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Bacterial STIs

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Martin Jones, MSc, RN, CNS.

Co-ordinator, Sexual Health, Eastbourne and County Healthcare NHS Trust

This Factfile focuses on the more common bacterial sexually transmitted infections (STIs), which are probably most relevant to nurses outside genitourinary medicine (GUM) departments.
This Factfile focuses on the more common bacterial sexually transmitted infections (STIs), which are probably most relevant to nurses outside genitourinary medicine (GUM) departments.


The three infections described are chlamydia, gonorrhoea and syphilis.


For the first time in 30 years, a bacterial STI is the most common diagnosis made in GUM clinics in England. Indeed there has been an upsurge of all common bacterial STIs: over the five years 1996-2001 new episodes of gonorrhoea increased 86%, chlamydia 108%, and syphilis 501% (PHLS, 2003).


Bacterial STIs, unlike their viral counterparts, can be cured with a short course of antibiotics. However, gonorrhoea is associated with increasing antibiotic resistance. Bacterial STIs are a key public health concern as they are variously associated with serious morbidity including: pelvic inflammatory disease; ectopic pregnancy; infertility; chronic pelvic pain and co-factors in HIV transmission.


The effects of tertiary syphilis are seldom seen in the UK today.


Chlamydia trachomatis
Commonly known as chlamydia, genital chlamydia trachomatis infection replaced genital wart virus infection as the most common diagnosis in GUM departments in England, Wales and Northern Ireland in 2001, with 71 055 cases reported. The surge in new cases is probably multifactorial: more sex without condoms, increased public awareness, increased health professional awareness, the introduction of highly sensitive molecular tests, and so on.


Prevalence of chlamydia varies according to the population studied. It is particularly common in young people. In 2001, more than 1% of women aged 16-19 in England and Wales was diagnosed with chlamydia (PHLS, 2003). In the National Survey of Sexual Attitudes and Lifestyles (Fenton, 2001) 2.2% of men and 1.5% of women, randomly selected, aged 16-44 were found to have chlamydia.


Chlamydia features in the Department of Health's national strategy for sexual health (DoH, 2001 and 2002). Following a pilot study, there is a commitment to roll out chlamydia screening to other parts of the country. Two pilot sites in Portsmouth and the Wirral have shown the feasibility of screening, and the high prevalence in young women: in 1999-2000, 66% of women in Portsmouth aged 18-24 had opportunistic screening and 9.8% were positive; in the Wirral 39% and 11.2% respectively.


See below for possible chlamydia symptoms and diagnosis. But remember, chlamydial infection is asymptomatic in 80% of women and up to 50% of men.


Nurses working with patient group directions can manage uncomplicated chlamydia. Treatment is usually with one of:


- Doxycycline 100mg twice daily (BD) for seven days


- Azithromycin 1000mg immediately (stat)


- Erythromycin 500mg BD for 14 days (in pregnancy or if pregnancy is suspected).


Other regimens are described in the national guidelines (AGUM/MSSVD CEG, 2002a).


Successful treatment also requires:


- Partner notification: ensuring that sexual partner(s) are similarly treated


- Abstinence from sexual intercourse during treatment of patient and/or sexual partner(s).


Perinatal transmission of chlamydia may cause neonatal conjunctivitis and rarely pneumonitis. Complications of chlamydia in women include pelvic inflammatory disease, endometritis, salpingitis, ectopic pregnancy, infertility and, rarely, perihepatitis, and in men, epididymitis and Reiter's syndrome.


Gonorrhoea
The number of cases of gonorrhoea has risen since the mid-1990s, after a fall during the safer sex campaigns of the 1980s.


Diagnoses of uncomplicated gonorrhoea, the second most common bacterial STI, rose by 8% in males (14 721 to 15 900) and 6% in females (6404 to 6785) in 2000-2001.


Young people are particularly affected, with higher prevalence in men who have sex with men, black ethnic-minority populations and in urban areas (PHLS, 2003) (see panel, left).


Syphilis
While the number of syphilis cases, compared with chlamydia and gonorrhoea, is much lower, recent years have seen a resurgence, with outbreaks in urban areas, including Bristol, London, Brighton and Manchester. The most recent have been seen in men who have sex with men, including HIV-positive men. With the possibility of genital ulcer disease, the risk of HIV transmission may be increased. All cases of adult syphilis should be referred to GUM departments.


Diagnosis is usually made by serological testing, although dark ground microscopy of exudate from a chancre (genital ulcer) in a GUM clinic may enable a presumptive diagnosis. Table 1 lists signs and symptoms.


Treatment is usually long-acting penicillin, with duration dependent on disease stage.


FACTFILE - LACK OF SYMPTOMS IN CHLAMYDIA
Chlamydial infection is asymptomatic in 80% of women and up to 50% of men.


WHERE SYMPTOMS DO OCCUR
For some, the symptoms may be mild and/or transient. Women may notice:


- Post-coital or inter-menstrual bleeding


- Purulent vaginal discharge


- Lower abdominal pain including dyspareunia.


Examination may be normal or there may be cervicitis with mucopurulent discharge and contact bleeding from the cervix when swabs are taken.


Men may have:


- Urethral discharge, dysuria, testicular or epididymal pain.


In both sexes chlamydia may cause:


- Proctitis.


DIAGNOSIS
Chlamydia is a laboratory diagnosis. The type of test and sample requirement varies according to local facilities and protocols. Enzyme immuno-assays (EIA tests) may have a sensitivity as low as 40%, and are being replaced by molecular tests with high sensitivity and specificity.


In legal cases of sexual assault, where samples are obtained for forensic testing, chlamydia culture remains the 'gold standard'. Samples may be:


- In women: a cervical swab with or without urethral swab, or a first-catch urine sample. Research into self-administered low vaginal swabs is taking place.


- In men: urethral swab or first-catch urine. For both tests, men should have not passed urine for at least two hours.


FACTFILE - GONORRHOEA
Neisseria gonorrhoeae, the causative organism, can infect the urethra, cervix, rectum, throat and eye.


SYMPTOMS
In men, 85% with urethral gonorrhoea experience symptoms within 10 days of sexual intercourse. These usually include:


- Mucopurulent discharge, often with dysuria.


In women, the incubation period is less certain but may be similar to that for men in women with symptoms (10 days).


Symptoms at other sites are less common but may include:


- In cervical infection, vaginal discharge, low abdominal pain


- In rectal infection, rectal or anal discharge and/or pain.


DIAGNOSIS
- Swabs for culture and sensitivity should be taken from relevant sites


- A full sexual history is needed, with questions asked about oral, vaginal and anal sex


- Rectal gonorrhoea may occur in women without anal sex taking place


- In GUM clinics, microscopy allows a presumptive diagnosis to be made.


TREATMENT
Treatment is usually with one of:


- Ciprofloxacin 500mg stat (resistance to ciprofloxacin is on the increase)


- Ampicillin 2g stat with probenecid 1g stat (in regions where prevalence of penicillin resistance is <>


Other regimens are described in national guidelines (AGUM/MSSVD CEG, 2002b).


Successful treatment also requires:


- Abstinence from sexual intercourse during treatment


- Partner notification: ensuring that sexual partner(s) are similarly treated.


Further articles on the management of STIs appear in the next issue.

Association for Genito Urinary Medicine (AGUM) and Medical Society for the Study of Venereal Diseases (MSSVD) Clinical Effectiveness Group. (2002a) National Guideline for the Management of Chlamydia trachomatis Genital Tract Infection. Available at: www.mssvd.org.uk

AGUM and MSSVD Clinical Effectiveness Group. (2002b) National Guideline for the Management of Gonorrhoea in Adults. Available at: www.agum.org.uk

AGUM and MSSVD Clinical Effectiveness Group. (2002c) National Guideline for the Management of Early Syphilis. Available at: www.agum.org.uk

AGUM and MSSVD Clinical Effectiveness Group. (2002d) National Guideline for the Management of Late Syphilis. Available at: www.agum.org.uk

Department of Health. (2001) The National Strategy for Sexual Health and HIV. London: DoH.

Department of Health. (2002) The National Strategy for Sexual Health and HIV: Implementation action plan. London: DoH.

Fenton, K.A., Korevessis, C., Johnson, A.M. et al. (2001) Sexual behaviour in Britain: reported STIs and prevalent Chlamydia trachomatis infection. Lancet 358: 1851-1854.

Public Health Laboratory Service. (2003) HIV and Sexually Transmitted Infections. Available at: www.phls.org.uk
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