Review from last lecture Skin Infections: Contrasting Staph aureus with Strep pyogenes Folliculitis, boils and carbuncles Rocky mountain spotted fever (R. rickettsii) Lyme disease (B. burgdorferi) Anthrax (Bacillus anthracis) Bacterial infections of Wounds: Tetanus (C. tetani) Gangrene (C. perfringens) Burn infections (P. auerginosa) Actinomycosis (A. israelii)

Sexually-transmitted Diseases Denise Kirschner,PhD Dept of Micro/Immuno MICRO 532 Nov 29, 2001

Outline Epidemiological principles of STDs UTI/Bladder infections Infections of mucosal surfaces Neisseria gonorrhea and Chlamydia trachomatis Ulcerative Infections Syphilis (T. pallidium) and Chancroid (H. ducreyi)

General uro-genital tract information More female infections that males Urine is sterile Above bladder entrance-sterile, below lots of IM: Lactobacillus, Staphylococcus, Cornybacterium, Haemophilus, Streptococcus, Bacteriodes Urinary tract infections (UTI): More than 100,000 bacteria/ml indicated Bladder infection Catherization is the major cause of infection (usually IM) Intercourse (for women)

Mucosal infections Ulcerative infections Proliferative infections Sexually-transmitted Diseases gonorrhea chlamydia herpes simplex syphilis chancroid LGV papillomavirus Systemic infections HIV hepatitis B

Epidemiologic Principles of STDs

Disease Incidence Prevalence Chlamydia Gonorrhea Papillomavirus Herpes simplex Syphilis (primary) (all stages) HIV Chancroid 4,000,000 1,400, , ,000 50, ,000 70,000 ~4, ,000,000 30,000, ,000 1,500,000 ? Occurrence of STDs in the U.S.

Trends in common STDs Year chlamydia gonorrhea syphilis chancroid Note: 60% of all N. gonorrhea infection are ages 15-24

Determinants of STD Morbidity Rate of transmission Sexual behavior (rate of new partner acquisition) Duration of infectivity

Factors That Affect the Transmission of STDs: Age Gender Genetic susceptibility Sexual practices Contraceptive and "hygienic" practices Circumcision

Determinants of the Duration of Infectivity in STDs Etiologic agent tendency to asymptomatic carriage antimicrobial resistance Access and utilization of the health care system Compliance with therapy Contact tracing

Theoretical Structure of an STD Core Group

PPNG in Colorado Springs, Dec Dec D J F M A M J J A S O N D J F M A M J J A S O N D CASESCASES - not gang-related - gang-related

PPNG Outbreak, Colorado Spgs., cases in a 2-year period Traced to a network of 578 persons 410 (218 males and 192 females) were affiliated with a street gang that moved to the area in May Mean age: females (19.7 yrs); males (21.5 yrs) Prominent behaviors among females: multiple partners, heavy crack use, drugs for sex

CO-INFECTIONS

Relevance of STD Co-infections May identify a core group member i.e., a "sentinel event" STDs increase transmission of HIV ulcerative and mucosal infections only Effect of HIV on expression of STDs accelerates HPV-associated tumors facilitates spread of gonococcus alters the natural course of syphilis Presumptive therapy 80-90% of college men with 1 STD have others (50% with Chlamydia) May identify a core group member i.e., a "sentinel event" STDs increase transmission of HIV ulcerative and mucosal infections only Effect of HIV on expression of STDs accelerates HPV-associated tumors facilitates spread of gonococcus alters the natural course of syphilis Presumptive therapy 80-90% of college men with 1 STD have others (50% with Chlamydia)

Infections of mucosal surfaces

Infections caused by gonococci and chlamydiae urethritis cervicitis epididymitis proctitis pharyngitis eye infection > >> + + +

Epidemiologic characteristics of chlamydial and gonococcal infections GONOCOCCUS CHLAMYDIA PATIENT AGE SEXUAL HISTORY ASX INFECTION (male) ASX INFECTION (female) teenagers > young adults usually acquired from a recent contact ~ 5% of infected males ( higher in some areas) % of infected females teenagers > young adults may have been acquired in the remote past ~ 50% of infected sexual partners ~ 50% of infected sexual partners ASX=asymptomatic

Microbiology of gonorrhea Strict human pathogen Gram-negative diplococcus Adherent- pilus (antigenic variation) IgA protease (cleaves IgA) Oxidase-positive Fastidious growth Modified Thayer-Martin media (VCN)

Virulence determinants of Neisseria gonorrhoeae  pilus colonization factor--> antigenic variation  opa proteins > phase variation  lipooligosaccharide >antigenic variation  IgA1 protease  transferrin/lactoferrin binding proteins  intracellular environment?

Treatment of gonococcal infections PPNG Tetracycline resistance Quinolone resistance Single-dose treatment options for uncomplicated disease: ^5 units of penicillin ^7 units Resistance (R plasmids) PPNG strain PPNG Tetracycline resistance Quinolone resistance Single-dose treatment options for uncomplicated disease: ^5 units of penicillin ^7 units Resistance (R plasmids) PPNG strain

Microbiology of Chlamydia trachomatis Obligate intracellular bacteria Not G+/G- (lacks part of LPS) Complex, 2-stage life cycle Elementary body (spore like) Reticulated body (vegetative like) Treatment: antibiotics: tetracyclines (not penicillin-why?) Obligate intracellular bacteria Not G+/G- (lacks part of LPS) Complex, 2-stage life cycle Elementary body (spore like) Reticulated body (vegetative like) Treatment: antibiotics: tetracyclines (not penicillin-why?)

Chlamydial infections urethritis (NGU) epididymitis proctitis mucopurulent cervicitis pelvic inflammatory disease trachoma (serotypes A-C) LGV (L1, L2, L3)

50-60% of women with infertility have serologic evidence of chlamydia or gonococcus, but no history of symptoms!

Ulcerative infections

Frequency of genital ulcer infections HSV>>syphilis>>chancroid

Distinguishing features of genital ulcers anatomical location multiplicity pain induration

Microbiology of syphilis Treponema pallidum spirochete -- labile spiral bacterium with axial filaments man is the only recognized host non-cultivable Gram-negative like Treponema pallidum spirochete -- labile spiral bacterium with axial filaments man is the only recognized host non-cultivable Gram-negative like

T. pallidum darkfield examination

% reactive cases iary ge

Manifestations of 1° Syphilis Chancre (may be unnoticed) painless, but tender indurated highly contagious rapid dissemination motility of the organism? Congenital MANIFESTATIONS OF SECONDARY SYPHILIS Rash Lesions mucous patches Fever

Natural history of secondary syphilis Secondary infection spontaneous resolution infected without clinical disease tertiary syphilis: Neurosyphilis DTH Organisms rare 1/3

Syphilis- principles of treatment T. pallidum is exquisitely sensitive to penicillin Dosing and penicillin formulation used depends on the stage of the disease

Microbiology of chancroid Haemophilus ducreyi Gram-negative coccobacilli fastidious and labile Diagnosis is usually clinical, by exclusion of other agents of genital ulcers Haemophilus ducreyi Gram-negative coccobacilli fastidious and labile Diagnosis is usually clinical, by exclusion of other agents of genital ulcers

Epidemiology and treatment of chancroid CDC reported a 10-fold increase in incidence from % of patients are co-infected with either HSV or T. pallidum Males >> females Occurs in sustained, urban outbreaks Associated with female commercial sex workers and “sex-for-drugs” trade TREATMENT: sensitive to ceftriaxone or azithromycin in single dose