Current Concepts: STI

Current Concepts:

Diagnosis and Treatment of STI

JAMA 1/11/2022

Multiple Choice

Which of these has no cure?

• Gonorrhea

• Herpes

• Syphillis

• Trichomonas

​2015 to 2019 gonorrhea, chlamydia, syphilis increased in the US; while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. 

• Populations with higher rates of STIs:  <25yo,  sexual and gender minorities, racial and ethnic minorities 

• 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms

• Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis

antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.

Gonorrhea

• Epidemiology:  Rates highest in Black, people aged 20 through 24 years, southern US 

• Presentation: may infect the oropharynx, rectum, eye, and urogenital tract

  • 86.4% to 92.6% of urogenital infections among women with gonorrhea may be asymptomatic

  • Urethritis (dysuria, discharge, pruritus), PID, conjunctivitis in infants, pharyngitis, proctitis, disseminated (81% purulent arthritis, 19% triad of tenosynovitis, dermatitis, polyarthralgia) 

• Testing: NAATs (vaginal swab or clean catch urine)

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Multiple Choice

Which of these antibiotics have the highest resistance for gonorrhea?

• Ceftriaxone

• Ciprofloxacin

• Gentamicin

• Azithromycin

​Treatment and prevention: 

• 2019 based on 5480 samples from CDC, 35.4% were resistant to ciprofloxacin, 5.1% to azithromycin, and less than 0.5% to cephalosporins or gentamicin.

• Currently, recommended treatment in the US consists of 500 mg of intramuscular ceftriaxone 

• single dose of 5 mg/kg of parenteral gentamicin combined with 2 g of oral azithromycin

• Pharyngeal infection: ceftriaxone only, retest NAAT win 1-2 weeks

•  All sex partners within 60 days prior to an index patient’s diagnosis with gonorrhea should be treated presumptively

CHlamydia

​D through K serovars of Chlamydia trachomatis and is the most common notifiable STI in the US

Epidemiology:  2:1 women:men (because screening recommendations focus on women),  highest among young women aged 20 through 24 years, 5.6 times higher in people who are Black, highest in southern US

• LGV caused by the L1 through L3 serovars (ie, antigenic type) of Chlamydia trachomatis that has emerged predominantly in populations of men or transgender women who have sex with men, with outbreaks of rectal disease reported in the US and other high-income countries

Fill in the Blanks

​Presentation: oropharynx, rectum, eye, and the urogenital tract of both men and women.Pulmonary infections may occur in infants

• 70% of urogenital infections in women, more than 80% of urogenital infections in men, and more than 90% of rectal and pharyngeal infections are asymptomatic

• urethritis (dysuria, discharge), cervicitis (mucopurulent discharge), PID, epididymitis (fever, testicular pain), or proctitis (rectal pain, discharge, and bleeding). Rare complications :  perihepatitis (Fitz-HughCurtis syndrome) and reactive arthritis. Infants may acquire chlamydia during vaginal delivery, resulting in conjunctivitis or pneumonia.

• LGV stages:  painless, transient ulcer → 2 to 6 weeks later, large and tender inguinal lymph nodes (30% of these lymph nodes spontaneously perforate) → if the infection is untreated, scarring from chronic lymphadenitis, which may lead to lymphedema and genital elephantiasis.

  • . In patients with rectal exposure, the secondary stage primarily consists of proctitis or proctocolitis, with histological findings that may be indistinguishable from inflammatory bowel disease.

​Treatment and Prevention:

• 100 mg of doxycycline orally twice daily for 7 days.15 Alternative regimens: 1 g of azithromycin or 500 mg of levofloxacin once daily for 7 days

• All sex partners within the last 60 days of an individual’s chlamydia diagnosis should be treated presumptively (100mg BID doxy for 7 days)

• First-line treatment for LGV is doxycycline. Severe dz (21 days). Mild (7 days)

​SYPHILLIS

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​Epidemiology:  

• 2019: 38,992 patients were diagnosed with primary or secondary syphilis, an increase of 11.2% from 2018

• Men and transgender women who have sex with men make up 56.7% of diagnosed cases of primary or secondary syphilis

Higher among Black, western states, people with HIV (7.1% prevalence among MSM with HIV and 3.4% prevalence among MSM without HIV)​

Testing/ Screening:

• treponemal test (T pallidum particle agglutination assay (TPPA)) to establish the diagnosis of syphilis 

• rapid plasma reagin (RPR) or VDRL tests can be used to monitor disease activity. 

  • A titer decline of at least 4-fold is required after antibiotic therapy to indicate successful treatment at 12 months for early syphilis and at 24 months for late syphilis​

Treatment/ Prevention: 

• Penicillin 2.4 million units of long-acting benzathine penicillin G as a single intramuscular dose is optimal for early stage syphilis (primary and secondary syphilis and early latent syphilis)

• 2.4 million units administered intramuscularly weekly for 3 consecutive weeks is recommended for late latent syphilis.

• alternate therapy is 100 mg of oral doxycycline twice daily for 14 to 28 days. 

• In pregnancy, penicillin is the only recommended therapy. 

• Patients who are allergic to penicillin may require penicillin desensitization

•  Jarisch-Herxheimer reaction: fevers and chills, can occur as a result of inflammatory cytokine release and should not be confused with a penicillin allergy

• Sexual contacts of people with early syphilis require treatment with 2.4 million units of benzathine penicillin G intramuscularly.

• Neurosyphilis, ocular syphilis, and otic syphilis: 18 to 24 million units of intravenous aqueous crystalline penicillin G daily for 10 to 14 days

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Mycoplasma Genitalium

New, not notifiable STI yet

Clinical presentation: 30-40% have recurrent urethritis. Dysuria, penile irritation, urethral discomfort. In women: cervicitis, post-coital bleeding, painful periods, lower abd pain 

Testing: NAATs for testing urine and for swabs of the urethra, penile meatus, endocervix and vagina

Treatments: CDC guidelines recommend sequential treatment with 100 mg of doxycycline orally twice daily for 7 days followed by 400 mg of moxifloxacin orally once daily for 7 days - - Partners in the preceding 60 days should be treated using the same regimen

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Genital Herpes

HSV 2 - mostly anogenital      HSV 1 mostly orolabial

Epidemiology: prevalence have been declining 

• seroprevalence HSV-2 highest among non-Hispanic Black people (34.6%), Mexican American people (9.4%), non-Hispanic White people (8.1%), and Asian people (3.8%)

• People aged 40 through 49 years had 21.2% seroprevalence vs 0.8% among those aged 14 through 19 years

• women had a seroprevalence of 15.9% vs 8.2% in men

• 25%  HSV-1 in 15-49 yo are genital, 85% are presumed due to oral-genital transmission 

• Preexisting HSV-2 infections may provide some protection against acquiring new HSV-1 infections, whereas preexisting HSV-1 infections may decrease the probability of new symptomatic HSV-2 infections

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​Clinical presentations:

• 70% asymptomatic 

•  4-7 days incubation,symptoms: painful (95%-99%), bilateral (77%-82%), erythematous lesions that may progress through papular, vesicular, and ulcerative stages

• Lesions lastsf 16.5 to 19.7 days but may persist for weeks. Headache, fever, and lymphadenopathy occur in 39% - 68% of patients during the initial infection

• Symptoms of recurrent infections are less severe and often resolve within 5 to 10 days

• More complex presentations: meningitis, encephalitis, urinary retention

Multiple Choice

28 yo F comes to you at 37 weeks gestation with painful vesicles on her vulva. No prior history of such lesion, you make the presumptive diagnosis of genital herpes.

Of the following, the most specific and sensitive test is __

• Tzanck Test

• PCR TEST

• ELISA

• HSV Serology (IgG/IgM)

​Testing and Screenings:

• NAATs on swabs from lesions have a sensitivity of 96.7% to 100%

• When lesions are absent, serological testing can be used to detect IgG antibodies to the glycoprotein-G type–specific antigen (detectable 2 weeks to 3 months following initial infection)

• Routine screening is not recommended

Treatment and Prevention: 

• Oral and parenteral antivirals are available (acyclovir, valacyclovir, or famciclovir), but none cure the HSV infection

• In patients with primary infection, the initial 10-day course of antiviral therapy can be extended by 1 week if lesions persist

• pregnant women with hx of symptomatic recurrences, consider suppressive therapy with acyclovir at 36 weeks

Multiple Choice

A 52yo F sees you because of vaginal discharge. An examination reveals a mal-odorous, greenish yellow, frothy discharge and inflammation of the cervix and vagina.

Which of the following is the most likely diagnosis?

• atrophic vaginitis

• irritant vaginitis

• bacterial vaginosis

• trichomoniasis

• vulvovaginal candidiasis

Trichomonas

Epidemiology: most common non-viral STI. Prevalence higher among black women, women with HIV. Prevalence is similar or higher in older women >40 and is rare among transgender or MSM. 

Presentations: asymptomatic in approximately 85% of women and 77% of men

• causes urethritis, epididymitis, or prostatitis in men: dysuria and urethral discharge. 

• can infect the vagina, urethra, endocervix, and Skene and Bartholin glands in women → dysuria, vaginal discharge, and vaginal or vulvar irritation. 

• Coplitis macularis or “strawberry cervix” : 5% of infected women

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​Testing and screening: NAATs are the preferred and most sensitive diagnostic tests are FDA cleared for testing on vaginal, endocervical, or urine samples in women. Wet mount has 51-65% sensitivity for vaginal specimens. PAP is 61% sensitive. Rapid antigen test has 82-90% sensitivity. 

• Annual screening recommended for women with HIV​

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Treatment: First-line 2g single dose of oral metronidazole in men and 500 mg of oral metronidazole twice daily for 7 days for women. If refractory, can try higher doses or tinidazole

USPSTF Recommendations

Grade A recommendation:

• Prophylactic ocular topical medication for all newborns to prevent gonococcal opthalmia neonatoum

• Screening for syphilis for all pregnant women

Grade B recommendation

• screen chlamydia and gonorrhea in sexually active women <24yo or high risk women >25yo. (insufficient evidence for screening men)

• Recommends behavioral counseling in all sexually active adolescent and adults who are at risk for STIs

Recommends against routine screening for genital HSV in asymptomatic adolescents and adults

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