# Episode 202: Sexually Transmitted Infections 2.0

An episode of [Core EM - Emergency Medicine Podcast](https://invisiblenetwork.ai/podcast/1005774516), 1 Nov 2024.

Audio: https://media.blubrry.com/coreem/content.blubrry.com/coreem/Sexually_Transmitted_Infections_2_0.mp3

We review Sexually Transmitted Infections and pertinent updates in diagnosis and management. Hosts: Avir Mitra, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Sexually_Transmitted_Infections_2_0.mp3 Download Leave a Comment Tags: gynecology, Infectious Diseases, Urology Show Notes Table of Contents (1:49) Chlamydia (3:31) Gonorrhea (4:50) PID (6:14) Syphilis (8:08) Neurosyphilis (9:13) Tertiary Syphilis (10:06) Trichomoniasis (11:13) Herpes (12:49) HIV (14:10) PEP (15:13) Mycoplasma Genitalium (18:00) Take Home Points Chlamydia: • Prevalence: • • • Most common STI. • High percentage of asymptomatic cases (40% to 96%). • Presentation: • • • Urethritis, cervicitis, pelvic inflammatory disease (PID), prostatitis, proctitis, pharyngitis, arthritis. • Importance of considering extra-genital sites (oral and rectal infections). • Testing: • • • Gold Standard: Nucleic Acid Amplification Test (NAAT) via PCR. • Sampling Sites: • • • • Endocervical or urethral swabs preferred over urine samples due to higher sensitivity. • Triple-site testing (genital, rectal, pharyngeal) recommended for comprehensive detection. • Treatment Updates: • • • Previous Regimen: Azithromycin 1 g orally in a single dose. • Current First-Line Treatment: Doxycycline 100 mg orally twice daily for 7 days. • Alternatives: • • • Azithromycin remains an option for patients unlikely to adhere to a 7-day regimen or for pregnant patients. • Note: PID treatment differs and will be discussed separately. Gonorrhea: • Presentation: • • • Similar to chlamydia; can be asymptomatic. • Symptoms include urethritis, cervicitis, PID, prostatitis, proctitis, pharyngitis. • Testing: • • • Gold Standard: NAAT. • Sampling Sites: • • • • Endocervical swabs are more sensitive than urine samples. • Triple-site testing is crucial to avoid missing infections. • Treatment Updates: • • • Previous Regimen: Ceftriaxone 250 mg IM plus azithromycin 1 g orally. • Current Recommendation: Ceftriaxone 500 mg IM single dose. • Adjusted due to rising azithromycin resistance and updated pharmacokinetic data. • Co-Infection Considerations: • • High rates of chlamydia and gonorrhea co-infection (20% to 40%). • CDC recommends empiric treatment for chlamydia when treating gonorrhea to prevent complications like PID and infertility. Pelvic Inflammatory Disease (PID): • Etiology: • • • Not solely caused by chlamydia and gonorrhea; about 50% of cases involve other pathogens like bacterial vaginosis (BV) organisms and anaerobes. • Treatment Changes: • Expanded Coverage Regimen: • • • Ceftriaxone 500 mg IM once. • Doxycycline 100 mg orally twice daily for 14 days. • Metronidazole 500 mg orally twice daily for 14 days. • Inclusion of metronidazole addresses anaerobic bacteria contributing to PID. Syphilis: • Stages and Presentation: • Primary Syphilis: • • • Painless chancre on genitals. • Treatment: Penicillin G 2.4 million units IM single dose. • Secondary Syphilis: • • • Rash (often diffuse), mucocutaneous lesions, nonspecific joint pain. • Treatment: Same as primary syphilis. • Latent Syphilis: • • • Asymptomatic phase; divided into early (<1 year) and late (>1 year). • Treatment for Late Latent: • • Penicillin G 2.4 million units IM once weekly for 3 weeks. • Recommended when the timing of infection is unclear. Neurosyphilis: • Can occur at any stage. • Symptoms include visual changes, severe headaches, neurological deficits. • Diagnosis: Requires lumbar puncture (LP) for confirmation. • Treatment: Admission for intravenous penicillin G. Tertiary Syphilis: • Rare, advanced stage with severe manifestations (e.g., gummas, cardiovascular complications, neurological signs). • Treatment: Extended penicillin therapy similar to late latent syphilis. Trichomoniasis: • Presentation: • • • Often asymptomatic. • In women: Vaginal discharge. • In men: Urethritis. • Testing: • •…

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