Pharmacotherapy of Sexually Transmitted Diseases

Pharmacotherapy of Sexually Transmitted Diseases

Nicholas Tsourounis, PharmD Candidate 2007

Epidemiology1 / ·  Direct medical costs associated with STDs in the United States are estimated at $13 billion annually
·  Chlamydia
o  The most commonly reported infectious disease in the United States
o  976,445 cases of Chlamydia diagnoses were reported in 2005, and increase of 50,000 cases from the previous year
o  There are an estimated 2.8 million new cases of Chlamydia in the United States each year
·  Gonorrhea
o  The second most commonly reported infectious disease in the United States
o  There were 339,593 cases reported in 2005
o  This was the first increase in the number of cases per year since 1999
·  Syphilis
o  In 200 syphilis rates reached an all-time low, and the rates have been increasing ever since
o  In 2005 there were 8724 cases of primary and secondary syphilis reported, 8,176 cases of early latent syphilis, and 16,049 cases of late-latent, tertiary, and congenital syphilis for a total number of 33,278 cases of all stages of syphilis
·  Trichomoniasis
o  Trichomoniasis is the most common curable STD in young, sexually active women
o  An estimated 7.4 million new cases occur each year
·  HPV
o  Roughly 20 million people are currently infected with HPV
o  An estimated 50 percent of sexually active men and women acquire genital HPV infection at some point in their lives
o  By age 50, at least 80 percent of women will have acquired genital HPV infection
o  Around 6.2 million Americans get a new genital HPV infection each year
·  Herpes (HSV)
o  at least 45 million people ages 12 and older have had a genital HSV infection
·  Hepatitis B
o  In 2004, an estimated 60,000 people were infected with HBV
o  Every year 5,000 Americans will die of HBV related illnesses
·  Hepatitis C
o  Hepatitis C infection is the most common chronic bloodborne infection in the United States
o  Approximately 2.7 million persons are chronically infected
Disease State Definition / ·  Chlamydia - a sexually transmitted bacterial infection caused by the organism Chlamydia trachomatis
·  Gonorrhea – a sexually transmitted bacterial infection caused by the organism Neisseria gonorrhea.
·  Syphilis - a sexually transmitted bacterial infection caused by the organism Treponema pallidum
·  Trichomoniasis – A sexually transmitted disease caused by a single-celled protozoan parasite call Trichomonas vaginalis that affects both men and women.
·  HPV – a viral infection
·  Herpes – A sexually transmitted viral infection of the genitals caused by the herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2)
·  Hepatitis B - a serious liver disease caused by a virus which is called hepatitis B virus (HBV) that is transmitted through sexual contact or exposure to infected blood products
·  Hepatitis C - a serious liver disease caused by a virus which is called hepatitis C virus (HCV) that is inefficiently transmitted through sexual contact, and is usually transmitted by exposure to infected blood products
Patho-physiology / ·  Chlamydia – an obligate intracellular parasite with a unique cell wall, that requires host cellular machinery to replicate.
·  Gonorrhea – connect to squamous epithelial cells of the mucosa via pili. Bacteria are then pinocytosed into the tissues. PMN’s are recruited to the area forming an abscess and creating a thich, pussy exudate
·  Syphilis - penetrates abraded skin or intact mucous membranes easily and spreads rapidly through the blood and lymphatics causing granulomatous lesions along the linings of the arteries called gummas.
·  Trichomoniasis – typically infect the cells of the vagina, urethra, paraurethral ducts, glands, and endocervical tissue.
·  HPV – Innoculation of mucosal or epithelial cells leads to a variety of cellular changes, ranging from megaplasia, dysplasia, and neoplasia.
·  Herpes – Inocculation occurs at mucosal surfaces or at broken skin areas exposed to the virus. Following this is infection of the autonomic root ganglia, where HSV establishes latency. Reactivation occurs following stress, with subsequent recurrent infection.
·  Hepatitis B – After infection, the virus enters hepatocytes and begins replication where the virus starts replicating with or without developing symptoms. Symptoms are the result of immune system-mediated damage.
·  Hepatitis C – After infection, the virus enters hepatocytes and begins replication where the virus starts replicating with or without developing symptoms
Clinical Presentation 1, 2 / ·  Chlamydia –
o  three quarters of infected women and about half of infected men have no symptoms. If symptoms do occur, they usually appear within 1 to 3 weeks after exposure.
o  In women - abnormal vaginal discharge or a burning sensation when urinating, lower abdominal pain, low back pain, nausea, fever, pain during intercourse, or bleeding between menstrual periods
o  In men - discharge from their penis, a burning sensation when urinating, burning and itching around the opening of the penis, and pain and swelling in the testicle (uncommon)
·  Gonorrhea
o  Most women and many men with gonorrhea may have no symptoms at all. Symptoms, if they do occur, can take anywhere from 2-30 days to develop.
o  In women - painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods
o  In men - burning sensation when urinating, or a white, yellow, or green discharge from the penis, and painful or swollen testicles (occassionally)
·  Syphilis
o  Many people infected with syphilis do not have any symptoms for years
o  primary syphilis - appearance of a single (or multiple) sore called a chancre. The time between infection with syphilis and the start of the first symptom can range from 10 to 90 days (average 21 days)
o  secondary syphilis - Skin rash and mucous membrane lesions that occur as the chancre is healing, or up to several weeks after the chancre has healed.
o  Latent syphilis – an asymptomatic stage that begins when secondary symptoms disappear
o  Late syphilis - difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia
o  Congenital syphilis – the baby may be stillborn, or die soon after birth if treatment is not initiated. The child may also be developmentally delayed or have seizures.
·  Trichomoniasis
o  In men – most men are asymptomatic, but symptoms include an irritation inside the penis, mild discharge, or slight burning after urination or ejaculation
o  In women – symptoms that develop within 5-28 days of exposure include a frothy, yellow-green vaginal discharge with a strong odor, discomfort during intercourse and urination, irritation and itching of the female genital area, or lower abdominal pain
·  HPV
o  Most people who have a genital HPV infection do not know they are infected
o  Some people get visible genital warts, or have pre-cancerous changes in the cervix, vulva, anus, or penis which are soft, moist, pink, or flesh-colored single or multiple swellings that can be large, small, or cauliflower shaped
·  Herpes
o  Herpes is characterized by painful, itching sores. The first outbreak usually occurs within two weeks after the virus is transmitted, and the sores typically heal within two to four weeks. Other signs and symptoms during the primary episode may include a second crop of sores, and flu-like symptoms, including fever and swollen glands. Over time the frequency and severity of outbreaks may decrease.
·  Hepatitis B
o  Fever, anorexia, nausea, vomiting, jaundice, dark urine, clay or pale colored stool, and abdominal pain
·  Hepatitis C
o  Malaise, anorexia, jaundice
Risk Factors1 / All of these diseases have similar risk factors including
·  Unprotected sex
·  Promiscuous sexual behavior
·  Exposure to blood or other bodily fluids
·  IVDU
·  Contact with infected materials
Diagnosis2 / ·  Chlamydia – cell or urine culture
·  Gonorrhea – gram-smears, cell or urine culture, or the presence of gonorrhea-specific enzymes, DNA, antigens, or lipopolysaccharides in specimens
·  Syphilis – microscopic examination of serous material from a lesion or serological testing
·  Trichomoniasis – wet mount examination of vaginal discharge, KOH preparation and whiff test
·  HPV – pap smear, HPV-DNA tests, visual inspection
·  Herpes – sample from sores, visual inspection, or blood tests
·  Hepatitis B – Blood test
·  Hepatitis C – blood antibody test for anti-HCV antibodies
Desired Therapeutic Outcomes1
*Reference of
Guidelines Used / ·  Prevent infection from occuring through educational programs
·  Eradicate infective organism if present and possible
·  Prevent/reduce risk of disease recurrance/future outbreaks
·  Prevent morbidity/mortality due to disease
·  Test and treat sexual partners who may be infected
·  Provide education to prevent re-infection/spread of disease
Sexually Transmitted Disease Treatment Guidelines 2006 http://www.cdc.gov/std/treatment/2006/toc.htm
Treatment Options**
(Non-drug and Drug Therapy – include all therapeutic classes/agents available and preferences per treatment guidelines) / **See Treatment Options Table
Monitoring**
(Efficacy and Toxicity Parameters) / **See Treatment Options Table

References:

1.  www.cdc.gov

2.  Depiro

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation

University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD