Transcript OI_3 - I-TECH

Clinical Care of HIV/AIDS and
Opportunistic Infections
March 2007
Unit 3:
Sexually Transmitted
Infections (STIs)
Objectives
Participants will be able to:
• Describe the interaction of
HIV with other STIs
• Apply the Namibian
Syndromic STI Management
Guidelines
• Support STI management and
prevention as part of HIV care
and prevention
Unit 3: Sexually Transmitted Infections (STIs)
Slide 2
Etiology of STI in
Namibia, 1994
Male
urethral
discharge
Female
vaginal
discharge
Gonorrhea
69%
12%
Chlamydia
Trichomonas
Candida
Bacterial
Vaginosis
Syphilis
27%
46%
17%
49%
55%
27%
19%
HIV
24%
14%
Data from STD patients
NACOP/MOHSS, Windhoek, August 1994
Unit 3: Sexually Transmitted Infections (STIs)
Slide 3
Etiology of STI in
Namibia, 1994 (2)
Chancroid
16%
Syphilis
22%
Herpes
5%
LGV
1%
Chancroid & syphilis
18%
Chancroid & Herpes
7%
Chancroid & syphilis & Herpes
+/1 LGV
Syphilis & LGV
2%
Syphilis & Herpes
1%
Unknown
35%
HIV
26%
2%
Data from 91 genital ulcer patients
NACOP/MOHSS, Windhoek, August 1994
Unit 3: Sexually Transmitted Infections (STIs)
Slide 4
Clinical Management
• MOHSS 1999
• Guidelines for the syndromic
management of sexually
transmitted diseases
• WHO 2001
• Guidelines for the management
of sexually transmitted
infections
• US CDC 2002
• Sexually transmitted diseases
treatment guidelines
Unit 3: Sexually Transmitted Infections (STIs)
Slide 5
STIs and HIV
• Common modes of transmission
• Transmission of multiple STIs
(including HIV) at same time is
common
• This highlights the importance of
syndromic management for STIs
• STIs increase HIV transmission
during unprotected sex. A single
infection increases HIV
transmission by 4-8 times.
• Persons infected simultaneously
with HIV and STI are over 20x
more infectious than persons with
chronic HIV alone.
Unit 3: Sexually Transmitted Infections (STIs)
Slide 6
STIs and HIV
• HIV may change the
appearance or response to
therapy of STIs
• Improved syndromic
treatment of STIs reduced
HIV transmission in Tanzania
by 42%*
*Grosskurth H et al.
Lancet 1995;346:530
Unit 3: Sexually Transmitted Infections (STIs)
Slide 7
STI and HIV
HIV prevalence among STD patients at different sites,
Namibia 2002
70%
65%
60%
54%
54%
51%
47%
HIV Prevalence
50%
45%
40%
37%
40%
35%
33%
31%
28%
30%
24%
21%
20%
10%
10%
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0%
Unit 3: Sexually Transmitted Infections (STIs)
Slide 8
HIV in Semen of men
with Gonorrhoea
Unit 3: Sexually Transmitted Infections (STIs)
Slide 9
STIs and HIV
Light colour – HIV in blood stream
Dark colour – HIV in genital tract
Unit 3: Sexually Transmitted Infections (STIs)
Slide 10
STI Management
• Syndromic management
• Presumptive treatment of the most
likely diagnoses
• Addresses high rate of co-infections
• Avoids unnecessary screening tests
•
•
•
•
• Individual and public health benefit
Etiologic evaluation for complex cases
after failure of syndromic management
Most STIs require treatment of partner
even if asymptomatic
Always educate about transmission and
promote condom use
HIV +/- RPR testing should be offered to
all patients with STIs
• If HIV negative, repeat in 3 months
Unit 3: Sexually Transmitted Infections (STIs)
Slide 11
Topics Covered in
this Unit
• Genital ulcers
• Syphilis
•
•
•
•
•
Inguinal buboes
Male urethral discharge
Scrotal swelling
Female vaginal discharge
Lower abdominal pain and
Pelvic Inflammatory Disease
• Men who have sex with men
• Counselling about safer sex
Unit 3: Sexually Transmitted Infections (STIs)
Slide 12
Genital Ulcer
Disease (GUD)
• Each ulcer-causing condition has
typical features, but patients often
present with atypical features or
multiple simultaneous conditions.
• Without rigorous laboratory
testing, we cannot be certain of
the etiology.
• Syndromic management is
directed at the most common
curable conditions.
Unit 3: Sexually Transmitted Infections (STIs)
Slide 13
Genital Ulcer Disease (GUD):
Differential Diagnoses
Infectious
Non-infectious
• Syphilis*
• Chancroid*
• Lymphogranuloma
venereum
• Granuloma
inguinale
• Herpes simplex*
• Pyoderma
• Cutaneous amoeba
• Trauma
• Fixed drug
eruption
• Erythema
multiforme
• Squamous cell
cancer
• Autoimmune
ulcers
• Bechet’s
syndrome
• Reiter’s
syndrome
STIs in red
*Most common in Namibia
Unit 3: Sexually Transmitted Infections (STIs)
Slide 14
Treatment of Genital
Ulcers
• Primary Syphilis (Treponema
pallidum)
• Benzathine penicillin 2.4 million
units IM once
• Chancroid (Haemophilus
ducreyi)
• Ceftriaxone 250 mg IM once
• Alternatives*:
• Erythromycin 500 mg po qd for 7
days (Preferred by some for HIV+
patients)
• Ciprofloxacin 500 mg po bd for 3
days
• Azithromycin 1.0 gram po once
*The 1999 Namibian guidelines recommend only
ceftriaxone
Unit 3: Sexually Transmitted Infections (STIs)
Slide 15
Genital Ulcer
No
Blisters and
recurrent
blisters
Genital ulcer
Penicillin IM
Ceftriaxone IM
Health Ed
Partner Treatment
Condoms
HIV testing
Yes
Multiple blisters
Clean lesions
Health Ed
Condoms
HIV testing
Secondary infection:
Cotrimoxazole
No improvement?
Reinfection?
No
Refer
Re-evaluate
Yes
Treat partner
Repeat protocol
Unit 3: Sexually Transmitted Infections (STIs)
Refer to Handout 3.1 or
Section 4.4 (page 13) of the
MoHSS Guidelines for the
Syndromic Management of
STDs.
Slide 16
Primary Syphilis in Men:
Chancres
Source: ©Wellcome Trust, 2003
Frenulum
Source: ©Wellcome Trust, 2003
Coronal sulcus
Also shaft and
inner side of
prepuce
(foreskin)
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Corona
Slide 17
Primary Syphilis in
Women
• Primary syphilis is often
asymptomatic in women
• The most common sites of
chancres are the labia,
fourchette, and cervix.
Source: ©Wellcome Trust, 2003
Labia
Unit 3: Sexually Transmitted Infections (STIs)
Slide 18
Uncommon Locations
of Chancres
•
•
•
•
Mouth and lips
Anal area and buttocks
Fingers
Nipples of non-immune
woman breast feeding an
infant with congenital syphilis
Unit 3: Sexually Transmitted Infections (STIs)
Slide 19
Syphilis Natural History
• Characterized by episodes of
active disease and periods of
latent infection
• Primary disease involves skin and
mucosal surfaces
• Secondary disease involves skin,
mucous membranes, and many other
organs
• Latent disease has no signs or
symptoms
• Tertiary syphilis causes disease of
the aorta or masses (gummas) in any
organ
• Neurosyphilis can occur at any
stage
Unit 3: Sexually Transmitted Infections (STIs)
Slide 20
Secondary Syphilis
Signs and Symptoms
• Rash: often on palms and soles
of feet, trunk
• Malaise
• Generalized lymphadenopathy
• Mucous patches (oral cavity,
pharynx, larynx, genitals)
• Condylomata lata
• Alopecia
• Neurosyphilis
Unit 3: Sexually Transmitted Infections (STIs)
Slide 21
Rash of Secondary
Syphilis in a Pregnant
Woman
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 22
Condylomata Lata:
Mucosal Lesions of
Secondary Syphilis
Source: ©Wellcome Trust, 2003
• Painless warty lesions on moist
skin
• May have fever, adenopathy, rash
• Teeming with spirochetes
• Highly infectious
Unit 3: Sexually Transmitted Infections (STIs)
Slide 23
Syphilis
Signs and Symptoms
• Latent
• No clinical manifestations
• Only evidence is positive
serologic test
• Early Latent
• <1 year duration
• Late Latent
• >1 year duration or unknown
Unit 3: Sexually Transmitted Infections (STIs)
Slide 24
Neurosyphilis
• Symptomatic neurosyphilis
may present as:
•
•
•
•
•
•
Lymphocytic meningitis
Stroke syndromes
Seizure disorders
Progressive dementia
Psychosis
Spinal cord dysfunction (tabes
dorsalis)
Unit 3: Sexually Transmitted Infections (STIs)
Slide 25
Tertiary Syphilis
• Some untreated patients
develop other effects of
syphilis 15-25 years or more
after infection
• Benign tertiary syphilis
(gummas): liver masses, skin
disorders, eye lesions, bone
deterioration (6%)
• Syphilis of the heart and great
vessels (4%).
Unit 3: Sexually Transmitted Infections (STIs)
Slide 26
Serologic Diagnosis
of Syphilis
Non-Treponemal Antibody:
• 3 names, same test
• RPR (rapid plasma reagen)
• VDRL (venereal disease research
laboratory)
• WR (Wasserman reaction)
• Detects the immune reaction, but not an
antibody test
• RPR may be negative in primary
syphilis
• Titre is high in secondary disease and
drops over time and after treatment
Antibody Test: Treponema Pallidum
Haemagglutination (THPA)
• Done to confirm RPR (+) tests
Unit 3: Sexually Transmitted Infections (STIs)
Slide 27
Diagnosis of
Neurosyphilis
• Positive serum RPR or
treponemal antibody test
• Abnormal CSF
• increased WBC
• increased protein
• positive CSF VDRL (not RPR)
• Many false-negative tests occur
• In Namibia, patients with a
positive serum RPR, a
compatible clinical syndrome,
and an abnormal CSF should
be treated for neurosyphilis
Unit 3: Sexually Transmitted Infections (STIs)
Slide 28
Syphilis
Treatment
• Primary, secondary, early
latent:
• Benzathine penicillin 2.4 million
units IM once
• Latent or tertiary syphilis
• Benzathine penicillin 2.4
million units IM once weekly
for 3 weeks (3 injections)
• Neurosyphilis
• Penicillin G 2-4 million units IV
q4 hourly for 10-14 days
Unit 3: Sexually Transmitted Infections (STIs)
Slide 29
Syphilis and HIV
• In general, manage as in HIV
uninfected patients.
• Primary syphilis may not have
classical appearance
• Unusual serologic responses
may occur.
• Neurologic complications in
early syphilis more frequent
• If symptoms, RPR + and CSF
abnormal treat for
neurosyphilis
Unit 3: Sexually Transmitted Infections (STIs)
Slide 30
Chancroid in Men
• Painful
• Soft edge
• Clean, sharp
edges
• Yellow exudate
in base
Source: ©Wellcome Trust, 2003
• May be multiple
• Most common
locations:
foreskin,
corona,
frenulum
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 31
Chancroid in Women
• Painful
• Soft edges
• Clean, sharp
edges
• Yellow
exudate in
base
Source: ©Wellcome Trust, 2003
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
• May be
multiple
• Most common
locations:
• Labia,
fourchette,
clitoris,
introitus
Slide 32
Chancroid and HIV
• More likely to have multiple
ulcers
• May respond more slowly to
treatment
• Ceftriaxone IM
• Some recommend multiple
dose treatment erythromycin for
7 days
• Buboes require drainage
• Chancroid increases HIV
transmission
Unit 3: Sexually Transmitted Infections (STIs)
Slide 33
GUD Case Study
• A 22 year old
woman has 3
days of painful
urination,
vulvar pain,
and fever.
• She has
recently
become
sexually active
with a new
partner.
Source: ©Wellcome Trust, 2003
• She has had no prior episodes of
this condition, and has otherwise
been healthy.
Unit 3: Sexually Transmitted Infections (STIs)
Slide 34
Painful GUD:
Differential
• Clustered painful vesicles and
ulcers are typical of Herpes
Simplex Virus (HSV)
• Recurrent clustered painful
vesicles very typical of HSV
• Other painful genital ulcers:
• Chancroid: can be multiple
especially with HIV co-infection
• Bacterial super-infection of any
other genital ulcer
Unit 3: Sexually Transmitted Infections (STIs)
Slide 35
Treatment of HSV
•
•
•
•
•
Clean lesions and keep dry
Health Education/counselling
Condom promotion
HIV/RPR testing
For secondary infection
• Cotrimoxazole 800/160 bd x 7 days
• If severe and prolonged, consider
• Acyclovir* 200 mg 5x day x 7 days or
• Acyclovir* 400 mg 3x day for 7 days
*Acyclovir is not part of the 1999 Namibian
guidelines
Unit 3: Sexually Transmitted Infections (STIs)
Slide 36
HSV and HIV
• Very common co-infection
• HIV causes HSV to be more
severe, more prolonged, and
sometimes very large persistent
painful ulcers occur
• HSV thought to be a very
important factor in increasing HIV
transmission
• HSV can be transmitted even
when no lesions are visible
• Study in Kenya to learn if chronic
suppressive therapy of HSV can
reduce HIV transmission
Unit 3: Sexually Transmitted Infections (STIs)
Slide 37
Painful Ulcers:
Chancroid or HSV?
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 38
Painful Ulcers:
Chancroid or HSV?
• Chancroid: multiple ulcers on
foreskin with edema.
• Oval, well defined, granular base,
yellow exudate
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 39
Other Causes of
Genital Ulcers
Unit 3: Sexually Transmitted Infections (STIs)
Slide 40
Lymphogranuloma
venereum (C. trachomatis
L1, L2 or L3)
• Starts as papule
• May cause painless ulcer
• Papule/ulcer often unapparent
and heals spontaneously
• Cause inguinal
lymphadenopathy and buboes
• Treatment 14 days doxycline
or erythromicin
Unit 3: Sexually Transmitted Infections (STIs)
Slide 41
Granuloma Inguinale
Caused by
Calymmatobacterium
granulomatis
• Uncommon
• Large chronic
ulcers
• Painless
• Beefy red
• Bleed easily
Treatment
Source: ©Wellcome Trust, 2003
• 21 days of
Doxycycline 100 mg bd
OR
Erythromycin 500 mg 4x day
Unit 3: Sexually Transmitted Infections (STIs)
Slide 42
Inguinal Bubo
No
Genital
Ulcer
present?
Doxycycline 100 mg bd
14 days
Health ed/Partner
treatment
HIV/RPR test
Aspirate bubo if needed
Condoms
Pregnancy: erythromycin
500 mg qid 14 days
Use flowchart for
Genital Ulcer
Improvement in 7 days?
No
Yes
Yes
Fluctuance?
Continue treatment
Continue treatment
No
Yes
Aspirate bubo
Continue treatment
Unit 3: Sexually Transmitted Infections (STIs)
Refer to Handout 3.2 or
Section 4.6 (page 17) of the
MoHSS Guidelines for the
Syndromic Management of
STDs.
Slide 43
Inguinal Bubo (2)
• Swelling of lymph nodes in
groin area
• Painful or painless
• Unilateral or bilateral
• Often ‘bubo’ implies that the
swollen nodes are filled with
pus or are draining pus
Unit 3: Sexually Transmitted Infections (STIs)
Slide 44
Inguinal Adenopathy:
Differential Diagnosis
•
•
•
•
Chancroid
Lymphogranuloma venereum
Leg infections
Hernia
• Inguinal or femoral
• Cancer
Unit 3: Sexually Transmitted Infections (STIs)
Slide 45
Chancroid with Bubo
• Ulcer typical of chancroid
• 30-50% have lymphadenopathy
• 10-30% have fluctuant or
draining nodes
• Treated like Chancroid:
• Cetriaxone 250 mg IM
Aspirate
bubo if
needed.
HIV and
RPR tests.
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 46
Lymphogranuloma
venereum
Aspirate
bubo if
needed.
HIV and
RPR tests.
Source: ©Wellcome Trust, 2003
• No active papule or ulcer in this
case
• Bubo has ruptured
• Doxycycline 100 mg bd x 14 days
OR (in pregnancy) Erythromycin
500 mg 4 times daily x 14 days
• Sometimes longer treatment is
needed
Unit 3: Sexually Transmitted Infections (STIs)
Slide 47
Male Urethral
Discharge
Refer to Handout 3.3 or
Section 4.2 (page 9) of the
MoHSS Guidelines for the
Syndromic Management
of STDs.
Ciprofloxacin 500 mg po stat
Doxycycline 100 mg bd for 7 days
Health education
Partner treatment
Condoms
HIV testing
Return if symptoms persist
Re-infection?
Repeat Protocol
Treat Partner
Poor adherence?
Neither?
Extend doxycycline
to 10 days
Refer
Symptoms persist?
Unit 3: Sexually Transmitted Infections (STIs)
Slide 48
Male Urethral
Discharge (2)
Gonorrhea
• Neisseria
gonorrhea
Source: ©Wellcome Trust, 2003
Non-Gonococcal
Urethritis (NGU)
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
• Chlamydia
trachomatis
• Mycoplasma
genitalis
• Ureaplasma
urealiticum
• Others
Slide 49
Male Urethral
Discharge (3)
• Ciprofloxacin 500 mg po stat
• Treats gonorrhea
• Doxycycline 100 mg bd for 7
days
• Treats NGU, especially
Chlamydia
•
•
•
•
Health education
Partner treatment
Condoms
HIV and RPR testing
Unit 3: Sexually Transmitted Infections (STIs)
Slide 50
Scrotal Swelling
Acute onset of pain
and / or swelling?
History of trauma?
Refer urgently
Ciprofloxacin 500mg po stat
Doxycycline 100mg bd for 10 days
Health education
Partner treatment
Condoms
HIV / RPR tests
Improved in 5 days?
Refer
Unit 3: Sexually Transmitted Infections (STIs)
Continue
treatment
Refer to Handout 3.4 or
Section 4.5 (page 15) of
the MoHSS Guidelines for
the Syndromic
Management of STDs.
Slide 51
Scrotal Swelling:
differential diagnosis
• Acute Epididymo-orchitis
• May have urethritis, also
• Chronic Epididymo-orchitis
• Testicular torsion
• Acute severe pain, elevating
testes may greatly reduce pain
• Trauma
• history
• Hernia
• Swelling originates in inguinal
ring, bowel sounds?, reducible?
Unit 3: Sexually Transmitted Infections (STIs)
Slide 52
Scrotal Swelling:
differential diagnosis (2)
• Acute Epididymo-orchitis < 35
years old
• Neisseria gonorrhoea
• Chlamydia trachomatis
• Acute Epididymo-orchitis > 35
years old
• May include enteric organisms
from urinary tract
• Chronic Epididymo-orchitis
• Tuberculosis
Unit 3: Sexually Transmitted Infections (STIs)
Slide 53
Treatment of
Epididymo-Orchitis
• Ciprofloxacin 500 mg po stat
• Docycycline 100 mg po bd for
10 days
• Health education
• Partner treatment
• Condoms
• HIV test
• RPR test
Unit 3: Sexually Transmitted Infections (STIs)
Slide 54
Vaginal Discharge
Yes
Low risk for STD
Treat for vaginitis only
Metronidazole
Clotrimazole pessary
No
Treat for cervicitis & vaginitis
Ciprofloxacin
Doxycycline
Metronidazole
Health education
Partner treatment
Condoms
HIV testing
Re-infection?
Repeat Protocol
Treat Partner
Return if symptoms
persist
Return if symptoms
persist
Poor adherence
Good adherence
Repeat
Doxycycline
7 days
Clotrimazole
pessary 500 mg
stat
Symptoms persist
Refer
Refer to Handout 3.5 or Section 4.1 (page 7) of the MoHSS
Guidelines for the Syndromic Management of STDs.
Unit 3: Sexually Transmitted Infections (STIs)
Slide 55
Vaginal Discharge (2)
Vaginitis
Cervicitis
Urethritis
Candida
GC*
GC*
Bacterial
vaginosis
Chlamydia*
Chlamydia
(NGU)*
Trichomonas* Trichomonas*
(HSV*)
(Syphilis*)
*Sexually transmitted infections
*Partner should be treated
Unit 3: Sexually Transmitted Infections (STIs)
Slide 56
Treatment of Vaginal
Discharge
• Low Risk Women:
• Treat for vaginitis
• Candidiasis
• Bacterial vaginosis
• High Risk Women
• Treat for vaginitis
• Bacterial vaginosis
• Trichomoniasis
• Treat for cervicitis and urethritis
• Gonorrhoea
• Chlamydia
Unit 3: Sexually Transmitted Infections (STIs)
Slide 57
Vulvovaginal Candidiasis
Source: ©Wellcome Trust, 2003
• Clotrimazole 500 mg intravaginal pessary once
• Severe recurrence:
oral fluconazole 200 mg
3 doses in first week then
once weekly
Unit 3: Sexually Transmitted Infections (STIs)
Slide 58
Bacterial Vaginosis (BV)
• Metronidazole
• 400 mg bd x 7 days most
effective
• 400 mg 5 tabs once (same as
Trichomoniasis therapy)
Unit 3: Sexually Transmitted Infections (STIs)
Slide 59
Treatment of Women
at risk for STD
• All women with
• Age < 25 years
• Sexual partner with STD
symptoms
• New sexual partner in last 3
months
• Sexual partner had other
partners in last 3 months
Unit 3: Sexually Transmitted Infections (STIs)
Slide 60
Trichomoniasis
Source: ©Wellcome Trust, 2003
Source: ©Wellcome Trust, 2003
• Metronidazole
• 400 mg 5 tabs once
OR
• 400 mg bd x 7 days
Unit 3: Sexually Transmitted Infections (STIs)
Slide 61
Gonorrhoea and NGU
• Same organisms as in male
urethritis
• Ciprofloxacin 500 mg po once
and Doxycycline 100 mg bd x 7
days
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 62
Vaginal Discharge in
Pregnancy
Substitute
With
Doxycycline
• Erythromycin 500mg 4x daily
for 7 days
Ciprofloxacin
• Ceftriaxone 250mg IM stat
Metronidazole • Clotrimazole pessary 500 mg
once
• May give metronidazole 400
mg bd x 7 days for persistent
symptoms after first trimester
*Pregnant women should have an RPR checked as
well.
*Not in 1999 MOHSS guidelines
Unit 3: Sexually Transmitted Infections (STIs)
Slide 63
Lower Abdominal
Pain in Women
Yes
Rebound tenderness?
Guarding?
Refer
No
Overdue menses?
Abnormal vaginal bleeding?
Recent delivery/labour?
No
Yes
Yes
Suprapubic tenderness?
Vaginal discharge?
Fever?
PID risk factor?
Ciprofloxacin
500mg stat
Doxycycline
100 mg bd x 10 d
Metronidazole
400 mg tds x 7 d
Health education
Condoms
Partner treatment
HIV testing
No
Treat according to history
and other clinical findings
Refer to Handout 3.6 or Section 4.3
(page117) of the MoHSS Guidelines for
the Syndromic Management of STDs.
Unit 3: Sexually Transmitted Infections (STIs)
Improved
in 2
days?
Yes
Continue
Treatment
No
Refer
Slide 64
Lower Abdominal Pain:
Differential Diagnosis
• Pelvic inflammatory disease
•
•
•
•
•
•
•
•
•
•
Salpingitis
Endometritis
Tubo-ovarian abscess
Pelvic peritonitis
Ovarian cyst
Ectopic pregnancy
Septic abortion
Appendicitis
Cystitis and pyelonephritis
Mesenteric adenitis
Unit 3: Sexually Transmitted Infections (STIs)
Slide 65
Pelvic Inflammatory
Disease (PID)
• Risk Factors
• Intra-uterine contraceptive
devise (IUCD)
• Sexual partner with STD
• HIV infection
Unit 3: Sexually Transmitted Infections (STIs)
Slide 66
Factors Suggestive
of PID
• Suspect with findings on gyn
exam:
• Uterine or adnexal tenderness
• Cervical motion tenderness
• Clinical features
• Fever ≥ 38.3°C
• Cervical or vaginal mucopurulent
discharge
• WBCs on microscopic exam of saline
preparation of vaginal fluid
• Elevated ESR or CRP
• Laboratory documentation of N.
gonorrhea or C. trachomatis
• Negative pregnancy test
Unit 3: Sexually Transmitted Infections (STIs)
Slide 67
Pelvic Inflammatory
Disease (PID)
• Treatment for GC, chlamydia,
anaerobes also covers gram
negative enteric bacteria
• Oral therapy of suspected mildmoderate PID
• Ciprofloxacin 500 mg po stat
• Doxycycline 100 mg po bd for 10
days
• Metronidazole 400 mg po tds for 7
days
• Case of severe illness or inability
to take pills
• Ceftriaxone 250mg IM stat and refer
immediately
Unit 3: Sexually Transmitted Infections (STIs)
Slide 68
Severe PID is Treated
in the Hospital with
IV/IM Antibiotics
• IV/IM meds until patient
improves 24-48 hours
• Ceftriaxone IV/IM or
• Cefoxitin IV
• Doxycycline po +/metronidazole po
• Starts in hospital and continues
after release
• 14 day total course of
parenteral and oral antibiotics
• Surgical drainage of
abscesses as needed
Unit 3: Sexually Transmitted Infections (STIs)
Slide 69
Men who have Sex
with Men (MSM)
• Certainly exists in Namibia
although rarely discussed
• In many countries, MSM are
the most likely to have HIV
infection
• Anal receptive intercourse
• Practiced by MSM
• Also sometimes practiced by
women
• Highest risk of HIV transmission
of all sex practices
Unit 3: Sexually Transmitted Infections (STIs)
Slide 70
STDs Associated with
Anal Intercourse
• Proctitis
• GC and chlamydia most
common
• Treat like epidydimitis
• Perianal HSV and warts more
common
• Urethritis with enteric
organisms
• Treat like cystitis
Unit 3: Sexually Transmitted Infections (STIs)
Slide 71
Counselling
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 72
Male Condom
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 73
Female Condom
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Slide 74
Key Points
•
•
•
•
Use syndromic approach to
STIs in primary care and
initial visits
Further evaluation and other
therapy appropriate when
patients do not respond to
syndromic therapy
Persons with STIs should
have HIV testing
Improvement in STI
diagnosis and treatment can
reduce HIV transmission
Unit 3: Sexually Transmitted Infections (STIs)
Slide 75