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Detection and Treatment of Sexually Transmitted Infections

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Presentation on theme: "Detection and Treatment of Sexually Transmitted Infections"— Presentation transcript:

1 Detection and Treatment of Sexually Transmitted Infections
27 March 2014 Maj Jeremy King, M.D.

2 Objectives Understand the causes, signs, and symptoms of sexually transmitted infections (STIs) that cause: Genital ulcers Vaginitis Cervicitis Pelvic inflammatory disease Understand the rational for screening and the current recommended screening strategies Understand recommended screening in special conditions such as pregnancy and sexual assault

3 STIs in the US 20 million new infections per year.
110 million current infections. $16 billion in direct medical costs per year. Complications of untreated STIs: - upper genital tract infections - infertility, cervical cancer - enhanced transmission of HIV Satterwhite CL, et al. Sexually transmitted infections among U.S. women and men: Prevalence and incidence estimates, Sex Transm Dis 2013

4 Screening Screening tests detect early disease or risk factors for disease in large numbers of apparently healthy individuals Diagnostic tests confirm the presence (or absence) of disease in symptomatic or screen positive individuals

5 When should we screen? Tests are available Risk factors are present
relatively inexpensive, reliable, prevent morbidity age, current sexual practices, past infections eg: Chlamydia

6 Chlamydia Reported Chlamydia Cases in Texas, 1992-2012
Almost 125,000 cases reported in 2012 76% Female Disproportionately Black Reported Chlamydia Cases in Texas, 2012 Sexually Transmitted Diseases Surveillance

7 Chlamydia Reported Chlamydia Cases in Texas, 1992-2012
Chlamydia in TX: Almost 125,000 cases reported in 2012 76% Female Disproportionately Black Reported Chlamydia Cases in Texas, 2012 Texas STD and HIV Epidemiologic Profile February 2014

8 Chlamydia 85% of cases are asymptomatic Potential complications:
PID Chronic pelvic pain tubal infertility Ectopic pregnancy Screening recommendations: All sexually active women up to 25 y/o All women > 25 y/o with risk factors Men with risk factors Complications: (CDC) up to 30% of women with untreated PID. Left untreated, 20% of those with symptomatic PID might become infertile; 18% will experience debilitating, chronic pelvic pain; and 9% will have a life-threatening tubal pregnancy (8). The importance of subclinical PID became apparent with observations that most of the women with tubal factor infertility or ectopic pregnancy who had serologic evidence of chlamydial infection apparently had no history of PID (9,10). C. trachomatis infection during pregnancy might lead to infant conjunctivitis and pneumonia and maternal postpartum endometritis (11). Among men, urethritis is the most common illness resulting from C. trachomatis infection. Complications (e.g., epididymitis) affect a minority of infected men and rarely result in reproductive health sequelae (12). C. trachomatis infections of the rectum can result from unprotected anal intercourse and are typically asymptomatic but might progress to proctocolitis (13,14). Ocular infections can result in conjunctivitis in neonates and adults (15). Sexually acquired reactive arthritis also has been reported as a possible consequence of C. trachomatis infection (16). The CDC recommends that selected populations of high-risk men be screened because of high rates of chlamydial infection, if resources exist and if screening men would not materially impact screening in women. -men attending STD clinics; men participating in National Job Training programs; men <30 years of age in the military; men <30 years of age entering jail or juvenile detention; and men whose partners are diagnosed with chlamydia. The CDC also recommends retesting men treated for chlamydia within three months [24] because of the high risk of reinfection. The CDC also recommends that sexually active men who have sex with men (MSM) be screened at least annually.

9 Cervicitis Symptoms Signs Diagnosis Abnormal vaginal discharge
Intermenstrual vaginal bleeding Signs Mucopurulent endocervical exudate Sustained endocervical bleeding easily induced by cotton swab Leukorrhea (>10 WBC per HPF) is specific, but not sensitive Diagnosis Microscopy NAAT Culture The incubation period of symptomatic chlamydia generally ranges from 7 to 14 days following infection. However, it is unclear how long those with asymptomatic disease may carry the infection. In a systematic review of ten studies of untreated, uncomplicated genital chlamydial infections, detection of chlamydia persisted over the short term (weeks to months after diagnosis) in 56 to 89 percent

10 Cervicitis GC and Chlamydia most common organisms isolated
NAAT is preferred diagnostic test Saline prep to assess for PID, BV, Trich In majority of cases no organism isolated Presumptive treatment (azithromycin 1g PO) should be provided for women at increased risk for STIs (≤25 y/o, new or multiple sex partners, and those who engage in unprotected sex)

11 Chlamydia Chlamydial genital infection is the most frequently reported infectious disease in the US Intracellular bacterium May be asymptomatic, or sx may occur weeks to months after exposure

12 Screening Recommendations
Chlamydia Screening Recommendations Annually for all sexually active women ≤ 25 y/o Annually for women > 25 w/ risk factors Screen + patients for other STDs

13 Chlamydia Treatment Recommended regimens (97-98% cure rate):
Azithromycin 1 g PO single dose or Doxycyline 100 mg PO bid for 7d Alternative regimens: Erythromycin base 500 mg PO qid for 7d Erythromycin ethylsuccinate 800 mg PO qid for 7d Ofloxacin 300 mg PO bid for 7d Levofloxacin 500 mg PO qd for 7d

14 Chlamydia Treatment Patient counseling
Take first dose immediately (observed, on site, if possible) TOC is not advised routinely (except in pregnancy) Retest in 3 months to screen for re-infection Advise most recent partner and any other sex partners w/i 60 days preceding symptoms to seek evaluation/tx Abstain from IC until pt and partner(s) complete tx (7d after single dose regimen)

15 Gonorrhea N. gonorrhoeae infections are the 2nd most common reportable communicable disease in the US Tend to cause a stronger inflammatory response than C. trachomatis but are typically asymptomatic in women until complications such as PID develop In men, usually causes urethritis with painful urination. May cause epididymitis or disseminated gonococcal infection

16 Gonorrhea Screening based on population, at risk pts
Patients w/ + GC should be tested for chlamydia, syphilis, and HIV Culture and sensitivities for persistent infection Tx: cephalosprin + azithomycin No TOC needed, but consider retesting after 3 months to screen for reinfection Refer partners for testing/tx (most recent partner and all partners w/i 60d before onset of symptoms or + test)

17 Vaginitis Vaginal discharge, odor, vulvar itching and irritation
Most common causes are bacterial vaginosis (40%- 45%) vulvovaginal candidiasis (20%-25%) trichomoniasis (15%- 20%)

18 Bacterial Vaginosis (BV)
Polymicrobial clinical syndrome resulting from replacement of normal hydrogen peroxide-producing Lactobacillus species with anaerobic bacteria Prevotella, Mobiluncus, G. Vaginalis, M. Hominis Malodorous vaginal discharge reported more commonly after intercourse and after menses; +/- pruritus Sx may remit spontaneously Can be diagnosed by clinical criteria or gram stain (BV) is a common condition that is related to alterations in the normal vaginal flora. It is the most common cause of vaginitis and has a recurrence rate of approximately 20%-40% at one month after therapy. Information on the prevalence of BV is incomplete since BV is not reportable. National data show that the prevalence is 29% but varies by population: 5%-25% in college students, 12%-61% in STD patients. Organisms associated with BV do not persist in the male urethra, but may be present under the foreskin of uncircumcised men. BV has been identified in female same-sex partnerships. BV has been linked to premature rupture of membranes, premature delivery, low-birthweight delivery, acquisition of HIV and STDs, development of pelvic inflammatory disease (PID), post-operation infections after gynecological procedures and recurrence of BV. Occurrence of BV may be related to sexual activity, but BV is not considered a sexually transmitted disease. Certain species of lactobacillus also produces hydrogen peroxide (H2O2), which is in vitro, toxic to viruses such as HIV as well as to bacteria. These species are present in approximately 42%-74% of females, and is under investigation as a probiotic. The prevalence of BV in these women is low (4%). Amsel criteria. The presence of three of the following four criteria provides sufficient evidence for a clinical diagnosis of BV. 1.           Vaginal pH >4.5, which is most sensitive but least specific sign. 2.           The presence of clue cells (bacterial clumping upon the borders of epithelial cells) on wet mount examination. Clue cells should constitute at least 20% of all epithelial cells (an occasional clue cell does not fulfill this criteria). 3.           Positive amine, "whiff" or "fishy odor" test (liberation of biologic amines with or without the addition of 10% KOH). 4.           Homogeneous, nonviscous, milky-white discharge adherent to the vaginal walls. Gold standard for diagnosis of BV is vaginal Gram stain to assist in the diagnosis of BV (Nugent criteria).

19 BV Recommended Rx: Alternative Rx:
Metronidazole 500 mg PO bid for 7d Metrogel 0.75% 5 g vaginally qd for 5d Clindamycin cream 2% 5 g vaginally qd for 7d Do not use in second half of pregnancy Alternative Rx: Clindamycin 300 mg PO bid for 7d Clindamycin ovules 100mg vaginally qhs x3d Tinidazole 2 g po qd x2d Tinidazole 1 g po qd x5d For multiple recurrences, consider Metrogel 0.75% twice weekly for 6 months Treatment of male sex partners has not been beneficial in preventing recurrence Pregnancy - Treat all symptomatic pregnant patients

20 Trichomoniasis T. Vaginalis (a protozoan)
3% of US women currently infected 70%-85% asymptomatic Sx include "frothy" gray or yellow-green vaginal discharge and itching Almost always sexually transmitted Without treatment, trichomoniasis can increase a person’s chances of getting or spreading other STIs In women, infection with T. vaginalis has been suggested to be associated with adverse pregnancy outcomes, including premature rupture of membranes and pre-term labor, pelvic inflammatory disease, and increased risk for HIV infection 3% prevalence in the general female population. •         1.3% in non-Hispanic white women •         1.8% in Mexican American women •         13.3% in non-Hispanic black women •         Prevalence increases with age among non-Hispanic black women. •         40%-60% prevalence in female prison inmates and commercial sex workers. •         18%-50% prevalence in females with vaginal complaints. •         70%-85% of women are asymptomatic. •         Not routinely tested in men. A 17% prevalence rate was seen in males attending an STD clinic in one city. "frothy" gray or yellow-green vaginal discharge and pruritis. Cervical petechiae ("strawberry cervix") is a classic presentation which occurs <2% of cases. T. vaginalis may also infect the Skene's glands and the urethra where it can be difficult to treat.   T. vaginalis infection is often asymptomatic in women. Trichomoniasis has been associated with increased shedding of HIV in HIV- infected women.

21 Trichomoniasis Screening recommended in women: Diagnosis
Motile trichomonads on wet prep Only 60-70% sensitive Various point of care tests 80+% sensitive Can culture if negative wet prep and high suspicion Screening recommended in women: with new or multiple partners with a history of STIs who trade sex for drugs or money who use IV drugs Nucleic acid amplification tests (NAAT): Recently, the Trichomonas APTIMA test (GenProbe) was approved by the U.S. FDA for the diagnosis of vaginal trichomoniasis. This test is highly sensitive and specific and can be performed on self-collected or clinician-collected vaginal swab, urine or liquid endocervical cytology media. This test is considerably more sensitive than culture.

22 Trichomoniasis Recommended treatment options Counseling
Metronidazole 2 g PO x1 (or 500 mg BID x 7d) Tinidazole 2 g PO x1 Counseling Abstain from alcohol until 24h after last metronidazole (3d for tinidazole) Advise partners to seek eval and tx Avoid intercourse until all tx completed and both partners are asymptomatic Breastfeeding: withhold feeding for 12-24h after last dose of metronidazole (3d for tinidazole) Latex condoms, when used consistently and correctly, can reduce the risk of transmission of T. vaginalis.

23 Vulvovaginal Candidiasis (VVC)
“yeast infection” Caused by Candida albicans (85%- 90%), C. glabrata and C. parapsilosis are responsible for ~10% of cases Symptoms: vulvar itching; thick, white, clumpy Vaginal discharge Diagnosis: wet prep, gram stain, or culture Most cases of VVC are caused by Candida albicans (85%-90%). C. glabrata and C. parapsilosis are responsible for 5%-10% of cases. Although most patients have no risk factors, frequent infections may be linked to diabetes, corticosteroids, repeated courses of antibiotics, pregnancy, or HIV disease. Candida species are normal flora of the skin and the vagina and are not considered to be sexually transmitted pathogens. Yeast grows as oval budding cells and as chains of cells (pseudohyphae). Candida species may be isolated from the lower genital tract in approximately 20% of asymptomatic healthy women without abnormal discharge. Symptomatic candidiasis is caused by an overgrowth of Candida albicans and Candida species. It is thought that changes in the host vaginal environment are usually necessary before the organism induces pathologic effects. Disruption of normal vaginal ecology and host immunity can occur with diabetes, pregnancy, or HIV disease. In some women, disruption can occur with the use of antibiotics and douching. vulvar pruritus. Vaginal discharge is usually thick, white, and clumpy ("cottage-cheese-like"). However, it may be watery, minimal, or not present. Vaginal soreness, irritation, vulvar burning, dsypareunia, and external dysuria are often present. Cultures are not useful for routine diagnosis of VVC since positive cultures may detect colonization rather than clinically significant infections. However, cultures may be useful to detect non-albicans species or resistant organisms in women with recurrent disease.

24 Treatment of uncomplicated VVC
Multiple topical azoles, applied 1-7d OTC: butaconazole, clotrimazole, miconazole, tioconazole Rx: butoconazole, nystatin, terconazole nb: If symptoms persist after using OTC preparation or recur w/i 2 months should be evaluated with office- based testing Oral agent (Rx): Fluconazole 150 mg x1 Treat partners only if symptomatic (balanitis) Recurrent VVC ≥4 episodes per yr Obtain vaginal cultures Tx: longer topical regimen (7-10d) or fluconazole PO x3 three days apart Maintenance - Oral fluconazole 150 mg Qwk for 6 months Severe VVC Extensive erythema, edema, excoriation, fissures Tx: opical azole for 7-14d or fluconazole 150 mg PO x2 three days apart Non-albicans VVC 7-14d of topical azole For recurrence, boric acid 600 mg in gelatin capsule vaginally QD for 2 weeks Immunocompromised Pregnancy Topical azole x7 days

25 Complicated VVC Recurrent VVC Severe VVC Recurrent Severe
Non-albicans candidiasis Women with uncontrolled diabetes, debilitation, or immunosuppression Recurrent VVC ≥4 episodes per yr Obtain vaginal cultures Tx: longer topical regimen (7-10d) or fluconazole PO x3 three days apart Maintenance - Oral fluconazole 150 mg Qwk for 6 months Severe VVC Extensive erythema, edema, excoriation, fissures Tx: opical azole for 7-14d or fluconazole 150 mg PO x2 three days apart Non-albicans VVC 7-14d of topical azole For recurrence, boric acid 600 mg in gelatin capsule vaginally QD for 2 weeks Immunocompromised Pregnancy Topical azole x7 days

26 PID Minimum diagnostic criteria Treat empirically
Women at risk for STDs experiencing pelvic or lower abdominal pain, if no cause for the illness can be identified, and one or more of the following are present on pelvic examination: CMT Uterine tenderness Adnexal tenderness Treat empirically Screen all PID pts for N. gonorrhoeae, C. trachomatis, HIV

27 PID Recommended Parenteral Treatment: Regimen A Regimen B
Cefotetan 2 g IV q12h OR Cefoxitin 2 g IV q6h PLUS Doxycycline 100 mg PO or IV q12h Regimen B Clindamycin 900 mg IV q8h PLUS Gentamycin 2 mg/kg IV/IM load, then 1.5 mg/kg q8h (Can substitute single daily dosing) Alternative Parenteral Regimen: Ampicillin/Sulbactam 3 g IV q6h PLUS Doxy 100 mg IV or PO q12h

28 PID May discontinue parenteral therapy 24 hrs after a clinical improvement Continue doxycycline 100 mg PO bid OR clindamycin 450 mg PO qid to complete total of 14d of RX (Clindamycin preferred with TOA)

29 PID Recommended Oral Regimen Starts with single IM injection of
Ceftriaxone 250 mg Or Cefoxitin 2g PLUS Probenicid 1g PO x1 Or other 3rd gen cephalosporin (ceftizoxime, cefotaxime) PLUS 14 d PO Doxycycline 100 mg bid +/- Metronidazole 500 mg PO bid

30 PID Parental and oral therapy have similar efficacy in mild/moderate cases Suggested criteria for hospitalization: Cannot exclude appendicitis or other surgical emergency Pregnancy Inadequate response to PO Rx Unable to follow or tolerate PO Rx Severely ill, N/V, high fever, etc. TOA

31 Genital Ulcers In the U.S. most likely to be genital herpes or syphilis Other possiblities: Chancroid, syphilis Granuloma Inguinale Lymphogranuloma Venereum CDC: “All persons who seek evaluation and treatment for STDs should be screened for HIV infection. Screening should be routine, regardless of whether the patient is known or suspected to have specific behavioral risks for HIV infection.” Chancroid: Haemophilus ducreyi Rare in US; endemic in Africa Difficult to diagnose Gold standard = culture Special culture media required Sensitivity < 80% Presumptive dx by clinical criteria Painful genital ulcer(s) Typical appearance of ulcers and inguinal lymphadenopathy Negative test for syphilis and HSV LG: Klebsiella granulomatis Painless progressive ulcerative lesions without regional lymphadenopathy Lesions vascular and friable (beefy red) Dx requires visualization of dark-staining Donovan bodies on biopsy

32 Genital HSV U.S. statistics >50 million persons in the U.S. have genital HSV infection >1 million new cases occur each year 17% of adults aged affected Transmission HSV-2 is transmitted sexually (genital to genital, oral to genital, or genital to oral) and perinatally (mother to child) HSV-1 transmission is usually non-sexual; but sexual transmission is increasing CDC: 50 million persons in the U.S. have genital HSV infection. It is estimated that at least 1 million new cases occur each year. In the general U.S. population, 17% of adults aged years have HSV-2 antibodies. HSV-2 antibodies are not routinely detected until puberty, and then HSV-2 seroprevalence increases with age. HSV-2 seroprevalence is higher in women than men in all age groups and varies by race/ethnicity. The majority of persons infected with HSV-2 have not been diagnosed with genital herpes (86% in the general U.S. population). Transmission HSV-2 is transmitted sexually (genital to genital, oral to genital, or genital to oral) and perinatally (mother to child). HSV-1 is usually transmitted via a non-sexual route; however, sexual transmission appears to be increasing. The majority of genital herpes infections are transmitted by persons unaware that they have the infection or who are asymptomatic when transmission occurs. The risk of sexual transmission is difficult to quantify, but is estimated at >5% per year in

33 Genital HSV Primary (initial) infection
numerous bilateral painful lesions more severe, last longer, and have higher titers of virus than recurrent infections. papules  vesicles  pustules  ulcers  crusts  healed systemic symptoms Primary (initial) infection without treatment: characterized by the occurrence of numerous bilateral painful genital lesions. These lesions are more severe, last longer, and have higher titers of virus than recurrent infections. Typical lesion progression: papules  vesicles  pustules  ulcers  crusts  healed; though patients may present at any stage and lesions may be atypical (e.g., fissures). Often associated with systemic symptoms, including fever, headache, malaise, myalgia; may cause urinary retention in women. Illness lasts 2-4 weeks. Painful genital lesions that are numerous and bilateral last an average of days; full re-epithelialization takes an average of days. Systemic symptoms peak within 3-4 days of onset of lesions and gradually recede over the next 3-4 days Median duration of viral shedding detected by culture (from the onset of lesions to the last positive culture) is approximately 12 days, and correlates well with the mean time from the onset of vesicles to crusting.

34 Genital HSV Recurrent infection
Prodromal symptoms (localized tingling, irritation) hrs before lesions Recurrent infection without treatment Prodromal symptoms (localized tingling, irritation) are common and begin hours before lesions and sometimes occur without lesions ("false prodrome"). Duration of episodes is shorter than in primary infection: painful genital lesions last 4-6 days; average duration of viral shedding is 4 days. Lesions tend to be unilateral and much less extensive than with primary infection. Symptoms tend to be milder and less severe. Usually there are no systemic symptoms. Atypical presentations can occur, such as small linear ulcerations. Rate of cervical virus shedding during recurrences is 15-20%. Up to 90% of patients with symptomatic first episode HSV-2 infection will have a recurrence in the first 12 months of infection.

35 Genital HSV Culture is confirmatory test Type-specific serologic tests
Low sensitivity, esp. in recurrent lesions PCR more sensitive, not FDA-cleared Type-specific serologic tests Sensitivity 80-98%, Specificity ≥ 96% Routine screening not indicated Useful in the following scenarios: Recurrent genital symptoms or atypical symptoms with negative HSV cultures Clinical diagnosis of genital herpes without laboratory confirmation Partner with genital herpes Consider for persons requesting STD evaluation, and for HIV+ pts CDC: Clinical diagnosis is insensitive and nonspecific; therefore, the clinical diagnosis of genital herpes should be confirmed by laboratory testing.. The typical painful multiple vesicular or ulcerative lesions are absent in many infected persons. Up to 50% of symptomatic first-episode cases are caused by HSV-1 in some populations, but recurrences and subclinical shedding are much less frequent for genital HSV-1 infection than genital HSV-2 infection, therefore HSV serotype influences prognosis and counseling. There are 2 main types of lab tests used for confirmatory diagnosis: Virologic tests Type-specific serologic tests Both virologic and type-specific serologic tests for HSV should be available in clinical settings that provide care for patients with STDs or those at risk for STDs.

36 Genital HSV Treatment of initial episode
Systemic antivirals for 7-10 days Acyclovir, Famciclovir or Valacyclovir Use of topical antivirals discouraged Recurrent Infection Start tx within 1 day of lesion onset or during prodrome Suppressive Therapy Reduces frequency by 70-80% Decreases transmission While serologic assays from HSV-2 should be available for persons who request them, screening for HSV-1 or HSV-2 infection in the general population is not indicated. Acyclovir 400 mg PO TID, or 200 mg PO 5x/d Famciclovir 250 mg PO TID Valacyclovir 1g PO BID Suppressive Therapy QD Valacyclovir 500 mg Valacyclovir 1000 mg BID Acyclovir 400 mg Famcyclovir 250 mg

37 Genital HSV Patient counseling
Potential for recurrent episodes, asymptomatic viral shedding, risks of sexual transmission Inform current and future partners Abstain from sexual activity with uninfected partners when lesions or prodromal symptoms present Type-specific serologic testing recommended for asymptomatic partners HSV-2 seropositive persons are at increased risk for HIV acquisition if exposed to HIV Suppressive antiviral therapy does not reduce this risk

38 Genital HSV Pregnancy Women w/o genital herpes should abstain from intercourse during 3rd trimester w/ partners having known or suspected genital HSV Serologic testing is recommended for these women Daily suppression for patients w/ genital HSV begining at 36 weeks (ACOG recommendations) Acyclovir 400 mg PO TID (more data in pregnancy) or Valacyclovir 500 mg PO BID C-section for women with active lesions at onset of labor

39 Syphilis Primary Ulcer Secondary Rash, mucocutaneous, lymphadenopathy
Tertiary Cardiac, ophthalmic, auditory, gummas

40 Syphilis – Diagnosis Definative dx requires darkfield exam of lesion exudate or tissue Serologic tests can be used to make presumptive Dx Nontreponemal – VDRL, RPR Correlate with disease activity; should be reported quantitatively Low levels may persist Treponema pallidum Treponemal – FTA-ABS, TP-PA, EAIs Test will remain + in > 75% of pts treated for primary syphilis Must be + on both types of serologic tests to make dx

41 Syphilis - Rx Penicillin G
Primary, Secondary, Early Latent: Benzathine penicillin G 2.4 million units IM X1 Late latent, treatment failures, tertiary not neurosyphilis: Benzathine penicillin G 2.4 million units IM weekly X3 Neurosyphilis Aqueous crystalline PCN G million units per day for days Alternative: Procaine PCN 2.4 million units IM qd PLUS Probenecid 500mg po qid for days

42 Syphilis - Rx Special considerations
Partners exposed w/i 90 days of primary/secondary/ early latent syphilis should be treated presumptively Pregnant patients allergic to PCN should be skin tested and desensitized and treated w/ PCN

43 Human Papillomavirus (HPV)
> 100 types > 40 can infect the genital area Oncogenic, or high-risk types (e.g.16,18), cause cervical cancer Nononcogenic, or low-risk types (e.g. 6,11), cause genital warts and recurrent respiratory papillomatosis 14.1 million infections/year in the U.S. > 50% of sexually active persons are infected at least once Dx is usually clinical; can be confirmed by bx Genital warts Incidence may be as high as 100/100,000. An estimated 1.4 million may be affected at any one time. Cervical cancer Rates of cervical cancer have fallen by approximately 75% since the introduction of Pap screening programs. Incidence is estimated at 8.1/100,000.

44 HPV Clinical manifestations of infection: Genital warts
Cervical cellular abnormalities detected by Pap tests Some anogenital squamous cell cancers Some oropharyngeal cancers Recurrent respiratory papillomatosis Most infections are transient, asymptomatic or subclinical, and have no clinical consequences in immunocompetent individuals. Time to development of clinical manifestations is unclear, but most likely 3 weeks to months for genital warts, Several months to years for cervical cellular abnormalities, and Decades for cervical cancers. The median duration of new cervical infections (measured by detection of HPV DNA) is 8 months, but varies. 70% of new infections clear within 1 year. 90% of new infections clear within 2 years. The gradual development of an effective immune response is thought to be the likely mechanism for HPV DNA clearance.

45 HPV Prevention Two HPV vaccines are licensed in the US:
Cervarix® – types 16, 18 Gardasil® – types 6, 11, 16, 18 Indicated in 9 – 26 y/o CDC recommends first dose at age years Only Gardasil® has male indication Condoms may reduce risk but not fully protective Types 16 and 18 cause 70% of cervical cancers. types 6 and 11 cause 90% of genital warts. The Advisory Committee on Immunization Practices (ACIP) recommends that if the vaccination series is interrupted for any length of time, it can be resumed without restarting the series. HPV vaccination is not currently recommended for women over age 26 years. Clinical trials showed that, overall, HPV vaccination offered women limited or no protection against HPV-related diseases. For women over age 26 years, the best way to prevent cervical cancer is to get routine cervical cancer screening, as recommended.

46 HPV Treatment Goal is alleviation of symptoms; tx does not lower risk of transmission or development of malignancy Treatment method is guided by preference of the patient, available resources, and experience of the provider In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment Most genital warts respond within 3 months of therapy Recurrence common after tx, especially in first 3 mos Types 16 and 18 cause 70% of cervical cancers. types 6 and 11 cause 90% of genital warts. The Advisory Committee on Immunization Practices (ACIP) recommends that if the vaccination series is interrupted for any length of time, it can be resumed without restarting the series. HPV vaccination is not currently recommended for women over age 26 years. Clinical trials showed that, overall, HPV vaccination offered women limited or no protection against HPV-related diseases. For women over age 26 years, the best way to prevent cervical cancer is to get routine cervical cancer screening, as recommended.

47 HPV Patient-applied Wash w/ soap & water 6-10 hrs after application
Podofilox 0.5% solution/gel applied w/ cotton swab bid x 3d followed by 4d of no tx; repeat up to 4 cycles Imiquimod 5% cream QHS 3x per week for up to 16 weeks. Wash w/ soap & water 6-10 hrs after application Sinecatechins 15% ointment Safety in pregnancy not established (all 3) Provider-applied Cryotherapy every 1-2 weeks Podophyllin resin 10-25% in a compound tincture of benzoin TCA (or BCA) 80-90% solution weekly Surgical removal (sharp, currette, or laser) Intralesional interferon Available therapies for genital warts likely reduce, but probably do not eradicate, HPV infectivity. Whether the reduction in HPV viral DNA resulting from treatment reduces future transmission remains unclear No definitive evidence suggests that any of the available treatments are superior to any other, and no single treatment is ideal for all patients or all warts. Pdofilox: The total wart area treated should not exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day. If possible, the health-care provider should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated. Mild to moderate pain or local irritation might develop after treatment. The safety of podofilox during pregnancy has not been established. Imiquimod is a topically active immune enhancer that stimulates production of interferon and other cytokines. Sinecatechin ointment, a green-tea extract with an active product (catechins), should be applied three times daily (0.5-cm strand of ointment to each wart) using a finger to ensure coverage with a thin layer of ointment until complete clearance of warts. This product should not be continued for longer than 16 weeks (409–411). The medication should not be washed off after use. Sexual (i.e., genital, anal, or oral) contact should be avoided while the ointment is on the skin. Podophyllin resin 10%–25% should be applied to each wart and allowed to air-dry before the treated area comes into contact with clothing Both TCA and BCA are caustic agents that destroy warts by chemical coagulation of proteins. Although these preparations are widely used, they have not been investigated thoroughly. TCA solutions have a low viscosity comparable with that of water and can spread rapidly if applied excessively; therefore, they can damage adjacent tissues. A small amount should be applied only to the warts and allowed to dry before the patient sits or stands, at which time a white frosting develops. If pain is intense, the acid can be neutralized with soap or sodium bicarbonate. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate (i.e., baking soda), or liquid soap preparations to remove unreacted acid Surgical therapy has the advantage of usually eliminating warts at a single visit. However, such therapy requires substantial clinical training, additional equipment, and a longer office visit. After local anesthesia is applied, the visible genital warts can be physically destroyed by electrocautery, in which case no additional hemostasis is required. Care must be taken to control the depth of electrocautery to prevent scarring. Alternatively, the warts can be removed either by tangential excision with a pair of fine scissors or a scalpel, by laser, or by curettage. Because most warts are exophytic, this procedure can be accomplished with a resulting wound that only extends into the upper dermis. Hemostasis can be achieved with an electrocautery unit or a chemical styptic (e.g., an aluminum chloride solution). Suturing is neither required nor indicated in most cases if surgical removal is performed properly. Surgical therapy is most beneficial for patients who have a large number or area of genital warts. Both carbon dioxide laser and surgery might be useful in the management of extensive warts or intraurethral warts, particularly for those persons who have not responded to other treatments.

48 HPV Recommended Regimens for Vaginal or Anal Warts
Cryotherapy with liquid nitrogen or TCA Avoid Imiquimod, sinecatechins, podophyllin, and podofilox in pregnancy Rarely, HPV types 6 and 11 can cause respiratory papillomatosis in infants and children, although the route of transmission (i.e., transplacental, perinatal, or postnatal) is not completely understood. Whether cesarean section prevents respiratory papillomatosis in infants and children also is unclear; therefore, cesarean delivery should not be performed solely to prevent transmission of HPV infection to the newborn. Cesarean delivery is indicated for women with genital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding.

49 Hepatitis B Half symptomatic
Sx include jaundice, fatigue, mild fever, nausea, vomiting, abdominal pain, and dark urine 1% acute liver failure 2-6% result in chronic hepatitis (up to 25% mortality) Transmission percutaneous or mucous membrane exposure to body fluids that contain blood Vertical (birth), horizontal (premastication) risk factors: unprotected sex, multiple partners, MSM, history of other STDs, illegal injection-drug use

50 Hepatitis B No specific therapy for acute hepatitis B
Focus is on prevention hepatitis B immune globulin (HBIG) provides temporary (3–6 mo) protection from HBV infection hepatitis B vaccine

51 Hepatitis B CDC national strategy to eliminate HBV transmission
Prevention of perinatal infection routine screening of all pregnant women for HBsAg immunoprophylaxis of infants born to HBsAg + mothers or mothers with unknown status Routine infant vaccination Vaccination of unvaccinated children through 18 y/o Vaccination of previously unvaccinated adults at increased risk for infection

52 Hepatitis C Most common chronic blood-born infection in US
May be asx of have mild sx Chronic HCV infection develops in 70%–85% of HCV-infected persons; 60%–70% of chronically infected persons develop evidence of active liver disease. Transmission parenteral exposure to contaminated blood not efficiently transmitted sexually vertical Screening for Hep C: Anyone in the United States born between 1945 and 1965 Those with a history of illicit injection drug use or intranasal cocaine use, even if only used once Those who received clotting factors made before 1987 Those who received blood/organs before July 1992 Those who have been informed that they received blood from a donor who later tested positive for HCV Those who were ever on chronic hemodialysis Those with evidence of liver disease (persistently elevated alanine aminotransferase [ALT] level) Those infected with HIV Children born to HCV-infected mothers Those with a needle stick injury or mucosal exposure to HCV-positive blood Those who are a current sexual partner of an HCV-infected person Incarcerated individuals

53 Hepatitis C Prevention No vaccine No immune globulin prophylaxis
Condoms advise for anyone with more than one partner especially important for HIV-infected men may not be necessary in monogomous heterosexual partner-pairs Routine testing in pregnancy is not recommended Treatment Specialist referral - pegylated interferon and ribavirin

54 Pediculosis Pubis (Pubic Lice)
Usually transmitted by sexual contact Recommended Regimens Permethrin 1% cream rinse wash off after 10 min Pyrethrins w/ peperonyl butoxide wash off after 10 minutes Alternative Regimens Malathion 0.5% lotion apply for 8-12 hrs then wash off Ivermectin 250 mcg/kg repeat in 2 weeks Wash and heat dry bedding, linen Evaluate for other STDs Partners should be treated Permethrin ok for pregnant patients

55 Scabies Usually sexually acquired in adults (not so in children)
Recommended RX Permethrin cream 5% applied to all areas of body from neck down & washed off after 8-14h Ivermectin 200 mcg/kg PO, repeat in 2 wks Alternative RX Lindane 1% 1oz of lotion or 30 g cream applied to all areas from neck down & washed off after 8h Wash & dry bedding, clothing Rash may persist for up to 2 weeks after Rx Examine and treat sexual/household contacts Lindane is not recommended as first-line therapy because of toxicity; should not be used immediately after a bath or shower, and it should not be used by persons who have extensive dermatitis, women who are pregnant or lactating, or children aged <2 years. Permethrin for pregnant patients

56 Screening in Sexual Assault
GC and Chlamydia (NAAT); collect specimens from any site of attempted penetration Wet mount and culture of vaginal swab for Trichmonads If + vaginal discharge examine for BV and candida also Serum for HIV, Hep B, and syphilis (RPR/VDRL) Treat impiracally for Chlamydia, GC, Trich, BV; give Hep B vaccine for susceptible pts Follow up… Repeat exam for STIs in 1-2 weeks if prophylactic Rx was not given or if patient has symptoms Repeat HIV and RPR/VDRL at 6 wks, 3 mo, and 6 mo F/U Hep B vaccine 1-2 and 4-6 months Prophylactic therapy Emergency contraception in at-risk patients Empiric tx for Chlamydia, GC, Trich, BV: Ceftriaxone 250 mg IM x1 or cefixime 400mg po x1 Metronidazole 2 g PO x1 Azithro 1g PO x1 or Doxycyline 100 mg PO bid x7d HIV prophylaxis of unproven benefit but should be discussed

57 Screening in Pregnancy
Ask all about STD hx, symptoms, and risk factors Screening tests for all pregnant pts: HIV early in pregnancy* (opt-out screening) Syphilis at the first prenatal visit* Hepatitis B (HBsAg) early in pregnancy even if they have been previously vaccinated or tested Retest at the time of admission for delivery if + high risk behaviors or clinical hepatitis* Pregnant women at risk for HBV infection also should be vaccinated Chlamydia trachomatis during the 1st prenatal visit Retest in 3rd trimester if ≤25 y/o, increased risk for chlamydia, and those with + 1st trimester screening High risk behaviors for HBV = having had more than one sex partner in the previous 6 months, evaluation or treatment for an STD, recent or current injection-drug use, and an HBsAg-positive sex partner. Increased risk for chlamydia = women who have a new or more than one sex partner Rapid HIV test in labor if undocumented HIV status Evidence does not support routine testing for bacterial vaginosis (BV), Trichomonas vaginalis , or HSV-2 in pregnancy. * Some states (including TX) require repeat screening in 3rd trimester or at delivery

58 Screening in Pregnancy
Consider screening for: Neisseria gonorrhoeae for women at risk for gonorrhea or living in an area where prevalence is high Test at first prenatal visit Retest in 3rd trimester if + in 1st trimester or pt at high risk Hepatitis C at the first prenatal visit if high risk High risk behaviors for HBV = having had more than one sex partner in the previous 6 months, evaluation or treatment for an STD, recent or current injection-drug use, and an HBsAg-positive sex partner. Increased risk for chlamydia = women who have a new or more than one sex partner Rapid HIV test in labor if undocumented HIV status High risk for gonorrhea: aged <25 years, previous gonorrhea infection, other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use. High risk for hepatitis C infection = those with a history of injection-drug use and those with a history of blood transfusion or organ transplantion before 1992 Evidence does not support routine testing for bacterial vaginosis (BV), Trichomonas vaginalis , or HSV-2 in pregnancy.

59 Thank you!

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