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Review from last lecture Skin Infections:
Contrasting Staph aureus with Strep pyogenes Folliculitis, boils and carbuncles
Rocky mountain spotted fever (R. rickettsii) Lyme disease (B. burgdorferi) Anthrax (Bacillus anthracis)
Bacterial infections of Wounds: Tetanus (C. tetani) Gangrene (C. perfringens) Burn infections (P. auerginosa) Actinomycosis (A. israelii)
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Sexually-transmitted Diseases
Denise Kirschner,PhDDept of Micro/ImmunoMICRO 532 Nov 29, 2001
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Outline Epidemiological principles of STDs UTI/Bladder infections Infections of mucosal surfaces
Neisseria gonorrhea and Chlamydia trachomatis
Ulcerative Infections Syphilis (T. pallidium) and Chancroid (H.
ducreyi)
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General uro-genital tract information
More female infections that males Urine is sterile Above bladder entrance-sterile, below lots
of IM: Lactobacillus, Staphylococcus, Cornybacterium, Haemophilus, Streptococcus, Bacteriodes
Urinary tract infections (UTI): More than 100,000 bacteria/ml indicated
Bladder infection Catherization is the major cause of infection (usually
IM) Intercourse (for women)
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Mucosal infections
Ulcerative infections
Proliferative infections
Sexually-transmitted DiseasesSexually-transmitted Diseases
• gonorrhea• chlamydia
• herpes simplex• syphilis• chancroid• LGV
• papillomavirus
Systemic infections• HIV• hepatitis B
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Epidemiologic Principles of STDs
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Disease Incidence Prevalence ChlamydiaGonorrheaPapillomavirusHerpes simplexSyphilis (primary) (all stages)HIVChancroid
4,000,0001,400,000 800,000 300,000 50,000 100,000 70,000 ~4,000
-- --45,000,00030,000,000
100,000 1,500,000 ?
Occurrence of STDs in the U.S.
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Trends in common STDs
Year
0
100
200
300
400
500
1950 1960 1970 1980 1990 1995
chlamydiagonorrheasyphilischancroid
20
40
60
1980 1990 1995
Note: 60% of all N. gonorrhea infection are ages 15-24
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Determinants of STD Morbidity
Rate of transmission Sexual behavior (rate of new partner acquisition)
Duration of infectivity
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Factors That Affect the Transmission of STDs:Factors That Affect the Transmission of STDs:
• Age• Gender• Genetic susceptibility• Sexual practices• Contraceptive and "hygienic" practices• Circumcision
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Determinants of the Duration of Infectivity in STDs
Etiologic agent tendency to asymptomatic
carriage antimicrobial resistance
Access and utilization of the health care system
Compliance with therapy Contact tracing
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Theoretical Structure of an STD Core Group
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PPNG in Colorado Springs, Dec. 1989 - Dec. 1991
D J F M A M J J A S O N D J F M A M J J A S O N D
CASES
- not gang-related
- gang-related
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PPNG Outbreak, Colorado Spgs., 1989-91
56 cases in a 2-year periodTraced to a network of 578 persons
•410 (218 males and 192 females) were affiliated with a street gang that moved to the area in May 1988.
Mean age: females (19.7 yrs); males (21.5 yrs)
Prominent behaviors among females: multiple partners, heavy crack use, drugs for sex
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CO-INFECTIONS
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Relevance of STD Co-infections
May identify a core group member i.e., a "sentinel event"
STDs increase transmission of HIV ulcerative and mucosal infections only
Effect of HIV on expression of STDs accelerates HPV-associated tumors facilitates spread of gonococcus alters the natural course of syphilis
Presumptive therapy 80-90% of college men with 1 STD have others
(50% with Chlamydia)
May identify a core group member i.e., a "sentinel event"
STDs increase transmission of HIV ulcerative and mucosal infections only
Effect of HIV on expression of STDs accelerates HPV-associated tumors facilitates spread of gonococcus alters the natural course of syphilis
Presumptive therapy 80-90% of college men with 1 STD have others
(50% with Chlamydia)
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Infections of mucosal surfaces
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Infections caused by gonococci and chlamydiaeInfections caused by gonococci and chlamydiae urethritis cervicitis epididymitis proctitis pharyngitis eye infection
> >>
+
+
+
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Epidemiologic characteristics of chlamydial and gonococcal infections
GONOCOCCUS CHLAMYDIA
PATIENT AGE SEXUAL HISTORY
ASX INFECTION (male)
ASX INFECTION (female)
teenagers > young adults
usually acquired from a recent contact
~ 5% of infected males ( higher in some areas) 50 - 80% of infected females
teenagers > young adults
may have been acquired in the remote past
~ 50% of infected sexual partners
~ 50% of infected sexual partners
ASX=asymptomatic
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Microbiology of gonorrheaMicrobiology of gonorrhea Strict human pathogen Gram-negative diplococcus Adherent- pilus (antigenic variation) IgA protease (cleaves IgA) Oxidase-positive Fastidious growth Modified Thayer-Martin media (VCN)
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Virulence Virulence determinants of determinants of Neisseria gonorrhoeaeNeisseria gonorrhoeae
pilus colonization factor--> antigenic variation
opa proteins-------------------> phase variation lipooligosaccharide--------->antigenic
variation IgA1 protease transferrin/lactoferrin binding proteins intracellular environment?
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Treatment of gonococcal infectionsTreatment of gonococcal infections
PPNG Tetracycline resistance Quinolone resistanceSingle-dose treatment options
for uncomplicated disease: 1944 10^5 units of
penicillin 1970 10^7 units Resistance (R plasmids) PPNG strain
PPNG Tetracycline resistance Quinolone resistanceSingle-dose treatment options
for uncomplicated disease: 1944 10^5 units of
penicillin 1970 10^7 units Resistance (R plasmids) PPNG strain
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Microbiology of Chlamydia trachomatisMicrobiology of Chlamydia trachomatis
Obligate intracellular bacteria Not G+/G- (lacks part of LPS) Complex, 2-stage life cycle
Elementary body (spore like) Reticulated body (vegetative like)
Treatment: antibiotics: tetracyclines (not penicillin-why?)
Obligate intracellular bacteria Not G+/G- (lacks part of LPS) Complex, 2-stage life cycle
Elementary body (spore like) Reticulated body (vegetative like)
Treatment: antibiotics: tetracyclines (not penicillin-why?)
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Chlamydial infectionsChlamydial infections urethritis (NGU) epididymitis proctitis mucopurulent cervicitis pelvic inflammatory disease trachoma (serotypes A-C) LGV (L1, L2, L3)
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50-60% of women with 50-60% of women with infertility have serologic infertility have serologic evidence of chlamydia or evidence of chlamydia or gonococcus, but gonococcus, but nono history history of symptoms!of symptoms!
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Ulcerative infections
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Frequency of genital Frequency of genital ulcer infectionsulcer infections
HSV>>syphilis>>chancroidHSV>>syphilis>>chancroid
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Distinguishing features of genital ulcers
anatomical location multiplicity pain induration
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Microbiology of syphilisMicrobiology of syphilis Treponema pallidum spirochete -- labile spiral
bacterium with axial filaments man is the only recognized
host non-cultivable Gram-negative like
Treponema pallidum spirochete -- labile spiral
bacterium with axial filaments man is the only recognized
host non-cultivable Gram-negative like
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T. pallidum darkfield examination
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% reactive cases
iaryge
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Manifestations of 1° Syphilis Chancre (may be unnoticed)
painless, but tender indurated highly contagious rapid dissemination
motility of the organism? Congenital
MANIFESTATIONS OF SECONDARY SYPHILISRashLesions
mucous patchesFever
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Natural history of Natural history of secondary syphilissecondary syphilis
Secondary infection
spontaneous resolution
infected withoutclinical disease
tertiary syphilis:NeurosyphilisDTHOrganisms rare
1/3
1/3
1/3
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Syphilis- principles of Syphilis- principles of treatmenttreatment
T. pallidum is exquisitely sensitive to penicillin
Dosing and penicillin formulation used depends on the stage of the disease
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Microbiology of Microbiology of chancroidchancroid Haemophilus ducreyi Gram-negative coccobacilli fastidious and labile Diagnosis is usually clinical,
by exclusion of other agents of genital ulcers
Haemophilus ducreyi Gram-negative coccobacilli fastidious and labile Diagnosis is usually clinical,
by exclusion of other agents of genital ulcers
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Epidemiology and Epidemiology and treatment of chancroidtreatment of chancroid
CDC reported a 10-fold increase in incidence from 1978 - 1987
10% of patients are co-infected with either HSV or T. pallidum
Males >> females Occurs in sustained, urban outbreaks Associated with female commercial sex
workers and “sex-for-drugs” trade
TREATMENT: sensitive to ceftriaxone or azithromycin in single dose