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Sexually Transmissible Infections

Approximately 12 million patients are diagnosed with a sexually transmissible infection (STI) annually in the United States. Sequella of STIs include infertility, chronic pelvic pain, ectopic pregnancy, and other adverse pregnancy outcomes.

Diagnosis and Treatment of Bacterial Sexually Transmissible Infections

Chlamydia trachomatis

 

Direct fluorescent antibody

Enzyme immunoassay

Nucleic acid hybridization (DNA probe)

Cell culture

DNA amplification

Doxycycline 100 mg orally 2 times a day for 7 days or

Azithromycin (Zithromax) 1 g orally

Ofloxacin (Floxin)300 mg orally 2 times a day for 7 days or

Erythromycin base 500 mg orally 4 times a day for 7 days or erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days.

Neisseria gonorrhoeae

Gram stain of endocervical smear

Culture

DNA probe

Ceftriaxone (Rocephin) 125 mg IM or

Cefixime 400 mg orally or

Ciprofloxacin (Cipro) 500 mg orally or

Ofloxacin (Floxin) 400 mg orally

plus

Doxycycline 100 mg 2 times a day for 7 days or azithromycin 1 g orally

Spectinomycin 2 g IM or injectable cephalosporins given single IM dose such as ceftizoxime 500 mg, cefotaxime 500 mg, cefotetan 1 g IM, and cefoxitin (Mefoxin) 2 g IM with probenecid 1 g orally; or quinolones given single oral dose such as enoxacin 400 mg, lomefloxacin 400 mg, or norfloxacin 800 mg

 

Treponema pallidum

Clinical appearance

Dark-field microscopy

Nontreponemal serologic test

Rapid plasma reagin

VDRL

Treponemal test

MHA-TP

FTA-ABS

Primary and secondary syphilis and early latent syphilis (<1 year duration):

benzathine penicillin G 2.4 million units IM in a single dose.

Late latent syphilis or latent syphilis of unknown duration and late syphilis (gumma or cardiovascular syphilis, but not neurosyphilis): Benzathine penicillin G 7.2 million units total, as 3 doses of 2.4 million units IM, at 1-week intervals.

Neurosyphilis: Aqueous penicillin G, 18-24 million units a day, as 3-4 million units IV q4h for 10-14 days.

Penicillin allergy in patients with primary, secondary, or early latent syphilis (<1 year of duration): doxycycline 100 mg orally 2 times a day for 2 weeks.

Penicillin allergy in patients with late latent syphilis or latent syphilis of unknown duration: doxycycline 100 mg orally 2 times a day for 4 weeks. (If duration of infection is known to be <1 year, administer for 2 weeks.)

Neurosyphilis: procaine penicillin 2.4 million units IM daily, plus probenecid 500 mg orally 4 times a day, both for 10- 14 days

 

Diagnosis and Treatment of Viral Sexually Transmissible Infections

Organism

Diagnostic Methods

Recommended Treatment Regimens

Herpes simplex virus

Clinical appearance (confirm with culture)

Cell culture

First clinical episode: Acyclovir 400 mg orally 5 times a day for 7-10 days, or famciclovir 250 mg orally 3 times a day for 7-10 days, or valacyclovir 1 g orally 2 times a day for 7-10 days.

Recurrent episodes: acyclovir 400 mg orally 3 times a day for 5 days, or 800 mg orally 2 times a day for 5 days or famciclovir 125 mg orally 2 times a day for 5 days, or valacyclovir 500 mg orally 2 times a day for 5 days

Daily suppressive therapy: acyclovir 400 mg orally 2 times a day, or famciclovir 250 mg orally 2 times a day, or valacyclovir 250 mg orally 2 times a day, 500 mg orally 1 time a day, 1,000 mg orally 1 time a day

Human papilloma

virus

Clinical appearance of condyloma papules

Cytology

External warts: Patient may apply podofilox 0.5% solution or gel 2 times a day for 3 days, followed by 4 days of no therapy, for a total of up to 4 cycles, or imiquimod 5% cream at bedtime 3 times a week for up to 16 weeks. Treatment area should be washed with mild soap and water 6- 10 hours after application. Provider may administer cryotherapy with liquid nitrogen or cryoprobe, repeat every1-2 weeks; or podophyllin resin 10-25% in compound tincture of benzoin in small amounts to each wart, repeat weekly if necessary; or TCA or bichloracetic acid 80-90% in small amounts to each wart, repeat weekly if necessary; or surgical removal.

Vaginal warts: cryotherapy with liquid nitrogen, or TCA 80-90%, or podophyllin 10-25%

Human immuno

deficiency virus

Enzyme immunoassay

Western blot (for confirmation of enzyme

immunoassay)

Polymerase chain reaction

Antiretroviral agents

Centers for Disease Control and Prevention. 2006 Guidelines for the treatment of sexually transmitted diseases. MMWR 2006;47(RR-1)

II. Chlamydia Trachomatis

A. Chlamydia trachomatis infection is the most prevalent STI in the United States. About 4 million cases occur annually. The incidence of infection is two to three times higher.

III. Gonorrhea

A. Gonorrhea has an incidence of 800,000 cases annually. Rates of gonorrhea are highest in the southeastern United States and in large cities. Rates are higher among African Americans than among whites or other racial groups.

IV. Syphilis

A. Over the past five decades, syphilis has decreased dramatically in the United States, with a current incidence of 100,000 cases annually. The rates are highest in the South, among African Americans, and among those in the 20- to 24-year-old age group.

V. Herpes simplex virus and human papillomavirus

A. An estimated 200,000-500,000 new cases of herpes simplex occur annually in the United States, and 25-31 million individuals are infected with the virus. New infections are most common in adolescents and young adults. Routine screening for genital herpes simplex in asymptomatic

B. About 500,000 to 1 million new cases of human papillomavirus infection occur annually.

VI. Human immunodeficiency virus

A. More than 513,000 cases of AIDS have been reported in the United States, and more than 62% of these individuals have died. Women account for 19% of adult and adolescent AIDS.

B. Risk factors for HIV should be assessed in all patients by obtaining a sexual history and information about drug use. Women at high risk of HIV infection should be offered testing.

VII. Pelvic inflammatory disease

A. About 1 million cases of PID occur in the United States annually. Risk factors for PID include young age, low socioeconomic status, unmarried status, residence in an urban area, douching.

B. N gonorrhoeae is usually a symptomatic infection. PID attributable to C trachomatis frequently may be asymptomatic or associated with atypical symptoms such as intermenstrual bleeding.