Sexually Transmitted Diseases JFK pediatric core curriculum

1. Sexually Transmitted DiseasesJFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: CDC, STD Treatment Guidelines, 2006

2. Discussion outline • Common Sexually Transmitted Diseases • Symptoms/signs • Investigations • Treatment • Special notes • Screening • Men who have sex with men/women who have sex with women (MSM/ WSW) • Vaccinations • Sexual Assault

3. Common Sexually Transmitted Diseases • Ulcerative disease • Chancroid • Genital HSV • Granuloma inguinale • Lymphogranuloma venerum • Syphilis • Urethritis/Cervicitis • Vaginal discharge • Bacterial Vaginosis • Trichomoniasis • Vulvovaginal Candidiasis • Pelvic inflammatory disease • Epididymitis • Genital warts • Ectoparasitic infections • Pediculosis Pubis • Scabies

5. Chancroid (H. ducreyi) • Symptoms/signs • Painful genital ulcer, tender suppurative lymphadenopathy • Investigations • Criteria: 1. painful genital ulcer (s) 2. no syphilis 3. Ulcer exudates HSV (-) • Treatment • Azithro 1 g x 1 or CTX 250 mg x1 or Cipro 500 mg po bid x 3d or erythro 500 mg po tid x 7 day • Special notes • 10% co-infected with T. pallidum or HSV • Cofactor for HIV transmission

7. Genital HSV • Symptoms/signs • Mostly no sx • Small, painful, grouped vesicles/ shallow ulcers • Erythema multiforme, neuro sequellae, dissemination • Investigations • DFA or Viral cell cx with typing (low SN for healing lesions) • Neg. virologic test does not rule-out infection due to intermittent shedding • Type-specific serum Ab (after 7wks, persist indefinitely, SN 80-98%, SP>95%) • Treatment • Valacyclovir (1g PO BID) OR famciclovir (250mg PO TID) both have good oral bioavailability, acyclovir (400mg PO TID OR 200mg PO FID). Duration 7-10d. • Severe (complications, hospitalization, CNS): IV acyclovir • Acyclovir-resistant: ID consult, consider foscarnet/topical cidofovir • Special notes • Treat patients with initial genital herpes • Consider 2˚ prevention (suppressive or episodic tx if >5 episodes/yr, though does not clear latent virus) • Counsel re: pregnancy • HSV-2>HSV-1; First-episode likely HSV-1; Recurrence likely HSV-2

9. Granuloma inguinale (Donovanosis) (Klebsiella granulomatis) • Symptoms/signs • Painless, progressive, beefy-red, vascular ulcerative lesions, no LAD • Investigations • Visualization of dark-staining Donovan bodies on tissue crush preparation/biopsy • Treatment • Doxy 100mg PO BID x3wks/until lesions healed • Add gentamicin 1mg/kg IV q8h if no early improvement • Special notes • Tx halts lesion progression

11. Lymphogranuloma venereum (C. trachomatis L1, L2, L3) • Symptoms/signs • Unilateral, tender inguinal/femoral LAD, self-limited ulcer/papule often gone, proctocolitis if anal exposure • Investigations • Urine, genital and/or LN specimens for CT (cx, direct immunofluorescence, nucleic acid detection) • Treatment • Doxy 100mg PO BID x3wks • Buboes require aspiration • Special notes • Tx cures infection and prevents ongoing tissue damage

14. Syphilis (T. pallidum) • Symptoms/signs • 1˚: ulcer/chancre • 2˚: rash, mucocutaneous lesions, LAD • 3˚: cardiac/ophthalmic, auditory, gumma • Neurosyphilis • Latent: (early latent vs. late latent) no sx • Investigations • Definitive: Darkfield exam/DFA of lesion • Presumptive: • Non-treponemal (VDRL, RPR) correlate with disease activity/tx response • Treponemal (FTA-ABS, TP-PA) • If neurologic sx: • CSF: VDRL is SP, FTA-ABS is SN, serologies, CSF cell count/protein • Ocular slit-lamp exam • Treatment • Benzathine PCN G: • 2.4 million units IM x1 for 1˚/2˚/early latent (exposure within 1yr) • 2.4 million units x3wks for 3˚, late latent • Aqueous crystalline PCN G 18-24 million units/d (q4h or continuous) x10-14d • Presumptive tx for sex partners within 90d (tests may have false-negatives) • Special notes • Jarisch-Herxheimer rxn: acute febrile rxn with HA, myalgia within 24h of tx • Follow-up evaluation at 6 and 12 mos (and 24 mos. for latent, and q6 mos. for neurosyphilis)

16. Urethritis/Cervicitis • Symptoms/signs • Urethritis: Mucopurulent discharge, dysuria, pruritis, urgency, nocturia, frequency • Cervicitis: mucopurulent endocervical exudate, dyspareunia, postcoital bleeding, signs of PID • Investigations • Urethritis: Urethral Gram stain with ≥5 WBC (if GNID then NG), UA leukocyte esterase(+); Urethral/urine NAAT for CT/NG (urine preferred) • Cervicitis: Cervical/urine NAAT, wet prep, T. vaginalis cx/Ag (swab preferred, urine okay); leukorrhea by microscopy; GNID on endocervical fluid Gram stain • Treatment • Empiric tx for CT/NG if high risk (≤25yo, new/multiple partners, unprotected sex, poor follow-up) • NGU: azithro 1g PO x1 OR doxy 100mg PO BID x7d • Special notes • Abstinence for 7d post-tx + no sx + partner treated • If sx >3mos, consider chronic prostatitis, chronic pelvic pain syndrome • Retest ♀ 3mos. post-tx (both ♂ and ♀ if gonococcal) • Other causes: ureaplasma urealyticum, mycoplasma genitalium, T. vaginalis, HSV, HPV, adenovirus

18. Bacterial vaginosis (Gardnerella, other anaerobes) • Symptoms/signs • Homogenous, thin-white, malodorous discharge; pruritis • Investigations • Clue cells, pH<4.5, +Whiff test, Gram stain = gold standard, cx is nonspecific • Treatment • Metronidazole 500mg PO BID x7d OR gel 5mg intravaginally QD x5d OR clindamycin 2% cream 5g intravaginally QHS x7d • Special notes • Treating ♀ partners does not reduce recurrence • Can cause endometritis, PID, post-procedure cellulitis

20. Trichomoniasis (T. vaginalis) • Symptoms/signs • Malodorous, yellow-green discharge, vulvar irritation, or no sx • Investigations • nucleic acid probe, SN>83%, SP>97% • Wet prep 60-70% SN • Cx most SN/SP • Treatment • Metronidazole 2 g x1 or 500 mg bid x7days Tinidazole 2 g po single dose • Special notes • Low level metronidazole resistance in 2-5%; Tinidazole longer half-life and higher tissue penetration

22. Vulvovaginal candidiasis (VVC)(C. albicans or other species) • Symptoms/signs • Pruritus, soreness, dyspareunia, external dysuria, abnormal/curdy discharge • Vulvar edema, fissures, excoriations • Investigations • Saline, 10% KOH wet prep or Gram stain with yeast or pseudohyphae • Cx for yeast species (for negative wet mounts) • Treatment • Immunocompetent/sporadic:short course topicals (single dose and regimens of 1-3d) or fluconazole 150mg po x1 • Immunocompromised/ severe recurrent: longer courses • Special notes • 75% of ♀ will have one episode, 40-45% ≥2 • 10-20% will have VVC • Oil based creams may weaken condoms • Topical azoles more effective than nystatin

24. Pelvic inflammatory disease (Mostly C. trachomatis and N. gonorrhoeae) • Symptoms/signs • CMT, urterine/ adnexal tenderness, fever, discharge • Endometritis, salpingitis, TOA, pelvic peritonitis • Investigations • Abundant WBC on wet prep, ESR, CRP, microbiology • Most specific: endometerial bx, transvaginal U/S, laparoscopy • Treatment • Cefotetan 2g IV q12h OR cefoxitin 2g IV q12h PLUS doxy 100mg PO or IV q12h • After 24h of parenteral abx, continue doxy x14d • Add metronidazole or clindamycin if +TOA • Special notes • Empiric abx prevents long-term sequellae • Consider oral quinolone regimen + metronidazole if mild disease and no QRNG suspected

26. Epidydimitis (Mostly C. trachomatis and N. gonorrhoeae) • Symptoms/signs • Unilateral testicular pain, swelling, inflammation • Investigations • Urine NAAT, urethral Gram stain (>5 WBC/hpf), +leuk esterase on UA • Treatment • CTX 250mg IM x1 PLUS doxy 100mg PO BID x10d

28. Genital Warts (HPV types 6 and 11 common) • Symptoms/signs • Flat, papular or pedunculated growths on genital mucosa • Generally asymptomatic, can be painful, friable or pruritic • Investigations • 3-5% acetic acid turns infected genital mucosa white, but little evidence • Bx only if dx uncertain, no response to tx, or patient immunocompromised • Treatment • External: No definitive treatment • Podofilox 0.5% bid x3d, then 4d no therapy, repeat prn ≤ 4 cycles (total area≤10 cm2) • Imiquimod 5% cream QHS, TIW ≤ 16wks • Cryotherapy (various forms) • Podophylin resin 10-25% OR ticholoracetic acid OR bichloroacetic acid • Surgical removal, laser therapy, intralesional interferon • Special notes • Tx may reduce, does not eliminate infection, unclear impact on transmission • Genital warts not an indication for HPV testing, change in frequency of Pap, or colposcopy • Cervical: exclude HGSIL before tx, consult specialist • Vaginal: liquid nitrogen, TCA/BCA • Urethral meatus: liquid nitrogen or podophyllin • Anal: cryotherapy, TCA/ BCA, surgical removal

30. Pediculosis pubis (pubic lice) • Symptoms/signs • Lice or nits on pubic hair • Treatment Recommended: • Permethrin 1% cream or Pyrethrins with piperonyl butoxide • Alternative : • Malathion 0.5% lotion • Ivermectin 250 ug/kg repeated in 2 weeks • Special notes • Resistance to pediculides increasing • Use malathion when treatment failure believed because of resistance • Treat sex partners within previous month

32. Scabies (Sarcoptes cabiei) • Symptoms/signs • Classic burrowing rash, pruritus may persist for ≤ 2wks • Treatment • Recommended: permethrin cream 5% to all areas of the body from the neck down, washed off after 8-14h • Ivermectin 200 ug/kg PO, repeated in 2wks • Alternative: Lindane 1% total body, neck down (toxicity: aplastic anemia, seizure) • Decontaminate bedding/clothing • Special notes • Sensitization to Sarcoptesscabiei occurs before pruritus. With 1st infection takes ≤several wks to develop, may occur ≤24h of reinfection • In adults usually sexually acquired, but not in children • Norwegian scabies (i.e., crusted scabies): aggressive infestation occurs in immunodeficient, debilitated or malnourished persons

33. Key Points • Use syndrome classification to simplify differential diagnosis. • Most genital ulcer disease in the U.S. is HSV or syphilis. • If treating empirically for cervicitis/urethritis, treat for both NG and CT. • New diagnoses mandate testing for other STDs, especially HIV and syphilis. • Test and treat all sex partners. (not generally recommended for candidiasis)

34. Screening • Includes: • (1) education/counseling on safe sex, • (2) identification of asymptomatic infected persons and symptomatic persons unlikely to seek tx, • (3) diagnosis/treatment, • (4) evaluation of sex partners • (5) preexposure vaccination for those at risk of vaccine-preventable STDs • Prevention: abstinence, reduction of sex partners, male/female condoms • Partner management: encourage notification, evaluate sex partners within 60d, consider patient-delivered tx • Asymptomatic testing: • CT: Sexually active ♀ ≤25yo, older ♀ with risk factors • NG: Sexually active ♀ with increased risk (≤25yo, prior STDs, new/multiple partners, inconsistent condom use, drug use) • HIV: Voluntary, universal, opt-out provision. Also consider when other STDs are found or suspected • RPR, HBV sAg/sAb, HCV Ab

35. MSM/WSW • Consider additional sx: genital and perianal ulcers, regional LAD, skin rash, anorectal sx • Annual STD screening for MSM: HIV, RPR, urine/rectal/pharyngeal testing for CT/NG depending on history of insertive/receptive anal/receptive oral intercourse in past year, consider anal cytology/HPV screening. Screen q3-6mos if multiple partners or drug use. • All ♀ require routine Pap and STD screening regardless of sexual practices.

36. Vaccinations • HBV vaccine for all persons evaluated or treated for STDs and for MSM. • HAV vaccine for MSM and illegal-drug users • HPV vaccination in ♀ ≤26yo

37. A word about sexual assualut • Post exposure prophylaxis (see CDC website for current guidelines)