Treatment of sexual transmitted diseases STIs

 

SEXUALLY TRANSMITTED INFECTIONS

 

Treatment of STIs reduces transmission of HIV

WHO has developed syndromic approach to empirical treatment based on commonly seen signs and symptoms.

 

MALES:

Urethral discharge: confirm presence of discharge, evaluate gram stained specimen under microscope

Major pathogens causing urethral discharge: Neisseria gonorrhoeae (Gram negative intracellular diplococci) and Chlamydia trachomatis (obligate intracellular bacterium)

Treatment: Ciprofloxacin 500mg PO STAT or Ceftriaxone 125mg IM STAT (Gonorrhea) PLUS Doxycycline 100mg PO BD x 7 days or Azithromycin 1 gram PO STAT (Chlamydia)

 

Penile ulcers – confirm presence

Treatment: Benzathine penicillin G 2.4 million IU IM STAT (2 injections into separate sites) or Procaine penicillin G 1.2 million IU IM OD x 10 days (syphilis) PLUS Ciprofloxacin 500mg PO BD x 3 days (chancroid- H. ducreyi gram negative rods)

 

FEMALES:

Vaginal discharge: distinguish between vaginitis and cervicitis

Cervicitis caused by Neisseria gonorrhea and Chlamydia trachomatis (cervical discharge)

Treatment: Ciprofloxacin 500mg PO STAT or Ceftriaxone 125mg IM STAT (Gonorrhea) PLUS Doxycycline 100mg PO BD x 7 days or Azithromycin 1 gram PO STAT (Chlamydia)

 

Vaginitis caused by Trichomonas vaginalis, Candida albicans and Gardnerella

Treatment: Metronidazole 500mg PO BD x 7 days or 2grams PO STAT (Trich and BV) PLUS Fluconzaole 150mg PO STAT or Clotrimazole 200mg intravaginally OD x 3 days

 

Lower abdominal pain: evaluate for Pelvic Inflammatory Disease (PID)

** ALWAYS CHECK PREGNANCY TEST on women with lower abdominal pain**

WHO criteria for treatment:

Lower abdominal pain (without missed period, recent delivery/abortion, rebound tenderness, guarding, vaginal bleeding)

Temperature > 38.0oc

Cervical Motion Tenderness

Vaginal discharge

 

PID caused by Neisseria Gonorrheae, Chlamydia trachomatis, anaerobic bacteria

Treatment (inpatient): Ceftriaxone 250mg IM OD PLUS Doxycycline 100mg PO/IV BD PLUS Metronidazole 500mg PO/IV BD for at least 3 days after patient improved and then Doxycycline 100mg PO BD for 14 days.

 

 

 

1.  25 year-old M presents to H2 with 1 week of penile discharge.  He has noticed burning when he urinates and also yellowish-green discharge from his urethra after urination.  He has not had any fever, chills, nausea or vomiting.  He reports no abdominal pain.  Social history reveals patient smokes 1 pack of cigarettes per day for 10 years.  He does not drink alcohol or use drugs.  He is sexually active and does not use condoms.

 

On evaluation, patient is T 36.5^oc, PR 100, BP 120/80, RR 14.  He appears comfortable and is alert and oriented x 3.  He has normal heart, lung and abdomen exam.  On genital exam he has yellowish thick discharge from the urethra. 

 

1. How can you evaluate the cause of his urethral discharge?
2. Gram Stain of the discharge
2. What organisms are most likely to cause this discharge?
2. Neisseria, Chlamydia
3. How would you treat it without lab tests or microscopy?
2. Empiric therapy is warranted, can initiate based on symptoms using one of the two regimens listed above, importance is to COVER FOR BOTH NEISSERIA AND CHLAMYDIA
4. How would this case be different if the patient had a penile ulcer instead of discharge?
2. Would need to evaluate for likely Syphillis, using penicillin AND Ciprofloxacin to cover for H. Ducreyi

 

2.  28 year-old F presents to H2 with 2 weeks of vaginal discharge.  She reports her last menstrual period was 3 weeks ago and about 2 weeks ago she starting noticing white vaginal discharge without any odor.  She also reports vaginal pruritis and burning with urination.  She denies urinary frequency or urgency. 

 

On evaluation, she is T 37.7, PR 80, BP 110/70, RR 16.  She appears uncomfortable.  She has normal heart and lung exam and no tenderness on exam of the abdomen.  On pelvic exam she has erythematous, irritated vaginal mucosa with thick white discharge visible.  She does not have cervical motion tenderness or adnexal tenderness,

 

a.       How can you evaluate the cause of her vaginal discharge?

3.      Can be evaluated via wiff test, KOH prep, gram stain

b.      What different organisms cause cervicitis and vaginitis?

3.      Cervicitis is Chlamydia, Neisseria.

4.      Vaginitis is Candida, Trichomonads, and Gardnerella (BV)

c.       How would you treat this patient?

3.      Treat for Vaginitis, with anti-fungal agent + metronidazole

 

3.  38 year-old F present to H2 with severe lower abdominal pain, nausea and vomiting.  She is bent over in pain and unable to stand and walk.  She lies down on the bed and her family states she has been vomiting for 2 days and has not been able to eat anything.  She has been having fevers and chills.

 

On evaluation, she has T 39.2, PR 110, BP 96/58, RR 22.  She looks uncomfortable.  She has normal heart and lung exam but has tenderness to palpation bilateral lower quadrants on abdominal exam.  On pelvic exam she has cervical motion tenderness and green discharge from the cervical os.

 

1. What non-infectious test should be done first in all women presenting with lower abdominal pain?
1. UPT
2. How can you make the diagnosis of PID in this patient?
1. The criteris is clinical, and is met here.
3. How would you treat her for PID?
1. Treatment (inpatient): Ceftriaxone 250mg IM OD PLUS Doxycycline 100mg PO/IV BD PLUS Metronidazole 500mg PO/IV BD for at least 3 days after patient improved and then Doxycycline 100mg PO BD for 14 days.