Culture is the most widely available option for diagnosis in non-genital sites Non-culture tests cannot provide susceptibility. If test for gonorrhea, test for everything. Quinolone resistance in California, Hawaii (Europe, middle east, asia, pacific)
The most frequently reported infectious disease in the US. Greatest prevalence is in persons <25 years.
Test-of-cure not recommended unless compliance is questionable, symptoms persist pr reinfection is suspected. Has high false positive rates. However, retesting in 3 months is recommended.
Pneumonia - repetitive staccato cough with tachypnea + hyperinflation and bilateral infiltrates. Wheezing rare. Usually afebrile. Peripheral eosinophilia noted. Tissue culture is definitive. * Association between oral erythromycin and infantile hypertrophic pyloric stenosis in infants under 6 weeks.
Metronidazole gel not as effective as orals Follow up not required if symptoms resolve
URETHRITIS DR JHABAR SINGH CHAUDHARY
Urethritis - inflammation of urethra which is multifactorial condition and characterised by dysuria with/without urethral discharge or may be asymptomatic.Types- 1.Gonococcal urethritis-pathogen is gonococci 2. Non gonococcal urethritis –identified pathogen otherthan gonococci3.Non specific urethritis-unidentified pathogen.
Causes of Urethritis• Neisseria gonorrhoeae• Chlamydia trachomatis .Mycoplasma genitalium• Trichomonas vaginalisothers ureaplasma urealyticum N. Meningitidis Candida albicans.
Epidemiology• Gonos(seed)+rhoea(flow) mean abnormal flow of semen.• Only Natural reservoir-human• Infection almost always contracted during sexual activity• All age groups are susceptible(age 15-35yrs are more susceptible)
Risk Factors• Multiple or new sex partners .• Urban residence in areas with disease prevalence• Adolescents, females particularly• Lower socio-economic status• Exchange of sex for drugs or money• African Americans
Transmission• Transmitted by: – Male to female via semen – Female to male urethra – Rectal intercourse – Fellatio (pharyngeal infection) – Perinatal transmission (infected mother to infant)• Gonorrhea is associated with increased transmission and susceptibility to HIV infection
Etiopathogenesis• G-ve reniform(kidney bean shaped) diplococci,0.6-0.8um• 2-10% CO2, 7.2-7.6 Ph, 35-37°C temp.• Surface hairlike pili & lipo- oligosaccharide(LOS) acts as virulent factor• 1. Adherence – Pili & Opa for initial adhesion in additive fashion(increasing force & freq. of adhesion of other gonococci).
• 2. Invasion- after adhesion organism enfolded by pseudopods and endocytosed by epi. Cells transported to base of cell by exocytosis - divide and multiply• 3. Tissue damage -Epithelial cell damage is mediated by release of enzymes(phospholipase,peptidase)& TNF ( production is stimulated by LOS & peptidoglycan).• Neutrophilic response l/t microabscess formation followed by exudation of purulent
CLINICAL FEATURES Male• Symptoms – Typically purulent or mucopurulent urethral discharge – Often accompanied by dysuria – Discharge may be clear or cloudy• Asymptomatic in 10% of cases• Incubation period: usually 1-14 days for symptomatic disease, but may be longer
CLINICAL FEATURE - Female• 50% minimally affected/asymptomatic• Endo cervix-m.c. site of infection• urethritis-mucopurulent dis.,vaginal pruritus&dysuria.
Cervicitis• Non-specific symptoms: abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia• Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding• 50% of women with clinical cervicitis have no symptoms
Complication in female• Accessory gland infection – Bartholin’s glands – Skene’s glands(paraurethral gland)• Pelvic Inflammatory Disease (PID) – May be asymptomatic – May present with lower abdominal pain, discharge, dyspareunia, irregular menstrual bleeding and fever• Fitz-Hugh-Curtis Syndrome(perihepatitis)• Acute vulvovaginitis-in prepubescent female• Ophthalmia neonatorum in newborn-acute purulent conjuctivitis appears 2-5 days after infection from infected mother.
DIAGNOSIS.Clinical diagnosis-thick,creamy,sticky discharge is diagnostic..Definitive diagnosis by Gram stain or culture..Direct microscopy of Gram stained smear –sens. 80-95%,sp 95-99%.• Culture(Modified Thayer Martin media) -gold std test –senstivity-80-95%.• Non culture tech.- NAAT-sens. 92-96%, sp. 94- 99%.
Gram’s stain• Smear - air dry - heat and fix - crystal violet solution for 1 mint and rinse - Gram’s iodine for 1 mint and rinse - decolorised with acetone for 10-20 sec. and rinse - counterstan with safranin for 1 mint and rinse & examine under oil immersion 100x lens. . .
Gonorrhea Gram StainPMNL with G-ve kidney shaped extra/intracellular diplococci
Gonorrhea TreatmentUncomlicated infection of cervix, urethra& rectum- Ceftriaxone 125 mg IM single dose OR Cefixime 400 mg PO single dose OR Ciprofloxacin 500 mg PO single dose OR Ofloxacin 400 mg PO single dose OR Levofloxacin 250 mg PO single dose
Uncomplicated infectionPharynxCeftriaxone 125 mg IM single dose ORCiprofloxacin 500 mg PO single doseGonococcal conjunctivitis(adult)Ceftriaxone 1 g i/m single doseSaline lavage once.
Gonnorrhea - Special Considerations• Allergy, intolerance or adverse reaction – Use Spectinomycin 2g i/m statPregnancy – No quinolones• Management of sex partner• All sex partners in last 60 days should be treated for both gonorrhea & chlamydia.
Prophylaxis & t/t of Gonorrhea in Infants• Ceftriaxone 25-50 mg/kg IV or IM single dose, not to exceed 125 mg.• Topical antibiotics alone is inadequate & unnecessary with systemic therapy.
• Disseminated gonococcal infection• Recommended regimen:• Ceftriaxone, 1 g im or iv q24h • Alternative regimens: • Cefotaxime, 1 g iv q8h or • Ceftizoxime, 1 g iv q8h or • Ciprofloxacin, 400 mg iv q12h[*] or • Ofloxacin, 400 mg iv q12h[*] or • Levofloxacin, 250 mg iv qd[*] or • Spectinomycin, 2 g im q12h
• Contd..• Preceding regimen should be contd for 24-48 hrs after improvement begins ,following regimen to complete for 1 week therapy.• Cefixime, 400 mg po bd or Ciprofloxacin, 500 mg po bd or• Ofloxacin, 400 mg po bd or• Levoflox 400 mg po od daily.• Gonococcal meningitis/endocarditis• Ceftriaxone 1-2g i/v 12 hrly -10-14 days/4 wk
• Serovars D-K a/w genital infection/urethritis• Gram –ve obligate bacterium(energy requiring parasite),have CW,CM,DNA&RNA.• LIFE CYCLE-unique biphasic• Metabolically inert infectious EB has rigid cell wall attacks col. Epi. Cells.• After entering host cell EB becomes RB which is metabolically active.• RB divide by binary fission until an intracellular inclusion is formed .• EB released from this inclusion after host cell lysis.
Clinical featuresIn women-symptomatic 30%Endocervix is m.c siteSome women developeurethritis –odourless,mucoid dis.Pruritus +/-Dysuria without freq./Urgency.
• In men-symptomatic 75%• Mucoid/mucopurulent dis.• May complicate as epididym• -itis ,prostitis,vas deferentitis,Proctitis..
Laboratory Tests for Chlamydia• Gram stain –PMNL >5/hpf with no demonstrable organism.• Tissue culture–on Mc Coy cells. – Specificity approaching 100% – Sensitivity ranges from 60% to 90% – Role in medicolegal cases. – Non-amplified tests • Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2 – sensitivities ranging from 75% to 100%; specificities greater than 95% – detects chlamydial ribosomal RNA – able to detect gonorrhea and chlamydia from one swab . • Enzyme Immunoassay (EIA), e.g. Chlamydiazyme – sensitivity and specificity of 85% and 97% respectively .
Contd….• DNA amplification assays (NAAT) – polymerase chain reaction (PCR) – ligase chain reaction (LCR) – Cofirmatory test.• Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100%• LCR ability to detect chlamydia in first void urine• DFA Test –sensitivity 75-85%,sp 98-99%.
Chlamydia Treatment• Recommended: – Azithromycin 1 g PO single dose( toc)(preg) OR – Doxycycline 100 mg PO BID x 7 days• Alternative: – Erythromyin base 500 mg PO QID x 7 days( preg) – Ofloxacin 300 mg PO BID x 7 days OR – Levofloxacin 500 mg PO QD x 7 days OR – Amoxycillin 500 mg PO TDS x 7 days.( preg)
Chlamydia Treatment in Infants• Neonatal ocular prophylaxis does not prevent perinatal transmission of chlamydia• Erythromycin base 50 mg/kg/d PO divided into 4 doses daily for 14 days.
Mycoplasma genitalium• Atleast 13 spp are common commensals of human urogenital tract• Transmitted efficiently by sexual contact• T/t - Azithro 1gm PO stat (DOC).
TRICHOMONAS VAGINALIS• Common cause of STD in women• 20% of men with NGU are infected with T . vaginalis• Coinfection with gonococci is common.• Important cause of persistent/recurrent urethritis• PCR Assay is more sensitive than culture.
Trichomoniasis Treatment• Recommended: – Metronidazole 2 g po single dose OR – Tinidazole 2 g po single dose• Alternative: – Metronidazole 500 mg po BID x 7 days• Advise to abstain from alcohol during and up to 24 hours after completion of metronidazole and 72 hours after completion of tinidazole.
Trichomoniasis Treatment - Special Considerations• Allergy, intolerance or adverse reaction – Metronidazole desensitization(start with .04mg PO doubling dose every 15 min upto 250mg).• Pregnancy – Counsel on risk & benefits of treatment – Metronidazole 2 gm single dose (Category B) – Abstain from breastfeeding for 24 hours after last dose
Trichomoniasis Treatment - Special Considerations