STI

Genital Herpes: Caused by HSV, usually type 2.

Painful, grouped vesicles in the genital and perianal regions that rapidly ulcerate and form shallow tender lesions.

Initial episode associated with inguinal LAD, fever, HA, myalgias, and aseptic (Mollaret) meningitis; recurrences are usually less severe.

Dx: HSV PCR; clinical

Tx:

• Herpes simplex.

  • • 1st episode: Acyclovir 200 mg, 5 times day x 7-10 days or 400 mg PO tid x 7-10 days. Valacyclovir, 1 g PO bid x 7-10 days. Famiciclovir, 250 mg PO tid x 7-10 days.

    • Recurrent episodes: Acyclovir, 400 mg PO tid x 5 d or 800 mg PO tid x 2 days. Valacyclovir, 1 g PO qd x 5 d or 1 g PO bid x 1 d or 500 mg PO bid x 3 d. Famciclovir, 1 g PO bid x 1 d or 125 mg PO bid x 5 d.

    • Suppressive therapy: Acyclovir 400 mg PO bid. Valacylovir 500 mg or 1 g PO daily. Famciclovir, 250 mg PO bid.

• Syphilis

• • Chancroid: H. ducreyi. Produces a painful genital ulcer and tender suppurative inguinal lymphadenopathy. Identification of the organism is difficult and requires special culture media.

    • Azithromycin 1 g PO x 1. Ceftriaxone 250 mg IM single dose. OR

    • Ciprofloxacin, 500 mg PO bid x 3 d. Erythromycin base 500 mg PO bid x 7 d.

  • LGV: C. trachomatis (serovars L1, L2, or L3). Painless genital ulcer, followed by heaped up, matted inguinal lymphadenopathy. Test C. trachomatis ab testing.

    • Doxycycline, 100 mg PO bid x 21 days

    • Erythromycin base 500 mg PO qid x 21 days

• Urethritis/cervicitis:

  • • Gonorrhea: Ceftriaxone 125 mg IM x 1 or Cefepime 400 mg PO x 1 + Azithromycin/doxycycline if chlamydia in not ruled out.

      • If PCN allergic, use Spectinomycin 2 g IM x 1 (not for pharyngeal GC).

      • FQ are not recommended for GC.

    • Disseminated gonococcal infection: Ceftriaxone, 1 g IV daily or Cefotaxime, 1 g IV q8h x 7d (can switch to oral cefixime to complete treatment). Spectinomycin 2 g IM q12h (switch to cefixime to finish the course)

• • Chlamydia: Doxycycline 100 mg PO bid x 7 days, OR Azithromycin 1 g PO x 1. Alternatively, erythromycin 500 mg PO qid x 7 days.

  • PID: Upper genital tract infection in women, usually preceded by cervicitis either acute or chronic cervicitis, acute endometritis, acute salpingitis, tubo-ovarian abscess, pyosalpinx, peritonitis, hydrosalpinx & Fitz-Hugh-Curtis syndrome (periportal inf). Lower abdominal pain, and dyspareunia to peritonitis and tubo-ovarian abscess. Long term complications of untreated PID include chronic pain, infertility, and ectopic pregnancy. CMT, presence of 10 WBC/LPF on endocervical smear GS are consistent with PID. Endocervical cultures or probes for chlamydia and gonorrhea should be obtained.

    • OP Tx: Ceftriaxone 250 mg IM x 1 + Doxycycline 100 mg PO bid x 14 days + metronidazole, 500 mg PO bid x 14 days.

    • IP Tx: Cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h + Doxycycline 100 mg PO bid x 14 d + Metronidazole 500 mg PO bid x 14 d.

    • Alternatives: ampicillin-sulbactam, 3 g IV q6h + doxycyline. Clindamycin 900 mg IV q8h + gentamicin, 2 mg/kg loading dose, then 1.5 mg/kg q8h + doxycycline 100 mg PO bid x 14 d.

• Vagnitis/vaginosis:

  • • Trichomonas: Produces malodorous purulent vaginal discharge, dysuria, and genital inflammation. Profuse, frothy discharge and cervical petechiae. Dx requires visualization of motile trichomonads on a saline wet mount of discharge. pH of vaginal fluid is >4.5.

      • Metronidazole 2 g PO x 1. Tinidazole 2 g PO x 1. Metronidazole 500 mg PO bid x 7 d.

      • Pregnancy: Metronidazole 2 g PO x 1, as adverse outcomes associated with trichomonas during pregnancy.

    • Bacterial vanginosis: Results from replacement of normal lactobacillus in the vagina with high concentration of anaerobic bacteria. Dx requires three of the following critera:

      • • Homogenous, thin, white discharge

        • Clue cells on microscopic exam.

        • pH of vaginal fluid is >4.5

        • Fishy odor of vaginal discharge before or after addition of 10% of KOH (the whiff test)

      • Metronidazole, 500 mg PO bid x 7 day. Clindamycin cream 2% intravaginal at bedtime x 7 days. Metronidazole gel 0.75% intravaginal once a day for 5 days.

      • Clindamycin, 300 mg PO bid x 7 d

      • Clindamycin ovules 100 mg intravaginal qhs x 3 d.

• • Vulvovaginal Candidiasis: VVC ("yeast infection") is generally no a STI but commonly develops in relation to OCP, ABx use. If recurrent think unrecognized HIV. Check of fungal elements on KOH prep of vagnial fluid. Presents as thick, cottage-cheese-like vaginal discharge in conjunction with intense vulvar inflammation, pruritus, and dysuria.

    • Fluconazole, 150 mg PO x 1. Itraconazole, 200 mg PO bid x 1 d. Intravaginal azoles in variety of strengths for 1 - 14 d.

    • Recurrent candidiasis: Fluconazole 100, 150 or 200 mg PO qwk x 6 mo.

    • Fluconazole failure could indicate the presence of a non-albicans Candida species.

HIV and AIDS

Genital infections and STDs

Vaginal infections: Bacterial vaginosis (BV), Trichomonas vaginitis (TV) cadidia vulvovaginitis (CVV), inflammatory vaginits,

BV: Most common vaginitis

Gardnerella vaginalis overgrowth

Loss of lactobacilli: creates anaerobic env.

Etiology: unknown: repeated alkalinization, semen, pH: >4.5

Recurrence is common. Difficult to replace lactobacilli.

Dx: fishy odor 2° to amines; +ve whiff test = release amine with 10% KOH; DC is thin white/grey/yellow; clue cells present on wet prep.

Tx: Metrogel 0.75% (5 g cream per applicator containing 37.5 mg of metronidazole) intravaginally qhs x 7 d; Metronidazole 2 gm PO stat (no ETOH), or, 500 mg PO bid x 7d, or, 250 mg PO tid x 10 d. Cleocin 2% (5 gm per applicator containing 100 mg of clindamycin) intravaginally qhs x 7 d, or 300 gm PO bid x 7 d

In resistant cases extend above Tx to 14 d.

Partners are Tx in Europe. Consider if partner is uncircumcised or recurrence

TV: caused by T. vaginalis, anaerobic parasite-flagellated protozoan; highly contagious: 70% infected w/one exposure, co-inf w/BV is very common (>60%). Pt. has profuse, purulent, pruritic, malodorous DC - secretions exiting vagina. Dx: pH>5, motile Trichs, "strawberry" cervix, clue cells may be seen & Whiff's test +ve: if co-infection with BV

Tx: 2 g PO stat for pt and partner(s). Metronidazole 500 mg PO tid x 7d and partner.

In resistant cases: extend Tx for 14 - 21 d and/or increase the dosage of metronidazole to as high as 1500 mg bid. May add intravaginal gel as adjunct.

CVV:

Tx: Miconazole 200 mg vag. suppository 1 qhs x 3 d or 2% vaginal cream 1 app full intravag qhs x 7d or 100 mg vaginal suppository 1 qhs x 7 d

Clotrimazole 100 mg vag. supp 1 qhs x 7d, or 1% cream 1 app full intravag qhs x 7 d, or 500 mg vag. supp. 1 intravag stat.

other azoles:

Fluconazole 150 - 200 mg PO stat +/- 1% HC cream or antihistaminic or Itraconazole 100 mg, 2 tab PO qd x 3 d.

In persistent or recurrent cases: topical Tx are prolonged for 14 - 21 d

Maintenance regimens for recurrent dz: Miconazole 100 mg supp 2 times/wk, or Terconazole 0.8% vag. cream weekly

Fluconazole (Diflucan) 200 mg PO qod x 3

Inflammatory vaginitis: least common and most recently described type. Difficult to Dx as may mimic any of the above. Usually occurs before menses qmo, more common in menopause, profuse DC. Absent lactobacilli, streps, WBCs:

Tx: Clindamycin 2% vag. cream x 7 d. Augmentin 240 mg PO tid x 14 d

Recurrent: extend vag. cream x 14; oral ABX for 21 d; estrogen cream in menopausal. Tx partner if uncircumcised