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STDs II – Urethritis / Discharges

STDs II – Urethritis / Discharges. Tisha Titus Family & Preventive Medicine October 18, 2007. Urethritis & Discharge STDs. Urethritis/Cervicitis Chlamydia (NGU) Gonnorhea Gardnerella (BVG) Trichomoniasis (NGNCU) Candida. General Urethritis. Infectious or not

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STDs II – Urethritis / Discharges

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  1. STDs II – Urethritis / Discharges Tisha Titus Family & Preventive Medicine October 18, 2007

  2. Urethritis & Discharge STDs • Urethritis/Cervicitis • Chlamydia (NGU) • Gonnorhea • Gardnerella (BVG) • Trichomoniasis (NGNCU) • Candida

  3. General Urethritis • Infectious or not • Mucopurulent or purulent material, dysuria, or urethral prurutis • Asymptomatic infections are common • Treat for gonorrhea & chlamydia if confirmatory test not available if ; often co-infection • NGNCU - ureaplasma, mycoplasma, HSV, adenovirus, trich

  4. Urethritis Management • Diagnosis: • Mucopurulent or purulent discharge OR • > 5 WBC on gram stain (oil immersion) OR • + LE on first void urine or > 10 WBC per high power field • Test all for chlamydia and gonorrhea • Treat as per protocol for infectious agent

  5. Urethritis After Care • Return if symptoms persist or recur • Abstain from sexual intercourse until 7 days after treatment completion • If new STD diagnosis, test for additional STDs including HIV • Referral all sex partners in past 60 days for evaluation and treatment • Co-infection with HIV does not alter treatment regimen recommendations

  6. General Cervicitis • Diagnostic signs: • Purulent or mucopurulent endocervical exudate visible in canal or on swab specimen • Sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os • May be asymptomatic; c/o abnormal discharge or intermenstrual bleeding • Organism not isolated in most cases • Infectious or not (douching, abnormal flora)

  7. Cervicitis Management • Assess for PID & test for chlamydia and gonorrhea • Check for presence of BV and trichomoniasis • Treat according to protocol for infectious agent

  8. Cervicitis After Care • Reevaluate for STDs if cervicitis persists • Abstain from sexual intercourse until 7 days after treatment completion • If new STD diagnosis, test for additional STDs including HIV • Referral all sex partners in past 60 days for evaluation and treatment • Co-infection with HIV does not alter treatment regimen recommendations

  9. Chlamydia

  10. Chlamydia Treatment • Recommended: • Azithromycin 1 g PO single dose OR • Doxycycline 100 mg PO BID x 7 days * • Alternative: • Erythromyin base 500 mg PO QID x 7 days OR • Erythromycin ethylsuccinate 800 mg PO QID x 7 days OR • Ofloxacin 300 mg PO BID x 7 day * OR • Levofloxacin 500 mg PO QD x 7 days * * No use in pregnancy

  11. Chlamydia Treatment in Pregnancy • Recommended: • Azithromycin 1 g PO single dose OR • Amoxicillin 500 mg PO TID x 7 days • Alternative: • Erythromycin base 500 mg PO QID x 7 days OR • Erythromycin base 250 mg PO QID x 14 days OR • Erythromycin ethylsuccinate 800 mg PO QID x 7 days OR • Erythromycin ethylsuccinate 400 mg PO QID x 14 days

  12. Chlamydia Treatment in Infants • Neonatal ocular prophylaxis does not prevent perinatal transmission of chlamydia • Conjunctivitis at 5-12 days • Subacute afebrile pneumonia at 1-3 months • Erythromycin base or ethylsuccinate 50 mg/kg/d PO divided into 4 doses daily for 14 days • Efficacy is 80% • Hypertrophic pyloric stenosis in infants <6 weeks

  13. Chlamydia Treatment in Children • Weigh <45 Kg • Erythromycin base or ethylsuccinate 50 mg/kg/day PO divided into 4 doses daily for 14 days • Weigh <45 Kg, but > 8 yrs • Azithromycin 1 gm PO single dose • > 8 yrs • Azithromycin 1 gm PO single dose OR • Doxycycline 100 mg po BID x 7 days

  14. Gonorrhea

  15. Uncomplicated Genital Gonorrhea Treatment • Recommended: • Ceftriaxone 125 mg IM single dose OR • Cefixime 400 mg PO single dose OR • Ciprofloxacin 500 mg PO single dose * OR • Ofloxacin 400 mg PO single dose * OR • Levofloxacin 250 mg PO single dose * OR • Plus treatment for chlamydia if not ruled out • Quinolone resistance * Not for MSM or recent travel

  16. Genital Gonorrhea Treatment for MSM & Travelers • Recommended: • Ceftriaxone 125 mg IM single dose OR • Cefixime 400 mg PO single dose OR • Plus treatment for chlamydia if not ruled out • Alternative: • Spectinomycin 2 g IM single dose OR • Single dose cephalosporin regimen OR • Single dose quinolone regimen Several other antimicrobials are effective, but they do not have substantial advantages over the recommended regimens

  17. Uncomplicated Pharyngeal Gonorrhea Treatment • Recommended: • Ceftriaxone 125 mg IM single dose OR • Ciprofloxacin 500 mg PO single dose • Plus treatment for chlamydia if not ruled out • Quinolones should not be used in MSM or recent travelers, use alternative.

  18. Uncomplicated Pharyngeal Gonorrhea Treatment for MSM • Recommended: • Ceftriaxone 125 mg IM single dose • Plus treatment for chlamydia if not ruled out

  19. Gonnorrhea - Special Considerations • Allergy, intolerance or adverse reaction • Use Spectinomycin (unreliable for pharyngeal infection) • Pharyngeal cultures 3-5 days after treatment • Pregnancy • No quinolones or tetracycline • Use a recommended or alternative cephalosporin • OR single 2 gm IM dose of spectinomycin

  20. Gonnorrhea - Special Considerations • Adolescents • No fluoroquinolones in those <18 years • If >45 kg use any recommended adult regimen • HIV • No alteration of treatment regimen • Conjunctivitis • Ceftriaxone 1 gm IM single dose

  21. Disseminated Gonococcal Infection (24 - 48 hrs after initial improvement) • Recommended: • Ceftriaxone 1 gm IM or IV Q 24 hours • Alternative: • Cefotaxime 1 gm IV Q 8 hours OR • Ceftizoxime 1 gm IV Q 8 hours OR • Ciprofloxacin 400 mg IV Q 12 hours * OR • Ofloxacin 400 mg IV Q 12 hours * OR • Levofloxacin 250 mg IV QD * OR • Spectinomycin 2 gm IM Q 12 hours * Not for MSM or recent travelers

  22. Disseminated Gonococcal Infection (Subsequent regiment) • Recommended: • Cefixime 400 mg PO BID OR • Ciprofloxacin 500 mg PO BID * OR • Ofloxacin 400 mg PO BID * OR • Levofloxacin 500 mg PO QD * • All regimens should total 7 days of IV/IM and PO * not for MSM or recent travelers

  23. Gonococcal Meningitis & Endocarditis • Meningitis: • Ceftriaxone 1-2 gm IV Q 12 hours for 10-14 days • Endocarditis: • Ceftriaxone 1-2 gm IV Q 12 hours for 4 weeks

  24. Ophthalmia Neonatorum • More serious than chlamydia due to globe perforation and blindness • Topical antibiotic therapy is inadequate (erythromycin & tetracycline) • Use caution in hyperbilirubinemic infants • Hospitalize and observe for disseminated infection • Ceftriaxone 25-50mg/kg IV or IM single dose, not to exceed 125 mg

  25. DGI & Scalp Abscesses in Newborns • Requires cultures of blood, CSF, & joint aspirate on chocolate agar • Recommended: • Ceftrixone 25-50 mg/kg/day IV or IM QD x 7 days (10-14 days if meningitis present) • Cefotaxime 25 mg/kg IV ir IM Q 12 hours x 7 days (10-14 days if meningitis present)

  26. Prophylactic Gonococcal Treatment in Infants • Infants born to mothers with untreated gonorrhea • Both mother and infant should be tested for chlamydia • Ceftriaxone 25-50 mg/kg IV or IM single dose, not to exceed 125 mg

  27. Gonococcal Treatment in Children • >45 kg - treat with an adult regimen • <45 kg & uncomplicated infection • Ceftriaxone 125 mg IM single dose OR • Spectinomycin 40 mg/kg IM single dose, not to exceed 2 gm (needs f/u culture) • <45 kg & bacteremia/arthritis • Ceftriaxone 50 mg/kg IM or IV x 7 days, each dose not to exceed 1gm • >45 kg & bacteremia/arthritis • Ceftriaxone 50 mg/kg IM or IV x 7 days

  28. BV / Gardnerella

  29. BV Treatment • Recommended: • Metronidazole 500 mg po BID X 7 days OR • Metronidazole gel 0.75% one applicator (5g) intravaginally QD x 5 days OR • Clindamycin cream 2% one applicator (5g) intravaginally at HS x 7 days • Alternative: • Clindamycin 300 mg po BID x 7 days OR • Clindamycin ovules 100g intravaginally at HS x 3 days

  30. BV Treatment - Special Consideration • Allergy, intolerance or adverse reaction • Intravaginal clindamycin cream for those with difficulty tolerating metronidazole • Pregnancy • All pregnant, symptomatic women should be treated • Asymptomatic pregnant women of high risk should be treated (follow up in 1 month) • Metronidazole 500 mg PO BID X 7 days OR • Metronidazole 250 mg PO TID X 7 days OR • Clindamycin 300 mg PO BID X 7 days

  31. BV Treatment - Special Consideration • HIV • No special regimen • Infections can be more persistent • General follow up is not required is symptoms resolve

  32. Trichomoniasis

  33. Trichomoniasis Treatment • Recommended: • Metronidazole 2 g po single dose OR • Tinidazole 2 g po single dose • Alternative: • Metronidazole 500 mg po BID x 7 days • Advise to abstain from alcohol during and up to 24 hours after completion of metronidazole and 72 hours after completion of tinidazole

  34. Trichomoniasis Treatment - Special Considerations • Allergy, intolerance or adverse reaction • Metronidazole desensitization • Can use topical non-nitroimidazoles, but cure rates are low )>50%) • Pregnancy • Counsel on risk & benefits of treatment, condom use & risk of transmission • Metronidazole 2 gm single dose (Category B) • Abstain from breastfeeding for 24 hours after last dose

  35. Trichomoniasis Treatment - Special Considerations • HIV • No special regimen • Does not require usual follow-up if symptoms resolve

  36. Candida

  37. Uncomplicated Sporadic or infrequent Mild to moderate Likely to be C albicans Nonimmunocompromised women Complicated Recurrent Severe Nonalbicans candida Women with uncontrolled diabetes, debilitation, or immunosupression Pregnant women Candidiasis Classification

  38. Uncomplicated Candida Treatment • Intravaginal: • Butoconazole • 2% cream 5 g x 3 days (OTC) • 2% cream (sustained release) 5 g once • Clotrimazole • 1% cream 5 g x 7-14 days (OTC) • 100 mg single tablet x 7 days • 100 mg two tablets x 3 days • Nystatin 100,000 unit tablet QD x 14 days • Tioconazole 6.5% ointment 5 g single application

  39. Uncomplicated Candida Treatment • Intravaginal Cont: • Miconazole • 2% cream 5 g x 7 days (OTC) • 100 mg suppository QD x 7 days (OTC) • 200 mg suppository QD x 3 days (OTC) • 1200 mg suppository single dose (OTC) • Teraconazole • 0.8% cream 5 g x 3 days • 80 mg suppository QD x 3 days • Oral: • Fluconazole 150 mg single dose

  40. Uncomplicated Candida Treatment • Follow up only required is symptoms persist or recur within 2 months of initial symptom onset • Treatment of sex partners generally not recommended • Oral azoles may cause increased LFTs & may have clinically important interactions with several medication classes

  41. Recurrent Candida Treatment • 4 or more episodes in 1 year; culture • General treatment • 7-14 days of a topical agent • Fluconazole 100mg, 150 mg or 200 mg every 3rd day for a total of 3 doses • Maintenance • Fluconazole 100 mg, 150 mg or 200 mg weekly for 6 months OR • Topical clotrimazole 200 mg twice weekly • Clotrimazole 500 mg suppository weekly

  42. Severe Candida Treatment • Extensive vulvar erythema, edema, excoriation & fissure formation • General Treatment • 7-14 days of a topical azole OR • Fluconazole 150 mg in two sequential doses 72 hours apart

  43. Nonalbicans Treatment • Optimal treatment unknown • Treatment options • 7-14 days of a nonfluconazole azole (oral or topical) • Boric acid 600 mg gelatin capsule intravaginally for 2 weeks

  44. Candida Treatment - Special Considerations • Compromised host • Correct modifiable medical conditions • Prolonged (7-14 day) conventional antimycotic regimen • Pregnancy • Topical azoles only for 7 days • HIV infection • No special treatment regimen • Fluconazole 200 mg weekly for reduced colonization in recurrent infections

  45. Pelvic Inflammatory Disease (PID) ….to be held over for the final STD lecture

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