HTHSCI 2HH3 - Sexually Transmitted Infections

reportable STIs

chlamydia, gonorrhoea, syphilis

non-reportable STIs

herpes simplex virus (HSV), human papilloma virus (HPV)

importance of STIs

• 75% of adults will have at least 1 HPV infection in their lifetime, most will have no idea they’re infected

• ~ 1 in 7 Canadians aged 14-59 are infected with HSV

• rates of chlamydia, gonorrhoea, and syphilis are climbing due to antibiotic resistance (rates in 2020-2021 decreased due to reduced demand and access)

• the stigma, shame, and fear associated with STIs is real; talking about STIs, including prevention and testing is challenging compared to other infections

STI sequelae

if untreated, could lead to sterility, miscarriage, ectopic pregnancy, congenital defect, cancer, chronic pain, psychiatric disorder (neurosyphilis), synergystic nature with HIV; co-infection with some STIs increases viral shedding of HIV

chlamydia rates in Canada

Rate increase in the late ’90s, associated with increased screening related to “new” non-invasive Nucleic Acid Amplification Tests (NAAT) using urinary samples. Contact tracing has also improved, BUT RATES KEEP RISING as PCR is unable to do susceptibility testing so antibiotic resistance went unnoticed, they also weren’t doing tests of cure

chlamydia stats

• Most common reportable bacterial sexually transmitted infection in Canada

• Rates increased 22% between 2012-2019

• Women and AFAB account for 59% of reported chlamydia cases - women more likely to get screened due to more opportunities to have discussions when getting birth control

• Rates have increased by 45% in men and AMAB since 2012

• In 2021, those aged 20 – 24 years were highest proportion of reported cases

chlamydia sequelae

• Pelvic inflammatory disease, ectopic pregnancy, infertility, chronic pelvic pain, epididymoorchitis, Reiter’s syndrome (reactive arthritis)

• Transmission to newborn: conjunctivitis, trachoma (damage to inside lining of eyelid), pneumonia (infants < 6 months)

chlamydia trachomatis

• Gram negative, obligate intracellular bacteria

• Transmitted through vaginal, anal or oral sexual activity

  • Enters body through microscopic breaks in mucosal membranes and infects mucosal epithelial cells of the pharynx, urethra, cervix, uterus, fallopian tubes, anus or rectum

  • Autoinoculation may also occur from an infected genital site to conjunctivae or rectum

chlamydia symptoms

• Incubation period typically 2-3 weeks; can be as long as 6 weeks

• Clinical presentation reflects the site of infection, if symptomatic, any individual may experience

  • Dysuria - painful urination

  • Proctitis - inflammation of the lining of the rectum

  • Conjunctivitis - excessive tearing, discharge, inflammation, swelling or redness of the conjunctivae

  • Additional signs and symptoms are present depending on the genital site(s) affected

chlamydia symptoms in women

• Most infections in women and AFAB are asymptomatic (approximately 70%)

• Cervicitis - purulent or mucopurulent exudate in the endocervical canal, or induced/sustained bleeding/friability the cervix (erosions, spongy feeling)

• Change in vaginal discharge

• Lower abdominal pain

• Abnormal vaginal bleeding

• Dyspareunia (painful intercourse)

chlamydia symptoms in men

• Significant proportion of men and AMAB are also asymptomatic (approximately 50%)

• Urethral discharge

• Urethritis - inflammation of the urethra, with or without urethral discharge

• Urethral itch

• Testicular pain - epididymo-orchitis (testicular and epididymitis inflammation)

chlamydia screening

• Screening is effective for detecting and treating asymptomatic infections as well as preventing complications, transmission and reinfection

Annual Screening

• All sexually active people under 30 years of age

Targeted Screening

• Sexually active with increased risk factors (SDoH, substance use, incarceration, sex work, new sexual partner(s), sex without barrier protection, etc.)

• All pregnant people at first prenatal visit; rescreening at 3rd trimester for those who test positive or who are at ongoing risk of infection

• Neonates exposed to chlamydia during pregnancy, labour or delivery

chlamydia testing in asymptomatic individuals

• Clinical picture and sexual history determine which specimens should be collected and the type of test used

• Asymptomatic Individuals - Nucleic Acid Amplification Tests (NAATs)

  • First-void urine for all asymptomatic people

    • Person should not have voided for at least 2 hours prior to specimen collection

  • Vaginal swab (self obtained, or clinician) or cervical swab

  • Conjunctival, pharyngeal and rectal swabs for all asymptomatic people (based on history)

chlamydia testing in symptomatic individuals

• Physical examination is essential when an STI is suspected, collect specimens based on clinical presentation and history prior to treatment

• Symptomatic Individuals - Nucleic Acid Amplification Tests (NAATs)

  • First-void urine for all symptomatic people

  • Vaginal swab (self obtained, or clinician) or cervical swab

  • Conjunctival, pharyngeal and rectal swabs (based on clinical presentation)

  • Urethral swabs (men and AMAB only)

  • Swab of any visible lesions

• Due to high rates of co- infection, also collect specimens for the diagnosis of gonococcal infections NAAT can detect both C. trachomatis and N. gonorrhoeae from a single specimen

Who should be treated for chlamydia?

• Positive lab result for Chlamydia trachomatis

• Individuals presenting with compatible syndrome or symptoms (PID, cervicitis, urethritis, conjunctivitis), without waiting for results

• Positive lab result for Neisseria gonorrhoeae; due to high rates of co-infection

• Diagnosis of chlamydia in a sexual partner within 60 days prior to date of specimen collection or prior to symptom onset

chlamydia treatment

• Doxycycline 100 mg PO 2 times/day for 7 days or Azithromycin 1g PO, single dose

• Clients (and partners) should be encouraged to abstain from any sexual activity without barrier protection until treatment is complete and symptoms have resolved

• Test of cure (NAAT 4 weeks after treatment) recommended if...

  • Treatment compliance is suboptimal or uncertain

  • Alternative treatment is used

  • Client is pregnant

  • Prepubertal children

  • Persistent STBBI signs or symptoms post-treatment

pelvic inflammatory disease (PID)

• Infection and inflammation of the upper genital tract (ascending infection), females only

• Symptoms - fever and lower abdominal pain and/or tenderness, adnexal (ovaries) and cervical motion tenderness (pain upon palpation)

• Estimated that 40% of untreated lower genital tract infections will progress to PID, ~30% of cases attributed to Chlamydia trachomatis and Neisseria gonorrhoeae

• Estimated that up to 2/3 of cases may not be recognized (silent PID)

• Sequelae; infertility, ectopic pregnancy, chronic pelvic pain

• Diagnosis based on abdominal/pelvic examination, microbiology, diagnostic imaging (pelvic ultrasound)

pelvic inflammatory disease - treatment

• Early diagnosis and treatment are essential to minimizing the risk of long term sequalae; symptoms should resolve within 48-72 hrs post-Rx

• If no clinical improvement is observed, an escalation of therapy (including hospitalization and IV treatment) may be required

• Outpatient treatment regimen

  • Ceftriaxone 250 mg IM (single dose) plus Doxycyline 100 mg x 2-day PO for 14 days plus metronidazole 500 mg x 2-day PO for 14 days

  • Metronidazole is used to provide anaerobic coverage for non-STI related syndrome

• Management is not adequate, unless sexual partners are also evaluated and treated in cases of STI related syndrome

gonorrhoea stats

• Second most reportable bacterial sexually transmitted infection in Canada

• Rates have increased 151% from 2012 to 2019

• Rates have increased 191% in men and AMAB between 2012 and 2018; account for 63% of total reported cases

• The national rate in 2021 was TWO TIMES greater than in 2012

gonorrhoea sequelae

• Pelvic inflammatory disease, ectopic pregnancy, infertility, chronic pelvic pain, epididymo-orchitis, Reiter’s syndrome, disseminated infections

• Transmission to newborn: ophthalmia neonatorum (eyelid edema, conjunctival erythema, purulent discharge)

neisseria gonorrhoeae

• Gram negative diplococci, facultative intracellular bacteria

• Develops antimicrobial resistance rapidly, often co-infection with C. trachomatis

• Transmitted through vaginal, anal or oral sexual activity

• Adheres via fimbriae and capsules to mucosal epithelial cells of the pharynx, urethra, cervix, uterus, fallopian tubes, anus or rectum

• Fimbriae allow N. gonorrhoeae to attach to sperm cells; higher risk of pelvic inflammatory disease (pass through female reproductive tract dragging bacteria along)

• Phagocytized bacteria can survive and multiply in neutrophils, traveling to distal sites in the body such as the joints, meninges and heart (endocarditis)

gonorrhoea symptoms

• Incubation period is usually 2 – 7 days; but can range from 1-14 days

• Clinical presentation reflects the site of infection, if symptomatic, any individual may experience…

  • Dysuria – painful urination

  • Proctitis – inflammation of the lining of the rectum (with rectal pain and discharge)

  • Additional signs and symptoms are present depending on the genital site(s) affected

  • No autoinoculation

gonorrhoea symptoms in women

• Most infections in women and AFAB are asymptomatic (approximately 75%)

• Cervicitis - purulent or mucopurulent exudate in the endocervical canal, or induced/sustained bleeding/friability the cervix (spongy feel, not firm)

• Change in vaginal discharge

• Lower abdominal pain, abnormal vaginal bleeding

• Dyspareunia (painful intercourse)

• Bartholinitis - inflammation of Bartholin’s glands (found in the lower 3rd of the labia majora on the inner side)

gonorrhoea symptoms in men

• Most infections in men and AMAB are symptomatic

• Urethral discharge - thick, white, more easily detected than discharge associated with chlamydia

• Urethral itch

• Testicular pain - epididymo-orchitis (testicular and epididymitis inflammation)

gonorrhoea screening

• Screening is effective for detecting and treating asymptomatic infections as well as preventing complications, transmission and reinfection

• People being evaluated or treated for gonorrhea should also be screened for chlamydia, syphilis, and HIV

Annual Screening

• All sexually active people under 30 years of age

Targeted Screening

• Sexually active people older than 30 years of age based on risk factors

• SDoH, drug use, incarceration, sex work, new sexual partner, sex without barrier protection, etc.

• All pregnant people at first prenatal visit

  • Rescreening at 3rd trimester for those who test positive or who are at ongoing risk of infection

  • Screen at delivery for those not screened during pregnancy, or those that were not re-screened during the 3rd trimester

• Neonates born to individuals with gonorrhea

gonorrhoea testing in asymptomatic individuals

• Clinical picture and sexual history determine which specimens should be collected and the type of test used

• Asymptomatic Individuals - Nucleic Acid Amplification Tests (NAATs)

  • First-void urine for all asymptomatic people - person should not have voided for at lease 2 hours prior to specimen collection

  • Vaginal swab (self obtained, or clinician) or cervical swabs - vaginal swabs are preferred, as they may identify more infections

  • Pharyngeal and rectal swabs for all asymptomatic people (based on history)

gonorrhoea testing in symptomatic individuals

• Symptomatic Individuals

  • Pharyngeal and rectal swabs for all symptomatic people (based on history)

• Men and AMAB

  • Urethral swab for Gram stain and culture (sensitivity and specificity of 95%)

  • Urethral specimen for NAAT (urethral swab or first-void urine)

• Women and AFAB

  • Cervical swab for NAAT and culture (vaginal swabs & first-void urine can also be used for NAAT)

• Due to high rates of concomitant infection, collect specimens for diagnosis of both gonorrhea and chlamydia by NAAT and for culture for the diagnosis of gonorrhea

When is gonorrhoea culture recommended in addition to NAAT?

• All symptomatic patients (including pelvic inflammatory disease)

• Pregnant people

• When the client is notified through contact tracing

• If the infection was acquired in countries with high rates or antimicrobial resistance

• Sexual abuse/assault (rectal, pharyngeal, vaginal)

Who should be treated for gonorrhoea?

• Positive lab result for Neisseria gonorrhoeae (NAAT, culture or Gram stain) or sexually active and symptomatic

• Diagnosis of gonorrhea in a sexual partner (within 60 days of symptom onset or date of collection)

• Individuals with gonorrhea should also be treated for chlamydia

gonorrhoea treatment

• Ceftriaxone 500 mg IM plus Doxycycline 100 mg PO 2 times/day 7 days

• Clients and partners should be encouraged to abstain from any sexual activity without barrier protection for at least 7 days after treatment is complete and until signs and symptoms have resolved

• Test of Cure recommended for…

  • All positive cases from all positive sites (particularly when first line treatment is not used)

  • Culture (preferred) at least 3 - 7 days, but can be collected up to 4 weeks after treatment completion

  • NAAT can be collected 2 - 4 weeks after treatment completion for asymptomatic cases

• Repeat testing in all individuals with gonorrhoea is recommended 6 months post-treatment, as re-infection is high

syphilis stats

• Third most reportable bacterial sexually transmitted infection in Canada

• Men and AMAB account for 65% of reported syphilis cases

• Rates have increased 218% from 2012 – 2019 in men and AMAB

• Rates have increased 2182% from 2012 – 2019 in women and AFAB

• SDoH play a role in the rates of syphilis across different populations

congenital syphilis

• Infectious syphilis can be transmitted to fetus during pregnancy or delivery (congenital syphilis)

• Leads to fetal death (40%), cerebral palsy, cognitive disability, organ and tissue malformation

• In Canada, there were 96 cases of congenital syphilis in 2021, compared to 7 in 2017; an increase of 1271%

treponema pallidum

• Helical shaped bacteria, transmitted through vaginal, anal or oral sexual activity - enters the host through breaches in mucosal membranes

• Transmitted through vertical transmission during pregnancy (pregnant person → fetus)

  • Transplacental transmission can occur as early as 9 weeks gestation, and throughout pregnancy

  • Transmission also occurs through contact with an active genital lesion during delivery

  • Risk of transmission to fetus (70 - 100%) in untreated pregnant people with primary or secondary syphilis, 40% with early latent syphilis

• Primary, secondary and early latent stages are considered infectious

primary syphilis (infectious)

• Characterized by small, hard and painless ulcers (chancres) occurring at site of infection (cervix, vulva, vaginal wall, penis, anus, mouth)

• Manifest 3 weeks post-infection (but can range from 3 - 90 days) and symptoms can resolve without treatment

secondary syphilis (infectious)

• Systemic symptoms: rash (can occur anywhere on body), fever, malaise, headaches, mucosal/oral lesions (like a cold sore, gray-ish white erosion), lymphadenopathy, patchy alopecia, condylomata lata (wart like lesions), meningitis, retinitis, otic symptoms

• Symptoms can resolve without treatment

• Symptoms occur between 6 weeks to 6 months post-exposure, symptoms can persist up to 12 weeks; relapse can occur for up to 1 year

latent syphilis

• early latent (infectious) syphilis - asymptomatic phase less than 1 year post secondary stage

• late latent (non-infectious) syphilis - asymptomatic phase greater than 1 year post secondary stage, patient may never develop any long-term complications

tertiary syphilis

can occur decades after initial infection, can cause cardiovascular syphilis, neurosyphilis, or gumma (skin & soft tissue infection)

neurosyphilis

• may occur at any stage of syphilis (untreated primary infection, up to 20 years or more after infection)

• symptoms include headaches, ataxia, vertigo, dementia, personality changes, visual & auditory symptoms (can be confused with other issues)

syphilis screening

• Screen all sexually active persons with a new or multiple partners, and/or upon request of the individual - screening every 3 to 6 months is recommended in individuals with multiple partners

• Screening for all pregnant people in first trimester, repeat screening at 28-32 weeks and again at delivery for those in areas with outbreaks or for pregnant people at ongoing risk of infection or reinfection

• Screen all people who deliver a stillborn infant after 20 weeks

• People being screened for syphilis should also be screened for other STBBIs (chlamydia, gonorrhea and HIV)

syphilis testing

• Consider a diagnosis of syphilis in anyone with signs or symptoms compatible with syphilis

  • Depending on stage and clinical presentation, diagnostic testing may involve blood specimens, lesion sampling and/or samples of cerebral spinal fluid

• Serologic Testing

  • Should be performed (regardless of suspected stage) to detect IgG and IgM antibodies

• Lesion Sampling

  • NAAT to detect T. pallidum in mucosa and skin from lesions of suspected cases of primary and secondary syphilis

• Cerebrospinal fluid

  • Used in suspected cases of neurosyphilis

syphilis treatment

• T. Pallidum is highly sensitive to penicillin; bacteria are rendered non-infectious (on average) within 24 hours of treatment of long-acting benzathine penicillin G

• Primary, secondary and early-latent syphilis (in non-pregnant people)

  • Benzathine penicillin G-LA (IM, single dose)

• Late-latent syphilis, cardiovascular syphilis and gumma

  • Benzathine penicillin G-LA (IM, weekly for 3 doses)

• Clients and partners should be encouraged to abstain from any sexual activity without barrier protection for at least 7 days after treatment is complete and until signs and symptoms have resolved

• Treatment response is evaluated based on clinical picture and serology

  • Primary, secondary, early latent; serologic testing at 3, 6, and 12 months

genital herpes

• Caused by the Herpes Simplex Virus (HSV-1 and HSV-2)

• Transmission is associated with oral, anal and vaginal sex without the use of barrier protection

• Asymptomatic shedding is frequent, and transmission can occur from both asymptomatic and symptomatic people

• Both HSV-1 and HSV-2 can be transmitted vertically and lead to neonatal disease (risk of transmission is 30-50%)

• Incubation period for newly acquired (primary) infections varies from 1 – 26 days (median 6-8 days)

• HSV enters the mucocutaneous tissues and replicates; after initial replication, HSV enters a latent phase where it may remain dormant for years

• A primary (newly acquired) infection may be asymptomatic, and thus go undiagnosed

• Episodic reactivation may cause asymptomatic or symptomatic episodes of viral shedding

• Neonatal herpes; symptoms usually present by 4-6 weeks of age

  • prophylactic treatment critical for good outcome; without can lead to death and neurologic damage

primary manifestations of anogenital infection (symptomatic)

• Clear, straw-coloured fluid-filled vesicles appear first and then develop into painful, burning ulcers as they rupture

• Systemic symptoms of fever, malaise, myalgia in 67% of cases

• Tender inguinal lymphadenopathy in 80% of cases

• Without treatment, mean duration of symptoms if 17-20 days

• Complications of primary infection include; extragenital lesions, meningitis/encephalitis (16- 26% of cases)

secondary manifestations of anogenital infection (recurrences)

• Virus persists in a latent phase (hibernates within the sacral sensory ganglia)

• Reoccurrence induced by emotional or physical stress

  • Menstruation, emotional stress, illness (fever), sexual intercourse, immunosuppression - most will have recurrences within the first year after primary infection

• Prodromal (warning) symptoms; pain, tingling, burning, itching, and skin sensitivity at sites where new vesicles will form lasting 1-2 days

• Unilateral, localized small erythematous patch, painful genital vesicles and ulcers along distribution of sacral nerves; systemic symptoms in 5-12% of cases

• Mean duration of 9-11 days without treatment

genital herpes screening

• Screening for HSV is not recommended in people with no history of anogenital lesions

• People being evaluated or treated for genital herpes should be screened for syphilis, gonorrhea, chlamydia and HIV

• Pregnancy

  • Health care providers should routinely inquire about any history of signs and symptoms that may suggest genital herpes

  • Insufficient evidence to support screening during pregnancy when no risk factors, or a history of genital lesions is identified

  • First episode of genital herpes in pregnancy warrants oral antiviral therapy; caesarean section should be considered if first episode occurs in 3rd trimester of pregnancy; in cases of HSV history, suppressive therapy at 36 weeks gestation until delivery is recommended

genital herpes diagnosis in symptomatic individuals

• NAAT or viral culture of fresh lesions

• Testing by NAAT is appropriate when HSV infection is suspected, and viral culture could fail to detect HSV

• Viral culture sensitivity varies depending on the lesion being sampled; sensitivity declines as lesions start to heal

• Viral culture allows for typing and sensitivity testing

genital herpes treatment

• No cure

• Management for people with genital herpes includes psychological support and counselling to help them understand and cope with chronic infection

• Treatment can accelerate healing, prevent complications, reduce psychological burden, improve quality of life and reduce the risk of transmission

• Important to start antiviral medications as soon as possible, as they reduce the duration of viral shedding, time to crusting and healing of lesions, and duration of pain

• Antiviral therapy - acyclovir

Why are some strains of HPV oncogenic?

they are able to integrate into host cell DNA

human papillomavirus (HPV)

• ~ 80% of sexually active adults will acquire an HPV infection during their lifetime, majority resolve within 18 months with no long-term sequelae

• Of the 100+ types of HPV, there are 13 high risk (oncogenic) genotypes ▪ 16, 18 and 45 are attributed to 75% of cervical cancers, also associated with anogenital and oropharyngeal cancers

• There are low risk (non-oncogenic) genotypes including 6 & 11 which cause 90% of anogenital warts

• Genital warts: painful lesions that typically present 3 – 4 months post-exposure

genital wart treatment

• May resolve spontaneously (without treatment)

• In most cases of genial warts, treatment is topical, and patient applied

• As the number of warts increase in size, surgical excision or cryotherapy may be warranted

HPV prevention - immunization

• Gardasil-9

• Consists of VLPs assembled from recombinant HPV proteins

• Antibodies protect and prevent infection caused by viral strains covered in the vaccine

• Targets HPV genotypes 16, 18, 6, 11, 31, 33, 45, 52 & 58

• Indicated for people 9 - 45 years of age

• Provincially funded for all Grade 7 students (2 doses, at least 6 months apart)

• For those 15 years of age and older (3 doses: 0, 2, 6 months)

• Gardasil is NOT effective at reducing cancer risk for those already infected with HPV

HPV testing & screening

screen every 5 years

urinary tract infection (UTI) symptoms

dysuria, urgency, frequency, abdominal pain, fever, incontinence, abdominal pain, dyspareunia (present in 83% of UTI cases in women and AFAB)

UTI diagnosis

• midstream urine, ideally first morning specimen

• Urinalysis

  • Leukocyte esterase; enzyme produced by neutrophils; consistent with active infection

  • Nitrites; bacteria that cause UTIs (e.g., E. coli) make an enzyme that changes urinary nitrates to nitrites

  • Microscopic evaluation for bacteria, WBCs and RBCs

  • May culture if 1000 bacteria/mL found on microscopy

UTI complications

• pyelonephritis - ascending infection, severe abdominal, flank and back pain, fever ( >39 C) that persists for more than 2 days, chills, nausea, vomiting, fatigue, pyuria, kidney damage

• urosepsis - hypotension, tachypnea, difficulty breathing, tachycardia