8/12/19 Disclosures • Lupin: Advisory committee for Solosec • Merck: Nexplanon trainer • Pfizer pharmaceutical: Advisory Committee for Menopause Questionnaire/teaching tool • TherapeuticsMD: Advisory Committee for vaginal hormone insert Shelagh Larson DNP, APRN, WHNP, NCMP Distinguish the differential diagnosis of STI. Objectives • 1. The attendees will recognize the non-genital presentations of sexually transmitted infection in women and men. •Chlamydia •Herpes • 2. The attendees will understand the prescription therapy for STIs in alternative sites. •Gonorrhea •HPV • 3. The attendees will know the differential diagnosis of STI and other tradition infections. •Trichomoniasis •HIV *Syphilis STI Presentations Discharge Syndrome Genital Ulcer Syndromes Dermatologic Syndromes • Chlamydia • Herpes Simplex HPV Virus • Gonorrhea Secondary Syphilis • Primary Syphilis Disseminated Gonococcal • Trichomoniasis • Chancroid Infection • Bacterial vaginosis Pediculosis Pubis • Candidiasis 1 8/12/19 Facts • most frequently reported bacterial sexually transmitted infection in the US • The silent disease 75% of infected females and 50% males do not realize they have it • Transmitted: vaginally, anal, oral • Once an infected person has completed antibiotic treatment, they should be re-tested after approximately three months to make sure the condition is cured. • Almost 2/3 of new chlamydia infections occur among youth aged 15-24 years. most frequently reported bacterial STI in the United States • known as a ‘silent’ infection because most infected people are asymptomatic and It is estimated that 1 in 20 sexually active young women aged 14-24 years lack abnormal physical examination findings. has chlamydia Easily treated with Azithromycin Symptoms (if any) occur 1-3 weeks after exposure • Women • Men • –Abnormal Vaginal Discharge (Odor or Odorless) • Cloudy or Clear Discharge From the Tip of the Penis • –Spotting/Bleeding Between Periods • –Painful and Swollen Testicles • –Painful Periods • –Itching and/or Burning Around • –Pain During Sexual Intercourse the Opening of the Penis • –Painful Urination • –Painful Urination • –Abdominal Pain With Fever • –Burning and/or Itching in or Around the Vagina unilateral eye discomfort with hyperemia. The secretions may be mucopurulent, but are more typically clear to cloudy Chlamydial tonsillopharyngitis is marked by generalized pharyngeal and tonsillar hyperemia with possible addition of swollen anterior pillars and uvula, as well as diffuse purulent exudate on the tonsils Oztürk O, Seven H. Chlamydia trachomatis tonsillopharyngitis. Case Rep CDC/ Susan Lindsley Otolaryngol. 2012;2012:736107 2 8/12/19 Reactive arthritis (formerly Reiter’s syndrome) “Fitz-Hugh-Curtis Syndrome” • a post-inflammatory autoimmune disease that can result from urogenital chlamydia infection. • Characteristics of the syndrome include Some patients with chlamydial PID develop conjunctivitis, urethritis, oligoarthritis, and skin lesions (keratoderma perihepatitis, an inflammation of the liver blennorrhagica) and circinate balanitis • the onset is typically 3 to 6 weeks after capsule and surrounding peritoneum, which urogenital chlamydia infection and it can occur even in persons who receive effective treatment for chlamydia is associated with right upper quadrant pain. infection. • affects predominantly males, particularly those positive for HLA-B27, and it usually Source: photograph from Public Health—Seattle & King County STD Clinic. resolves within 3 to 6 months Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Chlamydial infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137 Treatment : CZ, and you would be mad! Screening recommendations: Azithromycin 1 g po a single dose Women Men (Doxycycline 100 mg po BID x 7 days) • Sexually active women under 25 years of age, • *Consider screening young men in high prevalence clinical settings or in • Sexually active women aged 25 years and older if at • an oropharyngeal infection should be treated increased risk populations with high burden of infection (e.g. MSM) with azithromycin or doxycycline. • Test for reinfection approximately 3 months after treatment Men Who have Sex With Men (MSM) For rectal chlamydial infections, some experts prefer Pregnant Women • At least annually for sexually active MSM using doxycycline rather than azithromycin • Retest during the 3rd trimester for women under 25 at sites of contact (urethra, rectum) years of age or at risk regardless of condom use Pregnancy with Azithromycin allergy: • Should have a TOC 3-4 weeks after treatment and be • Every 3 to 6 months if at increased risk Amoxicillin 500 mg po TID x 7 days retested during the third trimester. Persons with HIV • Routine oropharyngeal screening for CT is not Alternative Regimens recommended, although evidence suggests it can be • sexually transmitted to genital sites For sexually active individuals, screen at first HIV evaluation, and at least annually Erythromycin base 500 mg po QID x 7 days • diagnostic accuracy indicate that screening for thereafter Erythromycin ethyl succinate 800 mg po QID x 7 days chlamydia and gonorrhea with NAATs is highly accurate for specimens from various anatomical sites Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted Levofloxacin 500 mg po qD x7 days for women and men CDC, 2017. Chlamydia Fact sheet. detailed diseases treatment guidelines, 2015. Chlamydial infections. MMWR Recomm Rep. 2015;64(No. https://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm RR-3):1-137 Ofloxacin 300 mg PO BID x7 days Gonorrhea • caused by the bacteria Neisseria gonorrhoeae • When symptoms are present they can include thick white or yellow/greenish discharge, painful urination, increased urination, sore throat and severe pain in lower abdomen. 3 8/12/19 Who gets it? Symptoms • Any sexually active person can be infected with gonorrhea. • Unpleasant smelling and • Discomfort while having • In the United States, the highest reported rates of infection are among frothy vaginal discharge intercourse sexually active teenagers, young adults, and African Americans • Itching in and around the • Green, white, yellow or gray • transmitted through sexual contact with the penis, vagina, mouth, or vaginal area vaginal discharge anus of an infected partner. • • • Ejaculation does not have to occur for gonorrhea to be transmitted or Blood spotting in discharge Genital swelling or redness acquired. • Frequent urination • Low abdominal pain in rare • Gonorrhea can also be spread perinatally from mother to baby during accompanied by burning cases childbirth. sensation and pain • Groin swelling Screening recommendations: Gonorrhea Women Men Who have Sex With Men (MSM) • Sexually active women under 25 • At least annually for sexually active MSM at sites of years of age contact (urethra, rectum, pharynx) regardless of condom use • Sexually active women age 25 years • Every 3 to 6 months if at increased risk Pharyngeal infection may cause a and older if at increased risk • testing of urine specimens was slightly more sore throat, but usually is sensitive than urethral specimens Courtesy of the CDC asymptomatic • Retest 3 months after treatment Consider one-time lavage of the Pregnant Women infected eye with saline solution Persons with HIV • All under 25 years of age and older • For sexually active individuals, screen at first HIV Culture is available for detection of rectal, women if at increased risk evaluation, and at least annually thereafter oropharyngeal, and conjunctival gonococcal • More frequent screening for might be appropriate infection, but NAAT is not FDA-cleared for • Retest 3 months after treatment depending on individual risk behaviors and the local use with these specimens. Yet some have epidemiology met CLIA regulatory requirements and • Retest in 3rd Trimester if continual risk Courtesy of the CDC/Joe Miller Courtesy of the CDC established performance specifications for Culture is available for detection of rectal, oropharyngeal, and conjunctival gonococcal infection, WorkowskiKA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. using NAAT with rectal and oropharyngeal Gonococcal infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137. but NAAT is not FDA-cleared for use with these specimens. swab specimens . https://www.std.uw.edu/custom/self-study/gonorrhea Gonorrhea: • Ceftriaxone 250 mg IM/single dose “Happy Hour” PLUS If ceftriaxone is not available or • Azithromycin 1g po/single dose Expedited Partner Therapy: on the same day, same time • safe and effective for tx of uncomplicated gonorrhea at all anatomic sites, curing 99.2% of •Cefixime 400 mg orally in a single dose urogenital and anorectal infections and 98.9% of pharyngeal infections in clinical trial. PLUS Conjunctivitis: Ceftriaxone 1 g IM/single dose +Azithromycin 1 g po/single dose • Azithromycin 1 g orally in a single dose • Laws and regulations in all states require clinicians, laboratories, or both to report persons Laws and regulations in all states require clinicians, laboratories, or both to report persons with gonorrhea to public with gonorrhea to public health authorities. health authorities. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Gonococcal infections. MMWR Recomm Rep. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted