Overview of Sexually Transmitted Diseases Rebecca A. Lillis, M.D. Assistant Professor of Medicine, Section of Infectious Diseases LSUHSC, New Orleans

DISCLOSURE I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

Major STDs Type of Agent Name Disease Viruses Human Papillomavirus Warts Herpes Simplex Herpes Hepatitis B Hepatitis HIV AIDS Bacteria Chlamydia Neisseria Gonorrheae Gonorrhea Treponema pallidum Syphilis Hemophilus ducreyi Chancroid Fungi Candida albicans Candidiasis Protozoa Trichomonas vaginalis Trichomoniasis Insects Sarcoptes scabii Scabies

Syphilis Cause: Spirochete - Treponema pallidum Symptoms: Genital ulcer, rash Diagnosis: Dark Field exam Blood test: RPR, VDRL,MHA-TP, IgG Complications: Late syphilis Congenital syphilis HIV transmission Treatment - Penicillin

Stages and Manifestations Syphilis Stages and Manifestations Early Syphilis - 1st 12 months Primary - Genital ulcer (chancre) Secondary - Generalized rash (palms & soles) Oral and genital lesions Alopecia Early latent - No signs or symptoms Late latent - Years Late - Neurosyphilis Cardiovascular syphilis

Syphilis: Treatment Early syphilis Benzathine penicillin G (Bicillin L-A) 2.4 million units IM x 1 Late latent Benzathine penicillin G 2.4 million units IM per week x 3 Neurosyphilis and cardiovascular syphilis Intravenous penicillin G

P&S Syphilis, Louisiana vs. U.S. 1981-1999 Cases/100,000 80 Louisiana 60 40 20 U.S. Year 2000 Objective 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year of Report

Louisiana rate 7.34 cases/ 100,000 is highest in nation for 2004 Primary and secondary syphilis — Rates: United States, 1970–2004 and the Healthy People 2010 target Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000 population. Louisiana rate 7.34 cases/ 100,000 is highest in nation for 2004

P&S Syphilis Cases in Louisiana Actual cases and projection to elimination goal Cases of P&S syphilis 3500 3000 2500 2000 1500 1000 500 1991 1993 1995 1997 1999 2001 2003 2005 Year of Report

Rates of Syphilis in Industrialized Countries Country P&S Cases Rate Canada 248 0.8 England 117 0.4 Sweden 52 0.6 Denmark 39 0.7 U.S. (1996) 11,387 4.3 U.S. (1998) 6,993 2.6 U.S. (2005 goal) 1,000 0.4

Causes of Genital Ulcers Herpes Syphilis Chancroid

Herpes Herpes Simplex Virus (HSV) I and II Symptoms: Painful blisters that recur Complications (rare): Spread to infants at delivery Severe infections in AIDS patients

Herpes: Treatment No cure Antivirals shorten duration, reduce frequency and severity of recurrences Acyclovir (Zovirax) Famcyclovir (Famvir) Valcyclovir (Valtrex) Different dosages for initial treatment vs. recurrent or suppressive treatment

Chancroid Cause: Hemophilus ducreyi Symptoms: Male:female ratio 10:1 Epidemiology: Uncommon in U.S., occurs in outbreaks Symptoms: Painful sore (may be multiple) that looks like chancre Male:female ratio 10:1 Treatment: Azithromycin, Ceftriaxone

Causes of Genital Ulcers Herpes Painful, blister - ulcer, shallow, multiple, recurrent Syphilis Painless, single, not recurrent Chancroid Painful, single or multiple, not recurrent

Causes of Urethral or Cervical Discharge Gonorrhea Chlamydia

Gonorrhea Cause: Neisseria gonorrheae Symptoms: Complications: Men - painful discharge from urethra Women - cervical discharge often no symptoms Complications: Women - Pelvic Inflammatory Disease (PID) Infertility, ectopic pregnancy - Infants - Eye infection "ophthalmia neonatorum"

Tests for Gonorrhea Culture Gram Stain Non-culture tests DNA Probe test (GenProbe) PCR/LCR test

Chlamydia Cause: Chlamydia trachomatis Symptoms: Complications: Men – scant clear discharge from urethra Women - cervical discharge Usually no symptoms for men or women Complications: Women - Pelvic Inflammatory Disease (PID) Infertility, ectopic pregnancy - Infants – Pneumonia at 6 week age, eye infection

Tests for Chlamydia Culture Non-culture tests DFA test EIA Lab -Chlamydiazyme, Microtrak, others Rapid - Clearview, TestPack, SureCell DNA Probe test (GenProbe) PCR and LCR tests

Sensitivity of Different Tests for Chlamydia Test type PCR/LCR Culture DFA DNA Probe EIA 1 10 100 1000 10000 100000 1000000 Number of organisms detectable

Gonorrhea: Treatment Antibiotics for gonorrhea Cefixime (Suprax) 400 mg PO x 1 Ciprofloxacin (Cipro) 500 mg PO x 1 Azithromycin (Zithromax) 2 gm PO x 1 Ceftriaxone (Rocephin) 125 mg IM x 1 Always treat for chlamydia also

Chlamydia: Treatment Azithromycin 1 gm PO x 1 Doxycycline 100 mg PO BID x 7 days

Rates of STDs Louisiana, 1992-1999 Chlamydia Gonorrhea P&S Syphilis Cases/100,000 500 400 Chlamydia 300 Gonorrhea 200 100 P&S Syphilis 1992 1993 1994 1995 1996 1997 1998 1999 Year of Report *projected from first 8 months

Chlamydia — Rates: United States, 1984–2004 Louisiana’s rate for 2004 was 488.26 per 100,000, third highest in the nation Note: As of January 2000, all 50 states and the District of Columbia had regulations requiring the reporting of chlamydia cases.

Gonorrhea — Rates: United States, 1970–2004 Louisiana’s rate for 2004 was 235.46 per 100,000 – second highest in the nation Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

Rates of Gonorrhea and Chlamydia by Agegroup Louisiana, 1999 Cases per 100,000 2,500 Chlamydia Gonorrhea 2,000 1,500 1,000 500 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Age Group

Vaginitis Candidiasis Trichomoniasis Bacterial vaginosis

Trichomoniasis Cause: Trichomonas vaginalis (protozoan) Symptoms: Frothy white vaginal discharge Diagnosis: Trich. on wet mount Complications: ? Increased HIV transmission Treatment: Metronidazole (Flagyl) Very high recurrence rate after treatment

Bacterial Vaginosis Cause: Increase in Gardnerella vaginalis & others, decrease in lactobacilli Symptoms: Malodorous vaginal discharge Diagnosis: Clue cells on wet mount Positive "whiff test" Complications: Premature delivery Treatment: Metronidazole (Flagyl) High recurrence rate after treatment

Candidiasis Cause: Candida albicans Not an STD Symptoms: Cheesy white adherent discharge Treatment: Fluconazole (Diflucan) Terconazole (Terazol) OTC creams

Differentiating Among Causes of Vaginitis Candidiasis Discharge is thick, adherent Trichomoniasis Frothy discharge Protozoa on wet prep Bacterial vaginosis Thick, clear-white malodorous discharge Clue cells on wet prep

Treatment of Vaginitis Candidiasis Diflucan 150 mg PO x 1 Trichomoniasis Metronidazole (Flagyl) 2 gm PO Bacterial Vaginosis Metronidazole (Flagyl) 500 mg BID x 7 days

Syndromic Treatment for STDs Most common situations Genital ulcer - treat for syphilis Benzathine penicillin 2.4 million units IM Urethral discharge/cervical discharge - treat for gonorrhea and chlamydia Cefixime 400 mg or Cipro 500 mg AND Azithromycin 1.0 gm or Doxycycline 100 mg b.i.d. x 7 days Vaginal discharge in female - treat for trichomoniasis and bacterial vaginosis Metronidazole 2 gm

Prevention Counseling Get partners treated Decrease number of partners Use a condom every time