STD

Question 1

What are the mode of transmission of STIs?

Answer 1

Childbirth
Breastfeeding
Infected mother to child during pregnancy

Sexual contact with an infected person

Direct contact of broken skin with open sores, blood or genital discharge

Receiving contaminated blood

Question 2

What are the risk factors associated with STDs?

Answer 2

Unprotected sexual intercourse
Number of sexual partners
Male sex with male
Prostitution
Illicit drug use

Question 3

What are the preventive methods to advice sexually active patients?

Answer 3

Abstinence and decrease number of sexual partners

Barrier contraception

Avoid drug use and sharing of needles

DO your pre-exposure vaccinations such as HPV and Hep B

Do your pre and post exposure prophylaxis especially those having sex with high risk patients and healthcare workers

Question 4

What are the clinical presentations of gonorrhea?

Answer 4

Purulent urethral / vaginal discharge, dysuria and urinary frequency

Question 5

What are the potential complications associated with gonorrhea?

Answer 5

Male: Epididymitis, prostatitis, urethral stricture and disseminated disease

Females: Pelvic inflammatory disease, ectopic pregnancy, infertility, disseminated disease

Question 6

What is the pathogen and how is gonorrhea detected?

Answer 6

Gram stain of genital discharge
Culture
NAAT

Question 7

What are the treatments recommended for gonorrhea? List the dose, frequency and duration.

Answer 7

<150kg: Ceftriaxone 500mg IM single dose

> 150kg: Ceftriaxone 1g IM single dose

Question 8

What is the alternative treatment for gonorrhea? List the dose, duration and frequency

Answer 8

Gentamicin 240 IM single dose + Azithromycin 2g PO single dose

Question 9

How should I monitor response for patients and their sex partners?

Answer 9

Patients: Abstain from sexual activity for 7 days after treatment and until all sexual partners have been tested

Sex partners: Those < 60 days exposure need to be tested; those > 60 days exposed, most recent sexual encounter need to be tested

Question 10

How is chlamydia diagnosed? What bacteria is of concern?

Answer 10

NAAT
Chlamydia trachomatis

Question 11

What is the first line regimen for chlamydia?

Answer 11

Doxycycline 100mg BD for 7 days

Question 12

What are the other alternative regimens for chlamydia if patient has issues with adherence?

Answer 12

Azithromycin 1g orally in a single dose

Question 13

What should you advice patients and sex partners upon diagnosis of chlamydia?

Answer 13

Patients: abstain from sexual intercourse for 7 days after single dose was initiated OR upon completion of 7 days regimen and resolution of symptoms if present

Abstain from sex until all partners have been tested

Sex partners: Last 60 days evaluate and tested; > 60 days most recent partner to be tested

Question 14

Name the various stages of syphilis and describe the various clinical presentations?

Answer 14

Primary: single painless ulcer at site or infection OR multiple, atypical and painful lesions at external genitalia

Secondary: skin rash, mucocutaneous lesions, patchy alopecia, lymphadectomy

Latent: Asymptomatic but picked by serology testing

Tertiary: Gummateous lesions in joints and potential cardiac involvement

Neuropsychiatric

Question 14

How is syphilis diagnosed?

Answer 14

Treponemal and non-treponemal antibody tests

Question 15

What is the treponemal antibody test used for?

Answer 15

Acts as a confirmatory test for the diagnosis of syphilis

Question 16

What is the nontreponemal serology antibody test used for? How are the results analysed?

Answer 16

Screening tool that detects any stage of syphilis

Monitor the response of treatment as it will decline after treatment initiation

Quantitative result with dilute serum concentration with positive results

Question 17

What is one special considerations in the use of nontreponemal serology antibody testing?

Answer 17

VDRL and RPR are not interchangeable, need to use the same test for monitoring purposes

Question 18

What is the first line for primary, secondary and early latent syphilis?

Answer 18

IM Benzthiane penicillin G 2.4 mil units in a single dose

Question 19

What is the alternative for primary, secondary and early latent syphilis?

Answer 19

PO Doxycycline 100mg BD for 14 days

Question 20

What is the first line regimen for late latent or tertiary syphilis?

Answer 20

IM Benzthiane Penicillin G 2.4 mil units once a week (3 doses)

Question 21

What is the alternative for late latent or tertiary syphilis?

Answer 21

PO Doxycycline 100mg BD for 28 days

Question 22

What is the first line regimen for neurosyphilis?

Answer 22

IV Crystalline Penicillin G 3-4 MU q4h OR 18-24 MU/day as continuous infusion for 10 to 14 days

OR
IM Procaine penicillin G 2.4MU daily + PO Probenacid 500mg QD

Question 23

What is the alternative regimen for penicillin resistant neurosyphilis?

Answer 23

IV/IM Ceftriaxone 2g daily for 10-14 days

Question 24

What should we monitor for upon administration of drug for syphilis?

Answer 24

Jarisch-Herxheimer reaction where patient experiences acute febrile reaction of headache, myalgia within 24h A four-fold reduction of titre to indicate treatment success

Question 25

How frequent should therapeutic response be monitored for syphilis?

Answer 25

3, 6, 12, 18 and 24 months Neurosyphilis should check CSF every 6 months

Question 26

What to advice patients and sex partners upon diagnosis of syphilis?

Answer 26

Patients: Abstain from sex intercourse until lesions completely healed; advice to also check with doctor if fully treated Sex partners: All to be evaluated and treat if positive

Question 27

What are the physical clinical presentation, flu like and prodromal symptoms of genital herpes?

Answer 27

Physical clinical presentation: multiple painful vesicular/ulcerative lesions Flu like: fever, headache, malaise Prodromal symptoms: Mild burning, itching and tingling

Question 28

How is genital herpes diagnosed?

Answer 28

Virulogic test done by viral cell culture / NAAT/ PCR Type specific serologic test

Question 29

What should you consider before ordering a type specific serologic test?

Answer 29

Not useful for detecting a first episode infection as it takes 6-8 weeks for serologic detection

Question 30

What non-pharmacological advice can you give to patients with genital herpes?

Answer 30

Warm saline bath Manage symptoms with antihistamines and analgesics Good genital hygiene to be done Educate natural history

Question 31

What is the place in therapy of antivirals like acyclovir and valacyclovir?

Answer 31

Decrease viral shedding Decrease duration of symptoms Decrease time of healing from 1st episode

Question 32

Does drug discontinuation affect genital herpes condition?

Answer 32

Yes Drug does not prevent latency or affect frequency and severity of recurrent disease

Question 33

What is the dose of acyclovir for first episode uncomplicated and complicated genital herpes? List the dose, duration, route and frequency

Answer 33

Uncomplicated: PO 400mg TDS for 7-10 days Complicated: IV 5-10mg /kg q8h for 2-7 days

Question 33

What are some counselling advice to give patients on acyclovir and valacylcovir?

Answer 33

Maintain hydration to prevent crystallisation in renal tubule Take without food or after food if GI upset

Question 34

What is the dose of valacyclovir for initial episodes of genital herpes?

Answer 34

PO 1g BD for 7-10 days

Question 35

What are the types of therapy for recurrent genital herpes?

Answer 35

Chronic suppression or episodic

Question 36

What are the advantages and disadvantages of chronic suppressive therapy?

Answer 36

Advantages: - Decreased frequency of recurrences - No symptomatic outbreak - Improve QOL - Long term safety and efficacy - Decreases risk of transmission Disadvantages: Cost and compliance

Question 37

What is the dose of acyclovir for chronic suppressive therapy?

Answer 37

Acyclovir 400mg orally once a day

Question 38

What is the dose of valacylclovir for chronic suppressive therapy?

Answer 38

Valacyclovir 500mg once a day if less than 10 episodes a year OR Valacyclovir 1g once a day

Question 39

How frequent should chronic suppressive therapy be monitored?

Answer 39

Yearly

Question 40

What are the pros and cons of episodic therapy?

Answer 40

Pros - Decreases duration and severity of symptoms - Decreased cost - Increased compliance Cons: - requires initiation of therapy within 1 day of lesion onset - Does not decrease risk of transmission

Question 41

What is the dose of acyclovir for episodic therapy?

Answer 41

PO 800mg BD for 5 days OR PO 800mg TD for 2 days

Question 42

What is the dose of valacyclovir for episodic therapy?

Answer 42

PO 500mg BD for 3 days OR PO 1g OM for 5 days