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Therapeutics V: Exam #1 - STDs
n/a
37
Health Care
Graduate
12/11/2010

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Term
Gonorrhea
Definition
Caused by Neisseria gonorrhoeae (Gram-Neg cocci);
Presentation (may be asymptomatic):
Men - purulent discharge, painful/swollen testicles, pain during urination;
- Women: cervicitis, urethritis, increased discharge, dysuria, abdominal pain;
Complications: PID, disseminated dx, neonatal conjunctivitis;
Diagnosis: Gram-stain, culture;
Term
General Principles of Treatment for Gonorrhea
Definition
Commonly co-infected w/ Chlamydia, should receive empiric therapy for both;
- Fluoroquinolones (most resistance) & broad-spectrum cephalosporins (least resistance) have best activity;
DO NOT USE fluoroquinolones in MSM, pts w/ recent foreign travel, or pts acquiring infections in CA or HA;
Term
Treatment of Uncomplicated cervical, urethral, or rectal gonorrhea infection
Definition
Ceftriaxone 125 mg IM x 1 dose OR cefixime 400 mg PO x 1 dose;
- use fluoroquinolones ONLY if susceptability tests have been performed --> levofloxacin 250 mg PO x 1 dose or ciprofloxacin 500 mg PO x 1 dose;
In pts who have MSM or recent travel:
- ceftriaxone IM OR cefixime PO x 1 dose
Term
Treatment of Uncomplicated Gonorrhea Infection of Pharynx
Definition
ceftriaxone IM (preferred) or ciprofloxacin PO (requires susceptibility testing)
Term
Treatment of Gonorrhea in Pregnant Women
Definition
ceftriaxone IM (preferred) OR cefixime PO OR spectinomycin 2 g IM (not available in US);
- CANNOT use FQ's
Term
Last line Treatment of Gonorrhea Infections
Definition
azithromycin 2 g PO x 1 dose (NOT effective in pharyngeal infections)
- use if pts have allergy to cephalosporins &/or FQ resistance
--> also covers Chlamydial infection
Term
Disseminated Gonococcal Infections
Definition
arthritis dermatitis syndrome: migratory polyarthralgia w/ or w/o tenosynovitis, maculopapular or pustular lesions;
gonococcal arthritis of knee;
meningitis or endocarditis (rare)
Term
Risk Factors for Disseminated Gonococcal Infection
Definition
complement deficiency;
female sex (menses);
pharyngeal infection;
pregnancy;
Term
Treatment of Disseminated Gonococcal Infection
Definition
Ceftriaxone 1 g IM/IV q24 hrs OR cefotaxime 1 g IV q8 hrs (preferred drugs) OR levofloxacin 250 mg IV q24 hr OR spectinomycin 2 g IM q48 for at least 24-48 hrs;
- continue for up to 7 days in pts w/ arthritis if possible;
Follow with: cefixime 400 mg PO BID to complete 7 day course (use FQ's [cipro 500 mg BID or levofloxacin 500 mg qday] if susceptible)
Term
Ophthalmia Neonatorum
Definition
gonococcal or chlamydial infection caused by transmission during passage through birth canal;
Prophylaxis: erythromycin 0.5% ophthalmic ointment
Neonates born to mothers w/ UNTREATED gonococcal infections --> ceftriaxone 50 mg/kg IV or IM x 1 dose
Term
Chlamyidia
Definition
Caused by: Chlamydia trachomatis;
Presentation:
- asymptomatic, may develop S/Sx after 7-21 days;
- Women: tender cervix, watery discharge
- Men: watery discharge;
Complications: epididymitis (men), PID (women), neonatal conjunctivitis or pneumonia, increased risk of HIV transmission;
Diagnosis: culture, monoclonal antibody tests;
***ASSUME AND TX CONCOMITTANT GONOCOCCAL INFECTION***
Term
Treatment of Uncomplicated Urethra, Endocervical, or Rectal Chlamydial Infection
Definition
PREFERRED: azithromycin 1 g PO x 1 dose
- doxycycline 100 mg PO BID x 7 days (avoid in pregnancy);
Alternative: erythromycin 500 mg QID or levofloxacin 500 mg qday x 7 days;
***ASSUME AND TX CONCOMITTANT GONOCOCCAL INFECTION***
Term
Treatment of Chlamydial Infections in Pregnant Women
Definition
Azithromycin 1 g TID x 7 days OR amoxicillin 500 mg TID x 7 days;
Alternative: erythromycin
***ASSUME AND TX CONCOMITTANT GONOCOCCAL INFECTION***
Term
Pelvic Inflammatory Disease (PID)
Definition
Caused by C. trachomatis and N. gonorroeae;
More common in women under age 25;
Presentation (vague):
- lower abdominal pain, malodorous vaginal discharge, abnormal bleeding, dysparenuia, dysuria, N/V/D, fever;
Complications (severe):
- ectopic pregnancy, infertility, tubo-ovarian abscess, chronic pelvic pain;
Diagnosis (based on clinical presentation):
- uterine tenderness, cervical motion tenderness, adnexal tenderness + temp >101 F, abnormal cervical or vaginal discharge, WMCs in vag secretions, elevated ESR or CRP
Term
Treatmnet for Pelvic Inflammatory Disease
Definition
IV (severe Sx):
- cefotetan 2 g q12 hrs or cefoxitin 2 g q6 hrs + doxycycline 100 mg PO/IV q12 hrs;
- clindamycin 900 mg q8 hr + gentamicin;
- levofloxacin 500 mg q24 hr +/- metronidazole 500 mg q8hr;
- ampicillin-sulbactam 3 g q6hr + doxycycline IV/PO;
Oral (non-severe Sx):
ceftriaxone 250 mg IM x 1 dose + doxycycline BID +/- metronidazole BID;
- levofloxacin 500 mg qday +/- metronidazole 500 mg BID
Generally Tx for 14 days
Term
Syphillis
Definition
Caused by Treponema pallidum;
**DETERMINE Sexual partners***
Diagnosis:
- Nontreponemal (VDRL slide test, RPR card test) --> 1st line
- Treponemal (FTA-ABS, ELISA, TPHA) --> used as confirmatory, more sensitive
Term
Primary Syphillis
Definition
appearance of chancre on cutaneous or mucocutaneous tissue;
Develops 3 wks after exposure;
Highly infectious;
Heals spontaneously after 1-8 wks if untreated;
Treatment:
- benzathine penicillin G 2.4 MU IM x 1 dose (Bicillin L-A);
ALternates:
- doxycycline 100 mg PO BID or tetracycline 500 mg PO QID x 14 days (if allergic to PCNs);
Follow-up (IMPORTANT):
- quantitative nontreponemal testing q6 & 12 months
Term
Secondary Syphillis
Definition
Mucocutaneous, nonpuritic rash (generalized or localized);
Fever, fatigue, lymphadenopathy, anorexia;
If untreated, disappears after 4-10 wks but lesions may recur at any time within 4 yrs;
Treatment:
- benzathine penicillin G 2.4 MU IM x 1 dose (Bicillin L-A);
ALternates:
- doxycycline 100 mg PO BID or tetracycline 500 mg PO QID x 14 days (if allergic to PCNs);
Follow-up (IMPORTANT):
- quantitative nontreponemal testing q6 & 12 months
Term
Jarisch-Herxheimer Reaction
Definition
benign, self-limiting flu-like rxn after tx for primary or secondary dx;
- HA, fever, chills, malaise, arthralgia, tachycardia, aggravation of syphilitic lesions;
**INDEPENDENT of Drug & dose used**
- confused for PCN allergy;
Begins after 2-4 hrs, peaks @ 8 hrs, resolves after 12-24 hrs;
Symptomatic management
Term
Latent Syphillis
Definition
positive serologic test w/ no evidence of Dx;
Early: <1 yr from onset of infection
- potentially infectious;
Treatment:
- benzathine penicillin G 2.4 MU IM x 1 dose (Bicillin L-A);
ALternates:
- doxycycline 100 mg PO BID or tetracycline 500 mg PO QID x 14 days (if allergic to PCNs);
Follow-up (IMPORTANT):
- quantitative nontreponemal testing q6 & 12 months & FOLLOW-UP at 24 MONTHS;
Late: >1 yr from onset
- noninfectious
- if untreated, most pts will have no other S/Sx (except for 25-30%);
Treatment:
- benzathine penicillin 2.4 MU IM q week x 3 doses;
- Alternative: doxycycline or tetracycline PO x 28 days;
Follow-up: serologic testing at 6,12, & 24 months;
Term
Tertiary Syphillis
Definition
develops 10-30 yrs after initial infection;
May affect CNS, heart, eyes, bone, & joints;
Tx & Monitoring:
- benzathine penicillin G 2.4 MU IM x 1 dose (Bicillin L-A);
ALternates:
- doxycycline 100 mg PO BID or tetracycline 500 mg PO QID x 14 days (if allergic to PCNs);
Follow-up (IMPORTANT):
- quantitative nontreponemal testing q6 & 12 months & FOLLOW-UP at 24 MONTHS;
Late: >1 yr from onset
- noninfectious
- if untreated, most pts will have no other S/Sx (except for 25-30%);
Treatment:
- benzathine penicillin 2.4 MU IM q week x 3 doses;
- Alternative: doxycycline or tetracycline PO x 28 days;
Follow-up: serologic testing at 6,12, & 24 months;
Term
Neurosyphillis
Definition
CSF abnormalities consistent w/ CNS infection --> perform lumbar puncture (LP);
Most common in HIV-infected pts;
Treatment:
- aqueous crystalline penicillin G 18-24 MU IV (3-4 MU q4 hrs) x 10-14 days
- OR procaine PCN G 2.4 MU IM daily + probenecid 500 mg PO QID x 10-14 days;
- follow up w/ benzathine G 2.4 MU IM weekly x 1-3 wks;
Follow-UP:
- CSF exam q6 months until cell count near normal; Consider retreatment if not decreased at 6 months or normal at 2 yrs follow-up
Term
Congenital Syphilis
Definition
fetus infected w/ T. pallidum due to hematogenous spread from infected mother or direct contact w/ genitalia;
Can result in fetal death, prematurity or congenital dx (Sx occur anywhere from birth to adolescence);
Diagnosis:
- clinical Lab or radiographic evidence;
- maternal nontreponemal titers at delivery compared to neonatal titers
- neonatal titers > 4x maternal titer = confirmatory for dx
Term
Treatment of Congenital Syphilis
Definition
Asymptomatic: benzathin penicllin G 50,000 units/kg IM x 1 dose;
Symptomatic: aqueous crystalline PCN G 50,000 units/kg IV q12 hr during 1st 7 days of life & q8 hr for next 3 days (10-day course);
Alternative: procaine PCN G 50,000 units/kg IM daily x 10 days;
Follow-UP: Observation of clinical & serological clearance for 6 months
Term
Genital Herpes
Definition
Caused by HSV-1 & -2;
Diagnosis:
Confirmatory lab testing
- tissue culture
- serologic tests, PCR assays
Clincal Findings:
- dark-field-neg, vesicular or ulcerative genital lesions;
- prior hx of similar lesions or sexual contact w/ infected person;
Presentation:
- cluster of painful vesicles on erythematous base (1st episode develops over 7-10 days & heals w/in 2-4 wks)
- itching, burning, tingling, urinary frequency, flu-like prodrome;
Complications: 2ndary infections, disseminated infection, extragenital lesions, meningitis, neonatal transmission (50% fatality rate);
Term
Treatment for Genital Herpes
Definition
NO CURE - Goal: relieve Sx & shorten course, prevent recurrence, decrease transmission;
1st Episode: PO acyclovir, famciclovir, valacyclovir; Alternative: acyclovir IV followed by PO;
Episodic Therapy:
- REQUIRES INITIATION W/IN 24 HRS of LESION ONSET OR DURING PRODROME FOR EFFICACY;
- acyclovir, famciclovir, or valacyclovir PO x 5 days;
Side Effects: HA, confusion, N/V, thrombocytopenia, renal insufficiency, rash, pruritis, hallucinations, depression
Term
Genital Warts (HPV)
Definition
Caused by Human Papillomavirus (HPV);
Presentation:
- most are asymptomatic;
- rough, thick, cauliflower-like lesions, keratotic warts w/ thick, horny surface, anogenital pruritis, burning, vaginal discharge or bleeding;
Complications:
- cervical cancer, other cancers;
Diagnosis:
- DNA/RNA capsid protein detection, clinical presentation
Term
Treatment of Genital Warts
Definition
Goal: remove visible warts & reduce infectivity;
Pt-applied Tx:
- podofilox 0.5% gel/soln BID x 3 days, repeat after 4 days if wart still visible;
- imiquimod 5% cream qHS 3x/wk for up to 16 wks OR QOD x 3 applications;
Physician-applied Tx:
- podophyllin resin 10-25%
- bicholroacetic & tricholoacetic acids 80-90% (may be used in pregnancy);
Ablative therapy: cryotherapy, surgical removal, vaporization
Term
Gardasil
Definition
HPV vaccine
-recommended for women age 9-26
- protects against strains 6, 11, 16, & 18
- approved for men age 9-26 for genital wart prevention
Term
Cervarix
Definition
HPV vaccine
recommended for women age 10-25;
- protects against strains 16 & 19
- no recommendation for use in men
Term
Chancroid
Definition
Caused by: Haemophilus ducreyi;
Most common in South Atlantic states;
Presentation:
- genital ulcer w/ ragged & poorly defined edge;
- erthematous papule develops 4-7 days after infection that progresses to pustule stage that ruptures
Term
CDC Recommendations for Tx of Chancroid
Definition
- erithromycin 500 mg PO TID-QID x 7 days;
- azithromycin 1 g x 1 dose;
- ciprofloxacin 500 mg BID x 3 days;
Term
WHO Recommendations for Tx of Chancroid
Definition
erythromycin 500 mg PO TID-QID x 7 days;
ceftriaxone 250 mg IM x 1 dose;
ciprofloxacin 500 mg x 1 dose;
spectinomycin 2 g IM x 1 dose
Term
Trichomoniasis
Definition
Caused by Trichomonas vaginalis;
Most common curable STI;
Presentation:
- women: asymptomatic, vaginal erythemia, foul-smelling yellow-green discharge, dysuria;
- Men: asymptomatic, urethral discharge or irritation;
Complications: premature labor, decreased sperm viability;
Term
Tx for Trichomoniasis
Definition
Metronidazole 2 g x 1 dose or 500 m BID x 7 days, use 2 g dose if pregnant;
- C/I in 1st trimester;
Alternative: tinidazole 2 g
Term
Bacterial Vaginosis
Definition
Caused by: Anaerobic overgrowth [Gardenella vaginalis, Prevotella, Mycoplasma hominis, Mobiluncus];
More common in sexually active women;
Presentation:
- fishy-smelling vag discharge, may be asymptomatic;
Diagnosis (Amsel criteria [3 of 4]):
- thin, white, homogenous discharge
- clue cells on microscopy
- pH >4.5
- release of fishy odor upon addition of alkali to vaginal sample
- Gram-stain vaginal smear;
Term
Treatment of Bacterial Vaginosis
Definition
Metronidazole 500 mg PO BID x 7 days
Metronidazole 0.75% gel --> 5 g intravaginally daily x 5 days;
Clindamycin 2% cream --> 5 g intravaginally qHS x 7 days
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