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Home , Mycoplasma, Pediculosis pubis, Treponema pallidum

SEXUAL TRANSMITTED UPDATE 2021 OBJECTIVES

• Establish the epidemiological change in STI incidence and prevalence • Review diagnostic tests • Acknowledge treatment changes WHAT DISEASE KILLED THESE MEN? VENEREAL DISEASES

Syphilis

1 STIs

Chlamydia trachomatis immunodeficiency virus Human papilloma virus Anaerobic B virus Candidiasis Ebola virus pubis

1 HISTORY OF VENEREAL DISEASES

• In 1836, Donne found Trichomonas to a sexually transmitted disease. • In 1905,Schaudinn and Hoffman discovered pale spiral rotating organisms and Landsteiner created the new genus pallidum. • Initial treatment included mercury, arsenic, bismuth. • According to a 2020 study, more than 20% of individuals in the range of 15–34 years old in late 18th century London were treated for syphilis • Syphilis 10th leading cause of death in the US in 1923. • WW1 prompted the International Union against Venereal Disease IUVDT

1,2 Prevalence STIs 2018 CDC

CHLAMYDIA

• is a gram negative bacterium. • Leading cause of blindness in the world. • Risk factors • Lack of use • Lower socioeconomic status • Living in an urban area • Multiple sex partners

4 Chlamydia Symptoms

• Women • Abnormal vaginal discharge • Vaginal Bleeding • Dysuria

• Men • Penile discharge • Itching • Dysuria

4 Chlamydia Epidemiology: By age and sex

CDC Chlamydia Epidemiology: By Sex

CDC EPIDEMIOLOGY BY STATE

CDC EPIDEMIOLOGY STD CLINICS BY AGE

CDC

CHLAMYDIA: DIAGNOSIS

• Women: two methods (or three) • Provider obtained vaginal swabs analyzed by NAAT • Vaginal self swab analyzed by NAAT • Urinary sample analyzed by NAAT • Men: • Urine sample analyzed by NAAT • Provider obtained anal swabs

4 CHLAMYDIA: SCREENING

• USPSTF recommends screening all sexually active women age 24 and younger. • USPSTF recommends screening women age 25 and older who are at increased risk because of having multiple sex partners or a new sex partner • CDC recommends screening sexually active men in certain situations • STD clinics • Adolescent clinics • Correctional facilities • CDC recommends screening men who have sex with men

4 CHLAMYDIA DIAGNOSIS: BETTER?

• Canadian study compared self-collected vaginal swabs (SCVS) with provider obtained endocervical swabs, • SCVS sensitivity greater than endocervical swabs for chlamydia (97% vs. 88%)

• In another study, SCVS and endocervical swabs were more sensitive than first-catch urine (FCU) samples (97% vs. 88%

5 CHLAMYDIA DIAGNOSIS: BETTER 2?

• In two FQHCs in LA, a total of 4684 women had extragenital screening which includes taking , rectal, and pharyngeal samples. • Of the 460 women found to have chlamydia rectal chlamydia infections, 91.3% reported not having • Of those who reported no anal sex, 29.3% of the 460 had a negative vaginal chlamydia test • 25.5% of chlamydia infections would have been missed if extragenital screening had not been performed.

6 CHLAMYDIA: TREATMENT

• : 1 gram single dose or doxycycline: 100 mg twice daily for 7 days • Alternative treatments • 500 mg 4 times a day for 7 days • Erythromycin ethylsuccinate 800 mg 4 times a day for 7 days • Levofloxacin 500 mg once daily for 7 days • Pregnant women • Azithromycin 1 gram for one dose or amoxicillin 500 mg 3 times a day for 7 days. • Test of cure in 3-4 weeks for pregnant women only

4,7 CHLAMYDIA: TREATMENT 2

• Expedited partner therapy improves clinical and behavioral outcomes • Partners need to abstain from sex for 7 days after completion of treatment • For caused by chlamydia treatment is doxycycline 100 mg twice daily for 10 days

4,7 CHLAMYDIA: COMPLICATIONS

• Increased risk in women of: • Pelvic inflammatory disease • • Perihepatitis (Fitz-Hugh-Curtis syndrome) • Increased risk in men of: • Epididymo-orchitis • Infertility • Susceptibility of acquiring HIV

4 CHLAMYDIA: COMPLICATIONS 2

• Reactive Arthritis (Reiter Syndrome) • Aseptic arthritis • Non-gonococcal • • Neonatal pneumonia: 12,000 cases/year • 1-3 months following birth • Tachypnea, staccato cough, and no fever • Ophthalmia neonatorum • Sampling needs to include epithelial cells, not just the exudate

4 CHLAMYDIA COMPLICATIONS 3

• • A chronic or recurrent ocular that scars the eyelids. • The eyelashes then scratch and infect the bulbar conjunctiva • Primary cause of infectious blindness in the world, primarily rural Africa and Asia • WHO promotes SAFE (surgery, , facial cleaning, environmental improvement) • Mass community treatment with antibiotics effective up to two years. • Lymphogranuloma venereum: a unilateral, tender inguinal or femoral node • Test for chlamydia: if positive treat with doxycycline for 21 days.

4,7 GONORRHEA

• Gonorrhea is caused by the bacterium . • Same risk factors as with Chlamydia • Predominant site of infection is the cervix in females and the anterior in males. • Symptoms include a cervical or urethral purulent discharge, dysuria, urethritis, or .

8 GONORRHEA: EPIDEMIOLOGY RATES BY YEAR

CDC 4/14/2021 GONORRHEA EPIDEMIOLOGY RATES BY STATE

CDC GONORRHEA EPIDEMIOLOGY RATES BY AGE

CDC GONORRHEA: EPIDEMIOLOGY RATES AT A STD CLINIC BY AGE, SEX AND SEX OF SEX PARTNERS

CDC GONORRHEA: DIAGNOSIS

• Like chlamydia, self-collected vaginal swabs of the vagina, rectum and pharynx will have the highest sensitivity • In the LA trial mentioned above: In 4684 women tested • 193 tested positive for gonorrhea • 61% of these tested positive rectally • 78% percent of those positive rectally reported not having condomless anal sex in the 3 prior months • Of those positive rectally, 53.3% had a negative vaginal test • In men, first-catch urine is the preferred test

6 GONORRHEA: TREATMENT

• Most important recent change • Both the CDC and WHO recommends ceftriaxone 500 mg with 1 gram azithromycin • An alternative if allergic or if not available: Gentamicin 240 mg + Azithromycin 2 grams x 1 • Cefixime is no longer recommended. • In 2018 5% of gonorrhea isolates were resistant • In regions with high levels of resistance (like northern England) 1 gram of ceftriaxone is the preferred treatment • Retesting men or women in three months is recommended

8,9 GONORRHEA:

• DIFFICULT • Unlike its cousin Neisseria meningitidis, Neisseria gonorrhoeae does not express a surface capsule, which constitutes a potent immunogenic target. • Four vaccine trials since the early 1900s have been shown not to be effective • The most appealing trial underway delivers DNA by a bacterial “ghost”, which is a empty bacterial envelope.

8 GONORRHEA: COMPLICATIONS

• Females • PID: 10-20 % of all PID caused by gonorrhea • Chronic pelvic pain • Ectopic pregnancy • Infertility • Males: rare • Penile edema • Urethral stricture • Epididymitis • Prostatitis • Reactive Arthritis: correlates with human leukocyte antigen-B27,

8 SYPHILIS

• Syphilis is caused by the spirochete , and is spread primarily through sexual contact. • The Great Imitator, syphilis can have a myriad of symptoms and signs. SYPHILIS EPIDEMIOLOGY RATES SINCE 1941

CDC SYPHILIS: EPIDEMIOLOGY RATES BY STATE

CDC SYPHILIS RATES BY SEX AND SEX OF PARTNERS

CDC SYPHILIS: SYMPTOMS AND SIGNS

• It can take several weeks between exposure and development of signs • Primary: 10-90 days • • • Secondary: 1-3 months • Arthralgia, lymphadenopathy, myalgia • Maculopapular exanthema, pharyngitis

9 SYPHILIS: SYMPTOMS AND SIGNS 2

• LATENT SYPHILIS • Early Latent • First year after infection in patients who: • seroconverted within the past year • who have had symptoms of primary or secondary syphilis within the past year, • who have had a sexual partner with primary, secondary, or early latent syphilis within the past year • Late Latent • Quantitative nontreponemal titers should be measured at six, 12, and 24 months • should be strongly considered in patients who show a fourfold increase in titers

10 SYPHILIS: SYMPTOMS AND SIGNS 3

• Tertiary: months to years • Late neurosyphilis (neurosyphilis can occur at any stage) • Diagnosed from CSF after a lumbar puncture • Order VDRL, white blood cell count (greater than 10 per mm cubed), (greater than 50 mg/ml) • Symptoms caused by neuronal degeneration and vascular lesions. • Seizures, ataxia, aphasia, paresis, hyperreflexia, personality changes, cognitive disturbance, visual changes, hearing loss, neuropathy, loss of bowel or bladder function, others • Gummatous syphilis • benign soft, rubbery tumorous lesions, called gummas • These break and rupture to form ulcers • Cardio syphilis

9 SYPHILIS: DIAGNOSIS

• RPR: positive within 3 weeks of infection • Dark-Field : fastest way to diagnose • FT-ABS: confirmatory test with a low false positive rate

9 SYPHILIS: TREATMENT

• Primary • G benzathine, 2.4 million units intramuscularly once • In persons allergic to penicillin: Doxycycline,100 mg orally twice daily for 14 days • ,† 500 mg orally four times daily for 14 days • Ceftriaxone (Rocephin),‡ 1 g intravenously or intramuscularly once daily for 10 to 14 days • Azithromycin (Zithromax),‡ 2 g orally once

9 SYPHILIS: TREATMENT 2

• SECONDARY • PENICILLIN G BENZATHINE, 2.4 MILLION UNITS INTRAMUSCULARLY ONCE • IN PERSONS ALLERGIC TO PENICILLIN: • DOXYCYCLINE,* 100 MG ORALLY TWICE DAILY FOR 14 DAYS • TETRACYCLINE,† 500 MG ORALLY FOUR TIMES DAILY FOR 14 DAYS • CEFTRIAXONE,‡ 1 G INTRAVENOUSLY OR INTRAMUSCULARLY ONCE DAILY FOR 10 TO 14 DAYS • AZITHROMYCIN,‡ 2 G ORALLY ONCE

9 SYPHILIS: TREATMENT 3

• Early latent: Same as secondary syphilis • Late Latent: • 4 million units of penicillin G benzathine administered intramuscularly once a week for three weeks • doxycycline 100 mg taken orally twice daily for four weeks • tetracycline 500 mg taken orally four times daily for four weeks.

10 SYPHILIS: TREATMENT 4

• TERTIARY: • PENICILLIN G BENZATHINE, 2.4 MILLION UNITS INTRAMUSCULARLY WEEKLY FOR THREE WEEKS

• NEURO-SYPHILIS • AQUEOUS CRYSTALLINE PENICILLIN G, 18 TO 24 MILLION UNITS DAILY ADMINISTERED AS 3 TO 4 MILLION UNITS INTRAVENOUSLY EVERY 4 HOURS FOR 10 TO 14 DAYS • OR • PENICILLIN G PROCAINE, 2.4 MILLION UNITS INTRAMUSCULARLY ONCE DAILY FOR 10 TO 14 DAYS • PLUS • PROBENECID, 500 MG ORALLY FOUR TIMES DAILY FOR 10 TO 14 DAYS

10 SEXUALLY TRANSMITTED DISEASES IN THE COVID-19 PANDEMIC

11 References

1. Stary, A. The Changing Spectrum of Sexually Transmitted Infections in Europe. Acta Derm Venereal 2020;100:242- 247. 2. Szreter S, Siena K (2020). "The pox in Boswell's London: an estimate of the extent of syphilis infection in the metropolis in the 1770s". The Economic History Review. 2020. doi:10.1111/ehr.13000. 3. Centers for Disease Control 4. Mishori R, McClaskey E, Winklerprins V. Chlamydia trachomatis Infections: Screening, Diagnosis, and Management. Am Fam Physician. 2012; 86(12):1127-1132. 5. Korownyk, C, Kraut M, Kolber M. Vaginal self-swabs for chlamydia and gonorrhea. Can Fam Physician. 2018: 64(6): 448. 6. Jamieson T, Cunningham N, Assaf R, Bolan R. Evidence supporting the standardization of extragenital gonorrhea and chlamydial screenings for women. Sex Transm Infect. Doi.10.1136/sextrans-2020-054577. REFERENCES

7. Jefferson A, Smith A, Fasinu P, Thompson D. Sexually Transmitted Neisseria gonorrhoeae Infections- Update on Drug Treatment and Vaccine development. Medicenes. 2021:8(11):1-22. 8. Cyr S. Thorpe P, et al. Update to CDC’s Treatment Guidelines for Gonococcal infection, 2020. Morb Mortal Wkly Rep. 69(50),:1911-1916

9. Mattei P, Beachkofsky t, Gilson R, Wisco O. Syphilis: A Reemerging Infection. Am Fam Physician. 2012;86(5): 433-440

10. Brown D, Frank J. Diagnosis and Management of Syphilis. Am fam physician; 2003 15;68(2):283-290. 11. Crane M, Popovic A, Stolbach A, Ghanem K. Reporting of sexually transmitted infections during the pandemic. Sex Transm Infect. 17 October 2020.doi:20.1136/sextrans-2020-054805