1. Sexual Transmitted Infections June 2012 Huda Taha SpR

3. Gonorrhoea  Gram negative diplococcus Neisseria gonorrhoeae  Primary sites; mucous membranes of the urethra, endocervix, rectum, pharynx and conjunctiva WWW.BASHH.org

4. Clinical features Men:  Urethral discharge and/ or dysuria within 2–5 days of exposure  Mucopurulent or purulent urethral discharge  Rarely, epididymal tenderness/swelling WWW.BASHH.org

5. Women:  Infection at the endocervix is frequently asymptomatic  Increased or altered vaginal discharge is common  Lower abdominal pain may be present  Urethral infection may cause dysuria but not frequency  Mucopurulent endocervical discharge, easily induced endocervical bleeding  Commonly, no abnormal findings WWW.BASHH.org

6. Complications  Transluminal spread of N.G from the urethra or endocervix/ epididymo-orchitis or prostatitis, and PID  Haematogenous dissemination may also occur from infected mucous membranes to cause skin lesions, arthralgia, arthritis and tenosynovitis (disseminated gonococcal infection) WWW.BASHH.org

7. Diagnosis  Microscopy of Gram-stained genital specimens direct visualization of N.G  Sensitivity (90–95%) in men with urethral discharge, recommended to facilitate immediate diagnosis in symptomatic men  Microscopy is not recommended for urethral smears in women WWW.BASHH.org

8.  Detection of N.G can be achieved by NAATs or culture  NAATs are generally more sensitive than culture  NAATs show high sensitivity (96%) in both symptomatic and asymptomatic infection.  Antimicrobial susceptibility testing WWW.BASHH.org

9. Specimen collection Men:  First pass urine is the preferred sample for NAAT testing  Microscopy and culture require a urethral swab specimen  Rectal and pharyngeal swab specimens should be directed by sexual history, symptoms at these sites WWW.BASHH.org

10. Women;  Vaginal/ endocervical swab specimens are equally sensitive for detecting N.G by NAAT testing  Culture; endocervical and urethral swab specimen for maximum sensitivity  Urine is a suboptimal sample for the detection of N.G in women WWW.BASHH.org

11. Management  Patients; detailed explanation of their condition, long-term implications for the health of themselves and their partner(s).  Clear and accurate written information  Abstain from sexual intercourse, until they and their partner(s) have completed treatment WWW.BASHH.org

12. Treatment  Intracellular Gram-negative diplococci on microscopy of a smear from the genital tract  A positive culture for N. G from any site  A positive NAAT for N. G from any site  Recent sexual partner(s) of confirmed gonococcal infection  Consider offering on epidemiological grounds following sexual assault. WWW.BASHH.org

13.  Ceftriaxone 500 mg IM stat dose with azithromycin1g po ALTERNATIVE REGIMENS  Cefixime 400 mg po  Spectinomycin 2 g IM  Quinolones not recommended, high prevalence of quinolone resistance worldwide. WWW.BASHH.org

14. TREATMENT OF COMPLICATED INFECTIONS Gonococcal PID  Ceftriaxone 500 mg IM, doxycycline 100 mg bd po plus metronidazole 400 mg bd for 14 days Gonococcal epididymo-orchitis  Ceftriaxone 500 mg IM, doxycycline 100 mg for 10–14 days WWW.BASHH.org

15. PREGNANCY AND BREASTFEEDING  Pregnant and breastfeeding women should not be treated with quinolone or tetracycline  Ceftriaxone 500 mg IM stat with Spectinomycin 2 g IM WWW.BASHH.org

16. SEXUAL PARTNERS  Partner notification should be pursued in all patients identified with gonococcal infection Follow up  Confirm compliance with treatment  Ensure resolution of symptoms  Enquire about adverse reactions  Take a sexual history if possibility of reinfection WWW.BASHH.org

20. Genital Herpes Initial episode  First episode HSV-1 or HSV-2 dependent on whether the individual has had prior exposure to the other type, this is further subdivided into:  Primary infection: first infection with either HSV-1 or HSV-2 with no pre-existing antibodies to either type  Non-primary infection: Infection with either HSV-1 or HSV-2 with pre- existing antibodies to the other type WWW.BASHH.org

21. Recurrent episode  Recurrence, due to reactivation of pre-existent HSV-1 or HSV-2 infection after a period of latency Clinical Features  Patient may be asymptomatic, the disease unrecognised  Local symptoms; painful ulceration, dysuria, blistering, ulceration of the external genitalia, tender lymphadenitis  Systemic symptoms; fever and myalgia WWW.BASHH.org

22. Complications  Autonomic neuropathy, resulting in urinary retention  Autoinoculation to fingers and adjacent skin e.g thighs  Aseptic meningitis WWW.BASHH.org

23. Diagnosis  Virus detection and characterization, by direct detection of HSV in genital lesions  Virus typing to differentiate between HSV-1 and HSV-2 in all patients  HSV DNA detection by PCR WWW.BASHH.org

24. Management  Saline bathing/ analgesia  Antiviral drugs; within 5 days of the start of the episode  Aciclovir, 200 mg 5x/d reduce the severity, duration of episodes  Antiviral does not alter the natural history of the disease  Topical agents are less effective than oral agents.  Combined oral and topical treatment is of no benefit WWW.BASHH.org

25. Recurrent Genital Herpes  Self-limiting, minor symptoms  Management made in partnership with the patient  Strategies include o supportive therapy only o episodic antiviral treatments o suppressive antiviral therapy (aciclovir 400mg bd)  The best strategy for managing an individual patient may change over time according to recurrence frequency, symptom severity, and relationship status WWW.BASHH.org

26. Pregnancy  First and second trimester acquisition  First episode HSV has been associated with first trimester miscarriage  Vaginal delivery should be anticipated  Daily suppressive aciclovir from 36 weeks gestation may be considered WWW.BASHH.org

27.  C S; all women presenting with first-episode HSV at delivery, within 6 weeks of the EDD  If VD is unavoidable or mother opts for a NVD, prolonged ROM, invasive procedures to be avoided  IV aciclovir given intraparum to the mother, subsequently to the neonate may be considered  Neonatologists WWW.BASHH.org

28.  Recurrent Genital Herpes  Antiviral treatment is rarely indicated  Symptomatic recurrences during the third trimester; likely to be brief; NVD if no lesions are present at delivery WWW.BASHH.org

31. Chlamydia trachomatis  Most common curable STI in Britain  ~ 5-10% of sexually active women under 24, men 20-24 may be currently infected  Risk factors; age under 25yrs, new sexual partner or >1 sexual partner in the past year  New sexual partner being more important than number of partners and lack of consistent use of condoms WWW.BASHH.org

32. Clinical features  Women  Asymptomatic in approximately 70%  PCB or IMB  Lower abdominal pain  Purulent vaginal discharge  Mucopurulent cervicitis and/or contact bleeding  Dysuria WWW.BASHH.org

33. Men  Asymptomatic in over 50%  Urethral discharge  Dysuria Diagnosis Nucleic Acid Amplification Technique 90-95% sensitive WWW.BASHH.org

34. Treatment  Doxycycline 100mg bd for 7 days OR  Azithromycin 1gm po stat dose Alternative regimens:  Erythromycin 500mg bd for 10-14 days OR  Ofloxacin 200mg bd for 7 days WWW.BASHH.org

35. Pregnancy and breast feeding  Erythromycin 500mg qds for 7 days OR  Amoxicillin 500 mg tds for 7 days OR  Azithromycin 1 gm stat WWW.BASHH.org

37. Syphilis  Infection with the spirochete bacterium Treponema pallidum subsp pallidum. Classificaation Acquired or congenital Acquired syphilis: Early (primary, secondary, early latent < years of infection) Late (late latent>2 years of infection, tertiary including gummatous, cardiovascular and neurological) WWW.BASHH.org

38. Primary syphilis  Painless ulcer ( chancre), regional ymphadenopathy Secondary syphilis  Multisystem involvement first 2 years of infection  Generalized maculo papular rash affecting palms and soles  Condylomata lata, mucocutaneous lesions, generalized lymphadenopathy  Less commonly: patchy alopecia, ant. uveitis, meningitis, cranial nerve palsies, hepatitis, splenomegaly, periosteitis and glomerulonephritis

39. DIAGNOSIS  Hx and examination  Symptoms of early syphilis  Details, previous Rx, blood donation, antenatal screening  Other treponemal infections; yaws, pinta, Hx of living in endemic region  Examination of the genitals, skin, mucosal surfaces and lymph nodes for signs of primary and secondary syphilis  Late and congenital syphilis a thorough clinical examination  Full systems review WWW.BASHH.org

40. DEMONSTRATION OF T. PALLIDUM  Dark ground microscopy  If the initial test is negative repeat daily for three days  PCR  Serological test for syphilis WWW.BASHH.org -

41. Treponemal and non-treponemal  Treponemal tests; look for a direct antigen from the T. P or antibody to it, TPPA  remain in the bloodstream for years post exposure to syphilis  Thus, +ve result for a treponemal test does not necessarily indicate active syphilis infection  Non-treponemal tests; cardiolipin, VDRL; incidental marker, released when treponeme damages cells during infection  +ve non-treponemal tests indicative of an active infection  But a confirmatory test with a treponemal test is required to verify that it is indeed a syphilis infection that is causing elevated cardiolipin levels WWW.BASHH.org

42. Treatment Incubating syphilis/ epidemiological Rx  Benzathine penicillin G 2.4 MU i.m. stat  Doxycycline 100 mg PO b.d. 14 days  Azithromycin 1 g po stat Early syphilis (primary, secondary and early latent)  Benzathine penicillin G 2.4 MU i.m. stat  Procaine penicillin G 600 000 U i.m. 10 days WWW.BASHH.org

43. Alternative regimens  Penicillin allergy or refusing parenteral treatment.  Doxycycline 100 mg po b.d. 14 days  Azithromycin 2 g po stat  Ceftriaxone 500 mg i.m. daily 10 days Late latent, cardiovascular, gummatous syphilis  Benzathine penicillin 2.4 MU i.m. weekly for two weeks (three doses)  Procaine penicillin 600,000 units i.m. o.d. for 17 days WWW.BASHH.org

44. Early syphilis in pregnancy  Benzathine penicillin G 2.4 MU i.m. stat in 1 st & 2ed trimesters  3 rd trimester, 2ed dose Alternative regimens  Amoxycillin 500 mg po q.d.s. plus probenecid 500 mg po q.d.s. 14 days  Ceftriaxone 500 mg i.m. daily 10 days Late syphilis in pregnancy  Manage as in non-pregnant patients but without the use of doxycycline.

45. Follow up  Early syphilis, clinical, serological (VDRL) f u at months 1, 2, 3, 6 and 12, then six monthly until VDRL/RPR negative or serofast  Late syphilis minimum serological f u is three monthly until serofast WWW.BASHH.org

51. Warts  Ano-genital warts are caused by HPV of which over 100 genotypes have been identified  Symptoms  Treatment: Cryotherapy podophyllotoxin Imiquimod Surgical/scissor excision TCA WWW.BASHH.org

54. Vaginal discharge WWW.BASHH.org