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8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 1/15
15-01-2015
1
Yasmin ElSobky, BCPS
Herpes Simplex Virus (HSV) Infection
Genital Herpes
Herpes Encepha
litis
Yasmin ElSobky, BCPS
Yasmin ElSobky, BCPS
After the primary infection, the virus is latent in the sacral dorsal root ganglia.
From 50% to 80% of patients have recurrent infections
(generally less severe and of shorter duration).
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 2/15
15-01-2015
2
Symptoms:
Itching
Genital burning
Ulcer formation
Vesicle formation
Yasmin ElSobky, BCPS Yasmin ElSobky, BCPS
Treatment can partly control symptoms
but does not affect the risk, frequency, or severity
of recurrences.
Drug Dose Frequency Duration
Initial HSV
infection
Acyclovir
Acyclovir
Famciclovir
Valacyclovir
200 mg orally
400 mg orally
250 mg orally
1 g orally
Five ti mes daily
three times daily
three times daily
twice daily
for 7 days
for 7–10 days
for 7–10 days
for 7–10 days
Recurrent HSV
infection
If treatment is initiated within 1 day of lesion onset,
patients with recurrent infections may benefit.
Acyclovir
Acyclovir
Famciclovir
Famciclovir
Famciclovir
Valacyclovir
Valacyclovir
400 mg orally
800 mg orally
125mg orally
500m g orally once
Then 250mg Orally
1000mg orally
500m g orally
1000mg/day Orally
three times daily
Five ti mes daily
Twice daily
Once then
Twice daily
Twice daily
Twice daily
once
for 5 days
for 2 days
for 5 days
For 2 days
For 1 day
For 3 days
For 5 days
Daily
suppressive
therapy
≥ 6
episodes/year
recommended in patients with six or more episodes yearly
(reassess annually the need for suppressive therapy)
Acyclovir
Famciclovir
Valacyclovir
Valacyclovir
400 mg orally
250 mg orally
500 mg orally
1 000mg orally
Twice daily
Twice daily
Once daily
Once daily
DailyYasmin ElSobky, BCPS
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 3/15
15-01-2015
3
Herpes Encephalitis
Primarily caused by HSV-1
Spreads through neural routes during Primary infection or
Recurrent infection
Primarily temporal lobe involvement with eventual hemorrhagic
encephalitis
High mortality i f untreated
and frequent neurologic sequelae
Yasmin ElSobky, BCPS Yasmin ElSobky, BCPS
CSF Analysis Report
WBC: Moderate Pleocytosis
(lymphocytosis)
Glucose: Normal
Protein: Elevated
Diagnosis of Herpes Encephalitis
1. Presence of Sign and symptoms
2. CSF analysis
3. Brain biopsy (rarly performed)
Yasmin ElSobky, BCPS
Herpes encephalitis Therapy:
Acyclovir IV 5–10 mg/kg q8 h for 2–7 days,
followed by oral antiviral therapy for at least 10
days of total therapy
Yasmin ElSobky, BCPS
When symptoms resolve shift to oral
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 4/15
15-01-2015
4
Yasmin ElSobky, BCPS
Types Description Symptoms
Primary
syphilis
From 10 to 90
days after
exposure
(mean = 21
days)
The primary symptom
is the development of achancre.
It resolves
spontaneously in 2–6
weeks even without
treatment.
Secondarysyphilis/
Early
latentsyphilis
From 4 to 10weeks after
exposure Skin lesions:
Characteristically on
the palms and soles
Latent phase begins
when all symptoms
have resolved.
Late latent
syphilis
(more than 1
year in
duration) orunkn duration:
Tertiary
syphilis
Infectious granulomas
cardiovascular effects:-Aortic insufficiency
-Aortitis
N
e u r o s y p h i l i s At any stage Personality
change (cognitive
and/or behavioral
impairment) - 33%
Ataxia - 28%
Stroke - 23% Yasmin ElSobky, BCPS
Infectious granulomas and
cardiovascular effects:
Aortic insufficiency and aortitis
3ry Syphilis
Skin lesion
Yasmin ElSobky, BCPS Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 5/15
15-01-2015
5
Yasmin ElSobky, BCPS Yasmin ElSobky, BCPS
Type s D esc ription Symptoms Re commended treatment Penic illin alle rgy
Primary
syphilis
From 10 to 90
days after
exposure
(mean = 21
days)
The primary symptom
is the development of a
chancre.
It resolves
spontaneously in 2–6
weeks even without
treatment.
Benzathine penicillin G
2.4 million units IM
in a single dose (adults)
If penicillin allergy:
Doxycycline orally bid
or tetracycline500 mg four
times daily for 2 weeks
Secondary
syphilis/
Early
latent
syphilis
From 4 to 10
weeks after
exposure Skin lesions:
Characteristically on
the palms and solesLatent phase begins
when all symptoms
have resolved.
Late latent
syphilis
(more than 1
year in
duration) or
unkn duration:
Benzathine penicillin G
2.4 million units IM every weekfor 3 weeks
(total dose 7.2 million units)
If penicillin allergy:
Doxycycline bidor tetracycline500 mg four
times daily for 4 weeksTertiary
syphilis
Infectious granulomas
cardiovascular effects:-Aortic insufficiency
-Aortitis
N e u r o s y p h i l i s At any stage Personality change
(cognitive and/or
behavioral impairment) -
33%
Ataxia - 28%
Stroke - 23%
Aqueous crystalline penicillin G
3–4 million units I V q4h or continuous
inf. 10–14 days
Alternative regimen
Procaine penicillin 2.4 million
units/day IM plus probenecid
four times daily for 10–14 days
If penicillin allergy:
Ceftriaxone 2 g/day IM/IV
for 10–14 days or
patients should bedesensitized& given
penicillin(see CDC recommendations for
skin testing &desensitization)Yasmin ElSobky, BCPS
Treatment of sexual partners
a. Sexual partners should be presumptively treated if exposed
within 90 days preceding the diagnosis in their partner.
b. If exposure occurred more than 90 days prior, sexual partners
should be tested and monitored closely or treated presumptively
if serologic test results are not available immediately.
Syphilis
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 6/15
15-01-2015
6
Yasmin ElSobky, BCPS
Can lead to
•PID,
•Ectopic pregnancy
•Infertility
Yasmin ElSobky, BCPS
Less dysuriaand
Less penile discharge in men
compared with gonococcal infection
Chlamydial TreatmentDrug Of choice (DOC)
Alternatives
Erythromycin
Levofloxacin
Ofloxacin
Diagnosis:
Chlamydial infection
Rx:Azithromycin 1G
orDoxycycline for 7 days
Yasmin ElSobky, BCPS
Abstain from sexual intercourse for at least 7 days
and until sexual partners are adequately treated.
All sexual partners within the past 60 days should be
assessed and treated .
Chlamydial infection
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 7/15
15-01-2015
7
Yasmin ElSobky, BCPS
women are often asymptomatic
(which can lead to PID);
symptoms in women include
Vaginal discharge
Dysuria
Penile discharge and
dysuria common in men,
Yasmin ElSobky, BCPS
Site of infection Gonococcal Treatment
Infections of cervix,
urethra & rectum
Ceftriaxone 250mgIM or
cefixime** 400mg Oral+
treatment of chlamydiaif not ruled out
Infection of PharynxCeftriaxoneonly (not cefixime ) +
treatment of chlamydia
Cephalosporin
allergy
Azithromycin 2G Oral
(GI side effects, resistance increasing )
test for cure in 1 week
Chlamydial infection
Rx:Azithromycin 1G
orDoxycycline for 7 days
**New in 2012 – Alternative if ceftriaxone not an optionYasmin ElSobky, BCPS
Abstain from sexual intercourse for at least 7 days
and until sexual partners are adequately treated.All sexual partners within the past 60 days should
be assessed and treated.
Gonococcal infection
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 8/15
15-01-2015
8
Urethritis
Yasmin ElSobky, BCPS
Chlamydial infection Gonococcal infection
Symptoms of UrethritisSymptoms in Women
Some signs of urethritis in women include:
•
More frequent urge to urinate•Discomfort during urination
•Pain in the abdominal area
•Fever (chills)
•An abnormal vaginal discharge
Symptoms in Men
Males with urethritis may experience the
following symptoms:
• Burning sensation while urinating
•Itching or burning near the penis opening
•The presence of blood
in semen and/or urine
Yasmin ElSobky, BCPS
Urethritis Treatment
Undiagnosed Treatfor Chlamydia and Gonococcus
Nongonococcal Treat for Chlamydia ONLY
Recurrent or persistent
Ensure adherence &
NO reinfection from infected partner
Then
Treat for trichomonas vaginalis&
azithromycin (not doxycycline)
Yasmin ElSobky, BCPS
All sexual partners within the past 60 daysshould be assessed and treated.
Urethritis infection
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 9/15
15-01-2015
9
Trichomoniasis
(Trichomonas vaginalis)
Yasmin ElSobky, BCPS
Asymptomatic
Vaginal discharge
(Malodorous)
Vaginal irritation
Trichomoniasis symptoms
Yasmin ElSobky, BCPS
Trichomoniasis Treatment
DOCMetronidazole 2G (Single)
Tinidazole2G (Single)
AlternativeregimenMetronidazole 500mg 2 times/day for
7 days
Metronidazole-allergic patients Patient should be desensitized
Yasmin ElSobky, BCPS
•Pelvic inflammatory diseases•Bacterial Vaginosis
•Vulvovaginal Candidiasis
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
http://slidepdf.com/reader/full/cdc-std-yasmin-cdc-final 10/15
15-01-2015
10
Yasmin ElSobky, BCPS
PID Clinical PresentationClinical presentation
a. Lower abdominal tenderness
b. Adnexal tenderness
c. Cervical motion tenderness
d. Oral temperature greater than 101°F (38.3)
e. Abnormal cervical or vaginal discharge
f. Menorrhagia
g. Dysuria
Lab Investigation:
Elevated ESR erythrocyte sedimentation rate
Elevated CRP C-reactive protein
Abscess in pelvic or fallopian tubes, tubal
occlusion, fibrosis, infertilityYasmin ElSobky, BCPS
PID
Anaerobes
Neisseria gonorrhoeae
Chlamydia trachomatis
gram-ve facultat ive bacteria
Streptococci
C a u s e d b
y
Yasmin ElSobky, BCPS
Parenteral treatment
Regimen A: Cefotetan Doxycycline IV
Or Cefox it in or Dox ycycl ine orall y q1 2 hrs.
Regimen B: Clindamycin Gentamicin IV/ IM
Alternative
regimens:
Ampicillin/ Doxycycline IV or
Sulbactam Doxycycline orally every 12 hrs
Oral treatment
Ceftriaxone 250 mg IM once
or Cefoxitin 2 g IM
Parenteral therapy can be discontinued 24 hours after clinical improvement
and changed to oral therapy for 14 days.
Plus
Plus
Plus
Plus Probenecid 1 g
orally once + Metronidazole
14 daysYasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
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15-01-2015
11
Bacterial vaginosis
Yasmin ElSobky, BCPS
High in PH
Clue cellsWhiff test positive
(10% KOH fishy odor)
Bacterial vaginosis diagnosis:
Malodorous
vaginal discharge
> 50% are
Asymptomatic
Symptoms
Yasmin ElSobky, BCPS
Bacterial Vaginosis Treatment
Nonpregnant women
Metronidazole (oral) 7 days
Metronidazole 0.75% (intravaginal) 5 days
Clindamycin2% (intravaginal) 7 days
Alternative regimen Clindamycinovules 3 days
Clindamycinoral 7 days
Tinidazole 2G for 2 days
Tinidazole 1G for 5 days
Pregnant women
Oral regimens ONLY
Metronidazole or clindamycin (oral) for 7 days
Yasmin ElSobky, BCPS
Treatment of sexual partners is not necessary
Bacterial Vaginosis
Increased infection
risk ONLYSexual transmission
Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
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15-01-2015
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Vulvovaginal candidiasis
Yasmin ElSobky, BCPS
OCs & corticosteroids Chemotherapy & Antibiotics
Obesity & DM Pregnancy
Predisposing factor for Vulvovaginal Candidiasis
Yasmin ElSobky, BCPS
Pruritis (irritation)
Vaginal discharge
Symptoms
KOH smears
DiagnosisSymptoms
Yasmin ElSobky, BCPS Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
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15-01-2015
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Yasmin ElSobky, BCPS
Vulvovaginal candidiasis treatment
Recurrent ( ≥ 4 /year) Use prescriptionNOT OTC
Loading
Initial therapy for 7-14 days
Or
Fluconazole 100, 150, 200 every third day for 3
doses
MaintenanceFluconazole 100, 150, 200 every week for 6
months
Prophylaxis
(While taking
antibiotics)
Use one full applicator at bed time
If infection 7 days OTC
Pregnant women 7 days OTC azolesYasmin ElSobky, BCPS
Yasmin ElSobky, BCPS Yasmin ElSobky, BCPS
8/9/2019 CDC STD Yasmin CDC Final
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15-01-2015
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References
• ACCP book
Yasmin ElSobky, BCPS