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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