Sexually Transmitted Diseases

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Sexually Transmitted Diseases

• Capital Conference, June 2007
• Gregory Perron, MD

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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

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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
  STDs

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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

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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

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HSV, Primary Infection

• 5-30 due to HSV1
• HSV-2 mostly anogenital
• Patient Education
• a. Natural history of disease
• b. Sexual perinatal transmissionc.
  Methods to reduce risk of transmission

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Primary HSV, female patient
Primary infection in pregnancy highest risk of
fetal transmission
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Medical Treatment First Clinical Episode

• Recommended RegimensAcyclovir 400 mg po tid x
  7-10 days, ORAcyclovir 200
  mg po 5x/day for 7-10 days,
  ORFamciclovir 250 mg po tid x 7-10 days,
  ORValacyclovir 1 gm po bid x 7-10
  days.

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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

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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

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Syphilis - Treponema pallidum

• Systemic disease caused by T. pallidum
• Stage of infection
• Primary
• Secondary
• Tertiary
• Latent

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Primary syphilis-chancre
Hallmark PAINLESS!
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Secondary syphilis
-skin rash mucocutaneous lesions, regional
lymphadenopathy characteristic
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Secondary syphilis - condyloma lata
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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

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Syphilis- Diagnostic Considerations

• Treponemal Tests
• Darkfield exam
• Direct Fluorescent Antibody Tests
• Nontreponemal Tests
• Venereal Disease Research Laboratory (VDRL)
• RPR

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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

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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

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Syphilis Diagnosis

• No single test reliable enough to diagnose
• Need combination of treponemal non-treponemal
  tests and associated clinical picture

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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

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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

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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

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Primary Secondary cont

• If symptoms persist, recur, or sustained
  titersfailure or reinfection
• Retest for HIV, perform LP, and retreat x3 weekly
  doses unless CSF studies show neurosyphilis
  present

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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

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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 entirelynormal
  after 2 years, re-treatment should be considered

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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

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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

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Urethritis/Cervicitis Diseases

• Chlamydia
• GC
• MPC
• NGU

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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

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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
• Some data supports Q6mo screening for women female military recruits

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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

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Chlamydia in Pregnancy

• Screen all women in 1st trimester, selective
  screening in 3rd 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!

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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

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Gonorrhea

• 300,000 cases reported estimated total 700,000
• Men typically symptomatic
• Women often asymptomatic
• Complications epididymitis, PID, infertility,
  ectopic pregnancy

ick
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Gonococcal cervicitis

• Diagnose with DNA probe or culture
• CO2-rich environment for culture
• Cannot diagnose women with gram stain

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Gonorrhea - gram stain of urethral discharge
Diagnosis by gram stain MEN only
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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
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GC Treatment

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

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MPC, NGU

• MPC- mucopurulent cervicitis
• Dx mucopurulent discharge from os or on
  endocervical swab.
• ? Value of increased PMNs 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

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Diseases Characterized by Vaginal Discharge

• Vulvovaginal Candidiasis
• Bacterial Vaginosis
• Trichomonas vaginitis
• Recommend targeted history, exam, KOH, wet prep,
  vaginal pH. Consider GC/Chlamdyia testing

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Vulvovaginal Candidiasis

• pH
• 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

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VVC, Contd

• 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

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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

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Trichomonas

• -motile, pear-shaped, 10 µm by 7 µm, organisms
  with visible flagella. Wet prep 60-70 sensitive
• whiff test WBCs 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

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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 ("whiff
  test")
• Vaginal pH greater than 4.5
• Absence of the normal vaginal lactobacilli
• 3 above criteria for diagnosis.

• Vaginosis not Vaginitis

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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

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Human Papilloma Virus

• HPV 40 types in anogenital infection
• Visible warts 6/11
• Cervical dysplasia especially 16/18
• Diagnosis clinical exam

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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 dont typically cause dysplasia

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HPV Counselling

• Once youve got it, youve got it clearance
  questionable.
• Counsel re link to dysplasia transmissibility
  routine pap testing
• No role for HPV typing or routine colposcopy for
  visible warts

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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

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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

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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

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HPV, HSV Vaccines

• Wont be on Boards tests
• HPV
• Merks Gardisil approved by FDA panel
• GSKs Cervarix in Phase 3 testing
• HSV vaccines still in testing phase

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Questions?