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Gonorrhea and Chlamydia Background Gonorrhea, caused by Neisseria gonorrhoeae (GC), and chlamydia, caused by Chlamydia trachomatis (CT), are sexually transmitted infections (STIs). These infections may be transmitted during oral, vaginal, or anal sex; they can also be transmitted from the mother to baby during delivery and cause significant illness in the infant. Both organisms can infect the urethra, oropharynx, and rectum in women and men; the epididymis in men, and the cervix, uterus, and fallopian tubes in women. Untreated GC or CT in women may lead to pelvic inflammatory disease, which can cause scarring of the fallopian tubes and result in infertility or ectopic pregnancy (tubal pregnancy). The organisms can also affect other sites; N gonorrhoeae can cause disseminated infection involving the skin, joints, and other systems. Certain strains of CT can cause lymphogranuloma venereum (LGV). This infection is common in parts of Africa, India, Southeast Asia, and the Caribbean. Outbreaks among men who have sex with men (MSM) have been reported over the past several years in Europe and the United States. LGV may cause genital ulcers followed by inguinal adenopathy; it can also (as in the recent cases in MSM) cause gastrointestinal symptoms, notably anorectal discharge and pain. Patients with symptoms of gonorrhea or chlamydia should be evaluated and treated as indicated below. Although GC or CT urethritis in men typically causes symptoms, urethral infection in women and oral or rectal infections in both men and women often cause no symptoms. In fact, a substantial number of individuals with GC or CT infection have no symptoms. Thus, sexually active individuals at risk for GC and CT should receive regular screening for these infections as well as for syphilis and other STIs. Patients are frequently infected with both N gonorrhoeae and C trachomatis, so they should be tested and treated for both. S: Subjective Section 6—Disease-Specific Treatment | 6–33 Symptoms will depend on the site of infection (eg, oropharynx, urethra, cervix, rectum). Symptoms are not present in all patients. If symptoms are present, women may notice: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Vaginal discharge Urinary hesitancy Pain with sexual intercourse Pain or burning on urination Abdominal or pelvic pain Sore throat Mouth sores Rectal discharge Anal discomfort If symptoms are present, men may notice: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Increased urinary frequency or urgency Urethral discharge Red or swollen urethra Incontinence Pain on urination Testicular tenderness or pain Rectal discharge Anal discomfort During the history, ask the patient about the following: ♦ ♦ ♦ ♦ ♦ ♦ Any of the symptoms listed above, and their duration Previous diagnosis of gonorrhea or chlamydia New sex partner(s) Unprotected sex (oral, vaginal, anal) Use of an intrauterine device Last menstrual period, and whether the patient could be pregnant
6–34 | Clinical Manual for Management of the HIV-Infected Adult/2006 O: Objective Physical Examination During the physical examination, check for fever and document other vital signs. In women, focus the physical examination on the mouth, abdomen, and pelvis. Inspect the oropharynx for discharge and lesions; check the abdomen for bowel sounds, distention, rebound, guarding, masses, and suprapubic or costovertebral angle tenderness; perform a complete pelvic examination for abnormal discharge or bleeding; check for uterine, adnexal, or cervical motion tenderness; and search for pelvic masses or adnexal enlargement. Check the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy. In men, focus the physical examination on the mouth, genitals, and anus/rectum. Check the oropharynx for discharge and lesions, the urethra for discharge, the external genitalia for other lesions, and the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy. A: Assessment A partial differential diagnosis includes the following: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Urinary tract infection Dysmenorrhea Appendicitis Cystitis Proctitis Pelvic inflammatory disease (PID) Irritable bowel syndrome Pyelonephritis P: Plan Diagnostic Evaluation Test for oral, urethral, or anorectal infection, according to symptoms and possible exposures. Perform concurrent testing for both gonorrhea and chlamydia. The availability of the various testing methods depends on the clinical site. Consider the following: ♦ ♦ ♦ ♦ ♦ Gram stain (pharyngeal, cervical, or urethral discharge) Culture (oropharynx, endocervix, urethra, rectum) Nucleic acid amplification test (NAAT): urine specimens (first stream) and urethral, vaginal, and endocervical swab specimens; has also been used for pharyngeal and rectal swab specimens, although it is not currently approved for this use Nucleic acid hybridization assay (DNA probe): endocervical and male urethral swab specimens Serologic tests (microimmunofluorescence test or complement fixation test) for suspected LGV Treatment Treatments for gonorrhea and chlamydia are indicated below. High rates of fluoroquinolone-resistant N gonorrhoeae exist in California, Hawaii and the Pacific Islands, Asia, and Great Britain. Fluoroquinoloneresistant GC is also common among MSM in the United States. Thus, the U.S. Centers for Disease Control and Prevention (CDC) recommends that fluoroquinolones not be used for treatment of GC in MSM or in any patient infected in the areas listed above, unless antimicrobial susceptibility test results are used to guide therapy. Because dual infection is common, patients diagnosed with either GC or CT should receive empiric treatment for both infections, unless the other infection has been ruled out. Reinfection is likely if reexposure occurs. Any sex partners within the last 60 days, or the most recent sex partner from >60 days before diagnosis, also should receive treatment. Patients should abstain from sexual activity for 7 days after a single-dose treatment or until a 7-day treatment course is completed. Adherence is essential for treatment success. Singledose treatments maximize the likeliness of adherence and are preferred. Other considerations in choosing the treatment include antibiotic resistance, cost, allergies, and pregnancy. For further information, see the CDC STD treatment guidelines and the revised recommendations (references below).
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Table of Contents Clinical Manual f
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Patient Education ♦ ♦ ♦ ♦
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Page 254 and 255: Cryptosporidiosis Background Crypto
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Page 270 and 271: Hepatitis B Infection Background He
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Page 274 and 275: Hepatitis C Infection Background He
Page 276 and 277: pregnancy. Ribavirin is teratogenic
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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