SEXUAL TRANSMITED DISEASES

Current Overview of Sexually Transmitted Diseases (STDs) Linda Creegan, FNP California STD/HIV Prevention Training Center

Common STDs Bacterial diseases Bacterial diseases Chlamydia (CT) Chlamydia (CT) Gonorrhea (GC) Gonorrhea (GC) Syphilis Syphilis Trichomoniasis (Trich) Trichomoniasis (Trich) Viral diseases Viral diseases Human Papillomavirus (HPV) Human Papillomavirus (HPV) Genital herpes (HSV-2 or HSV-1) Genital herpes (HSV-2 or HSV-1) Hepatitis B Hepatitis B

Reportable STDs Regulations vary from state to state Regulations vary from state to state Reportable in all states Chlamydia Gonorrhea Syphilis Chancroid Hepatitis B AIDS Generally not reportable Human Papillomavirus Genital herpes Trichomoniasis

Chlamydia Infection Incidence is highest among sexually active adolescents and young adults Incidence is highest among sexually active adolescents and young adults Most infections are asymptomatic Most infections are asymptomatic Leading cause of preventable infertility in women Leading cause of preventable infertility in women

Chlamydia Infections in Women, Men, and Neonates Genitals GenitalsCervicitisPIDUrethritis Eye (Conjunctivitis) Eye (Conjunctivitis) Throat (Pharyngitis) Throat (Pharyngitis) Rectum Rectum(Proctitis) Eye (conjunctivitis) Lungs (pneumonia) 70-80% ASYMPTOMATIC Genitals (Urethritis) (Epididymitis) Rectum (Proctitis) Throat (Pharyngitis) Eye (Conjunctivitis) Systemic (Reiter’s Syndrome) >50% ASYMPTOMATIC

Genital Chlamydia in Women: Complications Untreated genital CT infection Ectopic pregnancy Infertility Chronic pelvic pain Acute PID Silent PID 9% 14-20% 18% 20-50%

Chlamydia Infection Clinical Manifestations

Cervical Ectopy Ectopy SCJMinimal ectopy STD Atlas, 1997

What IS Screening????? Screening testing Screening testing Looking for disease which gives no symptoms Looking for disease which gives no symptoms Most effective when done for a common disease with bad consequences using a highly accurate, non-invasive, inexpensive test Most effective when done for a common disease with bad consequences using a highly accurate, non-invasive, inexpensive test Diagnostic testing Diagnostic testing Looking for the cause of abnormal signs, symptoms, etc Looking for the cause of abnormal signs, symptoms, etc

Chlamydia Screening & Treatment  Decreases community prevalence  Prevents pelvic inflammatory disease  Scholes et al., NEJM, 1996; 334:  Cost effective CDC estimates that “for every dollar spent on chlamydia screening, we could save $12” CDC estimates that “for every dollar spent on chlamydia screening, we could save $12”  Opportunity to increase awareness and provide risk reduction counseling

What about chlamydia screening among men? Obvious source of transmission Obvious source of transmission Urine-based testing advantage Urine-based testing advantage Unpublished cost effectiveness analysis demonstrate community and future partner benefits Unpublished cost effectiveness analysis demonstrate community and future partner benefits Limited data on prevalence & outcomes Limited data on prevalence & outcomes No guidelines available No guidelines available

Chlamydia Screening Recommendations CDC, NCQA HEDIS, USPSTF, ACOG and others are similar CDC, NCQA HEDIS, USPSTF, ACOG and others are similar All sexually active women under 26 yoa All sexually active women under 26 yoa Initial screen Initial screen Repeat annually Repeat annually Consider repeat with new or multiple sex partners Consider repeat with new or multiple sex partners Repeat 2-3 months after an infection Repeat 2-3 months after an infection All pregnant women under 26 yoa All pregnant women under 26 yoa Men, and women 26 and older, consider with Men, and women 26 and older, consider with New or multiple sex partners, New or multiple sex partners, Inconsistent condom use Inconsistent condom use

Urine-Based CT Tests Highly accurate Highly accurate Non-invasive collection Non-invasive collection High patient acceptability High patient acceptability Only test appropriate for screening asymptomatic males Only test appropriate for screening asymptomatic males Screening in non-clinical settings Screening in non-clinical settings Community settings Community settings Home testing Home testing

Chlamydia Partner Management Transmissibility: Transmissibility: male to female: 45-55% (culture) to 70% (PCR) male to female: 45-55% (culture) to 70% (PCR) female to male: 28-42% (culture) to 68% (PCR) female to male: 28-42% (culture) to 68% (PCR) Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated

Patient-Delivered Partner Therapy Repeat CT infections place women at greater risk for PID and infertility than first infection Repeat CT infections place women at greater risk for PID and infertility than first infection Most important risk factor for re-infection is an untreated partner Most important risk factor for re-infection is an untreated partner Multi-center CDC trial demonstrated 20% decrease in re-infection with PDT Multi-center CDC trial demonstrated 20% decrease in re-infection with PDT Single-dose azithromycin has very few adverse reactions Single-dose azithromycin has very few adverse reactions Authorized by law in California Authorized by law in California

Chlamydia: KEY POINTS Most common bacterial (curable) STD Most common bacterial (curable) STD Most cases in women and men give no symptoms Most cases in women and men give no symptoms Leading cause of PID and infertility in women Leading cause of PID and infertility in women All sexually active women 25 y.o.a. and younger should be tested at least annually All sexually active women 25 y.o.a. and younger should be tested at least annually

Gonorrhea Infection Gonorrhea Infection Caused by Neisseria gonorrhoeae Caused by Neisseria gonorrhoeae Overall rates falling, but incidence in certain groups remains high Overall rates falling, but incidence in certain groups remains high Most common in young adults and adolescents Most common in young adults and adolescents CT co-infection of GC cases remains at about 40% CT co-infection of GC cases remains at about 40% Resistance to medication is an spreading problem Resistance to medication is an spreading problem

Gonorrhea Infections in Men, Women and Neonoates Men are usually symptomatic (urethra), women are commonly asymptomatic Men are usually symptomatic (urethra), women are commonly asymptomatic Men: urethral infection, epididymitis Men: urethral infection, epididymitis Usually gives pain with urination and heavy, thick penile discharge; few may be asymptomatic carriers Usually gives pain with urination and heavy, thick penile discharge; few may be asymptomatic carriers Women: cervical infection, PID Women: cervical infection, PID ~50% women asymptomatic, others have pain with urination, vaginal discharge or bleeding ~50% women asymptomatic, others have pain with urination, vaginal discharge or bleeding Other sites of infection: throat, rectum, eye Other sites of infection: throat, rectum, eye Neonates: eye and skin infections Neonates: eye and skin infections

Gonorrhea Infections Clinical Manifestations

GC Partner Management Transmissibility: Transmissibility: Male to female: % Male to female: % Female to male: % Female to male: % Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated If no sex partners in previous 60 days, treat the most recent partner If no sex partners in previous 60 days, treat the most recent partner

Increasing Medication Resistance Almost all GC isolates testing in Asia are resistant to fluoroquinolones (Cipro and related medications) Almost all GC isolates testing in Asia are resistant to fluoroquinolones (Cipro and related medications) Resistant GC is spreading to the U.S. Resistant GC is spreading to the U.S. About 9% of isolates in Hawaii, 2002 About 9% of isolates in Hawaii, 2002 More than 10% of isolates in California, 2002 More than 10% of isolates in California, 2002

Gonorrhea Infection Screening Considerations Screening is probably not warranted when GC prevalence is under 1% Screening is probably not warranted when GC prevalence is under 1% Accuracy of screening is dependent on: Accuracy of screening is dependent on: Prevalence of disease in the population Prevalence of disease in the population Sensitivity and specificity of test used Sensitivity and specificity of test used Screening a low-prevalence population can result in more false-positives than true-positives Screening a low-prevalence population can result in more false-positives than true-positives

Syphilis Incidence had been steadily declining in the U.S. since 1990 Incidence had been steadily declining in the U.S. since U.S. counties account for 50% of the reported cases 28 U.S. counties account for 50% of the reported cases In 1999, the CDC initiated a nation-wide Syphilis Elimination Effort, targeting these areas In 1999, the CDC initiated a nation-wide Syphilis Elimination Effort, targeting these areas Recently, local outbreaks centered in urban areas among MSM Recently, local outbreaks centered in urban areas among MSM

Syphilis Distribution of the Organism STD Atlas, 1997

Primary Syphilis Photos: Dr. Joseph Engelman, San Francisco City Clinic

Rash of Secondary Syphilis Photo: Dr. Joseph Engelman, San Francisco City Clinic STD Atlas, 1997

Secondary Syphilis Other Symptoms Photo: Dr. Joseph Engelman San Francisco City Clinic Comdyloma lata DOIA Website, 2000 STD Atlas, 1997

Syphilis New Therapies Penicillin G (an injectable) remains the first line treatment Penicillin G (an injectable) remains the first line treatment Limited data support the use of Azithromycin (in a one-time oral dose) as an alternative regimen Limited data support the use of Azithromycin (in a one-time oral dose) as an alternative regimen Azithromycin 2 gm orally in a single dose as treatment for early syphilis Azithromycin 2 gm orally in a single dose as treatment for early syphilis Azithromycin 1 gm orally in a single dose as prophylactic treatment for contacts to infectious syphilis Azithromycin 1 gm orally in a single dose as prophylactic treatment for contacts to infectious syphilis Has not been well-studied in HIV + patients; larger trials ongoing Has not been well-studied in HIV + patients; larger trials ongoing Cefrtiaxone almost certainly effective, but best dose/duration has not been established Cefrtiaxone almost certainly effective, but best dose/duration has not been established

Syphilis: KEY POINTS Serious systemic infection Serious systemic infection Strong connection with HIV transmission Strong connection with HIV transmission Yearly testing of all HIV-positive patients is recommended Yearly testing of all HIV-positive patients is recommended

Genital Herpes: Overview Genital Herpes: Overview Caused by Herpes Simplex Viruses Caused by Herpes Simplex Viruses HSV 1: orolabial herpes HSV 1: orolabial herpes HSV 2: genital herpes HSV 2: genital herpes Both symptomatic & asymptomatic infections are common Both symptomatic & asymptomatic infections are common Can cause serious complications Can cause serious complications Asymptomatic shedding is well documented Asymptomatic shedding is well documented

Genital Herpes Infection Epidemiology u Estimated annual incidence: 600,000 to 1 million cases NHANES data provided new view of HSV-2 prevalence in the U.S. NHANES data provided new view of HSV-2 prevalence in the U.S. Twenty-two percent of adults estimated to be infected with HSV-2 Twenty-two percent of adults estimated to be infected with HSV-2 Rates are higher in HIV infected persons, African Americans and adults of lower socioeconomic status Rates are higher in HIV infected persons, African Americans and adults of lower socioeconomic status Most infections are unrecognized because of mild symptoms or absence of symptoms Most infections are unrecognized because of mild symptoms or absence of symptoms

Genital Herpes Transmission u Major routes: sexual & mother-to-infant u Most sexual transmission probably occurs when index case is asymptomatic u Efficiency of transmission is greater from men to women than women to men u Mertz, et al: 144 serodiscordant couples u Almost 17% man-to-woman transmission u Almost 4% woman-to-man transmission

Genital Herpes Natural History Initial infection Initial infection Virus enters through microscopic breaks in skin Virus enters through microscopic breaks in skin Establishes chronic infection Establishes chronic infection Virus becomes latent in nerves cells along spinal cord Virus becomes latent in nerves cells along spinal cord Infection persists despite host immune response Infection persists despite host immune response Virus may remain latent indefinitely or can reactivate Virus may remain latent indefinitely or can reactivate Virus can reactivate Virus can reactivate Precipitating factors: trauma, fever, UVL, stress Precipitating factors: trauma, fever, UVL, stress Virus reproduces and moves along nerve axon to skin or mucosa, and recurrent lesions can occur Virus reproduces and moves along nerve axon to skin or mucosa, and recurrent lesions can occur Reactivation (shedding) can also be asymptomatic Reactivation (shedding) can also be asymptomatic

Genital Herpes Educating to Recognize Symptoms 62 HSV-2 seropositive women denying history of genital symptoms were intensively educated 62 HSV-2 seropositive women denying history of genital symptoms were intensively educated 77% then presented with culture-+ lesions 77% then presented with culture-+ lesions 53 seropositive asymptomatic men and women with education 53 seropositive asymptomatic men and women with education 87% with subsequent symptoms 87% with subsequent symptoms Landenberg, 1989 & Wald, 2000

Genital Herpes Patient’s Perception of Etiology Women Yeast infection Yeast infection Vaginitis Vaginitis UTI UTI Menstrual complaint Menstrual complaint Hemorrhoids Hemorrhoids Allergies (condoms, sperm, spermicide, pantyhose Allergies (condoms, sperm, spermicide, pantyhose Rash from sex, shaving, bike seat Rash from sex, shaving, bike seat Men Folliculitis Jock itch “Normal” itch Zipper burns Hemorrhoids Allergy to condom Irritation from tight jeans, sex, bike seat Insect bite Koutsky, NEJM, 1992

Genital Herpes Asymptomatic Shedding Multiple studies have documented asymptomatic shedding with culture and DNA amplification techniques Multiple studies have documented asymptomatic shedding with culture and DNA amplification techniques Occurs in up to 90% of patients with HSV-2 Occurs in up to 90% of patients with HSV-2 Most common in first two years after infection (5-10% of days), less common thereafter (2% of days) Most common in first two years after infection (5-10% of days), less common thereafter (2% of days) Shedding may occur from cervix, vulva, urethra, rectum, penis Shedding may occur from cervix, vulva, urethra, rectum, penis Asymptomatic shedding reduced by antiviral suppression Asymptomatic shedding reduced by antiviral suppression

Neonatal Herpes Infection u Neonatal infection occurs u Clinical disease manifests at 3-30 days of age u Skin, eye or mucous membrane: low mortality, but recurrences possible CNS: 30% mortality, 50% serious sequelae CNS: 30% mortality, 50% serious sequelae Disseminated: 80% mortality, 10% serious sequelae Disseminated: 80% mortality, 10% serious sequelae u Overall mortality ~ 20%

Herpes Transmission in Pregnancy u Most transmission occurs at time of delivery, rarely in utero u Risk factors: primary infection, new infection, scalp electrodes u Over half of infants with neonatal infection are born to mothers with no history of genital herpes

Blood Tests for Herpes Older blood tests did not distinguish HSV-1 from HSV-2 antibody Older blood tests did not distinguish HSV-1 from HSV-2 antibody Newer blood tests accurately distinguish type-specific glycoproteins gG1 and gG2 Newer blood tests accurately distinguish type-specific glycoproteins gG1 and gG2

HSV Serology Testing Potential Uses, Diagnostic Testing Confirm diagnosis Confirm diagnosis Recurrent undiagnosed GUD Recurrent undiagnosed GUD Atypical presentations (e.g. urinary symptoms) Atypical presentations (e.g. urinary symptoms) Note: positive test does not necessarily correlate with symptoms Note: positive test does not necessarily correlate with symptoms Can help differentiate between Can help differentiate between Primary & non-primary infections Primary & non-primary infections Newly-acquired and older infections Newly-acquired and older infections

HSV Serology Testing Benefits and Limitations of Screening May be useful to patients for informing partners May be useful to patients for informing partners May be helpful for pregnant couples or for planning pregnancy May be helpful for pregnant couples or for planning pregnancy Does not tell Does not tell How long infected How long infected If person has had or will have symptoms If person has had or will have symptoms How likely a person is to shed asymptomatically How likely a person is to shed asymptomatically

HSV Serology Testing Potential Uses, Screening Not recommended for routine screening Not recommended for routine screening May be useful in certain at-risk populations and individuals May be useful in certain at-risk populations and individuals Patients with other STDs Patients with other STDs HIV infected persons and contacts HIV infected persons and contacts Contacts to HSV Contacts to HSV Certain prenatal patients Certain prenatal patients

Genital Herpes Treatment Options Treatment of symptomatic outbreaks Treatment of symptomatic outbreaks Suppression of symptoms by daily medication Suppression of symptoms by daily medication Daily medication to lessen chance of transmission Daily medication to lessen chance of transmission

Genital Herpes Psychological Impact A diagnosis of herpes can cause significant psychological distress A diagnosis of herpes can cause significant psychological distress Depression Depression Anger Anger Fear of rejection/discord in relationship Fear of rejection/discord in relationship Fear of passing infection to sex partners or infants Fear of passing infection to sex partners or infants Frustration regarding lack of a cure Frustration regarding lack of a cure Uncertainty about asymptomatic shedding Uncertainty about asymptomatic shedding

Genital Herpes Counseling about Transmission Encourage patients to inform their sex partners of the herpes diagnosis Encourage patients to inform their sex partners of the herpes diagnosis Advise patients to abstain from sexual activity when lesions are present Advise patients to abstain from sexual activity when lesions are present Discuss possibility of asymptomatic shedding Discuss possibility of asymptomatic shedding Discuss treatment options Discuss treatment options Encourage condom use with new or uninfected partners Encourage condom use with new or uninfected partners

Perinatal Herpes Infection Prevention Emphasize preventing acquisition of genital HSV during late pregnancy Emphasize preventing acquisition of genital HSV during late pregnancy u Counsel susceptible pregnant women whose partners have oral or genital HSV to avoid unprotected genital & oral sexual contact in late pregnancy Examine women in labor for genital herpes Examine women in labor for genital herpes Abdominal delivery is recommended with prodrome or active lesions at onset of labor Abdominal delivery is recommended with prodrome or active lesions at onset of labor Suppressive therapy near term to reduce number of C-sections in women with recurrent herpes is under investigation Suppressive therapy near term to reduce number of C-sections in women with recurrent herpes is under investigation

Genital Herpes Condom Effectiveness Latex condoms, when used consistently and correctly, are highly effective for: HIV HIV And can reduce the risk of: GC, CT, and Trichomonas GC, CT, and Trichomonas Genital herpes, syphilis, chancroid, and HPV, only when the infected areas are covered by the condom Genital herpes, syphilis, chancroid, and HPV, only when the infected areas are covered by the condom CDC, 2002

Genital Herpes Vaccine Development SmithKline Beecham Biologicals SmithKline Beecham Biologicals Two multicenter, double-blind, randomized placebo- controlled trials Two multicenter, double-blind, randomized placebo- controlled trials Participants had no history of genital herpes and a regular sex partner with HSV-2 Participants had no history of genital herpes and a regular sex partner with HSV-2 73% reduction in symptomatic cases in women who were also HSV-1 negative 73% reduction in symptomatic cases in women who were also HSV-1 negative Protects against symptoms of genital herpes, although not against acquisition of HSV-2 virus Protects against symptoms of genital herpes, although not against acquisition of HSV-2 virus No protective effect found in men No protective effect found in men

Genital Human Papillomavirus (HPV) Two disease processes caused by different viral types Two disease processes caused by different viral types Precancer and cancer of the genital tissues (abnormal Paps and anal carcinoma) Precancer and cancer of the genital tissues (abnormal Paps and anal carcinoma) Skin growths in the anogenital area (genital warts) Skin growths in the anogenital area (genital warts)

> 80 HPV Types Dermal HPVs nonsexual contact (>50 types) “Common” Warts (e.g., hands/feet) Genital HPVs sexual contact (>30 types) “High-risk” types “Low-risk” types low grade cervical abnormalities cancer precursors genital cancers low grade cervical abnormalities genital warts respiratory papillomatosis 6,11,42,43,44 16,18, 31,33,35,39, 45,51,52,56,58

What happens once people get infected with HPV? For most people, nothing will happen For most people, nothing will happen The body’s immune system usually eliminates HPV infection The body’s immune system usually eliminates HPV infection After HPV is found on the cervix, it becomes undetectable within 2 years in at least 90% of women After HPV is found on the cervix, it becomes undetectable within 2 years in at least 90% of women Some people who get “low-risk” types will develop: Some people who get “low-risk” types will develop: Visible genital warts Visible genital warts Low-grade Pap smear abnormalities that usually go away on their own Low-grade Pap smear abnormalities that usually go away on their own

What happens once people get infected with HPV? Some women who get “high-risk” types will develop: Some women who get “high-risk” types will develop: Low or high grade Pap smear abnormalities Low or high grade Pap smear abnormalities Cervical cancer (rarely) Cervical cancer (rarely) Persistent infection with high-risk HPV types is associated with the development of pre- cancerous and cancerous cervical changes Persistent infection with high-risk HPV types is associated with the development of pre- cancerous and cancerous cervical changes The course of penile infection in men has not been well studied The course of penile infection in men has not been well studied

Typical Genital Warts DOIA Website, 2000

Do Condoms Prevent HPV? Effectiveness of condoms to prevent HPV infection has not been determined Effectiveness of condoms to prevent HPV infection has not been determined A few studies in women show no protective effect A few studies in women show no protective effect However, these studies were not designed to assess condom effectiveness However, these studies were not designed to assess condom effectiveness No prospective studies have evaluated the effectiveness of condom use to protect men from genital HPV infection No prospective studies have evaluated the effectiveness of condom use to protect men from genital HPV infection Condoms work only if they cover infected areas Condoms work only if they cover infected areas HPV often infects genital areas not covered by condoms HPV often infects genital areas not covered by condoms

The “New” Kind of Pap Thin-Layer Paps vs Conventional Paps Thin-Layer Paps vs Conventional Paps Generally compare favorably Generally compare favorably Simple collection procedure for the clinician Simple collection procedure for the clinician Provides a better sample Provides a better sample Can be read more accurately in the lab Can be read more accurately in the lab More expensive More expensive ThinPrep Pap Test Conventional Pap

The “New” Test for HPV HPV DNA Tests Hybrid Capture Test (Digene) detects high-risk HPV by typing nucleic acids Hybrid Capture Test (Digene) detects high-risk HPV by typing nucleic acids Results are reported as positive or negative for the most common cancer-associated HPV types(16,18,31,33,35 etc) Results are reported as positive or negative for the most common cancer-associated HPV types(16,18,31,33,35 etc) Can be performed on same specimen collected for thin- layer Pap Can be performed on same specimen collected for thin- layer Pap

HPV DNA Tests: Possible Uses NOT recommended for screening NOT recommended for screening NOT recommended for diagnostic purposes with external genital warts NOT recommended for diagnostic purposes with external genital warts Can be useful in management of certain abnormal Paps Can be useful in management of certain abnormal Paps

ASCUS Paps: Proposed Algorithm Routine Pap smear, including specimen collection for HPV ASCUS Conduct HPV test on stored specimen SIL Normal Routine Pap schedule Usual follow-up and treatment Repeat Pap moColposcopy HPV (+) HPV ( - )

Cervical Disease Management of HIV Infected Women Dysplasia more common Dysplasia more common Progression of dysplasia is more likely if untreated Progression of dysplasia is more likely if untreated Risk dependent on CD4 count and viral load Risk dependent on CD4 count and viral load Sensitivity of Pap probably equal Sensitivity of Pap probably equal Colposcopic exam may be warranted if follow-up is uncertain (ASC-US or higher) Colposcopic exam may be warranted if follow-up is uncertain (ASC-US or higher) Recommend semi-annual Pap and careful follow- up Recommend semi-annual Pap and careful follow- up

HPV, Anal Ca and MSM High prevalence of anal HPV infection High prevalence of anal HPV infection Incidence of anal carcinoma 35/100,000 MSM Incidence of anal carcinoma 35/100,000 MSM Anal cancer x higher in AIDS patients Anal cancer x higher in AIDS patients Small studies and models demonstrate that routine anal Pap screening may be beneficial Small studies and models demonstrate that routine anal Pap screening may be beneficial No current guidelines given uncertain natural history, laboratory issues, and treatment outcomes No current guidelines given uncertain natural history, laboratory issues, and treatment outcomes Goldie et al. JAMA 1999; 281: Prevention of Genital HPV Infection and Sequelae DHHS, Atlanta: CDC, 1999

HPV: KEY POINTS Extremely common virus Extremely common virus Some types cause genital warts Some types cause genital warts Other types cause cervical and anal cancer Other types cause cervical and anal cancer HPV tests can help in managing female patients with abnormal Paps HPV tests can help in managing female patients with abnormal Paps Best approach to anal dysplasia is unclear Best approach to anal dysplasia is unclear

Trichomoniasis: KEY POINTS Caused by Trichomonas vaginalis, flagellated anaerobic protozoa Caused by Trichomonas vaginalis, flagellated anaerobic protozoa In women, causes malodorous yellow-grey discharge with irritation and vulvar itching In women, causes malodorous yellow-grey discharge with irritation and vulvar itching In men, usually gives no symptoms but can cause urethritis In men, usually gives no symptoms but can cause urethritis Resistance to common treatment (metronidazole) does occur Resistance to common treatment (metronidazole) does occur

The Ends The Ends

STD Prevention and Control Education and counseling to reduce risk of STD acquisition Education and counseling to reduce risk of STD acquisition Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation Effective diagnosis and treatment Effective diagnosis and treatment Evaluation, treatment, and counseling of sexual partners Evaluation, treatment, and counseling of sexual partners Preexposure vaccination--hepatitis A, B Preexposure vaccination--hepatitis A, B

Prevention Messages Prevention messages tailored to the client’s personal risk; interactive counseling approaches are effective 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 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 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 Clients seeking evaluation or treatment for STDs should be informed which specific tests will be performed

Prevention Methods Male Condoms Consistent/correct use of latex condoms are effective in preventing sexual transmission of HIV infection and can reduce risk of other STDs 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) 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 Methods Spermicides N-9 vaginal spermicides are not effective in preventing CT, GC, or HIV infection 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 Frequent use of spermicides/N-9 have been associated with genital lesions Spermicides alone are not recommended for STD/HIV prevention Spermicides alone are not recommended for STD/HIV prevention N-9 should not be used a microbicide or lubricant during anal intercourse N-9 should not be used a microbicide or lubricant during anal intercourse

Early HIV Infection Initial Evaluation Medical/sexual history, previous STD Medical/sexual history, previous STD Pex, pelvic (pap, wet mount), GC, CT Pex, pelvic (pap, wet mount), GC, CT Syphilis serology Syphilis serology CD4 count, HIV viral load CD4 count, HIV viral load CBC, blood chemistry CBC, blood chemistry PPD, urinalysis, CXR PPD, urinalysis, CXR Hepatitis A, B, C serology Hepatitis A, B, C serology

Genital Ulcer Evaluation Diagnosis based on medical history and physical examination often inaccurate Diagnosis based on medical history and physical examination often inaccurate Serologic test for syphilis Serologic test for syphilis Culture/antigen test for herpes simplex Culture/antigen test for herpes simplex Haemophilus ducreyi culture in settings where chancroid is prevalent Haemophilus ducreyi culture in settings where chancroid is prevalent Biopsy may be useful Biopsy may be useful

HSV Serologic Tests Type-Specific HSV-specific glycoprotein G2 for HSV 2 infection and glycoprotein G1 for HSV 1 HSV-specific glycoprotein G2 for HSV 2 infection and glycoprotein G1 for HSV 1 Available gG type-specific assays- POCkit HSV-2, HerpeSelect HSV1/2 IgG ELISA and HerpeSelect 1/2 immunoblot IgG Available gG type-specific assays- POCkit HSV-2, HerpeSelect HSV1/2 IgG ELISA and HerpeSelect 1/2 immunoblot IgG Sensitivity 80-98%, Specificity > 96% Sensitivity 80-98%, Specificity > 96% Confirmatory testing may be indicated in some settings Confirmatory testing may be indicated in some settings

Genital Herpes First Clinical Episode Acyclovir 400 mg tid Acyclovir 400 mg tid or or Famciclovir 250 mg tid Famciclovir 250 mg tid or or Valacyclovir 1000 mg bid Valacyclovir 1000 mg bid Duration of Therapy 7-10 days Duration of Therapy 7-10 days

Genital Herpes Episodic Therapy Acyclovir 400 mg three times daily x 5 days or Acyclovir 800 mg twice daily x 5 days or Famciclovir 125 mg twice daily x 5 days or Valacyclovir 500 mg twice daily x 3-5 days or Valacyclovir 1 gm orally daily x 5 days

Genital Herpes Daily Suppression Acyclovir 400 mg bid Acyclovir 400 mg bidor Famciclovir 250 mg bid Famciclovir 250 mg bidor Valacyclovir mg daily Valacyclovir mg daily

Genital Herpes HIV Infection May have prolonged or severe episodes with extensive genital or perianal disease May have prolonged or severe episodes with extensive genital or perianal disease Episodic or suppressive antiviral therapy often beneficial Episodic or suppressive antiviral therapy often beneficial For severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary For severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary

Genital Herpes HIV Infection/Episodic Therapy Acyclovir 400 mg three times daily Acyclovir 400 mg three times dailyor Famciclovir 500 mg twice daily Famciclovir 500 mg twice dailyor Valacyclovir 1 gm twice daily Valacyclovir 1 gm twice daily Duration of Therapy 5-10 days Duration of Therapy 5-10 days

Genital Herpes HIV Infection/Daily Suppression Acyclovir mg twice to three times daily or Famciclovir 500 mg twice daily or Valacyclovir 500 mg twice daily

Genital Herpes Antiviral Resistance Persistent or recurrent lesions on antivirals Persistent or recurrent lesions on antivirals Obtain viral isolate for viral susceptability Obtain viral isolate for viral susceptability 5% immunocomprised patients 5% immunocomprised patients Acyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovir Acyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovir Alternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days) Alternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days)

Genital Herpes Treatment in Pregnancy Available data do not indicate an increased risk of major birth defects (first trimester) Available data do not indicate an increased risk of major birth defects (first trimester) Limited experience on pregnancy outcomes with prenatal exposure to valacyclovir or famciclovir Limited experience on pregnancy outcomes with prenatal exposure to valacyclovir or famciclovir Acyclovir may be used with first episode or severe recurrent disease Acyclovir may be used with first episode or severe recurrent disease Risk of transmission to the neonate is 30-50% among women who acquire HSV near delivery Risk of transmission to the neonate is 30-50% among women who acquire HSV near delivery

Genital Herpes Counseling Natural history of infection, recurrences, asymptomatic shedding, transmission risk Natural history of infection, recurrences, asymptomatic shedding, transmission risk Individualize use of episodic or suppressive therapy Individualize use of episodic or suppressive therapy Abstain from sexual activity when lesions or prodromal symptoms present Abstain from sexual activity when lesions or prodromal symptoms present Risk of neonatal infection Risk of neonatal infection

Syphilis Primary, Secondary, Early Latent Recommended regimen Benzathine Penicillin G, 2.4 million units IM Benzathine Penicillin G, 2.4 million units IM Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days or Doxycycline 100 mg twice daily x 14 days or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies) or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies) or Azithromycin 2 gm single oral dose (preliminary data) Azithromycin 2 gm single oral dose (preliminary data) *Use in HIV-infection has not been studied *Use in HIV-infection has not been studied

Primary/Secondary Syphilis Response to Treatment No definitive criteria for cure or failure are established No definitive criteria for cure or failure are established Re-examine clinically and serologically at 6 and 12 months Re-examine clinically and serologically at 6 and 12 months Consider treatment failure if signs/symptoms persist or sustained 4x increase in nontreponemal test Consider treatment failure if signs/symptoms persist or sustained 4x increase in nontreponemal test Treatment failure: HIV test, CSF analysis; administer benzathine pcn weekly x 3 wks Treatment failure: HIV test, CSF analysis; administer benzathine pcn weekly x 3 wks Additional therapy not warranted in instances when titers don’t decline despite nl CSF and repeat therapy Additional therapy not warranted in instances when titers don’t decline despite nl CSF and repeat therapy

Primary/Secondary Syphilis Response to Therapy/HIV Infection Most respond appropriately to benzathine penicillin 2.4 million units IM Most respond appropriately to benzathine penicillin 2.4 million units IM Some experts recommend CSF exam before therapy and additional tx (wkly benz pen IM x 3) Some experts recommend CSF exam before therapy and additional tx (wkly benz pen IM x 3) Clinical/serologic evaluation at 3, 6, 9, 12, 24 mo; some perform CSF exam at 6 mo Clinical/serologic evaluation at 3, 6, 9, 12, 24 mo; some perform CSF exam at 6 mo Tx/serologic failure (6-12 mo after tx)- CSF exam, retreat with benz penicillin 2.4 mu wkly x 3 Tx/serologic failure (6-12 mo after tx)- CSF exam, retreat with benz penicillin 2.4 mu wkly x 3

Syphilis Latent Syphilis Recommended regimen Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses Penicillin allergy* Doxycycline 100 mg orally twice daily or or Tetracycline 500 mg orally four times daily Duration of therapy 28 days; close clinical and serologic Duration of therapy 28 days; close clinical and serologic follow-up; data to support alternatives to pcn are limited follow-up; data to support alternatives to pcn are limited

Latent Syphilis Management Considerations Clinical evaluation of tertiary disease (aorititis, gumma, iritis) Clinical evaluation of tertiary disease (aorititis, gumma, iritis) CSF analysis: neurologic or ophthalmic signs/sx, active tertiary disease, tx failure, HIV infection CSF analysis: neurologic or ophthalmic signs/sx, active tertiary disease, tx failure, HIV infection Some experts recommend CSF exam in those with nontreponemal titer of >1:32 Some experts recommend CSF exam in those with nontreponemal titer of >1:32 Pharmacologic considerations suggest an interval of days between benz pen doses may be acceptable before restarting treatment course in nonpregnant patients Pharmacologic considerations suggest an interval of days between benz pen doses may be acceptable before restarting treatment course in nonpregnant patients

Latent Syphilis Response to Treatment Limited data available to guide evaluation Limited data available to guide evaluation Repeat quantitative nontreponemal tests at 6, 12, 24 months Repeat quantitative nontreponemal tests at 6, 12, 24 months Perform CSF exam and re-treat for latent syphilis: 4x increase in titer, initial nontreponemal titer >1:32 fails to decline mo after tx, or signs/sx Perform CSF exam and re-treat for latent syphilis: 4x increase in titer, initial nontreponemal titer >1:32 fails to decline mo after tx, or signs/sx

Latent Syphilis Response to Therapy/HIV Infection CSF exam before treatment CSF exam before treatment Normal CSF exam-benzathine penicillin 2.4 million units IM wkly x 3 weeks Normal CSF exam-benzathine penicillin 2.4 million units IM wkly x 3 weeks Clinical/serologic evaluation at 6, 12, 18, 24 months Clinical/serologic evaluation at 6, 12, 18, 24 months Development of sx or 4x titer rise-repeat CSF exam and treat Development of sx or 4x titer rise-repeat CSF exam and treat Repeat CSF exam and treatment if nontreponemal titer does not decline in months Repeat CSF exam and treatment if nontreponemal titer does not decline in months

Syphilis Management of Sex Partners At risk- 3 mo + sx for primary, 6 mo + sx for secondary, one yr for early latent At risk- 3 mo + sx for primary, 6 mo + sx for secondary, one yr for early latent Exposure to primary, secondary, or early latent within 90 days, tx presumptively Exposure to primary, secondary, or early latent within 90 days, tx presumptively Exposure to primary, secondary, or early latent > 90 days, tx presumptively if serology not available Exposure to primary, secondary, or early latent > 90 days, tx presumptively if serology not available Exposure to latent syphilis who have high nontreponemal titers > 1:32, consider presumptive tx for early syphilis Exposure to latent syphilis who have high nontreponemal titers > 1:32, consider presumptive tx for early syphilis

Neurosyphilis Recommended regimen Aqueous crystalline penicillin G, million units administered 3-4 million units IV every 4 hours for days Alternative regimen Procaine penicillin 2.4 million units IM daily plus probenecid 500 mg orally four times daily for days Some experts administer benzathine penicillin 2.4 million units IM wkly x 3 after completion of these regimens to provide comparable duration of treatment with latent syphilis

Neurosyphilis Penicillin Allergy Ceftriaxone 2 gm daily IM/IV for days Ceftriaxone 2 gm daily IM/IV for days Consideration of cross-reactivity Consideration of cross-reactivity Pregnant patients should undergo penicillin desensitization Pregnant patients should undergo penicillin desensitization Other regimens have not been evaluated Other regimens have not been evaluated

Neurosyphilis Response to Treatment Initial CSF pleocytosis--repeat CSF exam every 6 months until cell count normal Initial CSF pleocytosis--repeat CSF exam every 6 months until cell count normal CSF VDRL and protein decline slowly CSF VDRL and protein decline slowly Consider re-treatment if cell count has not decreased by 6 months or if CSF is not normal by 2 years Consider re-treatment if cell count has not decreased by 6 months or if CSF is not normal by 2 years

Syphilis Treatment in Pregnancy Screen for syphilis at first prenatal visit; repeat RPR third trimester/delivery for those at high risk or high prevalence areas Screen for syphilis at first prenatal visit; repeat RPR third trimester/delivery for those at high risk or high prevalence areas Treat for the appropriate stage of syphilis Treat for the appropriate stage of syphilis Some experts recommend additional benzathine penicillin 2.4 mu IM after the initial dose for primary, secondary, or early latent syphilis Some experts recommend additional benzathine penicillin 2.4 mu IM after the initial dose for primary, secondary, or early latent syphilis Management and counseling may be facilitated by sonographic fetal evaluation for congenital syphilis in the second half of pregnancy Management and counseling may be facilitated by sonographic fetal evaluation for congenital syphilis in the second half of pregnancy

Congenital Syphilis Infants with Seroreactive Mothers Nontreponemal test on infant serum Nontreponemal test on infant serum Examination (nonimmune hydrops, jaundice, HSM, rhinitis, rash) Examination (nonimmune hydrops, jaundice, HSM, rhinitis, rash) Pathologic exam of placenta or umbilical cord (fluorescent antitreponemal antibody) Pathologic exam of placenta or umbilical cord (fluorescent antitreponemal antibody) Darkfield or DFA of suspicious lesions or body fluids Darkfield or DFA of suspicious lesions or body fluids

Congenital Syphilis Proven/highly probable disease Abnormal physical exam consistent with congenital syphilis Abnormal physical exam consistent with congenital syphilis Nontreponemal titer 4X > maternal titer or + DFA or darkfield Nontreponemal titer 4X > maternal titer or + DFA or darkfield Evaluation: CSF exam, CBC; other tests as clinically indicated--long bone films, LFTs, cranial US, eye exam, auditory brain stem response Evaluation: CSF exam, CBC; other tests as clinically indicated--long bone films, LFTs, cranial US, eye exam, auditory brain stem response

Congenital Syphilis Proven/highly probable disease Aqueous crystalline penicillin G 100, ,000 units/kg/day, administered as 50,000 units/kg/dose IV q 12 hours during the first 7 days and thereafter q 8 hours for 10 days or or Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days

Congenital Syphilis Normal exam/RPR < 4X maternal titer Mother inadequately treated; treated with nonpenicillin regimen; received tx < 4 wks before delivery; or mother has early syphilis with serologic response Mother inadequately treated; treated with nonpenicillin regimen; received tx < 4 wks before delivery; or mother has early syphilis with serologic response Evaluation: CSF analysis, CBC/plt, long bone xray Evaluation: CSF analysis, CBC/plt, long bone xray

Congenital Syphilis Normal Exam/RPR < 4X maternal titer Aqueous penicillin G 100, ,000 units/kg/day as 50,000 units/kg/dose IV every 12 hours for first 7 d then q 8 hours for total of 10 d or Procaine penicillin G 50,000 units/kg/dose IM in single daily dose for 10 d or Benzathine penicillin G 50,000 units/kg/dose IM in single dose

Congenital Syphilis Normal exam/RPR < 4X maternal titer Mother treated appropriately > 4 wks before delivery; maternal RPR titers decreased 4X; no relapse or reinfection Mother treated appropriately > 4 wks before delivery; maternal RPR titers decreased 4X; no relapse or reinfection No evaluation required No evaluation required Benzathine pcn G 50,000 units/kg/dose IM Benzathine pcn G 50,000 units/kg/dose IM

Congenital Syphilis Normal exam/RPR < 4X maternal titer Mother received adequate tx before pregnancy; maternal RPR remained low and stable during pregnancy and delivery Mother received adequate tx before pregnancy; maternal RPR remained low and stable during pregnancy and delivery No evaluation necessary No evaluation necessary No treatment required; some specialists would tx with single dose of benz pen G No treatment required; some specialists would tx with single dose of benz pen G

Congenital Syphilis Subsequent Evaluation Clinical/serologic evaluation q 2-3 mo Clinical/serologic evaluation q 2-3 mo RPR should decline by 3 mo, nonreactive at 6 mo RPR should decline by 3 mo, nonreactive at 6 mo Stable or increasing titers after 6-12 mo--CSF analysis/parenteral pcn X 10 d Stable or increasing titers after 6-12 mo--CSF analysis/parenteral pcn X 10 d Reactive treponemal/RPR after 18 mo re-evaluate and treat for congenital syphilis Reactive treponemal/RPR after 18 mo re-evaluate and treat for congenital syphilis

Congenital Syphilis Older Infants and Children Review records and maternal serology- congenital vs acquired Review records and maternal serology- congenital vs acquired Evaluation- CSF analysis, CBC/pts; +/- long bone films, auditory brain stem response Evaluation- CSF analysis, CBC/pts; +/- long bone films, auditory brain stem response Treatment- Aqueous pcn G 50,000 units/kg q 4-6 hours for 10 days Treatment- Aqueous pcn G 50,000 units/kg q 4-6 hours for 10 days

Chancroid Azithromycin 1 gm orally or Ceftriaxone 250 mg IM in a single dose or Ciprofloxacin 500 mg twice daily x 3 days or Erythromycin base 500 mg tid x 7 days

Chancroid Management Considerations Re-examination 3-7 days after treatment Re-examination 3-7 days after treatment Time required for complete healing related to ulcer size Time required for complete healing related to ulcer size Lack of improvement: incorrect diagnosis, co- infection, non-compliance, antimicrobial resistance Lack of improvement: incorrect diagnosis, co- infection, non-compliance, antimicrobial resistance Resolution of lymphadenopathy may require drainage Resolution of lymphadenopathy may require drainage

Chancroid Management of Sex Partners Examine and treat partner whether symptomatic or not if partner contact < 10 days prior to onset

Lymphogranuloma Venereum Recommended regimen Doxycycline 100 mg twice daily for 21 days Alternative regimen Erythromycin base 500 mg four times daily for 21 days

Granuloma Inguinale Doxycycline 100 mg twice daily or Trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily Minimum treatment duration three weeks Minimum treatment duration three weeks

Granuloma Inguinale Alternative regimens Ciprofloxacin 750 mg twice daily or or Erythromycin base 500 mg four times daily or or Azithromycin 1 gm orally weekly Minimum treatment duration three weeks Minimum treatment duration three weeks

Urethritis Mucopurulent or purulent discharge Mucopurulent or purulent discharge Gram stain of urethral secretions > 5 WBC per oil immersion field 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 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

Nongonococcal Urethritis Azithromycin 1 gm in a single dose or Doxycycline 100 mg bid x 7 days

Nongonococcal Urethritis Alternative 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 Objective signs of urethritis Objective signs of urethritis Re-treat with initial regimen if non-compliant or re-exposure occurs Re-treat with initial regimen if non-compliant or re-exposure occurs Intraurethral culture for trichomonas Intraurethral culture for trichomonas Effective regimens not identified in those with persistent symptoms without signs Effective regimens not identified in those with persistent symptoms without signs

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 Annual screening of sexually active women < 25 yrs Annual screening of sexually active women < 25 yrs Annual screening of sexually active women > 25 yrs with risk factors Annual screening of sexually active women > 25 yrs with risk factors Sexual risk assessment may indicate more frequent screening for some women Sexual risk assessment may indicate more frequent screening for some women Rescreen women 3-4 months after treatment due to high prevalence of repeat infection Rescreen women 3-4 months after treatment due to high prevalence of repeat infection

Chlamydia trachomatis Azithromycin 1 gm single dose or Doxycycline 100 mg bid x 7d

Chlamydia trachomatis Alternative 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 for 7 days

Chlamydia trachomatis Treatment in Pregnancy Recommended regimens Erythromycin base 500 mg qid for 7 days or Amoxicillin 500 mg three times daily for 7 days Alternative regimens Erythromycin base 250 mg qid for 14 days or Erythromycin ethylsuccinate 800 mg qid for 14 days or Erythromycin ethylsuccinate 400 mg qid for 14 days or Azithromycin 1 gm in a single dose

Neisseria gonorrhoeae Cervix, 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, 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 Ceftriaxone 125 IM in a single dose or Ciprofloxacin 500 mg in a single dose PLUS Chlamydial therapy if infection not ruled out

Neisseria gonorrhoeae Treatment in Pregnancy Cephalosporin regimen Cephalosporin regimen Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM No quinolone or tetracycline regimen No quinolone or tetracycline regimen Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection Erythromycin or amoxicillin for presumptive or diagnosed chlamydial 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 Geographic variation in resistance to penicillin and tetracycline Geographic variation in resistance to penicillin and tetracycline No significant resistance to ceftriaxone No significant resistance to ceftriaxone Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California Surveillance is crucial for guiding therapy recommendations Surveillance is crucial for guiding therapy recommendations

Candida Vaginitis Classification UncomplicatedComplicated Sporadic, infrequentRecurrent Mild-to-moderateSevere Likely C albicansNon-albicans Non-immunocomprisedDiabetes, pregnancy, immunosuppression

Candida Vulvovaginitis Intravaginal regimens Butoconazole, clotrimazole, miconazole, nystatin, tioconazole, terconazole Oral regimen Fluconazole 150 mg in a single dose

Recurrent VVC Four or more symptomatic episodes/year Four or more symptomatic episodes/year Vaginal culture useful to confirm diagnosis and identify unusual species Vaginal culture useful to confirm diagnosis and identify unusual species Initial regimen of 7-14 days topical therapy or fluconazole 150 mg (repeat 72 hr) Initial regimen of 7-14 days topical therapy or fluconazole 150 mg (repeat 72 hr) Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole Non-albicans VVC- longer duration of therapy with non-azole regimen Non-albicans VVC- longer duration of therapy with non-azole regimen

Vulvovaginal Candidiasis Management of Sex Partners Treatment not recommended Treatment not recommended Treatment of male partners does not reduce frequency of recurrences in the female Treatment of male partners does not reduce frequency of recurrences in the female Male partners with balanitis may benefit from treatment Male partners with balanitis may benefit from treatment

Vulvovaginal Candidiasis Treatment in Pregnancy Only topical intravaginal regimens recommended Only topical intravaginal regimens recommended Most specialists recommend 7 days of therapy Most specialists recommend 7 days of therapy

Trichomoniasis Recommended regimen Metronidazole 2 gm orally in a single dose Alternative regimen Alternative regimen Metronidazole 500 mg twice a day for 7 days Pregnancy Metronidazole 2 gm orally in a single dose

Trichomoniasis Treatment Failure Re-treat with metronidazole 500 mg twice daily for 7 days Re-treat with metronidazole 500 mg twice daily for 7 days If repeated failure occurs, treat with metronidazole 2 gm single dose for 3-5 days If repeated failure occurs, treat with metronidazole 2 gm single dose for 3-5 days If repeated failure, consider metronidazole susceptibility testing through the CDC If repeated failure, consider metronidazole susceptibility testing through the CDC

Trichomoniasis Management of Sex Partners Sex partners should be treated Sex partners should be treated Avoid intercourse until therapy is completed and patient and partner are asymptomatic Avoid intercourse until therapy is completed and patient and partner are asymptomatic

Bacterial Vaginosis Metronidazole 500 mg twice daily for 7 days or Metronidazole gel 0.75%, 5 g intravaginally once daily for 5 days or Clindamycin cream 5%, 5 g intravaginally qhs for 7 days

Bacterial Vaginosis Alternative regimens Metronidazole 2 gm in a single dose or Clindamycin 300 mg twice daily for 7 days or Clindamycin ovules 100 g intravaginally qhs for 3 days

Bacterial Vaginosis Treatment in Pregnancy Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes Existing data do not support use of topical agents in pregnancy Existing data do not support use of topical agents in pregnancy Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatal visit; optimal regimen not established Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatal visit; optimal regimen not established

Bacterial Vaginosis Treatment in Pregnancy Metronidazole 250 mg three times daily for 7 days or Clindamycin 300 mg twice daily for 7 days

Bacterial Vaginosis Management of Sex Partners Woman’s response to therapy and the likelihood of relapse or recurrence not affected by treatment of sex partner

Pelvic Inflammatory Disease Minimum Diagnostic Criteria Uterine/adnexal tenderness or cervical motion tenderness Additional Diagnostic Criteria Oral temperature >38.3 CElevated ESR Cervical CT or GCElevated CRP WBCs/saline microscopyCx discharge

Pelvic Inflammatory Disease Definitive Diagnostic Criteria Endometrial biopsy with histopathologic evidence of endometritis Endometrial biopsy with histopathologic evidence of endometritis Transvaginal sonography or MRI showing thick fluid- filled tubes Transvaginal sonography or MRI showing thick fluid- filled tubes Laparoscopic abnormalities consistent with PID Laparoscopic abnormalities consistent with PID

Pelvic Inflammatory Disease Hospitalization Surgical emergencies not excluded Surgical emergencies not excluded Pregnancy Pregnancy Clinical failure of oral antimicrobials Clinical failure of oral antimicrobials Inability to follow or tolerate oral regimen Inability to follow or tolerate oral regimen Severe illness, nausea/vomiting, high fever Severe illness, nausea/vomiting, high fever Tubo-ovarian abscess Tubo-ovarian abscess

Pelvic Inflammatory Disease No efficacy data compare parenteral with oral regimens No efficacy data compare parenteral with oral regimens Clinical experience should guide decisions regarding transition to oral therapy 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 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 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 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 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 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 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 WITH or WITHOUT Metronidazole 500 mg twice daily for 14 days

Pelvic Inflammatory Disease Management 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 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 Sex partners should be treated empirically with regimens effective against CT and GC

Epididymitis Diagnostic Considerations Gram stain smear of urethral exudate for diagnosis of urethritis Gram stain smear of urethral exudate for diagnosis of urethritis Intraurethral culture or nucleic acid amplification test for GC and CT Intraurethral culture or nucleic acid amplification test for GC and CT Examination of first void uncentrifuged urine for WBCs if urethral gram stain negative Examination of first void uncentrifuged urine for WBCs if urethral gram stain negative

Epididymitis Infection likely due to GC or CT Ceftriaxone 250 mg IM in a single dose PLUS PLUS Doxycycline 100 mg twice daily for 10 days Infection likely due to enteric organisms or age > 35 Ofloxacin 300 mg twice daily for 10 days or or Levofloxacin 500 mg once daily for 10 days

Papillomavirus Treatment Primary goal for treatment of visible warts is the removal of symptomatic warts Primary goal for treatment of visible warts is the removal of symptomatic warts Therapy may reduce but probably does not eradicate infectivity Therapy may reduce but probably does not eradicate infectivity Difficult to determine if treatment reduces transmission Difficult to determine if treatment reduces transmission No laboratory marker of infectivity No laboratory marker of infectivity Variable results utilizing viral DNA Variable results utilizing viral DNA

Papillomavirus Source of therapy guided by preference of patient, experience of provider, resources Source of therapy guided by preference of patient, experience of provider, resources No evidence that any regimen is superior No evidence that any regimen is superior Locally developed/monitored treatment algorithms associated with improved clinical outcomes Locally developed/monitored treatment algorithms associated with improved clinical outcomes Acceptable alternative may be to observe; possible regression/uncertain transmission Acceptable alternative may be to observe; possible regression/uncertain transmission

Papillomavirus Patient-applied Podofilox 0.5% solution or gel or Imiquimod 5% cream Provider-administeredCryotherapyor Podophyllin resin 10-25% or Trichloroacetic or Bichloroacetic acid 80-90% or Surgical removal

Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80-90% Urethral meatal warts Cryotherapy or podophyllin 10-25% Anal warts Cryotherapy or TCA/BCA 80-90%

Papillomavirus Treatment in Pregnancy Imiquimod, podophyllin, podofilox should not be used in pregnancy Imiquimod, podophyllin, podofilox should not be used in pregnancy Many specialists advocate wart removal due to possible proliferation and friability Many specialists advocate wart removal due to possible proliferation and friability HPV types 6 and 11 can cause respiratory papillomatosis in infants and children HPV types 6 and 11 can cause respiratory papillomatosis in infants and children Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction

Cervical Cancer Screening Women with History of STDs Women with STD hx may be at increased risk of cervical cancer Women with STD hx may be at increased risk of cervical cancer Clinics that offer pap screening without colposcopic f/u should arrange for referral Clinics that offer pap screening without colposcopic f/u should arrange for referral Management of abnormal pap provided per Interim Guidelines for Management of Abnormal Cervical Cytology (NCI Consensus Panel) Management of abnormal pap provided per Interim Guidelines for Management of Abnormal Cervical Cytology (NCI Consensus Panel) Emerging data support HPV testing for the triage of women with ASCUS Pap tests Emerging data support HPV testing for the triage of women with ASCUS Pap tests

Proctitis Anoscopic examination for HSV, GC, CT, syphilis Anoscopic examination for HSV, GC, CT, syphilis Painful perianal or mucosal ulceration on anoscopy- presumptive therapy for HSV Painful perianal or mucosal ulceration on anoscopy- presumptive therapy for HSV Recommended regimen Recommended regimen Cefriaxone 125 mg IM PLUS Doxycycline 100 mg twice daily for 10 days

Pediculosis Pubis Pruritus or lice or nits on pubic hair Pruritus or lice or nits on pubic hair Decontaminate bedding and clothing Decontaminate bedding and clothing Recommended regimens Recommended regimens Permethrin 1% Permethrin 1% Lindane 1% shampoo Lindane 1% shampoo Pyrethrins with piperonyl butoxide Pyrethrins with piperonyl butoxide Re-treatment may be necessary if sx persist Re-treatment may be necessary if sx persist Treatment of sex partners within the last month Treatment of sex partners within the last month

Scabies Predominant symptom is pruritus Predominant symptom is pruritus Recommended regimen Recommended regimen Permethrin cream 5% Alternative regimen Alternative regimen Lindane 1% or Invermectin 200 ug/kg, repeat in 2 wks Sex partners and household contacts within the preceding month should be treated Sex partners and household contacts within the preceding month should be treated

Scabies Persistent Symptoms Rash and pruritus may persist for 2 wks Rash and pruritus may persist for 2 wks Persistence > 2 wks: tx failure, resistance, reinfection, drug allergy, cross reactivity with household mites Persistence > 2 wks: tx failure, resistance, reinfection, drug allergy, cross reactivity with household mites Attention to fingernails of infected patients Attention to fingernails of infected patients Treat close contacts empirically Treat close contacts empirically Wash linens, bedding, clothing Wash linens, bedding, clothing

Ophthalmia Neonatorum Prophylaxis Silver nitrate 1% aqueous solution in a single application or Erythromycin 0.5% ophthalmic ointment in a single application or Tetracycline ophthalmic ointment 1% in a single application

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