STDs: Urethritis, Cervicitis and PID

1. STDs: Urethritis, Cervicitis and PID Shahbaz Hasan Infectious Care

2. OUTLINE • Management of male patients with urethritis • Management of cervicitis • Chlamydial infections • Gonococcal infections • Diseases causing vaginal discharge: BV and Trichomonas • Pelvic Inflammatory Diseases

3. Urethritis in male patients • Can be infectious or noninfectious • Asymptomatic infections are common • Symptoms: discharge of purulent or mucopurulent material; dysuria; itching • In absence of clinic-based diagnostic tools, treat empirically for GC and Chlamydia • Diagnosis is recommended: partner notification, reportable diseases, improved treatment and compliance

4. Etiology of urethritis in males • GNID (Gram Negative Intracellular Diplococci) • NGU (Nongonococcalurethritis) • Chlamydia trachomatis: 15-55%. Varies by STD risk factors • Ureaplasmaurealyticum • Mycoplasmagenitalium • Trichomonasvaginalis • HSV, adenovirus • Enteric bacteria: insertive anal sex

5. Confirming a diagnosis • Presence of purulent or mucopurulent discharge. OR • Gram stain of urethral secretion with >5 WBC/hpf. High Sen/Sp. OR • First-void urine specimen with pyuria, either microscopic or dipstick test • In the absence of above, test specifically for GC/Chlamydia before treatment. An exception can be made for high risk individuals.

6. Followup after treatment • Abstain from sex for 7d after treatment initiation and partner is adequately treated • Recurrent symptoms alone should not be treated without objective evidence of urethral inflammation • True persistence: consider reinfection, chronic prostatitis, Trichomonas, drug resistant microorganisms

7. Management of Cervicitis: Diagnosis • Often asymptomatic • Abnormal vaginal discharge or intermenstrual bleeding • Purulent or mucopurulentendocervicalexudate • Easily inducible endocervical bleeding • Leukorrhea (>10 WBC/hpf) • All cases of cervicitis should be assessed for PID

8. Etiology of cervicitis • Majority of cases will not have a clear etiology: persistent abnormal vaginal flora, douching, exposure to chemical irritants • Chlamydia • GC • Trichomonas • HSV2 • BV • Mycoplasmagenitalium, ureaplasma

9. Followup after treatment • Abstain from sex for 7d after treatment initiation and partner is adequately treated • Recurrent symptoms need exclusion of reinfection. Exclude BV and trich and drug resistant microorganisms • Persistent symptoms in absence of infection: ablative therapy?

10. Chlamydial infections • Commonest STD in the US. Highest prevalence in <25yr age group • Asymptomatic infection is common in both sexes • Serious sequelae: PID, ectopic pregnancy, infertility • Annual screening is recommended in all high risk women and is suggested in high risk men

11. Chlamydia: Diagnosis • Specimens: Urine; Swabs (urethra, endocervix, vagina, rectum) • Culture, direct immunofluorescence, EIA, nucleic acid hybridization tests, NAAT • NAATs are the most sensitive and FDA-approved for all source specimens EXCEPT Rectal

12. Chlamydia: diagnosis, PHD • BD Probetec (SDA-Strand Displacement Amplification) a form of NAAT • For urethral, endocervical and urine only • Blue cap for male urethral specimens • Pink cap for female specimens

13. Chlamydia: Treatment • Azithromycin: 1gm oral in a single dose • Doxycycline: 100mg bid for 7d • Erythromycin base: 500mg qid for 7d • Levofloxacin: 500mg once daily for 7d

14. Chlamydia: followup after treatment • Abstain from sex for 7d after single-dose treatment or until completion of the 7d course and partner is adequately treated • Test of cure, at 3-4 weeks, is recommended for • Pregnant women • Concern for noncompliance • Concern for reinfection • Consider retesting all women at 3 months

15. Chlamydia: Pregnancy • Azithromycin and erythromycin (except estolate which carries risk of hepatotoxicity) are safe • Amoxicillin 500mg tid for 7d is an alternative • Test of cure at 3-4 weeks is necessary to prevent risk of infant infections (ophthalmia neonatorum and pneumonia)

16. Gonococcal infections • Second most commonly reported bacterial STD. 600,000 new cases each year in US • Majority of men are symptomatic. Women can be asymptomatic • USPSTF recommends screening all high risk women for GC: prior h/o GC, other STDs, new or multiple sex partners, inconsistent condom use, commercial sex workers, drug users, pregnant women

17. GC: diagnosis • Gram stain of male uretheral specimen in symptomatic patients has high Sen (>95%)/Sp (>99%) • Gram stain not sensitive in asymptomatic men or for endocervical, pharyngeal or rectal specimen • Specific diagnosis (culture, nucleic acid hybridization tests and NAAT) are indicated • NAAT is FDA-cleared for urine and genital sites • Culture is indicated for non-genital sites: pharynx, rectum, joints, blood.

18. GC: diagnosis at PHD • For culture: use the Duo blue top swabs with gel (anaerobic transport swabs). Walk specimen down to lab • Chocolate agar and Thayer-Martin are available. Jembec plates are available if you want to plate at the bedside • Most genital specimens are run with the BD Probetec. (Blue cap for male and Pink cap for female specimens)

19. GC: Treatment: uncomplicated Genital and Rectal infections • Ceftriaxone 125mg IM single dose • Cefixime 400mg po single dose • Spectinomycin 2gm IM single dose • Azithromycin 2gm po single dose • Fluoroquinolones no longer acceptable • Other cephalosporins: ?

20. GC: Treatment: Uncomplicated Pharyngeal infections • Eradication is more difficult. • Use Rocephin 125mg IM single dose • Use other cephalosporins with caution • Spectinomycin is unreliable. Perform test of cure 3-5d after administration

21. GC: Treatment: Conjunctivitis • Ceftriaxone 1gm IM single dose • Local care

22. Disseminated Gonococcal Infection (DGI) • Results from gonococcal bacteremia • Petechial or pustular acral skin lesions • Asymmetric arthralgias • Tenosynovitis • Septic arthritis • Endocarditis • Meningitis

23. DGI: Treatment • Ceftriaxone 1gm IV daily for 7d • Spectinomycin 2gm IM bid for 7d • Meningitis and endocarditis need higher doses and longer courses

24. GC: Followup • Uncomplicated cases do not need tests of cure • May consider tests of cure in subjects being treated with alternative regimens or pharyngeal infections • Persistent symptoms should be evaluated by culture for antimicrobial susceptibility testing. • Avoid sex till 7d after completion of therapy and partner is adequately treated

25. Bacterial Vaginosis • Polymicrobial clinical syndrome resulting from the replacement of normal H2O2 producing lactobacillus in the vagina with anaerobic bacteria (prevotella, gardnerella, mycoplasmahominis) • Associations: multiple sex partners, new sex partner, douching, lack of vaginal lactobacilli • Most prevalent cause of vaginal discharge and malodor. More than 50% of women are asymptomatic • Associated with adverse pregnancy outcomes: preterm labor, preterm birth, PROM, postpartum endometritis • Increased risk of infectious complications following hysterectomy and abortions

26. BV: Diagnosis • Any 3 of the following: • Homogenous, thin, white discharge • ‘clue cells’ on wet prep • pH of vaginal fluid >4.5 • ‘whiff test’: fishy odor with 10% KOH • Other commercial tests and culture not recommended

27. BV: Treatment • All women with symptomatic disease • Pregnant women, whether symptomatic or asymptomatic should be treated • Metronidazole 500mg po bid for 7d • Metrogel 0.75%, intravag daily for 5d • Clindamycin cream 2%, intravag daily for 7d • Clindamycin 300mg po bid for 7d • Metronidazole 2gm single dose po is no longer recommended.

28. Trichomonas • Caused by the protozoan Trichomonas vaginalis. • May be asymptomatic in both sexes • Men generally present as NGU, women with diffuse, malodorous, yellow-green, vaginal discharge and vulvar irritation • Association with adverse pregnancy outcomes

29. Trichomonas: Diagnosis • Microscopic exam of vaginal secretions has a sensitivity of only 60-70% • FDA approved POC tests are more sensitive and specific • Culture is the most sensitive and specific commercially available method of diagnosis • Wet preps are very insensitive for men. Culture is required for a confirmed diagnosis

30. Trichomonas: Treatment • Metronidazole 2gm po single dose • Tinidazole 2gm po single dose • Metronidazole 500mg po bid for 7d • Avoid alcohol for 24hr after metronidazole and 72h after tinidazole • Metronidazole is pregnancy category B, while tinidazole is category C. • Lactating women should hold off breast feeding for 24h after metronidazole and 72h after tinidazole • Consult CDC in cases of allergies or resistance issues.

31. Pelvic Inflammatory Disease • Spectrum of inflammatory disorders of the upper female genital tract: endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis • STDs: GC and chlamydia • Vaginal flora: anaerobes, enteric GNR, GBStrep, H influenzae • Mycoplasmahominis and genitalium, Ureaplasma

32. PID: Diagnosis • Clinical diagnosis is imprecise • Many episodes of PID go unrecognized • Due to the potential of damage to the reproductive health of women and difficulty in diagnosis, maintain a low threshold for the diagnosis and treatment of PID.

33. PID: low threshold of diagnosis • Woman at risk for STD, experiencing lower abdominal or pelvic pain, AND has • Cervical motion tenderness, OR • Uterine tenderness OR • Adnexal tenderness • Presence of lower genital tract inflammation increases specificity of diagnosis

34. PID: additional criteria for diagnosis • Fever • Abnormal vaginal or cervical discharge • Leucorrhea • Elevated markers of inflammation: ESR, crp • Documentation of cervical infection with GC or chlamydia

35. PID: specific criteria for diagnosis • Histopath evidence of endometritis on biopsy • Imaging: Transvag US or MRI showing fluid filled, thick tubes; pelvic fluid; tuboovarian complex; tubal hyperemia • Laparoscopic evidence of PID

36. PID: Treatment • Regimens must cover GC and chlamydia • Anaerobes must be covered • Enteric GNRods must be covered. • Treat for 14 days