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FINAL - STIs > STI lecture > Flashcards

STI lecture Flashcards

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1
Q

What is the most common bacteria STI we see in Canada?

A

Chlamydia - No 1
Gohnnorhea - No2

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2
Q

Why did STI Cases go down during covid?

A

Lack of access to testing

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3
Q

Which STIs are supposed to be reported to public health?

A
  • Chlamydia
  • Gonorrhea
  • Chancroid
  • Syphilis
  • Viral Hepatitis
  • HIV

Sexyal partners of all reportable STIs should be notified for evaluation and treatment - Trace back period depends on STI

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4
Q

Why are STIs reported to public health?

A
  • Contact tracing
  • Surveillance
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5
Q

Which sex does chlamydia affect more?

A

Females and more likely in those < 30

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6
Q

Gonorrhea occurs in who?

A

Men and those < 30

Chlamydia and Gonorrhea often exist together

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7
Q

What how much is syphilis increasing across Canada in the past few years?

A

Increasing 5 fold, also increasing rates of congenital syphilis across Canada.

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8
Q

How common is HPV infection?

A

About 70% of adults have had at least one HPV infection in their life
Young adult women and men are effect

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9
Q

Genital herpes causes? Which groups get this?

A

Caused by HSV 1 and 2
Common in adolescent and adult men and women

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10
Q

What are risk factors for STIs?

A
  • uprotected sexual activity
  • A new sexual partner or more than 2 sexual partners in the past
  • serially monogamous indivuals
  • Homelessness
  • Risky behaviors,
  • injection drug use
  • Other substance use (alcohol, marijuana)
  • Sex workers
  • Survival sex
  • Anonymous sexual partnering
  • Rape
  • Previous STI
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11
Q

STI screening offering?

A
  • Typically should be routine approach
  • Offer STI screening as part of their routine care
  • Routine testing should normally include testing for chlamydia, gonorrhea, syphilis, HIV and viral hepatitis
  • Trichomonas should be added for women
  • Genital herpes and HPV should also be considered (serologic testing not recommended.
  • PAP testing indicated for HPV screening.
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12
Q

What is the recommendation regarding what to screen for if a patient presents with symptoms of STI?

A

Screening recommended for ALL STIs indicated if pt presents with symptoms of one.
In General - Infection with one STI increases the risk of HIV transmission. Syphillis, genital herpes, trichomoniasis, HIV-infected patients may be less responsive to some STI treatments, especially if they are quite immune-suppressed. Consult guidelines for specific management info
Informed consent required for HIV testing.

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13
Q

Does STI increase risk of HIV intransmission?

A

YES!!!

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14
Q

What are the three typical times people/ populations that should be screened for STIs?

A
  1. Prenatal screening - at first visit and repeated depending on risk factors
  2. Risk factor screening - those> 25 years - (risk factors include: Mutiple sex partners, partner with STI, anonymous sex partners, sex while under influence, and those who don’t use condoms
  3. Annual screening - <30 years old
  4. Gay, bisexual and MSM, and transgender populations
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15
Q

How is chlamydia and Gonorrhea screened for?

A

Urine test - NAAT
ALSO a swab a reported symptom sites (urethral, vginal or cervical area, rectal, pharyngeal) - PATIENT COLLECTED SWABS ARE ACCEPTABLE

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16
Q

How is syphilis screened?

A

Blood serology

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17
Q

Chlamydia and Gonorrhea screening how is this done?

A
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18
Q

How to counsel patients on how to prevent STIs?

A

Condoms for all sexual activity - Latex and polyurethane condoms prevent the majority of STIs, including HIV, HBV, Chlamydia and gonorrhea, but they do NOT protect against - HPV, HSV or syphilis

  • Ensure all pts know how to put on a condom, avoid condoms with nonoxylnol-9 (spermacide) Increases the risk of HIV and STI by causing disruptions and lesion in genital and anal mucosa
  • STI modes of transmission
  • Risks of various sexual activity
  • barrier method options (male condom, female condom, dental dam
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19
Q

Chlamydia is cause by what type of bacteria?

A
  • Chlamydia trachomatis serovars D-K
  • It is a weakly gram-negative intracellular bacteria
  • Serovars L1, L2, and L3 Cause Lymphogranuloma venereum
  • Preferentially affect lymphatic tissue.
  • Important cause of proctitis in MSM
  • Can present as small painless ulcers or painful hemorrhagic proctitis - anal fistulaw and strictures
  • ## MOST COMMON TYPE OF INFECTIOn
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20
Q

What is the bacteria that causes gonorrhea?
INcubation period?

A

Nisseria, Gonorrhaea
Gram-negative intracellular diploccocus bacter

  • 2nd most common bacterial STI in Canada - Affects males aged 20 to 24 and females age 15 to 19
  • Networks of people with high transmission activities contribute to current prevalence and sustained infections in some communities

Incubation period - 2 to 7 days
- Symptoms typically occur within a week of exposure; however, may be asymptomatic especially in females
- Rectal and pharyngeal infections are more likely to be asymtomatic.

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21
Q

What is the clinical presentation of Chlamydia and Gonorrhea in:
Males vs. females genital symptoms

Extra genital symptoms

A

Genital symptoms - Urethritis in pts with penis - dysuria, urethral pruritis, and discharge
- Acute epididymitis - unilateral, posterior testicular pain and swelling
- Cervicitis - may be asymptomatic - abnormal vaginal discharge, intermenstrual bleeding
- Pelvic inflammatory disease -Abdominal or pelvic pain, dyspareunia abnormal uterine bleeding, can lead to infertility

EXTRA genital symptoms
- Proctitis with tenesmus, anorectal pain, bleeding and mucopurulent discharge
- LGV (L1, L2, and L3) can cause invasives infections -
- Oropharyngeal infections - commonly asymptomatic
- Uncommon - bacteremia: septic arthritis, disseminated GC infection
- reactive arthritis

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22
Q

When is treatment indicated for Chlamydia?

A
  • positive chlamydia test
  • Diagnosis of syndrome compatible with chlamydia infection with out results
  • Diagnosis of chlamydia in a sexual partner
  • As co-treatment along with diagnosis of N. Gonorrhaoeae
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23
Q

What is the preferred treatment for chlamydia?

A

Doxycycline 100mg BID for 7 days OR
Azithromycin 1g as a single dose (if poor compliance expected)

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24
Q

What is the treatment for LGV infection?

A

Doxycycline 100mg BID for 21 days

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25
What is EPT?
Expedited partner therapy - prescription for individual to fill for partner.
26
What are treatment considerations for a positive gonorrhea test?
- Treat for both chlamydia and gonorrhea - Antibiotic resistance is a growing concern - Combination therapy is indicated - Quinolones, tetracyclines no recommended for routine therapy - Macrolide monotherapy should be avoided - High dose azith may be considered in cephalosporin allergy Cephalosporins - More data supports ceftriaxone vs. cefixime in uncomplicated infections and when high tossue penetration is necessary to achieve cure (eg. pharyngeal infection and complicated cases - PID, epididymu\itis, epididymo-orchitis ** Penetration of cefixime in oropharynx is not idea, and failures have been reported - Combination therapy to cover chlamydia is recommended in Canada - Directly observed therapy with single dose regimen is desirable - Disseminated gonococcal infections may require hospitalization
27
What is the treatment of gonorrhea for: 1. Anogenital infection (Not MSM) 2. MSM - anogenital infection or Pharyngeal infection
1. Ceftriaxone 250mg IM as a single dose PLUS azithromycin 1g OR Cefixime 800mg as a single dose PLUS azithromycin 1g po in a single dose 2. Ceftriaxone 250mg IM as a single dose PLUS azithromycin 1g as a single dose Alternatively - cefixime 800mg as a single dose PLUS azithromycin 1g as a single dose
28
What are important patient counselling and monitoring for CT and GC
1. Adherence 2. All sexual partners in the past 60 days should be tested and empirically treated - if no partner in last 60 days, trace back to last known partner 3. Abstain from unprotected sex until full course of treatment is complete for all partners, or for 7 days after single dose treatment 4. CT - test of cure not routinely indicated except in pregnancy and pre-pubertal children, or if adherence concerns - at 4 weeks using NAAT 5. GC - follow up cultures for test of cure from all positive sites should be done 3 to 7 days after completion of therapy - treatment failure is defined as absence of reported sexual contact during post treatment period and either a. Positive gram stain or culture b. positive NAAT of specimens taken 4 weeks after completion of treatment Repeat testing is recommended at 3 to 6 months due to high reinfection risk
29
What organism causes syphilis?
Treponema pallidum
30
How is syphilis spread?
Highly transmissible through contact with active lesions or infected body fluids even in absence of symptoms. - Primarily through vaginal and oral sexual contact (60% risk of transmission per contact) - Kissing, sharing of needles and injection equiptment, blood transfusion, needlestick injury and solid organ transplantation have also been reported routes of transmission
31
What are the stages of syphilis?
32
Describe primary syphilis: 1. When does it occur after contact 2. What does it look like if symptomatic 3. Recollection of primary chancre
1.Occurs 3 to 90 days after contact 2.Chancre/lesion on genitals,anus or in the mouth 3.Regional lymphadenopathy 4.High proportion of individuals fail to recall a primary chancre
33
Describe Secondary syphilis: 1. When does it occur 2. What does it look like?
1. Occurs 2 weeks to 6 months after contact 2. Rash (often on palms of hands, soles of feet and trunk/back area) fever,malaise, lymphadeopathy, mucosial lesions, patchy or diffuse alopecia, meningitis, headaches, uveitis, retinitis
34
Desccribe the following: 1. Early latent Syphilis 2. Late Latent syphilis 3. Tertriary (Late) syphilis 4. Neurosyphilis
1. Early latent - <1 year duration (infectious) 2. Late latent: >1 year duration (non-infectious) Only evidence of latent infection is positive serology because it is asymptomatic 3. Tertiary - symptomatic - Cardiovascular, gumma, and neurosyphilis 4. Neurosyphilis - Headaches, vertigo, loss of hearing, personality changing, dementia, ataxia
35
Describe treponemal testing for syphilis
- Measures antibody vs. T. pallidum antigens - Usually reactive for life - Includes TP, and TP-PA - T. Pallidum particle agglutination
36
Describe non-treponemal tests
- Non-specific for T. Pallidum - Measures antibody directed at cardiolipid-lecithin cholesterol antigen - Titres correlate with disease activity - used to follow response to treatment - includes VDRL and RPR
37
What are some important testing considerations with regards to syphilis testing?
1. Serology can yield false negative results in primary syphilis - Negative result should be repeated in 2 to 4 weeks in suspicious case contacts of positive syphilis case 2. Successful treatment reduced RPR and VDRL titres 3. Indications for testing CSF in suspected confirmed syphilis with - Neurological or opthalmic signs and symptoms, congenital syphilis, treatment failure
38
What are the treatments for syphilis? a. Primary, secondary, and early latent b. Late latent, latent syphilis of unknown duration, cardiovascular and other tertiary syphilis not involving CNS c. Neurosyphilis
39
What is the follow up for syphilis?
40
What is the estimated lifetime risk of infection of HPV?
75%
41
How is HPV transmitted?
Transmitted through penetrative vaginal, anal and oral sex, as well as digital- vaginal sex and skin-to-skin contact * Vertical transmission is also possible
42
What are the various ways HPV is screened and prevented?
Condoms * Cancer screening * Pap smears (cervical, anal) HPV vaccination * Gardasil® 9 (HPV9)– protects vs. HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
43
WHich type of HPV is oncogenic?
16 and 18
44
What percentage of cervical cancers does immunization of HPV types 16 and 18 prevent? Genital warts
70% of cancers 90% of genital warts
45
What are the vaccine schedules for HPV?
46
What is the cause of genital herpes?
- Usually caused by HSV-2 but may be from HSV-1 - Incubation period ~6 days following initial infection, virus remains dormant in lumbar-sacral ganglia (HSV-2) - Transmission occurs through contact with lesions, mucosa genital secretions and oral secretions where HSV is present
47
HOw is genital herpes transmitted?
Transmission occurs through contact with lesions, mucosa, genital secretions and oral secretions where HSV is present * Virus may be shed through contact even when no visible lesions are present (one study showed this occurred in about 70% of cases) * Condoms reduce transmission by ~50% * Infections present more commonly in women and is more easily transmitted from men to women, then vice versa * Increases risk of HIV infection ~2-fold
48
How does genital herpes present?
Diagnostic lesion is a cluster of vesicles on an erythematous background * Presentations can be considered in terms of initial symptomatic episodes (primary and non-primary) and recurrent disease, with periods of asymptomatic shedding * Triggers may include menstrual cycle, emotional emotional stress, illness (esp w/fever), sexual sexual intercourse, surgery, certain meds
49
Describe genital herpes primary infection? a. What does it look like? b. Symptoms c. Complications d. Mean time to resolution?
Primary * Extensive painful vesiculoulcerative lesions * Fever, myalgia (~60%) * Tender lymphadenopathy (80%) * Complications: aseptic meningitis (16-26%), extragenital lesions (10-28%) * Mean time to resolution 16.5 (men) to 22.7 (women) days
50
What are the symptoms for a non-primary infection HSV (1st Clinically evident episode in someone who has prior heterologous Ab's) 1. More or less extensive than primary? 2. Likelihood of systemic symptoms 3. Duration?
* Less extensive genital lesions * Less likely to have systemic symptoms or complications * Duration less prolonged: mean 15.5 days
51
What is current disease of herpes like?
Due to reactivation of latent sacral sensory ganglion infection * Typically localized small painful genital lesions (mean lesion area <10% of primary infection) * Systemic symptoms only in 5-12% * Prodromal symptoms in ~50% for 1-1.5 days * Mild burning, itching or tingling * Mean duration of lesions: 9-10.5 days
52
How is genital herpes screened and diagnosed?
* Routine screening not indicated * Culture of lesions can confirm infection with HSV (1 or 2) – not commonly performed
53
What is the point of treating genital herpes infection?
* Treatment is recommended for clinically important symptoms * Goals are to relieve symptoms and shorten clinical course * Treatment may reduce disease transmission * Non-pharmacologic advice: * Keep lesions clean with gentle washing (mild soap and water) * Saline baths, antipyretics or analgesics as needed
54
What are the recommended treatments for 1st episode of genital herpes? Recurrent?
55
Is there a difference in efficacy for treating genital herpes between acyclovir, famiciclovir, valacyclovir? What about topical?
Comparatively effective! TOPICAL ACYCLOVIR SUCKS for genital herpes
56
When should therapy be initiated for genital herpes with: a. acyclovir b. famciclovir c. Valacycolovir
Acyclovir - up to 5 to 7 days after onset of symptoms Fam - fewer than 5 days Val - fewer than 72 hours * Start asap during development of recurrent lesion – ideally within 6 hr (fam) or 12 hrs (val) after 1st sxs appear * Keep meds on hand and start when prodromal sxs recognized
57
When is suppressive therpay indicated for pts with frequently recurring lesions of genital herpes?
Suppressive therapy may be indicated for patients with frequently recurring lesions (at least every 2 months or 6x/year) to improve QOL * Episodic therapy is indicated for less frequent recurrences
58
What is the dosing for suppressive therapy for genital herpes with acyclovir, famciclovir, valacyclovir?
Acyclovir - 200mg 3 to 5 times per day OR 400mg BID Famciclovir 250mg BID Valacyclovir 500mg daily or 1g daily Reassess after 12 months
59
Which antivirals are used in pregnancy for genital herpes?
* In pregnancy, acyclovir or valacyclovir have been evaluated and shown to be efficacious * Administration may reduce need for caesarian section to prevent neonatal herpes * Neonatal herpes – treat with acyclovir 45-60 mg/kg/d IV in three divided doses for 14-21 days
60
Describe what type of screening should occur with STIS in pregancy?
At 1st prenatal visit, all pregnant women should undergo screening for: * HIV, HBV, chlamydia, gonorrhea and syphilis * Repeat screening each trimester based on ongoing risk * Some STI may increase risk of miscarriage or preterm birth * Presence of STIs at delivery poses risk to newborn – will also require testing and treatment
61
Which medications should be avoided in pregnancy specific to potential STI meds? Is follow-up and test of cure recommended?
STIs should be treated, considering safety of medications in pregnancy * Avoid: Erythromycin estolate, sulfamethoxazole, fluoroquinolones, doxy/tetracycline, podophyllin/podophyllotoxin/imiquimod, * Refer to pregnancy chapter of Canadian STI guidelines for appropriate, safe therapy * Follow up and test of cure is usually recommended
62
63
What is the incubation period for Chlamydia?
incubation period is 2 to 6 weeks - Symptoms appear within 3 weeks; however infection is asymptomatic in 50 to 70 % of cases
64
What is the preferred test to screen for chlamydia and gonnorhea for patients with vagina? First void urine, or Swab?
A swab for NAAT is PREFERRED - Self collected swab just as good as practitioner collected. REMEMBER TO SWAB PHARYNGEAL or ANAL if they have ANAL OR ORAL SEX But for penile reconstruction or gender affirming genitals - a urine for NAAT is the preferred specimen.

FINAL - STIs (2 decks)

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