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MFSRH part 2 > GUM > Flashcards

GUM Flashcards

1
Q

Symptoms of candidal vulvovaginitis

A

Soreness
Itching
Red skin - possible peeling, pustules or apples
White discharge

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2
Q

When to refer candidal vulvovaginitis

A 
Unclear diagnosis
No improvement despite treatment
Immunocompromised patient
Systemic treatment needed 
Recurrent candida - specialist GUM clinic
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3
Q

Treatment of candidal vulvovaginitis

A

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

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4
Q

Types of candida species

A 
Candida albicans
Candida tropicalis
Candida glabrata
Candida krusei
Candida parasilosis
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5
Q

Common species involved in bacterial vaginosis

A

Gardnerella vaginalis
Mycoplasma hominis
Bacteroides
Mobilincus

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6
Q

Which STI is a flagellate Protozoan

A

Trichomonas vaginalis

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7
Q

Symptoms of Trichomonas vaginalis in women

A 
10 - 50% asymptomatic
non-specific symtoms
Vaginal discharge
Vulval soreness + itching 
Odour
Discharge may be frothy / green
Dysuria 
occasionally - low abdominal pain, vulval ulcers
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8
Q

Diagnosis of Trichomonas vaginalis

A

Microscopy of vaginal discharge

and TV NAATs

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9
Q

Treatment of Trichomonas vaginalis

A

Metronidazole (2g) single dose

Both partners simultaneously

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10
Q

signs of TV on examination of female patients

A 
Vaginal discharge in 70%
Frothy yellow / green discharge
Vulvitis
Strawberry cervix (punctate haemorrhages) - 2%
Frothy discharge
5-15% NAD
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11
Q

Symptoms of TV in men

A 
15 - 50% asymptomatic
Urethral discharge
dysuria
Urethral irritation
Urinary frequency
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12
Q

signs of TV on examination of male patients

A

urethral discharge - 20-60%
No signs - up to 70%
rare - balanoposthitis

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13
Q

what is balanoposthitis

A

inflammation of the foreskin and glans

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14
Q

Complications of TV

A

impact on pregnancy - low birth weight, pre-term delivery, maternal post-partum sepsis
Association with HIV
May enhance HIV transmission

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15
Q

diagnostic findings of TV on microscopy

A

detection of motile trichomonads by light field microscopy from wet prep slide

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16
Q

general advice when treating TV

A

Treat both partners simultaneously

Avoid sexual intercourse until 1 week after both partners completed treatment

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17
Q

Treatment used for TV

A

metronidazole 2g PO STAT
or metronidazole 400-500mg BD 5-7 days

Alternative = tinidazole 2g PO STAT (expensive)

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18
Q

can metronidazole be used in pregnancy and breastfeeding

A

Safe in all trimesters
Non Teratogenic
Safe in breastfeeding but may affect milk taste (avoid STAT dose)

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19
Q

Can tinidazole be used in pregnancy and breastfeeding

A

No - unsafe in animal trials

No evidence re human use in pregnancy and breastfeeding

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20
Q

Treatment of TV in a HIV positive patient

A

Use metronidazole 500mg BD for 7 days

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21
Q

what possible reaction should patients be warned about when taking metronidazole

A

disulfram-like reaction if taken with alcohol

Avoid all alcohol for duration of treatment and 48 hours afterwards

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22
Q

causes of treatment failure in TV

A

inadequate therapy
re-infection
resistance

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23
Q

Follow up recommendations for patient with TV

A

window period tests and bloods

No FU for TV unless symptoms continue

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24
Q

treatment protocol for non-response to standard TV therapy

A

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

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25
Q

Symptoms of bacterial vaginosis

A

Malodorous fishy discharge
Asymptomatic carriers
More prominent during menstruation
Cream / grey discharge - commonly adheres to wall of vagina

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26
Q

What do clue cells suggest

A

Bacterial vaginosis

Clue cell = epithelial cell covered in bacteria

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27
Q

What is a clue cell

A

Clue cell = epithelial cell covered in bacteria

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28
Q

Management of bacterial vaginosis

A

metronidazole 400-500mg BD 5-7 days or metronidazole 2g PO STAT (not in pregnancy)

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29
Q

Problems with bacterial vaginosis in pregnancy

A

In 1st T can –> second trimester miscarriages or preterm labour
Treat with metronidazole

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30
Q

Which STI is a gram -ve diplococcus

A

Neisseria gonorrhoea

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31
Q

Symptoms of gonorrhoea

A 
Asymptomatic 
Increased vaginal discharge
Abdo / pelivic pain
Dysuria
Urethral discharge 
Proctitis / rectal bleeding 
Cervical bleeding on contact
Cervical excitation
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32
Q

Causes of cervical excitation

A

Ectopic pregnancy
PID
gonorrhoea

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33
Q

Treatment of gonorrhea

A

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

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34
Q

primary sites of infection of Gonorrhoea

A 
columnar lined epithelium of
urethra
endocervix
rectum
pharynx
conjunctiva
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35
Q

Which STI is an obligate intracellular pathogen

A

Chlamydia

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36
Q

symptoms of male urethral gonorrhea

A 
90% symptomatic
mucopurulent urethral discharge 
\+/- offensive smell
dysuria
rare - testicular / epididymal pain and swelling
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37
Q

signs of male urethral gonorrhoea

A

mucopurulent urethral discharge on examination

Rare - tenderness of testicles / epididymis

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38
Q

Typical time frame for symptom development in men exposed to gonorrhoea

A

2-5 days

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39
Q

female presentation of urethral gonorrhoea

A

dysuria WITHOUT urinary frequency

50% of women with GC are asymptomatic

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40
Q

female symptoms of endocervical gonorrhoea

A

altered / increased discharge
lower abdominal pain
rare - IMB, PCB, HMB
50% of women with GC are asymptomatic

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41
Q

what proportion of men and women have symptoms with gonorrhoea

A

90% men

50% female

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42
Q

female signs of urethral gonorrhoea on examination

A

mucopurulent endocervical discharge
contact cervical bleeding
uncommon - pelvic tenderness

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43
Q

symptoms of rectal gonorroea

A

usually asymptomatic
anal discharge
peri-anal / anal pain

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44
Q

symptoms of pharyngeal gonorrhoea

A

usually asymptomatic

sore throat

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45
Q

complications of gonorrhea infection

A

transluminal spread - epididymo-orchitis, prostatitis, PID

Haematogenous dissemination - skin lesions, arthralgia, arthritis, tenosynovitis

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46
Q

features of gonorrhoea on microscopy

A

monomorphic gram-negative diplococci within polymorphonuclear leucocytes

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47
Q

when should microscopy got gonorrhoea be carried out

A

penile urethral discharge

ano-rectal symptoms

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48
Q

what sample is used for GC testing in men

A

first pass urine NAAT

+/- pharyngeal and rectal NAAT swab

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49
Q

what sample is used for GC testing in women

A

vulvovaginal swab NAATs

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50
Q

what sample is used for GC testing in hysterectomised women

A

vulvovaginal swab NAATs

AND first pass urine

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51
Q

what is the role of cultures in gonorrhoea management

A

primary role is susceptibility testing

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52
Q

when should culture plates for gonorrhoea be taken

A

alongside NAATs if clinically suspected GC or a contact of GC
before treatment for GC diagnosed by NAATs

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53
Q

what percentage of gonorrhea patients have concurrent chlamydia

A

~20%

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54
Q

recommended testing for transgender patients after gential reconstruction surgery

A

transwomen - swabs of neovagina and first pass urine
Transmen - first pass urine of the neopenis
+/- pharyngeal and rectal

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55
Q

look back period for partner testing for a patient with TV

A

current partner and last 4 weeks

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56
Q

window period for CT and GC

A

2 weeks

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57
Q

treatment of gonorrhoea when anti-microbial sensitivities is not known

A

ceftriaxone 1g IM STAT

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58
Q

treatment of gonorrhoea when anti-microbial sensitivities are known

A

Ciprofloxacin 500mg STAT if sensitive at all sites

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59
Q

prevalence of ciprofloxacin resistant gonorrhea in the UK

A

~36%

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60
Q

serious side effects of quinolone and fluroquinolone antibiotics

A 
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
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61
Q

In what patients should ciprofloxacin be used with caution (or avoided)

A

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

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62
Q

When should fluroquinolone treatment (such as ciprofloxacin) be discontinued due to SE

A

First sign of tendon pain or inflammation

consider stopping if symptoms of neuropathy - pain, burning, tingling, numbness/ weakness

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63
Q

treatment of gonorrhoea with penicillin allergy

A

ceftriaxone 1g IM STAT

or cefixime 400mg PO STAT and azithromycin 2g PO STAT (only if IM refused or CI)

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64
Q

Treatment of gonorrhoea if IM treatment is refused or contraindicated

A

cefixime 400mg PO STAT

AND azithromycin 2g PO STAT

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65
Q

treatment of gonoccocal PID

A

Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7

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66
Q

symptoms of PID

A 
lower abdominal / pelvic pain
Deep dysparunia
PCB
IMB
HMB
Vaginal discharge
Fever / generally unwell
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67
Q

signs of PID

A 
abdominal or pelvic tenderness
Adnexal tenderness
fever >38 degrees
Cervicitis
Mucopurulent discharge
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68
Q

management of gonococcal epididymo-orchitis

A

Ceftriaxone 1g IM STAT

AND doxycycline 100mg BD 10-14 days

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69
Q

Management of gonoccocal conjunctivitis in adults

A

Ceftriaxone 1g IM STAT

saline irrigation

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70
Q

management of disseminated gonoccocal infection

A

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

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71
Q

What PO medication can be used for disseminated gonoccocal infection 24-48 hours after symptoms start improving

A

after IV abx switch to PO 24-48 hours after syx improving

  • Cefixime 400mg BD
  • OR ciprofloxacin 500mg BD
  • OR ofloxacin 400mg BD
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72
Q

Treatment of gonorrhoea in pregnancy

A 
Pregnancy doesnt diminish treatment effect
AVOID ciprofloxacin or tetracyclines
1st = Ceftriaxone 1g IM STAT
or Spectinomycin 2g IM STAT
or Azithromycin 2g PO STAT
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73
Q

Treatment of gonorrhoea in HIV positive patients

A

HIV does not effect treatment
Ceftriaxone 1g IM
OR Ciprofloxacin 500mg STAT if sensitive at all sites

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74
Q

Treatment of gonorrhoea with co-existing chlamydia

A

Ceftriaxone 1g IM
OR Ciprofloxacin 500mg STAT if sensitive at all sites
AND doxycycline 100mg BD 7/7

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75
Q

Partner notification look back period for gonorrhoea

A

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

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76
Q

Treatment of contacts of gonorrhoea

A

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

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77
Q

Follow up and TOC for gonorrhea

A

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

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78
Q

What should be discussed at a FU visit after treatment of GC

A 
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
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79
Q

When does PHE need to be notified of gonorrhea infections

A

If possible treatment failure / resistance

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80
Q

Symptoms / signs of chlamydia infection

A 
Asymptomatic 
Vaginal discharge 
Lower abdo pain
Intermenstrual bleeding
Cervical discharge 
Post-coital (contact) bleeding
Dysuria 
Urethral discharge
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81
Q

Complications of chlamydia

A 
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
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82
Q

what Serotypes and serovars of chlamydia exist

A

Genital chlamydial infection is caused by serotypes D–K. Serovars L1-L3 cause
LGV.

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83
Q

what is the rate of concomittant Mycoplasma Genitalium with chlamydia infection

A

3-15%

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84
Q

1st line treatment for uncomplicated chlamydia

A

Doxycycline 100mg BD 7/7

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85
Q

When is a TOC required for chlamydia infection

A

rectal chlamydia requires TOC at 3/52

In pregnant women

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86
Q

treatment of chlamydia in pregnancy

A

Azithromycin 1g STAT and 500mg for 2/7

TOC at 3/52

87
Q

risk factors for chlamydia infection

A

Age <25yo
new sexual partner
>1 partner in 12m
Inconsistent condom use

88
Q

Symptoms of chlamydia in women

A 
Most Asymptomatic
Vaginal discharge
PCB
IMB
dysuria
lower abdominal / pelvic pain
deep dysparunia
89
Q

Signs of chlamydia in women

A

Mucopurulent discharge
contact bleeding of cervix
pelvic tenderness
cervical motion tenderness

90
Q

Symptoms of chlamydia in men

A

Asymptomatic
urethral discharge
dysuria

91
Q

signs of chlamydia in men

A

urethral discharge

92
Q

symptoms of rectal chlamydia

A

asymptomatic
anal discharge
anorectal discomfort

93
Q

symptoms of pharyngeal chlamydia infections

A

usually asymptomatic

94
Q

symptoms of chlamydia conjunctivitis in adults

A 
usually unilateral (can be bilateral) 
chronic, low grade irritation
95
Q

% risk of developing PID after genital chlamydia infection

A

between 1-30%

96
Q

what reproductive and gynecological morbidity is associated with symptomatic PID

A

tubal infertility
ectopic pregnancy
chronic pelvic pain

97
Q

% of tubal infertility after CT PID

A

1-20%

98
Q

symptoms of LGV

A

tenesmus
anorectal discharge - often bloody
anal discomfort
diarrhoea / altered bowel habit

99
Q

When should testing for LGV be done?

A

any patient with symptoms of proctitis

HIV positive MSM with CT at any site

100
Q

management of chlamydia with and IUD / IUS in situ

A

doxycycline 100mg BD 7/7

Leave IUCD in situ

101
Q

2nd line treatment for uncomplicated chlamydia

A

Azithromycin 1g PO STAT and 500mg OD for 2/7

102
Q

treatment of rectal chlamydia

A

Doxycycline 100mg BD 7/7

and TOC at 3/52

103
Q

treatment of pharyngeal or urethral / vulvo-vaginal chlamydia in HIV positive patients

A

1st line = Doxycycline 100mg BD 7/7

2nd line = Azithromycin 1g PO STAT and 500mg OD for 2/7

104
Q

treatment of rectal chlamydia in HIV positive patients

A

if no result for LGV treat with 3/52 of Doxycycline 100mg BD

and TOC

105
Q

can ofloxacin be used in pregnancy

A

no

106
Q

treatment of chlamydia in pregnancy

A

AVOID doxycyline or ofloxacin

Azithromycin 1g STAT and 500mg OD 2/7

107
Q

Common side effects of Azithromycin, erythromycin, doxycycline, ofloxacin and amoxicillin

A

GI upset - N+V
abdominal discomfort
Diarrhoea

108
Q

What cardiac side effect can occur with azithromycin

A

prolongation of the QT interval

109
Q

Advice for taking doxycycline

A

take with plenty of water or with food to avoid oesophageal irritation / dysphagia
Avoid sunlamps / sunbathing / strong sunlight

110
Q

what group of patients who test positive for chlamydia are advised to be re-tested in 3-6months

A

<25yrs due to high rates of repeat infection

111
Q

common manifestations of neonatal chlamydia from vertical transmission

A

opthalmia neonatorium

pneumonia

112
Q

treatment of neonatal chlamydia

A

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

113
Q

Treatment of PID

A

Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7

114
Q

look back period for partner notification for men with symptomatic urethral chlamydia

A

4 weeks before symptom onset and any partners since symptom onset / testing

115
Q

look back period for partner notification for asymptomatic chlamydia

A

all contacts in preceding 6m

116
Q

Possible complications of Intravenous drug

A

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
117
Q

Potential medical benefits of circumcision

A

reduces the risk of penile cancer
reduces the risk of UTI
reduces the risk of acquiring sexually transmitted infections including HIV

118
Q

Medical indications for circumcision

A 
Medical indications for circumcision
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
119
Q

What virus causes kaposi’s sarcoma

A

Kaposi’s sarcoma - caused by HHV-8 (human herpes virus 8)

120
Q

presentation of Kaposi’s sarcoma

A

Purple papules or plaques on the skin or mucosa
skin lesions may later ulcerate
respiratory involvement may cause massive haemoptysis and pleural effusion

121
Q

Management of infants born to HBV +ve mothers

A

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.

122
Q

Advice re breastfeeding for HBV +ve patients

A

hepatitis B cannot be transmitted via breastfeeding

123
Q

What is epididymo-orchitis?

A

Pain, swelling, inflammation of the epididymis/ testis

124
Q

What is the most common route of infection for epididymo-orchitis?

A

Local extension - from urethra (STIs) or bladder

125
Q

Most common pathogen causing epididymo-orchitis in <35yo

A

CT

GC

126
Q

Most common pathogen causing epididymo-orchitis in >35yo

A

Gram negative enteric organisms causing UTIs

Esp if recent catheterisation or instrumentation

127
Q

What are possible infective causes of epididymo-orchitis?

A 
STIs
UTI
TB
Mumps
Ureaplasma urealyticum
Mycoplasma genitalia
Brucellosis 
Candida
128
Q

possible non-infective causes of epididymo-orchitis?

A

Behçet’s disease

SE of amiodarone

129
Q

Symptoms of epididymo-orchitis?

A

Unilateral scrotal pain and swelling
Relatively acute
If STI - urethritis / urethral discharge
Urinary symptoms

130
Q

Symptoms of testicular torsion

A

Acute onset
Severe pain
Testicular swelling
Usually <20yo

131
Q

Signs of epididymo-orchitis on examination

A 
Tenderness on palpation 
Swollen epididymis 
May be - urethral discharge / secondary hydrocele
Erythema / oedema of scrotum 
Pyrexia
132
Q

Complications of epididymo-orchitis

A

Reactive hydrocele
Abscess
Infarction of testicle
Infertility

133
Q

Investigations for epididymo-orchitis

A

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

134
Q

General advice for epididymo-orchitis

A

Rest
Analgesia - NSAID
Scrotal support
abstain from SI

135
Q

What empirical treatment of epididymo-orchitis is recommended

A

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

136
Q

Cefuroxime 1.5g TDS

+/- gentamicin 3-5 days

A

What IV treatment is recommended for severe epididymo-orchitis

137
Q

Management if epididymo-orchitis tenderness and swelling persists after antimicrobial treatment

A

Confirm compliance and sensitivities
If GC confirm TOC
Ref for testicular USS

138
Q

Causative agents of PID

A 
GC
CT
Gardnerella vaginalis 
Anaerobes (prevotella, atopobium, leptotrichia)
Mycoplasma genitalium

Pathogen negative PID is common

139
Q

Most common causative agent of PID

A

CT - 14-35%

140
Q

Symptoms of PID

A 
Low abdo pain 
Vaginal discharge 
 Deep dysparunia
PCB
IMB
HMB
Secondary dysmenorrhea
141
Q

Signs of PID

A

Low abdo tenderness - usually bilateral
Adnexal tenderness
Cervical motion tenderness
Fever >38 in moderate / severe disease

142
Q

Complications of PID

A 
More severe symptoms in women with HIV
Fitz-Curtis syndrome 
Tubo-ovarian abscess 
Future ectopic pregnancy
Future subfertility
Chronic pelvic pain
143
Q

First line treatment of PID

A

IM ceftriaxone 1g STAT
And doxycycline 100mg BD
And metronidazole 400mg BD 14/7

144
Q

When May IV treatment of PID be indicated

A 
Severe disease 
Lack of response to oral treatment 
Pregnancy 
Tubo-ovarian abscess
Intolerance of oral treatment
145
Q

General management advice for PID

A

Rest if severe disease
Analgesia
Avoid sexual contact until treatment complete and partner treated
Explain condition and long term risks

146
Q

Management of M. Gen PID

A

Moxifloxacin 400mg OD 14/7

147
Q

Potential serious side effect of moxifloxacin

A

Serious Liver reaction (uncommon, no deaths reported)

Disabling potentially permanent damage to tendons, muscles, joints and nervous system

148
Q

Timeframe for M. Gen test of cure in PID

A

4 weeks

149
Q

Treatment of gonorrhoea if anaphylaxis to any beta-lactam

A

Gentamycin 240mg IM STAT

and 2g Azithromycin PO STAT

150
Q

window period for STS

A

3 months (12/52)

151
Q

window period for HIV

A

4weeks with 4th generation test

otherwise 3m

152
Q

Sexually transmitted causes of genital ulcers

A 
Herpes Simplex
Syphilis
Chancroid
Granuloma inguinale
LGV
153
Q

What % of patients with gonorrhoea are co-infected with chlamydia?

A

19%

154
Q

Sensitivity of NAATs test for gonorrhoea

A

> 95% sensitive for gonorrhoea in symptomatic and asymptomatic patients

155
Q

Sensitivity of microscopy for gonorroea for:

  • a penile sample with discharge
  • Penile sample without discharge
A
  • Penile sample with discharge = 90% sensitivity

- Penile sample without discharge = 50 - 75% sensitivity

156
Q

Sensitivity of microscopy for gonorroea for:

  • Female urethral sample
  • Endocervical sample
A
  • Female urethral sample = 20% sensitivity

- Endocervical sample = 37-50% sensitivity

157
Q

Look back interval for PN for chancroid

A

10 days before symptoms

158
Q

Look back interval for PN for CT

A

M with urethral symptoms - 4 weeks before symptoms

M without urethral symptoms / all F - last 6 months

159
Q

Look back interval for PN for Epididymo-orchitis

A

If CT and GC +ve - use these look back intervals

If CT / GC negative - 6m before symptoms

160
Q

Look back interval for PN for GC

A

M with urethral symptoms - 2 weeks before syx

M without urethral symptoms / all F - last 3 months

161
Q

Look back interval for PN for Hep A

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

162
Q

Look back interval for PN for Hep B

A

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

163
Q

Look back interval for PN for Hep C

A

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

164
Q

Look back interval for PN for HIV

A

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

165
Q

Look back interval for PN for LGV

A

4 weeks before symptoms

166
Q

Look back interval for PN for NGU

A

4 weeks before syx

167
Q

Look back interval for PN for PID

A

if CT or GC +ve use these look back periods

Otherwise - 6m before symptom onset

168
Q

Look back interval for PN for pubic lice

A

3m before symptoms

169
Q

Look back interval for PN for scabies

A

all contacts - 2m before symptoms

and non-sexual contacts with prolonged skin contact / share bed or clothes / towels

170
Q

Look back interval for PN for STS

A

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

171
Q

Look back interval for PN for TV

A

4 weeks before symptoms

172
Q

GC treatment

A

antimicrobial susceptibility is not known =
Ceftriaxone 1g IM STAT

If antimicrobial susceptibility known
Ciprofloxacin 500mg PO STAT

173
Q

Alternative regimens for GC treatment

if needle phobic or absolute CI to ceftriaxone / ciprofloxacin

A

Cefixime 400mg PO STAT + azithromycin 2g PO

Gentamicin 240mg IM STAT + azithromycin 2g PO

Spectinomycin 2g IM STAT + azithromycin 2g PO

Azithromycin 2g PO

174
Q

CT treatment

A

Doxycycline 100mg PO BD 7/7 (CI in pregnancy)

Azithromycin 1g PO STAT then 500mg OD 2/7

175
Q

Alternative tx for CT if doxy and azithro CI

A

Erythromycin 500mg BD PO 10–14 days

Ofloxacin 200mg BD or 400mg OD for 7/7

176
Q

CT treatment in pregnancy

A

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
177
Q

When is TOC recommended for CT

A
  • Pregnancy
  • poor compliance suspected
  • Symptoms persist
178
Q

TREATMENT OF FIRST EPISODE NGU

A

Doxycycline 100mg twice daily for 7 days

179
Q

Alternative treatment for NGU

A

Azithromycin 1g STAT then 500mg OD 2/7
or
Ofloxacin 200mg BD or 400mg OD 7/7

180
Q

TREATMENT OF RECURRENT OR PERSISTENT NGU

If treated with doxycycline regimen first line:

A

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.

181
Q

TREATMENT OF RECURRENT OR PERSISTENT NGU

If treated with Azithromycin 1ST LINE

A 
Moxifloxacin 400mg OD 10/7 
AND metronidazole 400mg BD 5/7 
or
Doxycycline 100mg BD 7/7 
plus metronidazole 400mg BD 5/7
182
Q

Indications for testing for M. genitalium

A

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

183
Q

Specimen choice for M. genitalium testing

A 
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
184
Q

Treatment of uncomplicated urogenital M. genitalium

A

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

185
Q

Treatment of uncomplicated urogenital M. genitalium in pregnancy / breastfeeding

A

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

186
Q

Treatment of TV

A

Metronidazole 2g PO STAT
or
Metronidazole 400-500mg BD 5-7 days

Alternative - Tinidazole 2g PO STAT

187
Q

When is treatment for BV indicated?

A

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

188
Q

treatment of BV

A

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

189
Q

Managing recurrent BV

A

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

190
Q

General advice for 1st episode anogenital HSV

A

. Saline bathing
. Analgesia
. Topical anaesthetic agents, e.g. 5% lidocaine ointment esp prior to micturition

191
Q

Antiviral treatment for HSV

A

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

192
Q

When may hospitalisation be required for HSV

A

Management of complications

  • urinary retention
  • meningism
  • severe constitutional symptoms.
193
Q

Episodic treatment for recurrent HSV

A

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

194
Q

When is suppressive treatment indicated for recurrent HSV

A

six recurrences per annum
or
patients suffering from psychological morbidity for who the diagnosis causes significant anxiety

195
Q

Recommended regimens for suppressive treatment for HSV

A

Recommended regimens

  • Aciclovir 400 mg BD or 200mg QDS
  • Valaciclovir 500 mg OD
  • Famciclovir 250 mg BD (expensive)
196
Q

Management of recurrent HSV in pregnancy

A

Recurrent HSV - treat with Aciclovir 400 mg TDS 5/7

Consider aciclovir 400 mg TDS from 36/40 gestation

197
Q

Management of Primary acquisition of HSV in pregnancy

A

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

198
Q

Clinical features of primary STS

A

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

199
Q

Clinical features of secondary syphilis

A

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

200
Q

Clinical features of latent STS

A

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

201
Q

Clinical features of Late (tertiary) STS

A

Occurs in approximately 1/3 untreated patients
20-40 years after intial infection

Divided into gummatous, cardiovascular and neurological complications.

202
Q

Clinical features of Early Congenital syphilis

A

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
203
Q

Clinical features of late Congenital syphilis

A

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)
204
Q

STS serology
EIA +ve
TPHA / TPPA +ve
RPR ≤16

A

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

205
Q

STS serology
EIA +ve
TPHA / TPPA +ve
RPR >16

A

recent or active treponemal infection

206
Q

STS serology
EIA +ve
TPHA / TPPA -ve

A

Request further sample for repeat testing - to confirm

207
Q

STS serology

with persisting RPR titre of >16

A

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

208
Q

Follow up testing advice after STS treatment

A

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

209
Q

Serology results suggestive of early congenital syphilis

A 
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

210
Q

Treatment of Early syphilis (primary, secondary and early latent)

A 
Early syphilis (primary, secondary and early latent)
Benzathine penicillin G 2.4 MU IM single dose
211
Q

Treatment of Neurosyphilis

including neurological/ophthalmic involvement in early syphilis

A 
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
212
Q

define Late latent syphilis

A

Late latent syphilis: asymptomatic syphilis of two years’ duration or longer

213
Q

Treatment of late latent, cardiovascular and gummatous syphilis

A

Benzathine penicillin 2.4 MU IM weekly for three weeks (three doses)

214
Q

what is the Jarisch-Herxheimer reaction

A

Reaction to syphilis treatment

Jarisch-Herxheimer reaction = acute febrile illness
headache, myalgia, chills and rigours
resolves within 24 hours

MFSRH part 2 (24 decks)

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