Download GTIs - Dr.Amr Nadim

Reproductive Tract Infections
• The relationships of reproductive tract
infections (RTI’s), STDs and sexually
transmitted infections (STI’s)
• “Infection” means the
microorganism in the body
presence
of
a
• “Disease” means the presence of an adverse
bodily state
All infections that occur in the genital
tract are RTI’s, but not all of them are
sexually transmitted
• Although not all infections
result in disease:
– STI’s need to be identified
and treated because they are
capable of ultimately causing
disease, either in the person
infected or in someone who
might be infected by that
person.
The natural protection of the lower genital
tract is provided by several factors
• The integrity of the cell layers of the lower
genital tract:
– The vagina is covered with stratified squamous
epithelium uninterrupted by any opening : the
vaginal skin.
• The thickness of that epithelium is determined by the
balance of the sex hormones.
– In young girls and older women the lining of the vagina is
only few cell layers thick
• The balance between the natural micro-organisms.
– The Normal Vaginal Flora: many micro-organisms living in balance with eachother.
1) The Lactobacillus acidophilus (L. vaginalis, Doderlein's bacilli)
2) Other types of bacterial flora: The cocci belong to the bowel flora and
accepted in a "healthy vaginal environment" (the mixed flora).
3)Other bacteria in the normal flora include Gardnerella vaginalis, E coli and
several anaerobic bacteria, and mycoplasma.
• The acidity of the vagina (pH).
– The vagina usually has an acidic environment (a low pH).
• This is due to the action of the Lactobacillus vaginalis which acts on the glycogen
content of the vaginal cells to produce lactic acid.
• The normal vaginal pH is 3.8-4.2, preventing the overgrowth of bacteria and yeast.
– Conditions that makes the pH of the vagina alkaline: Menstrual flow, certain
infections, and semen.
– "Lactobacillosis": Abnormal condition of too many lactobacilli. Frequently
there are associated symptoms similar to candidiasis (too many is too much).
There is no symptomatic improvement if given treatment of candidiasis.
Normal Vaginal Flora
• 108-109 anaerobes / ml.
• 107-108 aerobes / ml.
–
–
–
–
–
–
–
Corynebacterium
Lactobacilli ( Doderlein)
Staph
Micrococci
Strept Faecalis
Anaerobic Strept.
Candida albicans
84%
82%
66%
37%
34%
22%
17%
The Normal Vaginal Discharge
• Composition:
– Cervical secretions.
– Vaginal secretions as epithelial transudation.
– Epithelial cells.
– Bacterial flora.
• Characters:
– Milky white or mucoid, with specific smell.
– It is not associated with itching or burning.
• The amount of the normal discharge varies according
to time of cycle:
– It increases premenstrual and at mid-cycle when it is watery and may constitute
the ovulatory cascade which is sometimes blood tinged.
– It is scantier immediately postmenstrual and is generally viscid in the second half
of the cycle.
– Personal behavior
• Vulval hypersensitivity: menstrual pads, soaps, synthetic fibers, toilet tissue, and
medications.
• Local contraceptives: Sensitivity may develop to spermicides, or condoms or
diaphragms.
• Fostering of fungal and bacterial growth: Tight, non-porous underclothing or poor
hygiene.
• Leucorrhea is a term used in two ways.
–
Usually it is used to indicate the flow of excessive normal vaginal discharge.
– Sometimes, the term is used to indicate all abnormal vaginal discharge except
when stained with blood.
Candidiasis
Dimorphic organisms
exist in yeast and
mycelial phases.
Candidiasis
• 75%
of women will experience an episode at some time
during their life.
• 1/10 will suffer recurrent attacks
• Genus: Candida
» albicans
»
»
»
»
»
»
tropicalis
pseudotropicalis
stellatoidea
krusei
parapsilosis
guilliermondi
90%
10%
Predisposing Factors:
• Decrease in host local or systemic immunity:
– Pregnancy
– Diabetes Mellitus
– Debilitating diseases: uremia, malignancy
• Broad spectrum antibiotics: disturb normal
flora
• Other genital infections , genital trauma
• Oral Contraceptive Pills
Precipitating Factors:
• Improper genital hygiene:
– Direction of wiping
– Vaginal douching
– Self medications
• Clothing:
– Tight
– Non-absorbent
• Humidity
All dresssed up for candidiasis
Source of Infection
• Endogenous:
75%
– GIT
– Deep layers of vagina where yeast
penetrates and is impervious to topical
treatment.
• Exogenous:
– Male partner
– Instrumental contamination
25%
Clinical picture
• Itching
– more with warmth
– more at night
– causes Dysuria and Dyspareunia
• Discharge
– not a constant feature
– cottage cheese curds
– may be thin, mucopurulent
Clinical Picture
ITCHING
Warmth
Night
Dysuria/Dyspareunia
Diagnosis
• Clinical Features:
Unreliable
• Confirm by microscopy:
– Wet mount + 10-20% K(OH)
• Germinated Filamentous Candida
– Gram stain
Diagnosis
• High Vaginal Swab Culture:
– Sabouraud’s Agar
– Nickerson’s media
– Trichosel broth
Diagnosis
• Slide latex agglutination test
– particles coated with immunoglobulin against cell
wall fragments of candida albicans
• If the patient is symptomatic and wet mounts
and KOH preparations fail to reveal
trichomonads,
bacterial
vaginosis
or
candidiasis, Fungal culture should be done
Treatment
• Success depends upon:
• Identifying Symptomatic women with
definite Candida organisms.
• Correcting the predisposing &
precipitating factors.
• Avoiding short term erratic treatment.
Treatment
• Gentian Violet: Hexamethyl-Pararosaniline
(1%)
– Paint the vulvovaginal area, repeat every 72 h. for
2-3 weeks. ( Friedrich’s technique)
– Allergy (1%), Messy, Office procedure.
– Resistant and recurrent cases respond well
Treatment
• Boric Acid:
– Not commercially available
– Easy produced using size 0 gelatin capsules
and 600 mg of boric acid powder.
– One capsule daily for 14 days
– 100% cure rate immediately, 5%
recurrence in 30 days.
– 90% cure rate in case of Nystatin failure
Treatment
• Azole Compounds:
–
–
–
–
Clotrimazole
Miconazole
Butoconazole
Terconazole
• Non of these compounds are more effective than the
other, nor does any treatment schedule seem superior.
• All exhibit their antifungal action through inhibiting
cytochrome enzymes [C450].
Treatment
Azole Compounds:
• Clotrimazole
– 100 mg x 7
– 200 mg x 3
– 500 mg x 1
• Miconazole
• 100 mg x 7
• 200 mg x 3
• Butoconazole
• 5 gm of 2% cream x 3
• Terconazole
• 80 mg x 3
• 5 gm of 0.4% cream x 7
Treatment
• Nystatin:
– Polyene antibiotic produced by
Streptomyces noursei
– Vaginal supp. 100 000 units / night / 14
nights
– Least active antifungal, poor for recurrent
infection, oral form ineffective to eliminate
rectal reservoir.
Treatment
• Fluconazole:
– Orally absorbed antifungal with a
BISTRIAZOLE structure.
– Less side effects
– Single oral dose = better compliance
– Rapid relieve of symptoms
– Effective elimination of the rectal reservoir
Treatment
• Ketoconazole:
– Orally absorbable IMIDAZOLE
– 400 mg / day x 5 days
– Hepatic toxicity:
• Hepatocellular liver injury 1 in 10 000
• nonprogressive serum transaminase elevation 5%
• REVERSIBLE
• Itraconazole
Trichomoniasis
Etiology/Epidemiology:
Caused by Trichomonos Vaginalis
Women affected more than men
Transmitted sexually and by communal bathes
Clinical Presentation:
• Women: 25% ae asymptomatic
– Discharge, Pruritus, Dysuria, Dyspareunia,
Excoriated vulva, post coital spotting
• Men are in most of the cases asymptomatic
Trichomoniasis
Diagnosis:
Vaginal Discharge is malodorous, yellow-green,
foamy
Excoriated vulva and vagina
Organism apparent on wet mount
Treatment:
Metronidazole 2 gram PO once ( both partners)
Recurrent cases: repeat treatment for 3-5 days
Bacterial Vaginosis
Etiology/Epidemiology:
Overgrowth of vaginal flora with 100 times
increase in Gardenerella vaginalis.
Some women are asymptomatic, others present
with PID
Commenest cause of vaginal discharge
Clinical Picture:
Discharge plus little or no itching or burning.
Bacterial Vaginosis
Diagnosis:
– Whiff test (amine test) with 10% KOH
– Clue cells
– Culture and pH are not helpfull
Treatment:
–
–
–
–
Metronidazole 2 gram orally once
Metronidazole vaginal suppositories over 5 days
Clindamycine orally over 7 days
Clindamycin vaginal cream over 3 days
Genital Herpes
5 H.S.V. particles attacking surface of cell
Genital Herpes
Early HSV
Advanced HSV
Genital Herpes
 Genital herpes affects an estimated 60 million
Americans.
 Approximately 500,000 new cases of this
incurable viral infection develop annually.
 Herpes infections are caused by
herpes simplex virus (HSV).
E-M image of Herpes Simplex viral particle
Genital Herpes
 The major symptoms of herpes infection are
painful blisters or open sores in the genital
area.
 These may be preceded by a tingling or burning
sensation in the legs, buttocks, or genital region.
 The herpes sores usually disappear within two to
three weeks, but the virus remains in the body for
life and the lesions may recur
from time to time.
Genital Herpes
 Severe or frequently recurrent genital herpes
is treated with one of several antiviral drugs
that are available by prescription.
 These drugs help control the symptoms but
do not eliminate the herpes virus from the
body.
 Suppressive antiviral therapy can be used to
prevent occurrences and perhaps
transmission.
Genital Herpes
 Local therapy and Supportive care:
Sitz bath, warm compressants, analgesics for local
relief
 Episodic treatment
Acyclovir: 400 mg x 3 / day for 7 days
Famciclovir: 250 mg x 3 / day for 7 days
Valacyclovir: 1 gram orally twice
 Parentral Therapy:
Acyclovir 5 to 10 mg/Kg three times daily 5-7 days
Genital Herpes
 Women who acquire genital herpes during
pregnancy can transmit the virus to their
babies.
 Untreated HSV infection in newborns can
result in
mental retardation
and death.
Genital Warts
• Genital warts (condylomata acuminata)
are caused by human
papillomavirus, a virus related to the
virus that causes common skin warts.
Genital Warts
• Genital warts usually first appear as small,
hard painless bumps in the vaginal area, on
the cervix, the penis, or around the anus.
Genital Warts
• If untreated, they may grow and
develop a fleshy, cauliflower-like
appearance.
Genital Warts
• Genital warts infect an estimated 1
million Americans each year.
• In addition to genital warts, certain
high-risk types ( 16 & 18) of HPV cause
cervical cancer and other genital
cancers.
Genital Warts
• Genital warts are treated by:
– Topical drug (applied to the skin)
• 25% podophyllin in benzoin
• Trichloroacetic acid and Bichloroacetic acid
• Imiquinod 5% topical cream (Interferon-alpha inducer)
– Freezing , Laser therapy, Electrocautery.
– Injections of a type of interferon.
– If the warts are very large, they can be removed
by surgery
Understanding the basic facts about
STDs
• The ways they are spread
• Their common symptoms
• How they can be treated
Is the first step toward prevention.
Key points
 STDs affect men and women of all
backgrounds and economic levels.
 They are most prevalent among
teenagers and young adults.
 Nearly two-thirds of all STDs occur in
people younger than 25 years of age.
Key points
The incidence of STDs is rising:
– Earlier sexual activity
– Later marriage.
– Divorce is more common.
Key points
 Most of the time, STDs cause no
symptoms, particularly in women.
 When and if symptoms develop, they
may be confused with those of other
diseases not transmitted through
sexual contact.
Key points
 Health problems caused by STDs tend
to be more severe and more frequent
for women than for men.
•
•
•
PID
HPV causes genital warts and cervical and
other genital cancers.
STDs can be passed from a mother to her
baby before, during, or immediately after
birth.
Key points
 When diagnosed and treated early, many
STDs are curable.
 Some infections have become resistant to
the drugs used to treat them and now
require newer types of antibiotics.
 Experts believe that having STDs other than
AIDS increases one's risk for becoming
infected with the AIDS virus.
Pelvic inflammatory disease
(PID)
• Clinical syndrome resulting from the ascending spread of
microorganisms from the vagina and endocervix to the
endometrium, the fallopian tubes and/or to contiguous
structures .
Pelvic Inflammatory Disease
PID…A neglected Issue
• Low disease awareness
• Sub-optimal management
– 50% named correct antibiotic regimen
– < 25% examined the sexual partners
A National Audit of PID Diagnosis &
Management in GP: England and Wales
Int. J STD AIDS 2000 Jul;11(7):440-4
WHAT YOU SHOULD KNOW ABOUT
IT…
• What is Pelvic Inflammatory
Disease?
• Why is it important to treat timely?
• Causative factors and
transmission?
• How does the patient present?
• Treatment Plan?
– Drug therapies
– Surgical procedures
Why Should it be treated?
•
•
•
•
Systemic upset / Tubo-ovarian abscess
Chronic Pain (15-20 %)→ Hysterectomy
Ectopic pregnancy (6-10 fold)
Infertility (Tubal):
– 20% ~ 2 episodes
– 40% ~ 3 episodes
• Recurrence (25%)
• Male genital disease (25%)
• Cancer Cervix/ Ovarian Cancer ?
Definition
• Acute or Chronic Inflammatory
disorders of the female upper genital
tract
–
–
–
–
–
–
Endometritis
Parametritis
Salpingitis
Oophoritis
Tubo-ovarian abscess
Pelvic peritonitis
Typical Presentation-Acute PID:
Non specific (40-70%)
• Dull, continuous, bilateral lower abdominal
and/or pelvic pain
– Indolent to severe
– Cervical tenderness on moving the cervix
• Other
–
–
–
–
–
Fever, Tachycardia
Vomiting
Abnormal vaginal discharge
Irregular bleeding
Tubo-ovarian mass
• Asymptomatic!!!
Chronic PID
•
•
•
•
•
•
•
•
Chronic lower abdominal pain, Backache
General malaise & fatigue
Deep dyspareunia, Dysmennorhea
Intermittent offensive vaginal discharge
Irregular menstrual periods
Lower abdominal/ pelvic tenderness
Bulky, tender uterus
Infertility ( “Silent epidemic” )
Epidemiology (USA)
• 70% of females with PID are <25 years old.
• Adolescents age 15-19 have highest
incidence:
– 15 y.o. 1 in 8
– 16 y.o. 1 in 10
– 24 y.o. 1 in 80
• Affects 1 million women annually
Etiology
• POLYMICROBIAL
• Chlamydia trachomatis
• Neisseria gonorrhea
• Anaerobes
– Bacteroides, Peptostreptococcus, Peptococcus
• Facultative organisms
– Gardnerella, Streptococcus, E. Coli
• May involve Chlamydia, Neisseria, both or
neither
Pathogenesis
•
•
•
•
Infected cervix with ascending infection
Lymphatic drainage with parametrial spread
Bacterial adherence to sperm
Neisseria and Chlamydia may initiate
changes
– invasion by other organisms
Risk Factors
•
•
•
•
•
•
•
Infection with Neisseria or Chlamydia
Previous episodes of PID
Sexual behavior (multiple partners)
Age
Menstrual cycle influences
Contraceptive choices
Douching
Risk Factors: Age
• Teenagers have highest risk based on:
– Cervical ectropion
• bacteria adhere to columnar epithelial cells
– Low prevalence of protective antibodies
– Greater penetrability of cervical mucus
– Risky sexual behavior
Risk Factors: Menstrual Cycle
• Symptoms of PID usually present within first
7 days of menstrual cycle
• Due to transmission of organisms from cervix
to upper genital tract during menses
– Cervical mucus acts as mechanical barrier; lost during
menses
– Bacteriostatic effect of cervical mucus lowest at onset
of menses
– Retrograde menstruation
• bacteria from endometrium to fallopian tubes
• Frequent High-jet vaginal Douching
Risk Factors: Contraception
• Barrier methods reduce risk for PID
– condoms, spermicides, diaphragms
• IUD’s increase risk for PID
– Risk highest for 4 months after placement
– This NO more holds true
• Oral contraceptives decrease risk for
symptomatic PID
– Protective changes in cervical mucus
– Diminished menstrual flow, less retrograde flow
– BUT: Induces and supports formation of ectropion
Diagnosis
• Laparoscopy is gold standard
• BUT…Usually a clinical diagnosis
– Speculum and bimanual exam are key
– Cervical cultures
• Cultures positive for C. trachomatis and N. gonorrhea
support put do not confirm the diagnosis of PID
Other things to do…
• U/S
– Rules out other pelvic pathology and appy
• Urine HCG
– r/o ectopic pregnancy
• UA and culture
CDC criteria for diagnosis (2002)
• Minimum criteria
– Lower abdominal tenderness
– Adnexal tenderness
AND
– Cervical motion tenderness
With NO other apparent cause…
You Should put it in mind in order to
diagnose it
Supportive criteria (CDC,
2002)
•
•
•
•
•
Temp > 38.3°C
Abnormal cervical/vaginal discharge
High ESR
High C-reactive Protein
Culture positive cervicitis
– Negative cultures do NOT rule out PID
Definitive CDC Criteria
• Endometrial biopsy with histopathology
evidence of endometritis
• TVS/ MRI: Thickened fluid filled tubes/
• Free pelvic fluid / tubo-ovarian complex
• Laparoscopic abnormalities consistent
with PID
Endometritis (thickened heterogenous endometrium)
Hydrosalpinx (anechoic tubular structure)
Hydrosalpinx.
Pyosalpinx (tubular structure with debris in adnexa
Tuboovarian abscess resulting from tuberculosis
Right hydrosalpinx with an occluded left fallopian tube
• The violin strings of
the FHC syndrome
Management Issues
• Inpatient vs. outpatient management ?
• Broad-spectrum antibiotic therapy without
microbiological findings
vs.
•
•
•
•
Antibiotic treatment adapted to the
microbiological agent identified ?
Oral vs. Parenteral therapy?
Duration of the treatment ?
Associated treatment ?
Prevention of re-infection ?
To admit or not to admit…
• Patients should be treated IV if:
– Surgical emergency cannot be excluded
• Abscess, ectopic, appy
– Questions of compliance
• Every single adolescent???
–
–
–
–
Severe illness
Immunodeficiency
Pregnancy
Failure of outpatient management
• 48 hours, if not responded, r/o abscess
Antibiotic Regimens (CDC, 2002)
• Parenteral regimen A
– Cefoxitin 2 g IV q 6h / cefotetan 2 g IV q 12h
+ Doxycycline 100 mg PO/IV q12h
+ Metronidazole or Clindamycin (TO abscess)
•
Parenteral regimen B
– Clindamycin 900 mg IV q 8h
+ Gentamicin Loading dose 2 mg/kg IV/IM,
maintenance 1.5 mg/kg IV/ IM q 8h
Alternative Regimens (CDC,2002)
Ofloxacin 400 mg IV q 12 hours
or
Levofloxacin 500 mg IV once daily
WITH OR WITHOUT
Metronidazole 500 mg IV q 8 hours
or
Ampicillin/Sulbactam 3 g IV q 6 hrs
PLUS
Doxycycline 100 mg orally/ IV q 12 hrs
Outpatient Therapy (A)
Ofloxacin 400 mg twice daily for 14
days
or
Levofloxacin 500 mg once daily for
14 days
WITH OR WITHOUT
Metronidazole 500 mg twice daily for
14 days
Outpatient Regimen (B)
• Ceftriaxone 250 mg IM once
OR
•
Cefoxitin 2 g IM ē probenecid 1 g PO once
+Doxycycline 100 mg PO bid for 14
• WITH OR WITHOUT Metronidazole 500 mg BD
x 14 d
Other things to think about
•
•
•
•
•
•
Hep B immunization
Treat the partner(s)
Test for syphilis and HIV
Follow-up culture for ‘proof of cure’
Pap smear
Re-education regarding contraception
and protection from STDs
Oral Versus Parentral
• No efficacy data compare parenteral
with oral regimens
• Clinical experience should guide
decisions reg. transition to oral therapy
• Until regimens that do not adequately
cover anaerobes have been
demonstrated to prevent sequelae as
successfully as
regimens active
against these microbes, anaerobic
coverage should be provided
When Should Treatment Be Stopped?
• Parenteral changed to oral therapy after
72 hrs, if substantial clinical improvement
• Continue Oral therapy until clinical &
biological signs (leukocytosis, ESR, CRP)
disappear or for at least 14 days
• If no improvement, additional diagnostic
tests/ surgical intervention for pelvic mass/
abscess rupture
Additional Measures
•
•
•
•
•
•
Rest at the hospital or at home
Sexual abstinence until cure is achieved
Anti-inflammatory treatment
Dexamethasone 3 tablets of 0.5 mg a day
or Non steroidal anti-inflammatory drugs
COCs: contraceptive effect + protection of
the ovaries against a peritoneal
inflammatory reaction + cervical mucus
induced by OP has preventive effect
against re-infection.
Surgery
• Acute PID
–
- Ruptured abscess
–
- Failed response to medical treatment
–
- Uncertain diagnosis
• Chronic PID
–
- Severe, progressive pelvic pain
–
- Repeated exacerbations of PID
–
- Bilateral abscesses / > 8 cm. diameter
–
- Bilateral uretral obstruction
Timing, Type and Extent…
• Timing of Surgery
– No improvement within 24-72 hours
– Quiescent (2-3 months after acute stage)
• Type of Surgery
– Colpotomy
– Percutaneus drainage/ aspiration
– Exploratory Laparotomy
•
Extent of Surgery
– Conservation if fertility desired
– U/L or B/L S.Ophrectomy ē/ š subtotal/ TAH
• Drainage of abscess at laporortomy
• Identification of ureters
Ruptured Pelvic Abcess
•
•
•
•
•
•
Generalized Septic Peritonitis
↑ absorption of bacterial endotoxins
↑ fluid from inflamed peritoneal surfaces
Fluid shift intravascular to interstitial
spaces
Hypovolemia, ↓ CO, VC, ↑ PR
↓ tissue perfusion, ARDS, hyoxemia
Multi-organ system failure
A life-threatening Condirtion
Ruptured Tubo-ovarian Abcess
• Pre-Operative
– Rapid/ adequate metabolic/hemodynamic
preparation
– Blood chemistry, CVP monitoring, ABG
– X-match blood, IV fluids, aggressive antibiotics
• Operative Management
–
–
–
–
Technical difficulties
Aggressive lavage of peritoneal cavity
Exploration for sub-diaphragmatic collection
Closed suction drain
• Post- Operative
– Shock, infection, ileus, fluid balance
Long-term complications
• 25% with PID
• More common in
adolescents
– delay in seeking treatment
• Infertility
– 1st episode 20%
– >3 episodes 50-80%
•
•
•
•
•
•
•
Ectopic pregnancy
Chronic abd pain
TOA
Pyosalpinx
Pelvic adhesions
Dsypareunia
Fitz-Hugh Curtis
Fitz-Hugh Curtis Syndrome
• Acute perihepatitis
• Direct extension from fallopian tube to
liver capsule and peritoneum
• ‘violin strings’ appearance
• Presents with RUQ pain
Any questions..?
Well… I have some
Most common etiologies of
PID
• POLYMICROBIAL
• Neisseria
• Gonorrhea
• Anaerobes
• Enteric gram negatives
3 complications of PID
• INFERTILITY
• Ectopic pregnancy
• Chronic abdominal pain
• Dyspareunia
• adhesions
QOD
• A sexually active 15 year old girl complains of
lower abdominal pain.
• Which of the following clinical findings would be
MOST suggestive of a diagnosis of pelvic
inflammatory disease?
A.
B.
C.
D.
E.
Cervical motion tenderness
Fever > 38oC
Palpable adnexal mass
Purulent cervical discharge
Unilateral adnexal tenderness
QOD#2
• A 15 year old girl has lower abd pain. Findings include
guarding and tenderness to palpation of the abdomen,
mucopurulent discharge from the cervical os, pain on cervical
motion, and adnexal tenderness. You suspect PID and begin
treatment. Two days later she still complains of severe lower
abd pain.
• Which of the following studies would be MOST helpful in the
management of this patient? A. Abd U/S
B.
C.
D.
E.
Blood culture
ESR
Pap smear
WBC count
PID
Infertility
STDs
Chlamydial Infection
The Organism
Infected cells
(Gene probe images)
Chlamydial Infection
The most common of all STDs, with an
estimated 4 to 8 million new cases
occurring each year.
In both men and women, chlamydial infection
may cause an abnormal genital discharge
and burning micturition.
Chlamydial Infection
In women, untreated chlamydial infection
may lead to pelvic inflammatory
disease, one of the most common
causes of ectopic pregnancy and
infertility in women.
Many people (80%) with chlamydial
infection have few or no symptoms of
infection.
Chlamydial Infection
Chlamydial Infection
Chlamydial Infection
DIAGNOSIS:
Cell culture
ELISA
DNA probe
Direct immunofluorescent antibody slide staining
Clinically:
85% of women with a Hypertrophic cervical eversion and
yellow mucopurulent discharge test +ve to
C.Trachomatis
Chlamydial Infection
Chlamydial Infection
Checking for
WBC’s in cervical
Discharge
Electron Microscopic Image
of Infected cell
Chlamydial Infection
• TREATMENT:
– Non Pregnant Women:
•
•
•
•
•
•
Azithromycin 1 gram PO x 1 dose
Azrolid (Amerya) [Tablet form] 18 LE
Doxycycline 100 mg PO BID x 7 days
Erythromycine base 500 mg PO QID x 7 days
Erythromycine ethylsuccinate 800 mg PO QID x 7 days
Ofloxacin 300 mg PO BID x 7 days
– Pregnant Women:
• Erythromycine base 500 mg PO QID x 7 days
• Amoxicillin 500 mg PO TID x 7 days
Prevention of STD’s
Prevention of STD’s
• The best way to prevent STDs is to
avoid sexual contact with others.
• If you decide to be sexually active,
there are things that you can do to
reduce your risk of developing an STD.
HIV Infection and AIDS
HIV viral
particle
HIV Infection and AIDS
AIDS (acquired immunodeficiency syndrome)
was first reported in the United States in
1981.
It is caused by the human immunodeficiency
virus (HIV), a virus that destroys the body's
ability to fight off infection.
An estimated 900,000 people in the United
States are currently infected with HIV.
People who have AIDS are very susceptible to
many opportunistic infections, and to certain
forms of cancer.
HIV Infection and AIDS
Transmission of the virus occurs
during
• sexual activity sharing needles
used to inject intravenous drugs
• transplacental.
HIV Infection and AIDS
Primary stage:
Average 14 weeks after exposure:
Self-limited, febrile, non-specific illness.
After this, the condition remains silent for variable
durations despite viral replication.
The virus is sequestered in a variety of organs while the
amount of measurable free virus in the blood stream
may decrease.
Abnormal laboratory values associated with immune
dysfunction: lymphocytopenia with CD4+ cell
depletion, thrombocytopenia, neutropenia.
HIV Infection and AIDS
T-lymphocyte
attacked by
HIV virus
HIV Infection and AIDS
AIDS
The last stage of the disease.
The absolute CD4+ count is less than 200
Acquiring any of the following (Key) illnesses:
Pneumocystis carinii pneumonia.
Disseminated viral, fungal, protozoa or helminthes infections.
Atypical malignancies as Kaposi’s sarcoma, non-Hodgkin
lymphoma, primary brain lymphoma.
Dementia, inexorable weight loss, persistent intractable diarrhea
Invasive cervical cancer, persistent vulvovaginal candidiasis and
PID
Gonorrhea
• Approximately 400,000 cases of gonorrhea
are reported to the U.S. Centers for Disease
Control and Prevention (CDC) each year in
the USA.
Gram negative diplococci
N. gonorrhoeae
Gonorrhea
• The most common symptoms of gonorrhea
are a discharge from the vagina or penis and
painful or difficult urination.
Gonorrhea
• The most common and serious
complications occur in women and, as
with
chlamydial
infection,
these
complications include PID, ectopic
pregnancy, and infertility.
Gonorrhea
• Historically, penicillin has been used to treat
gonorrhea, but in the last decade, four types of
antibiotic resistance have emerged:
– Penicillinase producing N. gonorrhoea (PPNG).
– Plasmid mediated tetracycline resistant
N.gonorrhoea.
– Chromosome mediated tetracycline resistant
N.gonorrhoea.
– Fluoroquinolone resistant N. gonorrhoea .
Gonorrhea
• Recommended Therapy:
– Ceftriaxone 125 mg IM x 1 dose
– Ciprofloxacin 500 mg PO x 1 dose
– Ofloxacin 400 mg PO x 1 dose
• Disseminated Infection:
–
–
–
–
Ceftriaxone 1 g IM or IV qid
Cefotaxime 1 g IV q 8hrs
Ciprofloxacine 500 mg IV q 12 hrs
Spectinomycin 2 gm IM q 12 hrs.
Syphilis
• The incidence of syphilis has increased
and decreased dramatically in recent
years, with more than 11,000 cases
reported in 1996.
Syphilis
• The initial symptom is a chancre; it is usually a
painless open sore that usually appears on the
penis or around or in the vagina. It can also
occur near the mouth, anus, or on the hands.
Syphilis
• If untreated, syphilis may go on to more
advanced stages, including a transient rash
and, eventually, serious involvement of the
heart and central nervous system.
Syphilis
• Diagnosis:
– Dark field Examination revealing Spirochetes
– Serologic Methods:
• Non Treponemal: Detecting cardiolipin
– Venereal Disease Research Laboratory
– Rapid Plasma Reagin Circle Card Test
• Treponemal:
– Flourescent Treponemal Antibody Absorption Test
– MicroHemAgglutination –T.pallidum Test
Syphilis
• Penicillin remains the most effective
drug to treat people with syphilis.
– Benzathine Penicillin 2.4 M Unit IM single
dose.
– Doxycycline 100 mg PO twice daily 2
weeks.
Other STDs
• Other diseases that may be sexually
transmitted include:
– Trichomoniasis.
– Bacterial vaginosis.
– Cytomegalovirus infections.
– Scabies.
– Pubic lice.
Prevention of STD’s
Have a mutually monogamous sexual
relationship with an uninfected partner.
Prevention of STD’s
Correctly and consistently use a male or
female condom.
Prevention of STD’s
Use clean needles if injecting intravenous
drugs.
Disinfection
Decontamination
Cleaning
High level disinfection
Sterilization
Antisepsis
Prevention of STD’s
RELIGION
EDUCATION
SCREENING