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Chapter 11 Posttravel Evaluation

Sexually Transmitted Infections

Jodie Dionne-Odom, Kimberly Workowski

INFECTIOUS AGENT

More than two dozen bacterial, viral, and parasitic pathogens can cause sexually transmitted infections (STIs).

TRANSMISSION

This chapter focuses on infections transmitted from person to person during sexual activity with genital, anal, or oral mucosal contact.

EPIDEMIOLOGY

STIs are among the most common infectious diseases reported worldwide. There were an estimated 20 million new cases of sexually transmitted infections in the United States in 2016 and 357 million cases globally in 2012.

Casual sex during travel is common (20% prevalence in a systematic review), and some people travel for sex tourism (see Chapter 9, Sex & Travel). Sex partners abroad may include male or female commercial sex workers with elevated STI prevalence. Documented risk factors for STI/HIV acquisition among travelers to low- and middle-income countries include male gender, men who have sex with men (MSM), single marital status, and longer duration of stay. Providers caring for returning travelers should know where to find up-to-date information about global epidemiology and antimicrobial resistance patterns of STI from national (CDC, www.cdc.gov/drugresistance/index.html) and international public health authorities (World Health Organization [WHO], www.who.int/gho/sti/en).

The epidemiology and clinical manifestations of common STIs are shown in Table 11-6. Returning travelers should be asked about sexual activity during their trip, with specific questions about region of travel, sexual partners, sites of sexual exposure, and condom use. Assessing risk in MSM is important because they have elevated rates of certain infections (syphilis, chlamydia, gonorrhea, and lymphogranuloma venereum). Screen travelers seeking an evaluation for STI or with evidence of STI for HIV infection. Provide anyone with HIV infection linkage to HIV care and treatment services if they are not already receiving care.

CLINICAL PRESENTATION

Returning travelers should be assessed for chlamydia, gonorrhea, and syphilis, since many curable bacterial STIs are asymptomatic. Advise any traveler with sexual exposure who develops STI symptoms (vaginal, urethral, or rectal discharge, an unexplained rash or genital lesion, or genital or pelvic pain) to abstain from sex and seek pro­mpt medical evaluation. Human papillomavirus (HPV) infection is commonly acquired within 2 years of sexual debut and usually clears spontaneously. Although most STIs involve the genital tract, some also cause disseminated disease (such as syphilis and herpes). Consider STI in returning travelers since infection can result in serious and long-term complications, including pelvic inflammatory disease, infertility, adverse birth outcomes, cervical cancer, anal cancer, and an increased risk of HIV acquisition and transmission.

Table 11-06. Epidemiology and clinical manifestations of common STIs

STI (CAUSE) GEOGRAPHIC LOCATION TYPICAL CLINICAL PRESENTATION (BUT OFTEN ASYMPTOMATIC) INCUBATION PERIOD (DAYS) DIAGNOSIS FIRST- LINE THERAPY
BACTERIAL          
Chancroid
(Haemophilus ducreyi)
Regional in Africa, Asia, Caribbean Irregular, painful genital ulcer; tender, suppurative inguinal lymphadenopathy 4– 7 Culture with specialized media Azithromycin 1 g PO once OR Ceftriaxone 250 mg IM once

Chlamydia

(Chlamydia trachomatis)
Widespread Cervicitis, urethritis 7–21 NAAT

Azithromycin 1 g PO once OR

Doxycycline 100 mg PO bid x 7 days

Gonorrhea

(Neisseria gonorrhoeae)
Widespread Cervicitis, urethritis 1–14 NAAT

Ceftriaxone 250 mg IM once AND

Azithromycin 1 g PO once

Granuloma inguinale or donovanosis

(Klebsiella granulomatis)
Southern Africa, India, Papua New Guinea, Australia Extensive genital ulcerations with granulation and easy bleeding; tender lymphadenopathy 4–28 days

Microscopy:

donovan bodies in macrophages
Azithromycin 1 g PO weekly until resolution

Lymphogranuloma venereum

(Chlamydia trachomatis serovar L1-3)
Widespread Self-limited ulcer; tender inguinal lymphadenopathy, proctocolitis 3–30 days NAAT, serology Doxycycline 100 mg PO bid x 21 days

Syphilis

(Treponema pallidum)
Widespread Primary: painless genital ulcer, regional lymphadenopathy; secondary: maculopapular skin rash 10–90 days Darkfield microscopy (primary infection), serology Benzathine penicillin G 2.4 MU IM (once for primary, secondary, and early latent infection), 2.4 MU IM once weekly x 3 weeks for late latent infection or latent syphilis of unknown duration
VIRAL          
Hepatitis A virus Widespread Malaise, fatigue, anorexia, jaundice 28 days Serology Supportive care
Hepatitis B virus Widespread Malaise, fatigue, anorexia, jaundice 60–150 days Serology Several options, consult with expert
Hepatitis C virus Widespread Malaise, fatigue, anorexia, jaundice 15–50 days Serology Several options, consult with expert
Herpes simplex virus (HSV) Widespread ≥1 painful genital ulcers 2–7 days Culture or PCR Acyclovir 400 mg PO tid x 7–10 days OR valacyclovir 1 g PO bid x 7–10 days OR famciclovir 250 mg PO tid x 7–10 days
Human papillomavirus Widespread Warts 14–240 days Clinical or pathologic Topical therapy or removal of lesion
Zika virus Widespread Fever, rash, joint pain, conjunctivitis 3–14 days Serology or PCR Supportive care
PARASITIC          

Trichomoniasis

(Trichomonas vaginalis)
Widespread Vaginal discharge and itching 5–28 days NAAT Metronidazole 2 g PO once OR tinidazole 2 g PO once Metronidazole 500 mg bid x 7 days in women with HIV infection

Abbreviations: STI, sexually transmitted infection; PO, orally; IM, intramuscularly; NAAT, nucleic acid amplification testing; bid, twice daily; tid, 3 times daily.

 

TREATMENT

Base STI evaluation, management, and follow-up on the most recent national and international guidelines from CDC and WHO. In the United States, CDC guidelines are preferred since WHO follows a syndromic approach to STI management given limited availability of diagnostic testing in many countries. Treatment failure is a possibility if an infection does not respond, which is particularly relevant in a traveler with persistent gonococcal infection given the global spread of multidrug-resistant Neisseria gonorrhoeae.

PREVENTION

Prevention and control of STIs is based on accurate risk assessment, education, counseling, early identification of asymptomatic infection, and effective treatment of travelers and their sex partners. Pretravel advice should include specific messages with strategies to avoid acquiring or transmitting STIs. Abstinence or mutual monogamy with an uninfected partner is the most reliable way to avoid acquiring and transmitting STIs.

For people whose sexual behaviors place them at risk for STIs, correct and consistent use of the male latex condom can reduce the risk of HIV infection and other STIs, including chlamydia, gonorrhea, and trichomoniasis. Preventing lower genital tract infections might reduce the risk of pelvic inflammatory disease in women. Correct and consistent use of male latex condoms also reduces the risk of HPV infection, genital herpes, syphilis, and chancroid, although data are limited. Only water-based lubricants, such as K-Y Jelly, should be used with latex condoms because oil-based lubricants (such as petroleum jelly, shortening, mineral oil, or massage oil) can weaken latex condoms. Spermicides containing nonoxynol-9 are not recommended for STI/HIV prevention. Contraceptive methods that are not mechanical barriers do not protect against HIV or other STIs.

Prompt evaluation of sex partners is necessary to prevent reinfection and disrupt STI transmission. Preexposure vaccination is among the most effective methods for preventing certain STIs. HPV vaccines are available and licensed for girls and boys to prevent transmission. Consider all travelers as candidates for hepatitis A and hepatitis B vaccines, as these infections can be sexually transmitted. Hepatitis B vaccine is recommended for all people being evaluated or treated for an STI. Hepatitis A and hepatitis B vaccines are also recommended for MSM. Travelers at risk of acquiring HIV infection may benefit from preexposure prophylaxis (see www.cdc.gov/hiv/prep and Chapter 4, HIV).

CDC website: www.cdc.gov/std

BIBLIOGRAPHY

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