2Sexually Transmitted Infections Ataei Behrooz,MD.MPH Medical University Isfahan Department of Infectious Diseases
3Now many persons call them “sexually transmitted infections or “STIs.” The name of this group of diseases was changed from “venereal diseases” to “sexually transmitted diseases” or “STDs”Now many persons call them “sexually transmitted infections or “STIs.”
4Sexually Transmitted Infections A STI is an infection that is transmitted through sexually activity
5Importance of STIsMost neglected area of healthcare in developing countries (vaginitis, cervicitis and PID)Major cause of infertility in both females and males
6Importance of STIsAccount for up to 40% of gynecologic hospital admissionsCofactor in HIV and HBV transmissionSTDs are almost as common as malaria: 333 million new cases each year
7Importance of STIs Infertility: 20-40% of males with untreated chlamydia and gonorrhea55-85% of females with untreated PID(8-20% of females with untreated gonorrhea develop PID)Increased risk of HBV and HIV/AIDS transmission
8STDs are a Significant Problem The consequences of untreated STDsEctopic pregnancy (7-10 times increased risk in women with history of PID)Increased risk of cervical cancerChronic abdominal pain (18% of females with a history of PID)
15Epidemiology HSV has a world wide distribution Humans are the only reservoir of infectionSpread by direct contact with infected secretionsHSV – 2 more frequent cause of genital infectionMajor risk of infections 14 – 29 yrsSero prevalence rates in general papulation 22%
16Pathogenesis Incubation period 2 – 7 days HSV replicates with in epithelial cells and lyses themProducing thin – walled vesicleMulti nucleated cells with intra nuclear inclusionsRegional lymph nodes, enlarged and tender often bilateral
17HSV also migrates along sensory neurons to sensory ganglia (latent state) Virus migrate back to skin along sensory nerves (Reactivation)
18Clinical presentation : primary infection In male :Painful vesicle on the glans or penile shaft on erythematous base persist 7 – 14 daysIn female : painful vesicle on the vulva, perineum, buttocks, cervix or vaginaVaginal discharge frequentlyInguinal adenopathy, fever, malaise
19Recurrent :Grouped vesicles on erthematous base, painful few systemic symptom last days
20Diagnosis :Appearance of characteristic vesicles is strongly suggestive of HSV infectionTzanck smear (66% sensitive)Tissue culture isolation (gold standard)HSV-2 AntigenFour fold rise in antibodies to HSV-2 (for primary)
21TreatmentAcyclovir (topical, oral, IV) shorten course of HSV infectionDo not prevent latent stageCan not prevent recurrenceProphylactic oral acyclovir (4 -6 yrs) decrease frequency symptomatic recurrences (60% to 80%)Valacyclovir, famcyclovir
22Shedding of HSV active cervical or vulvar lesions late in pregnancy is indication for cesarean section
23Recommended Treatment First clinical episode:Acyclovir 400 mg orally 5 times a day for 7-10 days, or famciclovir 250 mg orally 3 times a day for 7-10 days, or valacyclovir 1 g orally 2 times a day for 7-10 days.
24Recommended Treatment Recurrent episodes:Acyclovir 400 mg orally 3 times a day for 5 days, or 800 mg orally 2 times a day for 5 days or famciclovir 125 mg orally 2 times a day for 5 days
26Epidemiology 90000 cases in U.S per year Caused by treponema pallidium Primary syphilis occurs mostly in sexually active 15 – 30 yrs50% sexual contacts of a patient with primary syphilis infectedIncubation period days (21 days)
27PathogenesisTreponema pallidium penetrate intact mucous membrane or abraded skin
28Primary lesion Chancre: Papule that ulcerates, painless, border raised, firm, ulcer indurated,base smooth,usually single, may be genital or almost anywhere, persists 3-6wk,leaving thin, atrophic scar
34Late syphilis After 1 to 10 yrs in 15% of untreated patient. Skin gumma (respond)Borne, liver, cardio vascular or CNS gummaProgressive cardiovascular syphilis within 10yrs more than 10% untreated patientCNS syphilis in 8%, 5 to 35 yrs after primary infectionTabes dorsalis, general paresis, meningovascular
36LABORATORY DIAGNOSIS Direct Examination for Spirochetes In primary, secondary, and early congenital syphilis, the darkfield examinationor immunofluorescent staining of mucocutaneous lesions is the quickest and most direct laboratory method of establishing the diagnosis.
38The standard nontreponemal test is the VDRL slide test. It is now most often used to monitor a patient's response to therapy.Most laboratories and blood banks have adapted a modification for routine screening for syphilis: the
39rapid plasma reagin (RPR) card test, the automated reagin test (ART), or the toluidine red unheated syphilis test (TRUST).A prozone phenomenon occurs in up to 2% of infected
40These tests are inexpensive, reliable, and easy to perform. They have utility for screening sera and in areas of high prevalence (e.g., southeastern United States) should still be used to screen hospital admissions.Also, they have great utility as a gauge of thesuccess of treatment.
43Specific Treponemal Tests These tests would be relatively expensive as screening tests,their principal use is to verify a positive nontreponemal reaginic test result.Once positive, the patient usually remains positive for life
44In summary, the reaginic antibody tests (RPR, VDRL, ART) are used for screening large numbers of sera, the specific treponemal tests(TPHA, MHA-TP, FTA-abs) for confirming the diagnosis, and thequantitative nontreponemal antibody tests (RPR, VDRL) for assessing the adequacy of therapy.
45Reversion to a non reactive status may occur in up to 10% of patients, especially in those who are treated early.
48Jarisch-Herxheimer Reaction Systemic reactionResembling gram negative sepsisUsual1y begins I to 2 hours after theinitial treatment of syphilis with effective antibiotics, especial1y penicillin.
49Follow after treatment Every patient who is treated for syphilis should be sero negative or sero fast with a low fixed titer before termination of follow – up if not therapy should be repeated
50Abrupt onset of fever, chills, myalgias, headache, tachycardia, hyperventilation, vasodilation with flushing,Varying degrees of obtundation, and mild hypotension.Particularly common when secondary syphilis is treated (70% to 90%) but can occur in any stage (10% to 25%).
51Lasts from 12 to 24 hoursand has been wel1 correlated with the release from the spirochetes .
52prevented or treated with an anti-inflammatory agent such as aspirin every 4 hours for a period of 24 to 48 hours.Prednisone can also abort the reaction, and one dose of 60 mg PO or IV should be given as adjunctive therapyto JH patients with cardiovascular or symptomatic neurosyphilisand to pregnant patients to avoid catastrophic consequences.
532000 cases in U.S. per year, caused by Haemophilus ducreyi Chancroid2000 cases in U.S. per year, caused by Haemophilus ducreyi
54Primary lesionIncubation 3-5 days; vesicle or papule to pustule to ulcer; soft, not indurate; very painful
55Adenopathy1 wk after primary in 50%; painful, unilateral (two thirds), suppurative
64Granuloma inguinale50 cases in U.S. per year, caused by Calymmatobacterium gronulomatis
65Incubation 9-50 days;at least one painless papule that gradually ulcerates; ulcers are large (l-4cm),irregular, non tender; with thickened, rolled margins and beefy red tissue of base older portions of ulcer show depigmented scarring, white advancing edge contains new papules
66adenopathyNo true adenopathy; in one fifth, subcutoneous spread through lymphatics leads to indurated swelling or abscesses of groin (“pseudobuboes”)
68Diagnosis / treatmentScraping or deep curetting at actively extending border; Wright or Giemso stain reveals short, plump, bipolar staining; “Donovan's bodies in macrophage vacuoles/Rx: tetracycline, 2 g/day for 21 days
69Condyloma acuminatumgenital warts, frequent, caused by human papillomavirus
70Primary lesionCharacteristic large ,soft, fleshy, cauliflower-like excrescences around vulva, glans, urethral orifice anus, perineum
75GONORRHEA Epidemiology Particular risk factors Urban habitatLow socioeconomic statusUn married statusUnprotected sexual contacts50% of females intercourse with a male with gonococcal, urethritis developed symptomatic infection
76For male 20%A symptomatic infection of male important factor transmission (40%)Co infection with C. trachomatis(30% to 40%)Group B blood increases susceptibility
77EtiologyNeisseria gonorrhea is a gram – Negative, kidney bean shaped diplococcus
78Clinical presentation Incubation period : 2 to 7 daysIn male : purulent discharge urethritis and severe DysuriaIn female cervicitis : coptous yellow vaginal discharge
79Females also may develop urethritis with dysuria and frequency Anorectal gonorrhea occurs in both homo sexual males and hetero sexual femaleExtragenital dissemination occurs in 1% male and 3% female (Arthritis – dermatitis syndrome)
80Laboratory diagnosis Gram stain (intracellular diplococci) Culter DNA probe
82CultureA single culture on antibiotic-containing selective medium, such asmodified Thayer-Martin agar, has a sensitivity of 95% or more for urethral specimens from men with symptomatic urethritis80% to 90% for endocervical infection in women.
83Non gonococcal urethritis (NGU) NGU predominate in higher socioeconomicChlamydia trachomatis causes 30 to 50% of NGUChlanmydia – Negative NGU U.urealyticum, trichomonas vaginals
84Clinical syndromes Incubation period 7 – 14 days Urethral discharge, itching, dysuriaDischarge is not spontaneousDischarge apparent after milking urethra in morningMucopurulent discharge consist of thin, cloudy fluid with purulent specksC. trachomatis common cause epididymitis in male 35 yrs age.
88Initial Treatment for Patient and Partners Treat gonorrhea (unless excluded): plusTreat chlamydial infection:Ceftriaxone, 125 mg IM; or Azithromycin, 1 g PO; or Cefpodoxime, 400 mg PO; or Doxycycline, 100 mg bid for 7 daysCefixime, 400 mg PO
89Alternative regimens Ceftizoxime (500 mg IM, single dose) or Cefotaxime (500 mg IM, single dose)Spectinomycin (2 g IM, single dose)Cefotetan (1 g IM, single dose) plus probenecid (1 g PO, single dose)Cefoxitin (2 g IM, single dose) plus probenecid (1 g PO, single dose)