TABLE 1371 Antimicrobial Therapy for STDs

GONOCOCCAL INFECTIONS Neisseria gonorrhoeae are gram-negative diplococci that remain sensitive to antibiotics, although recent years have seen the emergence of strains resistant to penicillin (up to 25 percent) and, less commonly, tetracycline. Gonococcal infection presents usually as urethritis in men and cervicitis or PID in women. Epididymitis and prostatitis also can occur in men. Rectal infection occurs in 30 to 50 percent of women with gonococcal cervicitis and can be the only site of infection in homosexual men. N. gonorrhoeae also can be isolated from the pharynx, but rarely does it cause a pharyngitis. The incubation period ranges from 3 to 21 days. Disseminated infection also occurs in approximately 2 percent of untreated primary gonorrhea. This manifestation is characterized by skin lesions (tender pustules on an erythematous base, 50 to 70 percent), arthralgias, tenosynovitis, or arthritis (30 to 40 percent), and fever or general malaise (80 percent). Gonococcal infections can decrease fertility in women, presumably by scarring the fallopian tubes. They also increase the chance of ectopic pregnancy by the same mechanism.

Diagnosis Cervical or urethral culture on a selective medium is the standard for diagnosis, having a sensitivity of 80 to 90 percent. A Gram stain of a urethral smear showing intracellular gram-negative diplococci is sensitive and specific in men but much less useful in women. Diagnosis of disseminated gonococcal infection is more difficult with only 20 to 50 percent of blood, lesion, or joint cultures being positive. Obtaining cervical, rectal, and pharyngeal samples may improve the chance of a culture diagnosis.

Treatment Cefixime 400 mg PO, ceftriaxone 125 mg IM or ciprofloxacin 500 mg PO, or ofloxacin 400 mg PO all in single doses are recommended. Patients also should be treated for presumed chlamydial infection. PID or disseminated disease is usually treated with higher doses of ceftriaxone. Decisions to admit patients with symptomatic disease are based on their overall clinical picture as well as their ability to follow up on an outpatient basis.

TRICHOMONAL INFECTIONS Trichomonas vaginalis is a flagellated protozoan that causes urogenital infections in men and women. The prevalence is less than 1 percent in women overall but up to 15 percent in those attending STD clinics. Disease is most commonly characterized by vaginosis with discharge. Abdominal pain also can be present. In men, the disease is often asymptomatic, but it can cause urethritis. Incubation ranges from 3 to 28 days.

Diagnosis Microscopic examination of wet preparations of cervical smears or spun urine samples that reveal the classic motile parasites is diagnostic. Treatment Metronidazole 2 g PO in a single dose is the usual treatment. STDs with Lesions

The diseases discussed in this section often present with genital lesions that may be difficult to distinguish from one another. Characteristics of the lesions and their accompanying signs and symptoms are provided in Table.. .1.37.-2.. Granuloma inguinale (donovanosis) rarely occurs in the United States, and readers are referred to the Bibliography for more information.

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