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Sexually Transmitted Infections

Sexually Transmitted Infections. Rontgene M. Solante, MD Internal Medicine-Infectious Diseases. Objectives:. To present common cases of STIs To review current methods in the approach to the diagnosis and management of these STIs. Case 1.

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Sexually Transmitted Infections

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  1. Sexually Transmitted Infections Rontgene M. Solante, MD Internal Medicine-Infectious Diseases

  2. Objectives: • To present common cases of STIs • To review current methods in the approach to the diagnosis and management of these STIs.

  3. Case 1 • 32 year old, male, seaman, presented with a complaint of difficulty of urination • Self-medication with Ampicillin 500 mg 3x daily with only slight relief • (+) unprotected sex with a freelance sex worker 9 days ago

  4. Case 1: Physical Exam • urethral discharge, yellowish mucopurulent • tenderness right scrotum, (-) masses • no prostatic tenderness • (+) right inguinal lymphadenopathy

  5. As the attending physician, your goal of Management in the approach of this patient should prioritize on: • controlling the signs and symptoms to prevent further transmission • b. establish the presence of urethritis • and identification of etiologic agents • c. prevention of complications and sequelae • d. counseling for HIV and other STI work-up

  6. Urethritis in Men • Clinical Criteria: Urethral discharge (mucopurulent) + Dysuria , Meatal erythema • Presumptive Laboratory Criteria: (1) Urethral Gram stain >5 WBC’s/oif (2) Pyuria (>10 WBC’s/hpf )on first voided urine sediment (3) Positive leukocyte esterase (LE )test on FVU

  7. What organisms are the most likely pathogens you consider in males with urethritis? • Neisseriagonorrheae • Chlamydia trachomatis • Ureaplasma and Mycoplasma • Herpes and Trichomonas • A and B only

  8. Urethritis in Male Etiology • Neisseriagonorrhoeae • Chlamydia trachomatis • Ureaplasmaurealyticum • Mycoplasmagenitalium • T. vaginalis, HSV, and adenovirus • Enteric bacteria: (E.coli, Proteus sp) anal sex, instrumentations,UTI

  9. Cervicitis/Urethritis in Women • Etiology • Neisseriagonorrhoea • Chlamydia trachomatis • Trichomoniasisand genital herpes (especially primary HSV-2 infection) • no etiology, non-infectious- majority of cases Non-infectious: (persistent abnormality of vaginal flora, douching or exposure to chemical irritants, or idiopathic inflammation in the zone of ectopy)

  10. Clinical Features of Gonococcal and NongonococcalUrethritis in Men Gonorrhea Nongonococcal Incubation 1 - 7 days 3-21 days Onset Abrupt Gradual Symptoms Prominent Milder Dysuria only 2% 27% Discharge only 27% 47% Both 71% 38% Discharge Purulent (91%) Mucoid (58%) Asymptomatic80% women 70-75% women 10% men Co-infection rate40% Mandell’s Prin Pract of Inf Dse 2005

  11. Sensitivity and Specificity of Gram-stained Smear for the Detection of Genital or Anorectal Gonorrhea Site and Clinical Setting Sensitivity Specificity Urethra Men, symptomatic urethritis 90-95% 95 – 100% Men, asymptomatic urethritis 50-70% 95 – 100% Endocervix Uncomplicated gonorrheae 50-70% 95-100% Pelvic inflammatory disease 60-70% 95-100% Anorectum Blind swabs 40- 60% 95-100% Anoscopically obtained specimen 70-80% 95-100% Hansfield et al, Sexually Trans Dse: 3rd Edition 1999

  12. Neisseriagonorrheae • Culture and Isolation - uses highly selective media Thayer Martin - definitive diagnosis , objective isolation - drug sensitivity assessment • Non-Culture Method of Diagnosis highly sensitive and specific • ANTIGEN DETECTION Enzyme Immunoassay • DNA HYBRIDIZATION : GenProbe • NUCLEIC ACID Amplification (PCR) advantage: urine/urethral specimen : asymptomatic diagnosis

  13. Chlamydia trachomatis • Screening test: Gram stain • 15 or more pus cells/hpf (urine) • > 5 pus cells / OIF (urethral discharge) • > 30 pus cells / OIF (cervical discharge) • absence of gram negative diplococci • Confirmatory tests: CELL CULTURE ANTIGEN DETECTION ASSAY - Direct Flourescent Antibody (DFA) - Enzyme ImmunoAssay NUCLEIC ACID AMPLIFICATION test(NAAT) : asymptomatic diagnosis

  14. Treatment: NeisseriagonorrhoeaeCervix, Urethra, Rectum Quinolone Resistant:(Philippines) Cefixime 400 mg or Ceftriaxone 125/250 mg IM PLUS Chlamydial therapy Azithromycin 1 gm single dose or Doxycycline 100 mg bid x 7days

  15. Treatment: NeisseriagonorrhoeaeCervix, Urethra, Rectum Quinolone-Sensitive: Ciprofloxacin 500 mg orally in a single dose* OR Ofloxacin 400 mg orally in a single dose* OR Levofloxacin 250 mg orally in a single dose* PLUS TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT

  16. Case 2: Vulvovaginal Discharge Women 2 weeks later, the patient came back because of recurrence of urethritis together with her wife who also complained of vaginal discharge. PE done and revealed: Vaginal wall Cervix OS

  17. Vulvovaginal Discharge Etiology • CANDIDIASIS (Candida albicans) • BACTERIAL VAGINOSIS • TRICHOMONIASIS (Trichomonasvaginalis)

  18. VulvovaginalCandidiasis • vulvar pruritus • vulvar erythema, edema,tenderness • thick, white, curdy plaques • burning sensation during urination

  19. Bacterial Vaginosis • profuse,malodorous, • non-irritating discharge • offensive odor • asymptomatic in 50% of cases • disappearance of lactobacilli & increase number of Gardnerella Mycoplasma & anaerobic gm(-) rods like:Mobiluncus sp., Prevotella

  20. Bacterial Vaginosis Diagnosis: High Specific Sign • clue cells • WHIFF TEST: Amine Odor Less Specific Signs • vaginal pH >4.5 • lactobacilli fewer than bacteria • homogenous discharge

  21. Trichomoniasis • Most common non-viral STI in women • purulent, homogenous, or frothy discharge • urinary symptoms: frequency & dysuria • vaginal pruritus • dyspareunia • offensive genital odor

  22. Trichomoniasis • Diagnosis: • Microscopy : • Wet Mount - 92% sensitivity • (+) clumps of WBC cells and • motile trichomonads • Culture: • Modified Diamond media • Feinberg-Whittington

  23. Complications: BV and Trichomoniasis • Preterm labor • PROM • Low birth weight infabts • Chorioamnionitis • Postpartum endometritis • Post-abortion infection

  24. Treatment: BV and Trichomoniasis • Metronidazole 2 gm p.o. single dose ALTERNATIVE • Metronidazole 500mg 2x daily x 7 days

  25. Case 3 : Genital Ulcers • 34 year old, male, call center agent, presented with a complaint of genital lesionsfor almost 2 weeks. • (-) dysuria, (-) urethral discharge • Self-medication with Ciprofloxacin but no relief noted • (+) unprotected sex with the same gender, being both the insertive and recipient partner a month ago

  26. Case 2: PE • Shallow, non-painful ulcers • indurated border • solitary • (+) inguinal lymphadenopathy

  27. Case 2: Genital Ulcers • Etiology: • Herpes simplex • Treponemapallidum • Haemophilusducreyi

  28. Non-genital lesions of syphilis palms/ soles mouth palate “rashes” “patches/ rashes” “ulcers”

  29. Primary and Secondary Syphilis (rashes and condylomalata)

  30. Non-Genital Manifestations of Syphilis (syphilis gumma)

  31. Diagnosis Serologic a. Screening: RPR , VDRL -uses non-treponemal antigen (cardiolipin, lecithin, cholesterol) - determine disease activity (>1:4) - monitor treatment response b. Confirmatory: TPPA / TPHA/FTA-Abs - uses treponemal antigen - confirms a positive RPR/VDRL - positive for lifetime

  32. SyphilisPrimary, Secondary, Early Latent Recommended regimen Benzathine Penicillin G, 2.4 million units IM Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days Latent Syphilis Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses

  33. Case 2: Herpes simplex, males Primary herpes, male Recurrent herpes, male

  34. Herpes Simplex Principles of Management • Antiviral chemotherapy offers benefits to majority of symptomatic patients • Antiviral drugs can partially control signs and symptoms of first clinical, and recurrent episodes or when used as daily suppressive therapy • Counseling regarding natural history and transmission is integral to management

  35. Genital HerpesFirst Clinical Episode Acyclovir 400 mg tid Famciclovir 250 mg tid Valacyclovir 1000 mg bid Duration of Therapy 7-10 days

  36. Chancroid: Haemophilusducreyi Chancroid ulcers Chancroid - regional adenopathy

  37. Treatment: Chancroid Azithromycin 1 gm orally or Ceftriaxone 250 mg IM in a single dose or Erythromycin base 500 mg tid x 7 days

  38. Papillomavirus: male

  39. Papillomavirus: female

  40. Papillomavirus Patient-applied Podofilox 0.5% solution or gel or Imiquimod 5% cream Provider-administered Cryotherapy or Podophyllin resin 10-25% or Trichloroacetic or Bichloroacetic acid 80-90% or Surgical removal

  41. Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80-90% Urethral meatal warts Cryotherapy or podophyllin 10-25% Anal warts Cryotherapy or TCA/BCA 80-90%

  42. STD Prevention and Control • Education and counseling to reduce risk of STD acquisition • Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation • Effective diagnosis and treatment • Evaluation, treatment, and counseling of sexual partners • Preexposure vaccination--hepatitis A, B, HPV vaccination (serotype 16,18,6 and 11)

  43. References: • Mandell’s Prin Practice of Inf Dse 2005. 6th ed • MMWR CDC STD Treatment Guideline Aug2006 vol 55 • Harrison’s Prin of Internal Medicine 2005. 6th ed • Washington Manual Inf Dse Consult 2005 • SACCL Data

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