2. INTRODUCTION
Sexually transmitted disease (STD),
is also known as sexually transmitted
infection (STI) or venereal disease
(VD).
In recent years the term sexually
transmitted infection (STI) has been
preferred
3. A person may be infected, and may
potentially infect others, without
showing signs of disease.
4. STIs can be transmitted via human
sexual behaviour including vaginal
intercourse, oral sex and anal sex.
It may also be transmitted via the
use of IV drug needles after its use
by an infected person, as well as
through childbirth or breastfeeding.
5. STI incidence rates remain high in most of the
world
In 1999, the WHO estimates that 340 million
new cases of STIs have occurred worldwide.
The largest number of new infections occurred
in the region of
South and Southeast Asia,
sub-Saharan Africa
Latin America and the Caribbean.
6. The highest rate of new cases per 1000
population has occurred in sub Saharan Africa
About 60% of these infections occur in young
people <25 years of age
11. SIGNS AND SYMPTOMS
Urethral (>80%) / Vaginal discharge – often
purulent
Dysuria(50% Men)+ frequency
Aymptomatic infection is common in females
Endocx: >50%
Rectum >85% ( also in Men)
Pharynx :>90% ( also in Men)
15. Recommended Treatment
IM Ceftriaxone 500 mg stat
AND
Azithromycin 1g orally
NB : Dose of Cefftriazone has been increased from 250mg
as development of resistance in other parts of the world
Addition of azithromycin is for synergestic therapeutic
effect, reduce resistance and treatment of co-infection
with C. trachomatis
16. Alternative treatment
Cefixime (ZINECEF) 400mg stat dose orally
IM Spectinomycin 2 gm stat or
IM Cefotaxime 500mg stat
NB : Penicillins, tetracyclines, quinolones no longer
recommended for Rx of Gonorrhoea: high resistant rates
Azithromycin alone not recommended RX for gomnorrhoea
17. Advice
No unprotected sex, no alcohol till they n their
partners complete treatment
Contact tracing
Examine and investigate sex partner( within 3
preceding months) ,
treat for gonorrhoea preferably after evaluation for
sexual acquired infection
18. Follow up
1 week – 2GT, urethral smear and culture to detect
PGU
2 weeks – 2GT, urethral smear
19. POST GONOCOCCAL URETHRITIS
Diagnosis
If 7 days or more after treatment of gonorrhea
2GT : 1st glass threads
: 2nd glass clear ( not done anymore as
not very useful)
Urethral smear negative, PC > 5 phf
Treatment
As for NSU
20. NON SPECIFIC URETHRITIS(NSU) /
CHLAMYDIA
Causative organism
Chlamydia sp
Incubation period
1-3 weeks
Clinical presentation : in women
Asymptomatic (60-70%)
Mucopurulent vaginal discharge (30-40%)
Intermenstrual/post coital bleed
Lower abd pain
Acute and chronic symptoms and signs of PID
21. NON SPECIFIC URETHRITIS(NSU) /
CHLAMYDIA
Clinical presentation : in men
Asymptomatic (50-60%)
Mucopurulent urethral discharge (30-40%)
Signs of epididymo-orchitis and prostatitis
Both Men and Women
Dysuria
Ano-rectal discomfort + discharge
Arthralgia
Pharyngeal infections
conjunctivitis
22. Diagnosis
Specimens for testing :
urethral/endocervical swab And or first void urine
Lab Tests
Gram stain : increase PMN> to 5 per high power in urethral
smear and >20 in endocervical smear/ /> 10 in first void
urine
Cell culture : considered gold std but not recommended for
routine use
Direct Fluorescent antibody test (DFAT)
Enzyme immunoassays(EIA)
Necleic acid amplification test (NAAT)
23. TREATMENT
Oral Doxycycline 100mg bd for 7 days or
Oral Azithromycin 1 gm stat
ALTERNATIVE
Ofloxacin for 500 mg bd for 7 days or
Oral Erythromycin stearate 500 mg qid for 7days or
Oral Erythromycin ES 800mg QID for 7 days
Advice
To avoid sex and alcohol until cured
24. TREATMENT in Pregnancy
Oral Erythromycin stearate 500 mg qid for 7days or
Oral Erythromycin ES 800mg QID for 7 days
Amoxycilling 500mg tds for 7 days
Oral Azithromycin 1 gm stat
Advice
To avoid sex for 7 days until they and their partners
have completed treatment
25. Contact tracing
Examine and investigate sex partner, treat if positive
If testing not available or partners are unwilling for
examination : treat emperically
Follow up
After 2-3 weeks
If remain symptomatic/do not complete their Rx/have unprotected
sex with untreated partner: retreated with appropriate contact
tracing
Test of cure in asymptomatic individual not recommended
26. VAGINAL CANDIDIASIS
Causative organism
Candida albicans (80-92%)and other yeasts
Clinical presentation
Vaginal/vulva - Intense pruritis and erythema
Vulva soreness
Vaginal excoriation and edema
Thick, white ‘ cheesy’ curdlike discharge
Discomfort in coitus
Dysuria
In Men : rash on glans penis /fissures over
prepuce/oedema of prepuce
29. Diagnosis
Lateral wall of vagina /subpreputial smear :
Gram stain (sensitivity 65-68%)
10% KOH microscopy ( sensitivity 70%)
Culture on Sabouraud’s agar
Treatment (topical/oral)
Clotrimazole vaginal pessary 200mg ON for 3 nights or
Clotrimazole vaginal pessary 500mg ON stat
alternative
Nystatin pessary100,000 units ON for 2 weeks
Tioconazole pessaries 200mg daily for 3 days
30. Treatment
Oral therapy
Fluconazole 150mg stat dose
Itraconazole 200mg bd for 1 day : contraindicated in
pregnancy
Advice
Avoid local irritants ; perume, soap, etc
Avoid tight fitting synthetic clothings
Follow up
Repeat vaginal smear and culture after 7-14 days
36. Diagnosis
Saline wet mount – oval or pear shape
organism ( positive in 30%) : Must be
performed ASAP as motility diminishes with
time
PCR
Treatment
Oral Metronodazole 400 mg bd for 5 days or
Oral Metronidazole 2 gm stat dose or
Tinidazole 2 g stat
37. Pregnancy :
Published data suggest no increased risk
of tetratogenicity in Normal doses
High dose metronidazole ( 2g) not
recommended in pregnancy and breast
feeding ( metallic taste in breast milk)
38. Advice
No sex, alcohol until 1 week treatment
completed
Contact tracing
Examine and investigate sex partners, treat
sex partners epidemiologically
Follow up
7-10 days- repeat wet mount film
39. BACTERIAL / ANAEROBIC VAGINOSIS
Causative organism
Mixed flora consisting of Gardnerella
vaginalis and other anerobes such as
Mycoplasma hominis.
Clinical presentation
Characteristic – copious whitish grey dc,
malodorous
No obvious vulvitis/vaginitis
+ Dysuria/dyspareunia
+ Pruritis
50% asymptomatic
40. Diagnosis:
Amsel’s criteria, diagnosis is made by the
presence of any 3 out of the 4 features given
below :-
Characteristic vaginal dc ie Homogeneous, thin, white
discharge that smoothly coats the vaginal walls
Wet prep or gram stain- clue cells
Amine Sniff test (Fishy odor of vaginal discharge
before or after addition of 10% KOH )
Vaginal fluid PH > 4.5
41. Recommended Treatment
Oral Metronidazole 400 mg bd for 5days or
Oral Metronidazole 2 gm stat dose or
Alternative treatment
Intravaginal metronidazole 0.75% gel once
daily for 5 days or
Intravaginal clindamycin 2% cream once
daily for 7 days or
Clindamycin 300 mg b.d. P.O. for 7 days
42. GENITAL HERPES
Commonest genital ulcer
50% recur but milder in form
Causative organism
Herpes simplex type 1 or 2
Incubation period
2-5 days
43. Genital ulcer/sore
Single/multiple
Superficially ulcerated, scabbed, red edged
PAINFUL
Symptoms
burning sensation at genital area – crops of
vesicles appears – burst after 24 hrs –
painful ulcers – scabs – heals + (may affect
buttock and thigh)
enlarged glands in groin
45. Diagnosis
Direct IF for HSV Ag
Serology- paired sera taken 2 weeks apart
Tzank test for multinucleated giant cells
Treatment
Oral Acyclovir 200 mg 5x/daily for 5 days
Start within first 3 days of onset of lesion
Saline Sitz bath
Analgesics
47. Syphillis
LATE SYPHILIS (>2 YEARS)
LATE LATENT SYPHILIS
TERTIARY SYPHILIS (GUMMA)
CARDIOVASCULAR SYPHILIS
NEUROSYPHILIS
CONGENITAL
EARLY (<2 YEARS OLD)
LATE (> 2 YEARS OLD)
48. SYPHILIS
Primary Syphilis
Clinical presentation
- Usually single, NON TENDER sharply
demarcated ulcer with indurated edges
and clean base
- Local lymph nodes enlarged
Diagnosis
- Dark ground microscopy
- VDRL/TPHA
52. Treatment
IM Benzathine Penicilline 2.4 mega single dose
Procaine penicillin G, 600,000 units I.M. daily
for 10 days
53. If allergic to Penicillin
Oral Doxycycline 100mg bd for 14 days or
Oral Erythromycin 500 mg qid for 14 days
Erythromycin ethyl succinate 800 mg q.i.d.
P.O. x 14 days or
Ceftriaxone 500 mg I.M. daily for 10 days (if
no anaphylaxis to penicillin
Azithromycin 2 g single dose P.O (concerns
regarding intrinsic macrolide resistance)
54. Contact tracing
Examine and investigate sex partner
and treat when indicated
Follow up
VDRL titre at 1,3,6,12,18,24 months
55. Secondary syphilis
Incubation period
- 6-8 weeks after chancre appear
Clinical presentation
- Rashes: macular/macular papular
usually symmetrical over palms and
soles
56. - Condylomata lata in moist areas
- Generalised lymphadenopathy, non
tender
Diagnosis/Treatment/contact tracing/follow up
- As for primary syphilis
57. Early Latent Syphilis
Syphilis infection of less than 2 years duration
Positive serology without sn and sx
Usually detected by screening (STD, ANC,
blood donors, contact tracing)
Treatment/Contact tracing/Follow up
- As for primary syphilis
58. Late latent syphilis
Syphilis infection of more than 2 years duration
Positive serology without sn and sx
Usually detected by screening or contact
tracing
Investigation
- LP, CXR
59. Treatment
- IM Benzathine Penicillin 2.4 mega units
weekly for 3 weeks
If allergic to Penicillin
- Oral Doxycycline 100 mg bd for 30 days or
- Oral Erythromycin 500 mg qid for 30 days
Follow up
- VDRL titre 6 monthly for first 2 years, there
after anually until sero negative or stable at
low titres
60. MODIFIED SYNDROMIC APPROACH
introduced in 1999 in all health centres in
Malaysia
sexually transmitted diseases that have the
same symptoms are grouped into a syndrome
to ensure early treatment can be given to sti
patients.
61. ADVANTAGES OF MSA
treating more than one infection at a time (estimated
60% of patients had > 1 infection at one time)
treating patients at first visit
client friendly services
counseling and advise given to patients
prevent self treatment
reduced possibilities of drug resistance
62. reduce complications and risk of transmitting
the disease to others.
minimum lab investigations needed
enable the paramedic to treat the disease*
64. CLIENT
REGISTRATION OF CLIENT
HISTORY TAKING AND PHYSICAL EXAMINATION
COMPLICATIONS??
NIL
TREAT ACCORDING TO MSA
DO SIMPLE LAB TEST
FILL IN MSA TREATMENT FORM
NOTIFICATION
GIVE 2 WEEKS APPOINTMENT
REFERYES
66. Patient complains of genital ulcer or sore
HISTORY AND PHYSICAL EXAMINATION
ULCER PRESENT?
TREATMENT FOR SYPHILIS & CHANCROID
**IST CHOICE: I/M B. PENICILLIN 2.4 MILL
U/ WEEKLY FOR 2 WEEK ,
PLUS
AZITHROMYCIN 1 GM STAT
** 2ND CHOICE: I/m B. PENICILLIN 2.4 MILL
U/ WEEK FOR 2 WEEK
PLUS
1/M CEFTRIAXONE 250 MG STAT
If allergy to 1ST dose Benzathine penicillin,
-avoid 2nd dose.
-give Oral Doxycycline100 mg bd x 14days Or
Oral Erythromycin ES 800mg BDX14days
NB: Doxycline – NO in pregnancy and lactation
Erythromycin in pregnancy, Rx baby as Congenital
Syphilis
NO
MULTIPLE SUPERCIAL EROSIONS OR
VESICLES PRESENT?
GENITAL HERPES MANAGEMENT
EDUCATE FOR BEHAVIORAL CHANGE
TCA 2 WEEKS FOR REVIEW
YES
68. Patient complains of urethral discharges/Dysuria in males
(1st time/ recurrences)
History and Physical Examination
INVESTIGATIONS NEEDED
* Urethral smear for GC
*Culture for GC/CHLAMYDIA
*VDRL<TPHA & HIV (after counseling)
DISCHARGE PRESENT?
YES
NO
DO 2 GLASS TEST
RESULT POSITIVE?
YES
TREATMENT OF GONORRHEA AND CHLAMYDIA
1ST CHOICE: AZITHROMYCIN 1 GM STAT
2ND CHOICE: I/M CEFTRIAXONE 250 MG STAT If Azithromycin and
plus Ceftriaxone NA
DOXYCLINE 100 MG BD x10-14 days use IM Spectinomycin
2 gm/dose
3RD CHOICE: 1/M CEFTRIAXONE 250 MG STAT
plus
ERYTHROMYCIN ES 800 MG BD X 10-14 DAYS
GC – STUARTS TRANSPORT
MEDIA
CHLAMYDIA – CHLAMYDIA
TRANSPORT MEDIA
70. Patient complains of vaginal discharges
HISTORY AND PHYSICAL EXAMINATION
INVESTIGATIONS NEEDED
1. VAGINAL SWAB
@WET MOUNT FOR TRICHOMONAS VAGINALIS AND CLUE CELLS FOR BACT VAGINOSIS
@GRAM STAIN FOR CANDIDA ALBICANS
2. CERVICAL SWAB
@ GRAM STAIN FOR GC AND PUS CELLS
@ CULTURE FOR GC
3.VDRL,TPHA & HIV TEST
TREATMENT FOR :
CERVICITIS VAGINITIS
1ST CHOICE: AZITHROMYCIN 1 GM STAT METRONIDAZOLE 2 GM STAT
plus
2ND CHOICE: I/M CEFTRIAXONE 250 MG STAT Nystatin pessary 100,00 u daily x 14 days
plus or
DOXYCLINE 100 MG BDX 10-14 DAYS Clotrimazole pessary 200mg daily x 3 hari
3RD CHOICE: IM CEFTRIAXONE 250MG S
Plus
ERYTHROMYCIN 800MG BD X 10-14 DAYS
TREAT CONTACT/PARTNER