Transcript STIs - Southern Regional AHEC

C. Brock Woodis, PharmD, BCACP, BCPS, CDE, BC-ADM, CPP
Associate Professor
Campbell University College of Pharmacy & Health Sciences
Duke Family Medicine
September 27, 2016
[email protected]

I do not have any financial relevance related to this
continuing education activity.



Identify most likely causative pathogens for a
variety of presented sexually transmitted infections
(STIs)
Recommend appropriate drug therapy for a variety
of STIs based on specific laboratory and patientspecific data
Formulate complete patient-specific treatment
plans including monitoring for safety and efficacy
for a variety of presented STIs

Workowski KA and Bolan KA. Sexually transmitted
diseases treatment guidelines. MMWR Recomm Rep
2015;64(No. RR-3):[1-137].
 http://www.cdc.gov/std/tg2015/
 Pocket guide
 Wall poster

Growing antibiotic resistance forces updates to
recommended treatment for sexually transmitted
infections. World heath organization website. Updated
Aug 30, 2016. Accessed Sept 22, 2016.
 http://www.who.int/reproductivehealth/topics/rtis/stis-new-
treatment-guidelines/en/





Each day > 1 million sexually transmitted infections
(STIs) are acquired worldwide
Estimated 357 million new infections with 1 of 4 STIs
occur each year: chlamydia, gonorrhea, syphilis and
trichomoniasis
> 500 million people are estimated to have genital
infection with herpes simplex virus (HSV)
> 290 million women have a human papillomavirus
(HPV) infection
Majority of STIs have no symptoms or only mild
symptoms that may not be recognized as an STI
Sexually transmitted infections fact sheet. World Health Organization website. Updated August 2016. Accessed Sept 22, 2016.




STIs such as HSV type 2 and syphilis can increase the
risk of HIV acquisition
> 900 000 pregnant women were infected with syphilis
resulting in approximately 350 000 adverse birth
outcomes including stillbirth in 2012
STIs can have serious reproductive health
consequences beyond the immediate impact of the
infection itself (e.g., infertility or mother-to-child
transmission)
Drug resistance (especially for gonorrhea) is a major
threat to reducing the impact of STIs worldwide
Sexually transmitted infections fact sheet. World Health Organization website. Updated August 2016. Accessed Sept 22, 2016.

STI transmission
 Variety of clinical syndromes and infections caused by
pathogens which are acquired and transmitted through
sexual activity
 Few STIs have been eradicated

STIs have reemerged secondary to social trends of
sexual activity
 ↑ numbers of adolescents engaging in unsafe sexual
practices
 ↑ incidence of men who have sex with men (MSM) and
women who have sex with women (WSW)
Pharmacotherapy: A Pathophysiologic Approach. 9th ed. 2014;Chapter 95.


Optimal detection and treatment of STIs depends
on knowledgeable and competent clinicians
Higher reported incidence of most major STIs in
men, but complications of STIs are generally more
frequent and severe in women
 Serious effects on maternal and child health during
pregnancy
 Possible damage to reproductive organs, cancer, and
transmission to fetus if untreated
Pharmacotherapy: A Pathophysiologic Approach. 9th ed. 2014;Chapter 95.





Partners
Practices
Prevention of pregnancy
Protection from STIs
Past history of STIs
IMPORTANCE OF STI PREVENTION COUNSELING
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Sociocultural
Host
susceptibility
Changes
of causative
pathogen
Demographics
STI
transmission
Economics
Patterns of
sexual
behavior
Pharmacotherapy: A Pathophysiologic Approach. 9th ed. 2014;Chapter 95.




Treatment of infection based on microbiologic
eradication
Alleviation of signs and symptoms
Prevention of sequelae
Prevention of transmission, including advantages
such as cost-effectiveness and other advantages
(e.g. single-dose formulations)
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
http://www.cdc.gov/std/ept



Do not assume that patients (especially
adolescents) consistently know how to use barrier
methods of contraception
↑ of adolescents engaging in unsafe sexual
practices, as well as men who have sex with men
(MSM) and women who have sex with women
(WSW)
Optimal to treat both partners for an STI
simultaneously
Pharmacotherapy: A Pathophysiologic Approach. 9th ed. 2014;Chapter 95.




All sexually active females aged 25 and younger, and
older women at risk for STIs should be screened for
chlamydia and gonorrhea
At-risk women include those with new sexual partners,
multiple partners, and inconsistent condom use
USPSTF says not enough evidence to weigh the
benefits and harms of such screening in men
Recommends intensive behavioral counseling for all
sexually active adolescents and for adults at increased
risk for STIs Interventions include at least 2 hours of
contact time, basic information about STIs, training in
condom use, and goal setting





Gram-stained smears
Culture
DNA hybridization probe
Nucleic acid amplification tests (NAATs)
Gram stain of male urethral specimen that
demonstrates polymorphonuclear leukocytes with
intracellular gram (-) diplococci considered
diagnostic in men
.MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Preferred drugs
Dose
Route
Frequency
Ceftriaxone
PLUS
250 mg
IM
X 1 dose
Azithromycin
OR
1g
PO
X 1 dose
Doxycycline
100 mg
PO
BID X 7 days
Cefixime
PLUS
400 mg
PO
X 1 dose
Azithromycin
OR
1g
PO
X 1 dose
Doxycycline
100 mg
PO
BID X 7 days
Alternative drugs
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
CDC recommends combination therapy with ceftriaxone
250 mg IM X 1 dose + azithromycin 1 g PO X1 dose OR
doxycycline 100 mg PO BID (in place of azithromycin) X 7
days as the most reliably effective treatment for
uncomplicated gonorrhea
 CDC no longer recommends cefixime at any dose as a
1st-line regimen for treatment of gonococcal infections
 Cefixime

 Alternative agent
 Patient should return in 1 week for a test-of-cure at the site of
infection
Centers for disease control and prevention. 25 Sept 2012 <http://www.cdc.gov/std>
Drug
Dose
Route
Frequency
Ceftriaxone
PLUS
250 mg
IM
X 1 dose
Azithromycin
OR
1g
PO
X 1 dose
Doxycycline
100 mg
PO
BID X 7 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].

Follow-up
 No “test-of-cure” unless cefixime used
 Retest 3 months after treatment to assess
REINFECTION


Cephalosporins are safe in pregnancy
Management of sex partners
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Gonococcal conjunctivitis-ceftriaxone 1g IM X1 dose PLUS
azithromycin 1 g PO X 1 dose
 Disemminated gonococcal infection (DGI)

 Results in petechial or pustular acral lesions, symmetrical




arthralgia, tenosynsovitis, or septic arthritis
Hospitalization initially
Rule out endocarditis and meningitis
Recommended-ceftriaxone 1 g IM or IV Q24H PLUS azithromycin
1 g PO X 1 dose then switch to cefixime 400 mg PO BID X 7 days
Alternatives (in combination with azithromycin 1 g PO X 1 dose)
▪ Cefotaxime 1 g IV Q8H OR
▪ Ceftizoxime 1g IV Q8H
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].



Meningitis-ceftriaxone 1-2 g IV Q12H-24H X 10-14
days
Endocarditis-ceftriaxone 1-2 g IV Q12H-24H X 4
weeks
Both should also receive azithromycin 1 g PO X
1 dose
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].






Culture
Enzyme immunoassay
DNA hybridization probe
Direct fluorescent monoclonal antibody test
Urine or swab specimen of endocervix (women)
Urethral swab or urine specimen (men)
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Resistance to azithromycin is emerging according to CDC
findings
 CDC currently recommends a combination gonorrhea
treatment with two antibiotics – an oral dose of azithromycin
and single shot of ceftriaxone
 Combination therapy currently recommended by CDC is still
effective

 No treatment failures have been reported in the United States
 Signs of emerging resistance to azithromycin suggests that this
drug will be next in the long line of antibiotics to which gonorrhea
bacteria have become resistant – a list that includes penicillin,
tetracycline, and fluoroquinolones
Antibiotic resistance threatens gonorrhea treatment. Centers for disease control and prevention website. Updated July 14, 2016. Accessed Sept 22, 2016.
Preferred drugs
Dose
Route
Frequency
Azithromycin
OR
1g
PO
X 1 dose
Doxycycline
100 mg
PO
BID X 7 days
Erythromycin base
OR
500 mg
PO
QID X 7 days
Erythromycin ethylsuccinate
OR
800 mg
PO
QID X 7 days
Levofloxacin
OR
500 mg
PO
QDAY X 7 days
Ofloxacin
300 mg
PO
BID X 7 days
Alternative drugs
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].




Abstinence from intercourse for 7 days from when
therapy was initiated
Test-of-cure is not recommended
Unlike test-of-cure, repeat C. trachomatis testing of
recently infected men and women should be
conducted 3 months after treatment
Azithromycin recommended for pregnancy and
chlamydial infection
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].

3 IMPORTANT signs
 Uterine tenderness
 Cervical motion tenderness
 Adnexal tenderness

Additional criteria





Oral temperature > 38.3° (101°F)
Abnormal cervical or vaginal discharge
WBC presence on saline microscopy of vaginal secretions
↑ Erythrocyte sedimentation rate
↑ C-reactive protein
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].



General-signs/symptoms may vary from mild to severe
Signs-vague
Symptoms
 Lower abdominal or pelvic pain
 Malodorous vaginal discharge
 Abnormal uterine bleeding
 Dyspareunia
 Nausea and/or vomiting
 Fever
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Treatment for sexually active young women and other
women at risk for STIs if they are experiencing pelvic
or lower abdominal pain AND
 No other cause other than PID can be identified
 One or more of 3 IMPORTANT SIGNS are present on
pelvic exam
 Additional criteria include oral temperature > 38.3°C,
abnormal cervical or vaginal discharge, WBC presence
on saline microscopy of vaginal secretions, ↑ ESR and
CRP

MMWR Recomm Rep 2015;64(No. RR-3):[1-137].

Therapy should provide empiric, broad spectrum
coverage of likely pathogens
 N. gonorrhoeae
 C. trachomatis

Microorganisms which comprise vaginal flora





Gardnerella vaginalis
Haemophilus influenzae
Enteric gram (-) rods
Streptococcus agalactiae
Anaerobes
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].




Anaerobic bacteria have been isolated from the
upper-reproductive tract of women who have PID
Data from in vitro studies have revealed some
anaerobes (e.g. Bacteroides fragilis) can cause
tubal and epithelial destruction
Bacterial vaginosis (BV) also present in many
women who have PID
Use of regimens with anaerobic activity should be
considered for PID treatment
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].


If mild to moderate clinical severity, outpatient therapy
has similar outcomes to inpatient management
Hospitalize if ANY of the following factors present
 Surgical emergencies
 Pregnancy
 Does not respond to oral antimicrobial therapy
 Unable to follow or tolerate oral regimen
 Severe illness, N/V, high fever
 Tubo-ovarian abscess
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Cefotetan
PLUS
2g
IV
Q12H
Doxycycline
OR
100 mg
PO/IV
Q12H
Cefoxitin
PLUS
2g
IV
Q6H
Doxycycline
100 mg
PO/IV
Q12H
May discontinue parenteral therapy 24 hours after clinical improvement,
but oral therapy with doxycycline should continue to complete 14 days
of therapy!
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route Frequency
Clindamycin
PLUS
900 mg
IV
Q8H
Gentamicin
Loading dose: 2 mg/kg IBW
Followed by maintenance dose of
1.5 mg/kg
IV
Q8H
OR
Single daily dose of 3-5 mg/kg IBW
May discontinue parenteral therapy 24 hours after clinical improvement,
but oral therapy with doxycycline at 100 mg PO BID or clindamycin 450
mg PO Q6H should continue to complete 14 days of therapy!
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Ceftriaxone
PLUS
250 mg
IM
X1 dose
Doxycycline
WITH or WITHOUT
100 mg
PO
BID X 14 days
Metronidazole
500 mg
PO
BID X 14 days
Cefoxitin
AND
2g
IM
X1
Probenecid
PLUS
1g
PO
X1
Doxycycline
WITH or WITHOUT
100 mg
PO
BID X 14 days
Metronidazole
500 mg
PO
BID X 14 days
OR
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].



Inflammation of the vagina, oftentimes caused by
infection
Usually characterized by discharge, itching, and
odor
Three infections most frequently associated with
discharge
 BV- NOT an STI
 Trichomoniasis
 Vulvovaginal candidiasis (VVC)- NOT an STI
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].


BV diagnosed according to Amsel’s Diagnostic
Criteria
3/4 criteria must be present





Thin, white, homogenous discharge
Clue cells on microscopy
Vaginal pH > 4.5
Release of “fishy” odor once 10% KOH (i.e. “whiff test”)
added to vaginal sample
Alternatively, gram-stain vaginal smear may be
used
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Metronidazole
OR
500 mg
PO
BID X 7 days
Metronidazole 0.75% gel
OR
1 full applicator
(5 g)
Intravaginally
QDAY X 5 days
Clindamycin 2% cream
1 full applicator
(5 g)
Intravaginally
QHS X 7 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Tinidazole
OR
2g
PO
QDAY X 2 days
Tinidazole
OR
1g
PO
QDAY X 5 days
Clindamycin
OR
300 mg
PO
BID X 7 days
Clindamycin ovules
100 mg
Intravaginally
QHS X 3 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Recommended
regimen
Dose
Route
Frequency
Metronidazole
OR
2g
PO
X1
Tinidazole
2g
PO
X1
500 mg
PO
BID X 7 days
Alternative
regimen
Metronidazole
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].

A disulfiram-like reaction may occur if taken with
alcohol
 Flushing, palpitations, tachycardia, nausea, vomiting,
may occur with concurrent use
 Although the risk for most patients may be slight, caution
is advised

Alcoholic beverages should be avoided while taking
metronidazole and for at least 1 day (metronidazole
tablets) or 3 days (metronidazole capsules and
extended release tablets) after discontinuing
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Butoconazole 2%
sustained-release
cream
OR
5g
Intravaginally
X 1 day
Fluconazole
OR
150 mg
PO
X 1 day
Tioconazole 6.5%
ointment
5g
Intravaginally
X 1 day
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Clotrimazole 2%
cream
OR
5g
Intravaginally
QHS X 3 days
Miconazole 200 mg
vaginal suppository
OR
1 suppository
Intravaginally
QHS X 3 days
Terconazole 0.8%
cream
OR
5g
Intravaginally
QHS X 3 days
Terconazole 80 mg
vaginal suppository
1 suppository
Intravaginally
QHS X 3 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Clotrimazole 1% cream
OR
5g
Intravaginally
QHS X 7-14 nights
Clotrimazole 100 mg
vaginal tab
OR
1 tablet
Intravaginally
QHS X 7 nights
Miconazole 2% cream
OR
5g
Intravaginally
QHS X 7 nights
Miconazole 100 mg
vaginal tab
OR
1 suppository
Intravaginally
QHS X 7 nights
Terconazole 0.4% cream
5g
Intravaginally
QDAY X 7 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Stage
General
Site
Signs/symptoms
Primary
Incubates 10-90 days
External genitalia,
mouth, throat
Single, painless lesion
(chancre)
Secondary
Develops 2-8 weeks
Multisystem
involvement due to
lymphatic spread
Pruritic or nonpruritic
rash; flu-like
symptoms
Latent
Develops 4-10 weeks
Potentially
multisystem (dormant)
Asymptomatic
Tertiary
Develops in 30% of
those untreated or
inadequately treated
CNS, heart, eyes,
bones, and joints
CV syphilis,
neurosyphilis,
gummatous lesions
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Stage
Characteristics
Adult Treatment
Primary
Solitary, painless chancre
Benzathine PCN 2.4 million units X 1 dose
Secondary
Fatigue, diffuse rash on palms of
hands and soles of feet, fever,
lymphadenopathy
Benzathine PCN 2.4 million units X 1 dose
Early latent
Involves 1st year after infection
Benzathine PCN 2.4 million units X 1 dose
Late latent
Usually asymptomatic; resolved
lesions; seropositive for T. pallidum
Benzathine PCN 7.2 million units total
2.4 million units IM weekly X 3 weeks
Tertiary
Develops years after infection; may
affect any organ in body
(gummatous and CV syphilis
treated same as tertiary)
Benzathine PCN 7.2 million units total
2.4 million units IM weekly X 3 weeks
Neurosyphilis and
ocular syphilis
CNS involvement (e.g. cognitive
dysfunction, motor deficits,
meningitis symptoms, etc.)
Aqueous PCN G 3-4 million units IV Q4H
X 10-14 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Am Fam Physician. 2003;68:283-290.



Reaction which occurs secondary to spirochete lysis
and pro-inflammatory cytokine cascades
Can transpire as early as 2 hours after PCN
administration and usually resolves within 24 hours
Clinical presentation





Fever
Chills
Tachycardia
Tachypnea
Treatment is supportive
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].






Syphilis infection during pregnancy can result in significant health problems
for an infant
Historical data indicate that up to 40% of pregnancies in women with
untreated syphilis will result in miscarriage, stillbirth, or infant death
Infants who live may develop severe illness, including skeletal
abnormalities; hepatosplenomegaly; jaundice; anemia; optic atrophy;
interstitial keratitis; sensorineural deafness; or meningitis, which can cause
developmental delays and seizures
All pregnant women should be screened for syphilis at their first prenatal
visit
Women at high risk should be rescreened early in their third trimester and
again at delivery
Pregnant women diagnosed with syphilis should be treated with penicillin
immediately and should last 30 days prior to delivery
Kidd S. Congenital Syphilis Is on the Rise? Reviewing Prevention Steps. Centers for disease control and prevention. Updated July 18, 2016.
Accessed Sept 22, 2016.





Patients should be advised tell sex partners about the
infection and encourage them to get tested and treated to
avoid reinfection
Before discharging any newborn infant from the hospital,
mothers should be tested for syphilis at least once during her
pregnancy or at delivery
If a woman delivers a stillborn infant, she should be tested for
syphilis
Safe sex practices should be discussed
Partner with health departments, prenatal care providers,
and other local organizations to address barriers to obtaining
early and adequate prenatal care for the most vulnerable
pregnant women in the community
Kidd S. Congenital Syphilis Is on the Rise? Reviewing Prevention Steps. Centers for disease control and prevention. Updated July 18, 2016.
Accessed Sept 22, 2016.



Recommended treatment for syphilis and the only recommended treatment for pregnant
women infected or exposed to syphilis is benzathine penicillin G)
Pfizer, the sole manufacturer of Bicillin L-A® (penicillin G benzathine) in the United States is
experiencing a manufacturing delay of this product
CDC recommendations until shortage resolves






Refrain from the use of Bicillin L-A® (penicillin G benzathine) for treatment of other infectious diseases
(e.g., streptococcal pharyngitis) where other effective antimicrobials are available
Adhere to the recommended dosing regimen of 2.4 million units of penicillin G benzathine IM for the
treatment of primary, secondary and early latent syphilis (i.e., early syphilis) as outlined in the 2015 STD
Treatment Guidelines(http://www.cdc.gov/std/tg2015/syphilis.htm)
Additional doses to treat early syphilis do not enhance efficacy, including in patients living with HIV
infection
Contact your pharmacists/distributors to procure Bicillin L-A® (penicillin G benzathine), if you do not have
product readily available
If product reaches a critical supply level of three weeks or less, contact Pfizer
Direct questions about syphilis clinical management to an infectious disease specialist or
the on-line National Network of STD Clinical Prevention Training Centers (NNPTC) STD
Clinical Consultation Network (https://www.stdccn.org ).
Bicillin-LA (benzathine penicillin G) shortage. Centers for disease control and prevention. Updated June 28, 2016. Accessed Sept 22, 2016.





Procaine Penicillin G IM is one of the recommended treatments
for congenital syphilis and an alternative treatment for both
neurosyphilis and ocular syphilis
Other recommended treatment for congenital syphilis is aqueous
crystalline penicillin G IV
Pfizer, the sole manufacturer of this product in the United States,
is experiencing manufacturing delays
CDC is continuing to work with FDA’s Drug Shortage Staff and
Pfizer to address this situation
If Procaine Penicillin G is unavailable and until normal quantities
of Procaine Penicillin G is available, CDC suggests using other
available and recommended regimens of penicillin to treat
congenital syphilis as outlined in the 2015 STD Treatment
Guidelines(https://www.cdc.gov/std/tg2015/syphilis.htm)
Procaine penicillin shortage. Centers for disease control and prevention. Updated Sept 19, 2016. Accessed Sept 22, 2016.


Desired outcome is to curtail number of episodic
prodromes and to minimize any side effects
experienced due to antivirals
Treatment is based on several factors
 Likelihood of patient compliance
 Whether it is the first or recurrent episode
 Host immunity
 Pregnancy
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Acyclovir
OR
200 mg
PO
5 X/day X 7-10 days
Acyclovir
OR
400 mg
PO
TID X 7-10 days
Valacyclovir
OR
1g
PO
BID X 7-10 days
Famciclovir
250 mg
PO
TID X 7-10 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Acyclovir
400 mg
PO
TID X 5 days
Acyclovir
800 mg
PO
BID X 5 days
Acyclovir
800 mg
PO
TID X 2 days
Valacyclovir
500 mg
PO
BID X 3 days
Valacyclovir
1g
PO
QDAY X 5 days
Famciclovir
125 mg
PO
BID X 5 days
Famciclovir
1000 mg
PO
BID X 1 day
Famciclovir
500 mg once, then
250 mg BID
PO
BID X 2 days
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Drug
Dose
Route
Frequency
Acyclovir
OR
400 mg
PO
BID up to a year
Valacyclovir
OR
500 mg
PO
DAILY up to a year
Valacyclovir
OR
1g
PO
DAILY up to a year
Famciclovir
250 mg
PO
BID up to a year
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].









Headache
Confusion
Nausea
Vomiting
Thrombocytopenia
Renal insufficiency
Rash
Pruritus
Fever
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Arthralgias
Myalgias
Thrombotic
thrombocytopenic purpura
(TTP)
 Hallucinations
 Somnolence
 Depression



Drug
Dose
Side effects
Acyclovir
5-10 mg/kg IV Q8H X 2-7 days
See previous slide
Foscarnet
40 mg/kg IV Q8-12H X 2-3 weeks or
until clinical resolution attained
Renal insufficiency, metabolic
disturbances,
hypophosphatemia
Cidofovir
0.3%, 1%, and 3% topical agent used
on a compassionate basis for acyclovirresistant herpes lesions (3-7 days)
Application site reactions,
lesion recrudescence
Trifluridine
1% topical agent used for acyclovirresistant herpes infections X 7-14 days
Transient burning or stinging,
palpebral edema, superficial
punctuate, keratopathy,
changes in intraocular pressure
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].



Predominant symptom is pruritus
Sarcoptes scabiei
Treatment
Drug
Permethrin
5% cream
Dose and Duration
Apply to all areas of the body from
neck down and wash off in 8-14
hours
Ivermectin
200 mcg/kg PO; repeat in 2 weeks
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].


Most common viral STI in the United States
Over 100 subtypes characterized
 30 types associated with genital tract lesions
 Types 6 and 11 associated with development of low-
grade dysplasia manifested as exophytic genital warts

Most warts will regress spontaneously within 1-2
years of initial appearance, but reinfection common
in young, sexually active populations
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].



Infection with several HPV subtypes (e.g. HPV-16
and HPV-18) is considered the major risk factor for
development of cervical neoplasia (2nd most
common cancer in women worldwide)
HPV infection alone is insufficient to cause cervical
cancer development
Pap smear is most cost-effective and frequently
used diagnostic test for HPV
MMWR Recomm Rep 2015;64(No. RR-3):[1-137].

Three HPV vaccines marketed in the United States
 Cervarix® (HPV2)-bivalent vaccine for HPV-16 and HPV-18
 Gardasil® (HPV4)-quadrivalent vaccine for HPV-6, -11, -16, and -
18
 Gardasil-9 (HPV9)-nine-valent vaccine for HPV 6, 11, 16, 18, 31,
33, 45, 52, 58
Vaccines are indicated for preventing cervical precancers
and cervical cancer in females 11 or 12 through 26 years of
age (but can be started as early as 9)
 HPV4 and HPV9 also indicated in males to prevent genital
warts (HPV-6 and -9) and anal cancers (HPV-16 and-18)

Centers for disease control and prevention. 06 Oct 2015 <http://www.cdc.gov/std>
Trade name
Cervarix
Gardasil
Gardasil 9
Synonym
HPV2
HPV4
HPV9
Components
16, 18
6, 11, 16, 18
6, 11, 16, 18, 31, 33,
45, 52, 58
Females
Males and females
Males and females
None
None
None
Not contraindicated
Not contraindicated
Not contraindicated
Recommended
Recommended
Recommended
Monitoring
30 min
30 min
30 min
Side effects
Injection-site reactions,
bruising, syncope
Injection-site reactions,
bruising, syncope
Injection-site reactions,
bruising, syncope
Drug interactions
Belimumab, fingolimod,
immosuppressants
Belimumab, fingolimod,
immosuppressants
Belimumab, fingolimod,
immosuppressants
Indications
Preservative
Immunosuppression
HIV infection

Females
 All vaccines are recommended in a 3-dose series for routine
vaccination at age 11 or 12 years
 For those aged 13 through 26 years, if not previously vaccinated

Males
 HPV4 and HPV9 are recommended in a 3-dose series for routine
vaccination at age 11 or 12 years, and for those aged 13 through
21 years, if not previously vaccinated
 Males aged 22 through 26 years may be vaccinated

HPV4 is recommended for MSM through age 26 years or
those who did not get any or all doses when they were
younger
Centers for disease control and prevention. 9 Oct 2015 <http://www.cdc.gov/std>
Vaccination is recommended for immunocompromised persons
(including those with HIV infection) through age 26 years for those
who did not get any or all doses when they were younger
 A complete series for all vaccines consists of 3 doses

 2nd dose should be administered 1–2 months after the first dose
 3rd dose should be administered 6 months after the first dose (at least 24
weeks after the first dose)

HPV vaccines are not recommended for use in pregnant women
 Pregnancy testing is not needed before vaccination
 If a woman is found to be pregnant after initiating the vaccination series,
no intervention is needed
 Remainder of the 3-dose series should be delayed until completion of
pregnancy
Centers for disease control and prevention. 9 Oct 2015 <http://www.cdc.gov/std>

Cervical cancer
 Most common HPV-associated cancer
 Almost all cervical cancer is caused by HPV





Vulvar cancer-~50% are linked to HPV
Vaginal cancer-~65% are linked to HPV
Penile cancer-~35% are linked to HPV
Anal cancer-~95% are linked to HPV
Oropharyngeal cancers
 Cancers of the back of the throat, including the base of the tongue
and tonsils
 ~60% are linked to HPV
 Many of these cancers may be related to tobacco and alcohol use
Centers for disease control and prevention. 9 Oct 2015 <http://www.cdc.gov/std>
Infection
Recommended regimen
Nongonococcal urethritis/cervicitis
Azithromycin 1 g PO X 1 dose
Chancroid (Haemophilus ducreyi)
Azithromycin 1 g PO X 1 dose
OR
Ceftriaxone 250 mg IM X 1 dose
OR
Ciprofloxacin 500 mg PO BID X 3 days
OR
Erythromycin 500 mg PO TID X 7 days
Lymphogranuloma venereum (C. trachomatis)
Doxycycline 100 mg PO BID X 21 days
HPV infection (genital warts)
Podofilox 0.5% solution or gel applied BID X 3
days, followed by 4 days of no therapy, cycle
repeated as necessary up to 4 cycles
OR
Imiquimod 5% cream applied QHS 3 times weekly
for up to 16 weeks
.MMWR Recomm Rep 2015;64(No. RR-3):[1-137].
Zika can be passed through sex from a person who has Zika to
his or her sex partners
 Sex includes vaginal, anal, oral sex, and the sharing of sex toys
Zika can be passed through sex, even if the person does not have
symptoms at the time

 It can be passed from a person with Zika before their symptoms start,
while they have symptoms, and after their symptoms end
 Though not well documented, the virus may also be passed by a person
who carries the virus but never develops symptoms
Studies are underway to find out how long Zika stays in the
semen and vaginal fluids of people who have Zika, and how long
it can be passed to sex partners
 It is known that Zika can remain in semen longer than in other
body fluids, including vaginal fluids, urine, and blood

Zika and sexual transmission. Centers for disease control and prevention. Updated Sept 1, 2016. Accessed Sept 22, 2016.

Condoms can reduce the chance of getting Zika from
sex
 Condoms include male and female condoms
 Dental dams (latex or polyurethane sheets) may also be
used for certain types of oral sex (mouth to vagina or mouth
to anus)
Condoms should be used from start to finish, every
time during vaginal, anal, and oral sex
 Not sharing sex toys can also reduce the risk of
spreading Zika to sex partners
 Not having sex eliminates the risk of getting Zika from
sex

Zika and sexual transmission. Centers for disease control and prevention. Updated Sept 1, 2016. Accessed Sept 22, 2016.
WHO has released new guidelines for treating gonorrhea, syphilis, and
chlamydia given their increasing resistance to treatment
 Gonorrhea treatment changes

 Quinolones are no longer recommended given the high prevalence of
resistance
 Dual therapy is preferred over single therapy
 Health authorities should advise providers to prescribe the antibiotic that would
be most effective, taking into account current local patterns of resistance
Oropharyngeal treatment recommendations and guidance on retreatment
after treatment failure are included
 Syphilis-new guidelines strongly recommend a dose of benzathine
penicillin, which has been in short supply, over procaine penicillin
 Chlamydia
 WHO developed recommendations for treating pregnant women
 Recommendations for preventing and treating chlamydia ophthalmia
neonatorum
Growing antibiotic resistance forces updates to recommended treatment for sexually transmitted
infections. World heath organization website. Updated Aug 30, 2016. Accessed Sept 22, 2016.
https://npin.cdc.gov/KABIChronicles




Several STIs may be encountered in clinical
practice
Open communication with patients is essential to
successful care
Variety of medications are available for treatment
Therapy must be chosen through a patientcentered approach
C. Brock Woodis, PharmD, BCACP, BCPS, CDE, BC-ADM, CPP
Associate Professor
Campbell University College of Pharmacy & Health Sciences
Duke Family Medicine
September 27, 2016
[email protected]