Episode 202: Sexually Transmitted Infections 2.0

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

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Tags: gynecology, Infectious Diseases, 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.