This document discusses sexually transmitted infections (STIs). It lists reportable STIs in South Carolina and provides statistics on STIs in the US, including that adolescents experience high rates of infection. It then covers specific STIs like chlamydia, gonorrhea, herpes, syphilis, and human papillomavirus. It discusses symptoms, treatments, and considerations for adolescents. Overall, the document is an informative overview of common STIs, reporting requirements, and management strategies.

1. Sexually Transmitted Infections
Mike Guyton, MD
Assistant Clinical Professor/Academic
Faculty in General Pediatrics

2. Reportable STI’s in SC (2014)
• 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. STI’s in the US
• 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. Quick CDC Facts
• 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. Specific To Adolescents
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. Expedited Partner Therapy
• 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

7. STI Clinical Patterns
• Discharge Syndromes
– Gonorrhea and Chlamydia
– Bacterial Vaginosis/Candidiasis
– Mycoplasma Genitalium
• Genital Ulcer Syndromes
– Herpes Simplex Virus
– Primary Syphilis
– Chancroid/Lymphogranuloma Venereum/ Granuloma Inguinale
• Pelvic Inflammatory Disease
• Dermatologic Syndromes
– HPV
– Secondary Syphilis
– Disseminated Gonococcal Infection
– Pediculosis Pubis

8. Chlamydia and Gonorrhea
• 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. Chlamydia and Gonorrhea: Treatment
• 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. Rescreening
• “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/Candidiasis
• 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. Mycoplasma Genitalium
• 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. PREP Question
• 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. PREP Question
• 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. Genital Herpes
• 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. Genital Herpes: Treatment
• 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

18. Primary Syphilis
• 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. Syphilis: Treatment
• 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/Lymphogranuloma
Venereum/Granuloma Inguinale
• 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 3 weeks

22. Pelvic Inflammatory Disease
• 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. Pelvic Inflammatory Disease:
Treatment
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. Genital Warts
• 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. Genital Warts: Treatment
• 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

27. Secondary Syphilis

28. Disseminated Gonococcus
• 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. Disseminated Gonococcus

30. Pediculosis Pubis
• 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. Which is Which?

32. A word on HIV screening
• 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

33. Questions?