Sexually Transmitted Infections Tory Davis, PA-C

1. Sexually Transmitted InfectionsTory Davis, PA-C

2. STD? STI? VD? • a.k.a. Venereal Diseases • Increasingly, the term sexually transmitted infection (STI) is used: a person may be infected, and may potentially infect others, without showing signs of disease. • An STI is an illness that is spread through sexual contact: • Vagina/penis, vulva/vulva, oral sex, and anal sex. • Other routes: kissing, IV drug administration, sharing of sex toys, childbirth or breastfeeding.

3. Facts • 65 million of people living in the US with STI • 15 million of new STI cases each year • 2/3 of all STIs occurs in people 25 yrs of age or younger • one in four new STI cases occur in teenagers • one in four Americans have genital herpes, and 80% of those with herpes are unaware they have it • at least one in four Americans will get STI at some point in their lives

4. One in Four • CDC study released last year shows that 26% of teen girls has at least one of the most common STIs • HPV • Chlamydia • Trich • HSV

5. Taking the History:The 5 Ps • Partners • Prevention of Pregnancy • Protection from STDs • Practices • Past History of STDs

6. Partners • “Do you have sex with men, women, or both?” • “In the past 2 months, how many partners have you had sex with?” • “In the past 12 months, how many partners have you had sex with?”

7. Prevention of pregnancy • Are you or your partner trying to get pregnant? • If no, what are you doing to prevent pregnancy? • Do you use condoms?

8. Protection from STIs • “What do you do to protect yourself from STIs and HIV?” • Do you use condoms? • How often? Always, sometimes, or rarely? • If “never:” “Why don’t you use condoms?” • If “sometimes”: “In what situations or with whom do you not use condoms?”

9. Practices • “To understand your risks for STDs, I need to understand the kind(s) of sex you have had recently.” • “Have you had vaginal sex, meaning ‘penis in vagina sex’”? • If yes, “Do you use condoms: never, sometimes, or always?” • “Have you had anal sex, meaning ‘penis in rectum/anus sex’”? • If yes, “Do you use condoms: never, sometimes, or always?” • “Have you had oral sex, meaning ‘mouth on penis/vagina/anus’”? • If yes, “Do you use a dental dam?”

10. Past History of STIs “Have you ever had an STI?” • “Have any of your partners had an STI?” • Additional questions to identify HIV and hepatitis risk • “Have you or any of your partners ever injected drugs? • “Have any of your partners exchanged money or drugs for sex?” • “Is there anything else about your sexual practices that you think I might need to know about?”

11. STIs Characterized by… Genital Ulcers: HSV, Syphilis, Chancroid Urethritis/Cervicitis: Gonorrhea, Chlamydia Vaginal Discharge: Bacterial vaginosis, Trichomoniasis, candidiasis Other: PID, Epididymitis/prostatitis, HPV/genital warts, proctitis/proctocolitis/enteritis Ectoparasites: Pediculosis pubis, scabies (covered in derm)

12. Diseases Characterized by Genital Ulcers • Herpes (*MC) • Syphilis • Chancroid • Associated with increase risk of HIV • Diagnosis based on history and physical is often inaccurate.

13. Chancroid • Cause: gram-negative bacillus—Haemophilus ducreyi • Incubation: 3-5 days • Initial lesion is a vesicopustule that breaks down to form a painful, soft ulcer with a necrotic base, surrounded by erythema • Multiple lesions develop by autoinoculation • Frequent inguinal adenitis often develops • Well established cofactor for HIV transmission (10% may be infected).

14. Chancroid Epi Transmission of H. ducreyi is almost exclusively by sexual contact Hygiene and cleanliness are important determinants of contagiousness The incidence in the U.S. has declined; <1,500 cases/year Prostitution is a major cause of spread (seen a lot during Korean and Vietnam wars)

15. Chancroid Dx • Hx • PE • Bacterial culture for H. ducreyi

16. Chancroid Treatment Azithromycin 1 g orally onceORCeftriaxone 250 mg intramuscularly (IM) ORCiprofloxacin 500 mg orally BID for 3 daysORErythromycin base 500 mg po TID for 7 days

17. Syphilis • Cause: spirochete (gram neg bac-t) Treponema pallidum • Capable of infecting any organ or tissue in the body. • Risk of transmission 30-50% in partner with primary syphilis. • Three stages: primary, secondary, and late (tertiary) syphilis • Also congenital and neurosyphilis

18. Syphilis Epidemiology -Humans are only known host -Transmission by direct contact with infectious lesions, generally through sexual contact -The incidence is highest in sexually active 20-29 year olds -Incidence: 70,000 case/year or about 7 per hour in the US -Higher risk for men, esp MSM

19. Primary Syphilis • 2-6 weeks after exposure • Chancre- genital ulcer, painless with clean base and firm, indurated borders • Regional lymphadenopathy • 10-30 days post exposure, heals in 3-6 weeks

20. Secondary Syphilis • 2-8 weeks after chancre onset • “The Great Imitator”- nonspecific sx: malaise, fatigue, HA, fever, sore throat • Generalized lymphadenopathy • Papulosquamous dermatosis- Pale, red discrete round lesions with scaling over surface on palms, soles, trunk • Condyloma lata-papules coalesce and become large, flat highly contagious lesions • Highly infectious mucous membrane lesions

21. Secondary Syphilis • Condyloma lata-moist, flat, confluent plaques

22. Latent syphilis • Period of time between P/S and tertiary syphilis where lab tests will be positive, pt is infected, but no clinical signs • Only infectious in pregnancy and transfusion

23. Tertiary Syphilis • 1-30 years after initial infection • Late benign tertiary syphilis (gumma) • Cardiovascular syphilis • Neurosyphilis

24. Gumma May form 1 to 10 years after initial infection Destructive granulomatous lesions affect any area Responds rapidly to treatment

25. Cardiovascular Syphilis Begins 5 to 10 years after initial infection Clinically seen 20-30 years after infection Obliterative endarteritis of vasa vasorum Ascending aorta develops aortic insufficiency and aneurysm

26. Neurosyphilis • Occurs in 10% of untreated pts • HA, mental deterioration, personality change plus • Tremor of lips, tongue or hands • Argyll-Robertson pupil – look up • Seizures • Ataxia • Aphasia • Hyperreflexia • Cognitive changes, can evolve into psychosis

27. Screeningfor Syphilis • Non-treponemal tests • VDRL (Venereal Disease Research Laboratory) test. Screen for antibodies, not specific to T. pallidum • RPR- rapid plasma reagin- antibody • EIA- enzyme immunoassay test

28. DiagnosingSyphilis-Treponemal tests • Fluorescent treponemal antibody absorption (FTA-ABS) test. Detects antibodies to T pallidum. Use after 3 weeks post-exposure. Blood or spinal fluid. • Treponema pallidum particle agglutination assay (TPPA). Same as above, but blood only. • Darkfield microscopy. Uses special microscope to examine fluid or tissue from a chancre. Mainly to diagnose syphilis in an early stage.

29. Treatment -Benzathine penicillin G 2.4 million units IM once (if infected < 1 year) If PCN allergic -Doxycycline, ceftriaxone, azithromycin Alternate tx for pregnancy, congenital, latent, neurosyphilis, and post-exposure prophylaxis (look-ups)

30. Response to Treatment • No definitive test of cure, reassess clinically and serologically in 6-12 months • Consider treatment failure if symptoms persist or titer remains 4x normal • If treatment failure; CSF testing, HIV testing, and benzathine penicillin G weekly x 3 weeks

31. Tuskegee Syphilis Study 1932-1972 • "The United States government did something that was wrong—deeply, profoundly, morally wrong. It was an outrage to our commitment to integrity and equality for all our citizens... clearly racist."—President Clinton's apology for the Tuskegee Syphilis Experiment to the eight remaining survivors, May 16, 1997

32. Genital Herpes • Chronic, life-long viral infection caused by human herpesviruses • Subclinical primary infections more common than clinically manifestations • HSV persists in a latent state for the remainder of the host’s life in the sensory ganglia, then reactivation lesions appear in the distal sensory nerve distribution • HSV 1 and 2

33. Etiology • HSV-1 primarily transmitted by nonsexual routes, (ie infected saliva) • Causes cold sores and oropharynx stomatitis • HSV-2 is usually transmitted sexually or maternally • causing genital herpes and neonatal infections • also it has been linked epidemiologically with carcinoma of the cervix

34. Etiology • This rough rule of HSV-1 above the waist and HSV-2 below the waist is no longer strictly true: • approximately 20% of genital herpes cases are due to HSV-1 • HSV-2 may induce oropharyngeal infections

35. Epidemiology • Risk of infection is approximately 75% following contact with a symptomatic case. • At least 50 million persons in the United States have genital HSV infection.

36. Genital Herpes (cont) • HSV type 2 usually involves the genital tract, latent virus is in presacral ganglia • Typical lesions are grouped, painful, small, and vesicular • Asymptomatic shedding is possible and establishing a first episode of HSV-2 is difficult. • Incubation is 2-7 days

37. Diagnosis • Usually done clinically however the classical painful multiple vesicular or ulcerative lesions are absent in many infected persons. • May be detected by viral cultures of vesicular fluid or direct fluorescent antibody staining of scraped lesions may confirm diagnosis • Presence of intranuclear inclusions and multinucleated giant cells on a Tzank preparation is supportive of a diagnosis of herpes viral infections.

38. Who Gave it to Me? • Often difficult to tell • Latent period • Difficult counseling • Emphasize prevention of spread

39. Treatment • Antivirals • Acyclovir • Famcyclovir • Valacyclovir • Dose and duration depends: • First episode • Recurrent episodes • Suppression

40. Diseases Characterized by Urethritis and Cervicitis • Gonoccocal infections • Chlamydial infections • Non-gonococcal infections

41. Gonorrhea • Caused by Neisseria gonorrhoeae • a.k.a. “the clap” • Can affect urethra, cervix, rectum, conjunctiva (ophthalmia neonatorum), oropharynx

42. Gonococcal Epi • 700,000 cases in US/year • But since a number of GC infections are asymptomatic or not reported it is estimated that there are 1-2 million total cases/year in the U.S • Humans=only host • Transmitted sexually

43. Gonorrhea Symptoms • Often asymptomatic – contributes spread • Male: dysuria, purulent or mucopurulent urethral discharge • (word of the day: gleet) • Female: vaginal discharge (actually from cervix), dysuria, post-coital bleeding, inter-menstrual bleeding

44. Complications • Men: epididymitis, prostatitis, proctitis • Women: vaginitis, salpingitis, pelvic inflammatory disease • Both: disseminated GC-systemic complication following the dissemination of gonococci from the primary site via the bloodstream. (arthralgias, fever, rash)

45. Diagnosis • Evaluation of the presenting symptoms and sexual history • Gram stain of urethral exudates and • Culturing for N. gonorrhoeae

46. Dual Therapy • Patients with GC should be treated routinely with a regimen effective against C. trachomatis.—10-30% co-infection rates • Once you dx GC, you don’t even have to test for chlamydia because it is more cost effective to treat for it.

47. Gonorrhea Treatment • Ceftriaxone 125 mg IM in a single doseORCefixime 400 mg orally in a single dose or 400 mg by suspension (200 mg/5ml)PLUSTREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT • NB- fluoroquinolones no longer recommended due to resistance

48. Gonorrhea-infant • During childbirth, gonococci infect the conjunctivitis, pharynx, respiratory tract and gastrointestinal tract of the body. • Routine prophylaxis with 1% AgNO4 or 0.5% erythromycin or 1% tetracycline applied directly to the eye following birth prevents opthalmia neonatorium

49. Chlamydia

50. Chlamydia • Very common STI caused by Chlamydia trachomatis • 1,030,911 reported cases in 2006 in US- likely very underreported • “The Silent Disease” asymptomatic in 75% of women and 50% of men