Tracy Irwin, MD, MPH Assistant Professor University of Illinois at Chicago. Men, Women, Both # in what period of time (i.e.

Transcription

1 STIs and PID Tracy Irwin, MD, MPH Assistant Professor University of Illinois at Chicago Sexual History Lifetime Partners Men, Women, Both # in what period of time (i.e. last 6 mos) Practices Oral, Vaginal, Anal, Objects History of STDs Contraception

2 Case 1 19 y/o G0 presents with vaginal discharge Color Quantity Associated Symptoms itching, pain Duration Vaginal Discharge Normal Vaginal Environment Lactobacilli Acidic Environment Non-Homogenous Discharge White to light yellow color No Odor No Itching

3 Vaginal Discharge Candidiasis Bacterial Vaginosis Trichomoniasis Mucopurulent Cervicitis Gonorrhea Chlamydia Candidasis 40% of vaginal infections Candida Albicans Increased in obese, diabetics, immuno- compromised Diagnosis Thick, curd-like discharge, inflammation, ph<4.5, Hyphae on KOH, Vaginal culture

4 Candidiasis candidiasis-candida-flourescent-stain.htmlstain.html Candidiasis Topical Treatment Azoles (Clotrimazole( Clotrimazole, Terazole, Gynazole) Nystatin Oral Treatment Fluconazole Ketoconazole Treatment Resistance Boric Acid Suppository, Gentian Violet, Flucytosine, Treatment of Partner

5 Bacterial Vaginosis (BV) 25% of vaginal infections 50% of women are assymptomatic Implicated in preterm labor, chorioamnionitis, endometritis,, PID, post- op infections Diagnosis milky white discharge, whiff test, clue cells, ph>4.5, gram stain, commercial tests (DNA probe, amines) Bacterial Vaginosis NORMAL CLUE CELL

6 Bacterial Vaginosis Treatment Oral or topical Metronidazole Oral or topical Clindamycin Trichomoniasis 25% of vaginal infections 50-80% of women are assymptomatic S/Sx Sx frothy discharge, strawberry cervix, lower abdominal pain Diagnosis wet mount, culture, PCR, pap smear, UA

7 Trichomoniasis Trichomoniasis Treatment Oral Metronidazole 2 grams PO x 1 dose Treatment of Partners

8 Chlamydia Endocervical Pathogen Can be diagnosed from urethral swab Risk factor for PID, Ectopic Pregnancy, infertility Tx Azithromycin 1g po x 1, Doxycycline 100mg po bid x 7d Treat partners Test of Cure pregnancy > 14 days after tx Gonorrhea Endocervical pathogen Risk factor for PID, ectopic pregnancy Tx Ceftriaxone 125mg IM x 1, Cefixime 400mg po x 1

9 PID Infection of upper genital tract 1 million cases/year Prevalence 1-2% 1 sexually active women Most common serious infection age y/o 2.5 million doctors visits/year ,000 hospitalizations/year Sequlae Ectopic,, Pelvic Pain, Infertility PID - Diagnosis Cervical Motion Tenderness (CMT) or Uterine or Adnexal Tenderness Temp >101 Purulent Vaginal Discharge Positive GC or CT Increased ESR or CRP Abundant WBCs on wet mount Endometrial biopsy w/endometritis TVUS with evidence of Tubo-Ovarian Abscess Laparscopic findings

10 PID ACUTE PID / TUBO-OVARIAN OVARIAN ABSCESS Pelvic Inflammatory Disease (PID) FITZ - HUGH - CURTIS

11 PID - Pathophysiology 30-40% Chlamydia or Gonorrhea Polymycrobial Sweet et al organisms cultured from L/S cases Aerobes Non-hemolytic Strep, Coag- Negative Staph, E.Coli,, Enteric pathogens, H. Influenza Anareobes Bacteroides, Prevotella, Peptostrep, Gardenerlla PID - Treatment 70 % Outpatient Monitor for response in 72 hours Inpatient vs. Outpatient Unable to tolerate PO Failed outpatient treatment TOA Peritonitis Non-compliant (adolescent, disabled)

12 PID - Treatment Outpatient Levoquin 500po qd x14 days and Flagyl 500mg po BID x 14 days Ceftriaxone 250mg IM x 1 and Doxycycline 100mg po BID x 14 days +/- Flagyl 500mg po BID x 14 days Inpatient Cefotetan 2g IV q12 and Doxycycline 100mg po/iv q 12, on d/c doxy to total 14 days Clindamycin 900mg IV q8 and Gent 2mg/kg IV loading dose then 5mg/kg IV qd,, on d/c doxy or clinda to total 14 days PID - Treatment IR drainage if abscess present Laparoscopy with conservative debridement and drainage Fails Inpatient Antibiotics Life Threatening Infection Persistant Symptomatic Mass

13 Case 2 25 y/o G2P2 with bumps down there and dysuria Where How many Character vesicles, rough, smooth Associated Sx dysuria,, discharge, groin pain, flu sx Duration Similar symptoms previously Herpes Simplex Virus (HSV) Chronic life-long long infection HSV-1 1 and HSV-2 Variable viral shedding Many patients assymptomatic S/Sx Sx flu-like like Sx,, painful vesicular ulcers Primary Outbreak and Recurrent Outbreak Diagnosis Culture, PCR, IgG, IgM

14 Herpes (HSV) HSV- Treatment Initial Outbreak Acylcovir 400mg TID x days Valcyclovir 1gram qd x days Recurrent Outbreak Acyclovir 800mg TID x 5d Valcyclovir 500mg BID x 5d Suppression Frequent outbreaks, non-concordant couples, pregnancy >36 wks Acyclovir 400mg BID or Valcyclovir 500-1gram qd

15 HSV Counseling episodic nature, recurrence, episodic vs. suppressive tx,, partner notification, perinatal transmission Pregnancy If primary outbreak acquired in third trimester 30-50% transmission risk If acquired 1 st trimester < 1% risk of transmission If active lesions visualized when in labor will need cesarean section Syphilis Treponema Pallidum Primary Painless Ulcer/Chancer Early lesions very infections 1/3 of those exposed will contract disease Secondary skin rash, mucocutaneous lesions, lympadenopathy 25% of untreated develop systemic illness Tertiary cardiac, opthalmic, neurologic problems, gummatous lesions Latent - < 1year is early latent, >1 year late latent Early latent still infectious Late latent probably not infectious

16 Syphilis Syphilis - Diagnosis Dark Field Microscopy or direct fluorescence antibodies SPIROCHETE Serology Non-Treponemal RPR or VDRL (increase titer by 4-fold) 4 Treponemal FTA-ABS ABS

17 Syphilis SPIROCHETE Syphilis Tuskegee US Govt experimented on 399 black sharecroppers. Largest non-therapeutic experiment ever Collected medical information from sx,, diseases and autopsies on tertiary syphilis Treatment Primary/Early Latent PCN G 2.4 mil units IM x 1 Late Latent/Unknown PCN G 2.4 mil units IM q wk for 3 wks PCN allergy Azithromycin or Doxycycline All pts clinically and serologically tested 6 and 12 months after initial treatment Four fold reduction in titer demonstrates response

18 Human Papiloma Virus (HPV) Most Common STI 43-64% of women infected High risk types (16,( 18 68, 73, 82) found in 90% of cervical cancers 16, 18,, 31, 33, 35, 39, 45, 51,52, 56, 58, 59, 70-80% of sexually active adults have been exposed Low risk types (6, 11,, 40, 42, 43, 44, 54, 61, 70, 72, 81, CP6108) risk factor for condyloma accuminata Cervical Dysplasia High Risk HPV

19 Condyloma / Genital Warts Low Risk HPV Condyloma - Treatment Patient Administered Podofilox 0.5% gel or solution (condylox( condylox) BID for 3 days, limit 10 cm² and cycles Imiquimod 5% cream (aldara( aldara) QHS 3 times a week, wash off in am, max 16 wks Provider Administered Trichloracetic Acid(80-90%) Interferon Cryotherapy Laser or Surgical Excision

20 Chancroid Haemophilus Ducreyi (gram (-)( ) rod) Clinical Diagnosis Painful soft ulcer Tender lymphadenopathy Culture (<80% sensitive) PCR (not FDA approved) Gram Stain ( school( of fish ) Chancroid

21 Chancroid - Treatment Azythromycin (single dose) Ceftriaxone (single dose) Ciprofloxacin (2 weeks) Erythromycin (2 weeks) Granuloma Inguinale Calymmatobacterium Granulomatis Rare in the US, endemic in tropical areas Painless, progressive, ulcerative lesions No lymphadenopathy Biopsy demonstrates Donovan Bodies Treatment Doxycycine 100mg BID x 3wks Azithromycin 1gm q wk x 3wks Ciprofloxacin 750mg BID x 3wks Bactrim DS BID x 3wks

22 Granuloma Inguinale Lymphogranuloma Venereum Chlamydia Trachomatis Serovars L1, L2, L3 Rare in US, endemic in tropical regions S/Sx Sx Stage 1 small painless sore Stage 2 unilateral lymphadenopathy Bubo puss filled bulge at lymph nodes near infection

23 Lymphogranuloma Venereum Lymphogranuloma Venereum Diagnosis Culture Enzyme Immunoassay Serologic Testing Treatment Doxycycline or Erythromycin x 3 wks

24 Global Estimates of New STI Cases Trichomoniasis Chlamydia Gonorrhea Syphilis 174 Million 92 Million 62 Million 12 Million WHO, 1999 Public Health and STIs Primary Prevention: Measures to prevent one from obtaining the disease Education Safer Sexual Behaviors Availability, Access, and Use of Condoms Encouraging Health-Seeking Behavior Voluntary Counseling and Testing

25 Public Health and STIs Secondary Prevention Recognition, early diagnosis and provision of care Access to Care Effective and Acceptable Treatment Strategies Educate providers to provide up to date Treatments