Open access peer-reviewed chapter - ONLINE FIRST

Treatment of Bacterial Sexually Transmitted Infections in Resource-Limited Settings

Written By

Simeon Chijioke Amadi, Chidiebere Nwakamma Ononuju, Joseph Okoeguale, Anthony Chukwuemeka Olobuah and Williams Amebeobari Mube

Submitted: September 16th, 2022 Reviewed: January 9th, 2023 Published: March 8th, 2023

DOI: 10.5772/intechopen.109930

Bacterial Sexually Transmitted Infections - New Findings, Diagnosis, Treatment, and Prevention IntechOpen
Bacterial Sexually Transmitted Infections - New Findings, Diagnosis, Treatment, and Preven... Edited by Mihaela Laura Vica

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Bacterial Sexually Transmitted Infections - New Findings, Diagnosis, Treatment, and Prevention [Working Title]

Dr. Mihaela Laura Vica

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Abstract

Globally, bacterial sexually transmitted infections (STIs) are a major health challenge. It is more challenging in resource-limited settings, where diagnostic capabilities are limited, health insurance is almost nonexistent and medical bills are settled out-of-pocket. In resource-limited settings, most clinicians adopt the syndromic case management approach for effective treatment due to the paucity of resources. The highest levels of multidrug resistant bacterial STIs have been found in resource-limited countries. The reasons are complex and include poor quality of health services, high burden of disease, lack of accessible, accurate, and confirmed diagnostic assays, ineffective regulations, overuse of antibiotics, inappropriate dosing, and lack of knowledge about the risks of microbial resistance. This chapter thus brings to the fore the challenges of treating bacterial sexually transmitted infections in resource-poor settings and the current evidence on the topic for scholars, researchers, and practitioners.

Keywords

  • treatment
  • bacterial
  • sexually transmitted
  • infections
  • resource-limited settings

1. Introduction

Sexually transmitted infection (STI) means organisms that lead to infection after sexual intercourse between two persons, while sexually transmitted disease (STD) simply means an obvious clinical disease that resulted from the STI [1]. Doctors and other health workers are the key stakeholders in the prevention and treatment of STIs [1]. The World Health Organization (WHO) estimates that approximately 340 million new cases of the four main curable STIs (gonorrhea, chlamydial infection, syphilis, and trichomoniasis) occur every year, and 75–85% of them in developing countries [2]. STIs impose an enormous burden of morbidity and mortality in developing countries, both directly through their impact on reproductive and child health, and indirectly through their role in facilitating the sexual transmission of Human Immuno-deficiency Virus (HIV) infection [3]. The high prevalence of STIs has contributed to the disproportionately high HIV incidence and prevalence in most resource-limited settings [3]. The greatest impact is on women and infants [3]. The World Bank has estimated that STIs, excluding HIV, are the second commonest cause of healthy life years lost by women within the age range of 15–44 age in Africa. These bacterial STIs are also responsible for up to 17% of the total disease burden [4].

These underscore the need for appropriate diagnosis and treatment of STI to mitigate the person-to-person transmission and the associated morbidity and mortality associated with the untreated infection acquired sexually [3, 5, 6]. In resource-poor countries, diagnosis based on causative organisms of STIs remains very difficult as a result of the unavailability of laboratory diagnostics that will direct practitioners on the best treatment modality [3]. In the few centers with laboratory support, tests results for the detection of causative organisms for suspected STIs take days/weeks, to be made available to physicians and this makes early definitive/targeted treatment based on etiologic diagnosis difficult/impossible [3, 7].

To solve this problem of lack of etiologic diagnosis and associated difficulty in the treatment of STIs, the WHO brought out the syndromic case management approach in 1984 to guide the practitioners in effective and timely treatment of STIs [8]. This syndromic case management approach remains the approach to STI treatment adopted in many countries of the world, especially developing countries [8]. This syndromic case management approach is based on the identification of consistent groups of symptoms and easily recognizable signs and treatment that will deal with most, or the most serious, organisms responsible for producing the syndrome [9]. Introduction of additional parameters in the syndromic diagnosis of nonviral sexually transmitted infections in low-resource settings and hence improved management has been advocated but is still far-fetched [10].

Consequently, the highest levels of multidrug resistant bacterial STIs have been found in resource-limited countries [11, 12, 13]. The reasons are complex and include poor quality of health services, high burden of disease, and lack of accessible, accurate, and confirmed diagnostic assays, ineffective regulations, overuse of antibiotics, inappropriate dosing, and lack of knowledge about the risks of microbial resistance [13]. Not surprisingly, scholarly reviews on syndromic case management, underscored the need for low-cost and accurate Point-of-Care Tests (POCTs) for the identification, first, of Chlamidia trachomatis (CT)/Neisseria gonorrhea (NG), and, second, of Mycoplasma genitalium (MG)/Trichomonas vaginalis (TV) and NG/MG resistance/susceptibility testing [14]. Near-patient POCT molecular assays for CT/NG/TV are commercially available, but the cost and other limitations remain prohibitive, especially in resource-constrained settings [7, 15, 16]. These challenges are driving the development of lower-cost solutions [14]. Also, advocacy and subsidization of available diagnostic, treatment, and prevention facilities or measures will immensely reduce the burden of these conditions in the resource-limited settings [14]. This chapter thus brings to the fore the challenges of treating bacterial sexually transmitted infections in resource-poor settings and the current evidence on the topic for scholars, researchers, and practitioners.

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2. Treatment of common bacterial infections acquired sexually

There is a paucity of guidelines for the treatment of bacterial sexually transmitted infections in the resource-limited setting. Study of health seeking behavior of patients in developing countries show that a significant number of people with symptomatic STIs seek treatment in the informal or private sector, from traditional healers, unqualified practitioners, street drug vendors, and from pharmacists and unregulated private practitioners, and they will only attend formal public health services (with trained personnel) after alternative treatments have failed [17]. Self-medication is also widely practiced in most resource-limited settings [17, 18, 19]. The reasons for these aberrant behavior/practices include but are not limited to the convenience, seeming low cost, flexible payment arrangements, greater accessibility, and the more confidential, less judgmental, and less stigmatizing nature of the services provided by the practitioners in the informal and the largely unregulated private sector [17].

The operational protocol for the treatment of bacterial sexually transmitted infections in formal public health facilities in the resource-limited settings is the “Syndromic Case Management Approach” recommended by the WHO. And so, in this section, the etiologic diagnosis-based treatment guidelines by the Center for Disease Control will be considered first.

Common sexually transmitted bacterial infections include:

2.1 Klebsiella granulomatis

This is an intracellular gram-negative bacterium responsible for the granuloma inguinale (donovanosis). Clinically, the disease is characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy; subcutaneous granulomas (pseudo buboes) also might occur. A study in Nigeria observed a prevalence of Klebsiella species of 12.3% among women with suspected genital tract infections in a tertiary hospital [20].

For the laboratory testing for Klebsiella, serologic testing is unhelpful. On gram staining, the organism appears as short, plump, and gram-negative bacilli. They are usually surrounded by a capsule and appear as clear space. The organism can be cultured in the laboratory from a specimen from urethral discharge, cervical discharge, vaginal discharge, etc. in infected patients. Klebsiella is micro-aerophilic and can grow in the presence or absence of oxygen. They have no special cultural requirements. Most species can use citrate and glucose as the sole carbon source and so they grow well in most ordinary culture media. But even so, most patients in the resource-limited settings are treated using the syndromic case management approach due to a lack of personnel and facilities and patronage of unskilled caregivers.

The Center for Disease Control (CDC) United States of America recommends oral Azithromycin, 1 g once weekly or 500 mg once a day for up to 3 weeks and until all lesions of Granuloma Inguinale (Donovanosis) have completely healed. Other recommended regimen includes (a) oral Doxycycline 100 mg twice daily for up to 3 weeks and until all lesions of Granuloma Inguinale (Donovanosis) have completely healed. (b) oral Erythromycin 500 mg orally four times/day for up to 3 weeks and until all lesions of Granuloma Inguinale (Donovanosis) have completely healed. (c) oral Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) twice daily for up to 3 weeks and until all lesions of Granuloma Inguinale (Donovanosis) have completely healed [1].

2.2 Chlamydia trachomatis

CT is the agent of the most common bacterial STI worldwide, with a significant clinical, economic, and public health impact [21]. This bacterial sexually transmitted infection is responsible for lymphogranuloma venerum (LGV). Some chlamydial infections may occur without clinical symptoms. Individuals with LGV commonly present with tender inguinal or femoral lymph nodes, which are mostly unilateral. Sometimes, an ulcer which is mostly self-limiting may occur at the site of the infection. Often, these lesions would have disappeared by the time the infected individual is seeking care in the hospital. The prevalence of CT in pregnancy in developing countries is between 7 and 31%. In sub-Saharan Africa, the prevalence of CT among high-risk groups in the 1980s was 2–25% while among the low-risk groups in the same period was 2–29% [22, 23, 24, 25]. The prevalence of the organism among high-risk groups in the 1990s was 2–13% and among the low-risk group in the same period was 4–18% [22, 23, 24, 25]. This high prevalence is occurring in places where we have a paucity of manpower and equipment for the treatment of patients with the resultant morbidity and mortality associated with the disease.

A definitive LGV diagnosis can be made only with LGV-specific molecular testing (e.g., PCR-based genotyping). These tests can differentiate LGV from non-LGV CT in rectal specimens. However, these tests are not widely available, and results are not typically available in a time frame that would influence clinical management. Therefore, diagnosis is based on clinical suspicion, epidemiologic information, and a CT Nucleic acid Amplification Test (NAAT) at the symptomatic anatomic site, along with the exclusion of other etiologies for proctocolitis, inguinal lymphadenopathy, or genital, oral, or rectal ulcers [26, 27]. Genital or oral lesions, rectal specimens, and lymph node specimens (i.e., lesion swab or bubo aspirate) can be tested for CT by NAAT or culture. NAAT is the preferred approach for testing because it can detect both LGV strains and non-LGV CT strains [28]. Therefore, all persons presenting with proctocolitis should be tested for CT with a NAAT performed on the rectal specimen. The facilities and personnel for these services are unavailable to most persons in the resource-limited settings who require these tests. This is due to poverty, ignorance, and poor governance.

For the treatment of CT cervicitis, the CDC recommends oral Doxycycline 100 milligram orally twice daily for 7 days. For individuals who are at risk for gonorrhea or who live in communities where gonorrhea is prevalent, treatment with potent antibiotics for the causative organism—Neisseria gonorrhea (NG)—may be considered. Alternatively, a single dose of oral Azithromycin 1 g may be used for the CT infection. The CDC recommended regimen for chlamydial infection among adolescents and adults includes (a) oral Doxycycline 100 mg twice daily for 1 week (b) oral Azithromycin 1 g in a single dose (c) oral Levofloxacin 500 mg once daily for 1 week. The recommended regimen for chlamydial infection during pregnancy includes oral Azithromycin 1 g in a single.

2.3 Neisseria gonorrhoeae

In 1879, Albert Neisser first described the gram-negative diplococcus, NG, in discharges from urethral and cervical infections [29]. NG affecting the urethra, endocervix, rectum, and pharynx is common and mostly asymptomatic. Up to 50% of female patients who came down with NG infection of the endocervix also develop a simultaneous rectal infection as a result of the contiguous spread of their genital infection [30]. Three days to 2 weeks postexposure, NG infection will appear and symptoms include abnormal vaginal/mucopurulent discharge, bloody discharge, dysuria, dyspareunia, pruritus vulvae, or even perineal pain. Although most times anorectal examination is normal, erythema or ulceration of the anus may be seen on inspection. Untreated gonococcal infection may lead to transient bacteremia, arthritis, or dermatitis. More severe sequelae, such as endocarditis and meningitis, are rare. Penicillinase-producing NG has rendered penicillin G inadequate therapy for infections caused by this organism.

The prevalence of NG in pregnancy in developing countries is between 10 and 20%. In sub-Saharan Africa, the prevalence of NG among high-risk groups in the 1980s was 7–66%, while among the low-risk groups in the same period was 0.3–40% [22, 23, 24, 25]. The prevalence of the organism among high-risk groups in the 1990s was 6–31% and among the low-risk group in the same period was 1.6–9% [28, 29, 30, 31]. Interestingly, this high prevalence is occurring in places where we have a paucity of manpower and equipment for the treatment of patients with the resultant high morbidity and mortality associated with the disease.

The confirmatory test for NG is by gram stain of directly visualized discharge or by culturing the organism on selective media, for example, Thayer-Martin. Where lubricant is needed during sample collection, water is recommended for use to avoid the reduction in a culture that may be occasioned by the use of antibacterial-containing lubricants. The non-culture techniques for the diagnosis of NG, for example, NAATs are becoming popular [31] but these diagnostic modalities are far-fetched in the resource-limited settings due to lack of equipment and personnel and also because patients patronize untrained personnel.

The CDC recommends the following treatment—Intramuscular Ceftriaxone 500 mg in a single dose for individuals with a total body weight of less than 150 kg. For patients in whom chlamydial infection has not been ruled out, treatment with oral doxycycline 100 mg twice daily for 7 days may be helpful. Patients who weigh ≥150 kg, should receive intramuscular ceftriaxone 1 g ceftriaxone in a single dose. Alternative treatment entails intramuscular Gentamicin 240 mg in a single dose plus oral Azithromycin 2 g in a single dose or oral Cefixime 800 mg in a single dose [1].

2.4 Treponema pallidum (TP)

This bacterium (a spirochete) causes the sexually transmitted disease called syphilis. It is among the oldest known infectious diseases. The categorization of the disease into clinical stages is based on the clinical manifestations, especially if left untreated and this categorization guides the patient’s treatment and follow-up. Patients with syphilis might seek treatment or be treated on the basis of signs or symptoms (clinical manifestations). The prevalence of syphilis in pregnancy in developing countries is between 2.5 and 17%. In sub-Saharan Africa, the prevalence of TP among high-risk groups in the 1980s was 4–32%, while among the low-risk groups in the same period was 0.01–33% [22, 23, 24, 25]. The prevalence of the organism among high-risk groups in the 1990s was 2–29% and among the low-risk group in the same period was 1–29% [22, 23, 24, 25]. In the same vein, this high prevalence is occurring in places where we have a paucity of manpower and equipment for testing and etiologic treatment of patients, with the resultant morbidity and mortality associated with the disease.

Primary syphilis: The classical presentation of primary syphilis is a single painless ulcer (chancre) at the infection site within 2–10 weeks postexposure and it can also manifest with atypical, multiple, or painful lesions [32]. The lesion will ulcerate eventually but heals within 2–4 weeks even without treatment [33].

Secondary syphilis: Hematogenous spread of syphilis occurs 4–10 weeks after primary syphilis and leads to secondary syphilis. This may manifest in the form of skin rash, mucocutaneous lesions, and lymphadenopathy. This age is characterized by nonspecific systemic symptoms, such as fever, malaise, arthralgia, weight loss, sore throat, and headache, in addition to a maculopapular rash on the trunk and extremities. Condyloma latum, which are gray or white wart-like spirochete-filled lesions that also appear in secondary syphilis. They appear adjacent to the primary chancre. If left untreated, the syphilitic symptoms will spontaneously resolve after 3–12 weeks. Relapse of symptoms in the first year (early latent syphilis) may be experienced by ¼ of the patients if the condition is left untreated.

Tertiary syphilis: This may manifest in the form of cardiac conditions, gummatous lesions, tabes dorsalis, and general paresis [32].

Latent syphilitic infections are otherwise subclinical infections (without symptoms and signs) and can be detected through serologic assays. Latent syphilitic infections are classified as (a) early latent syphilis—acquired within the preceding year, (b) late latent syphilis, and (c) latent syphilis of unknown duration.

Central Nervous System (CNS) syphilis, TP infection can spread to the CNS. This can happen at any stage of syphilis and result in neurosyphilis. Within the first few months or years of TP infection, CNS clinical symptoms and signs knowns as syphilitic meningitis can be noticed. These features may include cranial nerve abnormalities, meningitis, meningovascular syphilis, cerebrovascular accident, and acute altered mental state. Tabes dorsalis and general paresis are some of the neurologic features that may be noticed in patients with up to 10 to >30 years of TP infection [1].

The affection of the ocular/visual system or the auditory system is referred to as ocular syphilis and otosyphilis, respectively. These commonly occur at the early stages of the TP infection and can manifest with or without other CNS affectation. They can also occur at any other stage of the disease. Panuveitis is the most common manifestation of ocular syphilis. Other manifestations of ocular syphilis are affectation of the anterior and posterior segment of the eye, including conjunctivitis, anterior uveitis, posterior interstitial keratitis, optic neuropathy, and retinal vasculitis. Patients with ocular syphilis may develop permanent/irreversible blindness. Clinical manifestations of the otosyphilis are tinnitus, vertigo, and sensorineural deafness. Hearing loss can involve one side of the ear or both sides. The hearing loss may also be sudden in onset and progress fast. Otosyphilis may lead to irreversible deafness.

Dark-field examinations and molecular tests for detecting TP directly from lesion exudate or tissue are the definitive methods for diagnosing early syphilis and congenital syphilis [33]. Syphilis is diagnosed by seeing the spirochetes on a dark-field microscopic exam of scrapings from chancres. The next diagnostic method is a demonstration of spirochetes in biopsy specimens stained with Warthin-Starry silver. Alternatively, a direct fluorescent antibody test for TP is performed by some laboratories [33]. Other investigations include the non-treponemal (not specific for treponemal antibodies) serologic tests, such as rapid plasma regain and Venereal Disease Research Laboratory (VDRL), which have a false-negative rate of up to 25%. If the non-treponemal tests return positive, a confirmatory treponemal test such as the fluorescent treponemal antibody absorption test should be conducted on the patient.

The CDC recommended regimen for primary and secondary syphilis among adults includes benzathine penicillin G 2.4 million units intramuscularly in a single dose. The recommended regimen for syphilis among infants and children includes benzathine penicillin G 50,000 units/kg body weight intramuscularly, up to the adult dose of 2.4 million units in a single dose. For patients with penicillin allergy, the regimen of Doxycycline (100 mg orally two times/day for 14 days) [34, 35] or tetracycline (500 mg orally four times/day for 14 days) have been used for years and can be effective [34, 35]. Due to gastrointestinal side effects, Doxycycline may be preferred to tetracycline.

Most patients in developing countries may not be opportune to have diagnostic investigations carried out for their symptoms before treatment due to a lack of hospitals and trained personnel and poverty. They may even experience delayed or absent treatment with the attendant sequelae.

2.5 Mycoplasma genitalium

This infection in women may be symptomatic or asymptomatic. In women infected with these bacteria, there have been such findings as cervicitis, pelvic inflammatory disease (PID), preterm delivery, spontaneous abortion, and infertility, with an approximately two-fold increase in the risk for these outcomes in such women [36]. The prevalence of MG in developed countries with higher Human Development Index (HDI) was 1.3–1.6% but the prevalence in developing countries with lower HDI was 3.9–5.2% [37]. The figures show that the prevalence is lower in developed countries compared to developing countries. Despite this obvious trend, the availability of facilities and personnel for testing, treatment, and prevention of these diseases is limited in developing countries.

This organism grows slowly in the culture medium in the laboratory. It can take up to 6 months to culture this organism and this is mostly limited to research for now. The Food and Drug Administration (FDA) in the USA has approved the use of NAAT for detection of the MG from urine, urethral, penile meatal, endocervical, and vaginal swab samples. The needed molecular tests for quinolone and macrolide-resistant testing are not available commercially. Men with recurrent nongonococcal urethritis (NGU) should be tested for MG using an FDA-cleared NAAT. If resistance testing is available, it should be performed, and the results used to guide therapy. Women with recurrent cervicitis should be tested for MG, and testing should be considered among women with pelvic inflammatory disease (PID) [1]. Testing should be accompanied by resistance testing, if available. Screening of asymptomatic MG infection among women and men or extragenital testing for MG is not recommended. In clinical practice, if testing is unavailable, MG should be suspected in cases of persistent or recurrent urethritis or cervicitis and considered for PID [1]. The laboratory confirmation of this organism is tedious and also not available for most patients in developing countries for the same reasons already adduced above.

Treatment: Based on CDC recommendations, if the organism is macrolide sensitive: oral Doxycycline 100 mg twice daily for 7 days, followed by oral Azithromycin 1 g initial dose, followed by 500 mg once daily for 3 additional days (2.5 g total). If macrolide-resistant oral Doxycycline 100 mg daily for 7 days followed by oral moxifloxacin 400 mg once daily for 7 days should be administered.

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3. Peculiarities of bacterial STI treatment in resource-limited settings

The above treatment recommendations for bacterial sexually transmitted infections are mostly practicable in developed societies. Some health facilities in the resource-limited settings are able to promptly carry out etiologic diagnosis of bacterial STIs and as such the above guidelines may be very beneficial in the management of patients who seek care in such centers. Nevertheless, there is predominantly a paucity of trained personnel, equipment, hospitals, and even access road to go to the existing health facilities in most parts of these resource-limited countries. The functional tertiary and secondary health facilities in most developing countries are situated in a few cities in such countries. The communities are thus left without adequate coverage by skilled personnel. The diagnosis of STIs in such areas is clinical (based on symptoms and signs) and mostly inaccurate due to a lack of trained personnel and equipment. Consequently, the treatment for bacterial STIs is mostly based on WHO syndromic case management. This entails treatment with a combination of broad-spectrum antibiotics without etiologic diagnosis. Usually, a combination of antibiotics from different classes is employed in the treatment of suspected cases of bacterial STIs [20]. These antibiotics are mostly gotten over the counter in these resource-limited settings. Even so, these disease conditions are treated by patent medicine dealers (who do not have conventional training in health and medicine-related matters) and other health personnel who are not trained and/or licensed for drug prescription/patient treatment. These treatments in resource-limited communities are usually inadequate due to inappropriate choice of drugs, under-dosing, and poor compliance to the prescribed drug regimen occasioned by poverty and ignorance. This results in bacterial antibiotic resistance, immediate and long-term avoidable sequelae of the infections, transmission to other sex partners, and endemicity of such infections in the affected communities.

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4. Retesting posttreatment to diagnose recurrent infections

Population-based prevention may be improved through the retesting and diagnosis of chlamydia and gonorrhea 3 months after the initial diagnosis [38, 39]. Patients who were diagnosed with chlamydia or gonorrhea need to be retested 3 months after treatment to exclude recurrent infection and confirm treatment success. The fact that there could be a false diagnosis based only on signs and symptoms, further reemphasizes why retesting after the treatment is important. Also, it is recommended that any patient who had a diagnosis and treatment of syphilis need to have follow-up serologic syphilis screening. These recommendations are difficult to implement in resource-limited settings because most patients patronize the nonregulated private sector where services are mostly provided by untrained personnel.

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5. Prevention of the STIs in resource-limited settings

In view of the enormous burden of STIs, especially in developing countries, and the paucity of resources for their testing and treatment, prevention is very cost-effective and more reliable in reducing the morbidity and mortality associated with STIs. Firstly, knowing one’s STI status will aid one protect oneself and also protect one’s sexual partner from the infection and its sequelae. Many STIs can be easily diagnosed and treated; hence, concurrent treatment of sexual partners who have STIs has been found pivotal in the reduction of new cases and recurrence of the disease. Avoidance of multiple sexual partners is also key to the prevention of STIs in the resource-limited settings. Empowerment of the girl child through skills acquisition or formal education is another very important strategy. Use of barrier methods during sex, for example, condoms have been found to not only protect against STIs but also prevent unwanted pregnancies and their sequelae. Individuals who have allergies to latex condoms can resort to the use of synthetic non-latex condoms. Other multipurpose prevention technologies (for the prevention of STIs and pregnancy) are still at the level of research [1].

Pre-exposure prophylaxis and postexposure prophylaxis for STIs have been shown to aid its prevention. Oral Azithromycin 1 g every month has been found to bring down the number of new cases of both NG and CT but did not reduce the number of new cases of HIV [40]. Due to poverty and ignorance, prophylaxis is difficult in resource-limited settings. Most developing societies are male-dominated and women are unable to negotiate sex due to poverty, ignorance, and hunger and so, the use of barrier methods or even keeping one sex partner is difficult. Furthermore, implementation of some of these primary preventive measures in developing countries are difficult due to communal crisis/wars/terrorism (with citizens living in inhumane conditions in internally displaced person camps), poor leadership and lack of facilities to aid individuals adopt these measures. The females in these communities are not only unable to negotiate sex but are forced into sexual activities and have no authority/agency of government to report or run to for protection. And so, to effectively prevent STIs in resource-limited countries, these issues must be addressed, especially with the aid of technologically advanced/developed countries. Unless we all are protected, none of us is protected.

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6. Special considerations

6.1 Detection of bacterial sexually transmitted infection in pregnancy

The transmission of infections sexually during the intrauterine or perinatal period is associated with enormous consequences for both the woman and her fetus(es) or the newborn baby(ies) and even her partner. Sexually transmitted infections (STI) are risk factors for a number of adverse pregnancy outcomes, including spontaneous abortion, stillbirth, prematurity, low birth weight (LBW), postpartum endometritis, and various sequelae in surviving neonates. Preterm birth and low birth weight (LBW) are major determinants of infant morbidity and mortality, especially in developing countries, where neonatal intensive care facilities are often unavailable. In a study in Kenya, the incidence of LBW was 7.5%, and the perinatal mortality in LBW babies was 222 per 1000 live births [41]. STIs are believed to be of particular importance in determining pregnancy outcomes in the developing world because the prevalence of infection is so high [42]. During pregnancy, the gravidae and their partners should discuss with the health workers on the STIs and the risks of intrauterine/perinatal transmission to the fetus/neonate. They should also have access to the screening and treatment options available in their locality. In Nigeria and some other resource-limited settings, the only bacterial STI that has a routine screening at the first antenatal visit is syphilis using the VDRL test. Women with positive results from the VDRL test undergo the confirmatory tests (see the section on TP) and receive appropriate treatment as necessary. In many instances, the only available test in the rural and suburban areas of these developing countries is the VDRL or not at all. And so, treatment is given based on the positive VDRL (non-treponemal) test. The treatment may be inadequate based on wrong drug choice or inappropriate dosage of the correct drugs. Many women do not get tested and do not receive treatment for STIs because they receive care from unskilled personnel outside the health center settings.

6.2 Detection of bacterial sexually transmitted infection among adolescents

Adolescents are at an increased risk of STIs. The risk factors for STIs during the adolescent age are as follows: (a) having multiple sex partners, (b) having sequential sex partnerships of limited duration or concurrent partnerships, (c) none compliance to use barrier protection consistently and correctly, (d) low socioeconomic status, and (e) presence of multiple obstacles to health care access [43, 44]. In some developed countries, such as the United States of America, adolescents are allowed by law to seek STD services without the consent of their parents or caregivers. Their health insurance specifies the care needed by the adolescent and such care is provided as necessary [3]. In most developing countries, such as Nigeria, there is no law protecting adolescents with respect to STD services as parents or caregivers must consent before most adolescents can access care in those countries [45]. This is because health insurance is not available to most adolescents and their parents or caregivers pay out of pocket for their health care and there are no laws guiding the adolescents’ health care. Obviously, the majority of adolescents who contract STD(s) have to pay out of their pocket to receive care and they do not have the money. The few that have health insurance got it through their parents and the parents must give permission before such adolescents can access care. This compromises the confidentiality needed for the cooperation of adolescents in STI treatment [3]. These now predispose the adolescents to seek care from the alternative unregulated private sector mainly dominated by the herbalists in those resource-limited communities.

6.3 Use of antibiotics during pregnancy

Discoloration of the teeth is one of the dreaded complications of the use of Doxycycline in pregnancy, but the risk is not properly defined. Doxycycline is safe during breastfeeding [25]. Patients with glucose-6-phosphate dehydrogenase deficiency may have neonates who suffer neonatal jaundice/neonatal kernicterus due to sulfonamide use in pregnancy. And so, sulfonamides should be avoided in the third trimester and during breastfeeding [45]. Macrolide regimen (Erythromycin or Azithromycin) is the best suitable regimen of antibiotic treatment for pregnant and lactating women with granuloma inguinale. And so, pregnancy must be ruled out before the use of antibiotics in a sexually active woman of reproductive age. Again, this is not obtainable in most resource-limited settings due to a lack of trained personnel, ignorance, and poverty. In most developing countries, antibiotics can be bought over-the-counter, and sexually active women will usually go to the untrained personnel in the markets to procure antibiotics for treatment without prior doctors’ prescription/evaluation.

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7. Conclusions

The World Health Organization (WHO) syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed in the resource-limited settings to address asymptomatic STIs. Point-of-Care Tests (POCTs) that are accurate, rapid, simple, and affordable are urgently needed in resource-constrained settings to support the uptake of etiological diagnosis and treatment. Continued advocacy and support/aid for these countries and their communities will ensure the success of an updated WHO syndromic management guideline and help reduce the burden and adverse effects of STIs.

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Acknowledgments

We are grateful to our families, friends, and colleagues, who assisted in no small way in ensuring the completion of this book chapter.

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Written By

Simeon Chijioke Amadi, Chidiebere Nwakamma Ononuju, Joseph Okoeguale, Anthony Chukwuemeka Olobuah and Williams Amebeobari Mube

Submitted: September 16th, 2022 Reviewed: January 9th, 2023 Published: March 8th, 2023