Episode 202: Sexually Transmitted Infections 2.0
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We review Sexually Transmitted Infections and pertinent updates in diagnosis and management.

Hosts: Avir Mitra, MD Brian Gilberti, MD

        [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Sexually_Transmitted_Infections_2_0.mp3](https://media.blubrry.com/coreem/content.blubrry.com/coreem/Sexually_Transmitted_Infections_2_0.mp3))         
  
  
				
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				Tags: [gynecology](https://coreem.net/tag/gynecology/)), [Infectious Diseases](https://coreem.net/tag/infectious-diseases/)), [Urology](https://coreem.net/tag/urology/))				
				



  
              ## Show Notes

     ## Table of Contents

(1:49) Chlamydia 

(3:31) Gonorrhea

(4:50) PID

(6:14) Syphilis

(8:08) Neurosyphilis 

(9:13) Tertiary Syphilis

(10:06) Trichomoniasis 

(11:13) Herpes

(12:49) HIV

(14:10) PEP

(15:13) Mycoplasma Genitalium 

(18:00) Take Home Points

Chlamydia:

• Prevalence:

Most common STI.

High percentage of asymptomatic cases (40% to 96%).

• Presentation:

Urethritis, cervicitis, pelvic inflammatory disease (PID), prostatitis, proctitis, pharyngitis, arthritis.

Importance of considering extra-genital sites (oral and rectal infections).

• Testing:

Gold Standard: Nucleic Acid Amplification Test (NAAT) via PCR.

• Sampling Sites:

Endocervical or urethral swabs preferred over urine samples due to higher sensitivity.

Triple-site testing (genital, rectal, pharyngeal) recommended for comprehensive detection.

• Treatment Updates:

Previous Regimen: Azithromycin 1 g orally in a single dose.

Current First-Line Treatment: Doxycycline 100 mg orally twice daily for 7 days.

• Alternatives:

Azithromycin remains an option for patients unlikely to adhere to a 7-day regimen or for pregnant patients.

Note: PID treatment differs and will be discussed separately.

Gonorrhea:

• Presentation:

Similar to chlamydia; can be asymptomatic.

Symptoms include urethritis, cervicitis, PID, prostatitis, proctitis, pharyngitis.

• Testing:

Gold Standard: NAAT.

• Sampling Sites:

Endocervical swabs are more sensitive than urine samples.

Triple-site testing is crucial to avoid missing infections.

• Treatment Updates:

Previous Regimen: Ceftriaxone 250 mg IM plus azithromycin 1 g orally.

Current Recommendation: Ceftriaxone 500 mg IM single dose.

Adjusted due to rising azithromycin resistance and updated pharmacokinetic data.

• Co-Infection Considerations:

High rates of chlamydia and gonorrhea co-infection (20% to 40%).

CDC recommends empiric treatment for chlamydia when treating gonorrhea to prevent complications like PID and infertility.

Pelvic Inflammatory Disease (PID):

• Etiology:

Not solely caused by chlamydia and gonorrhea; about 50% of cases involve other pathogens like bacterial vaginosis (BV) organisms and anaerobes.

• Treatment Changes:

• Expanded Coverage Regimen:

Ceftriaxone 500 mg IM once.

Doxycycline 100 mg orally twice daily for 14 days.

Metronidazole 500 mg orally twice daily for 14 days.

Inclusion of metronidazole addresses anaerobic bacteria contributing to PID.

Syphilis:

• Stages and Presentation:

• Primary Syphilis:

Painless chancre on genitals.

Treatment: Penicillin G 2.4 million units IM single dose.

• Secondary Syphilis:

Rash (often diffuse), mucocutaneous lesions, nonspecific joint pain.

Treatment: Same as primary syphilis.

• Latent Syphilis:

Asymptomatic phase; divided into early (<1 year) and late (>1 year).

• Treatment for Late Latent:

Penicillin G 2.4 million units IM once weekly for 3 weeks.

Recommended when the timing of infection is unclear.

Neurosyphilis:

Can occur at any stage.

Symptoms include visual changes, severe headaches, neurological deficits.

Diagnosis: Requires lumbar puncture (LP) for confirmation.

Treatment: Admission for intravenous penicillin G.

Tertiary Syphilis:

Rare, advanced stage with severe manifestations (e.g., gummas, cardiovascular complications, neurological signs).

Treatment: Extended penicillin therapy similar to late latent syphilis.

Trichomoniasis:

• Presentation:

Often asymptomatic.

In women: Vaginal discharge.

In men: Urethritis.

• Testing:

Shift from wet mount microscopy to NAAT for improved detection.

Swab samples preferred over urine for higher sensitivity.

• Treatment Updates:

Previous Regimen: Metronidazole 2 g orally in a single dose.

• Current Recommendations:

Women: Metronidazole 500 mg orally twice daily for 7 days.

Men: Single 2 g dose remains acceptable.

Herpes Simplex Virus (HSV):

• Types and Transmission:

HSV-1 and HSV-2: Both can cause oral and genital infections.

Increasing crossover between oral and genital sites.

• Testing:

Serum IgG testing not useful for acute diagnosis due to widespread prior exposure.

Preferred Method: PCR testing from lesion swabs.

Clinical Tip: If the lesion is characteristic, clinicians may start treatment without waiting for test results.

• Treatment:

Preferred Medication: Valacyclovir (Valtrex) for ease of dosing.

• Dosage:

Initial episode: 1 g orally twice daily for 7 to 10 days.

Recurrence: 1 g daily for 5 days.

Alternative: Acyclovir for cost considerations.

Human Immunodeficiency Virus (HIV):

• Testing Limitations:

• Window Periods:

Fourth-generation tests have a window period of 2 to 4 weeks.

Negative results during this period may not rule out recent infection.

• Acute HIV Infection:

Presents with flu-like symptoms: malaise, joint pains, fatigue.

• Diagnosis Challenges:

Standard HIV tests may be negative during the window period.

• Options:

Empiric treatment with follow-up testing.

Order an HIV viral load test (more sensitive but expensive and delayed results).

• Post-Exposure Prophylaxis (PEP):

Timing: Initiate ideally within 72 hours of potential exposure.

Duration: 28-day regimen.

• Pre-Treatment Testing:

Baseline HIV test to rule out existing infection.

Renal and hepatic function tests to monitor for medication side effects.

Follow-Up: Reassess renal/hepatic function in 2 weeks.

Mycoplasma genitalium:

• Recognition:

Newly recognized STI by the CDC in 2021.

Causes cervicitis and urethritis.

Possible associations with PID and proctitis, but not definitively established.

• Testing:

• When to Test:

Only in patients with persistent symptoms after standard STI testing and treatment.

Not recommended for initial screening.

Method: NAAT.

• Treatment:

Step 1: Doxycycline 100 mg orally twice daily for 7 days.

Step 2: Moxifloxacin 400 mg orally once daily for 7 days.

Addresses antibiotic resistance concerns and ensures comprehensive treatment.

• General Management and Patient Counseling:

• Partner Notification:

Encourage patients to inform sexual partners for testing and treatment.

• Medication Adherence:

Emphasize the importance of completing the full course of prescribed medications.

• Prevention Measures:

Discuss the use of barrier protection (e.g., condoms) to prevent transmission and reinfection.

• Follow-Up Care:

Advise patients to return if symptoms persist, indicating possible infections like Mycoplasma genitalium.

Key Take-Home Points:

• Chlamydia Treatment Update:

Doxycycline 100 mg orally twice daily for 7 days is now first-line treatment for cervical infections.

For epididymitis, extend doxycycline to 10 days.

• Gonorrhea Treatment Update:

Treat with a single 500 mg IM dose of ceftriaxone.

• PID Management Update:

Expanded antimicrobial coverage includes:

Ceftriaxone 500 mg IM once.

Doxycycline 100 mg orally twice daily for 14 days.

Metronidazole 500 mg orally twice daily for 14 days.

• Mycoplasma genitalium Recognition:

Test in patients with persistent symptoms after standard treatment.

Treat with doxycycline followed by moxifloxacin.

• HIV Testing and PEP:

Be aware of HIV test window periods; negative results may not rule out recent infection.

Consider HIV viral load testing if acute infection is suspected.

Initiate PEP within 72 hours for a 28-day course, ensuring clear discharge planning and patient support.

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