GUM Flashcards
Chlamydia - microbiology, transmission, epidemiology
Microbiology - Chlamydia trachomatis; obligate intracellular bacteria (enters and replicates within cells before rupturing the cell and spreading to others)
Transmission - sexual contact and vertical
Epidemiology -
* Most common STI in UK
* Significant cause of infertility
Chlamydia - RFs, clinical features, complications
RFs -
*<25 y/o
* New sexual partner
*>1 sexual partner/year
*Not using condoms
Clinical features -
* Women; asymptomatic (75%), increased vaginal discharge, dysuria, pelvic pain, post-coital/intermenstrual bleeding, dyspareunia
*Men; asymptomatic (50%), urethral discharge/discomfort, dysuria, testicular pain, reactive arthritis
* Asymptomatic patients can still be infectious
*Examination - Pelvic or abdominal tenderness, Cervical motion tenderness (cervical excitation), Inflamed cervix (cervicitis), Purulent discharge
Complications -
* Epididymo-orchitis
* PID (1-30%)
* Chronic pelvic pain
* Infertility
* Ectopic pregnancies
* Reactive arthritis
* Conjunctivitis
* Lymphogranuloma venereum
Pregnancy related complications -
* Preterm delivery
* Premature rupture of membranes
* Low birth weight
* Postpartum endometritis
* Neonatal infection (conjunctivitis and pneumonia)
Chlamydia - diagnosis, treatment, advice, test of cure
Diagnosis -
* NAAT - sensitivity 96-98% and specificity >95%, men first catch urine, women vulvovaginal swab
* In MSM with rectal chlamydia test for LGV (especially if anorectal symptoms, like discomfort, discharge, bleeding and change in bowel habits)
*Swabs - vulvovaginal, endocervical, first catch urine (men + women), urethral swab (men), rectal swab (after anal sex), pharyngeal swab (after oral sex)
Treatment - always check local guidelines
* 1st line - uncomplicated chlamydia infection; 100mg doxycycline BDS for 7 days (contraindicated in pregnancy and breastfeeding)
*2nd Line (if doxy contraindicated) - options include:
Azithromycin 1g stat then 500mg once a day for 2 days
Erythromycin 500mg four times daily for 7 days
Erythromycin 500mg twice daily for 14 days
Amoxicillin 500mg three times daily for 7 days
Advice -
* Abstain from sex for 7 days of treatment of all partners to reduce the risk of re-infection
* Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners (through health advisor)
* Test for and treat any other sexually transmitted infections; beware co-infection
* Provide advice about ways to prevent future infection (patient information leaflet)
* Consider safeguarding issues and sexual abuse in children and young people
Test of cure - not routinely recommended but:
* Under 25 - can retest in 3 months
* Pregnant or rectal infection - retest in 6 weeks
Chlamydial Conjunctivitis - aetiology, presentation, epidemiology, DDx
Aetiology - through genital fluid contacting eye either as result of sexual activity or hand-to-eye contact
Presentation - 2 weeks of:
* Chronic erythema
* Irritation
* Discharge from eye
Epidemiology -
* Occurs more frequently in young adults
* Neonates - if mother infected ith chlamydia
DDx - gonococcal conjunctivitis; must test for
Lymphogranuloma Venereum (LGV) - definition, epidemiology, stages, management
Definition - condition affecting the lymphoid tissue around the site of infection with chlamydia
Epidemiology - most common in MSM
Stages -
* Primary; painless ulcer (primary lesion) typically occurring on penis in men and vaginal wall in women. Could also be on rectum after anal sex
* Secondary; lymphadenitis - swelling/inflammation/pain in lymph nodes infected with the bacteria. Inguinal/femoral lymph nodes may be affected
* Tertiary; proctitis (rectal inflammation) and anal inflammation. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge
Management -
* 1st Line - doxycycline 100mg BDS for 21 days
* Alternatives - erythromycin, azithromycin and ofloxacin
2 types of swabs used in sexual health testing
Charcoal -
* Allow for microscopy, culture and sensitivities
* Cotton bud in black transport medium (Amies transport medium) which contains a chemical to keep microorganisms alive during transport
* Used for endocervical and high vaginal swabs (HVS)
* Can confirm: Bacterial vaginosis, Candidiasis, Gonorrhoeae (specifically endocervical swab), Trichomonas vaginalis (specifically a swab from the posterior fornix), other bacteria such as group B streptococcus (GBS)
Nucleic Acid Amplification Test (NAAT) -
* Check directly for the DNA or RNA of the organism
* Used specifically for chlamydia and gonorrhoea
* Not useful for other pelvic infections unless specifically testing for Mycoplasma genitalium
* Women; endocervical swab > vulvovaginal swab > first-catch urine sample
* Men; first-catch urine sample or a urethral swab
* Rectal/Pharyngeal NAAT swabs; to diagnose chlamydia in rectum or throat (if anal/oral sex has occurred)
If gonorrhoea suspected/demonstrated on NAAT - endocervical swab needed for MCS
What is the National Chlamydia Screening Programme?
PHE set up NCSP
* Aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner
* Everyone that tests positive should have a re-test three months after treatment to ensure they haven’t contracted it again (not to check treatment has worked)
When a patient attends a GUM clinic for STI screening, what is the minimum they are tested for?
- Chlamydia
- Gonorrhoea
- Syphilis - blood test
- HIV - blood test
Gonorrhoea - microbiology, transmission, RFs
Microbiology - Neisseria gonorrhoea; gram negative diplococcus
* Infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx
Transmission - sexual contact and vertical via mucous secretions from infected areas
RFs -
* Being young
* Sexually active
* Having multiple partners
* Having other sexually transmitted infections, such as chlamydia or HIV
Issues with gonorrhoea treatment
High level of antibiotic resistance
* Traditionally ciprofloxacin or azithromycin was used to treat gonorrhoea
* Now high levels of resistance to these antibiotics
Gonorrhoea - clinical presentation and complications
Clinical presentation - more likely to be symptomatic than infection with chlamydia (90% men, 50% women)
* Women; asymptomatic (50%), mucopurulent discharge - odourless purulent discharge, possibly green or yellow (50%), pelvic pain (25%), dysuria (12%)
* Men; asymptomatic (<10%) mucopurulent discharge - odourless purulent discharge, possibly green or yellow (80%), dysuria (50%), testicular pain/swelling if epididymo-orchitis
* Rectal infection; anal/rectal discomfort/discharge but often asymptomatic
* Pharyngeal infection; sore throat but often asymptomatic
* Prostatitis; perineal pain, urinary symptoms, prostate tenderness O/E
* Conjunctivitis; erythema + purulent discharge
Complications -
* Men; epididymo-orchitis, prostatitis
* Women; PID
Chronic pelvic pain
Infertility
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh-Curtis syndrome
Septic arthritis
Endocarditis
Gonorrhoea - diagnosis, management, test for cure, advice
Diagnosis -
* NAAT (>96% sensitivity) - detects if gonococcal DNA/RNA present
* Charcoal swab + MCS - gives the info regarding specific bacteria and sensitivities/resistance. Microscopy is 90-95% sensitive if discharge present, 50% if not
Management - always look up local microbiology guidelines
* Sensitivity UNKNOWN - single dose IM ceftriaxone 1g (mixed with 3.5mls 1% lidocaine)
* Sensitivity KNOWN - single dose PO ciprofloxacin 500mg
* Different regimes for complicated infections/infections other sites/pregnant women - most involve single dose IM ceftriaxone
Key complication of gonorrhoea in neonates
Gonococcal conjunctivitis AKA ophthalmia neonatorum
* Medical emergency - associated with sepsis, perforation of the eye and blindness
* Gonococcal conjunctivitis contracted from mother during birth
Key complication of untreated gonorrhoeal infection
Disseminated gonococcal infection (GDI) - bacteria spreads to skin and joints
* Various non-specific skin lesions
* Polyarthralgia (joint aches and pains)
* Migratory polyarthritis (arthritis that moves between joints)
* Tenosynovitis
* Systemic symptoms such as fever and fatigue
Syphilis - microbiology and transmission
Microbiology - Treponema pallidum - gram negative spirochete (spiral-shaped bacteria)
* Gets through skin/mucous membranes -> replicates -> disseminates throughout the body
* STI
* Incubation period - 21 days average from initial infection and symptoms
Transmission -
* Sex - Oral, Vaginal, Anal
* Vertical - Mother to baby during pregnancy
* IVDU
* Blood Transfusions/Transplants - Rare due to screening of blood products
Syphilis - stages
Primary - Involves a painless ulcer called a chancre at the original site of infection (usually on the genitals)
Secondary - Involves systemic symptoms, particularly of the skin and mucous membranes
* Can resolve after 3 – 12 weeks and the patient can enter the latent stage
Latent - Symptoms disappear (after secondary stage) and patient becomes asymptomatic despite still being infected
* Early - Within 2 years of initial infection
* Late - From 2 years after the initial infection onwards
Tertiary - Can occur many years after the initial infection and affect many organs of the body, particularly with the development of:
* Gummas - a small soft swelling which is characteristic of the late stages of syphilis and occurs in the connective tissue of the liver, brain, testes, and heart
* Cardiovascular complications
* Neurological complications
Neurosyphilis - occurs if the infection involves the central nervous system, presenting with neurological symptoms
Syphilis - clinical presentation at different stages
Primary
* A painless genital ulcer (chancre) - tends to resolve over 3-8 weeks
* Local painless lymphadenopathy
Secondary
* Maculopapular rash
* Condylomata lata
* Low-grade fever
* Lymphadenopathy
* Alopecia - localised hair loss
* Oral lesions
Tertiary
* Gummatous lesions
* Aortic aneurysms
* Neurosyphilis
Neurosyphilis
* Headache
* Altered behaviour
* Dementia
* Tabes dorsalis
* Ocular syphilis - affecting the eyes
* Paralysis
* Sensory impairment
* Argyll-Robertson Pupil
Syphilis - key clinical features and explanations
Condylomata lata (Secondary) - grey wart-like lesions around the genitals and anus
Gummas (Tertiary) - are granulomatous lesions that can affect the skin, organs and bones
Tabes dorsalis (Neurosyphilis) - demyelination affecting the spinal cord posterior columns
Argyll-Robertson Pupil (Neurosyphilis) - Accommodates but does not react
* A constricted pupil that accommodates when focusing on a near object but does not react to light
* Often irregularly shaped
* Specific finding in neurosyphilis
* “Prostitutes pupil” - due to relation to neurosyphilis
Syphilis - diagnosis
Antibody Testing - Ab to T. pallidum bacteria can be used as a screening test (If positive antibodies or suspected syphilis, should be referred to GUM clinic for further testing)
Specific Tests:
1. Rapid Plasma Reagin (RPR)
2. Venereal Disease Research Laboratory (VDRL)Test
* Non-specific BUT sensitive tests (Often produce false-positives and skill required to both perform and interpret results)
* Assess quantity of Abs being produced by body in response to syphilis infection
○ Higher number = greater chance of active disease
* Involve introducing sample of serum to solution containing antigens and assessing reaction
○ More significant = higher quantity of Abs
Dark Field Microscopy - To confirm presence
PCR - To confirm presence
Syphilis - management
Follow Up - Specialist service like GUM
Protocol
* Full screening for other STIs
* Advice about avoiding sexual activity until treated
* Contact tracing
* Prevention of future infections
Treatment
* Early: Deep IM dose of benzathine benzylpenicillin 2.4mu - standard treatment
* Late syphilis/neurosyphilis - alternative regimes/types of penicillin
○ Ceftriaxone
○ Amoxicillin
○ Doxycycline
Mycoplasma genitalium (MGen) - overview
MG is a bacteria that causes non-gonococcal urethritis
* STI
* Developing problems with antibiotic resistance especially azithromycin
* Most cases asymptomatic
* Very similar presentation to chlamydia - may be co-infection
* Urethritis is key feature
MGen - issues with treatment
Chlamydia treatment - guidelines previously recommended a single dose of azithromycin 1g orally as an alternative
* This recommendation has been removed due to Mycoplasma genitalium resistance to azithromycin, and azithromycin being less effective for rectal chlamydia infection
MGen - investigations
NAAT
* Men - morning first urine sample
* Women - vaginal swabs (can be self taken)
Check for Macrolide Resistance - Every positive sample
MGen - management
ALWAYS CHECK LOCAL GUIDELINES
Uncomplicated
* Days 1-7 - 100mg Doxycycline PO BDS
* Contraindicated in pregnancy and breastfeeding
* Days 8-9 - Azithromycin (Unless it is known to be macrolide resistant)
* 1g stat
* 500mg OD for 2 days
Alternative/Complicated Infections - Moxifloxacin
Pregnancy and Breastfeeding - Azithromycin alone
Test of Cure - Required in every positive patient after treatment
