This document discusses sexually transmitted diseases (STDs) including epidemiology data from international, US, and Washington state sources. It provides CDC screening guidelines and details on prevention, clinical presentations, diagnosis, and treatment of common STDs like chlamydia, gonorrhea, HIV, herpes, syphilis, and human papillomavirus. Key points emphasized include taking a sexual history for all patients, vaccinating for HPV and HBV, testing all appropriate sites for STDs, and treating and testing partners of those with certain infections.

1. Sexually Transmitted Diseases
Carrie Horwitch MD, MPH, MACP
Virginia Mason Medical Center
Carrie.horwitch@virginiamason.org

2. Epidemiology: International
 357 million new infections (CT/GC/Syph/ Trich)
 >500 million with HSV
 78 million cases of GC annually
 131 million cases of Chlamydia annually
 5.6 million cases of syphilis annually
 In 2016, 988,000 pregnant women with syphilis-
200,000 stillbirths
●
Source: WHO 2019 data

3. Epidemiology: United States
 65+ million people live with incurable STD
 19 million new infections annually
 ½ will have lifelong infections:HIV,HSV,HPV,Hep
 50% in ages 15-24yo
 High rates in A.A. (71% GC, 48% chly, 52% syph)
 MSM have >60% of syphilis cases
 Chlamydia 1.7+million new cases in 2017-most
common reportable disease
 GC-555,608 new cases- 2nd most common (increase
of 75% from 2009)
 Source: CDC

4. Epidemiology: WA state
 2017 data from CDC
 Chlamydia- 32,231
 GC- 9,915
 Syphilis 1757 (continued increase over
5 yrs)

5. Prevention of STDs
 Abstinence or delay in age of first contact
 Condom use
 HPV vaccination
 HAV, HBV vaccination
 STD screening-treat asymptomatic
pts/partners
 HIV testing
 PrEP-pre-exposure prophylaxis for HIV

6. CDC Screening Guidelines
General
 Annual Chlamydia test in women < 25
 Chlamydia test in 3rd trimester
 HIV serology ages 13-64 (or older if risk) and
all pregnant women
 Syphilis testing in pregnancy and at risk
patients
 GC test for all at risk patients (age <25, CSW,
mult partners, IVDU, previous STD)
 If positive for Chly/GC- repeat test in 3 months

7. CDC Screening Guidelines
MSM
 Annual testing
 HIV serology
 Syphilis serology
 Urethral GC/Chly with NAAT
 Rectal GC/Chly w/NAAT(not FDA cleared)
 Pharyngeal GC w/NAAT (not FDA cleared)
 HbsAg, HAV (vaccinate if negative)
 HCV Ab
 Test more often if risk indicates (q 3 mo)

8. What is the average % of physicians that take a
sexual history?
 A. 5-15%
 B. 20-35%
 C. 50-65%
 D. >75%
 B-various studies show 20-35% of
physicians take a sexual history

9. Who should have a sexual history?
 Anyone who has not had sex yet?
 Remember adolescents/teens are at increased
risk of STDs/HIV
 Can do both STD and contraception prevention
 Anyone who is currently having sex?
 Anyone who has ever had sex?
 Age should not limit your taking a sexual history
 Being married/single/widowed/divorced does not
tell you about risk factors

10. Clinical presentation of STDs
 Acute mono
 Fatigue
 Rashes/skin lesions
 Diarrhea
 Sore throat
 Arthralgias
 Weight loss
 Vision changes
 Hearing loss
 Abnormal LFTs
 Memory loss
 Abnormal PAP
 Pelvic pain
 Abdominal pain
 Genital lesions
 Cardiomyopathy
 Acute renal failure

11. Key information for a sexual history
 Partners
 Practices
 Prevention of pregnancy
 Protection from STDs
 Past history of STDs
 Sexual (dys)function
 Source: CDC Sexually Transmitted Guidelines

12. Case 1
 41 yo married man comes to clinic with
his wife. He is c/o sore throat and low
grade fever. He says he is
monogamous with his wife
 PE: T 99F
 Pharynx has ulcer, mild cervical
lymphadenopathy

14. Which is the most reliable question for
assessing sexual risk behavior
 A. Are you sexually active?
 B. Are you in a mutually monogamous
relationship?
 C. How many partners have you had?
 D. I have no idea
 NO studies have shown any specific
question has more reliability

15. Carrie’s caveats
 Incorporate questions into HPI, SH, ROS etc’
 Patient should be alone in exam room
 Remain non-judgmental
 Non-verbal expressions
 Cover lifetime risk of patient initially, then update
 Specifically ask about oral sex
 Avoid ambiguous questions
 Sexually active? Mutually monogamous?
 Be mindful of cultural differences
 Avoid terms that label or are offensive
 Avoid moralizing….Use Ask-Listen before Tell

16. 2015 STD Guideline Updates
http://www.cdc.gov/std/tg2015/tg-2015-print.pdf
Treatment for GC
Treatment for Chly in pregnancy
Use of NAAT for T. vaginalis
Role of M. genitalium in urethritis/cervicitis and Rx
Genital wart treatment options
HPV vaccine for male and female
Screening for Hep C, HIV, GC, Chly

17. Oral Ulcers
 DDx: HSV, aphthous ulcers, syphilis,
viral
 Add’l hx: pt had MSM oral sex 8 days
before presentation
 HSV confirmed
 Rx: acyclovir 400 mg tid x 7-10 days
 HIV, syphilis, GC, CT were negative

18. Click to edit Master text styles
Second level
● Third level
● Fourth level
● Fifth level

20. Herpes simplex virus
 Seroprevalence: 17% (US) up to >80% (global
HIV+)
 Majority of infection asymptomatic
 Viral shedding w/both symptomatic and
asymptomatic infection
 Dx: PCR most sensitive
 Screening not currently recommended
 Antiviral can reduce shedding but not HIV
acquisition
 Acyclovir or valacyclovir equal efficacy

21. Case 2
 32 yo male presents w/2 day h/o blurry vision,
floaters and occ blue tint to his vision. No fevers,
chills, no rashes. Pt is seen in clinic and had normal
looking eye exam. No other findings noted. He was
seen by Ophthalmology and no acute findings were
noted. No testing was done
 Pt returned one week later with rash and vision
getting worse

25. Psoriasis vs syphilis ?

26. Bullous pemphigus vs syphilis?

27. Alopecia vs syphilis?

28. Pityriasis rosea vs syphilis?

29. Oral herpes vs syphilis?

30. Carrie’s Motto
Any rash is syphilis
until proven otherwise

31. EIA
EIA+ do RPR
RPR+
Syphilis-past
or present
RPR-
Do TP-PA
TP-PA+
syphilis
TP-PA neg
Syphilis
unlikely
EIA- stop

32. Syphilis
 Treponema Pallidum
 Wide clinical presentation “the great imitator”
 Diagnosis: RPR, Enzyme immunoassay
 Confirmation tests: Quantitative RPR and
treponemal tests
 Treatment: Benzanthine PCN (or IV PCN with
neurosyphilis)
 TREAT and test partners**
 LP not recommended unless presence of
neurologic symptoms
 Consider LP if no improvement in titer post Rx

33. Case 3
 25 yo male c/o redness and discharge
from the eye x 1 day. No past h/o STD
 Pt had new sexual contact 10 days ago
including oral sex with female partner
 PE: afebrile
 Exam: notable for erythematous
conjunctiva with discharge noted

35. Gonococcal evaluation & treatment
 Initial test: Gram stain discharge
 NAAT or cx from contact sites(oral,rectal,urethral,cx)
 First drug of choice: Ceftriaxone IM
 250 mg dose preferred esp if pharyngeal
 Cefixime or cefpodoxime is alternative
 Quinolones not recommended due to resistance
 Plus Azithromycin (or emycin) for chly
 TREAT and test partners**
 Test of cure recommended esp if pharyngeal
 If persistent-do culture and sensitivity

36. Gonococcal urethritis

37. Gonococcal cervicitis

38. Disseminated GC

40. Comparison of testing
Non-health care seeking young women entering military
N=1841 women who ever had sexual activity
rate of infection: CT:11.6%, GC 2.4%, Trich 1.7%
Shafer et al. J Clin Microbio 2003. 41:4295-9
Proportion of + by
specimen type
Chlamydia Gonorrhea
Endocervix 60% 40%
Urine 72% 24%
Vaginal swab 81% 72%
Cervix+urine 86% 49%
Cervix+vagina 91% 93%
Vagina+urine 94% 79%

41. Non-gonococcal urethritis
 Etiology: chly: 15-40%, M. genitalum 5-25%,
HSV 15-30% with primary, T. vaginalis 5-20%
 DX: NAAT from urine or urethra for chlamydia
 Dx: Gram stain with WBC on high power field
 RX: Azithromycin- first choice
 For M. genitalum may need longer dosing-higher
macrolide resistance with only single dose
●
Sex Trans Disease 2008:84:72-6

42. Trichomonas

44. Trichomonas
 Diagnosis can be difficult
 Vaginal secretion slide less sensitive
 FDA approved PCR for GC/CT can be
modified to include trichomonas and sensitivity
is higher
 Point of care with Trichomonas rapid test also
available
 Rx: metronidazole
 Partner treatment recommended

45. Human Papilloma virus
 Most common STD in US
 Associated with cervical, anal, head/neck CA
 Dx: clinical presentation
 Rx- depends on location-LN, topical, laser
 PREVENTION: HPV vaccine
 Approved for men/women age 9-26
 Recommended for HIV+ men/women age 9-26
 Quadrivalent or bivalent
 Must continue appropriate cancer screening
 condoms

48. By Salvatore Marra, from AIDS imaging
http://members.xoom.it/Aidsimaging

49. Key Points
 Take sexual hx on all patients
 Vaccinate for HPV and HBV
 Test all appropriate sites for STD
 TREAT and test partners of pts with GC, CT,
syphilis and trichomonas
 HIV and syphilis are great imitators