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Similar a management of common STIs at primary care level.pptx
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management of common STIs at primary care level.pptx
- 1. MANAGEMENT OF COMMON STIs AT PRIMARY CARE LEVEL
- 2. How do they present? • Genital ulceration • Urethral discharge • Vaginal discharge Common presentation • Genital growth • Dysuria or urinary retention • Testicular pain or swelling • Rectal pain or discharge • Abdominal pain • ** Serology Others
- 3. History • Ensure privacy • Least sensitive questions & proceed to sexual behaviours & substance used • Signs & symptoms & duration • Direct questioning on discharge, genital ulcer, micturation, eye discharge, skin rashes, joint pain, low backache
- 4. History Sexual history * • Non-judgmental, friendly, comfortable Assure confidentiality • Practices • (Heterosexual /homosexual, oral-genital or ano- genital) • Partners (Recent / previous 1-4 months, marital status) • Protection (Safe sex) • Pregnancy prevention (Use of contraception) • Past STDs – 5 “P”
- 5. History • Drug history - Recent anti-microbial therapy - Previous penicillin treatment - Drug allergy • Past medical history - Pre-existing medical conditions - Occupational & social history • Female patients - (Contraception, menstrual, obs & gynae history)
- 6. Physical examination • Privacy for patients • Good light source Two essentials • Eye, mouth, skin, joints, lymph nodes. • Liver & spleen General examination Genitalia, perianal and inguinal region exposed & examined
- 7. Investigation s • Urethral discharge (Male) – Gram stain (glass slide) – Chocolate agar plate for C&S – Thayer Martin Media (TMM) for gonorrhoea – 2 glass urine test • Anterior & posterior urethritis
- 8. Investigations • Vaginal discharge – Gram stain (glass slide) – Chocolate agar plate for C&S – Thayer Martin Media (TMM) for gonorrhoea – Sabouraud’s medium for monilia – Hanging drop of Trichomonas Vaginalis
- 9. Investigations • Gram stain (glass slide) • Chocolate agar plate for C&S • Dark Ground examination (DGE) • Giemsa stain for multinucleated giant cell or • Donovon bodies Genital ulcer (s)
- 10. Investigations Perianal & protoscopic exam for homosexual patients or patients with rectal symptoms Throat swab or rectal swab
- 11. Diagnosis • All pts with STD should be screened for other STDs – Often polymicrobial in etiology (6/10) – Syphilis, HIV & Hepatitis B/C
- 12. Treatment Appropriate anti-microbial • Prevention of disease transmission • Educated on the diagnosis, purpose & method of treatment, necessity to complete treatment regime & to report any side effects if any • Important of follow up for test of cure • Important of sex avoidance until cured Assurance & counseling
- 13. Treatment • Prevention of further infection • Abstinence or avoidance • Use of condoms or others prophylactic barrier • Seek medical attention if any symptoms • Should not self medicate or seek treatment from unqualified persons • Notification • (HIV/AIDS, Syphilis, Gonorrhea, Chancroid) • Ensure follow-up
- 14. Genital ulcers Diseases Organisms Syphilis Treponema pallidum Chancroid Haemophilus ducreyi Lymphogranuloma Venereum (LGV) Chlamydia trachomatis Granuloma inguinale (GI) Calymmatobacterium granulomatis Herpes genitalis Herpes Simplex virus
- 15. Syphilis the great imitator
- 17. Primary syphilis Chancre •Painless indurated •Clean base rolled edge Kissing ulcers
- 18. A chancre also may occur on lips, tongue, tonsils, anus, or other skin areas
- 19. Secondary syphilis Macular, papular, pustular maculopapular, nodular annular, follicular rashes Gen. rash affecting palms & soles Symmetrical, +/- pruritus
- 20. Papulosquamous
- 21. Pustular
- 23. Snail tract ulcer on buccal mucosa Painless mucous patches on tongue Patchy alopecia Condyloma lata; flat warty, infectious
- 24. Secondary syphilis • Other presentations – Ant. uveitis, cranial nerve (optic neuritis), meningitis, retinitis, laryngitis – Hepatospenomegaly, hepatitis, glomerulonephritis, periosteitis
- 25. Latent syphilis • Stage in which there is a positive serological test for syphilis in the absence of any clinical disease symptoms. • Early latent - First 2 yr. of infection (infectious ) • Late latent - Infection is >2 yr. duration - Non-infectious, but can be transmitted by a pregnant woman to her fetus
- 26. Tertiary or Late Syphilis • Non-contagious but highly destructive phase of syphilis which may take many years to develop • Several forms – Late benign or gummatous syphilis – Cardiovascular syphilis – Neurosyphilis
- 27. Gummatous syphilis • Gumma are nodular lesions characterized by a granulomatous inflammation • May be in any organ • (hepatosplenomegaly, snooker ball testis, ulcers, perforation/collapse of palate & nasal septum)
- 28. • Gummas are highly destructive lesions, necrotizing granulomas with numerous lymphocytes, giant cells, and epithelioid cells, but few treponemes.
- 29. Cardiovascular syphilis • Aortitis manifested by ―Aortic regurgitation ―Aneurysm ―Obstruction of the coronary ostia • Linear calcification of aortic arch
- 30. Neurosyphilis • Stroke syndrome & cranial palsies • Dementia, convulsion, bilateral UMN signs rarely delusion of grandeur • Tabes dorsalis • Dorsal column leads to loss of proprioception, ataxic gate • Loss of deep pain & tendon reflexes Presentation
- 31. Neurosyphilis • Argyll Robertson pupils (small, irregular pupils, non- reactive to light but accommodate reflex +) • Optic atrophy, bilateral ptosis, frontalis overcompensation
- 32. Diagnosis of syphilis 1. Evaluation of presenting signs & symptoms as well as contact history 2. Darkfield examination of exudative material in syphilitic lesions 3. Serological testings
- 33. Diagnosis of syphilis 3. Serological approaches Non-treponemal tests • (Non-specific anti-lipoidal antibodies) • Venereal Disease Research Laboratory, VDRL • Rapid plasma reagin, RPR Treponemal-specific tests • (Detect antibodies to antigenic components of T. pallidum) • T. Pallidum hemagglutination, TPHA • Fluorescent treponemal antibody absorption, • FTA-abs • T. Pallidum particle agglutination, TPPA
- 34. Non-treponemal tests (VDRL, RPR) • Biological false positive (BFP) – In 3% to 40% in these conditions • Pregnancy • Acute febrile illness, acute malaria, leptospirosis, viral pneumonia, infectious mononucleosis • TB, leprosy • Autoimmune disorders (RA, lupus) • Narcotics addiction – 1-2% of healthy individuals
- 35. Non-treponemal tests (VDRL, RPR) • Titers fall & eventually become non-reactive • Some persistent low-level positive (serofast reaction) • Four fold or greater rise in titers is indicative of re- infection (e.g, from 1:8 --- 1:32) • Persistence in moderate or high titer reflects continuing infection (VDRL / RPR >= 1:16)
- 36. Treponemal- specific tests (TPHA) • To confirm the diagnosis of syphilis in patients with reactive non-treponemal tests • Have poor prognostic value • Titers do not correlate with disease activity & should not be used to assess treatment response
- 37. Management • Benzathine penicillin G 2.4 mega units IM weekly x 1 week • Procaine penicillin 600mg IM daily x 10 days Primary, secondary & early latent syphilis • Benzathine penicillin G 2.4 mega units IM weekly x 3 week • Procaine penicillin 600 mg IM daily x 17 days Late latent or Latent Syphilis of Unknown Duration • As late latent Tertiary Syphilis (gumma & cardiovascular syphilis but not neurosyphilis)
- 38. Treatment failure or reinfection • Signs & symptoms persist or recur • 4 folds increase in non- treponemal test titer • Failure of 4 folds decrease after one year of treatment
- 39. Genital Herpes • Commonest cause of genital ulcer • Caused by HSV 2 (20% HSV 1) • Only 20% have clinical symptoms • Latent infection with tendency for recurrences • Lifelong infection
- 40. Papules, vesicles on an erythematous base, erosions. Vesicles uniform in size, with central umbilications. The lesions crust then reepithelialize, heal without scarring.
- 42. Primary Herpes genitalis • Severe blistering & ulceration of external genitalia (+- cervix & rectum) • Pain, dysuria, discharge • Local LN enlargement • Systemic symptoms • Urinary retention • Ulcerations peak in 10-12 days, heal 3-4 wks
- 43. Recurrent genital herpes • Less severe symptoms • Rapid involution • Prodrome • Trigger factors • More common with HSV 2
- 44. Diagnosis Tzanck smear : smear from base of erosion for giant cells Viral culture : gold standard Polymerase chain reaction (PCR) Antigen detection : Immunofluorescence Type specific serology
- 45. Management • Supportive therapy: Saline / KMNO4, topical antibiotics & analgesics • Antiviral therapy - Acyclovir 200mg 5x/day for 5 days or 400mg tds for 1week • Counselling :Natural history, Sexual and neonatal transmission, pregnancies,
- 46. Urethral discharge Diseases Organisms Gonorrhoea Neisseria gonorrhoeae Non-gonococcal urethritis Chlamydia trachomatis** (Serovars D to K) Ureaplasma urealyticum Trichomonas vaginalis/ Herpes simplex
- 47. Vaginal discharge Diseases Organisms Gonorrhoea Neisseria gonorrhoeae Chlamydia trachomatis infection Chlamydia trachomatis** (Serovars D to K) Bacterial vaginosis Haemophilus, Gardnerella vaginalis Trichomoniasis Trichomonas vaginalis Candidiasis Candida Albicans
- 48. Gonorrhoea Incubation period: 2-5 (10) days • Scant/mucoid to copious/ purulent discharge +/- dysuria Male • Mucopurulent cervicitis & vaginal discharge • 70% of cervical infection is asymptomatic Female
- 49. Diagnosis • Direct smear by gram stain – Gram negative diplococci intracellular & extracellular • Culture – Specimen best inoculated immediately – Medium used • Thayer Martin Media OR • New York Modified Media • Chocolate Agar
- 50. Gonorrhoea- Complications • Male – Epidydymitis, orchitis, tysonitis, – Periurethral abscess, prostatitis, penile edema • Female – Bartholinitis, endometritis – Salpingitis 🡪 peritonitis & tubo-ovarian abscess 🡪 infertility
- 51. Gonorrhoea-complications • Both: Urethral stricture & HIV transmission • Disseminated infection (hematogenous) - (Septicaemia, arthritis, dermatitis, endocarditis*, meningitis*) • Distal extremities (papules/petechiae rare microseptic pustular infarcts; < 5-6 lesions Gonococcal ophthalmia neonatorum Rash- disseminated arthritis
- 52. Gonorrhoea – treatment • Anogenital gonorrhoea – Ceftriaxone 500mg IM stat – Cefixime 400mg PO stat – Cefotaxime 500mg IM stat – Spectinomycin 2g IM stat • Pt with B-lactam allergy - Recommended regimen: - Spectinomycin 2gm IM
- 53. • Disseminated Gonococcal Infection - Ceftriaxone 1gm IM or IV every 24 hours or - Cefotaxime 1gm IV every 8 hours or - Spectinomycin 2gm IM every 12 hours * Therapy should continue for at least 7 days Gonorrhoea – treatment
- 54. Non-gonococcal urethritis •Cause • Chlamydia trachomatis (serovars D to K) • Ureaplasma urealyticum • Trichomonas vaginalis/ Herpes simplex • Others – N. meningitis – Candida spp. – Foreign bodies – Unknown
- 55. Non- gonococcal urethritis Diagnosis ( 2 out of 3 of the following) • Symptoms •Dysuria, urethral discharge • Threads in 1st voided urine sample • >/= 5 pus cells per hpf on Gram stain
- 56. Non- gonococcal urethritis- treatment Doxycycline 100mg PO bd x 7 days or Azithromycin 1gm PO stat Alternative: Ofloxacin 200mg bd for 14 days or Erythromycin ethyl succinate 800mg x 7 days
- 57. Non-specific vaginitis (Bacterial / anaerobic vaginosis) • Cause: Haemophilus, Gardnerella vaginalis, d/t alteration in vagina flora • Asymptomatic /foul-smelling vaginal discharge • Diagnosis (3 out of 4) – Thin, homogenous vaginal d/c – Positive amine (fish-like) odour in KOH tests (“sniff test) – Vaginal pH > 4.5 – Presence of clue cells on microscopy * Menses, semen, douching may effect pH * Exclude trichomoniasis
- 58. Non-specific vaginitis (Bacterial/anaerobic vaginosis •Treatment • Metronidazole 400mg PO bd x 7 day OR (Treat symptomatic cases only) • Ampicillin 500 mg qid PO x 7 days OR • Amoxycillin 500 mg tds PO x 7 days OR • Clindamycin 300 mg bd PO x 7 days * Metronidazole contraindicated first trimester of pregnancy
- 59. Genital warts • Condyloma Accuminata • Human papilloma viruses (HPV) - DNA papovirus • > 30 types of HPV • – Condyloma acuminatum:1-5, 6, 11, 10, 16, 18, 30, • 31, 33, 35, 39-45, 51-59, 70, and 83. • Spread of HPV infection is usually through skin-associated virus and not from blood- borne infection
- 61. Genital warts • Diagnosis usually made on clinical grounds • Serological test available but not offer in our hospital • Virus isolation is difficult • If needed diagnosed by biopsy 🡪HPE.
- 62. Genital warts • Treatment modalities ✔Podophyllin resin (10-25%) ✔Cryotherapy with liquid nitrogen ✔Surgical excision ✔Electrocautery cautery & CO2 laser ✔Imiquimod 5% cream ✔Tricholoacetic acid (80-90%)
- 63. Gardasil 9 Vaccine • Protects against 9 types of HPV (6,11,16,18,31,33,45,52 and 58) •HPV 6 &11 🡪cause 90% of genital warts •HPV 16 & 18 🡪 cause 70% of cervical cancers. • Recommended at ages 11-12 y.o, can be given starting at the age of 9 y.o • 2 doses of HPV vaccine 6-12 months apart.