STI ppt.ppt

1. Sexually Transmitted Infections Unit 13 HIV Care and ART: A Course for Pharmacists by Salahadin M.Ali

2. 2 Learning Objectives  Describe the association between STIs and HIV  Identify the etiologies and mode of transmission of some of the most common STIs  Understand the major symptoms of commonly encountered STIs  Determine the most effective treatment approaches for commonly encountered STIs

3. 3 STI versus STD  STI – Infections acquired through sexual intercourse (may be symptomatic or asymptomatic)  STD – Symptomatic disease acquired through sexual intercourse  STI is most commonly used because it applies to both symptomatic and asymptomatic infections

4. 4 Introduction  Most STIs are treatable  However, resistance to many of the older antibiotics is a challenge  Other have no cure, such as herpes, genital warts, HIV  Many STIs can lead to related conditions such as:  Pelvic inflammatory disease  Cervical cancer  Complications in pregnancy  STIs can have socio-economic consequences  Education about these diseases and prevention are important

5. 5 Link Between STIs & HIV/AIDS  STIs facilitate HIV transmission and acquisition  Chancroid, chlamydia, gonorrhea, syphilis, and trichomoniasis may increase the risk of HIV transmission by two to nine times  STI control reduces transmission of HIV  The prevalence of HIV in heterosexual populations is higher in Africa than in Europe and the US where STIs are more often treated and cured

6. 6 Link Between STIs & HIV/AIDS (2)  STIs and HIV infection share similar epidemiologic determinants  Result from risky sexual behavior  Affect the same age group  HIV affects the clinical presentation and management of STIs  In people with HIV infection, other STIs may be more resistant to treatment

7. 7 Interventions to Reduce Transmission  Decrease duration of infectivity  Early diagnosis & curative or suppressive therapy  Decrease efficiency of transmission  Promote safer sexual behavior  Decrease susceptible persons’ exposure rate to infected individuals  Counsel to modify sexual behavior

8. 8 Commonly Encountered STIs  Syphilis  Gonorrhea  Chlamydia  Chancroid  Genital Herpes  Genital warts  Trichomoniasis  Lymphogranularoma Venereal

9. 9 Syndromic Approach to STI Management  Identification of clinical syndrome  Giving treatment targeting all the locally known pathogens which can cause the syndrome

10. 10 Syndromic Approach to STI Management (2)  Advantages  Simple, rapid and inexpensive  Complete care offered at first visit  Patients are treated for possible mixed infections  Accessible to a broad range of health workers  Avoids unnecessary referrals to hospitals  Disadvantages  Over-treatment  Asymptomatic infections are missed

11. 11 STI Syndromes 1. Urethral discharge or burning on urination in men 2. Vaginal discharge 3. Genital ulcer in men and women 4. Lower abdominal pain in women 5. Scrotal swelling 6. Inguinal bubo

12. 12 Urethral Discharge Syndrome  Possible etiologies:  Gonococcal infection  Chlamydia Trachomatis

13. Patient complains of urethral discharge or dysuria Take history & Do P/E; milk urethra if necessary Discharge confirmed Other STIs present? •Educate and counsel •Offer VCT •Review if symptoms persist •Promote and provide condoms Use appropriate flow chart Treat for gonorrhea and chlamydia •Educate •Counsel •Promote and provide condoms •Offer VCT •Partner management •Advise to return in 7 days if discharge persists yes No No Yes Urethral Discharge Syndrome

14. 14 Recommended Treatment for Urethral Discharge and Burning on Urination  Ciprofloxacin 500 mg po stat, or Spectinomycin 2g IM stat and  Doxycycline 100 mg po BID for 7 days, or Tetracycline 500 mg po QID for 7 days, or Erythromycin 500 mg po QID for 7 days if the patient has contraindications for Tetracyclines

15. Persistent or Recurrent Urethral Discharge in Men Take history and examine Does history confirm reinfection or poor compliance Treat for trichomonas vaginalis •Educate/ counsel •Promote and provide condoms •Return in 7 days Improved Discharge confirmed Patient complains of Persistent/ recurrent Urethral discharge or dysuria Other STIs present Use appropriate flow chart Repeat urethral discharge treatment Refer •Educate/ counsel •Promote and provide condoms • Offer VCT Yes No No Yes Yes •Educate/ counsel •Promote and provide condoms • Offer VCT No Yes No

16. 16 Vaginal Discharge  Common causes:  Neisseria gonorrhea  Chlamydia trachomatis  Trichomonas vaginalis  Gardnerella vaginalis  Candida albicans

17. 17 Patient complains of vaginal discharge or vulval itching/ burning Abnormal discharge present Take history, examine patient (external speculum and bimanual) and assess risk Lower abdominal tenderness or cervical motion tenderness Was risk assessment positive? Is discharge from the cervix? Vulval edema/curd like discharge Erythema excoriation present Treat for bacterial vaginosis and trichomoniasis Treat for chlamydia, gonorrhea, bacterial vaginosis and trichomoniasis Use flow chart for lower abdominal pain Educate Counsel Promote and provide condoms Offer VCT Educate Counsel Promote and provide condoms Offer VCT Treat for Candida albicans No Yes Yes Yes No No No Yes Vaginal Discharge

18. 18 Recommended Treatment for Vaginal Discharge Metronidazole 500mg PO BID for 7 days and Clotrimazole vaginal tabs 200mg at bed time for 3 days Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat and Doxycycline 100mg PO BID for 7 days and Metronidazole 500mg BID for 10 days Risk Assessment Negative for STI Risk Assessment Positive for STI

19. 19 Genital Ulcer Disease Differential Diagnosis  Herpes simplex  Syphilis  Chancroid  Lymphogranuloma venereum  Granuloma inguinale  Others

20. Patient complains of genital ulcer Take history & examine Vesicles Or Recurrence Treat for HSV, Treat for syphilis if indicated •Educate and counsel •Promote and provide condoms •Offer VCT •Ask the patient to return in 7 days Ulcers healed Educate and counsel Promote and provide condoms Offer VCT Partner management Ulcers and sores Treat for syphilis, chancroid and HSV Educate Promote and provide condoms Offer VCT Ulcers improving Refer Continue treatment for further 7 days No No Yes Yes Yes Yes No No Genital Ulcer Syndrome

21. 21 Genital Ulcer Disease Treatment  Recommended treatment for non-vesicular genital ulcer  Benzanthine penicilline 2.4 million units IM stat, or Doxycycline 100 mg bid for 15 days and  Ciprofloxacin 500mg, po, bid for 3 days, or Erythromycin 500 mg, po, QID for 7 days  Recommended treatment for vesicular or recurrent genital ulcer  Acyclovir 200 mg five times per day for 10 days or  Acyclovir 400 mg TID for 10 days

22. 22 HSV Spectrum of Disease  Persistent ulcerative HSV infections are very common in AIDS  Candida and HSV often occur in association  Oral-facial  Primary: gingivostomatitis & pharyngitis  Reactivation: herpes labialis  Asymptomatic shedding is common  Thus, patients are potentially infectious even when lesions are absent

23. 23 Severe Chronic Herpes Simplex Ulcers © Slice of Life and Suzanne S. Stensaas

24. 24 HSV in the Immunocompromised Host  High frequency of reactivation  Increased severity  Widespread local extension  Higher incidence of dissemination  Viremic spread to visceral organs, which is rare but can be life threatening

25. 25 HSV Courtesy of CDC/ Susan Lindsley

26. 26 HSV circumferential ulcer Courtesy of CDC/ Dr. M. F. Rein; Susan Lindsley

27. 27 HSV Treatment  Primary infection  Acyclovir 200 mg PO 5x/day for 7-14 days or  Acyclovir 400mg PO tid for 7-14 days or  Famciclovir 500 mg PO bid for 7-14 days or  Valacyclovir 1 gm PO bid 7-14 days  Recurrences treated with same dosage, but may need only 5-10 days therapy  Suppressive therapy may be indicated for patients with frequent recurrences, BUT  Continued treatment risks developing resistant HSV

28. 28 Lower Abdominal Pain Due to PID (Pelvic Inflammatory Disease)  PID is ascending infection of the upper genital tract (uterus, tubes, etc) from the cervix and/or vagina  Common etiologies:  Sexually transmitted: Neisseria gonorrhea, Chlamydia trachomatis, Mycoplasma hominis  Others (non-STI): streptococci, E. coli, etc  Vaginal discharge is often present

29. 29 Patient complains of lower abdominal pain Take history including gynecological and examine (abdominal and vaginal) Any of the following present •Missed overdue period •Recent delivery/ abortion •Miscarriage •Abdominal guarding •And or rebound tenderness •Abdominal mass •Abnormal vaginal bleeding Refer the patient for surgical or gynecological opinion and assessment Before referral set up an Iv line and resuscitate if required Is there cervical excitation tenderness Or lower abdominal tenderness And vaginal discharge Manage for PID Review in three days Continue treatment until completed •Educate and counsel •Offer VCT •Promote and provide condom •Ask patient to return if necessary Patient has improved Refer patient Manage appropriately Any other illness found Lower Abdominal Pain Yes No Yes Yes No No Yes

30. 30 Recommended Treatment for PID Out patient Inpatient Ciprofloxacin 500mg PO bid for 7 days, or Spectinomycin 2gm IM stat plus Doxycycline 100mg BID for 14 days plus Metronidazole 500mg BID for 14 days Ceftriaxone 250mg IV BID, or Spectinomycin 2gm IM BID plus Doxycycline 100mg BID for 14 days plus Metronidazole 500mg BID for 14 days, or Chloramphenicol 500mg IV QID

31. 31 Scrotal Swelling  Common STI causes of scrotal swelling are similar to those of urethral discharge  Neisseria gonorrhea  Chlamydia trachomatis  Exclude non-STI causes of scrotal swelling:  TB  Inguinal hernia  Testicular torsion, etc

32. 32 Scrotal Swelling Patient complains of scrotal swelling or pain Take history, examine, offer HIV test Scrotal swelling or pain present? History of trauma or testis elevated or rotated? or Diagnosis in doubt? Refer patient to hospital Signs of other STI present? Reassure patient, educate, counsel, provide condoms. Review if symptoms persist Treat according to appropriate flowchart Treat for chlamydia and gonorrhea. Review in 7 days Patient has improved? Complete treatment course, reinforce education and counseling Review if symptoms persist Yes Yes No Yes No No Yes No

33. 33 Scrotal Swelling Recommended Therapy  Ciprofloxacin 500mg PO stat or Spectinomycin 2gm IM stat and  Doxycycline 100mg PO BID for 7 days, or Tetracycline 500mg BID for 7 days

34. 34 Inguinal Bubo  Swelling of inguinal lymph nodes as a result of STIs (or other causes)  Common causes:  Treponema pallidum (syphilis)  Chlamydia trachomatis (LGV)  Hemophylus ducreyi (chancroid)  Calymatobacterium granulomatis (granuloma inguinale)

35. Inguinal Bubo Patient complaining of inguinal swelling Take history and examine Ulcers present Treat for LGV, GI and chancroid •Aspirate if fluctuant •Educate on treatment compliance •Counsel on risk reduction •Promote and provide condoms •Partner management •Offer VCT if available •Advise to return in 07 days •Refer if no improvement Any other STI present Use appropriate flow chart •Educate •Counsel •Offer VCT •Promote and provide condoms Use genital ulcer flow chart No No Yes Yes No Inguinal/femoral bubo present?

36. 36 Inguinal Bubo  Recommended treatment:  Ciprofloxacin 500mg PO BID for 14 days and  Erythromycin 500mg PO QID for 14 to 21 days

37. 37 Neonatal Conjunctivitis  Infection of the eyes of the neonate as a result of genital infection of the mother, transmitted during birth  Causes:  Neisseria gonorrhea  Chlamydia trachomatis

38. Neonatal Conjunctivitis Neonate presents with eye discharge Take history and examine child Purulent conjunctivitis present? Complete treatment course, reinforce education and counseling Review if necessary Treat baby for gonococcal and chlamydial opthalmia AND Treat mother and partner for gonorrhoea and chlamydia Educate and counsel Review baby in 7 days or sooner if symptoms worsen Signs of other illness present? Treat appropriately Reassure mother, educate parents Review if symptoms persist Eye infection cleared? No No Yes Yes Review in 7 days Yes Refer for specialist opinion and management No

39. 39 Neonatal Conjunctivitis: Treatment  Treatment:  Spectinomycin 50mg/kg IM stat or ceftriaxone 125mg IM stat and  Erythromycin 50mg/kg PO in 4 divided doses for 10 days  May lead to blindness if not treated properly

40. 40 Key Points  STIs are among the most common causes of illness in the world  Emergence and spread of HIV infection and AIDS has major impact on the management and control of STIs  STIs increase the acquisition and transmission of HIV  HIV infection alters the clinical features and response to therapy of STIs

41. 41 Key Points (2)  The syndromic approach to STIs management is recommended by WHO  Syndromic management is simple, rapid and inexpensive

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