Sexually Transmitted Diseases
General Guidelines
Persons identified as having one sexually transmitted disease (STD) are at risk for others and should be screened as appropriate.Partners of persons with an STD should be evaluated and treated as appropriate.
Emphasis should be placed on prevention as well as treatment of STDs.
Considerations in HIV-infected Persons
Genital ulcer diseases, such as syphilis and herpes simplex virus (HSV) infection, predispose to transmission of HIV infection.The presentation, serology, natural history, and treatment response of syphilis may be altered in the context of HIV disease.
HSV infection is more severe and prone to relapse.
Human papillomavirus (HPV) infection is common and associated with cervical dysplasia and anal cancer.
Treatment of pelvic inflammatory disease may be problematic.
Routine periodic screening for STDs is recommended in HIV-infected patients.
Diagnosis and Treatment
Gonorrhea
Syndromes include urethritis, epididymitis in men, cervicitis and salpingitis in women, rectal, pharyngeal, and disseminated infection.Diagnosis is made presumptively by demonstration of intracellular gram-negative diplococci and confirmed by urinary nucleic acid amplification (men) or culture.
Treatment of uncomplicated infection:
- ceftriaxone 125 mg IM once or
- cefixime 400 mg po once or
- ciprofloxacin 500 mg po once or
- ofloxacin 400 mg po once
plus
- doxycycline 100 mg po bid x 7 days or
- azithromycin powder 1 gram po once
Treatment of complicated infection:
- ceftriaxone 1 gram IM or IV qd
Recent sex partners of patients with gonorrhea infection should be treated presumptively for gonorrhea and chlamydial infection.
Chlamydial Infection
Syndromes include urethritis, epididymitis, cervicitis, salpingitis, proctitis, and lymphogranuloma venereum.Diagnosis is made presumptively by demonstration of PMNs without gram-negative diplococci on gram stain of discharge and confirmed by urinary nucleic acid amplification assay (preferably of first void specimen).
Treatment:
- doxycycline 100 mg po bid x 7 days or
- azithromycin powder 1 gram po once
Recent sex partners of patients with chlamydial infection should be treated presumptively.
Chancroid
Syndrome is painful genital ulcer(s) with shaggy border and exudate at base associated with tender inguinal adenopathy.
Presumptive diagnosis is made by clinical appearance of lesion and ruling out other causes of genital ulcer disease (RPR; Tzanck smear, HSV culture, or dFA [direct fluorescent antibody] test).
Treatment:
- ceftriaxone 250 mg IM once or
- azithromycin 1 gram po once or
- ciprofloxacin 500 mg po bid x 3 days or
- erythromycin 500 mg po qid x 7 days
Syphilis
Syndromes: Primary stage manifested by chancre; secondary phase manifested by mucocutaneous disease; and tertiary phase, after prolonged latency period, manifested by neurologic disease.Diagnosis is made by clinical presentation and positive serology (RPR or VDRL plus confirmatory test [FTA-abs or MHA-Tp]).
Treatment:
- primary, secondary, and early latent (< 1 yr duration) --> benzathine penicillin 2.4 mU weekly x 1-2
- late latent (> 1 yr duration) and tertiary --> benzathine penicillin 2.4 mU weekly x 3
- neurosyphilis (any stage) --> penicillin G 18-24 mU/day x 10-14 days followed by regimen for late latent syphilis
- alternative Rx is doxycycline or tetracycline x 2-4 weeks (except for neurosyphilis)
RPR or VDRL will generally convert to negativity within 1-2 years in patients who have primary, secondary, or early latent syphilis. In patients with late latent and tertiary syphilis, RPR or VDRL may remain serofast at low positive titer.
Lumbar puncture should be performed in patients with neurologic symptoms or signs and in those with late latent syphilis to rule out central nervous system involvement.
Recent sex partners of patients with primary, secondary, or early latent syphilis should be treated presumptively.
Herpes Simplex Virus
Syndrome is multiple clustered vesicular lesions on erythematous base; primary infection is followed by variable frequency of recurrences.Diagnosis is made presumptively by clinical appearance of lesions and confirmed by Tzanck smear, HSV culture, or dFA test.
Treatment:
- primary infection --> acyclovir 400 mg po tid x 7-10 days
- recurrent infection --> acyclovir 400 mg po tid x 5 days
- alternative agents include famciclovir and valacyclovir
- topical acyclovir offers little or no therapeutic benefit
- prophylaxis for patients with frequent recurrences --> acyclovir 400 mg po bid
Genital Warts
Syndrome is one or more skin-colored papular lesions at sites of sexual contact. These may occur externally on the penis, vulva, or perineal region, or internally in the vagina or rectum. Genital warts are caused by human papillomavirus, which is a risk factor for cervical and anal dysplasia/cancer.
Diagnosis is made by clinical appearance.
Treatment: All of the listed modalities are about equally effective, and there is a high rate of relapse although frequency is variable.
- podophyllin 0.5% solution or gel (can be prescribed) apply bid x 3 days followed by 4 days of no therapy; may be repeated as necessary for total of 4 cycles
- imiquimod 5% cream (can be prescribed) apply qhs tiw for up to 16 weeks; wash area with soap and water in morning
- trichloroacetic acid
- cryotherapy
- laser therapy
- surgical removal
- local alpha-interferon injection
Molluscum Contagiosum
Syndrome is multiple clustered pearl-like papular lesions on site of physical contact, but autoinoculation may also occur.Diagnosis is made by clinical appearance.
Treatment:
- curettage
- cryotherapy
- trichloroacetic acid
Trichomonas
Syndrome is foamy vaginal discharge sometimes in association with urethritis.
Diagnosis is made by vaginal wet mount showing flagellated single-celled organisms.
Treatment:
- metronidazole 2 grams po x one or 500 mg po bid x 7 days
- alternative therapy during pregnancy is clotrimazole vaginal troches
Recent sex partners of patients with trichomonas infection should be treated presumptively.
Scabies
Syndrome is a scattered pruritic, papular eruption with characteristic "burrows" sometimes noted.Diagnosis is made by clinical appearance of skin lesions and confirmed by scraping/oil mount demonstrating the parasite.
Treatment:
- permethrin cream 5% applied from neck down and and washed off after 8-14 hours
- alternative therapies include lindane, sulfur, and oral ivermectin
Recent sex partners and household contacts of patients with scabies should be treated presumptively.
Pubic Lice
Syndrome is genital pruritus.
Diagnosis is made by recognition of lice or nits on pubic hair.
Treatment:
- permethrin 1% creme rinse applied to affected areas and washed off after 10 minutes
Recent sex partners of patients with pubic lice should be treated presumptively.
Prevention
Educate those at risk for STDs regarding effective means for reducing transmission through use of barrier methods and behavioral changes.
Identify and screen populations at high risk.
Promptly diagnose and treat patients with symptomatic infection.
Evaluate, treat, and counsel their sexual partners.
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Comments about these guidelines are welcome and can be sent to the author at hlibman@caregroup.harvard.edu