Canadian Guidelines on Sexually Transmitted disease:
    (attached is the recent PDF at time of this writing - May 16, 2012)
     
     
    STIChart.png
     

    External Genitalia Infections

    • HPV
    • HSV
      • HSV1 and HSV2 can cause primary genital infection.
      • HSV1 less asymptomatic shedding.
      • Diagnosis should be confirmed with viral cultures or PCR.  (Direct fluorescent antibody sensing worse test).
      • Generally, systemic symptoms (such as fever) are common in the primary infection.
      • Initiate prompt treatment.
        • Acyclovir, Valacyclovir, Famcyclovir x 7-10days.
        • Acyclovir  (3x/day) - generic, cheapest.
        • Valacyclovir (BID).
        • Famcyclovir (3x/day)
      • Chronic therapy with valacyclovir has been shown to reduce transmission rates.
      • Counsel risk of recurrence of transmission. Educate risk of neonatal infection.
    • Syphilis

    Vaginal Infections

    • Investigations of discharge
      • pH test, wet mount, KOH whiff test
      • Gram Stain
      • Culture
        • Although vaginosis is best diagnosed with wet mount, wet mounts are 50-60% sensitive for T. vaginalis & yeast, so culture is useful.
        • Useful for identifying other species of yeast (not just Candida albicans)
     Criteria Normal   Bacterial Vaginosis  Trichomonas Vaginitis  Candida vulvovaginitis
     Vaginal pH  3.8-4.2  >4.5  >4.5  <4.5 (NORMAL)
     Discharge  White, clear, flocculent  Thin, homogenous, white, grey, adherent, often increased  Yellow-green, frothy, adherent, increased  White, curdy, "cottage cheese like" sometimes increased
     Amine Odour (KOH Whiff Test)  Absent  Present (fishy)  May be present (fishy)  Absent
     Primary Symptoms  None  Discharge, bad odour (possibly worse after intercourse)
    Possible Itching
     Frothy discharge, vulvar pruritis, dysuria
    Sometimes bad odour, usually not.

     Itching/burning discharge

     

    "Complicated" if extensive vulvar erythema, edema, excoriation, and figure formation

     Microscopy  Lactobacilli, epithelial cells  Clue cells - epithelial cells with stippled borders due to adhering  coccoid bacteria, no WBC.  Trichomonas, WBC >10/hpf (flagellated cells)  Budding yeast, hyphae, pseudohyphae
     Treatment  

    metronidazole 500mg po bid x7d
    OR

    metronidazole cream

    OR
    Clindamycin cream or oral- 
    - No tx for male partner

    - No clindamycin for pregnancy

     metronidazole 2g po x1
    - Treat male sex partner

    Imidazole Therapy:

    Uncomplicated: 

    - Topical clotrimazole x7days

       OR oral fluconazole 150mg one dose.

     

    Complicated:

    - Clotrimazole topical 14d

    OR fluconazole oral 150mg x2 doses

     

    Recurrent VVC (>4x/year)

    - Intravaginal boric acid

     

    Non-albicans (recurrent)

    - voriconazole 7-14d (oral or topical)

     

    Oral fluconazole (Preg Category C - unknown) avoid.

    (nystatin less effective)

    - No tx for male partner (usually)

    DX Criteria  

    Amsel criteria:  (≥3 = yes)

    1. Homogeneous thin d/c
    2. Clue cells
    3. pH > 4.5
    4. Fishy order (before or after 10% KOH)

    Gold standard: Gram stain

       
     
    • Bacterial 

    clueCells.jpg

    Clue Cells

    Cervical Infections

    Treatment:
        Chlamydia
    • Need swab + nucleic acid amplification testing (NAAT)
    • Treat with:
      • Non-pregnant/non-lactating: doxycicline 100mg PO bid x7d
        • OR azithromycin 1g PO single dose (if poor compliance)
      • Pregnant/lactating:
        • Amox 500mg PO tid x7d
        • Erythromycin 2g/d PO 7d
        • Azithromycin 1g PO x1 dose
        Nisseria Gonorrhea
    • Need culture + sensitivity (may be negative in first 48hrs of contact)
    • Gram stain
    • Treat with:
      • Quinolone (cipro, ofloxacin) resistant in Canada
      • Also treat Chlamydia unless test is negative.
      • First line:
        • Ceftriaxone 250 mg IM + azithromycin 1g PO (for chlamydia, often concurrent)
      • Second line (if allergy or first-line not available)
        • Cefixime 400mg PO x1dose + azithromycin 1g PO
          OR:
        • Spectinomycin 2g IM + azithromycin 1g PO
          OR:
        • Azithromycin 2g PO
    • Need test of cure if using 2nd line, or if risk factors of tx failure
    • Risk factors for tx failure:
      • pharyngeal/rectal infection
      • Pregnancy
      • Potential reduced susceptibility
      • Potential tx failure
    • Test of cure:
      • Culture ≥4 days post treatment (preferred)
      • NAAT ≥2 weeks post treatment (alterantive)  (see infective disease)
    • For more info (see Public Health Ontario "Testing and Treatment of Gonorrhea in Ontario 2013" Quick reference guide)
    •  
      • GonorrheaTesting.png
      • Screen shot 2013-09-03 at 7.54.27 PM.png

     

     

     

    Urine vs Swab

    (Based on Toronto Public Health)

    Test - Chlamydia Sensitivity %   Specificity %   Recommendation
    Female Swab 88.9-98.4% 95.6-97.6%
    • Symptomatic for STI

    or

    • Due for Pap Test

    or

    • Had sexual contact with person infected with Chlamydia
    Female Urine 74.2-88.2% 96.0-98.0%
    • Not due for Pap

    or

    • Patient refuses pelvic exam

    or

    • Menstruating
    Male Swab 88.8-98.0% 89.1-93.8%  
    Male Urine 88.7-98.0% 86.1-91.5%  

     

    Upper Tract - Pelvic Inflammatory Disease (PID)

    • Very low theshold to diagnose due to high risk of infertility or future ectopic pregnancies.
    • Diagnose and treat PID in any woman with:
      • abdominal pain or pelvic pain
        AND
      • has cervical motion tenderness, adnexal tenderness, or uterine tenderness.
    • Always considered polymicrobial.
      • Must include coverage for N. gonorrhea, Chlamydia, aerobic gram negative rods, anaerobes.
    • Early follow-up within 72hrs must be arranged.
    • Hospitalization if:
      • Do not respond with oral therapy or cannot take oral therapy (nausea/vomiting)
      • If systemic signs and symptoms
    • Male partners of women with PID with sexual contact within 60 days should be referred for evaluation and treatment.
    Treatment:
        Regimen A15
    • Ceftriaxone 250mg IM in single dose PLUS doxycycline 100mg PO bid for 14 days
      • Many experts recommend adding metronidazole 500mg po bid x14d
    • OR:
    • Cefoxitin 2g IM PLUS probenecid 1g PO in single dose concurently once PLUS doxycycline 100mg PO bid x14d
    • OR
    • Other parenteral 3rd gen cephalosporin (ceftizoxime or cefotaxime) PLUS doxycycline 100mg PO bid x14d
        Regimen B16: (can also add metronidazole 500mg bid po x14d)
    • Ofloxacin 400mg PO bid x14d PLUS/MINUS metronidazole 500mg PO bid x14d
    • OR
    • Levofloxacin 500mg PO qd PLUS/MINUS metronidazole 500mg PO bid x14d.

    NOTES:

    • If admitted, often gentamycin + clinda is a choice (check newest guidelines)
    • Ciprofloxacin - no longer used for Neisseria gonorrhea due to increasing fluoroquinolone resistance.
    • IM ceftriaxone + oral azithromycin --> Appropriate for cervicitis but not PID

    Reporting

    • The following are reportable in Canada:
      • Gonococcal
      • Chlamydia
      • syphilis
      • Herpes (in some jurisdictions)
    ...end of document
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