1- STI's Flashcards
What are the 5 P’s of taking a sexual history?
Partners, Practices, Prevention of pregnancy, Protection from STIs, Past hx of STIs
What is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora?
Vaginitis
What are the sxs of vaginitis? (3)
Vaginal discharge, odor, pruritus/ discomfort
What are the most common causes of vaginitis? (3)
Candida vulvovaginitis, bacterial vaginosis, trichomoniasis
Vulvovaginal candidiasis (VVC) is aka what?
Yeast infection
Is vulvovaginal candidiasis (VVC) considered an STI?
No
What is the causative organism of vulvovaginal candidiasis (VVC)?
C. albicans (can also be other Candida species or yeast)
What is the dominant clinical feature of vulvovaginal candidiasis (VVC)?
Pruritus
Pt presents with vulvar soreness/ burning/ irritation, dysuria, dyspareunia, abn vaginal discharge and pruritus. What should you be concerned for?
Vulvovaginal candidiasis (VVC)
Upon PE you note erythema/ edema of the vulva and vaginal mucosa, discharge, and fissures/ excoriations. What should you be concerned for?
Vulvovaginal candidiasis (VVC)
Vaginal discharge that appears white, thick and curd-like (clumpy) and is adherent to vaginal walls is concerning for what?
Vulvovaginal candidiasis (VVC)
Aside from clinically, how is vulvovaginal candidiasis (VVC) diagnosed?
Wet mount (10% KOH)
On wet mount you note budding yeast, hyphae or pseudohyphae and measure a normal vaginal pH (<4.5). What should you be concerned for?
Vulvovaginal candidiasis (VVC)
When is treatment indicated for vulvovaginal candidiasis (VVC)?
Relief of sxs
What are the criteria for determining an uncomplicated infection for vulvovaginal candidiasis (VVC)? (sx severity, frequency, organism, host)
Sx severity- mild to mod, frequency- sporadic/ infrequent, organism- Candida albicans, host- healthy, non-preg, immunocompetent
What are the criteria for determining a complicated infection for vulvovaginal candidiasis (VVC)? (sx severity, frequency, organism, host)
Sx severity- severe, frequency- ≥ 4x/year, organism- nonalbicans, host- preg, poorly controlled DM, IMC, debilitation
What is the treatment for uncomplicated vulvovaginal candidiasis (VVC)?
Oral fluconazole 150mg PO x 1 OR topical azole- short course (1-3 days)
What is the treatment for complicated vulvovaginal candidiasis (VVC)?
Oral fluconazole 150mg PO q 72hrs x 2-3 doses OR topical azole- longer course (7-14 days)
When is maintenance treatment considered for vulvovaginal candidiasis (VVC)?
Recurrence
If a pt with vulvovaginal candidiasis (VVC) is pregnant, what is the treatment?
Topical (clotrimazole or miconazole x 7 days)
Is it recommended to treat the sexual partner of a pt infected with vulvovaginal candidiasis (VVC)?
No (but may benefit from tx if sx)
Is bacterial vaginosis considered an STI?
No
What is the most common cause of vaginal discharge in women of childbearing age?
Bacterial vaginosis
What is defined as the replacement of “healthy” vaginal flora with overgrowth of anaerobic bacteria?
Bacterial vaginosis
What is the most common causative organism of bacterial vaginosis (usually polymicrobial)?
Gardnerella vaginalis
Pt presents with vaginal discharge/ odor and occasional irritation. On PE you note a thin, off-white discharge and a “fishy odor”. What should you be concerned for?
Bacterial vaginosis (although often asx)
How is bacterial vaginosis most commonly diagnosed?
Clinical criteria (Amsel’s dx criteria)
What are Amsel’s dx criteria? (used for bacterial vaginosis) (4)
- thin, white, homogeneous discharge, 2. clue cells on saline wet mount, 3. vaginal pH > 4.5, 4. + whiff test (fishy odor when KOH added) (must have 3)
When should a pt with bacterial vaginosis be treated?
If sx (including sx if pregnant)
Is it recommended to treat the sexual partner of a pt infected with bacterial vaginosis?
No (not routinely)
What should be avoided while taking Metronidazole?
EtOH
What is the recommended treatment regimen for bacterial vaginosis?
Metronidazole 500mg PO BID x 7 days
What should be offered to all women diagnosed with bacterial vaginosis?
Testing for HIV and other STIs
What are the consequences of infection with bacterial vaginosis? (3)
↑ risk for preterm delivery, HIV, other STIs
BV is more common among women with what other condition? (independent risk factor)
PID
What is the most common nonviral STI worldwide?
Trichomoniasis (causative agent = trichomonas vaginalis)
Are most pts with trichomoniasis sx or asx?
Most have minimal or no sx
Coexistence is common between T. vaginalis and what other pathogens?
BV pathogens
Pt presents with vaginal discharge that is purulent, malodorous, frothy, and thin +/- vulvar irritation and postcoital bleeding. What should you be concerned for?
Trichomoniasis
On PE you note punctate hemorrhages on vagina and cervix/ “strawberry cervix” as well as a vaginal pH > 4.5. What should you be concerned for?
Trichomoniasis
What is the gold standard for dx of trichomoniasis?
NAAT
If you perform a wet mount (saline) for suspected trichomoniasis, what might you see?
Motile organisms
If trichomoniasis is left untreated, what might it lead to?
Urethritis or cystitis
What are the consequences of a trichomoniasis infection? (5)
PID, cervical neoplasia, infertility, HIV, pregnancy complications
What are the specific complications of pregnancy a/w trichomoniasis? (3)
Increased risk of premature membrane rupture, preterm delivery, low birth weight
When is treatment indicated for trichomoniasis?
Asx and sx pts
Is it recommended to treat the sexual partner of a pt infected with trichomoniasis?
Yes (Expedited Partner Therapy (EPT) available)
What is the recommended treatment regimen for trichomoniasis?
Metronidazole 2g (single dose) (same if pregnant)
What pt edu should be provided for trichomoniasis? (2)
Abstain from sex until 7 days after tx, test for other STIs (HIV included)
When should repeat testing (for reinfection not a test of cure) be performed for a pt with trichomoniasis?
3 months following initial tx
What populations should be screened for T. vaginalis? (3)
All HIV-infected women (annually and at prenatal visit), high prevalence settings, high risk pts
What is the most commonly reported bacterial infection in the US?
Chlamydia
Majority of women with chlamydia are sx or asx?
Asx
Patients with chlamydia are frequently co-infected with what?
Gonorrhea
Sx related to cervicitis such as change in vaginal discharge and intermenstrual or postcoital bleeding are associated with what conditions?
Chlamydia and gonorrhea
Sx related to urethritis such as dysuria and urinary frequency are associated with what conditions?
Chlamydia and gonorrhea
PE of pt with chamlydia or gonorrhea will show what?
Cervicitis- mucupurulent endocervical discharge, cervix-friability, erythema, edema
What is the diagnostic test of choice for both chamydia and gonorrhea?
NAAT (vaginal swab preferred)
The following are complications of what conditions? PID, ectopic pregnancy, infertility, chronic pelvic pain
Chlamydia and gonorrhea
Increased risk for premature rupture of membranes and preterm delivery are complications of pregnancy with what condition?
Chlamydia
Transmission of chlamyida to the neonate during delivery typically manifests as what condition?
Conjunctivitis
Transmission of gonorrhea to the neonate during delivery typically manifests as what condition?
Ophthalmia neonatorum
What is the treatment for a non-pregnant pt with chlamydia?
Azithro 1gm PO single dose OR doxy 100mg PO BID x 7 days (treat pt and sex partner)
What is the treatment for a pregnant women with chlamydia?
Azithro (avoid doxy), test of cure recommended
How long should a pt infected with chlamydia avoid intercourse?
Until tx is completed and sx resolved, 7 days after single dose or completion of 7 day regimen
A pt with chlamydia or gonorrhea should be tested for what?
Other STIs
Repeat testing for reinfection with chlamydia or gonorrhea should be performed when?
3 months
Who should be screened for chlamydia and gonorrhea?
Annual screening of all sexually active women < 25 yo and older women with RFs
The following are RFs for what? New/ multiple sex partners, sex partner recently treated with STI, no/ inconsistent condom use, hx of STI, exchange sex for drugs/ money
RFs of chlamydia and gonorrhea for older women (should be screened anually)
What is the 2nd most commonly reported communicable disease in the US?
Gonorrhea
There is increasing concern for what with gonorrhea?
Antimicrobial resistance
What dx study should be performed when antibiotic resistance is suspected for gonorrhea?
Culture
What complication is specific to gonorrhea?
Disseminated gonococcal infection (DGI)
Risk of preterm birth, low birth weight, and infection are pregnancy complications associated with what condition?
Gonorrhea
What is the treatment for a both pregnant and non-pregnant pt with gonorrhea?
Ceftriaxone 250mg IM PLUS Azithro 1gm PO single dose (treat pt and sex partner)
When is a test of cure recommended for a pregnant pt with gonorrhea?
If alternative tx regimen used (NOT Ceftriaxone 250mg IM PLUS Azithro 1gm PO single dose)
How long should a pt infected with gonorrhea avoid intercourse?
7 days after tx and until sx resolved
What condition is defined as an infection of the upper genital track (ascending infection)?
Pelvic inflammatory disease (PID)
The majority of PID infections are associated with what 2 pathogens?
N. gonorrhoeae or C. trachomatis
What disease represents a spectrum of infection and can present as any combination of endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/ or tubo-ovarian abscess?
PID
Women with a hx of PID may experience what future complication?
Difficulties getting pregnant
Who is at the highest risk of getting PID?
Women with multiple partners
Pt with an IUD is at greatest risk for PID when?
First 3 weeks after insertion
Pts with a disruption of the normal vaginal flora (ex. BV) are at higher risk for what condition?
PID
Although PID can present as a wide spectrum, what presentation is typical?
Acute, sx, over several days
PID sxs can range from mild, vague pelvic sxs to tubo-ovarian abscess, sepsis, and possible perihepatitis, which is aka?
Fitz-Hugh Curtis Syndrome
What is inflammation of the liver capsule and adjacent peritoneal surfaces?
Perihepatitis (Fitz-Hugh Curtis Syndrome)
Pt with infection suspicious for PID presents with RUQ pain and “violin string” adhesions of the liver. What are you concerned for?
Perihepatitis (Fitz-Hugh Curtis Syndrome)
Subclinical PID presents with sx not severe enough to present for care but severe enough to produce what?
Significant sequelae (tubal factor infertility)
Pt presents with lower abd pain (onset during/ shortly after menses), abn vaginal discharge, abn uterine bleeding, dyspareunia, and fever. What should you be concerned for?
Acute sx PID
On PE you note abd tenderness (lower quadrants), Chandelier sign, and purulent endocervical/ vaginal discharge. What should you be concerned for?
Acute sx PID
Uterine, adnexal, and/ or cervical motion tenderness is what? (PID)
Chandelier sign
What tests should be ordered for a pt with suspected PID? (5)
Pregnancy test, WBCs in vaginal discharge, NAATs, HIV screening, pelvic US (if uncertain)
What 3 things lead to a presumptive dx of PID?
Sexually active young female, pelvic/ lower abd pain, evidence of cervical motion/ uterine/ OR adnexal tenderness
When should treatment for PID be initiated?
As soon as the presumptive dx is made
What is the treatment of PID if outpt (mild-mod)?
Ceftriaxone 250mg IM single dose PLUS doxy 100mg BID x 14 days (w/ or w/o metronidazole 500mg PO BID x 14 days)
What is essential in the treatment/ management of a pt with PID?
Close f/u (48-72 hrs)
What should you if: pt with PID + pregnancy, lack of response or tolerance to oral meds, concern for nonadherence to therapy, inability to take oral meds, severe clinical illness, complicated PID w/ pelvic abscess, or surgical EMs cannot be excluded?
Hospitalize
What are common complications of PID? (4)
Hydrosalpinx, infertility, risk of ectopic pregnancy, chronic pelvic pain
How long should a pt with PID abstain from sexual intercourse?
Therapy completed, sx resolved, partners tx
Repeat testing after PID should be completed when?
3 months
Human papillomavirus (HPV) is aka?
Condyloma acuminata (aka anogenital warts)
What is the most common STI in the world?
HPV
How is HPV transmitted?
Contact w infected skin or mucosa (sexual activity greatest RF)
What types of HPV are detected in most cases?
6 and 11 (low oncogenic potential)
What types of HPV are high-risk and have oncogenic potential?
16 and 18 (cause most cervical (and other) cancers and precancers)
Pt who is asx or c/o pruritis w soft, flesh-colored, smooth or plaque like, cauliflower like lesions in the anogenital area is concerning for what?
Condyloma acuminata (aka anogenital warts)
How is condyloma acuminata (HPV) diagnosed?
Visualize warts on PE (bx if dx uncertain)
What are the 3 main treatment options for condyloma acuminata?
Cyto-destructive, immune-mediated, surgical
What is the most common cyto-destructive treatment option for HPV?
Podofilox
What are the most common immune-mediated treatment options for HPV?
Imiquimod, Sinecatechins
Cryotherapy, laser, electrocautery, excision are all surgical tx options for what?
HPV
What is the greatest form of prevention against HPV?
Vaccine (also condoms, limit sex partners)
Does treatment of genital warts cure the virus itself? What effect does this have?
NO, recurrence common (duration of viral persistence unknown)
What is important background info for genital herpes?
Chronic, life-long viral infection
What are the causative organisms of genital herpes?
2 HSV serotypes (HSV-1 and HSV-2)
Most cases of recurrent genital herpes are caused by what?
HSV-2
HSV is transmitted through herpes lesions, mucosal surfaces, genital secretions, or oral secretions and is typically sx or asx?
Asx
Majority of HSV transmission occurs during what viral period?
Asx HSV shedding
What is a primary genital herpes infection?
Infection without preexisting antibodies to either HSV-1 or HSV-2
What is a non-primary first episode of genital herpes?
Acquisition of genital HSV-2 with preexisting antibodies to HSV-1 (and visa-versa)
What is a recurrent infection with genital herpes?
Reactivation of genital HSV
What type of infection with genital herpes is of longer duration, increased viral shedding, systemic sxs, and sxs lasting 2-4 weeks if untreated?
Primary
How does a pt present with a non-primary first episode of genital herpes? (general, not specific sxs)
Sxs that are usually milder than primary (fewer lesions and less systemic sxs)
How does a pt present with a recurrent infection of genital herpes? (general, not specific sxs)
Less severe and shorter in duration (than both primary and non-primary first episode)
Pt presents with painful genital ulcers, dysuria, fever, tender inguinal lymphadenopathy, and HA. What are you concerned for?
Primary infection with genital herpes (although can be mild or asx)
What is the average incubation period after exposure to genital herpes?
2-12 days
Pt presents with prodromal sxs such as tingling, itching, and burning but nothing on PE. What are you concerned for?
Recurrent infection
What is the preferred dx test of choice for genital herpes?
Virologic tests (viral culture or PCR)
What is the benefit/ limitation of performing serologic tests if suspicious for genital herpes?
Detects HSV-1 and HSV-2 specific antibodies, limitations = false negative if in early stage
Presence of type-specific HSV-2 antibody implies what?
Anogenital infection
Presence of HSV-1 antibody alone can be consistent with what?
Either anogenital or orolabial infection
Is screening for HSV-1 and HSV-2 in the general population indicated?
No
What meds are used in the tx of genital herpes?
Valacyclovir, famciclovir, or acyclovir
What is the tx regimen for genital herpes if first episode?
7-10 day regimens, start w/i 72 hours
What is the tx regimen for genital herpes if episodic tx for recurrent outbreaks?
1-5 day regimens
What is the tx regimen for genital herpes for suppression? (reduces frequency of recurrences and risk of transmission)
1x daily - BID dosing (periodically reassess need)
What is important in the counseling/ pt edu for genital herpes?
Counsel to prevent sexual transmission, edu for potential for clinical recurrence, edu about vertical transmission, test for other STIs
