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SCREENING, DIAGNOSIS, AND TREATMENT OF SEXUALLY TRANSMITTED DISEASES IN PRIMARY CARE SETTINGS (14HC03)

Bonnie Richards, DO, BSN, Patricia Mason, BS, PHA and Sindy M. Paul, MD, MPH, FACPM

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GENITAL HERPES


Genital herpes
Acknowledgement: “Paul A. Volberding, MD, University of California San Francisco”

 

Genital herpes is caused by herpes simplex virus (HSV-1 or HSV-2). The majority of cases of genital herpes are due to HSV-2.

Epidemiology

In the United States, an estimated 16.2%, or 1 out of 6 people, ages 14 to 49 have genital HSV-2 infection. The infection is more common in females with nearly 1 out of 5 infected, compared to 1 out of 9 in men.6

Symptoms

The majority of those infected are unaware of their infection, and may be asymptomatic. However, a patient’s first outbreak of genital herpes may be moderately severe with development of genital lesions along with fever, flu like symptoms, and lymphadenopathy.2

Diagnosis

The clinical diagnosis of genital herpes is nonspecific, as many patients do not develop the typical painful vesicular or ulcerative lesions. The recommended tests for patients presenting with possible genital herpes is cell culture and polymerase chain reaction (PCR) for HSV DNAe. Serological tests can also be used which are type-specific for HSV-1 or HSV-2. Failure to detect HSV by culture or PCR does not rule out HSV infection, because viral shedding is intermittent. The CDC does not recommend the use of cytologic detection of cellular changes of HSV infection because it is an insensitive and nonspecific method of diagnosis, both for genital lesions (i.e., Tzanck preparation) and for cervical Pap smears.2

Screening

The USPSTF recommends against screening for HSV in asymptomatic patients.5

Treatment

As the first episode of genital herpes can lead to a prolonged illness, all patients presenting with a primary episode of genital herpes should be treated with antiviral medications.2

Recommended treatment for 1st episode:

  • Acyclovir 400mg po TID x 7–10 days or
  • Acyclovir 200 mg po five times daily x 7–10 days or
  • Famciclovir 250mg po TID x 7–10 days or
  • Valacyclovir 1 g po BID x 7–10 days

Consider using suppressive therapy in a patient with established infection who wishes to decrease the frequency of recurrent genital herpes.2 Recommended suppressive treatment:

  • Acyclovir 400mg po BID or
  • Famciclovir 250mg po BID or
  • Valacyclovir 500mg po once daily or
  • Valacyclovir 1 g po once daily

Patients may also opt to treat with episodic therapy for recurrent genital herpes. Recommended episodic treatment:

  • Acyclovir 400mg po TID x 5 days or
  • Acyclovir 800mg po BID x 5 days or
  • Acyclovir 800mg po TID x 2 days or
  • Famciclovir 125mg po BID x 5 days or
  • Famciclovir 1000mg po BID x 1 day or
  • Famciclovir 500mg po once, followed by 250mg po BID x 2 days or
  • Valacyclovir 500mg po BID x 3 days or
  • Valacyclovir 1 gm po once daily x 5 days

Treatment of Partners

Partners of patients with genital herpes should be informed of their risk of infection. Sexual activity should not occur while the patient is symptomatic. It should be remembered however, that transmission can occur during asymptomatic periods, as the virus continues to shed. Partners who develop symptoms should be evaluated and treated in the same manner as above.2

Special populations

Ask all pregnant women if they have a history of genital herpes. If a woman with a history of genital herpes is without symptoms at the time of delivery, she can deliver vaginally. However, if a woman has genital lesions at the time of delivery, a cesarean section should be performed to prevent neonatal HSV infection.2

HIV-positive patients infected with HSV can have prolonged or severe outbreaks of genital herpes due to immunosuppression. Daily suppressive therapy is recommended for these patients. Clinical manifestations of HSV may worsen during initiation of HIV treatment due to immune reconstitution syndrome.2

Follow Up

The psychological effect of HSV infection can be substantial. Schedule follow up appointments to provide educational counseling and support.

Ensure you dispel the misconception that HSV causes cancer. Counsel clients newly diagnosed with genital HSV infection on the following topics:

  • Natural history of the disease, with emphasis on the potential for recurrent episodes, asymptomatic viral shedding, and the attendant risks of sexual transmission, including the risk of sexual transmission during asymptomatic periods.
  • Availability and effectiveness of suppressive and episodic therapies.
  • The importance of informing their current sex partners that they have genital herpes and of informing future partners before initiating a sexual relationship.
  • The importance of remaining abstinent from sexual activity with uninfected partners when lesions or prodromal symptoms are present.
  • The risk for HSV-2 sexual transmission can be decreased by the daily use of antiviral therapy (such as valacyclovir, famiciclovir, or acyclovir) by the infected person. Episodic therapy does not reduce the risk for transmission.
  • Consistent and correct use of male and female condoms might reduce the risk for genital herpes transmission.
  • Sex partners of infected persons should be advised that they might be infected even if they have no symptoms. Consider offering type-specific serologic testing of asymptomatic partners to determine if there is risk of acquiring HSV.
  • Risk of perinatal transmission. If a female client with HSV is pregnant or planning to get pregnant, she will need additional counseling and support in response to her questions about mother-to-child transmission of HSV.
  • Increased risk for HIV acquisition. When exposed to HIV, HSV-2 seropositive persons are at increased risk of HIV. Suppressive therapy does not reduce this risk.

GONORRHEA

Penile discharge, Gonorrhea
Acknowledgement: “Cincinnati STD/HIV Prevention Training Center”

Gonorrhea is caused by the Gram-negative diplococci Neisseria gonorrhea (N. gonorrhea),which grows easily in the reproductive tract as well as the mouth, throat, eyes, and anus. Infection commonly manifests as cervicitis, urethritis, proctitis, and/or conjunctivitis. Untreated gonorrhea can lead to serious complications such as pelvic inflammatory disease (PID) in women and epididymitis in males. Rarely, infection can also lead to disseminated gonococcemia.7

Epidemiology

Gonorrhea is a major public health concern as it is the second most commonly reported STD after chlamydia. The CDC suspects an estimated 700,000 new cases occur each year – less than half of which are reported.7 In 2009 there were 301,174 reported cases in the United States, of which 4,762 were in New Jersey.4 According to the CDC, reported cases of gonorrhea have declined in recent years – 17% nationally since 20061 – and are now at their lowest level since the CDC began tracking the disease in 1941. In New Jersey, however, cases declined less dramatically – by approximately 3%4 – during the same timeframe.

The number of reported cases has declined for all races and ethnicities since 2006; however the decrease has been smaller for African Americans (declining 15%) than for Hispanics (declining 21%) or Caucasians (declining 25%).3 According to CDC, the gonorrhea rate among African Americans is approximately 20 times higher than for Caucasians, and 10 times higher than Hispanics.

Symptoms

In men, the majority of gonorrhea infections cause symptoms such as purulent penile discharge and dysuria without urinary urgency or frequency. As a result, most men seek treatment soon enough to prevent sequelae.2 However, treatment may not be sought soon enough to prevent transmission to others.2

In women, infection may not produce recognizable symptoms until complications such as PID have already occurred.2 When symptomatic, women may have mucopurulent discharge, dysuria, pelvic pain, and dyspareunia.7 Patients who participate in anal intercourse may also present with anal discharge along with rectal pain or bleeding.7

Infection should be suspected in infants presenting with conjunctivitis or sepsis. Infants at an increased risk are those who have not received ophthalmic prophylaxis, whose mothers have had no prenatal care, or whose mothers have a history of STDs or substance abuse.2

Diagnosis

In a symptomatic male, a gram stain of a urethral specimen showing polymorphonuclear leukocytes (PMNs) with intracellular gram negative diplococci is diagnostic for infection. However, a gram stain in an asymptomatic male is not sufficient to rule out infection.2

Multiple other methods are available for diagnosis. Culture and testing can be performed on female endocervical or male urethral swab specimens. NAATs are FDA cleared for use on endocervical swabs, vaginal swabs, male urethral swabs, and male or female urine specimens. NAAT tests are not FDA approved for use on specimens from the rectum, pharynx, or conjunctiva. However, some laboratories may have established protocols for using NAAT on these specimens.2

It is important to remember that non-culture tests will not provide antibiotic susceptibility information. Therefore, you should obtain cultures from suspected treatment failures.2

Screening

The USPSTF recommends annual testing for gonorrhea in asymptomatic females who:5

  • Are sexually active and younger than 26 years
  • Are inconsistent condom users
  • Have a history of multiple partners or a partner with multiple contacts
  • Had sexual contact with a partner who had an STD
  • Have a history of repeated episodes of STDs
  • Are sex workers or drug users
  • Are pregnant

The USPSTF did not find sufficient evidence to argue for or against routine screening of males as their infection is likely to be symptomatic.5 However, it should be considered in high-risk patient populations.

Treatment

Patients infected with gonorrhea are assumed to be co-infected with chlamydia and should be treated routinely with a regimen effective against both gonorrhea and chlamydia.2 Recommended treatment of uncomplicated infection of cervix, urethra, or rectum:

  • Ceftriaxone 250mg IM in a single dose or (if not an option) cefixime 400mg po in a single dose (gonorrhea coverage) plus
  • Azithromycin 1 gm po x 1 or doxycycline 100 mg po BID x 7 days (chlamydia coverage)

Alternative treatment (uncomplicated infection of cervix, urethra, or rectum):

  • Cefpodoxime 400mg po in a single dose or Cefuroxime axetil 1gm po x 1 plus
  • Azithromycin 1 gm po x 1 or doxycycline 100 mg po BID x 7 days (chlamydia coverage)

The development of antibiotic resistant gonorrhea is a growing concern. Dual therapy, with a cephalosporin (ceftriaxone or cefixime) and either azithromycin or doxycycline, is recommended to address the emergence of cephalosporin resistance. Due to the emergence of resistant strains:

  • As of April 2007,CDC no longer recommended fluoroquinolone/quinolones (i.e, ciprofloxacin, ofloxacin, or levofloxacin) in the treatment of gonorrhea.

Clinicians should remain vigilant for treatment failures as evidenced by persistent symptoms or a positive follow-up test despite treatment. In the event of suspected treatment failure, obtain from the patient specimens for gonococcal culture.

  • If a patient experiences cefixime treatment failure, re-treat the patient with 250mg ceftriaxone intramuscularly and 2 g azithromycin orally.

  • If a patient experiences a ceftriaxone treatment failure, consult with an infectious disease expert and CDC regarding re-treatment. Patients experiencing a ceftriaxone treatment failure should return for tests-of-cure within 1 week, preferably with culture, or if culture is not available, with NAAT. If the follow-up NAAT result is positive, obtain a specimen for culture. CDC also recommends that clinicians should ensure that the patient's sexual partners from the preceding 2 months are tested for gonorrhea (preferably with culture) and treated with ceftriaxone 250 mg intramuscularly and azithromycin 2 g orally. Ensure that all treatment failures are reported to the local or state health department within 24 hours.13

Laboratorians are requested to report gonococcal isolates with decreased ceftriaxone or cefixime susceptibility (≥0.5 μg/mL) to their local or state health departments within 24 hours of identification.13

Treatment of Partners

Patients should be instructed to refer their sex partners for evaluation and treatment. Anyone with whom the gonorrhea patient has had sex within 60 days of onset of patient symptoms, should be treated. If the patient’s last sexual intercourse was more than 60 days prior, then his/her most recent partner should be treated.

Special populations

Patients who are HIV-positive and infected with gonorrhea should receive the same treatment as HIV-negative patients.2

Pregnant women should be treated with a recommended cephalosporin (ceftriaxone or cefixime) and chlamydial coverage. Azithromycin 2 gm can be considered for women who cannot tolerate a cephalosporin.2

Follow Up

Test-of-cure: Patients diagnosed with uncomplicated gonorrhea who are treated with any of the recommended or alternative regimens do not need a test-of-cure (i.e., repeat testing 3 to 4 weeks after completing therapy).

Clients with symptoms persisting after treatment: Evaluate these patients by culture for N. gonorrhea, and any gonococci isolate should be tested for antimicrobial susceptibility.

Re-testing: Because of the high risk of reinfection, usually caused by a failure to treat sex partners, retest 3 months after treatment (or whenever the person next presents for medical care in the 12 months following initial treatment), regardless of treatment status of partners. 2


Changes in treatment recommendation

In 1993, CDC recommended the use of fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) to treat gonorrhea, as they were relatively cheap, effective, and allowed for a 1 dose treatment. But in less than a decade, fluoroquinolone-resistant N. gonorrhea emerged out of Asia and began showing up in Hawaii and then California. By 2006, data demonstrated that fluoroquinolone-resistant gonorrhea was increasing and present in all regions of the country, leading the CDC to announce in 2007 that fluoroquinolones were no longer recommended for the treatment of gonococcal infections. This decision left just one class of antibiotics – the cephalosporins – still recommended and available for the treatment of gonorrhea.


 
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