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Sexual Transmitted Infections June 2012 Huda Taha SpR

Sexual Transmitted Infections June 2012 Huda Taha SpR. Gonorrhoea. Gram negative diplococcus Neisseria gonorrhoeae Primary sites; mucous membranes of the urethra, endocervix , rectum, pharynx and conjunctiva WWW.BASHH.org. Clinical features Men:

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Sexual Transmitted Infections June 2012 Huda Taha SpR

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  1. Sexual Transmitted Infections June 2012Huda TahaSpR

  2. Gonorrhoea • Gram negative diplococcusNeisseria gonorrhoeae • Primary sites; mucous membranes of the urethra, endocervix, rectum, pharynx and conjunctiva WWW.BASHH.org

  3. Clinical features Men: • Urethral discharge and/ or dysuria within 2–5 days of exposure • Mucopurulentor purulent urethral discharge • Rarely, epididymal tenderness/swelling WWW.BASHH.org

  4. Women: • Infection at the endocervix is frequently asymptomatic • Increased or altered vaginal discharge is common • Lower abdominal pain may be present • Urethral infection may cause dysuria but not frequency • Mucopurulentendocervical discharge, easily induced endocervical bleeding • Commonly, no abnormal findings WWW.BASHH.org

  5. Complications • Transluminal spread of N.G from the urethra or endocervix/ epididymo-orchitis or prostatitis, and PID • Haematogenous dissemination may also occur from infected mucous membranes to cause skin lesions, arthralgia, arthritis and tenosynovitis (disseminated gonococcal infection) WWW.BASHH.org

  6. Diagnosis • Microscopy of Gram-stained genital specimens direct visualization of N.G • Sensitivity (90–95%) in men with urethral discharge, recommended to facilitate immediate diagnosis in symptomatic men • Microscopy is not recommended for urethral smears in women WWW.BASHH.org

  7. Detection of N.G can be achieved by NAATs or culture • NAATs are generally more sensitive than culture • NAATs show high sensitivity (96%) in both symptomatic and asymptomatic infection. • Antimicrobial susceptibility testing WWW.BASHH.org

  8. Specimen collection Men: • First pass urine is the preferred sample for NAAT testing • Microscopy and culture require a urethral swab specimen • Rectal and pharyngeal swab specimens should be directed by sexual history, symptoms at these sites WWW.BASHH.org

  9. Women; • Vaginal/ endocervical swab specimens are equally sensitive for detecting N.G by NAAT testing • Culture; endocervical and urethral swab specimen for maximum sensitivity • Urine is a suboptimal sample for the detection of N.G in women WWW.BASHH.org

  10. Management • Patients; detailed explanation of their condition, long-term implications for the health of themselves and their partner(s). • Clear and accurate written information • Abstain from sexual intercourse, until they and their partner(s) have completed treatment WWW.BASHH.org

  11. Treatment • Intracellular Gram-negative diplococci on microscopy of a smear from the genital tract • A positive culture for N. G from any site • A positive NAAT for N. G from any site • Recent sexual partner(s) of confirmed gonococcal infection • Consider offering on epidemiological grounds following sexual assault. WWW.BASHH.org

  12. Ceftriaxone 500 mg IM stat dose with azithromycin1g po ALTERNATIVE REGIMENS • Cefixime 400 mg po • Spectinomycin 2 g IM • Quinolones not recommended, high prevalence of quinolone resistance worldwide. WWW.BASHH.org

  13. TREATMENT OF COMPLICATED INFECTIONS Gonococcal PID • Ceftriaxone 500 mg IM, doxycycline 100 mg bdpo plus metronidazole 400 mg bd for 14 days Gonococcalepididymo-orchitis • Ceftriaxone 500 mg IM, doxycycline 100 mg for 10–14 days WWW.BASHH.org

  14. PREGNANCY AND BREASTFEEDING • Pregnant and breastfeeding women should not be treated with quinolone or tetracycline • Ceftriaxone 500 mg IM stat with Spectinomycin 2 g IM WWW.BASHH.org

  15. SEXUAL PARTNERS • Partner notification should be pursued in all patients identified with gonococcal infection Follow up • Confirm compliance with treatment • Ensure resolution of symptoms • Enquire about adverse reactions • Take a sexual history if possibility of reinfection WWW.BASHH.org

  16. Genital Herpes Initial episode • First episode HSV-1 or HSV-2 dependent on whether the individual has had prior exposure to the other type, this is further subdivided into: • Primary infection: first infection with either HSV-1 or HSV-2 with no pre-existing antibodies to either type • Non-primary infection: Infection with either HSV-1 or HSV-2 with pre- existing antibodies to the other type WWW.BASHH.org

  17. Recurrent episode • Recurrence, due to reactivation of pre-existent HSV-1 or HSV-2 infection after a period of latency Clinical Features • Patient may be asymptomatic, the disease unrecognised • Local symptoms; painful ulceration, dysuria, blistering, ulceration of the external genitalia, tender lymphadenitis • Systemic symptoms; fever and myalgia WWW.BASHH.org

  18. Complications • Autonomic neuropathy, resulting in urinary retention • Autoinoculation to fingers and adjacent skin e.g thighs • Aseptic meningitis WWW.BASHH.org

  19. Diagnosis • Virus detection and characterization, by direct detection of HSV in genital lesions • Virus typing to differentiate between HSV-1 and HSV-2 in all patients • HSV DNA detection by PCR WWW.BASHH.org

  20. Management • Saline bathing/ analgesia • Antiviral drugs; within 5 days of the start of the episode • Aciclovir, 200 mg 5x/d reduce the severity, duration of episodes • Antiviral does not alter the natural history of the disease • Topical agents are less effective than oral agents. • Combined oral and topical treatment is of no benefit WWW.BASHH.org

  21. Recurrent Genital Herpes • Self-limiting, minor symptoms • Management made in partnership with the patient • Strategies include o supportive therapy only o episodic antiviral treatments o suppressive antiviral therapy (aciclovir400mg bd) • The best strategy for managing an individual patient may change over time according to recurrence frequency, symptom severity, and relationship status WWW.BASHH.org

  22. Pregnancy • First and second trimester acquisition • First episode HSV has been associated with first trimester miscarriage • Vaginal delivery should be anticipated • Daily suppressive aciclovir from 36 weeks gestation may be considered WWW.BASHH.org

  23. C S; all women presenting with first-episode HSV at delivery, within 6 weeks of the EDD • If VD is unavoidable or mother opts for a NVD, prolonged ROM, invasive procedures to be avoided • IV aciclovir given intraparum to the mother, subsequently to the neonate may be considered • Neonatologists WWW.BASHH.org

  24. Recurrent Genital Herpes • Antiviral treatment is rarely indicated • Symptomatic recurrences during the third trimester; likely to be brief; NVD if no lesions are present at delivery WWW.BASHH.org

  25. Chlamydia trachomatis • Most common curable STI in Britain • ~ 5-10% of sexually active women under 24, men 20-24 may be currently infected • Risk factors; age under 25yrs, new sexual partner or >1 sexual partner in the past year • New sexual partner being more important than number of partners and lack of consistent use of condoms WWW.BASHH.org

  26. Clinical features • Women • Asymptomatic in approximately 70% • PCB or IMB • Lower abdominal pain • Purulent vaginal discharge • Mucopurulent cervicitis and/or contact bleeding • Dysuria WWW.BASHH.org

  27. Men • Asymptomatic in over 50% • Urethral discharge • Dysuria Diagnosis Nucleic Acid Amplification Technique 90-95% sensitive WWW.BASHH.org

  28. Treatment • Doxycycline 100mg bd for 7 days OR • Azithromycin 1gm po stat dose Alternative regimens: • Erythromycin 500mg bd for 10-14 days OR • Ofloxacin 200mg bd for 7 days WWW.BASHH.org

  29. Pregnancy and breast feeding • Erythromycin 500mg qds for 7 days OR • Amoxicillin 500 mg tds for 7 days OR • Azithromycin 1 gmstat WWW.BASHH.org

  30. Syphilis • Infection with the spirochete bacterium Treponemapallidum subsppallidum. Classificaation Acquired or congenital Acquired syphilis: Early (primary, secondary, early latent < years of infection) Late (late latent>2 years of infection, tertiary including gummatous, cardiovascular and neurological) WWW.BASHH.org

  31. Primary syphilis • Painless ulcer ( chancre), regional ymphadenopathy Secondary syphilis • Multisystem involvement first 2 years of infection • Generalized maculopapular rash affecting palms and soles • Condylomatalata, mucocutaneous lesions, generalized lymphadenopathy • Less commonly: patchy alopecia, ant. uveitis, meningitis, cranial nerve palsies, hepatitis, splenomegaly, periosteitis and glomerulonephritis

  32. DIAGNOSIS • Hx and examination • Symptoms of early syphilis • Details, previous Rx, blood donation, antenatal screening • Other treponemal infections; yaws, pinta, Hx of living in endemic region • Examination of the genitals, skin, mucosal surfaces and lymph nodes for signs of primary and secondary syphilis • Late and congenital syphilis a thorough clinical examination • Full systems review WWW.BASHH.org

  33. DEMONSTRATION OF T. PALLIDUM • Dark ground microscopy • If the initial test is negative repeat daily for three days • PCR • Serological test for syphilis WWW.BASHH.org -

  34. Treponemaland non-treponemal • Treponemaltests; look for a direct antigen from the T. P or antibody to it, TPPA • remain in the bloodstream for years post exposure to syphilis • Thus, +ve result for a treponemal test does not necessarily indicate active syphilis infection • Non-treponemaltests; cardiolipin, VDRL; incidental marker, released when treponeme damages cells during infection • +ve non-treponemal tests indicative of an active infection • But a confirmatory test with a treponemal test is required to verify that it is indeed a syphilis infection that is causing elevated cardiolipin levels WWW.BASHH.org

  35. Treatment Incubating syphilis/ epidemiological Rx • Benzathine penicillin G 2.4 MU i.m. stat • Doxycycline 100 mg PO b.d. 14 days • Azithromycin 1 g po stat Early syphilis (primary, secondary and early latent) • Benzathine penicillin G 2.4 MU i.m. stat • Procaine penicillin G 600 000 Ui.m. 10 days WWW.BASHH.org

  36. Alternative regimens • Penicillin allergy or refusing parenteral treatment. • Doxycycline 100 mg pob.d. 14 days • Azithromycin 2 g po stat • Ceftriaxone 500 mg i.m. daily 10 days Late latent, cardiovascular, gummatous syphilis • Benzathine penicillin 2.4 MU i.m. weekly for two weeks (three doses) • Procaine penicillin 600,000 units i.m. o.d. for 17 days WWW.BASHH.org

  37. Early syphilis in pregnancy • Benzathine penicillin G 2.4 MU i.m. stat in 1st & 2ed trimesters • 3rd trimester, 2ed dose Alternative regimens • Amoxycillin 500 mg poq.d.s. plus probenecid 500 mg poq.d.s. 14 days • Ceftriaxone 500 mg i.m. daily 10 days Late syphilis in pregnancy • Manage as in non-pregnant patients but without the use of doxycycline.

  38. Follow up • Early syphilis, clinical, serological (VDRL) f u at months 1, 2, 3, 6 and 12, then six monthly until VDRL/RPR negative or serofast • Late syphilis minimum serological f u is three monthly until serofast WWW.BASHH.org

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