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Sexually Transmitted Diseases Part 2

sexually transmitted diseases, STD prevention, STD treatment, STD education

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Sexually Transmitted Diseases Part 2

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  1. Sexually Transmitted DiseasesPart 2 Edward L. Goodman, MD February 9, 2004

  2. Background Information

  3. Background Knowledge About STDs Among Americans Source: Kaiser Family Foundation, 1996

  4. Background Where Do People Go for STD Treatment? • Population-based estimates from National Health and Social Life Survey Private provider 59% Other clinic 15% Emergency room 10% STD clinic 9% Family planning clinic 7% Source: Brackbill et al. Where do people go for treatment of sexually transmitted diseases? Family Planning Perspectives. 31(1):10-5, 1999

  5. Background Percent of Women Who Said Topic Was Discussed During First Visit With New Gynecological or Obstetrical Doctor/Health Care Professional Percentages may not total to 100% because of rounding or respondents answering “Don’t know” to the question “Who initiated this conversation?” Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997

  6. Background Estimated Burden of STD in U.S. - 1996 Source: The Tip of the Iceberg: How Big Is the STD Epidemic in the U.S.? Kaiser Family Foundation 1998

  7. Background “...the scope and impact of the STD epidemic are under-appreciated and the STD epidemic is largely hidden from public discourse.” IOM Report 1997

  8. STD Prevention and Control • Education and counseling to reduce risk of STD acquisition • Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation • Effective diagnosis and treatment • Evaluation, treatment, and counseling of sexual partners • Preexposure vaccination--hepatitis A, B

  9. Prevention Messages • Prevention messages tailored to the client’s personal risk; interactive counseling approaches are effective • Despite adolescents greater risk of STDs, providers often fail to inquire about sexual behavior, assess risk, counsel about risk reduction, screen for asx infection • Specific actions necessary to avoid acquisition or transmission of STDs • Clients seeking evaluation or treatment for STDs should be informed which specific tests will be performed

  10. Prevention MethodsMale Condoms • Consistent/correct use of latex condoms are effective in preventing sexual transmission of HIV infection and can reduce risk of other STDs • Likely to be more effective in prevention of infections transmitted by fluids from mucosal surfaces (GC,CT, trichomonas, HIV) than those transmitted by skin-skin contact (HSV,HPV, syphilis, chancroid)

  11. Prevention MethodsSpermicides • N-9 vaginal spermicides are not effective in preventing CT, GC, or HIV infection • Frequent use of spermicides/N-9 have been associated with genital lesions • Spermicides alone are not recommended for STD/HIV prevention • N-9 should not be used a microbicide or lubricant during anal intercourse

  12. MSM • STD/HIV sexual risk assessment and client-centered prevention counseling • Annual STD screening for MSM at risk -HIV and syphilis serology -Urethral cx or NAAT, GC/CT -Pharyngeal cx, GC (oro-genital) -Rectal cx, GC/CT (receptive anal IC)

  13. Background STDs of Concern • Actually, all of them • “Sores” (ulcers) • Syphilis • Genital herpes (HSV-2, HSV-1) • Others uncommon in the U.S. • Lymphogranuloma venereum • Chancroid • Granuloma inguinale

  14. Background STDs of Concern (continued) • “Drips” (discharges) • Gonorrhea • Chlamydia • Nongonococcal urethritis / mucopurulent cervicitis • Trichomonas vaginitis / urethritis • Candidiasis (vulvovaginal, less problems in men) • Other major concerns • Genital HPV (especially type 16, 18) and Cervical Cancer

  15. “Drips” Gonorrhea Nongonococcal urethritis Chlamydia Mucopurulent cervicitis Trichomonas vaginitis and urethritis Candidiasis

  16. Urethritis • Mucopurulent or purulent discharge • Gram stain of urethral secretions > 5 WBC per oil immersion field • Positive leukocyte esterase on first void urine or >10 WBC per high power field Empiric treatment in those with high risk who are unlikely to return

  17. Drips Gonorrhea - Clinical Manifestations • Urethritis - male • Incubation: 1-14 d (usually 2-5 d) • Sx: Dysuria and urethral discharge (5% asymptomatic) • Dx: Gram stain urethral smear (+) > 98% culture • Complications • Urogenital infection - female • Endocervical canal primary site • 70-90% also colonize urethra • Incubation: unclear; sx usually in l0 d • Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain • Dx: Gram stain smear (+) 50-70% culture • Complications

  18. Gonorrhea Epidemiology of Gonorrhea • Proportion of gonococcal infections caused by resistant organisms is increasing • Incidence remains high in some groups defined by geography, age and race/ethnicity, or sexual orientation • Gonorrhea associated with increased susceptibility to HIV infection

  19. Gonorrhea Gonorrhea — Reported rates: United States, 1970–2001 and the Healthy People year 2010 objective Note: The Healthy People 2010 (HP2010) objective for gonorrhea is 19.0 cases per 100,000 population. Source: CDC/NCHSTP 2001 STD Surveillance Report

  20. Gonorrhea Gonorrhea — Rates by state: United States and outlying areas, 2001 Note: The total rate of gonorrhea for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 126.9 per 100,000 population. The Healthy People year 2010 objective is 19.0 per 100,000 population. Source: CDC/NCHSTP 2001 STD Surveillance Report

  21. Gonorrhea Gonorrhea — Rates by gender: United States, 1981–2001 and the Healthy People year 2010 objective Source: CDC/NCHSTP 2001 STD Surveillance Report

  22. Gonorrhea Gonorrhea — Age- and gender-specific rates: United States, 2001 Source: CDC/NCHSTP 2001 STD Surveillance Report

  23. Drips Gonorrhea Source: Florida STD/HIV Prevention Training Center

  24. Drips Gonorrhea Gram Stain Source: Cincinnati STD/HIV Prevention Training Center

  25. Neisseria gonorrhoeaeCervix, Urethra, Rectum Cefixime 400 mg or Ceftriaxone 125 IM or Ciprofloxacin 500 mg or Ofloxacin 400 mg/Levofloxacin 250 mg PLUS Chlamydial therapy if infection not ruled out

  26. Neisseria gonorrhoeaeCervix, Urethra, Rectum Alternative regimens Spectinomycin 2 grams IM in a single dose or Single dose cephalosporin (cefotaxime 500 mg) or Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg) PLUS Chlamydial therapy if infection not ruled out

  27. Neisseria gonorrhoeaePharynx Ceftriaxone 125 IM in a single dose or Ciprofloxacin 500 mg in a single dose PLUSChlamydial therapy if infection not ruled out

  28. Neisseria gonorrhoeaeTreatment in Pregnancy • Cephalosporin regimen • Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM • No quinolone or tetracycline regimen • Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection

  29. Disseminated Gonococcal Infection Recommended regimen Ceftriaxone 1 gm IM or IV q 24 hr Alternative regimens Cefotaxime or Ceftizoxime 1 gm IV q8 hr or Ciprofloxacin 400 mg IV q 12 or Ofloxacin 400 mg IV q 12 or Levofloxacin 250 mg IV daily

  30. Neisseria gonorrhoeaeAntimicrobial Resistance • Geographic variation in resistance to penicillin and tetracycline • No significant resistance to ceftriaxone • Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California • Surveillance is crucial for guiding therapy recommendations

  31. Gonococcal Isolate Surveillance Project (GISP) — Penicillin and tetracycline resistance among GISP isolates, 2002 Note: PPNG=penicillinase-producing N. gonorrhoeae; TRNG=plasmid-mediated tetracycline resistant N. gonorrhoeae; PPNG-TRNG=plasmid-mediated penicillin and tetracycline resistant N. gonorrhoeae; PenR=chromosomally mediated penicillin resistant N. gonorrhoeae; TetR=chromosomally mediated tetracycline resistant N. gonorrhoeae; CMRNG=chromosomally mediated penicillin and tetracycline resistant N. gonorrhoeae.

  32. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2002 Note: Resistant isolates have ciprofloxacin MICs > 1 g/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 g/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

  33. Drips Nongonococcal Urethritis Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas

  34. Drips Nongonococcal Urethritis • Etiology: • 20-40% C. trachomatis • 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium) • Occasional Trichomonas vaginalis, HSV • Unknown in ~50% cases • Sx: Mild dysuria, mucoid discharge • Dx: Urethral smear  5 PMNs (usually 15)/OI field Urine microscopic  10 PMNs/HPF Leukocyte esterase (+)

  35. Chlamydia Epidemiology of Chlamydia • Incidence: Approximately 4 million estimated cases in U.S. per annum • Most frequently reported STD in U.S. • Rates 4x higher in females • Decreasing prevalence in selected areas with control programs that include clinic-based screening • High prevalence of coinfection in partners (>50%) • Perinatal transmission results in neonatal conjunctivitis in 30-50% of exposed babies

  36. Chlamydia Chlamydia — Rates by gender: United States, 1984–2001 Source: CDC/NCHSTP 2001 STD Surveillance Report

  37. Chlamydia Chlamydia — Age- and sex-specific rates: United States, 2001 Source: CDC/NCHSTP 2001 STD Surveillance Report

  38. Chlamydia Chlamydia — Rates by state: United States and outlying areas, 2001 Note: The total rate of chlamydia for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 275.5 per 100,000 population. Source: CDC/NCHSTP 2001 STD Surveillance Report

  39. Nongonococcal Urethritis Azithromycin 1 gm in a single dose or Doxycycline 100 mg bid x 7 days

  40. Nongonococcal UrethritisAlternative regimens Erythromycin base 500 mg qid for 7 days or Erythromycin ethylsuccinate 800 mg qid for 7 days or Ofloxacin 300 mg twice daily for 7 days or Levofloxacin 500 mg daily for 7 days

  41. Recurrent/Persistent Urethritis • Objective signs of urethritis • Re-treat with initial regimen if non-compliant or re-exposure occurs • Intraurethral culture for trichomonas • Effective regimens not identified in those with persistent symptoms without signs

  42. Recurrent/Persistent Urethritis Metronidazole 2 gm single dose PLUS Erythromycin base 500 mg qid x 7d or Erythromycin ethylsuccinate 800 mg qid x 7d

  43. Drips Chlamydia trachomatis • More than three million new cases annually • Responsible for causing cervicitis, urethritis, proctitis, lymphogranuloma venereum, and pelvic inflammatory disease • Direct and indirect cost of chlamydial infections run into billions of dollars • Potential to transmit to newborn during delivery • Conjunctivitis, pneumonia

  44. Drips Normal Cervix Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center

  45. Drips Chlamydia Cervicitis Source: St. Louis STD/HIV Prevention Training Center

  46. Drips Mucopurulent Cervicitis Source: Seattle STD/HIV Prevention Training Center

  47. Drips Chlamydia Life Cycle Source: California STD/HIV Prevention Training Center

  48. Drips Laboratory Tests for Chlamydia • Tissue culture has been the standard • Specificity approaching 100% • Sensitivity ranges from 60% to 90% • Non-amplified tests • Enzyme Immunoassay (EIA), e.g. Chlamydiazyme • sensitivity and specificity of 85% and 97% respectively • useful for high volume screening • false positives • Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2 • sensitivities ranging from 75% to 100%; specificities greater than 95% • detects chlamydial ribosomal RNA • able to detect gonorrhea and chlamydia from one swab • need for large amounts of sample DNA

  49. Drips Laboratory Tests for Chlamydia (continued) • DNA amplification assays • polymerase chain reaction (PCR) • ligase chain reaction (LCR) • Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100% • LCR ability to detect chlamydia in first void urine

  50. Drips Chlamydia Direct Fluorescent Antibody (DFA) Source: Centers for Disease Control and Prevention

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