Handout to go along with presentation

1. Sexually Transmitted Infections in Primary Care
Eric Meininger, M.D.
Community-University Health Care Center
Page 1 of 4
Bacterial STDs Treatment
Gonorrhea
Preferred Alternates
Cefixime 400mg po x1 (only available as liquid in US) or
Ciprofloxacin 500mg po x1
Ceftriaxone 125 mg IM with lidocaine or
Spectinomycin 2g IM for patients with cephalosporin or quinolone
Avoid in pregnancy
allergy or
Levofloxacin 250mg po x 1
Increased resistance in MSM. CDC recommends use of
alternative drug as of 2004 for MSM
Also treat for chlamydia unless it has been ruled out by laboratory testing
Chlamydia
Preferred Alternates
Doxycycline 100mg po bid x 7d or
Azithromycin 1000mg po x1
Erythromycin base 500mg po qid x 7d
Ureaplasma Urealyticum
Preferred Alternates
Doxycycline 100mg po bid x 7d or
Erythromycin base 500mg po qid x 7d
Trichomonas
Preferred Alternates
Metronidazole 2g po x 1 dose Metronidazole 500mg po bid x 7 days
Treponema pallidum - Syphilis
Treatment Followup
Repeat serologies at 6, 12 and 24 months
Benzathine penicillin 2.4 million units
Retreat if
Chancre present less than 1 year – single IM dose
High titers (>1:32) fail to fall in 12-24 months or
Unknown duration or tertiary symptoms – 3 doses IM 7-13 days apart
Titers increase four-fold or
Restart course of antibiotics if more than 14 days from last dose
new symptoms develop
Or, for non pregnant, penicillin allergic patients:
Doxycycline 100mg po bid
Chancre present less than 1 year – 2 weeks
Unknown duration or tertiary symptoms – 4 weeks
NSAIDS with first dose of antibiotics to prevent Jarisch-Herxheimer reaction
Pelvic Inflammatory Disease
Required Criterion (need one) Supporting Criterion
Fever
Uterine tenderness
Elevated ESR
Adnexal tenderness
Elevated CRP
Cervical motion tenderness
Documented cervical infection with GC or Chlamydia
Preferred Treatment Alternate Treatments
Ofloxacin 400mg po bid or Levofloxacin 500mg po qd x 14d
Ceftriaxone 250mg IM plus
with or without Metronidazole 500mg po bid x 14d
Doxycycline 100mg po bid x 14d with or without
Metronidazole 500mg po bid x 14d
Hospitalize when pregnant, acute abdomen cannot be ruled out, tubo-ovarian abscess, severe illness, or when there is no
substantial improvement within 3 days of initiation of oral treatment.
Recommend abstinence from intercourse until 7 days after treatment is initiated
•
Patients should be re-evaluated if symptoms persist or recur after completion of therapy
•
Partners should be referred for evaluation and treatment if sexual contact within the preceding 60 days and should be treated
•
empirically after collecting specimens, even if asymptomatic
Ciprofloxacin contraindicated for pregnant and lactating women and persons <18 years
•
Safety of Azithromycin in pregnant and lactating women is not established, but it is commonly used
•
Twin Cities Adolescent Medicine Seminar – February 16, 2006

2. Sexually Transmitted Infections in Primary Care
Eric Meininger, M.D.
Community-University Health Care Center
Page 2 of 4
Special Cases
STD Pharyngitis
Recommend treatment for both gonococcal and chlamydial infections
Treatment failures should be evaluated by culture and sensitivities
STD Conjunctivitis
Consider gonococcal if history of recent STD
Treat with Ceftriaxone 1g IM x1 dose and saline lavage infected eye.
Disseminated Gonococcal infection
Treat presumptively for concurrent chlamydia unless testing excludes this diagnosis
Treat with Ceftriaxone 1g IM/IV q24 x 1-2 days then Cefixime 400mg po bid or Ciprofloxacin 500mg po bid to complete a
week.
Consider hospitalization if
• Diagnosis is uncertain
• Patient is not deemed reliable to comply with therapy
• Clinical evidence of myocarditis or meningitis
Painful testicle
Treatment of epididymitis most likely caused by gonorrhea or chlamydia
Ceftriaxone 250mg IM x1 and Doxycycline 100mg po bid x 10d or
Ofloxacin 300mg po bid x 10d
Scrotal elevation with jock strap
Analgesics
Followup
Failure to improve within 3 days requires more extensive workup
Exophytic STDs
(vaccine currently being tested)
Genital Warts (Condyloma accuminatum)
Human Papilloma Virus
Treatment Followup
Podofilox 0.5% solution or gel May need multiple treatments until warts are cleared
May be applied by patient x 3d followed by 4d of no therapy Regular cytologic screening for women (PAP and colposcopy)
up to 4 cycles
antimitotic (unknown safety in pregnancy)
Podophyllin resin 10-25%
Hurts 12 hours later x 2-3 days
(unknown safety in pregnancy)
Trichloroacetic acid 80-90%
Hurts immediately x 5 minutes. Can repeat weekly
5% Florouricil
Can burn normal skin
Imiquimod 5% cream
May be applied by patient qhs 3x week up to 16 weeks
Wash area 6-10h after application
Immune enhancer (unknown safety in pregnancy)
Cryotherapy
Surgical excision
Twin Cities Adolescent Medicine Seminar – February 16, 2006

3. Sexually Transmitted Infections in Primary Care
Eric Meininger, M.D.
Community-University Health Care Center
Page 3 of 4
Genital Ulcer Disease
(vaccine currently being tested)
Herpes
Type Treatment
Acyclovir 200mg po 5x day or 400mg po tid x 7-10 days or
Primary
Famciclovir 250mg po tid x 7-10d or
Valacyclovir 1g po bid x 7-10d
Topical therapy substantially less effective and not recommended
Treatment may be extended if healing is incomplete after 10d
Acyclovir 200mg po 5x day or 400mg po tid or 800mg po bid x 5d or
Recurrent
Famciclovir 125mg po bid x 5d or
Valacyclovir 500mg po bid or 1 g po qd x 5d
Have drug at home and begin at first symptom
Acyclovir 400mg po bid x 1 year or
Suppressive Therapy
Documented safe & efficacious up to 6 years
After more than 6 recurrences in 1 year
Famciclovir 250mg po bid x 1 year or
Valacyclovir 500mg po qd or 1 g po qd x 1 year
For more than 10 recurrences / year, 1000mg po qd is more effective
Discuss discontinuing prophylaxis after one year because frequency of recurrences decreases
over time
Suppressive therapy reduces but does not eliminate asymptomatic viral shedding
Syphilis – Treponema pallidum
See bacterial STDs
Chancroid - Haemophilus ducreyi
Treatment
Azithromycin 1g po x 1 or
Ceftriaxone 250 mg IM x 1 or
Ciprofloxacin 500 mg po bid x 3 d or
some resistance worldwide
Erythromycin base 500 mg po qid x 7d
some resistance worldwide
Granuloma inguinale (Donovanosis
Treatment Followup
Trimethoprim Sulfamethoxazole DS po bid x 21 d or Follow clinically until all signs and symptoms have resolved
Doxycycline 100mg po bid x 21 d Continue treatment until all lesions have healed completely
Lymphogranuloma venereum Increased number of cases reported in Netherlands amongst MSM in
Invasive Chlamydia Trachomatis serovars L1, L2, L3 2004.
Treatment Followup
Doxycycline 100mg po bid x 21 d or Follow clinically until all signs and symptoms have resolved
Erythromycin base 500 mg po qid x 21 d Partners should be examined and tested for urethral or cervical
chlamydia. Treat partners regardless if they have had sexual contact
within 30 days preceding onset of symptoms in patient
Reference: Centers for Disease Control and Prevention. “Sexually transmitted diseases treatment
guidelines 2002.” Morbidity and Mortality Weekly Report 2002; 51(No. RR-6). Available online at
http://www.cdc.gov/std/treatment/
Twin Cities Adolescent Medicine Seminar – February 16, 2006

4. Sexually Transmitted Infections in Primary Care
Eric Meininger, M.D.
Community-University Health Care Center
Page 4 of 4
Vaginitis
Treatment
Diagnosis
Cause
KOH Prep Wet Prep Discharge Odor
Butoconazole 2% cream (OTC) 5g intravaginally qhs x 3d or
Yeast Candida Budding yeast, Creamy, curd-like, white Musty
pseudohyphae Butoconazole 2% cream sustained release 5g intravaginally qhs x 1 or
Clotrimazole 1% cream (OTC) 5g intravaginally qhs x 7 – 14 d or
Clotrimazole vaginal tablet 100mg 2 tablets intravaginally qhs x 3d or
Clotrimazole vaginal tablet 500mg 1 tablet intravaginally qhs x 1 or
Miconazole 2% cream 5g intravaginally qhs x 7d or
Miconazole vaginal suppository 200mg intravaginally x 3d or 100mg
intravaginally x 7d or
Fluconazole 150mg po x 1 dose
Concern for developing resistance plus potential for toxicity
plus many others . . .
Torulopsis Long yeast, no buds Donʼt treat on culture unless symptomatic
Trichomonas Unicellular flagellated Frothy, carbonated, white to Foul smelling Metronidazole 2g po x 1 dose
protozoan (moving), yellow-green, malodorous
many WBC with vulvar irritation
Metronidazole 500mg po bid x 7d or
Bacterial Vaginosis Clue cells (epithelial Gray-white, thin discharge Fishy
Gardnerella plus cells coated with smoothly coats vaginal Clindamycin 2% cream intravaginally qhs x 7d or
anaerobic species bacteria) walls, +whiff test, pH >4.5
Metronidazole 0.75% gel intravaginally bid x 7d or
Metronidazole 2g po x 1 dose
Lower efficacy
Better for compliance
Foreign body Foul smelling Remove foreign body, treat for presumptive PID
Physiologic Clear, mucoid discharge No odor
Caution! Creams and suppositories are oil based and may weaken latex condoms and diaphragms
Vaccine Preventable STDs
Type Treatment
Vaccine recommended for sexually active adolescent and adult males who have sex
Hepatitis A
with males and illegal drug uses (injection and non-injection)
Now required for school in Minnesota
Hepatitis B
Routine immunization
Combined Hepatitis A & B vaccine available for adults on 0, 1, 6 month schedule
Reference: Centers for Disease Control and Prevention. “Sexually transmitted diseases treatment guidelines 2002.” Morbidity and Mortality
Weekly Report 2002; 51(No. RR-6). Available online at http://www.cdc.gov/std/treatment/
Twin Cities Adolescent Medicine Seminar – February 16, 2006