CDC STD Yasmin CDC Final

8/9/2019 CDC STD Yasmin CDC Final

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Yasmin ElSobky, BCPS

Herpes Simplex Virus (HSV) Infection

Genital Herpes

Herpes Encepha

litis



After the primary infection, the virus is latent in the sacral dorsal root ganglia.

From 50% to 80% of patients have recurrent infections

(generally less severe and of shorter duration).




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Symptoms:

Itching

Genital burning

Ulcer formation

Vesicle formation

Yasmin ElSobky, BCPS Yasmin ElSobky, BCPS

Treatment can partly control symptoms

but does not affect the risk, frequency, or severity

of recurrences.

Drug Dose Frequency Duration

Initial HSV

infection

Acyclovir

Acyclovir

Famciclovir

Valacyclovir

200 mg orally

400 mg orally

250 mg orally

1 g orally

Five ti mes daily

three times daily

three times daily

twice daily

for 7 days

for 7–10 days

for 7–10 days

for 7–10 days

Recurrent HSV

infection

If treatment is initiated within 1 day of lesion onset,

patients with recurrent infections may benefit.

Acyclovir

Acyclovir

Famciclovir

Famciclovir

Famciclovir

Valacyclovir

Valacyclovir

400 mg orally

800 mg orally

125mg orally

500m g orally once

Then 250mg Orally

1000mg orally

500m g orally

1000mg/day Orally

three times daily

Five ti mes daily

Twice daily

Once then

Twice daily

Twice daily

Twice daily

once

for 5 days

for 2 days

for 5 days

For 2 days

For 1 day

For 3 days

For 5 days

Daily

suppressive

therapy

≥ 6

episodes/year

recommended in patients with six or more episodes yearly

(reassess annually the need for suppressive therapy)

Acyclovir

Famciclovir

Valacyclovir

Valacyclovir

400 mg orally

250 mg orally

500 mg orally

1 000mg orally

Twice daily

Twice daily

Once daily

Once daily

DailyYasmin ElSobky, BCPS




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Herpes Encephalitis

Primarily caused by HSV-1

Spreads through neural routes during Primary infection or

Recurrent infection

Primarily temporal lobe involvement with eventual hemorrhagic

encephalitis

High mortality i f untreated

and frequent neurologic sequelae


CSF Analysis Report

WBC: Moderate Pleocytosis

(lymphocytosis)

Glucose: Normal

Protein: Elevated

Diagnosis of Herpes Encephalitis

1. Presence of Sign and symptoms

2. CSF analysis

3. Brain biopsy (rarly performed)


Herpes encephalitis Therapy:

Acyclovir IV 5–10 mg/kg q8 h for 2–7 days,

followed by oral antiviral therapy for at least 10

days of total therapy


When symptoms resolve shift to oral



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Types Description Symptoms

Primary

syphilis

From 10 to 90

days after

exposure

(mean = 21

days)

The primary symptom

is the development of achancre.

It resolves

spontaneously in 2–6

weeks even without

treatment.

Secondarysyphilis/

Early

latentsyphilis

From 4 to 10weeks after

exposure Skin lesions:

Characteristically on

the palms and soles

Latent phase begins

when all symptoms

have resolved.

Late latent

syphilis

(more than 1

year in

duration) orunkn duration:

Tertiary

syphilis

Infectious granulomas

cardiovascular effects:-Aortic insufficiency

-Aortitis

N

e u r o s y p h i l i s At any stage Personality

change (cognitive

and/or behavioral

impairment) - 33%

Ataxia - 28%

Stroke - 23% Yasmin ElSobky, BCPS

Infectious granulomas and

cardiovascular effects:

Aortic insufficiency and aortitis

3ry Syphilis

Skin lesion




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Type s D esc ription Symptoms Re commended treatment Penic illin alle rgy

Primary

syphilis

From 10 to 90

days after

exposure

(mean = 21

days)

The primary symptom

is the development of a

chancre.

It resolves

spontaneously in 2–6

weeks even without

treatment.

Benzathine penicillin G

2.4 million units IM

in a single dose (adults)

If penicillin allergy:

Doxycycline orally bid

or tetracycline500 mg four

times daily for 2 weeks

Secondary

syphilis/

Early

latent

syphilis

From 4 to 10

weeks after

exposure Skin lesions:

Characteristically on

the palms and solesLatent phase begins

when all symptoms

have resolved.

Late latent

syphilis

(more than 1

year in

duration) or

unkn duration:

Benzathine penicillin G

2.4 million units IM every weekfor 3 weeks

(total dose 7.2 million units)


Doxycycline bidor tetracycline500 mg four

times daily for 4 weeksTertiary

syphilis

Infectious granulomas

cardiovascular effects:-Aortic insufficiency

-Aortitis

N e u r o s y p h i l i s At any stage Personality change

(cognitive and/or

behavioral impairment) -

33%

Ataxia - 28%

Stroke - 23%

Aqueous crystalline penicillin G

3–4 million units I V q4h or continuous

inf. 10–14 days

Alternative regimen

Procaine penicillin 2.4 million

units/day IM plus probenecid

four times daily for 10–14 days


Ceftriaxone 2 g/day IM/IV

for 10–14 days or

patients should bedesensitized& given

penicillin(see CDC recommendations for

skin testing &desensitization)Yasmin ElSobky, BCPS

Treatment of sexual partners

a. Sexual partners should be presumptively treated if exposed

within 90 days preceding the diagnosis in their partner.

b. If exposure occurred more than 90 days prior, sexual partners

should be tested and monitored closely or treated presumptively

if serologic test results are not available immediately.

Syphilis




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Can lead to

•PID,

•Ectopic pregnancy

•Infertility


Less dysuriaand

Less penile discharge in men

compared with gonococcal infection

Chlamydial TreatmentDrug Of choice (DOC)

Alternatives

Erythromycin

Levofloxacin

Ofloxacin

Diagnosis:

Chlamydial infection

Rx:Azithromycin 1G

orDoxycycline for 7 days


Abstain from sexual intercourse for at least 7 days

and until sexual partners are adequately treated.

All sexual partners within the past 60 days should be

assessed and treated .





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women are often asymptomatic

(which can lead to PID);

symptoms in women include

Vaginal discharge

Dysuria

Penile discharge and

dysuria common in men,


Site of infection Gonococcal Treatment

Infections of cervix,

urethra & rectum

Ceftriaxone 250mgIM or

cefixime** 400mg Oral+

treatment of chlamydiaif not ruled out

Infection of PharynxCeftriaxoneonly (not cefixime ) +

treatment of chlamydia

Cephalosporin

allergy

Azithromycin 2G Oral

(GI side effects, resistance increasing )

test for cure in 1 week


Rx:Azithromycin 1G

orDoxycycline for 7 days

**New in 2012 – Alternative if ceftriaxone not an optionYasmin ElSobky, BCPS

Abstain from sexual intercourse for at least 7 days

and until sexual partners are adequately treated.All sexual partners within the past 60 days should

be assessed and treated.

Gonococcal infection




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Urethritis


Chlamydial infection Gonococcal infection

Symptoms of UrethritisSymptoms in Women

Some signs of urethritis in women include:

•

More frequent urge to urinate•Discomfort during urination

•Pain in the abdominal area

•Fever (chills)

•An abnormal vaginal discharge

Symptoms in Men

Males with urethritis may experience the

following symptoms:

• Burning sensation while urinating

•Itching or burning near the penis opening

•The presence of blood

in semen and/or urine


Urethritis Treatment

Undiagnosed Treatfor Chlamydia and Gonococcus

Nongonococcal Treat for Chlamydia ONLY

Recurrent or persistent

Ensure adherence &

NO reinfection from infected partner

Then

Treat for trichomonas vaginalis&

azithromycin (not doxycycline)


All sexual partners within the past 60 daysshould be assessed and treated.

Urethritis infection




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Trichomoniasis

(Trichomonas vaginalis)


Asymptomatic

Vaginal discharge

(Malodorous)

Vaginal irritation

Trichomoniasis symptoms


Trichomoniasis Treatment

DOCMetronidazole 2G (Single)

Tinidazole2G (Single)

AlternativeregimenMetronidazole 500mg 2 times/day for

7 days

Metronidazole-allergic patients Patient should be desensitized


•Pelvic inflammatory diseases•Bacterial Vaginosis

•Vulvovaginal Candidiasis




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PID Clinical PresentationClinical presentation

a. Lower abdominal tenderness

b. Adnexal tenderness

c. Cervical motion tenderness

d. Oral temperature greater than 101°F (38.3)

e. Abnormal cervical or vaginal discharge

f. Menorrhagia

g. Dysuria

Lab Investigation:

Elevated ESR erythrocyte sedimentation rate

Elevated CRP C-reactive protein

Abscess in pelvic or fallopian tubes, tubal

occlusion, fibrosis, infertilityYasmin ElSobky, BCPS

PID

Anaerobes

Neisseria gonorrhoeae

Chlamydia trachomatis

gram-ve facultat ive bacteria

Streptococci

C a u s e d b

y


Parenteral treatment

Regimen A: Cefotetan Doxycycline IV

Or Cefox it in or Dox ycycl ine orall y q1 2 hrs.

Regimen B: Clindamycin Gentamicin IV/ IM

Alternative

regimens:

Ampicillin/ Doxycycline IV or

Sulbactam Doxycycline orally every 12 hrs

Oral treatment

Ceftriaxone 250 mg IM once

or Cefoxitin 2 g IM

Parenteral therapy can be discontinued 24 hours after clinical improvement

and changed to oral therapy for 14 days.

Plus

Plus

Plus

Plus Probenecid 1 g

orally once + Metronidazole

14 daysYasmin ElSobky, BCPS



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Bacterial vaginosis


High in PH

Clue cellsWhiff test positive

(10% KOH fishy odor)

Bacterial vaginosis diagnosis:

Malodorous

vaginal discharge

> 50% are

Asymptomatic

Symptoms


Bacterial Vaginosis Treatment

Nonpregnant women

Metronidazole (oral) 7 days

Metronidazole 0.75% (intravaginal) 5 days

Clindamycin2% (intravaginal) 7 days

Alternative regimen Clindamycinovules 3 days

Clindamycinoral 7 days

Tinidazole 2G for 2 days

Tinidazole 1G for 5 days

Pregnant women

Oral regimens ONLY

Metronidazole or clindamycin (oral) for 7 days


Treatment of sexual partners is not necessary

Bacterial Vaginosis

Increased infection

risk ONLYSexual transmission




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Vulvovaginal candidiasis


OCs & corticosteroids Chemotherapy & Antibiotics

Obesity & DM Pregnancy

Predisposing factor for Vulvovaginal Candidiasis


Pruritis (irritation)

Vaginal discharge

Symptoms

KOH smears

DiagnosisSymptoms




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Vulvovaginal candidiasis treatment

Recurrent ( ≥ 4 /year) Use prescriptionNOT OTC

Loading

Initial therapy for 7-14 days

Or

Fluconazole 100, 150, 200 every third day for 3

doses

MaintenanceFluconazole 100, 150, 200 every week for 6

months

Prophylaxis

(While taking

antibiotics)

Use one full applicator at bed time

If infection 7 days OTC

Pregnant women 7 days OTC azolesYasmin ElSobky, BCPS




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References

• ACCP book


CDC STD Yasmin CDC Final

Documents

Transcript of CDC STD Yasmin CDC Final