1 . The annual estimated medical cost of sexually transmitted infections (STIs) is
| A) | | $61 million. |
| B) | | $1.6 billion. |
| C) | | $16 billion. |
| D) | | $160 billion. |
CDC surveillance data show that from 2016 to 2020, increases
were observed in syphilis and gonorrhea [1].
More than 20 million new STI cases occurred, with people 15 to 24 years of age accounting for
around 50% of new cases. The annual estimated direct medical cost of STIs is $16 billion [2]. Most costs are attributable to HIV ($13.7
billion), chlamydia ($691 million), gonorrhea ($271 million), and herpes simplex virus-2
(HSV-2) ($91 million) [1].
2 . Chlamydia screening is recommended for
| A) | | all young men, regardless of setting. |
| B) | | all women younger than 25 years of age if sexually active. |
| C) | | persons with HIV infection every ten years. |
| D) | | all pregnant women, regardless of risk category. |
BACTERIAL STI SCREENING RECOMMENDATIONS
| Infection | Population Screened |
|---|
| Women | Pregnant Women | Men | MSM | Persons with HIV | Transgender and Gender-Diverse Persons |
|---|
| Chlamydia |
| All younger than 25 years of age if sexually active | | 25 years of age or older if sexually active and at risk |
|
| All younger than 25 years of age | | All 25 years of age or older if at risk | | Retest in third trimester if younger than 25 years of age or at
risk | | Test-of-cure 3 to 4 weeks after treatment and retest within 3
months |
| Consider for young men in high-risk settings |
At least yearly if sexually active, at sites of contact (urethra, rectum,
pharynx)a
Every 3 to 6 months if at risk
|
| If sexually active, screen at first HIV testing and then at least
yearly | | More frequent screening based on risk behaviors and local
prevalence |
|
| Recommendations should be adapted based on anatomy (e.g., recommendations
for women may be applied to any person with a cervix). | | Consider screening at the rectal site based on risk behaviors |
|
| Gonorrhea |
| All younger than 25 years of age if sexually active | | 25 years of age or older if sexually active and at risk | | Retest 3 months post-treatment |
|
| All younger than 25 years of age | | All 25 years of age or older if at risk | | Retest 3 months post-treatment |
| — |
| At least yearly if sexually active, at sites of sexual
contacta | | Every 3 to 6 months if at risk |
|
| If sexually active, screen at first HIV testing and then at least
yearly | | More frequent screening based on risk behaviors and local
prevalence |
|
| Recommendations should be adapted based on anatomy. | | Consider screening at the pharyngeal or rectal site based on risk
behaviors |
|
| Syphilis | Pharyngeal and/or rectal screening based on risk behaviors |
| All women at first prenatal visit | | Retest early in third trimester and at delivery if high risk |
| — |
| At least yearly if sexually active | | Every 3 to 6 months if at risk |
|
| If sexually active, screen at first HIV testing and then at least
yearly | | More frequent screening based on risk behaviors and local
prevalence |
| Consider screening at least annually based on risk behaviors |
| aRegardless of condom
use |
3 . All of the following settings are associated with higher STI prevalence, EXCEPT:
| A) | | STI clinics |
| B) | | Adolescent clinics |
| C) | | Correctional facilities |
| D) | | Birth centers |
Risk factors also determine STI screening frequency. Sexually
active MSM (regardless of HIV status) should be screened for oral gonorrhea and for rectal
gonorrhea and chlamydia at least annually (depending on reported sex practices) and every
three to six months when risk behaviors persist or if they or their sexual partners have
multiple partners [24]. STI risk factors
that help determine screening frequency for any given person include [4]:
Presentation in high-risk settings: Adolescent or STI clinics, correctional
facilities
At-risk women: A new sex partner, more than one sex partner, a sex partner with
concurrent partners or an STI
High-risk women: Multiple sex partners, exchanges sex for money or drugs, illicit
drug use, history of STI
Gonorrhea, in women: Same as high-risk, plus inconsistent condom use and not in
mutually monogamous relationships
Chlamydia, in women: Same as high-risk, plus previous chlamydia infections even if
treated and/or living in a detention facility
Men: Multiple sex partners
High-risk MSM: HIV infection and persistent risk behaviors, sexual partner has
multiple partners
4 . Standard STI partner services
| A) | | offer referral to evaluation, treatment, and care. |
| B) | | identify, locate, and notify sex partners of infected persons. |
| C) | | issue prescriptions to identified sex partners of infected persons. |
| D) | | Both A and B |
For decades, partner services programs have been a foundation
of state and local public health department STI control. Standard STI partner services
identify, locate, and notify sex partners of infected persons to offer referral to evaluation,
treatment, and care. The objective of partner services programs is to interrupt the chain of
STI transmission at a level sufficient to reduce morbidity, achieved by identifying and
treating undiagnosed STIs. Partner services intervene in disease progression (including
incubating disease) and prevent serious sequelae, such as congenital syphilis. Partner
services also contribute to understanding STI epidemiology by collecting data [31].
5 . Which of the following statements regarding the characteristics and clinical course of chlamydia is FALSE?
| A) | | Up to 60% of untreated women develop PID. |
| B) | | Reactive arthritis is an uncommon complication. |
| C) | | Up to 75% of persons become infected by sex partners with chlamydia. |
| D) | | Spontaneous remission occurs 1 year after detection in up to 45% of asymptomatic patients. |
The main route of infection is through penetrative sexual
intercourse, but chlamydia can be detected in the conjunctiva and oropharynx without genital
infection. Chlamydia infection is highly transmittable. Up
to 75% of persons become infected by sex partners with chlamydia, but with asymptomatic
infection the norm in men and women, most infected persons are unaware of their status. As
noted, up to 30% of untreated women develop PID and associated infertility, debilitating
chronic pelvic pain, or life-threatening tubal pregnancy. Chlamydia and other inflammatory
STIs can facilitate HIV transmission. Infected pregnant women can transmit Chlamydia to their infants during delivery, potentially leading to
pneumonia and ophthalmia neonatorum, a cause of blindness [27,36].
6 . Gonorrheal infection is caused by the organism
| A) | | Haemophilus ducreyi. |
| B) | | Treponema pallidum. |
| C) | | Neisseria gonorrhoeae. |
| D) | | lymphogranuloma venereum. |
Gonorrhea results from infection by the bacterium N. gonorrhoeae and can affect the cervix, uterus, and fallopian
tubes in women, and the urethra, mouth, throat, eyes, and anus of both sexes and manifest as
urethritis, cervicitis, proctitis, salpingitis, or pharyngitis [1]. If untreated, gonococcal infection may
disseminate to distant sites (e.g., joints) and become a life-threatening illness [51,52]. At an estimated 820,000 new infections annually, gonorrhea is the second
most commonly reported bacterial STI in the United States [34].
7 . What is the only remaining effective and recommended first-line treatment for uncomplicated gonorrhea?
| A) | | Fluoroquinolones |
| B) | | Penicillin and tetracycline |
| C) | | Sulfanomides and cefixime |
| D) | | Ceftriaxone monotherapy |
TREATMENT OF GONOCOCCAL INFECTIONS
| Site of Infection | Treatment Regimen |
|---|
| Recommended | Alternative |
|---|
| Uncomplicated infection |
| Cervix, urethra, or rectum | Single-dose ceftriaxone 500 mg
IMa | Single-dose gentamicin 240 mg IM PLUS azithromycin 2 g orally OR single-dose
cefixime 800 mg orally |
| Pharynx | — |
| Pregnancy | Consult infectious disease specialist |
| Gonococcal conjunctivitis | Single-dose ceftriaxone 1 g IM | — |
| Disseminated infection |
| Arthritis and arthritis-dermatitis syndrome | Ceftriaxone 1 g IM or IV every 24 hours | Cefotaxime 1 g IV every 8 hours OR ceftizoxime 1 g every 8 hours |
| Gonococcal meningitis and endocarditis | Ceftriaxone 1–2 g IV every 24 hours | — |
| aA dose of 1 g IM
should be used for patients weighing 150 kg or more. |
8 . In the treatment of gonorrhea, ceftriaxone
| A) | | is given as a single dose. |
| B) | | should be dosed at 500 mg for patients weighing less than 150 kg. |
| C) | | is recommended for all patients, regardless of infection site or pregnancy status. |
| D) | | All of the above |
TREATMENT OF GONOCOCCAL INFECTIONS
| Site of Infection | Treatment Regimen |
|---|
| Recommended | Alternative |
|---|
| Uncomplicated infection |
| Cervix, urethra, or rectum | Single-dose ceftriaxone 500 mg
IMa | Single-dose gentamicin 240 mg IM PLUS azithromycin 2 g orally OR single-dose
cefixime 800 mg orally |
| Pharynx | — |
| Pregnancy | Consult infectious disease specialist |
| Gonococcal conjunctivitis | Single-dose ceftriaxone 1 g IM | — |
| Disseminated infection |
| Arthritis and arthritis-dermatitis syndrome | Ceftriaxone 1 g IM or IV every 24 hours | Cefotaxime 1 g IV every 8 hours OR ceftizoxime 1 g every 8 hours |
| Gonococcal meningitis and endocarditis | Ceftriaxone 1–2 g IV every 24 hours | — |
| aA dose of 1 g IM
should be used for patients weighing 150 kg or more. |
9 . Which of the following statements regarding the natural history and characteristics of syphilis infection is TRUE?
| A) | | The disease affects multiple organs and the clinical course is highly variable. |
| B) | | Syphilis is caused by infection with Treponema syphilia. |
| C) | | The site of bacterial entry in heterosexual patients is typically anal. |
| D) | | Syphilis infection has little if any effect on the fetus in pregnant women. |
Syphilis is a multistage, multisystem STI caused by infection
with Treponema pallidum, a spirochete (i.e., a treponeme)
bacterium. Transmission occurs through direct contact with an infectious chancre (lesion) or
through vertical transmission during pregnancy. The site of bacterial entry in heterosexual
patients is typically genital. In MSM, extragenital sites (e.g., anal, rectal, oral) infected
through oral-anal or genital-anal contact account for 32% to 36% of transmissions [69]. The clinical course is highly variable [1].
10 . Syphilis is infectious and sexually transmittable during which stage?
| A) | | Primary |
| B) | | Secondary |
| C) | | Early latent |
| D) | | All of the above |
Untreated syphilis can progress through stages of primary, secondary, latent (early and late), and tertiary disease. Syphilis is infectious and transmittable during early disease (primary, secondary, early latent). Clinical manifestations of syphilis vary by stage [7,51,52,69,70].
11 . The "classical triad" during secondary syphilis includes all of the following, EXCEPT:
| A) | | Rash |
| B) | | Gummatous lesions |
| C) | | Mucocutaneous lesions |
| D) | | Generalized lymphadenopathy |
Rash, mucocutaneous lesions, and generalized lymphadenopathy, the "classical triad" reflecting multisystem involvement, develop 4 to 10 weeks after the initial chancre [71]. Roughly 1% to 2% of patients develop neurologic complications during secondary syphilis.
12 . Tertiary syphilis
| A) | | is the only transmittable stage. |
| B) | | can occur at any clinical stage. |
| C) | | is followed by a dormant phase. |
| D) | | develops in 33% of untreated patients. |
Tertiary (late) syphilis occurs 10 to 40 years after initial infection in 33% of untreated patients. Inflammatory lesions can develop in bone (osteitis), skin (gummatous lesions), connective tissues of the cardiovascular system (aortitis, coronary vessel disease), and less often, in the respiratory tract, reproductive organs, lymph nodes, liver, or brain/CNS. This stage is potentially fatal.
13 . What is the recommended route of administration for syphilis treatment with penicillin G?
| A) | | IV |
| B) | | IM |
| C) | | Oral |
| D) | | Transdermal |
TREATMENT OF SYPHILIS INFECTIONS
| Infection Stage or Patient Group | Treatment Regimen |
|---|
| Recommended | Alternative |
|---|
| Primary, secondary, or early latent infection with or without HIV
co-infection | Single-dose benzathine penicillin G 2.4 million units IM | — |
| Late/latent infection of unknown duration | Benzathine penicillin G 7.2 million units IM total, given in 3
doses of 2.4 million units at one-week intervals | — |
| Tertiarya |
| Late/latent infection with HIV co-infection |
| Neurosyphilis or ocular syphilis with or without HIV co-infection |
| For 10 to 14 days: | | Aqueous crystalline penicillin G 18–24 million units IV per day, given in
doses of 3–4 million units every 4 hours or continuous infusion |
|
| For 10 to 14 days: | | Procaine penicillin G 2.4 million units IM once daily, plus probenecid 500
mg oral four times per day |
|
| During pregnancy | Treat according to infection stage |
| aIn patients not
allergic to penicillin and without evidence of neurosyphilis. |
14 . Although U.S. data are scarce, the population most affected by lymphogranuloma venereum in the UK is
| A) | | adolescents. |
| B) | | persons of Asian origin. |
| C) | | men who have sex with men. |
| D) | | women who have sex with women. |
Lymphogranuloma venereum is endemic in parts of Africa, India,
Southeast Asia, South America, and the Caribbean but occurs sporadically in the United States.
Most patients diagnosed with lymphogranuloma venereum are MSM. Lymphogranuloma venereum has
been a non-reportable STI in the United States since 1994, and prevalence rates are difficult
to estimate. However, lymphogranuloma venereum has been tracked since 2004 in the UK, where
99% of lymphogranuloma venereum cases occur in MSM, frequently involved in dense sexual
networks associated with the sex party scene and without obvious link to known lymphogranuloma
venereum-endemic countries. MSM show a strong association between HIV and lymphogranuloma
venereum, and compared with MSM with rectal chlamydial infection, those with rectal
lymphogranuloma venereum are more likely to have proctitis symptoms and HIV infection [91,92,93].
15 . Which of the following is a risk factor for bacterial vaginosis?
| A) | | Antibiotic use |
| B) | | Receptive oral sex |
| C) | | Frequent vaginal douching |
| D) | | All of the above |
Bacterial vaginosis is the most common cause of abnormal
vaginal discharge in women of childbearing age. Normally, hydrogen peroxide-producing
lactobacilli are the dominant vaginal bacteria and maintain vaginal pH <4.5. In bacterial
vaginosis, the pH rises above 4.5, up to 6.0. Lactobacilli remain present, but flora becomes
dominated by anaerobic and facultative anaerobic bacteria in concentrations up to 1,000 times
greater than normal. Gardnerella vaginalis and Atopobium vagainae are critical to bacterial vaginosis etiology;
other commonly found bacteria belong to Prevotella,
Mobiluncus, Clostridiales, Leptotrichia, and Sneathia species and Mycoplasma
hominis
[99,100]. Risk factors for bacterial vaginosis include frequent vaginal douching,
antibiotic use, poor hygiene, receptive oral sex, lack of condom use, multiple or a new sex
partner, smoking, presence of STIs (chlamydia or herpes in particular), poorly controlled
diabetes, dermatitis, and immune system disorders [102].
16 . Patients with acute epididymis require urgent hospitalization and medical attention with signs or symptoms of
| A) | | testicular torsion. |
| B) | | epididymo-orchitis. |
| C) | | granulomatous disease. |
| D) | | positive leukocyte esterase. |
Acute epididymitis is inflammation of the epididymis with an
acute onset of unilateral testicular pain and swelling, often with tenderness of the
epididymis and vas deferens, and occasionally with erythema and edema of the overlying skin.
Testis involvement is termed epididymo-orchitis. Sexually transmitted acute epididymitis
usually is accompanied by urethritis, typically asymptomatic [117]. Clinicians should be vigilant for
non-infectious testicular (spermatic cord) torsion in men who present with a sudden onset of
symptoms associated with epididymitis, as this condition is a surgical emergency [117].
17 . Chancroid
| A) | | is caused by infection with Haemophilus influenzae. |
| B) | | can be transmitted even when an ulceration is not present. |
| C) | | is widespread in areas of the world where STI control is adequate. |
| D) | | is an STI characterized by painful genital ulceration and inflammatory inguinal adenopathy. |
RARE AND EMERGING BACTERIAL STIs
Chancroid is an STI characterized by painful genital
ulceration and inflammatory inguinal adenopathy caused by infection with Haemophilus ducreyi
[1]. Chancroid has been widespread in areas
of the world where STI control is inadequate, often transmitted by female sex workers with
little access to care. Chancroid can only be transmitted when ulceration is present [124]. The importance of chancroid as an STI
became elevated in the 1980s when its role in HIV transmission was apparent; risk of HIV
transmission increases by 10- to 50-fold from sexual exposure to a person with H. ducreyi and HIV co-infection [124].
18 . Granuloma inguinale
| A) | | is rapidly progressive. |
| B) | | rarely appears on the face. |
| C) | | is often accompanied by regional lymphadenopathy. |
| D) | | commonly occurs on the penis, scrotum, groin, and thighs in men. |
RARE AND EMERGING BACTERIAL STIs
Granuloma inguinale is characterized by slowly
progressive, painless, red, raised, and ulcerated skin lesions. Regional lymphadenopathy
is uncommon. Common sites of infection include [128,129]:
Penis, scrotum, groin, and thighs in men
Vulva, vagina, and perineum in women
Anus and buttocks in patients who engage in anal-receptive intercourse
Face in both sexes
19 . All of following statements regarding Mycoplasma genitalium are true, EXCEPT:
| A) | | It has only recently become a concerning STI. |
| B) | | This organism lacks a cell wall, making it vulnerable to antibiotics. |
| C) | | It is present in up to 40% of chronic male nongonococcal urethritis. |
| D) | | It probably accounts for a large proportion of pelvic inflammatory disease (PID) cases. |
RARE AND EMERGING BACTERIAL STIs
First identified in the early 1980s, Mycoplasma genitalium causes nongonococcal urethritis in men.
It is detected in 10% to 30% of men presenting with nonchlamydial nongonococcal urethritis
and up to 40% with chronic nongonococcal urethritis [131]. The recent emergence and spread of M.
genitalium are concerning because of increasing antimicrobial resistance to
macrolides, the preferred mode of antibiotic treatment. The penicillins, cephalosporins,
and other beta-lactam antibiotics disrupt bacterial cell wall synthesis and are
ineffective against M. genitalium, which lacks a cell
wall [132]. The prevalence of resistance
to oral single-dose azithromycin 1 g (the common first-line treatment of urogenital
M. genitalium) ranges from 44% to 90% in the United
States, Canada, and Western Europe [4,131].
20 . Desensitization is recommended for making penicillin treatment feasible in patients with penicillin allergy characterized by
| A) | | IgE mediation. |
| B) | | IgM mediation. |
| C) | | Stevens-Johnson syndrome. |
| D) | | All of the above |
GENERAL MANAGEMENT ISSUES
Penicillin is the foundation of antimicrobial treatment for
syphilis infection, but some patients have histories of penicillin allergy. The estimated
prevalence of penicillin allergy in the United States is 8% to 10%; this may be higher in
hospitalized patients [136,137]. Penicillin allergy imposes a therapeutic
quandary, because 10% to 15% of these patients are at risk for an IgE-mediated allergic
response to penicillin, with anaphylaxis, bronchospasm, urticaria, or angioedema.
Anaphylactic reactions to penicillin can be fatal, and penicillin should be avoided in these
patients unless they undergo induction of drug tolerance, termed "desensitization," to
temporarily eliminate IgE-mediated hypersensitivity [65,138,139,140].
Many patients with a reported history of penicillin allergy
have other types of adverse drug reactions or lose their penicillin sensitivity over time,
and in these cases, penicillin can be safely used. Because of the increasing evidence that
most persons with documented penicillin allergy do not actually have sensitivity to
penicillins and associated beta-lactams, clinicians should make efforts to delabel these
patients, if at all possible. Penicillin skin testing with the major and minor determinants
of penicillin reliably identifies patients at high risk for IgE-mediated reactions to
penicillin [139,141]. Many tests have used the major
determinants only, but without minor determinants, 1% to 10% of patients with true allergy
will show false-negative results and risk serious or fatal reactions to penicillin. Patients
with a history of severe non-IgE-mediated reactions (e.g., Stevens-Johnson syndrome, toxic
epidermal necrolysis, interstitial nephritis, hemolytic anemia) are not candidates for skin
testing or challenge and should avoid penicillins indefinitely [141,142,143].
