STD Flashcards
What is the most common reportable STD in US
Chlamydia
Chlamydia Incidence (Who, what age, what race, what region?)
Females, 15-24, Black (d/t access to care), South
Risk factors for Chlamydia
new or multiple sex partners, a history of STIs, presence of another STI, and lack of barrier contraception. The presence of columnar epithelial cells on the ectocervix, referred to as ectopy, is a condition that may increase susceptibility to chlamydial infection; oral contraceptive use contributes to ectopy.
RIsk of untreated Chlamydia
pelvic inflammatory disease, chronic pelvic pain, fallopian tube scarring, and infertility
Why doesn’t Chlamydia pop up on a gram stain?
Chlamydia trachomatis is an obligate intracellular bacterium with a cell wall and ribosomes similar to those of gram-negative organisms. The C. trachomatis cell wall is unique in that it contains an outer lipopolysaccharide membrane, but it lacks peptidoglycan; The absence of peptidoglycan explains why the organism is not seen with standard Gram’s staining and why beta-lactam antimicrobials are not effective for treatment.
What is the infectious form and replicating form of C. trachomatis?
elementary body is the infectious form and the reticulate body is the replicative form.
Most common findings in men and women with Chlamydia?
Asymptomatic
Later (uncomplicated) Chlamydia complications in women
Cervicitis is asymptomatic in most cases. When symptoms are present, they can be nonspecific, such as vague discomfort or spotting. Signs on pelvic examination may include mucopurulent endocervical discharge and spontaneous or easily induced endocervical bleeding
Urethral infection with chlamydia in women is usually asymptomatic, but it can cause “dysuria-pyuria” syndrome, or an “acute urethral syndrome”, mimicking acute cystitis. Symptoms may include dysuria and urinary frequency, especially in young women with a recent, new sex partner. Since women with symptomatic chlamydia urethritis have a clinical presentation similar to women with urinary tract infection, the potential exists to miss the diagnosis of chlamydia if testing is not performed in this setting, which will likely result in untreated chlamydia as most treatments for urinary tract infection will not effectively treat chlamydia.
Later untreated complications of Chlamydia
Perihepatitis (Fitz-Hugh-Curtis Syndrome)
Untreated pelvic infection in women with C. trachomatis can cause inflammation of the liver capsule, which is commonly referred to as perihepatitis or the Fitz-Hugh-Curtis Syndrome. Perihepatitis is characterized by right upper quadrant pain, nausea, vomiting, and fever, which are generally accompanied by evidence of PID on physical examination
PID have subclinical infection, some present with lower abdominal pain along with bimanual findings of cervical motion tenderness, with or without uterine or adnexal tenderness
Other Chlamydia manifestations in men and women
Conjunctivitis
Infection of the eye with C. trachomatis can occur in adults as a result of autoinoculation from secretions from another site of infection, such as the genital tract. The signs and symptoms are unilateral eye discomfort with hyperemia. The secretions may be mucopurulent, but are more typically clear to cloudy.
Oropharyngeal Infection
Oropharyngeal infection with C. trachomatis most frequently is asymptomatic in both men and women.[31] It can also present as acute tonsillitis, acute pharyngitis or abnormal pharyngeal sensation syndrome. When clinical signs and symptoms are described, the presentation can range from minimally symptomatic disease (i.e. dry or pruritic throat) to exudative tonsillopharyngitis. Chlamydial tonsillopharyngitis is marked by generalized pharyngeal and tonsillar hyperemia with possible addition of swollen anterior pillars and uvula, as well as diffuse purulent exudate on the tonsils.[32]
Proctitis and Proctocolitis
Infection with C. trachomatis OmpA types D through K in the rectal region is usually asymptomatic, but can lead to proctitis or proctocolitis, which can manifest as rectal pain, mucoid or hemorrhagic discharge, fever, and/or tenesmus.[33] Diagnosis can be supported via anoscopy findings (mucopurulent discharge, pain, and spontaneous or induced bleeding). This infection can occur in men or women practicing receptive anal intercourse. Women may also be infected rectally as a result of local spread of the infection from cervical secretions. Chronic infection can rarely cause scarring and fistula formation. Lymphogranuloma venereum more often presents as proctitis or proctocolitis, and therefore additional diagnostic methods are required to differentiate LGV from nonLGV strains of C. trachomatis.[34,35]
Lymphogranuloma venereum (LGV) LGV is caused by C. trachomatis serovars L1, L2, or L3; it is an uncommon infection in the United States, but sporadic cases and outbreaks have been reported among MSM, most of whom have HIV infection. Although most cases of LGV in the United States are rectal infections, LGV can present with a distinct genital infection syndrome. Signs and symptoms include multiple, enlarged, matted, tender inguinal lymph nodes that may be suppurative and are usually bilateral. Systemic signs and symptoms, such as fever, chills, or myalgia, also may be present.[34] A self-limited genital ulcer sometimes occurs at the site of inoculation. Specimens from genital sites and lymph nodes can be obtained in an attempt to identify C. trachomatis by a nucleic acid amplification test. Nucleic acid testing does not distinguish standard strains of C. trachomatis from LGV strains. The duration of therapy is longer for infections caused by LGV strains (21 days) versus non-LGV chlamydia strains (7 days).[2]
Reactive Arthritis
Figure 10. Reiter’s Syndrome and Circinate Balanitis
Reactive arthritis, previously referred to as Reiter’s syndrome, is a post-inflammatory autoimmune disease that can result from urogenital chlamydia infection. The characteristics of the syndrome include conjunctivitis, urethritis, oligoarthritis, and skin lesions (keratoderma blennorrhagica) and circinate balanitis (Figure 10). Some studies have reported the presence of chlamydia antigens and DNA within the joints.[36] This complication infrequently occurs, but when it does, the onset is typically 3 to 6 weeks after urogenital chlamydia infection and it can occur even in persons who receive effective treatment for chlamydia infection. Reactive arthritis affects predominantly males, particularly those positive for HLA-B27, and it usually resolves within 3 to 6 months. Reactive arthritis may not respond to antimicrobial treatment, but symptoms usually respond to non-steroidal anti-inflammatory agents.
In adults in the United States, Chlamydia trachomatis conjunctivitis occurs most often as a result of which one of the following:
Autoinoculation from an individual’s genital infection
Chlamydial infections in infants and kids
-consequence of inadequate prental care:
Conjunctivitis
For infants, conjunctivitis is the most common clinical condition resulting from perinatal transmission of chlamydia. Ocular infection with C. trachomatis results from exposure of the neonate to infected secretions from the mother’s genital tract during birth and the exposure may also involve mucous membranes of the oropharynx, urogenital tract, and rectum. Inclusion conjunctivitis occurs 5 to 14 days after delivery. The signs range from mild scant mucoid discharge to severe copious purulent discharge, chemosis, pseudomembrane formation, erythema, friability, and edema. Neonatal ocular prophylaxis with silver nitrate solution or antibiotic ointments for prevention of gonorrhea transmission does not prevent perinatal transmission of C. trachomatis from mother to infant. A chlamydial etiology should be considered for all infants aged 30 days or younger who have conjunctivitis.
Trachoma
Trachoma is the leading cause of preventable blindness in the world and is caused primarily by C. trachomatis serotypes A, B, Ba, and C.[37] Trachoma is found in select regions of the world, mostly in the Middle East and Southeast Asia. The disease is most often contracted person-to-person through hand (or fomite) contact with an infected eye, followed by autoinoculation. Most cases of trachoma occur in the setting of poor sanitary conditions and some cases result from fly transmission.[38] Trachoma is not an STD. The process begins as a follicular conjunctivitis, which, if untreated, progresses to an entropion wherein the eyelid turns inward and lashes ulcerate the corneal surface over time. The disease is diagnosed clinically and treatment with single-dose azithromycin is usually effective. This disorder is not a sexually transmitted disease and it is not transmitted from mother-to-child during birth.
Pneumonia
Chlamydia pneumonia in infants occurs 4 to 12 weeks after delivery. Notably, infection of the nasopharynx is thought to be a precursor condition that is usually asymptomatic, but can progress to pneumonia. The signs are cough, congestion, and tachypnea. Infants are usually afebrile, and rales are apparent with auscultation of the lungs.
Urogenital Infection
Urogenital infections in preadolescent males and females are usually asymptomatic and can be the result of vertical transmission during the perinatal period.[2] Genital or rectal infection can persist for as long as two to three years, so infection in young children may be the result of perinatally-acquired infection. Sexual abuse is a major concern when chlamydia (or any STI) is detected in preadolescent males or females. The STI evaluation in a case of suspected abuse should be performed by, or in consultation with, an expert in the assessment of child sexual abuse. Only tests with high specificity should be used because of the legal and psychosocial consequences of a false-positive diagnosis.
In the United States, which one of the following is the most common clinical condition caused by chlamydial infection among neonates (younger than 1 month of age)?
Perinatal eye infection causing inclusion conjunctivitis
What diagnostic test do we use for Chlamydia?
Nucleic acid amplification tests (NAATs) amplify nucleic acid sequences (either DNA or RNA) that are specific for the organism being detected. Similar to other nonculture tests, NAATs can detect live or non-viable organisms.
In women, vaginal swab superior than urine
Which one of the following statements best describes the reporting requirements for a person diagnosed with Chlamydia trachomatis infection in the United States?
Reporting is required in all states
SCREENING FOR CHLAMYDIAL INFECTION TEST USED?
Screening for chlamydia in asymptomatic persons has been found to significantly reduce the incidence of chlamydia–associated PID.
routine screening for chlamydia should utilize NAAT as the diagnostic test; the United States FDA has cleared NAATs for chlamydia testing on (1) male and female urine samples, (2) male and female rectal and throat samples; (3) clinician-collected endocervical, vaginal, and male urethral samples, and (4) self-collected vaginal swabs if obtained in a clinical setting.
Screening for chlamydial indications:
Women Who Have Sex with Men: The high frequency of asymptomatic infection among young women combined with greater risk for morbidity led to the recommendation by the CDC and the USPSTF that all sexually active females younger than 25 years of age undergo annual screening for chlamydial infection.[2,4] More frequent screenings may be appropriate for sexually active adolescents and women with recent C. trachomatis infections. In addition, women 25 and older should undergo routine screening if they are considered to have increased risk for chlamydial infection, such as a new sex partner, more than one sex partner, a sex partner with concurrent (overlapping) partners, or a sex partner who has been diagnosed with an STI. Women diagnosed with chlamydia should have repeat testing approximately 3 months after completing treatment.
Women Who Have Sex with Women: The CDC recommends that chlamydia screening for sexually active women who have sex with women should be based on the same recommendations as for sexually active women who have sex with men.[50]
Pregnancy: At the first prenatal visit, screen all pregnant women younger than 25 and those older than 25 who have increased risk of acquiring chlamydial infection.[50] Identified factors associated with increased risk for chlamydial infection include a new sex partner, more than one sex partner, a sex partner with concurrent (overlapping) partners, or a sex partner who has been diagnosed with an STI. Retest for chlamydial infection during the third trimester in women younger than 25 and in women older than 25 who have increased risk of acquiring chlamydial infection. Pregnant women diagnosed with chlamydia should have a test-of-cure 3 to 4 weeks after completing treatment, and they should have repeat testing for chlamydia approximately 3 months after completing treatment.
Men Who Have Sex Only with Women: Routine screening for chlamydial infection is not recommended by either the CDC or the USPSTF for sexually active men who have sex only with women.[2,4] The CDC recommends considering screening for chlamydia in sexually active young men who only have sex with women in populations with a high prevalence of chlamydia, including those seen at adolescent clinics, correctional facilities, and STD clinics.[2]
Men Who Have Sex with Men: The CDC recommends routine chlamydia screening in sexually active men who have sex with men at least annually; the screening should consist of testing genital and rectal sites exposed during sexual activity, regardless of a history of condom use during sexual exposure.[50] Routine testing of oropharyngeal testing for chlamydia infection is not recommended. More frequent screening at 3- to 6-month intervals is indicated for men who have sex, including those with HIV infection, if risk behaviors persist or their sexual partners have multiple partners. The USPSTF does not recommend routine screening for chlamydia in men who have sex with men.[4]
Transgender Men and Transgender Women: The CDC recommends that screening for chlamydia in transgender men and transgender women should be based on age, current anatomy, and sexual practices.[50]
Persons with HIV Infection: The CDC recommends performing routine screening for chlamydia for persons with HIV infection who are sexually active; testing for chlamydia should be performed at the initial evaluation and at least annually thereafter (more frequent screening may be indicated based on risk).[51] The testing should consist of obtaining samples from the anatomic sites of sexual exposure, with the exception that routine screening for oropharyngeal chlamydia infection is not recommended.
Correctional Facilities: The CDC recommends performing routine screening for chlamydial infection at the initial intake in a correctional facility for all women 35 year of age and younger and men younger than 30 years of age
Which one of the following is most consistent with current CDC recommendation for screening for chlamydial infection?
Routine annual screening for all sexually active females younger than 25 years of age
T or F? No recommendations for routine chlamydia screening in men?
True. There is no recommendation for routine screening for chlamydial infection in males, although it is reasonable in male populations who have a higher risk of acquiring chlamydial infection.
Chlamydia tx.
First-line therapy for urogenital infection
Azithromycin 1 gram orally in a single dose
Chlamydia partner management
Which one of the following statements is TRUE for CDC recommendations for the management of sex partners of a patient diagnosed with urogenital chlamydia infection?
You chose this option correctly:
All sex partners during the 60 days preceding the onset of symptoms should be referred for treatment
Partners with exposure greater than 60 days preceding the onset of symptoms or diagnosis of chlamydia do not need to be routinely screened or treated.
Referral and treatment should occur for the most recent partner, even if this contact occurred more than 60 days prior. Similarly, all symptomatic contacts should be referred, regardless of time since diagnosis
What is a contraindication to expedited partner therapy in chlamydia?
contraindicated in a female partner who have current signs or symptoms that are suggestive of PID. Female partners who have current signs and symptoms suggestive of PID should undergo prompt evaluation by a health care provider.
When can someone with chlamydia resume sex?
7 days after 1 dose azithromycin or after 7 days of doxy or until all symptoms gone and partner is treated
POSTTREATMENT FOLLOW-UP in chlamydia
The CDC does not recommend routine test-of-cure after completing therapy for chlamydia in nonpregnant persons, but all females and males should return for repeat testing approximately 3 months after receiving treatment for chlamydia due to the substantial risk of reinfection during the 3-month period following initial diagnosis of chlamydial infection
TREATMENT OF CHLAMYDIAL INFECTIONS DURING PREGNANCY
azithromycin 1 gram orally in a single dose.
Doxycycline is pregnancy category D because of potential toxicity for fetal bone development and possible discoloration of teeth in the unborn baby;
Erythromycin estolate is contraindicated during pregnancy because of hepatotoxicity risk.
The alternative regimens in pregnancy are amoxicillin, erythromycin base, or erythromycin ethylsuccinate
Pregnant women should have a test-of-cure performed 3 weeks after completion of therapy. Women younger than 25 years of age and those at increased risk for chlamydial infection also should be retested during the third trimester.
NEONATES WITH OPHTHALMIA NEONATORUM
recommended regimen for the neonate is erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days =An association between oral erythromycin and infantile hypertrophic pyloric stenosis has been reported in infants less than 6 weeks of age who were treated with this drugThus, infants treated with erythromycin should be followed for signs and symptoms of infantile hypertrophic pyloric stenosis
Data on the use of other macrolides (azithromycin and clarithromycin) f limited. azithromycin, 20 mg/kg/day orally, one dose daily for three days may be effective. This regimen is considered a recommended alternative to erythromycin. However, use of azithromycin in the neonatal period has also been associated with a higher risk of infantile hypertrophic pyloric stenosis, particularly if given in the first 2 weeks of life
INFANT PNEUMONIA
or infants with pneumonia caused by C. trachomatis, the recommended treatment is a 14-day course of erythromycin base or erythromycin ethylsuccinate; azithromycin, which is much easier to administer and requires only a 3-day course, is considered an alternative regimen
CHLAMYDIAL INFECTIONS IN INFANTS AND CHILDREN
weight less than 45 kg?
erythromycin base or erythromycin ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days.
younger than 8 years of age and weighing 45 kg or greater,
azithromycin 1 gram orally in a single dose.
Children older than 8 years of age
azithromycin 1 gram orally in a single dose or doxycycline 100 mg twice daily for 7 days.
A follow-up visit with chlamydia culture is recommended approximately 2 weeks after completion of treatment to evaluate for treatment effectiveness.[
Gonnorhea Incidence
Men rates increased d/t MSM.
Ages 20-24
in Black/Alaskan populations
GONOCOCCAL ANTIMICROBIAL SUSCEPTIBILITY
Ceftriaxone is the preferred agent and widely used to treat gonorrhea. Fortunately, rates of resistance to ceftriaxone have remained less than 0.5%. In contrast, fluoroquinolone resistance with Neisseria gonorrhoeae is highly problematic and rates of ciprofloxacin are approximately 30%.
Microbiology and Pathogenesis
Neisseria gonorrhoeae is a gram-negative diplococcus that binds preferentially to mucus-secreting epithelial cells. Although N. gonorrhoeae can bind to other cell types, it utilizes its surface structures to bind to the urogenital epithelial cells.
What is the rate of male-to-female transmission of Neisseria gonorrhoeae via semen per episode of vaginal intercourse?
50-70%
The estimated rate of male-to-female transmission of Neisseria gonorrhoeae is 50-70% per episode of vaginal intercourse. Female-to-male genital transmission is estimated to be about 20% per episode. Rectal intercourse and fellatio have not been quantified, but are likely efficient modes of transmission. Cunnilingus appears to carry much lower risk, though transmission can occur.
Gonorrhea Risk Factors
Multiple or new sex partners Inconsistent or incorrect condom use Living in an urban area where gonorrhea prevalence is high Being adolescent (especially female) Having a lower socio-economic status Using drugs including alcohol (in association with higher risk sex) Exchanging sex for drugs or money African American race
GENITAL INFECTION IN MEN
Urethritis
Urethritis is a common manifestation of gonorrhea in men. Most men develop overt, symptomatic urethritis,
purulent or mucopurulent urethral discharge accompanied by dysuria.
The discharge may also be clear or cloudy. T
he incubation period ranges from 1-14 days, with most men becoming symptomatic within 2-5 days after exposure
Anorectal Infections
Anorectal infection most often occurs in men who have sex with men, Most patients with anorectal infection are asymptomatic, although proctitis can occur. Symptoms of proctitis include anal irritation, painful defecation, constipation, scant rectal bleeding, painless mucopurulent discharge, anal pruritus, and tenesmus.
Complications of Genital Infection in Men
Men with untreated gonococcal genital infection can develop epididymitis, with typical symptoms of unilateral testicular pain and swelling, and epididymal tenderness. Notably, up to 70% of epididymitis caused by a sexually transmitted pathogen are due to Chlamydia trachomatis. Other less common complications associated with gonococcal infection in men include inguinal lymphadenitis, penile edema, periurethral abscess or fistula, accessory gland infection (Tyson’s glands), balanitis, urethral stricture, and prostatitis, and rarely perirectal abscess.
clinical sign and symptoms of urethritis caused by infection with Neisseria gonorrhoeae in men?
Most men complain of urethral discharge
In contrast to chlamydial urethritis, which is more frequently asymptomatic, most men with urethritis due to Neisseria gonorrhoeae infection complain of urethral discharge and/or urethral discomfort.
Epididymitis is a possible complication of genitourinary gonococcal infection, but most men with gonorrhea do not develop epididymitis. Coinfection with Chlamydia trachomatis does not significantly alter the clinical presentation of urethritis caused by N. gonorrhoeae.
GENITAL INFECTION IN WOMEN
Cervicitis
Symptomatic gonococcal infection in women most often manifests as cervicitis and/or urethritis, but at least 50% of women with genital gonococcal infection are asymptomatic. Symptoms of cervicitis: nonspecific vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, and dyspareunia. Clinically, examination of the cervix may show mucopurulent or purulent cervical discharge and easily bleed with minimal contact.
The incubation period in women is variable, but symptoms, when they do occur, usually develop within 10 days of the exposure. 70-90% of women with genital gonococcal infection have laboratory evidence of urethral infection (urethritis); dysuria may be present, but these women frequently do not have specific urethral symptoms.
Anorectal Infections
Anorectal gonococcal infection is uncommon in women, but can occur via anal intercourse. Anorectal infection has been reported in women with gonococcal cervicitis who do not acknowledge rectal sexual contact, presumably these infections result from perineal contamination with infected cervical secretions.
Complications in Genital Infection in Women
There are several complications associated with gonorrhea in women:
Accessory gland infections: Infection of female sex accessory glands (Bartholin’s glands or Skene’s glands) is often a unilateral infection. Occlusion of the ducts of these glands due to inflammation may result in the formation of an abscess.
Pelvic inflammatory disease (PID): If cervical gonococcal infection ascends to the endometrium and/or fallopian tubes, PID may develop, typically causing symptoms that include lower abdominal pain, vaginal discharge, dyspareunia, intermenstrual bleeding, and fever.
Perihepatitis (Fitz-Hugh-Curtis Syndrome): In situations where gonococcal infection ascends from the cervix, infection may produce inflammation of the liver capsule and the adjacent peritoneum. Most women with perihepatitis have associated PID, but perihepatitis can occur independently. Gonococcal perihepatitis is characterized by right upper quadrant pain, and may be accompanied by abnormal liver function tests.
what are known potential complications of genitourinary gonococcal infection in women?
Pelvic inflammatory disease, accessory gland infection, and perihepatitis (Fitz-Hugh-Curtis Syndrome)
Well-described complications of genitourinary infection with Neisseria gonorrhoeae include pelvic inflammatory disease, accessory gland infection, and perihepatitis (Fitz-Hugh-Curtis Syndrome).
3 additional syndromes of gonnorhea seen in men and women
Pharyngeal Infection
most often asymptomatic. The pharynx may be the sole site of infection iExudative pharyngitis is rare. Symptoms :pharyngitis, tonsillitis, fever, and cervical adenitis.
Ocular Infection
presents as conjunctivitis. initially develop a mild non-purulent conjunctivitis, that, if untreated, typically progress to marked conjunctival redness, copious purulent discharge, and conjunctival edema Less often, the manifestations include an ulcerative keratitis. Untreated gonococcal conjunctivitis can cause complications that may include corneal perforation, endophthalmitis, and blindness.
Disseminated Gonococcal Infection
multiple cutaneous lesions on the feet
Disseminated gonococcal infection, a systemic gonococcal infection, occurs infrequently/more common in women. associated strains that have a propensity to produce bacteremia without associated urogenital symptoms. patients with complement deficiency have greater risk of developing disseminated gonococcal infection. Clinical manifestations of disseminated gonococcal infection include skin lesions arthralgia, tenosynovitis, arthritis hepatitis, myocarditis, endocarditis, and meningitis.
INFECTION IN CHILDREN
Perinatal infections most often occur during childbirth when the neonatal conjunctiva, pharynx, respiratory tract, or anal canal may become infected. Conjunctivitis (ophthalmia neonatorum) is preventable by ocular antimicrobial prophylaxis in the newborn
LABORATORY DIAGNOSIS
The approach to diagnostic testing for N. gonorrhoeae has evolved from traditional cultivation to widespread use of nucleic acid amplification tests (NAATs)
Gram’s stain, another non-culture test, is used for the diagnosis of urethral gonorrhea in symptomatic males. Culture is still recommended if antimicrobial resistance is a concern, especially in cases of treatment failure.
