1. STD Dr.Nasrin jalilian

2. CLINICAL MANIFESTATIONS AND DIAGNOSIS OF CHLAMYDIA TRACHOMATIS INFECTIONS

3.  Chlamydia trachomatis is the most common bacterial cause of sexually transmitted genital infections.The majority of affected persons are asymptomatic, and thus provide an ongoing reservoir for infection. In infants born to mothers through an infected birth canal, conjunctivitis and pneumonia can occur. Moreover, both men and women can experience clinical syndromes due to infection at common epithelial sites, including the rectum and conjunctivae.

4.  In women, C. trachomatis most commonly affects the cervix. The majority of infected women are asymptomatic, although some may present with the typical findings of cervicitis, including vaginal discharge, abnormal vaginal bleeding, and purulent endocervical discharge on exam.

5.  The majority (at least 85 percent) of women infected at the cervix have neither signs nor symptoms, which is the rationale for routine annual screening of young sexually active women.  When symptoms do occur, they are highly nonspecific, and can easily be confused with vaginitis or endometrial pathology: a change in vaginal discharge, intermenstrual vaginal bleeding, and post-coital bleeding.

6.  The incubation period of symptomatic disease generally ranges from 7 to 14 days following infection. However, it is unclear how long those with asymptomatic disease may carry the infection.

7.  Dysuria-pyuria syndrome due to urethritis — Chlamydial infection of the female urethra typically occurs in a relatively small proportion (approximately 25 percent) of women with cervical infection. Most of these women do not report symptoms specific to the urethral tract, but some complain of typical symptoms of a urinary tract infection (UTI) such as frequency and dysuria. Urinalysis reveals pyuria, but bacteriuria is absent on dipstick analysis, and no organisms are seen on Gram stain or in bacterial culture. This combination of pyuria but no bacteriuria in a young, sexually active woman should prompt strong suspicion for chlamydial infection of the urethra.

8. The most concerning complication of untreated cervical chlamydial infection is pelvic inflammatory disease, which in turn can lead to infertility, ectopic pregnancy, or chronic pelvic pain

9.  Pelvic inflammatory disease — C. trachomatis can ascend to the upper reproductive tract, where pelvic inflammatory disease (PID) can result.  When symptoms of PID are present, abdominal or pelvic pain are the most common, and their presence in the setting of cervicitis or a diagnosis of chlamydial infection should prompt strong suspicion for upper genital tract involvement. Signs of PID include cervical motion and uterine or adnexal tenderness. PID due to C. trachomatis is associated with higher rates of subsequent tubal infertility, ectopic pregnancy, and chronic pelvic pain when compared with PID caused by gonorrhea, which typically causes a more acute symptomatic presentation.

10. The diagnostic test of choice for chlamydial infection of the genitourinary tract is nucleic acid amplification testing (NAAT) of vaginal swabs for women or urine for men. Many laboratories have also validated NAAT on rectal swabs to diagnose chlamydial proctitis. If non-NAAT-based testing is used for diagnosis or if adequate follow-up cannot be insured, patients with signs and symptoms consistent with chlamydia should be treated empirically before diagnostic test results return.

11.  Any sexually active individual with signs and symptoms consistent with the clinical syndromes associated with chlamydia and patients with documented gonococcal infection should undergo diagnostic testing for C. trachomatis. Because the majority of chlamydial infections are asymptomatic, routine screening with NAAT should be offered to sexually active patients at high risk of infection and complications of chlamydia

12. The GOALS of treatment are to prevent complicated infections related to chlamydia (eg, pelvic inflammatory disease, infertility, ectopic pregnancy), decrease the risk of transmission to others, and attain resolution of symptoms. ●Antimicrobial agents that have excellent activity against C. trachomatis include doxycycline (a tetracycline) and azithromycin (a macrolide). doxycyclinetetracyclineazithromycin

13.  Uncomplicated genital chlamydial infections include urethritis in men and urethritis and cervicitis in women. For patients with uncomplicated genital chlamydial infections, we suggest directly observed azithromycin rather than unobserved azithromycin or doxycycline.,Azithromycin is given as a 1000 mg single dose. Doxycycline is dosed at 100 mg twice daily for seven days. Both are highly effective, but directly observed therapy ensures completion of the regimen. Patients who are prescribed doxycycline should be counseled on treatment adherence. Women should also have pregnancy testing since doxycycline is not recommended for pregnant women.azithromycindoxycycline

14. ●Chlamydial and gonococcal infections may coexist in a significant percentage of community patients, which has a direct impact on treatment since first-line agents for chlamydia do not have activity against gonococci. Additional empiric therapy for gonorrhea should be based on a high suspicion of infection (eg, a positive Gram stain in men, a sexual partner recently diagnosed with gonorrhea). ●Empiric therapy for chlamydial infection should be offered to persons who present with symptoms suggestive of infection (cervicitis, pelvic inflammatory disease, urethritis). This is especially true if follow-up cannot be ensured and if relatively insensitive diagnostic testing is being used.

15.  Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection

16.  The gram-negative coccus N. gonorrhoeae causes sexually-transmitted urogenital and extragenital infections among men and women worldwide.  ●Most genital gonococcal infections in women are asymptomatic. The cervix is the most commonly infected mucosal site in women.

17.  Bacteremic spread of N. gonorrhoeae from the initial site of infection occurs in a small minority of patients.Disseminated infection often manifests as purulent arthritis or a triad of tenosynovitis, dermatitis, and polyarthralgia.

18.  Nucleic acid amplification testing (NAAT) is the preferred test for the microbiologic diagnosis of N. gonorrhoeae because of its superior accuracy and use with various specimen types. For urogenital infections, vaginal swabs in women (clinician-collected and self- collected) and first-catch urine in men are the preferred specimens for NAAT. For extragenital infections, NAAT, used on pharyngeal and rectal swabs, is also the preferred test.

19.  Culture remains important for its ability to assess antibiotic susceptibilities of the isolate when resistance is suspected.  Culture requires endocervical, urethral, pharyngeal, or rectal swabs with specific handling.

20.  For the treatment of suspected or confirmed uncomplicated urogenital gonococcal infection, we recommend ceftriaxone as the first agent.For the second agent, we suggest azithromycin.Doxycycline is an alternate option. Ceftriaxone is administered as a single injection of a 250 mg dose at the point of care. Azithromycin is given orally as a single dose (1 g) while doxycycline is given twice daily for seven days (100 mg). Azithromycin and doxycycline also have activity against chlamydia, which is a common copathogen.ceftriaxoneazithromycinDoxycycline

21.  Pregnant women with uncomplicated gonorrheal infection should be treated with dual therapy with ceftriaxone plus azithromycin since doxycycline should be avoided during pregnancy.ceftriaxoneazithromycindoxycycline

22.  Treatment of sexual partners is essential for preventing reinfection and controlling the spread of N. gonorrhoeae.

23.  Patients who finish a recommended regimen for treatment of uncomplicated gonorrheal infections do not need to return for a test of cure.

25.  Trichomoniasis is caused by the protozoa Trichomonas vaginalis. It is virtually always sexually transmitted and can be identified in 70 percent of the male sexual partners of infected women. Coinfection with other sexually transmitted diseases (STDs) and bacterial vaginosis is common.

26.  Clinical manifestations in women range from an asymptomatic carrier state to an acute, severe inflammatory disease. Signs and symptoms include a purulent, malodorous, thin discharge with associated burning, pruritus, dysuria, frequency, and dyspareunia. Men are often asymptomatic, but have developed urethritis.

27. DIAGNOSIS

28.  If NAAT for trichomoniasis is not available, rapid antigen tests or DNA hybridization probes for diagnosis ofT. vaginalis are commercially available and can be used as an alternative to NAAT or culture. NAAT are the standard.

29.  Treatment is indicated for both symptomatic and asymptomatic women and men.  For nonpregnant women and their sex partners, we recommend a single oral dose of 2 grams of a 5-nitroimidazole drug (eg, metronidazole, tinidazole) compared with multi-dose regimens.Single dose therapy is more convenient and appears to be as effective as multiple dose therapy. Oral administration is more effective than topical administration.metronidazoletinidazole

30.  Patients should be screened for other sexually transmitted infections

31.  We recommend treating symptomatic pregnant women with confirmed T. vaginalis infections.In addition, we suggest treating asymptomatic pregnant women with confirmed infection.Metronidazole 2 g orally in a single dose is used in pregnancy. Alternate dosing with metronidazole 500 mg twice daily for five to seven days may be associated with less nausea and vomiting. Either regimen is acceptable.Metronidazole

32.  For patients with refractory trichomoniasis, increasing the dose and duration of metronidazole or tinidazoleare the primary options. ●Patients should be instructed to avoid intercourse until they and their partners have completed treatment and are asymptomatic, which generally takes about a week..metronidazoletinidazole

33.  Women treated for a documented trichomonal infection are retested within three months following treatment regardless of whether they believe their sex partners were treated. Testing with NAAT can be done as soon as two weeks after completing treatment

34. CANDIDA  The clinical manifestations of infection with Candida species range from local mucous membrane infections to widespread dissemination with multisystem organ failure.

35.  Candida albicans accounts for 80 to 92 percent of episodes of vulvovaginal candidiasis; Candida glabrata is the next most common species.

36.  There is often little or no discharge; when present, it is classically white, thick, adherent, and clumpy (curd- like or cottage cheese-like) with no or minimal odor.

38.  The diagnosis of vulvovaginal candidiasis is based on the presence of Candida on wet mount, Gram’s stain, or culture of vaginal discharge in a woman with characteristic clinical findings.

39.  Culture is not necessary for diagnosis if microscopy shows yeast, but should be obtained in :  Women with clinical features of vulvovaginal candidiasis, normal vaginal pH, and negative microscopy.

40.  Treatment  Treatment is indicated to relieve symptoms. Asymptomatic women and sexual partners do not require treatment.  The treatment regimen is based on whether the woman has an uncomplicated infection (90 percent of patients) or complicated infection (10 percent of patients).

41.  Uncomplicated infections — ●We suggest a single dose of oral fluconazole (150 mg) for treatment of uncomplicated infections rather than multidose and topical regimens fluconazole

42.  Complicated infections — ●For women with severe symptoms, we suggest fluconazole (150 mg) in two sequential doses given three days apart rather than topical antimycotic agents.fluconazole ●For pregnant women, we suggest a topical imidazole (clotrimazole, miconazole) vaginally for seven days rather than a nystatin pessary or an oral azole.Case reports have described a pattern of birth defects (abnormalities of cranium, face, bones, and heart) after first trimester exposure to high dose oral azole therapy (400 to 800 mg/day) and cohort studies have reported conflicting data on risk of miscarriage. clotrimazolemiconazolenystatin

43.  For women with recurrent vulvovaginitis (≥4 episodes/year), we suggest suppressive maintenance therapy rather than treatment of individual episodes.We prescribe initial induction therapy withfluconazole 150 mg every 72 hours for three doses, then maintenance fluconazole 150 mg once per week for six months. Women with recurrent infection should try to eliminate or reduce risk factors for infection. fluconazole

46. BACTERIAL VAGINOSIS  Bacterial vaginosis (BV) is the most common cause of vaginitis in women of childbearing age.

47.  PATHOGENESIS AND MICROBIOLOGY — Bacterial vaginosis (BV) represents a complex change in the vaginal flora characterized by a reduction in concentration of the normally dominant hydrogen-peroxide producing lactobacilli and an increase in concentration of other organisms, especially anaerobic gram negative rods.The major bacteria detected are Gardnerella vaginalis, Prevotella species, Porphyromonas species, Bacteroides species, Peptostreptococcus species, Mycoplasma hominis, Ureaplasma urealyticum, and Mobiluncus species.Fusobacterium species and Atopobium vaginae are also common. The mechanism by which the floral imbalance occurs and the role of sexual activity in the pathogenesis of BV are not clear, but formation of an epithelial biofilm containing G. vaginalis appears to play an important role.

48. CONSEQUENCES  Pregnant women with bacterial vaginosis (BV) are at higher risk of preterm delivery  BV is a cause of :  Endometrial bacterial colonization  Plasma-cell endometritis  Postpartum fever  Posthysterectomy vaginal cuff cellulitis  Postabortal infection  BV is a risk factor for human immunodeficiency virus (HIV) acquisition and transmission.  BV is a risk factor for acquisition of herpes simplex virus type 2 (HSV-2), gonorrhea, chlamydia, and trichomonas infection.Although BV is more common among women with pelvic inflammatory disease (PID), it is not clear whether it is a causal factor or an independent risk factor for this disease.  BV may be a factor in development of precancerous cervical lesions.

49.  Approximately 50 to 75 percent of women with BV are asymptomatic. Those with symptoms often present with an off- white, thin, and homogeneous "fishy smelling" discharge that is more noticeable after coitus and during menses. ●Sequelae of BV can include an increased risk of preterm birth, plasma-cell endometritis, postpartum fever, post-hysterectomy vaginal cuff cellulitis, postabortal infection, pelvic inflammatory disease, and acquisition of other sexually transmitted infections.

50. Diagnosis  When microscopy is available, the diagnosis of BV is based on the presence of at least three of the following four Amsel criteria Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls  Vaginal pH greater than 4.5  Positive whiff-amine test, defined as the presence of a fishy odor when 10 percent potassium hydroxide (KOH) is added to a sample of vaginal discharge  Clue cells on saline wet mount, comprising at least 20 percent of epithelial cells  If microscopy is not available, we suggest using physical examination, pH testing, whiff-amine test, and a commercial test using a DNA probe (eg, Affirm VP III) to make the diagnosis of BV. Vaginal culture is not useful.

51.  TREATMENT — Bacterial vaginosis (BV) resolves spontaneously in up to one-third of nonpregnant and one-half of pregnant women.Treatment is indicated for relief of symptoms in women with symptomatic infection and to prevent postoperative infection in those with asymptomatic infection prior to abortion or hysterectomy. we agree with the United States Centers for Disease Control and Prevention (CDC) recommendations to not treat asymptomatic women.  Asymptomatic pregnant women with previous preterm births may also benefit, but screening and treatment of these women is controversial

52. Treatment of nonpregnant women ●Treatment of symptomatic women with bacterial vaginosis is indicated to reduce vaginal discharge and odor. We recommend metronidazole or clindamycin. Options include:metronidazoleclindamycin Metronidazole 500 mg twice daily orally for seven daysMetronidazole Metronidazole gel 0.75 percent (5 grams containing 37.5 mg metronidazole) once daily vaginally for 5 daysMetronidazole Clindamycin 2% vaginal cream once daily at bedtime for seven daysClindamycin Clindamycin 300 mg twice per day orally for seven daysClindamycin Clindamycin 100 mg vaginal suppositories at bedtime for three daysClindamycin Clindamycin bioadhesive cream (Clindesse) 2% as a single vaginal dose of 5 grams of cream containing 100 mg of clindamycin phosphate.Clindamycin

53. Managment of pregnant women ●Pregnant women with BV are at increased risk of preterm birth. We recommend not screening all pregnant women for BV, given there is no evidence that screening and treatment of asymptomatic infection reduces the risk of preterm birth ●We treat pregnant women with symptomatic BV infection to relieve symptoms. We prescribe clindamycin300 mg orally twice daily for seven days or metronidazole 500 mg orally twice daily for seven days.clindamycinmetronidazole We suggest treatment of asymptomatic women who are to undergo pregnancy termination.Preoperative treatment decreases the frequency of postoperative infectious complications.

54. THE END