4/12/2017
Sexually Transmitted Diseases
Burning Questions
Jeffrey D. Klausner, MD, MPH
Professor of Medicine and Public Health
University of California Los Angeles
Los Angeles, California
FORMATTED: 04-03-17
Los Angeles, California: April 28, 2017
Learning Objectives
After attending this presentation, learners will be
able to:
 Diagnose and manage gonorrhea
 List treatment options for chlamydia
 Describe manifestations of syphilis
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Case
 28 year old man with
urethral discharge
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Differential Diagnosis of Urethritis
 Infectious
Neisseria gonorrhoeae
Chlamydia trachomatis
Mycoplasma genitalium
Trichomonas vaginalis
Herpes simplex virus 1 and 2
Oral flora---streptococci, anaerobes, haemophilus
 Non-infectious
Trauma—physical, chemical, sex-play related
Autoimmune—Reactive arthritis
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Uncomplicated gonococcal infection
Neisseria gonorrhoeae
Urethra
Cervix
Pharynx
Rectum
Gram-negative
intracellular diplococci
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Detection of N. gonorrhoeae infection
Sensitivity
Gram stain
Specificity
92%
90%
Culture
95%
100%
DNA/RNA amplification*
95%
99%
*May be used on clinician- or self-collected vaginal, cervical,
rectal, pharyngeal specimens and urine
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Gonorrhea — Rates of Reported Cases by
Race/Ethnicity, United States, 2011–2015
* AI/AN = American Indians/Alaska Natives; NHOPI = Native Hawaiian/Other Pacific Islanders.
Susceptibility changes of Neisseria gonorrhoeae
to cefixime and ceftriaxone
Multi-drug treatment for gonorrhea
Ceftriaxone 250 mg IM once
Azithromycin 1 gm PO once
Plus partner treatment
Retesting at 3 months
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CID, 2017
Case
28 year old HIV-infected male here for a check-up.
He has one regular partner and occasional partners
he meets at various venues, clubs
He has no symptoms
What STD screening tests are appropriate?
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STI screening in Men who have Sex with Men
 Chlamydia trachomatis/ Neisseria gonorrhoeae
– throat,
rectum, urine
 Syphilis (Treponemal then RPR)
 Avoid
– Anal PAP smear
– Routine HSV-1/2 antibody testing
US CDC 2015; USPSTF, 2013
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Test results
Throat – CT/NG negative
Urine – CT/NG negative
Rectum – CT positive, NG negative
Blood – TPPA positive, RPR negative
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Case
Case
44 year old man with new
lesion near his anus
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Differential diagnosis of genital ulcer
STDs
Other
 Genital herpes
 Fixed drug reactions
 Primary syphilis
 Staph/strep
 Chancroid
 Autoimmune
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Treponema pallidum pallidum, bacterial spirochete
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Primary syphilis – penile chancres
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Secondary syphilis: trunk rash
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Secondary syphilis: palmar and plantar lesions
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Secondary syphilis: split papules, “moth-eaten” alopecia, mucous patches and
condyloma lata
J. Engelman
Split papule (mucous patch)
Katz
www.merckmedicus.com
Moth-eaten alopecia
Condyloma lata
Mucous patch
J. Engelman
Katz
Klausner
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Latent syphilis
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Those syphilis tests
 Non-treponemal tests (RPR, VDRL)
–
–
–
–
Antibody to cardiolipin-lecithin-phospholipids
Rise and fall with infection and treatment over time
4-fold change in titer (1:2 to 1:8 or 1:64 to 1:16) is
significant
Specificity = 98% (false-positives in IDU, auto-immune,
etc)
 Treponemal tests (FTA-Abs, TPPA, TP EIA)
–
–
–
–
Antibody to Treponemal antigen
More sensitive and develop earlier
Stay positive for “life” (85%)
Indicate past or current infection
Klausner, Current STD Diagnosis and Management 2007
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Injectable penicillin is treatment of choice for
early syphilis
• Single intramuscular
injection 2.4 MU
benzathine penicillin
• Prophylactic treatment:
•
Syphilis case contacts
< 90 days
• Doxycycline
chemoprophylaxis
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Syphilis — Rates of Reported Cases by
Stage of Infection, United States, 1941–2015
NOTE: Data collection for syphilis began in 1941; however, syphilis became nationally notifiable in 1944. Refer to the
National Notifiable Disease Surveillance System (NNDSS) website for more information:
https://wwwn.cdc.gov/nndss/conditions/syphilis/.
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CDC recommended indications for lumbar puncture
1) Neurologic symptoms or signs
2) Suspected ocular syphilis
3) Treatment failure
4) Tertiary syphilis
HIV infection, immunosuppression or elevated RPR titer while associated
with increased risk for neurosyphilis are not indications for CSF analysis
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Sources for more STD information
 CDC
– www.cdc.gov/std
 Current STD Textbook
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Thank you
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Dr Klausner Suggested Readings
Activity #: HIV 17 LA (F)
04-26-17
Page: 1
SUGGESTED READINGS
1.Kojima N, Davey DJ, Klausner JD. Pre-exposure prophylaxis for HIV infection
and new sexually transmitted infections among men who have sex with men.
AIDS. 2016;30(14):2251-2252.
Ref ID: 15053
2. Scott HM, Klausner JD. Sexually transmitted infections and pre-exposure
prophylaxis: challenges and opportunities among men who have sex with men
in the US. AIDS Res Ther. 2016;13:5.
Ref ID: 15054
3. Bolan RK, Beymer MR, Weiss RE, Flynn RP, Leibowitz AA, Klausner JD.
Doxycycline prophylaxis to reduce incident syphilis among HIV-infected
men who have sex with men who continue to engage in high-risk sex: a
randomized, controlled pilot study. Sex Transm Dis. 2015;42(2):98-103.
Ref ID: 15055
4. Andrade R, Rodriguez-Barradas MC, Yasukawa K, Villarreal E, Ross M, Serpa
JA. Single dose versus 3 Doses of intramuscular benzathine penicillin for
early syphilis in HIV: a randomized clinical trial. Clin Infect Dis.
2017;64(6):759-764.
Ref ID: 15056
5. de Voux A, Kidd S, Grey JA, et al. State-specific rates of primary and
secondary syphilis among men who have sex with men - United States, 2015.
Morb Mortal Wkly Rep. 2017;66(13):349-354.
Ref ID: 15057
6. Buchacz K, Patel P, Taylor M, et al. Syphilis increases HIV viral load
and decreases CD4 cell counts in HIV-infected patients with new syphilis
infections. AIDS. 2004;18(15):2075-2079.
Ref ID: 11444
7. Steedman NM, McMillan A. Treatment of asymptomatic rectal Chlamydia
trachomatis: is single-dose azithromycin effective? Int J STD AIDS.
2009;20(1):16-18.
Ref ID: 15061
8. Hathorn E, Opie C, Goold P. What is the appropriate treatment for the
management of rectal Chlamydia trachomatis in men and women? Sex Transm
Infect. 2012;88(5):352-354.
Ref ID: 15058
9. Kong FY, Tabrizi SN, Fairley CK, et al. The efficacy of azithromycin and
doxycycline for the treatment of rectal chlamydia infection: a systematic
review and meta-analysis. J Antimicrob Chemother. 2015;70(5):1290-1297.
Ref ID: 14672
10. Allan-Blitz LT, Wang X, Klausner JD. Wild-type gyrase A genotype of
Neisseria gonorrhoeae predicts in vitro susceptibility to ciprofloxacin:
a systematic review of the literature and meta-analysis. Sex Transm Dis.
2017;44(5):261-265.
Dr Klausner Suggested Readings
Activity #: HIV 17 LA (F)
04-26-17
Page: 2
Ref ID: 15059
11. Allan-Blitz LT, Humphries RM, Hemarajata P, et al. Implementation of a
rapid genotypic assay to promote targeted ciprofloxacin therapy of
Neisseria gonorrhoeae in a large health system. Clin Infect Dis.
2017;64(9):1268-1270.
Ref ID: 15060