Module: Pharmacotherapy III Coordinator: Dr. Arwa M. Amin Mostafa Academic Level: Postgraduate, Master of Pharmacy in Clinical Pharmacy School: Dubai Pharmacy College Year of first presented in Class: 2018 This presentation is for Educational purpose. It has no commercial value associated with it.

1. ARWA M. AMIN MOSTAFA
PHD, M. PHARM CLINICAL PHARMACY, DIP. MANAGEMENT, BSC. PHARM.
T
SYPHILIS, CHLAMYDIA & GONORRHEA

2. Arwa M. Amin
WHAT WE WILL DISCUSS TODAY?
• What are the STDs? What are the common STDs?
• What are the risk factors of STDs?
• What are the pathogens’ cause of common Bacterial STDs?
• What are the clinical manifestations of common Bacterial
STDs (Syphilis, Gonorrhea & Chlamydia)?
• How to Diagnose Syphilis, Chlamydia & Gonorrhea?
• How to manage Syphilis, Chlamydia & Gonorrhea?
• How to prevent STDs?
• Case Discussion Task
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3. Arwa M. Amin
SEXUALLY TRANSMITTED DISEASES (STDS)
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•Sexually Transmitted Diseases (STDs) are Diseases caused by
infections which are mostly transmitted by sexual contact.
•Sexually Transmitted Infections (STIs) are
infections which cause STDs.
•STDs have very severe long term
consequences and it can be fatal if untreated
or inadequately treated.
Figure Source: What is an STI? https://www.youtube.com/watch?v=QfrbXGgMaAc

4. Arwa M. Amin
COMMON STDS
•Bacterial: Syphilis, Chlamydia, Gonorrheal Urethritis (Gonorrhea)
•Viral: Human Immunodeficiency Virus (HIV), Genital herpes;
Herpes simplex virus (HSV), Genital warts; Human Papilloma
Virus (HPV)
•Fungal: Candidiasis (Yeast Infection)
•Parasitic: Trichomoniasis, Pubic lice
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5. Arwa M. Amin
RISK FACTORS OF STDS
• Age (15 – 24)
• 2/3 of STIs occur in persons in teens &
twenties
• Unprotected sex with infected person.
• Men having sex with Men (MSM).
• Injected Drug use (IDU) or having sex with
IDU person.
• Having more than one sexual partner.
• Sharing contaminated private personal items
with infected person.
• Blood Transfusion of contaminated Blood. 5

6. Arwa M. Amin
STDS RISK POPULATIONS
•Sexually active people
•Young people
•Tend to have risky sexual Behavior
•IDU persons.
•MSM.
•Bisexual men.
•Spouses of infected persons.
•Women working in sex.
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IDU: Injectable Drug use, MSM: Men having sex with men

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8. Arwa M. Amin
BACTERIAL STDS
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9. Arwa M. Amin
BACTERIAL PATHOGENS OF COMMON BACTERIAL STDS
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Pathogen CauseSTD
Treponema PallidumSyphilis
Chlamydia TrachomatisChlamydia
Neisseria GonorrheaGonorrhea

10. Arwa M. Amin
SYPHILIS
• Pathogen Cause: Treponema pallidum (Spirochete)
• Pathogenesis:
•Routes of Syphilis Transmission:
•Acquired
•Sexual contact
• Any type of sexual contact (Anal, Oral, Vaginal)
•Blood transfusion of contaminated blood (Rare)
•Congenital transmission
•Transplacental during pregnancy
•During delivery due to the passage of the baby through
an infected canal.
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11. Arwa M. Amin
SYPHILIS
• Pathophysiology:
• Organism penetrates intact membrane or break in epithelium, resulting in
spirochetemia.
• Enters Lymphatic system to regional lymph nodes and spread in blood
throughout the body.
• It can attach to the endothelial lining of Blood Inflammation Endocarditis.
• Invasion of the CNS may happen at any stage of Syphilis.
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12. Arwa M. Amin
CLINICAL PRESENTATIONS OF SYPHILIS
Signs & SymptomsSite of InfectionGeneralSyphilis Stage
Chancre, Regional
Lymphadenopathy, painful
purulent lesions
Externa Genitalia,
Perianal region, mouth
& Throat
Incubation (10 – 90) days
Mean (21) days
Primary
Pruritic or Non-pruritic
rash
Multisystem secondary
to Hematogenous &
Lymphatic spread
2-8 weeks after initial infection
in untreated patients or
inadequately treated individuals
Secondary (2nd)
AsymptomaticPotentially multisystem
involvement (dormant)
4-10 weeks after 2nd stage in
untreated or inadequately treated
individuals
Latent
CV syphilis, neurosyphilis,
gummatous lesions
involving any organ or
tissue
CNS, heart, eyes, bones,
and joints
10-30 years after initial infection
in ~30% of untreated or
inadequately treated individuals
Tertiary
12CNS: Central Nervous system. CV: Cardiovascular

13. Arwa M. Amin
STAGES OF SYPHILIS
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Figure Source:
AshishSukthankar,
Syphilis (2010)
https://www.sciencedir
ect.com/science/article
/pii/S135730391000
0332

14. Arwa M. Amin
CLINICAL PRESENTATIONS OF SYPHILIS
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Secondary Syphilis
Figure Sources: Syphilitic chancre of the mouth: http://www.cmaj.ca/content/183/17/2015, Secondary Syphilis: https://www.healthline.com/health/syphilis-secondary
Syphilis Chancre

15. Arwa M. Amin
SYPHLLIS
• Complications of Untreated Syphilis
• Gummatous lesions
• Syphilis ↑↑ the risk of HIV
transmission
• Cardiovascular syphilis
• Neurosyphilis
• Syphilis is fatal if untreated with
↑↑ mortality rate in Males than
females.
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16. Arwa M. Amin
SYPHLLIS
• Clinical Presentations of Syphilis
• Cardiovascular Syphilis
• Aortitis or aortic insufficiency, Coronary
disease, aortic aneurysm
• Neurosyphilis
• Meningitis, General Paresis, Dementia,
Tabes Dorsalis, eighth cranial nerve
deafness, blindness
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17. Arwa M. Amin
SYPHLLIS
Diagnosis:
• History & Physical Examination
• Laboratory tests:
• T. pallidum is difficult to culture in-vitro
• Microscopy:
•Dark-field illumination in fresh preparation
•Direct Fluorescent antibody staining
• Treponemal antibody tests.
•Florescent Treponemal antibody absorption
• Lumpur puncture and CSF analysis if Neurosyphilis is suspected 17

18. Arwa M. Amin
MANAGEMENT OF SYPHLLIS
• Therapeutic Outcome
• Resolution of Infection
• Pharmacological Treatment
• Penicillin G 2.4 million units IM for all stages of Syphilis.
• Benzathine penicillin G only penicillin effective for single-dose therapy.
• Primary, Secondary or early latent Syphilis (Single dose)
• Late latent Syphilis (once a week for 3 weeks)
• Neurosyphilis:
• Aqueous crystalline penicillin G 18-24 million units IV for 10 – 14 days
• Given as 3 – 4 million every 4 hours or by continuous infusion
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19. Arwa M. Amin
MANAGEMENT OF SYPHLLIS
Pharmacological Treatment cont..
• Congenital (Infants)
• Aqueous crystalline penicillin G 50,000 units/kg IV for 10 days
•Given every 12 h during the 1st seven days of life
•Then, every 8 h
• Penicillin allergic patient ?
• Doxycycline 100 mg PO BD or Tetracycline 500 mg PO, 4 times daily
• Treatment Duration for Primary, secondary or early latent syphilis: 14 days
• Treatment Duration for Late latent syphilis: 28 days
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20. Arwa M. Amin
MANAGEMENT OF SYPHLLIS
Syphilis in Pregnancy:
• Penicillin at the recommended dosages of the stage.
• Additional IM dose of Benzathine penicillin G, 2.4 million units,
1 week after completion of recommended regimen, why?
•To ensure treatment success and prevent transmission to fetus.
• What if … Penicillin allergic Pregnancy patient?
• Desensitization then treat with Penicillin
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21. Arwa M. Amin
MANAGEMENT OF SYPHLLIS
Monitoring of Therapy:
• Patients counseling: NO sexual activity until confirmed to be
Non-infectious
• Re-test at 6-12 months for primary & secondary Syphilis
• Re-test at 6, 12, 24 months for early and late latent Syphilis
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22. Arwa M. Amin
GONORRHEA
• Pathogen Cause: Neisseria gonorrhea
• Gram negative diplococcus
• Humans are the only known host of
Gonococci
• Highly co-exist with Chlamydia
• Route of Transmission:
• Sexual contact:
• Any type of sexual contact
(Anal, Oral, Vaginal)
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23. Arwa M. Amin
GONORRHEA
Pathophysiology
•Gonococci attach to mucosal cell membranes
via surface pili
•Mucosal damage leads to tissue invasion by
polymorphonuclear leukocytes followed by
formation of submucosal abscesses and
secretion of purulent exudates.
•Gonococci may invade bloodstream and
produce disseminated disease.
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24. Arwa M. Amin
PATHOPHYSIOLOGY OF GONORRHEA
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Figure Source: Neisseria gonorrhoeae host adaptation and pathogenesis; https://www.nature.com/articles/nrmicro.2017.169
lipooligosaccharide (LOS), outer membrane vesicles (OMVs), Toll-like receptor (TLR), nucleotide-binding oligomerization domain-containing
protein (NOD) dendritic cells (DCs)

25. Arwa M. Amin
GONORRHEA
• Clinical Presentations:
• Patients may be:
• Symptomatic or Asymptomatic
• Suffer from Complicated or Uncomplicated Infections
• Gonorrheal infections may involve several anatomical sites.
Clinical presentations of disseminated gonococcal infection:
• Tender, necrotic skin lesions.
• Tenosynovitis.
• Monoarticular arthritis.
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26. Arwa M. Amin
CLINICAL PRESENTATIONS OF GONORRHEA
WomenMen
Incubation (1 – 14) days
Symptoms onset: 10 days
Incubation period (1 – 14) days
Symptoms onset: 2-8 days
General
Endocervical Canal*Urethra*Site of Infection
May be Asymptomatic or minimally
symptomatic
• Endocervical infection: Asymptomatic or
mildly symptomatic
• Urethral, Anorectal and pharyngeal
infection: symptoms similar to men
Commonly Symptomatic
May be Asymptomatic
• Urethral Infection: Dysuria & urinary
frequency
• Anorectal infection: Asymptomatic to
severe rectal pain
• Pharyngeal Infection: Asymptomatic to
mild pharyngitis
Symptoms
Abnormal vaginal Discharge or uterine
Bleeding; Purulent urethral or rectal
discharge
Purulent urethral or rectal dischargeSigns
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*Most common

27. Arwa M. Amin
GONORRHEA
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Complications of Untreated Gonorrhea
• Disseminated Gonorrhea
• ♀ > ♂
• Women:
• Pelvic Inflammatory Disease
• Ectopic Pregnancy
• Infertility
• Ophthalmic neonatorum
• Men
• Rare (epididymitis, prostatitis, inguinal lymphadenopathy, urethral
stricture)

28. Arwa M. Amin
GONORRHEA
Diagnosis:
• Clinical Examination
• Laboratory tests:
• Gram-stain smears.
• Culture of infected fluids.
• Detection of cellular components of gonococcus (eg, enzymes, antigens, DNA,
or lipopolysaccharide) in clinical specimens.
• Alternative methods of diagnosis:
•Enzyme immunoassay.
•Nucleic acid amplification techniques.
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29. Arwa M. Amin
MANAGEMENT OF GONORRHEA
• Therapeutic Outcome
• Resolution of the infection
• Prevention of Ophthalmic neonatorum
• General Approach:
• Consider treating Chlamydia with Gonorrhea due to high coexistence risk
• Refer recent sex partners (within 60 days before onset of symptoms or
diagnosis) for evaluation and treatment.
• Partners should abstain from unprotected sexual intercourse for 7 days after
both have completed treatment and symptoms have resolved.
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30. Arwa M. Amin
MANAGEMENT OF GONORRHEA
• Pharmacological Treatment
• Gonorrhea treatment
• Ceftriaxone 250 mg IM once or
• Cefixime 400 mg Orally once
PLUS
• Chlamydia treatment
• Azithromycin 1 g orally once or
• Doxycycline 100mg BID for 7 days
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31. Arwa M. Amin
CHLAMYDIA GENITAL INFECTION
• Pathogen cause:
• Chlamydia trachomatis
• Weakly Gm (-) Bacterium
• Pathophysiology:
• C. trachomatis requires
cellular material from host cell
for replication
• Frequent coinfection with
gonorrhea.
• up to 50% of women and
20% of men. 31
Life Cycle of Chlamydia
Figure Source: https://www.tuyenlab.net/2016/09/microbiology-atlas-of-spirochetes.html

32. Arwa M. Amin
CHLAMYDIA GENITAL INFECTION
• Clinical Presentations:
• Mostly Asymptomatic
• If symptoms present tends to be LESS NOTICEABLE
• Complications of Untreated Chlamydia:
•Women
• Pelvic inflammatory Disease
• Pregnancy Complications
• Infertility
• Conjunctivitis and pneumonia in Newborns
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•Men
• Inflammation in the penis,
prostate and testes.
• Sterility.

33. Arwa M. Amin
CHLAMYDIA GENITAL INFECTION
Diagnosis:
Laboratory Tests:
Culture of endocervical or urethral epithelial cell scrapings.
• Results available in 3–7 days.
Nonculture tests:
• DNA hybridization, nucleic acid amplification tests (NAATs)
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34. Arwa M. Amin
MANAGEMENT OF CHLAMYDIA GENITAL INFECTION
• Therapeutic Outcome
• Resolution of the infection
• Pharmacological Treatment
• Azithromycin 1 g orally once or
• Doxycycline 100mg BID for 7 days
• Pregnancy:
• Azithromycin 1 g orally once or Amoxicillin 500 mg orally TID for 7 days
• Conjunctivitis or Pneumonia in infants
•Erythromycin base or ethylsuccinate 50 mg/kg/day orally in 4 divided doses for 14
days
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35. Arwa M. Amin
PREVENTING STDS
• Best Prevention of STDS is Abstinence &
Fidelity
• Mutually monogamous sexual relationship
between uninfected partners.
• Protected Sex
• Using Barrier Contraceptive Methods (e.g.
Condoms)
• Proper hygiene
• Syphilis can be destroyed by heat, cold and
antiseptics.
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36. Arwa M. Amin
CASE DISCUSSION
A 24-year-old man presented with a three-week history of a 1-cm painless,
ulcerative lesion on his lower lip and a three-day history of symmetrically distributed
nonpruritic macules on his trunk and limbs. He was HIV-negative and was otherwise
healthy. He had performed unprotected sex with a female partner about three weeks
before the onset of the ulcer. On examination, generalized nontender
lymphadenopathy was noted along with the rash and chancre. A serologic test for
syphilis showed a reactive rapid plasma reagin test result (titer 1:64) and a positive
agglutination test result for Treponema pallidum. Syphilis was diagnosed.
36Case Source: Syphilitic chancre of the mouth, http://www.cmaj.ca/content/183/17/2015

37. Arwa M. Amin
CASE DISCUSSION TASK
Discussion Questions:
• What are the signs and symptoms that confirm the diagnosis of Syphilis in this
patient?
• What is the Syphilis stage of the patient?
• What is the best treatment of Syphilis for this patient?
• What are the common routes of STDs transmission?
• Discuss Briefly STDs prevention methods
37Case Source: Syphilitic chancre of the mouth, http://www.cmaj.ca/content/183/17/2015

38. Arwa M. Amin