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SEXUALLY TRASMISSIBLE INFECTION Dr . Esraa AL- Maini

Learn about different types of STIs, their modes of transmission, clinical features, and treatment options. Get insights into prevention strategies and the importance of screening for pregnant women.

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SEXUALLY TRASMISSIBLE INFECTION Dr . Esraa AL- Maini

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  1. SEXUALLY TRASMISSIBLE INFECTIONDr .Esraa AL-Maini Objective: Different types of infection transmitted sexual intercourse Mode of transmission clinical features treatment

  2. Once known as Venereal Diseases (VD) STIs are infections that are transmitted primarily through sexual contact with an infected person. STIs are very common. An estimated 15-16 million new cases occur each year in the U.S. alone. 1 in 4 adolescents will get an STI

  3. Clinical Prevention GuidanceThe prevention and control of STDs are based on the following five major strategies (5):1-accurate risk assessment and education and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services;2-pre-exposure vaccination of persons at risk for vaccine-preventable STDs;3-identification of asymptomatically infected persons and persons with symptoms associated with STDs;4-effective diagnosis, treatment, counseling, and follow up of infected persons and5-evaluation, treatment, and counseling of sex partners of persons who are infected with an STD.

  4. in order to assess the patient it is necessary to find out the following: • When sexual intercourse last took place • Whether this was oral, vaginal • What contraception was used? • When the women last had a different sexual partner • A travel history and knowledge about the origin of partner might indicate risk of tropical infection. • Information about previous pregnancies and menstruation • Enquire about I.V drug use in the patient and her partners • Mix infection possible so full screen should be performed

  5. Partners Need to Be Treated • All partners should be examined and treated

  6. To break the chain of infection and prevent re-infection, it is essential to avoids to intercourse until she is that her partners has been screen and received appropriate treatment • Follow up evaluation and test of cure

  7. STI Pathogens *Not classified as an STI

  8. Every Pregnant women Needs Screening Dr.T.V.Rao MD

  9. Recommended Screening Tests A serologic test for syphilis should be performed for all pregnant women at the first prenatal visit.Women who are at high risk for syphilis or live in areas of high syphilis morbidity should be screened again early in the third trimester (28weeks) and at delivery. Any woman who delivers a stillborn infant should be tested for syphilis. All pregnant women should be routinely tested for hepatitis B surface antigen (HBsAg) at the first prenatal visit even if they have been previously vaccinated or tested

  10. . All pregnant women aged <25 years and older women at increased risk for infection be routinely screened for Chlamydia trachomatis and N. gonorrhoeae at the first prenatal visit . also should be retested during the third trimester to prevent maternal postnatal complications and chlamydial infection in the neonate. Pregnant women found to have chlamydial infection should have a test-of-cure to document chlamydial eradication (preferably by nucleic acid amplification testing [NAAT]) 3–4 weeks after treatment and then retested within 3 months

  11. All pregnant women should be tested for HIV infection during the first prenatal visit. A second test during the third trimester, preferably at <36 weeks' gestation, should be considered for all pregnant women and is recommended for those known to be at high risk for acquiring HIV, importance of retesting during each pregnancy. Women with no prenatal care should be tested for HIV at the time of delivery

  12. Areas of Infection

  13. CHLAMYDIA TRACHOMATIS It is commonest bacterial STD,obligate intracellular bacteria that grows in vitro only in tissue culture infect columnar epithelium of endocervix urethra endometriumfallopain tubes and rectum . This organism can persist for long periods in an asymptomatic carrier state. There s no vaccine available and even though chlamydia antibodies are produced, they do not protect against reinfection.

  14. .Annual screening of all sexually active women aged <25 years is recommended, as is screening of older women at increased risk for infection (e.g., those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection

  15. Screening and opportunistic testing: 1-Partner of the patient diagnosed or suspected with infection 2-History of Chlamydia in the last year 3-Patient attending GUM clinics 4-Patients with two or more partners with in 12monthes 5-Women undergoing termination of pregnancy 6-History of other sexually transmitted infection and HIV

  16. Clinical features: 1-Asymptomatic in 50% of male 2-Or can cause non gonococcalurethritis in male In female 1-Asymptomatic 80%in female 2-Vaginal discharge and lower abdominal pain 3-Postcoital bleeding 4-Intermenstrual bleeding 5-Mucopurulent cervical discharge with contact bleeding 6-Dysuria with urethral discharge

  17. Drips Laboratory Tests for Chlamydia Tissue culture has been the standard Tissue culture expensive not routinely recommended Sensitivity ranges from 60% to 90% Non-amplified tests Enzyme Immunoassay (EIA), e.g. Chlamydiazyme ELISA limited sensitivity samples are collected from the endocervix sensitivity and specificity of 85% and 97% respectively useful for high volume screening false positives 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 need for large amounts of sample DNA

  18. Laboratory Tests DNA amplification assays NAATs that are FDA-cleared for use with vaginal swab specimens can be collected by a provider or self-collected in a clinical setting. 90% sensitive should used replace the old ELIZA -polymerase chain reaction (PCR) -ligase chain reaction (LCR) first void urine vaginal swab NAATs are not FDA-cleared for use with rectal or or opharyngeal swab specimens.

  19. Chlamydia Direct Fluorescent Antibody (DFA) DFA on cx smear, rectal conjunctiva swabs Dr.T.V.Rao MD Source: Centers for Disease Control and Prevention

  20. Chlamydia Symptoms in WomenMucopurulentCervicitis

  21. Antibiotic treatment Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice a day for 7 days  Alternative Regimens Erythromycin base 500 mg orally four times a day for Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days Levofloxacin 500 mg orally once daily for 7 days Ofloxacin 300 mg orally twice a day for 7 days

  22. Although the clinical significance of oropharyngealC. trachomatis infection is unclear and routine oropharyngeal screening for CT is not recommended, available evidence suggests oropharyngealC. trachomatis can be sexually transmitted to genital sites .therefore, detection of C. trachomatis from an oropharyngeal specimen should be treated with azithromycin or doxycycline.

  23. 1-. To minimize disease transmission to sex partners, persons treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen and resolution of symptoms if present. 2-To minimize risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated. 3-Persons who receive a diagnosis of chlamydia should be tested for HIV, GC, and syphilis.p

  24. 4-Test-of-cure to detect therapeutic failure (i.e., repeat testing 3–4 weeks after completing therapy) is not advised unless therapeutic adherence is in question, symptoms persist, or reinfection is suspected If change of partner restarting between 3 to 12 months is recommended

  25. In pregnancy: -PTL -Chorioamnionitis Post partum endometritis -Neonatal conjunctivitis and pneumnia

  26. GONORRHOEA It is the 2nd most common bacterial STI Chronic a symptomatic infection is common. It infect columnar epithelium No vaccine No immunity,even antibodies present

  27. Clinical features: 1-Most of infected female are asymptomatic 2-Increase vaginal discharge with lower abdominal pain 3-dysuria with urethral discharge 4-proctitis with rectal bleeding discharge and pain 5-Endometritis 6-Mucopurluent urethral discharge 7-pelvic tenderness with cervical exittion In male more than 70% have symptoms sever urethritis, green urethral discharge, also cause exudativetonsillitis,conjunctivitis, proctitis in female and homosexual male

  28. DX 1-Demonstrating typical gram –ve intracellular diplococcic (columnar cubical epith) on gram stained smear of end cervical and rectal pharynx swabs if symptomatic infection

  29. Gonorrhea Gram Stain Dr.T.V.Rao MD Source: Cincinnati STD/HIV Prevention Training Center

  30. Culture required co2 7%, blood agar antibiotic to inhibit growth of other bacteria(Thayer-Martin or Transgrow media culture) 2-Nnuclic acid amplification test(NAATs) 3-Nuclic acid hybridization tests 4-Serological test not useful

  31. Treatment: 1-Screen both partners and refer them to genitourinary medicine clinic 2-Counselled regarding the long term implications of infection leading to chronic pelvic pain and tubal infection and subfertilty 1-Azithromycin 1g single dose 2-Amoxycillin 1g +probencid 2g single dose 3-ciprofloxacin 500mg single dose 4- single dose cefixime 400mg Sex partner should screened fully Treat other associated infection Abstinence during treatment at least 7 days ,

  32. in pregnancy it is safe to use Amoxycillin cefixime. • Swabs repeated if; • 1-If there is any doubt of compliance , • 2-if symptoms persistent • 3-suspecions of resistance • Swab should be repeated within week following treatment to check for complete cure

  33. COMPLECATIONS OF CHLAMYDIA AND GC -1-Fitz –hugh –curytis syndromeintra abd spread of GC can cause per appendicitis, per hepatitis patient presented with right hypochondria pain tenderness, pyrexia . Examination: usually sign of salpingitis, laparoscopy (fine violin string adhesions)seen between the liver capsule and visceral peritoneum ,treatment 3weeks antibiotic per hepatitis cured 2-Ritters syndromor sexually acquired reactive arthritis, uveitis and rash 3-PID 4-Adult conjunctivitis

  34. HERPS SIMPLEX VIRUS Incurable STD HSV1 caused oral lesion (cold sores),30% of genital herps HSV2 cause genital lesion and 90%of recurrent genital herps. The ferquency of reurranceis much heigher in type 2 than in type 1 Infection is frequently sub clinical, presentation can occur many years later as newly acquired infection 10-20% of infected person know that they are infected 70% of transmissions are from asymptomatic infected person with no visible lesion

  35. C.F. PRIMARY HERPS • Presents up to 3 weeks after acquisition wide spread lesion involve vulva, vagina ,cx painful vesicles coalesce in to multiple ulcers, per urethral involvement may cause sever pain ,urine retention ,rectal infection after oro genital sex or anal intercourse ,primary pharyngeal. • Systemic symptoms may be also present such as fever,headache ,malaise and lymphadenopathy. • Acute cervicitis may be present.the lesion heal without scarring in 14-21 days

  36. RECURRENT HERPS • After primary herpes, virus colonizes the neuron in the dorsal root ganglia establishing latent infection, intermittent infection when virus particles are produce and tract down the axons to the skin. • Ulcer, vesicles in the same area or area supply by the same dermatome

  37. The clinical diagnosis of genital herpes can be difficult, because the painful multiple vesicular or ulcerative lesions typically associated with HSV are absent in many infected persons. A patient's prognosis and the type of counseling needed depend on the type of genital herpes (HSV-1 or HSV-2) causing the infection; therefore, the clinical diagnosis of genital herpes should be confirmed by type-specific laboratory testing . Both type-specific virologic and type-specific serologic tests for HSV should be available in clinical settings that provide care to persons with or at risk for STDs. Persons with genital herpes should be tested for HIV infection.

  38. Diagnosis Collecting serum from vesicle by syringe Swab the ulcer demonstrating the virus by electron microscopy Tissue culture Serological test differentiated between type 1 and 2

  39. Treatment 1-analgesics 2-bathing in salt and water 3-lignocaine gel to sore area cyclovir 400 mg orally three times a day for 7–10 days Acyclovir 200 mg orally five times a day for 7–10 days Valacyclovir 1 g orally twice a day for 7–10 dayOR Famciclovir 250 mg orally three times a day for 7–10 days * Treatment can be extended if healing is incomplete after 10 days of therapy.

  40. The spectrum of severity varies • 1-asymptomatic shedding of virus • 2-apparently trivial ulcers resembling small abrasion on the vulva, • 3-locolized clusters of vesicles and ulcers over an area 1-2 cm diameter • 4-wide spread or chronic ulceration resembling a primary infection can be seen in pregnant female if a women is immune suppressed, large atypical chronic ulcers may develop • 5-a herpetic ulcer persisting for more than 1 month in ADIS individual DX • Swabbing small ulcer in female if initial swab –ve repeated if ulcer recurs

  41. Recurrent episodesAttack will resolve quickly with out specific treatment keep the area by washing with salt and water to avoid sexual intercourse until fully healed.Antiviral therapy for recurrent genital herpes (6-8 per year) can be administered either: as suppressive therapy to reduce the frequency of recurrences episodically to ameliorate or shorten the duration of lesions

  42. Some persons, including those with mild or infrequent recurrent outbreaks, benefit from antiviral therapy; therefore, options for treatment should be discussed. Many persons prefer suppressive therapy, which has the additional advantage . Safety and efficacy have been documented among patients receiving daily therapy with acyclovir for as long as 6 years and with valacyclovir or famciclovir for 1 year of decreasing the risk for genital HSV-2 transmission to susceptible person.

  43. Recommended Regimens Acyclovir 400 mg orally twice a day Valacyclovir 500 mg orally once a day*(less effective than others with those with infequent recurrences) Valacyclovir 1 g orally once a day Famiciclovir 250 mg orally twice a day somewhat less effective for suppression of viral shedding

  44. Episodic Therapy for Recurrent Genital Herpes Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome that precedes some outbreaks. The patient should be provided with a supply of drug or a prescription for the medication with instructions to initiate treatment immediately when symptoms begin.

  45. Recommended Regimens Acyclovir 400 mg orally three times a day for 5 days Acyclovir 800 mg orally twice a day for 5 days Acyclovir 800 mg orally three times a day for 2 days Valacyclovir 500 mg orally twice a day for 3 days Valacyclovir 1 g orally once a day for 5 daysOR Famciclovir 125 mg orally twice daily for 5 daysOR Famciclovir 1 gram orally twice daily for 1 dayOR Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days

  46. Severe Disease Intravenous (IV) acyclovir therapy should be provided for patients who have severe HSV disease or complications that necessitate hospitalization (e.g.,) or CNS complications (e.g., meningoencephalitis). The recommended regimen is acyclovir 5–10 mg/kg IV every 8 hours for 2–7 days or until clinical improvement is observed, followed by oral antiviral therapy to complete at least 10 days of total therapy. HSV encephalitis requires 21 days of intravenous therapy. Impaired renal function warrants an adjustment in acyclovir dosage.

  47. COMPLECATIONS • 1-Psychological distress • 2-neurological involvement during primary herpes ,aseptic meningitis ,transverse myelitis, autonomic neuropathy 1-2 months resolve.HSV2 cause encephalitis in adult • 3-Herpes keratitis cause corneal scarring blindness • 4-disseminated infection, pneumonitis, or hepatitis

  48. Management of Sex Partners Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital herpes. Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type-specific serologic testing for HSV infection.

  49. very early vulvae affect small area, so antiviral treatment for 5days for all patients presenting with the first attack even if clinical suspicious of 2nd episodes • An infected mother can transmit the virus to her infant during delivery resulting insignificant fetal mortality and morbidity.

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