Dela
We review Sexually Transmitted Infections and pertinent updates in diagnosis and management.
Hosts:
Avir Mitra, MD
Brian Gilberti, MD
Tags: gynecology, Infectious Diseases, Urology
Show NotesTable of Contents
(1:49) Chlamydia
(3:31) Gonorrhea
(4:50) PID
(6:14) Syphilis
(8:08) Neurosyphilis
(9:13) Tertiary Syphilis
(10:06) Trichomoniasis
(11:13) Herpes
(12:49) HIV
(14:10) PEP
(15:13) Mycoplasma Genitalium
(18:00) Take Home Points
Chlamydia:
Prevalence:Most common STI.High percentage of asymptomatic cases (40% to 96%).Presentation:Urethritis, cervicitis, pelvic inflammatory disease (PID), prostatitis, proctitis, pharyngitis, arthritis.Importance of considering extra-genital sites (oral and rectal infections).Testing:Gold Standard: Nucleic Acid Amplification Test (NAAT) via PCR.Sampling Sites:Endocervical or urethral swabs preferred over urine samples due to higher sensitivity.Triple-site testing (genital, rectal, pharyngeal) recommended for comprehensive detection.Treatment Updates:Previous Regimen: Azithromycin 1 g orally in a single dose.Current First-Line Treatment: Doxycycline 100 mg orally twice daily for 7 days.Alternatives:Azithromycin remains an option for patients unlikely to adhere to a 7-day regimen or for pregnant patients.Note: PID treatment differs and will be discussed separately.Gonorrhea:
Presentation:Similar to chlamydia; can be asymptomatic.Symptoms include urethritis, cervicitis, PID, prostatitis, proctitis, pharyngitis.Testing:Gold Standard: NAAT.Sampling Sites:Endocervical swabs are more sensitive than urine samples.Triple-site testing is crucial to avoid missing infections.Treatment Updates:Previous Regimen: Ceftriaxone 250 mg IM plus azithromycin 1 g orally.Current Recommendation: Ceftriaxone 500 mg IM single dose.Adjusted due to rising azithromycin resistance and updated pharmacokinetic data.Co-Infection Considerations:High rates of chlamydia and gonorrhea co-infection (20% to 40%).CDC recommends empiric treatment for chlamydia when treating gonorrhea to prevent complications like PID and infertility.Pelvic Inflammatory Disease (PID):
Etiology:Not solely caused by chlamydia and gonorrhea; about 50% of cases involve other pathogens like bacterial vaginosis (BV) organisms and anaerobes.Treatment Changes:Expanded Coverage Regimen:Ceftriaxone 500 mg IM once.Doxycycline 100 mg orally twice daily for 14 days.Metronidazole 500 mg orally twice daily for 14 days.Inclusion of metronidazole addresses anaerobic bacteria contributing to PID.Syphilis:
Stages and Presentation:Primary Syphilis:Painless chancre on genitals.Treatment: Penicillin G 2.4 million units IM single dose.Secondary Syphilis:Rash (often diffuse), mucocutaneous lesions, nonspecific joint pain.Treatment: Same as primary syphilis.Latent Syphilis:Asymptomatic phase; divided into early (<1 year) and late (>1 year).Treatment for Late Latent:Penicillin G 2.4 million units IM once weekly for 3 weeks.Recommended when the timing of infection is unclear.Neurosyphilis:
Can occur at any stage.Symptoms include visual changes, severe headaches, neurological deficits.Diagnosis: Requires lumbar puncture (LP) for confirmation.Treatment: Admission for intravenous penicillin G.Tertiary Syphilis:
Rare, advanced stage with severe manifestations (e.g., gummas, cardiovascular complications, neurological signs).Treatment: Extended penicillin therapy similar to late latent syphilis.Trichomoniasis:
Presentation:Often asymptomatic.In women: Vaginal discharge.In men: Urethritis.Testing:Shift from wet mount microscopy to NAAT for improved detection.Swab samples preferred over urine for higher sensitivity.Treatment Updates:Previous Regimen: Metronidazole 2 g orally in a single dose.Current Recommendations:Women: Metronidazole 500 mg orally twice daily for 7 days.Men: Single 2 g dose remains acceptable.Herpes Simplex Virus (HSV):
Types and Transmission:HSV-1 and HSV-2: Both can cause oral and genital infections.Increasing crossover between oral and genital sites.Testing:Serum IgG testing not useful for acute diagnosis due to widespread prior exposure.Preferred Method: PCR testing from lesion swabs.Clinical Tip: If the lesion is characteristic, clinicians may start treatment without waiting for test results.Treatment:Preferred Medication: Valacyclovir (Valtrex) for ease of dosing.Dosage:Initial episode: 1 g orally twice daily for 7 to 10 days.Recurrence: 1 g daily for 5 days.Alternative: Acyclovir for cost considerations.Human Immunodeficiency Virus (HIV):
Testing Limitations:Window Periods:Fourth-generation tests have a window period of 2 to 4 weeks.Negative results during this period may not rule out recent infection.Acute HIV Infection:Presents with flu-like symptoms: malaise, joint pains, fatigue.Diagnosis Challenges:Standard HIV tests may be negative during the window period.Options:Empiric treatment with follow-up testing.Order an HIV viral load test (more sensitive but expensive and delayed results).Post-Exposure Prophylaxis (PEP):Timing: Initiate ideally within 72 hours of potential exposure.Duration: 28-day regimen.Pre-Treatment Testing:Baseline HIV test to rule out existing infection.Renal and hepatic function tests to monitor for medication side effects.Follow-Up: Reassess renal/hepatic function in 2 weeks.Mycoplasma genitalium:
Recognition:Newly recognized STI by the CDC in 2021.Causes cervicitis and urethritis.Possible associations with PID and proctitis, but not definitively established.Testing:When to Test:Only in patients with persistent symptoms after standard STI testing and treatment.Not recommended for initial screening.Method: NAAT.Treatment:Step 1: Doxycycline 100 mg orally twice daily for 7 days.Step 2: Moxifloxacin 400 mg orally once daily for 7 days.Addresses antibiotic resistance concerns and ensures comprehensive treatment.General Management and Patient Counseling:Partner Notification:Encourage patients to inform sexual partners for testing and treatment.Medication Adherence:Emphasize the importance of completing the full course of prescribed medications.Prevention Measures:Discuss the use of barrier protection (e.g., condoms) to prevent transmission and reinfection.Follow-Up Care:Advise patients to return if symptoms persist, indicating possible infections like Mycoplasma genitalium.Key Take-Home Points:
Chlamydia Treatment Update:Doxycycline 100 mg orally twice daily for 7 days is now first-line treatment for cervical infections.For epididymitis, extend doxycycline to 10 days.Gonorrhea Treatment Update:Treat with a single 500 mg IM dose of ceftriaxone.PID Management Update:Expanded antimicrobial coverage includes:Ceftriaxone 500 mg IM once.Doxycycline 100 mg orally twice daily for 14 days.Metronidazole 500 mg orally twice daily for 14 days.Mycoplasma genitalium Recognition:Test in patients with persistent symptoms after standard treatment.Treat with doxycycline followed by moxifloxacin.HIV Testing and PEP:Be aware of HIV test window periods; negative results may not rule out recent infection.Consider HIV viral load testing if acute infection is suspected.Initiate PEP within 72 hours for a 28-day course, ensuring clear discharge planning and patient support.Podden och tillhörande omslagsbild på den här sidan tillhör Core EM. Innehållet i podden är skapat av Core EM och inte av, eller tillsammans med, Poddtoppen.