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S exually Transmitted Infections ( STIs ) Update: 2014. Joseph M. Gastaldo, MD OhioHealth, Riverside Methodist Hospital April 23, 2014. Evolution of words .

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s exually transmitted infections stis update 2014

Sexually Transmitted Infections (STIs) Update: 2014

Joseph M. Gastaldo, MD

OhioHealth, Riverside Methodist Hospital

April 23, 2014

evolution of words
Evolution of words ...

Venereal Disease (VD): venereus (Venus; Roman goddess of love); relating to sexual intercourse or desire; term lost favor in late 20th century

Sexually Transmitted Disease (STD) symptomatic

Sexually Transmitted Infection (STI) term introduced by public health officials; more inclusive; may be symptomatic or asymptomatic

what are stis how are they transmitted
What are STIs & How are They Transmitted ?

Caused by more than 30 different bacteria, viruses, & parasites & are spread predominantly by sexual contact (vaginal, oral, anal)

Pathogens with greatest incidence of illness: syphilis, gonorrhea, chlamydia, trichomoniasis HBV, herpes, HIV, HPV

Variable presentation: vaginal discharge, urethral discharge in men, oral or anogenital ulcers, abdominal pain, asymptomatic

objectives outline
Objectives / Outline

Recognize the public health burden & spectrum of pathology associated with STIs

Understand the association of STIs and risk of HIV transmission; STI prevention is part of HIV prevention

Appreciate the common presentation and disease spectrum associated with various STIs; recognize treatment regimens

Have an appreciation to the complexity of a practicing venereologist

cdc statistics april is std awareness month
CDC Statistics April is STD Awareness Month

STIs are a significant health challenge; costing the nation an estimated $16 billion annually

20 million new STIs annually; half among persons ages 15-24 years

Reported data is only a fraction of the true burden; many cases of chlamydia, gonorrhea, & syphilis go undiagnosed & underreported; HPV, HSV, trichomoniasis are not routinely reported

CDC.Gov Fact Sheet; 2012

who statistics who int
WHO Statistics who.int

More than 1 million people acquire an STI every day

Each year, an estimated 500 million people become ill with one of 4 STIs: chlamydia, gonorrhea, syphilis, and trichomoniasis

More than 530 million people have the virus mostly associated with genital HSV (HSV2)

More than 290 million women have HPV infection

The majority of STIs are present without symptoms

estimated new cases of curable stis gonorrhea chlamydia syphilis trichomoniasis 2008 who int
Estimated new cases of curable STIs (gonorrhea, chlamydia, syphilis, trichomoniasis), 2008 who.int
stis widespread health implications
STIs: Widespread Health Implications

Infertility/reproductive health: pregnancy complications, infertility, PID Int J Gyn Ob. 2013 Dec; 123(3): 183-4

Neonatal health: in utero & perinatal transmission; stillbirth, pneumonia, congenital deformities J FamPract 1990 Apr; 30(4):448-56

Malignancy: worldwide, HPV infection causes 530K cases of cervical cancer (275K deaths) WHO fact sheet; updated 2013; who.int

Antibiotic resistance: gonorrhea with evolving resistance to ceftriaxoneExpert Rev Anti In Ther 2014 Apr 4

Transmission of HIV; STD prevention is part of HIV prevention

Strong association between STIs & Increased risk of HIV infection CurrOpin HIV AIDS Jul 2010; 5(4):305-10

Infections that disrupt the the epithelial surface of the genital tract  facilitate the the access of HIV to target cells under the epithelial surface

Ulcerative diseases: herpes, syphilis BMJ 1989; 298(6674):623-4 inflammatory conditions: trichomoniasis

Observed striking increase in the prevalence of concordant HIV infection & syphilis CID (2007) 44(9):1222-8

HIV patient: conditions that recruits PMNs to the genital tract are associated with increase in HIV shedding STDs 2008; 35(11):946-59

stis hiv infected persons
STIs & HIV Infected Persons

In HIV infected persons, new STIs are events that signal HIV exposure to others

Baltimore City HD; 796 men/354 women diagnosed with HIV from 1993-8; 13.9% of men & 11.9% of women were diagnosed with an STI after there HIV diagnosis JAIDS 33:247-52

Higher risk for HIV/STI coinfections: MSM, minorities, lower socioeconomic class AIDS Behav 2011 15(sup 1)

dr gastaldo s suggestions for intervention slide 1
Dr. Gastaldo’s Suggestions for Intervention; slide 1

Assume that all HIV infected/STI patients are sexually active ! (Duh)

Sexual inquiries; lack of HCWs “comfort level”, lack of sensitivity, lack of training to sensitive questioning.

Risk behavior counseling: mental health screening, substance abuse/PNP, “hook up” smart phone apps

Routine STI screening: syphilis antibody,NAAT for gonorrhea & chlamydia

dr gastaldo s suggestions for intervention slide 2
Dr. Gastaldo’s Suggestions for Intervention; slide 2

Safe sexual practice discussion

Discussion & consideration for PrEP in appropriate HIV (-) person

Immunizations: HAV, HBV, HPV: ACIP recommends vaccination with HPV4 through age 26 in: MSM, immunocompromised males, HIV infected males

pathogens presentation treatment
Pathogens / Presentation / Treatment

Bacterial: syphilis, gonorrhea, chlamydia

Protozoa: Trichomonasvaginalis

Viruses: HSV, HPV

neisseria gonorrhoeae cdc gov practice guidelines
NeisseriagonorrhoeaeCDC.gov, practice guidelines

Gram (-) diplococcus; infects surfaces lined with columnar epithelial cells (endocervix, urethra, anogenital, oropharyngeal, conjuctiva); always considered a pathogen

Men: usually causes symptomatic urethritis, up to 25% may be asymtomatic, epididymitis: most frequent complication

MSM, screening: urethral, rectal, & pharyngeal infection (NAAT)

neisseria gonorrhoeae cdc gov practice guidelines1
NeisseriagonorrhoeaeCDC.gov, practice guidelines

Women: up to 50% asymptomatic; cervicitis, perihepatitis, PID, perinatal morbidity

Both sexes: anorectal infection, pharyngitis, conjuctivitis, disseminated infection (tenosynovitis, severe: meningitis, IE)

Incubation period: 3-7 days in men, unclear in women (10 days?)

Diagnosis: culture & gram stain: only test that determines antibiotic sensitivity; gram stain alone is diagnostic for urethral (SYMPTOMATIC men) testing; preferred method when dx unclear; used to confirm positive NAAT result in low prevalence areas, culture all sites will increase yield NAAT: routinely used for urine, vaginal, penile/urethral (FDA approved) more rapid turnaround time than culture; use culture for dx from extra-genital sites (rectal & pharyngeal) unless the lab has conducted internal validation of non-cultured based method (Quest Diagnostics & Laboratory Corporation of America have validated)

neisseria gonorrhoeae rx cdc gov practice guidelines
Neisseriagonorrhoeae: RxCDC.gov, practice guidelines

Resistance rates (>25%) to fluoroquinolones: No

Oral cephalosporins are not preferred

Uncomplicated infections of cervix, urethra, rectum, & pharynx: 250 mg IM plus azithromycin 1 gram single dose or PO doxycycline for 7 days (for specific circumstances, other regimens exist, but TOC needed)

Disseminated infections: IV ceftriaxone; consideration to PO antibiotic transition 24-48 hours after improvement; meningitis/IE: IV ceftriaxone

Evaluate & treat partners

chlamydia trachomatis cdc gov guidelines
Chlamydia trachomatisCDC.gov, guidelines

Does not gram stain; intracellular; D-K biovars: GU infection;L serovars: lymphogranulomavenereum (LGV); systemic infection; genital ulcer-adenopathy syndrome

Only 10% of men & 5-30% of women develop symptoms

Spectrum of disease: urethritis, cervicitis, PID, epididymitis, prostatitis (rare), protitis, colitis, pharyngitis, sexually associated reactive arthritis, SARA, formerly known as Reiter’s syndrome

MSM: 3-10% test positive on rectal screening; 1-2% on pharyngeal screening

J Am Coll Health 60:481, 2012

Testing: NAATsmore sensitive than non amplification tests Endocervical, vaginal (self collected), urethral, oropharyngeal**, urine, rectal swabs** (not FDA approved, some labs have met CLIA requirements & validated NAAT testing on rectal swabs) Check with your lab.

chlamydia trachomatis rx cdc gov practice guidelines
Chlamydia trachomatis: RxCDC.gov, practice guidelines

Azithromycin 1 gram orally in a single dose or doxycycline 100 mg orally BID for 7 days.

Treat sexual partners

To minimize disease transmission, persons treated should obstain from from sexual intercourse for 7 days after a single dose Rx or until 7 day Rx is complete

Test of cure: pregnant women

Infected persons should be retested 3 months after Rx; post treatment infection: re-infection

syphilis treponema pallidum cdc gov practice guidelines
Syphilis; TreponemapallidumCDC.gov, practice guidelines

Systemic infection; protean signs & symptoms

Primary: chancre (painless, clean based ulcer with indurated edges) occurs at point of introduction/contact 10-90 days after exposure; chancre can occur in many places Regional adenopathy; patient is contagious

Untreated lesions spontaneously heal in 3-6 weeks

Diagnosis: examination, darkfield microscopy or DFA, RPR often (-)

secondary syphilis highly variable cdc gov practice guidelines
Secondary syphilis; highly variable CDC.gov, practice guidelines

“Copper penny” macular lesions on palms & soles, generalized or focal, non-puritic/painless

Fever, malaise, anorexia, occasionally meningismus

Onset up to 6 months after exposure

Highly infectious; lesions will heal without Rx

Diagnosis: RPR, high titers can be seen, examination

early latent late latent syphilis cdc gov practice guidelines
Early latent & late latent syphilisCDC.gov, practice guidelines

Early: asymptomatic period from spontaneous resolution of primary or secondary  first year 25% will have relapse of secondary; patients considered infectious; unrecognized relapse Diagnosis: both non-trepomenal & treponemal tests (+)

Late: asymptomatic infection; non-infectious evaluate for clinical evidence of teriary or ocular disease Diagnosis: serology, non-treponemal test may revert to normal Consider CSF exam if neurologic symptoms; HIV patient with neurologic symptoms

neurosyphilis can occur at any stage cdc gov practice guidelines
Neurosyphilis: can occur at any stageCDC.gov, practice guidelines

Meningitis & eye disease may occur during primary or secondary stages & during the first 5-10 years of untreated infection

Syphilitic eye disease eye disease: uveitis, iritis, optic neuritis, neuroretinitis

“Classic manifestations” after 15-20 years of untreated infection: tabesdorsalis & general paresis (can be with psychotoc or dementia features)

Diagnosis: CSF examination; serology (pleocytosis, elevated protein, VDRL)

syphilis rx penicillin cdc gov guidelines
Syphilis: Rx: penicillinCDC. Gov, guidelines

Primary & secondary: benzathine PCN (BPG) 2.4 mu IM as a single dose; allergy: 14 days doxycycline, 2 grams PO azithromycin: need CLOSE f/u; Jarisch-Herxheimer reaction

Early latent: BPG IM times 1 dose

Late latent or unknown: BPG IM q 7 days time 3 doses; being late >2 days not recommended

Neurosyphilis/ocular: IV PCN-G for 10-14 days consider desensitization with PCN allergy

Pregnant women: use PCN; desensitize

HIV: PCN is drug of choice

syphilis follow up cdc gov practice guidelines
Syphilis: follow upCDC.gov, practice guidelines

NTAT (RPR): 4 fold change in titer (2 dilutions) considered a significant change; use same test & lab

NTAT usual revert to NR status over time; persistent low levels: serofast

Treponemal EIA: identifies previously treated & untreated persons

Neurosyphilis: if pleocytosis initially seen, repeat CSF every 6 months until cell count is normal; if cell count is not decreased at 6 months or normal at 2 years, consider re-treatment.

HIV: RPR at 3,6,9,12, & 24 months; failure: persistant or recurrent symptoms, sustained rise in RPR. If failure: consider CSF exam & retreatment; consider Rx for late latent

trichomonas vaginalis cdc gov practice guidelines
TrichomonasvaginalisCDC.gov, practice guidelines

Most common non-viral STI in US; 7.3 million estimated annual new cases

Pear shaped, motile, flagellated protozoan parasite

Parasites invade superficial epithelium; inflammation; enhances acquisition of HIV infection; can survive up to 45 minutes on clothing & bathwater

Women: 50% asymptomatic; vaginal discharge; profuse, sometimes frothyvulvovaginal irritation, “strawberry” cervix, consider PID with abdominal pain

Men: up to 75% asymptomatic, urethritis, epididymitis, prostatitis, balantitis

trichomonas vaginalis cdc gov practice guidelines1
TrichomonasvaginalisCDC.gov, practice guidelines

Diagnosis women: microscopy of vaginal secretions (60-70% sensitive), “whiff test”, pH >4.5, POC testing; nucleic acid probe tests (Affirm VP III), culture

Diagnosis men: wet prep with poor sensitivity, no approved point-of-care tests; culture of urethral swab, urine, or semen

APTIMA T. vaginalisAnalyte Specific Reagents (ASR); detects RNA using same methodology for GC & Chlamydia; CLIA verification studies

T. vaginalishas not been found to infect oral sites

Rectal prevalence appears low in MSM

trichomonas vaginalis rx cdc gov practice guidelines
Trichomonasvaginalis: RxCDC.gov, practice guidelines

Uncomplicated: metronidazole 2 gr PO x 1 dose

Cystitis, prostatitis, epididymitis: longer duration

PO metronidazole with 95% cure rate

Metronidazole gel: 50% efficacy; not recommended

Low level metronidazole resistance: 2-5% high level resistance is rare; retreat patients with 7 day course if Rx failure

Metronidazole: Antabuse reaction; avoid EtOH

Treat partners

Herpes Simplex virus (HSV)“Most people infected with genital herpes do not know they have it” CDC.gov, practice guidelines

HSV-1 & HSV-2, Herpes DNA virus family (HHV-1 & HHV-2)

After primary infection, establishes latency in neurons, potential for reactivation, usually near site of primary infection

Most infections are asymptomatic: HSV-1: 50-80% of adults seropositive, HSV-2: 20-40% of adults are seropositive(US data)

HSV-1: herpes labialis most common form of recurrent HSV-1, 30% of genital HSV is HSV-1

Diagnosis for GU/mucocutaneousinfx: clinical presentation; viral culture of ulcer/vesicle

Primary infection: Asymptomatic in two-thirds of both HSV-1 & HSV-2; clinical presentation: vesicular infection; primary gingivostomatitis; mononucleosis syndrome; genital infection: small painful, clustered vesicles; shallow ulcerations; can be “systemically ill”

hsv fyi cdc gov practice guidelines
HSV: FYICDC.gov, practice guidelines

HSV-2 more likely to have clinical recurrences

Genital ulcer disease (HSV, chancre) increases the risk of acquisition & transmission of HIV

Psychological impact of HSV cannot be overestimated

Both condom use & daily valacyclovir use: reduce the transmission course in discordant couples NEJM 350:11, 2004

HIV infection: 60-70% infected with HVS-2; disseminated/severe infections can occur with CD4<200

Acute immunosuppression may reactivate

hsv rx cdc gov practice guidelines
HSV: RxCDC.gov, practice guidelines

Acyclovir, valacyclovir*, famciclovir*

Generally well tolerated; nausea, vomiting, HA

Dose adjustment need for GFR < 50 mL/min

Dosing based on indication: use reference

Valacyclovir: first episode of genital HSV: 1 gr BID for 7-10 days Recurrent genital HSV: 500 mg BID (1 gr BID if severe) Suppressive therapy: 500 mg BID Herpes labialis: 1 grq 12 hours for 2 doses