Presentation on theme: "Sexually Transmitted Infections"— Presentation transcript:
1 Sexually Transmitted Infections Unit 15 HIV Care and ART: A Course for PhysiciansUnit 15 should take approximately 2 hours and 10 minutesStep 1: Unit Learning Objectives (Slide 1-2) – 5 minutesStep 2: Overview of STIs (Slides 3-13) – 15 minutesStep 3: Skills for STI Management (Slides 14-23) – 15 minutesStep 4: Management of STI Syndromes (Slides 24-85) – 1 hour and 30 minutesStep 5: Key Points (Slides 86-88) – 5 minutes
2 Learning Objectives Differentiate STI and STD Describe the epidemiology of STIsDescribe syndromic management of STIsIllustrate:The impact of STI on HIVThe impact of HIV on STIDemonstrate the importance of HIV testing and counseling in patients with STIsStep 1: Unit Learning Objectives (Slide 1-2) – 5 minutes
3 STI versus STDSTI – Infections acquired through sexual intercourse (may be symptomatic or asymptomatic)STD – Symptomatic disease acquired through sexual intercourseSTI is most commonly used because it applies to both symptomatic and asymptomatic infectionsStep 2: Overview of STIs (Slides 3-13) – 15 minutesSome people use the terms STI and STD interchangeably but they actually have different meaning.
4 Estimated New Cases of Curable* STIs Among Adults Source: Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections Overview and Estimates. WHO
5 Prevalence and Incidence of STIs Higher among urban residents, unmarried, and young adultsDiffers between countries and regions within countriesDifferences can be caused by social, cultural, and economic factors, or levels of access to care
6 STIs in Ethiopia No uniformity in reporting STI cases Only surveillance system is for HIV and syphilis among pregnant womenAll regions (except SNNPR) reported 451,686 cases of STIs between June 1998 and June 2002This number reflects severe underreporting
7 STI Dissemination The rate of STI dissemination depends upon: Rate of exposureEfficiency of transmission per exposureDuration of infectiousnessSTI dissemination can be reduced by:Behavior modification: limiting partners, condom useScreening of risk groups, pregnant women, and their partnersTreating all infectionsHealth education and risk reduction counselingPartner notification
8 Challenges to Prevention Difficult to change human behaviorCo-infection with multiple STIs is commonNot all STIs are treatableMany STIs are asymptomaticTransmission can occur during asymptomatic viral shedding
9 How Symptomatic are STIs? Males are generally more symptomatic than females.Most STIs are asymptomatic! Think about it: if everyone with a STI had pain, discharge, etc., most people would seek treatment and the amount of STIs in the general population would drop dramatically. Asymptomatic infection exists as a large “reservoir” that perpetuates STI.This emphasizes the need to screen, diagnose, and treat asymptomatic cases.Source:Source: WHO HIV/AIDS/STI Initiative
10 Impact of STIs Considerable morbidity High rate of complications Facilitate HIV transmission and acquisitionMay cause infertilityTreatment can be a high financial burdenMay cause problems in relationships—divorce, abandonment, beatings
11 Interaction Between HIV and STIs Significant interaction exists between HIV and STIsAffect similar populationsHave a similar route of transmissionThe interaction is bidirectionalHIV influences conventional STIsSTIs influence HIV
12 Influence of HIV Infection on STIs HIV alters the clinical features of STIsSyphilis: Neurosyphilis develops more frequently and rapidlyHSV: Ulcers are more severe, chronic, and possibly disseminate throughout bodyResponse to treatment may be reducedHigh rates of treatment failure for neurosyphilisComplications may increase and occur more quickly
13 Influence of STI on HIV infection Increased transmission of HIVA person with STI has greater chance of transmitting and acquiring HIV infectionImplications of the interaction:Reduction in conventional STI could result in reduction of HIV incidenceEffective STI prevention and control should be components of HIV prevention programs
14 STI ManagementStep 3: Skills for STI Management (Slides 14-23) – 15 minutes
15 Syndromic Approach to STI Management Identification of clinical syndromeGiving treatment targeting all the locally known pathogens which can cause the syndrome“Syndromic Management” contrasts with “Etiologic Management.” Whereas etiologic management focuses on identifying and treating a specific etiology causing clinical symptoms, syndromic management considers the likely causative agent(s) for a given clinical syndrome and treats accordingly, without regard for identifying the specific infection.Benefits of etiologic management: focused, specific therapy, avoiding the cost and toxicity of unnecessary medications.Benefits of syndromic management: laboratory testing not needed; treatment provided immediately; effective in resource-limited settings.
16 Syndromic Approach to STI Management (2) AdvantagesSimple, rapid and inexpensiveComplete care offered at first visitPatients are treated for possible mixed infectionsAccessible to a broad range of health workersAvoids unnecessary referrals to hospitalsDisadvantagesOver-treatmentAsymptomatic infections are missed
17 Examination of the STI Patient Physical examination should include:Examination of anogenital areaExamination of any other symptomatic areas, e.g., skin, joints, neurological, etc.Additional examinations in femalesSpeculum examinationBimanual pelvic examination
18 History of the STI Patient Presenting symptomsPrevious diagnosis of STISexual historySymptoms and diagnosis in sexual partnerPast general medical historyCurrent medicationsRisk factors for the acquisition of HIV and STIsIn females: obstetric, menstrual history, and use of contraceptives
19 Talking about STIs with Patients Important to understand the patient’s perspective on talking about sexEmbarrassedNervousGuiltyShame, fearPatients would like their medical provider to beNonjudgmentalRespectfulMaintain privacy and confidentialityDISCUSSION SUGGESTIONSHave the group list other feelings that patients experience when asked or talking about sexual behaviors or symptoms they are experiencing. Other feelings may include: anger at self or others; disappointment; fear of being judged; thinking of excuses; worried about telling provider of opposite sex or different sexual orientation; skepticism about benefit of telling; editing or lying; desire to present self in best light.Ask group for other qualities that they think medical providers should exhibit when talking about sexual behavior. Additional qualities may be: empathetic, caring, honest, forgiving, warm and friendly, patient, validates feelings, good listener, considerate, and genuinely interested.Source: Partnership for Health, University of Southern California, 2004
20 Group Discussion: Patient-centered vs Group Discussion: Patient-centered vs. Provider-centered Approach to CareWhat are the key differences between the patient- and provider-centered approaches to care?What are the positive and negative aspects of each approach?How would these different approaches possibly impact patient outcomes?DISCUSSION SUGGESTIONAsk the group to discuss these three questions regarding patient-centered versus provider-centered approach.(The next slide contains a description of patient-centered care)
21 Principles of Patient-Centered Care Communicate in a nonjudgmental mannerExplore the disease and the patient’s feelings and perceptions about their conditionUnderstand the patient as a whole personCome to a mutual understanding with the patient regarding disease managementExplore the disease and the patient’s feelings and perceptions about their condition:Feelings about being illIdeas about what is wrong with themImpact of the problem on their daily functioningExpectations of what should be doneUnderstand patient as a whole personRecognize that your patient is more than just someone with an illnessAcknowledge that this illness may affect other people in the patient’s lifeLook for ways to tie the patient’s daily experiences into the discussionCome to a mutual understanding with the patient regarding disease management:Find recommendations that fit in the context of the patient’s lifeMake sure the patient understands the nature of their diseaseWork together with the patient to come up with management strategies
22 Building Rapport Begin with a non-medical interaction Create an atmosphere that is open and supportivePractice “active listening”Discuss a detailed agenda of what will occurAnswer questions using simple terms the patient can understandDISCUSSION SUGGESTIONDiscuss the ways in which physicians can build rapport with their patients.
23 Expert Communication Skills Maintain good eye contactUse active listening and watch the patient’s nonverbal cuesHave warm and accepting body languageRely on open ended questionsAvoid interruptingUse summaries and reflections
24 STI Syndromes and Management Step 4: Management of STI Syndromes (Slides 24-85) – 1 hour and 30 minutes
25 Common STI Syndromes Urethral discharge or burning on urination in men Vaginal dischargeGenital ulcer in men and womenLower abdominal pain in womenScrotal swellingInguinal bubo
26 Case Study: TsegenetTsegenet is a 48 year-old woman who presents with a new genital lesion noted 4 days ago by her sex partner.The lesions is essentially asymptomatic except occasional mild pruritus.She reports a new male sex partner starting 2 months ago.
27 Case Study: Tsegenet (2) Periurethal lesions on vestibule
28 Case Study: Tsegenet (3) What additional information do you wish to know about this patient?Based on the history you have and the appearance of the lesion, what does your differential diagnosis include?DISCUSSION SUGGESTIONSThe correct answer to the first question on this slide is “a complete medical history.” Attempt to have the group volunteer the items shown on the next slide, and reinforce with praise the items that are particularly related to STIs. For example, if someone volunteers “past general medical history” acknowledge that is correct, but if someone volunteers “the patient’s sexual history” you might reply, “Excellent! That is important and often overlooked.”In discussing the DDx, at minimum attempt to have the group identify:Herpes simplexSyphilisChancroidLymphogranuloma venereumGranuloma inguinale
30 Genital Ulcer Disease: Differential Diagnosis Herpes simplexSyphilisChancroidLymphogranuloma venereumGranuloma inguinaleOthersDISCUSSION SUGGESTIONS1. At minimum, the group should identify these causes. Other STIs and non-STI causes may also be proposed (and could well be correct).
31 Differential Diagnosis? Syphilitic chancre, showing well-demarcated boundary and clean ulcer base (in contrast to chancroid, which typically has a more exudative appearance).Courtesy of the Division of STD Prevention/CDC
32 Differential Diagnosis? This is also syphilis, but varies from classic appearance of a single ulcer.Up to 40% of cases of primary syphilis may have > 1 chancre.Courtesy of the Division of STD Prevention/CDC
33 Differential Diagnosis? Genital UlcerCourtesy of the Cincinnati STD/ HIV Prevention Training Center
34 Differential Diagnosis? Genital ulcer disease caused by multiple pathogens
35 Differential Diagnosis? Secondary syphilis. Erythematous maculopapular rash of secondary syphilis. Note presence on sole of foot; syphilis is one of only a few skin disorders to manifest on soles of feet or palms of hands.Courtesy of Peter Katsufrakis, MD
36 Differential Diagnosis? Erythematous maculopapular rash of secondary syphilis.Courtesy of Peter Katsufrakis, MD
37 Differential Diagnosis? Condyloma lata of secondary syphilis. Grossly, it would be difficult to differentiate these from condylomata lata caused by HPV infection.Condyloma lata are teeming with spirochetes and very infectious.Courtesy of the Public Health Image Library/CDC
38 Differential Diagnosis? Scabies excoriations. Although not typically thought of as a cause of GUD, patient scratching can cause excoriated ulcers.Courtesy of the Public Health Image Library/CDC
39 Genital Ulcer Disease Treatment Recommended treatment for non-vesicular genital ulcerBenzanthine penicilline 2.4 million units IM statorDoxycycline 100 mg bid for 15 days and Ciprofloxacin 500mg, po, bid for 3 days,Erythromycin 500 mg, po, QID for 7 daysRecommended treatment for vesicular or recurrent genital ulcerAcyclovir 200 mg five times per day for 10 days,Acyclovir 400 mg TID for 10 daysSource of above recommendations: National guideline for the management of STIs , March 2005, EthiopiaAccording to the validation study conducted by MOH/EHNRI in Ethiopia , it was found out that in genital ulcer diseases, one or more pathogens were found in males and females in 76% and of the cases respectively. HSV2 alone was the leading cause of GUD in both males and females constituting 44% and 75.5% of cases respectively. But the prevalence of HSV2 as it occurs in combination with other pathogens or alone constituted 52 and in males and females respectively. Altogether, HSV2 was responsible for 70% of all GUD causes. Syphilis was the second leading cause in males, 28%, as compared with females, 6%. Chanchroid constituted only 4% of GUD cases. (Source: Validation study of the syndromic algorithm approach of the management of STIs in Ethiopia, August 2004)
40 Herpes Viruses 8 human herpesviruses (HHVs) α-herpesviruses include : Herpes simplex virus (HSV)-1Herpes simplex virus (HSV)-2Varicella zoster virusβ-herpesviruses include:Epstein-Barr virusKaposi’s sarcoma-associated herpes virus (KSHV or HHV-8)
41 HSV Spectrum of Disease Persistent ulcerative HSV infections are very common in AIDSCandida and HSV often occur in associationOral-facialPrimary: gingivostomatitis & pharyngitisReactivation: herpes labialisAsymptomatic shedding is commonThus, patients are potentially infectious even when lesions are absentIn about 75% of EM, HSV is the precipitating event. Patients with severe HSV-associated EM should be on chronic oral suppressive Tx
42 HSV Spectrum of Disease: Primary genital infection Fever, malaise, myalgia, HA, pain, itching, dysuria, vaginal and urethral dischargeTender inguinal adenopathy, widely-spaced bilateral extra-genital lesionsCervix and urethra involved in 80% of womenIf a pregnant woman has active lesions, C-section is indicated to prevent herpes neonatorum in infantOccasionally: endometritis, proctitis & prostatitisExtensive perianal disease, proctitis, or both are common among HIV patients
43 Extensive Herpes Simplex Ulcers Extensive herpes simplex virus lesions on the scrotum and penile shaft as the presenting manifestation of HIV infectionPersistence for > 1 month is an AIDS-defining condition.Chronic herpes simplex can be painful and debilitating involving not only the genital area but the mouth, lips, esophagus and skin. Treatment is available for suppression but can be very expensive and will need to be taken for a long time. These can last months and may be improved with ARV treatment. Herpetic lesions can also become secondarily infected leading to more morbidity in the HIV infected patient.Image source: Toby A. Maurer, MD, University of California San Francisco Timothy G. Berger, MD, University of California San Francisco From HIV InSite Knowledge BaseCourtesy of HIV In Site,
44 HSV in the Immunocompromised Host High frequency of reactivationIncreased severityWidespread local extensionHigher incidence of disseminationViremic spread to visceral organs, which is rare but can be life threatening
45 HSV Epidemiology By age 50, >90% people have HSV-1 antibodies Prevalence correlates with socioeconomic statusHSV-2 appears at puberty and correlates with sexual activityAverage world prevalence is about 25%
46 HSV vesiclesThis was an outbreak of herpes genitalis manifested as blistering around the vaginal introitus due to the HSV-2 virus.Courtesy of CDC/ Susan Lindsley
47 HSV circumferential ulcer Coalescence of herpes genitalis “micro-ulcers”.Courtesy of CDC/ Dr. M. F. Rein; Susan Lindsley
48 HSV DiagnosisClinical – characteristic multiple vesicular lesions or ulcersStaining of scrapings from base of lesions to demonstrate characteristic giant cells or intranuclear inclusionsWright stainTzanck preparationPapanicolaou smearThese tests are relatively insensitive and do not differentiate between HSV and varicella zoster infections.Other, more sensitive, HSV tests exist, including viral culture from vesicle or ulcer.Serum tests can identify and differentiate between antibodies to HSV-1 and HSV-2. A weakness of antibody tests, however, is that they simply confirm (or refute) evidence of past infection; they cannot tell whether a specific lesion reflects HSV or some other cause.
49 Treatment Primary infection Acyclovir 200 mg PO 5x/day for 7-14 days, orAcyclovir 400mg PO tid for 7-14 days, orFamciclovir 500 mg PO bid for days, orValacyclovir 1 gm PO bid 7-14 daysRecurrences treated with same dosage, but may need only 5-10 days therapySuppressive therapy may be indicated for patients with frequent recurrences, BUTContinued treatment risks developing resistant HSV
50 Case Study: AbelAbel is a 26 year-old man who presents with tingling that has progressed to frank burning with urination, beginning 3 days ago.He also reports copious purulent urethral discharge.When asked, he admits to unprotected intercourse last weekend with a new partner.
51 Case Study: Abel (2)Courtesy of Peter Katsufrakis, MD
52 Case Study: Abel (3)What additional information do you wish to know about this patient?Based on the history you have and the appearance of the lesion, what does your differential diagnosis include?If the patient instead appeared as on the following slide, how would this affect your differential diagnosis and management?DISCUSSION SUGGESTIONSThis is the same slide seen previously. Use it to briefly reinforce the elements of the history that are important in evaluating an STI patient.At minimum, the group should include gonorrhea and chlamydia in its differential diagnosis. If the group is more advanced, push them to identify other causes of urethral discharge.The previous slide showed a man with a thick, purulent discharge, most consistent with gonorrhea. The next slide shows a man with a more watery discharge, consistent with Chlamydia or other non-GC etiology.Show the next slide, then ask the group to describe the difference. Make the point that, although the appearance and probable etiology are likely different, management is the same.
53 Case Study: Abel (4)Courtesy of Peter Katsufrakis, MD
56 Recommended Treatment for Urethral Discharge and Burning on Urination Ciprofloxacin 500 mg po stat, orSpectinomycin 2g IM statPlusDoxycycline 100 mg po BID for 7 days, orTetracycline 500 mg po QID for 7 days, orErythromycin 500 mg po QID for 7 days if the patient has contraindications for TetracyclinesSource: National guideline for the management of STIs, March 2005The gonococcal isolates in the validation study conducted by EHNRI/MOH in Ethiopia were uniformly sensitive to ciprofloxacin making it the drug of choice. However, it cannot be given for pregnant women and children, in which case Spectinomycin can be used.
57 persistent/ recurrent urethral discharge or dysuria Take historyand examineDoes historyconfirm reinfectionor poor compliance?Treat for trichomonasvaginalisEducate/counselPromote and provide condomsReturn in 7 daysImprovedDischarge confirmedPatient complains ofpersistent/ recurrenturethral discharge or dysuriaOther STIspresentUse appropriateflow chartRepeaturethral dischargetreatmentReferOffer VCTYesNoPromote and provide condomsPersistent or Recurrent Urethral Discharge in MenT. vaginalis was found to be common (second among causes of urethral discharge) among Ethiopian men with urethral discharge syndrome as seen in the validation study conducted by EHNRI/MOH.Treatment – Metronidazole 2g po, stat.Recurrent discharge may reflect poor adherence to initial treatment regimen, e.g., due to GI upset.Recurrent discharge may also reflect re-infection.If neither of these seem to be present, treat for T. vaginalis.Source: validation of STI treatment algorithms, , EHNRI/MOH
58 Case Study: AidaAida, a 34 year-old woman, presents with a 2 month history of increasing, painless lesions she calls “hemorrhoids”.She also notes frequent, minimal bright red blood following bowel movements, and complains of perianal itching, and feeling “wet”.
59 Case Study: Aida (2)Genital warts may present only in anal area, and may not be obvious without careful examination.External genital warts should prompt internal examination (anoscopy, speculum examination)Genital warts are due to infection with HPV, human papillomavirus. Certain types of HPV (16, 18, 31, 33, 35, others) increase risk for cervical and squamous cell cancers.HIV patients are at increased risk of having persistent HPV infection, and of having HPV progress to cancer.Courtesy of Peter Katsufrakis, MD
60 Condyloma accuminata This slide shows both condyloma and skin tags. The condyloma (whitish, cauliflower-like surface) should be treated and should respond to treatments typically used.The skin tags will not respond to most wart treatments (except perhaps surgery, cautery & laser).Courtesy of Peter Katsufrakis, MD
61 Condyloma accuminataForeskin must be retracted during physical examination to perform a complete exam (in this patient, his presenting complaint had nothing to do with warts, and these were an incidental finding).Courtesy of Peter Katsufrakis, MD
62 Chlamydial Cervicitis Characteristic findings include edema of the zone of cervical ectopy and a propensity of the mucosa to bleed on minor trauma e.g., when specimens are collected with a swab.Courtesy of STD/HIV Prevention Training Center at the University of Washington/Connie Celum and Walter Stamm
63 Genital Wart Treatments InternalBi- or tri-chloroacetic acidCryotherapyCauteryLaser or other surgeryExternalPodophyllinImiquimodBi- or tri-chloroacetic acidCryotherapyCauteryLaser or other surgery
64 Case Study: RedeitRedeit is a 26 year-old woman in a steady relationship with her boyfriend of 1 year. She presents complaining of a vaginal discharge for the past week.She describes increased discharge, change in color, and a foul odor.
65 Case Study: Redeit (cont.) Is this a sexually transmitted infection?What are the likely causative organisms?Vaginal discharge may or may not be an STI.STI is unlikely if her boyfriend is monogamous, very possible if not. History is notoriously unreliable in determining whether both partners are monogamous, so we must act as if STI is possible even if history suggests otherwise.In leading discussion, ensure that both STIs and non-STIs are named as possible causes.
66 Vaginal Discharge Common causes: Neisseria gonorrhea Chlamydia trachomatisTrichomonas vaginalisGardnerella vaginalisCandida albicansThe first three are sexually acquired and the last two are endogenous infections
67 Vaginal Discharge Patient complains of vaginal discharge or vulval itching/ burningTake history, examine patient(external speculum and bimanual)and assess riskNoEducateCounselPromote and provide condomsOffer VCTAbnormal discharge presentYesLower abdominal tendernessor cervical motion tendernessYesUse flow chart for lower abdominal painNoWas risk assessment positive?Is discharge from the cervix?YesTreat for chlamydia, gonorrhea,bacterial vaginosis and trichomoniasisNoVulval edema/curd like dischargeErythema excoriation presentTreat for bacterial vaginosisand trichomoniasisYesTreat forcandida albicansNoEducateCounselPromote and provide condomsOffer VCT
68 Recommended Treatment for Vaginal Discharge Risk Assessment Positive for STIRisk Assessment Negative for STICiprofloxacin 500mg PO stat, orSpectinomycin 2gm IM statplusDoxycycline 100mg PO BID for 7 daysMetronidazole 500mg BID for 10 daysMetronidazole 500mg PO BID for 7 daysplusClotrimazole vaginal tabs 200mg at bed time for 3 daysIf assessment of risk for STI is positive (i.e. multiple sexual partners, recent unprotected sex, age < 25, etc), likely etiologies include Neisseria, Chlamydia and Trichomonas and hence Ciprofloxacin or spectinomycin, doxycycline and metronidazole are drugs of choice respectively.If assessment of risk of STI is negative, likely etiologies are Gardnerella and candida; the drugs of choice being Metronidazole and clotrimazoleSource: National guideline for the management of sexually transmitted infections, March 2005
69 Prevention Counseling Nature of the infectionChlamydia is commonly asymptomatic in men & womenGonorrhea is usually asymptomatic in womenBoth easily transmitted during asymptomatic phaseBoth have serious adverse effects on women’s reproductive health if untreatedCDC
70 Prevention Counseling (2) Transmission issuesEffective treatment of chlamydia and/or gonorrhea may reduce HIV transmissionAbstain from sexual intercourse until both partners are treated and for seven days after single dose therapy or until completion of a seven day regimen
71 Case Study: Redeit (cont.) Redeit leaves the OPD following evaluation for her vaginal discharge, but on the way home she loses the medication she was given.She does not return for additional medication out of embarrassment, but now two weeks later returns complaining of 3 days history of increasing pelvic pain and fever.
72 Case Study: Redeit (cont.) What is happening?What should be done now?DISCUSSION SUGGESTIONSGroup should note that she likely had an untreated STI, e.g., gonorrhea or chlamydia, that has progressed to cause PID.Management should be as shown in flow chart (upcoming slide).
73 Lower Abdominal Pain Due to PID (Pelvic Inflammatory Disease) PID is ascending infection of the upper genital tract (uterus, tubes, etc) from the cervix and/or vaginaCommon etiologies:Sexually transmitted: Neisseria gonorrhea, Chlamydia trachomatis, Mycoplasma hominisOthers (non-STI): streptococci, E. coli, etcVaginal discharge is often present
74 Lower Abdominal Pain Any of the following present Patient complains oflower abdominal painTake history including gynecologicalAnd examine (abdominal and vaginal)Any of the following presentMissed overdue periodRecent delivery/ abortionMiscarriageAbdominal guardingAnd/or rebound tendernessAbdominal massAbnormal vaginal bleedingRefer the patient for surgical orgynecological opinionand assessmentBefore referral set upan IV line and resuscitateif requiredIs there cervical excitation tendernessOr lower abdominal tendernessAnd vaginal dischargeManage for PIDReview in three daysContinue treatment until completedEducate and counselOffer VCTPromote and provide condomAsk patient to return if necessaryPatient has improvedRefer patientManageappropriatelyAny otherillness foundYesNoLower Abdominal Pain
75 Recommended Treatment for PID Out patientInpatientCiprofloxacin 500mg PO bid for 7 days, ORSpectinomycin 2gm IM statplusDoxycycline 100mg BID for 14 daysMetronidazole 500mg BID for 14 daysCeftriaxone 250mg IV BID, ORSpectinomycin 2gm IM BIDMetronidazole 500mg BID for 14 days, OR Chloramphenicol 500mg IV QIDDISCUSSION SUGGESTIONAsk participants to identify what organisms are being treated with each antibiotic:Ciprofloxacin, Spectinomycin, Ceftriaxone: GonorrheaDoxycycline: ChlamydiaMetronidazole, Chloramphenicol: Anaerobic (and other) bacteria2. Note: antibiotics have broader spectrum of action than just the organisms identified above, but this exercise helps reinforce what organisms cause PID, and the connection between causative agents and specific treatments.Source- National guideline for the management of sexually transmitted infections, March 2005
76 Neonatal Conjunctivitis Infection of the eyes of the neonate as a result of genital infection of the mother, transmitted during birthCauses:Neisseria gonorrheaChlamydia trachomatisTreatment:Spectinomycin 50mg/kg IM stat or ceftriaxone 125mg IM statplusErythromycin 50mg/kg PO in 4 divided doses for 10 daysMay lead to blindness if not treated properly
77 Neonatal Conjunctivitis Neonate presents with eye dischargeTake history and examine childPurulent conjunctivitis present?Complete treatment course,reinforce education and counselingReview if necessaryTreat baby for gonococcal andchlamydial opthalmiaANDTreat mother and partner for gonorrhoeaand chlamydiaEducate and counselReview baby in 7 days or soonerif symptoms worsenSigns of other illnesspresent?Treat appropriatelyReassure mother,educate parentsReview if symptoms persistEye infection cleared?NoYesReview in 7 daysRefer for specialist opinionand managementSpectinomycin 50 mg /kg im stat can be replaced for ceftriaxone for gonococcal ophtalmia in Ethiopian setting.In the case of herpes conjunctivitis Acyclovir 5-10 mg /kg iv daily for 10 days is indicatedSource: National Guideline for the management of STIs, March 2005
78 Case Study: YimanYiman is a 17 year-old boy who presents complaining of three days of increasing pain and swelling of his right scrotum.Symptoms began gradually, and he does not recall any trauma.He denies sexual activity.Patient denial of sexual activity is often unreliable, especially in younger patients or when discussing sexual activity outside a primary relationship.Time course of symptoms is important to differentiate serious causes of scrotal swelling. Torsion – a surgical emergency – typically has sudden onset. This patient’s age makes torsion a possibility, but time course makes it doubtful.
79 Scrotal SwellingCommon STI causes of scrotal swelling are similar to those of urethral dischargeNeisseria gonorrheaChlamydia trachomatisExclude non-STI causes of scrotal swelling:TBInguinal herniaTesticular torsion, etc
80 Scrotal Swelling Patient complains of scrotal swelling or pain Take history, examine,offer HIV testReassure patient, educate,counsel, provide condoms.Review if symptoms persistNoNoScrotal swelling orpain present?Signs of otherSTI present?YesYesTreat according toappropriate flowchartHistory of trauma or testiselevated or rotated?orDiagnosis in doubt?NoTreat for chlamydiaand gonorrhea.Review in 7 daysYesNoRefer patient tohospitalYesComplete treatment course,reinforce education and counselingReview if symptoms persistPatient has improved?
81 Scrotal Swelling Recommended Therapy Ciprofloxacin 500mg PO stat, orSpectinomycin 2gm IM statplusDoxycycline 100mg PO BID for 7 days, orTetracycline 500mg BID for 7 daysSource: National Guideline for the management of STIs, March 2005
82 Inguinal BuboSwelling of inguinal lymph nodes as a result of STIs (or other causes)Common causes:Treponema pallidum (syphilis)Chlamydia trachomatis (LGV)Hemophylus ducreyi (chancroid)Calymatobacterium granulomatis (granuloma inguinale)
84 Patient complaining of Use genital ulcer flow chart inguinal swellingInguinal BuboTake historyand examineEducateCounselOffer VCTPromote and provide condomsInguinal/femoralbubo present?Any other STI presentNoNoYesUse appropriate flow chartUlcerspresentYesUse genital ulcer flow chartNoTreat for LGV, GI and chancroidAspirate if fluctuantEducate on treatment complianceCounsel on risk reductionPromote and provide condomsPartner managementOffer VCT if availableAdvise to return in 07 daysRefer if no improvement
85 Inguinal Bubo Recommended treatment: Ciprofloxacin 500mg PO BID for 14 days, andErythromycin 500mg PO QID for 14 to 21 days
86 Key PointsSTIs are among the most common causes of illness in the worldEmergence and spread of HIV infection and AIDS has major impact on the management and control of STIsSTIs increase the acquisition and transmission of HIVHIV infection alters the clinical features and response to therapy of STIsStep 5: Key Points (Slides 86-88) – 5 minutes
87 Key Points (2)The syndromic approach to STIs management is recommended by WHOSyndromic management is simple, rapid and inexpensiveHowever, the syndromic approach leads to unnecessary over-treatment
88 Key Points (3)Partner notification and treatment are vital to interrupting STI spreadRisk reduction education is key to preventing recurrenceEvery STD (or genital symptom) provides an occasion for patient educationCultural and interpersonal factors provide some of the greatest barriers to STD treatment and eradication