Vaginal isolates

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Vaginal isolates

• Gram-positive rods (lactobacilli) 50-75
• Gram-positive cocci (stafilo-strepto) 40-55
• Gram-negative organisms (Coli,others) 10-30
• Anaerobic organisms
• peptococcus
  5-65
• peptostreptococcus
  25-35
• bacteroides
  20-40

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Epidemiologia
Infezioni vaginali (CDC 2000)
Visits (in thousands)
anno
SOURCE National Disease and Therapeutic Index
(IMS America, Ltd.)
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Epidemiologia
MST (CDC 2000)
Percentuale dei ceppi
anno
Mod da Sexually Transmitted Surveillance 2000 -
CDC report Dic 3, 2001
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Eziologia delle vulvovaginiti
COMUNE vaginosi batterica candidosi
vaginale Trichomoniasi MENO COMUNE infezione
batterica secondaria in pz. con vaginite
atrofica infezione batterica secondaria a corpo
estraneo Vaginite desquamativa infiammatoria
(sensibile alla clindamicina) Vaginite
streptococcica (Gruppo A) Vaginite ulcerativa
associata a S aureus e toxic shock
syndrome Vaginite idiopatica in pazienti HIV
Cause infettive
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Epidemiologia
Vaginiti sintomatiche (N3661)
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STD III Other Agents Bacterial G. vaginalis
Gardnerella vaginalis is associated with
non-specific vaginitis/urethritis Found with
resident anaerobes within the vaginal tract
(Bacteroides spp.) Clue cells in vaginal smear
is diagnostic for non-specific vaginitis--bacteria
l vaginosis (BV) BV characterized
by -excessive malodorous discharge -vaginal
pH gt4.5 -clue cells -fishy, amine-like odor
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STD III Other Agents Bacterial G. vaginalis
Women with BV have a resident increase in both G.
vaginalis and Bacteroides spp. G. vaginalis is
also found in 20-40 of healthy
women Pathogenesis of BV is still unclear -loss
of vaginal acidic pH -due to disruption of the
vaginal flora? -precipitated by sexual
transmission?
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STD III Other Agents Bacterial Mycoplasma
Etiologic agents Mycoplasma hominis Ureaplasma
urealyticum Found in genital tracts of sexually
active men and women Not found as often in
populations who are not sexually
active Associated with NGU, especially U.
urealyticum -urethritis and prostatitis in
men Both organisms are susceptible to
tetracyclines
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STD III Other Agents Mycotic Candida
C. albicans normal vaginal flora For unknown
reasons, growth increases dramatically
commensurate with increase in vaginal pH Range
of disease is mild (normal) to severe
(immunocom-promised) Presents as irritating
vaginitis with cheesy/thick discharge Can be
accompanied by urethritis and dysuria
(UTI) Balanitis--infection of male is rare and
usually asymptomatic
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STD III Other Agents Mycotic Candida
Diagnosis Microscopic examination of vaginal
discharge or culture can confirm diagnosis
Treatment Oral Fluconazole or Topical
Nystatin
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STD III Other Agents Protozoal Trichomonas
Etiologic agent Trichomonas vaginalis Found in
vaginal tract in women and urethra (and sometimes
the prostate) of men Spread during
intercourse In women, infection results in
vaginitis with a copious, foul-smelling
discharge -intense vaginal itch -foamy white/
green In men, mild urethritis rarely pathogenic
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Trichomonas

• Parasite isolated in 30-40 of partners
• Highly contagious (two third infected after a
  single contact)
• More prevalent in black race
• Reportedly associated with other STD (HIV!)

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Pelvic inflammatory disease
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Epidemiology

• Definition- ascending infection of upper female
  genital tract unrelated to pregnancy/surgery
• Incidence-gt1million women In USA 1 in 9 1
• Impact on health-ectopic, infertility8
  after1,20 after2, 40 aftergt3, pelvic pain,
  menstrual irregularity
• Financial impact-gtUS 4.2bn(USA),gt200m(UK) per
  yr
• Predisposing factors-Smoking, sexual behaviour,
  IUD etc
• Types-_at_ organs involvement,
• _at_ duration of illness
• 1.Price B, Martens M.Outpatient management of
  pelvic inflammatory disease. Curr Womens health
  Rep 20011(1) 36-40

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RISK FACTORS-PID

• Frequent sexual activity
• Multiple sex partners
• Adolescence
• Presence of IUD
• Gonococcal or chlamydial infection
• Previous history PID
• Untreated male partner
• Bacterial Vaginosis

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Unique Risks for Adolescents

• Non- barrier methods of contraception
• Multiple partners (4.6 fold increase risk PID)
• Increased ectropian and estrogenization of cervix
  associated with normal adolescent female and OCP
  use

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Unique Risks for Adolescents

• PID risk 15 year old- 1in 8 compared gt24
  year old- 1 in 80
• Experience more dysfunctional uterine bleeding

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HISTORY-PID

• Pain
• low abdominal, pelvic pain
• recent gradual onset
• usually bilateral
• intensity variable
• dyspareunia
• often occurs post menses

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HISTORY-PID

• Post-coital bleeding
• Vaginal discharge
• /- fever

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Pelvic inflammatory disease
Hospitalizations of women 15-44 years of age
United States, 19801999
Note The relative standard error for the
estimates of the overall total number of PID
cases range from 6 to 9. SOURCE National
Hospital Discharge Survey (National Center for
Health Statistics, CDC)
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Microbiology-endo/exogeneous

• Chlamydia
• Neisseria gonorrhoeae
• Escherichia coli
• Bacteroides
• Beta haemolytic streptococci
• Actinomyces israelli,Prevotella
  sp,Peptostreptococci1
• Mycoplasma hominis, Gardnerella vaginalis-

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Incidence of Sexually Transmitted Diseases in U.S.
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STD III Other Agents Bacterial
1. Pathogenic Chlamydia Obligate intracellular
pathogen developmental lifecycle C.
psittaci pneumonia C. pneumoniae acute
respiratory disease atherosclerosis? C.
trachomatis trachoma STD LGV Chlamydia
trachomatis Leading cause of bacterial STD in
United States NGU--Non-gonococcal
urethritis Asymptomatic (particularly in
women) 3 catagories of serovars associated with
disease
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STD III Other Agents Bacterial C. trachomatis
Chlamydia trachomatis serovar catagories


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STD III Other Agents Bacterial C. trachomatis
Trachoma is the leading preventable cause of
blindness in developing countries. serovars A,
B, and C Most C. trachomatis infections are
genital and acquired during intercourse. serovars
D-K (most common in U.S.) serovars L1, L2, and
L3 (LGV) (more common in Africa, Asia, and
both Central and S. America than U.S.)
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STD III Other Agents Bacterial C. trachomatis
Properties of the bacterium Gram negative
bacteria lacking a cell wall -do not respond to
b-lactam antibiotics -many cross-linked
molecules on surface protein-protein sulphydryl
groups Two primary phases of lifecycle EB
elementary body (infectious) RB reticulate
body (fragile)
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STD III Other Agents Bacterial C. trachomatis
Developmental lifecycle
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STD III Other Agents Bacterial C. trachomatis
Developmental lifecycle
EB spore-like metabolically less active RB
bacteria-like metabolically active
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C. trachomatis Trafficking
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STD III Other Agents Bacterial C. trachomatis
Pathogenesis and clinical features Entry C.
trachomatis enters via small abrasions in the
mucosal surfaces Attachment bind to specific
receptors taken up by parasite-induced
endocytosis Intracellular inhibit fusing of
lysosomes differentiate from EB to RB RB
replicate RB differentiate back to EB Lysis of
cell release reinfect additional
cells released into bloodstream, lymph can
spread systemically
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STD III Other Agents Bacterial C. trachomatis
Pathogenesis and clinical features
(continued) C. trachomatis disease (serovars
D-K) is clinically similar to gonococcal
infection SYMPTOMS males usually
symptomatic in addition to urethritis can
develop an orchitis and epididymitis Reiter
s syndrome females often asymptomatic
salpingitis (ectopic pregnancy) PID newbor
ns conjunctivitis pneumonia
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Diagnosis of Chlamydia

• Swab-endocervical, urethral
• First voided urine sample(FVU)
• Methods-culture, EIA(enzyme immunoassay), DNA
  Probe,DFA ( direct fluorescent antibodies), NAA(
  nucleic acid amplification), serology

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Swabs

• Endocervical-
• Clean the mucus/discharge
• 1-2 cm deep
• rotated several turns to obtain columnar cells
• Urethral-
• (10-23 infected in the urethra only!)
• male patients-2-4 cms deep
• Vulval or vaginal-
• even self-obtained can be alternative way to
  collect sample for nucleic acid amplification
  assay( NAA)

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Urine specimen

• FVU-
• an excellent sample for NAA
• no need to clean the urethra or perineum prior
  to collection.
• NOT mid stream urine as first bit will contain
  epithelial cell which might contain Chlamydia.

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Culture

• Only swabs, urine not suitable for culture
• use cotton, dacron, rayon on plastic/metal shaft
  for collection of swab
• NOT wooden spatula as it is toxic to cells.
• Use transport media-FlexTrans, M4
• Keep refrigerated, trasport at 40C
• Innoculation within 48hrs

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Nucleic acid amplification assay (NAA)

• Polymerase chain reaction(PCR)
• Ligase chain reaction(LCR)
• Transcription-mediated amplification
• strand displacement amplification
• -excellent tool for public screening
• -specimen needed-FVUCx swab for female,
  FVU for male

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PATHOPHYSIOLOGY-Several theories

• PID starts as GC or CT cervicitis
• ascension into upper genital tract
• Polymicrobial infection occurs without GC or CT
• GC and/or CT initiate tubal inflammatory reaction
• Primes tubal mucosa for infection by endogenous
  flora of lower genital tract

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Diagnosis- Acute

• Symptoms-severe lower abd pain, worse on
  movement,offensive vag discharge, generally
  unwell and feverish/pyrexial
• Sign-fever, tachycardia,may be hypotensive-if
  septic,tender lower abd-guarding/rebound
  tenderness,
• Pelvic exam-tender both adnexae, cervical
  excitation tenderness marked,? a palpable mass

 
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Diagnosis-chronic

• Symptoms-general malaise, fatigue, backache,lower
  chronic abd pain, constant with occasional
  exacerbations(typically during menstruations),
  intermittent offensive vaginal discharge, deep
  dyspareunia
• Sign-generalised lower abd tenderness esp on deep
  palpation, pelvic esp cervical excitation
  tenderness,bulky tender uterus, and/or tender
  adnexal mass of tubo-ovarian origin
• Investigation-FBC,Bacteriology-swabs-endo-cervical
  , high vaginal, urethral, rectal-CS, laparoscopy

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MINIMUM CRITERIA FOR CLINICAL DIAGNOSIS OF PID

• Lower abdominal tenderness
• Bilateral adnexal tenderness
• Cervical motion tenderness

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DIAGNOSTIC/LAB TESTS PID

• Wet mount
• Cervical gram stain
• Endocervical tests- GC and CT
• HCG
• /-UA, CBC, sed rate(dependent on s/s)
• /- Postural BP, Psupine and seated

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Diagnosis of PID
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Laparoscopy-gold standard?

• Pitfalls-surgeons bias,carbonic anhydrase on
  tubes, early chlamydial infection
• 50 sensitive, 80 specific( Sellors etal, 1991)
• Hagers criteria for diagnosis and grading-Mild,
  moderate, severe.

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Image folder-USS as diagnostic tool!/lap view
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Image folder specific chronic PID-Tubercular
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Image folder Tubo-ovarian abscess
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PID Fitz-Hugh-Curtis
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Treatment-Principle -CDC, AGUM, RCOG-

• Prevention-health education-barrier
  contraception, OCP, Identifying risk
  factor-smoking, douching, IUCD-RR1.5-2.6 lt
  20days,
• Treatment directed against chlamydia, neisseria
  and anaerobes
• High suspicion
• Early treatment before bacteriological results
• Aggressive treatment in adolescents

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OUTPATIENT REGIMEN

• Regimen A
• Ofloxacin 400mg po bid for 14 days
  plus
• Metronidazole 500mg po bid for 14 days
  

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OUTPATIENT REGIMEN

• Regimen B
• Cefriaxone 250 mg IM once, or
• Cefoxitin 2g IM plus Probenecid 1 g orally in
  single dose concurrently once or
• Parenteral third-generation cephalosporin
  plus
• Doxycycline 100 mg po bid for 14 days

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OUTPATIENT REGIMEN

• Regimen B
• Theoretical limitations in anaerobic coverage may
  require addition of metronidazole
• Alternate Oral Regimens
• Amoxacillin/clavulanic acid plus doxycycline-
  limited clinical trials
• Azithromycin- data insufficient to recommend for
  PID
  

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MINIMUM CRITERIA FOR ADMISSION

• Severe peritonitis
• Unable tolerate oral meds
• Temperature gt 38C
• Adnexal abscess or mass(gt6cm)
• Uncertain diagnosis
• Failure to respond to outpatient therapy
• Pregnancy

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Treatment-contd

• Laparoscopy-
• grading of PID
• bacteriological culture from peritoneal fluid,
• drainage of infective pelvic collection,
• removal sequelae of PID
• Genitourinary Medicine Clinic referral- for
• test of cure,
• sexual health counselling
• contact tracing

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Sequelae

• Chronic pelvic pain
• Tubal infertility
• Ectopic pregnancy
• Recurrences

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PID consequences
Risk of ectopic pregnancy increased by 9 times
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PID consequences
Tubal infertility from 9 to 25 of
patients Number and severity of episodes
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PIDconsequences
The rate of recurrence approach 40
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PID consequences
The risk of chronic pelvic pain is increased by
10 times
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Salient points

• PID a threat to female reproductive health
• Secret agents-chlamydia, neisseria
• Misdiagnosis in about 35 cases
• Laparoscopy-still a gold standard in diagnosis
• Microbiological and cinical cure do NOT guarantee
  restored normal reproductive function
• Tubal factor infertility is dependent on the
  number and severity of PID
• Delay t/t for 3 days to ? likelihood of ectopic
  and infertility by 3 times!!
• Effective t/t contact tracing and treatment of
  sexual partner/s test of cure.