INFEKSI GINEKOLOGI

Husni Samadin

GONORRHEA

GONORRHEA
Gram-negative diplococcus (Neisseria
gonorrhoeae)
Causes a variety of illnesses and is
usually transmitted through sexual
intercourse
Vertical transmission is uncommon
Risk of transmission is higher from males
to females (50% per contact)
3

GONORRHEA

Manifestations
MANIFESTATIONS

Cervicitis
Urethritis
Anorectal infection
Pharyngeal Gonococcal Infection
Pelvic Inflammatory Disease
Ocular Autoinfection
Perihepatitis (Fitz-Hugh-Curtis
Syndrome)

GONORRHEA
5

GONORRHEA
MANIFESTATIONS

Manifestations

Disseminated Gonococcal
Infection (occurs in 1% to 2%
of patients)
Arthralgias
Asymmetric polyarthritis
Dermatitis
6

GONORRHEA
N. gonorrhoeae infects columnar
or cubodial epithelium
It attaches via pili and penetrates within
1-2 days

There is a neutrophilic response

which creates a purulent discharge

GONORRHEA
CERVICITIS
Females infected with gonorrhea are usually
symptomatic
Symptoms usually include:
Increased vaginal discharge
Dysuria
Variable amount of vaginal bleeding

The classic sign of Mucopurulent Cervicitis

is not always present if present it is usually
similar to that caused by other genitourinary
pathogens
8

GONORRHEA
ANORECTAL
Symptoms include:
Anal pain and pruritus
Tenesmus
Purulent discharge
Rectal bleeding

More common among men but occurs

in up to 40% of women who have
endocervical disease
9

GONORRHEA
PHARYNGEAL GONOCOCCAL INFECTION

Usually contracted by fellatio

Typically asymptomatic
May resolve spontaneously

10

GONORRHEA
PELVIC INFLAMMATORY DISEASE

Present in 10%-20% of gonococcal

infections in women
Risk factors for ascending infection include

Age <20 yrs

Prior PID
Vaginal douching
Bacterial vaginosis

Symptoms range from:

Minimal (lower abdominal tenderness) to
Severe Pain
11

GONORRHEA
DIAGNOSIS
Culture of endocervical region
Gold standard, used in all medico legal
arenas
Specimen acquisition is the key
Swab should have a wire shaft and a
synthetic fiber tip
Avoid swabs with wooden shafts or cotton
tips because they may be toxic to N.
gonorrhoeae
12

GONORRHEA
DIAGNOSIS
Gram Stain
Highly specific, less costly, quick
Diagnostic if gram negative diplococci
are seen within polymorphonuclear
leukocytes
13

GONORRHEA
DIAGNOSIS
DNA probes
High sensitivity and specificity
Concurrently test for N. gonorrhea and
C. trachomatis with a single specimen
More widely used than cultures and
cost
is similar
14

GONORRHEA
DIAGNOSIS
Ligase chain reaction (LCR) assays
More expensive but also more convenient
Can perform on urine samples or vaginal
swabs
Sensitivity of 95% and specificity of 98%-100%
Tests performance in asymptomatic, low
prevalence setting, is unknown
Not to be used as a test of cure
(Will identify nonviable gonococcal
nucleic acid)
15

GONORRHEA
Sensitivity and specificity of tests for gonorrhea
Method*
Sensitivity
Specificity
(%)

(%)

40-60

95-100

Pharynx

59

94

Rectum

40-60

90-95

95-100

95-100

50-70

95-100

Culture
Endocervix

Urethra (with
symptoms)
Urethra (no symptoms

16

GONORRHEA
Sensitivity and specificity of tests for
gonorrhea
Method*
Sensitivity Specificity
(%)
(%)
DNA probe
Endocervix
Pharynx
Rectum
Urethra

92

100

77

100

96

100

96

98

17

GONORRHEA
Sensitivity and specificity of tests for
gonorrhea
Method*
Sensitivit Specificity
y (%)
(%)
Gram stain+
Endocervix

40-60

95-100

Urethra (with
symptoms)

95-98

95-100

40-60

90-95

Urethra (no symptoms

18

GONORRHEA
Sensitivity and specificity of tests for
gonorrhea
Method*

Sensitivit
y (%)

Specificity

Endocervix

97

98

Urethra

99

98

Urine (women)

96

99

Urine (men)
Vaginal swab

98

99

100

100

(%)

Ligase chain reaction

(obtained by patient)

19

GONORRHEA
TREATMENT
All recommended therapies are given as
a single dose
Should be given to symptomatic patients
at the time of testing
Enhances compliance profoundly:
Reduces further transmission
Reduces resistance
20

Recommended treatment regimens for

gonococcal infections*: cervicitis, urethritis,
proctitis
Preferre Cefixime (Suprax), 400 mg PO in a single dose or
d
Ceftriaxone sodium (Rocephin), 125 mg IM in a single
regimen dose or
Ciprofloxacin (Cipro), 500 mg PO in a single dose

or

Ofloxacin (Floxin), 400 mg PO in a single dose

plus Chlamydia coverage: Azithromycin (Zithromax),
1 g PO
in a single dose

or

Doxycycline, 100 mg PO bid x 7 days

21

Recommended treatment regimens for

gonococcal infections*: cervicitis, urethritis,
proctitis
Alternati
ve
Regimen

Cefotetan disodium (Cefotan), 1 g IM in a single dose

or Ceftizoxime sodium (Cefizox), 500 mg IM in a
single dose

or

Cefotaxime sodium (Claforan), 500 mg IM in a single

dose or
Cefoxitin sodium (Mefoxin), 2 g IM with probenecid, 1
g PO or
Enoxacin (Penetrex), 400 mg PO in a single dose

or

Lomefloxacin HCI (Maxaquin), 400 mg PO in a single

dose or
22

Recommended treatment regimens for

gonococcal infections*: pelvic inflammatory
disease
Preferred Cefotetan disodium (Cefotan), 2 g IV q 12h or cefoxitin
regimen
sodium (Mefoxin), 2 g IV q6h
(inpatient
plus Chlamydia coverage: Doxycycline, 100 mg PO+
)
q12h x 14 days or
Clindamycin (Cleocin Phosphate), 900 mg IV q8h
plus Chlamydia coverage: Gentamicin (Garamycin), 2
mg/kg loading dose IM/IV followed by 1.5 mg/kg
maintenance dose IV q8h, then doxycycline, 100 mg
PO
23
q12h to complete 14 days or clindamycin (Cleocin),

Recommended treatment regimens for

gonococcal infections*: pelvic inflammatory
disease
Alternativ Ofloxacin (Floxin), 400 mg IV q12h
plus Chlamydia coverage: Metronidazole (Flagyl
e
regimen IV,
Metro IV), 500 mg IV q8h
(inpatient
Or
)

Ampicillin sodium and sulbactam sodium (Unasyn), 3

g IV q6h
plus Chlamydia coverage: Doxycycline, 100 mg
PO+
q12 h x 14 days
Or
Ciprofloxacin (Cipro IV), 200 mg IV q12h

24

Recommended treatment regimens for

gonococcal infections*: pelvic inflammatory
disease
Outpatie
nt

Ofloxacin, 400 mg PO bid x 14 days

plus Chlamydia coverage: Metronidazole, 500 mg
PO bid
x 14 days

or

Ceftriaxone sodium (Rocephin), 250 mg IM in a single

dose

Or
Cefoxitin, 2 g IM with probenecid, 1 g PO, in a single
dose (concurrently ) or
Other parenteral 3rd-generation cephalosporin (eg.,
25
ceftizoxime sodium [Cefizox], Cefotaxime sodium

GONORRHEA
FOLLOW-UP
Tests of cure are not
needed for
uncomplicated gonococcal infections
If patient fails to improve, a culture is
required for antimicrobial susceptibility
testing
Infections identified after completion of
treatment are said to be due to reinfection
rather than treatment failure
26

GONORRHEA
FOLLOW-UP

Some experts advocate the testing

of all sexually active teenagers
twice a year
(this is based on the frequent
reinfection rates in this age group)

27

GONORRHEA
FOLLOW-UP

Patients should be encouraged to

refer their sexual partners for testing
and treatment
Patients should be advised to abstain
from sexual intercourse until they
have fully completed therapy and are
asymptomatic
28

GONORRHEA
PREVENTION
Condoms are effective in preventing the
transmission of N. gonorrhoeae
Diaphragms in combination with vaginal
spermicides also reduce the risk of
gonococcal transmission (no impact on
HIV risk)
Female condoms ????
29

SYPHILIS

SYPHILIS
Causative agent is the spirochete
(Treponema pallidum)
Although the incidence of the disease
has markedly declined in the U.S. over
the past decade, recent peaks in the
South, Midwest and the Northeast
point to the need for continued
vigilance
31

SYPHILIS
Syphilis should always be
considered in any patient who is
found to have an ulcerative lesion
in the genital region

32

Primary Chancre of the Penile Shaft

33

SYPHILIS
Patients in the later stages of
syphilis can present with a variety
of systemic manifestations
This is especially true in women who
are asymptomatic in the primary
phase and therefore often go
untreated for a longer period of time

34

SYPHILIS
MANIFESTATIONS (1O)
Primary (1o) syphilis manifests as a single,
painless, clean-based ulcer which
untreated resolves in 4-6 weeks
The lesion usually appears within 3 weeks
of infection (can range from 10-90 days)
In women the labia and vaginal wall are
most often affected, but the cervix may
also be involved
35

SYPHILIS

36

SYPHILIS
37

SYPHILIS
DIFFERENTIAL DIAGNOSIS

Herpes Simplex Virus (HSV) Infection

HSV lesions are more commonly painful
and numerous

Chancroid, Haemophilus ducreyi

Manifests as a single, painful ulcer
Regional tender adenopathy is
characteristic
38

SYPHILIS
O
MANIFESTATIONS
(2
)
o

The Secondary (2 ) stage of syphilis

develops 2-8 weeks after exposure in
persons who go untreated
2o syphilis is more common in female
than in male patients (due to
syphilis asymptomatic presentation
in women)
39

SYPHILIS
MANIFESTATIONS (2O)
Symptoms include:
Maculopapular rash generalized and
inclusive of palms and soles
Lesions which may occur on the mucous
membranes and in the genital region
Systemic symptoms:

Fever
Arthralgias
Pharyngitis
Lymphadenopathy
40

SYPHILIS
MANIFESTATIONS (2O)

The signs and symptoms of

2o syphilis usually resolve
even
without treatment
41

SYPHILIS
MANIFESTATIONS (LATENT)

The 3rd stage of untreated syphilis is called

Latent syphilis
The diagnosis is only through serologic testing
Illness occurring up to 1 year after inoculation is
considered early latent disease
Illness presenting more than 1 year after
inoculation is considered late latent disease
The stage of disease has important treatment
implications
42

SYPHILIS
MANIFESTATIONS (3O)

Tertiary (late) syphilis develops in

about 10%-40% of untreated
persons
This phase produces a variety of
neurologic, cardiovascular and other
systemic manifestations many years
after the initial infection
43

Syphilis Dementia

How common in
the new
millenium
44

SYPHILIS
Standard screeningDIAGNOSIS
tests are the VDRL test
and the rapid plasma reagin (RPR) test
The tests are reported quantitatively as
serologic dilutions (1:2, 1:4, 1:8)
The level of the titer generally reflects the
degree of disease activity and is most useful
for monitoring a patients response to
therapy
45

SYPHILIS
DIAGNOSIS
The highest titers are seen in 2o and early
latent disease
If either test is positive a confirmatory
fluorescent treponemal antibody
absorption (FTA-ABS) test should be done
The FTA-ABS measures specific IgG
antibody against T. pallidum
46

SYPHILIS
DIAGNOSIS
The primary reason for confirmatory
testing is the false-positive results
which can occur due to a variety of
acute and chronic illnesses
False-positive results yield lower
titers (1:1 to 1:4) and occur in 1% to
2% of the general population
47

SYPHILIS
Causes of false-positive results on serologic tests for
syphilis
Advanced age
Bacterial infections (eg, endocarditis, malaria, mycoplasma,
tuberculosis)
Chronic liver disease
Injecting drug use
Lyme disease
Malignancies
Pregnancy
Viral infections (eg, varicella, measles, HIV, mononucleosis)

48

SYPHILIS
TREATMENT
Penicillin is 1st Line
therapy
Stage of infection and patients HIV status
determine the route and duration of therapy
and the amount of patient follow-up needed
Penicillin is the only acceptable treatment
for patients who have neurosyphilis or are
pregnant
49

SYPHILIS
Recommended treatment for syphilis
Primary,
secondary,
or early
latent
disease

Penicillin G benzathine, 2.4 million units

IM as a single dose
Or
Doxycycline, 100 mg PO bid x 14 days
Or
Erythromycin, 500 mg qid x 14 days
Or
Ceftriaxone sodium (Rocephin), 1 g IM x
8-10 days
50

SYPHILIS
Recommended treatment for syphilis
Late latent
disease

Penicillin G benzathine, 2.4 million units IM

weekly x 3 wk

Neurosyphilis

Penicillin G (aqueous), 18-24 million units in

divided doses q4h x 10-14 days

Or
Penicillin G procaine, 2.4 million units IM
daily, plus probenecid, 500 mg PO qid x 1014 days
Pregnancy
(primary,
secondary or
early latent
disease)

Penicillin G benzathine, 2.4 million units IM in

a single dose

51

SYPHILIS
TREATMENT
Skin testing and desensitization are
recommended for pregnant patients
who have an actual penicillin allergy
(erythromycin, formally
recommended, has been found to
have erratic placental transfer).

52

SYPHILIS
TREATMENT
Patients with late latent disease or
who are HIV-positive should
receive a Lumbar puncture (LP) to
rule out neurosyphilis

53

SYPHILIS
Indications for lumbar puncture in latent
syphilis

Disease of unknown duration

Evidence of active tertiary syphilis (eg, aorthtis,
iritis, gummas)
HIV infection
Neurologic or ophthalmic signs or symptoms
Treatment failure
54

SYPHILIS
JARISCH-HERXHEIMER REACTION

Manifests as fever, chills, myalgias and

headaches
Occurs in 50% or more of patients
treated for syphilis
It may begin 1-2 hours after treatment
is started and last up to 24 hours
In certain instances it can be associated
with increased morbidity and mortality
55

SYPHILIS
FOLLOW-UP
Serologic titers should be obtained at both 6 and 12
months, and in certain instances, at 3 month
intervals
Patients titers should decline by a factor of 4, 6
months after treatment is completed
The FTA-ABS test usually remains positive for Life,
though in one retrospective study of 882 patients,
24% seroreverted to negative by 3 years post
treatment

56

SYPHILIS
FOLLOW-UP
Notification and Treatment of the sexual
partner(s) is essential
HIV testing is recommended for all
patients who have syphilis

57

CHLAMYDIA TRACHOMATIS

CHLAMYDIA TRACHOMATIS
Most commonly reported STD in the U.S.
There are more than 4 million cases
annually
Highest prevalence occurs in women
under 20 years of age
59

CHLAMYDIA TRACHOMATIS
There are severe sequelae of this
infection in women including:
PID
Tubal infertility
Ectopic pregnancy
Chronic pelvic pain

60

CHLAMYDIA TRACHOMATIS

90% of women with endocervical

infection caused by chlamydia
are
asymptomatic and may harbor
the
organism for months to years
61

CHLAMYDIA TRACHOMATIS
Chlamydia upper genital tract
infection is asymptomatic and
is believed to occur 3x more
often than that which is
accompanied by symptoms

62

CHLAMYDIA TRACHOMATIS
MANIFESTATIONS
Usually asymptomatic,
especially in
women
Mucopurulent discharge may be seen on
examination, but is non specific
Advanced disease may present with a
variety of clinical manifestations

63

Normal Cervix with Ectopy

64

Chlamydial Cervicitis

65

CHLAMYDIA TRACHOMATIS
Clinical manifestations of Chlamydia
trachomatis infection in women
Acute urethral syndrome
Bartholinitis
Conjunctivitis
Endometritis
Mucopurulent cervicitis
Perihepatitis (Fitz-Hugh-Curtis syndrome)
Reactive arthritis (Reiters syndrome)
Salpingitis (pelvic inflammatory disease)
66

CHLAMYDIA TRACHOMATIS
Treatment regimens for chlamydial
infections
Most adults

Or
Azithromycin (Zithromax), 1 g in a single dose* Or
Erythromycin base, 500 mg qid x 7 days
Or
Doxycycline, 100 mg bid x 7 days*

Erythromycin ethylsuccinate (E.E.S., EryPed), 800 mg qid x 7

days
Or
Ofloxacin (Floxin), 300 mg bid x 7 days
Pregnant women
Azithromycin, 1 g PO in a single dose Or
Erythromycin base, 500 mg PO quid x 7 days Or

67

CHLAMYDIA TRACHOMATIS
DIAGNOSIS

All sexually active adolescents

should be screened for chlamydia
during annual pelvic exams.
(some
experts recommend every 6
months)
68

CHLAMYDIA TRACHOMATIS
Cell Culture

DIAGNOSIS

Gold standard
Specificity of 100% with a sensitivity of
only 70% - 85%
Since C. trachomatis is an intracellular
pathogen it needs a cell culture to
propagate
Remains the standard test for cases of
sexual assault or child abuse
69

CHLAMYDIA TRACHOMATIS
DIAGNOSIS
Specimen collection is key
Use a cotton tipped swab or cytological brush
Leave inside the endocervix for at least 30
seconds this is important to ensure the
collection of columnar epithelial cells

70

CHLAMYDIA TRACHOMATIS
DIAGNOSIS
Direct fluorescent antibody testing
and enzyme linked immunosorbent
Assay
Easier to perform than cell culture
Yields specific results
Quicker turnaround time
Sensitivity is only 50% to 90%
71

CHLAMYDIA TRACHOMATIS
DIAGNOSISand
Nucleic Acid Identification
Hybridization
DNA test probe id. Both C. trachomatis
and Neisseria gonorrhoeae
Specificity is very good
Specimen collection from the endocervix
must be done precisely to ensure
adequate sensitivity

72

CHLAMYDIA TRACHOMATIS
DIAGNOSIS
Ligase Chain Reaction (LCR) and Polymerase
Chain Reaction (PCR)
Uses DNA or RNA amplification
The sensitivity and specificity approach 100%
Advantage is their use in urine specimens and/or
on swabbed vaginal specimens collected by the
patient
Screening for disease in populations is much easier
with these techniques
More expensive than culture but allows for easier
screening and perhaps earlier treatment and avoidance
of long term sequalae
73

CHLAMYDIA TRACHOMATIS
TREATMENT
Azithromycin
1st Line therapy
Can be taken as a single dose
Compliance can be directly observed
Safe and efficacious in pregnant women
Cost is higher
GI symptoms occur in about 3% of
patients
74

CHLAMYDIA TRACHOMATIS
TREATMENT
Test of cure may be
done in certain situations
Follow-up testing should be done in pregnant
women or if a patients symptoms persist or
there is concern regarding reinfection
A follow-up test should occur at least 3 weeks
after the completion of antibiotic therapy

75

CHLAMYDIA TRACHOMATIS

FOLLOW-UP
Partners should be notified, tested
and treated where appropriate
Empirical treatment of the partner(s)
should be considered
HIV testing should occur
Refraining from sexual intercourse
until treatment is completed is
important
76

AIDS Monster
Term recently used to describe an HIV
positive woman with self-confessed
bitterness towards the ex who infected
her. As a result, Pamela Wiser, 29, went
on an unsafe-sex binge in Tennessee,
allegedly bedding 50 men. She was
indicted in two counties on 12 counts of
willfully exposing others to HIV
77

AIDS Predator
Term used to describe an HIV positive man
accused in 1997 of exposing women in New
York City and upstate New York (Chautaqua
County) to HIV. He was sentenced to 4-12
years behind bars after his lawyers struck a
plea bargain. Prosecutors wanted a tougher
sentence but could not persuade more than
two
of the thirteen infected women to testify
78

HERPES SIMPLEX VIRUS

HERPES SIMPLEX VIRUS (HSV)

HSV-1 and HSV-2 infect more than
one-third of the worlds population
HSV-2 is responsible for the majority
of cases of genital herpes, although
HSV-1 can also lead to genital
infections
80

HERPES SIMPLEX VIRUS (HSV)

HSV is a double-stranded DNA
virus
HSV targets epithelial cells and is
then transported via neural tissue
to sensory ganglia where lifelong
latent infection is established
81

HERPES SIMPLEX VIRUS (HSV)

Triggers for viral reactivation include:
Immunodeficiency
Fever
Ultraviolet light
Stress ????
Trauma
Menstruation
Sexual Intercourse
82

HERPES SIMPLEX VIRUS (HSV)

MANIFESTATIONS
Initial episodes
are more severe than
recurrences
After an incubation period of several
days patients notice a prodrome:
Itching
Burning
Erythema
83

HERPES SIMPLEX VIRUS (HSV)

MANIFESTATIONS
Classic vesicles which are painful
appear on the:
Cervix
Vagina
Vulva
Rectum
Perineum
Surrounding skin
84

HERPES
85

HERPES

86

HERPES SIMPLEX VIRUS (HSV)

MANIFESTATIONS

Vesicles will usually rupture and

ulcerate leading to crusting by
14-21 days after the initial
appearance

87

HERPES SIMPLEX VIRUS (HSV)

MANIFESTATIONS
Systemic symptoms may occur
during the initial infection and
include:
Fever
Headache
Myalgias
Malaise
Abdominal pain
88

HERPES SIMPLEX VIRUS (HSV)

MANIFESTATIONS
Shedding of viral particles takes
place during asymptomatic periods
and hence HSV-2 transmission may
occur even when visible lesions are
not present

89

HERPES SIMPLEX VIRUS (HSV)

Clinical diagnosis DIAGNOSIS
is made by recognition
of multiple, shallow and tender ulcerations
or vesicles on or around the genitalia
Laboratory diagnosis
Viral isolation by tissue culture
Gold standard
Can take up to 5 days
Sensitivity is only 70% - 80%

90

HERPES SIMPLEX VIRUS (HSV)

DIAGNOSIS
Antigen Detection and Tzanck Tests
Lower sensitivity

Serologic studies
Not helpful during the primary illness
because of the delay in antibody production

PCR testing
Sensitive (96%) and specific (99%)
High cost
Limited availability
91

HERPES SIMPLEX VIRUS (HSV)

DIAGNOSIS

Patient with genital ulcers

should also be tested for
syphilis and HIV

92

HERPES SIMPLEX VIRUS (HSV)

TREATMENT - ACYCLOVIR

Acyclovir binds viral DNA

polymerase and ends replication
Medications must be administered
early in the course of the illness
because HSV replication may end as
soon as 48 hours into a recurrence
Only to be used in pregnancy if there
is a severe infection
93

HERPES SIMPLEX VIRUS (HSV)

TREATMENT - ACYCLOVIR

Oral bioavailability with acyclovir is

Treatment
only 15% to 30%
T1/2 is 2 1/2 hrs
Must adjust dose in renal failure

94

HERPES SIMPLEX VIRUS (HSV)

TREATMENT - ACYCLOVIR

Side effects include:

Nausea
Vomiting
Rash
Headache

Toxicity can occur but is rare,

monitor creatinine levels
95

HERPES SIMPLEX VIRUS (HSV)

TREATMENT VALACYCLOVIR AND FAMCICLOVIR

Higher bioavailability and less

frequent dosing
Good safety profiles
Much higher costs
96

HERPES SIMPLEX VIRUS (HSV)

TREATMENT VALACYCLOVIR AND FAMCICLOVIR

Recommended for initial episodes of genital

herpes infection
Effective in shortening the duration of lesions
and making the symptoms less severe
IV therapy may be necessary for
immunocomprised patients and in cases of
severe disseminated infection
Therapy for recurrences
Suppressive therapy
Episodic treatment
97

HERPES SIMPLEX VIRUS (HSV)

Treatment regimens for initial episodes of
genital HSV infection

Drug
Acyclovir* (Zovirax)
10 days

Dosage
200 mg PO 5 times a day x
Or
400 mg PO tid x 10 days

Or
Famciclovir* (Famvir)
Or
Valacyclovir HCI (Valtrex)

250 mg PO tid x 10 days

1 g PO bid x 10 days

98

HERPES SIMPLEX VIRUS (HSV)

Antiviral regimens for suppressive treatment of
HSV infection

Drug
Acyclovir (Zovirax)
Or
Famciclovir (Famvir)
Or
Valacyclovir HCI (Valtrex)

Dosage
400 mg PO bid
250 mg PO bid
500 mg PO qd
Or
250 mg PO bid*
Or
1 g PO qd if > 10 episodes99

HERPES SIMPLEX VIRUS (HSV)

Antiviral regimens for episodic treatment of
HSV infection

Drug
Acyclovir* (Zovirax)
5 days

Dosage
200 mg PO 5 times a day x
Or
400 mg PO tid x 5 days
Or
800 mg PO bid x 5 days

Or
Famciclovir (Famvir)
Or

125 mg PO bid x 5 days

100

HERPES SIMPLEX VIRUS (HSV)

FOLLOW-UP
Patient education
is essential and
should emphasize:
Viral shedding (discuss when it occurs)
The current lack of a cure
Condom use and its limitation in
preventing transmission
Pregnant women should be educated
about potential harm to the newborn

101