Transcript Common STI in Primary Care

Common STI in Primary Care
Dr Sadia Shaikh
GP Registrar
MBBS,DRCOG,DFSRH,
Letter of Competence in IUT and Sub dermal implants
Certificate of Competence in Sexual Health Clinical Skills.
Quiz
► When
should you suspect Chlamydia ?
► What are the symptoms in women ?
► What are the symptoms in men?
► When you should start treatment & what
will you give?
► What antibiotic –if pregnant or breast
feeding?
When should you suspect and test for
Chlamydia?
► Women:
 Test for Chlamydia if they are sexually active
with symptoms and signs suggesting
Chlamydia:
► Post-coital
or intermenstrual bleeding.
► Purulent vaginal discharge.
► Mucopurulent cervical discharge or/contact bleeding
► Deep dyspareunia.
► Dysuria.
► Pelvic pain and tenderness.
► Asymptomatic in approx 70%.
Continued….
► Men:
 Test for Chlamydia if they are sexually
active with symptoms and signs
suggesting Chlamydia:
►Dysuria
(urinary frequency or nocturia is more
suggestive of a urinary tract infection).
►Urethral discharge.
►Urethral discomfort.
►Asymptomatic in over 50%.
Management
In people with signs or symptoms strongly
suggestive of Chlamydia, start treatment without
waiting for laboratory
confirmation (after testing for other sexually
transmitted infections as appropriate).
► Strongly
encourage all people who test positive for
Chlamydia to undergo screening for other sexually
transmitted infections, including an HIV test and,
where indicated, hepatitis B screening and
vaccination.
Management
► First-line
treatment:
 Azithromycin 1 g single dose, or
 Doxycycline 100 mg twice a day for 7 days.
► In
women who are pregnant or
breastfeeding:
 Azithromycin 1 g single dose, or
 Amoxicillin 500 mg three times a day for 7 days, or
 Erythromycin 500 mg four times a day for 7 days.
Contact Tracing
► Tracing
of all sexual contacts in the previous
6 months is recommended.
Quiz Gonorrhea
► How
you will diagnose in Men?
► What is the incubation period?
► How will you diagnose in women?
► Which antibiotic for anogenital G?
► How to treat pharyngeal G?
► How to do follow up?
► Test of cure?
► Partner notification?& how?
Gonorrhea
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How will you Diagnose in men?
Symptoms usually develop after 2–5 days incubation, although they
may appear after 10 days or more.
Genital infection is most common and causes:
 Urethral discharge in 80% of men.
 Dysuria in about 50% of men. Usually there is no frequency or
urgency.
 No symptoms in 10% of men.
Rectal infection is asymptomatic in most men (about 75%), but may
cause acute proctitis. This presents as anal pruritus, pain and spasm of
the anal sphincter (tenesmus), purulent discharge, or bleeding.
Pharyngeal infection is asymptomatic in 90% of men, but may cause
overt pharyngitis.
How will you diagnose in women
► Asymptomatic
in 50%
► Increased or altered vaginal discharge in up to
50% of women
► dysuria in 12% of women.
► Intermenstrual bleeding, sometimes triggered by
intercourse (less commonly).
► Most
commonly, purulent or mucopurulent
endocervical discharge, or easily induced
endocervical bleeding (in <50 of women).
Management
►
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Ideally, refer all people with confirmed or suspected
gonorrhea to a GUM clinic or to a general practice
providing an enhanced sexual health service.
For confirmed anogenital gonorrhea, prescribe:
 A cephalosporin first line.
►Cefixime (400 mg, single oral dose) is usually
preferred owing to convenience (off-label indication).
►Ceftriaxone (500mg, intramuscular injection) is
licensed but is often not readily available in primary
care.
Management cont…
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Ciprofloxacin (500 mg, single oral dose) if ceph is CI.
For confirmed pharyngeal gonorrhea:
 Ceftriaxone (500 mg, intramuscular injection) first line if this is
available.
 If Ceftriaxone is unavailable, consider a 3-day course of oral
Cefixime (400 mg loading dose, followed by 200 mg twice a day for
3 days). Note this regimen is off label and is recommended on the
basis of expert opinion rather than trial-based evidence.
 Prescribe oral ciprofloxacin (if a cephalosporin is contraindicated)
only if the infection is known to be sensitive to it.
If gonorrhea has not been confirmed, treat empirically whilst waiting
for laboratory confirmation, and consider offering an antibiotic to
cover Chlamydia trachomatis (azithromycin or doxycyline).
Follow up
► After
1 week to verify the success of
treatment.
 Test of cure (swab for culture and sensitivity at
least 3 days after antibiotic treatment) is
required .
► Advise
the person to abstain from sex until
they and any partners have successfully
completed treatment, and to practice safe
sex in the future.
Partner Notification
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►
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symptomatic anogenital gonorrhea, all partners within the
preceding 2 weeks should be notified,
asymptomatic gonorrhea, or gonorrhea at other sites, all
partners within the preceding 3 months should be notified.
Notified partners should be screened for STD’s and
treated empirically for gonorrhea and
chlamydia whilst waiting for results (azithromycin 1 gram
as a single oral dose or doxycycline 100 mg twice a day for
7 days are suitable choices).
Quiz HS
► How
will you diagnose?
► How to treat primary episode?
► How to manage recurrent attacks?
► When to start suppressive therapy?
► What are the triggers factors?
Herpes simplex - genital
► How
will you diagnose?
► Ask about symptoms including painful
ulcers, dysuria, vaginal or urethral
discharge, malaise, and fever; their onset
and duration, and whether similar
symptoms have been experienced
previously .
► Clinical finding & + viral culture.
Contin….
► Ideally,
all people with suspected genital
herpes should be referred to a specialist in
genito-urinary medicine for diagnosis,
treatment, screening for sexually
transmitted infections, counseling, and
follow up.
Treatment in Primary care
► Prescribe
oral aciclovir (200 mg five times a day)
within 5 days of the start of the episode or while
new lesions are forming.
► Apply vaseline or a topical anaesthetic (e.g.
lidocaine 5%) to lesions to help with painful
micturition, if required .
► Increase fluid intake to produce dilute urine (which
is less painful to void). Urinate in a bath or with
water flowing over the area to reduce stinging.
Managing Recurrent Genital Herpes
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Suppressive antiviral treatment (e.g. oral aciclovir 400 mg
twice daily for 6–12 months) if attacks are frequent (e.g.
six or more attacks per year), causing psychological
distress, or affecting the person's social life:
After 1 year, stop treatment for a minimum period of two
recurrences .
If attacks are still considered problematic, restart
suppressive treatment. If attacks are not considered
problematic (off treatment), future attacks can be
controlled with episodic antiviral treatment (if needed).
If the person has breakthrough attacks on suppressive
treatment, seek specialist advice.
Advice
►
►
Episodes usually last up to 10 days and on average people have 4–
5 attacks in the first 2 years. Thereafter, attacks reduce in frequency
and severity, but there is no cure for genital herpes at present.
Transmission can occur when there are no symptoms (asymptomatic
shedding), but that the risk is higher when symptomatic. Advise the
person to:
 Avoid sex (including orogenital sex) if lesions are present.
 Use condoms with new or uninfected partners. Explain that
condoms cannot completely prevent transmission, due to close skin
contact or contact with infected secretions during foreplay.
 Identified personal trigger factors (e.g. sexual intercourse, sunlight,
physical illness, excess alcohol, stress).
Quiz PID
► When
will you suspect?
► What are signs & symptoms?
► What are the risk factors?
► Which antibiotics to treat empirically?
► What are the complication?
► Partner notification
► Follow up?
PID
► How
will you diagnose?
► On clinical grounds.
► Negative swab results do not rule out a
diagnosis of PID.
► Do not delay making a diagnosis and
initiating treatment whilst waiting for the
results of laboratory tests.
When will you suspect?
Pelvic or lower abdominal pain (usually bilateral).
► Deep dyspareunia particularly of recent onset.
► Abnormal vaginal bleeding (intermenstrual, postcoital, or
'breakthrough') which may be secondary to associated
cervicitis and endometritis.
► Abnormal vaginal or cervical discharge as a result of
associated cervicitis, endometritis, or bacterial vaginosis.
► Right upper quadrant pain due to peri-hepatitis (Fitz–
Hugh–Curtis syndrome).
►
What signs to look for?
► Lower
abdominal tenderness — usually bilateral.
► Adnexal tenderness (with or without a palpable
mass), cervical motion tenderness, uterine
tenderness (on bimanual vaginal examination).
► Abnormal cervical or vaginal mucopurulent
discharge (on speculum examination).
► A fever of greater than 38°C, although the
temperature is often normal.
Risk Factors
► Factors
related to sexual behaviour:
Young age (less than 25 years).
Early age of first coitus.
Multiple sexual partners.
Recent new partner (within the previous
3 months).
 History of sexually transmitted infection in the
woman or her partner.
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Continue……
► Recent
instrumentation of the uterus
or interruption of the cervical barrier:
 Termination of pregnancy.
 Insertion of an intrauterine device (within the
past 6 weeks).
 Hysterosalpingography.
 In vitro fertilization and intrauterine
insemination
Management
Women with suspected mild or moderate (PID) may
be treated in primary care if an ectopic pregnancy
can be ruled out.
► Test for other STD’s and other genital infections.
► Provide pain relief with ibuprofen or paracetamol.
► Ceftriaxone 500 mg as a single intramuscular
dose, plus oral doxycycline 100 mg twice daily and oral
metronidazole 400 mg twice daily, both for 14 days .
► Oral cefixime 400 mg as a single dose (off-label use) can
be used as an alternative to ceftriaxone 500 mg in the
above regimen.
►
What advice should I give?
►
The importance of completing the course of antibiotics (even if swabs
are negative) in order to reduce the risk of long-term complications
such as infertility, ectopic pregnancy, and chronic pelvic pain.
 The exception to this is if the woman has mild or moderate pelvic
inflammatory disease (PID) and is unable to tolerate metronidazole. She
may stop taking the metronidazole but must continue with the other
antibiotics in the regimen.
►
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The importance of screening for STD’s.
The need for contact tracing, and screening and treatment of sexual
partners to prevent reinfection.
The need to avoid unprotected intercourse until both the woman and
her partner's) have completed treatment.
That fertility is usually not affected in mild PID if it is treated promptly,
but repeated episodes of PID are associated with an exponential
increase in the risk of infertility.
How will you manage sexual
partners?
► Ideally,
current partners and recent partners
(within the last 6 months) should be seen in
a genito-urinary medicine (GUM) clinic, or
primary care facility with equivalent
expertise for screening, treatment, and
contact tracing.
► Partners may need to be managed in
primary care if they refuse or are unable to
attend a GUM clinic, or if there is likely to be
an unacceptable delay in accessing
specialist services.
Continue…..
► If
it is not possible to adequately screen the
partner for chlamydia and gonorrhea,
empirical treatment for Chlamydia
and gonorrhea should be given.
► Advise sexual abstinence until both
the woman with pelvic inflammatory
disease and her partner have
completed the course of treatment.
Follow up
► Review
within 72 hours.
 There should be demonstrable clinical
improvement (such as a reduction in abdominal
tenderness, and a reduction in uterine, adnexal,
and cervical motion tenderness).
 Check the antibiotic sensitivities from swab
results. Even if swabs are negative, treatment
should be continued.
Quiz Testicular discomfort
► How
will you manage men who present with
testicular discomfort?
► <35 yr/sexually active/multiple partners?
► >35 yr/not sexually active /regular partner
► Follow up
Epididymo-orchititis
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How do you further assess a man or adolescent
with testicular discomfort?
Identify the most likely causative organism based
on risk factors.
Any sexually transmitted infection:
 Age less than 35 years.
 More than one sexual partner in the past 12 months.
 Any urethral discharge.
In sexually active adolescents and men younger than
35 years of age, the causative organism is likely to be
Chlamydia trachomatis or Neisseria gonorrhea.
Continue….
► If
epididymo-orchitis is thought to be
due any sexually transmitted
organism, including gonorrhea:
 Treat without waiting for test results with oral
doxycyline 100 mg twice daily for 10–
14 days, plus a single dose of either
intramuscular ceftriaxone 500 mg, if available,
or oral cefixime 400 mg stat as an alternative to
intramuscular ceftriaxone.
Continued…
► Enteric
organisms associated with lower urinary
tract infections:

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
► In
Low risk sexual history.
Age 35 years or older.
History of penetrative anal intercourse.
Recent urological instrumentation or catheterization.
men 35 years or older and adolescents and
men younger than 35 years of age who are not
sexually active, the causative organisms are
typically enteric organisms found in lower urinary
tract infections, such as Escherichia coli.
Continued….
► If
epididymo-orchitis is thought to be
due to an enteric organism (for
example, Escherichia coli):
 Treat without waiting for test results with
ciprofloxacin 500 mg by mouth twice daily for
10 days, or ofloxacin 200 mg by mouth twice
daily for 14 days.
Advice
► Advice:
 Bed rest, scrotal elevation (such as with
supportive underwear), and analgesia.
 If ciprofloxacin or ofloxacin is prescribed, avoid
nonsteroidal anti-inflammatories, and
discontinue treatment and seek immediate
medical advice if joint or tendon pain occur.
 If symptoms worsen, or do not begin to
improve within 3 days, return for reassessment.
Anogenital Warts
► Diagnosis
is made by examination with the
naked eye in most cases .
► Lesions may be single or multiple and tend
to occur in areas that are traumatized
during sexual intercourse .
► Referral to a sexual health specialist is
recommended for all people with anogenital
warts .