ATAEI.B, MD. MPH. Sexually Transmitted Infections

 مرد جوانی 4 روز بعد از تماس جنسی مشکوک دچار ضایعه دردناک الت تناسلی می شود د. در معاینه زخم نمای کثیف دارد وبه اسانی خونریزی می نماید. ودر لمس سفتی ندارد. غده لنفاوی بزرگ و دردناک نیز در ناحیه اینگوینال لمس میگردد.  تشخیص بالینی شما چیست؟

 Usual causes  Herpes simplex virus (HSV)  Haemophilus ducreyi (chancroid)

 Herpes confirmed or suspected (history or sign of vesicles):  Treat for genital herpes with :  acyclovir, valacyclovir, or famciclovir

 First episodes:  acyclovir (200 mg 5 times per day or 400 mg tid),  valacyclovir (1 g bid),  famciclovir (250 mg bid) for 7–14 days is effective.

 Chancroid confirmed or suspected (diagnostic test positive, or HSV and syphilis excluded, and lesion persists):  Ciprofloxacin 500 mg PO as single dose or  Ceftriaxone 250 mg IM as single dose or  Azithromycin 1 g PO as single dose

 بیمار 30 ساله ای 3هفته بعد از یک تماس جنسی مشکوک دچار یک پاپول روی دستگاه تناسلی شده است این ضایعه 3 روز بعد تبدیل به اولسر با جدار منظم می شود که بدون درد ودر معاینه سفت است وهمراه با لنفادنوپاتی بدون درد یکطرفه میباشد.  تشخیص بالینی شما چیست؟

 Usual causes  Treponema pallidum (primary syphilis)  lymphogranuloma venereum

 Dark-field exam,  direct FA,  PCR for T. pallidum;  RPR or VDRL test for syphilis (if negative but primary syphilis suspected, repeat in 1 week);

 Syphilis confirmed (dark-field, FA, or PCR showing T. pallidum, or RPR reactive):  Benzathine penicillin 2.4 million units IM once to patient,  Preventive treatment  Recent (e.g., within 3 months)  Seronegative partner(s),  All seropositive partners

Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be examined, tested for urethral or cervical chlamydial infection, and treated with a chlamydia regimen (azithromycin 1 gm orally single dose or doxycycline 100 mg orally twice a day for 7 days).

 جوان 23 ساله ای 4 روز بعد از تماس جنسی مشکوک به علت ترشح از مجرا و سوزش ادرار به مطب شما مراجعه می نماید.  تشخیص بالینی شما چیست؟

 (1) mucopurulent or purulent urethral discharge,  (2) Gram stain of urethral secretions demonstrating 5 or more leukocytes per oil immersion microscopic field, or

 (3) a positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine demonstrating 10 or more leukocytes per high-power field.

 Neisseria gonorrhoeae*  CAUSES OF NONGONOCOCCAL URETHRITIS  Chlamydia trachomatis (15–50%)*  Ureaplasma urealyticum (10–40%)*  Mycoplasma genitalium (30%??)  Trichomonas vaginalis (1–17%)*  Herpes simplex virus (primary) (?%)

Treat chlamydial infection: plusTreat gonorrhea (unless excluded): Azithromycin, 1 g PO; or Ceftriaxone, 125 mg IM; or Doxycycline, 100 mg bid for 7 days Cefpodoxime, 400 mg PO; or Cefixime, 400 mg PO Initial Treatment for Patient and Partners * Epidemiologic treatment of sexual partners is recommended

 Ceftizoxime (500 mg IM, single dose) or  Cefotaxime (500 mg IM, single dose) or  Spectinomycin (2 g IM, single dose) or  Cefotetan (1 g IM, single dose) plus probenecid (1 g PO, single dose) or  Cefoxitin (2 g IM, single dose) plus probenecid (1 g PO, single dose)

male partners should be evaluated and treated with either tinidazole in a single dose of 2 g orally or metronidazole twice a day at 500 mg orally for 7 days.

Recommended Empirical Treatment Mitigating Circumstances Characteristic Pathogens Condition 3-Day regimens: oral TMP-SMX, TMP, quinolone; 7-day regimen: macrocrystalline nitrofurantoin None Escherichia coli, Staphylococcus saprophyticus, Proteus mirabilis, Klebsiella pneumoniae Acute uncomplicated cystitis in women Consider 7-day regimen: oral TMP- SMX, TMP, quinolone Consider 7-day regimen: oral amoxicillin, macrocrystalline nitrofurantoin, cefpodoxime proxetil, or TMP-SMX Diabetes, symptoms for >7 d, recent UTI, use of diaphragm, age >65 years Pregnancy

Recommended Empirical Treatment Mitigating Circumstances Characteristic Pathogens Condition Oral quinolone for 7– 14 d (initial dose given IV if desired); or single- dose ceftriaxone (1 g) or gentamicin (3–5 mg/kg) IV followed by oral TMP-SMX for 14 Mild to moderate illness, no nausea or vomiting; outpatient therapy E. coli, P. mirabilis, S. saprophyticus Acute uncomplicated pyelonephritis in women Parenteral quinolone, gentamicin (± ampicillin), ceftriaxone, or aztreonam until defervescence; then oral quinolone, cephalosporin, or TMP-SMX for 14 d Severe illness or possible urosepsis: hospitalization required

Recommended Empirical Treatment Mitigating Circumstances Characteristic Pathogens Condition Oral quinolone for 10–14 d Mild to moderate illness, no nausea or vomiting: outpatient therapy E. coli, Proteus, Klebsiella, Pseudomonas, Serratia, enterococci, staphylococci Complicated UTI in men and women Parenteral ampicillin and gentamicin, quinolone, ceftriaxone, aztreonam, ticarcillin/clavulanate, or imipenem-cilastatin until defervescence; then oral c quinolone or TMP-SMX for 10– 21 d Severe illness or possible urosepsis: hospitalization required