General infection review

Question 1

What is the most common infectious cause of vaginitis in general? In pregnancy?

Answer 1

BV for both

Question 2

What are the Amsel criteria for diagnosis of BV?

Answer 2

Diagnosis is made if three of the following are present:

• homogeneous thin grey discharge coating vagina
• pH > 4.5
• positive whiff test
• clue cells seen on saline wet mount

Question 3

Describe how the whiff test is performed.

Answer 3

Potassium hydroxide is added to a sample of vaginal discharge - if a fishy odour ensues, the whiff test is positive

Question 4

When you send a vaginal swab to the lab, what score does the lab use to diagnose BV?

Answer 4

Nugent score (points awarded for presence of lactobacillus, gardnerella, bacteroides on Gram stain)

Question 5

List two options for treatment of BV. What treatment modalities are contraindicated in pregnancy?

Answer 5

Flagyl 500 mg bid x7d
Flagyl 0.75% gel 5 g pv daily x5d
Clindamycin 300 mg bid x7d
Clindamycin 2% gel 5 g pv daily x7d

Vaginal treatments are contraindicated in pregnancy

Question 6

List five exam findings or office tests supportive of a diagnosis of trichomoniasis.

Answer 6

Yellow-green malodorous discharge
Patchy vaginal erythema
Colpitis macularis (strawberry cervix)
pH > 5
\+ whiff test
Wet mount showing motile trichomonads

Question 7

For which organisms must you also treat the patient’s sexual partner?

Answer 7

Trichomonas
Chlamydia
Gonorrhea

Question 8

Define complicated vulvovaginal candidiasis.

Answer 8

• Recurrent (4+ episodes/y)
• Severely symptomatic
• Host is immune compromised
• Non-albicans species

Question 9

What congenital anomaly is associated with oral fluconazole use in the first trimester of pregnancy?

Answer 9

Tetralogy of Fallot

Question 10

What is the most common cause of ophthalmia neonatorum?

Answer 10

Chlamydia

Question 11

List three risk factors for chlamydial infection.

Answer 11

New partner
Previous STI
Street-involved
Young age (< 25)
Contact with a known case
2+ partners in the past 6m

Question 12

When is a test of cure required following treatment of chlamydia?

Answer 12

In pregnancy

Question 13

Which is more strongly linked to obstetrical complications: chlamydia or gonorrhea?

Answer 13

Gonorrhea - associated w/ PPROM, PTB, chorioamnionitis, postpartum infection, septic abortion, post-abortal PID

Question 14

What are the risk factors for PID?

Answer 14

Age < 25
Previous PID
Recent upper genital tract instrumentation
IUD

Question 15

What are the minimal & specific criteria for diagnosis of PID?

Answer 15

Minimal: uterine, adnexal, or cervical motion tenderness
Specific: laparoscopy w/ evidence of salpingitis/peritonitis (gold standard), endometrial biopsy showing endometritis, imaging showing hydrosalpinx/TOA

Question 16

In cases of PID:

• When should you remove an IUD?
• When is your approach to TOA?

Answer 16

Remove IUD after 48h if not responding to tx (in mild-to-moderate disease; less evidence to guide management in severe dz)
Approach to TOA: antibiotics first, percutaneous drainage if not responding to antibiotics, washout last

Question 17

Give two options for treatment of:

• Primary herpes
• Recurrent herpes
• Suppression

Answer 17

Primary:

• Acyclovir 400 mg tid x7d
• Famciclovir 250 mg tid x7d
• Valacyclovir 1g bid x7d

Recurrent:

• Acyclovir 400 mg tid x5d
• Famciclovir 250 mg bid x5d
• Valacyclovir 500 mg bid x5d

Suppression:

• Acyclovir 400 mg bid
• Famciclovir 250 mg bid
• Valacyclovir 1 g daily

Question 18

How many episodes of clinically apparent herpes in a single year warrant suppressive treatment?

Answer 18

6 episodes/year

Question 19

What are the symptoms of secondary syphilis?

Answer 19

Non-pruritic maculopapular rash on trunk, palms, or soles
Genital condylomata lata
Alopecia
Generalized non-tender lymphadenopathy
Mucous patches
Fever
Malaise

Question 20

How long after primary syphilis does secondary syphilis occur?

Answer 20

4-10 weeks (the ulcer of primary syphilis may still be present)

Question 21

What is being measured when a non-treponemal test for syphilis is done?

Answer 21

Anti-cardiolipin antibodies (cardiolipin is a component of the mitochondrial cell membrane that is released when the spirochete damages the membrane, allowing formation of antibodies)

Question 22

List two causes of a false positive treponemal test.

Answer 22

Any other spirochete:
Malaria
Leprosy

Question 23

Management of abnormal FHR secondary to Jarisch-Herxheimer reaction.

Answer 23

Expectant management (if possible) - will resolve with resolution of the reaction in 24-48h

Question 24

What is your differential for painful genital ulcers?

Answer 24

HSV
Chancroid (Haemophilus ducreyi)
LGV (although ulcer is usually gone by the time this comes to clinical attention)
Behcet’s disease

Question 25

What is your differential for painless genital ulcers?

Answer 25

Primary syphilis

Granuloma inguinale/Donovanosis

Question 26

Match the syndrome to the responsible bacterium:
Syndromes - chancroid, LGV, granuloma inguinale
Bacteria - chlamydia, calymmatobacterium, haemophilus

Answer 26

Chancroid = haemophilus ducreyi
LGV = chlamydia (serovars L1, L2, L3)
Granuloma inguinale = calymmatobacterium granulomatous

Question 27

Which of the following is not associated w/ lymphadenopathy: chancroid, LGV, granuloma inguinale?

Answer 27

Granuloma inguinale

Question 28

List two options for self-applied treatment of genital warts.

Answer 28

Podophyllotoxin 0.5% - apply to warts bid 3x/week x6w

Imiquimod 5% - apply to warts 3x/week x16w

Question 29

Your patient is not keen on any of the available treatment modalities for genital warts. What is the rate of spontaneous regression?

Answer 29

10-30% in 6m

Question 30

What is the treatment of molluscum contagiosum?

Answer 30

No treatment as this is self-resolving (rarely immunocompromised patients may require surgical excision or ablation of lesions)