Recent Review Article Highlights Chlamydia, Neisseria, PID, and Genital herpes
 

A recent review article by Richard A. Johnson, MD, in Clinical Cornerstone considers the current diagnoses and treatments of three common sexually transmitted infections in women, Chlamydia trachomatis, Neisseria gonorrhoeae, and Herpes simplex virus, paying particular attention to the 1998 Guidelines for Treatment of Sexually Transmitted Diseases from the Centers for Disease Control and Prevention (CDC). This article also discusses the issues surrounding the impact of screening asymptomatic sexually active individuals.
 

Following is a summary of the findings adapted from the review article but readers are encouraged to read the entire review article (free registration required at Medscape.com).
 

Chlamydia trachomatis
 

This is the most commonly reported sexually transmitted disease in the United States. The majority of infections are asymptomatic and the organism remains latent in infected individuals for months to years but continues to infect sexual partners. Development of immunity following infection is unlikely and reinfection is common in sexually active patients.
 

Diagnosis
 

• Tissue Culture; Pap tests are of no value.

   

• Serologic techniques, such as direct fluorescent antibody (DFA) and enzyme immunoassay (EIA). EIAs can be office-based and are quick and are especially useful in situations where patient follow-up may be problematic.

   

• DNA amplification (ligase chain reaction (LCR) and polymerase chain reaction (PCR)) is the new gold standard.

Treatment
 

• Doxycycline or azithromycin has been shown to be equally effective and either is recommended.

   

• Azithromycin has been shown to be effective in pregnant patients and recommended for this population.

   

• Table I from the review lists other current acceptable treatments.

   

• Test-of-cure testing is not generally recommended for C. trachomatis infections if any of the recommended or alternative treatments is employed because of the high success rate with these treatments.

Neisseria gonorrhoeae
 

N. gonorrhoeae infections are less common than chlamydial infections but about 600,000 new cases appear annually. In men, infection is usually symptomatic so treatment is usually sought, although transmission to other sexual partners can occur prior to treatment. In women, infection is generally asymptomatic until the development of pelvic inflammatory disease (PID).
 

Diagnosis
 

• Culture on Thayer-Martin agar.

   

• Gram stain of urethral or cervical secretions.

   

• DNA amplification techniques, such as LCR and PCR, are almost 100 percent specific.

Treatment
 

• Coinfection with both C. trachomatis and N. gonorrhoeae is sufficiently high to justify dual therapy for both organisms, in the absence of specific culture or LCR/PCR data to the contrary.

   

• The cephalosporins cefixime or ceftriaxone are effective single-dose therapy options.
• Many quinolones are effective against N. gonorrhoeae, but quinolone resistance is increasing.

   

• Test-of-cure testing is not generally recommended for N. gonorrhoeae infections if any of the recommended or alternative treatments is employed because of the high success rate with these treatments.

   

• Table II of the review article provides a list of acceptable treatments.

Pelvic Inflammatory Disease (PID)
 

PID is a serious condition resulting from the breakdown of the antimicrobial protective physiology of the woman's upper genital tract. This condition frequently results from an ascending infection with either N. gonorrhoeae or C. trachomatis. The scarring and inflammation that results may lead to tubal abnormalities.
 

Diagnosis
 

• Symptoms are mild or subtle and thus diagnosis can be difficult.

   

• Laparoscopy, but this is not usually practical.

   

• History-taking and examination are the usual methods for diagnosis, recognizing that inaccuracy of diagnosis is probable.

   

• Frequent follow-up and examination to ensure resolution of symptoms or to evaluate for the possibility of a misdiagnosis is thus recommended.

Treatment
 

• Experts believe that early treatment will forestall extensive tissue damage and thus recommend empiric treatment.

   

• CDC recommends that empiric treatment be commenced for PID in sexually active young women if all of the following minimum criteria are present and no other cause for illness can be determined:.

   

  1. Lower abdominal tenderness.
  2. Adnexal tenderness.
  3. Cervical motion tenderness.
• If a woman is symptomatic with PID, there is the strong likelihood that she has a polymicrobial infection that includes infection with either N. gonorrhoeae or C. trachomatis, gram-negative bacteria, anaerobes, and streptococci.

   

• A broad-spectrum antibiotic therapy is thus recommended, such as ofloxacin plus metronidazole in an ambulatory setting or cefotetan or cefoxitin plus doxycycline in a parenteral setting.

   

• Table III in the review article provides a listing of possible interventions.

   

• Follow-up in 72 hours is recommended if treatment is occurring in an ambulatory setting.

   

• Hospitalization should be considered if:

   

  1. 1.Surgical emergencies, such as appendicitis, cannot be excluded.
  2. The patient is pregnant.
  3. The patient is not responding to oral antimicrobial therapy.
  4. The patient cannot follow an outpatient oral antibiotic regimen.
  5. The patient has severe illness, nausea and vomiting, or high fever.
  6. The patient has a tubo-ovarian abscess.
  7. The patient is immunocompromised.

Herpes Simplex Virus
 

More than 25 percent of the US population is infected with human herpesvirus 2 (HHV-2), the virus responsible for over 90 percent of genital herpes infections. Less than a fifth of those infected will have any history of symptoms recognizable as that of clinical genital herpes. During a symptomatic occurrence of HHV-2, viral shedding can be determined in over 67 percent of patients. However, HHV-2-infected individuals who are externally asymptomatic will shed intact HHV-2 virus from their perineums and in genital secretions approximately 3 percent of the time. Thus, avoidance of sexual contact on only those days where there are external lesions is NOT effective at preventing transmission of the virus. Additionally, data indicates that the majority of the spread of HHV-s occurs from individuals who are unaware of their HHV-s infection. HHV-2 infecton is extremely serious in immunocompromised patients and infants. Infection with HHV-2 late in the final trimester of pregnancy is associated with a greater incidence of neonatal HHV-2 infection.
 

Diagnosis
 

• Usually made on clinical grounds, with exclusion of other causes of genitourinary ulceration.

   

• DNA amplification techniques now available offering high diagnostic accuracy.

Treatment
 

• For primary or recurrent episodes, or in order to suppress episodes, acyclovir, famciclovir, or valacyclovir are recommended, but in different regimens. Table V of the review article provides this information.

   

• Studies support treating primary HHV-2 infections and also support treating patients with frequent recurrent episodes with daily therapy for suppression.
• Treatment for INDIVIDUAL episodes of recurrent HHV-2 genital ulcers is minimally effective.

   

• Topical treatment with acyclovir cream is not effective and is NOT FDA-approved for treatment of recurrent lesions in non-immunocompromised patients.

   

• Topical treatment with penciclovir cream is FDA-approved in normal individuals but must be applied within an hour of onset of symptoms.