Currently, sexually transmitted infections (STIs), which, according to the ICD-10 classification, include syphilis, gonococcal infection, urogenital chlamydia, urogenital trichomoniasis, lymphogranuloma venereum, chancroid, granuloma inguinal, anogenital (venereal) warts and anogenital herpesvirus infection are a significant public health problem. This group of diseases is distinguished by a significant prevalence, the risk of developing reproductive dysfunction and other serious complications.
Kalyuzhnaya Lydia Denisovna, Doctor of Medical Sciences, Professor, Honored Worker of Science and Technology of Ukraine, Head of the Department of Dermatovenereology, National Medical Academy of Postgraduate Education named after I.I. P.L. Shupyk, Kyiv
Among STIs, syphilis is subject to statistical accounting, the incidence rate of which is mainly used to judge the epidemiological intensity of STIs, as well as gonorrhea, chlamydia, trichomoniasis, mycoplasmosis.
Urogenital chlamydia
Urogenital chlamydial infection caused by Chlamydia trachomatis (Chl. trachomatis), a Gram-negative obligate intracellular bacterium, is the most common STI in Europe and the United States, occurring predominantly in people under 25 years of age. The incidence of urogenital chlamydial infection in young women is > 10%. According to the World Health Organization, 100 million new cases of Chl infection are registered annually in the world. trachomatis.
Infection occurs through sexual contact with the patient, intrauterine infection is possible and when a newborn passes through the birth canal.
Clinical features are not pathognomonic for this STI. Symptoms of urogenital chlamydia in women include mucopurulent discharge from the cervical canal and / or vagina, pain in the lower abdomen, dysuria, postcoital and intermenstrual bleeding, chronic pelvic pain, infertility, in men - mucous and mucopurulent discharge from the urethra, dysuria, pain in the lower abdomen radiating to the perineum, erectile dysfunction (it should be noted that most episodes of urogenital chlamydial infection of the lower urogenital tract in both women and men are asymptomatic and remain undiagnosed). In addition, chlamydial conjunctivitis, chlamydial pharyngitis are possible.
According to ICD-10, there are:
- chlamydial infection of the lower urinary tract (cervicitis, urethritis);
- chlamydial infection of the pelvic organs and other genitourinary organs (epididymitis, inflammatory diseases of the pelvic organs in women, orchitis);
- chlamydial infection of the anogenital area;
- chlamydial pharyngitis;
- chlamydial infection of another localization.
Pregnancy is a rather vulnerable condition in which manifestation of urogenital chlamydial infection is possible. Note that STIs can lead to spontaneous abortion, fetal malformations, premature rupture of membranes and premature birth, placenta previa, placental insufficiency, fetal growth retardation syndrome and its hypoxia, intrauterine infection of the fetus.
The diagnosis is established on the basis of the clinical picture and laboratory data, which include molecular biological methods (nucleic acid amplification methods or polymerase chain reaction (PCR) diagnostics), cultural examination, direct immunofluorescence method. PCR diagnostics, due to its high sensitivity and specificity, as well as the possibility of using samples of clinical material obtained in a non-invasive way, showed advantages over other methods for identifying Chl. trachomatis and is recommended for this purpose by the Centers for Disease Control and Prevention (CDC) and the European guidelines for the management of patients with infection caused by Chl. trachomatis (Lanjouw E. et al., 2010; Workowski KA et al., 2010).
Control of the cure of urogenital chlamydial infection by PCR is recommended to be carried out no earlier than 4 weeks after its completion due to the possibility of a false positive result due to the presence of “debris” of microorganisms perceived as Chl. trachomatis.
High sensitivity of Chl. trachomatis to macrolides, so there is no need to study it (Shipitsyna E.V. et al., 2004). According to CDC and European guidelines for the management of Chl. trachomatis, the drug of choice (including in pregnant women) among all members of the macrolide class is azithromycin, given its not only proven efficacy, but also high safety for the mother and fetus (Lanjouw E. et al., 2010; Workowski KA et al., 2010). Given that chlamydial infection is one of the main factors in the development of inflammatory diseases of the pelvic organs (which, in turn, lead to such serious complications as infertility, ectopic pregnancy, premature birth, neonatal infections),
To date, azithromycin is the only modern macrolide for which a sufficient amount of information on the use during pregnancy has been accumulated and analyzed, which makes it possible to reasonably judge its safety and efficacy in this category of patients. Azithromycin, due to structural features, has been isolated in a separate group of azalides and has a fairly high in vitro activity against most STI pathogens, and its antichlamydial activity is many times higher than other macrolides. Due to the achievement of a high therapeutic concentration of azithromycin in the tissues after a single dose of a standard dose of antibiotic and keeping it in the area of inflammation for at least 5 days, it is possible to effectively treat urogenital chlamydial infection by a single dose of the antibiotic orally at a dose of 1.0 g.Azithromycin and erythromycin are classified as Risk Category B during pregnancy by the Food and Drug Administration (FDA). However, it has been found that children whose mothers took erythromycin during pregnancy may be at increased risk of congenital malformations (Källén BA et al., 2005). In addition, when taking erythromycin, adverse effects from the gastrointestinal tract often occur, which largely affect compliance. As studies show, azithromycin is characterized by significantly better tolerance compared to erythromycin, disorders of the gastrointestinal tract during its use were noted much less frequently (Hopkins S., 1991).
A meta-analysis of 12 randomized clinical trials of azithromycin versus doxycycline in the treatment of urogenital chlamydia showed the same efficacy of therapy (97 and 98%, respectively). Thus, azithromycin is preferable for patients for whom adherence to a multi-day treatment regimen is impossible or problematic (Workowski KA et al., 2010). According to a meta-analysis of 8 randomized controlled trials by E. Pitsouni and co-authors (2007), azithromycin (at a dose of 1.0 g once) was not inferior in efficacy to 7-day courses of treatment with comparator drugs - erythromycin / amoxicillin in the treatment of microbiologically confirmed chlamydial infection in pregnant women.
Large-scale efficacy and safety studies of josamycin in pregnant women have not been conducted, the risk category for it has not been determined by the FDA, therefore it is not classified as either a first-line drug or an alternative drug for use in pregnancy (Lanjouw E. et al., 2010).Levofloxacin and ofloxacin can be considered as alternatives, but do not offer advantages in dosing regimens and duration of use (Workowski KA et al., 2010).
Genital mycoplasma infection
The genital tracts of both men and women are often colonized by mycoplasma/ureaplasma, most of which are not absolute pathogens. They belong to the group of residents, constantly present in the human urogenital tract and associated with STIs. Sexually transmitted, under certain conditions they cause infectious and inflammatory processes in the genitourinary organs, more often in association with other pathogenic or opportunistic microorganisms (Taylor-Robinson D., 1995; 2002; Björnelius E. et al., 2000).
At present, the etiological role of a single species of mycoplasmas in the pathogenesis of urinary tract infections in humans, Mycoplasma genitalium (M. genitalium), has been proven.
It is important to note that M. genitalium exists more frequently independently of Chl. trachomatis (Taypor-Robinson D., 1995). The spectrum of sensitivity to antibiotics they have is the same. Thus, azithromycin is at least 100 times more active in vitro against M. genitalium compared with drugs from the fluoroquinolones or tetracyclines group (Hannan PC, 1998).
According to the European Guidelines for the Management of Chl. trachomatis, azithromycin is also recommended in the treatment of inflammatory diseases caused by M. genitalium, according to the regimen 1 g once or 500 mg on day 1 and 250 mg for another 4 days (Lanjouw E. et al., 2010; Workowski KA et al., 2010). Doxycycline is weakly active against M. genitalium. According to the results of studies, azithromycin is more preferable in the treatment of infections caused by M. genitalium in men, compared with erythromycin / doxycycline, which in many cases do not lead to the eradication of the pathogen (Wikström A., Jensen JS, 2006).
Urogenital trichomoniasis
Another of the most common STIs is urogenital trichomoniasis, caused by Trichomonas vaginalis, a single-celled flagellate protozoan. Infection occurs through sexual contact with the patient, as well as when the newborn passes through the birth canal. Incubation period 3 days to 3-4 weeks
As a rule, women are more likely to complain of characteristic symptoms, since their clinical picture is more obvious: gray-yellow vaginal discharge, itching, burning in the vulva, swelling and hyperemia of the vulva, vagina and cervix, dysuria , erosive and ulcerative lesions, pain in the lower abdomen. In men, symptoms are usually torpid: dysuria, scanty discharge from the urethra, itching in the urethra, pain in the perineum radiating to the rectum, and occasionally hematospermia. It has been established that 10–50% of patients with urogenital trichomoniasis are asymptomatic. Possible adverse effects of the disease on the outcome of pregnancy - early rupture of the membranes and premature birth.
Laboratory diagnosis of urogenital trichomoniasis consists in microscopic examination of a native (dark field) or stained preparation.
Treatment is prescribed both in the presence of clinical manifestations and in the asymptomatic course of the disease. The drugs of choice are drugs of the nitroimidazole group (metronidazole, tinidazole, ornidazole.
Syphilis
Syphilis is an infectious disease caused by the gram-negative spirochete Treponema pallidum (T. pallidum), which is transmitted mainly through sexual contact (other ways of infection transmission are transplacental, transfusion, rarely household) and is characterized by a periodic course.
Highlight:
primary syphilis;
- secondary syphilis;
- latent early syphilis (<2 years from infection);
- latent late syphilis (≥2 years from infection);
- tertiary syphilis (active, latent);
- congenital syphilis (fetal syphilis, early, late, overt, latent);
- visceral syphilis;
- syphilis of the nervous system (neurosyphilis) (asymptomatic neurosyphilis, meningeal and/or vascular neurosyphilis (cerebral (meningitis, stroke), spinal (meningomyelitis, stroke), parenchymal neurosyphilis (tasca dorsalis, progressive paralysis, optic atrophy, gumma).
- Infection is followed by an incubation period of 3-4 weeks, then primary syphilis, which is characterized by the appearance of a hard chancre at the site of entry of the pathogen. Clinical signs of chancre - erosion (rarely ulcer) oval or rounded, painless, with a smooth shiny bottom, meat-red color, with scanty discharge, compaction at the base of the erosion of a dense-elastic consistency. Primary syphilis is characterized by a consistent increase in clinical symptoms: unilateral lymphadenitis (painless, mobile, densely elastic consistency) on the side of the chancre, then bilateral lymphadenitis. After 3–4 weeks, standard serological reactions become positive, after another 1 week, polyadenitis develops, and after another 1 week, the secondary period of syphilis begins. The latter is characterized by the appearance of profuse rashes on the skin and mucous membranes. The appearance of rashes may be preceded by malaise, increased fatigue, headache, moderate fever. Rashes in secondary syphilis are predominantly roseolous, papular, and may be pustular. With secondary recurrent syphilis, leukoderma, syphilitic small-focal alopecia are possible.
Infection of the nervous system occurs quite early - within a few weeks / months after infection. Changes in the composition of the cerebrospinal fluid are already observed in primary syphilis, and among patients with latent syphilis - in 10-30% of cases.
The diagnosis of latent syphilis is established in the absence of specific manifestations in the patient from the skin, mucous membranes, internal organs, nervous system and musculoskeletal system. The diagnosis is based only on positive serological tests. If it is impossible to determine the duration of the disease, a diagnosis of latent, unspecified syphilis is established.
Early and late congenital syphilis may be symptomatic or latent. The transmission of syphilis depends on its stage in the pregnant woman, the gestational age at which syphilis was detected and treatment was started, as well as the effectiveness of the latter. With manifest early congenital syphilis, the clinical picture manifests itself in the form of syphilitic pemphigus, diffuse Hochsinger infiltration, specific rhinitis, osteochondritis of long tubular bones. Currently, cases of early latent congenital syphilis are predominantly noted, when the diagnosis is based on serological signs and their mandatory comparison with the serological picture of the mother. Pathognomonic features of late congenital syphilis include Hutchinson's triad (parenchymal keratitis, congenital syphilitic late labyrinthitis,
The diagnosis of syphilis is established on the basis of the clinical picture, detection of T. pallidum in the discharge of syphilides (dark field microscopy of native preparations), positive results of serological tests. It is worth noting that, in addition to the spiral shape, T. pallidum can exist in the form of cysts and L-forms, which are forms of survival and reproduction of the microorganism in adverse environmental conditions. L-transformation occurs under the influence of chemicals (antibiotics, sulfonamides), physical and immune factors. When the L-transforming agent is eliminated, the L-forms can be reversed to their original helical shape. This feature of T. pallidum should be taken into account in cases of incomplete interrupted treatment, an unidentified source of infection, when interpreting the diagnosis of latent syphilis, seroresistance. Latent periods of syphilis are associated with a decrease in the number of the pathogen in the body and the predominance of altered forms. Cysts have antigenic activity and, if present in the body, both non-treponemal and treponemal serological tests are positive. L-forms do not have antigenic activity or have it partially; if they are present in the body, all serological tests can be negative, only treponemal tests can remain positive. Therefore, in venereology there are such concepts as seroresistance, clinical and serological relapse.
L-forms do not have antigenic activity or have it partially; if they are present in the body, all serological tests can be negative, only treponemal tests can remain positive. Therefore, in venereology there are such concepts as seroresistance, clinical and serological relapse.L-forms do not have antigenic activity or have it partially; if they are present in the body, all serological tests can be negative, only treponemal tests can remain positive. Therefore, in venereology there are such concepts as seroresistance, clinical and serological relapse.
Penicillin preparations form the basis of the treatment of syphilis. There are long-acting penicillins (benzathine benzylpenicillin), medium duration (benzylpenicillin, procaine) and short-acting (benzylpenicillin). Syphilis treatment regimens provide for a course dose depending on the duration (stage) of the disease. When the infection is >1 year old, treatment with long-acting drugs increases the risk of adverse outcome, the development of seroresistance, therefore, in such cases, it is advisable to use drugs of an average duration of action or a water-soluble form of short-acting benzylpenicillin. Thus, if the patient has late manifestations of secondary syphilis (alopecia, leukoderma, hypertrophic papules, wide condylomas),
The problem of treating syphilis in pregnant women is currently given considerable attention, since today not only the problem of intolerance to penicillin preparations is fundamental, but also an increase in the number of cases of seroresistance during their use, including in this category of patients. Therefore, the choice of alternative drugs is extremely relevant - semi-synthetic penicillins (oxacillin, ampicillin), ceftriaxone, macrolides.Treatment in pregnant women should be given taking into account the possible penetration of antimicrobials through the placenta and the risk of adverse (teratogenic or toxic) effects on the fetus. Thus, taking into account the revealed weak teratogenic effect of erythromycin, its use during pregnancy should be avoided in the treatment of any STI, including syphilis. Azithromycin is considered as an effective and safe alternative in this case.
According to a meta-analysis of 4 randomized controlled trials conducted by ZG Bai et al (2008), the use of azithromycin in patients with early syphilis achieved a higher cure rate compared to benzathine penicillin G during a long period of observation.
Indications for prophylactic treatment of children include: no treatment, delayed or insufficient specific treatment of the mother; lack of preventive treatment of the mother, if indicated. Preventive treatment of children and treatment of early congenital syphilis is carried out with penicillin preparations, semi-synthetic penicillins, ceftriaxone.
Gonococcal infection
The recent decline in the incidence of gonorrhea can hardly be considered true. This is mainly due to the underregistration of patients, the predominance of chronic gonorrhea in women, in whom the disease is usually asymptomatic or with minimal clinical manifestations and is detected only during preventive examinations or with the development of complications.
Gonorrhea is caused by Neisseria gonorrhoeae (N. gonorrhoeae) is a Gram-negative aerobic diplococcus. The L-forms of the pathogen are described, the reversion of which to the original form can cause a recurrence of the infection. An increase in the number of strains of N. gonorrhoeae producing β-lactamase is now noted worldwide.
Infection occurs through sexual contact with the patient, when a newborn passes through the birth canal, through everyday use through care items. The incubation period is from 1 day to 1 month. Perhaps lymphogenous and hematogenous spread of the pathogen with damage to various organs and systems. Uncomplicated forms of gonorrhea of the lower genitourinary system include urethritis, cystitis, cervicitis, vulvovaginitis. Symptoms of the acute process include dysuria; purulent-mucous and purulent discharge from the urethra, cervical canal, vagina; itching, burning, discomfort in the vulva. Complicated forms of gonorrhea include: abscess formation of the periurethral and adnexal glands, endometritis, metroendometritis, salpingo-oophoritis, pelvioperitonitis, prostatitis, epididymitis, orchitis.
The diagnosis of gonorrhea is established on the basis of clinical data, anamnesis, laboratory data. Laboratory studies include: microscopic examination with Gram stain of smears from the urethra, cervical canal, rectum, as well as bacteriological examination. In women, the examination plan must include bacterial culture, which is necessary for the differentiation of banal cocci, which are part of the normal microflora of the vagina, and gonococcus.
Antibiotics active against N. gonorrhoeae are the drugs of choice in the treatment of gonorrhea - ceftriaxone, ofloxacin, spectinomycin, cefodizyme, azithromycin.
Anogenital herpetic viral infection
Anogenital herpetic viral infection is a chronic relapsing viral disease, predominantly sexually transmitted and characterized by lesions of the skin and mucous membrane of the genitourinary organs. Genital herpes is caused by herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2), which is known to infect 65–90% of the world's population. When an infection caused by HSV-1, the skin of exposed parts of the body (face, limbs), mucous membranes of the eyes, oral cavity, upper respiratory tract is usually affected, and HSV-2, which enters the human body mainly through sexual contact, affects the skin and mucous membranes. genitals. HSV is capable of latent existence with subsequent reactivation, which is the cause of relapses.
Manifestations of anogenital herpetic viral infection can be of varying severity with the characteristic appearance of vesicles, erosions, crusts, often along with malaise, headache, low-grade fever, sleep disturbance, nervousness. In women, lesions are located in the perineum, on the small and large labia, clitoris, vagina, cervix. In men, the usual localization is the glans penis, foreskin, coronal sulcus, the area of the external opening of the urethra or inside it, the perineum and buttocks. Infection caused by HSV-2 is characterized by an earlier and more frequent development of relapses than HSV-1. The occurrence of a relapse of the disease is facilitated by a decrease in immunity, hypothermia, concomitant diseases, medical manipulations.
Diagnostics of anogenital herpetic viral infection includes virological, molecular genetic methods, detection of HSV antigens, electron microscopy.
The main drugs in therapy for anogenital herpesvirus infection are specific systemic antiviral drugs (acyclovir preparations), interferons, inducers interferon, immunomodulators.According to http://www.umj.com.ua
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