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.
                                                                                                                                • 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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