Cure for

The causative agent for syphilis is Treponema pallidum, a spirochete. Syphilis is still fairly common disease (it is a sexually transmitted disease), despite presence of very effective antibiotics such as penicillin. At present globally more than 10 million people contact syphilis, annually. But there is a sharp decline of more than 95% in the past 50 years in the incidence of syphilis after advent of penicillin therapy to treat syphilis effectively.

The antibiotic of choice for treatment of syphilis is still penicillin for all the stages of syphilis. There is no reported incidence of resistance of Treponema pallidum to penicillin and hence still the drug of choice.

The CDC has given a guideline for treatment of syphilis in the year 2006 which is given below:

• Treatment of syphilis in Primary, secondary, and early latent phase of syphilis is Penicillin G benzathine (a single dose of 2.4 million units intramuscularly).
• Late latent phase, or cardiovascular involvement, CSF (cerebrospinal fluid) analysis should be done. If CSF is normal Penicillin G benzathine 2.4 million units intramuscularly weekly for 3 weeks. If CSF is abnormal it should be treated as neurosyphilis.
• Neurosyphilis, either symptomatic or asymptomatic is to be treated with aqueous penicillin G, 18–24 million units intravenously, given every 4 hourly (3–4 million units) or by continuous intravenous infusion. Alternative regimen is aqueous penicillin G procaine, 2.4 million units intramuscularly plus oral probenecid (500 mg every 6 hourly), both for 10–14 days.
• During pregnancy the treatment is same as with general population and according to stages.
• If patient is sensitive to penicillin, alternative includes Tetracycline hydrochloride (500 mg orally 4 times a day) or doxycycline (100 mg orally two times a day) for 14 days. Penicillin sensitive pregnant patients or patients with neurosyphilis have to be treated with penicillin after desensitization.

Urethritis in men is caused by many different types of organisms and ideal treatment would be to identify the infecting organism and treat it with specific antibiotics highly effective in treating such infection. But it may not be possible in every cases of urethritis. In practice after diagnosing a case of urethritis in men, initially Gram’s staining is done, if it reveals gonococci, treatment for gonococci is done and if it does not reveal gonococci than treatment for NGU (nongonococcal urethritis) is done.

Treatment of gonococci infection:

Gonococci infection is treated with cephalosporin antibiotics. Among cephalosporin antibiotics ceftriaxone (125 mg intramuscularly single dose), cefpodoxime (400 mg orally single dose) or cefixime (400 mg orally single dose) can be used.

If no diagnostic test is available or performed in a patient with urethritis, than treatment regimen should be single-dose regimen for gonorrhea (as above) plus azithromycin (1 gram orally as single dose) or doxycycline (100 mg twice a day for 7 days) for treatment of clamidial infection (C. tracomatis) which occurs frequently in patients suffering from urethritis due to gonococci.

If gonococci are not demonstrated by Gram’s staining, it should be treated as NGU (nongonococcal urethritis) like azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally 2 times a day for 7 days).

How to treat recurrent cases of urethritis?

Recurrent cases of urethritis should be treated with the same regimen as before if they did not comply with the earlier treatment or if they are reexposed to same infection. If the patient was treated appropriately previously, than an intraurethral swab specimen and a first-voided morning urine sample should be tested (culture of the swabs and antibiotic sensitivity done). If compliance to the initial treatment can be confirmed and reexposure excluded (in persistent cases) the treatment should include metronidazole or tinidazole (2 gram orally in a single dose) plus azithromycin (1 gram orally in a single dose).

N.B.- The sexual partner/partners (should be tested for gonorrhea and chlamydial infection) also should be treated with the same regimen as given to the male urethritis patient.

Urethritis is inflammation of urethra (the passage through which urine is passed from urinary bladder to the outside). Urethritis is fairly common STI (sexually transmitted infection) among sexually active males (more so among adolescence age group).

What are the symptoms of urethritis?

The common symptoms of urethritis are discharge from urethra and pain during micturition or urination. Commonly both of these symptoms are seen in case of urethritis. Generally there is no change in frequency of urination.

What are the causative agents of urethritis?

The commonest cause of urethritis in men is Neisseria gonorrhoeae (the causative agent for gonorrhea). Other common organisms which can cause urethritis are Clamidia. trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, HSV (herpes simplex virus), coliform (commonly seen in men practicing insertive anal intercourse) etc. Among nongonococcal urethritis (NGU), approximately one third of the cases are due to Clamidia. Trachomatis (older men with urethritis generally are less likely be due to chlamydial infection), although the cases are declining these days.

In many populations, the urethritis in men due to Clamidia. trachomatis, has declined to an extent due to effective chlamydial-control programs. HSV and T. vaginalis cause a small proportion nongonococcal urethritis (NGU) in men. Other causes of NGU are M. genitalium, Ureaplasma urealyticum, Ureaplasma parvum, coliform etc.

If a case of urethritis is suspected it should be properly investigated and treated appropriately without delay. At first, only Neisseria gonorrhoeae and Clamidia. trachomatis, should be tested with specific tests.

Worldwide it is estimated that most adults acquire at least one STI in their lifetime. Throughout the world sexually transmitted diseases (STDs) or STIs (sexually transmitted infections) rank among the most common infections.Certain STIs are distributed evenly throughout any society, e.g. are chlamydial infections, genital infections with HPV, genital herpes etc.

Some STIs are distributed among “core populations”. The ‘core populations’ include high rates of sexual partner change, some homosexual men, multiple concurrent sexual partners, highly connected sexual networks (involving prostitutes and their clients), users of illicit drugs (drug abusers especially crack cocaine, methamphetamine etc.). Examples of these “core populations” STIs are syphilis, gonorrhea, HIV infection, hepatitis B, chancroid etc.

At present more than 30 infections are there which can be classified under STDs (sexually transmitted diseases, sexually transmissible diseases with sexual mode as minor mode and sexually transmissible diseases). 90% of the worlds STIs (sexually transmitted infections) are seen in the developing countries where 75% of the world population resides. There are many factors for high numbers of STIs in the developing countries, like rural to urban migration, high population growth (especially high number of young adults), poverty, wars etc. which causes risky sexual behavior.

Generally three factors influence the rate of spread of STDs in a community. These factors are rate of sexual exposure of susceptible individuals to infectious (STDs) people, duration of infectivity (longer duration if not treated adequately) and efficiency of transmission of STDs per sexual exposure. So aim and efforts of preventing (and reducing) STDs should be to decrease the rate of sexual exposure of susceptible individuals to infected persons (by individual counseling), reduce duration of infectivity by early diagnosis and prompt curative or suppressive treatment and to reduce efficiency of transmission by use of barrier methods like condoms and safer sexual practices and recently through male circumcision (in selected cases).

STDs or sexually transmitted diseases are pretty common throughout the world and it is estimated that most of the adults acquire at least one sexually transmitted disease in their life time. For example in United States alone more than 6 million people acquire new genital human papillomavirus (HPV) infection and worst is, most of these people who acquire genital human papillomavirus infection are at risk of developing genital neoplasm. From this one example it is not difficult to estimate how common STD is. In all societies of the world sexually transmitted diseases are among the most common infectious diseases.

There are more than 30 infections which are classified as predominantly sexually transmitted or as sexually transmissible (frequently). These are named below:

Transmitted predominantly by sexual intercourse in adults (name of the organism given in brackets):

Bacterial:

Gonorrhea (Neisseria gonorrhoeae), syphilis (Treponema pallidum), lower genital tract infections in females and epididymitis in males (Chlamydia trachomatis), genital ulcers (Haemophilus ducreyi), urethritis in males (Ureaplasma urealyticum), genital ulcers (Calymmatobacterium granulomatis).  

Viral:

AIDS (HIV or human immune deficiency virus types 1 and 2), genital herpes (Herpes simplex virus type 2), Hepatitis B (Hepatitis B virus), genital and anal warts (Human papillomavirus), Molluscum contagiosum (Molluscum contagiosum virus), T cell leukemia (Human T-cell lymphotropic virus type I).

Others:

Trichomonas vaginalis infection and pediculosis of pubic area (Phthirus pubis).

Sexual Transmission Repeatedly Described but Not the Predominant Mode (name of the organism given in brackets):

Bacterial:

Urethritis in males (Mycoplasma genitalium), bacterial vaginosis (Gardnerella vaginalis), (Mycoplasma hominis), (Group B Streptococcus), (Helicobacter cinaedi), (Helicobacter fennelliae).

Viral:

CMV or cytomegalovirus mononucleosis (Cytomegalovirus), lymphoma (Human T-cell lymphotropic virus type II), hepatitis (Hepatitis C, D viruses), genital herpes (Herpes simplex virus type 1), infectious mononucleosis (Epstein-Barr virus).

Others:

Candidiasis (Candida albicans) and scabies (Sarcoptes scabiei).

Transmissible by sexual contacts (Oral-Fecal Exposure) mainly in Homosexual Men:

Bacterial:

Shigellosis (Shigella species) and Proctocolitis or enterocolitis (Campylobacter species).

Viral:

Hepatitis (Hepatitis A).  

Others:

Giardiasis (Giardia lamblia) and amebiasis (Entamoeba histolytica).

Treatment of non typhoid Salmonella infection is different from typhoid infection due to Salmonella Typhi. In the treatment of non typhoid Salmonella infection antibiotic should not be used routinely as used in typhoid. Antibiotics should only be used if required, as most of the infections of non typhoid Salmonella are self limiting type and the duration of diarrhea and fever are not much affected by use of antibiotics. Additionally antibiotic therapy can increase relapse of the infection and also prolong the duration of gastrointestinal carrier state.

The main treatment should be aimed at correcting dehydration that may arise due to prolonged diarrhea, by fluid and electrolyte replacement.

Preemptive antibiotic treatment is required in case of neonates (up to 3 months of age), persons with age of more than 50 years with suspected atherosclerosis, patients with immunosuppression, cardiac valvular disease, endovascular abnormalities, significant joint disease etc. The preemptive treatment of non typhoid Salmonella infection should be done by oral or intra venous (IV) administration of antibiotics (Ciprofloxacin 500 mg twice a day; Trimethoprim-sulfamethoxazole 160/800 mg twice a day; Ceftriaxone 2000 mg/day; Amoxicillin 100 mg three times a day or Ampicillin 2000 mg every 4 hourly) for 2 to 3 days (48 to 72 hours) or till fever subsides. If patient is immunocompromised treatment may have to be continued for 1 to 2 weeks. Due to high incidences of antibiotic resistance, a third generation cephalosporin (Ceftriaxone) antibiotic or a fluoroquinolone (Ciprofloxacin) should be included in the empirical therapy for life-threatening NTS bacteremia or focal NTS infection. If a patient is suffering from non typhoid Salmonella infection with bacteremia (bacteria in blood) and AIDS, he/she should be treated for 1 to 2 weeks of intravenous antibiotics and followed by 4 weeks of treatment with oral Ciprofloxacin. If there is relapse of the infection, after the therapy (in AIDS patients) than the patient should be given long term suppressive therapy with a fluoroquinolone or trimethoprim-sulfamethoxazole (after doing culture and sensitivity test).

If patient has endocarditis or arteritis the treatment is by intravenous beta-lactum antibiotics like ceftriaxone or ampicillin. Surgical intervention is recommended where required.

For extraintestinal nonvascular non typhoid Salmonella infections, a 2 to 4 weeks course of antibiotic therapy (depending on the infection site) is recommended. In case of chronic osteomyelitis, abscess, urinary infection or hepatobiliary (liver and gall bladder) infection associated with anatomic abnormalities, surgical resection or drainage may be required in addition to prolonged antibiotic therapy for eradication of infection.