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Sexually Transmitted Infection

Dr Tony Worthington School of Life and Health Sciences Room 455a T.Worthington@aston.ac.uk

Sexually Transmitted Infection:


Lecture Overview
STI background; current figures Aetiological agents of STI Overview of gonorrhoea, chlamydia, herpes, genital warts

Epidemiology, clinical manifestations, laboratory diagnosis, pathogenesis and treatment of gonorrhoea


Treatment / prevention of STI

Sexually Transmitted Infection: the silent menace


Sexually transmitted Infection (STI) an illness caused by an infectious microorganism with a propensity for transfer between humans through sexual contact (vaginal, oral, anal, sex toys) Major problem worldwide In the UK, STIs, are the greatest communicable disease problem today: >1.5 million attendances at genitourinary medicine (GUM) clinics

Cost burden to the NHS: approx 750 million / annum


(a) HIV: 580 million (b) chlamydia / gonorrhoea / syphilis / herpes / warts: 165 million

The morbidity and associated mortality is high and disproportionately affects: (a) Men who have sex with men (MSM) (b) Disadvantaged socio-economic communities (c) Young people with high risk sexual lifestyles

Microorganisms associated with common STI


Infectious agent category
Bacteria

Organism

Disease

No. of new cases UK (2011)


186,000 21,000 2, 900 76,000 30,000 (5 million in UK) 7,093 80,000 8,000 -

Chlamydia trachomatis Neisseria gonorrhoae Treponema pallidum* Papillomavirus Herpes simplex Hepatitis B/C* HIV* Candida albicans Trichomonas vaginalis Sarcoptes scabei Phthirus pubis (crab louse)

Non-specific urethritis Gonorrhoea Syphilis Genital warts Genital herpes Hepatitis AIDS Thrush Vaginitis Genital scabies Pediculosis pubis

Viruses

Fungi Parasites Arthropods

*may be transmitted through contaminated blood or blood products

Incidence of STI is increasing: where are we going wrong?


Modern way of life (perception of sex)
(a) Multiple partners; more promiscuous

(b) Pregnancy morning after pill

Drugs / alcohol
(a) Alcohol consumption; binge drinking (b) Ecstasy / amphetamines / heroin

MSM
Increased numbers; multiple partners; risky sexual practices

Contraceptive pill Lack of education / awareness

STIs on the rise - and in the press (2007)

Chlamydia: Chlamydia trachomatis


MICROORGANISM Chlamydia trachomatis 2011: 186,000; (2002-2011: 135% increase) TRANSMISSION Via vaginal, anal and oral sex Transmitted from mother to baby Incubation: 1-3 weeks

CLINICAL MANIFESTATIONS
Cervicitis

Vaginitis

Frequently asymptomatic (the silent epidemic): 75% women / 50% men; reservoirs of infection
Male: urethritis (watery, mucoid discharge) Female: urethritis / cervicitis / vaginitis

COMPLICATIONS
(a) Pelvic Inflammatory Disease (PID): 40% (b) Infertility in male and female (c) Ocular infection: neonates / adults
Male urethral discharge

Chlamydia ocular infection

Chlamydia; NCSP and Treatment


The National Chlamydia Screening Programme (NCSP)
-Established in 2003: Control and prevention programme -AIM: detection / treatment of asymptomatic carriers -TARGET GROUP: people < 25 who are sexually active (1:10 POSITIVE) -LOCATION: Contraceptive services; abortion clinics; GP surgeries; community pharmacies; outreach clinics; non-health settings

2012: 5.5 million tests / 370,000 silent infection diagnoses

Treatment:
Azithromycin (Clamelle): single dose; 2 x 500mg

Doxycycline (vibramycin): 7-14 days; 200mg

Genital warts; Human Papillomavirus (HPV)


MICROORGANISM HPV >100 types (6, 11, 16, 18: >70% of infections) 2011: 76,000 (2002-2011: 21% increase) TRANSMISSION Via vaginal, anal and oral sex Incubation: 1-6 months; years Prevalence greatest in persons aged 17-33; peak: 20-24

HPV warts; oral

HPV warts; vaginal

CLINICAL MANIFESTATIONS Warts: Penis, vulva / vagina, perianal /anal, throat, mouth Genital warts (90%=types HPV 6 / HPV 11); multiple, dry, keratinised, cauliflower in appearance; painless
Anal warts Penile warts: typical cauliflower appearance

NEOPLASIA (CANCER) Neoplastic conversion (eg. cervical cancer): HPV 33, 35, 39, 40, 43, 45, 51-56, 58) moderate risk; HPV 16 / 18- high risk

Number of HPV-induces cancers (worldwide)


Parkin, D. M. (2006) "The global health burden of infection-associated cancers in the year 2002." Int J Cancer 118(12): 3030-44

(100%) 90%

40%

40%

3%

20%

HPV: Treatment / Prevention


Treatment:
Genital warts - podophyllin / Imiquimod Cervical / intraurethral CO2 laser removal

Prevention:
Vaccination -Gardasil (HPV 6, 11, 16, 18) -Cervarix (HPV 16, 18) Safe sex

Herpes; Herpes simplex


MICROORGANISM Herpes simplex virus (HSV1 -40%; HSV2 -60%) 2011: 30,000 (2002-2011: 81% increase)

TRANSMISSION Via vaginal, anal and oral sex Incubation: 3-7 days
Oral herpes (predominantly HSV1)

CLINICAL MANIFESTATIONS Primary infection Asymptomatic in 70% cases Symptoms: constitutional and localised Untreated attack lasts approx 28 days; latency

Reactivation Tenderness, pain, and burning at the site of eruption lasting 2 hours to 2 days Women: Lesions on the labia and perineum Men: Lesions on the shaft, prepuce, glans.
Genital herpes (predominantly HSV 2)

Lesions heal in 7-10 days; Dissemination, encephalitis

Herpes: Treatment / Prevention


Aciclovir (Zovirax): 200mg, 5 x daily for 1 week Famciclovir (Famvir): 200250mg, 3 x daily for 1 week

Safe sex

Gonorrhoea (the clap)


MICROORGANISM Nessieria gonorrhoeae 2011: 21,000 (2002-2011: 13% decrease) Gram-negative diplococcus; intracellular survival Strict human pathogen TRANSMISSION Via vaginal, anal and oral sex Incubation period: 2-7 days Transmission rates following single exposure: male-20%; female-80% Mother to baby transmission
N. gonorrhoea GC on horse-blood agar

EPIDEMIOLOGY Rates higher in urban regions esp. London Men form 70% of the diagnoses; MSM and black ethnic groups account for 1/3 of these Female16-19 years; male 20-24 years
Gram- negative intracellular diplococci in urethral discharge

Gonorrhoea: Clinical Manifestations


Asymptomatic in many cases (70% female) Male (a) Urethritis (urethral inflammation) (b) Dysuria (pain on urination) (c) Thick, purulent penile discharge Female (a) Dysuria (b) Cervicitis (c) Thick, purulent (sometimes bloody) vaginal discharge Rectal infection: anal discharge, pain on anal sex Throat infection: tonsillitis; purulent exudate

Complications of gonorrhoea
(a) Males: epididymitis, prostatitis (b) Females (20%): spread to fallopian tubes (salpingitis); pelvic inflammatory disease (PID); infertility Opthalmia neonatorum 1% DGI: bloodstream infection fever, sepsis, arthritis, skin lesions
Skin lesions and arthritis

Opthalmia neonatorum

PID

Pathogenesis: Virulence Factors


(a) (b) (c) (a) (b) Stage 1: Adherence and endocytosis Pili Opa proteins and LOS (lipooligosaccharide) Por proteins Stage 2: Avoidance of host defences Capsule IgA protease

(a) (b)

Stage 3: Formation of transferrin and lactoferrin binding receptors Tbp1 , Tbp2 Lbp 1

Laboratory diagnosis of gonococcal infection


(A) Sample collection Males: urethral swab (3cm insertion and rotation) Females: multiple samples; urethral / endocervical / vaginal Other samples depending upon patient history / clinical presentation : throat / rectal / blood cultures Transport medium eg. Stuarts Direct examination and culture of clinical samples in GUM clinic preferred

Urethral swab (left)

Laboratory diagnosis of gonococcal infection


(A) Non Culture Techniques Direct microscopy of discharge Presumptive diagnosis if positive; initiate treatment Nucleic acid amplification tests (NAAT) PCR-based: Rapid; detects / amplifies specific DNA; bacterial viability not essential (B) Culture Non selective agar: Blood / chocolate agar Selective agar: Modified Thayer-Martin / New York City agar; vancomycin, colistin, nystatin, trimethoprim 37oC / 48h / 5% CO2 Opaque, convex, grey, glistening colonies, 2mm
Gonococcal culture Direct microscopy: Gram-negative intracellular diplococci

Laboratory diagnosis of gonococcal infection


(C) Identification and confirmation of N. gonorrhoeae isolated by culture Colonies: Gram-negative diplococci

Oxidase +
Catalase + CHO fermentation (glucose+, maltose-, sucrose-); API Prolylaminopeptidase + (Gonochek II, commercially available)

Oxidase +

Gonochek +

Catalase +

CHO fermentation

Treatment and prevention of gonococcal infection


Many strains now resistant to common antibiotics eg. penicillin (18%), ciprofloxacin (22%), tetracycline (48%): sensitivity testing essential Current guidelines:

(a) ceftriaxone (250mg; IM; single injection) (b) cefixime (400mg; oral; single dose) (c) spectinomycin (2g; IM; single injection) (a) (b) Safe sex Minimise number of sexual partners Use condoms during mouth-to-penis sex, vaginal and anal intercourse

Key points: STI

STI are caused by numerous microorganisms


Risk factors: promiscuous lifestyle (partners, alcohol, drugs etc) Top 5 acute STI are chlamydia, genital warts, herpes, gonorrhoea and syphilis N. gonorrhoeae possesses a variety of virulence factors Clinical spectrum of gonorrhoea: asymptomatic symptomatic; associated with complications

Laboratory diagnosis is essential to confirm the identity of the causative agent and determine antimicrobial sensitivity
Ceftriaxone, cefixime, spectinomycin: first line treatment for GC Prevention is better than cure!

Student Directed Learning


Mims C. Medical Microbiology: Sexually transmitted diseases Lydyard. Case studies in Infectious Disease: Case 24, Neisseria gonnorhoeae Blackboard:

A complex picture: HIV and other sexually transmitted infections in the UK. Health Protection Agency (2006)
STIs in the 21st century. Royal Institute of Public Health supplement

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