Core EM - Emergency Medicine Podcast

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Episode 202: Sexually Transmitted Infections 2.0

November 01, 2024





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.






  • 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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