Click Here to Listen to the Podcast on Soundcloud
Click Here to Download the Podcast's Audio File
Click Here to Download the Outline File
Click Here to Download the Podcast's Audio File
Click Here to Download the Outline File
Chlamydia, Gonorrhea, Trichomonas, Syphilis, Mycoplasma
1.
General Principles of Treatment
a.
Goals include resolution of symptoms, decrease
in transmission to other individuals, and prevention of infection-related
complications
b.
Observed therapy is better than not-observed
therapy
c.
Expedited partner therapy is legal in nearly all
50 states
d.
Most of the infections are required to be
reported to public health authorities
2.
Chlamydia
a.
C. trachomatis, Bacteria
b.
Most common cause of bacterial STI in men and
women
c.
May cause Cervicitis, Endometritis, PID/TOA,
Proctitis, Epididymitis
i. Long-term
sequelae include scarring, chronic pelvic pain, infertility, ectopic pregnancy
ii. Pregnancy:
Associated with PROM, PTB, Vertical conjunctivitis
d.
Testing
i. Frequently
in pregnancy (New OB and third trimester at a minimum)
ii. Generally
performed (or at least offered) annually at GYN visits
1.
May be more frequently performed in high-risk
persons
iii. Most
common testing is nucleic acid amplification testing (NAAT)
e.
Treatment
i. First
Line
1.
Azithromycin 1g PO once
a.
Preferred in pregnancy
2.
Doxycycline 100mg PO BID x7d
ii. Alternative
Regimens
1.
Quinolones (Ofloxacin and Levofloxacin)
a.
Should not be used in pregnancy, breastfeeding,
or for adolescents <18yo 2/2 concerns for bone abnormalities
2.
Erythomycin, Penicillin
a.
Used in pregnancy when the patient cannot
tolerate Azithromycin
b.
Significantly lower cure rate than other
regimens
f.
Test of Cure Vs Testing for Reinfection
i. Test
of Cure
1.
A test of cure is when testing is performed
after treatment to see if the patient has been treated adequately
ii. Testing
for Reinfection
1.
Testing to see if the patient has infected a
second time after having received successful treatment
iii. A
positive test of cure could mean either inadequate treatment or reinfection
iv. TOC
is generally performed on:
1.
Pregnant Patients
2.
Patients who received a sub-optimal treatment
regimen
3.
Patients with persistent symptoms
v. Test
of Reinfection is generally performed on:
1.
Anyone at risk of reinfection (realistically
this is everyone who had previously been infected)
vi. Because
the test is DNA-based, you must wait a minimum of 3 weeks to assess treatment
success
3.
Gonorrhea
a.
N. gonorrhoeae, Bacteria
b.
Common cause of urethritis, cervicitis,
endometritis, PID/TOA, epididymitis, proctitis
i. Other
than urogenital/anogenital infections, may also be pharyngeal and ocular.
ii. Pregnancy:
Associated with chorioamnionitis, PROM, PTB, LBW, SAb, conjunctivitis
c.
Testing
i. In
general, the same as Chlamydia, including for retesting and tests of cure
d.
Treatment
i. Dual
Treatment
1.
Uncomplicated gonorrhea is demonstrating
increasing resistant rates to ceftriaxone
a.
Ceftriaxone was formerly used as a single agent
treatment, but there are currently no preferred single agent treatments
ii. First
line
1.
Ceftriaxone 250mg IM once
2.
Plus either
a.
Azithromycin 1g PO once [Preferred]
b.
Doxycycline 100mg BID PO x7d
iii. Alternative
Regimens
1.
Severe PCN allergy
a.
Azithromycin 2g PO once
b.
Plus either
i. Gemfloxacin
320mg PO once
ii. Gentamicin
240mg IM once
iii. Spectinomycin
2g IM
1.
Least effective, poor treatment of pharyngeal
infections
2.
Recommended to have TOC
2.
Ceftriaxone unavailable
a.
Azithromycin or Doxycycline
b.
Plus either
i. Ceftizoxime
500mg IM once
ii. Cefoxitin
2g IM w/ probenecid PO 1g once
iii. Cefotaxime
500mg IM once
iv. Cefixime
400mg PO
1.
Less effective for pharyngeal infections
e.
Test of Cure or Testing for Reinfection
i. Same
as Chlamydia
4.
Trichomonas
a.
T. vaginalis, Protozoan
b.
Most common non-viral STI, with women more
likely affected than men.
i. Women
can transfer infection to other women, but men typically do not transfer to other
men
c.
Often can be asymptomatic urogenital infections,
but can also range in severity to an acute, inflammatory infection with
malodorous, purulent, often thin, discharge.
d.
Pregnancy: Associated with PROM, PTB, LBW
infants
e.
Testing
i. Wet
mount visualization of trichomonads
1.
Usually also see PMNLs and elevated pH >4.5
ii. NAAT
testing
iii. Sometimes
reported as an incidental finding on cervical cytology
iv. Screening
is reasonable for at-risk women
1.
HIV-infected women are recommended screening
annually and at initial prenatal visit.
v. Screening
is not recommended for men.
f.
Treatment
i. Recommended
in any patient with infection, regardless of symptoms.
ii. 5-nitroimidazole
is the only class of drugs available
1.
Metronidazole 2g PO once (cheaper)
2.
Tinidazole 2g PO once (better tolerated with
fewer GI side effects)
iii. Allergy
to 5-nitroimidazole medications
1.
Severe allergies need to be admitted for
desensitization
iv. Single
dose vs Multi dose therapy
1.
Single dose has better compliance, decreased
candida infections
2.
Multi dose has longer period of alcohol
avoidance, less side effects, and slightly lower treatment failure rates
3.
Patient with HIV should received metronidazole
500mg PO BID x7d as they are higher risk of treatment failure with single dose
treatment
g.
Test of Cure and Testing for Reinfection
i. Same
as Gonorrhea/Chlamydia
5.
Syphilis
a.
T. pallidum, Bacteria
b.
Common infection globally, but nationally rates
have been increasing in recent years in all regions
i. Patient
with HIV, MSM
c.
Infection is generally mucocutaneous, but may
also be transmitted vertically
d.
Syphilis Stages
i. Early
vs Late
1.
Early: Primary, Secondary, and Early Latent Syphilis
a.
Within weeks to months of initial infection
2.
Late: Late Latent or Tertiary Syphilis
a.
A patient can present with late syphilis without
prior symptoms of early syphilis
ii. Primary
1.
Chancre
a.
Local skin lesion, begins as a papule and is
typically painless, then ulcerates to become a 1-2cm ulcer with a raised,
indurated margin
b.
Heals spontaneously after ~1 month
iii. Secondary
1.
Occurs in 25% of individuals with untreated
primary syphilis
a.
Can present multiple times, names relapsing
secondary syphilis
2.
Caused by immune response to widespread
spirochete infection
3.
Systemic symptoms of fever, headache,
maculopapular rash (includes palm/soles), malaise, alopecia, lymphadenopathy
(minimally tender), elevated LFTs/Cr, GI ulcerations, CN deficits,
meningovascular disease, meningitis
a.
Patients with HIV may have a severe ulcerative
form termed lues maligna
iv. Latent
1.
Asymptomatic
2.
Early Latent: Asymptomatic but still <1yr
since infection
v. Tertiary
1.
May be 1-30 years after initial primary
infection
2.
Caused by immune response to widespread
spirochete infection
3.
Manifestations
a.
Cardiovascular: Vasculitis of the vasa vasorum
results in a dilated aorta and aortic valve regurgitation, producing a left
heart failure
b.
Gummas: Lesions described by a firm necrotic center
surrounded by inflamed tissues, sometimes appearing granulomatous, which may
appear on skin, bones, internal organs.
c.
Neurosyphilis:
i. General
paresis (progressive dementia)
ii. Tabes
dorsalis (disease of the posterior columns of the spinal cord and dorsal roots)
1.
Absent LE reflexes, impaired vibratory and
position sensation, ataxia. Inability to sense or feel LEs
2.
Argyll-Robertson pupil (pupil is small and
constricts to accommodation but not to light
3.
Positive Romberg sign (swaying or falling if
eyes closed when standing upright with feet together)
vi. Pregnancy
1.
Vertical Transmission
a.
T. pallidum easily crosses the placenta
b.
Transmission increases with
i. Greater
gestational age, but severity of fetal infection decreases with later
gestational age
ii. Shorter
duration of maternal infection
iii. Lack
of treatment
2.
Manifestations
a.
Associated with perinatal death, PTB, LBW
b.
Congenital Syphilis
i. Early
(onset <2yo)
1.
Hepatomegaly, jaundice
2.
Nasal discharge (snuffles)
3.
Rash/lymphadenopathy
4.
Skeletal abnormalities – pathologic fractures,
limitations of limb movements, ‘moth-eaten’ appearance from irregularities in
bone densities, and irregular new bone formation
5.
Pneumonia alba – pneumonia characterized by
complete opacification of bilateral lung fields on CXR
ii. Late
(onset >2yo)
1.
Skeletal: ‘Saber shins’ due to anterior bowing, Frontal
bossing, saddle nose, Hutchinson teeth (hypoplastic, widely spaced), mulberry
molars (maldevelopment of cusps of first molars), hard palate perforation
2.
Neuro/Ocular: Interstitial keratitis (corneal
scarring) and sensorineural hearing loss (these two findings often appear
together and around 8-10yo), intellectual disability, CN palsies
3.
Gummas
e.
Testing
i. Screening
should be performed in
1.
Pregnant women, in prenatal battery and often
repeated
2.
High risk of infection: Partner w/ syphilis,
MSM, HIV, other STIs, multiple sex partners, incarceration, exchange sex for
drugs/money
ii. Tests
1.
Two types of serologic tests: treponemal and
non-treponemal.
2.
Non-Treponemal:
a.
RPR, VDRL, TRUST
b.
Results reported as a titer, marking the level
of antibody and activity of the infection. Titers wane over time, but decrease
more quickly with treatment.
3.
Treponemal:
a.
FTA-ABS, MHA-TP, TPPA, TP-EIA, CIA
b.
Detect antibodies specific to treponemal
antigens
i. More
specific than non-treponemal tests
ii. Tests
likely to be positive for life and therefore do not help diagnose reinfection
4.
Other
a.
Direct visualization on microscopy and DNA
testing are possible but infrequently performed due to limitations of cost,
equipment required, and accuracy
5.
Testing Algorithms
a.
Initial screening with a non-treponemal test
i. If
a high clinical suspicion but negative testing, it is recommended to repeat
testing in 2-4wks
b.
Initial screening with a treponemal test
i. Higher
false positive rate, but higher specificity
1.
More likely to diagnose very early syphilis,
those who have had prior treatment, and those with latent or late latent
syphilis whose titers have decreased over time
f.
Treatment
i. Penicillin-G
is treatment of choice for all stages of syphilis
1.
Continuous, prolonged levels are necessary to
treat infection
2.
Treatment is based upon syphilis stage
a.
Early Syphilis:
i. Penicillin-G
2.4m U IM Once
b.
Late Latent Syphilis, Asymptomatic patients who
are unsure when they became infected, and Tertiary Syphilis:
i. Penicillin-G
2.4m U IM weekly x3 doses
ii. Those
with tertiary syphilis should receive LP to ensure they do not have
neurosyphilis
c.
Neurosyphilis:
i. Penicillin-G
3-4m U IV q4h x10-14d
ii. IM
doses do not effectively enter the CSF. These patients should receive IV
therapy.
3.
Alternative regimens
a.
Early Syphilis:
i. Doxycycline
100mg PO BID x14d
ii. Tetracycline
500mg PO QID x14d
iii. Ceftriaxone
1-2g IM/IV QD x10-14d
iv. Azithromycin
2g PO once
1.
Use extremely limited by resistance
b.
Late Latent Syphilis, Asymptomatic patients who
are unsure when they became infected, and Tertiary Syphilis:
i. Doxycycline
100mg PO BID x28d
ii. Ceftriaxone
2g IM/IV QD x10-14d
c.
Neurosyphilis
i. Procaine
Penicillin 2.4m U IM QD x10-14d Plus Probenecid 500mg PO QID x10-14d
ii. Ceftriaxone
2g IV QD x10-14d
d.
Pregnancy w/ a severe PCN allergy
i. Admission
for penicillin desensitization
ii. Jarisch-Herxheimer
Reaction
1.
Acute febrile reaction w/ HA and myalgias due to
lysing of the treponemes and immune response to this
6.
Mycoplasma Genitalium
a.
M. genitalium
b.
Causes non-gonococcal urethritis in men, and
cervicitis and PID in women, can cause purulent discharge or increased PMNs/hpf
on microscopy
c.
Testing
i. NAATs
are only clinically useful method but not widely available – can be performed
on symptomatic patients if available
ii. Lacks
cell wall and therefore not seen on Gram staining, and grows slowly so
culturing is unfeasible
d.
Treatment
i. Azithromycin
1g PO once (preferred)
ii. Doxycycline
100mg PO BID x7d
e.
Persistent/Recurrence
i. Retesting
can be performed, or if azithromycin was not part of original therapy, can trial
azithromycin first
Comments
Post a Comment