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Sexually Transm itted lnfections TABI-E 30. Treatment of Chlamydia trachomatis and Neisseria gonorrhoeae lnfections and Their Complications ClinicalSyndrome PreferredRegimen Alternate Regimen Cervicitis and Ceftriaxone,250 mg lM single dose, plus azithromycin, Cefixime,400 mg PO single dose, plus urethritis (empiric 1 g PO single dose (preferred), or doxycyclineb, 100 mg azithromycin, 1 g PO single dose (preferred), or therapy)" PO twice daily for 7 d (only if azithromycin cannot be used) doxycycline, 100 mg PO twice daily for 7 d Chlamydia Azithromycin, 1 g PO single dose, or doxycycline, 100 mg Erythromycin base, 500 mg PO fourtimes daily, or cervicitis, urethritis, PO twice daily for 7 d (21 d if C. trachomatis LGV serovars erythromycin ethylsuccinate,800 mg PO four or proctitisa suspected or confirmed) times daily, or levofloxacin, 500 mg PO daily, or ofloxacin, 300 mg PO twice daily for 7 d Gonococcal Ceftriaxone,500 mg lM single dose (1 g lM single dose for ln patients allergic to cephalosporins, gentamicin, cervicitis, ureth ritis, persons >150 kg [300 lbs]), p/us 240 mg IM single dose, plus azithromycin, 2 gPO or proctitis and single dose pharyngeal doxycycline, 100 mg PO twice daily for 7 d; or, if pregnant, infection',d azithromycin, 1 g PO single dose (if concomitant Cefixime', 800 mg PO single dose, p/us chlamydial infection is not ruled out) doxycycline, 100 mg PO twice daily for 7 d, or,if pregnant, azithromycin 1 g PO single dose (if concomitant chlamydial infection is not ruled out) Test of cure 2 weeks after treatment for pharyngeal gonorrhea treated with an alternate regimen Disseminated Ceftriaxone, 1 g lM or lV every 24 h, plus azithromycin, 1 g Cefotaximee, 1 g lV every 8 h, or ceftizoximes, 1 g gonococcal PO single dose lV every 8 h, plus azithromycin, 1 g PO single dose infectionuJ

TABI-E 30. Treatment of Chlamydia trachomatis and Neisseria gonorrhoeae lnfections and Their Complications ClinicalSyndrome PreferredRegimen Alternate Regimen Cervicitis and Ceftriaxone,250 mg lM single dose, plus azithromycin, Cefixime,400 mg PO single dose, plus urethritis (empiric 1 g PO single dose (preferred), or doxycyclineb, 100 mg azithromycin, 1 g PO single dose (preferred), or therapy)" PO twice daily for 7 d (only if azithromycin cannot be used) doxycycline, 100 mg PO twice daily for 7 d Chlamydia Azithromycin, 1 g PO single dose, or doxycycline, 100 mg Erythromycin base, 500 mg PO fourtimes daily, or cervicitis, urethritis, PO twice daily for 7 d (21 d if C. trachomatis LGV serovars erythromycin ethylsuccinate,800 mg PO four or proctitisa suspected or confirmed) times daily, or levofloxacin, 500 mg PO daily, or ofloxacin, 300 mg PO twice daily for 7 d Gonococcal Ceftriaxone,500 mg lM single dose (1 g lM single dose for ln patients allergic to cephalosporins, gentamicin, cervicitis, ureth ritis, persons >150 kg [300 lbs]), p/us 240 mg IM single dose, plus azithromycin, 2 gPO or proctitis and single dose pharyngeal doxycycline, 100 mg PO twice daily for 7 d; or, if pregnant, infection',d azithromycin, 1 g PO single dose (if concomitant Cefixime', 800 mg PO single dose, p/us chlamydial infection is not ruled out) doxycycline, 100 mg PO twice daily for 7 d, or,if pregnant, azithromycin 1 g PO single dose (if concomitant chlamydial infection is not ruled out) Test of cure 2 weeks after treatment for pharyngeal gonorrhea treated with an alternate regimen Disseminated Ceftriaxone, 1 g lM or lV every 24 h, plus azithromycin, 1 g Cefotaximee, 1 g lV every 8 h, or ceftizoximes, 1 g gonococcal PO single dose lV every 8 h, plus azithromycin, 1 g PO single dose infectionuJ Pelvic inflammatory disease Parenteral Cefotetan, 2 glY every 1 2h, or cefoxitin, 2 glY every 6 h, Ampicillin-sulbactam, 3 g lV every 6 h, plus therapyh plus doxycycline, 100 mg lV or PO every 12 h doxycycline, 100 mg lV or PO every 12 h OR

Pelvic inflammatory disease Parenteral Cefotetan, 2 glY every 1 2h, or cefoxitin, 2 glY every 6 h, Ampicillin-sulbactam, 3 g lV every 6 h, plus therapyh plus doxycycline, 100 mg lV or PO every 12 h doxycycline, 100 mg lV or PO every 12 h OR Clindamycin, 900 mg lV every 8 h, plus gentamicin ,2 mg/kg lV loading dose followed by 1 .5 mg/kg lV every 8 hours or a single daily dose of 3-5 mglkg/d Oral/lM therapy Ceftriaxone,250 mg lM single dose, plus doxycycline, 100 mg PO twice daily for 14 d, with or without metronidazole, 500 mg PO twice daily {or 14 d, or cefoxitin,2 g lM single dose, with probenecid, 1 g PO, plus doxycycline, 100 mg PO every 12h for 1 4 d, with or without metronidazole, 500 mg PO twice daily for 14 d Epididymitis Ceftriaxone,250 mg lM single dose, plus doxycycline, 100 mg PO twice daily for 10 d if infection most likely due to ch la myd ialgonorrhea Ceftriaxone,250 mg lM single dose, plus levofloxacin, 500 mg PO once daily, or ofloxacin, 300 mg PO twice daily for 10 d if infection might be caused by chlamydia/ gonorrhea and enteric organisms (insertive anal intercourse) Levofloxacin, 500 mg PO once daily, or ofloxacin, 300 mg PO twice daily, for 10 d if infection most likely caused by enteric organisms lM = intramuscularly; lV = intravenously; LGV = lymphogranuloma venereum; PO = orally. "Updated CDC treatment regimens are pending. bDoxycyline should be avoided or used with caution in pregnant patients.

Clindamycin, 900 mg lV every 8 h, plus gentamicin ,2 mg/kg lV loading dose followed by 1 .5 mg/kg lV every 8 hours or a single daily dose of 3-5 mglkg/d Oral/lM therapy Ceftriaxone,250 mg lM single dose, plus doxycycline, 100 mg PO twice daily for 14 d, with or without metronidazole, 500 mg PO twice daily {or 14 d, or cefoxitin,2 g lM single dose, with probenecid, 1 g PO, plus doxycycline, 100 mg PO every 12h for 1 4 d, with or without metronidazole, 500 mg PO twice daily for 14 d Epididymitis Ceftriaxone,250 mg lM single dose, plus doxycycline, 100 mg PO twice daily for 10 d if infection most likely due to ch la myd ialgonorrhea Ceftriaxone,250 mg lM single dose, plus levofloxacin, 500 mg PO once daily, or ofloxacin, 300 mg PO twice daily for 10 d if infection might be caused by chlamydia/ gonorrhea and enteric organisms (insertive anal intercourse) Levofloxacin, 500 mg PO once daily, or ofloxacin, 300 mg PO twice daily, for 10 d if infection most likely caused by enteric organisms lM = intramuscularly; lV = intravenously; LGV = lymphogranuloma venereum; PO = orally. "Updated CDC treatment regimens are pending. bDoxycyline should be avoided or used with caution in pregnant patients. covera9e. dNo reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a p-lactam allergy, a thorough assessment of the reaction is recommended. has been increasingly reported' "Cefixime should be used only if ceftriaxone is unavailable because oral cephalosporin resistance to N. gonorrhoeae least 2B days). gNot available in the United States.

covera9e. dNo reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a p-lactam allergy, a thorough assessment of the reaction is recommended. has been increasingly reported' "Cefixime should be used only if ceftriaxone is unavailable because oral cephalosporin resistance to N. gonorrhoeae least 2B days). gNot available in the United States. hPatients can be switched to oral therapy within 24 to 48 hours of clinical improvement using doxycycline, 100 mg PO twice daily, with or without metronidazole' 500 mg PO twice daily, to complete a total of 14 days of therapy. 46

Sexually Transmitted lnfections evaluated using NAAT; MSM should be screened yearly for t(EY P0rllrs urethral and rectal infection. o Screening for lfeisserio gonorrhoeae infection is recom- Treatment of clinical syndromes caused by C. trachomo- mended for women younger than 25 years and those tis is outlined in Table 3O. Test of cure is not recommended, 25 years and older with risk factors (new partner, more except in pregnancy. Because of the high risk of repeat infec- than one partner, a partner with an STI, or a partner tion, men and women should be retested after 3 months or the who has concurrent partners). next time they are seen for medical care. . Nucleic acid amplification testing is the preferred screen- t(EY POl ltTS ing and diagnostic method for Neisseria gonorrhoeae . Nucleic acid amplification testing is the preferred infection. screening and diagnostic methodfor Chlamydia o Parenteral ceftriaxone is the preferred regimen for the trochomatis infe ction. treatment of uncomplicate d I{e isserio gonorrho e ae HVC o Test of cure is not recommended in patients with infection. Chlomy dia trqchomotis infectio n except in pregnancy ; o Test of cure in patients with l{eisserio gonorrhoeae however, patients should be retested for possible repeat infection is recommended 2 weeks after therapy only infection after 3 months or at their next medical visit. when pharyngeal gonorrhea is treated with an alternate antibiotic regimen. Neisse ria gonorrhoeae lnfestion Persons aged 20 to 24 years are at highest risk for I{. gonor- rhoeae infection. In addition to cervicitis, urethritis, pharyn- Mycopl asma genitaliu m I nfection gitis, and rectal infection, disseminated gonococcal infection M. genitalium is an emerging STI that is a cause of urethritis in (presenting as arthritis-dermatitis syndrome) can occur (see men. It has been reported to cause up to 20'2, of nongonococcal MKSAP 19 Rheumatolory). Infection can be asymptomatic, urethritis and 46o/,, of nongonococcal/nonchlamydial urethri- especially in women, so screening is recommended for women tis in men. As an STI pathogen in women, it is implicated in younger than 25 years and those 25 years and older with STI cervicitis and pelvic inflammatory disease (PID). The optimal risk factors. The USPSTF does not recommend screening for role for testing with NAAT in clinical practice has yet to be men; the CDC recommends screening men at high risk, as for defined, and no recommendations have been published for C. trachomatis. routine screening. Recommended treatment for nongonococ- For screening and diagnosis, NAAT is preferred. Men and cal urethritis is azithromycin (1 g single dose); however, women can be screened using a first-catch urine sample; azithromycin resistance is increasingly reported, and a longer endocervical, urethral, rectal, and pharyngeal swabs may also course or alternate therapy may be required. be used. Pharyngeal, urethral and rectal sites should be tested at least yearly in MSM. In patients with disseminated gonococ- cal infection, all N. gonorrhoeoe isolates should be tested for Clinical Syndromes antimicrobial susceptibility. Patients with suspected dissemi- Ceruicitis nated gonococcal infection should have cultures performed on Women with cervicitis may have vaginal discharge and inter- blood, joint fluid (if arthritis is present), purulent skin lesions menstrual bleeding, but many are asymptomatic. The major (if present), and cerebrospinal fluid (if meningitis is sus- diagnostic criteria are visualization of mucopurulent dis pected); however, culture yield is not high, so NAAT from all charge from the cervical os or on a swab obtained from the potential sites of exposure (genital, pharyngeal, rectal) should endocervical canal and eliciting bleeding by passing a swab be obtained. into the cervical os. N. gonorrhoeoe and C. trachomotis are Treatment is outlined in Table 30. For uncomplicated the most commonly isolated pathogens; however, many cases gonococcal infections of the cervix, urethra, or rectum, ceftri- are enigmatic. The role of M. genitalium is still unclear; her- axone monotherapy is recommended because l{. gonorrhoeae pes simplex virus is occasionally implicated. Noninfectious remains susceptible to ceftriaxone, and azithromycin resist- causes (for example, chemical irritation from douching) ance is increasing; the recommended ceftriaxone dose has should be sought. Patients should be tested for lf. gonor- increased. In patients with an allergz precluding use of cepha- rhoeae and C. trachomatis with NAAT, as well as being evalu- losporins, oral gemifloxacin or parenteral gentamicin plus oral ated for bacterial vaginosis and trichomoniasis (see MKSAP 19 azithromycin is an option. General Internal Medicine 2). Patients with infections caused by N. gonorrhoeoe who do not respond to treatment should have repeat testing with Pelvic lnflammatory Disease NAAT and culture so that susceptibility data can be obtained; Unrecognized PID may result in long-term sequelae, including consultation with an expert in nonresponsive infections is infertility, chronic pelvic pain, and ectopic pregnancy. advised. Symptoms include lower abdominal pain, vaginal discharge,

evaluated using NAAT; MSM should be screened yearly for t(EY P0rllrs urethral and rectal infection. o Screening for lfeisserio gonorrhoeae infection is recom- Treatment of clinical syndromes caused by C. trachomo- mended for women younger than 25 years and those tis is outlined in Table 3O. Test of cure is not recommended, 25 years and older with risk factors (new partner, more except in pregnancy. Because of the high risk of repeat infec- than one partner, a partner with an STI, or a partner tion, men and women should be retested after 3 months or the who has concurrent partners). next time they are seen for medical care. . Nucleic acid amplification testing is the preferred screen- t(EY POl ltTS ing and diagnostic method for Neisseria gonorrhoeae . Nucleic acid amplification testing is the preferred infection. screening and diagnostic methodfor Chlamydia o Parenteral ceftriaxone is the preferred regimen for the trochomatis infe ction. treatment of uncomplicate d I{e isserio gonorrho e ae HVC o Test of cure is not recommended in patients with infection. Chlomy dia trqchomotis infectio n except in pregnancy ; o Test of cure in patients with l{eisserio gonorrhoeae however, patients should be retested for possible repeat infection is recommended 2 weeks after therapy only infection after 3 months or at their next medical visit. when pharyngeal gonorrhea is treated with an alternate antibiotic regimen. Neisse ria gonorrhoeae lnfestion Persons aged 20 to 24 years are at highest risk for I{. gonor- rhoeae infection. In addition to cervicitis, urethritis, pharyn- Mycopl asma genitaliu m I nfection gitis, and rectal infection, disseminated gonococcal infection M. genitalium is an emerging STI that is a cause of urethritis in (presenting as arthritis-dermatitis syndrome) can occur (see men. It has been reported to cause up to 20'2, of nongonococcal MKSAP 19 Rheumatolory). Infection can be asymptomatic, urethritis and 46o/,, of nongonococcal/nonchlamydial urethri- especially in women, so screening is recommended for women tis in men. As an STI pathogen in women, it is implicated in younger than 25 years and those 25 years and older with STI cervicitis and pelvic inflammatory disease (PID). The optimal risk factors. The USPSTF does not recommend screening for role for testing with NAAT in clinical practice has yet to be men; the CDC recommends screening men at high risk, as for defined, and no recommendations have been published for C. trachomatis. routine screening. Recommended treatment for nongonococ- For screening and diagnosis, NAAT is preferred. Men and cal urethritis is azithromycin (1 g single dose); however, women can be screened using a first-catch urine sample; azithromycin resistance is increasingly reported, and a longer endocervical, urethral, rectal, and pharyngeal swabs may also course or alternate therapy may be required. be used. Pharyngeal, urethral and rectal sites should be tested at least yearly in MSM. In patients with disseminated gonococ- cal infection, all N. gonorrhoeoe isolates should be tested for Clinical Syndromes antimicrobial susceptibility. Patients with suspected dissemi- Ceruicitis nated gonococcal infection should have cultures performed on Women with cervicitis may have vaginal discharge and inter- blood, joint fluid (if arthritis is present), purulent skin lesions menstrual bleeding, but many are asymptomatic. The major (if present), and cerebrospinal fluid (if meningitis is sus- diagnostic criteria are visualization of mucopurulent dis pected); however, culture yield is not high, so NAAT from all charge from the cervical os or on a swab obtained from the potential sites of exposure (genital, pharyngeal, rectal) should endocervical canal and eliciting bleeding by passing a swab be obtained. into the cervical os. N. gonorrhoeoe and C. trachomotis are Treatment is outlined in Table 30. For uncomplicated the most commonly isolated pathogens; however, many cases gonococcal infections of the cervix, urethra, or rectum, ceftri- are enigmatic. The role of M. genitalium is still unclear; her- axone monotherapy is recommended because l{. gonorrhoeae pes simplex virus is occasionally implicated. Noninfectious remains susceptible to ceftriaxone, and azithromycin resist- causes (for example, chemical irritation from douching) ance is increasing; the recommended ceftriaxone dose has should be sought. Patients should be tested for lf. gonor- increased. In patients with an allergz precluding use of cepha- rhoeae and C. trachomatis with NAAT, as well as being evalu- losporins, oral gemifloxacin or parenteral gentamicin plus oral ated for bacterial vaginosis and trichomoniasis (see MKSAP 19 azithromycin is an option. General Internal Medicine 2). Patients with infections caused by N. gonorrhoeoe who do not respond to treatment should have repeat testing with Pelvic lnflammatory Disease NAAT and culture so that susceptibility data can be obtained; Unrecognized PID may result in long-term sequelae, including consultation with an expert in nonresponsive infections is infertility, chronic pelvic pain, and ectopic pregnancy. advised. Symptoms include lower abdominal pain, vaginal discharge, 45

Sexually Transm itted lnfections Antiviral therapy for primary infection has been shown to decrease time to resolution of symptoms, lesion healing, and viral shedding (taUte Sr). Recurrent genital HSV infections are less severe. Many patients will experience prodromal itching, burning, or tin- gling before ulcers appear. Atypical presentations such as fissures and excoriations may occur. Recurrent infection can be managed with either episodic self-start therapy (initiated within 24 hours of symptoms) or long-term suppressive ther- apy (see Table 31). Long-term suppressive therapy should be considered for persons with frequent recurrences and should be discussed with all patients because this strategz can decrease the risk of transmission to sexual partners. t lG U R E 21 . Penile lesions seen in herpes simplex virus (HSV)type 2. Patients Laboratory monitoring is not required for patients undergo- with genital HSV infection initially have painful lesions that begin as vesicles and ing long-term suppressive therapy; however, the continued progress to ulcers on an erythematous base. need for therapy should be reviewed annually. Length of time since last recurrence and potential benefits of continued sup- primary infection than HSV-2. HSV-1is less likely than HSV-2 pression in preventing transmission to sexual partners are to cause symptomatic recurrent ulcers and subclinical shed- factors that can inform the decision to stop suppressive ding. Differentiation between the two viral subtypes is impor- therapy. tant in counseling patients regarding the natural history of rEY POIlITS their infection. o In primary infection, the viral cause and herpes simplex Primary infection presents as multiple painful lesions that virus subtype should be confirmed by nucleic acid begin as erythematous papules, progress to vesicles, then ulcer- amplification testing using a swab obtained from the ate, crust, and eventually heal within 2 to 3 weeks (Figure 21). ulcer base. Primary infection is often accompanied by significant sys- temic symptoms. Tender inguinal lymphadenopathy may be . Long-term suppressive therapy for recurrent herpes present. simplex virus infection may be preferred over self-start NAAT for HSV-I and HSV-2 using a swab obtained from episodic therapy because of decreased risk of transmis- the ulcer base is preferred to confirm the diagnosis. Type- sion to sexual partners. specific serologic testing is not advised for diagnosing sympto matic ulcer disease because patients can be seropositive for Syphilis HSV-1 or HSV-2 yet have genital ulcers from another cause. The incidence of primary and secondary syphilis has been Serologic testing may be performed when evaluating the increasing in the United States since 2000, and an alarming potential benefits of long-term suppressive therapy to decrease increase in congenital infections has been reported. The the transmission risk in serodiscordant couples. The CDC rec- USPSTF recommends screening all pregnant women, non- ommends considering HSV serologic testing in persons who pregnant adolescents, and adults at high risk of infection. present for STI evaluation, MSM, and persons with HIV infec- Persons at risk include MSM and commercial sex workers and tion. Serologic screening in the general population is not those with HIV infection, multiple sexual partners, and previ- recommended. ous syphilis.

Antiviral therapy for primary infection has been shown to decrease time to resolution of symptoms, lesion healing, and viral shedding (taUte Sr). Recurrent genital HSV infections are less severe. Many patients will experience prodromal itching, burning, or tin- gling before ulcers appear. Atypical presentations such as fissures and excoriations may occur. Recurrent infection can be managed with either episodic self-start therapy (initiated within 24 hours of symptoms) or long-term suppressive ther- apy (see Table 31). Long-term suppressive therapy should be considered for persons with frequent recurrences and should be discussed with all patients because this strategz can decrease the risk of transmission to sexual partners. t lG U R E 21 . Penile lesions seen in herpes simplex virus (HSV)type 2. Patients Laboratory monitoring is not required for patients undergo- with genital HSV infection initially have painful lesions that begin as vesicles and ing long-term suppressive therapy; however, the continued progress to ulcers on an erythematous base. need for therapy should be reviewed annually. Length of time since last recurrence and potential benefits of continued sup- primary infection than HSV-2. HSV-1is less likely than HSV-2 pression in preventing transmission to sexual partners are to cause symptomatic recurrent ulcers and subclinical shed- factors that can inform the decision to stop suppressive ding. Differentiation between the two viral subtypes is impor- therapy. tant in counseling patients regarding the natural history of rEY POIlITS their infection. o In primary infection, the viral cause and herpes simplex Primary infection presents as multiple painful lesions that virus subtype should be confirmed by nucleic acid begin as erythematous papules, progress to vesicles, then ulcer- amplification testing using a swab obtained from the ate, crust, and eventually heal within 2 to 3 weeks (Figure 21). ulcer base. Primary infection is often accompanied by significant sys- temic symptoms. Tender inguinal lymphadenopathy may be . Long-term suppressive therapy for recurrent herpes present. simplex virus infection may be preferred over self-start NAAT for HSV-I and HSV-2 using a swab obtained from episodic therapy because of decreased risk of transmis- the ulcer base is preferred to confirm the diagnosis. Type- sion to sexual partners. specific serologic testing is not advised for diagnosing sympto matic ulcer disease because patients can be seropositive for Syphilis HSV-1 or HSV-2 yet have genital ulcers from another cause. The incidence of primary and secondary syphilis has been Serologic testing may be performed when evaluating the increasing in the United States since 2000, and an alarming potential benefits of long-term suppressive therapy to decrease increase in congenital infections has been reported. The the transmission risk in serodiscordant couples. The CDC rec- USPSTF recommends screening all pregnant women, non- ommends considering HSV serologic testing in persons who pregnant adolescents, and adults at high risk of infection. present for STI evaluation, MSM, and persons with HIV infec- Persons at risk include MSM and commercial sex workers and tion. Serologic screening in the general population is not those with HIV infection, multiple sexual partners, and previ- recommended. ous syphilis. TAELE 31 . Treatment of Herpes Sinrplex Virus Genital lnfections ClinicalSyndrome Recommended Regimen" Primary infectionb Acyclovir, 400 mg three times daily, or acyclovir, 200 mg five times daily, orfamciclovir, 250 mg three times daily, orvalacyclovir, 1 g twice daily; all regimens forT-10 days Recurrent infection Acyclovir, 400 mg three times daily for 5 days, or acyclovil 800 mg twice daily for 5 days, or acyclovir, 800 mg three times daily for 2 days, or famciclovir, 125 mg twice daily for 5 days, or famciclovir, 1 g twice daily for 1 day, or famciclovir, 500 mg once followed by 250 mg twice daily for 2 days, or valacyclovir, 500 mg twice daily for 3 days, or valacyclovir, 1 g once daily for 5 days

TAELE 31 . Treatment of Herpes Sinrplex Virus Genital lnfections ClinicalSyndrome Recommended Regimen" Primary infectionb Acyclovir, 400 mg three times daily, or acyclovir, 200 mg five times daily, orfamciclovir, 250 mg three times daily, orvalacyclovir, 1 g twice daily; all regimens forT-10 days Recurrent infection Acyclovir, 400 mg three times daily for 5 days, or acyclovil 800 mg twice daily for 5 days, or acyclovir, 800 mg three times daily for 2 days, or famciclovir, 125 mg twice daily for 5 days, or famciclovir, 1 g twice daily for 1 day, or famciclovir, 500 mg once followed by 250 mg twice daily for 2 days, or valacyclovir, 500 mg twice daily for 3 days, or valacyclovir, 1 g once daily for 5 days Suppressive therapy Acyclovir,400 mg twice daily, orfamciclovir,250 mg twice daily, orvalacyclovir,500 mg daily', orvalacyclovir, 1 g daily "All regimens are given orally; topical preparations are not recommended for treatment o{ genital herpes simplex virus. bTherapy can be extended if healing is incomplete after 10 days of treatment. 'The 500-mg dose of valacyclovir may be less effective than the 1-g dose in patients who have very frequent recurrences (>1 0 episodes per year). 48

Sexually Transmitted lnfections intermenstrual bleeding or bleeding after intercourse, and for syphilis. Additional molecular testing is required to iden- dyspareunia. Some women have fever and other signs of sys- tify LGV serovars of C. trachomatis, but it is not widely avail- temic toxicity, but this is uncommon. able commercially; LGV serovars of C. trachomatis will be The presence ofuterine tenderness, adnexal tenderness, detected by currently available NAATs. or cervical motion tenderness is sufficient to make a clinical I(EY POIHTS diagnosis of PID, especially if accompanied by mucopurulent cervical discharge. . ChlamUdia trachomatis and Neisseria gonorrhoeae are PID is believed to be polymicrobial; however, testing is the primary causative organisms in cervicitis, pelvic only indicated for N. gonorrhoeae and C. trachomotis. Most inflammatory disease, urethritis, epididymitis, and infections can be managed in the ambulatory setting with oral anorectal infections, although other organisms may also antibiotics (see Table 30). Indications for hospitalization be implicated. include inability to exclude a surgical emergency such as o The two major diagnostic criteria of cervicitis are visu- app endicitis, pregnancy, severe systemic toxicity, tub o - ovaria n alization of mucopurulent discharge from the cervical abscess, inabilig to tolerate oral antibiotics, and failure of ini os or on a swab obtained from the endocervical canal or tial outpatient management. eliciting bleeding by passing a swab into the cervical os. . The presence ofuterine tenderness, adnexal tenderness, Urethritis or cervical motion tenderness is sufficient to make a clin- Men with urethritis present with dysuria, urethral pruritus, ical diagnosis of pelvic inflammatory disease, especially if and clinically diagnostic mucopurulent discharge. N. gonor- accompanied by mucopumlent cervical discharge. rhoeae, C. trachomotis, and M. genitaliumare common causes; . Neisseria gonorrhoeae and Chlamydia trachomotis are Trichomonos may also be causative. A first-catch urine sample likely causes of epididymitis in younger, sexually active should be tested for N. gonorrhoeoe and C. trachomotis by men; older men and men who practice insertive anal NAAT; an FDA approved NAAT for M. genitalium is available. intercourse may be infected with enteric gram-negative Microscopic examination of a urethral sample that reveals organisms such as Escherichia coli. more than 2 leukocytes per high-powered field has a high posi tive predictive value for infectious urethritis, but the negative Treatment predictive value is poor. A positive leukocyte esterase test result Treatment of the clinical syndromes discussed previously is or a microscopic examination with 10 or more leukocytes on a outlined in Table 30. Symptomatic patients evaluated in urgent first-void urine specimen is also diagnostic for infectious ure care centers or emergency departments and others who may thritis. This testing is not required if mucoid, mucopumlent, or not be able to return for follow up should be treated empiri purulent urethral discharge is demonstrated on examination. cally based on clinical syndrome. Diagnostic testing should still be obtained because STIs are reportable, and test results Epididymitis will be informative if the infection fails to respond to empiric Men with epididymitis present with unilateral pain and swell- therapy. ing in the epididymis; the testes may also be inflamed Patients should abstain from sexual contact until 7 days (epididymo-orchitis) . N. gonorrhoeae and C. trachomatis are after completion of therapy and all sexual partners have been likely causes in younger, sexually active men. Older men and treated. Sexual partners in the previous 60 days, or the most men who practice insertive anal intercourse may be infected recent partner if greater than 60 days, should be referred for with enteric gram-negative organisms such as Escherichia coli. evaluation and treatment. Although independent evaluation NAAT for STI pathogens should be performed on first-catch and testing of sexual partners is preferred, most states have urine, and a urine culture should be obtained. See MKSAP 19 provisions for providing empiric antibiotic therapy prescrip- General Internal Medicine 2 for further information. tions to the patient for their partners (expedited partner ther apy, or EPT). Anorectal lnfections I(EY POII{T Patients who present with anorectal pain, rectal discharge, or tenesmus should be questioned regarding sexual practices. In o Most states have provisions for providing empiric anti- addition to receptive anal intercourse, infection may occur in biotic therapy prescriptions for sexual partners (expe- women because of autoinoculation from vaginal discharge. dited partner therapy). Causes include C. trachomotis, N. gonorrhoeoe, syphilis, and herpes simplex virus (HSV). Infections caused by lymphogran- uloma venereum (LGV) serovars (Ll,L2, or L3) of C. trachoma- Genital Ulcers fis are an increasing cause of proctitis and proctocolitis. Herpes Simplex Virus Diagnostic evaluation should include NAAT for C. tra- In some populations, such as young heterosexual rvomen and chomatis, N. gonorrhoeae, and HSV as well as serologic testing MSM, HSV-1 is now a more common cause of symptomatic

intermenstrual bleeding or bleeding after intercourse, and for syphilis. Additional molecular testing is required to iden- dyspareunia. Some women have fever and other signs of sys- tify LGV serovars of C. trachomatis, but it is not widely avail- temic toxicity, but this is uncommon. able commercially; LGV serovars of C. trachomatis will be The presence ofuterine tenderness, adnexal tenderness, detected by currently available NAATs. or cervical motion tenderness is sufficient to make a clinical I(EY POIHTS diagnosis of PID, especially if accompanied by mucopurulent cervical discharge. . ChlamUdia trachomatis and Neisseria gonorrhoeae are PID is believed to be polymicrobial; however, testing is the primary causative organisms in cervicitis, pelvic only indicated for N. gonorrhoeae and C. trachomotis. Most inflammatory disease, urethritis, epididymitis, and infections can be managed in the ambulatory setting with oral anorectal infections, although other organisms may also antibiotics (see Table 30). Indications for hospitalization be implicated. include inability to exclude a surgical emergency such as o The two major diagnostic criteria of cervicitis are visu- app endicitis, pregnancy, severe systemic toxicity, tub o - ovaria n alization of mucopurulent discharge from the cervical abscess, inabilig to tolerate oral antibiotics, and failure of ini os or on a swab obtained from the endocervical canal or tial outpatient management. eliciting bleeding by passing a swab into the cervical os. . The presence ofuterine tenderness, adnexal tenderness, Urethritis or cervical motion tenderness is sufficient to make a clin- Men with urethritis present with dysuria, urethral pruritus, ical diagnosis of pelvic inflammatory disease, especially if and clinically diagnostic mucopurulent discharge. N. gonor- accompanied by mucopumlent cervical discharge. rhoeae, C. trachomotis, and M. genitaliumare common causes; . Neisseria gonorrhoeae and Chlamydia trachomotis are Trichomonos may also be causative. A first-catch urine sample likely causes of epididymitis in younger, sexually active should be tested for N. gonorrhoeoe and C. trachomotis by men; older men and men who practice insertive anal NAAT; an FDA approved NAAT for M. genitalium is available. intercourse may be infected with enteric gram-negative Microscopic examination of a urethral sample that reveals organisms such as Escherichia coli. more than 2 leukocytes per high-powered field has a high posi tive predictive value for infectious urethritis, but the negative Treatment predictive value is poor. A positive leukocyte esterase test result Treatment of the clinical syndromes discussed previously is or a microscopic examination with 10 or more leukocytes on a outlined in Table 30. Symptomatic patients evaluated in urgent first-void urine specimen is also diagnostic for infectious ure care centers or emergency departments and others who may thritis. This testing is not required if mucoid, mucopumlent, or not be able to return for follow up should be treated empiri purulent urethral discharge is demonstrated on examination. cally based on clinical syndrome. Diagnostic testing should still be obtained because STIs are reportable, and test results Epididymitis will be informative if the infection fails to respond to empiric Men with epididymitis present with unilateral pain and swell- therapy. ing in the epididymis; the testes may also be inflamed Patients should abstain from sexual contact until 7 days (epididymo-orchitis) . N. gonorrhoeae and C. trachomatis are after completion of therapy and all sexual partners have been likely causes in younger, sexually active men. Older men and treated. Sexual partners in the previous 60 days, or the most men who practice insertive anal intercourse may be infected recent partner if greater than 60 days, should be referred for with enteric gram-negative organisms such as Escherichia coli. evaluation and treatment. Although independent evaluation NAAT for STI pathogens should be performed on first-catch and testing of sexual partners is preferred, most states have urine, and a urine culture should be obtained. See MKSAP 19 provisions for providing empiric antibiotic therapy prescrip- General Internal Medicine 2 for further information. tions to the patient for their partners (expedited partner ther apy, or EPT). Anorectal lnfections I(EY POII{T Patients who present with anorectal pain, rectal discharge, or tenesmus should be questioned regarding sexual practices. In o Most states have provisions for providing empiric anti- addition to receptive anal intercourse, infection may occur in biotic therapy prescriptions for sexual partners (expe- women because of autoinoculation from vaginal discharge. dited partner therapy). Causes include C. trachomotis, N. gonorrhoeoe, syphilis, and herpes simplex virus (HSV). Infections caused by lymphogran- uloma venereum (LGV) serovars (Ll,L2, or L3) of C. trachoma- Genital Ulcers fis are an increasing cause of proctitis and proctocolitis. Herpes Simplex Virus Diagnostic evaluation should include NAAT for C. tra- In some populations, such as young heterosexual rvomen and chomatis, N. gonorrhoeae, and HSV as well as serologic testing MSM, HSV-1 is now a more common cause of symptomatic 47

t ; I ,' i I i Sexua lly Transm itted I nfections i I I i i I I I I t L I I I t I I I I L I I t I I I I I L ! : t t I G U R E 22. The primary ulcerative lesion (chancre) in patients with syphilis F lG U R E 23. ln patients with rash caused by secondary syphilis, papules may develops approximately 3 weeks after infection occurs, has a clean appearance with coalesce in intertriginous areas to form plaque-like lesions called condyloma lata. heaped-up borders, and is indurated and usually painless.lt is often unrecognized.

t I G U R E 22. The primary ulcerative lesion (chancre) in patients with syphilis F lG U R E 23. ln patients with rash caused by secondary syphilis, papules may develops approximately 3 weeks after infection occurs, has a clean appearance with coalesce in intertriginous areas to form plaque-like lesions called condyloma lata. heaped-up borders, and is indurated and usually painless.lt is often unrecognized. Primary syphilis presents as a painless genital ulcer syphilis as well as in those who do not demonstrate an appro (chancre) with a raised regular border that demonstrates firm priate serologic response to syphilis treatment. induration on palpation (Figure 22). Several chancres may be Secondary and tertiary syphilis diagnosis relies on sero- present and may occur in the oral cavity. Regional lymphade logic testing. Many laboratories use the "reverse" serologic nopathy may be present. Serologic test results may be negative testing strates/, starting with an automated enzyme immuno- in early primary infection. Even without treatment, lesions assay followed by a nonspecific test (rapid plasma reagin or heal spontaneously in 3 to 6 weeks. Venereal Disease Research Lab test). Patients with a positive The most common manifestation of secondary syphilis is enzyme immunoassay result but negative rapid plasma reagin rash. Various forms are described; involvement of the palms or Venereal Disease Research Lab test result should have a and soles is characteristic. In intertriginous areas, papules may second specific treponemal antibody test to confirm the result. coalesce to form condyloma lata (Figure 23). Mucous patches (superficial erosions on mucosal surfaces) may occur in the oral cavity and moist genital regions and are highly infectious (Figure 24). Prominent systemic symptoms and generalized lymphadenopathy are common. Uveitis and neurosyphilis (meningitis) can occur. Secondary syphilis manifestations can also resolve without treatment, followed by latent infection (a positive serologic test result without clinical manifestations). If latent infection is of less than 12 months'duration, it is termed early latent; if greater than 12 months' duration, it is late latent. Practically, these determinations can be made only if past serologr results are available. Otherwise, patients are consid- ered to have syphilis of unknown duration. Tertiary syphilis is uncommonly seen in the United States, although neurologic disease still occurs, including stroke, altered mental status, and auditory or ophthalmic abnormali- FtG U R E 24. Mucous patches are often slightly raised, plaque-like lesions that ties. Spinal fluid should be examined in any patient with can be seen in the oral or genital mucosal regions. They occasionally ulcerate and unexplained neurologic symptoms and serologic evidence of are covered by a grayish membrane.

Primary syphilis presents as a painless genital ulcer syphilis as well as in those who do not demonstrate an appro (chancre) with a raised regular border that demonstrates firm priate serologic response to syphilis treatment. induration on palpation (Figure 22). Several chancres may be Secondary and tertiary syphilis diagnosis relies on sero- present and may occur in the oral cavity. Regional lymphade logic testing. Many laboratories use the "reverse" serologic nopathy may be present. Serologic test results may be negative testing strates/, starting with an automated enzyme immuno- in early primary infection. Even without treatment, lesions assay followed by a nonspecific test (rapid plasma reagin or heal spontaneously in 3 to 6 weeks. Venereal Disease Research Lab test). Patients with a positive The most common manifestation of secondary syphilis is enzyme immunoassay result but negative rapid plasma reagin rash. Various forms are described; involvement of the palms or Venereal Disease Research Lab test result should have a and soles is characteristic. In intertriginous areas, papules may second specific treponemal antibody test to confirm the result. coalesce to form condyloma lata (Figure 23). Mucous patches (superficial erosions on mucosal surfaces) may occur in the oral cavity and moist genital regions and are highly infectious (Figure 24). Prominent systemic symptoms and generalized lymphadenopathy are common. Uveitis and neurosyphilis (meningitis) can occur. Secondary syphilis manifestations can also resolve without treatment, followed by latent infection (a positive serologic test result without clinical manifestations). If latent infection is of less than 12 months'duration, it is termed early latent; if greater than 12 months' duration, it is late latent. Practically, these determinations can be made only if past serologr results are available. Otherwise, patients are consid- ered to have syphilis of unknown duration. Tertiary syphilis is uncommonly seen in the United States, although neurologic disease still occurs, including stroke, altered mental status, and auditory or ophthalmic abnormali- FtG U R E 24. Mucous patches are often slightly raised, plaque-like lesions that ties. Spinal fluid should be examined in any patient with can be seen in the oral or genital mucosal regions. They occasionally ulcerate and unexplained neurologic symptoms and serologic evidence of are covered by a grayish membrane. 49