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Sexually Transmitted Diseases Part 2. Edward L. Goodman, MD February 9, 2004. Background Information. Background. Knowledge About STDs Among Americans. Source : Kaiser Family Foundation, 1996. Background. Where Do People Go for STD Treatment?.

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sexually transmitted diseases part 2

Sexually Transmitted DiseasesPart 2

Edward L. Goodman, MD

February 9, 2004

knowledge about stds among americans

Background

Knowledge About STDs Among Americans

Source: Kaiser Family Foundation, 1996

where do people go for std treatment

Background

Where Do People Go for STD Treatment?
  • Population-based estimates from National Health and Social Life Survey

Private provider 59%

Other clinic 15%

Emergency room 10%

STD clinic 9%

Family planning clinic 7%

Source: Brackbill et al. Where do people go for treatment of sexually transmitted diseases? Family Planning Perspectives. 31(1):10-5, 1999

slide5

Background

Percent of Women Who Said Topic Was Discussed During First Visit With New Gynecological or Obstetrical Doctor/Health Care Professional

Percentages may not total to 100% because of rounding or respondents answering “Don’t know” to the question “Who initiated this conversation?”

Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997

estimated burden of std in u s 1996

Background

Estimated Burden of STD in U.S. - 1996

Source: The Tip of the Iceberg: How Big Is the STD Epidemic in the U.S.? Kaiser Family Foundation 1998

slide7

Background

“...the scope and impact of the STD epidemic are under-appreciated and the STD epidemic is largely hidden from public discourse.”

IOM Report 1997

std prevention and control
STD Prevention and Control
  • Education and counseling to reduce risk of STD acquisition
  • Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation
  • Effective diagnosis and treatment
  • Evaluation, treatment, and counseling of sexual partners
  • Preexposure vaccination--hepatitis A, B
prevention messages
Prevention Messages
  • Prevention messages tailored to the client’s personal risk; interactive counseling approaches are effective
  • Despite adolescents greater risk of STDs, providers often fail to inquire about sexual behavior, assess risk, counsel about risk reduction, screen for asx infection
  • Specific actions necessary to avoid acquisition or transmission of STDs
  • Clients seeking evaluation or treatment for STDs should be informed which specific tests will be performed
prevention methods male condoms
Prevention MethodsMale Condoms
  • Consistent/correct use of latex condoms are effective in preventing sexual transmission of HIV infection and can reduce risk of other STDs
  • Likely to be more effective in prevention of infections transmitted by fluids from mucosal surfaces (GC,CT, trichomonas, HIV) than those transmitted by skin-skin contact (HSV,HPV, syphilis, chancroid)
prevention methods spermicides
Prevention MethodsSpermicides
  • N-9 vaginal spermicides are not effective in preventing CT, GC, or HIV infection
  • Frequent use of spermicides/N-9 have been associated with genital lesions
  • Spermicides alone are not recommended for STD/HIV prevention
  • N-9 should not be used a microbicide or lubricant during anal intercourse
slide12
MSM
  • STD/HIV sexual risk assessment and client-centered prevention counseling
  • Annual STD screening for MSM at risk

-HIV and syphilis serology

-Urethral cx or NAAT, GC/CT

-Pharyngeal cx, GC (oro-genital)

-Rectal cx, GC/CT (receptive anal IC)

stds of concern

Background

STDs of Concern
  • Actually, all of them
  • “Sores” (ulcers)
    • Syphilis
    • Genital herpes (HSV-2, HSV-1)
    • Others uncommon in the U.S.
      • Lymphogranuloma venereum
      • Chancroid
      • Granuloma inguinale
stds of concern continued

Background

STDs of Concern (continued)
  • “Drips” (discharges)
    • Gonorrhea
    • Chlamydia
    • Nongonococcal urethritis / mucopurulent cervicitis
    • Trichomonas vaginitis / urethritis
    • Candidiasis (vulvovaginal, less problems in men)
  • Other major concerns
    • Genital HPV (especially type 16, 18) and Cervical Cancer
drips

“Drips”

Gonorrhea

Nongonococcal urethritis

Chlamydia

Mucopurulent cervicitis

Trichomonas vaginitis and urethritis

Candidiasis

urethritis
Urethritis
  • Mucopurulent or purulent discharge
  • Gram stain of urethral secretions > 5 WBC per oil immersion field
  • Positive leukocyte esterase on first void urine or >10 WBC per high power field

Empiric treatment in those with high risk who are unlikely to return

gonorrhea clinical manifestations

Drips

Gonorrhea - Clinical Manifestations
  • Urethritis - male
    • Incubation: 1-14 d (usually 2-5 d)
    • Sx: Dysuria and urethral discharge (5% asymptomatic)
    • Dx: Gram stain urethral smear (+) > 98% culture
    • Complications
  • Urogenital infection - female
    • Endocervical canal primary site
    • 70-90% also colonize urethra
    • Incubation: unclear; sx usually in l0 d
    • Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain
    • Dx: Gram stain smear (+) 50-70% culture
    • Complications
epidemiology of gonorrhea

Gonorrhea

Epidemiology of Gonorrhea
  • Proportion of gonococcal infections caused by resistant organisms is increasing
  • Incidence remains high in some groups defined by geography, age and race/ethnicity, or sexual orientation
  • Gonorrhea associated with increased susceptibility to HIV infection
gonorrhea reported rates united states 1970 2001 and the healthy people year 2010 objective

Gonorrhea

Gonorrhea — Reported rates: United States, 1970–2001 and the Healthy People year 2010 objective

Note: The Healthy People 2010 (HP2010) objective for gonorrhea is 19.0 cases per 100,000 population.

Source: CDC/NCHSTP 2001 STD Surveillance Report

gonorrhea rates by state united states and outlying areas 2001

Gonorrhea

Gonorrhea — Rates by state: United States and outlying areas, 2001

Note: The total rate of gonorrhea for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 126.9 per 100,000 population. The Healthy People year 2010 objective is 19.0 per 100,000 population.

Source: CDC/NCHSTP 2001 STD Surveillance Report

gonorrhea rates by gender united states 1981 2001 and the healthy people year 2010 objective

Gonorrhea

Gonorrhea — Rates by gender: United States, 1981–2001 and the Healthy People year 2010 objective

Source: CDC/NCHSTP 2001 STD Surveillance Report

gonorrhea age and gender specific rates united states 2001

Gonorrhea

Gonorrhea — Age- and gender-specific rates: United States, 2001

Source: CDC/NCHSTP 2001 STD Surveillance Report

gonorrhea

Drips

Gonorrhea

Source: Florida STD/HIV Prevention Training Center

gonorrhea gram stain

Drips

Gonorrhea Gram Stain

Source: Cincinnati STD/HIV Prevention Training Center

neisseria gonorrhoeae cervix urethra rectum
Neisseria gonorrhoeaeCervix, Urethra, Rectum

Cefixime 400 mg

or

Ceftriaxone 125 IM

or

Ciprofloxacin 500 mg

or

Ofloxacin 400 mg/Levofloxacin 250 mg

PLUS Chlamydial therapy if infection not ruled out

neisseria gonorrhoeae cervix urethra rectum26
Neisseria gonorrhoeaeCervix, Urethra, Rectum

Alternative regimens

Spectinomycin 2 grams IM in a single dose

or

Single dose cephalosporin (cefotaxime 500 mg)

or

Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg)

PLUS Chlamydial therapy if infection not ruled out

neisseria gonorrhoeae pharynx
Neisseria gonorrhoeaePharynx

Ceftriaxone 125 IM in a single dose

or

Ciprofloxacin 500 mg in a single dose

PLUSChlamydial therapy if infection not ruled out

neisseria gonorrhoeae treatment in pregnancy
Neisseria gonorrhoeaeTreatment in Pregnancy
  • Cephalosporin regimen
  • Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM
  • No quinolone or tetracycline regimen
  • Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection
disseminated gonococcal infection
Disseminated Gonococcal Infection

Recommended regimen

Ceftriaxone 1 gm IM or IV q 24 hr

Alternative regimens

Cefotaxime or Ceftizoxime 1 gm IV q8 hr

or

Ciprofloxacin 400 mg IV q 12

or

Ofloxacin 400 mg IV q 12

or

Levofloxacin 250 mg IV daily

neisseria gonorrhoeae antimicrobial resistance
Neisseria gonorrhoeaeAntimicrobial Resistance
  • Geographic variation in resistance to penicillin and tetracycline
  • No significant resistance to ceftriaxone
  • Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California
  • Surveillance is crucial for guiding therapy recommendations
slide31
Gonococcal Isolate Surveillance Project (GISP) — Penicillin and tetracycline resistance among GISP isolates, 2002

Note: PPNG=penicillinase-producing N. gonorrhoeae; TRNG=plasmid-mediated tetracycline resistant N. gonorrhoeae; PPNG-TRNG=plasmid-mediated penicillin and tetracycline resistant N. gonorrhoeae; PenR=chromosomally mediated penicillin resistant N. gonorrhoeae; TetR=chromosomally mediated tetracycline resistant N. gonorrhoeae; CMRNG=chromosomally mediated penicillin and tetracycline resistant N. gonorrhoeae.

slide32

Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2002

Note: Resistant isolates have ciprofloxacin MICs > 1 g/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 g/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

nongonococcal urethritis

Drips

Nongonococcal Urethritis

Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas

nongonococcal urethritis34

Drips

Nongonococcal Urethritis
  • Etiology:
    • 20-40% C. trachomatis
    • 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium)
    • Occasional Trichomonas vaginalis, HSV
    • Unknown in ~50% cases
  • Sx: Mild dysuria, mucoid discharge
  • Dx: Urethral smear  5 PMNs (usually 15)/OI field Urine microscopic  10 PMNs/HPF Leukocyte esterase (+)
epidemiology of chlamydia

Chlamydia

Epidemiology of Chlamydia
  • Incidence: Approximately 4 million estimated cases in U.S. per annum
  • Most frequently reported STD in U.S.
  • Rates 4x higher in females
  • Decreasing prevalence in selected areas with control programs that include clinic-based screening
  • High prevalence of coinfection in partners (>50%)
  • Perinatal transmission results in neonatal conjunctivitis in 30-50% of exposed babies
chlamydia rates by gender united states 1984 2001

Chlamydia

Chlamydia — Rates by gender: United States, 1984–2001

Source: CDC/NCHSTP 2001 STD Surveillance Report

chlamydia age and sex specific rates united states 2001

Chlamydia

Chlamydia — Age- and sex-specific rates: United States, 2001

Source: CDC/NCHSTP 2001 STD Surveillance Report

chlamydia rates by state united states and outlying areas 2001

Chlamydia

Chlamydia — Rates by state: United States and outlying areas, 2001

Note: The total rate of chlamydia for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 275.5 per 100,000 population.

Source: CDC/NCHSTP 2001 STD Surveillance Report

nongonococcal urethritis39
Nongonococcal Urethritis

Azithromycin 1 gm in a single dose

or

Doxycycline 100 mg bid x 7 days

nongonococcal urethritis alternative regimens
Nongonococcal UrethritisAlternative regimens

Erythromycin base 500 mg qid for 7 days

or

Erythromycin ethylsuccinate 800 mg qid for 7 days

or

Ofloxacin 300 mg twice daily for 7 days

or

Levofloxacin 500 mg daily for 7 days

recurrent persistent urethritis
Recurrent/Persistent Urethritis
  • Objective signs of urethritis
  • Re-treat with initial regimen if non-compliant or re-exposure occurs
  • Intraurethral culture for trichomonas
  • Effective regimens not identified in those with persistent symptoms without signs
recurrent persistent urethritis42
Recurrent/Persistent Urethritis

Metronidazole 2 gm single dose

PLUS

Erythromycin base 500 mg qid x 7d

or

Erythromycin ethylsuccinate 800 mg qid x 7d

chlamydia trachomatis

Drips

Chlamydia trachomatis
  • More than three million new cases annually
  • Responsible for causing cervicitis, urethritis, proctitis, lymphogranuloma venereum, and pelvic inflammatory disease
  • Direct and indirect cost of chlamydial infections run into billions of dollars
  • Potential to transmit to newborn during delivery
    • Conjunctivitis, pneumonia
normal cervix

Drips

Normal Cervix

Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center

chlamydia cervicitis

Drips

Chlamydia Cervicitis

Source: St. Louis STD/HIV Prevention Training Center

mucopurulent cervicitis

Drips

Mucopurulent Cervicitis

Source: Seattle STD/HIV Prevention Training Center

chlamydia life cycle

Drips

Chlamydia Life Cycle

Source: California STD/HIV Prevention Training Center

laboratory tests for chlamydia

Drips

Laboratory Tests for Chlamydia
  • Tissue culture has been the standard
    • Specificity approaching 100%
    • Sensitivity ranges from 60% to 90%
  • Non-amplified tests
    • Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
      • sensitivity and specificity of 85% and 97% respectively
      • useful for high volume screening
      • false positives
    • Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2
      • sensitivities ranging from 75% to 100%; specificities greater than 95%
      • detects chlamydial ribosomal RNA
      • able to detect gonorrhea and chlamydia from one swab
      • need for large amounts of sample DNA
laboratory tests for chlamydia continued

Drips

Laboratory Tests for Chlamydia (continued)
  • DNA amplification assays
    • polymerase chain reaction (PCR)
    • ligase chain reaction (LCR)
  • Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100%
  • LCR ability to detect chlamydia in first void urine
chlamydia direct fluorescent antibody dfa

Drips

Chlamydia Direct Fluorescent Antibody (DFA)

Source: Centers for Disease Control and Prevention

pelvic inflammatory disease pid

Drips

Pelvic Inflammatory Disease (PID)
  • l0%-20% women with GC develop PID
  • In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID
  • CDC minimal criteria
    • uterine adnexal tenderness, cervical motion tenderness
  • Other symptoms include
    • endocervical discharge, fever, lower abd. pain
  • Complications:
    • Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia
    • 7X risk of ectopic pregnancy with 1 episode PID
    • chronic pelvic pain in 18%
pelvic inflammatory disease

Drips

Pelvic Inflammatory Disease

Source: Cincinnati STD/HIV Prevention Training Center

c trachomatis infection pid

Drips

C. trachomatis Infection (PID)

Normal Human

Fallopian Tube Tissue

PID Infection

Source: Patton, D.L. University of Washington, Seattle, Washington

pelvic inflammatory disease54
Pelvic Inflammatory Disease

Minimum Diagnostic Criteria

Uterine/adnexal tenderness or cervical motion tenderness

Additional Diagnostic Criteria

Oral temperature >38.3 C Elevated ESR

Cervical CT or GC Elevated CRP

WBCs/saline microscopy Cx discharge

pelvic inflammatory disease definitive diagnostic criteria
Pelvic Inflammatory DiseaseDefinitive Diagnostic Criteria
  • Endometrial biopsy with histopathologic evidence of endometritis
  • Transvaginal sonography or MRI showing thick fluid-filled tubes
  • Laparoscopic abnormalities consistent with PID
pelvic inflammatory disease hospitalization
Pelvic Inflammatory DiseaseHospitalization
  • Surgical emergencies not excluded
  • Pregnancy
  • Clinical failure of oral antimicrobials
  • Inability to follow or tolerate oral regimen
  • Severe illness, nausea/vomiting, high fever
  • Tubo-ovarian abscess
pelvic inflammatory disease57
Pelvic Inflammatory Disease
  • No efficacy data compare parenteral with oral regimens
  • Clinical experience should guide decisions regarding transition to oral therapy
  • Until regimens that do not adequately cover anaerobes have been demonstrated to prevent sequelae as successfully as regimens active against these microbes, regimens should provide anaerobic coverage
pelvic inflammatory disease parenteral regimen a
Pelvic Inflammatory DiseaseParenteral Regimen A

Cefotetan 2 g IV q 12 hours

or

Cefoxitin 2 g IV q 6 hours

PLUS

Doxycycline 100 mg orally/IV

q 12 hrs

pelvic inflammatory disease parenteral regimen b
Pelvic Inflammatory DiseaseParenteral Regimen B

Clindamycin 900 mg IV q 8 hours

PLUS

Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.

pelvic inflammatory disease alternative parenteral regimens
Pelvic Inflammatory DiseaseAlternative Parenteral Regimens

Ofloxacin 400 mg IV q 12 hours

or

Levofloxacin 500 mg IV once daily

WITH OR WITHOUT

Metronidazole 500 mg IV q 8 hours

or

Ampicillin/Sulbactam 3 g IV q 6 hrs

PLUS

Doxycycline 100 mg orally/IV q 12 hrs

pelvic inflammatory disease oral regimen a
Pelvic Inflammatory DiseaseOral Regimen A

Ofloxacin 400 mg twice daily for 14 days

or

Levofloxacin 500 mg once daily for 14 days

WITH OR WITHOUT

Metronidazole 500 mg twice daily for 14 days

pelvic inflammatory disease oral regimen b
Pelvic Inflammatory DiseaseOral Regimen B

Ceftriaxone 250 mg IM in a single dose

or

Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently

PLUS

Doxycycline 100 mg twice daily for 14 days

WITH or WITHOUT

Metronidazole 500 mg twice daily for 14 days

pelvic inflammatory disease management of sex partners
Pelvic Inflammatory DiseaseManagement of Sex Partners
  • Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt’s onset of symptoms
  • Sex partners should be treated empirically with regimens effective against CT and GC