Adolescent Health Care: A Practical Guide

Chapter 60

Overview of Sexually Transmitted Diseases

  1. Dennis Fortenberry

Lawrence S. Neinstein

From a clinical and public health perspective, sexually transmitted diseases (STDs) are one of the visible tracks marking the occasionally obscure developmental trails of sexuality through adolescence. Sexual activity itself occupies an uncomfortable, ambiguous position among the health challenges of adolescence—development of healthy sexuality balanced against the fear and stigma associated with STDs and their genuine threats to health.

The key clinical considerations include direct attention to issues of sexuality within the adolescent's developmental path, attention to behaviors that increase or reduce risk of acquiring an STD, immunization, screening by physical examination and laboratory testing, treatment of identified infections, and counseling for partner treatment and prevention of infections. Annual attention to these issues is recommended and some experts suggest even more frequent risk-reduction counseling and STD screening, particularly in teens with prior infections or in those involved in higher risk sexual behaviors. STD screening provides an opportunity to discuss risk of human immunodeficiency virus (HIV) testing and prevention.

STDs are associated with significant disease burden among adolescents. In 2005, 15- to 19-year-old female adolescents had the highest gonorrhea and chlamydia rates of any age-group. Gonorrhea rates among male and female adolescents have slowly declined during the last decade. Chlamydia rates are typically 6% to 18% among female adolescents, although rates decrease when aggressive screening and treatment policies are implemented. Trichomonas vaginalis rates are up to 14% in female adolescents and 3% to 5% in asymptomatic males. Serological studies show positivity rates for herpes simplex virus (HSV) of up to 30% for some groups of adolescents; most do not have symptomatic infection. HSV type 1 is now a common cause of genital herpes among adolescents and young adults. Evidence for human papillomavirus (HPV) infection may be seen in up to one third of some clinical samples. A vaccine for some HPV types (types 6, 11, 16, 18) is now commercially available.

The elevated STD risk in adolescents is almost certainly multifactorial in origin. Developmental susceptibility of the reproductive tract of female adolescents, the substantial rates of sex partner infections, and inconsistent or incorrect condom use are potential contributors. Socioenvironmental risks such as high endemic STD rates, sexual and physical abuse, social chaos, poverty, drug trafficking and use, and inadequate health care access also contribute and may be more powerful explanations of STD risk than developmental or individual behaviors.

Diagnostic possibilities for many STDs, particularly gonorrhea and chlamydia, have been revolutionized by nucleic acid amplification (NAATs) and hybrid capture (HC) techniques. NAATs and HC techniques have superior sensitivity and specificity compared with culture or other diagnostic tests such as direct fluorescent antibody (DFA) or DNA probe tests. NAATs and HC also allow use of urine and vaginal specimens, in addition to cervical or urethral specimens. Higher initial costs, compared with other tests, may be offset by reductions in morbidity.

In view of the fact that most adolescents complain of a particular set of symptoms and not a specific organism, a list of presenting symptoms for the STDs is also included (Table60.1). As a broad overview, the Appendix to this chapter summarizes the clinical features and treatments of many of the well-known STDs. The remaining chapters in Section XIIIfocus on individual STDs in more detail.

P.768

TABLE 60.1
Sexually Transmitted Diseases by Presenting Symptom

1.  Urethral discharge/dysuria

1.  Neisseria gonorrhoeae

2.  Chlamydia trachomatis

3.  Ureaplasma urealyticum

4.  Herpes genitalis

5.  Trichomonas vaginalis

2.  Vaginal discharge
Vaginal site of infection:

1.  Candida species

2.  T. vaginalis

3.  Bacterial vaginosis

Cervical site of infection:

4.  N. gonorrhoeae

5.  C. trachomatis

6.  Herpes genitalis

3.  Genital ulcer/lymphadenopathy

1.  Herpes genitalis

2.  Treponema pallidum

3.  Haemophilus ducreyi

4.  C. trachomatis (LGV types)

5.  Calymmatobacterium granulomatis

4.  Genital growths

1.  Human papillomavirus (genital warts)

2.  Molluscum contagiosum

3.  Condyloma latum (secondary syphilis)

5.  Abdominal/pelvic pain

1.  Pelvic inflammatory disease

6.  Anorectal pain/discharge/bleeding

1.  N. gonorrhoeae

2.  C. trachomatis

3.  Shigella species

4.  Campylobacter species

5.  Entamoeba histolytica

6.  Giardia lamblia

7.  Epididymitis

1.  N. gonorrhoeae

2.  C. trachomatis

3.  Coliform/enteric bacteria

8.  Hepatitis

1.  Hepatitis A and B virus

2.  Cytomegalovirus

3.  T. pallidum

9.  Arthralgia/arthritis

1.  N. gonorrhoeae

2.  Hepatitis B virus

10.      Pruritus

1.  Pthirus pubis

2.  Sarcoptes scabiei

3.  T. pallidum

11.      Flu-like or mononucleosis syndrome

1.  Cytomegalovirus

2.  Herpes genitalis

3.  Hepatitis A and B virus

4.  Human immunodeficiency virus

Web Sites

For Teenagers and Parents

http://www.iwannaknow.org. The American Social Health Association Web site designed specifically for teens. Sexuality and STD prevention are directly and explicitly addressed.

http://www.scarleteen.com/index.html. A teen-friendly, accurate and up-to-date site targeted at young women.

http://www.niaid.nih.gov/publications/stds.htm. National Institute of Allergy and Infectious Diseases fact sheet on STDs.

http://www.cdc.gov/women/. Centers for Disease Control and Prevention (CDC) women's health home page on STDs.

For Health Professionals

http://www.cdc.gov/STD/treatment/. The CDC Web site with recent statistics and treatment guidelines.

http://www.ashastd.org. The American Social Health Association home page. Lots of information and hotline access.

http://www.cdc.gov/std/training/. CDC site with a variety of training resources related to STDs.

Appendix 60.1

Sexually Transmitted Diseases Summary

Note: Adapted from the Centers for Disease Control and Prevention, Department of Health and Human Services. 2006 guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep 2006;55(RR-11), with permission. For a copy of this publication, write to CDC, Technical Information Services, Atlanta, GA 30333. Copies, updates, downloadable PDA versions and slide show summaries are available on-line, at http://www.cdc.gov/STD/treatment/.

P.769

 

Nongonococcal Urethritis

Etiological Agents

Chlamydia trachomatis (15%–55%)
Ureaplasma urealyticum (10%–40%)
Mycoplasma genitalium (5%–15%)
Trichomonas vaginalis (2%–5%)

HSV on occasion

Typical Clinical Presentation

Men usually have dysuria, frequency, and mucoid-to-purulent urethral discharge. Some men have asymptomatic infections.

Urethral discharge associated with nongonococcal urethritis (NGU) tends to occur 1 to 5 weeks after infection; NGU produces less discharge and dysuria than gonococcal urethritis.

However, no symptoms or signs reliably distinguish gonococcal urethritis from NGU or among various etiological causes of NGU.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

Mucopurulent or purulent discharge.

Absence of gram-negative intracellular diplococci and ≥5 polymorphonuclear (PMN) leukocytes/oil immersion field on a smear of an intraurethral swab specimen.

Positive leukocyte esterase test (LET) results on first-void urine or microscopic examination of first-void urine demonstrating ≥10 PMN leukocytes/high-power field. Positive LET results should always be confirmed with a Gram stain of a urethral swab specimen and/or gonorrhea and chlamydia testing.

Asymptomatic men with negative gonorrhea test results are presumed to have NGU if they have ≥5 PMN/oil immersion field on an intraurethral smear.

Definitive Diagnosis

An agent etiologically associated with NGU is recovered from the male urethra. Specific diagnostic tests for organisms other than Neisseria gonorrhoeae and C. trachomatis are not indicated in the evaluation of males with urethritis.

Note: Coinfection by multiple organisms is common.

Therapy

Recommended Regimen:

Azithromycin 1 g PO in a single dose, OR

Doxycycline 100 mg PO b.i.d. for 7 days.

Alternative Regimens:

Erythromycin base 500 mg PO q.i.d. for 7 days, OR

Erythromycin ethylsuccinate 800 mg PO q.i.d. for 7 days, OR

Ofloxacin 300 mg PO b.i.d. for 7 days, OR

Levofloxacin 500 mg PO once a day for 7 days.

Complications and Sequelae

Urethral strictures

Prostatitis

Epididymitis

Reiter syndrome

Chlamydial NGU may be transmitted to female sex partners, resulting in mucopurulent endocervicitis, pelvic inflammatory disease (PID), and other adverse outcomes. (See entries related to these conditions in the succeeding pages.) Now that quinolones are not recommended for gonorrhea treatment, testing with culture or NAAT for gonorrhea is essential when treating Chlamydia or NGU.

Other Considerations

Follow-up:

Regimens for persistent/recurrent urethritis have not been rigorously evaluated. Noncompliant patients and those with reexposure to untreated partners should be re-treated with the initial regimen. Azithromycin is more active against M. genitalium infections. Patients with objective evidence of persistent/recurrent urethritis should be evaluated for T. vaginalis infection. A recommended treatment for persistent/recurrent urethritis is as follows:

Metronidazole 2.0 g PO in a single dose, OR

Tinidazole 2.0 g PO in a single dose, PLUS

Azithromycin 1.0 g PO (if not used in initial treatment)

Management of Sex Partners:

Sex partners should be referred for evaluation and treatment.

HIV Infection:

Patients with HIV infection should receive the same treatment as patients without HIV.

P.770

 

Epididymitis

Etiological Agents

  1. trachomatis
    Neisseria gonorrhoeae

Coliform/enteric bacteria

Typical Clinical Presentation

Scrotal, inguinal, or flank pain and scrotal swelling. Subacute onset is typical, but acute symptoms are not uncommon. Most patients with epididymitis associated with sexually transmitted organisms have accompanying dysuria, urethral discharge, or both.

Presumptive Diagnosis

Requires ruling out testicular torsion. Gram stain of urethral secretions may show PMN leukocytes and gram-negative intracellular diplococci. Urinalysis is often positive for white blood cells (WBCs).

Definitive Diagnosis

Definitive bacterial diagnosis may be made after ruling out testicular torsion. Positive Chlamydia test result (culture, direct immunofluorescence assay, DNA probe, or NAAT) or a positive gonorrhea test result (gram stain, culture, DNA probe, or NAAT). Rarely, epididymal aspiration is used to establish a diagnosis before surgery.

Therapy

For epididymitis most likely caused by gonococcal or chlamydial infection:

Ceftriaxone 250 mg IM in single dose, PLUS

Doxycycline 100 mg PO b.i.d. for 10 days.

For epididymitis most likely caused by coliform/enteric organisms, or for patients allergic to cephalosporins or tetracyclines:

Ofloxacin 300 mg PO b.i.d. for 10 days, OR

Levofloxacin 500 mg PO once a day for 10 days.

Complications and Sequelae

Testicular/scrotal abscess

Testicular infarction

Chronic epididymitis

Infertility

Other Considerations

Follow-up:

Failure to improve within 3 days requires reevaluation.

Management of Sex Partners:

Sex partners should be managed as appropriate for the identified STD. Partners of presumptively treated patients should be notified, evaluated, and treated for infections identified or suspected in the index patient.

HIV Infection:

Patients with HIV infection should receive the same treatment as patients without HIV infection. Fungal and mycobacterial causes are more common among immunosuppressed patients and should be considered if initial treatment fails.

P.771

 

Mucopurulent Cervicitis

Etiological Agents

  1. gonorrhoeae
    C. trachomatis

In most cases, neither of these organisms are isolated.

Typical Clinical Presentation

Most patients are asymptomatic. Symptomatic patients may complain of yellow vaginal discharge or abnormal vaginal bleeding (e.g., after coitus).

Presumptive Diagnosis

Mucopurulent cervicitis (MPC) is not a sensitive and specific predictor of infection by C. trachomatis or N. gonorrhoeae.

The presence of yellow mucopurulent endocervical discharge or the finding of yellow discharge on a white cotton-tipped swab of endocervical secretions suggests infection.

The presence of increased numbers of PMN leukocytes on a Gram stain of endocervical mucus is not standardized and has low predictive value. This evaluation is not recommended.

Definitive Diagnosis

Definitive diagnosis is made by a positive Chlamydia test result (culture, direct immunofluorescence assay [DFA], DNA probe, or NAAT) or a positive gonorrhea test result (culture, DNA probe, or NAAT).

Therapy

Treatment is based on the results of Chlamydia and gonorrhea testing. If the patient is unreliable or in an area of high likelihood of gonorrhea or chlamydial infection, treat presumptively with coverage for both gonorrhea and Chlamydia.

Complications and Sequelae

Complications are those associated with etiological microbiological agents.

Other Considerations

Follow-up:

Follow-up should be appropriate for identified sexually transmitted organisms.

Management of Sex Partners:

Sex partners should be managed as appropriate for the identified STD. Partners of presumptively treated patients should be notified, evaluated, and treated for infections identified or suspected in the index patient.

HIV Infection:

Patients with HIV infection should receive the same treatment as patients without HIV infection.

P.772

 

Gonorrhea

Etiological Agent

  1. gonorrhoeae

Typical Clinical Presentation

When symptomatic, men complain of dysuria, urinary frequency, and purulent urethral discharge. Variable degrees of edema and erythema of the urethral meatus are often present.

Many infections in women are asymptomatic. Symptoms in women include abnormal vaginal discharge, intermenstrual bleeding, menorrhagia, or dysuria.

Symptoms of rectal gonococcal infection include mild anal pruritus, painless mucopurulent discharge, and mild bleeding. Symptoms of severe proctitis sometimes occur.

Pharyngeal infections are usually asymptomatic.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

Identification of typical gram-negative intracellular diplococci on smear of urethral discharge (men) or endocervical mucus (women). Gram stain is insufficiently sensitive for diagnosis in women and should be supplemented (if used) by culture, DNA probe, or NAAT confirmation.

Definitive Diagnosis

Growth on selective medium, demonstrating typical colonial morphology, positive oxidase reaction, and typical Gram stain morphology. Nucleic acid probes and NAATs are highly sensitive and specific for the diagnosis of gonorrhea. Tests based on several methods are U.S. Food and Drug Administration (FDA)-approved and commercially available. Approved specimen sources include urethral and cervical discharge/mucus and urine. Urine is generally less sensitive for diagnosis of gonococcal infections in women. Provider and self-obtained vaginal swabs show high sensitivity and specificity in research settings, but are FDA-approved specimen sources for only one of the commercially available tests. False-positive tests may be due to other nonpathogenic bacterial species and should be considered when screening patients with low probability of infection.

Therapy

Uncomplicated Urogenital or Anorectal Gonococcal Infections (see Other Considerations):

Ceftriaxone 125 mg IM at one time.

Cefixime 400 mg PO in a single dose.

Treatment for coinfection by C. trachomatis should be added unless appropriate diagnostic test results are negative for Chlamydia.

Uncomplicated Pharyngeal Infections (see Other Considerations):

Ceftriaxone 125 mg IM at one time, OR

Concomitant treatment for pharyngeal chlamydial infection is recommended, although coinfection is unusual.

Alternative Regimens:

Spectinomycin 2 g IM a single dose (for potential shortage see Other Considerations) Injectable cephalosporin regimens such as ceftizoxime (500 mg IM in a single dose), cefotaxime (500 mg IM in a single dose), cefotetan (1 g IM in a single dose), and cefoxitin (2 g IM in a single dose).

Azithromycin 2 g orally is effective against uncomplicated gonococcal infection but is expensive and causes gastrointestinal distress and therefore is not recommended for treatment of gonorrhea. Azithromycin 1 g orally is not recommended because of concerns regarding the possible rapid emergence of antimicrobial resistance.

Complications and Sequelae

Ten percent to 20% of women develop PID and are at risk for its sequelae (see following entry).

Men are at risk for epididymitis, sterility, urethral stricture, and infertility. Newborns are at risk for ophthalmia neonatorum, scalp abscess at the site of fetal monitors, rhinitis, pneumonia, or anorectal infections.

All infected, untreated persons are at risk for disseminated gonococcal infection (includes septicemia, arthritis, dermatitis, meningitis, and endocarditis).

P.773

 

Other Considerations

Because of rising quinolone resistance among gonococci, fluoroquinolones are no longer recommended for treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease.

Note on spectinomycin shortage (http://www.cdc.gov/std/specshortage.htm): With the possible discontinuation of spectinomycin in the United States, patients allergic to cephalosporins may need desensitization treatment by a specialist. Two grams of azithromycin is an approved regimen, but is not recommended due to the gastrointestinal distress, and there is no data documenting the safety and efficacy in pregnant women. If used, patients should be observed for at least 30 minutes after ingestion to monitor tolerance.

Pregnant Women:

Should not be treated with tetracycline or quinolones.

Follow-up:

No test of cure is needed for patients with uncomplicated gonorrhea who are treated with one of the regimens in these guidelines. Treatment failures are most likely due to reinfection.

Management of Sex Partners:

Sex partners should be referred for evaluation and treatment. Sexual intercourse should be avoided until the patient and partner are cured.

HIV Infection:

Patients with HIV infection should receive the same treatment as patients without HIV infection.

P.774

 

Chlamydia

Etiological Agent

  1. trachomatis

Typical Clinical Presentation

Many patients are asymptomatic. Symptomatic women complain of dysuria or abnormal vaginal discharge. Symptomatic men usually have dysuria, urinary frequency, and a mucopurulent urethral discharge.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

Women:

Sexual contact with a partner with diagnosed nongonococcal or chlamydial urethritis. MPC is sometimes used as presumptive diagnosis of cervical chlamydial infection.

Men:

Sexual contact with partners with urogenital chlamydial infection. NGU (i.e., typical clinical symptoms and ≥5 PMN leukocytes/oil immersion field on a smear of an intraurethral swab specimen).

Definitive Diagnosis

Definitive diagnosis is made with a positive Chlamydia test result (culture, DFA, nucleic acid probe or NAAT).

Therapy

Recommended Regimens:

Azithromycin 1 g PO in a single dose, OR

Doxycycline 100 mg PO b.i.d. for 7 days.

Alternative Regimens:

Ofloxacin 300 mg PO b.i.d. for 7 days, OR

Levofloxacin 500 mg PO once a day for 7 days, OR

Erythromycin base 500 mg PO q.i.d. for 7 days, OR

Erythromycin ethylsuccinate 800 mg PO q.i.d. for 7 days.

Complications and Sequelae

Ascending infections may lead to symptomatic or asymptomatic endometritis and salpingitis and subsequent infertility. Ascending infection during pregnancy may lead to adverse obstetric outcomes, conjunctivitis, or pneumonia in the infant, and to puerperal infection.

Other Considerations

Pregnant Women:

Doxycycline, ofloxacin, and levofloxacin are contraindicated for use during pregnancy. Azithromycin is a Class B drug, so its safety for pregnant and lactating women is not known. However, there is now extensive clinical experience with azithromycin treatment during pregnancy.

Recommended Regimen for Pregnant Women:

Azithromycin 1.0 g PO as a single oral dose, OR

Amoxicillin 500 mg PO t.i.d. for 7 days.

Alternative Regimens:

Erythromycin base 500 mg PO q.i.d., for 7 days, OR

Erythromycin base 250 mg PO q.i.d. for 14 days, OR

Erythromycin ethylsuccinate 800 mg PO q.i.d. for 7 days, OR

Erythromycin ethylsuccinate 400 mg PO q.i.d for 14 days

Follow-up:

No need for retesting after completing treatment with doxycycline or azithromycin. Retesting at 3 weeks after completion of therapy may be useful for pregnant women because none of the regimens are highly efficacious and the erythromycin side effects may prevent compliance. Reinfection is common in women with C. trachomatis and rescreening in 3 to 4 months after treatment is recommended, particularly in adolescents.

Management of Sex Partners:

Sex partners should be referred for evaluation and treatment.

HIV Infection:

Patients with HIV infection should receive the same treatment as patients without HIV infection.

P.775

 

Pelvic Inflammatory Disease

Etiological Agents

In most cases, sexually transmitted organisms, especially N. gonorrhoeae and C. trachomatis, are implicated. However, other microorganisms that can be part of vaginal flora, such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae can cause PID. Mycoplasma hominis and U. urealyticum may also play a role.

Typical Clinical Presentation

The spectrum of PID includes any combination of endometritis, salpingitis, tuboovarian abscess (TOA), and pelvic peritonitis. The patient may present with pain and tenderness involving the lower abdomen, cervix, uterus, and adnexa. Fever, chills, elevated WBC count, and elevated erythrocyte sedimentation rate (ESR) are often absent.

Presumptive Diagnosis

The clinical diagnosis of PID is difficult because of the wide variation in symptoms and signs. No combination of symptoms, signs, or laboratory findings is both sensitive and specific for PID. Because delay in treatment increases the potential for damage to the reproductive health of the woman with PID, a low threshold for the diagnosis of PID is necessary.

Minimum Criteria:

  • Adnexal tenderness, OR
  • Uterine tenderness, OR
  • Cervical motion tenderness

Empirical treatment of PID should be initiated in sexually active young women and others at risk for STDs if the minimum criteria are present and no other cause(s) for the illness can be identified. Although PID occurs during pregnancy, patients with positive pregnancy tests require careful evaluation for ectopic pregnancy as a cause for pelvic pain.

Additional Criteria:

Additional criteria may increase the specificity of the diagnosis. The likelihood of PID is reduced if all of these criteria are normal or negative.

Routine Criteria:

  • Oral temperature >38.3°C
  • Abnormal cervical or vaginal discharge
  • Presence of WBCs on saline microscopy of vaginal secretions
  • Elevated ESR
  • Elevated C-reactive protein
  • Laboratory documentation of cervical infection with N. gonorrhoeaeor trachomatis

If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and another diagnosis should be explored.

Elaborate Criteria:

  • Histopathological evidence of endometritis on endometrial biopsy
  • TOA on sonography
  • Laparoscopic abnormalities consistent with PID

Definitive Diagnosis

Direct visualization of inflamed (edema, hyperemia, or tubal exudate) fallopian tube at laparoscopy or laparotomy makes the diagnosis of PID definitive. A culture of tubal exudate establishes the etiology.

Therapy

Some experts recommend that all patients with PID be hospitalized to initiate parenteral antibiotics. Hospitalization of patients with PID is particularly recommended in the following circumstances:

  1. The diagnosis is uncertain; and surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded.
  2. A pelvic abscess is suspected.
  3. The patient is pregnant.
  4. The patient has HIV infection.
  5. Severe illness or nausea and vomiting preclude outpatient management.
  6. The patient is unable to follow or tolerate an outpatient regimen.
  7. The patient has failed to respond to outpatient therapy.
  8. Clinical follow-up within 72 hours of starting antibiotic treatment cannot be arranged.

Oral Treatment

Little information is available from clinical trials on intermediate and long-term outcomes using outpatient regimens. If patients do not respond within 72 hours to outpatient regimens, they should be hospitalized to confirm diagnosis and receive parenteral treatment.

Ceftriaxone 250 mg IM once, OR

Cefoxitin 2 g IM, plus probenecid 1 g concurrently, OR

Other parenteral third-generation cephalosporin such as ceftizoxime or cefotaxime, PLUS

Doxycycline 100 mg orally twice a day for 14 days

WITH or WITHOUT

Metronidazole 500 mg PO b.i.d. for 14 days.

P.776

 

Parenteral Treatment

Regimen A:

Cefoxitin 2 g IV q6h, OR cefotetan 2 g IV q12h, PLUS

Doxycycline 100 mg IV or PO q12h.

Oral and IV doxycycline have similar bioavailability. Oral administration should be used when possible because of pain of IV administration.

Regimen B:

Clindamycin 900 mg IV q8h, PLUS

Gentamicin loading dose IV or IM 2 mg/kg of body weight, followed by a maintenance dose, 1.5 mg/kg q8h.

These regimens should be continued for at least 48 hours after the patient demonstrates improvement. Thereafter, doxycycline (100 mg PO b.i.d.) or clindamycin (450 mg PO q.i.d.) should be continued for 14 days. When TOA is present, many health care providers use clindamycin for continued therapy, rather than doxycycline, because clindamycin provides more effective anaerobic coverage.

Alternative Parenteral Regimens:

Few data support the use of other parenteral regimens, but the following regimen has been investigated in at least one clinical trial:

Ampicillin/sulbactam 3 g IV q6h PLUS

Doxycycline 100 mg IV or PO q12h.

Complications and Sequelae

Life-threatening complications include ectopic pregnancy and pelvic abscess. Other complications are involuntary infertility, recurrent PID, chronic PID, chronic abdominal pain, pelvic adhesions, premature hysterectomy, and depression.

Other Considerations

Pregnant Women:

Should be treated as inpatients.

Follow-up:

Hospitalized patients should show substantial clinical improvement within 3 to 5 days or require further diagnostic work-up. Patients treated as outpatients should be followed up for 72 hours and after significant clinical improvement. Some experts recommend retesting for N. gonorrhoeae and C. trachomatis 4 to 6 weeks after completing therapy.

Management of Sex Partners:

Sex partners should be referred for evaluation and treatment. Treatment should include coverage for both N. gonorrhoeae and C. trachomatis infections. Sexual intercourse should be avoided until the patient and partner are cured.

HIV Infection:

Patients with HIV infection should be managed aggressively, including hospitalization.

P.777

 

Vaginitis

Etiological Agent

The three diseases most frequently associated with vaginal discharge are the following:

  • Bacterial vaginosis (sometimes incorrectly called nonspecific vaginitis or G. vaginalis-associated vaginitis). Clinical syndrome resulting from replacement of normal vaginal flora with anaerobic bacteria, G. vaginalis,and M. hominis.
  • Trichomoniasis (T. vaginalis)
  • Candidiasis (vulvovaginal candidiasis [VVC]) usually caused by Candida albicans

Other vaginitides (vaginitis caused by other infectious, chemical, allergenic, and physical agents).

Typical Clinical Presentation

Presentations vary from no signs or symptoms to erythema, edema, and pruritus of the external genitalia. Excessive or malodorous discharge is a common finding. Symptoms and clinical findings do not reliably distinguish among etiologies.

Male sex partners may develop urethritis, balanitis, or cutaneous lesions on penis.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

The diagnosis of vaginitis is made by vaginal pH and microscopic examination of fresh samples of the discharge.

  1. vaginalisVaginitis:

Small, punctate cervical hemorrhages called colpitis macularis or strawberry cervix are highly specific for the diagnosis of vaginal trichomoniasis. However, this finding is present on routine speculum examination in fewer than 5% of women. Vaginal pH level is almost always >4.5 and wet mount examination often shows many WBCs.

Bacterial Vaginosis:

The clinical criteria include three of the following:

  • A homogeneous gray or white noninflammatory discharge that adheres to vaginal walls
  • Vaginal pH level >4.5
  • A fishy odor from vaginal fluid before or after addition of 10% potassium hydroxide (KOH)
  • Presence of “clue cells” on microscopic examination

Vulvovaginal Candidiasis:

The presumptive criteria are the typical symptoms of vaginitis or vulvitis and microscopic identification of yeast forms (budding cells or hyphae) in Gram stain or KOH wet mount preparation of vaginal discharge.

Definitive Diagnosis

  1. vaginalisVaginitis:

A vaginal culture, or commercially available test (e.g., detection of T. vaginalis DNA or rapid antigen tests) is positive for T. vaginalis, OR

Typical motile trichomonads are identified in a saline wet mount of vaginal discharge (only 60%–70% sensitive). NAATs are currently under development but are commercially unavailable.

Bacterial Vaginosis:

Gram stain demonstration of few or no lactobacilli, with a predominance of gram-variable rods (likely representing G. vaginalis) plus other organisms resembling gram-negativeBacteroides sp, anaerobic gram-positive cocci, or curved rods.

Vulvovaginal Candidiasis:

Culture may be useful when signs and symptoms are suggestive but when the fungus cannot be identified by direct microscopy. Therapy of apparent treatment failures is best guided by culture.

Therapy

  1. vaginalisVaginitis:

Recommended regimen:

Metronidazole 2 g PO in a single dose, OR

Tinidazole 2 g PO in a single dose.

Alternative regimen:

Metronidazole 500 mg b.i.d. for 7 days.

Both regimens have cure rates of approximately 95%. Metronidazole resistance is reported, but its prevalence is not known. Tinidazole has a longer half-life and reaches higher concentrations in genital fluids and may be useful if metronidazole resistance is suspected. Metronidazole gel is associated with unacceptably high failure rates.

Bacterial Vaginosis:

Recommended Regimen:

Metronidazole 500 mg PO b.i.d. for 7 days, OR

Clindamycin cream 2% one applicator (5 g) intravaginally at bedtime for 7 days, OR

Metronidazole gel 0.75% one applicator (5 g) intravaginally q.d. for 5 days.

Alternative Regimens:

Clindamycin 300 mg PO b.i.d. for 7 days OR

Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days.

P.778

 

Vulvovaginal Candidiasis:

Intravaginal Agents:

Clotrimazole, miconazole nitrate, terconazole, or butoconazole creams or vaginal tablets are recommended. Regimens range from 1 to 14 days of treatment. Several are available for over-the-counter purchase. Some contain oils that may weaken latex condoms.

Oral Agent:

Fluconazole 150-mg tablet in a single dose.

Complications and Sequelae

Secondary excoriations are common.

Recurrent infections are common.

Bacterial vaginosis and trichomoniasis are associated with infectious complications of pregnancy, such as chorioamnionitis and puerperal infection, and with polymicrobial upper genital tract infections in nonpregnant women, such as endometritis and salpingitis. Intravaginal preparations are not recommended during pregnancy.

VVC in pregnancy increases the risk of neonatal oral thrush.

Other Considerations

Pregnant Women

Metronidazole may be used during pregnancy in a single dose of 2 g.

Clindamycin vaginal cream should be avoided during pregnancy.

VVC should be treated with topical azole therapies during pregnancy. Many experts recommend 7 days of therapy.

Follow-up:

Bacterial vaginosis: No follow-up visits are necessary.

Trichomoniasis: Follow-up is unnecessary for patients who become asymptomatic after treatment.

Vulvovaginal candidiasis: Follow-up is unnecessary for patients who respond to therapy.

Management Of Sex Partners

Bacterial Vaginosis: Treatment of partners is not recommended.

Trichomoniasis: Sex partners should be treated and sexual contact should be avoided until the patient and partner are cured.

Vulvovaginal candidiasis: Treatment of sex partners is not routinely warranted unless male sex partner has balanitis.

HIV Infection:

Bacterial vaginosis, trichomoniasis, and VVC: Patients with HIV infection should be managed in the same manner as patients without HIV infection.

P.779

 

Condylomata Acuminata (Genital Warts)

Etiological Agent

Human papillomavirus

More than 130 types have been identified and more than 25 types infect the genital tract. Certain types (usually 6 and 11) cause exophytic benign genital and anal warts. Other types (e.g., 16, 18, 31, 33, and 35 among others) are associated with several types of anogenital carcinomas.

Typical Clinical Presentation

Condylomata acuminata present as single or multiple soft, fleshy, papillary or sessile, painless growths around the anus, vulvovaginal area, penis, urethra, or perineum.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

A diagnosis is made on the basis of the typical clinical presentation.

Colposcopy may also aid in the diagnosis of certain cervical lesions.

Condylomata lata can be excluded by dark-field microscopy or a serological test for syphilis.

Definitive Diagnosis

A biopsy, although usually unnecessary, can make a definitive diagnosis. Atypical lesions, in which neoplasia is a consideration, should be biopsied before initiating therapy.

A Papanicolaou (Pap) smear of cervical lesions shows typical cytological changes of koilocytosis. Direct DNA immunofluorescence staining techniques can diagnose certain types of HPV.

A HC test for detection of high-risk HPV types is now FDA-approved for triage of atypical squamous cells of undetermined significance (ASCUS). Women with ASCUS by Pap smear and a positive HC test result can be further evaluated by colposcopy. The role of HPV screening among women with low-grade squamous intraepithelial lesions is under investigation. Routine HPV screening, for women or for men, is not recommended.

Therapy

The goal of therapy is removal of exophytic warts and alleviation of signs and symptoms, not the eradication of HPV.

External Genital Warts

Patient Applied:

Podofilox 0.5% solution or gel: Apply to visible warts b.i.d. for 3 days, followed by 4 days without therapy. Repeat as necessary up to four cycles. Total area treated should not exceed 10 cm2 and total volume should not exceed 0.5 mL/day.

Imiquimod 5% cream: Apply to visible warts at bedtime, three times per week. Treatment area should be washed with soap and water 6 to 10 hours after application.

Provider Applied:

Cryotherapy with liquid nitrogen or cryoprobe: For vaginal warts, do not use cryoprobe (to avoid perforations), OR

Podophyllin 10% to 25% in compound tincture of benzoin: Wash off in 1 to 4 hours to reduce irritation, OR

Trichloroacetic acid (TCA) or bichloracetic acid 80% to 90%: Weekly for maximum of 6 weeks, OR

Electrodesiccation or electrocautery.

Cervical Warts:

Cervical dysplasia must be excluded before treatment is begun. Management is complicated and should be carried out in consultation with an expert.

Vaginal Warts:

Cryotherapy with liquid nitrogen, TCA, or podophyllin. Podophyllin treatments should be limited to ≤2 cm2 and the treated area should be dry before speculum removal.

Anal or Oral Warts:

Cryotherapy with liquid nitrogen or TCA or surgical removal.

Complications and Sequelae

Lesions may enlarge and produce tissue destruction. Giant condyloma, although histologically benign, may stimulate carcinoma. Cervical lesions are associated with neoplasia.

In pregnancy, warts enlarge, are extremely vascular, and may obstruct the birth canal, necessitating cesarean section delivery.

P.780

 

Other Considerations

Prevention/Immunization:

An effective vaccine against four HPV types (6, 11, 16, 18) is available for females 9 to 26 years of age (see Chapter 66).

Pregnancy:

Use of podophyllin and podofilox are contraindicated. The safety of imiquimod during pregnancy is not established.

Follow-up:

Not necessary after warts have responded to therapy. Annual cytological screening is recommended for women with or without genital warts.

Management of Sex Partners:

Routine referral of partners for examination and treatment is not recommended. Partners may wish to be treated for clinical lesions. Reinfection from a partner is unusual. Use of condoms reduces (but does not eliminate) transmission to uninfected partners, and may shorten the duration of viral persistence.

HIV Infection:

Patients with HIV may not respond to therapy for HPV, as well as persons without HIV. Cervical dysplasia may progress more rapidly among HIV-infected persons.

P.781

 

Herpes Genitalis

Etiological Agents

HSV types 1 and 2

Typical Clinical Presentation

Single or multiple vesicles appear anywhere on the genitalia. Vesicles spontaneously rupture to form shallow ulcers that may be very painful. Lesions resolve spontaneously without scarring. The first occurrence is termed initial infection (mean duration, 12 days). Subsequent, usually milder, occurrences are termed recurrent infections (mean duration, 4–5 days). The interval between clinical episodes is termed latency. Viral shedding occurs intermittently and unpredictably during latency.

Diagnosis

(Warrants full treatment and follow-up.)

Clinical diagnosis of genital herpes is both insensitive and nonspecific. However, when typical genital lesions are present or a pattern of recurrence has developed, herpes infection is likely. Classic, painful multiple vesicular or ulcerative lesions are often not seen in many infected individuals. While approximately 50% of first-episode cases of genital herpes are caused by HIV-1, most cases of recurrent genital herpes are caused by HSV-2. Therefore, the type of HSV could influence prognosis and counseling. Therefore, the clinical diagnosis of genital herpes should be confirmed by laboratory testing. Both virological and type-specific serological tests for HSV should be available in clinical settings that provide care for individuals.

Virological Tests:

Cell culture is the preferred virological test but the sensitivity of culture is low, especially in recurrent lesions. Polymerase chain reaction (PCR) assays for HSV DNA are more sensitive but are not yet FDA-cleared for genital specimens. Viral culture isolates should be typed for HSV-1 or HSV-2.

Type-Specific Serological Tests:

Accurate type-specific HSV serological assays should be used and are based on the HSV-specific glycoprotein G2 (HSV-2) and G1 (HSV-1). The newer type-specific glycoprotein G (gG)-based assays should be requested. HSV-2 positivity generally implies a genital infection whereas HSV-1 positivity is difficult to interpret because most are related to oral infections. Sensitivities range from 80% to 98% for HSV-2 antibody and >96% for specificity. These tests might be useful in:

  • Recurrent genital symptoms or atypical symptoms with negative HSV cultures
  • A clinical diagnosis of genital herpes without laboratory confirmation
  • A partner with genital herpes

Therapy

First Clinical Episode Of Genital Herpes:

Acyclovir 400 mg PO t.i.d. for 7 to 10 days, OR

Acyclovir 200 mg PO 5 times daily for 7 to 10 days, OR

Famciclovir 250 mg PO t.i.d. for 7 to 10 days, OR

Valacyclovir 1 g PO b.i.d. for 7 to 10 days.

Treatment may be extended if healing is incomplete after 10 days of therapy.

First Clinical Episode of Herpes Proctitis:

Acyclovir 400 mg PO 5 times a day for 10 days or until clinical resolution is attained.

Famciclovir and valacyclovir may also be effective, but clinical experience is lacking.

Episodic Treatment of Recurrent Episodes of Genital Herpes and Herpes Proctitis:

When treatment is started during prodrome or within 1 day of onset of lesions, many patients experience shortened duration of symptoms.

Acyclovir 400 mg PO t.i.d. for 5 days, OR

Acyclovir 800 mg PO b.i.d. for 5 days, OR

Acyclovir 800 mg t.i.d. for 2 days, OR

Famciclovir 125 mg PO b.i.d. for 5 days, OR

Famciclovir 1,000 mg PO twice daily for 1 day OR

Valacyclovir 500 mg PO b.i.d. for 3 days, OR

Valacyclovir 1.0 g PO once a day for 5 days.

Daily Suppressive Therapy of Genital Herpes and Herpes Proctitis:

Daily suppressive therapy can reduce frequency of HSV recurrences by at least 75% with patients with six or more recurrences per year. Suppressive therapy reduces viral shedding and reduces risk of transmission to partners.

Acyclovir 400 mg PO b.i.d., OR

Famciclovir 250 mg PO b.i.d., OR

Valacyclovir 500 mg PO once a day, OR

Valacyclovir 1.0 g PO once a day

Complications and Sequelae

Neuralgia, meningitis, ascending myelitis, urethral strictures, and lymphatic suppuration may occur.

Neonates:

Virus from an active genital infection may be transmitted during vaginal delivery, causing neonatal herpes infection, which has a high case fatality rate, and many survivors have ocular or neurological sequelae.

P.782

 

Other Considerations

Pregnant Women:

The safety of systemic acyclovir, valacyclovir, and famciclovir during pregnancy has not been established. Available data do not indicate increased risk of birth defects among women receiving acyclovir during the first trimester.

Counseling:

Counseling of infected persons and their sex partners is critical. All persons with genital HSV should be strongly encouraged to inform their current and future sex partners that they have genital herpes. Individuals need to be aware of asymptomatic shedding, about potential decreased risk of transmission through use of antivirals, the protective effects of condoms, the possibility of acquisition by partners even if partners do not develop symptoms, and the risk of neonatal transmission.

Management of Sex Partners:

Patients should abstain from sexual activity while lesions are present. Sexual transmission of HSV can occur during periods without evidence of lesions. The use of condoms should be encouraged during all sexual contact. Sex partners may require evaluation and counseling.

HIV Infection:

HSV lesions are common among HIV-infected patients. Intermittent or suppressive therapy with oral acyclovir may be required.

P.783

 

Syphilis

Etiological Agent

Treponema pallidum

Typical Clinical Presentation

Primary:

The classic chancre is painless, indurated, and located at the site of exposure. Genital chancres are often accompanied by tender inguinal lymphadenopathy.

Secondary:

Patients may have a macular, maculopapular, or papulosquamous skin rash. Other signs include mucous patches and condylomata lata.

Tertiary:

Patients have cardiac, neurological, ophthalmic, auditory, or gummatous lesions.

Latent:

Patients are without clinical signs.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

Presumptive diagnosis relies on both nontreponemal serological tests for syphilis (STS) (e.g., Venereal Disease Research Laboratories or rapid plasma reagin) and treponemal tests (fluorescent treponemal antibody-absorption, T. pallidum particle agglutination (TP-PA), and enzyme immunoassays). Nontreponemal test antibody titers usually correlate with disease activity, and decline with therapy.

Primary:

Patients have typical lesions and either a newly positive STS or STS titer at least fourfold greater than the last, or syphilis exposure within 90 days of lesion onset.

Secondary:

Patients have the typical clinical presentation and a strongly reactive STS.

Latent:

Patients have serological evidence of untreated syphilis without clinical signs.

HIV-infected patients:

When clinical findings indicate presence of syphilis but serological test results are negative, alternative tests, such as biopsy, dark-field examination, and DFA staining of lesion material, should be employed.

Definitive Diagnosis

Demonstration of characteristic spirochetes with dark-field microscopy of serous transudate from genital lesions. DFA of material from a chancre, regional lymph node, or other lesion.

Therapy

Primary and Secondary Syphilis:

Penicillin G benzathine 2.4 million units IM in a single dose

For penicillin-allergic patients

Doxycycline 100 mg PO b.i.d. for 2 weeks, OR

Tetracycline 500 mg PO q.i.d. for 2 weeks.

Ceftriaxone 1 g IM or IV daily for 8 to 10 days.

Note: The optimal dose and duration of treatment have not been established. Some penicillin-allergic patients are also allergic to ceftriaxone.

Azithromycin 2.0 g PO in a single oral dose.

Note: Some areas have noted rapid emergence of resistant T. pallidum strains, suggesting need for careful clinical and serological follow-up if this regimen is used.

Latent Syphilis:

Early latent (<1 year) syphilis: Penicillin G benzathine, 2.4 million units IM in a single dose.

Late latent (>1 year) syphilis or latent syphilis of unknown duration: Penicillin G benzathine, 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.

Late Syphilis:

Patients with gumma or cardiovascular syphilis but not neurosyphilis: Penicillin G benzathine, 7.2 million units total, administered as three doses of 2.4 million units IM at 1-week intervals.

Neurosyphilis:

Recommended regimen: Aqueous crystalline penicillin G, 18 to 24 million units daily, administered as 3 to 4 million units IV q4h for 10 to 14 days.

Alternative regimen: 2.4 million units procaine penicillin IM daily, plus probenecid 500 mg PO q.i.d., both for 10 to 14 days.

Complications and Sequelae

Both late syphilis and congenital syphilis are complications, because they are preventable with prompt diagnosis and treatment of early syphilis. Sequelae of late syphilis include neurological complications (general paresis, tabes dorsalis, and focal neurological signs), cardiovascular syphilis (thoracic aortic aneurysm, aortic insufficiency), and localized gumma formation.

P.784

 

Other Considerations

Pregnant Women:

Pregnant women should receive the same therapy as listed earlier, except that tetracycline, doxycycline, and erythromycin should not be used. Pregnant women with a history of penicillin allergy should be skin tested, desensitized if allergy is documented, and then treated with penicillin.

Follow-up:

Patients should be reexamined clinically and serologically at 3 and 6 months for primary and secondary syphilis and at 6 and 12 months for latent syphilis. STS results become negative or reactive only in low titers (<1:8) in most successfully treated patients.

Management of Sex Partners:

Persons exposed to a patient with primary, secondary, or early latent syphilis within 90 days should be treated presumptively. Those exposed >90 days should be treated presumptively if serological tests are not available immediately or follow-up is uncertain. Partners considered at risk are those exposed within 3 months plus duration of symptoms for primary syphilis, within 6 months plus duration of symptoms for secondary syphilis, and within 1 year for early latent syphilis.

HIV Infection:

Unusual serological response may occur in HIV-infected persons. Penicillin regimens should be used whenever possible. Some authorities recommend cerebrospinal fluid examination or treatment with a regimen appropriate for neurosyphilis for all patients coinfected with syphilis and HIV. Patients should be followed up clinically and serologically at 1, 2, 3, 6, 9, and 12 months after therapy.

P.785

 

Chancroid

Etiological Agent

Haemophilus ducreyi

A gram-negative bacillus with rounded ends, commonly observed in small clusters along strands of mucus. On culture, the organism tends to form straight or tangled chains.

Typical Clinical Presentation

Usually a single (but sometimes multiple), superficial, painful ulcer surrounded by an erythematous halo. Ulcers may also be necrotic or severely erosive with ragged serpiginous borders. Accompanying adenopathy is usually unilateral. A characteristic inguinal bubo occurs in 25% to 60% of cases.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

Chancroid is the third most common sexually transmitted cause of genital ulcer in the United States, although it is far less frequently seen than genital herpes or primary syphilis. Presumptive diagnosis depends on a clinically consistent lesion, a negative dark-field examination of lesion fluid, and absence of serological evidence of syphilis.

Definitive Diagnosis

Culture identification of H. ducreyi. No FDA-cleared PCR test of H. ducreyi is available in the United States, but such testing can be performed by clinical laboratories that have developed their own PCR test and conducted a Clinical Laboratory Improvement Amendments (CLIA) verification study.

Therapy

Recommended Regimens:

Azithromycin 1 g PO in a single dose, OR

Ceftriaxone 250 mg IM in a single dose, OR

Ciprofloxacin 500 mg PO b.i.d. for 3 days, OR

Erythromycin base 500 mg PO t.i.d. for 7 days.

Complications and Sequelae

Systemic spread is not known to occur.

Lesions may become secondarily infected and necrotic.

Bubo may rupture and suppurate, resulting in fistulae.

Ulcers on the prepuce may cause paraphimosis or phimosis.

Other Considerations

Pregnant Women:

Safety of azithromycin during pregnancy has not been established. Ciprofloxacin is contraindicated during pregnancy.

Follow-up:

Successfully treated ulcers clinically improve by 7 days after institution of therapy. If the condition does not improve, the clinician should consider whether antimicrobials were taken as prescribed; the H. ducreyi is resistant to the prescribed antimicrobial; the diagnosis is correct; there is a coinfection with another STD; or the patient is infected with HIV.

Management of Sex Partners:

Partners who had contact within 10 days before the onset of symptoms should be examined and treated.

HIV Infection:

Patients with HIV infections should be closely monitored and may require longer courses of therapy.

P.786

 

Lymphogranuloma Venereum

Etiological Agent

  1. trachomatis

An obligate intracellular organism of serovars L1, L2, or L3.

Typical Clinical Presentation

The primary lesion of lymphogranuloma venereum (LGV) is a 2- to 3-mm painless vesicle or nonindurated ulcer at the site of inoculation. Patients commonly fail to notice this primary lesion. Regional adenopathy, typically unilateral, follows a week to a month later and is the most common clinical presentation.

Sensation of stiffness and aching in the groin, followed by swelling of the inguinal region, may be the first indications of infection in most patients. Adenopathy may subside spontaneously or proceed to the formation of abscesses that rupture to produce draining sinuses or fistulae.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

The LGV complement-fixation test result is typically positive, with titers of 1:64 or higher. Cross-reactions due to other chlamydial infections may be misleading. Because the sequelae of LGV are serious and preventable, treatment should be provided pending laboratory confirmation.

Definitive Diagnosis

A definitive diagnosis requires isolation of C. trachomatis from an appropriate specimen and confirmation of the isolate as an LGV immunotype. However, such laboratory diagnostic capabilities are not widely available.

Therapy

Recommended regimen:

Doxycycline 100 mg PO b.i.d. for 21 days.

Alternative regimen:

Erythromycin 500 mg PO q.i.d. for 21 days.

Complications and Sequelae

Dissemination may occur with nephropathy, hepatomegaly, or phlebitis.

Large polypoid swellings of the vulva, anal margin, or rectal mucosa may occur.

The most common severe morbidity results from rectal involvement; perianal abscess and rectovaginal or other fistulae are early consequences, and rectal stricture may develop 1 to 10 years after infection.

Other Considerations

Pregnant Women:

Pregnant patients should be treated with the erythromycin regimen.

Follow-up:

Patients should be followed up clinically until signs and symptoms have resolved.

Management of Sex Partners:

Persons having had sexual contact with a patient who has LGV within 30 days before onset of the patient's symptoms should be examined and treated.

HIV Infection:

Patients with HIV infection are managed in the same manner as patients without HIV infection.

P.787

 

Molluscum Contagiosum

Etiological Agent

Molluscum contagiosum virus

The largest DNA virus of the poxvirus group.

Typical Clinical Presentation

Both sexual and nonsexual transmission modes are likely. Lesions are 1 to 5 mm, smooth, rounded, shiny, firm, and flesh-colored to pearly white papules with umbilicated centers. They are most commonly seen on the trunk and anogenital. Itching or tenderness is occasionally noted but most patients are asymptomatic. Extensive skin involvement is seen in immunocompromised hosts, particularly in those with advanced HIV disease. Dissemination does not occur.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

Usually diagnosed on the basis of the typical clinical presentation.

Definitive Diagnosis

Microscopic examination of lesions or lesion material reveals the pathognomonic molluscum inclusion bodies.

Therapy

Lesions resolve spontaneously; most within 2 months. However, they may be removed by curettage after cryoanesthesia.

Caustic chemicals (podophyllin, TCA, silver nitrate) and cryotherapy (liquid nitrogen) have been used successfully. Self-applied podophyllotoxin may also be effective. Recurrence is reported in 15% to 35% of cases.

Complications and Sequelae

Secondary infection, usually with Staphylococcus, occurs.

Lesions rarely attain a size >10 mm in diameter.

Other Considerations

Pregnant Women:

Podophyllin should be avoided during pregnancy.

Follow-up:

Patients should return for evaluation 1 month after treatment so any new lesions can be removed.

Management of Sex Partners:

Sex partners should be examined.

HIV Infection:

Patients with HIV infection should be managed in the same manner as patients without HIV infection.

P.788

 

Pediculosis Pubis

Etiological Agent

Pthirus pubis (pubic or crab louse)

A grayish ectoparasite that is 1 to 4 mm long with segmented tarsi and claws for clinging to hairs.

Typical Clinical Presentation

Symptoms range from slight discomfort to intolerable itching. Erythematous papules, nits, or adult lice clinging to pubic, perineal, or perianal hairs are present and often noticed by patients.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

A presumptive diagnosis is made when a patient with a history of recent exposure to pubic lice has pruritic, erythematous macules, papules, or secondary excoriations in the genital area.

Definitive Diagnosis

A definitive diagnosis is made by finding lice or nits attached to genital hairs.

Therapy

Recommended Regimens:

Permethrin 1% creme rinse applied to affected areas and washed off after 10 minutes, OR

Pyrethrins with piperonyl butoxide applied to the infested area and washed off after 10 minutes.

Alternative Regimens

Malathion 0.5% lotion applied for 8 to 12 hours and then thoroughly washed off, OR

Ivermectin 250 µg/kg by mouth, repeated in 2 weeks.

Owing to increased risk of neurotoxicity, lindane should be used only if other treatments are not tolerated or have failed.

The recommended regimens should not be applied to the eyes. Involvement of the eyelashes should be treated by applying occlusive ophthalmic ointment to the eyelid margins b.i.d. for 10 days.

Clothing and linen should be disinfected by washing them in hot water, by dry cleaning them, or by removing them from human exposure for at least 72 hours.

Complications and Sequelae

Secondary excoriations; lymphadenitis; pyoderma

Other Considerations

Pregnant Women:

Lindane is contraindicated in pregnant or lactating women.

Follow-up:

Patients should be evaluated after 1 week if symptoms persist. If lice are found or if eggs are observed at the hair-skin junction, re-treatment may be necessary. Increasing resistance of lice to permethrin is reported in some studies and may account for treatment failures.

Management of Sex Partners:

Sex partners within the last month should be treated.

HIV Infection:

Patients with HIV infection are managed in the same manner as patients without HIV infection.

P.789

 

Scabies

Etiological Agent

Sarcoptes scabiei

The female organism is 0.3 to 0.4 mm; the male is somewhat smaller. The female burrows under the skin to deposit eggs.

Typical Clinical Presentation

Symptoms include itching, often worse at night, and the presence of erythematous, papular eruptions. Excoriations and secondary infections are common. Reddish-brown nodules are caused by hypersensitivity and develop 1 or more months after infection has occurred. The primary lesion is the burrow. When not obliterated by excoriations, burrows are usually seen on the fingers, penis, and wrists.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

The diagnosis is often made on clinical grounds alone. Exposure to a person with scabies within the previous 2 months supports the diagnosis.

Definitive Diagnosis

Definitive diagnosis is made by microscopic identification of the mite or its eggs, larvae, or feces in scrapings from an elevated papule or burrow.

Therapy

Recommended Regimen:

Permethrin cream 5% applied to all areas of the body from the neck down and washed off after 8 to 14 hours, OR

Ivermectin 200 µg/kg orally, repeated in 2 weeks.

Alternative Regimens:

Lindane (1%) 1 oz of lotion or 30 g of cream applied thinly to all areas of the body from the neck down and washed off thoroughly after 8 hours.

Lindane should not be used after a bath and should not be used by persons with extensive dermatitis, pregnant or lactating women, and children younger than 2 years. Not recommended for pregnant or lactating women, or infants and young children. Lindane should be used only if other treatments fail or are not tolerated.

Complications and Sequelae

Secondary bacterial infection occurs, particularly with nephritogenic strains of streptococci. Norwegian or crusted scabies (with up to 2 million adult mites in the crusts) is a risk for patients with neurological defects and for the immunologically compromised.

Other Considerations

Pregnant Women:

Lindane is contraindicated in pregnant or lactating women.

Follow-up:

Pruritus may persist for several weeks. Re-treatment should be considered in patients who are symptomatic after 1 week, particularly if live mites are observed.

Management of Sex Partners:

Sex partners and close personal or household contacts within the last month should be examined and treated.

HIV Infection:

Patients with HIV infection are managed in the same manner as patients without HIV infection.

P.790

 

Hepatitis B

Etiological Agent

Hepatitis B virus (HBV)

A DNA virus with multiple antigenic components.

Sexual transmission accounts for an estimated one third to two thirds of the estimated 200,000 to 300,000 new HBV infections that occur annually in the United States.

Typical Clinical Presentation

Hepatitis B is clinically indistinguishable from other forms of hepatitis. Most infections are clinically inapparent. Clinical symptoms and signs include various combinations of anorexia, malaise, nausea, vomiting, abdominal pain, and jaundice. Skin rashes, arthralgias, and arthritis can also occur.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

HBV infection is clinically indistinguishable from other forms of viral hepatitis and many times from hepatitis caused by toxins or drugs. The diagnosis should be considered in a symptomatic patient with symptoms suggestive of an acute viral illness and with an occupational exposure or sexual history that places the patient in a high-risk group.

Groups at high risk of acquiring infection include immigrants or refugees from areas of high HBV endemicity, patients in institutions for the mentally retarded, persons with multiple sex partners, users of illicit parenteral drugs, men who have sex with men, household contacts of HBV carriers, and patients of hemodialysis units.

Definitive Diagnosis

Serodiagnosis of HBV infection is the only method for clinicians to reach a definitive diagnosis. A positive result for hepatitis B surface antigen (HBsAg) indicates active infection with HBV, either acute hepatitis B or the chronic carrier state. Hepatitis B e antigen (HBeAg) correlates with infectivity. Antibody to HBsAg (anti-HBs) usually indicates past infection with present immunity.

Therapy

No specific therapy is available for the various types of acute hepatitis, whether sexually transmitted or not. Vaccination for hepatitis B is recommended for:

  • All infants
  • All unvaccinated children and adolescents through age 18
  • All previously unvaccinated adults at increased risk for infection such as those with multiple sex partners within the past 6 months, intravenous drug users, men and women diagnosed as having recently acquired another STD, and residents of correctional or long-term care facilities
  • In addition, immunoprophylaxis of infants born to HBsAg-positive mothers or infants born to mothers with unknown HBsAg status

For immunization recommendations, refer to Chapter 30.

Complications and Sequelae

Long-term sequelae include chronic persistent and chronic active hepatitis, cirrhosis, hepatocellular carcinoma, hepatic failure, and death. Rarely, the course may be fulminant with hepatic failure, resulting in early death. Infectious chronic carriers may be completely asymptomatic.

Other Considerations

Oral contraceptives are contraindicated for women with active hepatitis.

Pregnant Women:

Pregnancy is not a contraindication to HBV or hepatitis B immune globulin (HBIG) vaccine administration.

Management of Sex Partners:

Susceptible persons who have been exposed to HBV through sexual contact with a person who has acute or chronic HBV infection should receive postexposure prophylaxis. This should include 0.06 mL/kg of HBIG in a single IM dose within 14 days of their last exposure. This should be followed with the standard three-dose immunization series with HBV vaccine.

HIV Infection:

Patients with HIV infection who have HBV are more likely to develop a chronic HBV state. HIV infection may also impair the response to HBV vaccine. HIV-infected persons should be tested for anti-HBs 1 to 2 months after the third vaccine and those who have not responded should be revaccinated with one or more doses.

P.791

 

Enteric Infections

Etiological Agent

Proctitis: N. gonorrhoeae, C. trachomatis, T. pallidum, and HSV.

Proctocolitis: Campylobacter sp. Shigella sp. Entamoeba histolytica, and rarely C. trachomatis.

Enteritis: Giardia lamblia. Among HIV-infected patients, others include cytomegalovirus (CMV), Mycobacterium avium-intracellulare, Salmonella sp, Cryptosporidium, microsporidia, and Isospora.

These are particularly common among persons who participate in anal intercourse (proctitis) or whose sexual practices include oral-fecal contact (enteritis).

Typical Clinical Presentation

Infections are frequently asymptomatic or minimally symptomatic. Symptoms include the following:

Proctitis:

Anorectal pain, tenesmus, and rectal discharge.

Proctocolitis:

Symptoms of proctitis plus diarrhea or abdominal cramps.

Enteritis:

Diarrhea and abdominal cramping.

Presumptive Diagnosis

(Warrants full treatment and follow-up.)

The typical clinical findings suggest enteric infection. Examination of a fresh stool specimen can be helpful. The finding of WBCs on direct microscopy of a suspension of fresh stool or the finding of occult or grossly bloody stools supports the diagnosis.

Definitive Diagnosis

Definitive diagnostic tests vary according to the agent and site of infection involved.

Therapy

Treatment of proctitis and enteritis should be based on etiological diagnosis. Some asymptomatic infected individuals for whom anal-oral contact is a sexual practice should be treated in accordance with recommendations for symptomatic individuals, as should persons whose work or social situation is associated with a likelihood of infection transmission (e.g., food handlers, hospital workers, day-care center employees). Until laboratory test results are available, persons with acute proctitis who have recently practiced receptive anal intercourse and have either anorectal pus on examination or PMN leukocytes on a Gram stain should receive treatment for anogenital gonorrhea and doxycycline (100 mg PO b.i.d. for 7 days).

Complications and Sequelae

Complications and sequelae vary with the disease agent, health of the host, therapy, and other factors. Spontaneous cures are common. Morbidity may be severe, requiring hospitalization and intravenous hydration. Infections may become systemic (such as gram-negative septicemia) or distantly localized (amebic hepatic cyst). Some infections may be rarely fatal (hepatitis A, disseminated bacterial disease).

Other Considerations

Follow-up:

Follow-up should be based on severity of clinical symptoms and specific etiological agent involved.

Management of Sex Partners:

Sex partners should be evaluated for any diseases diagnosed in the index patient.

HIV Infection:

Patients with HIV infection should be managed in the same manner as patients without HIV infection. HIV-infected patients are at risk for infections not commonly found in non-HIV–infected patients.

P.792

 

Human Immunodeficiency Virus Infections and Acquired Immunodeficiency Syndrome

Etiological Agent

HIV-1 or HIV-2

HIV-1 and HIV-2 are members of one of seven genera of retroviruses.

Typical Clinical Presentation

The range of symptoms associated with HIV infection extends from an acute illness shortly after infection to the full clinical syndrome of acquired immunodeficiency syndrome (AIDS). Acute HIV infection includes a mononucleosis-like syndrome consisting of headache, myalgia, sore throat, rash, diarrhea, fever, and lymphadenopathy. The acute HIV retroviral syndrome is reported 1 to 3 weeks after initial infection and resolves within a few weeks. This is a period of high levels of viral replication and viremia, with great potential for transmission. A latent or asymptomatic stage, lasting from a year to a decade or more, often follows. Disease progression appears inevitable, with ongoing destruction of the host immune system, followed by wasting and weight loss, symptoms specific to opportunistic infections (e.g., shortness of breath and cough from Pneumocystis carinii pneumonia Pneumonia [PCP] infection), or purple to bluish skin lesions associated with Kaposi sarcoma. Virtually all organ systems are affected by advanced HIV disease.

Presumptive Diagnosis

Presumptive diagnosis of HIV infection is made usually by clinical evidence, supported by tests for antibodies to HIV infection. Screening tests are based on enzyme immunoassay, with positive results confirmed by immunoblot (Western blot). Rapid serological tests are now available that provide results within 15 to 30 minutes, although these tests always require confirmation by immunoblot. Screening may also be done with whole blood, saliva, or urine. These tests increase the ease of screening, but their results should be confirmed by immunoblot. Clinicians and patients should keep in mind that the median time between infection and confirmed seropositivity is 3 months and may be as long as 6 months. Retesting is recommended when suspicion is high, particularly when the clinical presentation is consistent with the acute HIV syndrome.

Definitive Diagnosis

Currently, isolation of the virus from body fluids is the most highly specific means to make a definitive diagnosis of HIV infection. Only very few research laboratories have the technology to perform viral isolation. Results from reactive enzyme immunoassay tests, confirmed by immunoblot (Western blots) or other confirmatory tests, are considered diagnostic. Indeterminate test results are usually resolved by retesting, combined with examination of the pattern of the indeterminate Western blot and a careful risk-assessment interview.

Therapy

To date, no treatments eradicate either HIV-1 or HIV-2. A number of antiretroviral drugs are used to limit viral replication, restore immunocompetence, and delay onset of AIDS-related illness.

Acute Retroviral Syndrome

Immediate initiation of antiretroviral treatments improves prognosis of HIV-related infection. The optimal regimen is not known. Single-drug therapy with zidovudine may be effective, but many experts recommend two nucleoside reverse-transcriptase inhibitors and a protease inhibitor. Antiretroviral therapy is central to the treatment of HIV disease. Three classes of antiretroviral agents are available and are typically used in combination. Therapy can be monitored with highly sensitive viral load assays. Tuberculin skin testing, review of vaccination status, provision of pneumococcal and influenza vaccines, and STS are all important aspects of comprehensive therapy. PCP prophylaxis with trimethoprim-sulfamethoxazole, dapsone, or aerosolized pentamidine should be instituted for adolescents and adults with <200 CD4+ T cells/mL, or after an initial episode of PCP. Prophylaxis should be continued for the lifetime of the patient. Prophylaxis for individuals seropositive for Toxoplasma gondii and CD4+ counts <100 T cells/mL includes trimethoprim-sulfamethoxazole, or dapsone with pyrimethamine.

Complications and Sequelae

Most people with HIV will eventually have symptoms related to the infection. Aggressive antiretroviral therapy improves disease-free survival, but relapse is expected when therapy is stopped. In many HIV-infected persons it may be years, even decades, before there is a development of AIDS-related condition.

Other Considerations

Management of Sex Partners:

Sex partners should be notified either by their partners or through a referral to health department partner-notification programs. Partners should receive counseling and testing.