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STD Treatment Guidelines
Steve Randall, PA The Medical Practice Association of KUSM-W - HIV Program HIV Educator, The Kansas AIDS Education and Training Center The University of Kansas School of Medicine - Wichita

STD Prevention and Control
• Education and counseling to reduce risk of • Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation • Effective diagnosis and treatment • Evaluation, treatment, and counseling of • Preexposure vaccination--hepatitis A, B

• Prevention messages tailored to the client's personal risk; interactive counseling approaches are effective • Despite adolescents greater risk of STDs, providers often fail to inquire about sexual behavior, assess risk, counsel about risk reduction, screen for as infection • Specific actions necessary to avoid acquisition or transmission of STDs • Clients seeking evaluation or treatment for STDs should be informed which specific tests will be performed

Male Condoms
• Consistent/correct use of latex condoms are effective in preventing sexual transmission of HIV infection and can reduce risk of other STDs • Likely to be more effective in prevention of infections transmitted by fluids from mucosal surfaces (GC,CT, trichomonas, HIV) than those transmitted by skin-skin contact (HSV,HPV, syphilis, chancroid)

• N-9 vaginal spermicides are not effective in preventing CT, GC, or HIV infection • Frequent use of spermicides/N-9 have been associated with genital lesions • Spermicides alone are not recommended for STD/HIV prevention • N-9 should not be used a microbicide or lubricant during anal intercourse

• STD/HIV sexual risk assessment and client- centered prevention counseling • Annual STD screening for MSM at risk -HIV and syphilis serology -Urethral cx or NAAT, GC/CT -Pharyngeal cx, GC (oro-genital) -Rectal cx, GC/CT (receptive anal IC)

Early HIV Infection
• Medical/sexual history, previous STD • PX, pelvic (pap, wet mount), GC, CT • Syphilis serology • CD4 count, HIV viral load • CBC, blood chemistry • PPD, urinalysis, CXR • Hepatitis A, B, C serology • Diagnosis based on medical history and physical examination often inaccurate • Serologic test for syphilis • Culture/antigen test for herpes simplex • Haemophilus ducreyi culture in settings where chancroid is prevalent • Biopsy may be useful First Clinical Episode
Acyclovir 400 mg tid Famciclovir 250 mg tid Valacyclovir 1000 mg bid Duration of Therapy 7-10 days
Genital Herpes
Acyclovir 400 mg three times daily x 5 days Acyclovir 800 mg twice daily x 5 days Famciclovir 125 mg twice daily x 5 days Valacyclovir 500 mg twice daily x 3-5 days Valacyclovir 1 gm orally daily x 5 days Acyclovir 400 mg bid Famciclovir 250 mg bid Valacyclovir 500-1000 mg daily Treatment in Pregnancy
• Available data do not indicate an increased risk of major birth defects (first trimester) • Limited experience on pregnancy outcomes with prenatal exposure to valacyclovir or famciclovir • Acyclovir may be used with first episode or severe recurrent disease • Risk of transmission to the neonate is 30-50% among women who acquire HSV near delivery • Natural history of infection, recurrences, asymptomatic shedding, transmission risk • Individualize use of episodic or suppressive • Abstain from sexual activity when lesions or prodromal symptoms present • Risk of neonatal infection Primary, Secondary, Early Latent
Benzathine Penicillin G, 2.4 million units IM Doxycycline 100 mg twice daily x 14 days Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited Azithromycin 2 gm single oral dose (preliminary data) *Use in HIV-infection has not been studied
Response to Treatment
• No definitive criteria for cure or failure are established • Re-examine clinically and serologically at 6 and 12 • Consider treatment failure if signs/symptoms persist or sustained 4x increase in nontreponemal test • Treatment failure: HIV test, CSF analysis; administer benzathine pcn weekly x 3 wks • Additional therapy not warranted in instances when titers don't decline despite nl CSF and repeat therapy Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses Doxycycline 100 mg orally twice daily Tetracycline 500 mg orally four times daily Duration of therapy 28 days; close clinical and
follow-up; data to support alternatives to pcn are
• Clinical evaluation of tertiary disease (aorititis, • CSF analysis: neurologic or ophthalmic signs/sx, active tertiary disease, tx failure, HIV infection • Some experts recommend CSF exam in those with nontreponemal titer of >1:32 • Pharmacologic considerations suggest an interval of 10-14 days between benz pen doses may be acceptable before restarting treatment course in nonpregnant patients Management of Sex Partners
• At risk- 3 mo + sx for primary, 6 mo + sx for secondary, one yr for early latent • Exposure to primary, secondary, or early latent within 90 days, tx presumptively • Exposure to primary, secondary, or early latent > 90 days, tx presumptively if serology not available • Exposure to latent syphilis who have high nontreponemal titers > 1:32, consider presumptive tx for early syphilis Treatment in Pregnancy
• Screen for syphilis at first prenatal visit; repeat RPR third trimester/delivery for those at high risk or high prevalence areas • Treat for the appropriate stage of syphilis • Some experts recommend additional benzathine penicillin 2.4 mu IM after the initial dose for primary, secondary, or early latent syphilis • Management and counseling may be facilitated by sonographic fetal evaluation for congenital syphilis in the second half of pregnancy Infants with Seroreactive Mothers
• Nontreponemal test on infant serum • Examination (nonimmune hydrops, jaundice, HSM, rhinitis, rash) • Pathologic exam of placenta or umbilical cord (fluorescent antitreponemal antibody) • Darkfield or DFA of suspicious lesions or Proven/highly probable disease
• Abnormal physical exam consistent with congenital syphilis • Nontreponemal titer 4X > maternal titer or + • Evaluation: CSF exam, CBC; other tests as clinically indicated--long bone films, LFTs, cranial US, eye exam, auditory brain stem response Proven/highly probable disease
Aqueous crystalline penicillin G 100,000- 150,000 units/kg/day, administered as 50,000 units/kg/dose IV q 12 hours during the first 7 days and thereafter q 8 hours for 10 days Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days • Clinical/serologic evaluation q 2-3 mo • RPR should decline by 3 mo, nonreactive at • Stable or increasing titers after 6-12 mo--CSF analysis/parenteral pcn X 10 d • Reactive treponemal/RPR after 18 mo re- evaluate and treat for congenital syphilis Older Infants and Children
• Review records and maternal serology- congenital vs acquired • Evaluation- CSF analysis, CBC/pts; +/- long bone films, auditory brain stem response • Treatment- Aqueous pcn G 50,000 units/kg q 4-6 hours for 10 days Azithromycin 1 gm orally Ceftriaxone 250 mg IM in a single dose Ciprofloxacin 500 mg twice daily x 3 days Erythromycin base 500 mg tid x 7 days • Re-examination 3-7 days after treatment • Time required for complete healing related to ulcer size • Lack of improvement: incorrect diagnosis, co-infection, non-compliance, antimicrobial resistance • Resolution of lymphadenopathy may Management of Sex Partners
Examine and treat partner whether symptomatic or not if partner contact < 10 days prior to onset October 28, 2004 Rare Infection a Risk to Gay & Bisexual Men in US Lymphogranuloma Venereum A recent outbreak of the disease in gay and bisexual men in the Netherlands has brought about a concern that it will be overlooked in the US as doctors are not required to report these infections to local health departments in US LGV primary lesion Chronic lymphogranuloma venereum in female. Genital elephantiasis Doxycycline 100 mg twice daily for 21 days Erythromycin base 500 mg four times daily for 21 days Doxycycline 100 mg twice daily Trimethoprim-sulfamethoxazole 800 mg/160 Minimum treatment duration three
Ciprofloxacin 750 mg twice daily Erythromycin base 500 mg four times daily Azithromycin 1 gm orally weekly Minimum treatment duration three
• Mucopurulent or purulent discharge • Gram stain of urethral secretions > 5 WBC per oil immersion field • Positive leukocyte esterase on first void urine or >10 WBC per high power field Empiric treatment in those with high risk
who are unlikely to return
Azithromycin 1 gm in a single dose Doxycycline 100 mg bid x 7 days • Objective signs of urethritis • Re-treat with initial regimen if non-compliant or re-exposure occurs • Intraurethral culture for trichomonas • Effective regimens not identified in those with persistent symptoms without signs Metronidazole 2 gm single dose Erythromycin base 500 mg qid x 7d Erythromycin ethylsuccinate 800 mg qid x • Annual screening of sexually active women • Annual screening of sexually active women > 25 yrs with risk factors • Sexual risk assessment may indicate more frequent screening for some women • Rescreen women 3-4 months after treatment due to high prevalence of repeat infection Azithromycin 1 gm single dose Doxycycline 100 mg bid x 7d Treatment in Pregnancy
Erythromycin base 500 mg qid for 7 days Amoxicillin 500 mg three times daily for 7 days Erythromycin base 250 mg qid for 14 days Erythromycin ethylsuccinate 800 mg qid for 14 days Erythromycin ethylsuccinate 400 mg qid for 14 days Azithromycin 1 gm in a single dose Gonococcal urethritis Disseminated gonorrhea –
skin lesion
Cervix, Urethra, Rectum
Ceftriaxone 125 IM Ciprofloxacin 500 mg Ofloxacin 400 mg/Levofloxacin 250 mg PLUS Chlamydial therapy if infection not ruled out
Cervix, Urethra, Rectum
Spectinomycin 2 grams IM in a single dose Single dose cephalosporin (cefotaxime 500 mg) Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg) PLUS Chlamydial therapy if infection not ruled
Ceftriaxone 125 IM in a single dose Ciprofloxacin 500 mg in a single dose PLUS Chlamydial therapy if infection not ruled
Treatment in Pregnancy
• Cephalosporin regimen • Women who can't tolerate cephalosporin regimen may receive 2 g spectinomycin IM • No quinolone or tetracycline regimen • Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection Disseminated Gonococcal
Ceftriaxone 1 gm IM or IV q 24 hr Cefotaxime or Ceftizoxime 1 gm IV q8 hr Ciprofloxacin 400 mg IV q 12 Ofloxacin 400 mg IV q 12 Levofloxacin 250 mg IV daily Sporadic, infrequent Likely C albicans Butoconazole, clotrimazole, miconazole, nystatin, tioconazole, terconazole Oral regimen
Fluconazole 150 mg in a single dose • Four or more symptomatic episodes/year • Vaginal culture useful to confirm diagnosis and identify unusual species • Initial regimen of 7-14 days topical therapy or fluconazole 150 mg (repeat 72 hr) • Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole • Non-albicans VVC- longer duration of therapy with non-azole regimen Management of Sex Partners
• Treatment not recommended • Treatment of male partners does not reduce frequency of recurrences in the female • Male partners with balanitis may benefit Treatment in Pregnancy
• Only topical intravaginal regimens recommended • Most specialists recommend 7 Metronidazole 2 gm orally in a single dose Metronidazole 500 mg twice a day for 7 days Metronidazole 2 gm orally in a single dose Management of Sex Partners
• Sex partners should be treated • Avoid intercourse until therapy is completed and patient and partner are asymptomatic Metronidazole 500 mg twice daily for 7 days Metronidazole gel 0.75%, 5 g intravaginally once daily for 5 days Clindamycin cream 5%, 5 g intravaginally qhs Treatment in Pregnancy
Metronidazole 250 mg three times daily for 7 days Clindamycin 300 mg twice daily Management of Sex Partners
Woman's response to therapy and the likelihood of relapse or recurrence not affected by treatment of sex partner Pelvic Inflammatory Disease
Minimum Diagnostic Criteria
Uterine/adnexal tenderness or cervical motion Additional Diagnostic Criteria
Oral temperature >38.3 C Cervical CT or GC WBCs/saline microscopy Pelvic Inflammatory Disease
Definitive Diagnostic Criteria
• Endometrial biopsy with histopathologic evidence of endometritis • Transvaginal sonography or MRI showing thick fluid-filled tubes • Laparoscopic abnormalities consistent with PID Pelvic Inflammatory Disease
• Surgical emergencies not excluded • Clinical failure of oral antimicrobials • Inability to follow or tolerate oral regimen • Severe illness, nausea/vomiting, high fever • Tubo-ovarian abscess Pelvic Inflammatory Disease
Parenteral Regimen A
Cefotetan 2 g IV q 12 hours Cefoxitin 2 g IV q 6 hours Doxycycline 100 mg orally/IV Pelvic Inflammatory Disease
Oral Regimen A
Ofloxacin 400 mg twice daily for 14 days Levofloxacin 500 mg once daily for 14 days WITH OR WITHOUT
Metronidazole 500 mg twice daily for 14 days Pelvic Inflammatory Disease
Management of Sex Partners
• Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt's onset of symptoms • Sex partners should be treated empirically with regimens effective against CT and GC • Gram stain smear of urethral exudate for diagnosis of urethritis • Intraurethral culture or nucleic acid amplification test for GC and CT • Examination of first void uncentrifuged urine for WBCs if urethral gram stain negative Infection likely due to GC or CT
Ceftriaxone 250 mg IM in a single dose Doxycycline 100 mg twice daily for 10 days Infection likely due to enteric organisms or
age > 35

Ofloxacin 300 mg twice daily for 10 days Levofloxacin 500 mg once daily for 10 days • Primary goal for treatment of visible warts is the removal of symptomatic warts • Therapy may reduce but probably does not eradicate infectivity • Difficult to determine if treatment reduces –No laboratory marker of infectivity –Variable results utilizing viral DNA Podofilox 0.5% solution or gel Imiquimod 5% cream Podophyllin resin 10-25% Trichloroacetic or Bichloroacetic acid 80-90% Treatment in Pregnancy
• Imiquimod, podophyllin, podofilox should not be used in pregnancy • Many specialists advocate wart removal due to possible proliferation and friability • HPV types 6 and 11 can cause respiratory papillomatosis in infants and children • Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction Cervical Cancer Screening
Women with History of STDs
• Women with STD hx may be at increased risk of cervical cancer • Clinics that offer pap screening without colposcopic f/u should arrange for referral • Management of abnormal pap provided per Interim Guidelines for Management of Abnormal Cervical Cytology (NCI Consensus Panel) • Emerging data support HPV testing for the triage of women with ASCUS Pap tests Vaccine Preventable STDs
Hepatitis A
• Illegal drug users • Chronic liver disease, hepatitis B and C infection Vaccine Preventable STDs
Hepatitis B
• History of STD, multiple sex partners, sexually active MSM • Illegal drug use • Household members, sex partners of those with chronic hepatitis B • Hemodialysis, occupational blood • Pruritus or lice or nits on pubic hair • Decontaminate bedding and clothing • Recommended regimens
– Permethrin 1% – Lindane 1% shampoo – Pyrethrins with piperonyl butoxide • Re-treatment may be necessary if sx persist • Treatment of sex partners within the last month • Predominant symptom is pruritus • Recommended regimen
Permethrin cream 5% • Alternative regimen
Lindane 1% or Invermectin 200 ug/kg, repeat in 2 wks • Sex partners and household contacts within the preceding month should be treated • Cultures for GC and CT from sites of penetration; if Nucleic Acid Amplification Test (NAAT)is used, positive test should be confirmed by a second FDA licensed NAAT utilizing a different primer sequence • Wet mount and culture for trichomonias • HIV, hepatitis and syphilis serology • Suggested preventative therapy -Postexposure hepatitis B vaccination -Empiric regimen for chlamydia, gonorrhea, trichomonas, and BV • Efficacy of antimicrobial regimens in the prevention of genitourinary infections after sexual assault has not been evaluated


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