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Overview of Sexually Transmitted Diseases

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

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Overview of Sexually Transmitted Diseases

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  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 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) 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. 1981-1999 Cases/100,000 80 Louisiana 60 40 20 U.S. Year 2000 Objective 0 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year of Report

  8. 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 0 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 • 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 Test type PCR/LCR Culture DFA DNA Probe EIA 1 10 100 1000 10000 100000 1000000 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 Cases/100,000 500 400 Chlamydia 300 Gonorrhea 200 100 P&S Syphilis 0 1992 1993 1994 1995 1996 1997 1998 1999 Year of Report *projected from first 8 months

  25. Chlamydia — Rates: United States, 1984–2004Louisiana’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.

  26. Gonorrhea — Rates: United States, 1970–2004Louisiana’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.

  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 0 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

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