ANDSexually Transmitted Diseases

Sexually Transmitted Diseases

• “Disease transmitted most commonly and efficiently by sexual contact”

• Organisms easily inactivated• Suited to transmission by contact

of mucus membrane• Organisms: Bacteria, spirochetes,

chlamydia, viruses, protozoa, fungus

Diseases

• Gonorrhea• Syphilis• Chancroid• L.G.V• Granuloma ingiunale• Hepes virus,HIV, T.vaginitis• Scabies, louse, bacterial vaginosis• Shigellosis, hepatitis A,B,C,

cryptosporidiosis, salmonosis, etc.

SyphilisSyphilis

Primary Syphilis

Seconda-ry syphilis

Benzathine pen.2.4 M.U/i.m ORDox 100mg BD x 2 weeks ORT.C. 500 mg. QID x 2weeks ORCeftriaxone 1g.od im/iv x 10d ORAzithromycin 2 g.oral single dose

Same as above

Syphilis contdSyphilis contd…..…..LatentSyphilis

TertiarySyphilis

Neurosyphilis

•Benzathine pen. 2.4 MU x once a week x 3 weeks OR•Dox.100 mg.BID x 4 weeks OR•T.C. 500mg.BID x 4 weeks OR

Same as above

•Pen G 4 MU iv x 4h x 10-14 days OR•Pro pen.2.4MU.im OD x 10-14 days+ probenecid 500mg.QIDx10-14 days or•Ceftriaxone 2 g.im x 10-14 days

GonorrheaGonorrhea

Gonorrhea(Uncomp.)

Gonorrhea(Comp.)Salphingitis,Prostatitis, arthritis

•Ceftriaxone 125mg. Im single•Cefpodoxime 400 mg.oral single•Spectinomycin 1g. Im single dose

•Pen G 10MU iv daily x 5 days OR•Ceftriaxone 1 g. iv daily x 5 days•Cipro 500mg.BID x 5 days

Chancroid.,G.I.,L.G.VChancroid.,G.I.,L.G.V

Chancroid

G.I

LGV

•Azithromycin 1 g. oral single dose•OR Ceftriaxone 250 im single•OR Amox/Clav.500mg.TIDx7days•E.mycin 500mg.qidx7 days•OR Cipro 500mg OD x 3 days•E.mycin or T.C. 500mg.QID.3 weeks•Amp. 500mg.QIDx12 weeks•Dox. 100mg. BIDx3 weeks•E.Mycin 500mg.QIDx3weeks (pregnancy)

Urinary Tract InfectionsUrinary Tract Infections

• Classification• Risk factors• Patho-physiology• Host defenses• Organisms• Drugs• Pharmacotherapy• Chemoprophylaxis

Classification:• Urethritis. Cystitis. Pyelonephritis.

Prostatitis. Epidydymitis.

• Upper UTI and Lower UTI

Classification contd….Classification contd….

• Uncomplicated- Previously healthy, Lower risk of failure, Lower risk of complications

• Complicated: Metabolic, Functional, Structural abnormalities

Risk FactorsRisk Factors

• Children…Congenital anomalies• Healthy women..Sexual activity,

Barrier methods, AMA• Healthy men…Instrumentation,

Lack of circumcission, Anal intercourse,

• Elderly…Ut.prolapse, EP, DM, Bowel incont.

• All ages.. Catheter, Stone,Tumor, Stricture, CRF,Transplantation

Patho-PhysioPatho-Physio(Ascending-Descending)(Ascending-Descending)

•Ascending-Bowel…Perinium…Introitus…Vagina…Bladder…Host defence vs Virulence …Mucosal invasion …. Pyelonephritis

•Descending: Only 3%

Host DefenseHost Defense

• Mechanical not immunological-Neurogenic bladder, EP, Pregnancy.

• Antibact. sub in bladder• Prostate secretion• Dilute urine and Ph

• Immune system has no role in prevention. No higher incidence in immunocompromised. But severe

OrganismsOrganisms

G(-)ve…95%E.Coli (Uropathogen!)..80%Staphy SaprophyticusCoag.neg.StaphKlebsiellaProteusPseudomonasEnterococciEntero bacterCandida

DrugsDrugs• Bacteriostatic: Sulfanomides, T.C.• Bacteriocidal:

* Co-Trimox * Extended spectrum

penicillins * Aminoglycosides * Fluoroquinolones * Cephalosporins * Monobactams * Imipenem+Cilastatin * Teicoplanin

Drugs

• Urinary Antiseptics: NItrofurantoin Methenamine

Nalidixic acid

• Urinary Anaelgesics: Phenazopyridine

Urinary AntisepticsUrinary Antiseptics

•Toxic drugs•Produce adequate conc. in

urine•Not for systemic use•Only UTI( Local use)

NitrofurantoinNitrofurantoin

• Spectrum - Bacteriostatic, E.coli.• MOA: Nitrofurantoin reduced to

toxic sub-damages DNA• PK: Rapid absorption, 40% excreted

unchanged in urine• Colours urine brown• Ph less than 5.5• Antagonizes Nalidixic acid

Nitrofurantoin contd….Nitrofurantoin contd….

ADE:• GIT symptoms-Macrocrystalline prep.

Well tolerated• Hypersensitivity-Chills, rigors,

leukopenia, cholestatic jaundice,Hepatic damage

• Hemolysis(G6PD def)• Pneumonitis, Pulm.fibrosis• Neuropathy

Nitrofurantoin contd….Nitrofurantoin contd….

Uses:• Not routinely used• Dose-50-100 mg qid• Chemoprophylaxis( Recurrent

infection)

C.I.: Not more than 14 daysImpaired renal functionChildren<1 yr.

MethenamineMethenamine

Spectrum: All organisms, No resistanceMOA:• Breaks down in water in acidic Ph to

formaldehyde

• NH4(CH²)6+6H²O+4H+=4NH4+6HCHO

• Proteus raise Ph (Urea splitting)• Organism do not develop resistance• Methenamine+ Mandelic(Ascorbic,

Hippuric) acid , enteric coated tab.

MethenamineMethenamine

ADE:• GIT• Albuminurea, Hematuria• C.I. in renal insufficiency• False +ve test for catecholamine

metabolites Uses:• Not routinely used, only in resistant

infections

PhenazopyridinePhenazopyridine

• An azo dye• Not antiseptic• Urinary analgesic• Reduces-Dysurea,frequency,

burning,urgency• ADE: GIT, methemoglobinemia• Dose: 200mg tid

Nalidixic acid

PharmacotherapyPharmacotherapy

• Bactericidal• High sustained conc in tissues and

urine• Should eliminate pathogens from

vagina, bowel. Normal flora should not be affected

• Orally effective• Minimal ADE• Low cost

Treatment goalsTreatment goals• Microbiological cure• Clinical cure• Prevent morbidity and mortality• Pt compliance• Prevent recurrence and relapse.• Minimum secondary infection

Uncomplicated (women)

CystitisComplicated

• AcuteMild,Mod

UncomplicatedSevere

PyelonephritisMild,Mod

ComplicatedSevere

• Chronic

Condition Empirical Tt

AcuteUncomplicated cystitis in women

3 day regimenOral TMP-SMX,TMP,Quinolones

7 day regimenMacrocrystallineNitrofurantoin

Condition Circumstances Empirical Tt

Acute cystitiscomplicated

Men, Failure of 3 d. regimen, Children, Renal disease,DM

7 DayOral TMP-SMX, Quinolone

Pregnancy

7 day-Oral Amox., Nitro.,Cephalosporin,TMP-SMX

Condition Circumstance Empirical Tt

Acute uncomplicated pyelonephritis

•Mild-mod. illness•No nausea, vomiting•O.P.D.

•Oral quinolone7-14DOR•Single dose Ceftriaxone(1G)or•GM(3-5mg/kg)i.v

Followed by

•TMP-SMX 14 D

ConditionCircumstances

Empirical Tt

Acute uncomplicated pyelonephritis

Sever illness I.P

•Parenteral quinolone, GM,Ceftriaxone, Aztreonam, until defervescence•Followed byOral quinolone, cephalosporin or TMP-SMX for 14 Days

Condition Circumstances Empirical Tt

Complicated pyelo.acute(Catheterization, Urologic abnormalities, stones,Immunosuppre-ssion,Renal disease,DM)

Mild,ModerateOral quinolone 10-14 days

Sever

Parenteral amp., GM, quinolone, ceftriaxone, aztreonam, ticarcillin, imipenem

↓Oral quinolone or TMP/SMX 10-21D

Chronic PyelonephritisChronic Pyelonephritis

•Obstruction eliminated•If not possible

Long term therapy ( Indefinite) with TMP-SMX, TPM, Nitrofurantoin.

ChemoprophylaxisChemoprophylaxis

• Recurrence of uncomplicated cystitis, uncorrectable ab., inoperable EP, chronic indwelling catheter(Amp,TMP-SMX, Nitro)

• Infants-VUR• Post coital prophy: > than 3 per year

--Voiding after sex.intercourse--Cranberry juice or--Cipro 125mg single dose, or--TMP-SMX40/200, or--Cephelexin 250mg, or--Nitrofurantoin 50 mg. or

Asymptomatic BacteriuriaAsymptomatic Bacteriuria

• Elderly or with catheter- no Tt.• Pregnancy, neurotropic pts., recent

renal transplantation, young children- Require Tt.

• Sulfa, Betalactams, Nitrofurantoin.

Drug DosageDrug Dosage

• Cystitis: TMP-SMZ-160/800 mg.BID TMP 100mg. BID Cipro.-250mg. QID Nitrofurantoin- 100mg.QID Amox-250mg. TID Cefpodoxime proxetil-100mg.QID

Pyelonephritis: TMP-SMX-As above Cipro- 500mg.BID Cefpodoxime proxetil-200mg BID

ParenteralCipro 200-400mg.BIDGM-1mg/kg TIDAmpicillin-1g qidImipenem/cilastat-in-500mgTIDAztreonam-1g bid