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Sexually Transmitted Infections ATAEI .B , MD. MPH. CASE 1 مرد جوانی 4روز بعد از تماس جنسی مشکوک دچار ضایعه دردناک الت تناسلی می شود د .در معاینه زخم نمای کثیف دارد وبه اسانی خونریزی می نماید .ودر لمس سفتی ندارد. غده لنفاوی بزرگ و دردناک نیز در ناحیه اینگوینال لمس میگردد. تشخیص بالینی شما چیست؟ ETIOLOGY Usual causes Herpes simplex virus (HSV) Haemophilus ducreyi (chancroid) INITIAL TREATMENT Herpes confirmed or suspected (history or sign of vesicles): Treat for genital herpes with : acyclovir, valacyclovir, or famciclovir INITIAL TREATMENT First episodes: acyclovir (200 mg 5 times per day or 400 mg tid), valacyclovir (1 g bid), famciclovir (250 mg bid) for 7–14 days is effective. INITIAL TREATMENT Chancroid confirmed or suspected (diagnostic test positive, or HSV and syphilis excluded, and lesion persists): Ciprofloxacin 500 mg PO as single dose or Ceftriaxone 250 mg IM as single dose or Azithromycin 1 g PO as single dose CASE 2 بیمار 30ساله ای 3هفته بعد از یک تماس جنسی مشکوک دچار یک پاپول روی دستگاه تناسلی شده است این ضایعه 3 روز بعد تبدیل به اولسر با جدار منظم می شود که بدون درد ودر معاینه سفت است وهمراه با لنفادنوپاتی بدون درد یکطرفه میباشد. تشخیص بالینی شما چیست؟ ETIOLOGY Usual causes Treponema pallidum (primary syphilis) lymphogranuloma venereum USUAL INITIAL LABORATORY EVALUATION Dark-field exam, direct FA, PCR for T. pallidum; RPR or VDRL test for syphilis (if negative but primary syphilis suspected, repeat in 1 week); INITIAL TREATMENT Syphilis confirmed (dark-field, FA, or PCR showing T. pallidum, or RPR reactive): Benzathine penicillin 2.4 million units IM once to patient, Preventive treatment Recent (e.g., within 3 months) Seronegative partner(s), All seropositive partners STDS (LYMPHOGRANULOMA VENEREUM) Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be examined, tested for urethral or cervical chlamydial infection, and treated with a chlamydia regimen (azithromycin 1 gm orally single dose or doxycycline 100 mg orally twice a day for 7 days). CASE 3 جوان 23ساله ای 4روز بعد از تماس جنسی مشکوک به علت ترشح از مجرا و سوزش ادرار به مطب شما مراجعه می نماید. تشخیص بالینی شما چیست؟ URETHRITIS (1) mucopurulent or purulent urethral discharge, (2) Gram stain of urethral secretions demonstrating 5 or more leukocytes per oil immersion microscopic field, or URETHRITIS (3) a positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine demonstrating 10 or more leukocytes per high-power field. ETIOLOGY Neisseria gonorrhoeae* CAUSES OF NONGONOCOCCAL URETHRITIS Chlamydia trachomatis (15–50%)* Ureaplasma urealyticum (10–40%)* Mycoplasma genitalium (30%??) Trichomonas vaginalis (1–17%)* Herpes simplex virus (primary) (?%) TREATMENT Initial Treatment for Patient and Partners Treat gonorrhea (unless excluded): plus Treat chlamydial infection: Ceftriaxone, 125 mg IM; or Azithromycin, 1 g PO; or Cefpodoxime, 400 mg PO; or Doxycycline, 100 mg bid for 7 days Cefixime, 400 mg PO *Epidemiologic treatment of sexual partners is recommended ALTERNATIVE REGIMENS Ceftizoxime (500 mg IM, single dose) or Cefotaxime (500 mg IM, single dose) or Spectinomycin (2 g IM, single dose) or Cefotetan (1 g IM, single dose) plus probenecid (1 g PO, single dose) or Cefoxitin (2 g IM, single dose) plus probenecid (1 g PO, single dose) STDS (TRICHOMONIASIS) male partners should be evaluated and treated with either tinidazole in a single dose of 2 g orally or metronidazole twice a day at 500 mg orally for 7 days. TREATMENT REGIMENS FOR BACTERIAL URINARY TRACT INFECTIONS Condition Characteristic Pathogens Mitigating Circumstances Acute uncomplicated cystitis in women Escherichia coli, None Staphylococcus saprophyticus, Proteus mirabilis, Klebsiella pneumoniae Diabetes, symptoms for >7 d, recent UTI, use of diaphragm, age >65 years Pregnancy Recommended Empirical Treatment 3-Day regimens: oral TMP-SMX, TMP, quinolone; 7-day regimen: macrocrystalline nitrofurantoin Consider 7-day regimen: oral TMPSMX, TMP, quinolone Consider 7-day regimen: oral amoxicillin, macrocrystalline nitrofurantoin, cefpodoxime proxetil, or TMP-SMX TREATMENT REGIMENS FOR BACTERIAL URINARY TRACT INFECTIONS Condition Characteristic Pathogens Mitigating Circumstances Recommended Empirical Treatment Acute uncomplicated pyelonephritis in women E. coli, P. mirabilis, S. saprophyticus Mild to moderate illness, no nausea or vomiting; outpatient therapy Oral quinolone for 7– 14 d (initial dose given IV if desired); or singledose ceftriaxone (1 g) or gentamicin (3–5 mg/kg) IV followed by oral TMP-SMX for 14 Severe illness or possible urosepsis: hospitalization required Parenteral quinolone, gentamicin (± ampicillin), ceftriaxone, or aztreonam until defervescence; then oral quinolone, cephalosporin, or TMP-SMX for 14 d TREATMENT REGIMENS FOR BACTERIAL URINARY TRACT INFECTIONS Condition Characteristic Pathogens Mitigating Circumstances Recommended Empirical Treatment Complicated UTI in men and women E. coli, Proteus, Klebsiella, Pseudomonas, Serratia, enterococci, staphylococci Mild to moderate illness, no nausea or vomiting: outpatient therapy Oral quinolone for 10–14 d Severe illness or possible urosepsis: hospitalization required Parenteral ampicillin and gentamicin, quinolone, ceftriaxone, aztreonam, ticarcillin/clavulanate, or imipenem-cilastatin until defervescence; then oralc quinolone or TMP-SMX for 10– 21 d