Colin Roberts RN RM BNurs. PGCert-SexHealth PGDip-Ed. INP MSc FRCN
Everything old is new again –
managing the resurgence of
bacterial STI’s
By the conclusion of todays session we will
have • reviewed three key bacterial STI – Chlamydia
Trachomatis, Neisseria Gonorrhoea &
Syphilis.
• looked at current challenges in practice – 1st
contact principles.
• explored how to deal with the consequences
– partners and friends with benefits.
• Two or more people
• Unable / unwilling to agree - negotiate safer
sex
• Infection(s)
• Sexual contact
• Non use or poor use of barrier methods
• Partner notification dilemmas
• 37 year old woman, known to your service – attends
for routine cervical cytology.
• Quick review of personal history – nil of note
• Speculum examination: cervix shows ectropian,
cervical area dimpled and following sample
collection, bleeding occurs – not unusual.
• Sally says is getting bleeding on an off between
routine menses and is still on her progesterone only
pill, none missed. You note she has been on the
same POP for 8 years now.
• You recall she had been recently separated from her
husband at her last renewal of her POP.
• Chlamydia is the most commonly reported curable bacterial
STI in the UK
• 200,288 diagnoses made in 2015 - Public Health England
• 70% in sexually active young adults aged less than 25 years
• The highest prevalence rates are in 15–24-year olds
• Risk factors
– age under 25 years,
– a new sexual partner or more than one sexual partner in
the past year
– lack of consistent condom use
• high frequency of transmission, concordance rates of up to
75% of partners.
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Symptoms are not present in up to 80%
Abnormal vaginal discharge
Lower abdominal pain (if PID)
Dyspareunia
Dysuria (due to urethritis)
Post-coital or intermenstrual bleeding
The commonest findings are:
– Purulent vaginal discharge
– Mucopurulent cervicitis and / or contact bleeding
– PID is suggested by abdominal tenderness, pyrexia, and
cervical excitation and adnexal tenderness on pelvic
examination.
• Incubation
– 5 to 7 days
• Mode of infection
– sexual contact
• Infectivity
– variable
• Treatment - oral
– Azithromycin 1 gram stat then 500 mg daily for two
additional days* or Doxycycline 100 mg twice daily 7 days
http://www.researchgate.net/publication/274401864
• Mustapha is a 29 year old man who attends clinic
complaining of dysuria
• You have recently seen him with his partner as they are
enquiring about IVF as he and his wife have been trying for
a baby for the past 2 years.
• The dysuria has been slowly getting worse over the past 4
– 6 days.
• You do a urinalysis and there is protein, blood, leucocytes
on the strip. You send a sample for MC&S
• The urine has strands of mucous.
• Mustapha seems uncomfortable and you sense there is
something wrong.
• He says something happened recently when he was out on
a works event.
Men
• urethral discharge (>80%) and/or dysuria (>50%).
• urethral can be asymptomatic (<10%).
• rectal in MSM usually asymptomatic
– anal discharge (12%)
– peri-anal / anal pain or discomfort (7%).
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pharyngeal usually asymptomatic (>90%).
NAATs are more sensitive than culture
Culture needed for MC&S
Caution if local prevalence is low and risk is
assessed as minimal
Women
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Greenish yellow or whitish discharge from the vagina
Lower abdominal or pelvic pain
Burning when urinating
Conjunctivitis (red, itchy eyes)
Bleeding between periods
Spotting after intercourse
Swelling of the vulva (vulvitis)
Burning in the throat (due to oral sex)
Swollen glands in the throat (due to oral sex)
• Incubation
– 2 – 14 days
• Mode of infection
– sexual contact
• Infectivity
– variable
• Treatment –
– Ceftriaxone 500 mg IM as a single dose + Azithromycin
1G stat orally.
– Cefixime 400mg oral as a single dose.
– Spectinomycin* 2g IM as a single dose.
https://www.gov.uk/government/publications/guidance-for-thedetection-of-gonorrhoea-in-england
• Nigel is a 24 year old rugby player who rarely comes to
surgery now
• He has recently returned from a rugby tour in Europe and
you are seeing him today as he has developed a rash on
his chest and he has a really sore throat that he says is
like his usual tonsillitis.
• You see on his EPR he was asthmatic as a child and had
eczema until puberty.
• Nigel says it was a tough tour and he is a bit bashed up
with various cuts and scratches.
• You consider amoxycillin for the tonsillitis after seeing
that his tonsils are red inflamed & look infected
http://thestdproject.wpengine.netdna-cdn.com/wp-content/uploads/2012/07/std_pictures_syphilis_pictures.pdf
• Incubation
– 9 to 90 days
• Mode of infection
– direct contact with lesions, mucus membranes, body fluids
during sexual contact
• Infectivity
– variable during 1° & 2° stages
• Treatment
– Variable dependant on stage : routinely penicillin IMI is first
choice all stages, can be oral doxycycline but 28 days
duration – compliance is essential
• Each year, WHO estimates 131 million people are
infected with chlamydia, 78 million with
gonorrhoea, and 5.6 million with syphilis.
• Outbreak of high level azithromycin resistant
gonorrhoea first detected in Leeds March 2015
• Eleven cases have been reported in the Leeds
outbreak, further four cases have been detected in
Macclesfield, Oldham and Scunthorpe.
• BASHH state: Ceftriaxone plus azithromycin is
advised for the treatment of gonorrhoea
(irrespective of the results of chlamydia testing)
• BASHH state: Ceftriaxone combined with
azithromycin for the gonorrhoea, with the addition
of doxycycline for concurrent rectal chlamydia.
http://www.bashh.org/documents/GRASP%20statement%20lett
er%20HF.docx
• Basic rule of epidemiology: if a person has an
infectious disease, the source must be traced and
treated.
• PN is crucial public health activity and can be done by
any healthcare provider – following some core
education and competence.
• The aim of PN must be to reduce the onward
transmission of infections.
• Everyone who has a confirmed STI/BBV should have at
least one discussion (which may be a face-to-face or
telephone discussion) to start the PN process.
• Should the person decline to talk about PN, please
record this and why if possible.
Client
referral
Conditional
referral
Client
Provider
referral
You may need
to negotiate all
three methods
for your
patient
• Regular testing for those at risk of HIV and STIs is
essential for good sexual health = sexually active people
• Anyone under 25 who is sexually active should be
screened for chlamydia annually, and on change of
sexual partner
• MSM should test annually for HIV and STIs and every 3
months if having condom less sex with new or casual
partners
• All new registrants to your practice should be offered
HIV testing regardless of ethnicity.
• Is sexual health part of your history taking? It can be a
simple few questions – screen on risk
• continuing and rapid rise in syphilis and gonorrhoea, =
?condomless sex.
• HIV serosorting,
– increases STIs, hepatitis B and C, and sexually transmissible
enteric infections e.g. Shigella spp.
• increases the risk of HIV seroconversion as 14% of HIV +ve MSM
unaware.
• Cluster of hepatitis B in MSM who identify as heterosexual
• PrEP = pre exposure prophylaxis verses PEPSE post exposure
prophylaxis sexual exposure
Want to know more about PrEP
• http://www.bashh.org/documents/Practical-PrEPguidance_21Apr16.pdf
• http://www.iwantprepnow.co.uk/
• http://www.tht.org.uk/sexual-health/About-HIV/Pre-exposureProphylaxis
• http://i-base.info/guides/testing/pep-pepse-and-prep
• http://www2.sandyford.org/media/293497/swishh%20pninte
rnetmay13%20-%20mm.pdf
• http://letthemknow.org.au/sms.html
• https://www.gov.uk/government/uploads/system/uploads/att
achment_data/file/534601/hpr2216_stis.pdf