Transcript دكتر عطايي
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