STI Fundamentals: From Chlamydia to Warts

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STI Fundamentals: From Chlamydia to Warts

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

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