2002 STD Treatment
Guidelines
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Division of STD Prevention, CDC |
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STD Prevention and Control
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Education and counseling to reduce risk
of STD acquisition |
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Detection of asymptomatic and/or
symptomatic persons unlikely to seek evaluation |
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Effective diagnosis and treatment |
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Evaluation, treatment, and counseling
of sexual partners |
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Preexposure vaccination--hepatitis A, B |
Prevention Messages
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Prevention messages tailored to the
client’s personal risk; interactive counseling approaches are effective |
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Despite adolescents greater risk
of STDs, providers often fail to
inquire about sexual behavior, assess risk, counsel about risk reduction,
screen for asx infection |
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Specific actions necessary to avoid
acquisition or transmission of STDs |
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Clients seeking evaluation or treatment
for STDs should be informed which specific tests will be performed |
Prevention Methods
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Male Condoms |
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Consistent/correct use of latex condoms
are effective in preventing sexual transmission of HIV infection and can
reduce risk of other STDs |
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Likely to be more effective in
prevention of infections transmitted by fluids from mucosal surfaces (GC,CT,
trichomonas, HIV) than those transmitted by skin-skin contact (HSV,HPV,
syphilis, chancroid) |
Prevention Methods
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Spermicides |
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N-9 vaginal spermicides are not
effective in preventing CT, GC, or HIV infection |
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Frequent use of spermicides/N-9 have
been associated with genital lesions |
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Spermicides alone are not recommended
for STD/HIV prevention |
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N-9 should not be used a microbicide or
lubricant during anal intercourse |
The Diseases
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Curable? |
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Characteristics |
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Treatment: Learn the basics |
HSV 1 & 2
HSV Serologic Tests
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If you are sending cultures to lab you
must specify type specific assay for HSV1 and HSV2 infection. Request the most specific assay available
at your institution. |
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Often it is difficult to get a good
sample and you must rely on history and clinical |
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Characteristics of HSV
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Incurable with chronic recurrences |
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Asymptomatic shedding |
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Painful lesions |
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Frequency and severity of outbreaks
varies with regard to health, stress, individual |
Treatment Genital Herpes
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First Clinical Episode |
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Acyclovir 400 mg tid |
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or |
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Famciclovir 250 mg tid |
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or |
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(Valtrex) Valacyclovir 1000 mg bid |
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Duration of Therapy 7-10 days |
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Treatment Genital Herpes
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Episodic Therapy |
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Acyclovir 400 mg three times daily x 5 days |
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or |
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Acyclovir 800 mg twice daily x 5 days |
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or |
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Famciclovir 125 mg twice daily x 5
days |
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or |
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Valacyclovir 500 mg twice daily x 3-5
days |
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or |
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Valacyclovir 1 gm orally daily x 5
days |
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Treatment Genital Herpes
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Daily Suppression |
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Acyclovir 400 mg bid |
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or |
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Famciclovir 250 mg bid |
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or |
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Valacyclovir 500-1000 mg daily |
Genital Herpes in HIV
Infected
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May have prolonged or severe episodes
with extensive genital or perianal disease |
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Episodic or suppressive antiviral
therapy often beneficial |
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Genital Herpes in Pregnancy
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Available data do not indicate an
increased risk of major birth defects (first trimester) |
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Limited experience on pregnancy
outcomes with prenatal exposure to valacyclovir or famciclovir |
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Acyclovir may be used with first
episode or severe recurrent disease |
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Risk of transmission to the neonate is
30-50% among women who acquire HSV near delivery |
Genital Herpes Counseling
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Natural history of infection,
recurrences, asymptomatic shedding, transmission risk |
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Individualize use of episodic or
suppressive therapy |
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Abstain from sexual activity when
lesions or prodromal symptoms present |
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Risk of neonatal infection |
Syphilis
Characteristics of Syphilis
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T.Pallidium |
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Primay, Secondary and Tertiary stages |
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Curable, but can be latent &
asymptomatic |
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Skin lesions |
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Neurodegenerative |
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“the great imitator” |
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Always positive RPR |
Treatment of Syphilis
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Primary, Secondary, Early Latent |
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Recommended regimen |
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Benzathine Penicillin G, 2.4 million units IM |
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Penicillin Allergy* |
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Doxycycline 100 mg twice daily x 14 days or |
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Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies) or |
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Azithromycin 2 gm single oral dose (preliminary data) |
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*Use in HIV-infection has not been studied |
Primary/Secondary
Syphilis
Response to Treatment
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No definitive criteria for cure or
failure are established |
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Re-examine clinically and serologically
at 6 and 12 months |
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Consider treatment failure if
signs/symptoms persist or sustained 4x increase in nontreponemal test |
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Treatment failure: HIV test, CSF
analysis; administer benzathine pcn weekly x 3 wks |
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Additional therapy not warranted in
instances when titers don’t decline despite nl CSF and repeat therapy |
Treatment of Syphilis
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Latent Syphilis |
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Recommended regimen |
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Benzathine penicillin G 2.4 million
units IM at one week intervals x 3 doses |
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Penicillin allergy* |
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Doxycycline 100 mg orally twice daily |
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or |
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Tetracycline 500 mg orally four times
daily |
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Duration of therapy 28 days; close clinical and serologic |
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follow-up; data to support alternatives to pcn are limited |
Special Considerations in
Syphilis
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Management of sex partners |
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Pregnancy |
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Congenital syphilis |
Chancroid
Characteristics of
Chancroid
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Curable |
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Haemophilus ducreyi |
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Genital ulcer |
Treatment of Chancroid
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Azithromycin 1 gm orally |
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or |
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Ceftriaxone 250 mg IM in a single dose |
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or |
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Ciprofloxacin 500 mg twice daily x 3
days |
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or |
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Erythromycin base 500 mg tid x 7 days |
Chancroid: Management
Considerations
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Re-examination 3-7 days after treatment |
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Time required for complete healing
related to ulcer size |
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Lack of improvement: incorrect diagnosis, co-infection, non-compliance,
antimicrobial resistance |
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Resolution of lymphadenopathy may
require drainage |
Chancroid: Management of
Sex Partners
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Examine and treat partner whether
symptomatic or not if partner contact < 10 days prior to onset |
Urethritis
Characteristics of
Urethritis
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Curable |
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Mucopurulent or purulent discharge |
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Can be asymptomatic |
Treatment of Nongonococcal
Urethritis
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Azithromycin 1 gm in a single dose |
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or |
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Doxycycline 100 mg bid x 7 days |
Treatment of Nongonococcal
Urethritis
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Alternative regimens |
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Erythromycin base 500 mg qid for 7 days |
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or |
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Erythromycin ethylsuccinate 800 mg qid
for 7 days |
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or |
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Ofloxacin 300 mg twice daily for 7 days |
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or |
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Levofloxacin 500 mg daily for 7 days |
Chlamydia trachomatis
Chlamydia Screening
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Annual screening of sexually active
women < 25 yrs |
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Annual screening of sexually active
women > 25 yrs with risk
factors |
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Sexual risk assessment may indicate
more frequent screening for some women |
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Re-screen women 3-4 months after
treatment due to high prevalence of
repeat infection |
Characteristics of
Chlamydia
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Curable, but can cause permanent damage |
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Asymptomatic |
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Mucopurulent discharge |
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Slide 34
Treatment of Chlamydia
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Azithromycin 1 gm single dose |
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or |
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Doxycycline 100 mg bid x 7d |
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Treatment of Chlamydia
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Alternative regimens |
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Erythromycin base 500 mg qid for 7 days |
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or |
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Erythromycin ethylsuccinate 800 mg qid
for 7 days |
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or |
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Ofloxacin 300 mg twice daily for 7 days |
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or |
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Levofloxacin 500 mg for 7 days |
Treatment of
Chlamydia
in Pregnancy
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Recommended regimens |
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Erythromycin base 500 mg qid for 7
days |
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or |
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Amoxicillin 500 mg three times daily
for 7 days |
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Alternative regimens |
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Erythromycin base 250 mg qid for 14
days |
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or |
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Erythromycin ethylsuccinate 800 mg qid
for 14 days |
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or |
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Erythromycin ethylsuccinate 400 mg qid
for 14 days |
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or |
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Azithromycin 1 gm in a single dose |
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Neisseria gonorrhoeae
Characteristics of
gonorrhoeae
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Curable, but can cause permanent damage |
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Asymptomatic |
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Mucopurulent discharge |
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Treatment of gonorrhoeae
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Cervix, Urethra, Rectum |
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Cefixime 400 mg |
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or |
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Ceftriaxone 125 IM |
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or |
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Ciprofloxacin 500 mg |
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or |
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Ofloxacin 400 mg/Levofloxacin 250 mg |
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PLUS Chlamydial therapy if infection
not ruled out |
Treatment of gonorrhoeae
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Cervix, Urethra, Rectum |
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Alternative regimens |
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Spectinomycin 2 grams IM in a single
dose |
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or |
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Single dose cephalosporin (cefotaxime
500 mg) |
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or |
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Single dose quinolone (gatifloxacin
400 mg, lomefloxacin 400 mg, norfloxacin 800 mg) |
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PLUS Chlamydial therapy if infection
not ruled out |
Treatment of gonorrhoeae
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Pharynx |
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Ceftriaxone 125 IM in a single dose |
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or |
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Ciprofloxacin 500 mg in a single dose |
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PLUS Chlamydial therapy if infection
not ruled out |
Treatment of gonorrhoeae in
pregnancy
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Cephalosporin regimen |
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Women who can’t tolerate cephalosporin
regimen may receive 2 g spectinomycin IM |
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No quinolone or tetracycline regimen |
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Erythromycin or amoxicillin for
presumptive or diagnosed chlamydial infection |
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Antimicrobial Resistance in
the treatment of gonorrhoeae
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Geographic variation in resistance to
penicillin and tetracycline |
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No significant resistance to
ceftriaxone |
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Fluoroquinolone resistance in SE Asia,
Pacific, Hawaii, California |
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Surveillance is crucial for guiding
therapy recommendations |
Vaginitis
Characteristics of Candida
Vaginitis
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Curable |
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Thick white discharge, “cottage cheese” |
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Itchy |
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Microscopy |
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Treatment of Candida
Vaginitis
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Intravaginal regimens |
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Butoconazole, clotrimazole,
miconazole, |
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nystatin, tioconazole, terconazole |
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Oral regimen |
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Fluconazole 150 mg in a single dose |
Recurrent Candida Vaginitis
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Four or more symptomatic episodes/year |
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Vaginal culture useful to confirm
diagnosis and identify unusual species |
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Initial regimen of 7-14 days topical
therapy or fluconazole 150 mg (repeat 72 hr) |
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Maintenance regimens- clotrimazole,
ketoconazole, fluconazole, itraconazole |
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Non-albicans VVC- longer duration of
therapy with non-azole regimen |
Candida Vaginitis:
Management of Sex Partners
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Treatment not recommended |
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Treatment of male partners does not
reduce frequency of recurrences in the female |
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Male partners with balanitis may
benefit from treatment |
Treatment of Candida
Vaginitis in Pregnancy
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Only topical intravaginal regimens
recommended |
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Most specialists recommend 7 days of
therapy |
Trichomoniasis
Characteristics of
Trichomoniasis
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Curable |
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Discharge |
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Microscopy |
Treatment of Trichomoniasis
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Recommended regimen |
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Metronidazole 2 gm orally in a single
dose |
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Alternative
regimen |
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Metronidazole 500 mg twice a day for 7
days |
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Pregnancy |
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Metronidazole 2 gm orally in a single
dose |
Trichomoniasis: Management
of Sex Partners
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Sex partners should be treated |
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Avoid intercourse until therapy is
completed and patient and partner are asymptomatic |
Bacterial Vaginitis
Characterstics Bacterial
Vaginosis
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Curable |
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Fishy odor |
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KOH test |
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Microscopy, clue cells |
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Treatment of Bacterial
Vaginitis
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Metronidazole 500 mg twice daily for 7
days |
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or |
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Metronidazole gel 0.75%, 5 g
intravaginally once daily for 5 days |
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or |
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Clindamycin cream 5%, 5 g
intravaginally qhs for 7 days |
Bacterial Vaginitis:
Management of Sex Partners
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Woman’s response to therapy and the
likelihood of relapse or recurrence not affected by treatment of sex partner |
Pelvic Inflammatory Disease
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Curable, but can cause permanent
damage! |
Characteristics of Pelvic
Inflammatory Disease
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Minimum Diagnostic Criteria |
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Uterine/adnexal tenderness or cervical
motion tenderness |
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Additional Diagnostic Criteria |
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Oral temperature >38.3 C Elevated
ESR |
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Cervical CT or GC Elevated CRP |
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WBCs/saline microscopy Cx discharge |
Pelvic Inflammatory Disease
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Definitive Diagnostic Criteria |
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Endometrial biopsy with histopathologic
evidence of endometritis |
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Transvaginal sonography or MRI showing
thick fluid-filled tubes |
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Laparoscopic abnormalities consistent
with PID |
Hospitalization in Pelvic
Inflammatory Disease
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Surgical emergencies not excluded |
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Pregnancy |
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Clinical failure of oral antimicrobials |
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Inability to follow or tolerate oral
regimen |
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Severe illness, nausea/vomiting, high
fever |
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Tubo-ovarian abscess |
Treatment of Pelvic
Inflammatory Disease
Pelvic Inflammatory
Disease: Management of Sex Partners
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Male sex partners of women with PID
should be examined and treated for sexual contact 60 days preceding pt’s
onset of symptoms |
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Sex partners should be treated
empirically with regimens effective against CT and GC |
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Human Papilloma Virus
Characteristics of Human
Papilloma Virus
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Incurable, chronic disease |
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Asymptomatic |
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Genital warts |
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Link to cervical cancer |
Treatment of Papillomavirus
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Primary goal for treatment of visible
warts is the removal of symptomatic warts |
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Difficult to determine if treatment
reduces transmission |
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Treatment of Papillomavirus
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Patient-applied |
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Podofilox 0.5% solution or gel |
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or |
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Imiquimod 5% cream (Aldara) |
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Provider-administered |
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Cryotherapy |
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or |
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Podophyllin resin 10-25% |
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or |
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Trichloroacetic or Bichloroacetic acid
80-90% |
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or |
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Surgical removal |
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Treatment of Papillomavirus
in pregnancy
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Imiquimod (Aldara), podophyllin,
podofilox should not be used in pregnancy |
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Many specialists advocate wart removal
due to possible proliferation and friability |
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HPV types 6 and 11 can cause
respiratory papillomatosis in infants and children |
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Preventative value of cesarean section
is unknown; may be indicated for pelvic outlet obstruction |
Cervical Cancer Screening
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Women with STD hx may be at increased
risk of cervical cancer |
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Clinics that offer pap screening
without colposcopic f/u should arrange for referral |
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Management of abnormal pap provided per
Interim Guidelines for Management of Abnormal Cervical Cytology (NCI
Consensus Panel) |
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Emerging data support HPV testing for
the triage of women with ASCUS Pap tests |
Vaccine Preventable STDs
Hepatitis A
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MSM |
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Illegal drug users |
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Chronic liver disease, hepatitis B and
C infection |
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Hepatitis B
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History of STD, multiple sex partners,
sexually active MSM |
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Illegal drug use |
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Household members, sex partners of
those with chronic hepatitis B |
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Hemodialysis, occupational blood
exposure |