The document summarizes key points from a presentation on sexually transmitted diseases given at a 2007 conference. It covers various genital infections including herpes, syphilis, chlamydia, gonorrhea, bacterial vaginosis, trichomoniasis, human papillomavirus, and their signs, symptoms, diagnostic testing, and treatment recommendations. Resources on STD guidelines and management from the CDC are also referenced.

1. Sexually Transmitted Diseases Capital Conference, June 2007 Gregory Perron, MD

2. Introduction Diseases Covered Genital Ulcer Disease HSV, syphilis, others Urethritis/Cervicitis GC, Chlamydia Vaginal Discharge BV, vulvovaginal candidiasis, trichomonas HPV Not Covered HIV, PID Future Trends

3. Useful Resources CDC: Center for Disease Control Sexually Transmitted Diseases Treatment Guidelines, 2002 http://www.cdc.gov/std/treatment/TOC2002TG.htm Also a good source of patient handouts, statistical information, MMWR bulletins American Family Physician – article series on STD’s

5. Genital Ulcer Diseases Differential includes: HSV-1 vs HSV-2 : most common in US Primary Syphilis Chancroid - rare LGV-- lymphogranuloma venereum - rare Granuloma Inguinale - rare

6. Herpes Simplex Virus Recurrent, incurable viral disease HSV-1 and HSV-2: Over 50 million affected patients in US; ~1 million new cases/year Most HSV-2 infections undiagnosed Most transmission from undiagnosed or asymptomatic pts Diagnose by clinical suspicion and type-specific testing (e.g. culture or DFA)- not Tzank

7. HSV, Primary Infection 5-30% due to HSV1 HSV-2 mostly anogenital Patient Education: a. Natural history of disease b. Sexual & perinatal transmission c. Methods to reduce risk of transmission

8. Primary HSV, female patient Primary infection in pregnancy: highest risk of fetal transmission

9. Medical Treatment First Clinical Episode 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.

10. HSV – Recurrent Episodes HSV-2 significant more likely to recur Recurrent episodes less severe than initial Episodic Treatment: Acyclovir 400 TID or 200 5X/Day or 800 BID X 5days Famvir 125 BID X 5 days Valacyclovir 500 BID X 3-5 days

11. HSV Suppression Suppression in pregnancy not routinely suggested by ACOG or CDC Reduces frequency of clinical flares by 70-80%, significantly reduces shedding Acyclovir 400 BID Famvir 250 BID Valacyclovir 500mg-1000mg QD Start at 36 wks in pregnancy, or if recurrent episodes

12. Syphilis - Treponema pallidum Systemic disease caused by T. pallidum Stage of infection Primary Secondary Tertiary Latent

13. Primary syphilis-chancre Hallmark: PAINLESS!

14. Secondary syphilis -skin rash; mucocutaneous lesions, regional lymphadenopathy characteristic

15. Secondary syphilis - condyloma lata

16. Syphilis Stages cont Tertiary - cardiac, neurologic, ophthalmic, auditory, gummatous lesions Latent - active infection diagnosed by serology without clinical signs of infection Early Latent - infection acquired within preceding year Late Latent - infection acquired >1 yr ago Syphilis of Unknown Duration - self explanatory

17. Syphilis- Diagnostic Considerations Treponemal Tests Darkfield exam Direct Fluorescent Antibody Tests Nontreponemal Tests Venereal Disease Research Laboratory (VDRL) RPR

18. Nontreponemal Tests Titers may wax & wane as course of disease changes 4 fold change in titer considered clinically significant Should (but not always) become undetectable with treatment Multiple etiologies for false positives

19. Treponemal Tests Fluorescent Treponemal Antibody Absorbed (FTA-ABS) CSF FTA-ABS highly sensitive for neurosyphilis (i.e. if negative it excludes neurosyphilis) Microhemagglutination Assay for Antibody to T. pallidum (MHA-TP) Most patients positive for remainder of their lives Poor marker for disease activity

20. Syphilis Diagnosis No single test reliable enough to diagnose Need combination of treponemal & non-treponemal tests and associated clinical picture

21. Syphilis Treatment Primary, Secondary, Early Latent No PCN allergy: Penicillin G 2.4 MU IM X1 PCN allergy Pregnant: desensitize and give penicillin Others: Doxycycline 100mg BID X 14 days - or- TCN 500 QID X 14 days

22. Syphilis Treatment Late Latent, Unknown Duration, Tertiary No PCN allergy penicillin G 2.4 MU IM Qweek X 3 PCN allergy Pregnant: Desensitize and treat with PCN Nonpregnant: Doxy 100 BID X 28 days, TCN 500 QID X 28 days

23. Primary & Secondary cont No definitive criteria for cure or failure Follow-up VDRL/RPR at 1,3,6,12 months Think failure if titer fails to fall fourfold, or if titers rise

24. Primary & Secondary cont If symptoms persist, recur, or sustained titers=failure or reinfection Retest for HIV, perform LP, and retreat x3 weekly doses unless CSF studies show neurosyphilis present

25. Neurosyphilis Non PCN Allergic Adults Aqueous crystalline penicillin G 3-4 million units IV every 4 hours for 10-14 days Procaine penicillin 2.4 million units IM a day, PLUS Probenecid 500 mg orally four times a day, both for 10-14 days

26. Neurosyphilis cont Follow-Up: If CSF pleocytosis present initially, CSF examination every 6 months until the cell count is normal 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

27. Chancroid ulcers Diagnose by culture for H. ducreyi (rarely available) Clinical Diagnosis: painful genital ulcer negative test for syphilis, HSV suggestive clinical picture: endemic area; exposure; regional lymphadenopathy, risk factors such as HIV. Treatment: Azithromycin 1gm OR ceftriaxone 250mg IM OR cipro 500 BID X 3D OR erythromycin 500 TID X7D

28. Granuloma inguinale, male Rare in US Painless, progressive ulcers without LAN May need biopsy to diagnose- donovan bodies RX: doxycycline 100 BID –or- Bactrim DS BID, 3+ weeks

29. Urethritis/Cervicitis Diseases Chlamydia GC MPC NGU

30. Chlamydia 467 per 100,000 population in 2003 Up from 79/100,000 in 1987 Asymptomatic infection common in women, less common in men Complications: infertility, PID, ectopic pregnancy

31. Chlamydia Diagnosis Culture- rarely recommended DNA amplification testing PCR, Ligase Chain Reaction – urine or swab Antigen detection with EIA acceptable Annual Screening for all women <25 Some data supports Q6mo screening for women < 18, female military recruits

32. Chlamydia Treatment Direct Observed Therapy Is Best! Azithromycin 1gm po X 1 Doxycycline 100mg BID X 7 days Alternatives: Erythromycin 500 QID X 7D EES 800 QID X 7D Ofloxacin 300BID X 7D Levofloxacin 500 QD X 7D ALL: Treat sexual partner; screen for other STDs counsel patients to abstain from sex until 7 days after patient and partner treated

33. Chlamydia in Pregnancy Screen all women in 1 st trimester, selective screening in 3 rd trimester Treat with Azithryomycin 1gm X single dose erythromycin 500 QID X 7D amoxicillin 500 TID X 7d Treat partners; abstain from sex until 7 days after treatment & partner treated Test of Cure in 3 weeks recommended!

34. Chlamydia Followup Test of Cure: recommended if doxy/azithro not used, or in pregnancy Test for REINFECTION-– test 3-4 months later, definitely by 12 months after diagnosis urine chlamydia testing ideal

35. Gonorrhea 300,000 cases reported; estimated total 700,000 Men typically symptomatic Women often asymptomatic Complications: epididymitis, PID, infertility, ectopic pregnancy ick

36. Gonococcal cervicitis Diagnose with DNA probe or culture CO2-rich environment for culture Cannot diagnose women with gram stain

37. Gonorrhea - gram stain of urethral discharge Diagnosis by gram stain– MEN only

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

39. GC Treatment Ceftriaxone 125mg IM; ALWAYS presume chlamydia and treat Fluoroquinolones are OUT: no longer recommended due to resistance . (cefixime 400mg PO)

40. MPC, NGU MPC- mucopurulent cervicitis Dx: mucopurulent discharge from os or on endocervical swab. ? Value of increased PMN’s on endocervical gram stain Test for GC, Chlamydia Consider empiric Rx NGU- nongonococcal urethritis Dx: urethral smear w/ >5WBC/hpf; no GNID; clinical hx of discharge RX: 1gm azithro or doxy 100 BID X 7d Test for GC ,Chlamdyia

41. Diseases Characterized by Vaginal Discharge Vulvovaginal Candidiasis Bacterial Vaginosis Trichomonas vaginitis Recommend targeted history, exam, KOH, wet prep, vaginal pH. Consider GC/Chlamdyia testing

42. Vulvovaginal Candidiasis pH <4 (yellow) KOH, Wet Prep Candida albicans most common ( C. glabrata, C. tropicalis, C. parapsilosis are next most common) Diagnosis is by: Characteristic discharge Appropriate pH Budding yeast or pseudohyphae Culture + for yeast

43. VVC, Cont’d Uncomplicated VVC Sporadic/infrequent episodes Mild-to-moderate VVC Likely C. albicans Non-immunocompromised patient Complicated VVC Recurrent VVC Severe VVC disease Non-albicans candidiasis Patient factors: immunocompromised, uncontrolled DM, debilitated patients, pregnancy

44. Treatment of VVC Topical agents vs. Oral Agents? Why pick one over others? Treatment with two agents? Diflucan 150mg PO X 1 dose Terazol 7: 0.4% IVA X 7 days Monistat 1,3,7 (OTC) etc

45. Trichomonas -motile, pear-shaped, 10 µm by 7 µm, organisms with visible flagella. Wet prep ~60-70% sensitive + whiff test; WBC’s on wet prep; vaginal pH >4.5 Diffuse, yellow-green, malodorous discharge Treat with metronidazole 2gm PO; or 500 BID X 7D Treat sexual partner

46. Bacterial Vaginosis Diagnostic Criteria for Bacterial Vaginosis Homogeneous vaginal discharge (color and amount may vary) Presence of clue cells (greater than 20%) Amine (fishy) odor when potassium hydroxide solution is added to vaginal secretions (&quot;whiff test&quot;) Vaginal pH greater than 4.5 Absence of the normal vaginal lactobacilli 3+ above criteria for diagnosis. Vagin osis – not Vagin itis

47. Bacterial Vaginosis Treatment Treatment Regimens: Metronidazole 500 BID PO X 7D Metronidazole 2gm PO X 1 dose Metronidazole gel 0.75% IVA BID X 5D Clindamycin 300mg PO BID X 7D Clindamycin 2% cream 5GM IVA QHS X7D Recurrence is common Treatment of sexual partners not suggested

48. Human Papilloma Virus HPV: > 40 types in anogenital infection Visible warts: 6/11 Cervical dysplasia: especially 16/18 Diagnosis: clinical exam

49. HPV Factoids Most common STD (6.2 million PER YR!) Risk correlated to # of lifetime sexual partners Most infections self-limited Asymptomatic/Subclinical disease is common Visible warts don’t typically cause dysplasia

50. HPV Counselling Once you’ve got it, you’ve got it – clearance questionable. Counsel re: link to dysplasia; transmissibility; routine pap testing No role for HPV typing or routine colposcopy for visible warts

51. HPV- Treatment Patient-applied Podophilox 0.5% BID X 3 days, off 4 days, repeat up to 4 cycles. Inimiquod 5% cream QHS, 3X/wk, 16wks max, wash off 6-10 hrs later Provider-applied LN2 Q 1-2 wks Podophyllin resin 10-25% TCA 80-90%, weekly Laser therapy Suggest referral for meatal warts, laryngeal warts

52. HPV Vaccine - Gardisil Approved for use in women only, 9-26 Recommended at ages 11-12 Catch-up older patients 3 vaccine series (0,2,6 mo) Efficacy varies, outcomes studied vary But efficacy in the 90+ percentile for reduction of type-specific dysplasia Targets HPV 6/11,16/18 Based on primary capsid proteins

53. Other Vaccines for STDs Hepatitis A: MSM (men who have sex with men); illicit drug users, patients with chronic liver disease Hepatitis B: as per hepA, plus all teenagers; all treated for an STD; household contacts of chronic hep B patients

54. HPV, HSV Vaccines Won’t be on Boards tests HPV Merk’s Gardisil approved by FDA panel GSK’s Cervarix in Phase 3 testing HSV vaccines still in testing phase

55. Questions?