STDs


 Testing:
STD Image Comment Tx
Chlamydia infection
Caused by: Chlamydia trachomatis,
-The most commonly reported STD in the US.
 
-Infection is generally asymptomatic but symptoms may include an odorless, mucoid vaginal discharge (cloudy or yellow) with no external genital symptoms and friable cervix in women; and mucoid penile discharge (clear to whitish) and dysuria in men.
Test:
-
Nucleic acid amplification test (NAAT) is the recommended first test for diagnosis.
-Tests in men are performed on urine or urethral samples.
- Tests in women are performed on urine, or cervical or self-collected vaginal samples. Untreated or inadequately treated infections can lead to more serious problems such as epididymitis and prostatitis in men, and pelvic inflammatory disease and infertility in women.

- Screening for common coinfections such as gonorrhea should be routinely performed.
- Patients should be strongly advised to refer their sexual partner(s) for evaluation and treatment.
- Empiric antibiotics for immediate treatment are recommended if there is a high index of suspicion for infection.
- Azithromycin or doxycycline are recommended first-line antibiotic agents in men and nonpregnant women.
- Doxycycline is contraindicated in pregnancy; an alternative first-line antibiotic in pregnant women is amoxicillin.


Ceftriaxone, 250 mg intramuscularly,
PLUS

Azithromycin (Zithromax), 1 g orally

NOTE: The patient should be given azithromycin, 1 g orally, because of the high incidence of coinfection with Chlamydia, even if testing is negative, and to decrease the risk for cephalosporin resistance.

 

Gonorrhea infection - Caused by: Neisseria gonorrhoeae, and the most commonly reported STD after chlamydial infection.

- Infection may be asymptomatic but commonly presents as urethral irritation and discharge; and dysuria in men.
- Other key diagnostic factors include tenderness and/or swelling of the epididymis; and in women, pelvic pain and mucopurulent or purulent exudate at the endocervix.
- Other presentations include pharyngeal infection, conjunctivitis, meningitis, endocarditis, and disseminated gonococcal infection.
- Infection among infants usually results from exposure to infected cervical exudates at birth, and may present with rhinitis, urethritis, or vaginitis.
Test:
- Nucleic acid amplification test (NAAT) is the recommended first test for diagnosis.

- Patients should be strongly advised to refer their sexual partner(s) for evaluation and treatment.
Ceftriaxone, 250 mg intramuscularly,
PLUS

Azithromycin (Zithromax), 1 g orally

NOTE: The patient should be given azithromycin, 1 g orally, because of the high incidence of coinfection with Chlamydia, even if testing is negative, and to decrease the risk for cephalosporin resistance.

Syphilis infection

 
- Caused by: Spirochete bacterium Treponema pallidum subspecies pallidum, found only in human hosts.
- It is often asymptomatic (it may be detected on routine screening) but a solitary painless genital ulcer strongly suggests primary syphilis.
- Other signs and symptoms include "snail track" mouth ulcers, lymphadenopathy, rash, memory impairment/dementia (due to neurosyphilis), neurologic symptoms (e.g., headache, meningism, iritis, uveitis, hearing loss, seizures, or neuropathy), and condylomata lata (raised, flat, round, or oval papules covered by gray exudates, which may be mistaken for genital warts).
- Dark-field microscopy of the skin lesion, with treponemal-specific and nontreponemal-specific serology tests, is used to confirm diagnosis.
- Prompt diagnosis and antibiotic therapy is important because of the possibility of long-term complications, either from untreated or from prolonged infection.
 
Primary Options
  • Penicillin G benzathine : 2.4 million units intramuscularly as a single dose

Secondary Options

  • Doxycycline : 100 mg orally twice daily and Prednisone : 40-60 mg orally once daily for 3 days; start 24 hours before penicillin

 

Lymphogranuloma venereum - Caused by: Chlamydia trachomatis serovars L1, L2, or L3, which are endemic to the tropics but rare in developed regions.
Presentation:
- The primary manifestation of infection is a painless penile or vulvar inflammation and genital or anal ulceration, often not noticed by the patient.
- Chronic inflammation can lead to genital elephantiasis, saxophone penis, esthiomene, anogenital sinus tracts, strictures, or fistulae.
- Diagnosis: is by exclusion of other causes of proctocolitis, genital/anal ulceration or inguinal lymphadenopathy with definitive diagnosis by identification of C trachomatis from the swab of a genital ulcer or aspiration of a bubo (via culture, direct immunofluorescence, or nucleic acid detection).
 
Primary Options
  • Doxycycline : 100 mg orally twice daily for 21 days

Secondary Options

  • Erythromycin base : 500 mg orally four times daily for 21 days
  • Azithromycin : 1 g/dose orally once weekly for 3 weeks

 

Chancroid

- Caused by: Haemophilus ducreyi (PainFUL ulcer)

- Classically presents with the acute onset of a painful genital ulcer with fluctuant lymphadenitis (bubo formation),

- Diagnosis: is based on clinical features and isolation of the causative organism.
- Microbial confirmation is not always possible, and HSV and syphilis infection must be excluded.
- Azithromycin : 1 g orally as a single dose
- Ceftriaxone : 250 mg intramuscularly as a single dose
- Ciprofloxacin : 500 mg orally twice daily for 3 days
- Erythromycin base : 500 mg orally three times daily for 7 days

 

Pelvic inflammatory disease   - An acute ascending polymicrobial infection of the female upper genital tract that is frequently associated with Neisseria gonorrhoeae or Chlamydia trachomatis.
- Infection usually begins in the cervix or vagina.
- Pelvic inflammatory disease includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
- May be asymptomatic or present with fever, vomiting, back pain, dyspareunia, lower abdominal pain/discomfort, abnormal vaginal odor, itching, bleeding, or discharge.
 
- Possible laboratory findings include abundant WBCs on saline microscopy of vaginal secretions, elevated ESR, elevated C-reactive protein, and laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis.
- Antibiotic therapy should be started in patients who are sexually active and who have pelvic pain, cervical motion tenderness, or adnexal or uterine tenderness for which no other cause can be found.

- All treatment regimens should be effective against N gonorrhoeae and C trachomatis because negative results of endocervical screening for these organisms does not rule out upper reproductive tract infection.
- Regimens with anaerobic activity are also recommended.
HIGH FEVER = Hospitalize

Ceftriaxone : 250 mg intramuscularly as a single dose and Azithromycin : 1 g orally once weekly for 2 weeks

Ceftriaxone : 250 mg intramuscularly as a single dose and doxycycline : 100 mg orally twice daily for 14 days

Cefoxitin : 2 g intramuscularly as a single dose and probenecid: 1g orally as a single dose and doxycycline : 100 mg orally twice daily for 14 days

Cefotaxime : 500 mg intramuscularly as a single dose and doxycycline : 100 mg orally twice daily for 14 days

Levofloxacin : 500 mg orally once daily for 14 days and Azithromycin : 2 g orally as a single dose

PLUS

Metronidazole : 500 mg orally twice daily for 14 days

PLUS

Treat Sexual partner

Urethritis   Classically presents as acute urethral discharge following unprotected sex. Associated with the main symptom of dysuria. Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causes; Mycoplasma genitalium and Trichomonas vaginalis are less common.  Diagnostic tests include Gram stain and culture of the urethral discharge and nucleic acid amplification tests (PCR) for organisms. Presumptive treatment for both gonoccocal (GU) and nongonococcal urethritis (NGU) should be given pending test results, with subsequent treatment based upon confirmed etiology. Patients should be strongly advised to refer their sexual partner(s) for evaluation and treatment.  
Cervicitis   Inflammation of the cervix characterized by a purulent endocervical exudate and/or easily induced endocervical bleeding on manipulation with an atraumatic instrument such as a cotton swab. It may be associated with noninfectious causes, but if an organism is isolated it is most often Neisseria gonorrhoeae or Chlamydia trachomatis. Common presentations include dysuria, pruritic vaginal discharge, dyspareunia, and intermenstrual or postcoital bleeding. If the presentation suggests cervicitis, and the patient is deemed at high risk for STD, patients are empirically treated with a regimen targeting STDs. Patients should be strongly advised to refer their sexual partner(s) for evaluation and treatment.  
Vaginitis   May be caused by bacterial vaginosis, trichomoniasis, or candidiasis infections. Trichomoniasis is an STD caused by the protozoan Trichomonas vaginalis, identified in up to 80% of male partners of infected women.
 Common symptoms include frothy and odorous discharge, pruritus, and dyspareunia. If bacterial vaginosis or trichomoniasis is suspected, vaginal samples for vaginal pH, amine ("whiff") test, saline, and KOH microscopy (wet mount) aid diagnosis. Treatment is initiated following diagnosis, which is based on clinical symptoms and microscopy of vaginal secretions
 
Epididymitis   In sexually active men (aged <35 years), epididymitis is most commonly caused by Neisseria gonorrhoeae or Chlamydia trachomatis. Diagnostic tests include a Gram stain of urethral secretions, taken as a urethral swab, prior to obtaining a urine specimen for nucleic acid amplification tests for both organisms. Treatment relies on supportive measures, including bed rest, scrotal elevation, and analgesics, in conjunction with empiric antibiotic therapy based on the patient's age and clinical and sexual history. If N gonorrhoeae or C trachomatis is the confirmed or suspected pathogen, patients should be strongly advised to refer their sexual partner(s) for evaluation and treatment.  
Herpes simplex virus infection   Infection with HSV-1 or HSV-2 can cause oral, genital, and ocular ulcers. Women may have genital pain, discharge, and dysuria with ulcerative lesions on the vulva, perineum, buttocks, cervix, and vagina. Men may have vesicles on the penis shaft or glans with urethritis. First episodes may present with fever and lymphadenopathy. HSV establishes latency and periodically reactivates. Most reactivations are asymptomatic but can result in transmission of the virus. Active lesions should be swabbed for HSV culture or HSV PCR. Treatment should be started immediately after clinical diagnosis of active disease, or before confirmation if clinical suspicion is high. Oral antivirals (acyclovir, famciclovir, and valacyclovir) are effective at shortening the duration and severity of an episode, with ongoing suppressive therapy for patients with frequent or severe recurrences. - Acyclovir : 400 mg orally three times daily for 7-10 days; or 200 mg orally five times daily for 7-10 days
- Valacyclovir : 1000 mg orally twice daily for 7-10 day
- Famciclovir : 250 mg orally three times daily for 7-10 day

Symptomatic Treatment:
- Lidocaine ointment : (5%) apply to the affected area(s) two to three times daily when required
- Acetaminophen : 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
- Ibuprofen : 400-600 mg orally every 4-6 hours when required, maximum 3200 mg/day
- Sitz bath

 

Genital warts The most prevalent form of viral genital mucosal lesions, caused by infection with several types of human papillomavirus (HPV). Lesions are usually 1 to 3 mm, flesh-colored, whitish, or hyperpigmented, discrete, sessile, smooth-surfaced exophytic papillomas, or they may coalesce into larger plaques. Maceration may be present. Commonly presents as asymptomatic lesions or pruritus, bleeding (due to local trauma), pain, terminal hematuria, or abnormal stream of urine (which may indicate lesions in the distal urethra and meatus). Diagnosis is made based on clinical presentation. Given the benign course of genital warts and the potential for them to resolve spontaneously, treatment is not always indicated. If treated, the goal of treatment is to destroy or remove visible lesions. A variety of treatments exist but there is no clear first-line treatment. No single agent is ideal for all patients or all warts.  
HIV infection   Human immunodeficiency virus (HIV) is a retrovirus that destroys CD4 T-cells and is the etiologic agent of AIDS. AIDS, which usually occurs after approximately 6 to 9 years of untreated HIV infection, is a constellation of opportunistic and other infections, conditions, or malignancies. HIV infection may be divided into 4 stages, determined by measuring CD4 T-cell count and level of HIV (viral load) in the blood. Patients can present at any stage, and may be fully active and asymptomatic, or show symptoms of acute retroviral syndrome, weight loss, chronic diarrhea, and typical opportunistic infections. Diagnosis is established using an HIV antibody test and confirmed using a more specific test such as Western blotting or ELISA. Patients should be clinically staged according to WHO or CDC criteria. Treatment principles include counseling, use of highly active antiretroviral therapy (HAART), and prevention of opportunistic infections.  
Postexposure HIV prophylaxis   Antiretroviral medication given to HIV-negative people reduces the likelihood of HIV seroconversion by approximately 80%. Benefits of postexposure prophylaxis (PEP) need to be balanced against potential toxicities and adverse effects; counseling is an important step in patient management. PEP must be initiated as soon as possible and within 72 hours of exposure to HIV. A 28-day course of treatment is recommended.  
Cervical cancer   A human papilloma virus (HPV)-related malignancy, preventable by HPV vaccination, screening, and treatment of high-grade dysplasia. Pap smear screening followed by colposcopy may diagnose preinvasive disease. The diagnostic approach depends on the abnormality seen on Pap smear in asymptomatic disease. In symptomatic disease, all patients require colposcopy and biopsy in the initial workup. Preinvasive disease is treated by local excision. Treatment of invasive cervical cancer is based on stage, with hysterectomy, chemoradiation, and chemotherapy.  
Reactive arthritis (Reiter syndrome)   Reactive arthritis (ReA) is an inflammatory arthritis that occurs after exposure to certain gastrointestinal and genitourinary infections. The classic triad of postinfectious arthritis, nongonococcal urethritis, and conjunctivitis is frequently described but found in only a minority of cases and not required for diagnosis. There is no specific test for diagnosing ReA. Rather, a group of tests is used to confirm the suspicion in someone who has clinical symptoms suggestive of an inflammatory arthritis in the postvenereal or postdysentery period. Treatment is aimed at symptomatic relief and preventing or halting further joint damage. Typical agents include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying antirheumatic drugs (DMARDs).  
Sexual abuse   Frequent or persistent genitourinary complaints in children may indicate STDs or child psychological stress. HIV, chlamydial, gonorrhea, or syphilis infection is diagnostic of sexual contact. Trichomonas or herpes simplex virus infection suggests sexual contact. However, STDs are uncommon in sexually abused, prepubertal children  
Hepatitis B   Hepatitis B virus (HBV) is a DNA virus transmitted by percutaneous and permucosal routes and is also a sexually transmitted disease. Sexual contact with infected partners is an important method of transmission. In one study, 27% of patients with acute HBV had a history of heterosexual contact with an infected partner or multiple partners, and 13% of patients were men who had a history of sex with men. Diagnosis of HBV infection is made through clinical suspicion in at-risk individuals, and evaluation of the results of specific liver-related and HBV serologic tests. Approximately 70% of patients with acute HBV are asymptomatic, and thus diagnosis is often difficult. Patients chronically infected with hepatitis B may also be asymptomatic, or may have signs and symptoms of chronic liver disease, including cirrhosis and its complications, hepatocellular carcinoma (HCC), and liver failure. In acute HBV infection, patients usually need only supportive care. Patients who develop fulminant hepatitis or hepatic failure from acute HBV are treated with nucleoside analogs and, at the same time, should be evaluated for liver transplantation due to a high risk for mortality associated with liver failure without a liver transplant. In chronic HBV, treatment with interferon or an antiviral agent (nucleoside or nucleotide analog) is indicated for patients with a high pretreatment ALT level, detectable serum HBV DNA, and moderately active necroinflammation with or without fibrosis on liver biopsy. Choice of agents will depend on co-morbidities.  
Hepatitis C   Hepatitis C virus (HCV) belongs to the Flavivirus family. It is a single-stranded, enveloped RNA virus with a genome about 10,000 nucleotides in length. The virus may be transmitted by any percutaneous blood exposure, most commonly among intravenous drug users. The risk for sexual transmission of HCV is low, accounting for about 15% of cases. Most infections are asymptomatic. Following acute exposure, about 55% to 85% of patients develop chronic hepatitis C. Diagnosis is via enzyme immunoassay (EIA), nucleic acid amplification tests (NAATs), and recombinant immunoblot assay (RIBA).  Treatment usually includes pegylated interferon and ribavirin, with the goal of eradicating viremia. Triple therapy with pegylated interferon, ribavirin, and hepatitis C protease inhibitors (boceprevir, telaprevir) is indicated in some patients  
Evaluation of vaginal discharge   Some STDs may have characteristic discharge (e.g., greenish-gray and fishy odor with bacterial vaginosis; thin, grayish, frothy vaginal discharge in the vaginal vault with Trichomonas vaginalis; yellow, cloudy discharge from the cervical os in chlamydial infection).  
Evaluation of dyspareunia   Dyspareunia (painful intercourse) may be associated with various conditions, including vulvovaginitis, herpes simplex virus infection, and pelvic inflammatory disease, which may result from STDs.  
Evaluation of dysuria   Dysuria is defined as pain or discomfort with urination, and the most common cause is infection (e.g., cystitis, urethritis, cervicitis, vulvovaginitis, prostatitis, and pyelonephritis). Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causes of urethritis; Mycoplasma genitalium, Trichomonas vaginalis, and herpes simplex virus are less common causes. Associated symptoms (e.g., discharge), other medical conditions, and patient history may help elucidate the diagnosis. For example, if discomfort is felt at termination of urination, urethritis and vaginitis are likely; if genital irritation has occurred, vaginitis is more likely