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Sexually Transmitted Diseases JFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: CDC, STD.

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Presentation on theme: "Sexually Transmitted Diseases JFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: CDC, STD."— Presentation transcript:

1 Sexually Transmitted Diseases JFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: CDC, STD Treatment Guidelines, 2006

2 Discussion outline Common Sexually Transmitted Diseases –Symptoms/signs –Investigations –Treatment –Special notes Screening Men who have sex with men/women who have sex with women (MSM/ WSW) Vaccinations Sexual Assault

3 Common Sexually Transmitted Diseases Ulcerative disease –Chancroid –Genital HSV –Granuloma inguinale –Lymphogranuloma venerum –Syphilis Urethritis/Cervicitis Vaginal discharge –Bacterial Vaginosis –Trichomoniasis –Vulvovaginal Candidiasis Pelvic inflammatory disease Epididymitis Genital warts Ectoparasitic infections –Pediculosis Pubis –Scabies

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5 Chancroid (H. ducreyi) Symptoms/signs –Painful genital ulcer, tender suppurative lymphadenopathy Investigations –Criteria: 1. painful genital ulcer (s) 2. no syphilis 3. Ulcer exudates HSV (-) Treatment –Azithro 1 g x 1 or CTX 250 mg x1 or Cipro 500 mg po bid x 3d or erythro 500 mg po tid x 7 day Special notes –10% co-infected with T. pallidum or HSV –Cofactor for HIV transmission

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7 Genital HSV Symptoms/signs –Mostly no sx –Small, painful, grouped vesicles/ shallow ulcers –Erythema multiforme, neuro sequellae, dissemination Investigations –DFA or Viral cell cx with typing (low SN for healing lesions) –Neg. virologic test does not rule-out infection due to intermittent shedding –Type-specific serum Ab (after 7wks, persist indefinitely, SN 80-98%, SP>95%) Treatment –Valacyclovir (1g PO BID) OR famciclovir (250mg PO TID) both have good oral bioavailability, acyclovir (400mg PO TID OR 200mg PO FID). Duration 7-10d. –Severe (complications, hospitalization, CNS): IV acyclovir –Acyclovir-resistant: ID consult, consider foscarnet/topical cidofovir Special notes –Treat patients with initial genital herpes –Consider 2˚ prevention (suppressive or episodic tx if >5 episodes/yr, though does not clear latent virus) –Counsel re: pregnancy – HSV-2>HSV-1; First-episode likely HSV-1; Recurrence likely HSV-2

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9 Granuloma inguinale (Donovanosis) (Klebsiella granulomatis ) Symptoms/signs –Painless, progressive, beefy-red, vascular ulcerative lesions, no LAD Investigations –Visualization of dark-staining Donovan bodies on tissue crush preparation/biopsy Treatment –Doxy 100mg PO BID x3wks/until lesions healed –Add gentamicin 1mg/kg IV q8h if no early improvement Special notes –Tx halts lesion progression

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11 Lymphogranuloma venereum (C. trachomatis L1, L2, L3) Symptoms/signs –Unilateral, tender inguinal/femoral LAD, self-limited ulcer/papule often gone, proctocolitis if anal exposure Investigations –Urine, genital and/or LN specimens for CT (cx, direct immunofluorescence, nucleic acid detection) Treatment –Doxy 100mg PO BID x3wks –Buboes require aspiration Special notes –Tx cures infection and prevents ongoing tissue damage

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14 Syphilis (T. pallidum) Symptoms/signs –1˚: ulcer/chancre –2˚: rash, mucocutaneous lesions, LAD –3˚: cardiac/ophthalmic, auditory, gumma –Neurosyphilis –Latent: (early latent vs. late latent) no sx Investigations –Definitive: Darkfield exam/DFA of lesion –Presumptive: –Non-treponemal (VDRL, RPR) correlate with disease activity/tx response –Treponemal (FTA-ABS, TP-PA) –If neurologic sx: –CSF: VDRL is SP, FTA-ABS is SN, serologies, CSF cell count/protein –Ocular slit-lamp exam Treatment –Benzathine PCN G: –2.4 million units IM x1 for 1˚/2˚/early latent (exposure within 1yr) –2.4 million units x3wks for 3˚, late latent –Aqueous crystalline PCN G million units/d (q4h or continuous) x10-14d –Presumptive tx for sex partners within 90d (tests may have false-negatives) Special notes –Jarisch-Herxheimer rxn: acute febrile rxn with HA, myalgia within 24h of tx –Follow-up evaluation at 6 and 12 mos (and 24 mos. for latent, and q6 mos. for neurosyphilis)

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16 Urethritis/Cervicitis Symptoms/signs –Urethritis: Mucopurulent discharge, dysuria, pruritis, urgency, nocturia, frequency –Cervicitis: mucopurulent endocervical exudate, dyspareunia, postcoital bleeding, signs of PID Investigations –Urethritis: Urethral Gram stain with ≥5 WBC (if GNID then NG), UA leukocyte esterase(+); Urethral/urine NAAT for CT/NG (urine preferred) –Cervicitis: Cervical/urine NAAT, wet prep, T. vaginalis cx/Ag (swab preferred, urine okay); leukorrhea by microscopy; GNID on endocervical fluid Gram stain Treatment –Empiric tx for CT/NG if high risk (≤25yo, new/multiple partners, unprotected sex, poor follow- up) –NGU: azithro 1g PO x1 OR doxy 100mg PO BID x7d Special notes –Abstinence for 7d post-tx + no sx + partner treated –If sx >3mos, consider chronic prostatitis, chronic pelvic pain syndrome –Retest ♀ 3mos. post-tx (both ♂ and ♀ if gonococcal) –Other causes: ureaplasma urealyticum, mycoplasma genitalium, T. vaginalis, HSV, HPV, adenovirus

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18 Bacterial vaginosis (Gardnerella, other anaerobes) Symptoms/signs –Homogenous, thin-white, malodorous discharge; pruritis Investigations –Clue cells, pH<4.5, +Whiff test, Gram stain = gold standard, cx is nonspecific Treatment –Metronidazole 500mg PO BID x7d OR gel 5mg intravaginally QD x5d OR clindamycin 2% cream 5g intravaginally QHS x7d Special notes –Treating ♀ partners does not reduce recurrence –Can cause endometritis, PID, post-procedure cellulitis

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20 Trichomoniasis (T. vaginalis) Symptoms/signs –Malodorous, yellow-green discharge, vulvar irritation, or no sx Investigations –nucleic acid probe, SN>83%, SP>97% –Wet prep 60-70% SN –Cx most SN/SP Treatment –Metronidazole 2 g x1 or 500 mg bid x7days Tinidazole 2 g po single dose Special notes –Low level metronidazole resistance in 2-5%; Tinidazole longer half-life and higher tissue penetration

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22 Vulvovaginal candidiasis (VVC) (C. albicans or other species) Symptoms/signs –Pruritus, soreness, dyspareunia, external dysuria, abnormal/curdy discharge –Vulvar edema, fissures, excoriations Investigations –Saline, 10% KOH wet prep or Gram stain with yeast or pseudohyphae –Cx for yeast species (for negative wet mounts) Treatment –Immunocompetent/sporadic:short course topicals (single dose and regimens of 1-3d) or fluconazole 150mg po x1 –Immunocompromised/ severe recurrent: longer courses Special notes –75% of ♀ will have one episode, 40-45% ≥2 –10-20% will have VVC –Oil based creams may weaken condoms –Topical azoles more effective than nystatin

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24 Pelvic inflammatory disease (Mostly C. trachomatis and N. gonorrhoeae) Symptoms/signs –CMT, urterine/ adnexal tenderness, fever, discharge –Endometritis, salpingitis, TOA, pelvic peritonitis Investigations –Abundant WBC on wet prep, ESR, CRP, microbiology –Most specific: endometerial bx, transvaginal U/S, laparoscopy Treatment –Cefotetan 2g IV q12h OR cefoxitin 2g IV q12h PLUS doxy 100mg PO or IV q12h –After 24h of parenteral abx, continue doxy x14d –Add metronidazole or clindamycin if +TOA Special notes –Empiric abx prevents long-term sequellae –Consider oral quinolone regimen + metronidazole if mild disease and no QRNG suspected

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26 Epidydimitis (Mostly C. trachomatis and N. gonorrhoeae) Symptoms/signs –Unilateral testicular pain, swelling, inflammation Investigations –Urine NAAT, urethral Gram stain (>5 WBC/hpf), +leuk esterase on UA Treatment –CTX 250mg IM x1 PLUS doxy 100mg PO BID x10d

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28 Genital Warts (HPV types 6 and 11 common) Symptoms/signs –Flat, papular or pedunculated growths on genital mucosa –Generally asymptomatic, can be painful, friable or pruritic Investigations –3-5% acetic acid turns infected genital mucosa white, but little evidence –Bx only if dx uncertain, no response to tx, or patient immunocompromised Treatment –External: No definitive treatment –Podofilox 0.5% bid x3d, then 4d no therapy, repeat prn ≤ 4 cycles (total area≤10 cm2) –Imiquimod 5% cream QHS, TIW ≤ 16wks –Cryotherapy (various forms) –Podophylin resin 10-25% OR ticholoracetic acid OR bichloroacetic acid –Surgical removal, laser therapy, intralesional interferon Special notes –Tx may reduce, does not eliminate infection, unclear impact on transmission –Genital warts not an indication for HPV testing, change in frequency of Pap, or colposcopy –Cervical: exclude HGSIL before tx, consult specialist –Vaginal: liquid nitrogen, TCA/BCA –Urethral meatus: liquid nitrogen or podophyllin –Anal: cryotherapy, TCA/ BCA, surgical removal

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30 Pediculosis pubis (pubic lice) Symptoms/signs –Lice or nits on pubic hair Treatment Recommended: –Permethrin 1% cream or Pyrethrins with piperonyl butoxide –Alternative : –Malathion 0.5% lotion –Ivermectin 250 ug/kg repeated in 2 weeks Special notes –Resistance to pediculides increasing –Use malathion when treatment failure believed because of resistance –Treat sex partners within previous month

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32 Scabies (Sarcoptes cabiei) Symptoms/signs –Classic burrowing rash, pruritus may persist for ≤ 2wks Treatment –Recommended: permethrin cream 5% to all areas of the body from the neck down, washed off after 8-14h –Ivermectin 200 ug/kg PO, repeated in 2wks –Alternative: Lindane 1% total body, neck down (toxicity: aplastic anemia, seizure) –Decontaminate bedding/clothing Special notes –Sensitization to Sarcoptes scabiei occurs before pruritus. With 1st infection takes ≤several wks to develop, may occur ≤24h of reinfection –In adults usually sexually acquired, but not in children –Norwegian scabies (i.e., crusted scabies): aggressive infestation occurs in immunodeficient, debilitated or malnourished persons

33 Key Points Use syndrome classification to simplify differential diagnosis. Most genital ulcer disease in the U.S. is HSV or syphilis. If treating empirically for cervicitis/urethritis, treat for both NG and CT. New diagnoses mandate testing for other STDs, especially HIV and syphilis. Test and treat all sex partners. (not generally recommended for candidiasis)

34 Screening Includes: –(1) education/counseling on safe sex, –(2) identification of asymptomatic infected persons and symptomatic persons unlikely to seek tx, –(3) diagnosis/treatment, –(4) evaluation of sex partners –(5) preexposure vaccination for those at risk of vaccine-preventable STDs Prevention: abstinence, reduction of sex partners, male/female condoms Partner management: encourage notification, evaluate sex partners within 60d, consider patient-delivered tx Asymptomatic testing: –CT: Sexually active ♀ ≤25yo, older ♀ with risk factors –NG: Sexually active ♀ with increased risk (≤25yo, prior STDs, new/multiple partners, inconsistent condom use, drug use) –HIV: Voluntary, universal, opt-out provision. Also consider when other STDs are found or suspected –RPR, HBV sAg/sAb, HCV Ab

35 MSM/WSW Consider additional sx: genital and perianal ulcers, regional LAD, skin rash, anorectal sx Annual STD screening for MSM: HIV, RPR, urine/rectal/pharyngeal testing for CT/NG depending on history of insertive/receptive anal/receptive oral intercourse in past year, consider anal cytology/HPV screening. Screen q3-6mos if multiple partners or drug use. All ♀ require routine Pap and STD screening regardless of sexual practices.

36 Vaccinations HBV vaccine for all persons evaluated or treated for STDs and for MSM. HAV vaccine for MSM and illegal-drug users HPV vaccination in ♀ ≤26yo

37 A word about sexual assualut Post exposure prophylaxis (see CDC website for current guidelines)


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