Gail Itokazu, Pharm.D.
Spring 1998
Sexually Transmitted Diseases (STDs)
Gail Itokazu, Pharm.D.
Spring 1998
Sexually Transmitted Diseases
(STDs)
Required Reading
1. Knodel LC et al. Sexually Transmitted Diseases. In: Pharmacotherapy: A Pathophysiologic Approach. DiPiro JT, et al., eds. Elsevier, NY, 3rd Edition, 1997. Chapter 110, pp 2195-2219.
Optional Reading
The following reading is not required, but may enhance your understanding of the material in this section.
1. Centers for Disease Control and Prevention (CDC), 1993 Sexually Transmitted Diseases Treatment Guidelines. MMWR 1993; 42(no. RR-14):1-99.
1. Be able to discuss the treatment options for patients with various STDs.
2. Be able to recommend monitoring parameters to evaluate the efficacy and toxicity of various the treatments.
EPIDEMIOLOGY
Risk factors for various STDs include age (particularly teenagers and individuals in their twenties), race (greater in blacks and hispanics vs whites, though genital herpes is more common in whites than blacks), sexual preference (greater in homosexual men), marital status (less in married couples), and socioeconomic status.
PREVENTION AND CONTROL GUIDELINES
Preventing transmission of STDs can be accomplished via detection of disease in asymptomatic patients; and notification, evaluation, treatment (if necessary), and counseling of partners of persons with STDs. Latex condoms with or without spermicide are more effective in preventing transmission of STDs than are other condoms; and vaginal spermicides have been found to decrease the risk for cervical chlamydia and gonorrhea.
1. Discuss factors that make control of gonorrhea so difficult.
Clinical Presentation
1. Discuss the most common clinical presentation of gonorrhea in males and females.
Diagnosis
The gram stain in the most commonly used method in clincal practice to identify gonococci microspcopcally. A positive gram stain will demonstrate gram-negative diplococci of typical kidney bean morphology found within polymorphonuclear leukocytes.
Treatment
Evaluation of Therapeutic Outcome
1. After treatment for gonococcal infection is completed, discuss the follow-up plan recommended by the CDC.
1. Discuss the consequences of untreated syphilis.
2. Discuss the major mode via which syphilis is acquired.
3. Know the organism responsible for causing syphilis.
Clinical Presentation
Primary Syphilis
Discuss the clinical presentation of primary syphilis. Include in your discussion, the usual incubation period and definition of chancre.
Secondary Syphilis
Discuss the clinical presentation of secondary syphilis. Include in your discussion, the usual onset, and the dermatologic and systemic manifestations.
Latent Syphilis
1. Define latent syphilis.
2. Define early latency as per the U.S. Public Health Service.
3. Discuss why treatment of latent syphilis is essential.
Tertiary (Late) Syphilis
The onset of tertiary syphilis can range from 2-30 years after the onset of infection. The most common manifeststions are benign gumma, neurosyphilis, and cardiovascular syphilis.
1. Be familiar with the terms benign gumma, neurosyphilis and cardiovascular syphilis.
2. Be familiar with the clinical presentation of these forms of syphilis.
Congenital Syphilis
1. Be aware that pregnant women may transmit infection to their fetus.
Diagnosis
Serologic tests are commonly used for the diagnosis of syphilis. These tests are categorized as non-treponemal (VDRL and RPR are commonly used) or treponemal (FTAABVS and MHATP are commonly used). Advantages of non-treponemal tests are that they are easy to perform and are inexpensive; disadvantages are that they are non-specific and may lead to false-positive reactions.
As a result, non-treponemal tests are used as a screening test for this infection. If a non-treponemal test is positive, a treponemal test (which is more expensive) is used to confirm a diagnosis of syphilis.
Despite the fact that non-treponemal serologic tests are non-specific tests, be aware that they are useful in the following ways: 1) to follow the progression of the disease, 2) to follow recovery from the disease after therapy is completed, and 3) to detect reinfection.
Treatment
- Know the drug of choice for syphilis.
- Be aware that the treatment regimen for patients with syphilis is dependent on the stage of syphilis infection.
- The drug of choice for pregnant women is penicillin. Discuss the recommendations for pregnant patients intolerant to penicillin.
- Be familiar with the Jarish-Herxheimer reaction; including its presentation, proposed mechanism, onset, and management options.
Evaluation of Therapeutic Outcome
Be aware that there are recommendations from the CDC for quantitative non-treponemal tests to determine the adequacy of treatment.
Chlamydia trachomatis, an obligate intracellular organism is thought to be the most common organism causing STDs in the United States. As previously mentioned, co-infection with N. gonorrhoea occurs in up to 45% of individuals.
Clinical Presentation
- Discuss the most common symptoms of chlamydial genital tract infection in males and females.
- Left untreated, what are the clinical outcomes of chlamydial infection in men and women.
Diagnosis
1. Be aware of the tests that allow rapid identification of chlamydial antigens in genital secretions, e.g., DFA and ELISA.
Treatment
- Discuss the treatment options (including their advantages/disadvantages) for uncomplicated urethral, endocervical, or rectal infection in adults.
- Be aware of the regimens which are contraindicated in pregnancy.
- Discuss the reasons why treatment of chlamydia urogenital infections in pregnant women is important.
Evaluation of Therapeutic Outcome
In general, because the treatment regimens are so effective, follow-up cultures are not routinely recommended.
1. Discuss the reasons why genital herpes has received increasing attention in recent years.
2. Discuss the mode via which herpes virus infection is transmitted.
Clinical Presentation
1. Discuss the clinical presentation of patients with primary infection.
Diagnosis
1. In general, the diagnosis of herpes infection in clinical practice is made via characteristic physical findings or clinical history.
Treatment
- Discuss the goals of therapy in genital herpes infection.
- Discuss the mechanism of action of acyclovir, including why it has a low potential for toxicity in norma, uninfected cells.
- Be aware of the CDC recommended regimen for first clinical episode of genital herpes.
- Discuss the patient population that would benefit from suppressive therapy with multiple daily doses of oral acyclovir.
Evaluation of Therapeutic Outcome
Drugs such as acyclovir provide effective symptomatic and prophylactic therapy, but are not curative. Other antiviral agents that are similar to acyclovir are famciclovir and valacyclovir
Trichomoniasis is caused by the protozoan, Trichomonas vaginalis. Infection is more common in women, and may be responsible for causing premature rupture of membranes and pre-term delivery. Though many women are asymptomatic, symptoms include vaginal discharge and vulvar pruritus. Physical examination of the vulva and surrounding areas may be erythematous and excoriated.
Rapid diagnosis is frequently made via a wet-mount examination of vaginal discharge which reveals the pear-shaped, flagellating organisms.
1. Discuss the treatment options for vaginal trichomoniasis.
Evaluation of Therapeutic Outcome
1. Discuss a follow-up plan for patients the following groups of patients: 1) those who are asymptomatic after treatment with metronidazole and 2) those who remain symptomatic after treatment with metronidazole.
CC: pain on urination, frequency, discharge from my penis.
HPI: DD is a 21 year old male with no significant past medical history. He presents to his local physician with complaints of dysuria and frequency which began 7 days ago. Today, he also noted a purulent urethral discharge, which prompted him to seek medical attention.
PHM: None.
ALLERGIES: None.
SH: Sexually active with one partner for the past 1 year, last unprotected intercourse was 1 week ago.
PE: temp 98.6 degrees Fahrenheit, other vital signs are within normal limits.
Physical exam is normal except for a purulent urethral discharge.
1. What is your assessment of this patient (ie problem list and possible cause(s) of his chief complaints)?
This is a previously healthy male with complaints of dysuria, frequency, and purulent urethral discharge. Complaints of dysuria and frequency brings to mind a urinary tract infection. However, he has no prior history of urinary infections as may sometimes occur in childhood, and he is too young to have prostatitis. However, his third problem, urethral discharge, in conjunction with the dysuria and frequency, and history sexual history puts a sexually transmitted disease high on the cause of his complaints.
2. Given the above discussion, which of the sexually transmitted diseases does this patient potentially have? At a minimum, support your answer in terms of the usual clinical presentation and incubation period of the STDs outlined in your handout.
The major STDs outlined in the handout are gonorrhoea, syphilis, chlamydia, genital herpes, and trichomoniasis. Based on the clinical presentation and incubation period of this patient, he most likely has an uncomplicated gonococcal and chlamydial infection. (Note: This would be a good time to review the clinical presentation and incubation periods of the STDs outlined in your handout).
3. Given the presumptive diagnosis of uncomplicated gonococcal and chlamydial infection, what would you recommend (Include a discussion of diagnostic tests and treatment recommendations)?
Review Table 110.3 for recommended treatment regimens for uncomplicated gonococcal infection. Quinolones (ciprofloxacin and ofloxacin are alternatives to patients with a penicillin allergy, but remember that they are contraindicated in pregnant or nursing women, and in persons age < 17 years.
Because co-infection with chlamydia occurs in a large majority of patients with gonococcal infection, concurrent treatment of this STD is recommended. See Table 110.5 for treatment options of this infection.
Finally, his partner should be evaluated for the treatment of STDs.
4. Discuss treatment options if this patient had a severe penicillin allergy, precluding use of any beta-lactam.
Review table 110.3.
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