Guidelines for diagnosis and treatment of genital herpes and genital Chlamydia trachomatis infection (2014)Chinese Center for Disease Contro
Guidelines for diagnosis and treatment of genital herpes and genital Chlamydia trachomatis infection (2014)
Chinese Center for Disease Control and prevention of venereal disease control center, China Medical Association dermatology, venereology group, Chinese Medical Doctor Association dermatologist branch sub Specialized Committee STD
Author unit: Dermatology of China Academy of Medical Sciences, Beijing Union Medical College, China Center for disease prevention and control center for STD control (Wang Qianqiu) (Liu Quanzhong); General Hospital Affiliated to Tianjin Medical University; Huashan Hospital Affiliated to Fudan University (Xu Jinhua)
Chinese Journal of Department of Dermatology, 2014, 47 (): 369-372
The Commission for Disease Control Bureau of guidance and arrangement in the national health plan, by China Center for Disease Control and prevention of venereal disease control center, China Medical Association dermatology, venereology group, Chinese Medical Doctor Association, Specialized Committee organization sub dermatologist branch STD experts to discuss the development of the "clinical diagnosis and treatment of sexually transmitted diseases and Prevention Guide" for dermatologists and obstetricians. Urologist, preventive medicine, physicians and other relevant disciplines physicians in clinical practice and STD prevention and control work. The guidelines for the diagnosis and treatment of 4 sexually transmitted diseases are published as follows. The experts participating in the guideline (surname stroke order): Wang Qianqiu, Wang Baoxi, Yin Yueping, Feng Wenli, Tian Hongqing, Liu Qiao, Liu Quanzhong, Qi Shuzhen, Li Wenzhu, Li Dongning, sun Ling, Li Shanshan, Su Xiaohong, Zhang Jianzhong, Yang Fan, Chengxiong Ho, Yang Bin, Yang Sen, Yang Ligang, Zhou Pingyu, Chen Xiangsheng, Zheng Heyi, Zheng Heping, Duan Yiqun, Luo Dan, Tu Ya Ting, Xu Jinhua, Liang Guojun, Gong Xiangdong, Jiang Juan, Jiang Faxing, Han Jiande, Cheng Hao, Lai wei.
Genital herpes (genital herpes) is a sexually transmitted disease caused by herpes simplex virus (herpes simplex virus, HSV) infection of the genital and genital mucosa. Herpes simplex virus that causes genital herpes has type HSV-1 and type HSV-2. Most genital herpes is caused by HSV-2. HSV into the human body, can be latent for life, latent virus in a certain condition can be active and recurrence, therefore, genital herpes often occur in the process of repeated attacks. HSV can cause genital herpes, can also pass through the birth canal in childbirth newborn, caused by neonatal HSV infection.
1 history of epidemiology: history of unsafe sexual behavior, multiple sexual partners, or sexual partners.
2 clinical manifestations:
(1) primary genital herpes: refers to the first clinical manifestations of genital herpes. Primary genital herpes may be a primary infection or a non primary infection. Primary genital herpes: no HSV infection in the past, serum HSV antibody test negative, for the first time HSV infection and symptoms. Is one of the most serious clinical manifestations. Incubation period 1 weeks (~ 2 ~ 12 d). The male is good at glans, coronal channel, phallic body, the female is good at the size labium, vaginal mouth, perineal, anus week. Rare sites include the scrotum, monsveneris, thighs and buttocks. Anal and rectal involvement. Initially manifested as erythema, papules or papulovesicles, soon developed into a cluster of small blisters or scattered in the 2 ~ 4 d after the rupture to form erosions and ulcers. Local itching, pain or burning sensation. Duration of about 15 ~ 20 D. Often accompanied by fever, headache, myalgia, malaise and fatigue and other symptoms. Can have urethritis, cystitis or palace neck phlogistic wait for expression. Inguinal lymph nodes may be swollen, tenderness; non primary genital herpes: history of HSV infection (mainly for the lips or facial herpes), serum HSV antibody positive, another type of HSV re infection and the emergence of the first episode of genital herpes. Compared with the primary genital herpes, the subjective symptoms are lighter, the skin lesions are limited, the course of disease is short, systemic symptoms are rare, inguinal lymph nodes are not swelling.
(2) recurrent genital herpes: the first recurrence occurred more than 1 to 4 months after primary infection. There was a great difference in the frequency of recurrence among individuals, with an average of 3 to 4 times a year, with up to 10 times. In the hours before the rash to 5 d prodromal symptoms, showed local itching, burning, tingling, pain, numbness and bilge feeling. The lesions are limited in number, as a cluster of small blisters, quickly burst erosion or superficial ulcer, asymmetry, slight pain, itching, burning sensation. The course of disease is usually 6 to 10 d, and the lesions are healed within the range of 4 to 5 d. Systemic symptoms are rare, there is no inguinal lymph node enlargement.
(3) subclinical infection: HSV infection without clinical signs and symptoms. But there is no symptoms of detoxification, can be contagious.
(4) atypical or unrecognized genital herpes: atypical lesions can be nonspecific erythema, induration, fissure (or furuncle), folliculitis, skin scrape, foreskin swelling exudate etc..
(5) special types of genital herpes: herpes cervicitis: the performance of purulent cervicitis. Increased, cervical hyperemia and brittle blisters and erosions, even necrosis; the herpetic proctitis: more common in anal actors, performance for perianal blisters or ulcers, anus pain, tenesmus, constipation and rectal mucous bloody secretions, often accompanied by fever, malaise and myalgia; the neonatal herpes: adverse consequences during the period of pregnancy of genital herpes. It can be divided into localized type, central nervous system type and disseminated type. Often appear 3 to 30 d after the onset of symptoms, invasion of the skin and mucous membranes, internal organs and the central nervous system. As infants sucking weakness, lethargy, fever, convulsions, seizures or lesions, there may be conjunctivitis, keratitis, accompanied by jaundice, cyanosis, dyspnea, circulatory failure and death; the complications: rare. Central nervous system complications include aseptic meningitis, autonomic dysfunction, transverse myelitis, and radiculopathy. Disseminated HSV infections include disseminated skin infections, herpes meningitis, hepatitis, pneumonia, etc..
3 laboratory examination:
Culture method: HSV positive cell culture; antigen detection: enzyme linked immunosorbent assay or immunofluorescence test to detect HSV antigen positive; nucleic acid detection: PCR and other detection of HSV nucleic acid positive. Nucleic acid detection by the relevant agencies shall carry out the certification laboratory; antibody detection: the antibody of serum HSV-2 specific test positive. In addition, type specific serological diagnostic test serum antibody detection of different type of HSV, can be used in the diagnosis of patients with recurrent genital herpes lesions without period, also can be used in the diagnosis of infection in patients with the judgment of HSV and atypical genital herpes. Different types of IgM antibodies were detected in serum, which indicated that there was the first infection of this type of HSV, and only in the near future. However, the duration of IgG antibody was longer, and the positive rate of HSV antibody was more helpful for the diagnosis of aids. However, the sensitivity and specificity of different reagents are different, and the results of the test can not be used as the basis for the confirmed cases.
4 diagnostic categories:
Clinical diagnosis: consistent with clinical manifestations, with or without epidemiological history. Confirmed cases: at the same time meet the requirements of clinical diagnosis and laboratory examination of any 1.
(a) general principles:
Asymptomatic or subclinical genital HSV infection usually without medication. Symptomatic treatment includes two aspects: systemic therapy and local treatment. Systemic therapy is mainly antiviral treatment and treatment of infection, local treatment, including clean wounds and prevent secondary infection. Because genital bleb is easy to relapse, patients often bring psychological pressure, cause tension, depression or anxiety, and psychological factors can influence the natural course of the disease. Therefore, in the early stages of the disease in time to give medical advice, counseling, drug treatment and other comprehensive treatment measures to reduce the recurrence of the disease. All patients infected with genital herpes should be tested for syphilis and HIV.
(two) treatment plan:
1 systemic antiviral therapy: (1) primary genital herpes: recommended oral acyclovir for 200 mg, 5 times a day, a total of 7 ~ 10 d; 400 mg or acyclovir, 3 times a day, a total of 7 ~ 10 d; or valacyclovir 500 mg, 2 times a day, a total of 7 ~ 10 d; or famciclovir 250 mg, 3 times per day, a total of 7 ~ 10 d.
(2) herpetic stomatitis, pharyngitis or proctitis: increasing the dose or extend the treatment to 10 ~ 14 d.
(3) disseminated HSV infection: the effect of 5 ~ 10 mg/kg, intravenous drip, 1 times every 8 hours, for the treatment of 5 ~ 7 d or until the clinical symptoms disappeared. Patients with impaired renal function, acyclovir dosage should be adjusted according to the degree of renal damage.
(4) intermittent treatment of recurrent genital herpes: for the recurrence of the disease, can reduce the severity of the disease, shorten the time of recurrence, reduce the virus. Intermittent therapy is best used in patients with prodromal symptoms or symptoms within 24 h. Recommendation: oral acyclovir 200 mg, 5 times a day, a total of 5 d or 400 mg; acyclovir, 3 times a day, a total of 5 d; or valacyclovir 500 mg, 2 times a day, a total of 5 d; or famciclovir 250 mg, 3 times a day, a total of 5 D.
(5) recurrent genital herpes (recurrent more than 6 times per year): long term suppression therapy may be used. Recommendation: oral acyclovir 400 mg, 2 times a day; or valacyclovir 500 mg, 1 times a day; or famciclovir 250 mg, 2 times a day. Need long-term sustained administration, the course of treatment is generally 4 to 12 months.
(6) during the period of genital herpes: pregnancy in pregnant women, the safety of drugs such as acyclovir is not yet clear, if used, should be weighed and obtain the patient's informed consent. At present, pregnant women with primary genital herpes can be oral A Silowe; complications, intravenous drip of A Silowe. For frequent relapse or newly pregnant women infected with genital herpes patients in the last 4 weeks of pregnancy, there can continue to reduce the activity of acyclovir in the treatment of damage, so as to reduce the rate of cesarean section. Have a history of recurrent genital herpes in the past, when there is no evidence of recurrence of near full-term pregnant women, not for acyclovir treatment. For pregnant women with active skin lesions or symptoms of onset, in the absence of contraindications under the premise of cesarean section can be broken before, but cesarean section can not completely prevent neonatal herpes. The activity of the skin lesions of pregnant patients, from vaginal delivery, but after delivery of the newborn is fever, lethargy, when sucking sucking force, or the occurrence of convulsions lesions were closely monitored for timely treatment. At the end of pregnancy of primary genital herpes occurred in mother to child transmission opportunity is 10 times of recurrent genital herpes, so for serological antibody negative pregnant women, which never infected with herpes simplex virus in pregnant women, pregnant women in late pregnancy should prevent infection of primary genital herpes. Preventive measures include a desire to quit during late pregnancy, avoiding oral sex, or the use of condoms in sexual life.
2 local treatment: the local lesions can use Sodium Chloride Physiological Solution or 3% boric acid solution cleaning, to keep the affected area clean and dry. 3% or 1% topical Aciclovir ointment Penciclovir Cream, but the efficacy of single local treatment was less than the system drugs.
(three) follow-up and prognosis:
For patients with primary genital herpes, after treatment, systemic symptoms disappear, skin lesions subsided, local pain, paresthesia and lymph node enlargement disappeared, that is, clinical recovery. However, the disease is easy to relapse, especially in the first 1 years after the recurrence of recurrent infection. Genital HSV-2 infection than HSV-1 infected Yi Fufa. With the course of time, the recurrence of a decreasing trend. Patients with clinical seizures were subclinical or asymptomatic, and the spread and vertical transmission of genital herpes mostly occurred during subclinical or asymptomatic detoxification. Genital herpes recurrence and some predisposing factors, drinking, spicy food, fatigue, cold, anxiety, tension, sexual intercourse, menstruation and other common causes. Regular living habits, proper physical exercise, good psychological state and avoid inducing factors are important measures to reduce and prevent recurrence. The purpose of follow-up is to provide patients with further health education and counseling, while taking into account the follow-up to the patient to provide the next treatment of drugs, so that patients with prodromal symptoms or seizures within 24 h timely medication.
The prevention of genital herpes has its own characteristics.
1 advice: explanation the natural course of the disease, emphasizing its recurrent and asymptomatic shedding possibility, no symptoms can also occur during the sexual transmission of HSV; the common cause of the disease relapse patients tell, avoid mental tension, depression or anxiety and other negative emotions, by avoiding the relapse can reduce the recurrence of the childbearing age; inform patients (including male patients) to risk for fetal and neonatal HSV infection; to tell patients with antiviral therapy, can shorten the course, antiviral therapy can reduce or prevent recurrence; the patients of treatment achieved positive cooperation, in order to reduce the spread of disease.
2 health education: emphasizing the disease to inform their partners, made with the understanding and cooperation, to avoid sexual contact in the recurrence of prodromal symptoms or lesions, or make better use of barrier contraceptive measures, in order to reduce the HSV risk of transmission to sexual partners; advocated condom barrier contraceptive measures, condom can reduce the risk of transmission of genital herpes, but skin lesions when sexual intercourse, even if the use of condoms may also occur HSV sexual transmission; the change of behavior, avoid premarital sexual behavior, to eliminate multiple sex partners, is the root of the measures for preventing genital herpes.
genital chlamydial infections
Genital tract Chlamydia trachomatis infection (genital chlamydial infections) is a common sexually transmitted disease. Chlamydia trachomatis caused by a wide range of diseases, involving the eye, genital tract, rectum and other organs, can also cause mother to child transmission. Therefore, the prevention and treatment of Chlamydia trachomatis infection has important public health and clinical significance.
A diagnosis [1-3]
History of unsafe sexual behavior, multiple sexual partners or sexual partners. The history of Chlamydia trachomatis infection in urogenital tract of mothers of newborns.
2 clinical manifestations:
(1) male specific performance: urethritis: latent period of 1 ~ 3 weeks. Expression is urethral discomfort, dysuria or urethral secretion. The symptoms are relatively mild dysuria, sometimes only showed a slight tingling and itching of the urethra, urethral secretion for mucinous or mucopurulent, thinner, less; the epididymitis: if no treatment or improper treatment, a few patients can cause epididymitis. Showed unilateral epididymal enlargement, pain, edema, induration, local or systemic fever, induration occurred in the epididymis seminiferous tube, palpable pain of epididymal induration. Sometimes the testis can also involve the emergence, testicular swelling, pain and tenderness, edema of scrotum; prostatitis: the patient had a history of Chlamydia urethritis or prevalence of Chlamydia urethritis. The expression is perineal ministry and its periphery slight ache or acid bilges feeling, have rectum to drop bilge feeling, can be accompanied by ejaculation. Physical examination showed prostate enlargement, asymmetric hardening or induration and tenderness. Can appear transparent filaments or gray lumps in the urine; the arthritis (Reiter syndrome) is a rare complication. Often occurs in 1 to 4 weeks after urethritis. It is a kind of asymmetry, non - erosive arthritis that occurs in the joint of lower limb and sacrum. Reiter syndrome refers to the lesion, and eye (conjunctivitis, uveitis), skin (cyclic balanitis, palmoplantar keratoderma), mucosa (palate, tongue and oral mucosa ulcer) damage.
(2) the specific performance of women: cervicitis: often asymptomatic infection, it is difficult to determine the incubation period. Symptoms may have abnormal vaginal secretions, non menstrual period or after sexual intercourse bleeding and abdominal discomfort. Physical examination can be found in cervical hyperemia, edema, contact bleeding (fragility) and cervical mucus purulent secretion, vaginal mucosa is normal; the urethritis: can appear dysuria, frequent micturition, urgency, often combined with cervicitis. Physical examination can be found in urethral mouth hyperaemia flushing, micro swelling or normal, can have a small amount of mucus purulent secretions overflow; the pelvic inflammatory disease: without treatment or improper treatment, some patients of pelvic inflammatory disease and ascending infection. Abdominal pain, low back pain, sexual intercourse pain, abnormal vaginal bleeding, abnormal vaginal discharge, etc.. Acute onset of fever, chills, headache, loss of appetite and other symptoms. When mild, mild abdominal pain, erythrocyte sedimentation rate slightly faster. Physical examination can be found in the lower abdominal tenderness, cervical pain, palpable thickening of the fallopian tube or inflammatory mass. The disease process is usually chronic persistent. Long term outcomes include tubal infertility, ectopic pregnancy, and chronic pelvic pain.
(3) performance of common men and women: proctitis: male is more common in homosexual sex. The light had no symptoms, severe rectal pain, hematochezia, diarrhea and mucous secretion; 2 conjunctivitis: eyelid swelling, conjunctival hyperemia and follicle, can have mucous purulent secretions.
(4) asymptomatic infection: the majority of male urethra and female cervical Chlamydia trachomatis infection were asymptomatic.
(5) neonatal infection: neonatal conjunctivitis: caused by the infection of the mother. 5 to 12 d after birth. The light had no symptoms, symptoms of neonatal performance for varying severity of purulent conjunctivitis, mucous or purulent mucus, eyelid edema, conjunctival diffuse swelling, ball conjunctivitis of papillary hyperplasia, a long time can cause scar, micro pannus; neonatal pneumonia: often in the 3 to 16 week old place. For nasal congestion, runny nose, shortness of breath, characteristic (short time interval, intermittent cough, often no fever). The examination found shortness of breath, audible and rales.
3 laboratory examination [1-2, 4-5]:
The microscope examination: smear Giemsa staining and iodine staining PAP staining or direct microscopic examination can be found in Chlamydia trachomatis inclusion. Only applicable to neonatal conjunctival scrapings examined; the culture method: Chlamydia trachomatis positive cell culture; the antigen detection: enzyme linked immunosorbent assay, immunofluorescence or immunochromatographic assay for detection of Chlamydia trachomatis antigen positive; the antibody titer increased: IgM antibody of Chlamydia trachomatis chlamydia pneumonia in neonatal body, diagnosis the significance of the detection of nucleic acid; PCR, RNA fluorescent nucleic acid isothermal amplification method (SAT), nucleic acid transcription mediated isothermal amplification assay (TMA) detection of Chlamydia trachomatis nucleic acid positive. PCR testing shall be carried out in a laboratory accredited by the relevant authorities.
4 diagnostic categories:
The confirmed cases: at the same time to meet any of their clinical manifestations and laboratory examination, with or without the epidemiological history; asymptomatic infection: to meet any of the laboratory (mainly for the detection of antigen and nucleic acid detection method, culture), and no symptoms.
Two treatment [1-2, 6-13]
The purpose of the treatment of Chlamydia trachomatis infection is to kill Chlamydia trachomatis, eliminate symptoms, prevent complications, prevent further spread. Because of the unique biological properties of Chlamydia trachomatis, it is necessary to improve the efficacy of antibiotics, which can prolong the course of antibiotics, or use a long half-life of antibiotics.
1 general principles:
Early diagnosis, early treatment. Timely, adequate, regular medication. According to the different conditions of the corresponding treatment program. Sexual partners should receive treatment at the same time. Follow up after treatment.
2 treatment options:
(1) recommended adult Chlamydia trachomatis infection: Azithromycin 1 G single oral dose, or doxycycline 0.1 g, 2 times a day, a total of 7 ~ 10 d. Alternative: minocycline 0.1 g, 2 times a day, a total of 10 d, or 0.5 g of tetracycline, 4 times a day, a total of 2 ~ 3 weeks, or erythromycin 0.5 g, 4 times a day, a total of 7 d or 0.15 g, roxithromycin, 2 times a day, a total of 10 d or 0.25 g, clarithromycin 2 times. A day, a total of 10 d, or oxygen pefloxacin 0.3 g, 2 times a day, a total of 7 or 0.5 D, levofloxacin g, 1 times a day, a total of 7 d or 0.2 g, sparfloxacin, 1 times a day, a total of 10 d, or 0.4 g of moxifloxacin, 1 times a day, a total of 7 d. Studies have shown that azithromycin regimen for some patients with poor efficacy, and 3 ~ 5 d regimen may be better. However, the exact efficacy evaluation and the most appropriate treatment plan should be further studied.
(2) neonatal Chlamydia trachomatis pneumonia and recommendations: erythromycin ophthalmic dry syrup powder, 50 mg? Kg-1? D-1, 4 times a day, a total of 14 d. If effective, and then extend 1 ~ 2 weeks.
(3) recommended scheme for Chlamydia trachomatis infection in children: body weight < 45 kg, erythromycin base or erythromycin dry syrup powder, Mg, kg-1, D-1, oral for 4 times, a total of 14 d. > 8 years of age or weight more than 45 kg azithromycin treatment scheme with adults. Erythromycin treatment of Chlamydia trachomatis infection in infants or children about 80%, may require a course of treatment of second.
(4) Chlamydia trachomatis infection in genital tract in pregnancy: (azithromycin), single dose of oral administration, or amoxicillin 0.5 g, a daily dose of 3 D, a total of 7 G. Alternative: erythromycin base 0.5 g, a total of 7 d a day, or erythromycin a base of 0.25 g, daily 4 times, a total of 14 d.
Taking azithromycin or doxycycline in the treatment of patients, in general after completing treatment without follow-up microbiology. Any of the following conditions: consider microbiology follow-up symptoms persist; the suspected infection; the suspect did not comply with treatment; the asymptomatic infection; the treatment of erythromycin.
The time of the trial: the antigen test was second weeks after the end of the treatment period, and the nucleic acid amplification test was the end of the treatment period of fourth weeks. For women, it is recommended that Chlamydia trachomatis should be tested again for 3 to 4 months after treatment to detect possible reinfection and to prevent pelvic inflammatory disease and other complications.