overview of sexually transmitted diseases

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

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. Syphilis 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) 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

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

8. Primary and secondary syphilis — Rates: United States, 1970–2004 and the Healthy People 2010 target

9. P&S Syphilis Cases in Louisiana

10. Rates of Syphilis in Industrialized Countries

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 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: 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: 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

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

25. Chlamydia — Rates: United States, 1984–2004Louisiana’s rate for 2004 was 488.26 per 100,000, third highest in the nation

26. Gonorrhea — Rates: United States, 1970–2004Louisiana’s rate for 2004 was 235.46 per 100,000 – second highest in the nation

27. Rates of Gonorrhea and Chlamydia by Agegroup

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 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