herpes:
• Reduces the duration of lesions.
• Most effective if initiated within 1 day of onset of
lesions or during the prodrome.
Recommended regimens for episodic therapy:
• Acyclovir 800 mg orally 2 times/day for 5 days or
• Acyclovir 800 mg orally 3 times/day for 2 days or
• Famciclovir 1 gm orally 2 times/day for 1 day or
• Famciclovir 500 mg orally once followed by 250
mg orally 2 times/day for 2 days or
• Famciclovir 125 mg orally 2 times/day for 5 days
or
• Valacyclovir 1 gm orally once a day for 5 days or
• Valacyclovir 500 mg 2 times/day for 3 days.

28. Severe disease:
• IV acyclovir therapy (5-10 mg/kg body
weight/dose, 8 hourly) should be given to
persons with disseminated disease, hepatitis,
pneumonitis, meningitis and encephalitis.
• For HSV-2 meningitis, acyclovir 5-10 mg/kg
body weight/dose IV, 8 hourly until the clinical
improvement is observed followed by oral high
dose valacyclovir therapy 1 gm 3 times/day to
complete a 10-14 day course of therapy.
• HSV encephalitis requires 14-21 day course of IV
acyclovir therapy.

29. Patients with HSV-HIV coinfection:
• Recommended therapy for first episode of genital
herpes in HIV-positive individuals is same as for
persons without HIV infection. However, the duration of
therapy might need to be extended.
• The risk of genitourinary lesions is increased during the
first 6 months of starting ART, especially among
persons with a low CD4+ helper T-cell count <200
cells/µL.
• The suppressive antiviral therapy reduces the risk of
genital lesions and should be continued for at least 6
months after the ART initiation.

30. Recommended regimens for suppressive therapy
for genital herpes among persons with HIV
infection:
• Acyclovir 400-800 mg orally 2-3 times/day or
• Valacyclovir 500 mg orally 2 times/day or
• Famciclovir 500 mg orally 2 times/day.

31. Recommended regimens for episodic therapy for
genital herpes among persons with HIV infection:
• Acyclovir 400 mg 3 times/day orally for 5-10
days or
• Famciclovir 500 mg 2 times/day orally for 5-10
days or
• Valacyclovir 1 gm 2 times/day orally for 5-10
days.

32. Antiviral resistant HIV infection:
All acyclovir resistant strains are also resistant to
valacyclovir and majority are resistant to famciclovir
also.
Treatment:
• Foscarnet 40-80 mg/kg body weight IV every 8 hours
until the clinical resolution occurs: treatment of
choice for acyclovir resistant genital herpes.
• Cidofovir 5 mg/kg body weight IV once weekly or
cidofovir 1% gel applied over the lesions 2-4
times/day.
• Imiquimod 5% applied to lesions for 8 hours 3
times/week

33. Pregnancy:
• If the mother has an active genital lesion at the
time of delivery, the baby should be delivered by
caesarean section.
• The suppressive antiviral therapy starting at 36
weeks of gestation reduces the frequency of
recurrences near term.
• Recommended suppressive therapy in pregnancy:
Acyclovir 400 mg orally 3 times/day or
Valacyclovir 500 mg orally 2 times/day.

34. • Acyclovir is considered to be safe
in pregnancy. But a recent study
has shown an increased risk of
gastroschisis (paraumblical, full-
thickness abdominal wall defect
associated with the protrusion of
bowel through the defect) in
newborns among mothers who
used acyclovir between the
month before conception and 3
months of pregnancy.

35. Neonatal HSV
Mucocutaneous CNS disease
Disseminated disease
disease
• IV acyclovir therapy 20 mg/kg body weight/dose
3 times/day for 14 days in infants with
mucocutaneous disease and for ≥21 days in
infants with CNS/disseminated disease.
• In patients with CNS involvement, IV therapy

36. • Patients after completing IV therapy should be
transitioned to oral acyclovir therapy (300 mg/m2
of BSA/dose, 3 times/day) to complete a 6 month
course of therapy.

37. Case: B.J., a 28-year-old, sexually active man,
complains of painful penile lesions and tender
inguinal adenopathy. The lesions are vesicular and
limited to the scrotum, glands, and shaft of the
penis. The onset of the lesions was preceded by a 1-
week period of fever, malaise, headache, and
itching. What is your provisional diagnosis and how
will you treat B.J.?

38. p p
Ulcers Lymph nodes
np np
Chancroid/Genital herpes
Syphilis
LGV
Donovanosi
s

39. CASE: D.S., a 23 year old male naval officer
recently stationed in Philippines, complains
of dysuria and a profuse yellow urethral
discharge for 2 days. He admits to have
extramarital sex with a commercial sex
worker during the past week. He engages in
vaginal sex but there is no history of anal or
oral sex. How will you manage the patient?

40. Vaginal
sex
(Infected)
Purulent urethral
discharge and dysuria
Risk of transmission=
50%
Incubation period= 1-7
days
If left
unmanaged
Epididymitis
Sterility
Urethral strictures
Gram’s stain of urethral
discharge
Diagnosis
PMN cells with
intracellular Gram
negative diplococci
Go for
NAAT/culture
If positive If negative
Treatment
Recommended regimen:
Ceftriaxone 500 mg IM single dose (1 gm if
patient weight is ≥ 150 kg)@
Alternative regimens:
-Genatamicin 240 mg IM single dose +
Azithromycin 2 gm oral single dose
-Cefixime 800 mg oral single dose@
@If chlamydial infection has not been ruled out,
treat for chlamydia with Doxycycline 100 mg
orally BD for 7 days.
Also, abstain from condomless sexual
intercourse for 7 days after treatment.
Symptoms resolve
Test-of-cure not
needed
Retest 3 months after initial
treatment
If not possible, retest when patient next
seeks medical care within 12 months after
initial treatment
Symptoms do not resolve within 3-5 days of
recommended treatment with no sexual activity
reported during follow-up period OR
Positive test-of-cure (i.e., positive culture >3
days or positive NAAT >7 days after receiving
recommended treatment) with no sexual
activity reported during follow-up period
Treatment failure
Treatment failure
Culture preferably with
NAAT
Treatment:
Gentamicin 240 mg IM single
dose + Azithromycin 2 gm oral
single dose
Test-of-cure (culture preferably
with NAAT) 7-14 days after
retreatment

41. QUES: If patient DS also engages in cunnilingus in
addition to vaginal intercourse and in addition to dysuria
and purulent urethral discharge, also complains of sore
throat. Physician on physical examination observes
pharyngeal exudates and cervical lymphadenopathy.
How will you treat the patient now?

42. (Infected)
Cunnilingu
s
Sore throat, pharyngeal exudates and
cervical lymphadenopathy
Gram’s stain, NAAT,
culture
Treatment:
Ceftriaxone 500 mg IM
single dose.
No alternative regimen for
pharyngeal gonococcal
infection.

43. QUES: If patient DS is accompanied by his pregnant wife
CS, who is asymptomatic. Does she needs to be
evaluated? What is the natural course of gonorrhea in CS
if left untreated? What treatment will you give?
• The urogenital gonococcal infections in female are
commonly asymptomatic.
• The prevalence of infection in females who are
secondary sexual contact of infected males is 80-90%.
• So, definitely she needs to be tested and treated.
• If left untreated, the following complications may
occur:
In pregnancy:
-Premature rupture of
membranes
-Premature delivery
-Spontaneous abortion
-Chorioamnionitis
In female:
PID which in turn
may lead to
chronic pelvic
pain and
infertility.
In newborn:
Ophthalmia
neonatorum
Treatment: Ceftriaxone 500 mg IM single dose

44. QUES: Meanwhile on his way back to Shimla from
Philippines, he also stayed in Chandigarh, where he
had unprotected sexual contact with his female friend
DA. Due to social reasons she denies going to STD
clinic, how will you manage her?
• All the recent sex partners (i.e., persons having
sexual contact with the infected patient within 60
days of onset of symptoms or gonorrhea diagnosis)
need to be evaluated, tested and treated.
• If it is unlikely that the partner will seek timely
evaluation and treated EPT (Expedited Partner
Therapy).
EPT
Ceftriaxone 500 mg IM single dose
If EPT via injection is not
possible, Cefixime 800 mg oral
single dose