Pharmacotherapeutics - PID and STI 2024 PDF

PELVIC INFLAMATORY DISEASE AND SEXUALLY TRANSMITTED INFECTIONS PROF. (MRS) S.F. USIFOH BPharm, PharmD, MHPM, PhD DEPT. OF CLINICAL PHARMACY & PHARMACY PRACTICE  PID (Pelvic Inflammatory Disease) What is PID ? An infection of vagina (Colpitis) Cevix...

PELVIC INFLAMATORY DISEASE AND SEXUALLY TRANSMITTED INFECTIONS PROF. (MRS) S.F. USIFOH BPharm, PharmD, MHPM, PhD DEPT. OF CLINICAL PHARMACY & PHARMACY PRACTICE  PID (Pelvic Inflammatory Disease) What is PID ? An infection of vagina (Colpitis) Cevix (Endocervicitis) Uterus ( Endometritis) Fallopian tubes ( Salpingitis) Ovaries (oophoritis), Pelvic peritonitis Tubo-ovarian abscess PID PID is a spectrum of infection and inflammation of the upper genital tract organs typically involving the uterus (endometrium), fallopian tubes, ovaries, pelvic peritoneum and surrounding structures Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures A common and serious complication of STDs (Sexual Transmitted Diseases) The clinical syndrome is not related to pregnancy and surgery. How do women get PID? Bacteria move upward from vagina or cervix into reproductive organs. 6 Epidemiology The incidence of pelvic infection is on the rise due to the rise in sexually transmitted diseases. The incidence varies from 1–2 percent per year among sexually active women. About 85% are spontaneous infection in sexually active females of reproductive age. The remaining 15% follow procedures (include endometrial biopsy, uterine curettage, insertion of IUD and hysterosalpingography. 7  Microbial Etiology Most cases of PID are polymicrobial infection caused by organisms ascending upstairs from downstairs. Most common primary pathogens: N. gonorrhoeae: recovered from cervix in 30%-80% of women with PID Chlamidia trachomatis: recovered from cervix in 20%- 40% of women with PID Mycoplasma hominis in 10%. The secondary organisms normally found in the vagina are almost always associated sooner or later. These are: ◆ Aerobic organisms—non-hemolytic streptococcus. E. coli, group B streptococcus and staphylococcus. ◆ Anaerobic organisms—Bacteroides species – fragilis and bivius, peptostreptococcus and peptococcus Risk factors Adolescence History of PID Area with high prevalence of sexually transmitted diseases e.g Gonorrhea or chlamydia, or a history of gonorrhea or chlamydia Male partners with gonorrhea or chlamydia Multiple partners Current douching Insertion of IUD Bacterial vaginosis Absence of Oral contraceptive use (in some cases) Demographics (socioeconomic status)  Protective factors Contraceptive practice Others Barrier methods, specially condom, Pregnancy diaphragm with spermicides. Menopause Oral steroidal contraceptives have got Vaccines: hepatitis B, two HPV preventive aspects. ○ Produce thick mucus plug preventing ascent of sperm and bacterial penetration. ○ Decrease in duration of menstruation, creates a shorter interval of bacterial 10 colo- nization of the upper tract. Monogamy or having a partner who had  Symptoms Patients with acute PID present with a wide range of non- specific clinical symptoms. Symptoms usually appear at the time and immediately after the menstruation. Bilateral lower abdomen pain, dull in nature but, may worse when move The onset of pain is more rapid and acute in gonococcal infection (3 days) than in chlamydial infection (5– 7 days). pain during or after sex bleeding between periods or after sex lower back pain sense of pressure or swelling in the lower abdomen fever (often with chills) and head aches feeling tired or unwell abnormal vaginal discharge which becomes purulent and or copious. nausea, vomiting and dizziness leg pain increased period pain increased pain at ovulation dysuria, frequently urination Differential diagnosis Appendicitis Gastroenteritis Cholecystitis Irritable bowel syndrome Ectopic pregnancy Hemorrhagic ovarian cyst Ovarian torsion Endometriosis Nephrolithiasis Somatization  Diagnosis Symptoms alone are not a good predictor , and clinical diagnosis alone is difficult Major criteria Minor criteria cervical motion tenderness Temperature >38°3 C and Abnormal cervical discharge uterine motion tenderness Pelvic abscess or inflammatory complex on and bimanual examination adnexal tenderness Gram stain of the endocervix showing gram negative intracellular diplococci Positive chlamydia test Leucocytosis >10x 109 WBC/L Elevated ESR Elevated C-reactive protein The definitive criteria histopathologic evidence of endometritis on endometrial biopsy transvaginal sonography or other imaging techniques showing thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex laparoscopic abnormalities consistent with PID  Clinical diagnostic criteria of PID (CDC 2015) Additional Criteria 1. Oral temperature >101°F (>38.3°C); 2. Abnormal cervical mucopurulent Minimum Criteria discharge or cervical friability; 1. Adnexal tenderness. 3. Presence of abundant numbers of WBC 2. Cervical motion on saline microscopy of vaginal fluid; tenderness. 4. Elevated ESR; 3. Uterine tenderness 5. Elevated CRP; 6. laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis. Definitive Criteria 1. Endometrial biopsy with histopathologic evidence of endometritis; 2. Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or 15 tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia); 3. Laparoscopic findings consistent with PID.  Investigation  A pregnancy test should always be performed to exclude the important differential diagnosis of ectopic pregnancy  Laboratory may be entirely normal.  Full blood count and C-reactive protein are important if the woman is systemically unwell, and urea and electrolytes should be analysed if she is vomiting.  An elevated leukocyte count does not distinguish PID from other diagnoses  High vaginal and endocervical swabs (high vaginal for Trichomonas vaginalis, Candida and bacterial vaginosis, endocervical for gonorrhoea and endocervical for Chlamydia) should be taken, paying attention to using the correct technique.  Midstream specimen of urine should be sent for microscopy and culture Cervical cultures for gonorrhea or Chlamydia require 3-7 days for results  Serological test for HIV and syphilis should be carried out for both the partners in all cases. Criteria for hospitalization surgical emergencies (e.g., appendicitis) cannot be excluded is pregnant does not respond to oral antimicrobial therapy unable to tolerate an outpatient oral regimen has severe illness, nausea and vomiting, or high fever has a tubo-ovarian abscess. HIV infection with low CD4 count Complications of PID IMMEDIATE: LATE: (1) Pelvic peritonitis (1) Dyspareunia. or even generalized (2) Infertility rate is 12%, after two episodes peritonitis. increases to 25% and after three raises to (2) Septicemia — 50%. It is due to tubal damage or tubo- producing arthritis or ovarian mass. myocarditis. (3) Chronic pelvic inflammation is due to recurrent or associated pyogenic infection. (4) Formation of adhesions or hydrosalpinx or pyosalpinx and tubo-ovarian abscess. (5) Chronic pelvic pain and ill health (24– 75%). (6) Increased risk of ectopic pregnancy (6- 18 10 fold). Treatment THE PRINCIPLES OF THERAPY ARE: 01 To control the infection energetically. 02 To prevent infertility and late sequelae. 03 To prevent reinfection.  Treatment Inpatient therapy: Bed rest is imposed. Oral feeding is restricted. Dehydration and acidosis are to be corrected by intravenous fluid. Intravenous antibiotic therapy is recommended for at least 48 hours but may be extended to 4 days, if necessary. Improvement of the patient is evidenced by remission of temperature, improvement of pelvic tenderness, normal white blood cell count and negative report on bacteriological study. 20 Treatment Outpatient therapy: Apart from adequate rest and analgesic, antibiotics are to be prescribed even before the microbiological report is available. As because the infection is polymicrobial in nature, instead of single, combination of antibiotics should be prescribed. Out-patients antibiotic therapy for acute PID is given in the next Table. 21  Parenteral Treatment Regimen A Doxycycline 100 mg Cefoxitin 2 g IV every 6 + orally or IV every 12 hours hours Regimen B Gentamicin loading dose (2 Clindamycin mg/kg ) IV or IM 900 mg IV every followed by a maintenance dose 8 hours (1.5 mg/kg) + every 8 hours 14 days Treatment All patients treated in the outpatients are evaluated after 48 hours and if no response, are to be hospitalised. 23 Surgery Rupture abscess invade to peritonium Failure medical treatment 48-72 hr Abscess does not go away after 2-3 week with persistent abdominal pain  SEXUALLY TRANSMITTED INFECTIONS Group of communicable diseases in which sexual contact is the most important mode of transmission. Importance: 1. Increasing incidence worldwide. 2. The cost and difficulties in the treatment of the diseases and their complications. 3. It is a socioeconomic problem as well as behavioral one since it is linked to addiction, low level of religious values, increase age of marriage, etc.  Bacteria Parasiti Viral Fung l c Trichomon us vaginitis Vagin AIDS Syphilis and thru urethritis. Genital Valvova herpes Gonorrhea Scabies tis simplex Non- Genital Pediculosis gonorrheal Balan warts pubis. urethritis Chancroid Non- specific vaginitis Granuloma inguinale  It is a worldwide disease affecting mainly the age group from 15-39 Recently it was found to be increasing.  Causative organism Spirochaete, treponema pallidum. It is delicate and is rapidly killed by drying, high temperature, disinfectants, and soap & water. Reservoir: Man: untreated case is infectious during the 1ry & 2ry stages of disease, usually for 2-4 years. Exit: exudates of skin & mucous membranes. blood & body fluids (semen, saliva, vaginal & cervical discharge). IP: About 3 weeks  Transmission 1. Contact with open lesion: Sexual contact (most important mode). Kissing. Contact with baby having congenital syphilis. Contact with contaminated articles. 2. Congenital infection: transplacental from the 4th month till delivery (not before because treponema cannot pass the placental barrier). 3. Inoculation infection: contaminated blood & body fluids (contaminated syringes & needles & blood transfusion).  Primary syphilis: Chancre at the portal of entry: firm, indurate, painless & highly infectious ulcer. Enlarged lymph nodes. Spontaneously disappears without treatment after 4-6 weeks.  Secondary: Generalized skin rash “Patchy lesions of mucous membranes especially the mouth”. Involvement of the other parts of the body. Spontaneously disappears within weeks or months followed after a latent period (years) by the 3rd stage.  Late symptomatic syphilis: Reappearance of symptoms. Characterized by the occurrence of neuro & cardiovascular syphilis and of the characteristic lesions involving different parts of the body.  Diagnosis 1. History & clinical picture. 2. Lab investigations: A. Demonstration of organism in exudates of lesions by dark field microscopic exam. B. Serologic testing: - Non-treponemal test (non-specific): used for screening e.g. Wassermann Reaction (WR) & Venereal Disease Research Laboratory test (VDRL) {high false +ve; so, +ves should be confirmed by specific tests}. - Treponemal tests (specific test): Use treponema antigens e.g. fluorescent treponema antibody absorption test.  Prevention A. General measures: 1. Avoidance of sexual promiscuity. 2. Health education to increase awareness. 3. Religious and social guidance especially of youth. 4. Convenient family life and supervision of youth. 5. Suitable places for leisure time and development of hobbies and talents. 6. Socioeconomic development and provide facility for marriage. B. Specific: Chemoprophylaxis: one dose of 2.4 million units of long acting penicillin I.M. soon after A. Cases: 1. Early case finding: during survey & on health appraisal: Premarital & prenatal examination. Exam of food handlers, blood donors, army recruits, child nurses. Suspected attendants of medical services. Diagnosis of congenital syphilis when the mother is syphilitic. 2. Measures for cases: Notification confidentially to local health authority. Isolation: not needed but avoid sexual contact till elimination of infectivity.  Specific treatment: Long acting penicillin 2.4 million units in a single dose I.M. Penicillin sensitive patients: doxycycline 100 mg twice daily for 14 days. Re-examination after treatment.  B. Contacts: Tracing and enlistment. Examination. Health education. Surveillance. Chemoprophylaxis: one dose of 2.4 million units of long acting penicillin I.M. C. Congenital syphilis: Serologic testing and treatment. Proper handling of baby with congenital syphilis with caution to avoid infection. Gonorrhe a Acute infectious STD which can become chronic if neglected.  Neisseria gonorrhea (Gonococcus) Delicate Gram -ve, intracellular diplococcus that perishes rapidly outside the body. Reservoir: Man: case who is infectious for months or years if not treated, while treatment eliminates the infection within days. Exit: Discharges of infected mucous membranes. Transmission: Direct sexual contact only.   Clinical picture It starts as an acute infection and if not properly treated it becomes chronic. In males: urethritis with purulent discharges. In females: urethritis and/or cervicitis with discharges. Arthritis, pharyngitis, rectal infection, septicaemia, endocarditis or meningitis may occur in both sexes. Diagnosis 1. History and clinical picture. 2. Lab investigations: Acute case: demonstration of causative organism from film of pus taken from cervix or urethra. Chronic case: serologic test such as complement fixation test.  Prevention Oral penicillin 400,000 I.U. just before or after sexual exposure.  Treatment Cases: Amoxicillin 3 gm orally as a single dose. Penicillin resistant strains: ceftrioxone 250 mg as a single dose. Re-examination after treatment. Contacts: Oral penicillin 400,000 I.U.  AIDS (Acquired Immune- Deficiency Syndrome)  It is a life threatening clinical condition that represent the late clinical stage of infection with HIV which results in progressive damage to the immune & other organ systems specially CNS.  Causative agent: Human immune deficiency virus (HIV) which is RNA retrovirus. 2 serologically & geographically distinct types with similar epidemiological characteristics: HIV-1 is found in America, Europe and Subsaharan Africa. HIV-2 is found mainly in West Africa. Has specific affinity to T-helper lymphocyte cells causing their depletion. TREATMENT Reservoir: man Exit: in blood and body fluids e.g. semen, vaginal secretion, saliva and tears. Period of communicability: so long the infected person is alive. IP.: variable, but 50% of those infected develop AIDS about 10 years after infection.  Modes of infection: 1-Sexual contact: most important mode especially homosexual and bisexual. 2-Parenteral infection:  Contaminated syringes & needles especially by i.v. drug abusers.  Contaminated blood transfusion. 3-Perinatal transmission: 25-35% of infants born to infected mothers are infected before, during or shortly after birth. Non-specific manifestatio ns:  Specific indicator diseases: (a) Opportunistic infections: pneumocystitis carenii pneumonia, chronic cryptosporidiosis, CNS toxoplasmosis. (b) Neurologic diseases: dementia or sensory neuropathy. (c) Cancers: Kaposi sarcoma and Hodgkin's lymphoma. (d) Others e.g. pulmonary or extra-pulmonary T.B. DIAGNOSIS  Laboratory diagnosis 37  Evidence of HIV infection: Evidence of clinical or immunologic deterioration  Virus isolation: HIV can be cultured from lymphocytes in peripheral blood.  Measurement of viral nucleic acid: By RT-PCR  Detection of viral antigen: P24 antigen tests  Detection of viral antibody: ELISA & Western Blot assay  Recognition of immunodeficiency  CD4+ T cell count  Recognition of AIDS related disease  69 Laboratory diagnosis  Window period:  Early in infection when the blood of an infected person can contain HIV but antibodies are not detectable.  Seroconversion:  Development of evidence of antibody response to a disease.  Viral Load:  The amount of HIV in the blood.  70 Window Period  A period of 4-6 weeks after HIV exposure when antibodies to HIV are not detectable in the blood  A person at high risk who initially tests negative should be retested at 3 months to confirm diagnosis  71 Window Period  Seropositive:  detectable antibodies to HIV in the serum  person becomes infectious within 2 weeks of exposure  72 Laboratory diagnosis E. CD4:CD8 cell count:  Absolute number of CD4+ cell and ratio of helper cell to inducer cell are abnormally low. TREATMENT  Antiretroviral therapy  There's no cure for HIV/AIDS, but many different drugs are available to control the virus called Antiretroviral therapy, or ART.  Each class of drug blocks the virus in different ways.  ART is now recommended for everyone, regardless of CD4 T cell counts.  It's recommended to combine three drugs from two classes to avoid creating drug- resistant strains of HIV.  Agents 50 I. Entry inhibitors: (Enfuvirtide (Fuzeon) II. Reverse Transcriptase inhibitors (Abacavir, Nevirapine) III. Protease inhibitors (Ritonavir – Saquinavir) IV. Integrase inhibitors (Raltegravir) https://www.youtube.com/watch? v=604tb9pehxE&feature=emb_imp_woyt  treatment 49  Everyone with HIV infection, regardless of CD4 T cell count, should be offered antiviral medication.  HIV therapy is particularly important for the following situations:  severe symptoms.  Presence of an opportunistic infection.  CD4 T cell count is under 350.  Pregnant.  HIV-related kidney disease.  Presence of hepatitis B or C. Antiretroviral Agents 78  79 Antiretroviral Agents  Entry Inhibitors:(fusion and penetration blockers)  Prevent HIV from entering healthy T cells in the body  enfuvirtide(Fuzeon)  80 Antiretroviral Agents  Reverse Transcriptase Inhibitors i. Nucleoside reverse transcriptase inhibitors  (NsRTIs)Incorporate into viral DNA terminating its construction  E.g. Lamivudine - Abacavir ii. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI’s)  Action is similar to NRTI’s; bind directly to reverse transcriptase  E.g. Nevirapine  81 Antiretroviral Agents  Reverse Transcriptase Inhibitors iii. Nucleotide Reverse Transctriptase Inhibitors (NtRTI’s)  E.g. Tenofovir  82 Antiretroviral Agents  Protease Inhibitors (PI’s) o Prevent assembly & release of new virus particles o E.g Ritonavir - Saquinavir  83 Antiretroviral Agents  Integrase inhibitors  work by disabling a protein called integrase, which HIV uses to insert its genetic material into CD4 T cells.  E.g raltegravir  84 Antiretroviral Agents Regimen  All recommended regimens for initial treatment contain an NNRTI, a ritonavir-boosted PI, or an INSTI in combination with tenofovir (NtRTI) and emtricitabine (NRTI).  The preferred agents are as follows: 1. NRTI/NtRTI combination: Tenofovir and emtricitabine 2. PIs: Atazanavir/ritonavir 3. NNRTI: Efavirenz 4. INSTI: Raltegravir  85 Evaluation of treatment  Criteria o HIV RNA (viral load) in blood o Count of T cells o Appropriate clinical response  Treatment Failure o viral load with low T-cell count o Clinical deterioration o New opportunistic infections  86 Strategies to maximize benefits/minimize toxicities 1) Alternating therapies 2) Combination therapy:  Demonstrated more beneficial than monotherapy i. Decreased emergence of resistance ii. Decreased risk of toxicity  87 Adherence  Major cause of resistance is sub-therapeutic dosing :  failure to take prescribed dose  failure to take prescribed dose at prescribed intervals  interactions with other drugs that decrease blood levels of ART  88 Adherence Factors affecting adherence 1. Complex dosing schedules 2. Adverse side effects 3. Unknown cross reactions 4. Cost 5. Access to Care  89 HIV infected Pregnant Female  Standard antiretroviral therapy should be used in the HIV infected pregnant female  Possible risk of premature delivery (highest in non-treated individuals) Drugs used in treatment of HIV infection Drug Category Mode of action Dose Adverse effects Zidovudine Nucleoside reverse Inhibits viral replication 250mg  Nausea transcriptase inhibitor by inhibiting the enzyme  Vomiting (NRTIs) nucleoside reverse  Headache transcriptase  Fatigue  Muscle pain Stavudine Nucleoside reverse Inhibits viral replication 30-40mg  Peripheral neuropathy transcriptase inhibitor by inhibiting the enzyme  Pancreatitis (NRTIs) nucleoside reverse  Lactic acidosis transcriptase Lamivudine Nucleoside reverse Inhibits viral replication 150mg-300mg  GI disturbances transcriptase inhibitor by inhibiting the enzyme  Lactic acidosis (NRTIs) nucleoside reverse  Hepatitis transcriptase Emitricitabine Nucleoside reverse Inhibits viral replication 200mg  Diarrhea transcriptase inhibitor by inhibiting the enzyme  Dizziness (NRTIs) nucleoside reverse  Insomnia transcriptase  Rashes  headache Efavirenz Non nucleoside reverse Inhibits viral replication 600mg  CNS disturbances transcriptase inhibitor by inhibiting the enzyme  Rashes (NNRTIs) non nucleoside reverse  Hepatitis transcriptase  Hyperlipidemia  Teratogenecity Nevirapine Non nucleoside reverse Inhibits viral replication 200mg  Rashes transcriptase inhibitor by inhibiting the enzyme  Hepatitis (NNRTIs) non nucleoside reverse  GI disturbances transcriptase  Neutropenia  Fever Ritonavir Protease inhibitor Inhibits viral replication 25-50mg  GI disturbances by inhibiting the enzyme  Triglycerides protease  Nausea  Vomiting Lopinavir Protease inhibitor Inhibits viral replication 100-200mg  Diarrhea by inhibiting the enzyme  Hyperlipidemia protease  Nausea  Rashes  Increased ALT levels Enfuviritide Entry inhibitor Inhibits viral replication 90mg  Injection site reaction by inhibiting the entry of  Pain and discomfort virus in to T cell  Erythema  Induration  Nodules and cysts Dolutegravir Integrase inhibitor Inhibits viral replication 50mg  Dyslipidemia by inhibiting the enzyme  Increased levels of lipase integrase  Hyperglycemia  Increased levels of creatinine kinase  Increased levels of AST  Control: A. Preventive measures: 1- Health education of youth about the disease & its modes of transmission. 2- Increase religion roots to avoid illegal sexual intercourse. 3- Use disposable syringes & needles. 4- Control of drug abuse. 5- Testing blood donors for AIDS & only screened blood & blood derivatives should be used. 6- Proper sterilization of instruments & sharp objects. 7- Care in handling, using & disposing needles & other sharp objects. 8- No tattooing or acupuncture. B. Measures for cases: 1- Case finding: screening of high risk groups e.g. male homosexuals, i.v. drug abusers, sexual partners of infected persons, patients taking repeated blood transfusion as haemophilics. 2- Notification: is obligatory to local health authority & WHO. 3- Isolation: Isolation of HIV+ive person is unnecessary, ineffective and unjustified. 4- Concurrent disinfection: of equipment contaminated with blood or body fluids and with excretions & secretions visibly 5 - Treatment: - treatment of opportunistic diseases that complicated HIV infection. - Antiretroviral treatment: it is complex, involving a combination of drugs as resistance will rapidly appear if a single drug is used. The drugs are toxic & treatment must be lifelong. A successful treatment is not a cure, although it results in suppression of viral replication.  N.B.: Patients & their sexual partners should not donate blood, plasma, organs for transplantation, tissues, cells, semen for artificial insemination or breast milk for human milk banks. C. Measures for contacts: 1- Notification of contacts and source of infection: The infected patient should ensure notification of sexual and needle sharing partners whenever possible. 2- Screening of contacts for HIV infection. 3- Health education. 4- No vaccination or chemoprophylaxis.  N.B.: WHO recommends immunization of asymptomatic HIV infected children with the EPI (Expanded program Immunization) vaccines; those who are symptomatic should not receive BCG vaccine. Live Measles-Mumps-Rubella (MMR) and polio vaccines are recommended for all HIV-infected  Chlamydia  It is most commonly diagnosed STI, especially in under 25-year –olds, and is caused by the bacterium Chlamydia trachomatis  Between 70- 80% of women affected by chlamydia are asymptomatic.  The organism affect the columnar and transitional epithelium of the genitourinary tract. The infection is mostly localized in the urethra, Bartholin’s gland and cervix. Incubation period is 6-14days.  Clinical features  it is non-specific and asymptomatic in most cases (75%).  Dysuria, dyspareunia, post-coital bleeding, and inter-menstruation bleeding, lower abdominal pain, cervical discharge, conjunctivitis, eye infections and sore throats following anal or oral sexual practices.  If left untreated, chlamydial infection can cause pelvic inflammation disease (PID), which increases infertility and the risk of miscarriage and ectopic pregnancy.  Diagnosis › Methods of testing include urine test, low vaginal swab and cervical swab. › Chlamydia antigen can be detected by ELISA technique.  Treatment of chlamydia › Azithromucin- 1g orally single dose › Doxycycline – 100mg orally BID * 7days › ofloxacin- 200 mg orally BID* 7days › Erythromycin – 500mg orally BID* 7days › The sexual partner should also be treated with the same drug regimen.  Hepatitis B  Globally, hepatitis B virus (HBV) infection is the most common form of chronic hepatitis around the world.  Chronic HBV infection leads to increased risk for chronic hepatic insuffi ciency, cirrhosis, and hepatocellular carcinoma (HCC).  The virus is transmitted by parenteral route, sexual contact, vertical transmission and also through breast milk.  Sign and symptoms Fever, fatigue, loss of appetite, nausea and vomiting Abdominal pain Dark urine Clay-colored bowel movements Joint pain Jaundice Hepatomegaly Symptoms begin an average of 3 months (range: 2–5months) after exposure to HBV. symptoms typically last for several weeks but can persist for up to 6 months.  Diagnosis HBsAg - used as a general marker of infection. HBsAb - used to document recovery and/or immunity to HBV infection. anti-HBc IgM - marker of acute infection. anti-HBcIgG - past or chronic infection. HBV-DNA - indicates active replication of virus. Treatment  Prevention for hepatitis B (1/4) Advocacy and raising awareness of all types of viral hepatitis infections help to reduce transmission in the community. Safe and effective vaccines are widely available for the prevention of HBV infection.  Prevention for hepatitis B (2/4)  Implementation of blood safety strategies, including blood supplies based on voluntary non-remunerated blood donations, effective public education on blood donation, donor selection, and quality-assured screening of all donated blood and blood components used for transfusion can prevent transmission of HBV and HCV.  Prevention for hepatitis B (3/4) › Infection control precautions in health care and community settings can prevent transmission of viral hepatitis as well as many other diseases. › Safe injection practices can protect against HBV and HCV transmission. › Safer sex practices.  Prevention for hepatitis B (4/4) › Harm reduction practices for injecting drug users prevent HBV transmission. › Occupational safety measures prevent transmission of viral hepatitis to health care workers.  Hepatitis B  Globally, hepatitis B virus (HBV) infection is the most common form of chronic hepatitis around the world.  Chronic HBV infection leads to increased risk for chronic hepatic insuffi ciency, cirrhosis, and hepatocellular carcinoma (HCC).  The virus is transmitted by parenteral route, sexual contact, vertical transmission and also through breast milk.  Sign and symptoms Fever, fatigue, loss of appetite, nausea and vomiting Abdominal pain Dark urine Clay-colored bowel movements Joint pain Jaundice Hepatomegaly Symptoms begin an average of 3 months (range: 2–5months) after exposure to HBV. symptoms typically last for several weeks but can persist for up to 6 months.  Diagnosis HBsAg - used as a general marker of infection. HBsAb - used to document recovery and/or immunity to HBV infection. anti-HBc IgM - marker of acute infection. anti-HBcIgG - past or chronic infection. HBV-DNA - indicates active replication of virus. Treatment  Prevention for hepatitis B (1/4)  Advocacy and raising awareness of all types of viral hepatitis infections help to reduce transmission in the community.  Safe and effective vaccines are widely available for the prevention of HBV infection.  Prevention for hepatitis B (2/4)  Implementation of blood safety strategies, including blood supplies based on voluntary non-remunerated blood donations, effective public education on blood donation, donor selection, and quality-assured screening of all donated blood and blood components used for transfusion can prevent transmission of HBV and HCV.  Prevention for hepatitis B (3/4) › Infection control precautions in health care and community settings can prevent transmission of viral hepatitis as well as many other diseases. › Safe injection practices can protect against HBV and HCV transmission. › Safer sex practices.  Prevention for hepatitis B (4/4) › Harm reduction practices for injecting drug users prevent HBV transmission. › Occupational safety measures prevent transmission of viral hepatitis to health care workers.  Chlamydia  It is most commonly diagnosed STI, especially in under 25-year –olds, and is caused by the bacterium Chlamydia trachomatis  Between 70- 80% of women affected by chlamydia are asymptomatic.  The organism affect the columnar and transitional epithelium of the genitourinary tract. The infection is mostly localized in the urethra, Bartholin’s gland and cervix. Incubation period is 6-14days.  Clinical features  it is non-specific and asymptomatic in most cases (75%).  Dysuria, dyspareunia, post-coital bleeding, and inter-menstruation bleeding, lower abdominal pain, cervical discharge, conjunctivitis, eye infections and sore throats following anal or oral sexual practices.  If left untreated, chlamydial infection can cause pelvic inflammation disease (PID), which increases infertility and the risk of miscarriage and ectopic pregnancy.  Diagnosis › Methods of testing include urine test, low vaginal swab and cervical swab. › Chlamydia antigen can be detected by ELISA technique.  Treatment of chlamydia › Azithromucin- 1g orally single dose › Doxycycline – 100mg orally BID * 7days › ofloxacin- 200 mg orally BID* 7days › Erythromycin – 500mg orally BID* 7days › The sexual partner should also be treated with the same drug regimen.