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

2. 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.

3. 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

4. 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

5. 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

6. Syphilis: Treatment Early syphilis
Benzathine penicillin G (Bicillin L-A) 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

7. P&S Syphilis, Louisiana vs. U.S.
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

8. 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

9. 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

10. 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

11. Causes of Genital Ulcers
Herpes
Syphilis
Chancroid

12. 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

13. 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

14. 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

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

16. Causes of Urethral or Cervical Discharge
Gonorrhea
Chlamydia

17. 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"

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

19. 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

20. 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

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

22. 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

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

24. 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

25. Chlamydia — Rates: United States, 1984–2004 Louisiana’s rate for 2004 was 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.

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

27. 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

28. Vaginitis
Candidiasis
Trichomoniasis
Bacterial vaginosis

29. 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

30. 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

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

32. 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

33. 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

34. 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

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