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Chapter 94Chapter 94

Drug Therapy of Sexually Drug Therapy of Sexually Transmitted DiseasesTransmitted Diseases

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Sexually Transmitted DiseasesSexually Transmitted Diseases

Sexually transmitted diseases (STDs)Sexually transmitted diseases (STDs) Infections or parasitic diseases transmitted Infections or parasitic diseases transmitted

primarily through sexual contactprimarily through sexual contact Types of STDsTypes of STDs

Chlamydia trachomatisChlamydia trachomatis Gonococcal infectionsGonococcal infections Pelvic inflammatory diseasePelvic inflammatory disease Acute epididymitisAcute epididymitis SyphilisSyphilis

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Sexually Transmitted DiseasesSexually Transmitted Diseases

Types of STDs (cont’d)Types of STDs (cont’d) AIDSAIDS TrichomoniasisTrichomoniasis Herpes simplexHerpes simplex Bacterial vaginosisBacterial vaginosis Condyloma acuminataCondyloma acuminata ProctitisProctitis Pediculosis pubis and scabiesPediculosis pubis and scabies

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Fig. 94-1. Incidence of sexually transmitted diseases.

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Chlamydia trachomatisChlamydia trachomatis

Most common bacterial STD in the U.S.Most common bacterial STD in the U.S. Can cause:Can cause:

Genital tract infectionsGenital tract infections ProctitisProctitis ConjunctivitisConjunctivitis Lymphogranuloma venereumLymphogranuloma venereum Ophthalmia and pneumonia in infantsOphthalmia and pneumonia in infants Pelvic inflammatory disease (PID) if untreated in Pelvic inflammatory disease (PID) if untreated in

womenwomen Sterility (often asymptomatic infection)Sterility (often asymptomatic infection)

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Chlamydia trachomatisChlamydia trachomatis

Treatment for uncomplicated infectionsTreatment for uncomplicated infections Adults and adolescentsAdults and adolescents

• Azithromycin (Zithromax)Azithromycin (Zithromax)• Doxycycline (Vibramycin)Doxycycline (Vibramycin)

Infection in pregnancyInfection in pregnancy InfantsInfants Preadolescent childrenPreadolescent children Lymphogranuloma venereumLymphogranuloma venereum

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Gonococcal InfectionsGonococcal Infections

Neisseria gonorrhoeaeNeisseria gonorrhoeae Gram-negative diplococcusGram-negative diplococcus 720,000 new cases each year (2nd to chlamydia)720,000 new cases each year (2nd to chlamydia) Transmitted almost exclusively by sexual contactTransmitted almost exclusively by sexual contact

SymptomsSymptoms Men – complaints of burning sensation with Men – complaints of burning sensation with

urination and pus draining from penisurination and pus draining from penis Women – often asymptomatic or mild cervicitis; Women – often asymptomatic or mild cervicitis;

serious infection may result in sterilityserious infection may result in sterility

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Gonococcal InfectionsGonococcal Infections

Neisseria gonorrhoeae Neisseria gonorrhoeae (cont’d)(cont’d) CausesCauses

• Urethral, cervical, and rectal infectionUrethral, cervical, and rectal infection• Pharyngeal infectionPharyngeal infection• ConjunctivitisConjunctivitis

Treatment (cephalosporins preferred)Treatment (cephalosporins preferred)• Cefixime (Suprax)Cefixime (Suprax)• Ceftriaxone (Rocephin)Ceftriaxone (Rocephin)• Ciprofloxacin (Cipro)Ciprofloxacin (Cipro)• 2007 CDC 2007 CDC – – recommends not using fluoroquinolones for recommends not using fluoroquinolones for

gonorrheagonorrhea

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Nongonococcal Urethritis (NGU)Nongonococcal Urethritis (NGU)

Caused by any organism other than Caused by any organism other than Neisseria Neisseria gonorrhoeaegonorrhoeae

Prevalent among sexually active adolescent Prevalent among sexually active adolescent girlsgirls

TreatmentTreatment Azithromycin (Zithromax) Azithromycin (Zithromax) Doxycycline (Vibramycin)Doxycycline (Vibramycin)

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Pelvic Inflammatory DiseasePelvic Inflammatory Disease

PID PID – – syndrome that includes endometritis, syndrome that includes endometritis, pelvic peritonitis, tubo-ovarian abscess, and pelvic peritonitis, tubo-ovarian abscess, and inflammation of the fallopian tubesinflammation of the fallopian tubes

Causes Causes Neisseria gonorrhoeaeNeisseria gonorrhoeae Chlamydia trachomatisChlamydia trachomatis

Treatment Treatment Caused by multiple organisms, so necessitates Caused by multiple organisms, so necessitates

broad coverage and combination therapybroad coverage and combination therapy

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Pelvic Inflammatory DiseasePelvic Inflammatory Disease

Treatment (cont’d)Treatment (cont’d) Hospitalized patientsHospitalized patients

• IV cefoxitin or cefotetan and doxycycline IV cefoxitin or cefotetan and doxycycline • Follow with oral doxycyclineFollow with oral doxycycline

OutpatientsOutpatients• Ceftriaxone or cefoxitin; should also include doxycyclineCeftriaxone or cefoxitin; should also include doxycycline• May be with or without metronidazoleMay be with or without metronidazole

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Acute EpididymitisAcute Epididymitis

May be acquired sexually or nonsexuallyMay be acquired sexually or nonsexually Fever accompanied by pain in the back of the Fever accompanied by pain in the back of the

testiclestesticles Treatment according to organismTreatment according to organism

Ceftriaxone (Rocephin) plus doxycyclineCeftriaxone (Rocephin) plus doxycycline Ofloxacin (Floxin) or levofloxacin (Levaquin)Ofloxacin (Floxin) or levofloxacin (Levaquin)

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SyphilisSyphilis

Caused by Caused by Treponema pallidumTreponema pallidum Develops in three stagesDevelops in three stages

Primary: “Chancre” – hard, red, protruding Primary: “Chancre” – hard, red, protruding painless sorepainless sore

Secondary: Two weeks after chancre heals – Secondary: Two weeks after chancre heals – secondary syphilis developssecondary syphilis develops

Tertiary: Develops 5-40 years after initial infectionTertiary: Develops 5-40 years after initial infection Highly responsive to penicillin GHighly responsive to penicillin G

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Other STDsOther STDs

See Chapter 93 for treatment of HIVSee Chapter 93 for treatment of HIV Bacterial vaginosisBacterial vaginosis

Nonpregnant women – metronidazole (Flagyl) or Nonpregnant women – metronidazole (Flagyl) or clindamycin creamclindamycin cream

Pregnant women – only oral clindamycin and metronidazolePregnant women – only oral clindamycin and metronidazole TrichomoniasisTrichomoniasis

Metronidazole (Flagyl)Metronidazole (Flagyl) ChancroidChancroid

Azithromycin (Zithromax), ceftriaxone (Rocephin), Azithromycin (Zithromax), ceftriaxone (Rocephin), ciprofloxacin (Cipro)ciprofloxacin (Cipro)

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Other STDsOther STDs

ProctitisProctitis Ceftriaxone and doxycyclineCeftriaxone and doxycycline

Genital and anal wartsGenital and anal warts Caused by HPV (over 40 types)Caused by HPV (over 40 types) Application done repeatedly until warts disappearApplication done repeatedly until warts disappear

• Professional application – podophyllin (Podocon-25, Professional application – podophyllin (Podocon-25, Podofin), TCA, BCAPodofin), TCA, BCA

• Patient application – podofilox (Condylox) and imiquimod Patient application – podofilox (Condylox) and imiquimod (Aldara)(Aldara)

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Herpes SimplexHerpes Simplex

Herpes simplex virusHerpes simplex virus Infection has reached epidemic proportions in U.S.Infection has reached epidemic proportions in U.S. Symptoms develop 6-8 days after contactSymptoms develop 6-8 days after contact After sores heal, virus remains latent and can After sores heal, virus remains latent and can

recurrecur Transmission possible even without sores presentTransmission possible even without sores present TreatmentTreatment

• Acyclovir (Zovirax)Acyclovir (Zovirax)• Famciclovir (Famvir) Famciclovir (Famvir) • Valacyclovir (Valtrex)Valacyclovir (Valtrex)