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Sexually Transmitted Infections

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1 Sexually Transmitted Infections
Unit 15 HIV Care and ART: A Course for Physicians Unit 15 should take approximately 2 hours and 10 minutes Step 1: Unit Learning Objectives (Slide 1-2) – 5 minutes Step 2: Overview of STIs (Slides 3-13) – 15 minutes Step 3: Skills for STI Management (Slides 14-23) – 15 minutes Step 4: Management of STI Syndromes (Slides 24-85) – 1 hour and 30 minutes Step 5: Key Points (Slides 86-88) – 5 minutes

2 Learning Objectives Differentiate STI and STD
Describe the epidemiology of STIs Describe syndromic management of STIs Illustrate: The impact of STI on HIV The impact of HIV on STI Demonstrate the importance of HIV testing and counseling in patients with STIs Step 1: Unit Learning Objectives (Slide 1-2) – 5 minutes

3 STI versus STD STI – Infections acquired through sexual intercourse (may be symptomatic or asymptomatic) STD – Symptomatic disease acquired through sexual intercourse STI is most commonly used because it applies to both symptomatic and asymptomatic infections Step 2: Overview of STIs (Slides 3-13) – 15 minutes Some 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 adults Differs between countries and regions within countries Differences 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 women All regions (except SNNPR) reported 451,686 cases of STIs between June 1998 and June 2002 This number reflects severe underreporting

7 STI Dissemination The rate of STI dissemination depends upon:
Rate of exposure Efficiency of transmission per exposure Duration of infectiousness STI dissemination can be reduced by: Behavior modification: limiting partners, condom use Screening of risk groups, pregnant women, and their partners Treating all infections Health education and risk reduction counseling Partner notification

8 Challenges to Prevention
Difficult to change human behavior Co-infection with multiple STIs is common Not all STIs are treatable Many STIs are asymptomatic Transmission 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 acquisition May cause infertility Treatment can be a high financial burden May cause problems in relationships—divorce, abandonment, beatings

11 Interaction Between HIV and STIs
Significant interaction exists between HIV and STIs Affect similar populations Have a similar route of transmission The interaction is bidirectional HIV influences conventional STIs STIs influence HIV

12 Influence of HIV Infection on STIs
HIV alters the clinical features of STIs Syphilis: Neurosyphilis develops more frequently and rapidly HSV: Ulcers are more severe, chronic, and possibly disseminate throughout body Response to treatment may be reduced High rates of treatment failure for neurosyphilis Complications may increase and occur more quickly

13 Influence of STI on HIV infection
Increased transmission of HIV A person with STI has greater chance of transmitting and acquiring HIV infection Implications of the interaction: Reduction in conventional STI could result in reduction of HIV incidence Effective STI prevention and control should be components of HIV prevention programs

14 STI Management Step 3: Skills for STI Management (Slides 14-23) – 15 minutes

15 Syndromic Approach to STI Management
Identification of clinical syndrome Giving 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)
Advantages Simple, rapid and inexpensive Complete care offered at first visit Patients are treated for possible mixed infections Accessible to a broad range of health workers Avoids unnecessary referrals to hospitals Disadvantages Over-treatment Asymptomatic infections are missed

17 Examination of the STI Patient
Physical examination should include: Examination of anogenital area Examination of any other symptomatic areas, e.g., skin, joints, neurological, etc. Additional examinations in females Speculum examination Bimanual pelvic examination

18 History of the STI Patient
Presenting symptoms Previous diagnosis of STI Sexual history Symptoms and diagnosis in sexual partner Past general medical history Current medications Risk factors for the acquisition of HIV and STIs In females: obstetric, menstrual history, and use of contraceptives

19 Talking about STIs with Patients
Important to understand the patient’s perspective on talking about sex Embarrassed Nervous Guilty Shame, fear Patients would like their medical provider to be Nonjudgmental Respectful Maintain privacy and confidentiality DISCUSSION SUGGESTIONS Have 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 Care What 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 SUGGESTION Ask 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 manner Explore the disease and the patient’s feelings and perceptions about their condition Understand the patient as a whole person Come to a mutual understanding with the patient regarding disease management Explore the disease and the patient’s feelings and perceptions about their condition: Feelings about being ill Ideas about what is wrong with them Impact of the problem on their daily functioning Expectations of what should be done Understand patient as a whole person Recognize that your patient is more than just someone with an illness Acknowledge that this illness may affect other people in the patient’s life Look for ways to tie the patient’s daily experiences into the discussion Come to a mutual understanding with the patient regarding disease management: Find recommendations that fit in the context of the patient’s life Make sure the patient understands the nature of their disease Work 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 supportive Practice “active listening” Discuss a detailed agenda of what will occur Answer questions using simple terms the patient can understand DISCUSSION SUGGESTION Discuss the ways in which physicians can build rapport with their patients.

23 Expert Communication Skills
Maintain good eye contact Use active listening and watch the patient’s nonverbal cues Have warm and accepting body language Rely on open ended questions Avoid interrupting Use 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 discharge Genital ulcer in men and women Lower abdominal pain in women Scrotal swelling Inguinal bubo

26 Case Study: Tsegenet Tsegenet 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 SUGGESTIONS The 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 simplex Syphilis Chancroid Lymphogranuloma venereum Granuloma inguinale

29 Genital Ulcer Syndrome

30 Genital Ulcer Disease: Differential Diagnosis
Herpes simplex Syphilis Chancroid Lymphogranuloma venereum Granuloma inguinale Others DISCUSSION SUGGESTIONS 1. 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 Ulcer Courtesy 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 ulcer Benzanthine penicilline 2.4 million units IM stat or Doxycycline 100 mg bid for 15 days and Ciprofloxacin 500mg, po, bid for 3 days, Erythromycin 500 mg, po, QID for 7 days Recommended treatment for vesicular or recurrent genital ulcer Acyclovir 200 mg five times per day for 10 days, Acyclovir 400 mg TID for 10 days Source of above recommendations: National guideline for the management of STIs , March 2005, Ethiopia According 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)-1 Herpes simplex virus (HSV)-2 Varicella zoster virus β-herpesviruses include: Epstein-Barr virus Kaposi’s sarcoma-associated herpes virus (KSHV or HHV-8)

41 HSV Spectrum of Disease
Persistent ulcerative HSV infections are very common in AIDS Candida and HSV often occur in association Oral-facial Primary: gingivostomatitis & pharyngitis Reactivation: herpes labialis Asymptomatic shedding is common Thus, patients are potentially infectious even when lesions are absent In 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 discharge Tender inguinal adenopathy, widely-spaced bilateral extra-genital lesions Cervix and urethra involved in 80% of women If a pregnant woman has active lesions, C-section is indicated to prevent herpes neonatorum in infant Occasionally: endometritis, proctitis & prostatitis Extensive 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 infection Persistence 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 Base Courtesy of HIV In Site,

44 HSV in the Immunocompromised Host
High frequency of reactivation Increased severity Widespread local extension Higher incidence of dissemination Viremic 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 status HSV-2 appears at puberty and correlates with sexual activity Average world prevalence is about 25%

46 HSV vesicles This 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 Diagnosis Clinical – characteristic multiple vesicular lesions or ulcers Staining of scrapings from base of lesions to demonstrate characteristic giant cells or intranuclear inclusions Wright stain Tzanck preparation Papanicolaou smear These 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, or Acyclovir 400mg PO tid for 7-14 days, or Famciclovir 500 mg PO bid for days, or Valacyclovir 1 gm PO bid 7-14 days Recurrences treated with same dosage, but may need only 5-10 days therapy Suppressive therapy may be indicated for patients with frequent recurrences, BUT Continued treatment risks developing resistant HSV

50 Case Study: Abel Abel 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 SUGGESTIONS This 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

54 Differential Diagnosis
Chlamydia Gonorrhea Mycoplasma hominis Ureaplasma urealyticum Hemophilus & Parahemophilus spp. Other bacteria

55 Urethral Discharge Syndrome

56 Recommended Treatment for Urethral Discharge and Burning on Urination
Ciprofloxacin 500 mg po stat, or Spectinomycin 2g IM stat Plus Doxycycline 100 mg po BID for 7 days, or Tetracycline 500 mg po QID for 7 days, or Erythromycin 500 mg po QID for 7 days if the patient has contraindications for Tetracyclines Source: National guideline for the management of STIs, March 2005 The 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 history and examine Does history confirm reinfection or poor compliance? Treat for trichomonas vaginalis Educate/counsel Promote and provide condoms Return in 7 days Improved Discharge confirmed Patient complains of persistent/ recurrent urethral discharge or dysuria Other STIs present Use appropriate flow chart Repeat urethral discharge treatment Refer Offer VCT Yes No Promote and provide condoms Persistent or Recurrent Urethral Discharge in Men T. 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: Aida Aida, 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 accuminata Foreskin 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
Internal Bi- or tri-chloroacetic acid Cryotherapy Cautery Laser or other surgery External Podophyllin Imiquimod Bi- or tri-chloroacetic acid Cryotherapy Cautery Laser or other surgery

64 Case Study: Redeit Redeit 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 trachomatis Trichomonas vaginalis Gardnerella vaginalis Candida albicans The first three are sexually acquired and the last two are endogenous infections

67 Vaginal Discharge Patient complains of vaginal discharge or
vulval itching/ burning Take history, examine patient (external speculum and bimanual) and assess risk No Educate Counsel Promote and provide condoms Offer VCT Abnormal discharge present Yes Lower abdominal tenderness or cervical motion tenderness Yes Use flow chart for lower abdominal pain No Was risk assessment positive? Is discharge from the cervix? Yes Treat for chlamydia, gonorrhea, bacterial vaginosis and trichomoniasis No Vulval edema/curd like discharge Erythema excoriation present Treat for bacterial vaginosis and trichomoniasis Yes Treat for candida albicans No Educate Counsel Promote and provide condoms Offer VCT

68 Recommended Treatment for Vaginal Discharge
Risk Assessment Positive for STI Risk Assessment Negative for STI Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days Metronidazole 500mg BID for 10 days Metronidazole 500mg PO BID for 7 days plus Clotrimazole vaginal tabs 200mg at bed time for 3 days If 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 clotrimazole Source: National guideline for the management of sexually transmitted infections, March 2005

69 Prevention Counseling
Nature of the infection Chlamydia is commonly asymptomatic in men & women Gonorrhea is usually asymptomatic in women Both easily transmitted during asymptomatic phase Both have serious adverse effects on women’s reproductive health if untreated CDC

70 Prevention Counseling (2)
Transmission issues Effective treatment of chlamydia and/or gonorrhea may reduce HIV transmission Abstain 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 SUGGESTIONS Group 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 vagina Common etiologies: Sexually transmitted: Neisseria gonorrhea, Chlamydia trachomatis, Mycoplasma hominis Others (non-STI): streptococci, E. coli, etc Vaginal discharge is often present

74 Lower Abdominal Pain Any of the following present
Patient complains of lower abdominal pain Take history including gynecological And examine (abdominal and vaginal) Any of the following present Missed overdue period Recent delivery/ abortion Miscarriage Abdominal guarding And/or rebound tenderness Abdominal mass Abnormal vaginal bleeding Refer the patient for surgical or gynecological opinion and assessment Before referral set up an IV line and resuscitate if required Is there cervical excitation tenderness Or lower abdominal tenderness And vaginal discharge Manage for PID Review in three days Continue treatment until completed Educate and counsel Offer VCT Promote and provide condom Ask patient to return if necessary Patient has improved Refer patient Manage appropriately Any other illness found Yes No Lower Abdominal Pain

75 Recommended Treatment for PID
Out patient Inpatient Ciprofloxacin 500mg PO bid for 7 days, OR Spectinomycin 2gm IM stat plus Doxycycline 100mg BID for 14 days Metronidazole 500mg BID for 14 days Ceftriaxone 250mg IV BID, OR Spectinomycin 2gm IM BID Metronidazole 500mg BID for 14 days, OR Chloramphenicol 500mg IV QID DISCUSSION SUGGESTION Ask participants to identify what organisms are being treated with each antibiotic: Ciprofloxacin, Spectinomycin, Ceftriaxone: Gonorrhea Doxycycline: Chlamydia Metronidazole, Chloramphenicol: Anaerobic (and other) bacteria 2. 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 birth Causes: Neisseria gonorrhea Chlamydia trachomatis Treatment: Spectinomycin 50mg/kg IM stat or ceftriaxone 125mg IM stat plus Erythromycin 50mg/kg PO in 4 divided doses for 10 days May lead to blindness if not treated properly

77 Neonatal Conjunctivitis
Neonate presents with eye discharge Take history and examine child Purulent conjunctivitis present? Complete treatment course, reinforce education and counseling Review if necessary Treat baby for gonococcal and chlamydial opthalmia AND Treat mother and partner for gonorrhoea and chlamydia Educate and counsel Review baby in 7 days or sooner if symptoms worsen Signs of other illness present? Treat appropriately Reassure mother, educate parents Review if symptoms persist Eye infection cleared? No Yes Review in 7 days Refer for specialist opinion and management Spectinomycin 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 indicated Source: National Guideline for the management of STIs, March 2005

78 Case Study: Yiman Yiman 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 Swelling Common STI causes of scrotal swelling are similar to those of urethral discharge Neisseria gonorrhea Chlamydia trachomatis Exclude non-STI causes of scrotal swelling: TB Inguinal hernia Testicular torsion, etc

80 Scrotal Swelling Patient complains of scrotal swelling or pain
Take history, examine, offer HIV test Reassure patient, educate, counsel, provide condoms. Review if symptoms persist No No Scrotal swelling or pain present? Signs of other STI present? Yes Yes Treat according to appropriate flowchart History of trauma or testis elevated or rotated? or Diagnosis in doubt? No Treat for chlamydia and gonorrhea. Review in 7 days Yes No Refer patient to hospital Yes Complete treatment course, reinforce education and counseling Review if symptoms persist Patient has improved?

81 Scrotal Swelling Recommended Therapy
Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days, or Tetracycline 500mg BID for 7 days Source: National Guideline for the management of STIs, March 2005

82 Inguinal Bubo Swelling 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)

83 Inguinal Bubo Courtesy of CDC/ Susan Lindsley

84 Patient complaining of Use genital ulcer flow chart
inguinal swelling Inguinal Bubo Take history and examine Educate Counsel Offer VCT Promote and provide condoms Inguinal/femoral bubo present? Any other STI present No No Yes Use appropriate flow chart Ulcers present Yes Use genital ulcer flow chart No Treat for LGV, GI and chancroid Aspirate if fluctuant Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Partner management Offer VCT if available Advise to return in 07 days Refer if no improvement

85 Inguinal Bubo Recommended treatment:
Ciprofloxacin 500mg PO BID for 14 days, and Erythromycin 500mg PO QID for 14 to 21 days

86 Key Points STIs are among the most common causes of illness in the world Emergence and spread of HIV infection and AIDS has major impact on the management and control of STIs STIs increase the acquisition and transmission of HIV HIV infection alters the clinical features and response to therapy of STIs Step 5: Key Points (Slides 86-88) – 5 minutes

87 Key Points (2) The syndromic approach to STIs management is recommended by WHO Syndromic management is simple, rapid and inexpensive However, the syndromic approach leads to unnecessary over-treatment

88 Key Points (3) Partner notification and treatment are vital to interrupting STI spread Risk reduction education is key to preventing recurrence Every STD (or genital symptom) provides an occasion for patient education Cultural and interpersonal factors provide some of the greatest barriers to STD treatment and eradication

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