HTHSCI 2HH3 Lecture Notes - Lecture 11: Itch, Immunosuppression, Valaciclovir
26 May 2018
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Department
Course
Professor
Sexually Transmitted Infections
• Importance of STIs & National Data Trends
• STIs - Symptoms, Diagnosis, Treatment
Notifiable STIs
• Chlamydia
• Gonorrhoea
• Syphilis
Non-notifiable STIs
• Herpes Simplex Virus (HSV)
• Human Papilloma Virus (HPV)
• Not reportable to public health because there is no cure
Importance of STIs
High burden of disease
• STIs represent ~70% of all notifiable diseases in Canada
o Chlamydia accounts for 51% of all cases of notifiable infectious diseases reported
• Steady rise in rates of chlamydia, gonorrhea & syphilis since 1997
Sequelae
• Sterility, ectopic pregnancy, birth defects, miscarriage, cancer, chronic pain, psychiatric illness
• Synergistic nature with HIV; 2-5 fold increased risk of HIV transmission, co-infected individuals
shed virus at much higher rate
Determinants of Health
• Correlation with poverty, high cost to society
Chlamydia Rates in Canada by Sex
• Rate irease i the late ’9s, assoiated ith ireased sreeig related to e o-invasive
Nucleic Acid Amplification Tests (NAAT)
• Contact tracing has also improved, but rates keep rising!
• Collecting urine is a lot easier and less painful which makes people test more often
1. Better screening and identifying people who need therapy → early intervention, we
have removed the bodies ability to experience the bacteria, intervening before the
immune system has the opportunity to gain immunity
2. we assume that we treat to cure ut e do’t ko if the atiiotis are orkig
eause e do’t ko hat atiiotis the ateria are suseptile to
3. Now that we have treatments, people engage in risky sexual behavior
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Chlamydia
Chlamydia trachomatis
Most prevalent bacterial STI in Canada
• Rates have increased by 49.2% from 2005 to 2014
• 80% of reported cases between the ages of 15 – 29*
• Rates have increased by 68% in the 25 – 29 age group
• Females account for over 2/3 of reported chlamydia cases
• More females identified as a result of physical exams
Sequelae
• Females: PID, infertility, ectopic pregnancy- embryo attaches outside of the uterus, chronic
peli pai, Reiter’s sydroe- reactive arthritis
• Males: Epididymo-orchitis- inflammation of the epididymis, Reiter’s sydroe- reactive arthritis
• Newborn: trachoma-roughening of the inner surface of the eyelids, pneumonia
• Incubation period of 2 to 3 weeks, can be as long as 6 weeks
Chlamydia trachomatis
Gram negative, obligate intracellular bacteria
• Entry: body through abrasions or lacerations and infects cells lining the mucous membranes of
the
o Pharynx, urethra, cervix, uterus, fallopian tubes, anus or rectum
• Lesion at site of infection commonly ignored (why cases often go unreported)
• Small, painless and heal rapidly
• Headache, fever and muscle pain may occur at this stage (40 hours post-infection)
• Signs and symptoms result from the destruction of infected cells and the resulting inflammatory
response
Females - Symptoms
Chlamydia
Most infected females are asymptomatic (70%)
Symptoms (if present) include:
• Urethritis
o Dysuria
• Cervicitis
o Painful intercourse
o Lower abdominal pain
o Purulent discharge
o Abnormal vaginal bleeding
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o Increased risk for cervical cancer (HPV co-infection)
• Proctitis (usually asymptomatic; can occur in absence of anal sex)
Physical exam observation: Abnormal cervix on physical exam. Usually the cervix is a light pink colour,
abnormal cervical discharge
Pelvic Inflammatory Disease
Infection and inflammation of the upper genital tract
• Fever and lower abdominal pain, abnormal discharge
• Adnexal and cervical motion tenderness- pain with palpation
• Chlamydia trachomatis, Neisseria gonorrhoeae
Incubation period
• Months to years post-infection, 2/3 of cases unrecognized (silent PID)
Age associated risk (age 15 ~ 12.5%, age 24 ~ 1.25%)
Maturation of reproductive organs → patient reaches puberty and becomes more resilient to infections
Sequelae
• Ectopic pregnancy, sterility, chronic pelvic pain
• 10% risk first episode, 40% risk third episode
Diagnosis based on symptoms, microbiology & diagnostic imaging
Treatment
• Early diagnosis and treatment are essential to maintaining fertility; symptoms should resolve
within 48-72 hrs post-Rx
Hospitalization
• If patient is pregnant, unable to tolerate oral therapy or does not respond clinically to oral
therapy, severe pain, nausea & vomiting, or if client presents with adherence issues
• Cefoxitin, 2 g IV every 6 hours + doxycyline 100 mg PO or IV every 12 hours
• May step-down to oral therapy 24 hrs after clinical improvement is observed (14 day course of
oral therapy)
Outpatient treatment regimen
• Ceftriaxone 250 mg IM (single dose) + Doxycyline 100 mg x 2 day for 14 days + metronidazole
500 mg x 2 day for 14 days
Males - Symptoms
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Document Summary
Importance of stis & national data trends: stis - symptoms, diagnosis, treatment. Non-notifiable stis: herpes simplex virus (hsv, human papilloma virus (hpv, not reportable to public health because there is no cure. High burden of disease: stis represent ~70% of all notifiable diseases in canada, chlamydia accounts for 51% of all cases of notifiable infectious diseases reported, steady rise in rates of chlamydia, gonorrhea & syphilis since 1997. Sequelae: sterility, ectopic pregnancy, birth defects, miscarriage, cancer, chronic pain, psychiatric illness, synergistic nature with hiv; 2-5 fold increased risk of hiv transmission, co-infected individuals shed virus at much higher rate. Determinants of health: correlation with poverty, high cost to society. Chlamydia rates in canada by sex: rate i(cid:374)(cid:272)rease i(cid:374) the late "9(cid:1004)s, asso(cid:272)iated (cid:449)ith i(cid:374)(cid:272)reased s(cid:272)ree(cid:374)i(cid:374)g related to (cid:374)e(cid:449) (cid:374)o(cid:374)-invasive. Incubation period of 2 to 3 weeks, can be as long as 6 weeks.
