Sexually Transmitted Infections Kelly Ruhstaller MD March 15, 2013

Sexually Transmitted
Kelly Ruhstaller MD
March 15, 2013
• Review pathophysiology of common sexually transmitted
infections including chlamydia, gonorrhea, trichimonas,
• Discuss pharmacologic treatment of the above listed
• Review complications and treatment of pelvic infections
including pelvic inflammatory disease and tuboovarian
Treatment Guidelines
• All pharmacologic regimen recommendations are based on
the 2010 CDC STD Treatment Guidelines publication
Chlamydia trachomatis:
Most common bacterial STD
In 2011 1.4 million cases reported to the CDC
1 in 15 teenage females infected
Risk factors:
Age (adolescents and young adults)
Black race
Being unmarried
Multiple sexual partners
History of STDs
• Infection does not result in immunity
Chlamydia: Infection
• Gram-negative bacteria, obligate intracellular organism
• Two part life-cycle:
• Elementary bodies infect cell and replicate
• Cell ruptures, elementary bodies infect surrounding cells
• Common for infection to be asymptomatic
• Approximately 7-14 day incubation period for women and 510 days for men
Chlamydia: symptoms
• In women, common manifestation is cervicitis and
mucopurulent discharge
Cervical friability or edema
Dull lower abdominal pain
Post-coital and intermenstrual bleeding
• In men, most common symptom is urethritis and urethral
Discharge white and thin
Prostatisis (?)
Reactive arthritis
Chlamydia: clinical signs
Chlaymdia: clinical signs
Chlamydia: testing/diagnosis
• CDC recommends annual testing for sexually active women
younger than 25, all pregnant women and older women with
risk factors
• Most common type of test is the NAAT
• Nucleic acid amplification testing
• Sample can be collected from cervix, vaginal discharge, urine
• Test of cure
• Pregnant women, persistent symptoms or suboptimal treatment
• Retesting
• Anyone treated should be test 3-12 months later to evaluate for
Chlamydia: treatment
• Due to the life cycle of chlamydia (ie only lives intracellularly)
the antibiotic regimen must have good cellular penetration
and intracellular activity
• Life cycle of bacterium is long, requiring either extended
treatment regimens or Abx with long half-life
• Both macrolides and tetracyclines have excellent activity
againist chlamydial infections
Chlamydia: treatment
Chlamydia: treatment
• Azithromycin and Doxycycline have 97 and 98% efficacy
• Azithromycin:
Half-life of 5-7 days, can be given as a single dose
Treatment can be witnessed by provider ensuring treatment
Safe in pregnancy
Minimal side effects: mild GI upset
Limitation to therapy is cost
• Doxycycline:
• Lower cost
• Longer treatment course, potential for decreased compliance
• Cannot be used in pregnancy due to skeletal and tooth damage in
children of mothers treated with drug
Chlamydia: treatment
• Levofloxacin and ofloxacin:
• Excellent efficacy, but requires a full week of treatment
• Cannot be used in pregnancy, breastfeeding women or
adolescents <18 yo due to concern for skeletal ab
• More expensive
• Erythromycin:
• High degree of GI upset
• Cure rates of only 85-89%
• For use in pregnant women who cannot tolerate Azithromycin
Chlamydia: complications
Pelvic Inflammatory Disease
Fitzhugh-Curtis Perihepatitis
Ectopic pregnancy
Increased risk of HIV infection
Lymphogranuloma venereum
Preterm delivery
Neisseria gonorrhea:
• Second most common bacterial STI
• Most common in adolescents and young adults:
• Women aged 15-19 yo
• Men aged 20-24 yo
• Risk factors:
African american
Southeastern US
Unmarried, young adults
Low educational and socioeconomic status
New partner
History of STD
Gonorrhea: Infection
• Four stages of infection:
• Attachment, local invasion, proliferation and local inflammatory
• In women:
• In men:
Gonnorhea: clinical signs
Gonorrhea: clinical signs
Gonorrhea: diagnosis
• Gram stain of urethral
discharge (men only)
• Culture
Gonorrhea: treatment
• Goal of therapy: highly effective at all anatomic sites, be able
to be given as a single dose and be well tolerated
Gonorrhea: treatment
Gonorrhea: treatment
Gonorrhea: antimicrobial
Gonorrhea: resistance
• Gonorrhea’s resistance to several classes of antibiotics was
first noted in the 1940s when resistance to sulfonamides was
• The CDC’s Gonococcal Isolate Sensitivity Project (GISP) was
started in 1986
• Has since determined resistance to penicillins, tetracyclines,
macrolides and fluroquinolones
Gonorrhea: resistance to
• MIC: minimum inhibitory concentration
• Increasing MICs to both cefixime and ceftriaxone indicating
increased resistance
• MIC > 0.25mcg/mL is considered “elevated”
• 15% of gonococcal isolates found to have elevated MIC
• Evidence of cefixime treatment failure in Japan and Europe
• Increased resistance to cetriaxone emerging
• Worldwide increasing resistance
• Several cases of resistance to ceftriaxone documented in Europe
and Asia
• Recommend dual therapy with azithromycin due to increasing
rates of cephalosporin resistance
Gonorrhea: Follow-up
• Test of cure:
• Pregnant women
• Any patient who receives alternative therapy
• Patient with persistent symptoms
• Partner treatment:
• Not recommended due to IM treatment being first-line therapy
and high rate of resistance
• Recommend patient abstain from intercourse for 7 days after
Gonorrhea: complications
Pelvic Inflammatory Disease
Fitzhugh-Curtis Perihepatitis
Disseminated gonorrhea
Preterm Labor/Delivery
Opthalmia Neonatorum
Disseminated disease in the newborn
Disseminated gonorrhea
• Two separate manifestations:
• Triad of tenosynovitis, dermatitis, polyarthralgia
• Purulent arthritis
• Treatment:
• Ceftriaxone 1g IV/IM daily until symptoms are gone, then 250mg
IM x 7 days
• Co-treatment with 1g po Azithromycin or 100mg Doxycycline BID
x 7 days – treatment for chlamydial co-infection
• Do not recommend treatment with agent other than
• No oral step-down regimen
• Documented PCN allergy: admission, desensitization and
treatment with ceftriaxone
Trichomonas: epidemiology and
Estimated 3-5 million cases in the US
Accounts for 4-35% of vaginitis cases
Transmitted by Trichomonas vaginalis
Sexually transmitted
Incubation period is unknown and infection is often
• Only 30-40% of male partners of infected women test positive
for the organism due to transient and self-limited infection in
Trichomonas: Infection
• Asymptomatic in 75% of men and usually resolves in <10 days
• Men may present with urethritis and/or clear to
mucopurulent discharge
• Women often present with purulent, malodorous discharge
• Acute inflammation of vagina and vulva
• Classic symptoms of green frothy discharge occurs in <10% of
patients and “strawberry cervix” with pinpoint hemorrhages
on the cervix occurs in <2% of cases
Trichomonas: clinical signs
Trichomonas: diagnosis
• Wet mount: pH >4.5 and motile trichomonads
• Culture: 95% sensitivity, but 7 days to obtain results
Affirm, Aptima and OSOM
Results rapidly available
Sensitivity: 88-100%
Can be collected from urine, vaginal secretions or endocervical
• Men: only reliable test is PCR, not widely available
Trichomonas: treatment
• Treat:
• All symptomatic women
• Non-pregnant, symptomatic women with incidental finding
• Male partners
Trichomonas: treatment
Trichomonas: treatment
• Treatment with metronidazole/tinidazole very effective
• Do not recommend treatment with topical nitromidazoles
• Pregnant women:
• Increased rate of premature rupture of membranes and delivery
• Treat symptomatic women with metronidazole during any
trimester of pregnancy
• Breastfeeding women should wait 12-24 hours after last dose to
resume feeding
• HIV-positive patients:
• Recommend treatment with 7 day course
• Patient with allergy to nitromidazoles:
• Desensitization and treatment with nitromidazole
Herpes simplex virus:
• 50 million individual infected with genital herpes in the US
• Mostly caused by HSV-2 but HSV-1 genital infections are
• Risk factors:
Increasing age
Increasing number of sexual partners
HSV: transmission
• Virus sheds from active lesions and 10% of days with no
• The virus invades through the skin and replicates within the
• Virus travels down through sensory and autonomic nerve
endings and then persists in latent form by residing in the
sacral ganglia
HSV: Types of Infection
• Primary
• Infection in a patient without prior antibodies to HSV1 or 2
• Nonprimary
• Infection in a patient who was previously infected with the other
HSV type (ie HSV 1 infection in a patient with a previous antibody
to HSV 2)
• Recurrent
• Infection with the same strain of HSV as the patient has
previously made antibodies against
HSV: symptoms
• Primary:
Incubation period: 4 days
Length of symptoms: 19 days
Spectrum of mild to severe symptoms
Bilateral, painful pustular, ulcerating lesions
Additional symptoms: systemic symptoms, local pain and itching,
dysuria, painful lymphadenopathy
• Nonprimary:
• Less severe than primary infection
• Recurrent:
• Least severe symptoms
• Shorter period of symptoms
HSV: clinical signs
HSV: diagnosis
• Culture
• Most accurate with vesicles present, unroof lesion and culture base
• Specimen collected from mucocutaneous sites, lesions does not
have to be present
• Most accurate and can yield results during asymptomatic shedding
• Serology
• Type specific serology present within weeks of infection and persist
• Cannot distinguish primary vs recurrent infection
HSV: treatment
• Anti-virals:
• Acyclovir: uptake by infected cells, converted to acyclovir
triphosphate and inhibits viral DNA polymerase
• Famciclovir: converted to penciclovir in the liver and inhibits viral
DNA polymerase
• Valcyclovir: converted to acyclovir in vivo, acts as acyclovir does
and inhibits viral DNA polymerase
HSV: treatment
• Primary infection (uncomplicated):
Oral therapy appropriate
Treatment should begin within 72 hours of symptoms
Treatment results is shorter and less severe course
Analgesics and sitz baths improve symptoms
Urinary retention can occur because of pain and/or due to sacral
root ganglion involvement
• Medications:
• Acyclovir: 400mg po TID or 200mg po q 5 days
• Valcyclovir: 1000mg po BID
• Famciclovir: 250mg po TID
HSV: treatment
• Recurrent infection:
• 1. No treatment
• 2. Episodic treatment
• 3. Suppressive therapy
HSV: episodic vs suppressive