Sexually Transmitted Infections: Diagnosis and Management

SEXUALLY TRANSMITTED INFECTIONS: DIAGNOSIS AND MANAGEMENT

STEPHANIE N. TAYLOR, MD LSUHSC SECTION OF INFECTIOUS DISEASES MEDICAL DIRECTOR, DELGADO CENTER PERSONAL HEALTH CENTER NEW ORLEANS, LA INTRODUCTION

Ê Tremendous Public Health Problem

Ê AtitdAn estimated 15 m illion AiAmericans acqu ire an STD each year

Ê $10 billion dollars in healthcare costs per year

Ê Substantial morbidity/mortality

Ê Ulcerative and non-ulcerative STDs associated with increased HIV transmission

STI PRINCIPLES

Ê Counseling – HIV infection, abstinence, and “safer sex” practices

Ê STD Screening of asymptomatic individuals and those with symptoms

Ê Patients with one STD often have another

Ê Partners should be evaluated and treated empirically at the time of presentation STI PRINCIPLES

Ê Serologic testing for syphilis should be done in all patients

Ê HIV t esti ng sh ould b e s trong ly encouraged i n all patients (New CDC Recommendation for “Opt-Out” testing)

Ê STDs are associated with HIV transmission Major STI Pathogens

Ê Bacteria Ê Viruses Ê HSV I & II, HPV, Ê Neisseria HBV, HIV , gonorrhoeae, molluscum Haemophilus ducreyi, Ê Protozoa GdGardnere lla vagi nali s Ê Trichomonas Ê Spirochetes vaginalis Ê Fungi Ê Treponema pallid um Ê Candida albicans Ê Chlamydia Ê Ectoparasites Ê Chlamy dia Ê Phthiris pubis, trachomatis Sarcoptes scabei MAJOR STI SYNDROMES

Ê GENITAL ULCER DISEASE

Ê URETHRITIS/CERVICITIS

Ê PELVIC INFLAMMATORY DISEASE

Ê VAGINITIS

Ê OTHER VIRAL STDs

Ê ECTOPARASITES GENITAL ULCER DISEASE

Differential Diagnosis: Ê STIs Ê Syphilis, Herpes, Chancroid Ê LGV, Granuloma inguinale

Ê Non-STIs Ê Trauma, fixed drug eruption, neoplasia Ê Aphthous ulcers, non-STD infection, Ê Behçet’s Syndrome – Oral and/or genital ulcers (not alone), cutaneous lesions , uveitis, arthritis, p hlebitis Ê Reiter’s Syndrome – arthritis, conjunctivitis, urethritis, circinate balanitis, keratoderma blennorrhagicum Primary and secondary syphilis — Rates by state: United States and outlying areas, 2008

2.8 VT 1.8 0.0 NH 1.5 0.7 0.8 0.7 MA 3.3 2.2 1.2 RI 1.7 0.5 010.1 636.3 CT 1.0 0.6 2.1 NJ 2.6 0.5 2.2 DE 1.9 3.0 0.8 3.1 MD 6.7 0.9 4.3 2.2 DC 24.8 6.0 2.6 0.7 3.4 1.1 3.8 2.2 Guam 3.5 3.2 Rate per 100,000 6.7 5.0 2.4 population 2.2 7.3 2.2 9.6 6.3 9.7 5.9 <=0.2 (n= 4) 16.5 0.1 0.21-2.2 (n= 23) 2.3 5.7>2.2 (n= 27)

Puerto to Rico co 4.2

Note: The total rate of P&S syphilis for the United StatesVirgin and Is. 0.0outlying areas (Guam, Puerto Rico and Virgin Islands) was 4.5 per 100,000 population. The Healthy People 2010 target is 0.2 case per 100,000 population. Primary and secondary syphilis — Rates by county: United States, 2008

Rate per 100,000 population <=0.2 (n= 2,184) 0.21-2.2 (n= 373) >2.2 (n= 584)

Note: In 2008, 2,180 (69.3%) of 3,141 counties in the U.S. reported no cases of P&S syphilis. Primary and secondary syphilis — Age- and sex-specific rates: United States, 2008

Men Rate (per 100,000 population) Women

20 16 12 8 4 0Age 0 4 8 12 16 20

0.110-14 0.2 5.315-19 3.0 17.3 20-24 5.1 17.2 25-29 29 3.9 15.030-34 2.5 14.735-39 2.3 14.440-44 1.8 838.3 45-54 54 111.1 2.655-64 0.3 0.665+ 0.0 7.6Total 1.5 Primary and secondary syphilis — Male-to- female rate ratios: United States, 1981–2006

Male-Female rate ratio 10:1

8:1

6:1

4:1

2:1

1997 98 99 2000 01 02 03 04 05 06 Primary and secondary syphilis — Male-to- female rate ratios: United States, 1989–2008

Rate (per 100,000 population) Rate Ratio (log scale) 25 Male Rate 16:1 Female Rate Total Rate

20 MlMale-to-Fema Fle Rate l RR atio R i 8:1

4:1

2:1

0 1:1

1989 91 93 95 97 99 2001 03 05 07 Primary and secondary syphilis — Rates by region: United States, 1999–2008

Rate (per 100,000 population) 10 West Midwest Northeast 8 South

1999 2000 01 02 03 04 05 06 07 08 Primary and secondary syphilis — Rates by race/ethnicity:United States, 1999 –2008

Rate (per 100,000 population) 40 American Indian/AK Native Asian/Pacific Islander Black 32 Hispanic White

1999 2000 01 02 03 04 05 06 07 08 Primary and secondary syphilis — Reported cases* by stage and sexual orientation, 2008

Cases

5000

Primary Secondary 3750

2500

1250

0 HtHeterosexual M lMen Women MSM† *20% of reported male cases with P&S syphilis were missing sex of sex partner information. †MSM denotes men who have sex with men. Primary and secondary syphilis — Cases by sexual orientation and race/ethnicity, 2008

Cases

3000

White Black 2250 Hispanic Other

1500

750

0 ‡ Heterosexual Men Women MSM Primary and secondary syphilis — Cases by source and sex: United States, 1999–2008

Cases (in thousands) 8 non-STD Clinic Male non-STD Clinic Female 7 STD Clinic Clinic Male Male STD Clinic Female 6

1999 2000 01 02 03 04 05 06 07 08 Congenital syphilis (CS) — Cases for infants <1 year of age and rates of primary and secondary syphilis among women: United States, 1999–2008

CS cases (in thousands) P&S rate (per 100,000 women)

0.8 4

CS Cases Cases

P&S Rate 0.6 3

0.4 2

0.2 1

000.0 0

1999 00 01 02 03 04 05 06 07 08 Conggypyenital Syphilis Rates by Race/Ethnicity Congenital Syphilis by State Parish vs. National Rates 2008

Ê National Rate – 4.5 cases/100,000

Ê Jefferson Parish – 11.6 cases/100,000

Ê Orleans Parish – 38.9 cases/100,000

Ê National Goal < 0.4 cases/100,000 Early Syphilis – Region 1 by Parish 2008 Early Syphilis – Region 1 by Parish 2009

1st Six Months of 2009

SYPHILIS STAGING

INFECTION (3 WEEKS) PRIMARY CHANCRE (1-3 MONTHS) SECONDARY (1-3 MONTHS / 60-90%) LATENCY (2-50 YEARS) 70% 30% LIFETIME LATENCY TERTIARY PRIMARY SYPHILIS

Ê Incubation period 3-90 days

Ê Begins as a macule/papule that erodes into a clean based, painless, indurated ulcer with smooth, firm borders

Ê Usually singular but can be multiple

Ê Goes unnoticed in 15-30% of patients

Ê If untreated, will heal in 1-5 weeks PRIMARY SYPHILIS PRIMARY SYPHILIS PRIMARY SYPHILIS SECONDARY SYPHILIS

Ê Hematogenous dissemination Ê Skin Rash (90%) - Maculopapular, or pustular lesions involving the palms and soles. Condyloma lata. Ê Mucous Membranes (70%) - Lesions include mucous patches, erosions, aphthous ulcers. Ê Constitutional symptoms (70%) - Fever, malaise, pharyngitis, anorexia, weight loss, andhlid arthralgias. Ê CNS - HA, meningitis, uveitis, tinnitis. SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS

Adenopathy Patchy Alopecia SECONDARY SYPHILIS

Condyloma lata SECONDARY SYPHILIS

Condyloma lata LATENT SYPHILIS

Ê Period during which there is no clinical evidence of disease

Ê Serological tests are positive

Ê Arbitrarily divided into “early latent” (infection occurred within the last year) or “late latent” TERTIARY SYPHILIS

Ê Slowly progressive disease - affects any organ system and produces clinical illness years after initial infection Ê NEUROSYPHILIS - meningitis, general paresis, optic neuritis ( ↑ WBCs, + CSF VDRL, ↑ Prot.) Ê CARDIOVASCULAR - aortic aneurysm, aortic regurgiiitation Ê GUMMATOUS - large indurated lesions of skin, GI tract, mouth DIAGNOSIS

Ê Darkfield examination of material from a moist lilesion – 70-80% sensitive

Ê Serologic Tests

Ê Non-treponemal – RPR, VDRL, ART

Ê Treponemal – FTA-ABS, TPHA, IgG

Ê Silver stain of bioppysy material

Ê DNA Methods (PCR, etc.) SEROLOGIC TESTS

Ê REMEMBER!!!

Ê No serologic test for syphilis can make a diagnosis by itself, or distinguish between active (never treated or inadequately treated) syphilis and inactive (adequately treated) syphilis

Ê Must be coupled with a careful history and a thorough physical examination before a diagnosis can be made BIOLOGIC FALSE POSITIVE

Ê Antibodies to phospholipid produced in other disorders

Ê Positive non-specific test (VDRL, RPR)

Ê Not confirmed with specific test (or negative TPHA, etc.)

Ê Seen in a number of conditions such as lupus, drug reactions, narcotic drug use, TB, pregnancy, hepatitis, rheumatoid arthritis, etc. Syphilis: 2006 CDC STD Treatment Guidelines

Ê Primary, Secondary, and Early Latent Ê Benzathine penicillin 2.4 MU IM X 1 Ê PCN a llergi c– Doxy. 100 mg po bid f or 14 d ays Ê Late Latent Ê Benzathine ppqenicillin 2.4 MU IM q wk. x 3 weeks Ê PCN allergic – Doxy. 100 mg po bid x 4 weeks Ê Neuro-Syphilis – Ê AiC3Aqueous crystalline PCN 3-44104 MU IV q 4 hrs 10-14 days – PCN Allergic need to be desensitized Ê Special Circumstances Ê Pregnant and PCN allergic – desensitize and treat Ê HIV – Same tx. for stage of syphilis in non-HIV pt. CHANCROID

Ê ETIOLOGY Ê EPIDEMIOLOGY

Ê Haemophilus ducreyi Ê Seen more commonly in third world Ê Fastidious organism countries difficult to isolate Ê Less than 1,000 cases Ê Requires seen in the U.S. ,but suppltdlemented outbrea ks or chocolate agar and epidemics have been seen 5% CO 2 for growth CLINICAL MANIFESTATIONS

Ê Incubation period 5-7 days

Ê A papule develops initially but goes on to erode itintoapaiflinful,soft,and non-idindurat tded ulcer

Ê 50% of patients will develop painful local adenoppyathy which may suppurateorrupture CHANCROID

Genital Ulcer with Inguinal Buboes in 50% Chancroid: 2006 CDC STD Treatment Guidelines

Ê Azithromyygcin 1 gm orally yg single dose

Ê Ceftriaxone 250 mggg IM single dose

Ê Ciprofloxacin 500 mg po bid for 3 days

Ê Erythromycin base 500 mg po qid for 7 days GENITAL HERPES

Ê Most common cause of genital ulcer disease in N.A. Ê Primary Infection Ê 80-90 % due to HSV-2 Ê Typically most severe, systemic symptoms common Ê Mult. painful vesicles , shallow ulcers , heal 2 -3wks3 wks Ê Recurrences Ê Less severe lesions Ê Shorter duration Ê Most patients with HSV-2 asymp. or do not recognize symptoms Ê Asymptomatic viral shedding occurs without outbreaks HERPES SIMPLEX HERPES SIMPLEX HERPES SIMPLEX HSV - 2006 STD Treatment Guidelines

Ê Initial Episode Ê Acyclovir, famcicloivir, or valacyclovir X 7-10 days

Ê Recurrences Ê Acyclovir, famcicloivir, or valacyclovir X 5 days Ê Acyc lov ir 800 mg tid X 2d ; F am 1000 mg BID X 1d; Val 500 mg BID X 3d

Ê SiSuppressive Therapy Ê Indicated for patients with 6 outbreaks a year Ê Reduces the freqqyuency and as ypymptomatic sheddin g URETHRITIS/CERVICITIS/PID URETHRITIS

Ê Clinical Syndrome Ê Dysuria, urethral discharge/itching, >5 WBCs/hpf Ê Dx.– DNA pro bes an d amp lificati on ( swab or uri ne) Ê Still need GC cultures to monitor resistance (GISP – Gonococcal Isolate Surveillance Program)

Ê Gonococcal Urethritis Ê 2-5 day incubation, copious amounts of purulent d/c Ê Intra-cellular diplococci seen in 95% of men

Ê Non-gonococcal Urethritis Ê Less profuse, thin, clear, or mucoid d/c Ê Urethral smear with WBCs only Etiology of NGU

Chlamydia trachomatis 20-40% Mycoplasma genitalium 15-25% Ureaplasma urealyticum 10-20% Trichomonas vaginalis 5-15% Adenovirus 1-4% Herpes simplex virus 1-2% History of Mycoplasma genitalium

Ê 1981 – First id entifi ed b y cult ure i n 2/13 men with NGU. (Tully and Taylor-Robinson) Ê 1982-90 – Attempts to obtain additional isolates from men with NGU fail. (Taylor-Robinson, et al; Samra, et al) Ê 1986-87 – Primate studies show M. genitalium causes NGU. (Tully, et al; Taylor-Robinson, et al) Ê 1988 - Direct DNA probes give mixed results. (Hooten, et al; Risi, et al.) Ê 1991 – First PCR assays described. (Jenson, et a l and Palmer et al. M. genitalium Infections in Women Attending the New Orleans STD Clinic

Organism No. Positive/(%)

M. genitalium 70 (17%) C. trachomatis 90 (()22%)

N. gonorrhoeae 58 (14%) T. vaginalis 87 (22%) Association of Mucosal Pathogens and Young Age in women

35 30 25 20 C. trachomatis 15 N. gonorrhoeae 10 M. genitaliumgenitalium 5 0 18-19 20-24 25-29 > 30 Chlamydia — Rates by state: United States and outlying areas, 2008 Louisiana was #5 with 527.8 cases per 100,000

331 VT 192 324 300 198 NH 160 287 276 MA 271 280 371 375 458 RI 314 302 446 CT 357 314 NJ 258 314 340 377 411 DE 447 228 460 349 MD 439 407 395 332 183 405 DC 1177 422 287 Guam 396 414 455 Rate pp,er 100,000 391 409 470 499 597 population 447 728 535 422 <=300 (n= 13) 528 711 300.1-400 (n= 17) 466 389 >400 (()n= 24)

Puerto Rico 174

Virgin Is. 535

Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 368.1 per 100,000 population. Gonorrhea — Rates by state: United States and outlyi tl ing areas, 2008

48.3 VT 6.0 12.7 22.4 7.3 NH 7.6 32.7 MA 33.0 58.4 12.5 108.7 RI 29.0 47.1 88.7 CT 80.0 23.7 169.4 NJ 61.0 56.9 89.0 82.3 DE 120.8 84.7 146.5 MD 118.6 18.0 160.9 138.2 70.5 77.3 81.9 9 41.2 2134.0 0 DC 451.5 5 136.3 107.2 Guam 62.8 176.3 142.6 Rate per 100,000 54.4 143.3 71.2 159.2 214.2 population

256.8 210.5170.5 <190<=19.0 ()(n= 7) 134.7 220.2 84.6 19.1-100.0(n= 24) 47.5 127.8 >100 (n= 23)

Puerto Rico 6.9

Virgin Is. 109.3 Chlamydia — Age- and sex-specific rates: United States, 2007

Men Rate (per 100,000 population) Women

3250 2600 1950 1300 650 0Age 0 650 1300 1950 2600 3250

11.810-14 123.0 615.0 15-19 3004.7 932.9 20-24 2948.8 518.625-29 1184.5 246.830-34 460.5 129.935-39 188.1 71.440-44 76.5 32.3 45-54 28.5 10.155-64 8.0 2.765+ 1.8 190.4Total 544.8 Gonorrhea — Age- and sex-specific rates: United States, 2007

Men Rate (per 100 ,000 population) Women

750 600 450 300 150 0Age 0 150 300 450 600 750

595.9 10-14 33.1 286.0 15-19 647.9 450.1 20-24 614.5 305.125-29 287.1 181.5 30-34 125.2 119.535-39 60.5 86.640-44 30.8 50.245-54 12.1 17.755-64 3.0 4.065+ 0.4 113.9Total 123.8 GC URETHRITIS AND NGU

Gonococcal Urethritis Non-gonococcal Urethritis GC URETHRITIS AND NGU

Gonococcal Urethritis Non-gonococcal Urethritis

URETHRAL SMEAR: GC VS. NGU

GC/Intracellular diplococci NGU/ >5 PMNs/hpf MUCOPURULENT CERVICITIS

Ê Infection and inflammation of the endocervix Ê Thick cervical discharge Ê Erythema and easily induced bleeding Ê Ectopy of endocervical mucosa Ê Pathogens Ê N. gonorrhea Ê C. trachomatis Ê Asymptomatic infection Ê ~40% o f women w ith GC Ê ~50% of women with CT MUCOPURULENT CERVICITIS(MPC) GC VS. CT

Gonococcal MPC Chlamydial MPC GC - 2006 STD Treatment Guidelines

Ê Gonococcal urethritis/cervicitis (MPC) Ê Ceftriaxone 125 mg IM single dose or Cefixime 400 mg po iildin single dose Ê **Quinolones no longer recommended in U.S. due to resistance Ê Azithromycin 1 gm or Doxy 100 mg bid x 7d for CT

Ê Alternatives Ê Spectinomycin 2 gm IM single dose Ê Single dose cephalosporin NGU/CT - 2006 STD Treatment Guidelines

Ê NGU or Chlamydia Urethritis/Cervicitis Ê Azithromycin 1 gm po single dose Ê Doxycycline 100 mg po bid x 7 days

Ê Alternatives Ê Erythromycin base 500 mg po qid x 7 days Ê Ofloxacin 300 mg bid po x 7 days Ê Levofloxacin 500 mg po x 7 days

Ê Recurrent or Persistent NGU Ê Metronidazole 2 gm po in a single dose Ê Tinidazole 2 gm po in a single dose Ê Azithromycin 1 gm po if not used for initial episode GC COMPLICATIONS

Ê Men Ê Women Ê Epididymitis Ê Bartholin’s glands abscess Ê Prostatitis Ê Perihepatitis (Fitz-Hugh- Curtis syndrome) Ê Conjunctivitis Ê PID Ê Periurethral abscess Ê In fer tilittility Ê Penile lymphangitis Ê Conjunctivitis Ê Disseminated gonococcal Ê Endometritis ifinfecti on (DGI) Ê Tubo-ovarian abscess Ê Ectopic pregnancy Ê Ophthalmia neonatorum Ê Disseminated gonococcal infection (DGI) COMPLICATIONS OF GC/CT

Epididymitis Tubo-ovarian abscess

Peri-hepatitis/Fitz-Hugh-Curtis Syn. GONOCOCCAL CONJUNCTIVITIS GONOCOCCAL PHARYNGITIS Disseminated Gonococcal Infection

Ê Most common cause of acute infectious arthritis among sexually active adults

Ê Migratory arthralgias, frank arthritis in one or two joints

Ê Skin les ions Ê Distal extremity location Ê Pustules on an eryy(y)thematous base (Usually < 20)

Ê Fever

Ê TitiTenosynovitis

Ê Genital symptoms usually absent Disseminated Gonococcal Infection

Ê 0.5-3% of genital inf./Recurrent Ds. – Complement Def.

Ê FlMlRtiFemale:Male Ratio - 414:1

Ê Associated with menstruation and ppgregnanc y in women

Ê Remember to culture the throat, cervix/urethra, and rectum in suspected DGI (Joints and blood rarely pos. )

Ê Tx. - Ceftriazone 1 ggq(p)m IM or IV q d (plus CT tx.) until clinical improvement – Finish 7 day course with Cefixime or Cefpodoxime DISSEMINATED GC (DGI) PID – Pelvic Inflammatory Ds .

Ê Etiology Ê C. trachomatis Ê NhN. gonorrhoeae Ê Gardnerella vaginalis Ê Other facultative aerobes and anaerobes Ê Diagnosis Ê Minimum Criteria Ê Lower abdomiiinal pain Ê Adnexal tenderness Ê Cervical motion tenderness Ê Other Criteria – cervical or vaginal discharge, T > 38.3°C, leukocytosis, ↑ ESR, U/S-inflammatory mass PID – 2006 STD Treatment Guidelines

Ê Criteria for Hospitalization Ê Can’t rule out surg. emergency, unable to tolerate oral meds 2° N/V, pregnancy, tubo-ovarian abscess Ê Parenteral Regimen Ê Cefotetan 2 gm IV q 12 hours or Cefoxitin 2 gm IV q 6 hours plus Doxycycline 100 mg IV q 12 hours Ê Discontinue 24 hours after clinical improvement then comppylete 14 day course with dox yyycycline Ê Oral Regimen – Both with or without metronidazole Ê A - Ceftriaxone 250 mg IM single dose or Cefoxitin 2 gm IM and Probenecid 1 gm po plu s Doxy x 14d Ê B – Other 3rd Gen. Cephalosporin plus Doxy x 14d Ê Both plus or minus metronidazole VAGINITIS

Ê Etiology Ê Bacterial vaginosis Ê Trichomonas Ê Vulvovaginal candidiasis Ê Diagnosis Ê BV –pH >4 .5 , +Whiff tes t on KOH, Clue cell s on wet prep Ê Trichomonas – Strawberry cervix, organism seen on wet prep Ê Vaginal Candidiasis – hyphae and pseudohyphae on KOH Ê Treatment Ê BV – Metro. 500mg bid x 7 d, Tinidazole, Metrogel, Clinda Ê Trichomonas – Metro. 2gm po single dose Ê Candida – OTC azole creams, Flucon. 150 mg po single dose WHAT IS BACTERIAL VAGINOSIS?

Ê Most prevalent cause of vaginal symptoms in women of childbearing age

Ê Characterized by: Ê Increased malodorous discharge Ê Decrease or absence of Lactobacillus sp . (L . crispatus and L. jensenii most common) Ê Overgrowth of Gardnerella vaginalis, Mycoplasma sp. and other anaerobic organisms Ê Altered pattern of organic acids from these bacteria (e.g., putrescine, cadaverine, etc.) producing odor

Ê Lack of inflammation – vaginosis (not vaginitis) WHAT’SINANAME? S IN A NAME?

Ê Leukorrhea

Ê Non-specific vaginitis

Ê Haemophilus vaginalis vaginitis

Ê Gardnerella vaginitis

Ê Anaerobic vaginosis (but not just anaerobes)

Ê Bacterial vaginosis (since inflammation is not a feature of BV, the term vaginosis has replaced vaginitis) EPIDEMIOLOGY

Ê Prevalence depends upon population studied

Ê Stu den t Hea lth Clini cs – 4-10%

Ê Family Planning Clinics – 17-19%

Ê Pregnant women – 16-29%

Ê In fer tility Cli ni cs – 30%

Ê STD Clinics – 24-40% EPIDEMIOLOGY

Ê Prevalence also depends on ethnicity Ê Larggypge U.S. Study of pregnant women Ê 13,747 at 23-26 weeks gestation Ê 16.3% of women had BV Ê Asians – 6.1% Ê Caucasians – 8.8% Ê Hispanics – 15.9% Ê African American – 22.7% Ê 51% of 4,718 women in Ugandan study EPIDEMIOLOGY

Ê BV is common in most populations

Ê More common in STD clinics than in family planning or prenatal clinics

Ê More common in women with discharge

Ê Related to ethnicity for unknown reasons

Ê Especially common in Sub-Saharan Africa WHAT ABOUT SEXUAL TRANSMISSION?

Ê Conflicting and controversial area

Ê WhWomen who use con dhdddoms have decreased prevalence of BV

Ê Yet multiple partner treatment trials have failed to demonstrate benefit to women with BV

Ê Evidence of sexual transmission of BV in women who have sex with women WHAT ABOUT SEXUAL TRANSMISSION?

Ê Females with no sexual exposure have significantly lower prevalence of BV

Ê Some studies have found association with younger age of sexual debut

Ê In college women, Amsel demonstrated that 0 of 18 virgins versus 69 of 293 (24%) sexually experienced women had BV WHAT ABOUT SEXUAL TRANSMISSION?

Ê Association with number of partners also seen

Ê Women with new or multiple sex partners also have higher prevalence of BV

Ê Evidence of NGU in male pppartners of patients with BV WHAT ABOUT SEXUAL TRANSMISSION?

Ê Sexual transmission of Gardnerella vaginalis has been demonstrated Ê Gardner and Pheifer detected G. vaginalis in the urethras of 79 and 86% of male sex partners of women with BV but not in controls

Ê Piot et al. developed a typing system and demonstrated that Gardnerella isolates in women with BV and from the urethras of their partners were the same

Ê Ison and Easmon recovered G. vaginalis and other anaerobes at 103 to 107 org/ml from semen in 16% of men attending a subfertility clinic PREDISPOSING/RISK FACTORS

Ê Douching

Ê IUD as contraceptive method

Ê Younger age

Ê New sex partner

Ê Multiple sex partners

Atopobium vaginae

Ê Small Gram positive cocco-bacillus Ê Produces lactic acid Ê Strict anaerobe Ê Genus first described about 10 years ago as a member of human oral flora Ê Only 2 isolates of A. vaginae reported in the literature prior to our report Ê The 4 existing cultured strains are highly resistant to metronidazole.

CLINICAL MANIFESTATIONS

Ê “Fishy-smelling” discharge – More noticeable after intercourse (Addition of semen with alkaline pH is similar to addition of KOH)

Ê Discharge is gray or off-white, thin, homogeneous, and adherent to vaginal wall

Ê No erythema or inflammation

Ê Some patients report vaginal itching

Ê Cervix usually normal BACTERIAL VAGINOSIS DIAGNOSIS

Ê Amsel’s Criteria (3 of 4 criteria for dx.) Ê Adherent, homogeneous gray-white discharge Ê Positive amine or whiff test with addition of 10% KOH Ê Elevated vaginal pH of >4.5 Ê Presence of “clue cells” – Squamous cells with adherent bacteria (>20% of cells on wet mount) pH PAPER

Whiff Test for “Fishy” Odor NORMAL VAGINAL GRAM STAIN Gram Stain offg Normal Vaginal Secretions CLUE CELLS CLUE CELL WET MOUNT Gram Stain of Vaginal Secretions Showing Bacterial Vaginosis BV AND HIV ASSOCIATION

Ê Presence of BV or absence of lactobacilli associated with heterosexual transmission of HIV

Ê 2-fold increased prevalence of HIV in Thai and Ugandan women with BV

Ê Study of African pregnant and postnatal women in Malawi found that women with BV were more likely to seroconvert to HIV

Ê These data raise the question of whether BV should be treated more aggressively (In the past – asymptomatic BV was not treated) TREATMENT OF BV 2006 CDC GUIDELINES

Ê Treatment Ê Metronidazole 500 mg po bid for 7 d Ê Metro. 0.75% gel qd or bid for 5 d Ê Clinda 2% Cr., 5 gm qd for 7 d Ê Clind a 300 mg po bid f or 7d (Ac tive agai nst Lactobacillus - interferes with re-establishment of normal flora Ê Partner tx. - No treatment required Ê Recently approved drug- Tinidazole 500 bid po x 5 days – 95% e fficacy / V ag inall y once d ail y – 80% e ff. RECURRENT BV

Ê 80-90% cure rates at 1 week

Ê 15-30% recur within 3 months

Ê Single Dose versus 7 day course – 73% vs. 82%

Ê Higher recurrence rates for single dose tx. RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS

Ê Replacement or Restoration of Lactobacilli (LB)((LB)(BacteriotherapyBacteriotherapy)) Ê Un for tuna te ly lack o f e fficacy with few con tro lled trials Ê LB used needs to be able to adhere and produce

H2O2 Ê If given orally, LB needs to survive pass through GI tract and ascend from the perianal area into the vaginal area

Ê Lactobacilli used have not been vaginal strains RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS

Ê Lactobacilli in yogurt strains do not bind to vaginal epithelial cells

Ê Only 1 of 14 women were cured after applying yogurt intravaginally twice daily for 7 days

Ê Little utility for therapies employing yogurt RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS

Ê Other types of capsules, powders, etc. in health food stores are also dairy derived

Ê In addition, 9 of 16 preparations were contaminated with other types of bacteria and 5 of 16 did not contain peroxide pro duc ing s tra ins

Ê Placebo-controlled trial of purified Lactobacillus suppositories studied by Sharon Hillier. Ê ~50% of women improved during therapy Ê Only 4 of 29 remained free of BV at 2 nd visit RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS

Ê Disinfectants Ê Chlorhexidine – 79% effective but 50% recurred at one month Ê Povidone-iodine – bid for 2 wks – only 20 % efficacy

Ê Acidifiers Ê Lactic Acid suppository – 20% efficacy Ê Lactic acid gel x 7 days – 77% - 7 day follow-up – not repeated Ê 5% acetic acid tampon – 38% efficacy

Ê Suppressive therapy – Currently being studied (Sobel) Ê Metronidazole or Tinidazole twice a week Ê Results pending WHAT CAN WE OFFER PATIENTS WITH RECURRENT BV?

Ê Clearly explain bacterial vaginosis

Ê Carefully go through personal hygiene practices to remove douching, etc. that may disrupt normal flora

Ê Explain that course of therapy may relieve symptoms but it takes time for the bacterial imbalance normalize and recolonize with Lactobacilli

Ê Longer course of antibiotics or combination therapy for recurrences (2 weeks/ oral + vaginal therapy)

Ê ???Suppressive and alternative combination therapy in the future TRICHOMONIASIS

Ê Sexually transmitted parasite

Ê Vaginal discharge, pruritis in females, but may be asymptomatic.

Ê Males usually asymptomatic, but can cause NGU TRICHOMONAS VAGINITIS

TRICHOMONAS VAGINALIS CANDIDA VAGINITIS CANDIDA DERMATITIS CANDIDA BALANITIS OTHER VIRAL STDs

Ê GENITAL WARTS Ê MOLLUSCUM Ê Human Papilloma Ê Seen in children but Virus can alblso be sexuall y Ê Incubation period if transmitted 4-8 weeks Ê Caused by a poxvirus Ê Involve any portion of the genitalia Ê Lesions appear as smooth papules Ê Cervical lesions usually 2-5 mm iiin size Ê Ulceration, secondary bacterial infection, with a central and cervical cancer umbilication OTHER VIRAL STDs

Genital Warts Molluscum contagiosum [Human Papii()illoma Virus (HPV)] OTHER VIRAL STDs

Genital Warts (HPV) Molluscum contagiosum ANAL HPV Pubic Lice and Scabies

Phthiris pubis (crabs) Sarcoptes scabei Tx. – 1. Permethrin Cream 1% Tx. – 1. Permethrin Cr. 5% Was h o ff aft er 10 m in. Whffi8Wash off in 8-14 hrs. 2. Lindane 1% for 4 min. 2. Lindane 1% for 8 h ECTOPARASITES - SCABIES HIV + SCABIES = NORWEGIAN SCABIES