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STI COUNSELLING Resident Author: Ashley Zaretsky MD Faculty Advisor: Jeff Weissberger MD, CCFP Created: December 2012 Overview5,14,15,20 Both in Canada and around the world, STIs are on the rise. As many individuals don’t realize that STIs can be asymptomatic, education and awareness are key to prevention and treatment of STIs. Furthermore, early intervention after potential infection, partner notification, and abstinence until completion of treatment are key principles to impart to patients. Education around the importance of condoms to reduce STI risk is paramount, even if other methods of birth control are being used to prevent pregnancy. Of the many infections responsible for STIs (bacterial, viral, parasitic, and fungal), the most common organisms include Chlamydia, gonorrhea, HPV and HSV. Less common infections include hepatitis B, HIV, syphilis and tricomoniasis. Rare STI include chancroid, lymphogranuloma venereum and granuloma inguinale. Common STI’s 1, 3, 4, 5, 7, 8, 9, 11, , 12, 13, 15, 17, 18, 20, 24, 25 Infection Description Signs & Symptoms Chlamydia • Most common bacterial STI in Canada • Gonorrhea a common co- pathogen • Incidence highest in 15-24 year old’s • Infectious sites include the cervix, urethra, rectum, throat, eyes • Can be asymptomatic • Often associated with other • Symptoms may occur 2-6 STIs weeks after exposure: • Individuals infected with o Mucopurulent vaginal or Chlamydia are at an urethral discharge increased risk of contracting oDysuria and transmitting HIV o Pelvic/abdo pain • PID, Ectopic, Infertility, oDyspareunia Chronic Pelvic Pain, rashes, o Testicular pain tenosynovitis, athralgias o Abnormal uterine bleeding Doxycycline 100 mg PO BID x 7d Or Azithromycin 1 g PO x1 • Often associated with Chlamydia • Infectious sites include the cervix, urethra, rectum, pharynx, disseminated • Can be asymptomatic (women > men) • Symptoms can include: o Mucopurulent urethral/ vaginal/anal discharge oDysuria o Pelvic/abdo pain oDyspareunia o Tenesmus/anorectal pain o Pharyngeal pain Ceftriaxone 250 mg IM OR Cefixime 800 mg PO x 1 + *must treat for chlamydia as high rates of co-infection Doxycycline 100 mg PO BID x 7d or Azithromycin 1g PO x 1 Gonorrhea Complications • Chlamydia a common co- pathogen • Increased risk of other STIs • PID, ectopic pregnancy, infertility, disseminated gonorrhea, tenosynovitis, dermatitis Treatment During pregnancy: Azithromycin 1g po x 1 Or Amoxicillin 500mg po TID x 7 days During pregnancy: use cefixime or ceftriaxone Please note: there are alternative regimens Human Papillomavirus (HPV) • Most common viral STI in Canada • Hundreds of subtypes: o 6, 11 classically associated with warts; o 16, 18 most oncogenic • Can be latent and thus Cervical cancer, oropharyngeal asymptomatic cancer, anal cancer, external • Subtype 6, 11 genital cancer (vulvar or vaginal) o Presents as warts • Subtype 16, 18 o Abnormal cervical or anal pap smear o Visible cervical lesion (dysplastic – cancerous) o Visible anal lesion (dysplastic – cancerous) o Visible oropharyngeal lesions (dysplastic – cancerous) o Visible external genital lesion (dysplastic – cancerous) HPV subtype 6, 11: • Imiquimod (Aldara) 5% cream self applied 3 days/ week x 4-16 weeks or imiquimod 3.75% (Vyloma) self applied daily x 8 wks • Podophyllotoxin 0.5% liquid solution elf applied BID 3 days/ week x 6 weeks • Podophyllin 25% topical liquid applied in once per week; may repeat 1-2 times) • Cryotherapy with liquid nitrogen • Dichloroacetic acid (DCA) or trichloroacetic acid (TCA) 50–80% solution in 70% alcohol applied in office (appropriate in pregnancy Oncogenic subtypes: • Surgical removal • laser Dr. Michael Evans developed the One-Pager concept to provide clinicians with useful clinical information on primary care topics. STI COUNSELLING Herpes Simplex Virus (HSV) • • Most common cause of genital ulcer disease High transmission rate during outbreaks, but potential for viral shedding in absence of ulcers • Chronic pain syndromes • Tingling, burning, pruritis can precede development of • Neonatal transmission lesions • Lesions appear as multiple, painful, shallow ulcerations with small vesicles • First episode accompanied by pharyngitis, inguinal lymphadenopathy, malaise, fever o Symptom onset typically 7 – 10 days after exposure • Chronic pain syndromes • Neonatal transmission First infection Acyclovir 400 mg PO TID x 5-7 d or Valacyclovir 1g PO BID x 7-10 d or Famciclovir 250 mg TID for 5-7d Recurrent Episode Acyclovir 400 mg PO TID x 3-5 d or Valacyclovir 500 mg PO BID x 3d or Famciclovir 125 mg PO BID x 5d Note: consider daily suppressive therapy if >6-8 occurrences/year During pregnancy, drug of choice is acyclovir Syphilis • • Chronic infection caused by Treponema pallidum Can exist in active or latent stages with a variety of signs or symptoms • Primary syphyllis: painless chancre • Secondary syphyllis: rash, myalgia, fever, pharyngitis, hepatitis, weight loss, arthritis • Early latent: < 1 year after secondary syphyllis • Late latent: > 1 year after secondary syphyllis • Tertiary: neurologic, cardiovascular and tissue complications Primary/Secondary/Early Latent: Benzathine Penicillin G 2.4 million units IM x 1 Late latent/Tertiary syphyllis: Benzathine Penicillin G 2.4 million unit IM weekly x 3 *if HIV infected, treat as late latent or tertiary syphyllis • • Increased risk of acquiring and transmitting HIV Chronic neurologic and cardiovascular sequelae Risk Factors for STI’s4,5,7,15,20 • • • • • History of previous STI Unprotected sex Early age of 1st intercourse Contact with person infected with STI Sexually active individuals <25 years old • • • • • New partner in last 3 months Multiple partners Lack of barrier protection Substance users/abusers Men who have sex with men Who should be screened?5,12,15,20,23 • High risk individuals • Pregnant individuals • With initiation of OCP (as usually stop using barrier methods) • Any interested individuals • Any sexually abused patient What can be done for prevention?4,7,10,13,15,16,20,25 • • Advise patients on safe sexual practices, including condoms Vaccination: o Gardasil: HPV types 6, 11, 16, 18; approved for females age 9 – 45, males age 9 – 26 o Cervarix: HPV types 16, 18 only o Hepatitis B vaccination What should women be told during pregnancy?2,15,21,22 • • • • • Vertical transmission occurs in Hepatitis B infections (10% risk); treatment of neonate with HBIG and vaccine (at birth, 1, 6 months) HIV transmission can occur in utero, at delivery and during breastfeeding; triple antiretroviral therapy decreases transmission to <1%, elective C/S an option Test of cure for Chlamydia and gonorrhea should be performed Acyclovir should be used to treat HSV in symptomatic women; if have active genital lesions, C/S should be performed to decrease transmission Many STIs including Chlamydia, Gonorrhea and Syphilis have been associated with risk of preterm labour; these STIs are thus screened for during the first trimester and later (if necessary and appropriate) Management4, 5. 7, 10, 15, 19, 20, 25 • • • • • • • • • Primary prevention is more effective than treating STIs and their sequalae Educate on STI risk factors in order to help decrease an individual’s risk Vaccination (HPV, Hep B) Condoms 100% of the time; even then, counsel around chance of HPV or HSV! (note: spermicidal lubricated condoms with nonoxynol 9 may increase risk of infection/transmission of STIs; therefore the best protection against STIs is a latex condom WITHOUT N-9) Rapid treatment of suspected infection, even if diagnostic testing not available yet Following treatment, abstinence from sexual activity for 10 days – 1 month (or until test of cure completed, if appropriate) STIs not considered treated until partner is also treated (Public Health will do contact tracing) Testing for cure is advised in the following: pregnant women, questionable therapeutic compliance, alternate regimen used, persistence of symptoms, re-exposure Note: mandatory reporting to Public Health for: Chlamydia, gonorrhea, hepatitis B, HIV, syphilis References can be found online at http://www.dfcm.utoronto.ca/programs/postgraduateprograme/One_Pager_Project_References.htm