STDs Urethritis Cervicitis and PID Shahbaz Hasan Infectious

STDs: Urethritis, Cervicitis and PID Shahbaz Hasan Infectious Care

OUTLINE Management of male patients with urethritis Management of cervicitis Chlamydial infections Gonococcal infections Diseases causing vaginal discharge: BV and Trichomonas • Pelvic Inflammatory Diseases • • •

Urethritis in male patients • Can be infectious or noninfectious • Asymptomatic infections are common • Symptoms: discharge of purulent or mucopurulent material; dysuria; itching • In absence of clinic-based diagnostic tools, treat empirically for GC and Chlamydia • Diagnosis is recommended: partner notification, reportable diseases, improved treatment and compliance

Etiology of urethritis in males • GNID (Gram Negative Intracellular Diplococci) • NGU (Nongonococcal urethritis) 1. Chlamydia trachomatis: 15 -55%. Varies by STD risk factors 2. Ureaplasma urealyticum 3. Mycoplasma genitalium 4. Trichomonas vaginalis 5. HSV, adenovirus 6. Enteric bacteria: insertive anal sex

Confirming a diagnosis • Presence of purulent or mucopurulent discharge. OR • Gram stain of urethral secretion with >5 WBC/hpf. High Sen/Sp. OR • First-void urine specimen with pyuria, either microscopic or dipstick test • In the absence of above, test specifically for GC/Chlamydia before treatment. An exception can be made for high risk individuals.

Followup after treatment • Abstain from sex for 7 d after treatment initiation and partner is adequately treated • Recurrent symptoms alone should not be treated without objective evidence of urethral inflammation • True persistence: consider reinfection, chronic prostatitis, Trichomonas, drug resistant microorganisms

Management of Cervicitis: Diagnosis • Often asymptomatic • Abnormal vaginal discharge or intermenstrual bleeding • Purulent or mucopurulent endocervical exudate • Easily inducible endocervical bleeding • Leukorrhea (>10 WBC/hpf) • All cases of cervicitis should be assessed for PID

Etiology of cervicitis • Majority of cases will not have a clear etiology: persistent abnormal vaginal flora, douching, exposure to chemical irritants • Chlamydia • GC • Trichomonas • HSV 2 • BV • Mycoplasma genitalium, ureaplasma

Followup after treatment • Abstain from sex for 7 d after treatment initiation and partner is adequately treated • Recurrent symptoms need exclusion of reinfection. Exclude BV and trich and drug resistant microorganisms • Persistent symptoms in absence of infection: ablative therapy?

Chlamydial infections • Commonest STD in the US. Highest prevalence in <25 yr age group • Asymptomatic infection is common in both sexes • Serious sequelae: PID, ectopic pregnancy, infertility • Annual screening is recommended in all high risk women and is suggested in high risk men

Chlamydia: Diagnosis • Specimens: Urine; Swabs (urethra, endocervix, vagina, rectum) • Culture, direct immunofluorescence, EIA, nucleic acid hybridization tests, NAAT • NAATs are the most sensitive and FDAapproved for all source specimens EXCEPT Rectal

Chlamydia: diagnosis, PHD • BD Probetec (SDA-Strand Displacement Amplification) a form of NAAT • For urethral, endocervical and urine only • Blue cap for male urethral specimens • Pink cap for female specimens

Chlamydia: Treatment • • Azithromycin: 1 gm oral in a single dose Doxycycline: 100 mg bid for 7 d Erythromycin base: 500 mg qid for 7 d Levofloxacin: 500 mg once daily for 7 d

Chlamydia: followup after treatment • Abstain from sex for 7 d after single-dose treatment or until completion of the 7 d course and partner is adequately treated • Test of cure, at 3 -4 weeks, is recommended for 1. Pregnant women 2. Concern for noncompliance 3. Concern for reinfection • Consider retesting all women at 3 months

Chlamydia: Pregnancy • Azithromycin and erythromycin (except estolate which carries risk of hepatotoxicity) are safe • Amoxicillin 500 mg tid for 7 d is an alternative • Test of cure at 3 -4 weeks is necessary to prevent risk of infant infections (ophthalmia neonatorum and pneumonia)

Gonococcal infections • Second most commonly reported bacterial STD. 600, 000 new cases each year in US • Majority of men are symptomatic. Women can be asymptomatic • USPSTF recommends screening all high risk women for GC: prior h/o GC, other STDs, new or multiple sex partners, inconsistent condom use, commercial sex workers, drug users, pregnant women

GC: diagnosis • Gram stain of male uretheral specimen in symptomatic patients has high Sen (>95%)/Sp (>99%) • Gram stain not sensitive in asymptomatic men or for endocervical, pharyngeal or rectal specimen • Specific diagnosis (culture, nucleic acid hybridization tests and NAAT) are indicated • NAAT is FDA-cleared for urine and genital sites • Culture is indicated for non-genital sites: pharynx, rectum, joints, blood.

GC: diagnosis at PHD • For culture: use the Duo blue top swabs with gel (anaerobic transport swabs). Walk specimen down to lab • Chocolate agar and Thayer-Martin are available. Jembec plates are available if you want to plate at the bedside • Most genital specimens are run with the BD Probetec. (Blue cap for male and Pink cap for female specimens)

GC: Treatment: uncomplicated Genital and Rectal infections • • • Ceftriaxone 125 mg IM single dose Cefixime 400 mg po single dose Spectinomycin 2 gm IM single dose Azithromycin 2 gm po single dose Fluoroquinolones no longer acceptable Other cephalosporins: ?

GC: Treatment: Uncomplicated Pharyngeal infections • • Eradication is more difficult. Use Rocephin 125 mg IM single dose Use other cephalosporins with caution Spectinomycin is unreliable. Perform test of cure 3 -5 d after administration

GC: Treatment: Conjunctivitis • Ceftriaxone 1 gm IM single dose • Local care

Disseminated Gonococcal Infection (DGI) • • Results from gonococcal bacteremia Petechial or pustular acral skin lesions Asymmetric arthralgias Tenosynovitis Septic arthritis Endocarditis Meningitis

DGI: Treatment • Ceftriaxone 1 gm IV daily for 7 d • Spectinomycin 2 gm IM bid for 7 d • Meningitis and endocarditis need higher doses and longer courses

GC: Followup • Uncomplicated cases do not need tests of cure • May consider tests of cure in subjects being treated with alternative regimens or pharyngeal infections • Persistent symptoms should be evaluated by culture for antimicrobial susceptibility testing. • Avoid sex till 7 d after completion of therapy and partner is adequately treated

Bacterial Vaginosis • Polymicrobial clinical syndrome resulting from the replacement of normal H 2 O 2 producing lactobacillus in the vagina with anaerobic bacteria (prevotella, gardnerella, mycoplasma hominis) • Associations: multiple sex partners, new sex partner, douching, lack of vaginal lactobacilli • Most prevalent cause of vaginal discharge and malodor. More than 50% of women are asymptomatic • Associated with adverse pregnancy outcomes: preterm labor, preterm birth, PROM, postpartum endometritis • Increased risk of infectious complications following hysterectomy and abortions

BV: Diagnosis • Any 3 of the following: 1. Homogenous, thin, white discharge 2. ‘clue cells’ on wet prep 3. p. H of vaginal fluid >4. 5 4. ‘whiff test’: fishy odor with 10% KOH • Other commercial tests and culture not recommended

BV: Treatment • All women with symptomatic disease • Pregnant women, whether symptomatic or asymptomatic should be treated • Metronidazole 500 mg po bid for 7 d • Metrogel 0. 75%, intravag daily for 5 d • Clindamycin cream 2%, intravag daily for 7 d • Clindamycin 300 mg po bid for 7 d • Metronidazole 2 gm single dose po is no longer recommended.

Trichomonas • Caused by the protozoan Trichomonas vaginalis. • May be asymptomatic in both sexes • Men generally present as NGU, women with diffuse, malodorous, yellow-green, vaginal discharge and vulvar irritation • Association with adverse pregnancy outcomes

Trichomonas: Diagnosis • Microscopic exam of vaginal secretions has a sensitivity of only 60 -70% • FDA approved POC tests are more sensitive and specific • Culture is the most sensitive and specific commercially available method of diagnosis • Wet preps are very insensitive for men. Culture is required for a confirmed diagnosis

Trichomonas: Treatment Metronidazole 2 gm po single dose Tinidazole 2 gm po single dose Metronidazole 500 mg po bid for 7 d Avoid alcohol for 24 hr after metronidazole and 72 h after tinidazole • Metronidazole is pregnancy category B, while tinidazole is category C. • Lactating women should hold off breast feeding for 24 h after metronidazole and 72 h after tinidazole • Consult CDC in cases of allergies or resistance issues. • •

Pelvic Inflammatory Disease • Spectrum of inflammatory disorders of the upper female genital tract: endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis • STDs: GC and chlamydia • Vaginal flora: anaerobes, enteric GNR, GBStrep, H influenzae • Mycoplasma hominis and genitalium, Ureaplasma

PID: Diagnosis • Clinical diagnosis is imprecise • Many episodes of PID go unrecognized • Due to the potential of damage to the reproductive health of women and difficulty in diagnosis, maintain a low threshold for the diagnosis and treatment of PID.

PID: low threshold of diagnosis • Woman at risk for STD, experiencing lower abdominal or pelvic pain, AND has • Cervical motion tenderness, OR • Uterine tenderness OR • Adnexal tenderness • Presence of lower genital tract inflammation increases specificity of diagnosis

PID: additional criteria for diagnosis • • • Fever Abnormal vaginal or cervical discharge Leucorrhea Elevated markers of inflammation: ESR, crp Documentation of cervical infection with GC or chlamydia

PID: specific criteria for diagnosis • Histopath evidence of endometritis on biopsy • Imaging: Transvag US or MRI showing fluid filled, thick tubes; pelvic fluid; tuboovarian complex; tubal hyperemia • Laparoscopic evidence of PID

PID: Treatment • • Regimens must cover GC and chlamydia Anaerobes must be covered Enteric GNRods must be covered. Treat for 14 days