SEXUALLY TRANSMITTED INFECTIONS

Tarek Mansi

Epidemiology and Trends

~19 million new cases every year ~65 million have incurable viral STIs 2/3 in adolescents and young age US: 4 out of 10 top notifiable diseases

(HSV and HPV not reportable) HPV: 50% of sexually active males and

females Gonorrhea: - - 20 times more in non-hispanic blacks - Increased Quinolone resistance

STI

Sores Drips

Sores (Ulcers)

Sexually Transmitted

Non- sexually Transmitted

Trauma Drug reactions Cancer Behcet’s syndrome Erythema multiforme Psoriasis & Lichen planus

Herpes Simplex

Cause: HSV I &II (85-90%) IP: 4-6 days Asymptomatic viral shedding for up to 3

months Diagnosis: - Definitive test: Viral culture, Tzank

smear - Serological tests: IgM and IgG

Treatment

First clinical episode (7-10d): Acyclovir: 400 mg TID / 200mg 5 times

per day Famciclovir: 250mg BID Valacyclovir: 1g BID TopicalLater on:

Chancroid

Cause: H. ducreyi IP: 1-21d Difficult to culture Painful ulcers, friable base, shaggy

border, purulet exudate.. Associated with unilateral inguinal lymphadenopathy

Treatment

Single dose: Azithromycin 1g PO or Ceftriaxone 250mg IM

Ciprofloxacin 500mg BID for 3d F/u 3-7 days. Sexual partner should be examined

Syphilis

Cause: T. pallidum IP: 10-90 days Immune response: - Non-specific Ab response: Anticariolipin

(VDRL and RPR) - Specific Ab response: anti- Treponemal

Ab FTA-ABS & TP-PA) Diagnosis: - Direct fluorescent Ab and Dark field

microscopy

Primary (Chancre)

Secondary

Represents hematogenous dissemination of spirochetes

Usually 2-8 weeks after chancre appears Findings:

rash - whole body (includes palms/soles) mucous patches condylomata lata – in moist areas and HIGHLY

infectious constitutional symptoms FAHM Rarely: Uveitis, iritis, arthritis, periostitis, GN

Symptoms and signs usually resolve in 2-10 weeks

Tertiary

Late benign (gummatous) syphilis Neuro-syphilis: Tabes dorsalis, Argyll-

Robertson’s pupil, lost proprioreception Cardio-syphilis: Aortitis, aortic aneurysm,

AV insufficiency

Treatment

1ry, 2ry, early latent: Benzathine Penicillin G 2.4 million IU IM once

- Allergic: doxycycline 100mg BID OR Tetracycline 500mg QID x2wks

Late latent: 2.4 mil. IU once per week X3wks

- Allergic: 4 weeks Jarisch-Herxheimer reaction

Lymphogranuloma Venereum

Cause: Chlamydia trachomatis (L1, L2, L3)

IP: Variable Groove sign Treatment: - Doxycycline - Erythromycin x 3wks

DRIPS

Chlamydia

Cause: Chlamydia trachomatis (D-k) IP: 3-14 days Often coexists with Gonorrhea Most common cause of epididymitis/orchitis in

young men 75% of females are asymptomatic, 40% of

untreated cases develop PID Diagnosis: - Culture - NAAT - EIA, DFA, NAH (non-amplified)

Treatment: - Azithromycin 1g once - Doxycycl. 100mg BID x7d - Amoxycillin 500mg TID x7d

Gonorrhea

Cause: N. gonorrhea

IP: 3-14d Diagnosis: - Culture: Thayer-

Martin or Chocolate agar

- G-stain: G-ve diplococci

- NAAT

Males Females - Fitz-Hugh-Curtis syndrome: Perihepatic

spread of adnexal gonorrhea Disseminated Gonorrhea: fever, rash,

Polyarthritis, Tenosynovitis (lover’s heel) Treatment: - Ceftriaxone 250mg IM once - cefixime 400mg PO once - Allergic: Spectinomycin 2g IM once

Trichomoniasis

Cause: T. vaginalis (flagellated protozoan) 174 million new cases yearly Males: Usually asymptomatic, Urethritis,

prostatitis (rare) Females: Usually symptomatic.. Vaiginitis

(fishy odorous d/c, ph>4.5), cervicitis (strawberry Cx)

Treatment: - Recommended: Metronidazole OR Tinidazole

2g PO once (x alchohol, x breast fedding) - If failed: metronidazole 500mg PO BID x7d

Chondyloma Acuminatum

Cause: HPV (ds DNA) Mode of tranmission: skin to skin contact IP: Variable ~3-12 months Many subtypes, 16 &18- 70% of Cx

cancer Most are asymptomatic Diagnosis: Papanicholas stain Biopsy of warts indicated if atypical,

pigmented, indurated, ulcerated, fixed, resistant to Rx

Treatment Primary goal: To treat visible warts Patient-Applied:

Podofilox 0.5% solution or gelORImiquimod 5% creamORSinecatechins 15% ointment

Provider–Administered:Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2 weeks.ORPodophyllin resin 10%–25% in a compound tincture of benzoinORTrichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90%ORSurgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.

HPV Vaccines : Cervarix and Gardasil Both vaccines protect against the two HPV types (HPV-16 and HPV-18) that cause 70% of cervical cancers and Gardasil protect against (6-11) that causing genital warts .

Molluscum contagiosum

Cause: MCV (ds DNA) IP: 14-50 days 4 subtypes, clinically

similar - MCV1: USA - MCV2&3: Europe,

Australia, HIV patients

Usually self-limiting. Cautery, TCA, etc. may cause scarring

Scabies and Pediculosis (lice)

Cause: Sarcoptes scabiei Treatment: - Permethrin cream (5%),

wash off after 8-14 hours - Ivermectin 200 mic/kg

PO, repeated after 2 weeks

- Lindane 1%.. C/I children <2yrs, pregnant & lactating women, extensive dermatitis

Pediculosis pubis (pubic lice)

Cause: Phthirus pubis Eggs (nits) glued to hair shaft Treatment: - Permethrin 1% - Ivermectin 250mic/kg PO, repeated

after 2 wks - Malathion 0.5% lotion - Topical insecticidal preparations - Kerosene/Oil

HIV

Cause: HIV 1&2 (retrovirus) IP: variable >3months Urologic manifestations: - Higher risk of renal, penile and testicular

Ca. - Neurologic bladder - Hypogonadism - Protease inhibitors may cause calculi

PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS

Expedited Partner Therapy

Treatment of the patient’s partner without referral, e.g. “Partner Package”

CDC 2006 guidelines: Only when other managements are

impractical or fail Not routine in homosexual males (high risk

of undiagnosed HIV) Not in Syphilis Not in partners of females with trich. Vag.

(comorbidity with Gonorrhea and Chlamydia)

THANK YOU