This document discusses sexually transmitted infections including syphilis, gonorrhea, chlamydia, and HSV. It provides details on the pathogenesis, transmission, clinical manifestations, diagnosis, and treatment of each STI. For syphilis, gonorrhea and chlamydia, it outlines the recommended screening, diagnostic tests including NAAT and culture, and CDC-recommended treatment regimens for pregnant and non-pregnant patients. Complications of untreated STIs for both mother and fetus are also discussed.

1. Sexually Transmitted
Infections (Syphilis,
Gonorrhea, Chlamydial
Infections, HSV)

2. Objectives
Define Syphilis, Gonorrhea, Chlamydial
infections and HSV
Pathogenesis and transmissions
Clinical Manifestations
Diagnosis
Treatment

3. SYPHILIS
 Most common cause of fetal death in the later moths of pregnancy
 Contagious disease caused by T. pallidum
 Chronic systemic disease
1.8 cases per 100,000 persons in 2015 in the U.S. for primary & secondary syphilis
12.4 per 100,000 live births in 2015 for congenital syphilis

4. Pathogenesis
T. pallidum
minute abrasions
replicate & disseminate in lymphatics within hours to days
Primary, Secondary, Latent, late or tertiary, Neurosyphilis
 Mean incubation period is 21 days (10-90 days)
transmission risk raised:
- Cervical eversion
- Hyperemia
- friability

5. Primary Syphilis
 Darkfield microscopy reveals spirochetes
 Serologic testing is reactive in 80-90%
 Spontaneously heal in 3-8 weeks without treatment
 Chancre accompanied by regional adenopathy 10-90 days after
exposure
(painless, red, round, firm ulcer with an indurated base with well-formed,
raised edges)
 70-80% have PAINLESS inguinal lymphadenopathy, multiple lesions
occur in 30% (HIV-1 co-infected women)

6. Secondary Syphilis
 Nearly all patients progress 6 weeks after the chancre
 Dermatologic abnormalities in 90%
(macular, maculopapular, and scaly lesions involving the face, torso and flexor
aspect of extremities)
 Systemic manifestations include generalized lymphadenopathy, hepatitis,
nephrosis, optic neuritis, uveitis, meningitis, alopecia and periostitis
 Diagnosed by darkfield microscopy and serology is positive
 May heal spontaneously without treatment within 2-6 weeks
Condyloma lata- flesh colored papule and nodules found on the perineal area

8. Latent Syphilis
 Untreated lesions of secondary syphilis resolve and patient progresses
 Overt manifestations of the disease are absent
 Diagnosis only made by reactive serologic testing
 Divided into
A. Early- within 12 months
B. Late latent- beyond 12 months, greater risk for developing tertiary or neurosyphilis
 Not infectious by sexual transmission
 Spirochotes may be transplacentally transmitted at any AOG

9. Late or Tertiary Syphilis
 Develop into 20-30 % of untreated patients
 Slowly progressive disease
 Benign late cases characterized by gumma, aortitis, meningovascular
disease, paresis, optic neuritis, Argyll-robertson pupil and tabes
dorsalis

11. Congenital Syphilis
 70% of women without screening and treatment will have an adverse outcome
 Maternal infection can cause:
- preterm labor
- fetal growth restriction
- fetal infection
 Immune incompetence prior to midpregnancy, fetus does not manifest inflammatory response
 Fetal hepatic abnormalities
 Stillborn remains a major complication
 Newborn may have jaundice with petechiae, purpuric skin lesion, lymphadenopathy, rhinitis, pneumonia, myocarditis, nephrosis or long bone
involvement

12. Neurosyphilis
 No single testing technique can diagnose
 CFS analysis remains controversial
 CDC recommends that all adults with latent syphilis be evaluated clinically for
tertiary disease
Criteria for performance of CSF analysis:
 Neurologic or ophthalmic signs and symptom
 Evidence of active tertiary syphilis
 Treatment failure
 HIV infection with latent syphilis or syphilis of unknown duration

13. Diagnosis
 Clinicians must screen all pregnant women
 Ideally performed at 1st prenatal visit
 In populations with high incidence of prevalence, serologic testing repeated at 3rd trimester
and after delivery
For direct diagnosis of early stage disease from lesions, exudates and body fluids:
A. Dark field microscopy- most accurate method to diagnose syphilis
B. PCR
C. DFA-TP (Direct Fluorescent Antibody Test for T. pallidum)

15. Diagnosis
 Serologic testing- used for diagnostic and screening purposes
 A. Non-treponemal testing- VDRL or RPR which measures patient’s IgG & IgM antibodies
against cardiolipin which is released from damage host cell
Other acute events that produce cardiolipin:
- Vaccination - IV drug abuse - leprosy
- Febrile illness - SLE - cancer
- Pregnancy - aging
 When there is + non treponemal tests, findings are then quantified and expressed as
TITERS (disease activity)
 Following treatment for primary and secondary syphilis, serologic testing at 3-6mos
confirms 4-fold drop in VDRL and RPR titers (treatment failure and reinfection may lack
expected decline
 The same test is recommended for surveillance
 Serofast- successfully treated patients that exhibit low-level + titers

16. Diagnosis
 B. Treponemal Specific Testing:
A. Flourescent treponemal-antibody absorption tests (FTA-ABS)
B. T. pallidum passive particle agglutination (TP-PA)
C. Various immunoassays (Assc of Public Health labs, 2015)
 these tests generally remain + throughout life
 Rapid point-of-care (POC) screening of blood or serum samples is now being developed to
those in hard to reach populations (Singh, 2015)
 Sonography is performed for fetuses >20 weeks AOG when there is maternal diagnosis
(hepatomegaly, placental thickening, hydramnios, ascites, hydrops fetalis and inc MCA on
doppler velocimetry)
 Treatment before 20 weeks AOG is highly successful (Nathan, 1997)

17. Treatment
 CDC 2015 STD GUIDELINES
 For Primary, Secondary and Early Latent Syphilis
Recommended regimen
 Benzathine penicillin G 2.4 million units IM in a single dose
 Late Latent and Tertiary Syphilis
Recommended regimen
 Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million
units IM each at 1 week intervals
 Neurosyphilis
Recommended regimen
 Aqueous crystalline penicillin G 18 to 24 million units per day, administered as 3 to 4
million units IV every 4 hours or cont infusion for 10-14 days

20. Penicillin Reactions
 Women with allergies should have oral stepwise dose challenge or skin test
to confirm the risk of IgE mediated anaphylaxis
 Jarisch-Herxheimer reaction- develops in women following penicillin
treatment with primary and approx half with secondary infection
- Mild uterine contractions
- Decreased fetal movement
- Maternal temp elevations
 Treatment is supported with antipyretics, hydration and O2 support

21. Gonorrhea
 Second most common bacterial STI
 Caused by N. gonorrhea
 Has a predilection for the columnar and pseudostratified epithelium and mucous membrane
 Untreated gonococcal cervicitis is assc with septic abortion
- Preterm labor - chorioamnionitis
- PROM - postpartum infection
 Vertical transmission is predominantly due to fetal contact with birth canal
Gonococcal ophthalmia neonatorum- corneal scarring, occular perforation and blindness
Prevalence approximates 0.6% (Blatt, 2012)
WHO estimates 62.6 million new cases of gonorrhea world wide among 15-49yo

22.  Transmission form male to female in a single sexual encounter is
80-90%
 Incubation period of 3-5 days
 Asymptomatic infection in 80%, urethral colonization is present in
70-90%
Mucopurulent cervicitis- hallmark of clinical infection, purulent or
mucopurulent endocervical exudation
Most common manifestations:
 Vaginal discharge
 Dysuria
Amniotic infection syndrome- placental, fetal, umbilical cord
inflammation after PROM and is assc w positive aspirate of N.
gonorrhea, leukocytosis, neonatal infection and maternal fever
Gonorrhea

23. Screening and Treatment
 1st trimester screening in high prevalence areas
 Risk factors:
- </= 25 yo prior to gonorrhea - prostitution - drug abuse - race
- Other STDs - multiple sex partners- inconsistent condom use
 Screening includes:
A. Nucleic Acid Amplification tests (NAATs) – gold standard, available for specific collection from
vagina, endocervix and urine (initial stream)
B. Culture

24.  CDC 2015 STD Guidelines
Uncomplicated Gonococcal Infection of the Cervix, Urethra and Rectum
Uncomplicated gonococcal pharyngitis, gonococcal conjunctivitis and Disseminated Gonococcal Infection
Recommended Regimens
 Ceftriaxone 250mg IM single dose + Azithromycin 1g orally in single dose OR Doxycycline 100mg orally
BID for 7 days
Alternative regimens if ceftriaxone is not available
Uncomplicated Gonococcal Infection of the Cervix, Urethra and Rectum
Recommended Regimens
 Cefixime 400mg orally in single dose + Azithromycin 1g orally in single dose OR Doxycycline 100mg
orally BID for 7 days
Uncomplicated gonococcal pharyngitis, gonococcal conjunctivitis and Disseminated Gonococcal Infection
 Ceftizoxime 1g IM q8h or Cefotaxime 1g IM q8h + Azithromycin 1g orally in single dose OR Doxycycline
100mg orally BID for 7 days
Screening and Treatment

25.  Uncomplicated Gonococcal Infection during Pregnancy
 Ceftriaxone 250mg IM + Azithromycin 1g PO
Alternative regimens
 Cefixime 400mg PO single dose + Azithromycin 1g PO
With cephalosporin allergy
 Gentamycin 240mg IM + Azithromycin 2g PO
 Repeat testing is recommended in the 3rd trimester
Screening and Treatment

26. Chlamydial Infections
 Caused by C. trachomatis
 Most common sexually transmitted bacterial pathogen
 Majority are asymptomatic
 Sexual contact- primary mode of transmission with male-female transmission of 40%
 Age is the most important risk factor
 Cervix is the most common site of infection that causes MUCOPURULENT CERVICITIS
(mucopuruluent discharge and cervical ectopy)
 Increased risk for:
- Preterm delivery - low BW
- PROM - perinatal mortality
 Incubation period of 1-3 weeks
646 cases per 100,000 in the U.S. in 2015

27.  Delayed postpartum uterine infection characterized by vaginal bleeding/discharge,
low grade fever and uterine tenderness
 Vertical transmission leads to infection in 8 to 44% of neonates (conjunctivitis is the
most common while pneumonia could also develop)
 Acute Salpingitis- most common complication that may lead to Fitz-Hugh Curtis
Syndrome
Chlamydial Infections

28.  Recommended screening for all women at 1st prenatal visit
 Diagnosis can be made predominantly through:
A. Nucleic Acid Amplification tests (NAATs)
B. Culture
 Treatment:
CDC 2015 STD Guidelines
Recommended regimens
 Azithromycin 1g PO in single dose OR Doxycycline 100mg PO BID x 7days
Screening and Treatment

29. Treatment
 CDC 2015 Guidelines
Recommended regimens
 Azithromycin 1gPO or
 Doxyxycline 100mg PO BID x 7 days
Alternative Regimens
 Erythromycin base 500mg 4x a day for 7 days or
 Erythromycin ethylsuccinate 800mg PO QID x 7 days or
 Ofloxacin 300mg PO OD x 7 days
 Levofloxacin 500mg PO OD x 7 days

30. Screening and Treatment

31. Lymphogranuloma venereum
 Caused by L1, L2 & L3 serovars of C. trachomati
 Matted inguinal adenitis develops at the inguinal ligament “GROOVE SIGN”
 Treatment:
 Erythromycin 500mg PO 4x a day for 21 days or Azithromycin 1g PO weekly for 21
days

32. Herpes Simplex Virus (HSV)
 Imposes higher risk for fetus than the mother
 Strategies aim to curb the rates for vertical transmission
Adult Disease:
 2 types based on immunologic differences:
A. HSV type 1- most non-genital infections and acquired through childhood
- however more than half of new cases of genital herpes in
adolescents and young adults are caused by this
- inc in oral genital sexual prectices
- acquision has declined through hygiene and living condition

33.  B. HSV type 2- almost exclusively from the genital tract and transmitted by
sexual contact
 Genital herpes affects 50million adolescents and adults and most women are
unaware of their infection
Herpes Simplex Virus (HSV)

35. Pathogenesis
HSV 1 or 2
Mucous membrane, epidermis (vesicular lesions)
Primary infection (dormant in sacral sensory neurons)
Reactivation
Recurrent HSV (shedding of infectious HSV)

36. Vertical transmission
 3 routes:
a. peripartum 85%- more frequent route
b. postnatal 10%- passed to newborn by contact w/ infected mother, family member or HC
worker
c. intaruterine 5%- rare, part of TORCH syndrome

37. Diagnosis
 Recommend against routine screening in asymptomatic gravidas
 Virological or type-specific serologic testing
Tzank smear- determine multinucleated giant cells (viral infection) with sensitivity of 50%
Direct virological tests
a. PCR- more sensitive and results are ready in 1-2 days
b. Culture- sensitivity is low in vesicular lesions
Serological assays- avail to detect antibodies produced against specific HSV glycoproteins,
G1 & G2

38. Treatment
 CDC 2015 STD Guidelines
1st clinical Episode of Genital Herpes
Recommended regimens
 Acyclovir 400mg PO TID x 7-10 days or
 Acyclovir 200mg PO 5x a day for 7-10 days or
 Famciclovir 250mg PO TID for 7-10 days
 Valacyclovir 1g PO bid for 7-10 days
Episodic therapy for recurrent genital herpes
 Acyclovir 400mg PO TID x 5 days or
 Acyclovir 800mg PO BID x 5 days or
 Acyclovir 800mg PO TID x 2 days or
 Famciclovir 1.0g PO BID x 1 day or
 Valacyclovir 500mg PO BID x 3 days
Suppresive therapy for recurrent Genital Herpes
Recommended regimens
 Acyclovir 400mg PO BID or
 Famciclovir 250mg PO BID or
 Valacyclovir 500mg PO OD or
 Valacyclovir 1.0g PO OD

40. SYPHILIS GONORRHEA CHLAMYDIA HSV
Lesion PAINLESS, red, round,
firm ulcer with an
indurated base with
well-formed, raised
edges
purulent or
mucopurulent
endocervical
exudation
mucopuruluent
discharge and
cervical ectopy
painful, tender,
shallow ulcers
Incubation
Period
21 days 3-5 days 7-21 days 2-12 days
Diagnosis Dark-field microscopy NAATs NAATs & Culture PCR
Treatment Benzathine Penicillin
G
Ceftriaxone +
Azithromycin
Azithromycin or
Doxycycline
Acyclovir

41. Thank you