Genital Infections Flashcards by Barbara Butler

Definition of recurrent vulvovaginal candidiasis

At least 4 episodes of infection per year and/or a positive microscopy of moderate to heavy growth of C. albicans

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Prevalence of C. albicans in asymptomatic women

30-40%

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Indications for treatment of vulvovaginal candidiasis

Only if symptomatic
Pregnancy is not an indication for treatment - no evidence of adverse outcomes and oral imidazoles are contraindicated in pregnancy

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Causes of vulvovaginal candidiasis

80-90% C. albicans
Non-albican species (tend to have similar symptoms but more severe and/or recurrent)
- C. tropicalis
- C. glabrata
- C. krusei
- C. parapsilosis

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Factors pre-disposing to vulvovaginal candidiasis

Pregnancy
High-dose COCP
Immunosuppression
Broad spectrum antibiotics
Diabetes
Hormone Replacement Therapy
HIV

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Microbiology of C. albicans

Diploid fungus
Gram positive spores + long pseudohyphae
Common commensal in gut flora

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Diagnosis of C. albicans

Vaginal swab Gram stain:
Gram +ve spores and long pseudohyphae
Numerous polymorphs
Abnormal bacterial flora (resembling bacterial vaginosis)

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Management of uncomplicated vulvovaginal candidiasis

Avoid soaps, perfumes, synthetic underwear
Change from high to low dose COCP or to progesterone only if recurrent
Either a single treatment or a course of several applications/pessaries
Local topical azole
Oral: fluconazole 150mg single dose
OR clotrimazole single 500mg pessary or 100mg pessaries over 6 days

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Maintenance treatment for recurrent vulvovaginal candidias

150mg Fluconazole weekly for 6 months
OR
weekly topical clotrimazole 500mg for 6-8 weeks

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Evidence for use of oral or vaginal lactobacillus or yeasts for vulvovaginal candidiasis

NO EVIDENCE. not recommended

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Definition of trichomonas vaginalis

A severe vulvovaginitis caused by the protozoan trichomonas that is usually sexually transmitted and commonly recurs if male partner is not treated

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Clinical features of trichomonas vaginalis

Vulval soreness and itching
Foul smelling frothy yellowish green discharge
Dysuria
Abdominal discomfort
Strawberry cervix - punctate haemorrhages
May be asymptomatic carrier

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Confirming diagnosis of trichomonas vaginalis

MCS of vaginal swab:

cone-shaped, flagellated organism with terminal spike
motile protozoa - i.e. amoeboid motion with flagella waving if looking at under microscope

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Management of trichomonas vaginalis

Metronidazole - 2g single oral dose

Ensure screening and treatment of partners too

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Normal vaginal pH

4.5 i.e. slightly acidic environment

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Definition of bacterial vaginosis

A common condition of the vagina characterised by the presence of foul-smelling vaginal discharge in the absence of obvious inflammation. It is caused by an increase in the vaginal pH secondary to a change in the flora of the vagina from normal lactobacilli to predominantly anaerobes

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Risk factors for bacterial vaginosis

Sexual activity
Woman-woman sexual intercourse
HSV-2 infection
HIV infection
Vaginal douching
Cigarette smoking

Common species involved in bacterial vaginosis

Gardnerella vaginalis
Mobilinicus spp.

Mycoplasma hominis
Bacteroides spp.

Clinical features of bacterial vaginosis

Fishy malodorous vaginal discharge
More prominent during and following menstruation
Creamy or greyish-white vaginal discharge adherent to vaginal wall
May be asymptomatic carrier

Diagnostic criteria for bacterial vaginosis

Amsel criteria:

Presence of clue cells on microscopic examination of vaginal swab
creamy greyish white discharge seen on naked eye examination
Vaginal pH >4.5
Positive whiff amine test (release of characteristic fishy odour on addition of alkali: 10% potassium hydroxide)

at least 3 of the 4 to make a diagnosis

What is a clue cell

An epithelial cell studded with adherent coccobacilli that gives the cell a stipple appearance - indicator of bacterial vaginosis

Management of bacterial vaginosis

ORAL
400mg metronidazole BD 5 days
2g metronidazole single dose
300mg clindamycin BD 7 days (preferred in pregnancy)
Tinidazole 2g orally single dose
OR TOPICAL METRONIDAZOLE OR CLINDAMYCIN

Microbiology of neisseria gonnorhoea

Gram-negative intracellular diplococcus
Has affinity to infect the mucous membranes of the genital tract - columnar and cuboidal epithelium in endocervical and urethral mucosa
Can also infect the rectal and oropharyngeal mucous membrane

Clinical features of gonorrhoea in a symptomatic females

Increased discharge
Lower abdo/pelvic pain
Dysuria with urethral discharge
Proctitis with rectal bleeding, discharge and pain (if anal sex)
Endovcercvical mucopurulent discharge and contact bleeding
Mucopurulent urethral discharge
Pelvic tenderness with cervical excitation

Clinical features of gonorrhoea in symptomatic males

Dysuria white, yellow or green urethral discharge Painful or swollen testicles (less common) Rectal infection: discharge, itching, soreness, bleeding, painful bowel movements

Diagnosis of gonorrhoea

Endocervical swabs/swabs from symptomatic areas - Gram-negative intracellular dipplococci OR nucleic acid amplification tests: can test samples from urine and lower vagina

management of gonorrhoea

Contact tracing Antibiotics: in urban Australia: Ceftriaxone 500mg IV or IM + Azithromycin 1g orally (single doses) In remote areas (less penicillin resistance): amoxycillin 3g, probenecid 1g, azithromycin 1g all as single oral doses

Groups at highest risk of STIs

``` Young people under 25 Men who have sex with men People who inject drugs Sex industry workers Known contacts of someone with an STI ```

5 Ps of sexual history taking

``` Partners Practices Protection from STIs Past history of STIs Prevention of pregnancy (contraception) ```

Chlamydia trachomitis serotypes responsible for genitourinary infection

Serotypes D-K | A-C infect the conjunctiva and cause trachoma

Clinical features of chlamydia in women

``` Majority asyptomatic Increased vaginal discharge Lower abdominal pain Postcoital bleeding Intermenstrual bleeding Mucopurulent cervical discharge with contact bleeding Dysuria with urethral discharge ```

Clinical features of chlamydia in men

Mucoid or watery urethral discharge - often clear and only seen upon milking the urethra Dysuria Incubation period approx 5-10 days i.e. longer than that of gonorrhoea

Gold standard investigation for diagnosis of chlamydia

Nucleid acid amplificationt test (NAAT) - first catch urine sample, low vaginal swab or endocervical swab Microscopy is not useful for the diagnosis of chlamydia

Management of uncomplicated chlamydia in women

Azithromycin 1g orally single dose OR Doxycycline 100mg orally BD for 7 days

Management of chlamydia in men

doxycycline 100mg BD for 14-21 days OR Azithromycin 1g orally stat, repeated 1 week later if concern of adherence

Management of STI suspected epididymo-orchitis without identified organism

``` Treat for both chlamydia and gonorrhoea: Ceftriaxone 500mg IM or IV PLUS Azithromycin 1g orally stat PLUS Doxycycline 100mg BD 14 days or Azithromycin 1g 1 week later ```

Factors affecting recurrent infection in genital herpes

More likely to occur in HSV2 (4x per year) v HSV1 (1x per year) Longer duration and greater severity of primary infection Recurrence rates highly variable

Management of genital herpes primary infection

Oral Aciclovir, famciclovir of valaciclovir for 5 days begin treatment as soon as clinical diagnosis is made up to 10 days of treatment may be needed for severe disease

Management of recurrent genital herpes

Most patients will not require treatment with mild infrequent recurrences Episodic treatment if infrequent and moderate severity Short courses started with onset of prodromal symptoms or with onset of lesions Aciclovir, famciclovir or valaciclovir for 1-5 days accordingly Suppressive therapy: indicated for frequent severe recurrences, reduces recurrence by 70-80% Aciclovir, famciclovir, (BD) valaciclovir (once daily), reassess at 6 months Can safely be continued long-term

Diagnosis of genital herpes

Confirm clinical diagnosis with PCR, viral culture of immunofluoresence of vesicular fluid ideally serology may be useful if repeat swabs negative, patients with partners who have genital herpes, risk of new infection in pregnancy

Management of gonorrhoea

500mg IM ceftriaxone

Gonorrhoea and chlamydia contact tracing

Gonorrhoea: sexual partners from past 2 months Chlamydia: sexual partners in last 6 months