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REPRODUCTIVE

TRACT INFECTIONS
• RTI - Reproductive Tract Infection

- Infections of the reproductive tract which include


both sexually transmitted and non-sexually
transmitted infections

• STI - Sexually Transmitted Infection


RTI
• Major public health problem
Cause serious complications Facilitate transmission of HIV Social and economic burden
RTI Situation
• About 333 Million new cases each year

• Among the five leading causes of adult morbidity


RTI
• Twenty types of RTI

• 685,000 infected per day


Who can be infected with RTI?

• Any age
• Male or female
• Sexually active individuals
Modes of Transmission
• Sexual intercourse
• Blood and blood products
• Mother to infant
• Close contact
Factors that Influence
Transmission
• Multiple sex partners
• Frequent change of partners
• Casual sex
• Unsafe sex
• Treatment delay
• Untreated sexual partners
• Poor treatment compliance
CONSEQUENCES of RTI
• SOCIAL
 Social stigma
 Psychological
- guilt
- loss of self esteem
- depression
 Marital instability
 Violence, abusive behavior
CONSEQUENCES of RTI
ECONOMIC
 Direct costs
- diagnostic and therapeutic
 Indirect costs
- Lost days of productivity
- Infant morbidity : cost of care
CONSEQUENCES of RTI
• HEALTH
PID & infertility
Urethral strictures
Adverse pregnancy & neonatal outcomes
Cervical cancer
COMMON RTI
VAGINITIS
 Trichomonas
 Candidiasis
 Bacterial vaginosis

URETHRITIS / CERVICITIS
√ Chlamydia trachomatis
√ Neisseria gonorrhea
COMMON RTI
GENITAL ULCERS
 Syphilis
 Primary Syphilis
 Secondary Syphilis
 Tertiary Syphilis
 Congenital Syphilis
 Herpes Simplex Virus Infection (HSV)

GENITAL WARTS (HPV)


COMMON RTI

PARASITIC INFECTIONS
 Pediculosis pubis
 Scabies
PELVIC INFLAMMATORY DISEASE
HIV / AIDS
Trichomoniasis

 Frothy foul -
smelling
discharge
adherent to
vaginal wall
 “strawberry” cervix
with punctate
bleeding erosions
 Vaginal pH>4.5
Microscopy:

 Wet smear:
pyriform shaped
motile organisms
TRICHOMONIASIS
Recommended regimen
 Metronidazole 2 g orally as single dose
 Tinidazole 2 g orally as single dose

Alternative regimen
 Metronidazole 500 mg BID x 7 days
Bacterial vaginosios
 Copious thin, white to
grayish yellow homogenous
discharge with fishy odor
 Vaginal pH >4.5
 Fishy odor with 10% KOH
(Whiff’s test)
Microscopy:

 Gram stain - “clue


cells”, decreased
number of
lactobacilli
BACTERIAL VAGINOSIS
Recommended regimen
 Metronidazole 500 mg BID x 7 days
 Clindamycin cream 2 % one full applicator intravaginally
at bedtime x 7 days
 Metronidazole gel 0.75 %, one full applicator
intravaginally BID x 5 days

Alternative regimen
 Metronidazole 2 g orally as single dose
 Clindamycin 300 mg BID x 7 days
Moniliasis
 Intense vaginal pruritus exacerbated by menstruation

 Vulvar edema and  Intertrigo extending to


erythema the perianal region
 Shallow erosions on the  Plaques of white cheesy
labia and perineum discharge
Microscopy:

 Potassium
hydroxide smear -
hyphal elements
Male Partner:
CANDIDIASIS
Intravaginal Agents:

 Butoconazole 2% cream 5 g intravaginally for 3 days,

 Butoconazole 2% cream 5 g (SR) single intravaginal application,

 Clotrimazole 1% cream 5 g intravaginally for 7--14 days,

 Clotrimazole 100 mg vaginal tablet for 7 days,

 Clotrimazole 100 mg vaginal tablet, two tablets for 3 days,

 Clotrimazole 500 mg vaginal tablet, one tablet in a single application,


CANDIDIASIS
Intravaginal Agents:

 Miconazole 2% cream 5 g intravaginally for 7 days,

 Miconazole 100 mg vaginal suppository, one suppository for 7 days,

 Miconazole 200 mg vaginal suppository, one suppository for 3 days,

 Nystatin 100,000-unit vaginal tablet, one tablet for 14 days,

 Tioconazole 6.5% ointment 5 g intravaginally in a single application,


CANDIDIASIS
Intravaginal Agents:

 Terconazole 0.4% cream 5 g intravaginally for 7 days,

 Terconazole 0.8% cream 5 g intravaginally for 3 days,

 Terconazole 80 mg vaginal supp, one suppository for 3 days

Oral Agent:

 Fluconazole 150 mg oral tablet, one tablet in single dose.


Gonorrhea
 Purulent urethral discharge with edema of the meatus
 Reddish andedematous cervix with
mucopurulent exudation
Microscopy
 Gram - stained smear of the endocervical swab:
gram negative intracellular diplococci
 Copious purulent discharge
 Meatal and distant shaft edema
 Balanoposthitis
GONORRHEA
 Cefixime 400 mg po single dose
 Ceftriaxone 125 mg IM single dose
 Ciprofloxacin 500 mg po single dose*
 Ofloxacin 400 mg po single dose*
 Levofloxacin 250 mg po single dose*

* Fluoroquinolones are not recommended in


Asia, ME, USA (CA, Ohio, Hawaii)
GONORRHEA

PLUS
 Doxycycline 100 mg po BID x 7 days
 Azithromycin 1 g po single dose
* if chlamydial infection is not ruled out
Chlamydia Trachomatis

 Presence of purulent
urethral discharge and
edema of the meatus noted
 Cervical edema and ectopy with
mucopurulent exudation
Microscopy
 Direct immunoflourescence test
detected elementary bodies
Male Partner
Chlamydia trachomatis infection
Recommended Regimen
 Doxycycline 100 mg po BID x 7 days

 Azithromycin 1 g po single dose

Alternative Regimen

 Erythromycin base 500 mg po q 6 hrs x 7 days


Chlamydia trachomatis infection

 Erythromycin ethylsuccinate 800 mg po q 6 hrs x 7 days

 Ofloxacin 300 mg po BID x 7 days

 Levofloxacin 500 mg po x 7 days


Syphilis
 Small ulcerated lesion on the labia majora
 Q-tip probing - hard,non-tender ulcer base
 Non-tender nodulations in the inguinal areas
Male partner:
Microscopy:
 Darkfield - thin, silvery spiral motile organism
Secondary stage
 Hyperpigmented skin eruptions-pink
to dull coppery-red
Secondary stage
 Condyloma lata - pale brown
or pale pinky gray
 5-20 mm diameter
 Slightly raised surface, flat,
clean, moist from exudates
 Highly infectious
Disease Progression:
Tertiary stage
 Classical syndromes:
aortic regurgitation
aneurysm
tabes
general paralysis
insanity

 Initially attended and diagnosed in other medical


departments and later referred to the STI clinic
Tertiary Syphilis
 Gumma:
area of tissue necrosis
resulting to ischemia
caused by endarteritis
and surrounded by
granulation tissue
SYPHILIS
 Primary / Secondary / Early Latent SY
- 2.4 million units Pen G IM single dose

 Late Latent / Tertiary SY


- 2.4 million units Pen G IM weekly for 3
doses
NEUROSYPHILIS
 Aqueous crystalline penicillin G 18–24 million units
per day, administered as 3–4 M units IV q 4 hrs or
continuous infusion for 10-14 days

 Procaine penicillin 2.4 million units IM OD PLUS


probenicid 500 mg 4 x a day, both for
10-14 days
Genital Herpes
 Severe vulvar pain and dysuria
 Tingling and burning sensation of the
vulva followed by very painful lesions
and sores
 Several days of feeling feverish
 Erythematous labia studded with
vesicular lesions and sores
 Multiple cervical erosions
Male Partner
Microscopy:
 Tzanck
 Electron
microphotograph
GENITAL HERPES
Primary Episode

 Acyclovir 400 mg po 3 x a day for 7-10 d


200 mg po 5 x a day for 7-10 d
 Valacyclovir 1g po BID for 7-10 d
 Famciclovir 125 mg po BID for 7-10 d
GENITAL HERPES
Recurrent Episode

 Acyclovir 400 mg 3 x a day for 5 d


800 mg twice a day for 5 d
800 mg 3 x a day for 2 d
 Valacyclovir 500mg BID 3 d
1g once a day for 5 d
 Famciclovir 100 mg po BID for 5 d
1000 mg po BID for 1 d
GENITAL HERPES

Suppressive Therapy (6 months)

 Acyclovir 400 mg BID


 Valacyclovir 500/1000 mg OD
 Famciclovir 250 mg BID
Genital Warts
 Raised warty lesions 2mm to 2
cm in diameter
 Bigger pedunculated lesions
 Cervical inspection - whitish lesions
Male Partner:
Microscopy:
 Biopsy - koilocytes  Electrom
microphotograph
- causative agent
GENITAL WARTS (HPV)
Recommended Regimen for External Genital Warts

 Patient-Applied:
 Podofilox 0.5% solution or gel
 Imiquimod 5% cream

 Provider-Administered:
 Electrocautery
 Podophyllin resin 10%--25%
 Trichloroacetic acid (TCA) 80%-90%
 Bichloroacetic acid (BCA) 80%-90%
 Surgical removal
GENITAL WARTS (HPV)
Alternative Regimen for External Genital Warts

 Intralesional interferon

 Laser surgery
GENITAL WARTS (HPV)
Regimen for Cervical Warts
• Electrocautery
 Cryotherapy with liquid nitrogen

High Grade Squamous Intraepithelial Lesion


(HSIL) must be excluded prior to therapy
GENITAL WARTS (HPV)

Regimen for Vaginal Warts


 Electrocautery
 Cryotherapy with liquid nitrogen
 Trichloroacetic acid (TCA) 80%-90%
 Bichloroacetic acid (BCA) 80%-90%
GENITAL WARTS (HPV)

Regimen for Urethral Meatal Warts


 Electrocautery
 Cryotherapy with liquid nitrogen
 Podophyllin 10%-25%
GENITAL WARTS (HPV)

Regimen for Anal Warts


 Electrocautery
 Cryotherapy with liquid nitrogen
 Trichloroacetic acid (TCA) 80%-90%
 Bichloroacetic acid (BCA) 80%-90%
 Surgical removal
GENITAL WARTS (HPV)

Regimen for Oral Warts

 Cryotherapy with liquid nitrogen


 Surgical removal
Pediculosis pubis
 Intense itching of
genital and groin areas
 Low grade fever
 General body malaise

 Excoriations and
erythema of the vulvar
skin
 Few bluish spots
Microscopy:
 Adult louse and nit containing larva
PEDICULOSIS PUBIS
Recommended Regimen
 Permethrin 1% creme rinse applied to affected areas and
washed off after 10 minutes

 Lindane 1% shampoo applied for 4 minutes to the affected


area and then thoroughly washed off

 Pyrethrins with piperonyl butoxide applied to the affected area


and washed off after 10 minutes.
Scabies
 Genital pruritus
 Gradual intensification at bedtime or after
hot baths
 Rashes over genital area
 Rashes
 Short, “wavy” rashes
in the buttocks and
interdigits
Male Partner:

 burrows in the penis


Microscopy:
 Adult mite
SCABIES
Recommended Regimen
 Permethrin cream (5%) applied to all areas of the body from
the neck down and washed off after 8-14 hours

Alternative Regimen
 Lindane (1%) 1 oz. of lotion or 30 g of cream applied in a thin
layer to all areas of the body from the neck down and
thoroughly washed off after 8 hours

 Ivermectin 200ug/kg orally, repeated in 2 weeks


Pelvic Inflammatory Disease
Minimum criteria Routine Criteria
 Abdominal tenderness  Fever
 Adnexal tenderness  Elevated ESR / CRP
 Cervical motion tenderness  Abnormal cervical or vaginal
discharge
 Laboratory documenetation
of GC and chlamydial
infection
 WBC on saline smear
Pelvic Inflammatory Disease

Elaborated criteria
 Endometritis on endometrial biopsy
 TOA on sonography / imaging study
 Laparoscopy
Laparoscopy:
 Evidence of perihepatitis
(Fitz-Hugh-Curtis
Syndrome)
Laparoscopy:

 Tuboovarian abscess  Adhesions


PELVIC INFLAMMATORY
DISEASE

Out-Patient Regimen A
 Ofloxacin 400 mg po BID
 Levofloxacin 500 mg po OD, for 14 days
PLUS
 Metronidazole 500 mg po BID, for 14 days
PELVIC INFLAMMATORY
DISEASE
Out-Patient Regimen B
 Cefoxitin 2 g IM plus probenecid 1g po single dose
 Ceftriaxone 250 mg IM
 Other IV third generation cephalosporins (Ceftizoxime or
cefotaxime)
PLUS
 Doxycycline 100 mg po 2 times daily for 14 days
with or without Metronidazole 500mg BID
PELVIC INFLAMMATORY
DISEASE
In-Patient Regimen A
 Cefoxitin 2 g IV every 6 hours
 Cefotetan 2 g IV every 12 hours,
PLUS
 Doxycycline 100 mg IV or po every 12 hours
with or without Metronidazole 500 mg BID
PELVIC INFLAMMATORY
DISEASE
In-Patient Regimen B
 Clindamycin 900 mg IV every 8 hours,
PLUS
 Gentamicin loading dose IV, or IM (2 mg/kg of bw) followed by
a maintenance dose (1.5 mg/kg) every 8 hours
( IV meds x 48 hrs), then shift to

 Doxycycline 100 mg BID or Clindamycin 450 mg QID


(both po) for 14 days
AIDS
 On and off fever
 Malaise
 Diffuse maculopapular
rash
 Weight loss
 Cervical
lymphadenopathy

 Whitish plaques adherent


to buccal mucosa
 Vesicular lesions on
the dermatome

 Speculum: white
cheesy discharge
Laboratory:
 Positive ELISA
 Positive Western Blot
 CD4 count
<200/mm3
 Cell culture
HIV/AIDS
 Antiretroviral Drugs Approved by FDA for HIV
 Nucleoside Analogs
 Zidovudine (AZT, ZDV)
 Didanosine (ddl)
 Zalcitabine (ddC)
 Stavudine (d4T)
 Zidovudine/Lamivudine (3TC)
 Abacavir (ABC)
HIV/AIDS
Antiretroviral Drugs Approved by FDA for HIV

 Protease Inhibitors
 Non-nucleoside
Reverse  Indanavir (IDV)
Transcriptase Inhibitors  Ritonavir (RTV)
(NNRTI)  Saquinavir (SQC)
- Nevirapine (NVP)  Nelfinavir (NFV)
- Delavirdine (DLV)  Amprenavir (APV)
- Eavirenz (EFV)  Lopinavir/Ritonavir
(LPV/RTV)
HIV/AIDS and STIs
 Punch lesions of
secondary syphilis

 Severe vulvar and


perianal herpes
HIV/AIDS and STIs
 Giant molluscum
contagiosum

 Florid genital wart


Kaposi’s Sarcoma
 Generalized skin lesions

 Gingival lesion
Non-Hodgkin’s Lymphoma
Toxoplasmosis Cytomegalovirus
Pneumocystis carinii

HIV / AIDS

Cryptococcosis
Tuberculosis

Aspergillosis Blastomycosis
Main Objectives of RTI
Control

 To interrupt transmission of RTI


 To prevent the development of complications and
sequelae
 To reduce the incidence of HIV infection
Major Concepts for the Prevention
and Control of RTI

 education and counseling of persons at risk on safe


sex
 identification of infected persons unlikely to seek
diagnostic and treatment services
 effective diagnosis and treatment
Major Concepts for the Prevention
and Control of RTI

 Evaluation, treatment, and counseling of sex


partners of persons who are infected with RTI
 Pre-exposure vaccination of persons at risk for
vaccine-preventable RTI
Pre-exposure vaccination
• Hepatitis B

• HPV
Counseling
 Inform the couple about the diagnosis and
complications

 Assess patient’s risk for HIV and decide if HIV


testing required

 Deal with incurable infections such as herpes


genitalis

 Recognize symptoms suggestive of HIV-related


disease
Counseling
 Prevent future infections
 Promote condom use
 Maintain confidentiality
 Notify partner/s
 Identify risks of violence or stigmatizing reactions
from partners, family and friends
POGS RTI MODULES:
Closing the Gaps