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Sexually Transmitted lnfections TABLE 32. Treatment of SyPhilis Stage Recommended Regimen" Atternate Regimen for Penicillin'Allergic Patients Primary and secondary Benzathine penicillin G,2.4 million units lM single Doxycycline, 100 mg PO twice daily, ortetracycline, dose 500 mg PO four times daily, for 14 days Early atent Benzathine penicillin G,2.4 million units lM single Doxycycline, 100 mg PO twice daily, ortetracycline, dose 500 mg PO fourtimes daily, for 14 days Late latent or syphilis of Benzathine penicillin G,2.4 million units lM at Doxycycline, 100 mg PO twice daily, ortetracycline, unknown duration 1-week intervals for 3 doses 500 mg PO fourtimes daily, for 28 days Neurosyphilis Aqueous crystalline penicillin G,18-24 million units Ceftriaxone ,2 glM or lV daily for 10-14 daysb daily given as 3-4 million units lV every 4 hours or by continuous infusion for 10-14 days, or procaine penicillin,2.4 million units lM daily, plus probenecid, 500 mg PO fourtimes daily, both for 10-14 days lM = intramuscularly; lV = intravenously; PO = orally. treated with the appropriate penicillin regimen as outlined above. cannot take ceftriaxone, penicillin desensitization is recommended.

Neurosyphilis Aqueous crystalline penicillin G,18-24 million units Ceftriaxone ,2 glM or lV daily for 10-14 daysb daily given as 3-4 million units lV every 4 hours or by continuous infusion for 10-14 days, or procaine penicillin,2.4 million units lM daily, plus probenecid, 500 mg PO fourtimes daily, both for 10-14 days lM = intramuscularly; lV = intravenously; PO = orally. treated with the appropriate penicillin regimen as outlined above. cannot take ceftriaxone, penicillin desensitization is recommended. Those with a confirmed positive result and no history of syphi l(tY P0l ilIS (continuedl lis treatment should be offered treatment for syphilis of o Secondary and tertiary syphilis diagnosis relies on sero- unknown duration. logic testing; patients with a positive enzyme immuno- Syphilis treatment is outlined in Table 32. Sexual partners assay result and positive rapid plasma reagin or Venereal of those with primary, secondary or early latent syphilis Disease Research Lab test result and no history of syphi- exposed in the preceding 90 days should be treated regardless lis treatment should be offered treatment for syphilis of of serologic results. unknown duration. XEY POIT{TS o Primary syphilis presents as a painless genital ulcer Chancroid and Lymphogranuloma Venereum (chancre) with a raised regular border that demon- Except for proctitis or proctocolitis caused by the LGV serovars strates firm induration on palpation; lesions heal spon- of C. trachomatis, these two STIs are rarely seen in the United taneously in 3 to 6 weeks even without treatment. States. The clinical presentation, evaluation, and treatment are o The most common manifestation of secondary q4philis is outlined in Table 33. rash, with characteristic involvement of the palms and soles; in intertriginous areas, papules may coalesce to form Genital Warts condyloma lata, and mucous patches may occur in the oral Genital warts have a variety of appearances, including cavlty and moist genital regions and are highly infectious. papular or pedunculated lesions (Figure 25). Larger, (Continued) verrucous, exophytic lesions can occur. Most are

Those with a confirmed positive result and no history of syphi l(tY P0l ilIS (continuedl lis treatment should be offered treatment for syphilis of o Secondary and tertiary syphilis diagnosis relies on sero- unknown duration. logic testing; patients with a positive enzyme immuno- Syphilis treatment is outlined in Table 32. Sexual partners assay result and positive rapid plasma reagin or Venereal of those with primary, secondary or early latent syphilis Disease Research Lab test result and no history of syphi- exposed in the preceding 90 days should be treated regardless lis treatment should be offered treatment for syphilis of of serologic results. unknown duration. XEY POIT{TS o Primary syphilis presents as a painless genital ulcer Chancroid and Lymphogranuloma Venereum (chancre) with a raised regular border that demon- Except for proctitis or proctocolitis caused by the LGV serovars strates firm induration on palpation; lesions heal spon- of C. trachomatis, these two STIs are rarely seen in the United taneously in 3 to 6 weeks even without treatment. States. The clinical presentation, evaluation, and treatment are o The most common manifestation of secondary q4philis is outlined in Table 33. rash, with characteristic involvement of the palms and soles; in intertriginous areas, papules may coalesce to form Genital Warts condyloma lata, and mucous patches may occur in the oral Genital warts have a variety of appearances, including cavlty and moist genital regions and are highly infectious. papular or pedunculated lesions (Figure 25). Larger, (Continued) verrucous, exophytic lesions can occur. Most are TABLE 33. Clinical Presentation, Diagnosis, and Treatment of Chancroid and Lymphogranuloma Venereum Clinical Entity Causative Agent Presentation Diagnosis Recommended Regimen Chancroid Haemophilus Painful genital ulcer; Culture is difficult; consider Azithromycin, 1 g PO single ducreyi tender inguinal lymph diagnosis if painful ulcer with dose, or ceftriaxone,250 mg nodes, which often tender and suppurative regional lM single dose, or suppurate lymphadenopathy, no evidence of ciprofloxacin, 500 mg PO syphilis by dark-field examination twice daily for 3 days, or or serology, and negative HSV PCR erythromycin base, 500 mg or HSV culture PO three times dailyfor 7 days

TABLE 33. Clinical Presentation, Diagnosis, and Treatment of Chancroid and Lymphogranuloma Venereum Clinical Entity Causative Agent Presentation Diagnosis Recommended Regimen Chancroid Haemophilus Painful genital ulcer; Culture is difficult; consider Azithromycin, 1 g PO single ducreyi tender inguinal lymph diagnosis if painful ulcer with dose, or ceftriaxone,250 mg nodes, which often tender and suppurative regional lM single dose, or suppurate lymphadenopathy, no evidence of ciprofloxacin, 500 mg PO syphilis by dark-field examination twice daily for 3 days, or or serology, and negative HSV PCR erythromycin base, 500 mg or HSV culture PO three times dailyfor 7 days LGV L1,L2, and L3 Painless genital papule NAAT f or C. trachomatis; does not Doxycycline", 100 mg PO serovars of or ulcer with unilateral distinguish the serovars, so twice daily for 21 days Chlamydia tender inguinal diagnosis is made based on clinical (preferred ), or eryth romyci n trachomatis lym phadenopathy; and epidemiologic findings base, 500 mg PO four times proctitis, proctocol itis daily for 21 days (alternate) in MSIr/ HSV = herpes simplex virus; lM = intramuscularly; LGV = lymphogranuloma venereum; MSM = men who have sex with men; NAAT = nucleic acid amplification test; PCR = polymerase chain reaction; PO = orally.

LGV L1,L2, and L3 Painless genital papule NAAT f or C. trachomatis; does not Doxycycline", 100 mg PO serovars of or ulcer with unilateral distinguish the serovars, so twice daily for 21 days Chlamydia tender inguinal diagnosis is made based on clinical (preferred ), or eryth romyci n trachomatis lym phadenopathy; and epidemiologic findings base, 500 mg PO four times proctitis, proctocol itis daily for 21 days (alternate) in MSIr/ HSV = herpes simplex virus; lM = intramuscularly; LGV = lymphogranuloma venereum; MSM = men who have sex with men; NAAT = nucleic acid amplification test; PCR = polymerase chain reaction; PO = orally. "Doxycyline should be avoided or used with caution in pregnant patients. 50

Osteomyelitis Clinical Manifestations Osteomyelitis commonly presents as subacute or chronic pain over the affected region of bone. If osteomyelitis has resulted from direct contamination of a wound, the wound may fail to heal or may reopen after healing. Spontaneously opening wounds accompanied by drainage (sinus tracts) are a manifes- tation of chronic infection. Underlying osteomyelitis should be considered when chronic wounds, such as pressure ulcers, do not respond to appropriate therapy. Fever and other systemic manifestations of infection are uncommon but are more likely in patients with acute hematogenously disseminated infec- tion. Clinical findings in patients with diabetes-associated foot ulcer osteomyelitis and vertebral osteomyelitis are discussed separately. FIG URE 2 5. Genital warts caused by human papillomavirus infection are typically flesh colored and exophytic; pedunculated lesions often occur. XEY POITTS . Chronic osteomyelitis frequently presents as subacute to chronic pain over the affected region of bone; fever asymptomatic; however, large lesions may cause irritation and other systemic manifestations of infection are or pain depending on their location. Nononcogenic types of uncommon. human papillomavirus (HPV) are responsible for most lesions. Specific testing for HPV is not recommended for . Underlying osteomyelitis should be considered when diagnosis. chronic wounds, such as pressure ulcers, do not respond Warts often resolve without therapy, but treatment is to appropriate therapy. indicated for symptomatic warts or psychological distress. Patients should be counseled that successful treatment might not eliminate the risk of transmission. Patient- Diagnosis applied therapies include imiquimod, podofilox, and sine- Laboratory and lmaging Studies catechins; provider-administered therapies include An elevated erythrocyte sedimentation rate or C-reactive trichloroacetic or bichloroacetic acid, cryotherapy with liq- protein level increase the probability of infection and are uid nitrogen or cryoprobe, or surgical removal. No evidence useful in monitoring therapeutic r€Spofls€; normal inflam- indicates any recommended modality is superior. Ulcerated matory markers do not exclude the diagnosis. Except in acute or pigmented warts and those that fail to respond to or hematogenous osteomyelitis, leukocytosis is uncommon; in worsen after therapy should be biopsied to exclude a can- chronic osteomyelitis, anemia may be present. Blood culture cerous lesion. results are rarely positive, except in patients with hematoge- nous osteomyelitis. Blood cultures should be obtained when I(EY POI TI hematogenous osteomyelitis (e.g., vertebral osteomyelitis) is o Nononcogenic types of human papillomavirus are suspected or in patients with systemic manifestations of responsible for most genital warts, which often resolve sepsis. without therapy. Plain radiography can confirm the diagnosis in most patients if typical findings are present but cannot exclude the diagnosis if negative. Because of its low cost and specificity, plain radiography is recommended as an initial imaging test. If Osteomyelitis a plain radiograph is not diagnostic, MRI, with and without Osteomyelitis is a result of hematogenous dissemination or intravenous contrast, is preferred (Figure 26). If MRI cannot be contiguous spread of bacteria. Hematogenous osteomyelitis obtained, CT with intravenous contrast is an alternative. in adults most commonly affects vertebral bodies, particu- Nuclear medicine studies are less sensitive and specific for larly in persons who inject drugs. Contiguous-spread osteo- osteomyelitis but can be used when neither CT with contrast myelitis may arise from direct contamination (fracture, nor MRI are possible. joint replacement, orthopedic implant), wounds (pressure KEY POIlII sores, foot ulcers), or adjacent soft tissue infection. . Because of its low cost and specificity, plain radiography HVC Population-based studies suggest the incidence of osteomy- is recommended as an initial imaging test for suspected elitis among adults is increasing in the United States, most osteomyelitis; if radiography is negative, MRI, with and likely because of the increasing prevalence of diabetes without intravenous contrast, should be obtained. mellitus.

Clinical Manifestations Osteomyelitis commonly presents as subacute or chronic pain over the affected region of bone. If osteomyelitis has resulted from direct contamination of a wound, the wound may fail to heal or may reopen after healing. Spontaneously opening wounds accompanied by drainage (sinus tracts) are a manifes- tation of chronic infection. Underlying osteomyelitis should be considered when chronic wounds, such as pressure ulcers, do not respond to appropriate therapy. Fever and other systemic manifestations of infection are uncommon but are more likely in patients with acute hematogenously disseminated infec- tion. Clinical findings in patients with diabetes-associated foot ulcer osteomyelitis and vertebral osteomyelitis are discussed separately. FIG URE 2 5. Genital warts caused by human papillomavirus infection are typically flesh colored and exophytic; pedunculated lesions often occur. XEY POITTS . Chronic osteomyelitis frequently presents as subacute to chronic pain over the affected region of bone; fever asymptomatic; however, large lesions may cause irritation and other systemic manifestations of infection are or pain depending on their location. Nononcogenic types of uncommon. human papillomavirus (HPV) are responsible for most lesions. Specific testing for HPV is not recommended for . Underlying osteomyelitis should be considered when diagnosis. chronic wounds, such as pressure ulcers, do not respond Warts often resolve without therapy, but treatment is to appropriate therapy. indicated for symptomatic warts or psychological distress. Patients should be counseled that successful treatment might not eliminate the risk of transmission. Patient- Diagnosis applied therapies include imiquimod, podofilox, and sine- Laboratory and lmaging Studies catechins; provider-administered therapies include An elevated erythrocyte sedimentation rate or C-reactive trichloroacetic or bichloroacetic acid, cryotherapy with liq- protein level increase the probability of infection and are uid nitrogen or cryoprobe, or surgical removal. No evidence useful in monitoring therapeutic r€Spofls€; normal inflam- indicates any recommended modality is superior. Ulcerated matory markers do not exclude the diagnosis. Except in acute or pigmented warts and those that fail to respond to or hematogenous osteomyelitis, leukocytosis is uncommon; in worsen after therapy should be biopsied to exclude a can- chronic osteomyelitis, anemia may be present. Blood culture cerous lesion. results are rarely positive, except in patients with hematoge- nous osteomyelitis. Blood cultures should be obtained when I(EY POI TI hematogenous osteomyelitis (e.g., vertebral osteomyelitis) is o Nononcogenic types of human papillomavirus are suspected or in patients with systemic manifestations of responsible for most genital warts, which often resolve sepsis. without therapy. Plain radiography can confirm the diagnosis in most patients if typical findings are present but cannot exclude the diagnosis if negative. Because of its low cost and specificity, plain radiography is recommended as an initial imaging test. If Osteomyelitis a plain radiograph is not diagnostic, MRI, with and without Osteomyelitis is a result of hematogenous dissemination or intravenous contrast, is preferred (Figure 26). If MRI cannot be contiguous spread of bacteria. Hematogenous osteomyelitis obtained, CT with intravenous contrast is an alternative. in adults most commonly affects vertebral bodies, particu- Nuclear medicine studies are less sensitive and specific for larly in persons who inject drugs. Contiguous-spread osteo- osteomyelitis but can be used when neither CT with contrast myelitis may arise from direct contamination (fracture, nor MRI are possible. joint replacement, orthopedic implant), wounds (pressure KEY POIlII sores, foot ulcers), or adjacent soft tissue infection. . Because of its low cost and specificity, plain radiography HVC Population-based studies suggest the incidence of osteomy- is recommended as an initial imaging test for suspected elitis among adults is increasing in the United States, most osteomyelitis; if radiography is negative, MRI, with and likely because of the increasing prevalence of diabetes without intravenous contrast, should be obtained. mellitus. 51