26. Infections transmissibles sexuellement Flashcards
Sx ITSS 5 + 3
discharge,
dysuria,
abdominal pain,
testicular or vag pain,
skin changes
fever, weight loss, lymphadenopathy
questionner les 5 P
Partners (past year)
Practices (vaginal, oral, anal, other)
Prevention
STI - condom use, Hep A/B vaccination
Pregnancy/contraception
Previous STI testing
STI risk factors name 5 (11 total)
Previous STI
Sexual contact with person(s) known STI
Sexually active <25yo
New sexual partner
> 2 sexual partners in last year or serial one-partner relationships
No barrier contraception use
IVDU
Homelessness
Substance use, especially if associated with sex
Sex workers
Sexual assault
Phyical examination - ne pas oublier
oropharynx
inguinal lymph nodes
perianal inspection
Tests
1) Gonorrhea/Chlamydia NAAT PCR (first catch urine (any time of the day), urethral, vaginal, cervical, pharynx, rectal)
2) gono culture prior to tx due to increasing resistance
3) VDRL
4) VIH - doit être répété
5) HBV
HBsAg (Hepatitis B surface antigen): + = person is infected
anti-HBs or HBsAb (Hepatitis B surface antibody) = protected (aka past recovered infx or immunizé)
Périodes latentes
GONO : 14 jrs
chlam : 21 jrs
VIH, syphillis, HbSAg HCV: 3 mois
Quoi demander pour HBV et HVC comme test
HBV antigen and anticorps are enough
HBsAg (Hepatitis B surface antigen): + = person is infected
anti-HBs or HBsAb (Hepatitis B surface antibody) = protected (aka past recovered infx or immunizé)
NE PAS demanded: anti-HBc or HBcAb total (Hepatitis B core antibody) = car tout seul intérpétation vaut rien
Anti VHC totaux
HIV prophylaxis
Truvada plus raltegravir
si pas vacciné pour Hep B et exposé
Immunoglobulin (ideally test contact and give only if HBsAb positive)
Vaccine
WHen to restest for HIV, HBV, HCV
HIV 6w, 12w after exposure
Repeat serology 2 months after vaccine series
HCV RNA 3w after exposure (or HCV Ab 6 months after exposure)
If Gono/chlam negative and persistent symptoms, consider other pathogens such as
Mycoplasma genitalium
Trichomonas vaginalis
Tx codes in Qc
Code K ( Patient)
Code L (Partner) (lover)
Gono antibiotic tx
Gonorrhea: Ceftriaxone 500mg IM x1 (or alternative: Cefixime 800mg PO x1)
If weight ≥150kg (300lb), Ceftriaxone 1g IM is recommended
Treat concurrently for chlamydia if chlamydial coinfection not excluded
Chlamydia tx
Doxycycline 100mg PO BID x7d
or
Azithromycin 1g PO x1(if risk of non compliance but resistance!)
Doxycycline PO preferred for rectal chlamydia
Azithromycin 2g PO preferred in pregnancy
Trichomoniasis tx
Metronidazole 2g PO x1
Treat partner
Bacterial STI or trichomonas should abstain from unprotected sex until 7d after treatment of both partners complete
Syphilis tx depending which stage vs late latent or teriary neurosyphilis
Primary, secondary, and early latent syphilis:
Pen G 2.4 million units IM x1
Late latent (>1y from likely infection) or tertiary (gummatous or cardiovascular disease):
Pen G 2.4 million units IM once weekly x 3 weeks
Tertiary neurosyphilis
Pen G 3-4 million units IV q4h x 10-14d
HSV1 tx
gingovostomatitis +/- pharyngitis, then recurrent herpes labialis
ACUTE
within 72h or ongoing new lesions/pain):
Valacyclovir 1000mg PO BID x 7-10d
if severe odynophagie - consider IV tx
Recurrent episodic: Famciclovir 1500mg PO x 1 dose or Valacyclovir 2g PO BID x 1 day
Chronic: Valacyclovir 500mg PO daily
HSV2
Genital herpes simplex
ACUTE
within 72h or ongoing new lesions/pain):
Valacyclovir 1000mg PO BID x 7-10d (idem à labial)
Recurrent episodic: Famciclovir 1000mg PO BID x 1 day, Valacyclovir 500mg PO BID x3d
Chronic suppressive: Valacyclovir 500-1000mg PO daily
HPV lesions
Imiquimod 5% cream qHS 3/week x 15w, wash off after 6-10h
Podofilox 0.5% solution BID x3d then none x4d, repeat PRN x4
Cryotherapy
bacterial vaginosis
metronidazole 500mg PO BID x 7-14 jrs
candidiase
fluconazole 150 mg PO x 1
MADO
gono
chlam
VIH - seulement si la personne infectée a donné ou reçu du sang, des produits sanguins, des organes ou des tissus*
Hépatites virales* (ex. : VHA, VHB, VHC)
malaria
coqueluche diphterie rougeole etc
WHen to do follow up testing
Chlamydia (PCR >3w after treatment)
Persistent symptoms
Re-exposure
Pregnancy
Poor adherence
Alternate antibiotic use (eg. Azithromycin to treat rectal)
Chlamydia genotype L
*
All gonorrhea given increasing resistance (PCR >2w after treatment, or culture >3d after treatment)
*
Syphilis
Primary, secondary, early latent infection: Repeat serology at 1, 3, 6 and 12 months after treatment
Late latent: Repeat serology 12 and 24 months after treatment
*
Follow-through on partner notification
PID : Pelvic inflammatory disease / Maladie inflammatoire pelvienne quand suspecter
Sexually active women with pelvic/lower abdominal pain and one of: Adnexal, cervical motion, uterine tenderness
Abnormal cervical or vaginal mucopurulent discharge or cervical friability
Positive Chlamydia/Gonorrhea
Oral T>38.3
Abundant WBC (>15 WBC per hpf) on saline microscopy of vaginal secretions
Elevated ESR/CRP (less specific)
??? Confirm with pelvic imaging (ultrasound, CT, MRI)
PID tx
Mild-moderate with Ceftriaxone 500mg IM x1 + Doxycycline 100mg PO BID x 14d (+/- Metronidazole 500mg PO BID x 14d for T vaginalis or anaerobic coverage for recent instrumentation)
Severe or complicated (eg. tubo-ovarian abscess) with Clindamycin 900mg IV q8h + Gentamicin 1.5mg/kg IV q8h x 14d (step down to Doxycycline)
Consider treating male partners if sexual contact 60d prior (or if >60d, most recent) to patient’s onset of symptoms (eg. Ceftriaxone 250mg IM, PLUS Azithromycin 1g PO x1 or Doxycycline 100mg PO BID x 7d)
Avoid sex until patient and partners adequately treated and asymptomatic
Re-assess if need to remove IUD 3d post -treatment
