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Sexually transmitted Infection
1. Lesson 6
Sexually transmitted infections
Tsegaye Melaku (BPharm, MSc)
Assistant Professor of Clinical Pharmacy
tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.et +251913765609December, 2020
2. Session Tips:
– Therapeutic relationship(communication matters!)
– Explain the routes of transmission and risk factors
– Behavioral considerations & importance of contraception
– ―Patient-delivered partner therapy‖
– Common causative microorganisms
– Corresponding clinical signs and symptoms
– Diagnostic procedures/techniques
– Treatment regimens & ‗‘Syndromic management approach‘‘
– Monitoring the Rx outcome
2
3. Aka sexually transmitted diseases (STDs) or venereal diseases
> 30 different infections transmitted mainly through:
– Sexual contact via the exchange of semen, vaginal fluid, blood &
other fluid
– Direct contact with the affected body areas of people with STIs
Its social and economic burden is high
– Loss of employment
– Broken marriages
3
4. 1. Sexual transmission: most common mode
Vaginal or anal sex
– In Ethiopia: vaginal route
– Heterosexual transmission: common
3. Mother-to-child
– During pregnancy (e.g. HIV & syphilis),
– At delivery (e.g. gonorrhoea & chlamydia),
– During breastfeeding (e.g. HIV)
3. Unsafe use of unsterile needles or injections
4. Contaminated blood or blood products (e.g. syphilis, HIV and hepatitis).
4
5. Biological factors
– Age, sex and immune status
Behavioural factors
– Unprotected sexual intercourse
– Frequent changing of sexual partners(multi-partner)
– Use of drug of abuse ↑ risk of unsafe sexual acts
Socio-cultural factors
– Gender bias of a community
– Women‘s economic dependence on men
– Young marriage
5
6. WHO estimates 357 million new cases of four curable STIs in 15-49
year-old
Curable STIs: chlamydia, gonorrhea, syphilis, trichomoniasis
Source: WHO. Global incidence and prevalence of selected curable sexually transmitted infections - 2012.
> 1 million new cases of
STI / day
7. In Ethiopia:
– At ANC sentinel surveillance
– The prevalence of syphilis is 1% (2012), 2.7% (2007) and
2.3% (2009)
– HIV (2014): 1.14%, Projection estimate [2018]: 0.96%
– In 2013 at selected facilities
– Vaginal discharge (50%), urethral discharge (31%), genital
ulcerative disease (9%), lower abdominal pain (7.3%)
– 16% co-infection with HIV
– Age group, 20-34 yrs, (highly affected); female 61%
7
8. Infertility,
Foetal wastage,
Ectopic pregnancy,
Anogenital cancer,
Premature death,
Neonatal & infant infections
8
HIV versus STI relationship
9. – History taking,
– Physical examination
– Correct diagnosis
– Early & effective treatment
– Advice/counsel on sexual
behaviour
– Offer HIV counselling and
testing
9
– Promotion and/or provision of condoms
– Partner notification and treatment
– Case reporting & clinical follow-up
– Advise to return in 7 days
– Refer (if necessary)
Components of case management:
10. 3 Rx approach
– Etiologic, clinical and syndromic approach
Based on groups of symptoms & easily recognized signs (syndromes)
– Etiological diagnosis of STI is problematic in many settings.
―The syndromic approach is not scientific.‖
– It is based on a wide range of epidemiological studies
―The syndromic approach results in a waste of drugs, because patients
are being over-treated.‖ Do you agree ?????
10
12. Recommended syndromic treatment
– Therapy for uncomplicated gonorrhoea
PLUS
– Therapy for chlamydia
If persistent/recurrent urethral discharge
– Suspect re-infection or poor compliance or Trichomonas vaginalis
12
13. Recommended syndromic treatment
– Therapy for syphilis PLUS
– Therapy for chancroid OR
– Therapy for granuloma inguinale OR
– Therapy for lymphogranuloma venereum (LGV)
13
14. Recommended syndromic treatment
– Therapy for uncomplicated gonorrhoea
PLUS
– Therapy for chlamydia
In older people, with low risk of STI E.coli, Klebsiella spp. or p.
aeruginosa.
14
15. Cervical infection
Recommended syndromic treatment
Therapy for uncomplicated gonorrhoea
PLUS
Therapy for chlamydia
15
Vaginal infection
Recommended syndromic treatment
Therapy for bacterial vaginosis PLUS
Therapy for Trichomonas vaginalis AND,
Therapy for Candida albicans
16. Evaluate for all sexually active women presenting with symptoms of
lower abdominal pain.
– Salpingitis and/or endometritis – pelvic inflammatory disease (PID)
– Signs & Symptoms:
– Abdominal pain, bleeding,
– Dyspareunia, vaginal discharge,
– Menometrorrhagia, dysuria,
– Pain associated with menses,
– Fever, nausea & vomiting,
– Uterine tenderness on pelvic exam
16
17. Etiology for PID
– N. gonorrhoeae, C. trachomatis, anaerobic bacteria (Bacteroides
spp. & Gm(+) cocci)
Recommended syndromic treatment
– Single-dose therapy for uncomplicated gonorrhoea (ceftriaxone
usually) PLUS
– Doxycycline 100mg PO BID x14 days PLUS
– Metronidazole 500mg PO BID x 14 days.
17
20. Common cause of urethritis in men & cervicitis in women.
2nd most common bacterial STI
– Incidence (US): ~700,000 per year
Common in adult in both sex (15- to 24-years)
– More case report: in male
Contributing/risk factors
– Low socioeconomic status
– Illicit drug use
– Age, Ethnic minorities
Associated sequelae: urethritis, cervicitis, or dysuria
20
34. Clinical presentations
Diagnostics
– Gram-stain, endocervical or vaginal specimens
– Culture, DNA hybridization probe
– Urethral specimen (male): PMN leukocytes; diplococci N. Gonorrhea
Stain: large numbers of gonococci within a few neutrophils
– If test +ve: test for other STIs is needed ! !
– NB: In asymptomatic don‘t use gm (-) stain to rule out infection
34
35. Can occur in the rectum, pharynx, and conjunctiva.
DGI classically presents as either
– A triad of polyarthritis, tenosynovitis, and dermatitis, or
– Septic arthritis(Knee most affected).
Disseminated gonococcal meningitis and endocarditis(rare)
35
36. Depends on clinical presentation
Evaluate for co-infection of C. trachomatis (often)
Preferred: Cephalosporins + Azithromycin (same day)
Alternatives: Cephalosporins + Doxycycline
36
37. Pharyngeal, cervix, urethra, & rectum infection
– Ceftriaxone 250 mg IM OR Cefixime 400 mg PO OR cefotaxime
500mg IM stat + Azithromycin 1 g PO stat OR Doxycycline 100 mg
PO BID X 7 days.
Co-infection C. trachomatis (always do not forget)
– Ceftriaxone 250 mg IM stat + Azithromycin 1 g PO.
37
38. Regimen should be given for 24-48hrs
– Ceftriaxone 1 g IM/IV QD + Azithromycin 1 g PO stat or
– Cefotaxime 1 g IV TID + Azithromycin 1 g PO stat or
– Ceftizoxime1 g IV TID + Azithromycin 1 g PO stat
PID
– Ceftriaxone + Doxycycline ± Metronidazole
38
39. 39
Neisseria gonorrhoeae — Percentage of Isolates with Elevated Azithromycin Minimum
Inhibitory Concentrations (MICs) (≥2.0 µg/ml), Elevated Ceftriaxone MICs (≥0.125
µg/ml), and Elevated Cefixime MICs (≥0.25 µg/ml), Gonococcal Isolate Surveillance
Project (GISP), 2008–2017
NOTE: Isolates not tested for cefixime susceptibility in 2008.
40. Neisseria gonorrhoeae — Prevalence of Tetracycline, Penicillin, or Fluoroquinolone
Resistance* or Elevated Cefixime, Ceftriaxone, or Azithromycin Minimum Inhibitory
Concentrations (MICs)†, by Year — Gonococcal Isolate Surveillance Project (GISP), 2000–
2017
* Resistance: Fluoroquinolone (ciprofloxacin) = MIC≥ 1.0 µg/mL; Penicillin = MIC≥ 2.0 µg/mL or B-lactamase positive; Tetracycline = MIC≥ 2.0 µg/mL.
† Elevated MICs: Azithromycin = MIC≥ 1.0 µg/mL (2000–2004); ≥ 2.0 µg/mL (2005–2017); Ceftriaxone = MIC≥ 0.125 µg/mL; Cefixime = MIC≥ 0.25 µg/mL.
NOTE: Cefixime susceptibility was not tested in 2007 and 2008.
ADAPTED FROM: Kirkcaldy RD, Harvey A, Papp JR, et al. Neisseria gonorrhoeae antimicrobial susceptibility surveillance — The Gonococcal Isolate
Surveillance Project, 27 Sites, United States, 2014. MMWR Surveill Summ 2016; 65(7):1–24.
41. Distribution of primary antimicrobial drugs used to treat gonorrhea among participants, gonococcal
Isolate Surveillance Project (GISP), 1988–2017
NOTE: For 2017, “Other” includes azithromycin 2g (0.3%), no therapy (0.3%), and other less frequently used drugs (0.1%).
42. Pregnancy
– 3rd generation cephalosporin + Azithromycin
– Cephalosporin intolerant: Azithromycin 2g PO stat
Ophthalmic Neonatorum Prophylaxis
– Erythromycin 0.5% ointment or
– Ceftriaxone 25–50 mg/kg IV/IM (max125 mg) stat
Gonococcal Conjunctivitis:
– Ceftriaxone 1 g IM/IV + Azithromycin 1 g PO stat
Allergy, tolerance, or adverse reactions
– Based on specific offending agents (You are drug therapy expert)
42
44. Caused by Chylmadia trachomatis[Gm(-)anaerobic bacteria]
Causes NGU (non-gonococcal urethritis in men; cervicitis in females)
Most common cause of non-gonococcal urethritis
8 serotypes.
Incubation period-7-21 days
Its transmission risk is lower than gonorrhea.
Complications
– Male: Epididymitis
– Female: Pelvic inflammatory disease
44
45. 2-3x more prevalent than gonorrhea
Most cases are asymptomatic (under reported)
– Annual screening recommended
Most common among young people
– 67% among age 15 to 24 yrs
Rectal infection common among MSM.
45
48. Rates of Reported Cases Among Women Aged 15–44 Years by
Age Group, US, 2008–2017
49. Rates of Reported Cases Among Men Aged 15–44 Years by Age
Group, US, 2008–2017
50. It lives inside a host in order to reproduce & survive[replicate inside
eukaryotic cells].
Has two developmental forms.
– Elementary bodies (EB) & reticulate bodies (RB)
EB (infectious version)
Metabolic inactive (EB) enter to host cell through endocytosis RB
(growth version) formed used host cell multiple RB(binary
fission) form EBs infect more cells cell rupture and
death
50
55. Specimen:
– Women: urine or endocervix swab
– Men: urethral swab or urine specimen.
Tests
– Nucleic acid amplification test
– Culture
– Enzyme immunoassay
– DNA hybridization probe or
– Direct fluorescent monoclonal antibody test.
55
56. Genital/Urethral/Endocervical chylmadia(uncomplicated)
– Preferred:
Azithromycin 1 g PO stat or
Doxycycline 100 mg PO BID x 7days
– Alternative:
Erythromycin 500 mg PO QID x 7 days
Levofloxacin 500 mg QD x 7 days or
Ofloxacin 300 mg BID (or 600 mg QD) x 7 days
56
57. Reactive arthritis(chronic)
– Doxycycline 100 mg PO BID + rifampin 300 mg QD x 6 months
Anorectal/rectal chylmadia
– Azithromycin 1 g PO stat
– Doxycycline 100 mg PO BID x 7 days or
57
58. Special cases
– Pregnancy
Azithromycin 1 g PO stat or Amoxicillin 500 mg PO TID x 7 days
or
Erythromycin 500 mg QID x 7 days or 250 mg QID x14 days.
– Infant infection [ophthalmia neonatorum or pneumonia]
Erythromycin 50 mg/kg/day PO divided into four doses daily x
14 days
58
60. Aka the great imitator
Causative Agents: Treponema pallidum (gram-negative spirochete)
Incubation: 10–90 days, Average: 3 weeks
Infections can be chronic
Progress through 4 stages: 1˚, 2˚, latent, & 3˚.
60
Fanxoo ቂጥኝ
61. Following penicillin, its incidence & prevalence ↓ed
– However, raised following HIV occurrence
In the US, MSM are at ↑risk of acquiring the infection.
Can also be acquired congenitally
More common among men and black
61
62. Rates of reported cases by stage of infection, US, 1941–2017
NOTE: Data collection for syphilis began in 1941; however, syphilis became nationally notifiable in 1944. Refer to the National Notifiable Disease
Surveillance System (NNDSS) website for more information: https://wwwn.cdc.gov/nndss/conditions/syphilis/.
HIV patients, pregnant women and blood donors had a syphilis
prevalence of 9.46% (95%CI; 6.52-12.4), 1.74% (95%CI; 0.96-
2.52), and 0.69% (95%CI; 0.42-0.97)
63. 1˚ & 2˚ syphilis — Distribution of Cases by Sex and Sexual Behavior, US,
2017
64. 1˚ & 2˚ syphilis — rates of reported cases by sex and male-to-
female rate ratios, US, 1990–2017
65. 1˚ & 2˚ syphilis — reported cases by sex and sexual behavior, US, 2013–
2017
* 37 states were able to classify ≥70% of reported cases of primary and secondary syphilis as either MSM, MSW, or women for each year during 2013–2017.
ACRONYMS: MSM = Gay, bisexual, and other men who have sex with men (collectively referred to as MSM); MSW = Men who have sex with women only.
66. 1˚ & 2˚ syphilis — rates of reported cases by age group and sex,
US, 2017
67. 1˚ & 2˚ syphilis — rates of reported cases among women aged 15–44 years
by age group, US, 2008–2017
68. 1˚ & 2˚ syphilis — rates of reported cases among men aged 15–44 years by
age group, US,2008–2017
69. Ethiopia
– It reaches up to 18.8%; Assefa et al, 1997
– Pooled prevalence: among infected HIV patients ~12.4%; pregnant
women ~ 2.52%; blood donors~0.97%; Siraj et al, 2019
– Among pregnant women: 1.9% (95 CI, 0.5-3.5%) Gondar area;
Getachew et al, 2019; 2.9% in Addis Ababa, Kebede et, 2000
– 10 years trend (2005-2014): 2.5% to 1.1% among pregnant
women; Desta et al, 2019
69
72. 73
1˚
• Solitary, painless chancre
• Occur after 3 weeks (@site of infection)
• Highly infectious; spirochetemia
2˚
• Advancement of 1˚ syphilis (if not Rx)
• Fatigue, diffuse rash, fever, lymphadenopathy, genital or perineal condyloma latum.
• Skin most affected; Rash can be macular, macropapular, or pustular lesions
Latent
• Can be early and late infection
• Asymptomatic; Previous lesions will resolve
• But, sero + for T.Pallidum
3˚
• Occurs years after infection
• Affect any of body parts
73. Infection of fetus by T.Pallidum
Symptoms: hepatomegaly, jaundice, and bone changes
Transmission
– Hematogenous spread from an infected mother
– Direct contact with the infectious genitalia of the mother
– Especially during 1˚ syphilis
74
74. Usually solitary, round-to-oval, painless genital ulcer.
Ulcer may be slightly painful, and several lesions are sometimes seen.
The base of the genital ulcer is dry in males, moist in females
Purulent fluid in the base is uncommon
The borders of the ulcer are often indurated
Bilateral, non-tender, non-fluctuant adenopathy
75
79. Neurosyphilis:
– Seizures, paresis, meningitis, stroke, hyperreflexia, visual
disturbances, hearing loss,
– Neuropathy, or loss of bowel and bladder function.
– Vascular lesions (meningovascular)
80
80. Clinical symptoms
Physical examination …..Very important
Laboratory
– Microscopy
– Venereal Disease Research Laboratory [VDRL]
– Rapid plasma reagin [RPR] test)
– T. pallidum hemagglutination test
– Fluorescent treponemal antibody test
– Enzyme-linked immunosorbent assay [ELISA])
81
81. 1˚ syphilis
– Benzathine penicillin, 2.4 million units IM [50,000 units/kg] stat.
– Alternative:
Doxycycline 100 mg PO BID x 14 days or
Tetracycline 500 mg PO BID x 14 days or
Ceftriaxone1g IM or IV QD x 10 days or
Azithromycin 2 g PO stat
2˚ syphilis & early latent syphilis (< 1-year duration)
– As 1˚ syphilis
82
82. Late Latent Syphilis & 3˚ syphilis
– Benzathine penicillin 2.4 million units IM (50,000 units/kg) once
weekly for 3 weeks.
– Alternatives
Doxycycline 100 mg PO BID x 28 days or
Tetracycline 500 mg PO QID x 28 days
Gummatous and Cardiovascular Syphilis
– As 3˚ syphilis
83
83. Neurosyphilis
– Ceftriaxone1g IM or IV QD x 8 to 10 days or
– Crystalline penicillin G 3 to 4 million units IV q4 hrs or continuous
infusion for 10 to 14 days
84
84. Congenital Syphilis
– Mother Rx
Benzathine penicillin 2.4 million units IM (50,000 units/kg) once
weekly for 3 weeks or
Ceftriaxone1g IM or IV QD x 8 to 10 days
– Neonates Rx (asymptomatic)
Benzathine penicillin G 50,000 units/kg IM stat
– Neonates Rx (symptomatic)
Crystalline penicillin G 50,000 units/kg BID IM for the first 7
days of life, then TID for 3 days or
Procaine penicillin G 50,000 IU/kg IM QD for 10 days.
85
88. It is the most common STD
An infection with a tiny parasite spread by sexual contact
Causative agent: Trichomonas vaginalis (anaerobic flagellated
single-celled protozoa parasite)
The human genital track is the only reservoir for this species.
It is transmitted through sexual/genital contact
Aka Trich, Trichomonas Vaginalis, TV
Incubation: 4–28 days
89
89. Prevalence: More > > than C. trachomatis or N. gonorrhoeae.
In US: 3.7 million people
– 2.1% among women ages 14-59
– 0.5% among men
7.4 million cases reported every year
180 million people infected worldwide
50% asymptomatic carriers
90
90. A risk for preterm delivery
Ethiopia
– Among symptomatic STI patient:14.2% (Gondar); Rozina et, 2017
– Among pregnant women: 4.98% [Jimma(JMC)]; Zeleke et al, 2013
91
91. Trichomonas vaginalis and Other Vaginal Infections Among Females, US,
1966–2016
NOTE: The relative standard errors for Trichomonas vaginalis infection estimates range from 23% to 17% and for other vaginal infection
estimates range from 13% to 8%. See Section A2.5 in the Appendix and Table 44.
SOURCE: National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services™, IMS Health Report, 1966–2016. The 2017 data
were not obtained in time to include them in this report.
92. Risk of infection
– Younger age at first sex
– Greater number of sex partners
– History of chlamydia infection in the past 12months
93
93. 94
Vaginal epithelium
(rich in glycogen)
Lactic Acid
Non-pathogenic
The vaginal secretions :
pH 3.8 - 4.4
Women under
normal condition
Bacilli (normal flora)
Convert
96. It is not an invasive parasite
It remains adherent to the squamous epithelium but not columnar
epithelium
Protozoan attachment to cells inflammatory response
discharge (contain high PMN leukocytes)
Direct damage to epithelium ulceration(micro)
97
97. Cause more symptoms in women than in men
– 50% of infected women are symptomatic compared to 25% of
infected men.
– Women often develop symptoms over time
– Men can often clear the infection spontaneously
Pelvic pain, dysuria, dyspareunia, vaginal burning, itching, and a scant,
frothy green, malodourous discharge.
On speculum exam, the cervix may have punctate hemorrhages
aka ―strawberry cervix.‖
98
99. In women
– Discomfort during intercourse
– Itching of the inner thighs
– Vaginal discharge (thin, greenish yellow, frothy or foamy)
– Itching or swelling of the labia
– Vaginal odor (foul or strong smell)
In men
– Burning after urination or ejaculation
– Burning of urethra
– Slight discharge from urethra
100
100. Clinical signs and symptoms
Physical exam: Small red ulceration (sores) on the vaginal walls
Laboratory:
– On saline wet mount or Papanicolaou smear(Vaginal scrapping)
– Nucleic acid amplification tests
– Rapid antigen detection tests
– Culture
– Vaginal pH >4.5
101
Pap smear
101. Metronidazole 2g PO stat (especially for pregnant) or
Metronidazole 500 mg PO BID X 7 days or
Tinidazole 2g PO stat
– For Metronidazole-resistant trichomoniasis
Current sex partners should be referred for treatment.
Avoid sexual intercourse until treatment is complete.
102
103. Aka Condyloma Acuminata
Causative agents: human papillomavirus (HPV)
– Very contagious/small bumps
– Small, non-enveloped, double-stranded DNA viruses
– >150 types: 6 & 11 genital warts; 16 & 18 cervical cancer.
– Some infect cutaneous or keratinized squamous epithelial cells skin
warts.
– Some (>40 types) infect the mucosa or non-keratinized squamous
epithelium have oncogenic potential[squamous cell carcinoma].
104
104. Size from 1 to 4 mm
Skin-to-skin contact (i.e, vaginal, anal, or oral) during sexual activity
with an infected person.
Asymptomatic can transmit the disease.
May be seen or felt by patients or their sexual partners
Effectiveness of condom is questionable: virus can infect areas not
covered by a condom.
105
105. ~50% of sexually active persons infected at least once in their lifetime.
– ~ 90% naturally cleared by immune system
US
– Prevalence: >50%
– Incidence: >14 million/year
– ~50% cases: among person age 15 to 24 years
106
106. Most people do not develop symptoms[usually asymptomatic]
– But, can be painful or pruritic
Rough, thick, cauliflower-like lesions
Signs
– Black dots within warts
– Disrupted surface
Symptoms
– Anogenital pruritus
– Burning
– Vaginal discharge or bleeding
– Dyspareunia (in vulvovaginal condyloma)
107
111. Clinical signs and symptoms
Physical exam[visual inspection]
– Classic condyloma acuminata; keratotic warts; flat warts
Laboratory
– DNA, RNA, or capsid protein detection
– Tissue biopsy or viral typing
– Colonoscopy
112
112. Goal of therapy
– Remove visible warts & ↓ of infectivity
– Alleviation of physical symptoms & cosmetic improvement
~>50% resolve spontaneously within 9-12 months
113
113. Podofilox 0.5% gel or solution:
– Apply BID for 3 days then 4 days of drug free day (repeat till no
visible warts) or for 1 month
– Don‘t use in the vagina, anus, or during pregnancy
Imiquimod 5% cream;
– Apply at bedtime, 3x a week for up to 16 weeks or
– Apply every other day for three applications
114
114. Podophyllin resin [10% to 25% solution]
– Apply once weekly
– CI in pregnancy
Caustic agents
– Includes Bichloroacetic (BCA) and Trichloroacetic (TCA) Acids
– Apply once a week
Ablative Therapy
– Cryotherapy with liquid nitrogen or
– Cryoprobe, surgical removal by excision, and vaporization
Prevention: vaccination[Gardasil vaccine]
115
116. Causative agents: herpes simplex virus (HSV) (HSV- 1 & HSV-2 )
– No cure (lifelong/chronic)
Transmission: oral to oral contact
HSV-2: cause for recurrent infection, especially genital herpes.
Incubation (initial presentation): 4 to 7 days after sexual exposure
117
117. US
– Prevalence: ~50 million
– HSV-2 infection: ~16.2% among 14–49 years age.
– Incidence: 500,000 cases/year
Common among PLHIV
118
118. HSV only found in humans
Almost all cases acquired sexually
Transmission from secretion mucosal surfaces (i.e, cervix or urethra)
Transmission from abrasion: direct contact with an active lesion
Asymptomatic case: a key factor for transmission.
Can be transmitted to neonate during delivery
119
119. Most asymptomatic
Signs
– Vesicular lesions(last up to 21 days)
– Small, cluster painful blisters vesicles (filled with fluid) (erythematous
base)
– 1st outbreak heal within 2-4 wks (severe presentation).
– Later presentation (attacks) are less severe
Symptoms
– Itching, Burning, Tingling, Groin lump, Dysuria
– Dyspareunia, ↑urinary frequency
– Ulcerative lesions, fissures, cervicitis
120
122. 123
Primary Lesions—Male. Multiple genital
vesicles of primary genital herpes
Primary Lesions—Male. Confluence of ulcerations on an
erythematous base in a patient with primary herpes simplex
type II
124. Test for HIV: epidemiologic synergy
No cure
– Rx reduce s & sxs, a number of attacks
Focus on the first episode (4- 7 days, but can occur after years)
– If Rx: favorable outcome in terms of lesion healing time, viral
shedding, & reduction in pain
125
125. Suppressive therapy
– To control symptoms
Preventive Therapy
– Valacyclovir 500 mg PO QD +
– Counsel on safe sex practices
– Provision of condom for new/uninfected partner
126
128. Non-pharmacologic Rx & related
– Lukewarm baths 3-4 x/days[ease itching & pain]
– Pat dry affected areas
– Wear loose-fitting underwear (aid drying of sore)
– Avoid sexual contact
129
129. Pregnant women[prevention of neonatal infection]
– CS + antiviral therapy
– Acyclovir 200 to 400 mg TID
– [Start at 36/38 weeks‘ gestation continue till delivery]
Neonates
– If s & sxs: fever, poor feeding, lethargy, or seizures
– Disseminated & CNS disease
– Acyclovir 20 mg/kg/day IV in three divided doses x 21 days
– Skin, eyes, & mucous membranes involvement
– Acyclovir 20 mg/kg/day IV in three divided doses x 14 days
130
131. Infection that ascends from the cervix or vagina to involve the
endometrium and/or fallopian tubes.
Inflammatory disorders of the upper female genital tract
Common cause: C. trachomatis & N. gonorrhoeae
Other causes: Anaerobes, enteric Gm(-) rods, & CMV
– Mycoplasma genitalium
– Bacteroides species
– E. coli
– H. influenza
– Streptococcus
132
132. Affects young, sexually active women
– Minority women, with multiple sex partners
US:
– >800,000 cases/year
– Highest in 1st time mothers & teens
133
133. Mov‘t of bacteria from Vagina pass cervix reach internal
reproductive organs.
Bacteria component aid its pathogenesis and cause tissue damage.
– Example: Heat-shock protein & cytotoxins from chylmadia
134
134. Ectopic pregnancy
Infertility (10% to 15% of PID)
Tubo-ovarian abscess
Chronic pelvic pain
Peritonitis and intra-abdominal abscess
135
135. Signs & symptoms
– Uterine tenderness
– Cervical motion tenderness
– Painful urination
– Lower abdominal pain
– Painful intercourse(Dyspareunia)
– Adnexal tenderness
– Fever> 38.3°C (101°F)
– Abnormal cervical or vaginal
discharge (green or yellow)
– Presence of WBC in vaginal secretions
– ↑ESR, ↑CR
136
– Inter-menstrual or post coital
bleeding
– Backache
136. Clinical signs and symptoms
Physical exam
Test for HIV (all women)
Laboratory
– N. gonorrhoeae or C. trachomatis
137