SEXUAL TRANSMITTED INFECTIONS 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 Gonorrhea Chancroid Lymphogranuloma venereum Granuloma inguinale 1 STIs Chlamydia trachomatis Scabies Mycoplasma genitalium Human immunodeficiency virus Mycoplasma hominis Herpes Simplex virus Ureaplasma urealyticum Human papilloma virus Anaerobic bacteria Hepatitis B virus Trichomonas vaginalis Candidiasis Ebola virus Pediculosis pubis Zika virus 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 Treponema pallidum. • Initial syphilis 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 • Chlamydia trachomatis is a gram negative bacterium. • Leading cause of blindness in the world. • Risk factors • Lack of condom 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 vagina, rectal, and pharyngeal samples. • Of the 460 women found to have chlamydia rectal chlamydia infections, 91.3% reported not having anal sex • 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 • Azithromycin: 1 gram single dose or doxycycline: 100 mg twice daily for 7 days • Alternative treatments • Erythromycin 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 epididymitis 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 • Infertility • 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 urethritis • Conjunctivitis • 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 • Trachoma • A chronic or recurrent ocular infection 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, antibiotics, 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 Neisseria gonorrhoeae. • Same risk factors as with Chlamydia • Predominant site of infection is the cervix in females and the anterior urethra in males. • Symptoms include a cervical or urethral purulent discharge, dysuria, urethritis, or cervicitis. 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: VACCINE • 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 cell 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 Treponema pallidum, 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 • Chancre • Lymphadenopathy • 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 • neurosyphilis 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), protein (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 microscopy: fastest way to diagnose • FT-ABS: confirmatory test with a low false positive rate 9 SYPHILIS: TREATMENT • Primary • 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 (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,*