1. Sexually Transmitted Infections: Screening and Treatment Update
Caroline Hacker, FNP-C and Christy Millican, FNP-C

2. Disclosures
We have no disclosures or conflicts of interest!

3. Learning Objectives
Review CDC guidelines about routine screening for STIs
Get familiar with common clinical presentations
Review CDC updates for treatment
Discuss special circumstances and reasons to seek specialty consultation

4. Routine Screening Guidelines
CDC
ACOG
AAP
USPSTF
HIV
All adults and adolescents at least once
All sexually active adolescents
All people at increased risk of transmission
Gonorrhea
Chlamydia
Women: All sexually active women <25 years old yearly
Men: consider screening in higher risk populations
MSM: Yearly in all contact sites (rectal, oral, urine); every 3-6 months high risk
**Start discussion about sexual activity years old
All women at increased risk of infection ages Inconclusive evidence regarding men
**Increased risk- sexually active, “high-risk” behaviors, high community prevalence
Create a routine screening guideline for your clinic that is followed by all providers. Consider your population.

5. Pap Smears and Pelvic Exams
ACOG recommends external genital exam only in patients younger than 21 years old, irrespective of sexual activity
A pelvic examination always is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract, pelvic, urologic, or rectal problems
Routine cervical cancer screening (PAP) is not recommended until age 21, irrespective of sexual activity

6. Case Study 1: Vaginal itching and discharge
A 15 year-old female Jane comes to clinic with a chief complaint of vaginal itching and discharge. It has been present for 2-3 weeks and she has also had some new breakthrough bleeding with her nexplanon she had placed last year. There is no particular odor; discharge is yellow. She is sexually active with one partner and believes they are monogamous. They use condoms sporadically. Denies pain with intercourse, fever, abdominal pain, nausea or vomiting.

7. Case Study 1: What to screen for?
Based on this patient’s history, what would you screen for? How would you obtain these screenings?
Chlamydia and gonorrhea screening by urine or vaginal swab (NAAT)
Wet prep by molecular probe
Screens for candida, bacterial vaginosis and trichomoniasis
Is an internal pelvic exam necessary?
Without pain with intercourse or other symptoms of pelvic inflammatory disease, initial pelvic exam is not necessary and patient can do a self swab for wet prep

8. Case Study 1: Results
Results return to you the next day. She is positive for chlamydia; negative for gonorrhea, yeast, bacterial vaginosis and trichomonas
Treatment recommendations:
Azithromycin 1 g orally in a single dose
Doxycycline 100 mg orally twice a day for 7 days
Treatment can be sent to the pharmacy for patient pick up or patients can be brought back to clinic for observed therapy if there is concern for compliance

9. Chlamydia
In men who have sex with men (MSM), always swab rectally and orally if concern for infection
All sex partner should be treated; patients should abstain from sex for 7 days until all parties are treated
Expedited partner therapy
Patients should be re-screened in 4-12 weeks for test of re-infection. Screening sooner than 4 weeks may pick up bacteria that is still shedding

10. Chlamydia Statistics #6 in the nation in NC
In 2017, 19,509 new cases in year olds; disproportionally high African American burden

11. Case Study 2: Urethral discharge
A 19 year-old male John comes to clinic with a chief complaint of some urethral discharge and burning with urination. This has been ongoing for about 1 week. The discharge is a yellowish-green. He denies fever, chills, testicular swelling or pain and rash. Sexual history reveals that he is sexually active with men and has had a new partner in the last month. They use condoms sporadically. They met on the grindr app; he believes this partner may have other partners as well. On physical exam there is no current urethral discharge, however, you do note an interesting rash on his palms and soles of feet. He is unsure how long that has been there and didn’t even really notice it prior to now.

12. John’s rash
plantar-rash-of-secondary-syphilisTypical-palmar-and-plantar-rash

13. Case Study 2: What to screen for?
Given this patient’s medical and social history, what would you screen for?
Chlamydia and gonorrhea by urine, oral and rectal swabs (NAAT)
Patient can self-swab rectally
Syphilis and HIV
HIV can be HIV antibody by blood or rapid HIV by oral swab if this is available in clinic
Counseling
Open a conversation about safe sex and condom use
Discuss increased risk of syphilis and HIV in this population
Consider pre-exposure prophylaxis for HIV?

14. Case Study 2: Results
John’s test results are positive for gonorrhea in the urine and oral swabs; negative for chlamydia. He is also unfortunately positive for syphilis; negative for HIV.
What now?
John has to return to clinic for treatment given his new diagnoses. In discussing the diagnoses with him, he does recall now having had a sore on his penis a few months ago

15. Gonorrhea Recommended treatment regimen:
Ceftriaxone 250 mg IM in a single dose PLUS
Azithromycin 1g orally in a single dose
It is very important to treat with both agents in clinic- there is increasing resistance to treatment being seen
Test of cure in 4-12 weeks- important considering resistance
All sex partners need to be treated- no sex for 7 days after treatment for all partners
If not already completed, all patients diagnosed with gonorrhea should be screened for chlamydia, HIV and syphilis as there is increased risk

16. Gonorrhea Statistics #6 in the nation in NC
2,768 new cases in 2017 among year olds; disproportionally African American burden

17. Syphilis
When reported to the CDC, they will make a home visit to help track epidemiology. Let your patient know!
John’s rash in clinic is a hallmark sign of secondary syphilis. In retrospect, he also had the chancre present with primary syphilis infection
Sexual transmission of T. pallidum is thought to occur only when mucocutaneous syphilitic lesions are present
Consider referral to infectious disease specialist if available in the area
Jarisch-Herxheimer Reaction
Counsel patients about potential for fever, myalgias and headaches that can occur within 24 hours of treatment; more common during early syphilis
Primary and Secondary Treatment:
Benzathine penicillin G 2.4 million units IM in a single dose
Titers must be followed over time for indication of treatment success and should decline fourfold (1:321:16). Testing should be completed at 6 and 12 months

18. Syphilis Statistics #9 in the nation in NC
250 new cases of syphilis in 2017 among year olds; disproportionately African American burden

19. New HIV diagnosis In NC, 1015 new HIV diagnoses from 2015-2017
Counsel patient on importance of follow-up and lifetime care
Provide emotional support
Assess for acute medical needs
Immediate referral to infectious disease for further workup and treatment

20. Pre-exposure Prophylaxis for HIV
Given that John is sexually active with men, has now had gonorrhea and syphilis and isn’t always using condoms consistently, it is important to discuss ways to prevent HIV which include condom use, testing of partners and possibly pre-exposure prophylaxis
 The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV. When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection.
When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently.
Patients must commit to taking medication consistently and following up every 3 months
Consider referral to adolescent medicine or infectious disease for an older teen interested in this therapy if unable to prescribe in office

21. Case 3: Vulvar rash
An 18 year-old female Sarah presents to clinic with a chief complaint of a rash on bilateral vulva. It is very painful and she has difficulty sitting down and urinating. She noticed some burning and tingling a few days ago and then the rash appeared. She has been sexually active in the past- about 3 months ago. She denies fever, chills or other vaginal discharge. On exam you find a significant rash of small lesions with ulcerated bases covering labia majora, minora and rectal area. Sarah has significant pain with your exam.

22. Common rash presentation

23. Case 3: What to test for?
Based on clinical exam this rash is very suspicious for herpes simplex virus (HSV). Given its severity, it is reasonably likely that it may be HSV-1 vs. HSV-2. HSV-2 often causes smaller, more scattered lesions that can sometimes go unnoticed and therefore undiagnosed. HSV-1 initial outbreaks are often diffuse and very painful
Testing:
HSV-1 and HSV-2 by PCR of the lesions or culture of the lesions is best practice for testing
Although serologic testing can be performed, it is not typically recommended. False negatives can be present in early infection. HSV-1 may be detected but is difficult to differentiate between exposure and oral lesions vs. vaginal lesions

24. Case 3: Treatment Cases are not tracked by the CDC Initial outbreaks
Consider lidocaine gel for comfort
Sitz baths
Easiest regimens:
Valacyclovir 1 g orally twice a day for 7–10 days
Acyclovir 400 mg orally three times a day for 7–10 days
Treatment can be extended if healing is incomplete at 10 days
Provide emotional support and information about preventing spread to future partners given that HSV does not have a cure
Always disclose previous HSV infections to care providers, especially to OB/GYN when pregnant
Suppressive therapy
Valacyclovir 1 g orally once a day
Acyclovir 400 mg orally twice a day

25. Case 4: Vaginal discharge and odor
A 14 year-old patient Emma comes to clinic with a chief complaint of vaginal discharge and odor. It has been ongoing for about 1 month and she describes it as a thin, watery discharge with a fishy odor that is particularly worse around her period. She occasionally has itching. She denies being sexually active. She is a dancer and stays in leotards frequently. She denies use of new soaps or detergents but does like to take bubble baths a few times a week. She denies bleeding between periods.

26. Case 4: What to test for? Wet prep by molecular probe Gram stain
Screens for candida, bacterial vaginosis and trichomonas
Gram stain
Wet mount in office
Would you elect to screen for chlamydia and gonorrhea given her report of no sexual activity ?
Does she need a pelvic exam?

27. Case 4: Results
Emma’s testing reveals bacterial vaginosis and candida. Trichomonas is negative
Chlamydia and gonorrhea testing negative

28. Bacterial Vaginosis (BV)
Characterized by fishy odor, watery discharge with ph >4.5 and clue cells
Treatment is recommended for women with symptoms:
Metronidazole 500 mg orally twice a day for 7 days
Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
Tinidazole 2 g orally once daily for 2 days
**Advise about disulfiram reaction with alcohol if using –azole therapy- no alcohol within 72 hours of last dose**
No partner therapy necessary if sexually active
During treatment, refrain from sexual activity
Recurrence is very common if treatment not completed
Limited evidence for role of probiotics
Discuss with patient good vaginal hygiene practices:
Avoid products with scents and dyes
Avoid wearing tight clothing
No douching
The vagina is a self cleaning oven! Do not use soap on mucocutaneous surfaces- just water.

30. Vulvovaginal Candidiasis (VVC)
Characterized by thick, white vaginal discharge, redness and itching
Many OTC products are available, however, compliance is often poor and efficacy can be limited
Treatment:
Fluconazole 150 mg orally in a single dose (2 doses 3 days apart for severe symptoms)
Clotrimazole 2% cream 5 g intravaginally daily for 3 days
Recurrence:
Retreat with 3 doses of fluconazole 150 mg (days 1, 3 and 7)
Consider once weekly fluconazole 150 mg for >4 recurrences a year
Consider rx for fluconazole 150 mg x 1 for patients who frequently get VVC after antibiotic therapy to prevent need for return visit

31. Trichomoniasis (Trich)
Trichomoniasis is the most prevalent nonviral sexually transmitted infection in the United States, affecting an estimated 3.7 million persons
T. vaginalis infection is associated with two- to threefold increased risk for HIV acquisition
Characterized by diffuse, malodorous, yellow-green frothy discharge that likely will cause irritation
Sensitivity of wet mount is low (51-65%)- therefore NAAT swab is preferred
Treatment
Metronidazole 2 g orally in a single dose OR
Tinidazole 2 g orally in a single dose
**Advise about disulfiram reaction with alcohol if using –azole therapy- no alcohol within 72 hours of last dose**
Partners should also be treated and abstain from sex for 7 days after treatment to prevent reinfection
Test for reinfection should be performed within 3 months (as soon as 2 weeks)
Test for other STIs in patients positive for trich
Can cause PID- consider internal pelvic exam and bimanual exam for patients who are positive and have dyspareunia, abdominal pain, cramping, fever etc.

32. Expedited Partner Therapy by State
Per the NC Medical Board:
Signed prescriptions of oral antibiotics
of the appropriate quantity and
strength sufficient to provide
curative treatment for each
partner named by the infected
patient. Notation on the
prescription should include
the statement:
“Expedited partner therapy.”

33. Other considerations
Always discuss contraception with patients who are sexually active and come in for STI testing
Consider providing condoms in your office that are easily accessible for patients and can be taken discreetly if desired

34. Resources www.dontspreadit.com – Anonymous partner reporting
- CDC treatment guidelines 2015
Can order hard copies of these materials to keep in clinic as well
– great teen friendly information about contraception

35. References
Gynecologic-Practice/Well-Woman-Visit
position-statements/position-statements/contact_with_patients_before_prescribing