# Presentation: 167358

## 2002 STD Treatment Guidelines

- Division of STD Prevention, CDC

## 2002 STD Treatment Guidelines	

- Evidence-based systematic review
- Consultants Meeting in September 2000
- 65 invited consultants- STD treatment experts, professional organizations, HMOs
- Background manuscripts in *Clinical Infectious Diseases *(October 2002)

## STD Prevention and Control

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

## Prevention Messages

- 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 asx 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

## Prevention Methods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)

##  Prevention MethodsSpermicides

- 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

## MSM

- 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Initial Evaluation

- Medical/sexual history, previous STD
- Pex, pelvic (pap, wet mount), GC, CT
- Syphilis serology
- CD4 count, HIV viral load
- CBC, blood chemistry
- PPD, urinalysis, CXR
- Hepatitis A, B, C serology

## Genital UlcerEvaluation

- 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

## HSV Serologic Tests Type-Specific 

- HSV-specific glycoprotein G2 for HSV 2 infection and glycoprotein G1 for HSV 1
- Available gG type-specific assays- POCkit HSV-2,  HerpeSelect HSV1/2 IgG ELISA  and HerpeSelect 1/2 immunoblot IgG
- Sensitivity 80-98%, Specificity _>_ 96%
- Confirmatory testing may be indicated in some settings

## Genital HerpesFirst Clinical Episode

- 			   Acyclovir 400 mg tid
- 						  or
- 			   Famciclovir 250 mg tid
- 						  or
- 			   Valacyclovir 1000 mg bid
*	**    ****Duration of Therapy 7-10 days***

## Genital Herpes Episodic Therapy

- 	Acyclovir 400 mg three times daily x 5 days
- 				or
- 	Acyclovir 800 mg twice daily x 5 days
- 				or
- 	Famciclovir 125 mg twice daily x 5 days
- 				or
- 	Valacyclovir 500 mg twice daily x 3-5 days
- 				or
- 	Valacyclovir 1 gm orally daily x 5 days

## Genital HerpesDaily Suppression

- 			   Acyclovir 400 mg bid
- 					or
- 			  Famciclovir 250 mg bid
- 					or
- 		        Valacyclovir 500-1000 mg daily

## Genital Herpes HIV Infection

- May have prolonged or severe episodes with extensive genital or perianal disease
- Episodic or suppressive antiviral therapy often beneficial
- For severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary

## Genital HerpesHIV Infection/Episodic Therapy 

- 		    Acyclovir 400 mg three times daily
- 					or
- 		     Famciclovir 500 mg twice daily
- 					or
- 		    Valacyclovir 1 gm twice daily
***	******	******      ******Duration of Therapy 5-10 days***

## Genital HerpesHIV Infection/Daily Suppression 

- 	Acyclovir 400-800 mg twice to three times daily
- 					or
- 	Famciclovir 500 mg twice daily
- 					or
- 	Valacyclovir 500 mg twice daily

## Genital HerpesAntiviral Resistance

- Persistent or recurrent lesions on antivirals
- Obtain viral isolate for viral susceptability
- 5% immunocomprised patients
- Acyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovir
- Alternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days)

## Genital Herpes 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

## Genital Herpes Counseling

- Natural history of infection, recurrences, asymptomatic shedding, transmission risk
- Individualize use of episodic or suppressive therapy
- Abstain from sexual activity when lesions or prodromal symptoms present
- Risk of neonatal infection

## SyphilisPrimary, Secondary, Early Latent

**Recommended regimen**
- 	  Benzathine Penicillin G, 2.4 million units IM
***Penicillin Allergy****
- 	  Doxycycline 100 mg twice daily x 14 days						  or
- 	  Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies) 				  or
- 	  Azithromycin 2 gm single oral dose (preliminary data)
*	**	**  *******Use in HIV-infection has not been studied******	***

## Primary/Secondary SyphilisResponse to Treatment

- No definitive criteria for cure or failure are established
- Re-examine clinically and serologically at 6 and 12 months
- 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

## Primary/Secondary SyphilisResponse to Therapy/HIV Infection

- Most respond appropriately to benzathine penicillin 2.4 million units IM
- Some experts recommend CSF exam before therapy and additional tx (wkly benz pen IM x 3)
- Clinical/serologic evaluation at 3, 6, 9, 12, 24 mo; some perform CSF exam at 6 mo
- Tx/serologic failure (6-12 mo after tx)- CSF exam, retreat with benz penicillin 2.4 mu wkly x 3

## SyphilisLatent Syphilis

**Recommended regimen**
- 	Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses
***Penicillin allergy****
- 	Doxycycline 100 mg orally twice daily
- 				 	or
- 	Tetracycline 500 mg orally four times daily
***    ******Duration of therapy 28 days; close clinical and serologic***
***    ******follow-up; data to support alternatives to pcn are limited***

## Latent SyphilisManagement Considerations

- Clinical evaluation of tertiary disease (aorititis, gumma, iritis)
- 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

## Latent SyphilisResponse to Treatment

- Limited data available to guide evaluation
- Repeat quantitative nontreponemal tests at 6, 12, 24 months
- Perform CSF exam and re-treat for latent syphilis: 4x increase in titer, initial nontreponemal titer_ >_1:32 fails to decline  12-24 mo after tx, or signs/sx

## Latent SyphilisResponse to Therapy/HIV Infection

- CSF exam before treatment
- Normal CSF exam-benzathine penicillin 2.4 million units IM wkly x 3 weeks
- Clinical/serologic evaluation at 6, 12, 18, 24 months
- Development of sx or 4x titer rise-repeat CSF exam and treat
- Repeat CSF exam and treatment  if nontreponemal titer does not decline in 12-24 months

## Syphilis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

## Neurosyphilis

**Recommended regimen**
- 	Aqueous crystalline penicillin G, 18-24 million 		units administered 3-4 million units IV every 4 		hours for 10-14 days
**Alternative regimen**
- 	Procaine penicillin 2.4 million units IM daily plus 		probenecid 500 mg orally four times daily for 10-14 days
*Some experts administer benzathine penicillin 2.4 million units IM wkly x 3 after completion of these regimens to provide comparable duration of treatment with latent syphilis*

## NeurosyphilisPenicillin Allergy

- Ceftriaxone 2 gm daily IM/IV for 10-14 days
- Consideration of cross-reactivity
- Pregnant patients should undergo penicillin desensitization
- Other regimens have not been evaluated

## NeurosyphilisResponse to Treatment

- Initial CSF pleocytosis--repeat CSF exam every    6 months until cell count normal
- CSF VDRL and protein decline slowly
- Consider re-treatment if cell count has not decreased by 6 months or if CSF is not normal by 2 years

## 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

## Congenital Syphilis 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 body fluids

## Congenital Syphilis Proven/highly probable disease

- Abnormal physical exam consistent with congenital syphilis
- Nontreponemal titer 4X _>_ maternal titer or + DFA or darkfield
- Evaluation: CSF exam, CBC; other tests as clinically indicated--long bone films, LFTs, cranial US, eye exam, auditory brain stem response

## Congenital Syphilis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
- 				 	or
- Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days

## Congenital Syphilis Normal exam/RPR < 4X maternal titer

- Mother inadequately treated; treated with nonpenicillin regimen; received tx < 4 wks before delivery; or mother has early syphilis with serologic response
- Evaluation: CSF analysis, CBC/plt, long bone xray

## Congenital SyphilisNormal Exam/RPR < 4X maternal titer

- Aqueous penicillin G 100,000-150,000 units/kg/day as 50,000 units/kg/dose IV every 12 hours for first 7 d then q 8 hours for total of 10 d
- 					or
- Procaine penicillin G 50,000 units/kg/dose IM in single daily dose for 10 d
- 					or
- Benzathine penicillin G 50,000 units/kg/dose IM in single dose

## Congenital Syphilis Normal exam/RPR < 4X maternal titer

- Mother treated appropriately > 4 wks before delivery; maternal RPR titers decreased 4X; no relapse or reinfection
- No evaluation required
- Benzathine pcn G 50,000 units/kg/dose IM

## Congenital Syphilis Normal exam/RPR < 4X maternal titer 

- Mother received adequate tx before pregnancy; maternal RPR remained low and stable during pregnancy and delivery
- No evaluation necessary
- No treatment required; some specialists would tx with single dose of benz pen G

## Congenital SyphilisSubsequent Evaluation

- Clinical/serologic evaluation q 2-3 mo
- RPR should decline by  3 mo, nonreactive at 6 mo
- 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

## 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

## Chancroid

- Azithromycin 1 gm orally
- 				or
- Ceftriaxone 250 mg IM in a single dose
- 				or
- Ciprofloxacin 500 mg twice daily x 3 days
- 				or
- Erythromycin base 500 mg tid x 7 days

## ChancroidManagement Considerations

- 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 require drainage

## ChancroidManagement of Sex Partners

- Examine and treat partner whether symptomatic or not if partner contact _<_ 10 days prior to onset

## Lymphogranuloma Venereum

**Recommended regimen**
- 	Doxycycline 100 mg twice daily for 21 days
**Alternative regimen**
- 	Erythromycin base 500 mg four times daily for 21 days

## Granuloma Inguinale

- Doxycycline 100 mg twice daily
- 				or
- Trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily
***   ******Minimum treatment duration three weeks***

## Granuloma Inguinale Alternative regimens

- 	Ciprofloxacin 750 mg twice daily
- 				   or
- 	Erythromycin base 500 mg four times daily
- 				   or
- 	Azithromycin 1 gm orally weekly
***  ******Minimum treatment duration three weeks***

## Urethritis

- 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***

## Nongonococcal Urethritis

- Azithromycin 1 gm in a single dose
- or
- Doxycycline 100 mg bid x 7 days

## Nongonococcal Urethritis Alternative regimens

- Erythromycin base 500 mg qid for 7 days
- or
- Erythromycin ethylsuccinate 800 mg qid for 7 days
- or
- Ofloxacin 300 mg twice daily for 7 days
- or
- Levofloxacin 500 mg daily for 7 days

## Recurrent/Persistent Urethritis

- 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

## Recurrent/Persistent Urethritis

- Metronidazole 2 gm single dose
***PLUS***
- Erythromycin base 500 mg qid x 7d
- or
- Erythromycin ethylsuccinate 800 mg qid x 7d
*	*

## Chlamydia trachomatis

- Annual screening of sexually active women          _<_ 25 yrs
- 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

## Chlamydia trachomatis

- Azithromycin 1 gm single dose
- or
- Doxycycline 100 mg bid x 7d

## Chlamydia trachomatis Alternative regimens

- Erythromycin base 500 mg qid for 7 days
- or
- Erythromycin ethylsuccinate 800 mg qid for 7 days
- or
- Ofloxacin 300 mg twice daily for 7 days
- or
- Levofloxacin 500 mg for 7 days

## Chlamydia trachomatis Treatment in Pregnancy

**Recommended regimens**
- 	Erythromycin base 500 mg qid for 7 days
- 					or
- 	Amoxicillin 500 mg three times daily for 7 days
**Alternative regimens**
- 	Erythromycin base 250 mg qid for 14 days
- 					or
- 	Erythromycin ethylsuccinate 800 mg qid for 14 days
- 					or
- 	Erythromycin ethylsuccinate 400 mg qid for 14 days
- 					or
- 	Azithromycin 1 gm in a single dose

## Neisseria gonorrhoeae Cervix, Urethra, Rectum 

- Cefixime 400 mg
- or
- Ceftriaxone 125 IM
- or
- Ciprofloxacin 500 mg
- or
- Ofloxacin 400 mg/Levofloxacin 250 mg
***PLUS ******Chlamydial therapy if infection not ruled out***

## Neisseria gonorrhoeae Cervix, Urethra, Rectum 

**Alternative regimens**
- 	Spectinomycin 2 grams IM in a single dose
- or
- 	Single dose cephalosporin (cefotaxime 500 mg)
- or
- 	Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg)
***PLUS Chlamydial therapy if infection not ruled out***

## Neisseria gonorrhoeae Pharynx 

- Ceftriaxone 125 IM in a single dose
- or
- Ciprofloxacin 500 mg in a single dose
***PLUS**** ****Chlamydial therapy if infection not ruled out***

## Neisseria gonorrhoeae 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 Infection

**Recommended regimen**
- 	Ceftriaxone 1 gm IM or IV q 24 hr
**Alternative regimens**
- 	Cefotaxime or Ceftizoxime 1 gm IV q8 hr
- or
- 	Ciprofloxacin 400 mg IV q 12
- or
- 	Ofloxacin 400 mg IV q 12
- or
- 	Levofloxacin 250 mg IV daily

## Neisseria gonorrhoeae Antimicrobial Resistance

- Geographic variation in resistance to penicillin and tetracycline
- No significant resistance to ceftriaxone
- Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California
- Surveillance is crucial for guiding therapy recommendations

## Candida VaginitisClassification

- _Uncomplicated_			_Complicated_
- Sporadic, infrequent		Recurrent
- Mild-to-moderate			Severe
- Likely *C albicans**	**	**	*Non-albicans
- Non-immunocomprised		Diabetes, pregnancy,
- 						immunosuppression

## Candida Vulvovaginitis

**Intravaginal regimens**
- 	Butoconazole, clotrimazole, miconazole,
- 	nystatin, tioconazole, terconazole
**Oral regimen**
- 	Fluconazole 150 mg in a single dose

## Recurrent VVC

- 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

## Vulvovaginal Candidiasis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 from treatment

## Vulvovaginal Candidiasis Treatment in Pregnancy

- Only topical intravaginal regimens recommended
- Most specialists recommend 7 days of therapy

## Trichomoniasis

**Recommended regimen**
- 	Metronidazole 2 gm orally in a single dose
-  **Alternative regimen**
- 	Metronidazole 500 mg twice a day for 7 days
**Pregnancy**
**	**Metronidazole 2 gm orally in a single dose

## TrichomoniasisTreatment Failure

- Re-treat with metronidazole 500 mg twice daily for 7 days
- If repeated failure occurs, treat with metronidazole 2 gm single dose for 3-5 days
- If repeated failure, consider metronidazole susceptibility testing through the CDC

## TrichomoniasisManagement of Sex Partners

- Sex partners should be treated
- Avoid intercourse until therapy is completed and patient and partner are asymptomatic

## Bacterial Vaginosis

- Metronidazole 500 mg twice daily for 7 days
- 				or
- Metronidazole gel 0.75%, 5 g intravaginally once daily for 5 days
- 				or
- Clindamycin cream 5%, 5 g intravaginally qhs for 7 days

## Bacterial Vaginosis Alternative regimens

- Metronidazole 2 gm in a single dose
- or
- Clindamycin 300 mg twice daily for 7 days
- or
- Clindamycin ovules 100 g intravaginally
- qhs for 3 days

## Bacterial VaginosisTreatment in Pregnancy

- Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes
- Existing data do not support use of topical agents in pregnancy
- Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatal visit; optimal regimen not established

## Bacterial VaginosisTreatment in Pregnancy

- Metronidazole 250 mg three times daily for 7 days
- or
- Clindamycin 300 mg twice daily for 7 days

## Bacterial Vaginosis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 tenderness
**Additional Diagnostic Criteria**
- Oral temperature >38.3 C		Elevated ESR
- Cervical CT or GC			Elevated CRP
- WBCs/saline microscopy		Cx discharge

## 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Hospitalization

- Surgical emergencies not excluded
- Pregnancy
- Clinical failure of oral antimicrobials
- Inability to follow or tolerate oral regimen
- Severe illness, nausea/vomiting, high fever
- Tubo-ovarian abscess

## Pelvic Inflammatory Disease

- No efficacy data compare parenteral with oral regimens
- Clinical experience should guide decisions regarding transition to oral therapy
- Until regimens that do not adequately cover anaerobes have been demonstrated to prevent sequelae as successfully as regimens active against these microbes, regimens should provide anaerobic coverage

## Pelvic Inflammatory DiseaseParenteral Regimen A

- Cefotetan 2 g IV q 12 hours
- or
- Cefoxitin 2 g IV q 6 hours
- PLUS
- Doxycycline 100 mg orally/IV
- q 12 hrs

## Pelvic Inflammatory DiseaseParenteral Regimen B

- Clindamycin 900 mg IV q 8 hours
- PLUS
- Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.

## Pelvic Inflammatory Disease Alternative Parenteral Regimens

- Ofloxacin 400 mg IV q 12 hours
- or
- Levofloxacin 500 mg IV once daily
**WITH OR WITHOUT**
- Metronidazole 500 mg IV q 8 hours
- or
- Ampicillin/Sulbactam 3 g IV q 6 hrs
**PLUS**
- Doxycycline 100 mg orally/IV q 12 hrs

## Pelvic Inflammatory DiseaseOral Regimen A

- Ofloxacin 400 mg twice daily for 14 days
- or
- Levofloxacin 500 mg once daily for 14 days
**WITH OR WITHOUT**
- Metronidazole 500 mg twice daily for 14 days

## Pelvic Inflammatory DiseaseOral Regimen B

- Ceftriaxone 250 mg IM in a single dose
- or
- Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently
**PLUS**
- Doxycycline 100 mg twice 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

## EpididymitisDiagnostic Considerations

- 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

## Epididymitis

**Infection likely due to GC or CT**
- 	Ceftriaxone 250 mg IM in a single dose
- 				  PLUS
- 	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
- 				     or
- 	Levofloxacin 500 mg once daily for 10 days

## Papillomavirus Treatment

- 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 transmission
- No laboratory marker of infectivity
- Variable results utilizing viral DNA

## Papillomavirus 

- Source of therapy guided by preference of patient, experience of provider, resources
- No evidence that any regimen is superior
- Locally developed/monitored treatment algorithms associated with improved clinical outcomes
- Acceptable alternative may be to observe; possible regression/uncertain transmission

## Papillomavirus

**Patient-applied**
- Podofilox 0.5% solution or gel
- or
- Imiquimod 5% cream
**Provider-administered**
- Cryotherapy
- or
- Podophyllin resin 10-25%
- or
- Trichloroacetic or Bichloroacetic acid 80-90%
- or
- Surgical removal

## Papillomavirus

**Vaginal warts**
- 	Cryotherapy or TCA/BCA 80-90%
**Urethral meatal warts**
- 	Cryotherapy or podophyllin 10-25%
**Anal warts**
- 	Cryotherapy or TCA/BCA 80-90%

## Papillomavirus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

- MSM
- 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 	exposure

## Proctitis

- Anoscopic examination for HSV, GC, CT, syphilis
- Painful perianal or mucosal ulceration on anoscopy- presumptive therapy for HSV
**Recommended regimen**
- 		Cefriaxone 125 mg IM PLUS 		Doxycycline 100 mg twice daily
- 		for 10 days

## Pediculosis Pubis

- 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

## Scabies

- 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

## Scabies Persistent Symptoms

- Rash and pruritus may persist for 2 wks
- Persistence > 2 wks: tx failure, resistance, reinfection, drug allergy, cross reactivity with household mites
- Attention to fingernails of infected patients
- Treat close contacts empirically
- Wash linens, bedding, clothing

## Norwegian Scabies

- Aggressive infestation in immunodeficient, debilitated, or malnourished
- Greater transmissibility
- Substantial treatment failure with topical scabicide or oral ivermectin; treatment recommendations--combination topical scabicide with ivermectin or repeated treatments with ivermectin

## Sexual AssaultEvaluation

- Cultures for GC and CT from sites of penetration; if NAAT 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

## Sexual Assault

- 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

## Ophthalmia Neonatorum Prophylaxis

- Silver nitrate 1% aqueous solution in a single application
- or
- Erythromycin 0.5% ophthalmic ointment in a single application
- or
- Tetracycline ophthalmic ointment 1% in a single application