rxPassport Pharmacy Newsletter
August 2014
Let’s Talk about Genital Herpes, Chlamydia & Gonorrhea
Patient Name: Jessica S.
Age: 24 year old female
  • Valacyclovir 1000mg bid for 10 days;
  • Suprax 800mg PO in a single dose; and
  • Azithromycin 1g PO in a single dose
    Jessica presents with the above prescription. She seems hesitant and embarrassed while she waits, constantly looking around. You offer to move to the private counselling room. She mentions that she was just diagnosed with genital herpes with symptoms of painful vaginal blisters, vaginal discharge and fever, and history of unprotected sex. She is also having lower abdominal pain and is worried that it might be something else.
    Upon further discussion, you find out that Jessica is in a new relationship, one month after her previous one ended, and she has had unprotected sex with both partners. Jessica had a few lab tests at her appointment and she is awaiting the results but wants to know if you could provide any information on what she was prescribed and why they are commonly used.
    Patient Assessment
    Before providing Jessica with any recommendations, it is important to gather a thorough history in order to assess her further risk for STIs. The questions should primarily be focused around her sexual risk behaviors, history of past STIs, and her relationship pattern. View a full list of questions.
    Based on the information we already know, what are the risk factors that predispose Jessica to STIs?
    Female gender
    Age group (15-24 years)
    Unprotected sex
    Multiple sex partners
    All of the above
    Find out now
    Clinical Practice Tip
    It is very important to probe patients on the number of sex partners as this is one of the main risk factors for STIs and can determine the overall STI risk of patients. 1
    Genital Herpes
    Etiology and epidemiology
    Genital herpes is a chronic viral infection caused by two types of herpes simplex virus: HSV 1 and HSV 2. HSV 2 is mainly responsible for recurrence of genital herpes; however, HSV 1 induced genital herpes is on the rise globally.2
    According to Statistics Canada, about 14% of the population aged 14-59 may have a HSV-2 infection. Moreover, females are at higher risk of acquiring genital herpes from male partners than vice versa. 3
    Clinical presentation
    The genital herpes infection presents itself in the following ways:
    Initial episodes
  • Can be primary or non-primary depending on previous exposure to HSV and severity of symptoms.
  • Symptoms include painful genital lesions, and systemic symptoms such as fever and myalgia.
    Recurrent episode
  • Patients present with milder symptoms that last for shorter duration.
  • Are characterized by prodromal symptoms such as itching, burning, tingling sensation minutes to an average of 1-2 days prior to development of lesions. 4
    Asymptomatic shedding
    In this type of infection, patients have HSV antibodies, but are asymptomatic or may have unrecognized symptoms. As a result, patients may shed the virus genitally and without being aware may increase the risk of transmission to sexual partners.
    Based on Jessica’s clinical presentation (painful lesions and fever), it points to a primary infection with HSV.
    Management of genital herpes
    The mainstay of managing genital herpes is to treat all symptomatic patients with oral antiviral therapy. The three commonly used oral antivirals are valacyclovir, famciclovir, and acyclovir (Table 1). The primary advantage of valacyclovir and famciclovir is their dosing schedule compared to acyclovir.
    *Click to enlarge
    Jessica has been prescribed Valacyclovir 1000mg bid for 10 days which is an ideal treatment strategy for a primary infection.
    Clinical Practice Tip
    Since recurrence of genital herpes is common, an ideal approach is to recommend to the physician to prescribe an additional course of valacyclovir 1000mg PO for 3 days for recurrent episodes. This can be put on hold and she can then use it immediately, if her symptoms recur.
    Other STIs to consider
    Gonococcal infections
    Gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae occurring most commonly in females.5 Jessica’s risk factors for acquiring gonorrhea are fourfold:
  • Female gender
  • Age less than 25
  • Multiple sex partners
  • History of probable STI (which in this case is genital herpes)
    Jessica is also experiencing lower abdominal pain and vaginal discharge which are key symptoms of gonorrhea. Other symptoms include dysuria (painful urination), and abnormal vaginal bleeding. Therefore, the diagnosis of gonorrhea should be confirmed using cervical culture. This allows for testing of antimicrobial susceptibility in lieu of increasing resistance of N.gonorrhoeae to antimicrobials.
    IMPORTANT: Due to increasing rates of resistance to antimicrobials quinolones are no longer recommended as first-line for the treatment of gonococcal infections.2, 5 Read more about the resistance pattern.
    The recommended combination therapies for treatment of gonorrhea are:
  • Ceftriaxone 250mg IM in a single dose

  • OR
  • Cefixime 800mg PO in a single dose instead of the previously recommended 400mg

  • PLUS
  • Azithromycin is 1g PO in a single dose.
    The use of combination therapy is to minimize development of resistance to cephalosporins and azithromycin, and to simultaneously treat chlamydial infections which very commonly coexist with gonococcal infections.
    Clinical Practice Tip
    Following treatment with the antimicrobials, a follow-up culture for test of cure should be done within 3-7 days to ensure that Jessica has responded to the antimicrobials effectively. This is especially important if she continues to experience symptoms of lower abdominal pain and vaginal discharge.
    Chlamydia is a bacterial infection caused by chlamydia trachomatis. In Canada, chlamydia is most commonly reported in individuals aged 15-24 years of age.6 The risk of acquiring a chlamydial infection increases in individuals with multiple sex partners, history of prior STIs, and sexual contact with an infected person.
    Returning to our case, Jessica has multiple risk factors such as her age, probable genital herpes, and sex with multiple partners. Therefore, Jessica is likely predisposed to chlamydial infection. In most women, chlamydial infection is asymptomatic which results in under diagnosis of the infection. Nevertheless, there is a 20-42% probability of co-infection between chlamydia and gonorrhea.6 So, if Jessica is tested positive for gonorrhea there is a very high chance that she may also test positive for chlamydia. As a result, empiric treatment for chlamydial infection is recommended without the need to perform a culture for C. trachomatis identification.
    The preferred treatment strategy for chlamydial infection is:
  • doxycycline 100mg PO for 7 days

  • OR
  • Azithromycin 1g PO in a single dose preferable for those who are unable to comply with multiple day regimens.
    Jessica is seeking advice on preventative strategies. This is an ideal opportunity to discuss the various ways in which she can control the transmission of her STI and prevent future recurrences.
    Although genital herpes is primarily due to genital intercourse, there is an increasing likelihood of it being contracted from oral sex. Jessica should therefore be counselled on the risk of contracting genital herpes from oral sex.
    Abstain from sexual activity until the vaginal sores have completely healed. Moreover, if Jessica is diagnosed with gonorrhea and chlamydia, she should abstain from unprotected sex until seven days after single dose treatment or completion of multiple-dose treatment.
    Condom use should be encouraged to reduce transmission of herpes simplex virus to other sex partners.
    Jessica should be educated on the prodromal signs of recurrent episodes such as vaginal burning, itching, and tingling in order to ensure the effectiveness of preventative valacyclovir.
    Jessica should be informed that there is no cure for genital herpes and that the antiviral therapy only helps to control the symptoms of the episodes.
    In Canada, both gonorrhea and chlamydia are reportable infections. Although it is not mandatory to report genital herpes, physicians and laboratories are strongly encouraged to report this infection to the public health authorities. 7
    Jessica should be encouraged to notify all sexual partners within the past 60 days about her diagnosis of STIs in order to prevent transmission and re-infection. 4,5,6
    Clinical Practice Tip
    Females between the ages of 9-26 are encouraged to get vaccinated against HPV.8 Jessica should be encouraged to get vaccinated against HPV if not already done.
    By: Nihal Abbas, PharmD Candidate
    With appreciation to Mike Boivin
    In this issue:
    Patient Assessment
    Genital herpes
    Gonococcal infections
    1. Public Health Agency of Canada: View Resource
    2. 2010 STD Treatment Guidelines: View Resource
    3. Prevalence of Chlamydia trachomatis and herpes simplex virus type 2: View Resource
    4. Differences in manifestations, symptoms, and major sequelae of gonorrhea between females and males: View Resource
    5. Differences in signs and symptoms of chlamydia between females and males: View Resource
    1. Joffe GP, Foxman B, Schmidt AJ, et al. Multiple partners and partner choice as risk factors for sexually transmitted disease among female college students. Sex Transm Dis. 1992;19(5):272-8.
    2. Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010 Aug 4;59(RR-12):1-110.
    3. Rotermann M, Langlois K, et al. Prevalence of Chlamydia trachomatis and herpes simplex virus type 2: Results from the 2009 to 2011 Canadian Health Measures Survey. Health Reports-Statistics Canada, April 2013; 24(4):10-15.
    4. Public Health Agency of Canada (PHAC). Canadian Guidelines on Sexually Transmitted infections- Genital Herpes Simplex Virus (HSV) Infections, January 2008.
    5. Public Health Agency of Canada (PHAC). Canadian Guidelines on Sexually Transmitted infections- Gonococcal Infections, July 2013.
    6. Public Health Agency of Canada (PHAC). Canadian Guidelines on Sexually Transmitted infections- Chlamydial infections, January 2010.
    7. Public Health Agency of Canada (PHAC). Canadian Guidelines on Sexually Transmitted infections- Primary Care and Sexually Transmitted Infections, January 2010.
    8. Warshawsky B, Gemmill I. What are the new active vaccine recommendations in the Canadian Immunization Guide?. CCDR 2014; 40.8:142-59.
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