SEXUALLY TRANSMITTED INFECTIONS: DIAGNOSIS AND MANAGEMENT STEPHANIE N. TAYLOR, MD LSUHSC SECTION OF INFECTIOUS DISEASES MEDICAL DIRECTOR, DELGADO CENTER PERSONAL HEALTH CENTER NEW ORLEANS, LA INTRODUCTION Ê Tremendous Public Health Problem Ê A estimated An ti t d 15 million illi Americans A i acquire i an STD each year Ê $10 billion dollars in healthcare costs per year Ê Substantial morbidity/mortality Ê Ulcerative and non-ulcerative STDs associated with increased HIV transmission STI PRINCIPLES Ê Counseling – HIV infection, abstinence, and “safer sex” practices Ê STD Screening of asymptomatic individuals and those with symptoms Ê Patients with one STD often have another Ê Partners should be evaluated and treated empirically at the time of presentation STI PRINCIPLES Ê Serologic testing for syphilis should be done in all patients Ê HIV testing t ti should h ld be b strongly t l encouraged d in i all patients (New CDC Recommendation for “Opt-Out” p testing) g) Ê STDs are associated with HIV transmission Major STI Pathogens Ê Bacteria Ê Ê Ê Spirochetes Ê Ê Neisseria gonorrhoeae, Haemophilus ducreyi, G d Gardnerella ll vaginalis i li Ê T Treponema pallidum llid Chlamydia Ê Chlamydia Chl di trachomatis Ê Ê Viruses Ê HSV I & II, HPV, HBV HIV, HBV, HIV molluscum Protozoa Ê Trichomonas vaginalis Fungi g Ê Candida albicans Ectoparasites Ê Phthiris pubis, Sarcoptes scabei MAJOR STI SYNDROMES Ê GENITAL ULCER DISEASE Ê URETHRITIS/CERVICITIS Ê PELVIC INFLAMMATORY DISEASE Ê VAGINITIS Ê OTHER VIRAL STDs Ê ECTOPARASITES GENITAL ULCER DISEASE Differential Diagnosis: Ê STIs Ê Ê Ê Syphilis, Herpes, Chancroid LGV, Granuloma inguinale Non-STIs Ê Ê Ê Trauma, fixed drug eruption, neoplasia Aphthous ulcers, non-STD infection, Behçet’s Syndrome – Oral and/or genital ulcers (not alone), ), cutaneous lesions,, uveitis,, arthritis,, phlebitis p Ê Reiter’s Syndrome – arthritis, conjunctivitis, urethritis, circinate balanitis, keratoderma blennorrhagicum Primary and secondary syphilis — Rates by state: United States and outlying areas, 2008 2.8 0.7 0.8 0.0 0.7 2.2 0.5 1.2 01 0.1 0.6 0.5 0.8 3.0 2.2 2.6 1.1 2.4 2.2 0.7 3.4 3.8 Guam 3.5 5.0 3.1 4.3 2.2 0.9 6.0 63 6.3 2.1 2.2 3.2 6.7 7.3 2.2 6.3 9.7 16.5 2.3 Rate per 100,000 population 9.6 5.9 0.1 VT 1.8 NH 1.5 MA 3.3 RI 1.7 CT 1.0 NJ 2.6 DE 1.9 MD 6.7 DC 24.8 5.7 <=0.2 0.21-2.2 >2.2 Puerto ue to Rico co 4.2 Note: The total rate of P&S syphilis for the United States Virginand Is. 0.0outlying areas (Guam, Puerto Rico and Virgin Islands) was 4.5 per 100,000 population. The Healthy People 2010 target is 0.2 case per 100,000 population. (n= 4) (n= 23) (n= 27) Primary and secondary syphilis — Rates by county: United States, 2008 Rate per 100,000 population Note: In 2008, 2,180 (69.3%) of 3,141 counties in the U.S. reported no cases of P&S syphilis. <=0.2 (n= 2,184) 0.21-2.2 (n= 373) >2.2 (n= 584) Primary and secondary syphilis — Age- and sex-specific rates: United States, 2008 Men 20 Rate (per 100,000 population) 16 12 8 4 0 0.1 5.3 17.3 17.2 15.0 14.7 14.4 83 8.3 2.6 0.6 7.6 Age 10-14 15-19 20-24 25 29 25-29 30-34 35-39 40-44 45 54 45-54 55-64 65+ Total Women 0 4 8 0.2 3.0 5.1 3.9 2.5 2.3 1.8 11 1.1 0.3 0.0 1.5 12 16 20 Primary and secondary syphilis — Male-tofemale rate ratios: United States, 1981–2006 Male-Female rate ratio 10:1 8:1 6:1 4:1 2:1 0 1997 98 99 2000 01 02 03 04 05 06 Primary and secondary syphilis — Male-tofemale rate ratios: United States, 1989–2008 Rate (per 100,000 population) 25 Rate Ratio (log scale) 16:1 Male Rate Female Rate Total Rate M l Male-to-Female F l R Rate R Ratio i 20 8:1 15 4:1 10 2:1 5 0 1:1 1989 91 93 95 97 99 2001 03 05 07 Primary and secondary syphilis — Rates by region: United States, 1999–2008 Rate (per 100,000 population) 10 West Midwest Northeast South 8 6 4 2 0 1999 2000 01 02 03 04 05 06 07 08 Primary and secondary syphilis — Rates by race/ethnicity:United States, States 1999–2008 1999 2008 Rate (per 100,000 population) 40 American Indian/AK Native Asian/Pacific Islander Black Hispanic White 32 24 16 8 0 1999 2000 01 02 03 04 05 06 07 08 Primary and secondary syphilis — Reported cases* by stage and sexual orientation, 2008 Cases 5000 3750 Primary Secondary 2500 1250 0 H t Heterosexual lM Men *20% W Women † MSM of reported male cases with P&S syphilis were missing sex of sex partner information. †MSM denotes men who have sex with men. Primary and secondary syphilis — Cases by sexual orientation and race/ethnicity, 2008 Cases 3000 2250 White Whit Black Hispanic Other 1500 750 0 Heterosexual Men Women ‡ MSM Primary and secondary syphilis — Cases by source and sex: United States, 1999–2008 Cases (in thousands) 8 non-STD Clinic Male non-STD Clinic Female STD Clinic Male STD Clinic Female 7 6 5 4 3 2 1 0 1999 2000 01 02 03 04 05 06 07 08 Congenital syphilis (CS) — Cases for infants <1 year of age and rates of primary and secondary syphilis among women: United States, 1999–2008 CS cases (in thousands) P&S rate (per 100,000 women) 0.8 4 CS Cases P&S Rate 0.6 3 0.4 2 0.2 1 00 0.0 0 1999 00 01 02 03 04 05 06 07 08 Congenital g Syphilis yp Rates byy Race/Ethnicityy Congenital Syphilis by State Parish vs vs. National Rates 2008 Ê National Rate – 4.5 cases/100,000 Ê Jefferson Parish – 11.6 cases/100,000 Ê Orleans Parish – 38.9 cases/100,000 Ê National Goal < 0.4 cases/100,000 Early Syphilis – Region 1 by Parish 2008 Early Syphilis – Region 1 by Parish 2009 1st Six Months of 2009 SYPHILIS STAGING INFECTION (3 WEEKS) PRIMARY CHANCRE (1-3 MONTHS) SECONDARY (1-3 MONTHS / 60-90%) LATENCY 70% 30% LIFETIME LATENCY (2-50 YEARS) TERTIARY PRIMARY SYPHILIS Ê Incubation period 3-90 days Ê Begins as a macule/papule that erodes into a clean based, painless, indurated ulcer with smooth firm borders smooth, Ê Usually singular but can be multiple Ê Goes unnoticed in 15-30% of patients Ê If untreated,, will heal in 1-5 weeks PRIMARY SYPHILIS PRIMARY SYPHILIS PRIMARY SYPHILIS SECONDARY SYPHILIS Ê Hematogenous dissemination Ê Skin Rash (90%) - Maculopapular, or pustular lesions involving the palms and soles. Condyloma lata. Ê Mucous Membranes (70%) - Lesions include mucous patches, erosions, aphthous ulcers. Ê Constitutional symptoms (70%) - Fever, malaise, pharyngitis, anorexia, weight loss, and d arthralgias. h l i Ê CNS - HA, meningitis, uveitis, tinnitis. SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS Adenopathy Patchy Alopecia SECONDARY SYPHILIS Condyloma lata SECONDARY SYPHILIS Condyloma lata LATENT SYPHILIS Ê Period during which there is no clinical evidence of disease Ê Serological tests are positive Ê Arbitrarily divided into “early latent” (infection occurred within the last year) or “late latent” TERTIARY SYPHILIS Ê Slowly progressive disease - affects any organ system and produces clinical illness years after initial infection Ê NEUROSYPHILIS - meningitis, general paresis, optic neuritis ( ↑ WBCs, + CSF VDRL, ↑ Prot.) Ê CARDIOVASCULAR - aortic aneurysm, aortic regurgitation i i Ê GUMMATOUS - large indurated lesions of skin, GI tract mouth tract, DIAGNOSIS Ê Darkfield examination of material from a moist l i – 70-80% lesion 70 80% sensitive iti Ê Serologic g Tests Ê Non-treponemal – RPR, VDRL, ART Ê Treponemal – FTA-ABS, TPHA, IgG Ê Silver stain of biopsy p y material Ê DNA Methods (PCR, etc.) SEROLOGIC TESTS Ê REMEMBER!!! Ê No serologic test for syphilis can make a diagnosis by itself, or distinguish between active (never treated or inadequately treated) syphilis and inactive (adequately treated) syphilis Ê Must be coupled with a careful history and a thorough physical examination before a diagnosis can be made BIOLOGIC FALSE POSITIVE Ê Antibodies to phospholipid produced in other disorders Ê Positive non-specific test (VDRL, RPR) Ê Not confirmed with specific test (or negative TPHA, etc.) Ê Seen in a number of conditions such as lupus, drug reactions, narcotic drug use, TB, pregnancy, hepatitis, rheumatoid arthritis, etc. Syphilis: 2006 CDC STD Treatment Guidelines Ê Ê Ê Ê Primary, Secondary, and Early Latent Ê Benzathine penicillin 2.4 MU IM X 1 Ê PCN allergic– ll i Doxy. D 100 mg po bid for f 14 days d Late Latent Ê Benzathine p penicillin 2.4 MU IM q wk. x 3 weeks Ê PCN allergic – Doxy. 100 mg po bid x 4 weeks Neuro-Syphilis – Ê Aqueous A crystalline i PCN C 33-44 MU IV q 4 hrs 10-14 10 14 days – PCN Allergic need to be desensitized Special p Circumstances Ê Pregnant and PCN allergic – desensitize and treat Ê HIV – Same tx. for stage of syphilis in non-HIV pt. CHANCROID Ê ETIOLOGY Ê Haemophilus ducreyi Ê Fastidious organism difficult to isolate Ê Requires supplemented l t d chocolate agar and 5% CO2 for growth Ê EPIDEMIOLOGY Ê Seen more commonlyy in third world countries Ê Less than 1,000 cases seen in the U.S. ,but outbreaks tb k or epidemics have been seen CLINICAL MANIFESTATIONS Ê Incubation period 5-7 days Ê A papule develops initially but goes on to erode i t a painful, into i f l soft, ft and d non-indurated i d t d ulcer l Ê 50% of patients will develop painful local p y which mayy suppurate pp or rupture p adenopathy CHANCROID Genital Ulcer with Inguinal Buboes in 50% Chancroid: 2006 CDC STD Treatment Guidelines Ê Azithromycin y 1 gm g orallyy single g dose Ê Ceftriaxone 250 mgg IM single g dose Ê Ciprofloxacin 500 mg po bid for 3 days Ê Erythromycin base 500 mg po qid for 7 days GENITAL HERPES Ê Ê Ê Ê Ê Most common cause of genital ulcer disease in N.A. Primary Infection Ê 80-90 % due to HSV-2 Ê Typically most severe, systemic symptoms common Ê Mult. Mult painful vesicles, vesicles shallow ulcers, ulcers heal 2-3 2 3 wks Recurrences Ê Less severe lesions Ê Shorter duration Most patients with HSV-2 asymp. or do not recognize symptoms Asymptomatic viral shedding occurs without outbreaks HERPES SIMPLEX HERPES SIMPLEX HERPES SIMPLEX HSV - 2006 STD Treatment Guidelines Ê Initial Episode Ê Acyclovir, famcicloivir, or valacyclovir X 7-10 days Ê Recurrences Ê Acyclovir, famcicloivir, or valacyclovir X 5 days Ê Acyclovir A l i 800mg 800 tid X 2d; 2d Fam F 1000mg 1000 BID X 1d 1d; Val 500 mg BID X 3d Ê Suppressive S i Therapy Ê Indicated for patients with 6 outbreaks a year Ê Reduces the frequency q y and asymptomatic y p shedding g URETHRITIS/CERVICITIS/PID URETHRITIS Ê Clinical Syndrome Ê Dysuria, urethral discharge/itching, >5 WBCs/hpf Ê Dx.– D DNA probes b and d amplification lifi ti (swab ( b or urine) i ) Ê Still need GC cultures to monitor resistance (GISP – Gonococcal Isolate Surveillance Program) Ê Gonococcal Urethritis Ê 2-5 day incubation, copious amounts of purulent d/c Ê Intra-cellular diplococci seen in 95% of men Ê Non-gonococcal Urethritis Ê Less profuse, thin, clear, or mucoid d/c Ê Urethral smear with WBCs only Etiology of NGU Chlamydia trachomatis 20-40% Mycoplasma genitalium 15 25% 15-25% Ureaplasma urealyticum 10-20% Trichomonas vaginalis 5-15% Adenovirus 1 4% 1-4% Herpes simplex virus 1-2% History of Mycoplasma genitalium Ê Ê 1981 – First Fi t identified id tifi d by b culture lt in i 2/13 men with NGU. (Tully and Taylor-Robinson) 1982 90 – Attempts to obtain additional isolates 1982-90 from men with NGU fail. (Taylor-Robinson, et al; Samra, et al) Ê Ê 1986-87 – Primate studies show M. genitalium causes NGU. (Tully, et al; Taylor-Robinson, et al) 1988 - Direct DNA probes give mixed results. (Hooten, et al; Risi, et al.) Ê 1991 – First PCR assays described described. (Jenson, (J et all and d Palmer et al. M. genitalium Infections in Women Attending the New Orleans STD Clinic Organism No. Positive/(%) M. genitalium 70 (17%) C. trachomatis 90 (22%) ( ) N. gonorrhoeae 58 (14%) T. vaginalis 87 (22%) Association of Mucosal Pathogens and Young Age in women 35 30 25 20 C. trachomatis N. gonorrhoeae M genitalium M. 15 10 5 0 18-19 20-24 25-29 > 30 Chlamydia — Rates by state: United States and outlying areas, 2008 Louisiana was #5 with 527.8 cases per 100,000 331 324 198 300 287 276 280 375 371 302 314 314 377 340 228 460 407 395 332 470 409 411 349 183 405 422 287 Guam 396 391 458 446 414 455 499 597 728 535 Rate p per 100,000 , population 447 422 528 711 466 VT 192 NH 160 MA 271 RI 314 CT 357 NJ 258 DE 447 MD 439 DC 1177 389 <=300 300.1-400 >400 Puerto Rico 174 Virgin Is. 535 Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 368.1 per 100,000 population. (n= 13) (n= 17) ((n= 24)) Gonorrhea — Rates by state: United States and d outlying tl i areas, 2008 48.3 12.7 7.3 22.4 32.7 58.4 12.5 108.7 47.1 23.7 82.3 84.7 56.9 77.3 89.0 160.9 138.2 18.0 70.5 81 9 81.9 71.2 143.3 146.5 41 2 134.0 41.2 134 0 136.3 107.2 Guam 62.8 54.4 88.7 169.4 176.3 142.6 159.2 214.2 134.7 220.2 47.5 6.0 7.6 33.0 29.0 80.0 61.0 120.8 118.6 451 5 451.5 Rate per 100,000 population 170.5 256.8 210.5 84.6 VT NH MA RI CT NJ DE MD DC 127.8 Puerto Rico 6.9 Virgin Is. 109.3 <=19.0 < 19 0 ((n= 7)) 19.1-100.0 (n= 24) >100 (n= 23) Chlamydia — Age- and sex-specific rates: United States, 2007 Men 3250 Rate (per 100,000 population) 2600 1950 1300 650 0 11.8 615.0 932.9 518.6 246.8 129.9 71.4 32 3 32.3 10.1 2.7 190.4 Age 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45 54 45-54 55-64 65+ Total 0 Women 650 1300 1950 2600 3250 123.0 3004.7 2948.8 1184.5 460.5 188.1 76.5 28 5 28.5 8.0 1.8 544.8 Gonorrhea — Age- and sex-specific rates: United States, 2007 Men 750 Rate (per 100 100,000 000 population) 600 450 300 150 0 59 5.9 286.0 450.1 305.1 181 5 181.5 119.5 86.6 50.2 17.7 4.0 113.9 Age 10 14 10-14 15-19 20-24 25-29 30 34 30-34 35-39 40-44 45-54 55-64 65+ Total 0 Women 150 300 450 600 750 33 1 33.1 647.9 614.5 287.1 125 2 125.2 60.5 30.8 12.1 3.0 0.4 123.8 GC URETHRITIS AND NGU Gonococcal Urethritis Non-gonococcal Urethritis GC URETHRITIS AND NGU Gonococcal Urethritis Non-gonococcal Urethritis URETHRAL SMEAR: GC VS. NGU GC/Intracellular diplococci NGU/ >5 PMNs/hpf MUCOPURULENT CERVICITIS Ê Ê Ê Infection and inflammation of the endocervix Ê Thick cervical discharge Ê Erythema and easily induced bleeding Ê Ectopy of endocervical mucosa Pathogens Ê N. gonorrhea Ê C. trachomatis Asymptomatic infection Ê ~40% 40% off women with ith GC Ê ~50% of women with CT MUCOPURULENT CERVICITIS(MPC) GC VS. CT Gonococcal MPC Chlamydial MPC GC - 2006 STD Treatment Guidelines Ê Gonococcal urethritis/cervicitis (MPC) Ê Ceftriaxone 125 mg IM single dose or Cefixime 400 mg po in i single i l dose d Ê **Quinolones no longer recommended in U.S. due to resistance Ê Azithromycin 1 gm or Doxy 100 mg bid x 7d for CT Ê Alternatives Ê Spectinomycin 2 gm IM single dose Ê Single dose cephalosporin NGU/CT - 2006 STD Treatment Guidelines Ê NGU or Chlamydia Urethritis/Cervicitis Ê Ê Ê Alternatives Ê Ê Ê Ê Azithromycin 1 gm po single dose Doxycycline 100 mg po bid x 7 days Erythromycin base 500 mg po qid x 7 days Ofloxacin 300 mg bid po x 7 days Levofloxacin 500 mg po x 7 days Recurrent or Persistent NGU Ê Ê Ê Metronidazole 2 gm po in a single dose Tinidazole 2 gm po in a single dose Azithromycin 1 gm po if not used for initial episode GC COMPLICATIONS Ê Men Ê Women Ê Epididymitis Prostatitis Conjunctivitis Periurethral abscess Penile lymphangitis Disseminated gonococcal i f i (DGI) infection Ê Bartholin’s glands abscess Perihepatitis (Fitz (Fitz-HughHugh Curtis syndrome) PID I f tilit Infertility Conjunctivitis Endometritis Tubo-ovarian abscess Ectopic pregnancy Ophthalmia neonatorum Disseminated gonococcal infection (DGI) Ê Ê Ê Ê Ê Ê Ê Ê Ê Ê Ê Ê Ê Ê COMPLICATIONS OF GC/CT Epididymitis Tubo-ovarian abscess Peri-hepatitis/Fitz-Hugh-Curtis Syn. GONOCOCCAL CONJUNCTIVITIS GONOCOCCAL PHARYNGITIS Disseminated Gonococcal Infection Ê Most common cause of acute infectious arthritis among sexually active adults Ê Migratory arthralgias, frank arthritis in one or two joints Ê Skin llesions Ski i Ê Distal extremity location Ê Pustules on an erythematous y base ((Usually y < 20)) Ê Fever Ê T Tenosynovitis iti Ê Genital symptoms usually absent Disseminated Gonococcal Infection Ê 0.5-3% of genital inf./Recurrent Ds. – Complement Def. Ê F Female:Male l M l Ratio R ti - 4:1 41 Ê Associated with menstruation and p pregnancy g y in women Ê Remember to culture the throat, cervix/urethra, and rectum in suspected DGI (Joints and blood rarely pos pos.)) Ê Tx. - Ceftriazone 1 ggm IM or IV q d (p (plus CT tx.)) until clinical improvement – Finish 7 day course with Cefixime or Cefpodoxime DISSEMINATED GC (DGI) PID – Pelvic Inflammatory Ds. Ds Ê Ê Etiology Ê C. trachomatis Ê N. N gonorrhoeae h Ê Gardnerella vaginalis Ê Other facultative aerobes and anaerobes Diagnosis Ê Minimum Criteria Ê Lower abdominal i pain i Ê Adnexal tenderness Ê Cervical motion tenderness Ê Other Criteria – cervical or vaginal discharge, T > 38.3°C, leukocytosis, ↑ ESR, U/S-inflammatory mass PID – 2006 STD Treatment Guidelines Ê Ê Ê Criteria for Hospitalization Ê Can’t rule out surg. emergency, unable to tolerate oral meds 2° 2 N/V, N/V pregnancy pregnancy, tubo-ovarian abscess Parenteral Regimen Ê Cefotetan 2 gm IV q 12 hours or Cefoxitin 2 gm IV q 6 hours plus Doxycycline 100 mg IV q 12 hours Ê Discontinue 24 hours after clinical improvement then complete p 14 day y course with doxycycline y y Oral Regimen – Both with or without metronidazole Ê A - Ceftriaxone 250 mg IM single dose or Cefoxitin 2 gm IM and Probenecid 1 gm po pl pluss Do Doxy x 14d Ê B – Other 3rd Gen. Cephalosporin plus Doxy x 14d Ê Both plus or minus metronidazole VAGINITIS Ê Etiology Ê Ê Ê Ê Diagnosis Ê Ê Ê Ê Bacterial vaginosis Trichomonas Vulvovaginal candidiasis BV – pH H >4.5, >4 5 +Whiff ttestt on KOH KOH, Cl Clue cells ll on wett prep Trichomonas – Strawberry cervix, organism seen on wet prep Vaginal Candidiasis – hyphae and pseudohyphae on KOH Treatment Ê Ê Ê BV – Metro. 500mg bid x 7 d, Tinidazole, Metrogel, Clinda Trichomonas – Metro. 2gm po single dose Candida – OTC azole creams, Flucon. 150 mg po single dose WHAT IS BACTERIAL VAGINOSIS? Ê Most prevalent cause of vaginal symptoms in women of childbearing age Ê Characterized by: Ê Increased malodorous discharge Ê Decrease or absence of Lactobacillus sp. sp (L. (L crispatus and L. jensenii most common) Ê Overgrowth of Gardnerella vaginalis, Mycoplasma sp. and other anaerobic organisms Ê Altered pattern of organic acids from these bacteria (e.g., putrescine, cadaverine, etc.) producing odor Ê Lack of inflammation – vaginosis (not vaginitis) WHAT’S WHAT S IN A NAME? Ê Leukorrhea Ê Non-specific vaginitis Ê Haemophilus vaginalis vaginitis Ê Gardnerella vaginitis Ê Anaerobic vaginosis (but not just anaerobes) Ê Bacterial vaginosis (since inflammation is not a feature of BV, the term vaginosis has replaced vaginitis) EPIDEMIOLOGY Ê Prevalence depends upon population studied Ê St d t H Student Health lth Cli Clinics i – 4-10% 4 10% Ê Family Planning Clinics – 17-19% Ê Pregnant women – 16-29% Ê I f tilit Clinics Infertility Cli i – 30% Ê STD Clinics – 24-40% EPIDEMIOLOGY Ê Ê Ê Ê Ê Ê Ê Ê Ê Prevalence also depends on ethnicity Large g U.S. Study y of pregnant p g women 13,747 at 23-26 weeks gestation 16.3% of women had BV Asians – 6.1% Caucasians – 8.8% Hispanics – 15.9% African American – 22.7% 22 7% 51% of 4,718 women in Ugandan study EPIDEMIOLOGY Ê BV is common in most populations Ê More common in STD clinics than in family planning or prenatal clinics Ê More common in women with discharge Ê Related to ethnicity for unknown reasons Ê Especially common in Sub-Saharan Africa WHAT ABOUT SEXUAL TRANSMISSION? Ê Conflicting and controversial area Ê Women who W h use condoms d h have d decreased d prevalence of BV Ê Yet multiple partner treatment trials have failed to demonstrate benefit to women with BV Ê Evidence of sexual transmission of BV V in women who have sex with women WHAT ABOUT SEXUAL TRANSMISSION? Ê Females with no sexual exposure have significantly lower prevalence of BV Ê Some studies have found association with younger age of sexual debut Ê In college women women, Amsel demonstrated that 0 of 18 virgins versus 69 of 293 (24%) sexually experienced women had BV WHAT ABOUT SEXUAL TRANSMISSION? Ê Association with number of partners also seen Ê Women with new or multiple sex partners also have higher prevalence of BV Ê Evidence of NGU in male p partners of p patients with BV WHAT ABOUT SEXUAL TRANSMISSION? Ê Sexual transmission of Gardnerella vaginalis has been demonstrated Ê Gardner and Pheifer detected G. G vaginalis in the urethras of 79 and 86% of male sex partners of women with BV but not in controls Ê Piot et al. developed a typing system and demonstrated that Gardnerella isolates in women with BV and from the urethras of their partners were the same Ê Ison and Easmon recovered G. G vaginalis and other anaerobes at 103 to 107 org/ml from semen in 16% of men attending a subfertility clinic PREDISPOSING/RISK FACTORS Ê Douching Ê IUD as contraceptive method Ê Younger age Ê New sex partner Ê Multiple sex partners Atopobium vaginae Ê Ê Ê Ê Ê Ê Small Gram positive cocco-bacillus cocco bacillus Produces lactic acid Strict anaerobe Genus first described about 10 years ago as a member of human oral flora Only 2 isolates of A. vaginae reported in the literature prior to our report The 4 existing cultured strains are highly resistant to metronidazole. CLINICAL MANIFESTATIONS Ê “Fishy-smelling” discharge – More noticeable after intercourse (Addition of semen with alkaline pH is similar to addition of KOH) Ê Discharge is gray or off-white, thin, homogeneous, and adherent to vaginal wall Ê No erythema or inflammation Ê Some patients report vaginal itching Ê Cervix usually normal BACTERIAL VAGINOSIS DIAGNOSIS Ê Amsel’s Criteria (3 of 4 criteria for dx.) Ê Adherent, homogeneous gray-white discharge Ê Positive amine or whiff test with addition of 10% KOH Ê Elevated vaginal pH of >4.5 Ê Presence of “clue cells” – Squamous cells with adherent bacteria (>20% of cells on wet mount) pH PAPER Whiff Test for “Fishy” Fishy Odor NORMAL VAGINAL GRAM STAIN Gram Stain off Normal Vaginal g Secretions CLUE CELLS CLUE CELL WET MOUNT Gram Stain of Vaginal Secretions Showing Bacterial Vaginosis BV AND HIV ASSOCIATION Ê Presence of BV or absence of lactobacilli associated with heterosexual transmission of HIV Ê 2-fold increased prevalence of HIV in Thai and Ugandan women with BV Ê Study of African pregnant and postnatal women in Malawi found that women with BV were more likely to seroconvert to HIV Ê These data raise the question of whether BV should be treated more aggressively (In the past – asymptomatic BV was not treated) TREATMENT OF BV 2006 CDC GUIDELINES Ê Ê Treatment Ê Metronidazole 500 mg po bid for 7 d Ê Metro. 0.75% gel qd or bid for 5 d Ê Clinda 2% Cr., 5 gm qd for 7 d Ê Clinda Cli d 300 mg po bid for f 7d (A (Active ti against i t Lactobacillus - interferes with re-establishment of normal flora Ê Partner tx. - No treatment required Recently approved drug- Tinidazole 500 bid po x 5 d days – 95% efficacy/ ffi / Vaginally V i ll once daily d il – 80% eff. ff RECURRENT BV Ê 80-90% cure rates at 1 week Ê 15-30% recur within 3 months Ê Single Dose versus 7 day course – 73% vs. 82% Ê Higher recurrence rates for single dose tx. RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Ê Replacement or Restoration of Lactobacilli (LB)(Bacteriotherapy (LB)( Bacteriotherapy)) Ê Unfortunately U f t t l lack l k off efficacy ffi with ith ffew controlled t ll d trials Ê LB used needs to be able to adhere and produce H2O2 Ê If given orally, LB needs to survive pass through GI tract and ascend from f the perianal i area into i the vaginal area Ê Lactobacilli used have not been vaginal strains RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Ê Lactobacilli in yogurt strains do not bind to vaginal epithelial cells Ê Only 1 of 14 women were cured after applying yogurt intravaginally twice daily for 7 days Ê Little utility for therapies employing yogurt RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Ê Other types of capsules, powders, etc. in health food stores are also dairy derived Ê In addition, 9 of 16 preparations were contaminated with other types of bacteria and 5 of 16 did not contain peroxide id producing d i strains t i Ê Placebo-controlled trial of p purified Lactobacillus suppositories studied by Sharon Hillier. Ê Ê ~50% of women improved during therapy Only 4 of 29 remained free of BV at 2nd visit RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Ê Disinfectants Ê Chlorhexidine – 79% effective but 50% recurred at one month Ê Povidone-iodine – bid for 2 wks – only 20 % efficacy Ê Acidifiers Ê Lactic Acid suppository – 20% efficacy Ê Lactic acid gel x 7 days – 77% - 7 day follow-up – not repeated Ê 5% acetic acid tampon – 38% efficacy Ê Suppressive therapy – Currently being studied (Sobel) Ê Metronidazole or Tinidazole twice a week Ê Results pending WHAT CAN WE OFFER PATIENTS WITH RECURRENT BV? Ê Clearly explain bacterial vaginosis Ê Carefully go through personal hygiene practices to remove douching, etc. that may disrupt normal flora Ê Explain that course of therapy may relieve symptoms but it takes time for the bacterial imbalance normalize and recolonize with Lactobacilli Ê Longer course of antibiotics or combination therapy for recurrences (2 weeks/ oral + vaginal therapy) Ê ???Suppressive and alternative combination therapy in the future TRICHOMONIASIS Ê Sexually transmitted parasite Ê Vaginal discharge, pruritis in females, but may be asymptomatic asymptomatic. Ê Males usually asymptomatic, but can cause NGU TRICHOMONAS VAGINITIS TRICHOMONAS VAGINALIS CANDIDA VAGINITIS CANDIDA DERMATITIS CANDIDA BALANITIS OTHER VIRAL STDs Ê GENITAL WARTS Ê Human Papilloma Virus Ê Incubation period if 4-8 weeks Ê Involve any portion of the genitalia Ê Cervical lesions Ê Ulceration, secondary bacterial infection, and cervical cancer Ê MOLLUSCUM Ê Seen in children but can also l be b sexually ll transmitted Ê Caused by a poxvirus Ê Lesions appear as smooth papules usually 2-5 2 mm in i size i with a central umbilication OTHER VIRAL STDs Genital Warts Molluscum contagiosum [Human Papilloma i Virus i (HPV)] ( ) OTHER VIRAL STDs Genital Warts (HPV) Molluscum contagiosum ANAL HPV Pubic Lice and Scabies Phthiris pubis (crabs) Tx. – 1. Permethrin Cream 1% W h off Wash ff after ft 10 min. i 2. Lindane 1% for 4 min. Sarcoptes scabei Tx. – 1. Permethrin Cr. 5% W h off Wash ff iin 88-14 14 h hrs. 2. Lindane 1% for 8 h ECTOPARASITES - SCABIES HIV + SCABIES = NORWEGIAN SCABIES