Sexually Transmitted Infections (STIs)

Sexually Transmitted Infections (STIs) Overview

• Over 1 million STIs are acquired daily
• Over 500 million people are likely infected with genital herpes
• Over 290 million women are infected with HPV
• Most STIs display no symptoms or minimal ones
• Drug resistance, particularly in gonorrhoea, is a major obstacle in reducing STIs worldwide
• More than 30 pathogens can spread through sexual contact
• Of the 8 predominant STI infections, 4 are curable, and 4 are incurable

Epidemiological Data for Ireland (2022-2023)

• There were no notifications of chancroid or granuloma inguinale for 2023
• The total number of STIs is underestimated since data on ano-genital warts (AGW) and non-Specific Urethritis (NSU) were unavailable for 2023
• Chlamydia cases rose from 10,934 in 2022 to 13,711 in 2023, a 25.4% increase
• Gonorrhoea cases showed a significant increase, from 4,060 in 2022 to 6,824 in 2023, a 68.1% increase
• Herpes simplex (genital) cases slightly increased from 1,614 in 2022 to 1,687 in 2023, a 4.5% increase
• Lymphogranuloma venereum (LGV) cases grew from 28 in 2022 to 37 in 2023, a 32.1% increase
• Mpox cases sharply dropped from 227 in 2022 to 13 in 2023, a -94.3% change
• Syphilis (early infectious) cases increased from 870 in 2022 to 930 in 2023, a 6.9% increase
• Trichomoniasis cases remained stable at 70 for both 2022 and 2023
• The total number of STI cases increased from 17,803 in 2022 to 23,272 in 2023, a 30.7% increase
• Highest age-specific rate applies to 20-24 year olds in most cases

STI Pathogens

• Syphilis
• Gonorrhoea
• Chlamydia
• Trichomoniasis
• Chancroid
• Herpes
• HPV
• Hepatitis B
• Mpox
• HIV

Taking a Sexual History

• Reason for the consultation
• Symptom review
• Sexual History elements include:
  • Who: Regular or Casual partners
  • When: Most recent, Past Year, or Total partners
  • Where: Ireland or Abroad
  • How: Types of sexual contact (A/V/O)
  • Protection: Condoms or HIV prophylaxis usage, recent or general use
  • History of risk factors in partners, IVDU
  • History of STIs
• Other components to consider:
  • Drug/alcohol/smoking
  • Drug allergies
  • Past Med/Surg Hx
  • Pregnancy risk
  • Vaccination history

Key Considerations for STIs

• More than one infection may be present
• Think about HIV testing
• Consider local and national antimicrobial resistance patterns
• Focus on partner management
• Consider the psychosocial issues

Syphilis Information

• Caused by Treponema pallidum
• Incubation period is 3-90 days
• Primary stage includes a painless ulcer (chancre) and regional lymphadenopathy

Progression of Untreated Syphilis

• Infection can develop into early latent syphilis in less than a year if untreated
• The primary phase can lead to concurrent chancre and rash in 9% of cases
• Secondary syphilis occurs 1-2 months post-primary syphilis; recurrent secondary syphilis occurs in 24% of cases
• Lifetime latency can occur with no symptoms
  • Without infection, it can lead to Late Neurosyphilis and Tertiary syphilis 2-50 years after

Secondary Syphilis

• It's a multi-system illness following untreated primary infection.
• It occurs 2-12 weeks post primary infection
• Parenchymal symptoms include lymphadenopathy and skin lesions/rashes
• Constitutional symptoms include malaise, sore throat, low-grade fevers, itch, myalgia, and weight loss
• CNS involvement is present in 35% of cases
• Condyloma lata may be present

Latent & Late Syphilis

• Asymptomatic state detected through serology
  • Early latent syphilis is less than 2 years since infection
  • Late latent syphilis is more than 2 years since infection
• Late/Tertiary Syphilis occurs in about 40% of untreated infections
  • Cardiovascular symptoms: aortitis
  • Neurosyphilis: meningitis, spinal cord lesions, neuropsychiatric disorders
  • Gummatous Syphilis

Congenital Syphilis

• It is acquired through transplacental transmission of spirochetes
• Is most likely to occur if primary or secondary syphilis is untreated, rather than latent
• In Early Congenital cases, evident before 2 years of age
  • Symptoms include hepatomegaly, rhinitis, rash, lymphadenopathy, and skeletal abnormalities
• In Late Congenital cases, evident after 2 years of age
  • Symptoms include facial features, keratitis, hearing loss, Hutchinson teeth, bowing of the shins, and intellectual disability

Syphilis Diagnosis

• Dark field microscopy requires expertise being not as commonly done
• Serology includes qualitative (specific) and quantitative (non-specific) tests
• Specific tests (generally positive for life)
  • Treponema pallidum EIA
  • Treponema pallidum particle agglutination test (TPPA)
  • Treponema pallidum immunoblot assay
  • Fluorescent treponemal antibody absorption (FTA-abs)
• Non-specific tests (reported as a titre of antibody)
  • Rapid plasma reagin (RPR)
  • Venereal disease research laboratory (VDRL)
• CSF serology to be performed if neurosyphilis is suspected while testing cell count, protein, and glucose

Syphilis Management

• Penicillin G is the treatment of choice for all stages of syphilis
  • Administer 2.4 million units IM as a one-time dose for early syphilis
  • Administer once weekly for 3 weeks in late syphilis
• For neurosyphilis: IV/IM penicillin G x 10-14 days
• Alternative treatment for penicillin allergy: doxycycline
• NB Jarisch Herxheimer reaction
• Notification to Public Health is required

Gonorrhoea - Overview

• Caused by Neisseria gonorrhoeae (gonococcus)
• Worldwide distribution of affliction
• It is the 2nd most common STI in Ireland, predominantly affecting the 15-24 age group and MSM
• Antimicrobial resistance major issue

Gonorrhoea Clinical Features

• <80% of men and 50% of women are asymptomatic
• In Males:
  • Urethritis
  • Epididymitis
• In Females:
  • Cervicitis
  • Pelvic inflammatory disease (PID)
• General symptoms:
  • Anorectal, pharyngeal, and disseminated infection – septicaemia, septic arthritis, endocarditis
• Neonatal symptom:
  • Ophthalmia neonatorum

Gonorrhoea Diagnosis

• In Males:
  • Urethral: FVU for NAAT, urethral swab for microscopy & culture
  • Rectal/pharyngeal: swab for NAAT
  • Conjunctival: swab for NAAT and culture
• In Females:
  • Endocervical: Vulvovaginal swab for NAAT, endocervical swab for NAAT/microscopy and culture
  • Rectal/pharyngeal: Swab for NAAT
  • Conjunctival: Swab for NAAT and culture

Gonorrhoea Treatment

• Notification to Public Health is required as well as testing for cure all patients
• Treatment:
  • Uncomplicated anogenital or pharyngeal gonorrhoea: Ceftriaxone 1gram deep IM
  • Dissolve 1g ceftriaxone in 3.5ml of 1% Lidocaine Injection for IM injection and not IV injection
  • Cephalosporin allergy OR previous or immediate and/or severe hypersensitivity to penicillin or another β-lactam
  • Refer to dedicated GUM service and where not possible discuss with a specialist in GUM/ID
  • Uncomplicated anogenital: Ciprofloxacin 500mg PO as single dose
  • Pharyngeal gonorrhoea: Ciprofloxacin 500mg PO every 12 hours for 1 day OR -Azithromycin (when known to be susceptible to azithromycin) 2g orally as a single dose

Chlamydia - Overview

• Caused by Chlamydia trachomatis
• Most common STI reported in Ireland
• ~50% of cases occur in age group 15-24
• Major cause of PID and infertility in women
• 15 serovars in total

Clinical Features of Chlamydia Trachomatis D-K

• In Females:
• Cervicitis: Majority asymptomatic, Non-specific symptoms of Inter-menstrual or post coital bleeding
  • Urethritis: Can be as high as 25%, pelvic inflammatory disease is developed if ascended
    • Complications of pregnancy (PROM/preterm delivery/transmission to new-born baby)
• In Males:
  • Urethritis: Half of them have symptoms, urethral discharge with dysuria.
  • Acute epididymitis has side effects such as Unilateral testicular pain and tenderness, palpals swelling
  • Proctitis (mostly LGV)

Chlamydia Diagnosis and Treatment

• Diagnosis: NAAT
  • Females: vulvo-vaginal, endo-cervical, urethral or rectal swab
  • Males: First void urine/urethral or rectal swab
• Treatment
  • Antibiotic choice, treat the partner
  • Check for other causes of STI, and notify the public health

Chlamydia Diagnosis Options

• Doxycycline 100mg every 12hr for 7 days
• Azithromycin, 1g stat with 500mg daily for 2 days

Lymphogranuloma venereum (LGV)

• Caused by Chlamydia trachomatis Serovars L1-L3
• Involves lymphatic tissues
• Clinical features
  • Primary infection: ulcer at infection site.
    • Secondary infection: More than 2 weeks later, systemic symptoms
      • Inguinal syndrome.
    • Anorectal symptoms.
    • Late infection is fibrosis. Diagnosis: NAAT
    • Anorectal NAAT of rectal swab and biopsy. - Inguinal swabbing of lesbian or aspirate bubo.
• Treatment Doxycycline x 21/7.

Trichomonas Vaginalis

• Flagellated protozoan
• Humans are only natural hosts
• Most common non-viral STI
• Transmitted through sexual contact Clinical features
• Females
• Vaginal discharge
• 10 to 50% asymptomatic
• Associated with PROM & LBW
• Males
  • Greater than 75% asymptomatic
  • Urethritis Diagnosis and treatment
• Diagnosis vulvovaginal swab NAAT
• Wet prep sensitive for trophozoites
• Treatment - Metronidazole 2g
• Metronidazole 400mgs BD x 5 - 7 days- Treat partner - Notify public health

Mycoplasma Genitalium

• Urethritis dysuria, Urethral discharge
• Females
• Cervicitis with dsyuria with PID
• Diagnosis FVU PCR
• Management - Azithromycin

Chancroid

• Pathogen Haemophilus ducregi
• Presentation -Incubation of 1 - 6 weeks
• Ulcer - Tender inguinal Lymphadenopathy
• Suppuration and adenitis
• Differential - HERPES
• Syphilis - LGV
• Diagnosis aspiration- Antibodies
• Azithromycin - Ceftriaxone

Genital Herpes

• Caused by HSV-1 or HSV-2
• Primary infection
• Fever
• Malaise
• Inguinal adenitis -Latency Sacral Nerve Root Ganglia Recurring Symptoms -Genital vesicular lesions
• Characteristics are vesicular lesions -Penis - Labia vagina and cervix
• Get Also to rectal oropharyngeal with HSV - 2

Genital Herpes - Ireland 2023

• Annual of HSV in Ireland 2023
• About 1,687 Cases genital HSV infection reported in Ireland
• Most women % 71
• More cases with HSV - 1- HSV-2- not specified

HSV-2: NEONATAL HERPES SIMPLEX

• Caused by HSV-2
• Acquired via canal -50 chances neonatal
• High risk with CNS infections Severe cases- Results with Intellectual and neurological

Laboratory Diagnosis of HSV 1 % 2

Lab test done for cold cores symptoms or Minor infections Diagnosis - PCR

• Used vesicular fluid -To make a differentiate HSV-1 with 2
• Tested with CSF
• Neonatal HSV tested on lesions -Conjunctivae. Mpox- -

Mpox

• DS DNA VIRUs
• Clades 1 & 2
• Clade lla2022 -WHO REPORTS ENDEMIC
• Global OUTBREAK -AFFECT - main Gb MSM Population - 2024. WHO HCID
• Human From Transmission-Direct contact membranes. Skin-touch-Mouth and Mounth
• Contaminated clothing’s etc. short -range - Aerosols
• Vertical-Sharps tattoos Animal - Transmission

Mpox - Features and Symptoms

• Incubation period 5 - 13 days -Persists
  • -Weeks
  • -Molecules Pseudo Umbilicate -Painful and itchy -Systematic head aches

Mpox - Complications (Clade II)

• Neurological GI -Obstruction Immunocompromised Patients with HIV

Management

• Viral DNA via PCR
• Symptoms Skin -Anal Swap
• Careful and skin infection
• Prevention Avoid Contact Person
• Condoms 12 weeks and after
• Vaccination Modified

Genital Warts

Causes – Human Papilloma Virus -Spread Other contact Apparent Months

• Recur visual to diagnose

Genital Warts Management

• Treatment - Chemical and Physical - Therapy - surgical excisions - Prevention Safe Sex -Vaccination

HIV Epidemiology

• 37.7 million
• 3.4 million
• First case Kaposi Sarcoma
• AID Symptoms- Blood and transfusion Tissues

HIV INFECTON

• Common Worldwide
• Risk - Contaminated Vertical
• MTC - congenital -Needles
• Tissues and organs
• Exposures
• Sharp and injuries

HIV PREVENTION

• Sexual Contact or PWID

• Key is -Education-Drug treatment and Prevention-Needle Exchange Transfusion with Voluntary self-exclusion-Screening

• Limited the occupational

• Testing - Check risk level ,screening

• Antenatal

• HIV Mothers