STIs

More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide. Each year, there are an estimated 376 million new infections with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis. More than 500 million people are estimated to have genital infection with herpes simplex virus (HSV). More than 290 million women have a human papillomavirus (HPV) infection. The majority of STIs have no symptoms or only mild symptoms that may not be recognized as an STI. STIs such as HSV type 2 and syphilis can increase the risk of HIV acquisition. 988 000 pregnant women were infected with syphilis in 2016, resulting in over 350 000 adverse birth outcomes including 200 000 stillbirths and new-born deaths. In some cases, STIs can have serious reproductive health consequences beyond the immediate impact of the infection itself (e.g., infertility or mother-to-child transmission). The Gonococcal Antimicrobial Resistance Surveillance Programme has shown high rates of quinolone resistance, increasing azithromycin resistance and emerging resistance to extended-spectrum cephalosporins. Drug resistance, especially for gonorrhoea, is a major threat to reducing the impact of STIs worldwide.

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. 8 of these pathogens are linked to the greatest incidence of sexually transmitted disease. Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are viral infections which are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). STDs (Sexually Transmitted Diseases) include all the infectious diseases, once defined as "venereal" (from Venus, the goddess of Love), which are or can be transmitted through:

• sexual activity (through direct contact with infected organic fluids sperm and vaginal secretions - with mucous membranes).

• intimate contacts (oral, kissing and petting - direct contact with infected organic fluids).

In the past there were four venereal diseases (syphilis, gonorrhoea, granuloma venereum and soft ulceration). Today these forms have been added to many other diseases that can be contracted during sexual activity or practices related to it and that differ in contagiousness, disease process and possibilities of treatment and prevention. How can someone get an STI? Vaginal, anal, oral sex; transmission from mother to baby during pregnancy and childbirth, skin to skin contact, sharing equipment; exchange of body fluids, blood or blood products. STDs can be roughly divided into:

• systemic diseases, when the genital region is the way in of the germ and the clinical manifestations are mainly systemic (HIV, hepatitis, Cytomegalovirus infections and EB virus)

• genital diseases, for which the infectious agent expresses its pathogenic potential mainly at the genital level.

Epidemiology

Every year around the world 357 million people contract a sexually transmitted disease. The most common is trichomoniasis (120 million cases), followed by chlamydia infections (50 million) and gonorrhoea (25 million) and syphilis. The number of HIV-positive people is currently estimated at 44-50 million. A concerted effort to rapidly scale up effective interventions and services can achieve the goal of ending sexually transmitted infection epidemics as public health global targets by 2030, by reaching this ambitious set of targets:

• 90% reduction of T. pallidum incidence globally (2018 global baseline);

• 90% reduction in N. gonorrhoeae incidence globally (2018 global baseline);

• 50 or fewer cases of congenital syphilis per 100 000 live births in 80% of countries;

• Sustain 90% national coverage and at least 80% in every district (or equivalent administrative unit) in countries with the human papillomavirus vaccine in their national immunization programme.

Bacterial STIs are curable with specific antibiotics and without treatment they cause serious consequences. The most common are Gonorrhea, Chlamydia and Syphilis.

Gonorrhea

Gonorrhea is a sexually transmitted bacterial infection passed along by having unprotected oral, anal or vaginal sex (Condoms or dental dams can be used for protection during oral sex). Remember gonorrhea is CURABLE!

Neisseria gonorrhea is a diplococcus (Gram -) with several pili for adhesion(coffee beans shape). It contains a capsule with several polysaccharides, and it is an obligated parasite. It develops at 35-37°C in the presence of moisture and CO2. The transmission can be:

• Direct, sexually or through saliva, vaginal or seminal fluid or from mother to fetus during childbirth (gonococcal conjunctivitis).

• Indirect, underwear, bathing suits, bed sheets, etc..

Human is the only reservoir of gonococcus, It affects the age group between 15 and 30 years, especially in the male population. No immunity is acquired. The incubation period is 2-14 days.

• in men it is localized in the anterior and back urethritis causing acute or chronic form of disease. Complication of the acute form can be infection in the prostatitis and cystitis and epididymitis. If the infection is not cured can cause male infertility. Symptoms are swollen testicles, discharge and inflammation, the infection can also reach the kidneys giving a burning sensation.

• in women it is localized in the uterine cervix or the urethra, possible complication can be endometritis, salpingovarite and pelvic peritonitis. If is not cured can cause female infertility. Symptoms are abdominal pain or pain with intercourse, vaginal discharge and bleeding.

Diagnostic assessments. It is directly done on the infected material and then watched with the optical microscope. The research of the gonococcus must be carried out in 4 locations: the uterine cervix, the urethra, the pharynx and the anus and it is more difficult than in man for the richness of the flora. The pharmacological therapy is often done with amoxicillin, streptomycin, tetracycline and sulphonamides. After treatment with antibiotics or sulphonamides, the infected person is no longer contagious. Many strains are drug-resistant so it’s important to follow the medical prescriptions, not use medicines from other patients, not have sexual intercourse until complete recovery and repeat diagnostic tests after medical treatment. The improper use of antibiotics could make the Neisseria gonorrhea incurable. The alarm is launched by the World Health Organization which warns against the inappropriate use of drugs, especially in Eastern countries. Doctors immediately prescribe the third-level antibiotics, cephalosporins, which should instead be taken as a last resort, like only after having tried the antibiotics of the first two levels. So far, three countries have reported the ineffectiveness of traditional treatments: Australia, Hong Kong and Japan. Others could be added soon.

Syphilis

Etiological agent. Syphilis is an infectious, contagious disease transmitted through wounds and ulcers that are formed in the genital/rectal areas and on the mouth following sexual contact; more rarely it is incidentally transmitted (puncture), by blood (transfusion) and also by transplacental. This disease is due to a spirochete highlighted in 1905 by the biologist F. Schaudinn and the syphilograph E. Hoffmann from Hamburg: the pathogen was first called "Spirochete pallidum", later "Treponema pallidum”. Treponema pallidum belongs to the family of Treponema, bacteria with helical shape, mobile and cross-divided. The in vitro culture of treponemes has not yet been carried out, therefore, their metabolism is poorly understood.

Current situation in Italy. The cases of syphilis, chlamydia and AIDS increase among adolescents. It is the alarm launched by Italian dermatologists gathered in Naples for the fourth National Unified Congress of Dermatology and Venereology. As regards syphilis, which seemed extinct thanks to the discovery of penicillin, there are now 1,200 new cases, especially among young people, with an increase of 5%.

CLINICAL ASPECTS.

1. Recent Syphilis. It includes: the incubation period (25 days on average); the primary clinical manifestations (45 days on average); the classic manifestations of the secondary period (beginning at 2 months from the contagion, duration from 1 to 2 years); Recent serological syphilis (from infection up to the third year of illness).

2. Latent Syphilis. It occurs when the recent lesions disappear and only serological positivity persists or in the case of positive serology when clinical lesions have not previously been observed. The increasing frequency of totally asymptomatic serological syphilides and spontaneous latent forms should be noted.

3. Late symptomatic syphilis (tertiary phase). It occurs from 5 to 20 years after infection, with cutaneous and / or visceral manifestations, mostly cardiovascular or nervous. Two out of three patients do not have any complications.

Clinical aspects.

1. Primary clinical manifestations. Syphiloma can appear in the genital area in the man in the balano-preputial sulcus or on the foreskin; in the woman on the big lips or small lips and in the fornix.

2. Secondary phase of syphilis. Examples of vesicular rash start to emerge, irritations without itching can manifest in hands, feet and trunk. The irritation ends in a few weeks. Syphilis is mainly diagnosed at this stage. Bacteria are present in the lesions.

Symptomatology. Latent/tertiary syphilis causes severe damage to the musculoskeletal and neurological system. It is treatable, but the alterations induced by the disease are incurable and permanent. If left untreated, syphilis is lethal. It can cause serious harm to the fetus and lead to an abortion. It can lead to disfiguring lesions, neurological and cognitive injuries.

PREGNANCY AND CONGENITAL SYPHILIS. Fetal infection is the rule in absence of therapy in the case of a mother suffering from primary and/or secondary syphilis (lue). We speak of congenital syphilis in the case of transmission of the disease to the fetus during pregnancy through the placenta, through contact with infected lesions during the passage in the birth canal or with lesions of the nipple during lactation. Transplacental infection of the fetus can occur at any stage of maternal infection and at every stage of pregnancy. The clinical manifestations of perinatal syphilis resemble those of other infections that spread via blood from mother to child. Fetal damage therefore depends on the stage of development of the infection, on the time between infection and treatment, on the adequacy of the treatment, on potential maternal re-infections, on the immune response of the fetus. Syphilis during pregnancy can determine abortion, birth of a dead fetus; premature birth; neonatal death; parturition with clinically silent infection (from one third to half of the cases): often newborns do not show signs and symptoms of the disease, which may appear after months or years or remain silent for life; parturition with clinically manifested infection. Depending on whether in the newborn the syphilitic infection occurs from birth or late, we distinguish respectively early congenital syphilis and late congenital syphilis.

Diagnosis. The combination of these tests is often used.

1. Bacteriological

2. Serological, looking from antigens

   1. Non-treponemal examinations

   2. Treponemal examinations

Screening. The possibility of becoming infected with syphilis can be reduced by avoiding risky sexual behavior: using latex or polyurethane condoms during sexual intercourse; limiting the number of sexual partners; avoiding sexual contact until complete recovery, in case of infection; making sure that the partners are also treated, in case of recent/ current treatment for syphilis, in order to avoid being infected again. Sex partners must receive treatment even if they have no symptoms. Serological screening is recommended in high-risk adults (prostitutes, people who have sex with multiple partners in areas where the prevalence of syphilis is high, cohabitants of people with active syphilis) and in high-risk adolescents. A vaccine is not currently available and in its absence, syphilis control depends on the implementation of preventive measures, as: raise awareness among health professionals; health and sex education, refrain from sexual promiscuity and random sexual relationships, teach personal prophylaxis methods (condom); guarantee free and anonymous access to facilities for early diagnosis and treatment; encourage the people to use them through education about the symptoms and the means of transmission.

Therapy. The disease is easily treated with the use of penicillin antibiotic. The preparation, the dosage and the duration of treatment depend on the stage of the disease and its clinical manifestations. The efficacy of this treatment has been confirmed by numerous case studies, clinical trials and fifty years of clinical experience. In addition to the antibiotic treatment, the infected person must abstain from any sexual activity with new partners until the wounds are fully recovered. Furthermore, diagnostic tests and treatment must also be performed on the patient's sexual partners.