Infections generally remain localised to the anogenital and pharyngeal mucosae, but may spread to the upper genital infection to cause epididymitis in men (1%) or pelvic inflammatory disease (PID) in women (approx. 3%)

Much less common are disseminated infections (DGI) These include: septicaemia, arthritis, dermatitis, endocarditis and meningitis.

If the infection was acquired in the UK the first line treatment is: Amoxycillin 3g + probenicid 1g orally as a single dose. Imported infection should be assumed to be Penicillin resistant when treated before antimicrobial sensitivity is known: Ciprofloxacin 500mg orally as a single dose.

Alternative regimens not usually used in the UK but valuable against imported infections from SE Asia are: Ceftriaxone 250mg im as a single dose, Spectinomycin 2g i/m as a single dose.

Symptomatic improvement with treatment does not guarantee eradication of GC. There should be at least one test of cure (which in women should include the rectum). And, the final test of cure should take place 48-72 hours after the last antibiotic therapy.

Patients with uncomplicated infection should be seen at 24-48hrs for a TOC which will pick up treatment failures.

All patients should see the health adviser and contacts should be traced for 3 months or to the last sexual partner (whichever is longer) In some situations epidemiological treatment may be given to named contacts where there is a likelihood of poor compliance, risk of complication or infection of others.

Herpes can only be transmitted when an already infected individual is shedding the virus which happens sporadically and not necessarily in association with symptoms.

It is transmitted through close physical contact, genital-genital and oro-genital. Infection is acquired through intact mucous membrane or when the virus comes in contact with damaged keratinised epithelium.

A minority of people will develop a severe primary attack or first clinical episode within 2-12 weeks of acquisition of the virus. It may not be possible to distinguish between a so-called primary attack, which implies new infection or first clinical episode where the patient has acquired genital herpes at some time in the past, but only recently developed symptoms.

Some develop minor lesions (blisters) only and 70-80% of people have no symptoms at all. Primary infection usually more severe in women. Febrile illness (prodrome) lasting 5-7 days Dysuria, urinary frequency, painful inguinal, lymphadenopathy, tingling neuropathic pain, genital blisters, ulcers, fissures.

An untreated episode may last 3 weeks or more.

Recurrent episodes are usually mild and symptoms may include neuropathic prodrome with tingling and burning, erythema, blisters, ulcers.

Usually only on the first episode and risk reduced with antiviral therapy. Include acute urinary retention, which occurs predominantly in women Constipation which may be a risk with first episode of perianal infection. Aseptic meningitis.

Herpes in pregnancy is usually only significant if the patient is experiencing a primary attack. In early pregnancy the usual outcome is either an unaffected foetus or a miscarriage. At term there is a 50% risk of neonatal transmission. In women with a history of genital herpes, the risk of transmission is in the range of 0-4%. However most neonatal herpes occurs in infants whose mothers have no history of genital herpes.

Treatment for a primary or first episode if within 5 days of lesions developing or beyond 5 days if new lesions are developing commence treatment immediately. Valaciclovir 500mg bd for 5 days. Analgesics, laxatives, advice about urinating, lignocaine gel.

A dilute saline solution (eg 1 tsp salt in a tumbler of warm water/1teacup of salt to medium bath) to relieve symptoms, reduce secondary infection and promote healing.

Counselling is of the utmost importance, may need to be repeated subsequently

Causative organism hepatitis B virus (small DNA virus). Endemic worldwide with high carriage rates up to 20% particularly in South and South east Asia, but also in Southern Europe, central and South America, Africa and Eastern Europe. In the UK carriage varies from 0.01-0.04% in blood donors to > 1% in IVDU and gay men.

About 10-100 times more infectious than HIVSexual transmission occurs in unvaccinated gay men and correlates with multiple partners, unprotected anal sex and also or anal sex (rimming). Transmission also occurs after heterosexual contact e.g. 18% infection rate for regular partners of patients with acute hepatitis B. Sex workers are also considered high risk.

Other routes of transmission areVertical transmission (mother to child) Blood, blood products, drug users sharing needles and equipment and occupational needlestick injuries. Infected mothers can continue to breastfeed.

Incubation period of 40-160 days. Virtually all infants and children have asymptomatic acute infection. Asymptomatic infection is also found in 10-50% of adults in the acute phase and is especially likely In those who are co infected with HIV. Women tend to have more severe disease than men. Less than 1% of patients will get fulminant hepatitis 5-10% will develop chronic infection but the rate is higher in those with asymptomatic acute infection and those with HIV co infection.

Almost all of infants born to Hep B positive mothers will become chronic carriers unless immunised. 20-30% of this group will go on to develop chronic hepatitis, cirrhosis or carcinoma of the liver. Carriers with the e antigen have a higher risk of developing complications.

Patients who present acutely in the primary care setting can be monitored and usually do not require hospital admission. In view of the possibility of chronic infection serology should be repeated after 6 months even if the LFT s are normal.

Patients who develop e antibodies but remain HbsAg positive should have annual liver function tests and referral considered of abnormality develops. Persistent HBeAg Carriers should be referred.

Hepatitis B testing should be considered in:
Gay men CSWsIVDU.
HIV positive patients.
Sexual assault victims.
People from countries where Hep B is common.
Needlestick injuries.
Sexual partners of positive or high risk patients.

If non immune vaccinations should be offered to non immune patients in most of the above groups. The main exceptions are those who have been sexually assaulted and those born in countries of high endemicity but not at continuing risk.

Vaccination schedule is 0 mths, 1 mnth and 6 mths

Accelerated vaccination is 0 mths, 1 mth and 3 mths. Test for antibody response at 8-12.