STD

Sexually transmitted diseasesSTD

STD are a group of communicable diseases that are transmitted predominantly by sexual contact. STD are very common. The most widely known are gonorrhea, syphilis and AIDS but there are more than 20 others. WHO estimates that every year there are > 330 million new cases of curable STD. About 1 million infections occurring every day
Classification: - Aetiological - Syndromic

Aetiological classification of STDs:

Bacterial infections N. gonorrhoeae (G.C) T. pallidum (syphilis) H. ducreyi (chancroid) Ureaplasma urealyticum Group B streptococci Calymmatobacterium granulomatis (donovosis) Mycoplasma hominis (vagnosis, salpingitis) Protozoal agents Trichomonus vaginalis Entamoeba histolytica Giardia lambia
Viral infections HIV Hepatitis B virus Herpes simplex v 1 or 2 Human papiloma HPV (genital and anal warts) Molloscum contagosum Chlamydial infections Chlamydia trachomatis Fungal infection Candida albicans Ectoparasites Pediculosis Sarcoptes scabiei (scabies)

Syndromic classification of STDs

This approach includes the syndromic management of STD, using the flow-charts. It offers many benefits: All trained 1st line service providers can diagnose and treat patients with STD Deliver comprehensive care to patient by following all instructions in the chart. Management of partner. Health education (safe sex).

Syndromes & the STD causing them

Syndrome
Cause of STD
Urethral discharge (men)
Gonorrhoea Chlamydial infection
Vaginal discharge
Trichomoniasis Bacterial vaginosis Candidiasis Gonorrhoea Chlamydial infection
Ulcer/s
Syphilis Chancroid Donovosis (granuloma inguinale)
Lower abdominal pain
Gonorrhoea Chlamydial infection Anaerobic bacteria

Patient complains of urethral discharge

Examine: milk urethra If necessary
Discharge Confirmed?
Ulcer (s) Present?
No
Educate Counsel if needed Promote/provide condoms
No
yes
yes
Treat for gonorrhea &Chlamydia: Ciprofloxacin 500 mg in a single dose AND Doxycycline 100 mg by mouth twice daily for 7 days Educate Promote/provide condoms Partner management Return if necessary
Use appropriate Flow-chart

Genital ulcer

Vesicular lesion(s) present or history of vesicular lesions, often recurrent?
- Treat for syphilis and chancroid - Examine and treat partner(s), - Health education and counseling.
Follow-up after 7 days
Improving ?
Refer
Herpes management
Clinical cure
NO
NO
Yes
Yes

LOWER ABDOMINAL PAIN SYNDROME Diagnosis and Management

Patient complains of lower abdominal pain
Take history and examine abdomen

Follow up if pain persists
No
Yes
Questions
1. Have you a missed or overdue period?
2. Have you had a recent delivery or miscarriage?
3. Is there rebound tenderness or guarding of the abdomen?
4. Is there any vaginal bleeding?
History and Risk Assessment:
No
Yes
Questions
Temperature > 38?
Pain during abdominal examination?
Vaginal discharge?
If answer to all questions is NO
ALL NO


AIDS

Spectrum of diseases caused by HIV infection

ARC
AIDS
HIV +ve
asymptomatic
Strictly speaking, the term AIDS refers only to the last stage of HIV infection.


Its 1st recognized 1981.Depletion of T-helper lymphocytes (CD4). CFR of untreated AIDS is 80 – 90 %.HIV +ve remain +ve life long.No vaccine has developed & fully tested yet (under trials).

DiagnosisClinical.Serological:HIV AB detected within 1 – 3 months after infection by EIA, ELISA and Western blot test. This gap time called window period (i.e. from infection and before detection of AB). Some time we repeat test for conformation.virus isolation. CBP: Lymphopenia, CD4 ↓↓ (normally 800 / mm3), when decrease below 200 / mm3 → prone to opportunistic infections. So CD4 count helps to predict course of disease.Anemia.Thrombocytopenia.↑ ESR.

Infectious agent: Human immunodeficiency virus (HIV). A retro-virus, HIV-1 and HIV-2. HIV-2 less pathogenic, slower disease progression and lower rates of mother to child transmission.

As of end of 2005

Estimated Number of People Living with HIV/AIDS, by Year

Estimated Global HIV Incidence, Number of New Infections, by Year

Estimated Global HIV Incidence, Number of New Infections, by Year1

Deaths Due to AIDS, by Year

3. Occurrence:Size of the problem:Prevalence December, 2014:37 million HIV / AIDS.Incidence in 2014:2.0 million new HIV infection,95% of new cases in developing countries.AIDS deaths in 2014:1.3 million. 38–39 million deaths since 1981.

4. Reservoir: Humans.5. Mode of transmission: HIV is transmitted by:Sexual rout – Most common (homo, heterosexual, vaginal, anal or oral sex)Blood &blood productsMother to her child (intrauterine, labor and milk). HIV is not transmitted by:Causal social contacts as in work, school,…Hand shaking &touches.Sneezing &coughing.Insects.Food /water &cups /spoons.Bathes /lavatories.Swimming pools.Second hand clothing.Telephones.

The virus found occasionally in saliva, tears, urine and bronchial secretion but transmission is not reported after contact with these secretions.Only the blood and semen transmit the virus.Blood Whole blood, platelets, factor 8 &9, plasma.No evidence of risk for albumin. Risk of transmission from infected one pint of blood is > 95% and its dose related.


Risky sexual behaviors:The risk of transmission of HIV via sexual intercourse is much lower than other STD.Every single act of unprotective intercourse with HIV infected person → 1 % risk of infection to the partner, however this risk increased by:Presence of other STD specially ulcerative types as chancroid → 2-5 times, syphilis → 3-9 times.Gender: Male → female twice female → male due to higher concentrations of HIV in semen than vaginal secretions & larger vaginal surface area.Age of uninfected partner: Female > 45 years → high risk due to thin mucosa.Adolescent girls high risk due to less effective cervix barrier.

Risky sexual behaviors: continueHigh risk in very early (window period) & very late infections. Because level of virus in blood is higher than other times.Low risk in circumcised males (8 folds in uncircumcised).Type of sexual act: anal sex → Higher risk → abrasions/ trauma. Prostitutes, homosexual male, multiple sexual partners, Also sexual act during menstruation.

VerticalPlacenta and during delivery → risk 15 - 30%. With prolonged breast feeding the risk increases to reaches 45%.Rx of infected pregnant with zidovudine → marked decrease of infant infection.6. I.P: variableHIV → AIDS < 1 year – 15 years or longer.In infants shorter I.P than adults.7. Period of communicability:Unknown, early after onset of HIV infection → through out life.8. Susceptibility: general + risky behavior.


9. Method of control:
A- Preventive measures: Health education of public and schools. Avoid extra marital sexual intercourse, otherwise use condoms. Adequately sterilization of syringes and needles and lancets, use disposable equipment whenever possible, wear gloves, eye protection and other protective equipment. In blood bank, all donors should be tested for HIV AB; reject donation from risky persons. WHO recommends immunization of asymptomatic HIV-infected children with routine schedule of vaccinations; those who are symptomatic should not receive BCG vaccine.

B- Control of patient, contacts and environment

Reporting: is obligatory in most of countries. Isolation: for HIV +ve individuals is unnecessary, ineffective and unjustified. Universal precautions to prevent exposures to blood and body fluids for all hospitalized patients. Disinfection: of equipment contaminated with blood or infectious body fluids. Quarantine: not applicable.


Immunization of contacts: not applicable.Notification of contacts and source of infection: none.Specific treatment: Prophylactic Rx of P. carinii pneumonia by methoprim. Check for TB infection.Antiretroviral treatment (ARV): complex, combination of drugs, drugs are toxic and treatment must be for life. It suppress viral replication and start the Rx aggressively. protease inhibitor + two non-nucleoside reverse transcriptase inhibitor started initially.Post exposure prophylaxis after accidental exposure to blood → (zidovudine + lamivudine) 4weeks.

HIV and TB

TB is one of the opportunistic infection in AIDS patients. No conclusive data indicate that any infection, including M. tuberculosis, accelerate progression to AIDS in HIV infected persons.


Almost always STD.45% of G. patients have also Chlamydial infection.Male → purulent discharge from urethra, orchitis, epididymitis and proctitis. urethral stricture → sub-fertility.Female → 80 – 90 % asymptomatic (source of infection), only 10% vaginal infection → discharge, bartholinitis, cervicitis → 20% uterine endomateritis and salpingitis, pyosalpinx → sub-fertility. Gonorrhoea


- Mode of transmission: Almost always as a result of sexual activity. In children over 1 year, it is considered an indicator of sexual abuse.- I P: 2 – 5 days. No immunity after infection.- Remain infectious for months if untreated.- Effective treatment ends communicability within hours.- Treatment:Ciprafloxacine 5oo mg single dose orspectinomycine 2 gm IM single dose+ Doxycycline 100 mg / twice/ 7 days or erythromycine 500 mg *4 / 7days. Gonorrhoea


Non-specific urethritis (non-gonococcal urethritis) NSUCauses:Chlamydial infection 50 – 60 %.Ureaplasma urealyticum 10-20%.Herpes virus-2rare.T. vaginalis rare.Unknwon 30 %.


Chlamydial infection Its an obligate intracellular bacteria, sensitive to broad spectrum AntibioticsC. trachomatis:Trachoma (non-STD)serotypes: A, B, C.Genital infection (NSU in male and cervical infection in female) same presentation as G.C.C. conjunctivitisserotypes: D – K. Infant pneumonia.Lymphogranuloma venerrum (other serotype L1, L2, L3).C. pneumoniae → pneumonia (non-STD).C. psittaci → Psittacosis (non-STD).