Sexually transmitted diseases

From WikEM
Jump to: navigation, search

Background

  • STD Prevalence: HPV> HSV-2 > Trichomonas > Chlamydia > HIV > HBV > Gonorrhea > Syphillis
  • STD New infections: HPV > Chlamydia > Trichomonas > Gonorrhea > HSV-2 > Syphillis > HIV > HBV [1]
  • It is important to treat sexual partners for all STDs

Visual Diagnosis

Bacterial Vaginosis

First Line Therapy[2]

  • Metronidazole 500 mg PO BID for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally qHS for 7 days

Alternative Regimin

  • Tinidazole 2 g PO qd for 2 days OR
  • Tinidazole 1 g PO qd for 5 days OR
  • Clindamycin 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hrs)

Pregnant

Prophylaxis (Sexual Assault)


Cervicitis/Urethritis

treatment cover gonorrhea and chlamydia jointly

  • Male: Urethritis with discharge or simply dysuria
  • Female: purulent discharge

Uncomplicated Infection

Partner treatment

Cephalosporin Allergy

  • Azithromycin 2g PO once PLUS
    • Gentamicin 240mg IM once[4]
    • In theory this high dose macrolide will provide treatment for both GC and Chlamydia

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

Pregnant

  • Only treat if the patient is symptomatic and avoid breast feeding until 24hrs after last Metronidazole treatment and 72hrs after Tinidazole
  • Metronidazole 2g PO once[5]

Sexual Partner Treatment

Women with HIV Infection

  • Metronidazole 500 mg PO BID x 7 days[6]


Epididymitis/Epididymorchitis

  • For acute epididymitis likely caused by STI
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

Treat sexual partner if possible


GC/Chlamydia Conjunctivitis

Chlamydial

  • Doxycycline 100mg BID for 7 days OR
  • Azithromycin 1g (20mg/kg) PO one time dose
  • Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days
    • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

  • Dual treatment for Chlamydia is recommended with azithromycin
  • Ceftriaxone 1g IM one dose PLUS
  • Azithromycin 1g PO one dose
  • Newborn Treatment:
    • Prophylaxis: Erythromycin ophthalmic 0.5% x1
    • Disease manifests 1st 5 days post delivery (early onset)
    • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg


Herpes

Initial Episode[7]

Recurrence[7]

  • Acyclovir OR
    • 400mg PO q8hrs x 5 days
    • or 800mg PO q12hrs x 5 days
    • or 800mg PO q8hrs x 2 days
  • Valacyclovir OR
    • 500mg PO q12hrs x 3 days
    • or 1g PO qd x 5 days
  • Famciclovir
    • 125mg PO q12hrs for 5 days
    • or 1g PO q12hrs for 1 day
    • or 500mg PO once, followed by 250mg PO q12hrs for 2 days

Suppressive Therapy[7]


Lymphogranuloma Venereum

  • Doxycycline 100mg PO BID x 21 days (first choice) OR
  • Erythromycin 500mg PO QID x 21 days OR
    • Preferred for pregnant and lactating females
  • Azithromycin 1g PO weekly for 3 weeks OR
    • Alternative for pregnant women - poor evidence for this treatment currently
  • Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
  • Treat sexual partner


Proctitis

Inflammation of the rectum (distal 10-12cm)


PID

Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Options

Alternative Outpatient Options

Inpatient


Syphilis

Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year.

Treatment Options:

  • Penicillin G Benzathine 2.4 million units IM x 1
    • Repeat dose after 7 days for pregnant patients and HIV infection
  • Doxycycline 100mg oral twice daily for 14 days as alternative

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease

Treatment Options:

Neurosyphilis

There are 3 Major options with none showing greater efficacy than others:

  • Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)

Pregnancy

  • Penicillin, dosage depends on stage [11]


Trichomonas vaginalis

Non-Pregnant

Pregnant

  • Only treat if the patient is symptomatic and avoid breast feeding until 24hrs after last Metronidazole treatment and 72hrs after Tinidazole
  • Metronidazole 2g PO once[12]

Sexual Partner Treatment

Women with HIV Infection

  • Metronidazole 500 mg PO BID x 7 days[13]


See Also

References

  1. CDC: STI Fact sheet 2013
  2. Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  3. 3.0 3.1 3.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
  4. CDC: 2015 Sexually Transmitted Diseases Treatment Guidelines
  5. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  6. CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2010;59(No. RR-12)
  7. 7.0 7.1 7.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  8. Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  9. CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  10. 10.0 10.1 Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60
  11. Mackay G. Chapter 43. Sexually Transmitted Diseases & Pelvic Infections. In:DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. New York, NY: McGraw-Hill; 2013
  12. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  13. CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2010;59(No. RR-12)