Sexually Transmitted Infections - Gonorrhea and Syphilis

Question 1

What are the prevention options for STIs?

Answer 1

• Mechanical barriers
• Pre-Exposure Prophylaxis (PrEP )
• Post-Exposure Prophylaxis (PEP)
• Human Papillomavirus (HPV) vaccine

Question 2

What are examples of mechanical barriers?

Answer 2

external condoms (male condoms)
internal condoms (female condoms)
condoms do NOT provide protection against STIs spread by skin-to-skin contact (genital herpes, HPV, syphilis)

Question 3

What is pre-exposure prophylaxis (PrEP)?

Answer 3

FDA approved medications to prevent HIV in adults and adolescents weighing ≥77 lb (35 kg): truvada, descovy, apretude (IM injection)

Question 4

What is post-exposure prophylaxis (PEP)?

Answer 4

People who are already using PrEP typically do not need PEP
substantial risk for HIV acquisition and </= 72 hours since exposure with source person known to have HIV –> PEP recommended
substantial risk for HIV acquisition and >/= 73 hours since exposure –> PEP NOT recommended

Question 5

What are PEP regimens?

Answer 5

preferred: tenofovir disoproxil fumarate + emtricitabine AND raltegravir or dolutegravir for 28 days
alternative: tenofovir disoproxil fumurate + emtricitabine AND darunavir + ritonavir for 28 days

Question 6

What is the HPV vaccine?

Answer 6

• CDC recommends HPV vaccination to protect against HPV infections that can cause some cancers
• HPV vaccine is recommended for routine vaccination at age 11 or 12 years (can be started at age 9)
• HPV vaccination prevents new HPV infections, but does not treat existing HPV infections or diseases

Question 7

What is the etiologic agent for gonorrhea?

Answer 7

Neisseria gonorrhoeae
(gram-negative, diplococci bacteria)

Question 8

What is the epidemiology of gonorrhea?

Answer 8

Second most common notifiable disease in the US
Associated with increased risk of HIV transmission
Major cause of pelvic inflammatory disease

Question 9

What are the risk factors for gonorrhea?

Answer 9

low socioeconomic status, urban residence, unmarried, IV drug use, sex work, h/o gonorrheal infection

Question 10

What are the clinical manifestations of gonorrhea - Uncomplicated genital infections in women?

Answer 10

Primary site – endocervix; Up to 80% of women are asymptomatic or mildly symptomatic; Symptoms: cervicitis and/or urethritis → increased vaginal discharge, dysuria, urinary frequency, intermenstrual bleeding, menorrhagia

Question 11

What are the clinical manifestations of gonorrhea - Genital infections in men?

Answer 11

Predominant manifestation – acute urethritis; Symptoms – purulent urethral discharge and dysuria

Question 12

What are the clinical manifestations of gonorrhea - anorectal infection?

Answer 12

Most patients are asymptomatic; If symptomatic – acute proctitis → anal pruritis, tenesmus, purulent discharge, rectal bleeding/discharge, rectal pain

Question 13

What are the clinical manifestations of gonorrhea - pharyngeal infection?

Answer 13

Major risk factor – orogenital sexual exposure; Most are asymptomatic; may cause pharyngitis or cervical lymphadenitis

Question 14

What are the clinical manifestations of gonorrhea - newborns?

Answer 14

Results from passage through the birth canal (may be transmitted in utero); Most common form – ophthalmia neonatorum; If not treated properly → corneal ulceration and blindness

Question 15

What is the diagnosis of gonorrhea?

Answer 15

Gram stain of a male urethral specimen – gram-negative diplococci within PMNs
Nucleic acid amplification tests (NAAT) - standard of care
Culture – endocervical or urethral swab
Test for other STIs (chlamydia, syphilis, HIV) if diagnosed with gonorrhea
o If HIV negative, offer PrEP

Question 16

What drugs are of concern for resistance in gonorrhea?

Answer 16

fluoroquinolones, cefixime, ceftriaxone, azithromycin

Question 17

What is the treatment for uncomplicated gonorrhea of the cervix, urethra, and rectum?

Answer 17

weight < 150 kg: ceftriaxone 500 mg IM x 1 and if chlamydia not exlcuded - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
weight >/= 150 kg: ceftriaxone 1 gm IM x 1 and if chlamydia not excluded - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1

Question 18

What is the treatment for uncomplicated gonorrhea of the cervix, urethra, and rectum if ceftriaxone is not available?

Answer 18

gentamicin 240 mg IM x 1 PLUS azithromycin 2 gm x 1
OR
cefixime 800 mg x 1 –> chlamydia not excluded - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1

Question 19

What is the treatment for uncomplicated gonorrhea of the pharynx?

Answer 19

weight < 150 kg: ceftriaxone 500 mg IM x 1 and if chlamydia (+) - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
weight >/= 150 kg: ceftriaxone 1 gm IM x 1 and if chlamydia (+) - doxycycline 100 mg 7 days, if pregnant: azithromycin 1 gm x 1
no reliable treatment alternatives for pharyngeal gonorrhea

Question 20

What is patient education for gonorrhea?

Answer 20

Instruct patients to abstain from sexual activity for 7 days after treatment and until all sex partners are adequately treated
Treatment of sexual partner – expedited partner therapy (EPT) may be delivered by patient: cefixime 800 mg x 1 plus doxycycline 100 mg x 7 days if chlamydia not excluded OR azithromycin 1 gm x 1 if adherence a concern

Question 21

What is the etiologic agent of syphilis?

Answer 21

Treponema pallidum
(spirochete)

Question 22

What is the epidemiology of syphilis?

Answer 22

Strong association between syphilis and HIV
o All patients with syphilis should be tested for HIV; in areas with high prevalence of HIV, patients with primary syphilis should be re-tested for HIV after 3 months if first HIV test was negative

Question 23

What is the clinical presentation of syphilis?

Answer 23

• Primary syphilis
• Secondary syphilis
• Latent syphilis
• Tertiary (late) syphilis
• Neurosyphilis
• Congenital syphilis

Question 24

What is primary syphilis?

Answer 24

painless lesion (chancre) appears at site of entry
Chancre – usually single, dull red macule → papule that erodes and ulcerates

Question 25

What is secondary syphilis?

Answer 25

* Develops 2-6 weeks after onset of primary stage * Characterized by a variety of mucocutaneous eruptions → secondary to widespread hematogenous and lymphatic spread * Lesions – anywhere on body including palms of hands and soles of feet * Other symptoms – malaise, fever, pharyngitis, headache, anorexia, arthralgias, generalized lymphadenopathy

Question 26

What is latent syphilis?

Answer 26

Patients have positive serologic tests but no other evidence of disease Early latent – patient is potentially infectious; defined as 1 year from the onset of infections Late latent – patient is considered non-infectious (exception – pregnancy)

Question 27

What is tertiary syphilis?

Answer 27

Slowly progressing, inflammatory phase of the disease Can affect any organ in the body

Question 28

What is neurosyphilis?

Answer 28

* May occur at any stage of syphilis * Headache, meningismus, increased CSF leukocyte count and protein * VDRL-CSF – when reactive, diagnostic for neurosyphilis

Question 29

What is congenital syphilis?

Answer 29

Early congenital syphilis – manifestations resemble secondary syphilis May result in fetal death, prematurity, or congenital syphilis

Question 30

What is the diagnosis for syphilis?

Answer 30

Microscopic examination of material from lesion: * Primary syphilis – presence of T. pallidum on dark-field microscopy * Secondary syphilis – spirochete may be found in cutaneous lesions and lymph nodes * Direct fluorescent antibody test (DFA-TP)

Question 31

What is the serologic testing used for diagnosis in syphilis?

Answer 31

use of only one type of serologic test is insufficient; presumptive diagnosis requires use of 2 tests 1. Nontreponemal tests – detect reagin (heterogeneous group of antibodies): Positive test indicates presence of any stage of syphilis; Negative in incubating syphilis and early primary syphilis 2. Treponemal tests (more sensitive than nontreponemal tests; confirmatory)

Question 32

What is the treatment for syphilis?

Answer 32

Penicillin G – treatment of choice for all stages of syphilis (parenteral)

Question 33

What is the treatment for primary and secondary syphilis?

Answer 33

benzathine pen G 2.4 million units IM x 1 if PCN allergy: doxycycline 100 mg x 14 days OR tetracycline 500 mg x 14 days OR azithromycin 2 g x 1 (*resistance to azithromycin with treatment failure has been documented)

Question 34

What is the treatment for early latent syphilis?

Answer 34

Early latent syphilis (< 1 year duration): benzathine pen G 2.4 million units IM x 1 if PCN allergy: doxycycline 100 mg x 14 days OR tetracycline 500 mg x 14 days

Question 35

What is the treatment for late latent syphilis?

Answer 35

Late latent (> 1 year duration) or unknown duration: benzathine pen G 2.4 million units IM once weekly x 3 weeks if PCN allergy: doxycycline 100 mg x 28 days OR tetracycline 500 mg x 28 days

Question 36

What is the treatment for tertiary syphilis?

Answer 36

benzathine pen G 2.4 million units IM once weekly x 3 weeks if PCN allergy: doxycycline 100 mg x 28 days OR tetracycline 500 mg x 28 days

Question 37

What is the treatment for neurosyphilis?

Answer 37

Aqueous crystalline penicillin G 3-4 million units x 10-14 days (or 18-24 million units per day as a continuous infusion) --> May administer benzathine penicillin 2.4 million units IM once weekly x 3 weeks after completion of IV therapy OR Procaine penicillin 2.4 million units IM daily + probenecid 500 mg x 10-14 days if PCN allergy: ceftriaxone 2g IM or IV x 10-14 days

Question 38

What is the treatment of syphilis in patients with HIV - primary and secondary syphilis?

Answer 38

primary and secondary syphilis: benzathine pen G 2.4 million units IM x 1 if PCN allergy: doxycycline 100 mg x 14 days OR tetracycline 500 mg x 14 days OR azithromycin 2 g x 1

Question 39

What is the treatment of syphilis in patients with HIV - early latent?

Answer 39

benzathine pen G 2.4 million units IM x 1

Question 40

What is the treatment of syphilis in patients with HIV - late latent or unknown duration?

Answer 40

benzathine pen G 2.4 million units IM once weekly x 3 weeks

Question 41

What is the treatment of syphilis in patients with HIV - neurosyphilis?

Answer 41

same as non-HIV infected pt

Question 42

What is the treatment of syphilis in pregnancy?

Answer 42

* Penicillin is only agent that reliably protects and treats the fetus * If penicillin allergic → skin testing → desensitization → treat with penicillin regimen appropriate for their stage of infection

Question 43

What are clinical pearls of syphilis treatment?

Answer 43

Jarisch-Herxheimer reaction: Acute febrile reaction characterized by flu-like symptoms, headache, fever, chills, malaise, arthralgia, myalgia, tachycardia, peripheral vasodilation, temporary exacerbation of pre-existing lesions treat with antipyretics (APAP)