1. What do u know about STis?
Rattiya Techakajornkeart MD.
Bangrak institute, Bureau of AIDS, TB and STIs,
Department of Disease Control, MOPH, Thailand

2. Thailand STIs situation

4. Reported total cases of STIs per 100,000 population by disease,Thailand,2010-2015 (B.E.2553-2558)
23.24
Median 20.65
2553
2554
2555
2556
2557
2558

5. Reported total cases of STIs per 100,000 population by disease,Thailand,2010-2015 (B.E.2553-2558)
Now a day increasing of STIs
2553
2554
2555
2556
2557
2558

6. โรคหนองใน และ ซิฟิลิส ประเทศไทย
ปี จำแนกตามอายุ
15-24
25-34
35-44

7. โรคหนองใน และ ซิฟิลิส ประเทศไทย
ปี จำแนกตามอาชีพ
รับจ้าง
นักเรียน

8. Sexually transmitted infections?

9. STIs
Infections are commonly spread by sex, especially vaginal intercourse, anal sex , neovagina intercourse, oral sex and skin- to skin contact.
Most STIs initially do not cause symptoms.

10. STD VS STIs

11. STD
STIs
The infections are commonly /have a high probability of being spread from person to person through sexual contact.
the infections may not cause any symptoms.
Silent epidemic

12. SEX?

14. STD VS HIV infection
they're three to five times more likely than individuals without STDs to transmit HIV during sexual activity.

15. Is Condom safe to avoid all STD ?

16. No Not 100% Better than nothing.
Condom prevents direct skin to skin contact.
Genital areas not covered by condoms may still be infected e.g. herpes, condyloma.
Condom ≠ safe sex
Condom = safer sex

17. Condoms

18. Female condom and oral dam
Anal sex can use famale condom.

19. Can we use male and female condom together?

21. Causes?

22. Causes of STIs
More than 30 different bacteria, viruses, and parasites can cause STis.
Bacteria chlamydia, gonorrhea, and syphilis
Virus e.g. herpes, HIV/AIDS, and genital warts
Parasite e.g. trichomoniasis

23. STIs Syphilis Gonorrhea Non-gonoccocal urethritis Chancroid LGV Herpes
Trichomoniasis
Wart

24. Syphilis

25. Caused :Treponema pallidum
A Gram-negative, thin, motile, spiral shaped bacterium in the order Spirochaetales.
Incubation period ~3 wk ( 10–90 days )

26. Caused :Treponema pallidum
A Gram-negative, thin, motile, spiral shaped bacterium in the order Spirochaetales.
Incubation period ~3 wk ( 10–90 days )
Transmission mode
1. Sexual contact with infected lesion or body fluid
(most common)
2. Tranplacenta (less common)
3. Blood tranfusion (rare)
4. Accidental inoculation (rare)

27. Manifestations of syphilis
Syphilis has 3 distinct stages
Primary syphilis
Secondary syphilis
Latent stages
Early latent syphilis
Late latent syphilis
Tertiary Syphilis

28. Primary syphilis Principal lesion = Hard chancre
( Hard chancre and regional lymphadenitis )
Principal lesion = Hard chancre
o Syphilitic chancres are indurated
o Painless
o Highly infectious
o Occur anywhere on the body
o Heal in 3-6 weeks.

29. Secondary syphilis Mucous patches Patchy alopecia
Begin 6-8 weeks after the appearance of the initial chancre
- There is a high bacteremia during secondary syphilis
Mucous patches
Patchy alopecia

31. Secondary syphilis

32. Same ?

33. Latent syphilis - Detectable by abnormal serologic test results
- Asymtomatic
Definition: persons with serological evidence for syphilis who have never received treatment for this disease and who have no clinical manifestations are said to have latent syphilis.

34. Latent syphilis Early latent syphilis ( infection onset ≤ 1 yr.)
Late latent syphilis ( infection onset ≥ 1 yr. or unknown duration)
1/3 slowly progress to 3 ° syphilis
The rest remain asymptomatic

35. Tertiary syphilis
years from the acute infection to clinical onset of the late or tertiary stages of disease.
In the preantibiotic era, about one-third of untreated infections were followed by tertiary syphilis.
In the antibiotic era, all but neurosyphilis are now curiosities in the developed world, probably because of the effects of intermittent antibiotics on the development of gummas and cardiovascular disease.

36. http://www. google. co. th/imgres. imgurl=http://jeffreysterlingmd

37. Serology 1. Nontreponemal test :
Use for screening and to follow therapeutic response
- VDRL(Venereal disease research laboratory)
- RPR (rapid plasma reagin)

38. Serology 1. Nontreponemal test :
Use for screening and to follow therapeutic response
- VDRL(Venereal disease research laboratory)
- RPR (rapid plasma reagin)
2. Treponemal tests :
Use to confirm reactive nontreponemal test result
- FTA-ABS (Fluorescent treponemal antibody absorption)
- TPHA (Treponema pallidum haemagglutination)
- CIA (Chemiluminescence immunoassays)

39. Peeling, R. W., & Ye, H. (2004). Diagnostic tools for preventing and managing maternal and congenital syphilis: an overview. 
Bulletin of the World Health Organization, 82(6),

40. - + +/- Contact Primary ( Chancre ) Secondary Early latent Late latent
VDRL/ RPR
FTA - ABS
TPH A - +
+/-
Contact
3 wk.
( 10 – 90 d)
Primary ( Chancre )
3 – 12 wk
Secondary
4 – 12 wk
Early latent
( 1 yr from contact )
Late latent
(≥ 1 yr )
Remission ( 2/3)
Tertiary ( 1/3 )

41. Interpretation of Different Serological Tests in Syphilis
Nontreponemal tests
Treponemal tests
Interpretation + -
Syphilis

42. Benzathine penicillin G 2.4 mu IM
Treatment
Contact
3 wk.
( 10 – 90 d)
Primary ( Chancre )
3 – 12 wk
Early syphilis
Secondary
4 – 12 wk
Early latent
( 1 yr from contact )
Benzathine penicillin G 2.4 mu IM
Late latent
(≥ 1 yr )
Late Syphilis
Remission ( 2/3)
Tertiary ( 1/3 )
Penicillin allergy:

43. Treatment failure in syphilis
New clinical symptom
Titers rise 4-fold
Titers do not decrease 4-fold

44. Special conditions Pregnancy HIV infection Benzathine penicillin G
If penicillin allergy :
HIV infection

45. Follow up F/U VDRL/RPR: 3,6,12,24 m
F/U VDRL/RPR (HIV infection): 3,6,9,12,24 m

46. Gonorrhea

47. Male Genitalia

48. Female Genitalia
Asymptomatic
Leucorrhea (some)
PID

49. Pharyngeal Gonorrhea Relatively common Asymptomatic
Reservoir for infection

50. Rectal Gonorrhea
It is a frequent site of infection in receptive anal intercourse.

51. proctitis Many rectal infections are asymptomatic.
The symptoms of rectal gonococcal infection
Minimal anal pruritus
Painless mucopurulent discharge (often manifested only by a coating of stools with exudate)
Scant rectal bleeding
Proctitis (severe rectal pain, tenesmus, and constipation)
proctitis

52. Gonorrhea conjuctivitis
conjunctivitis

53. Cause : Neisseria gonorrhoeae
Gram stain : Gram-Negative intracellular diplococci OR
Culture : Neisseria gonorrhoeae positive

54. Uncomplicated urogenital, anorectal gonorrhea
Ceftriaxone 250 mg IM
Azithromycin 1 gm or
Doxycycline(100)1*2 for 14 days
Avoid sex at least for 1 week following treatment.

55. Treatment of Pharyngeal Gonorrhea
Ceftriaxone 250 mg IM
and
Azithromycin 1 gm
Providers should ask their patients with urogenital or rectal GC about oral sexual exposure
Sex partener
Antimicrob. Agents Chemother. 2012, 56(7):4039.

56. Non-gonococcal urethritis

57. Male NGU

58. Female NGU
Mucopurulent discharge

59. Proctitis and Conjunctivitis

60. Cause : Not Neisseria gonorrhoeae
Other organism not gonorrhea
- Chlamydia trachomatis (50%)
- Ureaplasma urealyticum (10-40%)
- Mycoplasma genitalium (15-20%)
- Haemophilus vaginalis
- etc.

61. INVESTIGATIONS Gram stain (urethral) : WBC ≥ 5 cells/oil field OR
Mucopurulent discharge from cervix OR
Culture : Chlamydia positive

62. Treatments Azithromycin 1 gm OR Doxycycline (100) 1*2 pc 14 d
Avoid sex at least for 1 week following treatment.

63. WArt

64. Wart HPV type 6,11,16,18 Treatment 80-100%TCA 25% Podophyllin
5% Imiquimod
Electrocuatery

65. Don’t forget Sex partner(s) (60d) Avoid sex during treatment
Avoid alcohol when take doxycycline
Education
Follow up