16: Lower GT infections Flashcards
Syphilis is screened for with ? and confirmed with either ?
RPR and VDRL tests
fluorescent treponemal antibody absorption (FTA-ABS) test and the Treponema pallidum particle agglutination assay (TPPA).
drug of choice for syphilis
Benzathine penicillin 2.4 million units IM one time
late latent: 2.4 million units IM weekly for 3 weeks
Up to 80% of newly acquired genital herpes infections are caused by ?
HSV-1
Primary herpes infection classically appears as ?
multiple vesicles that develop into painful ulcers.
Treatment of genital herpes ?
usually palliative, although acyclovir can reduce the length of primary infection and suppressive therapy may decrease the number of recurrences.
Chancroid presentation
painful genital ulcer and usually concomitant LAD, but can be difficult to diagnose via Gs/Cx
- caused by Haemophilus ducreyi
- cofactor for HIV transmission, coinf. w. T. pallidum or HSV
Chancroid tx
single doses of PO azithromycin 1g or IM ceftriaxone 250mg
- or ciprofloxacin 500 mg PO BID x3, or erythromycin 500 mg 4x/day x7
- tx partner
Bacterial vaginosis is polymicrobial but usually attributed to ?
treatment ?
Gardnerella, and the first-line treatment is metronidazole (Flagyl) 500 mg BID x7
-alt: clindamycin 300 mg BID x7
75% of sexual partners of those with Trichomonas will also be colonized and should be presumptively treated with ?
first-line treatment of metronidazole 2 g orally single dose.
sequela of G/C infection
cervicitis, PID, TOA, and Bartholin abscess
Treatment for uncomplicated gonorrhea infections
ceftriaxone 125 mg IM or cefixime 400 mg orally single dose.
-also include azithromycin 1 g orally once to treat likely concomitant chlamydial infections. (or doxycycline 100 mg BID x7 or erythromycin 500mg PO 4x/day x7)
incidence and chlamydia and G/C infections
incidence of gonococcal infections has remained stable, whereas the incidence of chlamydial infections has increased.
how often is chlamydia asymptomatic?
treatment?
Up to 70% of chlamydial infections are entirely asymptomatic
-one-time 1 g oral dose of azithromycin
Approximately 80% to 85% of UTIs are caused by ?
E. coli and other organisms that colonize the GI tract.
- Staphylococcus saprophyticus, Proteus mirabilis, Klebsiella pneumoniae, and Enterococcus
- urethritis: Chlamydia trachomatis and Neisseria gonorrhoeae, HSV
In patients with symptoms of cystitis, but a negative culture, the diagnosis of ?should be entertained.
overactive bladder or painful bladder syndrome (interstitial cystitis)
treatment for uncomplicated UTI
TMP-SMX, nitrofurantoin, or a fluoroquinolone for 3 to 7 days
-Ampicillin or cephalexin has also been used; however, more recently, beta-lactams have become less effective in the treatment of uncomplicated UTIs
treatment of pyelonephritis
typically treated inpatient with IV antibiotics. Outpatient management for reliable pts
-14-day antimicrobial therapy
vulvitis typically caused by ? presents with ?
treatment ?
candidiasis, presents with vulvar erythema, pruritus, and small satellite lesions
topical or systemic antifungals
-rule out malignancy
-may be due to allergic reaction, chemical or fabric irritants, and vulvar dystrophies
conditions other than infections that can lead to vulvar ulcerations
Crohn’s: linear “knife cut” vulvar ulcers as its first manifestation, preceding GI or other systemic manifestations by months to years. Behçet disease: tender and highly destructive vulvar lesions that often cause fenestrations in the labia and extensive scarring.
T. pallidum most likely enters the body through ?
minute abrasions in the skin or mucosal surface and replicates locally. Initial lesions therefore commonly occur on the vulva, vagina, cervix, anus, nipples, or lips.
primary syphilis chancre
painless, red, round, firm ulcer approximately 1 cm in size with raised edges
-develops about 3 weeks after inoculation
secondary syphilis
develops approximately 3 weeks after inoculation
-flu-like symptoms, maculopapular rash may appear on the palms/soles
+/- meningitis, osteitis, nephritis, or hepatitis
-lesions respond spontaneously
early vs late syphilis based on time of initial symptoms
early (acquired <1 year)
late (acquired >1 year)
tertiary syphilis
granulomas (gummas) of the skin and bones; cardiovascular syphilis with aortitis; and neurosyphilis with meningovascular disease, paresis, and tabes dorsalis.
syphilis tx alternatives for PCN-allergic pts
doxycycline 100 mg orally twice a day for 14 days, tetracycline 500 mg orally four times a day for 14 days, ceftriaxone 1 g IM or IV daily for 10 to 14 days, or azithromycin 2 g single oral dose
-desensitize pregnant pts to PCN
Neurosyphilis tx
- requires IV penicillin
- aqueous crystalline penicillin G, 3 to 4 million units IV q4h x10-14
- alternatives: procaine penicillin 2.4 million units IM once daily plus probenecid 500 mg orally 4x/day both for x10-14
Syphilis Treatment success can be verified by
following RPR or VDRL titers at 6, 12, and 24 months. Titers should decrease 4x by 6 months and become nonreactive by 12 to 24 months after completion of treatment.
Jarisch-Herxheimer reaction
caused by ?
fever, chills, headache, myalgia, malaise, pharyngitis, rash, and other symptoms that usually occur within the first 24 hours (most 1st 8 hours) after any therapy for syphilis (up to 90% of patients with secondary syphilis)
-injured/dead organisms release endotoxins into the circulation marked by systemic release of cytokines.
primary HSV infection presentation
flulike symptoms including malaise, myalgias, nausea, diarrhea, and fever. Vulvar burning and pruritus precede the multiple vesicles that appear next and usually remain intact for 24 to 36 hours before evolving into painful genital ulcers
recurrent HSV episodes can occur as frequently as ?
when does shedding occur?
1-6x per year
-subclinical or asymptomatic shedding can occur and is more frequent during the first 6 months after acquisition and immediately before or after recurrent outbreaks.
pregnant women should have vaginal examinations around the time of delivery to check for HSV, if lesions?
C-section
HSV diagnosis
typically clinical + sexual history
- gold standard: viral cultures (low sn)
- Tzanck smear (low sn/sp)
- type-specific antibodies for HSV-1 and HSV-2 IgG
primary HSV tx
acyclovir 200 mg five times per day, acyclovir 400 mg three times per day, famciclovir 250 mg three times per day, or valacyclovir 1 g twice per day orally for 7 to 10 days
-reduce length and shedding
treatment of severe HSV infections, such as those that occur in immunocompromised patients
IV acyclovir should be used at a dose of 5 to 10 mg/kg q8hs
Tx of recurrent HSV
Oral acyclovir 400 mg three times daily or 800 mg twice daily for 5 days
lymphogranuloma venereum (LGV) caused by ? primary stage?
C. trachomatis L-serotypes (L1, L2, or L3)
-primary: local lesion that may be either a papule or a shallow ulcer, and is often painless, transient, and can go unnoticed
LGV second stage
(inguinal syndrome) occurs 2-6 wksafter the primary lesion and is characterized by painful inflammation and enlargement of the inguinal nodes (typically unilateral). Systemic manifestations include fever, headaches, malaise, and anorexia
? can result in the tertiary stage of LGV
characterized by ?
Rectal exposure
(anogenital syndrome)
proctocolitis, rectal stricture, rectovaginal fistula, and elephantiasis (lymphatic filariasis). Initially, an anal pruritus will develop with a concomitant mucous rectal discharge
LGV diagnosis
clinical suspicion, genital and lymph node specimens may be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection.
LGV treatment
doxycycline 100 mg PO BID or erythromycin 500 mg orally four times a day for 21 days
nonulcerative lesions
Condyloma acuminata (HPV genital warts), molluscum contagiosum, caused by a pox virus, and lesions caused by Phthirus pubis, the crab louse (just pubic hair), and Sarcoptes scabiei, the itch mite (whole body). -always include folliculitis in the differential
treatment of condyloma lesions
local excision, cryotherapy, topical trichloroacetic acid, topical 25% podophyllin, and 5-fluorouracil cream (Efudex 5%)
- topical: imiquimod (Aldara) and podofilox (Condylox)
- CO2 laser
Cervarix
bivalent vaccine, protects against HPV serotypes 16 and 18 and is FDA approved for girls and women aged 10 to 25
Gardasil
quadravalent vaccine protects against serotypes 6, 11, 16 and 18 and is FDA approved for girls and women as well as boys and men aged 9 to 26.
Molluscum contagiosum contain a ?
treatment ?
waxy material that reveals intracytoplasmic molluscum bodies under microscopic examination when stained with Wright stain or Giemsa stain, not on palms or soles
-local excision and/or treatment of the nodule base with trichloroacetic acid or cryotherapy.
Pubic lice treatment
permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes or pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes.
scabies treatment
permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8 to 14 hours or ivermectin 200 μg/kg orally, repeated in 2 weeks.
BV risk factors
BV associations
new or multiple sexual partners, douching, lack of vaginal lactobacilli, female sexual partners, and cigarette smoking
acquisition of some STIs, complications after gyne surgery, complications of pregnancy (preterm birth), and recurrence of BV.
BV symptoms
may be asymptomatic or have an isolated increase in vaginal discharge.
if symptomatic: profuse nonirritating discharge, often with a malodorous fishy amine odor
BV diagnosis
thin, white, homogeneous discharge coating the vaginal walls; an amine odor noted with addition of 10% KOH (“whiff” test); pH greater than 4.5; or presence of clue cells Gram stain with examination of bacteria in the vaginal discharge is considered the gold standard
-vaginal prep NOT culture
candidiasis diagnosis
KOH prep, gram stain and culture
often clinical diagnosis
candidiasis tx
short course (1 to 3 days) of any of the azole agents via topical applications or vaginal suppository, including miconazole as an OTC preparation or terconazole by prescription Oral therapy includes fluconazole (Diflucan) 150 mg PO 1x
treatment of recurrent/complicated candidiasis
7 to 14 days of topical regimen or two to three doses of fluconazole oral therapy every 72 hours
oral fluconazole weekly for 6 months
non-albicans candidiasis
600 mg vaginal boric acid capsules daily for 14 days
Trichomonas diagnosis
wet prep microscopic exam
nucleic acid probe study, mmunochromatographic capillary flow dipstick technology
culture
Trichomonas tx
metronidazole (Flagyl) 2 g orally or tinidazole 2 g orally in a single dose
cervical motion tenderness in the absence of other signs of pelvic inflammatory disease (PID) is diagnosed as
cervicitis
G/C risk
low SES, urban residence, nonwhite and non-Asian ethnicity, early age of first sexual activity, illicit drug use, being unmarried, and history of STIs.
higher rates seen among women 15- to 24-year-old (Clamydia as well)
Condoms, diaphragms, and spermicides decrease the risk of transmission
As many as 1% of recognized gonococcal infections may proceed to a disseminated infection, beginning with what s/s?
fevers and erythematous macular skin lesions and proceeds to a tenosynovitis and septic arthritis.
G/C diagnosis
modified Thayer-Martin chocolate agar
-nucleic acid amplification tests (NAAT) for both gonorrhea and chlamydial infection have largely supplanted the use of culture
reason for the higher prevalence of chlamydial infections is that carriers of both sexes are often ?
entirely asymptomatic- Up to 70% of women
CDC recommendations for Chlamydia screening
annual Chlamydia screening for sexually active women age 25 or younger, older women with risk factors for chlamydial infections (those with new sexual parters or multiple sexual partners), and all pregnant women.
common sites for Chlamydia
presentation?
endocervix, urethra, and rectum
cervicitis, urethritis, and PID
