Core EM - Emergency Medicine Podcast

Episode 202: Sexually Transmitted Infections 2.0

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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.
                                                                                                                                  • ...more
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