Sexually Transmitted Infections and 2010 CDC STD Treatment Guidelines April 11, 2012 HIV/STD/TB/Hepatitis Symposium B

1. Sexually Transmitted Infections and 2010 CDC STD Treatment Guidelines April 11, 2012 HIV/STD/TB/Hepatitis SymposiumBismarck ND David McNamara, M.D. Infectious Disease Division Gundersen Lutheran La Crosse WI

2. Disclosures • No commercial disclosures • Dakota AIDS Education & Training Center

3. Learning Objective • At the end of the presentation, participants should be familiar with basics of: • Common Sexually Transmitted Infections • 2010 CDC STD Treatment Guidelines • Common presentations of HIV • HIV Screening

4. What is Your Professional Discipline? • Nurse • Physician • Public Health (RN, Epidemiologist) • Allied Health • Laboratory • Social Worker • Other

5. Overview • Sexually Transmitted Infections • Case # 1 • Case # 2 • Case # 3 • Case # 4 • Summary

6. Sexually Transmitted Infections • Common • Wide variety of pathogens can be transmitted sexually • Often transmit more efficiently male→female than female→male • Sequelae • Direct effect of pathogen on body • Infertility, ectopic pregnancy, cancer, transmission to fetus

7. Some (not all) Pathogens Transmitted Sexually • T. pallidum (Syphilis) • Neisseria gonorrhoeae • Chlamydia trachomatis • Ureaplasmaurealyticum • Mycoplasma genitalium • Haemophilusducreyi (Chancroid) • Chlamydia trachomatis L1, L2, L3 (Lymphogranulomavenereum) • Klebsiellagranulomatis (Granuloma Inguinale) • Trichomonasvaginalis • Scabies, Pediculosis pubis • HSV, Herpes Simplex Virus • HIV • HBV, HDV • CMV, EBV • Human Papilloma Virus (HPV) • HHV-8, Kaposi’s Sarcoma Herpes Virus (KSHV)

9. ©FMH Graphics

10. Overview • Sexually Transmitted Infections • Case # 1 • Case # 2 • Case # 3 • Case # 4 • Summary

11. Case #1 • 19 year-old female student presents for routine care • Sexually active with male partner • Feels well, no GU symptoms • Cervical swab • Routine pap smear • Chlamydia/Gonorrhea Nucleic Acid Amplicification Test (NAAT) • Chlamydia NAAT returns positive

12. How should she be treated? • Ceftriaxone 250 mg IM x 1 dose • Azithromycin or doxycycline for patient • Azithromycin or doxycycline for both patient and her partner • Cipro 500 mg PO BID x 7 days • Confirm NAAT with culture prior to treatment

13. Chlamydia • Chlamydia trachomatis • Most common bacterial STI • Often asymptomatic • Can give urethritis in men • Common cause of infertility • Scarring of fallopian tube (Pelvic Inflammatory Disease) • 10-15% of women with untreated Chlamydia develop PID • Women often re-infected if partner not treated • Treat with azithromycin or doxycycline • Sexually active women need yearly Chlamydia/gonorrhea testing

15. Observed Single dose treatment advantage • treatment completed • No sexual intercourse for 7 days after treatment completed • Test of cure not recommended • 3 month re-testing recommended to screen for re-infection

16. How should her sexual partner be managed? • Timely treatment of sexual partner important to reduce risk of re-infecting index patient, others • Instruct patient to refer most recent sexual partner, and any other partners within 60 days of Chlamydia diagnosis, for testingand treatment • If sexual partner(s) unlikely to present for treatment, consider Expedited Partner Therapy • Patient must inform partner, provide written material to seek evaluation for symptoms of complications (testicular pain, pelvic pain) • Patient-delivered prescription or antibiotic for partner(s) • Not for Men who have sex with Men (MSM) • Very high HIV risk, partners need testing/treatment

19. Overview • Sexually Transmitted Infections • Case # 1 Chlamydia • Case # 2 • Case # 3 • Case # 4 • Summary

20. Case #2 • 28 year old man presents with painful, burning urination x 1 week • Yellow urethral discharge x 3 days • “I’ve never had this before!” • Reports 3 female sexual partners in last several months • Intermittent condom use, only when partner is new

21. Public Health Image Library • Urethral swab taken • Gram stain • Gram Negative Diplococci

22. Likely etiology of urethritis? Chlamydia Herpes Simplex Virus Gonorrhea E. coli UTI/ epididymitis Syphilis

23. How should this be treated? • Ceftriaxone 250 mg IM x 1 • Ceftriaxone 250 mg IM + Azithromycin 1g PO x 1 • Doxycycline 100 mg PO BID x 7 days • Ciprofloxacin 500 mg PO BID x 7 days • Cefixime 400 mg PO x 1

24. Gonorrhea • Neisseria gonorrhoeae • 700,000 cases/year in U.S. • Men: urethral discharge, urethritis • Women: asymptomatic, dysuria, vaginal discharge, PID • Diagnosis: • Gram Stain • Culture: Thayer-Martin media or chocolate agar • NAAT on urine, urethral swab, cervical swab • Will transmit to infant during birth

25. Provide treatment for Chlamydia together with Gonorrhea • Common co-infections • Cipro/Levofloxacin resistent Gonorrhea now common • Resistance to Cephalosporins rare but expected to increase • Routine test of cure not recommended (only if symptoms) • Rescreen at 3 months to detect re-infection

28. Overview • Sexually Transmitted Infections • Case # 1 Chlamydia • Case # 2 Gonorrhea • Case # 3 • Case # 4 • Case # 5 • Summary

29. Case # 3 • 32 year old man presents with ulcer on penis • Does not hurt, present for 1 week • Married, wife doesn’t have any symptoms • Travels frequently for business • several sexual encounters per year with other men • 2 years ago • Treated for gonorrhea • HIV test negative at that time • Uses condoms “most of the time”

30. Public Health Image Library

31. Most likely etiology of penile ulcer? • Herpes Simplex Virus • Syphilis • Gonorrhea • Chlamydia • Lymphogranuloma Venereum (LGV)

32. Syphilis • Treponemapallidum • 36,000 cases/year in U.S. • 2/3 in MSM • A systemic disease • Primary: painless genital ulcer (chancre) • Secondary: rash • Latent • asymptomatic at first • neurologic, bone, heart disease in 10-20 years • Pregnancy: transmission to infant • Diagnosis: RPR or VDRL blood test • All patients with Syphilis need HIV testing! • All partners need evaluation, usually presumptive treatment

33. Primary and secondary syphilis • Benzathine PCN G 2.4 Million Units IM x 1 dose • Latent Syphilis • Early: Benzathine PCN G 2.4 Million Units IM x 1 dose • Late, or unknown duration: Benzathine PCN G 2.4 Million Units IM x q week x 3 doses • Tertiary: cardiac, Gumma (need to rule out Neurosyphilis) • Benzathine PCN G 2.4 Million Units IM x q week x 3 doses • Neurosyphilis • Penicillin G 24 million units/day (continuous IV infusion) x 10-14 days

35. Overview • Sexually Transmitted Infections • Case # 1 Chlamydia • Case # 2 Gonorrhea • Case # 3 Syphilis • Case # 4 • Case # 5 • Summary

36. CC: Sore Throat • 20 year-old woman presents to University Student Health Service • sore throat • “achy all over” for past 5 days • joints ache, fevers, “I feel rotten” • missed classes for 3 days • “exhausted”

37. PMH: • otherwise well • Meds: • oral contraceptives • Social History • grew up in rural ND • sophomore business major • occasional alcohol use • no tobacco • new boyfriend for 3 months

38. Exam • VS: Temp 100.3° F • Awake, alert, looks tired and ill • Oropharynx red; tonsils swollen • Small, swollen mobile cervical lymph nodes • Lungs: clear • Cor: RRR with normal s1s2 no murmurs • Abdomen soft, nontender, no HSM • Joints: no effusions or synovitis • Skin: rash on chest, back

41. Labs • WBC 2.3 N45 L5 M28 B9 E4 • Hb 12.8 g/dL • platelets 112,000 • Group A Strep PCR: negative • Assessment? • Febrile illness with pharyngitis, leukopenia and rash • Differential diagnosis?

42. Likely Diagnosis? • Mononucleosis • Epstein-Barr Virus Infection • Streptococcal Pharyngitis • Acute HIV infection • Severe Cold

43. Further testing? • Monospot: negative • CMV Antibody • IgG positive, IgM negative • Testing for HIV infection? • HIV Antibody Screen: negative • HIV Viral Load: 770,000 copies/mL

44. Diagnosis: Acute HIV Infection • Illness associated with initial HIV infection • Fever, body aches, sore throat, swollen lymph nodes common • Rash in 50% • Uncommonly recognized • Important to make diagnosis: • reduce HIV transmission to others • sexual partners, infants • treat HIV before advanced AIDS develops

45. Is there HIV in North Dakota? • ND a low incidence state, but…