GUM Flashcards
Symptoms of candidal vulvovaginitis
Soreness
Itching
Red skin - possible peeling, pustules or apples
White discharge
When to refer candidal vulvovaginitis
Unclear diagnosis No improvement despite treatment Immunocompromised patient Systemic treatment needed Recurrent candida - specialist GUM clinic
Treatment of candidal vulvovaginitis
Topical imidazole e.g clotrimazole, ketoconazole, econazole
Alternative = topical terbinafine
If problematic itch/ inflammation add mild steroid cream
If tx ineffective try - oral fluconazole 50mg 2-4 wks
Types of candida species
Candida albicans Candida tropicalis Candida glabrata Candida krusei Candida parasilosis
Common species involved in bacterial vaginosis
Gardnerella vaginalis
Mycoplasma hominis
Bacteroides
Mobilincus
Which STI is a flagellate Protozoan
Trichomonas vaginalis
Symptoms of Trichomonas vaginalis in women
10 - 50% asymptomatic non-specific symtoms Vaginal discharge Vulval soreness + itching Odour Discharge may be frothy / green Dysuria occasionally - low abdominal pain, vulval ulcers
Diagnosis of Trichomonas vaginalis
Microscopy of vaginal discharge
and TV NAATs
Treatment of Trichomonas vaginalis
Metronidazole (2g) single dose
Both partners simultaneously
signs of TV on examination of female patients
Vaginal discharge in 70% Frothy yellow / green discharge Vulvitis Strawberry cervix (punctate haemorrhages) - 2% Frothy discharge 5-15% NAD
Symptoms of TV in men
15 - 50% asymptomatic Urethral discharge dysuria Urethral irritation Urinary frequency
signs of TV on examination of male patients
urethral discharge - 20-60%
No signs - up to 70%
rare - balanoposthitis
what is balanoposthitis
inflammation of the foreskin and glans
Complications of TV
impact on pregnancy - low birth weight, pre-term delivery, maternal post-partum sepsis
Association with HIV
May enhance HIV transmission
diagnostic findings of TV on microscopy
detection of motile trichomonads by light field microscopy from wet prep slide
general advice when treating TV
Treat both partners simultaneously
Avoid sexual intercourse until 1 week after both partners completed treatment
Treatment used for TV
metronidazole 2g PO STAT
or metronidazole 400-500mg BD 5-7 days
Alternative = tinidazole 2g PO STAT (expensive)
can metronidazole be used in pregnancy and breastfeeding
Safe in all trimesters
Non Teratogenic
Safe in breastfeeding but may affect milk taste (avoid STAT dose)
Can tinidazole be used in pregnancy and breastfeeding
No - unsafe in animal trials
No evidence re human use in pregnancy and breastfeeding
Treatment of TV in a HIV positive patient
Use metronidazole 500mg BD for 7 days
what possible reaction should patients be warned about when taking metronidazole
disulfram-like reaction if taken with alcohol
Avoid all alcohol for duration of treatment and 48 hours afterwards
causes of treatment failure in TV
inadequate therapy
re-infection
resistance
Follow up recommendations for patient with TV
window period tests and bloods
No FU for TV unless symptoms continue
treatment protocol for non-response to standard TV therapy
repeat 7 day course of metronidazole 500mg BD - 40% respond to second course
if 2nd regimen failed - use metronidazole 2g OD for 5-7 days
if 3rd regimen failed complete resistance testing and use tinidazole 1g BD - TDS for 14/7 and intravaginal tinidazole 500mg BD 14/7
Symptoms of bacterial vaginosis
Malodorous fishy discharge
Asymptomatic carriers
More prominent during menstruation
Cream / grey discharge - commonly adheres to wall of vagina
What do clue cells suggest
Bacterial vaginosis
Clue cell = epithelial cell covered in bacteria
What is a clue cell
Clue cell = epithelial cell covered in bacteria
Management of bacterial vaginosis
metronidazole 400-500mg BD 5-7 days or metronidazole 2g PO STAT (not in pregnancy)
Problems with bacterial vaginosis in pregnancy
In 1st T can –> second trimester miscarriages or preterm labour
Treat with metronidazole
Which STI is a gram -ve diplococcus
Neisseria gonorrhoea
Symptoms of gonorrhoea
Asymptomatic Increased vaginal discharge Abdo / pelivic pain Dysuria Urethral discharge Proctitis / rectal bleeding Cervical bleeding on contact Cervical excitation
Causes of cervical excitation
Ectopic pregnancy
PID
gonorrhoea
Treatment of gonorrhea
Uncomplicated ano-genital / pharyngeal infection
- IM ceftriaxone 1g intramuscularly
(Monotherapy 2019 guidelines)
- ciprofloxacin 500mg PO STAT if sensitivities from all sites are available before treatment
primary sites of infection of Gonorrhoea
columnar lined epithelium of urethra endocervix rectum pharynx conjunctiva
Which STI is an obligate intracellular pathogen
Chlamydia
symptoms of male urethral gonorrhea
90% symptomatic mucopurulent urethral discharge \+/- offensive smell dysuria rare - testicular / epididymal pain and swelling
signs of male urethral gonorrhoea
mucopurulent urethral discharge on examination
Rare - tenderness of testicles / epididymis
Typical time frame for symptom development in men exposed to gonorrhoea
2-5 days
female presentation of urethral gonorrhoea
dysuria WITHOUT urinary frequency
50% of women with GC are asymptomatic
female symptoms of endocervical gonorrhoea
altered / increased discharge
lower abdominal pain
rare - IMB, PCB, HMB
50% of women with GC are asymptomatic
what proportion of men and women have symptoms with gonorrhoea
90% men
50% female
female signs of urethral gonorrhoea on examination
mucopurulent endocervical discharge
contact cervical bleeding
uncommon - pelvic tenderness
symptoms of rectal gonorroea
usually asymptomatic
anal discharge
peri-anal / anal pain
symptoms of pharyngeal gonorrhoea
usually asymptomatic
sore throat
complications of gonorrhea infection
transluminal spread - epididymo-orchitis, prostatitis, PID
Haematogenous dissemination - skin lesions, arthralgia, arthritis, tenosynovitis
features of gonorrhoea on microscopy
monomorphic gram-negative diplococci within polymorphonuclear leucocytes
when should microscopy got gonorrhoea be carried out
penile urethral discharge
ano-rectal symptoms
what sample is used for GC testing in men
first pass urine NAAT
+/- pharyngeal and rectal NAAT swab
what sample is used for GC testing in women
vulvovaginal swab NAATs
what sample is used for GC testing in hysterectomised women
vulvovaginal swab NAATs
AND first pass urine
what is the role of cultures in gonorrhoea management
primary role is susceptibility testing
when should culture plates for gonorrhoea be taken
alongside NAATs if clinically suspected GC or a contact of GC
before treatment for GC diagnosed by NAATs
what percentage of gonorrhea patients have concurrent chlamydia
~20%
recommended testing for transgender patients after gential reconstruction surgery
transwomen - swabs of neovagina and first pass urine
Transmen - first pass urine of the neopenis
+/- pharyngeal and rectal
look back period for partner testing for a patient with TV
current partner and last 4 weeks
window period for CT and GC
2 weeks
treatment of gonorrhoea when anti-microbial sensitivities is not known
ceftriaxone 1g IM STAT
treatment of gonorrhoea when anti-microbial sensitivities are known
Ciprofloxacin 500mg STAT if sensitive at all sites
prevalence of ciprofloxacin resistant gonorrhea in the UK
~36%
serious side effects of quinolone and fluroquinolone antibiotics
prolonged (months -years) serious, disabling and potentially irreversible drug reactions Tendonitis / tendon rupture, Arthralgia Gait disturbance, Neuropathies Depression Fatigue Memory impairment Sleep disorders Impaired hearing / vision / taste / smell
In what patients should ciprofloxacin be used with caution (or avoided)
Older
Renal impairment
Solid organ transplantation Treated with a corticosteroid All are at higher risk of tendon damage
Avoid if previous adverse reaction with quinolone or fluroquinolone
When should fluroquinolone treatment (such as ciprofloxacin) be discontinued due to SE
First sign of tendon pain or inflammation
consider stopping if symptoms of neuropathy - pain, burning, tingling, numbness/ weakness
treatment of gonorrhoea with penicillin allergy
ceftriaxone 1g IM STAT
or cefixime 400mg PO STAT and azithromycin 2g PO STAT (only if IM refused or CI)
Treatment of gonorrhoea if IM treatment is refused or contraindicated
cefixime 400mg PO STAT
AND azithromycin 2g PO STAT
treatment of gonoccocal PID
Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7
symptoms of PID
lower abdominal / pelvic pain Deep dysparunia PCB IMB HMB Vaginal discharge Fever / generally unwell
signs of PID
abdominal or pelvic tenderness Adnexal tenderness fever >38 degrees Cervicitis Mucopurulent discharge
management of gonococcal epididymo-orchitis
Ceftriaxone 1g IM STAT
AND doxycycline 100mg BD 10-14 days
Management of gonoccocal conjunctivitis in adults
Ceftriaxone 1g IM STAT
saline irrigation
management of disseminated gonoccocal infection
Ceftriaxone 1g IM or IV every 24 hrs
OR Cefotaxime 1g IV 8 hourly
OR ciprofloxacin 500mg IV 12 hourly if susceptible.
Switch to PO 24-48hrs after syx improving - total treatment 7/7 min
What PO medication can be used for disseminated gonoccocal infection 24-48 hours after symptoms start improving
after IV abx switch to PO 24-48 hours after syx improving
- Cefixime 400mg BD
- OR ciprofloxacin 500mg BD
- OR ofloxacin 400mg BD
Treatment of gonorrhoea in pregnancy
Pregnancy doesnt diminish treatment effect AVOID ciprofloxacin or tetracyclines 1st = Ceftriaxone 1g IM STAT or Spectinomycin 2g IM STAT or Azithromycin 2g PO STAT
Treatment of gonorrhoea in HIV positive patients
HIV does not effect treatment
Ceftriaxone 1g IM
OR Ciprofloxacin 500mg STAT if sensitive at all sites
Treatment of gonorrhoea with co-existing chlamydia
Ceftriaxone 1g IM
OR Ciprofloxacin 500mg STAT if sensitive at all sites
AND doxycycline 100mg BD 7/7
Partner notification look back period for gonorrhoea
Symptomatic urethral infection in males - look back 2 weeks (or last partner if >2/52 ago)
All other sites of infection or asymptomatic patients - look back 3 months
Treatment of contacts of gonorrhoea
Window period is 2 weeks
If patient presents >2/52 after exposure treat only if positive test
If patient presents <2/52 consider epidemiological treatment, if asymptomatic consider repeat test once 2/52 and only treat if positive
Follow up and TOC for gonorrhea
ALL patients with GC should have a TOC at 14 days
Emphasis especially on:
- patients with persisting signs / symptoms.
- pharyngeal infection
- Treated with non-first line treatment
- infection acquired in Asia-Pacific area
What should be discussed at a FU visit after treatment of GC
TOC at 14/7 and repeat screening Confirm treatment compliance Ensure symptoms resolved Enquire about adverse reactions Sexual history to exclude re-infection or new infection Pursue partner notification Health promotion
When does PHE need to be notified of gonorrhea infections
If possible treatment failure / resistance
Symptoms / signs of chlamydia infection
Asymptomatic Vaginal discharge Lower abdo pain Intermenstrual bleeding Cervical discharge Post-coital (contact) bleeding Dysuria Urethral discharge
Complications of chlamydia
PID endometritis salpingitis tubal infertility Ectopic pregnancy Fitz-Hugh-Curtis syndrome =peri-hepatitis Neonatal or adult conjunctivitis Neonatal pneumonia conjunctivitis Sexually acquired reactive arthritis Epididymo-orchitis
what Serotypes and serovars of chlamydia exist
Genital chlamydial infection is caused by serotypes D–K. Serovars L1-L3 cause
LGV.
what is the rate of concomittant Mycoplasma Genitalium with chlamydia infection
3-15%
1st line treatment for uncomplicated chlamydia
Doxycycline 100mg BD 7/7
When is a TOC required for chlamydia infection
rectal chlamydia requires TOC at 3/52
In pregnant women
treatment of chlamydia in pregnancy
Azithromycin 1g STAT and 500mg for 2/7
TOC at 3/52
risk factors for chlamydia infection
Age <25yo
new sexual partner
>1 partner in 12m
Inconsistent condom use
Symptoms of chlamydia in women
Most Asymptomatic Vaginal discharge PCB IMB dysuria lower abdominal / pelvic pain deep dysparunia
Signs of chlamydia in women
Mucopurulent discharge
contact bleeding of cervix
pelvic tenderness
cervical motion tenderness
Symptoms of chlamydia in men
Asymptomatic
urethral discharge
dysuria
signs of chlamydia in men
urethral discharge
symptoms of rectal chlamydia
asymptomatic
anal discharge
anorectal discomfort
symptoms of pharyngeal chlamydia infections
usually asymptomatic
symptoms of chlamydia conjunctivitis in adults
usually unilateral (can be bilateral) chronic, low grade irritation
% risk of developing PID after genital chlamydia infection
between 1-30%
what reproductive and gynecological morbidity is associated with symptomatic PID
tubal infertility
ectopic pregnancy
chronic pelvic pain
% of tubal infertility after CT PID
1-20%
symptoms of LGV
tenesmus
anorectal discharge - often bloody
anal discomfort
diarrhoea / altered bowel habit
When should testing for LGV be done?
any patient with symptoms of proctitis
HIV positive MSM with CT at any site
management of chlamydia with and IUD / IUS in situ
doxycycline 100mg BD 7/7
Leave IUCD in situ
2nd line treatment for uncomplicated chlamydia
Azithromycin 1g PO STAT and 500mg OD for 2/7
treatment of rectal chlamydia
Doxycycline 100mg BD 7/7
and TOC at 3/52
treatment of pharyngeal or urethral / vulvo-vaginal chlamydia in HIV positive patients
1st line = Doxycycline 100mg BD 7/7
2nd line = Azithromycin 1g PO STAT and 500mg OD for 2/7
treatment of rectal chlamydia in HIV positive patients
if no result for LGV treat with 3/52 of Doxycycline 100mg BD
and TOC
can ofloxacin be used in pregnancy
no
treatment of chlamydia in pregnancy
AVOID doxycyline or ofloxacin
Azithromycin 1g STAT and 500mg OD 2/7
Common side effects of Azithromycin, erythromycin, doxycycline, ofloxacin and amoxicillin
GI upset - N+V
abdominal discomfort
Diarrhoea
What cardiac side effect can occur with azithromycin
prolongation of the QT interval
Advice for taking doxycycline
take with plenty of water or with food to avoid oesophageal irritation / dysphagia
Avoid sunlamps / sunbathing / strong sunlight
what group of patients who test positive for chlamydia are advised to be re-tested in 3-6months
<25yrs due to high rates of repeat infection
common manifestations of neonatal chlamydia from vertical transmission
opthalmia neonatorium
pneumonia
treatment of neonatal chlamydia
PO erythromycin 50mg/kg/day given in 4 divided doses for 14 days
Topical treatment not required
OR azithromycin 20mg/kd/day PO for 3/7
Treatment of PID
Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7
look back period for partner notification for men with symptomatic urethral chlamydia
4 weeks before symptom onset and any partners since symptom onset / testing
look back period for partner notification for asymptomatic chlamydia
all contacts in preceding 6m
Possible complications of Intravenous drug
Multiple medical complications,
- cellulitis
- abscesses at injecting sites
- deep vein thrombosis
- pulmonary embolism
- bacterial endocarditis
- septic embolization
- rhabdomyolysis
- death through overdose or contamination with toxins.
Sharing needles and syringes contributes to the risk for
- HIV
- hepatitis B and C
- syphilis,
Other drugs such as cocaine, crack cocaine and crystal methamphetamine can lead to
- cardiovascular disease
- neurological disease
- immunosuppression
Potential medical benefits of circumcision
reduces the risk of penile cancer
reduces the risk of UTI
reduces the risk of acquiring sexually transmitted infections including HIV
Medical indications for circumcision
Medical indications for circumcision phimosis recurrent balanitis balanitis xerotica obliterans paraphimosis
What virus causes kaposi’s sarcoma
Kaposi’s sarcoma - caused by HHV-8 (human herpes virus 8)
presentation of Kaposi’s sarcoma
Purple papules or plaques on the skin or mucosa
skin lesions may later ulcerate
respiratory involvement may cause massive haemoptysis and pleural effusion
Management of infants born to HBV +ve mothers
Infants of mothers who are hepatitis B surface antigen positive, or high risk of hepatitis B,
Should receive 1st dose HBV vaccine soon after birth
+ 0.5ml HBV immunoglobulin within 12 hours if mother is surface antigen positive
2nd HBV vaccine at 1-2 months and 3rd at 6 months.
Advice re breastfeeding for HBV +ve patients
hepatitis B cannot be transmitted via breastfeeding
What is epididymo-orchitis?
Pain, swelling, inflammation of the epididymis/ testis
What is the most common route of infection for epididymo-orchitis?
Local extension - from urethra (STIs) or bladder
Most common pathogen causing epididymo-orchitis in <35yo
CT
GC
Most common pathogen causing epididymo-orchitis in >35yo
Gram negative enteric organisms causing UTIs
Esp if recent catheterisation or instrumentation
What are possible infective causes of epididymo-orchitis?
STIs UTI TB Mumps Ureaplasma urealyticum Mycoplasma genitalia Brucellosis Candida
possible non-infective causes of epididymo-orchitis?
Behçet’s disease
SE of amiodarone
Symptoms of epididymo-orchitis?
Unilateral scrotal pain and swelling
Relatively acute
If STI - urethritis / urethral discharge
Urinary symptoms
Symptoms of testicular torsion
Acute onset
Severe pain
Testicular swelling
Usually <20yo
Signs of epididymo-orchitis on examination
Tenderness on palpation Swollen epididymis May be - urethral discharge / secondary hydrocele Erythema / oedema of scrotum Pyrexia
Complications of epididymo-orchitis
Reactive hydrocele
Abscess
Infarction of testicle
Infertility
Investigations for epididymo-orchitis
Gram stained urethral smear - for urethritis
CT and GC NAATS
MCS of MSU
Full STI screen
If urinary tract pathogen is causative send for KUB uss
General advice for epididymo-orchitis
Rest
Analgesia - NSAID
Scrotal support
abstain from SI
What empirical treatment of epididymo-orchitis is recommended
If likely STI related - ceftriaxone 1g IM STAT
AND doxycycline 100mg po bd 14/7
If likely enteric organisms - ofloxacin 200mg BD 14/7
Or ciprofloxacin 500mg BD 10/7
Cefuroxime 1.5g TDS
+/- gentamicin 3-5 days
What IV treatment is recommended for severe epididymo-orchitis
Management if epididymo-orchitis tenderness and swelling persists after antimicrobial treatment
Confirm compliance and sensitivities
If GC confirm TOC
Ref for testicular USS
Causative agents of PID
GC CT Gardnerella vaginalis Anaerobes (prevotella, atopobium, leptotrichia) Mycoplasma genitalium
Pathogen negative PID is common
Most common causative agent of PID
CT - 14-35%
Symptoms of PID
Low abdo pain Vaginal discharge Deep dysparunia PCB IMB HMB Secondary dysmenorrhea
Signs of PID
Low abdo tenderness - usually bilateral
Adnexal tenderness
Cervical motion tenderness
Fever >38 in moderate / severe disease
Complications of PID
More severe symptoms in women with HIV Fitz-Curtis syndrome Tubo-ovarian abscess Future ectopic pregnancy Future subfertility Chronic pelvic pain
First line treatment of PID
IM ceftriaxone 1g STAT
And doxycycline 100mg BD
And metronidazole 400mg BD 14/7
When May IV treatment of PID be indicated
Severe disease Lack of response to oral treatment Pregnancy Tubo-ovarian abscess Intolerance of oral treatment
General management advice for PID
Rest if severe disease
Analgesia
Avoid sexual contact until treatment complete and partner treated
Explain condition and long term risks
Management of M. Gen PID
Moxifloxacin 400mg OD 14/7
Potential serious side effect of moxifloxacin
Serious Liver reaction (uncommon, no deaths reported)
Disabling potentially permanent damage to tendons, muscles, joints and nervous system
Timeframe for M. Gen test of cure in PID
4 weeks
Treatment of gonorrhoea if anaphylaxis to any beta-lactam
Gentamycin 240mg IM STAT
and 2g Azithromycin PO STAT
window period for STS
3 months (12/52)
window period for HIV
4weeks with 4th generation test
otherwise 3m
Sexually transmitted causes of genital ulcers
Herpes Simplex Syphilis Chancroid Granuloma inguinale LGV
What % of patients with gonorrhoea are co-infected with chlamydia?
19%
Sensitivity of NAATs test for gonorrhoea
> 95% sensitive for gonorrhoea in symptomatic and asymptomatic patients
Sensitivity of microscopy for gonorroea for:
- a penile sample with discharge
- Penile sample without discharge
- Penile sample with discharge = 90% sensitivity
- Penile sample without discharge = 50 - 75% sensitivity
Sensitivity of microscopy for gonorroea for:
- Female urethral sample
- Endocervical sample
- Female urethral sample = 20% sensitivity
- Endocervical sample = 37-50% sensitivity
Look back interval for PN for chancroid
10 days before symptoms
Look back interval for PN for CT
M with urethral symptoms - 4 weeks before symptoms
M without urethral symptoms / all F - last 6 months
Look back interval for PN for Epididymo-orchitis
If CT and GC +ve - use these look back intervals
If CT / GC negative - 6m before symptoms
Look back interval for PN for GC
M with urethral symptoms - 2 weeks before syx
M without urethral symptoms / all F - last 3 months
Look back interval for PN for Hep A
With jaundice - 2 weeks before jaundice onset
without jaundice - try to estimate when infection occured and notify 2 weeks before
Inform PH if outbreak suspected
Look back interval for PN for Hep B
Any sexual contact or injection sharing person during the 2 weeks before jaundice onset
if no jaundice - estimate when infection likely or consider long look back
Look back interval for PN for Hep C
usually acute infection unknown
usually acquired by IVDU
or sexual contact where one of both partners is HIV positive
look back to likely time of infection
Look back interval for PN for HIV
estimate when infection likely to have occurred
Ask re possible sero-conversion type illness
PN for all contacts since and 3m before estimated date
or all prev partners since last negative test
Look back interval for PN for LGV
4 weeks before symptoms
Look back interval for PN for NGU
4 weeks before syx
Look back interval for PN for PID
if CT or GC +ve use these look back periods
Otherwise - 6m before symptom onset
Look back interval for PN for pubic lice
3m before symptoms
Look back interval for PN for scabies
all contacts - 2m before symptoms
and non-sexual contacts with prolonged skin contact / share bed or clothes / towels
Look back interval for PN for STS
For early STS - primary - 3m before symtoms
Early STS - secondary and early latent - 2 years before symptoms
late latent STS / late STS - All partners since last negative STS test or lifetime if no prev test
Look back interval for PN for TV
4 weeks before symptoms
GC treatment
antimicrobial susceptibility is not known =
Ceftriaxone 1g IM STAT
If antimicrobial susceptibility known
Ciprofloxacin 500mg PO STAT
Alternative regimens for GC treatment
if needle phobic or absolute CI to ceftriaxone / ciprofloxacin
Cefixime 400mg PO STAT + azithromycin 2g PO
Gentamicin 240mg IM STAT + azithromycin 2g PO
Spectinomycin 2g IM STAT + azithromycin 2g PO
Azithromycin 2g PO
CT treatment
Doxycycline 100mg PO BD 7/7 (CI in pregnancy)
Azithromycin 1g PO STAT then 500mg OD 2/7
Alternative tx for CT if doxy and azithro CI
Erythromycin 500mg BD PO 10–14 days
Ofloxacin 200mg BD or 400mg OD for 7/7
CT treatment in pregnancy
Avoid doxycyline and ofloxacin CI in pregnancy
Azithromycin 1g PO STAT and 500mg OD 2/7 d or Erythromycin 500mg QDS PO 7/7 or Erythromycin 500mg BD 14/7 or Amoxicillin 500mg TDS 7/7
When is TOC recommended for CT
- Pregnancy
- poor compliance suspected
- Symptoms persist
TREATMENT OF FIRST EPISODE NGU
Doxycycline 100mg twice daily for 7 days
Alternative treatment for NGU
Azithromycin 1g STAT then 500mg OD 2/7
or
Ofloxacin 200mg BD or 400mg OD 7/7
TREATMENT OF RECURRENT OR PERSISTENT NGU
If treated with doxycycline regimen first line:
Azithromycin 1g STAT then 500 mg OD 2/7 d
PLUS metronidazole 400mg BD 5/7
Azithromycin should be started within 2 weeks of finishing doxycycline. This is not necessary if the person has tested Mgen-negative.
TREATMENT OF RECURRENT OR PERSISTENT NGU
If treated with Azithromycin 1ST LINE
Moxifloxacin 400mg OD 10/7 AND metronidazole 400mg BD 5/7 or Doxycycline 100mg BD 7/7 plus metronidazole 400mg BD 5/7
Indications for testing for M. genitalium
Based on symptoms - testing recommended ror
people with NGU
people with signs /symptoms of PID
Consider testing for
people with muco-purulent cervicitis / PCB
people with epididymitis
people with sexually-acquired proctitis
Based on risk factors: recommend testing for
current sexual partners of persons infected with M. genitalium
Specimen choice for M. genitalium testing
first void urine in cisgender men vaginal swabs (clinician- or self-taken) in cisgender women where possible - all M. genitalium-positive specimens be tested for macrolide resistance mediating mutations
Treatment of uncomplicated urogenital M. genitalium
M. genitalium urethritis / cervicitis - treat with
Doxycycline 100mg BD 7/7 days
followed by azithromycin 1g PO STAT then 500mg PO OD 2/7
or
Use Moxifloxacin 400mg PO OD 10/7 if known macrolide-resistant or treatment with azithromycin failed
Treatment of complicated M. genitalium urogenital infection = PID / epididymo-orchitis
Moxifloxacin 400mg PO OD 14/7
Treatment of uncomplicated urogenital M. genitalium in pregnancy / breastfeeding
azithromycin 1g PO STAT then 500mg PO OD 2/7
Moxifloxacin is CI
Doxycycline considered safe in first trimester by FDA but BNF advises against it
Treatment of TV
Metronidazole 2g PO STAT
or
Metronidazole 400-500mg BD 5-7 days
Alternative - Tinidazole 2g PO STAT
When is treatment for BV indicated?
Symptomatic women
Women undergoing some surgical procedures
Pregnant women <20/40 with additional risk factors for preterm birth - may benefit
Women who do not volunteer symptoms may elect to take treatment if offered - may report a beneficial change in their discharge following treatment
treatment of BV
Metronidazole 400mg BD 5-7 days
Or
Metronidazole 2 g PO STAT
or
Intravaginal metronidazole gel (0.75%) OD 5/7 days
or
Intravaginal clindamycin cream (2%) OD 7 days
Managing recurrent BV
Suppressive 0.75% metronidazole vaginal gel - 2x per wk for 16 weeks
Probiotic therapy - probiotic lactobacilli applied daily
Antibiotics and probiotic therapy
clindamycin cream and lactobacilli
Lactic acid gel (or acetic acid gel - no longer available in UK) - not been evaluated adequately in well designed RCTs
General advice for 1st episode anogenital HSV
. Saline bathing
. Analgesia
. Topical anaesthetic agents, e.g. 5% lidocaine ointment esp prior to micturition
Antiviral treatment for HSV
Oral antiviral drugs indicated within 5 days of start of episode - while new lesions still forming or if systemic symptoms persist.
Aciclovir, valaciclovir, and famciclovir all effective
Aciclovir 400 mg TDS 5/7
Valaciclovir 500 mg BD 5/7
Review after 5 days + continue if new lesions still appearing or systemic symptoms still present
When may hospitalisation be required for HSV
Management of complications
- urinary retention
- meningism
- severe constitutional symptoms.
Episodic treatment for recurrent HSV
reduction in duration is 1–2 days.
Patient-initiated treatment started early is most effective
Treatment prior to the development of papules is best
- Aciclovir 800 mg TDS for 2 days
- Famciclovir 1 g BD for 1 day
- Valaciclovir 500 mg BD for 3 days
When is suppressive treatment indicated for recurrent HSV
six recurrences per annum
or
patients suffering from psychological morbidity for who the diagnosis causes significant anxiety
Recommended regimens for suppressive treatment for HSV
Recommended regimens
- Aciclovir 400 mg BD or 200mg QDS
- Valaciclovir 500 mg OD
- Famciclovir 250 mg BD (expensive)
Management of recurrent HSV in pregnancy
Recurrent HSV - treat with Aciclovir 400 mg TDS 5/7
Consider aciclovir 400 mg TDS from 36/40 gestation
Management of Primary acquisition of HSV in pregnancy
1st /2nd trimester - treat with Aciclovir 400 mg TDS 5/7
Consider aciclovir 400 mg TDS from 36/40 gestation
3rd trimester - treat with Aciclovir 400 mg TDS 5/7
Consider Aciclovir 400 mg TDS until delivery
Recommend planned CS - esp if within 6/52 of delivery
Inform neonatologist - monitor for 24hr - if well - home
Clinical features of primary STS
Primary Syphilis
Incubation 21 days
Signs - Chancre (develops from a single papule)
Anogenital, single, painless and indurated with clean base, non-purulent
Can be multiple, painful and purulent
Resolve over 3-8 weeks
Clinical features of secondary syphilis
secondary syphilis
If primary syphilis untreated - 25% develop secondary syphilis
Occurs 4-10 weeks after initial chancre
Multi-system
Signs - Rash / Widespread mucocutaneous - May be itchy - Can affect palms and soles
Mucous patches (buccal, lingual and genital)
Condylomata lata (higly infectious, mainly affecting perineum and anus)
Hepatitis
Splenomegaly
Glomerulonephritis
Neurological complications
Acute meningitis
Cranial nerve palsies
Uveitis
Optic neuropathy
Interstitial keratitis and retinal involvement
Clinical features of latent STS
Latent disease
Secondary syphilis will resolve spontaneously in 3–12 weeks
Disease enters an asymptomatic latent stage
Approximately 25% will develop a recurrence of secondary disease during the early latent stage
Clinical features of Late (tertiary) STS
Occurs in approximately 1/3 untreated patients
20-40 years after intial infection
Divided into gummatous, cardiovascular and neurological complications.
Clinical features of Early Congenital syphilis
Early (within two years of birth) Congenital syphilis
2/3 will be asymptomatic at birth but develop signs within 5 weeks
Common: rash haemorrhagic rhinitis generalised lymphadenopathy hepatosplenomegaly skeletal abnormalities
Other signs: condylomata lata vesiculobullous lesions osteochondritis / periostitis pseudoparalysis mucous patches perioral fissures non-immune hydrops glomerulonephritis neurological ocular involvement, haemolysis / thrombocytopenia
Clinical features of late Congenital syphilis
late Congenital syphilis (after two years)
interstitial keratitis; Clutton’s joints; Hutchinson’s incisors; mulberry molars ( high palatal arch; rhagades (peri-oralfissures); sensineural deafness; frontal bossing; short maxilla; protuberance of mandible; saddle-nose deformity; sterno-clavicular thickening; paroxysmal cold haemoglobinuria; neurological involvement (intellectual disability, cranial nerve palsies)
STS serology
EIA +ve
TPHA / TPPA +ve
RPR ≤16
Consistent with treponemal infection at some time.
Could be consistent with recent infection if
seroconversion,
repeat test to look for a four-fold rise in RPR titre
RPR titre ≤16 does not exclude active infection
especially if signs of syphilis or if
adequate treatment of prev dx is not documented / unknown
STS serology
EIA +ve
TPHA / TPPA +ve
RPR >16
recent or active treponemal infection
STS serology
EIA +ve
TPHA / TPPA -ve
Request further sample for repeat testing - to confirm
STS serology
with persisting RPR titre of >16
persisting RPR titre of >16 is seldom seen in patients with adequately treated infection.
Failure to achieve a fourfold fall in RPR titre by six months post-treatment
or an eightfold fall by one year post-treatment
raises concerns about treatment failure or reinfection.
A significant rise in RPR titre suggests reinfection
Follow up testing advice after STS treatment
suggested at 3, 6, 9 and 12 months.
RPR titre is expected to decline at least fourfold by 6 months after treatment of primary, secondary and early latent syphilis.
Further FU if necessary 6-monthly until RPR negative or serofast
no clear criterion for serological response in late latent syphilis
Serology results suggestive of early congenital syphilis
Do not use cord blood IgM +ve RPR - +ve with titre ≥4 times higher than mother’s RPR titre TPPA - +ve
Repeat to confirm and use RPR to monitor response to treatment
Treatment of Early syphilis (primary, secondary and early latent)
Early syphilis (primary, secondary and early latent) Benzathine penicillin G 2.4 MU IM single dose
Treatment of Neurosyphilis
including neurological/ophthalmic involvement in early syphilis
Procaine penicillin 1.8 MU–2.4 MU IM OD plus probenecid 500mg PO QDS for 14 days or Benzylpenicillin 1.8–2.4g IV every 4h for 14 days
define Late latent syphilis
Late latent syphilis: asymptomatic syphilis of two years’ duration or longer
Treatment of late latent, cardiovascular and gummatous syphilis
Benzathine penicillin 2.4 MU IM weekly for three weeks (three doses)
what is the Jarisch-Herxheimer reaction
Reaction to syphilis treatment
Jarisch-Herxheimer reaction = acute febrile illness
headache, myalgia, chills and rigours
resolves within 24 hours
