GUIDELINES

1. GUIDELINES • All patients being evaluated for STDs should be offered counseling and testing for HIV • Asymptomatic women with risk factors for STDs should be screened for gonococcal or chlamydial infection during their annual pelvic examination and cervical cytology should be obtained • Females between the ages of 9 - 26 years should be offered HPV vaccination • Pregnant women should be screened for chlamydia, HIV, hepatitis B, and syphilis infections

2. RISK FACTORS Risk factors for STDs include • Young age (15 to 24 years old) • African-American race • Unmarried status • Geographical residence • New sex partner in past 60 days • Multiple sexual partners • History of a prior STD • Illicit drug use

3. 5 P’s of Sexual History • Partners • “Do you have sex with men, women or both?” • “In the past 6 months how many sexual partners have you had?” • Prevention of Pregnancy • “Are you or your partner trying to get pregnant?” • Protection from STDs • “What do you do to protect yourself from STDs?” • Practices • “Do you use protection every time?” • Past Hx of STDs • “Have you ever had STD in the past?”

4. Chlamydia • C. trachomatis: small gram-negative bacterium • the rates are highest in adolescent women • Although the majority of women are asymptomatic, clinical manifestations range from cervicitis to PID • The incubation period of symptomatic disease ranges from 7 to 14 days.

5. Chlamydia in women Cervicitis • cervical infection is the most common chlamydial syndrome • More than 50 % are asymptomatic • Symptoms: • vaginal discharge • poorly differentiated abdominal pain • Physical examination may reveal • mucopurulent cervical discharge • cervical friability • cervical edema • Endocervical ulcers also may be seen. •  Chlamydial infection of the female urethra often accompanies cervicitis. Women with urethral infection complain of typical symptoms UTI • Frequency, dysuria, occasionally lower abdominal pain.

6. Chlamydia • Perihepatitis (Fitzhugh-Curtis syndrome) — Occasionally, patients with chlamydia infection develop perihepatitis, an inflammation of the liver capsule and adjacent peritoneal surfaces. • PID — Will occur in approx. 30% of women with chlamydia infection, if left untreated • PID caused by gonorrhea may be more symptomatic but PID caused by trichomatis causes higher rates of subsequent infertility • In Pregnancy — Untreated chlamydia infection can increase the risk for premature rupture of the membranes and low birth weight. If the mother is untreated, 20 to 50 percent of newborns will develop conjunctivitis, and 10 to 20 percent will develop pneumonia

7. Chlamydia in men CHLAMYDIAL URETHRITIS • Presentation • mucoid or watery discharge • Dysuria • Incubation period is variable but is typically 5 to 10 days after exposure • Gram stain of urethral secretions demonstrate • >5 WBC/hpf. • Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine sediment demonstrating >10 WBC/hpf. • Treatment: same as women cervicitis

8. Treatment • Drugs of choice • Azithromycin 1 g oral once OR • Doxycycline•Δ 100 mg oral twice daily for 7 days • Alternatives • OfloxacinΔ 300 mg oral twice daily for 7 days • LevofloxacinΔ 500 mg oral daily for 7 days • Erythromycin◊ 500 mg oral four times daily for 7 days • Infection in pregnancy • Azithromycin 1 g oral once OR • Amoxicillin 500 mg oral three times daily for seven days • Alternatives • Erythromycin◊ 500 mg oral four times daily for seven days • Public health issues — Sexual partners are often asymptomatic and, unless treated, will reinfect the index patient or spread infection to other partners.

9. Gonorrhea • Gonorrhea aka "the clap," • common bacterial STD • In general it infects the same organs as chlamydia, and has similar long-term effects • In women can involve any portion of the genital tract, the oropharynx or become disseminated • often asymptomatic compared to men

10. Gonorrhea in women • Cervical infection — MC site of infection is the cervix. • Approx. 50 % are asymptomatic • Symptoms: • vaginal pruritis and/or • mucopurulent discharge • On examination: • the cervix may appear normal or • show signs of frank discharge • Cervical mucosa is often friable

11. Gonorrhea in women • Urethritis - can occur in the absence of pelvic inflammatory disease and is responsible for up to 10 % of cases of dysuria among inner-city women • Anorectal infection and proctitis - The vast majority are asymptomatic. Only 3 % present with symptoms including anal itching, rectal discharge, rectal fullness and painful defecation • PID — occurs in approximately 10 to 40 % of women with cervical gonorrhea

12. GONORRHEA IN MEN CLINICAL MANIFESTATIONS  • can involve any part of the genital tract, either alone or in combination with other sites. Genital infections are generally symptomatic • Urethritis – Symptoms • penile discharge often present spontaneously at the urethral meatus, • purulent or mucopurulent in color • Dysuria • Epididymitis - Unilateral testicular pain and swelling may be the sole presenting complaints of men with epididymitis

13. Diagnosis • Culture - "gold standard" for the diagnosis using a modified Thayer-Martin medium. • Gram stain is only 60 % sensitive in symptomatic women compared with 95 percent in symptomatic men • DNA amplification techniques - available but much more expensive

14. Treatment • Cervical, urethral and anorectal infection   • Ceftriaxone 125 mg IM once OR • Cefixime 400 mg orally once • If allergic to Penicillin • azithromycin (2 grams as a single oral dose) • Pharyngeal infection • Ceftriaxone 125 mg IM once • In Pregnancy — Quinolones and tetracyclines should not be used. Pregnant women with uncomplicated gonorrheal infection should be treated with a recommended cephalosporin

15. SYPHILIS • Chronic infection caused by Treponema pallidum • Transmission usually occurs via direct contact with an infectious lesion during sex. • The early lesions of primary and secondary syphilis including chancres, mucous patches, and condyloma lata, are very infectious. • It has been estimated that transmission occurs in approximately one-third of patients exposed to these lesions. • Syphilis can also be spread by kissing or touching a person who has active lesions on the lips, oral cavity, breasts, or genitals. • The infection can also be acquired by passage through the placenta

16. Presentation • After an average incubation period of 2 to 3 weeks, a painless papule appears at the site of inoculation • Papule ulcerates to produce the classic chancre of primary syphilis, a one to two centimeter ulcer with a raised, indurated margin • Chancres heal spontaneously within three to six weeks even in the absence of treatment • Since the ulcer is painless, many patients do not seek medical attention, a feature that enhances the likelihood of transmission

17. Secondary Syphilis • Secondary syphilis — Weeks to months later, approx. 25 % of individuals with untreated infection will develop a systemic illness • Rash - most characteristic finding can take any form, except vesicular lesions. Classically it is a diffuse, symmetric macular or papular eruption involving the entire trunk and extremities, including the palms and soles • Systemic symptoms include fever, headache, malaise, anorexia, sore throat, myalgias, and weight loss.

18. Diagnosis • As with all stages of the disease, diagnosis of early syphilis is complicated because the organism has never been cultivated in vitro. • The chancre of primary syphilis is best diagnosed by darkfield microscopy • Secondary syphilis is reliably diagnosed by serologic testing.

19. Treatment • Early Syphilis can be treated by penicillin, doxycycline, azithromycin, and ceftriaxone • For Primary or early latent syphilis benzathine penicillin G, should be administered as a single dose. • In patients with severe penicillin allergy alternative include doxycycline or azithromycin • Patient monitoring: All patients should be reexamined clinically and serologically at six and 12 months after treatment. A fourfold reduction in titer of the nontreponemal antibody test is considered evidence of an appropriate response.

20. Trichomoniasis • MC STD in sexually active young women • organism is the flagellated protozoan trichomonas vaginalis, which may be found in the vagina, urethra, and paraurethral glands of infected women. • Other sites include cervix, Bartholin's and Skene's glands. Humans are the only natural host of T. vaginalis. • Commonly mistaken for yeast infection or bacterial vaginosis since the symptoms are similar • Symptons include: • frothy discharge • strong vaginal odor • pain on intercourse • irritation and itching • Men can get trichomoniasis too, but they don't tend to have symptoms

21. Trichomoniasis • In women ranges from an asymptomatic carrier state to a severe, acute, inflammatory disease • Physical examination often reveals • erythema of the vulva and vaginal mucosa • the classic green-yellow frothy discharge is present in 10 – 30% • Punctate hemorrhages may be visible on the vagina and cervix ("strawberry cervix", 2 % of cases). • In pregnant women infection is associated with premature rupture of the membranes and preterm delivery • Infants born to infected mothers may contract infection during delivery. Signs and symptoms in neonates may include fever, respiratory problems, urinary tract infection, nasal discharge, and, in girls, vaginal discharge

22. Diagnosis • The presence of motile trichomonads on wet mount is diagnostic of infection • Culture on Diamond's medium has a high sensitivity (95 percent) and specificity (>95 percent) • Rapid antigen and nucleic acid amplification tests are available but expensive

23. Treatment • Patients should be instructed to avoid intercourse until they and their partners have completed treatment and are asymptomatic, which generally takes about a week • After single dose therapy or treatment of asymptomatic patients, the couple should abstain from intercourse until BOTH partners have waited at least seven days since taking the last antibiotic dose.

24. Herpes Simplex • HSV-1 is associated with oropharynx lesions • HSV-2 is associated with lesions of genitalia • Transmission: • Through active ulcerations or shedding of virus from mucous membranes • HSV-1 usually acquired in childhood (80% of adults have been infected) • HSV-2 incidence has increased in recent years • Asymptomatic or unrecognized symptoms of genital herpes is still contagious

25. Herpes Simplex • Pathophysiology: • HSV replicates in dermis/epidermis and travels via sensory nerves to DRG • Resides as a latent infection until reactivated where it goes to peripheral nerves

26. Herpes Simplex • Clinical Features of HSV-1 • Systemic manifestations (fever, malaise, headache) • Vesicular lesions on patches of erythematous skin • Herpes labialis aka cold sores are common on lips • Usually painful; heal in 2-6 weeks • Clinical Features of HSV-2 • Primary lesion is more severe and prolonged than recurrent episodes • Painful genital vesicles or pustules • Tender inguinal lymphadenopathy • Vaginal/urethral discharge

27. Herpes Simplex • Disseminated HSV • Limited to immunocompromised patients • Encephalitis, meningitis, keratitis, chorioretinitis, pneumonitis, esophagitis • Rarely pregnant women can develop disseminated HSV, which can be fatal to mother and fetus • Neonatal HSV • Congenital malformations, IUGR, chorioamnionitis, neonatal death • Ocular Disease • Keratitis, blepharitis, keratoconjunctivitis

28. Herpes Simplex • Diagnosis • Usually made clinically • Confirmed by Tzanck smear • Swabbing the base of ulcer and staining with Wright’s stain shows multinucleated giant cells • Culture is the gold standard • Swab the base of ulcer; results available within 2-3 days • Fluorecent assay and ELISA • 80% sensitivity; results available within mins to hours

29. Herpes Simplex • Treatment • No cure; symptomatic relief and reduces symptoms • Mucocutaneous disease • Oral and/or topical acyclovir for 7-10 days • Valacyclovir and Famciclovir have better bioavailablity • Oral acyclovir for prophylaxis • Foscarnet for resistant disease in immunocompromised • Disseminated HSV • Hospital admission; parenteral acyclovir

30. HPV • General characteristics • Warts are transmitted via skin-to-skin contact and genital warts via sexual contact • Types • Most common wart (verruca vulgaris): elbows, knees, fingers, palms • Flat wart (V. plana): flesh-colored or whitish hyperkeratotic surface • Plantar wart (V. plantaris): foot pain on pressure areas • Anogenital wart (Condyloma acuminatum): most common STD associated with HPV 6 and 11 • HPV 16 and 18 leads to cervical cancer • Single or multiple soft, fleshy growths on genitalia, perineum, anus

31. HPV • Clinical Features • Warts are asymptomatic unless “bumped” • Plantar warts can be painful during walking • Warts can also bleed • Warts are unsightly and can be disfiguring • Treatment • Freezing lesion with liquid nitrogen applied on a cotton swab • Salicylic acid (Compound W) applied for weeks • 5-FU cream & retinoic acid cream for flat warts • Surgical excision or laser therapy • Podophyllin for genital warts

32. HIV • General characteristics • High risk individuals: homosexual or bisexual men, IVDA, transfusion recipients before 1985, contacts with HIV-positive people, unborn/newborn babies of positive mothers • Mortality secondary to opportunistic infections • Transmission • Sexual or parenteral • Fluids: semen, blood, breast milk, vaginal fluid • Pathophysiology: • Virus attaches to CD4, enters the cell, uncoats, and transcribes the RNA to DNA by reverse transcriptase • Activated CD4 cells produce billions of viral particles • Virus enters the lytic stage of infection resulting in CD4 destruction; eventual depletion of CD4 cells leading to weakened cellular immunity

33. HIV • Primary infection • Mononucleosis-like syndrome 2-4 weeks after exposure lasting 3 days to 2 weeks • Sx: fever, sweats, lethargy, headaches, diarrhea, arthralgias, lymphadenopathy, • Asymptomatic infection • Seropositive w/o clinical evidence • Normal CD4 counts (>500/mm3) • Longest phase lasting 4-7 years • Symptomatic infection (pre-AIDS) • First evidence of immune system dysfunction • Phase lasts 1-3 years without treatment

34. HIV • Other s/s • Persistent lymphadenopathy • Localized fungal infections • Vaginal yeast; trichomonal infections • Oral hairy luekoplakia on tongue • Seborrheic dermatitis, psoriasis exacerbation, warts • AIDS • Disseminated opportunistic infections/malignancies • CD4 < 200 cells/mm3 • Includes pulmonary, GI, neurologic, cutaneous, and systemic symptoms

35. HIV • Pulmonary: • Community acquired bacterial pneumonia, PCP, TB, CMV, MAC, crytococcus, histoplasmosis, Kaposi’s • Nervous: • AIDS dementia, toxoplasmosis, cryptococcal meningitis, CNS lymphoma, encephalopathies • GI • Diarrhea, oral lesions, dysphagia due to candidiasis, anorectal disease • Dermatologic: • Kaposi’s sarcoma, other infections • Misc: • CMV, MAC< HIV-1 wasting syndrome, Malignancies

36. HIV • Diagnosis of HIV infection • ELISA method = screening test detecting Abs • Becomes positive 1-12 weeks after infection • Negative ELISA excludes HIV (99% sensitivity) • Western blot = confirmatory test if positive ELISA • Diagnosis of AIDS • CD4 count lower than 200 or identification of an indicator condition aka AIDS defining illnesses

37. HIV • Antiretroviral therapy • Indications: symptomatic regardless of CD4 count or asymptomatic patients with CD4 < 500 • HAART = 2 NRTI + 1 NNRTI or 1 PI • Monitor tx response using plasma HIV RNA load (goal is to reduce viral load to undetectable loads) • HAART usually is continued in pregnancy • Opportunistic infection prophylaxis • P. carinii – TMP/SMX • TB – yearly PPD screen; INH + pyridoxine if positive • MAC – clarithromycin/azithromycin for prophylaxis • Toxoplasmosis – TMP/SMX • Vaccinations (NO LIVE-VIRUS VACCINES)

40. References • Agabegi, S.S. & Agabegi E. Step-up to Medicine. Lippincott Williams & Williams Inc. 2008. 2nd edition.