STI's Flashcards
Define STI
infection passed from one person to another through sexual activity, including vaginal, oral or anal sex as well as genital skin-to-skin contact. Some STIs are spread through the blood.
TYpes of STI’s
Viral – human papilloma virus (HPV), human immunodeficiency virus (HIV), hepatitis B, herpes simplex virus (HSV)
Bacterial – chlamydia, gonorrhea, syphilis
Parasitic/fungal – trichomoniasis
What is an STBBI?
= sexually transmitted and blood borne infection
RIsk FACtors STI
Multiple partners – concurrently or over time
Anonymous or casual sex partners
Sex without the use of barrier protection
Sex with person(s) with an STI
Previous STI
Substance use (drug, alcohol or both)
Use of medications for erectile dysfunction
History of intimate partner or sexual violence
Social environments (e.g. circuit parties, post-secondary institutions, bath houses)
What populations are disproprotiantely affected?
Indigenous Peoples
Gay, bisexual, and other men who have sex with men (gbMSM)
Transgender people
Youth and young adults
People who use drugs
Incarcerated or previously incarcerated people
People engaged in the sale or the purchase of sex
STI Symptoms
Many STIs are asymptomatic
Even if no symptoms are present, the infection can still be passed toother people
A person treated for an STI in the past can still be re-infected
SK Communicable Dx Control MAnual
Screen using risk assessment, offer testing based on results
Individuals with ongoing risks for infection should routinely be tested for chlamydia, gonorrhea, syphilis, HIV, Hep B, Hep C
Test for one – Test for all
PHAC Guidelines
PHAC Sexually transmitted and blood-borne infections: Guides for health professionals:
Screening recommendations specific to STI
Offer in the course of routine care with special attention to those with risk factors
CMAJ Guidelines
Screen for chlamydia and gonorrhea annually for age <30 and sexually active, more frequently if high-risk
Barrier sto seeking care
Underestimate personal risk
Perception that STIs are not serious
Fearful of procedures
Self-conscious about genital exam
Perceived and anticipated attitudes of health care professionals and clinic staff
Stigma
STI Reporting
STIs are reportable communicable disease
Under Public Health Act 1994, health care providers report to Medical Health Officer (MHO) who reports to Chief Medical Health Officer at Saskatchewan Ministry of Health
Reports available on Sask government website
Several STIs are also nationally notifiable – chlamydia, gonorrhea, syphilis, hepatitis, HIV, chancroid
Partner Notification
Critical to prevention and control
Goal – assist individuals to inform partners about risk and honour partner’s right to make informed decisions about their health
CONFIDENTIAL
Individual, health care provider, MHO may notify partner
Barrier Protetcion
External condoms, internal condoms, dental dams
Decrease risk of acquiring and transmitting the majority of STIs, including HIV, HBV, chlamydia, gonorrhea
Do not provide complete protection against syphilis, HPV or HSV because lesions and asymptomatic shedding can occur in areas not covered
Spermicidal lubricated condoms containing nonoxynol-9 not recommended
GOT STI
Treat the infection
Abolish symptoms
Decrease spread to sexual partners
Decrease vertical transmission to newborns
Reduce transmission of HIV
Decrease probability of complications, such asinfertility, chronic pain, sepsis
T Acquired Dirty D* Requiring Detamination
SASK HEALTH
Sask Health provides amoxicillin, azithromycin, cefixime, doxycycline free of charge
STI Transmisison
STIs are spread from person to person through:
Contact with semen, vaginal fluid or other body fluids during vaginal, anal or oral sex without a condom
Skin-to-skin contact during sexual activity
Sharing toys
Some STIs can be passed through blood transfusions and transplants
Some STIs can be transmitted vertically during pregnancy and labour
HIV can be transmitted through breast/chestfeeding
Preganncy
STIs can negatively affect fertility and pregnancy, and can also be harmful for babies
Chlamydia = preterm birth, conjunctivitis and pneumonia in newborn
Gonorrhea = endometritis and pelvic sepsis, ophthalmia neonatorum and systemic infection in newborn
Syphilis = systemic symptoms, fetal loss
Pregnant people should be tested early in pregnancy and again in third trimester if ongoing risk andtreated before giving birth to decrease therisk of problems during pregnancy anddelivery, and resulting complications for thebaby
STI SX
Many STIs are asymptomatic, but may present as syndrome/symptom
Syndromes: cervicitis, epididymitis, pelvic inflammatory disease, proctitis, urethritis, vaginitis, anogenital ulcers
May be caused by an STI, another infection, or have a non-infectious cause
Vulvovaginal Candidiasis
Candidia Albicans
Pruritis, white,clumpy discharge
FLuconazole 150 mg posingle dose
Topical azole antifungals
clotrimazole, miconazole, terconazole
Not necessary to tx partners
Trichomoniasis
Trichomoniasis Vaginalis
Pruritis
Odour
Off, white or yellow frothy discharge
Metronidiazole 2 g single dose or 500 mf BID f7d
Treat sexual partners
Bacterial Vaginosis
Mycoplasma and GArdnerella Vaginalis
Fishy odour
Grey or milky, thin, copious discharge
Metronidazole 500 mg po BID x 7 days or 2 g PO x single dose
Metronidazole 0.75%
5 g PV x 5 days (x 10 days plus twice weekly x 4-6 months if recurrent)
Clindamycin 2% 5 g PV x 7 days
Not necessary to treat asymptomatic patients unless undergoing procedure or high risk pregnancy
Angogentical Ulcers
Herpes simplex virus
Lymphogranuloma venereum (CT L1, L2, L3)
Syphilis
Anogenital Warts
HPV types 6 and 11
CHlamydia
Etiology: Chlamydia trachomatis
Most common nationally reportable STI in Canada
May be under-detected because majority of people with infection are asymptomatic
Empiric treatment may be given without lab testing
Chlamydia SX
dysuria → painful to pee
urethritis = inflammation of urethra → dysuria, dyspareunia
cervicitis = inflammation of cervix → abnormal bleeding, abnormal discharge, dyspareunia
proctitis = inflammation of lining of rectum → pain, diarrhea, bleeding, discharge
conjunctivitis → excessive tearing, discharge, inflammation, swelling or redness of eye
Clinical presentation reflects site of infection
Chlamydia SX Genders
Chlamydia Complications
Chlamydia TX
Doxycycline Counselling
Take with food
Taking with iron or calcium may decrease absorption
Photosensitivity
Azithromycin Counselling
GI upset - prophylactic antiemetics
CHalamydia Counselling
Counselling: abstain from sexual activity without barrier protection until treatment of person and partners is complete (7 days after one dose therapy, end of multiple dose therapy) and symptoms have resolved –> preferably abstinence
Follow Up Chlamydia
Test of cure (TOC) recommended when symptoms persist, compliance is suboptimal, preferred treatment not used, prepubertal, pregnancy
Repeat screening recommended 3 months post-treatment due to risk of reinfection
SK – TOC 3-4 weeks following positive. Repeat testing in all individuals6 months post as re-infection risk high.
LGV
Etiology: Chlamydia trachomatis genotypes L1, L2, L3 which are more invasive than non-LGV genotypes
Relatively rare, some outbreaks reported in Canada
Preferentially affect the lymph tissue
Divided into three stages: primary, secondary, tertiary
LGV SX
LGV TX
Gonorhhea ETyiology
Etiology: Neisseria gonorrhoeae
Second most common nationally reportable STI in Canada
Frequently asymptomatic
When left untreated, infections become chronic
Reinfections common
High rates of concomitant infection with chlamydia → treat for both
Gonorhhea SX
Gonorhhea Complications
Gonorhhea TX (Not Specifc)
Treat gonococcal infections with combination therapy →improve efficacy and potentially delay resistance
Therapy depends on site of infection and probability of resistance
Recommended combination includes a third-generation cephalosporin with either azithromycin or doxycycline
Gonorhhea TX
Gonorhhea Counselling
Penicillin allergy
Cross-sensitivity between penicillins and second- or third-generation cephalosporins is low.
Resistance is a concern – encourage adherence, treating all partners, other sexual health education
Azithromycin can be taken with food to minimize nausea (vomit within 1 hour, repeat dose) or anti-emetics
Abstain from sexual activity without barrier protection until treatment of person and partners is complete (7 days after one dose therapy, end of multiple dose therapy) and symptoms have resolved
Gonorhhea FOllow Up
Test of cure (TOC) cultures recommended within a week for all positive sites or NAAT 2-3 weeks after treatment completed
Repeat screening recommended 6 months post-treatment
SK – follow up TOC cultures 4-5 days following treatment incertain circumstances.
NAAT not recommended but if needed, atleast 4 weeks following positive. Repeat testing in all individuals6 months post as re-infection risk high
Syphillis
Etiology: Treponema pallidum
Third most common nationally notifiable STI in Canada
Rates of infection increasing rapidly
Transmission via contact with chancres
Untreated syphilis has many complications
Universal screening recommended in pregnancy
HIV → more rapid progression to neurosyphilis and more aggressive and atypical signs of infection
Syphillis Sx
Neurosphyllis is not tertiary syphillis
Congenital Sx syphilis
Syphillis Testing
National comitte SSTBI –> screening in all sexually active persons with multiple sexual partners or upon the patients request
New or multiple partners regardless sof risk factors
Screen every 3-6 months in people with risk factors
In patient at high risk, should be the norm to test high risk individuals. The norm should be that you “opt-out” rather than “opt-in”
Syphillis TX
Syphillis Counselling
Abstain from sexual contact until the lesions are completely healed and it has been 7 days since they received their final dose of treatment
Condoms should be advised and encouraged for all sexual encounters
PHAC: Advise all people with potentially infectious lesions such as chancres, condylomata lata and/or rash of secondary syphilis to abstain from sexual contact until symptoms have resolved and for 7 days after treatment
Syphillis Follow Up
No test of cure – treatment response based on clinical picture (symptom resolution) and nontreponemal test (NTT) titre change (ie: four-fold change at 6 months)
What is the Jarisch-Herxheimer RXn?
Acute febrile reaction accompanied by headache, myalgia, chills and rigors
Occurs within 1st 24 hours after initiation of any syphilis therapy
NOT an allergic reaction, but rather reaction to therapy
Manage with antipyretics (NSAID), but not proven to prevent reaction
May induce early labour or cause fetal distress in pregnancy
HPV
HPV is everywhere –over 200 types have been identified
Most common STI in the world
At least 40 types of HPV known to infect mucosa of the anogenital tract and oropharynx
Majority of infections are self-limited, asymptomatic, unrecognized
Infection with multiple types possible
HPV types
Infection with low-risk types (6, 11) associated with low/no cancer risk but may lead to anogenital warts, cervical lesions, and rare conditions such as recurrent respiratory papillomatosis
Persistent infection with oncogenic, high-risk types (16, 18) may lead to cancer – cervical, oropharyngeal, cancer of vulva, vagina, penis, anus
Virtually all cases of cervical cancer are attributable to HPV
Can lead to cancer
HPV SX
Tx Anogenital Warts
HPV TX counselling
Avoid contact with healthy skin
Refrain from sexual activity while undergoing treatment
Skin reactions: itching, tenderness, erythema, ulceration
Pain reduction – lidocaine/prilocaine, injectable lidocaine
HPV VAccination
Gardasil 9 – HPV types 6, 11, 16, 18, PLUS 31, 33, 45, 52, 58
Cervarix – HPV types 16 and 18
Gardasil 9
Approved for Individuals aged 9-45 years
IM injection (deltoid preferred)
Dose:
>15 years old: 0.5 ml x 3 doses – 0, 2, 6 months
9-14 yo: 0.5 ml x 2 doses – 0, 6 months (5-13 months)
Immunocompromised (no matter age): 3 dose series
97% vaccine efficacy for preventing CIN (cervical intraepithelial neoplasia, abnormal cervical cells) or more severe disease in HPV naïve 16-26 yos
Adverse effects: local injection site reaction, headache (7-20%), fever (2-10%), nausea, dizziness, fatigue, diarrhea, oropharyngeal pain, upper abdominal pain
Sk Coverage Gardasil-9 Criteria
Females and males in Grade 6
Those that did not receive vaccine in Grade 6 until they are 26 years old
Immunocompromised females and males aged 9-26 years
HSV
Etiology: herpes simplex virus type 1 and 2
HSV-1 is primarily associated with ORAL infection but may cause genital herpes
refer to Herpes Labialis management (guidelines on medSask)
HSV-2 is primarily associated with genital infection but may also present orally as a result of oro-genital transmission (rare)
HSV Transmisison
Transmitted by unprotected sex and via delivery of baby
Higher risk with open sores, also asymptomatic viral shedding
Common in adolescents and adults, women > men – but true incidence is not known since not reported
Virus establishes itself intracellularly within host cell ganglia for life
Genital herpes increases the risk of acquisition of HIV twofold
HSV Sx
Gential Herpes TX
Acyclovir 200mg PO five times per day for 5-10 days
OR
Famciclovir 250mg PO TID for 5 days
OR
Valacyclovir 1000mg PO BID for 10 days
Topicals not effective
Pregnancy
Acyclovir200 mg PO qid for 5-10 days
Severe: IV acyclovir 5mg/kg infused over 60 minutes every 8 hours, convert to oral therapy once significantly improved
Genital Herpes Recurrent TX
Valacyclovir500 mg PO bid OR 1 g PO daily for 3 days
OR
Famciclovir125 mg PO bid for 5 days
OR
Acyclovir200 mg PO 5 times/day for 5 days
800 mg PO TID x 2 days also shows efficacy
Neonatal Herpes
Occurs when baby is delivered through an infected vagina
Initial symptoms ~4 weeks of age
Results in generalized systemic infection involving liver, other organs, CNS and skin
Mortality in nearly 60% of cases, 70% will experience severe or fatal complications
Acyclovir45–60 mg/kg/day IV in three equal 8-hourly infusions, each over 60 minutes for 14 to 21 days
HSV Counselling
Antivirals will decrease severity and duration of symptoms, but not prevent recurrences
Use as early as possible (preferably fewer than 6h) and until lesions are healed
Abstain from sexual contact during symptomatic episodes until lesions are completely healed
Always use a condom as asymptomatic viral shedding can occur
May not eliminate risk of transmission when lesions not limited to genital area
Lifelong infection – encourage patient to seek support
