Therapeutics: STD's
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61 terms
Terms | Definitions |
|---|---|
 Roles of the provider: | -education and counseling -prevention of continued transmission -promoting compliance with treatment/preventive measures -promoting rational, cost effective pharmacotherapy |
| STD's in infants and children: concerns for infants? Children? | -infants: mother to fetus transmission; consequences: fetal demise, infections at birth (eye, CNS, lung); bacterial vaginosis, trichomoniasis associated with premature delivery -children: strongly suspicious of sexual abuse |
| Teenagers: who's high risk here? are viral infections cured? rates of HSV and HPV? | -high risk group: behavior and anatomy -HSV, HIV, HPV: rates of HPV, HSV highest in young adults; viral infections never "cured"; 15-20% of young adults are infected with HSV by the time they are in their 20's; 28-46% of women under age 25 are infected with HPV |
| Pregnant Women: what to screen for in pregnant women? when do you rescreen? what HSV infection is most concerning? considerations with Tx & pregnancy? | -screening during pregnance is routine: syphilis, hep B, gonorrhea, chlamydia, possible HIV and BV; rescreen in 3rd trimester if <25 or if older with increased risk for STD's -HSV: primary infection is most concerning; does not always require a c-section -Treatment: effects of abx's/antiviral agents on fetus |
| Herpes Simplex Virus: meaning of word herpes? Transmission? where? epidemiology? | -herpes= "to creep" -transmission: infected secretions contacted mucosa or broken skin -virus "lives" in nerve root ganglia-primary and recurrent episodes -most common STD in US- 45+ million people |
| HSV 2: primary episode? recurrent episode? | -primary episode: painful lesions, dysuria, vaginal discharge, HA, systemic symptoms; begin 2-14 days post exposure, resolve in 1-3 weeks; viral shedding continues for 11-12 days -recurrent episodes: may be asymptomatic, yet still shed virus; shorter duration; 50% have prodrome (tingling, itching) lasting a few hours to several days; decrease in frequency over time |
| HSV treatment of primary episode: | -acyclovir: 400 mg tid X 7-10 days - acyclovir: 200 mg 5X daily x 7-10 days -famciclovir: 250 mg tid x 7-10 days -valacyclovir: 1 gm bid x 7-10 days |
| HSV treatment of recurrent episodes: | -acyclovir: 400 mg tid x 5 days -acyclovir: 800 mg bid x 5 days -acyclovir: 800 mg tid x 2 days -famciclovir: 125 mg bid x 5 days -famciclovir: 1 gm bid x 1 day or 500 mg x 1, then 250 mg bid x 2 days -valacyclovir: 500 mg bid x 3 days -valacyclovir: 1 gm QD x 5 days |
| HSV daily suppressive therapy: (drugs) | -acyclovir: 400 mg bid -vamciclovir: 250 mg bid -valacyclovir: 500 mg QD (less effective than other regimens in pts with very frequent >10/yr episodes) -valacyclovir: 1 gm QD |
| HSV daily suppressive therapy: when to consider? effect on viral shedding? key benefit? | -consider if pt has >6 episodes per year: antiviral therapy can decrease recurrence by 75%; consider stopping after 1 yr to assess recurrence rate -reduces but does not eliminate viral shedding -key benefit= "reduction of psycholgical morbidity" |
| HSV treatment in pregnancy: when to intervene, with what? primary vs. recurrent at delivery? | -safety of antiviral agents during pregnancy not fully known-weigh risk vs. benefti -women with history of symptomatic genital herpes offered suppressive therapy @ 36 wks until delivery (acyclovir 400 mg tid or valcyclovir 500 mg bid) -c-section only if genital lesions or prodrome at time of delivery -primary episode during delivery= 30-50% transmission to infant vs 4% with recurrent episode at delivery |
| HSV other treatments: | -topical antiviral therapy: penciclovir- apply 5x daily, decreased time to healing by 17 hrs; acyclovir- apply 4x-6x/day, similar to penciclovir in efficacy, poor skin penetration -2010 guidelines: "topical antivirals offer minimal clinical benefit and use is discouraged" -other: abreva (docosanol) apply 5x daily, decreased time to healing by 18 hrs vs placebo; lysine- no effect o duration or severity, may decrease recurrence. Dose? adverse effects: GI |
| HSV counseling: 7 things | -adverse effects of meds -non-pharmacologic therapy -identify triggers -sexual partners -transmission prevention -pregnancy -cost of therapy |
| Syphilis: What causes it? Transmission? Dx test? | -spirochete: Treponema pallidum -transmission: sexual contact with infected mucosa or skin lesions -diagnosis: RPR and VDRL (nonspecific tests for screening), FTA-Abs (very specific test for confirmation) |
| Primary syphilis: | -chancre -onset 10 days- 3 months after exposure -painless, but very infecious -will disappear without treatment |
| Secondary syphilis: | -2-6 wks after chancre disappears -rash-may be on soles/palms -systematic flu like symptoms, lymphadenopathy -may last weeks to months -after this= early latent (<1 yr) asymptomatic |
| Syphilis Late Latent presentation: | -tertiary syphilis -gumma: may be on any part of the body, usually painless; spirochetes cannot be cultured from gumma -not infectious (except in pregnancy) |
| Tertiary syphilis presentation: | -cardiovascular problems usually occur 15-30 yrs after initial infection if untreated -neurosyphilis can be seen in all stages, but usually in tertiary. 25-30% will progress to neurosyphilis if untreated, result in deafness, blindness, dementia |
| Syphilis treatments: | -Primary/Secondary: benzathine PCN G 2.4 million units IM x 1 dose -PCN allergy: doxycycline 100 mg bid x 2 wks or TCN 500 QID x 2 wks or ceftriaxone 1 gm IV/IM qday x 8-10 days -Pregnant: PCN only, desensitize if allergic -Latent/Tertiary: early-same as primary/secondary; late or unknown- give 3 doses of benzathine PCN G at weekly intervals. If PCN allergy- no ceftriazone -Neurosyphilis: aqueous crystalline PCN G 3-4 mu q 4hrs x 10-14 days or procaine PCN 2.4 mu IM qd plus probenecid 500 mg qid x 10-14 days- desensitize if allergic or ceftriaxone 2 gm IM/IV qday x 10-14 days |
| Syphilis counseling: | -follow up: reexamine and test serologically at 6 and 12 months. If titers still +, treat with same dose of PCN as above at weekly intervals x 3 doses -adverse effects: Jarisch-Herxheimer reaction -Treatment of sexual partners -importance of treatment |
| Chlamydia: What causes it? Co-infections? Dx test? | -obligate intracellular parasite- chlamydia trachomatis -common co infections with gonorrhea: symptoms very similar, may also be referred to as "non-gonococcal urethritis" or NGU -Diagnosis: NAAT, test of cure not routinely necessary |
| Chlamydia presentation: common sites & symptoms in men/women, % asymptomatic, & onset? infants? | -Male: genital tract, rectum, eyes; onset 1-3 wks; dysuria, frequency, urethral d/c, proctitis -female: genital tract, eyes, rectum; onset 1-3 wks; endocervicitis, vaginal d/c, dysuria -infants: conjunctivitis or pneumonia -up to 50% of women, 25% men asymptomatic |
| Chlamydia treatment: initial (2 drugs)? tx pregnant? tx child? | -azithromycin 1 gm po x 1 dose directly observed -doxycycline 100 mg bid x7 days -pregnant women: axithromycin 1 gm x1; amox 500 mg tid x 7days; repeat testing after 3 weeks -infants: erythromycin po |
| Chlamydia counseling: | -adverse effects -treatment of sexual partners -abstinence until treatment completed (7days after single dose treatment) -advanced symptoms- rationale for treatment (PID& infertility) -breakthrough bleeding on OCPs may be a sign of chlamydia -focus on screening, re-screening: yearly screening of women <25 |
| Gonorrhea: What causes it? what's unique about its transmission? dx test? emerging issues? | -gram neg diplococci- neisseria gonorrhoeae -rapid incubation and high transmission from male to female -diagnosis: NAAT -emerging issues: abx resistance *pharyngeal gonorrhea increasing and often not detected |
| Clinical presentation of gonorrhea in men: | -just ask Matt :) -often have symptoms- dysuria, urethral d/c, proctitis -occur within 2-10 days |
| Clinical presentation of gonorrhea in women: | -often asymptomatic -may progress to PID and cause infertility -if symptomatic- similar to men |
| Clinical presentation of gonorrhea in infants: | -conjunctivitis or disseminated infection |
| Treatment for gonorrhea: What should you NEVER use? Tx for pharyngeal? allergy to ceph? | *always treat for both chlamydia and gonorrhea in patients with gonorrhea -cervical/urethral/rectal infections: cefixime 400 mg po x 1 dose OR -ceftriaxone 250 mg IM x 1 dose PLUS azithromycin 1 gm po x 1 or doxycycline 100 mg bid x 7 days -do not use quinolones... ever -pharyngeal- must use IM ceftriaxone -if allergy to cephalosorin: use azithromycin 2 gm x 1 dose (increasing resistance, increased GI side effects, decreased tolerability) |
| Gonorrhea counseling: | -adverse effects of meds -consequences of non-adherence with treatment like PID and infertility, newborn infection -treat all sexual partners within 60 days -abstain until all partners treated -all infants given prophylaxis at birth for ocular infections (silver nitrate or erythromycin or tetracycline ointment) |
| Bacterial Vaginosis: organisms? transmission? dx (4 things)? | -pathogen: Gardnerella vaginalis, ureaplasma urealyticum, -gram neg, anaerobic bacteria -not always sexually transmitted -diagnose: white, thin, non-inflammatory d/c, clue cells, ph>4.5 (vaginal fluid), a "fishy" odor prior to or after adding 10% KOH |
| Presentation of Bacterial Vaginosis: | -up to 50% asymptomatic -usually doesn't itch -discharge may be gray or white -doesn't always have a "fishy" odor (how would you know Jess?) |
| Treatment for Bacterial Vaginosis: non-pregnant | -metrondiazole 500 mg po bid x 7 days OR -metronidazole 0.75% Gel 5 gm vaginally x 7 days OR -clindamycin 2% cream 5 gm qhs x 7 days *NO SINGLE DOSE THERAPY |
| Treatment for Bacterial Vaginosis: pregnant | -metronidazole 500 mg bid x 7 days OR -metronidazole 250 po tid x 7 days OR -clindamycin 300 mg bid x 7 days no topical therapy in pregnancy |
| Bacterial Vaginosis counseling: tx of partners beneficial? | -adverse effects of medicines- especially metronidazole -treatment of sexual partners- not beneficial |
| Trichomoniasis: what is it? who's usually asymptomatic? dx? | -protozoan parasite- trichomoniasis vaginalis -men may be affected- usually asymptomatic -diagnosis: presence of protozoan on wet mount slide under microscope |
| Trichomoniasis presentation: | -onset of symptoms within 4-20 days of exposure -men: urethral discharge, dysuria -women: mild to severe "foamy" yellow green or gray dishcarge with an odor, pruritis, erythema, inflammation, dysuria, spotting |
| Trichomoniasis treatment: recommendations for pregnancy? | -metronidazole 2 gm po x 1 dose OR tinidazole 2 gm po x 1 dose -alternative therapy: metronidazole 500 mg bid x 7 days -repeated failures: metronidazole or tinidazole 2 gm daily x 5 days -pregnancy: CDC recommends single dose therapy, metronidazole, all trimesters |
| Trichomoniasis counseling: what's not effective? | -treat sexual partners -warn of adverse effects -gel not effective |
| Vulvovaginal Candidiasis: what causes it? transmission? dx? | -candida albicans primary pathogen -not usually sexually transmitted- but can be -diagnosis: yeast or pseudohyphae on microscopy |
| Vulvovaginal Candidiasis Presentation: women? men? | --symptoms similarto trich/BV: extreme pruritis, erythema, dysuria, discharge is white and thick, without odor -men usually asymptomatic |
| What questions to ask for Vulvovaginal Candidiasis: | -What symptoms are you experiencing? -Have you previously been diagnosed by a physician as having a vaginal yeast infection? Are these symptoms similar? -What were you treated with previously? -Do you have any allergies? Medical problems? Are you pregnant? |
| Vulvovaginal Candidiasis treatment: pregnancy? recurrent? | -OTC/RX azole antifungal vaginal cream, suppository, tablet or fluconazole oral tablet= 80-90% effective -pregnancy: use topical, 7 day therapy only -Recurrent VVC (>4 episodes/yr) may treat longer or continuously |
| VVC counseling: what to evaluate when infections are frequent? | -treatment of partners: usually not needed -Use OTC only if previously dx by provider, see provider if unrelieved by OTC med within 3 days of therapy -evaluate for diabetes, immunosuppression if infections are frequent |
| VVC treatment options: | -OTC: butoconazole, clotrimazole, miconazole, tioconazole -prescription azoles: fluconazole oral tab, miconazole vaginal suppository, terconazole |
| Recurrent VVC treatment options: | -more than 4 symptomatic episodes/year -get vaginal culture before starting maintenance therapy -TX: 7-14 days of topical therapy OR -fluconazole 100-200 mg q3 days x 3 doses -then followed by 6 months maintenance therapy of: fluconazole 100-200 mg po q week OR itraconazole 400 mg q month or 100 mg qday |
| Pelvic inflammatory disease: pathogens? what is it? | -Pathogen: gonorrhea, chlamydia, gram negatives, anaerobes, mycoplasma hominis -inflammation of the upper female genital tract (endometriosis, salpingitis, tubo-ovarian abcess, pelvic peritonitis) |
| PID presentation: | -lower abd pain, uterine/adnexal tenderness, cervical motion tenderness -may have vaginal or cervical discharge -fever, dysuria, dysparenunia -irregular menstrual bleeding -often misdiagnosed or underdiagnosed |
| PID treatment: Outpatient. what can you give if cephs can't? What can't you give? | -ofloxacin 400 mg bid or levofloxacin 500 mg qday x 14 days PLUS metronidazole 500 mg bid x 14 days or clindamycin 450 mg QID OR -ceftriaxone 250 mg IM x 1 PLUSdoxycycline 100 mg bid x 14 days +/- metronidazole 500 mg bid x 14 sYA *QUINOLONES only if cephalosporin can't be used and low prevalence of gonorrhea, and follow up likely. No oral cephalosporins, no azithro |
| PID counseling: | -treat all sexual partners for chlamydia and gonorrhea -adverse effects of drugs and parameters for ER/MD visit -long term consequences of non-adherence |
| Human Papillomavirus: (HPV): other names? Concerns? cure? | -AKA genital warts, conyloma acuminata -many different strains of virus -can be asymptomatic -concern especially with strains associated with cervical cancer -no cure. lifelong infection |
| HPV clinical presentation: | -can be found in multiple areas: cervix, urethra, vagina, penis, anus, perineum, conjunctiva, nose,oral cavity, larynx -may cause pain, itching, or bleeding |
| HPV vaccine: what types covered for gardasil/other? what age range? what's the series interval? | -gardasil: types 6,11,16,18 -recommended for 11-12 yr old females- can be given 9-26 -3 dose series: 0,2,6 months -males?? -cervarix: just approved, types 16,18 -3 dose series -0,1,6 months |
| HPV treatment: patient applied | -podofilox 0.5% solution or gel bid x 3 days, then four days off x four cycles -imiquimod 5% cream- QHS TIW x up to 16 weeks, wash off 6-10 hours after application -sinecatechins (green tea extract)- not very effective, tid application,external only |
| HPV treatment: provider applied | -cryotherapy -podophyllin resin 10-25% -TCA 80-90% -surgery -intralesional interferon -laser surgery |
| PID treatment: inpatient: | -if pregnant, no response to outpt tx, severe n/v or fever, abscess, or immunodeficient -cefotetan OR cefoxitin PLUS doxycycline OR clindamycin PLUS gentamycin -continue IV x 24 hrs post improvement, then PO clinda or doxy x 14 days total |
| HPV counseling: | -treat infected partners if symptomatic -can be transmitted even if lesions not visible -condoms! (decrease but don't elminate transmission) -pregnancy- avoid topical treatments |
| Pubic lice and scabies presentation: what's the difference? presentation? | -lice= parasitic insect -scabies= mite -presentation: itching, scabies- burrows or tracts, itching worse at night; visualization of nits/lice, may itch up to 2 weeks (scabies) |
| Treatment for lice: | --treat like head lice -alternative: ivermectin 250 mcg/kg po x 1 repeated in 2 weeks -non pharmacologic measures as for head lice -treat sexual contacts within past month -treat household members -don't use ivermectin in pregnancy |
| Treatment for scabies: what shouldn't you use during pregnancy? | -permethrin 5% OR ivermectin 200 mcg/kg po x1, repeat in 2 weeks -treat sexual contacts within past month -treat household members -do not use ivermectin in pregnancy |
| STD prevention: | -education -prevention -notification -adherence -reporting -confidentiality -referral |
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