STDs

Question 1

epidemiology

Answer 1

Single greatest risk factor for contracting an STD – number of sexual partners
Two-thirds of STD cases each year occur in persons in their teens and twenties
Rates for many STDs are higher in African-Americans and Hispanics
Rates are greater in “men who have sex with men” (MSM) than in heterosexuals for all major STDs
Marital status – more common in single, separated, and divorced persons
Higher rates of STDs in users of erectile dysfunction drugs (including HIV)
Congenital or neonatal infections – serious sequelae
-Acquired at birth – C. trachomatis, N. gonorrhoeae, herpes simplex virus
-Syphilis – transmitted transplacentally
-Ophthalmia neonatorum – results from chlamydia or gonorrheal infections
-Neurologic impairment – syphilis, herpes
Pregnancy – all pregnant women should be screened for chlamydia, HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibodies at the first prenatal visit; screen for gonorrhea if women is at high risk (age ≤ 24 years old, previous gonococcal infection, new or multiple sex partners, inconsistent condom use, commercial sex work, drug use).

Question 2

Gonorrhea etiologic agent

Answer 2

Neisseria gonorrhoeae

Question 3

Gonorrhea epidemiology

Answer 3

gonorrhea rate in African-Americans was 10.6 times greater than whites in 2014
Highest rates in females 15-24 years old and men 20-29 years old
Risk factors: low socioeconomic status, urban residence, unmarried, previous history of gonorrheal infection
High incidence in prostitutes and IVDA
Associated with increased HIV transmission
Major cause of pelvic inflammatory disease

Question 4

clinical manifestations of gonorrhea - genital infections in men

Answer 4

Predominant manifestation – acute urethritis
Symptoms – purulent urethral discharge and dysuria
If untreated, spontaneous resolution after several weeks

Question 5

clinical manifestations of gonorrhea - uncomplicated genital infections in women

Answer 5

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
≈ 15% of women with gonorrhea develop PID
Disseminated gonorrhea infection may occur – more common in women

Question 6

clinical manifestations of gonorrhea - anorectal infection

Answer 6

Most patients are asymptomatic

If symptomatic – acute proctitis → anal pruritis, tenesmus, purulent discharge, rectal bleeding/discharge, rectal pain

Question 7

clinical manifestations of gonorrhea - pharyngeal infection

Answer 7

Major risk factor – orogenital sexual exposure
Most are asymptomatic; may cause pharyngitis or cervical lymphadenitis
Poor response to some treatments

Question 8

clinical manifestations of gonorrhea - gonococcal infection in the newborn

Answer 8

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 9

Gonnorhea diagnosis

Answer 9

Gram stain of a male urethral specimen – gram-negative diplococci within PMNs
Nucleic acid amplification tests (NAAT) – standard of care (urine or endocervical, vaginal, and urethral swabs)
Culture – endocervical or urethral swab

Question 10

Gonorrhea treatment - potential efficacy of treatment of concurrent infections

Answer 10

Most common coexisting infection – genital chlamydial infection
15-25% of heterosexual men and 35-50% of women are also infected with C. trachomatis → concomitant treatment required***
Incubating syphilis – ceftriaxone is effective in eradicating GC and incubating syphilis

Question 11

Gonorrhea treatment - concerns for resistant N. gonorrheae

Answer 11

Fluoroquinolones
-In 2015, 22.3% of isolates were resistant to ciprofloxacin
-FQNG more common in MSM (32.1% in 2015 compared to 16.4% in
MSW)
-CDC revised treatment guidelines in April 2007 and no longer recommends fluoroquinolones to treat any gonorrhea case in the United States
Cefixime
-In 2015, 0.5% of isolates had cefixime MICs ≥ 0.25 µg/ml
-CDC revised treatment guidelines in 2010 and no longer recommend cefixime as first-line therapy
Ceftriaxone
-In 2015, 0.3% of isolates had ceftriaxone MIC ≥ 0.125 µg/ml
Azithromycin
-In 2013-15, 2.6% of isolates had azithromycin MIC ≥ 2 µg/ml

Question 12

treatment of uncomplicated gonococcal infections of the cervix, urethra and rectum***

Answer 12

1) Ceftriaxone 250 mg IM as a single dose PLUS Azithromycin 1 gram PO in a single dose OR doxycycline 100 mg PO BID for 7 days
2) Alternative if ceftriaxone is not available: Cefixime 400 mg PO in a single dose PLUS Azithromycin 1 gram PO in a single dose OR doxycycline 100 mg PO BID for 7 days PLUS Test-of-cure in 1 week
3) If patient has severe cephalosporin allergy: Spectinomycin 2 g IM x 1 PLUS Test-of-cure in 1 week

Question 13

treatment of uncomplicated gonococcal infection of the pharynx***

Answer 13

Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 gram PO in a single dose OR doxycycline 100 mg PO BID for 7 days

Question 14

Treatment of disseminated gonococcal infection**

Answer 14

Ceftriaxone 1 gram IM/IV q24h – recommended regimen
Cefotaxime 1 gram IV q8h
Ceftizoxime 1 gram IV q8h
Switch to cefixime 400 mg PO q12h after 24-48 hours of IV therapy to complete 1 week of therapy

Question 15

treatment of gonorrhea during pregnancy**

Answer 15

Ceftriaxone 250 mg IM x 1 plus azithromycin 1 g PO x 1
Do not treat with tetracycline
Spectinomycin 2 grams IM x 1 if allergic

Question 16

syphilis etiologic agent

Answer 16

Treponema pallidum (spirochete)

Question 17

syphilis epidemiology

Answer 17

men 10x more than women
african americans > hispanics and whites
strong association between HIV and syphilis

Question 18

primary syphilis

Answer 18

After exposure, a painless lesion (chancre) appears at the site of entry (≈ 3 weeks) → highly infectious
Chancre – usually single, dull red macule → papule that erodes and ulcerates; round or oval, indurated and well-marginated
Chancres disappear spontaneously without treatment (3-6 weeks)

Question 19

secondary syphilis

Answer 19

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
Signs disappear in 4-10 weeks

Question 20

latent syphilis

Answer 20

Patients have positive serologic tests but no other evidence of disease
Divided into early latent and late latent stages
-Early latent – patient is potentially infectious; defined as 1 year from the onset of infections
-Late latent – patient is considered non-infectious (exception – pregnancy)
≈ 25-30% of patients progress to tertiary syphilis

Question 21

tertiary (late) syphilis

Answer 21

Slowly progressing, inflammatory phase of the disease

Can affect any organ in the body

Question 22

neurosyphilis

Answer 22

Headache, meningismus, increased CSF leukocyte count and protein
VDRL-CSF – when reactive, diagnostic for neurosyphilis

Question 23

congenital syphilis

Answer 23

T. pallidum can cross placenta at any time
May result in fetal death, prematurity, or congenital syphilis
Early congenital syphilis – manifestations resemble secondary syphilis

Question 24

diagnosis of syphilis - microscopic examination of material from lesion

Answer 24

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)
-Greater specificity than dark-field microscopy
-Does require exam of fresh specimen
-More labor intensive and expensive

Question 25

diagnosis of syphilis - nontreponemal serologic testing

Answer 25

detect reagin (heterogeneous group of antibodies) Commonly used tests – Venereal Disease Research Laboratory (VDRL); Rapid plasma reagin (RPR), unheated serum reagin test (USR); toluidine red unheated serum test (TRUST) Positive test indicates presence of any stage of syphilis Negative in incubating syphilis and early primary syphilis Used primarily for screening; also useful in following progression of disease and response to therapy (repeat the same test by the same lab) Seronegativity occurs in patients successfully treated primary and secondary syphilis; early latent – may take up to 4 years; late latent and tertiary syphilis remain seropositive for life

Question 26

diagnosis of syphilis - treponemal serologic tests

Answer 26

more sensitive than nontreponemal tests; confirmatory Fluorescent treponemal antibody absorption (FTA-ABS) test -T. pallidum antigen used to detect antibodies to treponemal organisms -Becomes positive earlier than nontreponemal tests -Reactive for life after appropriate treatment of any syphilis stage T. pallidum hemagglutination assay (TPHA) T. pallidum passive particle agglutination (TP-PA) EIAs

Question 27

syphilis treatment

Answer 27

treatment of choice for all stages of syphilis

Question 28

primary and secondary syphilis treatment

Answer 28

Benzathine penicillin G 2.4 million units IM x 1 dose

Question 29

early latent syphilis treatment

Answer 29

less than 1 year duration | Benzathine penicillin 2.4 million units IM x 1 dose

Question 30

late latent syphilis treatment

Answer 30

> 1 year duration or latent syphilis of unknown duration | Benzathine penicillin G 2.4 million units IM once weekly x 3 weeks

Question 31

tertiary syphilis treatment

Answer 31

Benzathine penicillin G 2.4 million units IM once weekly x 3 weeks

Question 32

neurosyphilis treatment

Answer 32

Aqueous crystalline** penicillin G 3-4 million units IV q4h x 10-14 days (or 18-24 million units per day as a continuous infusion) - NOT benzathine penicillin (will kill pt if given IV) Alternative: procaine penicillin 2.4 million units IM QD plus probenecid 500 mg PO QID for 10-14 days May administer benzathine penicillin 2.4 million units IM once weekly x 3 weeks after completion of IV therapy Penicillin allergy – ceftriaxone 2 g IM or IV once daily for 10-14 days (? cross reactivity)

Question 33

treatment of syphilis in patients with HIV

Answer 33

Primary and secondary syphilis -Benzathine penicillin 2.4 million units IM x 1 dose -If penicillin allergic – same as non-HIV infected patient Early latent, late latent or syphilis of unknown duration -Early latent - benzathine penicillin 2.4 million units IM x 1 -Late latent or unknown duration – benzathine penicillin 2.4 million units IM once weekly for 3 weeks Neurosyphilis – same as non-HIV infected patient

Question 34

treatment of syphilis in pregnant women

Answer 34

penicillin is only agent that reliable protects and treats the fetus; if penicillin allergic → skin testing → desensitization → treat with penicillin regimen appropriate for their stage of infection

Question 35

Jarisch-Herxheimer reaction

Answer 35

Characterized by flu-like symptoms, headache, fever, chills, malaise, arthralgia, myalgia, tachycardia, peripheral vasodilation Begins 2-4 hours after initiating syphilis therapy; may last 12-24 hours Do not confuse with penicillin allergy

Question 36

chlamydia etiologic agent

Answer 36

Chlamydia trachomatis

Question 37

chlamydia epidemiology

Answer 37

females, AA

Question 38

clinical presentation of chlamydia

Answer 38

Males -Most common symptoms – dysuria, urinary frequency, mucoid urethral discharge (7-21 days after exposure) -≈ 50% are asymptomatic -Rectal infections occur in homosexual men; usually aymptomatic Females -Majority are asymptomatic; dysuria and frequency are uncommon -If symptomatic – endocervicitis with a mucopurulent discharge -Major cause of PID; increased risk of cervical dysplasia Infants -Transmitted via contact with cervicovaginal secretions (70%) -Most common cause of neonatal eye infection and of afebrile interstitial pneumonia in infants less than 6 months old

Question 39

chlamydia diagnosis

Answer 39

Nucleic acid amplification testing (NAAT) – detection of chlamydia antigen in urine – sensitivity and specificity 90-100% Giemsa stain of cell scrapings from the endocervix or urethra Direct immunofluorescence Cell culture - ≈ 100% specific, but time-consuming and expensive

Question 40

treatment of chlamydia

Answer 40

Azithromycin 1 gram PO as a single dose | Doxycycline 100 mg PO BID for 7 days

Question 41

treament of chlamydia in pregnancy

Answer 41

azithromycin 1 gram PO as a single dose

Question 42

clinical presentation of mycoplasma genitalium

Answer 42

same as C. trachomatis

Question 43

diagnosis of mycoplasma genitalium

Answer 43

Slow growing organism (no cell wall) – takes up to 6 weeks for positive culture Nucleic acid amplification testing (NAAT) – preferred (urine, urethral, vaginal, cervical swabs

Question 44

treatment of mycoplasma genitalium

Answer 44

Doxycycline for 7 days – only 30% cure rate Azithromycin 1 gram single dose – ≈85% cure rate (resistance emerges rapidly) Azithromycin 500 mg x 1, then 250 mg daily x 4 days (may be better than single dose regimen unless initial pathogen is macrolide-resistant) Moxifloxacin 400 mg daily for 10-14 days (if macrolide resistant)

Question 45

genital herpes etiology and epidemiology

Answer 45

HSV2 highest among non-Hispanic black females and non-Hispanic black males Increases risk of becoming infected with HIV – major role in heterosexual spread

Question 46

clinical presentation of genital herpes

Answer 46

Up to 50% of HSV-2 infections are asymptomatic | Effect of herpes on neonates exposed during pregnancy – high mortality and significant morbidity

Question 47

clinical presentation of primary infection of genital herpes

Answer 47

First-episode primary infections - characterized by a prolonged duration of symptoms -Flu-like symptoms – fever, headache, malaise, myalgias -Local symptoms – pustular or ulcerative lesions on external genitalia (painful), itching, vaginal or urethral discharge, inguinal adenopathy First-episode nonprimary genital herpes -Infection in patients who have clinical or serologic evidence of prior HSV (usually HSV-1) infection at another body site -Milder than true primary infections Recurrent infections -≈ 50% of patients experience a prodrome prior to appearance of recurrent lesions -Symptoms more severe in women and immunocompromised patients

Question 48

diagnosis of genital herpes

Answer 48

Viral culture – preferred virologic test -Sensitivity 80-90%; specificity 100% for 1st episode -Low sensitivity in recurrent infection -Expensive, time-consuming, false negatives if specimens improperly collected or transported HSV PCR Serologic tests – ELISA to detect antibodies to HSV (takes a few weeks)

Question 49

treatment of genital herpes - first clinical episode of genital herpes

Answer 49

Acyclovir 400 mg PO TID for 7-10 days Acyclovir 200 mg 5 times a day for 7-10 days Famciclovir 250 mg PO TID for 7-10 days Valacyclovir 1 g PO BID for 7-10 days

Question 50

treatment of genital herpes for episodic recurrent infection

Answer 50

benefit if started in prodrome or within 1 day after onset of lesions Acyclovir 400 mg PO TID for 5 days or 800 mg PO BID for 5 days or 800 mg PO TID for 2 days Famciclovir 125 mg PO BID for 5 days or 1 g PO BID for 1 day Valacyclovir 500 mg PO BID for 3 days or 1 g QD for 5 days

Question 51

treatment of genital herpes - regimens for daily suppressive therapy

Answer 51

Reduces frequency of recurrences by 70-80% in patients who have frequent recurrences (≥ 6/year) Acyclovir 400 mg PO BID Famciclovir 250 mg PO BID Valacylovir 500 mg PO QD or 1 g PO QD Valacyclovir 500 mg QD appears less effective than other regimens in patients who have very frequent recurrences (≥ 10/year)

Question 52

treatment of genital herpes in severe disease

Answer 52

acyclovir 5-10 mg/kg/dose IV q8h for 2-7 days or until clinical improvement is observed, followed by oral therapy to complete at least 10 days.

Question 53

treatment of gential herpes in patients with HIV

Answer 53

``` Regimens for episodic infections -Acyclovir 400 mg PO TID for 5-10 days -Famciclovir 500 mg PO BID for 5-10 days -Valacyclovir 1 g PO BID for 5-10 days Regimens for daily suppressive therapy -Acyclovir 400-800 mg PO BID to TID -Famciclovir 500 mg PO BID -Valacyclovir 500 mg PO BID ```

Question 54

treatment of genital herpes if acyclovir resistant

Answer 54

foscarnet 40-80 mg/kg/dose IV q8h or cidofovir 5 mg/kg IV once weekly

Question 55

trichomoniasis etiologic agent

Answer 55

Trichomonas vaginalis (flagellated, motile protozoan)

Question 56

clinical presentation of trichomoniasis

Answer 56

Women -Asymptomatic in up to 50% -Symptoms (non-specific) ---Vaginal discharge (malodorous, foamy, greenish-yellow) ---Vulvar pruritis ---Dysuria ---Symptoms may worsen during menstruation -Examine for other STDs – 3x risk of having gonorrhea Men -Majority are asymptomatic -Symptoms – urethral discharge, pruritis, dysuria -Trichomoniasis – a cause of treatment failure in patients with presumed NGU treated with tetracyclines or erythromycin -Examine for other STDs – 20% of men with gonococcal urethritis have trichomoniasis

Question 57

diagnosis of trichomoniasis

Answer 57

Wet mount examination of the discharge – characteristic pear-shaped, flagellating organisms (50-65% sensitive) NAAT Culture – highly specific and more sensitive than wet mount; takes 48 hours

Question 58

treatment of trichomoniasis

Answer 58

Metronidazole 2 g PO in a single dose Tinidazole 2 g PO in a single dose Metronidazole 500 mg BID for 7 days (more effective in men than single dose) Avoid alcohol with metronidazole (24 hours) and tinidazole (72 hours) Treat the sexual partner Metronidazole gel is much less effective than oral metronidazole

Question 59

PID

Answer 59

Spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis

Question 60

PID etiologic agents

Answer 60

``` N. gonorrhoeae C. trachomatis Vaginal flora (anaerobes, Gardnerella vaginalis, gram-negative bacilli, S. agalactiae) Mycoplasma hominis Ureaplasma urealyticum ```

Question 61

PID sxs and diagnosis

Answer 61

``` Pelvic or lower abdominal pain Dyspareunia Adnexal tenderness Cervical motion tenderness Temperature > 101°F Abnormal cervical or vaginal discharge Laboratory documentation of N. gonorrhoeae or C. trachomatis ```

Question 62

treatment of PID

Answer 62

**Cefotetan 2 g q12h OR cefoxitin 2 g IV q6h PLUS Doxycycline 100 mg IV or PO q12h **Clindamycin 900 mg IV q8h PLUS Gentamicin 2 mg/kg loading dose, then 1.5 mg/kg q8h (single daily dose of 3-5 mg/kg may be substituted) Alternative parenteral regimen: Ampicillin/sulbactam 3 g IV q6h PLUS Doxycycline 100 mg IV/PO q12h IM/Orally-Based Treatment Regimens: Ceftriaxone 250 mg IM x 1 PLUS Doxycycline 100 mg PO q12h for 14 days WITH OR WITHOUT Metronidazole 500 mg PO q12h for 14 days

Question 63

HPV epidemiology

Answer 63

Subclinical infection – untreatable; can lead to cervical, penile, anal cancer - Persistent cervical infection with high risk HPV types is the most important risk factor for cervical neoplasia - HPV types 6 and 11 can cause genital warts (account for 90% of genital warts) - HPV types 16, 18, 31, 33, and 35 are strongly associated with cervical neoplasias (16 and 18 account for 70% of cervical cancers)

Question 64

patient applied treatment of anogenital warts d/t HPV

Answer 64

Podofilox 0.5% solution or gel – apply BID for 3 days, followed by 4 days of no therapy; repeat for up to 4 cycles Imiquimod 3.75-5% cream – apply once HS, every night for 3.75% and 3 times/week for 5%, for up to 16 weeks; treatment area should be washed with soap and H2O 6-10 hours after application Sinecatechins 15% ointment – apply TID for no longer than 16 weeks; do not wash off after application

Question 65

provider applied treatment of anogenital warts d/t HPV

Answer 65

Cryotherapy with liquid nitrogen or cryoprobe Surgical removal Trichloroacetic acid or bichloroacetic acid 80-90% solution

Question 66

Vacciation of HPV

Answer 66

Gardasil, Gardasil-9, Cervarix Vaccination is not recommended in women who are pregnant or trying to become pregnant Sexually active women starting vaccination series should use contraception until series completed If pregnancy occurs during vaccination series, delay dosing until end of pregnancy (pregnancy and outcome of pregnancy should be reported to the vaccine manufacturer’s registry) Breastfeeding is permitted during vaccination series