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STI Fundamentals: From Chlamydia to Warts

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  • 1. STI Fundamentals Gina Dallabetta Family Health International May 2003
  • 2. Overview
    • Lightening review of:
      • common pathogens
      • complications
      • diagnostics/management
  • 3. STI Pathogens
    • Classifications:
    • Curable vs not-curable
    • Sexual transmission in adults predominantly by sexual intercourse vs. sexual transmission described but not predominant mode
    • About 30 pathogens described
  • 4. Rationale for Effective STI Prevention and Control
    • High priority for preserving reproductive health, especially among women.
    • Role in preventing some cancers and neurologic disease.
    • Cost-effective approach to prevent neonatal morbidity and mortality.
    • HIV prevention.
  • 5. Diseases Characterized by Genital Ulcers
    • Herpes simplex
    • Chancroid
    • Syhilis
    • Granuloma Inguinale
    • Lymphogranuloma venereum
  • 6. Herpes Simplex
    • Key features:
      • Life-long, recurrent viral infection
      • HSV-2 & HSV-1
      • Most don’t know they are infected, shed intermittently without symptoms, transmission inadvertent
      • 1 o infection severe, recurrent resolve except in HIV
    • Diagnosis
      • Culture, PCR, antigen detection (DFA), Tzanck prep
    • Management
      • Antiviral management symptoms, chronic suppressive Rx in frequent recurrences and in HIV
      • Partner counseling
    • Complications
      • neonatal herpes infections, HIV
  • 7. Chancroid
    • Key Features
      • Bacterial infection - H. ducreyi
      • Strongly associated with sex work
    • Diagnosis
      • Culture (fastidious organism)
      • PCR
    • Management
      • Antibiotics (single dose usually) or longer in HIV infected
      • Partner treatment for exposure 10 days prior
    • Complications
      • HIV infection
      • Slow healing (months)
  • 8. Syphilis
    • Key features
      • Systemic bacterial infection - T. pallidum
      • Multiple phases of disease, 1 o (ulcer), 2 o (rash +), latent, neurological, 3 o (cardiovascular, eye, gummas)
    • Diagnosis
      • Ulcers - PCR, dark-field
      • Other - serology - non-treponemal (RPR, VDRL, TRUST) and treponemal (FTA-ABS, MHATP, TPHA, TPPA),
      • Congenital - includes x-rays of long bones
    • Management
      • Antibiotics
      • Partner treatment (look back depends on stage of disease)
  • 9. Syphilis
    • Complications
      • HIV
      • Long term sequelae of untreated infection (cardiovascular and neurologic)
      • Transmission to fetus during pregnancy
        • fetal loss
        • stillbirth
        • neonatal death
        • infant death
        • congenital syphilis
    • (Zambia - 42% of stillbirths and 30% of perinatal deaths attributed to syphilis)
  • 10. Diseases Characterized by Urethritis and Cervicitis
    • Gonorrhea
    • Chlamydial infection
    • Non-gonococcal urethritis
    • Mucopuruluent cervicitis
  • 11. Gonorrhea
    • Key Features
      • Bacterial infection - N. gonorrhoeae
      • Men usually symptomatic, women usually not
      • Genital, anal and pharyngeal infections
      • Antibiotic resistance common and constantly changing
      • Co-infection with Chlamydia trachomatis common
    • Diagnosis
      • Gram stain (male urethra only), culture, PCR, antigen detection
    • Management
      • Single dose antibiotics (+ co-therapy for CT)
      • Partner management - 60 days or most recent partner
  • 12. Gonorrhea
    • Complications
      • Upper tract infections
        • epididymitis in men
        • PID in women -> infertility, ectopic pregnancy, death
        • DGI, meningitis, endocarditis
      • Congenital infections
        • ophthalmia neonatorum (30 - 47% transmission)
        • disseminated infections
      • HIV infection - marked increased viral shedding with infection
  • 13. Chlamydial infection
    • Key Features
      • Bacterial infection - C. trachomatis
      • More prevalent in adolescents and young adults
    • Diagnosis
      • PCR, culture, antigen detection
    • Management
      • Antibiotics (usually 7 days) or with long acting macrolides
      • Partner management - 60 days or most recent if longer
  • 14. Chlamydial infection
    • Complications
      • Upper tract infections
        • epididymitis in men
        • PID in women (often subclinical) -> infertility, ectopic pregnancy, death
      • Congenital infections
        • ophthalmia neonatorum
        • pneumonia
      • HIV infection (micro-ulcerations on cervix)
  • 15. NGU and MPC
    • NGU (non-gonococcal urethritis)
      • dysuria/urethal prutiis
      • > 5 WBCs gram stain
      • C. trachomatis majority of cases, T. vaginalis and U. urealyticum and indeterminate
      • Partner management 60 day look back
    • MPC (mucopurulent cervicitis)
      • mucopurulent discharge, friability, increased WBC on gram stain
      • C. trachomatis, N. gonorrhea can cause
      • Partner management - based on diagnosis
  • 16. Diseases Characterized by Vaginal Discharge
    • Bacterial Vaginosis
    • Trichomoniasis
    • Vulvovaginal Candidasis
  • 17. Bacterial Vaginosis
    • Key features
      • dis-equilibrium syndrome - high concentrations of anaerobic bacteria and low H 2 O 2 -producing lactobacilli
      • non-sexually active women rarely affected but treatment of male partner not-beneficial
    • Diagnosis
      • bedside tests, gram stain, commercially available tests
    • Treatment
      • topical or oral antibiotics
    • Complications
      • Adverse pregnancy outcomes - PROM, preterm birth, postpartum endometritis
      • Post surgical endometritis, PID, ?? HIV
  • 18. Trichomonaisis
    • Key features
      • Caused by a protozoan, T. vaginalis
      • Can be transmitted by fomites
    • Diagnosis
      • Wet mount microscopy, culture
    • Treatment
      • Metronidazole single dose of 7 days
      • Partner management - treatment of all partners
    • Complications
      • Associated with adverse pregnancy outcome - PROM and premature delivery and LBW
  • 19. Vulvovaginal Candidiasis
    • Key features:
      • Overgrowth syndrome usually caused by C. albicans , a yeast
      • Not-usually acquired through sexual intercourse
    • Diagnosis
      • Wet mount, gram stain of vaginal discharge
      • positive culture NOT an indication for treatment - found in 10 - 20% normal women
    • Management
      • Short-course topical formulations
      • oral antifungal available
    • Complications
      • none
      • Immunocompromised women require longer term therapy
  • 20. Human Papilloma Virus
    • Key features
      • Associated with Genital Warts and Genital Cancers
      • Infection with multiple HPV types possible
    • Diagnosis
      • Genital warts - visual
      • Subclinical - acetic acid, PAP tests, HPV DNA --> colposcopy
    • Management
      • Genital warts - possibility of spontaneous resolution
      • topical podophyllin, TCA; cryotherapy; surgical removal; intralesional interferon; lasar surgery
      • Abnormal PAP - surgical
  • 21. Hepatitis A, B, C
    • Hepatitis A
      • transmission by fecal-oral route
      • childhood illness in most of developing world
      • vaccine preventable
    • Hepatitis B
      • Sexual transmission accounts for most HBV in the US
      • vaccine preventable
    • Hepatitis C
      • Most common chronic bloodborne infection in US
      • Sexual transmission plays limited role
  • 22.  

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