Transcript Candida Albicans

AAFP Board Review: Sexually
Transmitted Diseases
Vu Tran, M.D.
PGY-2
LSUFP-Alexandria
October 30, 2014
Objectives
• Discuss common clinical presentations for patients
with STDs
• Demonstrate contemporary use of testing to
diagnose STIDs and treatment of STDs.
• Review major infections with identification of
appropriate therapy.
Vaginal Discharge
• Herpes Simplex Virus (HSV)
• Ulcerating, painful vesicles
• Trichomonas vaginalis
• Candida Albicans
• Pruritic, thick, white discharge
• Bacterial Vaginosis
• Vulvar and vaginal irritation
• Mixed vaginal flora
• Malodorous
• Overgrowth in bacterial flora
• Cervicitis can be tender to touch
• Malodorous
• Non-specific pelvic pain
• Vulvar itching
• No pelvic pain
• PAP Smears
I.
Trichomoniasis
Conventional
- Warrants treatment if high risk patient
II.
Liquid-Based Cytology
- Warrants treatment without further testing
• Best treated with Metronidazole 2 g PO single dose or
500 mg PO BID x7 days
- Clindamycin 300 mg PO BID for 7 days if allergic
• Alternative is Tinidazole 2 g PO x1
• Metronidazole gel less effective than PO.
• Repeat PO dose if initial treatment fails.
• Treat sexual partner as well.
• Pregnant women can be treated with 2 g at any stage of
pregnancy (Class B drug)
Follow-Up Exam
• High rate of re-infection (about 17%)
I.
2-5% of resistance to Metronidazole
• Most recurrent infections usually from sex with untreated
partners.
• Some studies suggest rescreening women after 3 months.
• No data to support re-screening men.
• If treatment fails and re-infection has been excluded:
I. First choice: Metronidazole 500 mg PO BID x7 days
II. If that fails: Tinidazole or Metronidazole 2 g PO daily for
5 days.
Bacterial Vaginosis
• Most common cause of vaginitis in women of childbearing age.
• Reduction in concentration of the normally dominant hydrogenperoxide producing lactobacilli and an increase in concentration of
other organisms
• Associated with PROM, preterm labor, postpartum endometritis,
salpingitis, PID, and acquisition of HIV.
• Amsel Criteria (needs 3 of 4)
1. Homogenous grayish-white discharge
2. pH >4.5 (needs vaginal pH paper; high sensitivity, low specificity)
3. Clue cells (>20% on HPF; most specific and sensitive)
4. Whiff Test positive (volatilized amines released after 10% KOH)
Treatment of BV
• Indicated to reduce vaginal discharge and odor
• Do not consume Etoh with Metronidazole
• Non-Pregnant Women
I. Metronidazole 500 mg twice daily orally for 7 days
II. Metronidazole gel 0.75 percent (5 grams containing 37.5 mg
metronidazole) once daily vaginally for 5 days
III. Clindamycin 2% vaginal cream once daily at bedtime for 7 days
• Pregnant Women
I. Clindamycin 300 mg orally twice daily for 7 days or metronidazole 500
mg orally twice daily for 7 days.
• Recommend not treating sexual partners of women with BV.
Recurrent BV
• Metronidazole vaginal gel (0.75%) 5 g in vagina 2x/week for 4-6 months
• Probiotics to prevent recurrence?
I. Results of different studies are controversial, most studies have been in
favor of the probiotics in the prevention or treatment of BV, and no adverse
effects have been reported. Therefore, it may be helpful to recommend
daily consumption of probiotic products to improve public health among
women.
II. Yogurt daily for 2 months (Cat B rec)
• Lactobacillus suppositories
• Daily for a week, stop for a week, then daily for second week.
Vulvovaginal Candidiasis (VVC)
• Candida Vulvovaginitis accounts for 45% of Vaginitis
• Candida is cultured in 20-50% asymptomatic women
• Vaginitis often self diagnosed incorrectly
• Acute: Candida albicans (90%)
I.
Normal commensal organism in vagina
II.
Infection when Corynebacterium suppressed
• Recurrent Vulvovaginal Candidiasis
I.
Candida glabrata (increasing Incidence, now 15%)
II.
Candida tropicalis
III. Candida parapsilosis
IV. Saccharomyces cerevisiae
Risk Factors for Candidiasis
• Diabetes Mellitus
• Medications: Corticosteroids, immunosuppressant, broad spectrum
antibiotics
• Oral Contraceptives
A. Increases frequency of Candida carrier state
B. Does not increase symptomatic vulvovaginitis
• Heat and moisture retaining clothing (e.g. nylon)
• Pregnancy (and other hyperestrogenic states)
• Premenstrual phase of the menstrual cycle
• Depressed cell mediated immunity (e.g. HIV or AIDS)
• Obesity
Signs and Symptoms
• Signs
I.
Adherent white cottage-cheese discharge in vagina
a. Sensitivity: 50%
b. Specificity: 90%
II.
Vulvar erythema and edema (24% of cases)
• Symptoms
I.
Asymptomatic in 20-50% of women
II.
Intense vaginal or Vulvar Pruritus (50% of cases)
III. Vulvar Burning, soreness, or irritation
IV. Thick white curd-like or "cottage cheese" discharge
V.
No odor
VI. Dyspareunia
VII. Dysuria (33% of cases)
Labs
• KOH Preparation
I. Test Sensitivity: 50%
II. Pseudohyphae or budding yeast forms
• Vaginal pH <4.5 (Normal acidity)
• Absent Amine odor
• White Blood Cells not increased
• Wet-Prep is not sensitive or specific for yeast
• Candida on Pap Smear
I. Specific but not sensitive
• Fungal PCR for candida strain
I.
Consider in cases refractory to standard therapy
Treatment of Vaginal Candidiasis
• All topical agents are highly effective. No evidence that one formulation is superior to another.
• Miconazole
I.
Monistat 1200 mg vaginal tab PV qhs, 1 dose
II.
Monistat 4% cream, 5 g PV qhs for 3 days
III.
Monistat-3 200mg PV qhs for 3 days ($30)
IV. Monistat-7 2% cream PV qhs for 7 days ($15)
V.
Monistat Vag tabs 100mg PV qhs for 7 days ($15)
• PO Fluconazole present in vagina for about 72 hours. Has more side effects, but preferred by
patients.
I.
Fluconazole 150 mg PO for 1 doseAs effective as Clotrimazole PV
II.
Do not use in pregnancy
III.
Consider repeat scheduled treatment for persistent symptoms
A. Consider prescribing Fluconazole 150 mg every 3 days for up to 3 doses for
persistent vaginitis symptoms
Genital Herpes Simplex Virus
• Most common cause of genital ulcer in United States
I.
Responsible for 60-70% of genital ulcers in sexually active patients
• Affects 10-30% of sexually active patients
• U.S. Prevalence: 30-45 Million
• U.S. Incidence: 300,000 new symptomatic cases yearly
• Not reportable
• Latex condoms are effective in preventing transmission
• Cause of Genital Herpes
I.
HSV II: 80-90% HSV I: 10-20%
• Associated with stressors
I.
Virus remains latent in spinal nerve roots
Primary HSV
• Skin Lesions
I.
Starts as shallow vesicle
II. Umbilicates with central depression
III. Ulcerate early in course
IV. Crusts and then re-epitheliazes without scarring
V. Multiple, grouped lesions are common and may coalesce
VI. Very painful on ulceration
VII.Present for 4-15 day
• Adenopathy
I.
Starts during second or third week of disease
II. Usually bilateral inguinal adenopathy
III. Slightly enlarged, mildly tender
• Viral shedding: 15-16 days. Complete lesion healing: 19-21 days
Primary HSV Management
• Outpatient: shortens duration of pain and period of viral shedding
I.
Acyclovir
A. Acyclovir 400 mg orally three times daily for 7-10 days or
B. Acyclovir 200 mg orally five times daily for 7-10 days
II.
Famciclovir 250 mg orally three times daily for 7-10 days
III. Valacyclovir 1000 mg orally twice daily for 7-10 days
• Inpatient: severe or complicated HSV infection
I. HSV-related hepatitis, encephalitis, or pneumonitis
II. Acyclovir 5-10 mg/kg IV q8h for 2 to 7 days
A. Convert to oral agents when able
Recurrent HSV
• Prodrome (occurs in 50% of cases, hours to days before
lesions): Tingling, dysesthesia, and numbness
• Adenopathy: slight, mildly tender
• Vessicles ulcerate and then crust
I.
Solitary or 3-4
II. Enlarges over 3-4 days
III. Peaks at 4-8 days
• Viral shedding during first 3-4 days
• Recurrence: 5-8 episodes per year
Episodic Management of Recurrent
HSV
• Start within 24 hrs of first symptoms
• Acyclovir
• Acyclovir 200 mg orally five times daily for 5 days or
• Acyclovir 400 mg orally three times daily for 5 days or
• Acyclovir 800 mg orally twice daily for 5 days or
• Acyclovir 800 mg orally three times daily for 2 days
• Famciclovir
• Famciclovir 125 mg orally twice daily for 5 days or
• Famciclovir 250 mg orally twice daily for 2 days (500 mg for first dose) or
• Famciclovir 1000 mg orally twice daily for 1 day
• Valacyclovir
• Valacyclovir 500 mg orally twice daily for 3 days or
• Valacyclovir 1000 mg orally once daily for 5 days
Suppressive Therapy of Recurrent
HSV
• Indication is more than 6 episodes per year
• Acyclovir
I.
Typically used for 12 months (Appears safe for up to 6 years)
II.
Consider as prophylaxis at stress times
III. Decreases episodes from 11.4 to 1.8 per year
• Valacyclovir reduces HSV-2 transmission to partner by 50%
Neisseria Gonorrhea
• Much less common than chlamydia
• Incidence: 500-700,000 cases per year
• Second most common reportable STD
• Highly contagious: 50% transmission
• Chlamydia coexists in 45-50% of patients with Gonorrhea
• Most common in young women
I.
Ages 15 to 19 years old
II. Incarcerated women under age 35 years
Signs and Symptoms
• Women (asymptomatic in 95% of cases)
I.
Delayed diagnosis is common with risk of pelvic inflammatory disease or disseminated gonococcus
II. Mucopurulent cervicitis (most common presentation)
III. Onset 5-10 days after exposure
IV. Odorless vaginal discharge (observed from os)
V. Vaginal Bleeding or spotting (may present as metrorrhagia)
VI. Friable cervix bleeds easily
VII. Bartholin's gland inflammation
VIII.Skene's gland inflammation ( anterior wall of the vagina, around the lower end of the urethra)
• Men (symptomatic in 90% of cases)
I.
Symptom onset within 2-6 days of exposure (may be delayed up to 30 days after exposure)
II. Dysuria
III. Epididymitis (unilateral testicular pain)
IV. Purulent discharge from urethra meatus
Complications
• Pelvic Inflammatory Disease (PID) in 10-20% of cases
• Fitz-Hugh Curtis Syndrome (rare)
I.
Perihepatitis syndrome that may present as right upper quadrant pain
• Systemic Gonorrhea
• Chronic Arthritis
• Neonatal Gonorrhea
I.
Gonorrheal Conjunctivitis
• Preterm Labor
• Endocarditis (rare)
• Meningitis (rare)
Treatment
• Treat for chlamydia (30-50% coinfection) if Gonorrhea positive
• Uncomplicated Non-Pregnant
I.
II.
Azithromycin 1 gram orally in all cases to treat the Gonorrhea infection (regardless of chlamydia status)
Ceftriaxone 250 mg IM for 1 dose
A. Cure rate: 99%
B. Previously dose was 125 mg
III. Severe Cephalosporin allergy (e.g. Anaphylaxis or Toxic Epidermal Necrolysis)
A. Give Azithromycin 2 grams orally for 1 dose as only medication AND
B. Recheck for cure in 1 week
• Uncomplicated Pregnant
I.
Ceftriaxone 250 mg IM
II.
Azithromycin 2 grams PO for 1 dose
Indicated for cephalosporin resistance
High-dose related GI intolerance is common
One gram dose may not be effective for Gonorrhea
Retest one week later to confirm clearance
A.
B.
C.
D.
Chlamydia Trachomatis
• Most common STD in the United States
• Incidence: 2.8 million cases/year in U.S. as of 2010
• Asymptomatic teenage female test positive: 5-10%
• Sexually active persons: 10%
• Chlamydia infection is 6 to 10 times more common than gonorrhea
• Screening
I.
Women
A. Screen all women with mucopurulent cervicitis, sexually active women age 25 and
younger, and all pregnant women
II.
Men
I. Urethritis in men (especially age <35 years)
Labs
• DNA-amplification test (Gold Standard)
I.
Same swab can be sent for gonorrhea DNA testing
II. Can be endocervical, rrethral, vaginal, pharyngeal or rectal
III. Dirty urine (no cleansing prior) can be tested as well (first morning
void is preferred)
IV. Sensitivity
A. Cervix: >90%
B. Male Urethra: >95%
C. Urine male and female: >90%
V. Specificity: 94 to 99.5%
Treatment
• Equally effective. No test of cure needed.
• Azithromycin 1 gram orally for 1 dose or Doxycycline 100 mg orally twice daily for 7
days
• Alternative agents
I.
Ofloxacin 300 mg orally twice daily (or 600 mg once daily) for 7 days or
II.
Levofloxacin (Levaquin) 500 mg orally daily for 7 days or
III.
Erythromycin 500 mg orally four times daily for 7 days or
IV. Erythromycin Ethylsuccinate (EES) 800 mg orally four times daily for 7 days or
• Pregnancy
I.
Azithromycin 1 gram orally once as single dose or
II.
Erythromycin OR EES as above for 7 days or
III.
Amoxicillin 500 mg orally three times daily for 7 days (Only 50% effective)
Question 1
Which one of the following is most appropriate for the treatment
of gonorrhea?
A) Azithromycin (Zithromax)
B) Azithromycin plus ceftriaxone (Rocephin)
C) Cefixime (Suprax)
D) Ciprofloxacin (Cipro)
Answer
B) Azithromycin plus ceftriaxone (Rocephin)
In 2011 the Centers for Disease Control and Prevention
recommended dual treatment with ceftriaxone, 250 mg
intramuscularly, and azithromycin, 1 g orally, as the most
effective treatment for uncomplicated gonorrhea.
Question 2
A 20-year-old white female presents with painful and frequent urination that
has had a gradual onset over the past week. She has never had a urinary
tract infection. There is no associated hematuria, flank pain, suprapubic pain,
or fever. She says she has not noted any itching or vaginal discharge. A
midstream urine specimen taken earlier in the week showed significant pyuria
but a culture was reported as no growth. She has taken an antibiotic for 2
days without relief. Her only other medication is an oral contraceptive agent.
Which one of the following is the most likely infectious agent?
A) Escherichia coli
B) Chlamydia trachomatis
C) Candida albicans
D) Staphylococcus saprophyticus
Answer
B) Chlamydia trachomatis
Gradual onset, absence of hematuria, and week-long duration of
symptoms suggest a sexually transmitted disease. A history of a new
sexual partner or a finding of mucopurulent cervicitis would confirm the
diagnosis. Empiric treatment with a tetracycline and a search for other
sexually transmitted diseases would then be indicated.
Another possible diagnosis is urinary tract infection with Escherichia coli
or Staphylococcus species; however, the onset of these infections is
usually abrupt and accompanied by other signs, such as suprapubic
pain or hematuria. Candida is unlikely because there is no
accompanying discharge or itching, and the patient’s symptoms predate
the use of antibiotics.
Question 3
A 28-year-old male presents with the recent onset of intermittent urethral discharge accompanied
by dysuria. He is heterosexual, has no prior history of a sexually transmitted infection, and
acquired a new sexual partner a month ago. He has no regional lymphadenopathy or ulcers, and
gentle milking of the urethra produces no discharge. Evaluation of a first-void urine specimen,
however, reveals 15 WBCs/hpf. You treat him with oral azithromycin (Zithromax), 1 g in a single
dose, and ceftriaxone (Rocephin), 125 mg intramuscularly. Test results for gonorrhea, Chlamydia,
syphilis, HIV, and hepatitis B are negative. He returns 2 months later because his urethral
discharge has persisted. He reports no relationships with a different sexual partner, and is
confident that his current partner has only had sexual contact with him. You repeat the previous
tests and again treat him with oral azithromycin. According to CDC testing and treatment
guidelines, which one of the following drugs should be added to his treatment regimen?
A) Metronidazole (Flagyl)
B) Amoxicillin/clavulanate (Augmentin)
C) Ciprofloxacin (Cipro)
D) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
E) Cefixime (Suprax)
Answer
A) Metronidazole (Flagyl)
Initial workup for urethritis in men includes gonorrhea and Chlamydia testing of the
penile discharge or urine, urinalysis with microscopy if no discharge is present,
VDRL or RPR testing for syphilis, and HIV and hepatitis B testing. Empiric treatment
for men with a purulent urethral discharge or a positive urine test (positive leukocyte
esterase or 10 WBCs/hpf in the first-void urine sediment) includes azithromycin, 1 g
orally as a single dose, OR doxycycline, 100 mg orally twice a day for 7 days, PLUS
ceftriaxone, 125 mg intramuscularly, OR cefixime, 400 mg orally as a single dose.
If the patient presents with the same complaint within 3 months, and does not have
a new sexual partner, the tests obtained at his first visit should be repeated, and
consideration should be given to obtaining cultures for Mycoplasma or Ureaplasma
and Trichomonas from the urethra or urine. Treatment should include azithromycin,
500 mg orally once daily for 5 days, or doxycycline, 100 mg orally twice daily for 7
days, plus metronidazole, 2 g orally as a single dose.
Question 4
An asymptomatic 32-year-old male requests screening for sexually transmitted
diseases. A nucleic acid amplification test is performed on a urine sample, and the
results are positive for gonorrhea and negative for Chlamydia. The patient has no
known drug allergies. Which one of the following is the recommended treatment for
this patient?
A) Ceftriaxone (Rocephin), 125 mg intramuscularly
B) Ceftriaxone, 250 mg intramuscularly
C) Ceftriaxone, 250 mg intramuscularly, plus azithromycin (Zithromax), 1 g orally
D) Ceftriaxone, 125 mg intramuscularly, plus doxycycline, 100 mg orally twice daily
for 7 days
E) Ciprofloxacin (Cipro), 500 mg orally
Answer
C) Ceftriaxone, 250 mg intramuscularly, plus azithromycin (Zithromax), 1 g
orally
The recommended treatment regimen for gonorrhea is ceftriaxone, 250 mg
intramuscularly. The 125-mg regimen is no longer recommended because of
treatment failures and limited effectiveness in pharyngeal infections. In
addition, the patient should be given azithromycin, 1 g orally, because of the
high incidence of co-infection with Chlamydia, even if testing is negative, and
to decrease the risk for cephalosporin resistance.
Pelvic Inflammatory Disease
• Incidence: 750,000 cases per year in United States
• Age: Peaks between ages 15 to 29 years
• Risk Factors
I.
Untreated Chlamydia or Gonorrhea is associated with a 10-20% risk of PID
II.
Age younger than 25 years
III. Onset sexual intercourse at a young age (younger than 15 years old)
IV. Prior history of Pelvic Inflammatory Disease
V.
High number of sexual partners
VI. Non-barrier contraception (e.g. IUD, Oral Contraceptives)
• Symptoms (usually in first half of menstrual cycle)
I.
Abdominal/pelvic Pain or cramping (varying intensity); vaginal Discharge (new or
abnormal); fever or chills (fever may be high grade); dyspareunia, dysuria; and heavy or
prolonged menses or post-coital bleeding
Diagnostic Criteria
• Major Criteria (Required)
I.
Uterine or adnexal tenderness to palpation or
II. Cervical motion tenderness
III. No other apparent cause
• Minor Criteria (Supporting, but not required)
I.
Fever >101 F (38.3 C)
II. Abnormal discharge per cervix or vagina
III. WBCs on Gram stain or saline of cervix swab
IV. Gonorrhea or chlamydia testing positive
V. Increased ESR or CRP
General Management
• Intrauterine Device (IUD) removal is controversial
I.
IUD increases PID for only first 3 weeks following insertion
A. Risks are similar between the Copper-T IUD and the Mirena IUD
II.
Historically, IUD has been removed at time of PID diagnosis
III. No evidence supports removal of IUD in PID
IV. Close follow-up is critical for those who developed PID with IUD in place
• Treat patient's sexual contacts within last 60 days
I.
Abstain from sexual intercourse until patient and partner have completed
treatment
• Start empiric therapy if minimal criteria present
I.
Do not delay treatment
II.
Delay >3 days increases ectopic and infertility risk
• Antibiotic should cover Gonorrhea and Chlamydia
Admission Criteria
• Severe illness
I.
Toxic appearance
II.
High fever
• Unable to take oral fluids or oral medications
• Unclear diagnosis
• Appendicitis, ectopic pregnancy, ovarian torsion
• Pelvic abscess (tubo-ovarian abscess)
I.
Requires at least 24 hours of parenteral therapy inpatient
• Pregnancy
• HIV positive
• Adolescents
• Outpatient treatment failure
• Unreliable patient
Treatment
• Outpatient
I.
Ceftriaxone 250 mg IM for 1 dose plus Doxycycline 100 mg PO bid for 14
days (75% cure, preferred agent) and with/without Metronidazole 500 mg
orally twice daily for 14 days
II.
Cefoxitin 2g IM and Probenecid 1g PO plus Doxycycline and Metronidazole
as above.
• Inpatient
I.
Treat for at least 48 hours IV
II. Regimen A (preferred)
A. Cefoxitin 2g IV q6h OR Cefotetan 2g IV q12h and
B. Doxycycline 100 mg PO or IV q12h
III. Regimen B
A. Clindamycin 900 mg IV q8h and
B. Gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h
i. Alternative: Conversion to single daily dosing (at 3-5 mg/kg)
HIV Screening (USPTF 2013)
• Screen all patients ages 15 to 65 years (unless patient opts out,
refuses)
I.
Screen up to annually depending on risk
II. CDC recommends starting screening at age 13 years
• High risk indications (more frequent screening, at least annually,
and regardless of age)
• New diagnosis of tuberculosis at onset of treatment
• All patients presenting with possible STD related concerns
• All pregnant patients with prenatal labs (and again in third trimester
in high risk patients and communities)
HIV Test Results
Genital Ulcers
• Causes: Mnemonic - CHISEL
• Chancroid (painful)
• Herpes Genitalis (painful)
• Inguinale (Granuloma Inguinale)
• Syphilis
• Eruption secondary to drugs (Fixed Drug Eruption)
• Lymphogranuloma venereum
• Haemophilus ducreyi
Chancroid
• Chancroid is very common in third world (e.g. Africa)
I.
Responsible for 50-70% of genital ulcers in third world
II.
Replaces genital herpes (rare in third world) as the most common genital ulcer cause in third
world
• Chancroid is rare in United States (except possibly urban centers)
I.
Outbreak in L.A. 1987
II.
Only 28 cases were reported to the State Health Departments in 2009
• Reportable disease
• Co-infection with HSV and syphilis is common
• Antibiotic options
• Azithromycin 1 gram orally for 1 dose
• Ceftriaxone 250 mg IM for 1 dose
• Ciprofloxacin 500 mg orally twice daily for 3 days
• Erythromycin 500 mg orally four times daily for 7 days
Granuloma Inguinale
• Rarest of the ulcerative sexually transmitted diseases
• Lymphadenopathy absent
• Papule or ulcer
• Persistent, painful, beefy-red papules or ulcers onset 2-3 months after exposure
• Necrosis or sclerosis may occur
• Klebsiella granulomatous (Donovan bodies on biopsy)
• Continue antibiotics until lesions are fully healed (at least 21 days)
• Antibiotics (Minimum course: 21 days)
• Doxycycline 100 mg orally twice daily
• Azithromycin 1 gram orally once weekly
• Ciprofloxacin 750 mg orally twice daily
• Erythromycin base 500 mg orally four times daily
• Trimethoprim-Sulfamethoxazole (Bactrim) DS 160/800 orally twice daily
Syphilis
• Screening
I.
Annually for all men who have sex with men
II. IVDA
III. Sex workers
IV. H/O other STDs
V. Known partner with syphillis
VI. HIV co-infection with syphilis is common
A. HIV patients are at higher risk of neurosyphilis
• If negative test with lesions present or other strong clinical indicators
I.
Repeat screening in 2-3 weeks
Diagnosis of Syphilis
• Definitive test is Dark Field microscopy
• Non-Treponemal Derived Substance precipitates antibody
• Venereal Disease Research Laboratory (VDRL) and Rapid Plasma
Reagin (RPR)
• Correlates with disease activity (4 fold decline in titer by 6 months)
• Rarely positive for life.
• Treponemal antigen precipitates Antibody
• Fluorescent Treponemal Antibody (FTA-ABS)
• Sensitivity: 80%
• Correlates poorly with disease activity. Not used to assess treatment
response. May remain positive.
• VDRL (Venereal Disease Research Lab Test) CSF
• High specificity with low sensitivity.
Syphilis Treatment
• Primary, secondary, early latent (under one year)
I.
II.
Benzathine Penicillin G
A. Adult: 2.4 MU IM for 1 dose
B. Child: 50,000 units/kg IM for 1 dose (max: 2.4 MU)
Aqueous Procaine Penicillin G 0.6 MU IM qd for 8 days
III. Jarisch-Herxheimer Reaction may occur
A. Acute febrile reaction in first 24 hours of Syphilis treatment
IV. If Penicillin allergic
A. Ceftriaxone 1 gram IM or IV for 10-14 days
B. Tetracycline 500 mg orally four times daily for 14 days
C. Doxycycline 100 mg orally twice daily for 14 days
D. Azithromycin 2 grams orally once
i.
High risk of resistance
ii. Use only in Penicillin allergic patients who can not take
doxycyline, Minocycline or Ceftriaxone
iii. Avoid in pregnant women or men who have sex with men
Syphilis Treatment continued…
• Late latent, Cardiovascular Syphilis (duration over 1 year)
I.
II.
Benzathine Penicillin G 2.4 MU IM qWeek for 3 weeks
If Penicillin allergic
A. Tetracycline 500 mg PO qid for 4 weeks
B. Doxycycline 100 mg PO bid for 4 weeks
• Neurosyphilis
I.
II.
Penicillin (with probenacid 500 mg orally four times daily for 10-14 days)
A. Aqueous crystalline Penicillin G
i.
Dose: 3-4 MU IV every 4 hours for 10-14 days (18-24 MU daily)
ii. Alternative: 0.75 to 1 MU/hour continuous IV
Procaine Penicillin G (only in compliant patients)
A. Dose 2.4 MU IM once daily for 14 days
B. Use with Probenecid 500 mg qid for 14 days
• Penicillin Allergy
I.
Desensitize and treat with Penicillin
Lymphogranuloma Venereum
• Previously rare in the United States. Recent outbreaks in U.S.
• More common in HIV patients and homosexual men
• Unilateral in 66% of cases
• Painful, tender inguinal or femoral lymphadenopathy
• Chlamydia trachomatis serotype L1, L2, L3 culture positive
• Management
I.
Doxycycline 100 mg orally twice daily for 21 days
II. Pregnancy or lactation: Erythromycin base 500 mg orally four times
daily for 21 days
III. Treat asymptomatic sexual contacts from last month:
Doxycycline 100 mg PO bid for 7 days or Azithromycin 1 gram PO x1
dose
Hepatitis B
• Transmission (100 fold more infectious than HIV)
I.
Percutaneous (needlestick) exposure
A. Sharing non-sterile needles
B. Tattooing
C. Health care accidents
II. Blood product exposure
III. Sexual contact
IV. Perinatal exposure
• Prevalence
I.
Endemic in sub-Saharan Africa, China, Southeast Asia
A. Acquired in early life in endemic areas
B. Chronic Hepatitis B: 5 to 20%
II. Worldwide: 300 million infected
III. United States: 1.5 million Hepatitis B carriers
• Incidence
I.
United States: 100,000 new cases per year
Hepatitis B Screening
• The USPSTF recommends screening for hepatitis B virus (HBV)
infection in pregnant women at their first prenatal visit (Grade A)
• USPSTF recommends that persons at high risk for hepatitis B virus
(HBV) infection should be screened (May 2014,Grade B)
I.
Those born in countries where the prevalence of HBV infection is 2%
or greater
II. Those born in the U.S., not vaccinated in infancy, and whose parents
were from a country with a high HBV prevalence
III. HIV-positive people
IV. Injection drug users
V. Household contacts of people with HBV
VI. Men who have sex with men
Hep B Post Exposure Prophylaxis
• Healthcare workers exposed to HBsAg positive patient
I.
Give Hep B Immune globulin (HBIG) after exposure and start
on Hep B vaccination series if not previously vaccinated.
• Newborn of mothers with HBV
I.
Give HBIG after delivery and start Hep B vaccination series.
Hepatitis C
• Prevalence
I.
U.S. Population: 1.8% (4 to 6.5 million)
II.
World: estimated at >150 million
III. Intravenous Drug Abuse: 97% (some communities)
• Incubation 7-8 weeks
I.
HCV RNA found in blood within 3 weeks post-exposure
• Sexual transmission is much less common
I.
Prevalence 1.5% in long term partners
II. Higher risk behaviors that raise transmission
A. Multiple partners
B. Early sex
C. Non-Condom use
D. Sex with associated trauma
E. Comorbid STD
Hepatitis C Screening
• The USPSTF recommends screening for hepatitis C
virus (HCV) infection in persons at high risk for
infection.
• The USPSTF also recommends offering 1-time
screening for HCV infection to adults born between
1945 and 1965. (Grade B, June 2013)
CDC Recommended testing sequence
for identifying current hepatitis C virus
(HCV) infection (May 2013)
- Testing for HCV infection begins with either
a rapid or a laboratory-conducted assay for
HCV antibody in blood.
- Non-reactive HCV antibody result indicates
no HCV antibody detected.
- A reactive result indicates one of the
following: 1) current HCV infection
2) past HCV infection that has resolved
3) false positivity.
- A reactive result should be followed by NAT
for HCV RNA.
- If HCV RNA is detected, that indicates
current HCV infection.
- If HCV RNA is not detected, that indicates
either past, resolved HCV infection, or false
HCV antibody positivity.
• Prevalence
Human Papilloma Virus
I.
Clinically evident in 1% of those sexually active in the U.S. (20 Million U.S.
adults)
II.
Lifetime risk: 10%
• Peak ages in United States
I.
Women: 20 to 24 years old
II.
Men: 25 to 29 years old
• HPV16 and HPV18 are known to cause around 70% of cervical cancer cases
• Sexually Transmitted
I.
Evaluate for other STDs if present
II.
Penile warts confer 50% transfer risk to cervix
• Incubation period
I.
Four weeks to more than a year after exposure
HPV in Pregnancy
• Indications for HPV treatment in pregnancy
• Treat only lesions that would obstruct labor or result in significant bleeding during
delivery
• CDC does not recommend treatment in pregnancy to prevent neonatal HPV exposure
• CDC also does not recommend Cesarean Section to avoid neonatal exposure
during delivery
• Despite the increased risk of neonatal respiratory papillomatosis, Cesarean section
and wart treatment does not reduce risk
• Absolute contraindications
• Avoid Podophyllin, Podofilox, and fluorouracil
• Agents with relative safety for use in pregnancy
• Trichloroacetic acid
• Cryotherapy
• Surgical excision
• Electrocautery
Question 5
A 19-year-old sexually active female comes to your office for a routine
checkup. She is generally healthy with no chronic conditions and does not
smoke. For this patient, screening for which one of the following is supported
by the best evidence?
A) Hypercholesterolemia
B) Cervical cancer
C) Chlamydia infection
D) HPV infection
E) Intimate partner violence
Answer
C) Chlamydia infection
According to the U.S. Preventive Services Task Force (USPSTF), there is
good evidence that screening for Chlamydia infection in women who are at
increased risk can reduce the incidence of pelvic inflammatory disease, while
the harms are minimal. The evidence regarding screening for cervical cancer
with Papanicolaou testing or human papillomavirus (HPV) testing, however,
shows that the harms outweigh any possible benefits. Harms include over
diagnosis and overtreatment, including invasive cervical procedures that can
affect future pregnancy outcomes. In addition, there is adequate evidence
that screening women younger than 21 years of age (regardless of sexual
history) does not reduce the incidence of cervical cancer or mortality
compared with beginning screening at age 21.
QUESTION 6
A 42-year-old male with a history of intravenous drug use
asks to be tested for hepatitis C. The hepatitis C virus
(HCV) antibody enzyme immunoassay and recombinant
immunoblot assay are both reported as positive. The
quantitative HCV RNA polymerase chain reaction test is
negative. These test results are most consistent with
A) very early HCV infection
B) current active HCV infection
C) a false-positive antibody test
D) past infection with HCV that is now resolved
Answer
D) past infection with HCV that is now resolved
A positive enzyme immunoassay should be followed by a
confirmatory test such as the recombinant immunoblot assay. If
negative, it indicates a false-positive antibody test. If positive, the
quantitative HCV RNA polymerase chain reaction is used to
measure the amount of virus in the blood to distinguish active
from resolved HCV infection. In this case, the results of the test
indicate that the patient had a past infection with HCV that is now
resolved.
Question 7
Which one of the following is recommended for routine
prenatal care?
A) Hepatitis C antibody testing
B) Parvovirus antibody testing
C) Cystic fibrosis carrier testing
D) HIV screening
E) Examination of a vaginal smear for clue cells
Answer
D) HIV screening
HIV screening is recommended as part of routine prenatal
care, even in low-risk pregnancies. Counseling about cystic
fibrosis carrier testing is recommended, but not routine
testing. Hepatitis C and parvovirus antibodies are not part of
routine prenatal screening. Routine screening for bacterial
vaginosis with a vaginal smear for clue cells is not
recommended.
Question 8
A 58-year-old healthy white female sees you for a routine visit. She is
monogamous with her husband, is a nonsmoker, has two alcoholic drinks a
week, and has mild GERD. Her BMI is normal. She takes an over-the-counter
H2-blocker and a multivitamin with calcium. She had a normal mammogram 1
month ago and a negative colonoscopy at age 53. She has never had a DXA
scan or screening for ovarian cancer. Her family history is noncontributory.
According to the U.S. Preventive Services Task Force, you should recommend
A) HIV screening
B) CA-125 testing for ovarian cancer screening
C) DXA for osteoporosis screening
D) colonoscopy for colorectal cancer screening
Answer
A) HIV screening
The U.S. Preventive Services Task Force (USPSTF) and the Centers for
Disease Control and Prevention (CDC) recommend that all adults age 65
years and under be screened for HIV regardless of risk factors.
The USPSTF does not recommend routine screening for ovarian cancer
with a bimanual examination, transvaginal ultrasonography, or CA-125
testing. The USPSTF recommends that women age 65 and older be
screened for osteoporosis with a DXA scan. Women younger than age 65
should be screened only if their risk of fracture is equal to or greater than
a 65-year-old white female with no additional risk factors.
Question 9
A 14-year-old female sees you for a well child visit. She is healthy and has
no complaints or concerns today. A review of her past immunizations
shows that she was up to date on all required immunizations at her 8-yearold well child visit. She also received HPV vaccine at age 11 and 12, and
quadrivalent meningococcal vaccine (MCV4) and TdaP at age 12. Which
one of the following vaccines should she receive at this visit?
A) Hepatitis C
B) HPV
C) Inactivated poliovirus
D) Measles
E) Rubella
Answer
B) HPV
HPV vaccine is given as a three-dose series, so this patient is due for her third
dose. The recommended interval between the first and third doses is 6 months,
with approximately 4 months recommended between the second and third
doses; however, the series can safely be completed at longer intervals (SOR
C). The patient received her second dose at age 12 and she is now 14 years of
age, so it has been over 4 months
References
• AAFP Board Review 2014
• UpToDate
• CDC Guidelines
• USPSTF Guidelines
• ABFM
• American Family Physician Journal