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Genital tract infection Flashcards

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1
Q

WHat are clinical indications of GTI?

A

Vag discharge, vaginitis/pruritus, suspected gonococcus candidasis, trichomoniasis, septic abortion, neonatal infection, puerperal sepsis, male urethral infection.

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2
Q

How do Genital tract infections manifest?

A

Not just venereal (sexually transmitted) infections (STIs)- can have endogenous infection with normal flora, exogenous infections (usually sexually transmitted)

some high incidence diseases are gonococcal and chlamydial infections- most common reportable diseases

vaginitis and vaginosis is the second most frequent outpatient microbio investigation

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3
Q

What are the main bacterial STIs that cause Gonorrhoea and PID, syphilis, chancroid, PID, lymphogranuloma venereum

A

Neiserria gonorrhoea causes gonorrhoea and PID, syphilis is caused by Treponema pallidum,
chancroid by Haemophilus ducreyi,
PID is caused by Chlamydia trachomatis, mycoplasma hominus, mycoplasma genitalium, ureaplasma urealyticum
lymphogranuloma venereum by chlamydia trachomatis

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4
Q

What are the main viral STIs that cause AIDS (acquired immuno deficiency syndrome), genital herpes, genital warts, hepatitis

A

AIDS caused by HIV (immunodeficiency virus), genital herpes caused by herpes simplex virus II (HSV II) is 60-70%, by HSV I 30-40%
genital warts caused by human papilloma virus (HPV 6 and 11)
hepatitis caused by Hepatitis B virus (main), Hep c, Hep D

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5
Q

What are the main parasitic STIs that cause public lice , scabies, trichomoniasis

A

Crabs caused by Phthirus pubis, scabies caused by Sarcoptes scabiei and trichomoniasis by trichomonas vaginalis

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6
Q

WHat are the female and male swabs and fluids for genital specimen? what organism requires charcoal transport media? which one does viruses need?

A

F: vulval, vaginal (HVS), cervical (ECS), urethral, rectal
M: urethral swab and smear, prostatic fluid, rectal
Neiserria gonorrhoea needs charchoal transport media, viruses - Hanks balanced salt solution

aspirates include pus samples for anaerobic culture for upper GTI, blood (serum) for syphilis, first void urine for Neiserria and chlamydia PCR, parasites in specimen jar

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7
Q

which swabs may be dry? What swabs recommended for bacteria and virus?
what can possibly inhibit bacteria ad viruses and PCRs

A

Chlamydia and gonorrhoea (dry so not suited for MC+S) PCR. Cotton, Rayon, Dacron
Calcium alginate can inhibit
Wooden tip swabs not suitable f0r viruses as contain toxins and formaldehyde

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8
Q

what is GC/TM/NYC agar used for?
what is SAB/Chromogenic candida used for?
What is used to ID strep agalactiae
what is A7 agar used for?

A
  1. for N gonorrhoea
  2. SAB for yeast
  3. Granada medium, Chromogenic STB, carrot broth, lim broth
  4. a7 for mycoplasma hominis and ureaplasma urealyticum
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9
Q

why is selective and differential media used for GNC?

A

So Neiserria can grow with minimum growth of NF and yeast

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10
Q

How does Thayer Martin- choc agar work

A

Thayer Martin - Chocolate agar with
- Isovitalex (Vitox)
- Vancomycin, colistin, nystatin- vancomycin inhibits gram pos, colistin inhibit gram neg, nystatin inhibits yeast moulds fungi
- + trimethoprim (Modified Thayer Martin)- prevent swarming proteus

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11
Q

How does NYC- lysed HBA work/what it contains

A

Yeast autolysate
- Vancomycin, colistin, amphoteracin B - + ,
vanco inhibits gram pos, colistin inhibits gram neg, amp B inhibits yeast, fungi, moulds
trimethoprim prevent swarming proteus

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12
Q

What does GC medium have- lysed horse blood use?

A

Yeast autolysate
- Lincomycin, colistin, amphoteracin B + trimethoprim, lincomycin inhibit gram pos, colistin inhibit gram neg amp B inhibit yeast fungi moulds
- Some strains of N. gonorrhoeae are sensitive to Vancomycin (TM and NYC medium)

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13
Q

What media should we use to culture vaginal discharge?

A

CHOC (48hr in CO2), and or GC/NYC/TM- also 48 in co2
BA, CNA? MAC/BA?
a quarter SAB and or chromogenic candida plate
Feinberg-Whittington (FW) broth (min 48h incubation) if Trichomonas PCR unavailable (urine or swab) - Anaerobic culture + MTZ (if Gram indicates polymicrobial picture)
- Two Sabouraud’s fungal slopes if indicated (37degrees C+RT)

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14
Q

What media is needed for an obstetric screen and or if STB (strep B) screen requested

A

1/4 granada medium/Lims broth for s. agalacticae

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15
Q

What media is needed for post partum pyrexia (fever), abortion or IUD or retained Tampon?

A

All the primary media listed above but ensure anaerobic culture performed
- Blood agar + metronidazole disc (AnO2) and/or LBAG + metronidazole disc - RCMB (Robertson’s cooked meat broth- anaerobic)

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16
Q

what media is needed for male urethra swabs?

A

CHOC and or TM GC NYC and BA

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17
Q

How can you process wet preps microscopically (reporting)

A

Wet preps distinguish between normal and abnormal, prep from swab after culture and gram smear
- report for Trichomonas vaginalis (+/occasional, up to +++ OR NOT SEEN)
yeast report same way - NOT SEEN (look for psuedohypae and budding)
epithelial cells covered with many bacteria- clue cells (vaginosis)
May or may not report on leucocytes and RBCs

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18
Q

How to process GRAM microscopy?

A

report presence of:
- Epithelial cells
- Leucocytes
- Yeast cells and mycelium - Lactobacilli (GBP)
- Other bacteria, especially resembling
* Neisseria gonorrhoeae (GNIDC)
* Anaerobic picture ± vaginosis
- Clue cells (vaginosis)

Report the absence of yeast if not already annotated with wet mount

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19
Q

what are clue cells and what is associated with it? what else might you see in gram microscopy?

A

Clue cells - epithelial cells covered with Gram variable cocco/bacilli - Associated with vaginosis (No leucocytes)
- Epithelial cells covered with lactobacilli – normal
* GNIDC – Gram negative intracellular diplococci
* Yeast - budding yeast, pseudohyphae
* Anaerobes – polymicrobial without clue cells
- and/or if specific anaerobic forms seen

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20
Q

Is bacteria vaginosis likely an exo or endogenous infection? what are the characteristics regarding discharge (colour), smell, presence of cells, symptoms?

A

Likely endogenous infection
- Malodorous vaginal discharge pH >4.5
* Fishy odour, “Whiff” test (10% KOH)
* Thin, grey-green discharge
* Presence of “clue” cells
- No inflammation (no WBCs)
- Little to no discomfort

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21
Q

When does bacterial vaginosis occur relating to PH?

A

Normal lactobacilli prod lactic acid which maintains pH to 4, so bacterial vaginosis happens when pH rises

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22
Q

WHat is the significance of bacterial vaginosis?

A
  • Increase risk of PID (UGTI) and cause of post op infections - Risk of endometrial infection
  • ? Role in pregnancy
  • Premature rupture of membranes
  • Pre-term labour
  • Post-partum infection
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23
Q

what is the normal chemical processes of lactobacilli producing lactic acid and vaginosis producing fishy odour?

A

Normal lactobacilli–>glycogen (polymer glucose)–>glucose–>Lactic acid (pH 4.0)
normal lactobacilli also produce bacteriocins and peroxide
Vaginosis: decrease lactate increased succinate increased acetate increased amines –>fishy odour (elevated pH)

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24
Q

What bacteria is vaginosis associated with?

what are general characteristics of G. vaginalis, bacteroides, peptostreptococcus, mobiluncus, mycoplasma hominis, ureaplasma urealyticum

A

Gardnerella vaginalis, “Clue” cells have been shown to be covered with Gardnerella
research shows multiple bacteria can be involved
Gardnerella vaginalis - Gram Variable – GNB, Faculative
Bacteroides sp. - GNB AnO2
Peptostreptococcus sp. - GPC AnO2
Mobiluncus sp. - GNHB AnO2- curved gram neg b
Mycoplasma hominis - No cell wall – membrane - GN
Ureaplasma urealyticum- No cell wall – membrane - GN

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25
Q

what is vaginitis? what are its symptoms and characteristics?

A

Inflammation of vaginal mucosa
symptoms= Abnormal discharge
* Offensive odour
* Itching
- Leucocytes

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26
Q

what is vaginitis commonly caused by?

A

Trichomonas vaginalis, candida albicans and candida sp- can ID by germ tube for c albicans, colony morph and chromogenic media

27
Q
  1. What are trichomonas vaginalis and what symptom do they cause in vaginitis?
  2. When do they multiply and how long do they survive in a host?
  3. How are they seen in wet preps?
  4. how can we test for their presence
  5. what do we treat it with?
A
  1. Flagellated protozoan (no known cyst form) Causes smelly, yellow-green vaginal discharge
  2. Multiplies when pH becomes more basic than normal (3.8-4.2) and can survive in host for 2 years
  3. seen as motile trophozoite
  4. Can test by PCR on first void urine or urethral swab - if no PCR use Feinberg Whittington broth to improve ID- promotes maintains growth, incubation 5-28 days
  5. treat with MTZ (flagyl)
28
Q

how does t. vaginalis reproduce and what are the diagnostic and infective stages
what is the definitive host?

A

multiply by longitudinal binary fission,
infective stage is when trophozoite in vag or orifice or urethra (exchange between people)
diagnostic when trophozoite in vag and prostatic secretions and urine
humans are the definitive host

29
Q

What are characteristics of yeast in gram stain

A

gram pos (purple) pseudohyphae, blastospores

30
Q

What are the characteristics of Chlamydia trachomatis?
can you culture them?

A

Very small, obligate intracellular bacteria (once considered a virus) Cell wall is similar to that of Gram-neg and cannot culture them

31
Q

What are the type of Chlamydia trachomatis which cause trachoma (eye infection)
STDs (NSU and PID)
LGV- Lymphogranuloma Venereum (ulcers on genitalia localise in the inguinal lymph nodes)

A

A-C -Trachoma
D-K - STDs (NSU non-specific urethritis often with N. gonorrhoeae +++ mucopurulent discharge and PID)
L1-3 LGV

32
Q

How can Chlamydia trachomatis be detected and treated

A

Organism can be detected in epithelial cells (urethra + cervix) and first drops of urine
- PCR methods - very sensitive
- Test often requested with concurrent request for N. gonorrhoeae PCR and/or MC+S
Treatment
- Tetracycline, Ciprofloxacin

33
Q

what is the life cycle of chlamydia?

A
  1. The elementary body (infectious particle) enters host cell
  2. EB transforms to reticulate body (reproducible element) inside and replicates
  3. Inside the cell still the replicated RB transforms to elementary bodies
  4. cell lyses and EB burst out of it
34
Q

Is N. gonorrhoea NF? what does it cause?

A

Strict human pathogen - NOT normal flora
causes Gonorrhoea
- Pyogenic (pus producing) infection of urethra (urethritis) and uterine cervix

35
Q

In which disease can 50% of females be asymptomatic ( decrease sensitivity Gram stain)
- 2.5-5% of men may be asymptomatic?

A

Gonorrhoea

36
Q

what can complications of both sexes be for gonorrhoea?
what about in women?
what about men and neonates?

A

Disseminated gonococcal infection (0.5-3%)
* Bacteraemia, Meningitis, Arthritis, Skin pustules

Women: PID (also by C. trachomatis)
- Infection of uterus, fallopian tubes where Acute salpingitis is inflammation of uterine tube or fallopian tubes - Resulting tissue damage can lead to infertility and increase risk of ectopic pregnancy.

Men
- Epididymitis (testes) - Prostatitis
* Neonates- Gonococcal ophthalmic neonatorum (conjunctivitis) - Neonatal pharyngitis

37
Q

what are pathogenic Neiserria sp lab characteristics?
cat, ox, optimal growth conditions, for CHO fermentation CTA- cystine triple agar sugars what is the basis?

What is the natural habitat in host?

A

GN diplococci (pairs)
Kidney bean shaped with adjacent sides flattened
- Clinical smears - seen intracellularly within PMN - GNIDC, Oxidase +, Catalase +

Optimal growth 35-37 ̊C
* Natural habitat is mucous membranes of host, rapidly die outside the human body
* Prefer CO2 and moisture

CTA- Relies on preformed enzymes - need heavy inoculum.Phenol red = indicator (alk=red, acid=yellow)- only yellow at tope of tube as OBLIGATE aerobe

38
Q

What are the virulence factors of N gonorrhoea? (7)

A
  1. Endotoxin activity, 2. lipo-oligosaccharides, 3. IgA1 protease, 4. Pili (fimbriae), 5. plasmids, 6. chromosomally mediated resistance, 7. outer membrane proteins

Endotoxin activity Gram Neg cell wall (no exotoxins)
Lipo-oligosaccharides - adherence, lysis of PMN & epithelial cells, stimulate TNFa (leads to tissue damage-spreading factor)
Pili- attachment to mucosal surfaces
- Five colony types T1, T2, T3, T4, (? T5)
T1 and T2 piliated -virulent(small,shiny raised colonies)
* T3-T5 non-piliated, avirulent(large flat colonies)
Plasmids - confer antimicrobial resistance
- Penicillin (penicillinase producing strains PPNG) - Tetracycline (TRNG)
Outer membrane proteins
- Variety of proteins with a variety of functions including:
* Enhanced mucosal cell invasion ,Confer resistance to bactericidal effects of normal serum

39
Q

GNC/GNDC and/or GNIDC - especially from a uro-genital site - Reliable in males (98%), 50-70% in females
* Doesn’t usually grow on BA initial culture
- Cystine trypticase agar (CTA) sugars
- Attacks glucose only
- ? Confirmation of carbohydrate results by API due to variants of other species having GLU only pos result or MALDI-TOF
* RapID NH, API NH, others - biochemical tests/ enzyme substrates (2-4 hrs)
PCR and molecular methods on first void urine or dry urethral swab

A

Neiserria gonorrhoea

40
Q

how do we treat N gonorrhoea?

A

inc resistance to penicillin (Penicillinase Producing N.gonorrhoeae -PPNG) inc R to fluoroquinolones=Ciprofloxacin 500 mg orally, ofloxacin, or levofloxacin
cephalosporins Ceftriaxone (IM), Cefixime (oral) but inc R means ceftriaxone used more
CDC Recommendation for uncomplicated infection of pharynx, cervix, urethra, rectum is Ceftriaxone
Spectinomycin single 2g,(IM) dose
- Traditionally used for strains that were resistant to oral antibiotics

41
Q

What does H ducreyi (small GN coccobacillus like others in genus) cause? how is it spread? where is it common? what is the only known reservoir

A

only known reservoir= humans, punched out ulcer, some women asymptom carrier

causes genital ulcers (soft sore/chancoid) which appear 4-10days after contact (last 1-35 days), ulcers usually affect skin prone to friction in sex, Lesions can be deep with purulent exudate at base, bleed easily and very painful
- If left untreated, ~50% of cases spread to inguinal lymph nodes leading to hard, painful lumps (buboes) - Responsible for 20-60% of genital ulcers in parts of Africa, Asia and Latin America
* Can also cause non-sexually transmitted skin lesions

42
Q

Diagnosis
* Presence of one or more painful ulcers ± lymphadenopathy
* Exclusion of syphilis, herpes simplex (I and II), LGV
* Sensitivity of culture is between 60-80% (very fastidious requirements)
- Swabs in transport media must arrive at lab < 4 hours
- Requires X factor
* Detection of typical GNB morphology in specimen
- Sensitivity (5% to 63%) and specificity (51% to 99%)
* PCR has high sensitivity (>95%) and specificity (99%), if available

GNB like school of fish- elongated chains/group and slightly yellow adherent colonies, culture needs v specialised media

A

Haemophilus ducreyi

43
Q

What is known as the flesh eating STI? what does it cause and past names. where is it more common?

A

Granuloma venereum/inguinale
Ulcers (primarily genital) caused by Klebsiella granulomatis- Taxonomic name change from Calymmatobacterium granulomatis
Historically called Donovanosis * Donovan bodies (organisms) can be seen inside macrophages
tropical and subtropical countries (incl central Australia)

Painless nodules appear from a few days up to a year after contact, break open leading to fleshy red ulcers (bleed on contact)
Organisms can spread from the open lesions and will mutilate (eat tissue)- * Can lead to cancer

44
Q

Diagnosis - cannot be grown on routine culture media
- Can be cultivated in human blood monocytes or epithelial cell lines
- Diagnosis can be made by histology/cytology of a biopsy or smear from the lesion- PCR is preferred if available
Must be a dry swab (no transport media) or test biopsy material
* Keep samples cool (4 ̊C)

how can you treat it?

A

Granuloma venereum- see macrophage w donovan bodies

Doxycycline for ≥21 days, SXT ≥21 days, CIP ≥21 days, Erythromycin ≥21 days - Possible relapse of infection after successful Tx at around18 months

45
Q

How can strep agalactiae be involved in GTIs? how can it affect neonates? what are the early and late onset consequences.

what other group of people is it opportunistic in?
what infections does group b strep cause?

A

NF in URT also primary reservoir in gastroint tract, 10-35% women carry it vaginally
Opportunistic
- Neonates acquire in utero before delivery, during birth or after birth * 1in2 infants from colonised mothers become colonised
Early onset
- Septicaemia, pneumonia, meningitis
* Late onset
- Bacteraemia, meningitis
we do screening for group B strep in pregnant women prior to delivery

Patients with carcinomas and/or debilitating disease
* Including diabetes, liver cirrhosis, stroke, neoplasia

Infections
- Cellulitis, abscesses, otitis media
- Endocarditis, meningitis, septicaemia

46
Q

compare early and late onset in terms of: onset, risk factors,mode of acquisition, symptoms, mortality, post infection sequelae

A

EO- birth to 5 days after, LO 7 days g3 months after birth
EO has maternal complications during delivery - prolonged rupture of membranes, fever, preterm labour while LO has none ID
EO has vertical transmission as mode of onset LO- nosocomial or at home
EO has pneumonia,bacteraemia, septic shock, and meningitis. LO= bacteraemia, meningitis
EO has mortality higher 2-8% higher in pre-term babies related to birth weight. LO= 10-15%
EO sequelae is neurological damage, LO has 50% of survivors

47
Q

WHat are the virulence factors of group B strep? (4)

A

Capsular polysaccharide antigens, enzymes (hyaluronidase- spreading factor to invade CT and CD5a peptidase), B haemolysin, lipoteichoic acid (adherence)

48
Q

How does B haemolysin contribute to virulence in s agalactiae

A

contributes to Pore-forming haemolysis
- Studies have shown activity against
alveolar lung tissue & endothelial cells
- Activity against endothelial cells of CNS
- Induces apoptosis of liver cells

49
Q

S agalactiae lab characteristics
what to treat it with?

A

lancefield group B, large colony narrow B haemolysis (rarely non haemolytis), bile tolerant- weak small colonies on MAC LF pink
orange on granada, pink red on ChromID Strepto B medium (STRB)
pos CAMP test, hippurate pos

treat with penicillin first choice som R to erythromycin and clindamycin. can also use AMP, cefotaxime CTX, ceftriaxone

50
Q

How does hippurate hydrolysis work?

A

Hippuric acid with the help of hippuricase in 2 hrs min will turn to Na benzoate and glycine.
glycine will react with ninhydrin (reagent) to form NH3 and CO2 and residual ninhydrin so there is purple colour

51
Q

how can you use CAMP test for s agalactiae?

A

pos= arrow head produced by B haemolysis, overnight at 35 degrees- staph and strep haemolysin enhanced area of haemolysis

52
Q

how does lims broth and carrot both compare for s agalactiae

A

LB for colonies enriched by selection by GPC, CB is indicator media
swab goes into both CB is selective and diff, lims broth enriched and colistin and nalidixic acid (inhibits gram neg)
LB incubate at 37 overnight while CB also 37 but not overnight
with LB after need to subculture to BA and incubate overnight while CB turns bright orange red after 16hrs for maj of strains
then for LB you ID by colony morph and group B antigen, CB you subculture any negatives

53
Q

what colour is s agalactiae, e coli, enterococcus faecalis on new granada medium?

A

group B= orange, e coli= bit yello tint, e faecalis is white

54
Q

how can we prevent GBS infection for babies?

A

Administer antibiotics to colonised pregnant women Administer antibiotics to pregnant women with risk factors (like past infact w gbs, premature birth)
Give antimicrobial prophylaxis to newborns

55
Q

Where is Listeria sp naturally found and isolated?

A

Found in the environment (vegetation, water and soil)
- Isolated from animals as commensals (faecal flora) and pathogens

56
Q

Which listeria sp is the most recognised pathogen in human and animal with 1-10% humans carrying it in the bowel after ingestion
when can you get outbreaks?
who does it primarily affect?
how can it be prevented?

A

L. monocytogenes
outbreaks following ingestion of contaminated food products ham etc

primarily affect pregnant women, immunocompromised, newborns-
Pregnant women may be asymptomatic or have flu like symptoms with/without vaginal discharge
* Infants can acquire in utero or during birth, often leads to septicaemia and meningitis
* 5th most common cause of meningitis
* 2nd most common cause of meningitis in babies and >60 years old

by having health campaigns for pregnant women, proper food prep and handling (contam after processing before packaging)

57
Q

Which diseases are caused by Listeria monocytogenes

how is early onset and late onset acquired in babies?and what is l monocytogenes causing in babies

A

Symptoms of acute listeriosis
- Days to weeks after initial exposure
- Flu like illness - fever, myalgia, sore throat, malaise - Possible diarrhoea and vomiting
- Septicaemia – fever, chills, hypotension, tachycardia - CNS involvement - meningitis
* Headache, stiff neck, confusion, loss of balance, or convulsions

Pregnancy - Mother
* May be asymptomatic (other wise as above) * May have a vaginal discharge
- Can lead to miscarriage or stillbirth - Premature birth
- Infection of the newborn
- Foetus/newborn
* Early onset-acquired through placental circulation
* Lateonset-vertical transmission during birth
* Septicaemia/meningitis
* Fever, irritability, pustular skin lesions, bulging fontanelles

58
Q

what is the infectious dose of L monocytogenes in immunocompetent and high risk individuals

A

10^7 to 10^9 cfu in immunocompetent
10^5 to 10^7 cfu in high-risk individuals (takes less cfu in high risk individuals)

59
Q

What are the virulence factors of L monocytogenes?

A

-Growth at a low pH in food and GIT
- Growth/survival at a high osmolality (salt cured foods)
- Compete with NF in GIT for nutrients
- Production of bacteriocins
- Growth/survival at low temperatures
- Efflux pump - resistance to disinfectants
- Biofilm production
Enable the organism to cross GIT into blood

  • Enable invasion and proliferation inside both phagocytic and non-
    phagocytic cells plus cell-to-cell transfer
60
Q

What is l monocytogenes lab characteristics?
motility differs by temperatures…
what temp is it also able to grow and does it grow on MAC
while agar produces blue colonies w white halo for it

A

SHORT non spore GPB may resemble strep, in PAIRS-coccobacillary and palisading
small grey white moist on BA- narrow zone B haemolysis, cat pos
tumbling motility at 25 non motile at 37 degrees
Aesculin and hippurate + (same as Gp B Strep)
* Grows at 4oC - important characteristic for pathogenesis and epidemiology
* Needs enrichment (BA or CHOC) – NO GROWTH on MAC
* Chromagar (Listeria) - blue colonies with a white halo

61
Q

what does mycobacterium hominis cause?

A

pelvic inflammation, pyelonepritis, post partum fever/abortion

62
Q

What is A7 agar use to grow and what does it contain?

A

Contains lots of growth factors (no cells) - serum, peptones, yeast extract, vitamins
Urea in there to grow Ureaplasma urealyticum and Arginine used to grow Mycoplasma hominis
U. urealyticum has black colonies with a sea urchin edge
mycoplasma V small on agar

63
Q
  • Smallest prokaryotes capable of self replication
  • No cell wall
  • All are capnophiles (if cultivatable, 5 days in 5% CO2 on A7 agar, otherwise test by PCR)
  • Multiple species are considered to be commensals of the urogenital tract
  • Mycoplasma hominis and Ureaplasma urealyticum are the most frequently encountered causes of infection
  • Mycoplasma genitalium is an emerging pathogen – ID by PCR
  • Can cause PID, urethritis and spontaneous abortion - Concern over antibiotic resistance
A

Mycoplasma and Ureaplasma

Microbiology Yr3 (13 decks)

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