HTHSCI 2HH3 - Sexually Transmitted Infections

reportable STIs (1 business day)

- chlamydia

- gonorrhea

- syphilis

non-reportable STIs

- HSV

- HPV

STI trends in Canada

INCREASING LIKE A MF

this proportion of adults will have at least 1 type of HPV infection in their lifetime

75%

chlamydia cases reported annually

100k

1 in x Canadians 14-59 may be infected with HSV

7

stigma, shame, fear associated with STIs leads to

- ppl less likely to seek Tx

- lots of worry associated with the infections

sequelae to STIs

- sterility

- miscarriage

- ectopic pregnancy

- congenital defects

- cancer

- chronic pain

- psychiatric disorder (syphilis)

STIs and HIV

STIs facilitate HIV transmission and vice versa. HIV can increase severity of some STIs. STIs stimulate WBC production which provide places for HIV to grow

why was it worrisome when syphilis made a resurgence in Canada?

- one company in France made the Long acting benzathine penicillin G we need to Tx it

- we didn't have a lot of the drug to treat it

increase in chlamydia cases in the 90s

- not reflective necessarily of new cases

- with new testing that was not a super invasive urethral swab, more ppl got tested and as a result found out they had chlamydia

- NAATs use urine testing to identify presence of chlamydia bacteria

what is chlamydia?

- most common reportable bacterial STI in Canada

chlamydia trends

- increasing

- young age group 15-29 most affected by it

- women/AFAB make up 60% of cases right now

chlamydia sequelae

- PID

- ectopic pregnancy

- infertility

- chronic pelvic pain

- epididymo-orchitis

- Reiter's Syndrome (systemic inflammation/reactive arthritis)

chlamydia transmission to the neonate (and manifestations)

- during birth

- conjunctivitis

- trachoma (blindness from scratchy eyelids)

- pneumonia (infants < 6 months)

chlamydia causative pathogen

chlamydia trachomatis

Chlamydia Trachomatis

- gram negative

- obligate IC bacteria (can't grow on agar, needs to be grown on tissue lines)

chlamydia transmission

- oral, anal, vaginal sexual activity

how does chlamydia enter the body

- microscopic breaks in mucosal membranes (friction with sex)

- infects mucosal epithelial cells of the pharynx, urethra, cervix, uterus, fallopian tubes, anus, or rectum

autoinoculation with chlamydia

if you touch an infected body site of your own and then another area like your eye, you can infect yourself with chlamydia in your eye too

when might symptoms (headache, fever, muscle aches) appear following chlamydia infection

~ 40 hours later (ppl don't often connect this to the fact they had sex two days ago but tbh I don't blame them why would you)

lab considerations for dealing with obligate intracellular bacteria like chlamydia trachomatis

- has to be grown on tissue lines, can't grow on agar

incubation period of chlamydia infection

2-3 weeks

clinical presentation of chlamydia reflects this

the body site infected

if symptomatic, chlamydia patients may experience:

- dysuria (pain with peeing)

- proctitis --> inflamed rectum (ow)

- conjunctivitis --> tearing, discharge, inflammation, swelling, redness

--> additional S+S depending on the site(s) infected

what proportion of chlamydia infections are asymptomatic in people AFAB?

about 70% have no symptoms so you might never know you got infected

cervicitis in chlamydia

- purulent or mucopurulent exudate in the endocervical canal, or induced/sustained bleeding/friability of the cervix

symptoms of chlamydia in AFAB people

- changes in vaginal discharge

- lower abdo pain

- abnormal vaginal bleeding

- painful intercourse

what proportion of chlamydia cases in AMAB people are asymptomatic?

about 50%

symptoms of chlamydia in AMAB people

- urethral discharge (but it's clear so they think it's precum)

- urethritis (with or without discharge)

- urethral itch

- testicular pain

- epididymo-orchitis (inflammation of testes and epididymis)

who should receive annual screening for chlamydia?

- all sexually active people under 30

- MSM, gay, bi, trans populations (underserved in sexual health)

what is the targeted screening population for chlamydia?

- sexually active people under 30 based on risk factors (SDoH, drug use, incarceration, sex work, new partners, unprotected sex)

- all pregnant ppl at first prenatal visit, re-screened in the 3rd trimester for those who are positive or at a higher risk of acquiring chlamydia

- neonates born to people with chlamydia

how are asymptomatic cases of chlamydia tested for?

- NAATs

- first void urine --> shouldn't pee for 2 hours before

- vaginal swab (can be self-obtained) or cervical swab

- conjunctival, pharyngeal, rectal swabs for all asymptomatic people based on history

why do we want a first void urine sample with STI testing?

we want to catch the initial flush out of the urethra that would contain the highest concentration of microorganism

how do we determine which tests to do?

clinical picture and sexual history

how do we test for chlamydia in symptomatic patients?

- NAATs again

--> first void urine

--> vaginal swab, cervical swab

--> urethral swab for men/AMAB people

--> conjunctival, pharyngeal, rectal swabs based on clinical presentation

--> swab of any visible lesions

due to high rates of co-infection, if we test for chlamydia, we also collect samples to test for this infection:

gonorrhea --> NAAT and Cultures

Who should be treated for chlamydia?

- positive lab result for C. Trachomatis

- suspected chlamydia in anyone presenting with compatible syndrome/symptoms (PID, cervicitis, urethritis, conjunctivitis), without waiting for results

- positive lab result for N. Gonorrhoeae

- Dx of chlamydia in a sexual partner within 60 days prior to date of specimen collection/symptom onset

what is the treatment for chlamydia (> 18 years of age)?

- Doxycycline 100mg PO 2 times/day for 7 days

OR

- Azithromycin 1g PO, single dose

sexual activity during treatment period for chlamydia

clients should be encouraged to abstain from any sexual activity without barrier protection until treatment is complete and symptoms have resolved; test to cure for some groups

what is PID

- pelvic inflammatory disease

- infection and inflammation of the upper genital tract

S+S of PID

- fever

- lower abdominal pain and tenderness

- adnexal and cervical motion tenderness (pain with examination)

how do you get PID

an untreated STI (you might not have ever known you had it so it's not ur fault!!)

what proportion of lower genital tract infections become PID?

~40%

of this 40%, 30% of these cases are attributed to STIs

what proportion of PID cases are silent?

up to 2/3

how many cases of symptomatic PID are diagnosed each year?

100k

sequelae of PID

- scarring of the fallopian tubes + uterus --> infertility

- ectopic pregnancy

- chronic pelvic pain

risk for PID sequelae with recurrent cases

10% risk (of sterility) after first incidence

40% risk after third incidence

how is PID diagnosed?

abdominal/pelvic exam, microbiology, Dx imaging (ultrasound)

best way to minimize long term risk with PID

early identification and treatment

how long does it take for symptoms of PID to go away with treatment?

48-72 hours --> if it doesn't get better, hospitalization may be required

outpatient treatment regimen for PID

- Ceftriaxone 250mg IM (one dose)

PLUS

- Doxycycline 100mg x2/day PO for 14 days

PLUS

- Metronidazole 500mg x2/day PO for 14 days

why the Metronidazole with PID treatment?

it provides anaerobic coverage for non-STI related syndromes

trend for gonorrhea in Canada

increasing (like a lot)

Gonorrhea

- second most common reportable bacterial STI in Canada

- rates up 190% from 2009 to 2018

- 56% of cases are in ppl 15-29

why are rates of gonorrhea so high in AMAB ppl compared to AFAB?

they have symptoms more often than AFAB people

Sequelae of Gonorrhea

- PID

- ectopic pregnancy

- infertility

- chronic pelvic pain

- epididymo-orchitis

- Reiter's syndrome

- disseminated infections (joints, skin, meninges, anything)

what type of bacteria is n. gonorrhea?

- gram negative

- diplococci

- facultative IC bacteria

transmission of gonorrhea to the newborn

ophthalmia neonatorum (eyelid edema, conjunctival erythema, purulent discharge) --> eye inflammation

why is gonorrhea so scary for us in the microbio world?

it develops resistance to ABx SUPER FAST.

it also has really high rates of co-infection with chlamydia trachomatis

how does gonorrhea cause disseminated infection?

it's a facultative IC bacteria, so it can survive inside of neutrophils and take the bloodstream superhighway to other sites in the body (joints, meninges, skin/soft tissues, heart)

transmission of gonorrhea

sexual contact

pathogenic factors of gonorrhea

- fimbriae

- capsules

--> uses these to adhere to mucosal epithelial cells of the pharynx, urethra, cervix, uterus, fallopian tubes, anus/rectum

Fimbriae allow n. gonorrhea to do this, leading to a high risk of PID with this infection

ATTACH TO SPERM CELLS.

incubation period of gonorrhea

2-7 days usually, but can be 1-14

clinical presentation of gonorrhea reflects this

the site of infection

IF symptomatic, individuals infected with gonorrhea may experience:

- dysuria

- proctitis

- additional S+S based on the sites affected

proportion of asymptomatic gonorrhea infections in women/AFAB

75%.

3/4 of people have no clue they have gonorrhea

S+S of gonorrhea in AFAB people

- cervicitis (purulent/mucopurulent exudate, bleeding at the cervix/friability)

- changes in vaginal discharge

- lower abdo pain

- abnormal vaginal bleeding

- pain with intercourse

- bartholinitis

S+S of gonorrhea in AMAB people

- urethral d/c --> thick, white

- urethral itch

- testicular pain

- epididymo-orchitis

screening for gonorrhea

- effective for detecting and treating asymptomatic infection as well as preventing complications, transmission, or reinfection

people being evaluated for gonorrhea should also be screened for these infections

- chlamydia

- syphilis

- HIV

who should receive annual screening for gonorrhea?

- all sexually active people under 30

- MSM and trans populations (underserved in sexual health)

targeted screening for gonorrhea should happen in these populations

- sexually active ppl under 30 with increased risk factors (SDoH, drug use, incarceration, sex work, new partner, sex without barrier protection)

- all pregnant ppl at first prenatal visit --> rescreen in 3rd trimester for those who test positive or who are at ongoing risk of infection

- screen at delivery for those not tested in pregnancy/no rescreen in 3rd trimester

- newborns of mothers with gonorrhea

testing for gonorrhea in asymptomatic people

NAATs

- first void urine test

- urethral swab for men/AMAB

- vaginal swab/cervical swab for AFAB

- pharyngeal and rectal swabs for all asymptomatic people (based on history)

why are vaginal swabs preferred in testing for gonorrhea

twofold answer

1. patient can do it themself which is kind of nice

2. may identify more infections than cervical swab

testing for gonorrhea in symptomatic people

- pharyngeal and rectal swabs for all symptomatic people (based on Hx)

AMAB/men

- urethral swab for gram stain and culture

- urethral specimen for NAAT (swab or first void)

AFAB/women

- cervical swab for NAAT and culture (vaginal swab and first-void can be used for NAAT)

--> always testing for chlamydia too because of how commonly they are coexisting infections

why do we do a culture for gonorrhea and not chlamydia?

we need to know what strain of gonorrhea someone has because of how quickly it can develop resistance to ABx --> we need to know that the treatment we give will actually work.

culture on top of NAAT is STRONGLY recommended in these situations (gonorrhea)

- as a test of cure for suspected treatment failure

- if the infection was acquired in a country with high rates of antimicrobial resistance

culture on top of NAAT is recommended in these situations (gonorrhea)

- Symptomatic patients

- PID

- Pregnant people

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

who should be treated for gonorrhea?

- positive lab result for gonorrhea (NAAT, culture, Gram stain)

- sexually active and symptomatic

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

- should also Tx for chlamydia

Treatment for uncomplicated gonorrhea in ppl 9+ years of age

- Ceftriaxone 500mg IM

PLUS

- Doxycycline (or azithromycin) 100mg PO 2x/day for 7 days

sexual activity during treatment period for gonorrhea

- abstinence for at least 7 days should be encouraged

--> wait until tx is complete and S+S have gone away

clients should be re-screened for gonorrhea at this time post treatment

6 months

treatment of gonorrhea is complicated by this factor

worldwide spread of gonococcal strains resistant to many antibiotics

do people develop long term immunity against n. gonorrhea

no, you can have it many times

why do we not have a vaccine against gonorrhea?

because there is high variability in surface antigens across strains

for all positive body sites, obtain cultures as a test of cure this many days after treatment is complete

3-7 days

if culture is not available and NAAT is used as a test of cure for gonorrhea, when should we perform this test after treatment is complete?

2-3 days

syphilis rates in Canada

increasing like all the other STIs

Syphilis

- third most common reportable STI in Canada

- 59% of cases in ppl 30-59

- men and AMAB make up 79% of cases

- rates in AFAB up 648% since '09

syphilis transmission to the fetus

- crosses the placenta

- transmission also possible in delivery

--> ALWAYS CAUSES DEFICIT IF IT GETS TO THE FETUS

complications that result from fetal infection with syphilis

- 40% of the time it causes fetal death

- acerebral palsy, cognitive disability, organ and tissue malfunction/malformation

causative pathogen for syphilis

- Treponema Pallidum

- helical shaped bacteria

transmission of treponema pallidum

- vaginal, oral, anal sexual contact

- enters through host breaches in mucosal membranes

- vertical transmission in pregnancy

transplacental transmission of syphilis can occur as early as this time in gestation

early as 9 weeks

risk of transmission of syphilis to the fetus in untreated pregnant people with primary or secondary syphilis

70-100%

risk of transmission to the fetus in pregnant people with early latent syphilis

40%

infectious stages of syphilis

primary, secondary, and early latent

Primary Syphilis

- small, hard, painless ulcers (chancres) on sites of infection

- symptoms can resolve without treatment