GUM Flashcards
Gonorrhoea symptoms per site
Men urethra - ax 90%
Women endocervical - 50%
Rectal - most asymp
Pharyngeal - most asymp
NAAT sampling for GC in women, where from?
Vulvovaginal recommended
Where to sample for GC if prev hysterectomy
VVS and
Urine
GC testing for trans woman with neovagina
Swab neovagina and
FPU
GC first line Rx if sensitivities known at all sites
Cipro 500mg PO single dose
Ses of cipro
Inflam of tendons, muscled, joints and nervous system
Caution if ckd or >60
GC Rx alternatives for penicillin allergic patients
2g azithromycin stat plus either:
Cefixime 400mg stat PO or
Gentamicin 240mg IM
Spectinomycin 2g IM (not for throat)
Disseminated GC infection
Rx
Ceftriaxone 1g IV OD or
Cipro 500mg IV BD or
Spectinomycin 2g IM BD
Continue for 7 days totally and switch when 24 hours of improvement to cefixime 400mg BD or cipro 500mg bd
GC Rx options in pregnancy
Ceftriaxone 1g IM or
Spectinomycin 2g IM or
Azithromycin 2g stat
GC PN
Male symptomatic urethral patients - prev 2 weeks
If other patients or asymp - 3/12
When to push GC TOC
Persistent Sx Pharyngeal infection Rx with alternative to first line Infection from Asia Pacific region Pregnancy
When to do TOC for GC
If still sx do culture as long as >72 hours from finishing Rx
If asymp - NAAT 14/7 post finishing Rx
When to test for LGV
MSM if proctitis
HIV pos MSM who are positive for CT at any other site ( even if asymp)
Women with proctitis
First line Rx for CT
Doxycycline 100mg BD for 7 days
Alternative to doxy for CT Rx
Erythromycin 500mg BD for 14/7
Ofloxacin 400mg OD for 7 days
HIV positive and CT what is the consideration re RX
May have LGV
Test for it but RX for 3/52 of doxy and make sure do TOC
CT Rx in pregnancy
Erythromycin 500mg BD for 14/7 or
Amoxicillin 500mg TDS for 7/7
Doxy and oflox contraindicated
TOC 3/52 post Rx
Caution with azithromycin
What is the SE?
Prolonged QT
Doxycycline SE
Dysphagia- swallow with lots of water
Avoid sunlight
When to do TOC following CT infection?
Pregnancy
Poor compliance
Sx persist
MSM with rectal CT if LGV test not done
Perform at least 3/52 post Rx
CT partner notification
Men with urethral Sx- 1/12 pre onset
All others 6/12 pre
Hay/ison criteria for BV diagnosis
Gram stain
Grade 1 normal lacto
Grade 2 intermediate - mixed with some lacto but gardnerella present
Grade 3 BV- mainly gardnerella, few or absent lacto
Mx options for BV
Metronidazole 400mg Bd for 5/7 or
Metronidazole 2g stat
Or
Intravaginal metronidazole gel OD for 5/7 ( good if breastfeeding as taste effects breast milk)
Same Rx in pregnancy
Recurrent Candida definition
4 documented episodes annually with at least partial resolution of Sx in between
Pos microscopy or culture on 2 occasions when symptomatic
5%
Rx of Candida
Clotrimazole 500mg stat, 200mg for 3 nights, 100mg for 6nights
Nystatin pessary 100,000 units per night for 14 nights
Fluconazole 150mg stat or
Itraconazole 200mg Bd for one day
Causes of recurrent Candida
Diabetes- check random blood glucose
HIV or immunosuppressed
HRT/cocp high dose oestrogen
Broad spectrum abx
Rx for recurrent Candida
Induction - fluconazole 150mg every 72 hours for 3 doses then
Maintenance- fluconazole 150mg once a week for 6/12
Alt
Clotrimazole pessary 500mg once a week
Describe non albicans species of candida and their Rx plan
Candida glabrata- still ok with azoles but higher MIC
Candida krusei- resistant to fluconazole
Need 2 weeks
1st nystatin pessary OD for 14/7
Discuss chancroid
H. Ducreyi Gram neg coccobacillus Anogential ulcers and lymphadenitis with bubo formation Transmits through break in skin 4-7 day incubation Diagnose with PCR Common in Africa
Rx azithromycin 1g stat or cef 500mg IM stat
PN - 10/7 pre
Discuss donovanosis
South Africa and papa New Guinea Klebsiella granulomatis Genital ulcer Raised edge Necrotic Lymphadenitis uncommon
Microscopy
Azithromycin weekly 1g weekly
PN 6/12
Sx of HIV seroconversion and how long post infection?
80% seroconvert within 2-4 weeks
Sx- headache, rash, fever, myalgia, pharyngitis
If on ART which contraceptives are ok?
Dmpa
IUC
Man HIV positive and conception plan
If HIV viral load less than 50 for 6/12 and on ART - UPSI at ovulation
Otherwise sperm washing and IUI for 3-6/12
Woman HIV positive and fertility options
If failure to conceive - full fertility screen pre conception
If HIV positive which contraceptive method not ok?
Diaphragm as need to use with N9 which damages condoms and causes ulcers of genitals
If HIV positive and on ART when to check CD4 count during pregnancy?
On booking and at delivery
If commencing ART in pregnancy which criteria need to be met?
Ideally don’t commence in 1st trimester unless viral load over 100,000 or CD4 less than 200
Wait until second trimester
Viral load check 4 weeks post starting ART, once every trimester, 36/40 and at delivery
Untreated HIV pos woman presenting in labour at term, Mx
Stay nevirapine 200mg
IV zidovudine for duration of labour
Screening in pregnancy for HIV pos women
Be aware that bhcg raises by HIV so possible combined test false positive
Invasive prenatal testing - if viral load less than 50
Can have ECV if low viral load
Mode of delivery for woman with HIV
Viral load at 36 weeks:
If <50 - vag del and less than 0.5
% transmission risk
If 50-399 - consider c/s
If over 400 - fed c/s
C/s at 38/40
HIV transmission risk as per site
Receptive anal 1 in 90
Insertive anal 1 in 666
Receptive vaginal 1 in 1000
Needle stick 1 in 333
Never give for oral sex/ semen in eye <1 in 10,000
Needle sharing equipment - 1 in 150
Factors increasing risk of transmission of HIV
Ejaculation
High plasma load (seroconverting)
Non circumcision
Breaches in mucosa in mouth anus or vagina
Sexual assault
Menses or other bleeding - theoretical risk
Stis in hiv positive or genital ulcers in HIV neg
If had UPSI with HIV positive on ART what are the criteria for not needing pepse?
On ART and adherent
Viral load less than 200
For total of 6/12 at least
Pepse regime
Truvada (tenofovir and emtricitabine)
Plus
Raltegrivir
Ideally within 24 hours but up to 72 hours and for 28 days
Missed pepse rules
< 24 hours - take missed dose and usual dose at same time
24-48 hours - continue
> 48 hours - stop pepse
MSM criteria to give pepse
Offer daily or on demand to:
MSM at high risk with condomless anal sez in prev 6/12 and ongoing
Or
Condomless anal sex with HIV pos partner who isn’t virally suppressed
Heterosexual prep who to consider it for
Daily oral prep for men and women if condomless sex with hiv pos partners and not suppressed
Women on dmpa
Trans woman - offer daily dosing if condomless anal sex
How to take prep depending on site
If anal sex - double dose of truvada (2-24hours pre sex) then one a day for 48hours post last UPSI
If less than 7 days since last dose- single dose to start
If vaginal sex - daily regimen and start 7 days pre risk and at least 7 days post. Start with double dose
If IVDU plus anal sex - 7/7 pre and post (daily dosing ideally)
When to give pepse if on prep
If 3 doses in prev week and MSM then can just take further dose and no need for pepse (at least 4 doses needed per week)
If fewer than 3 tablets in prev 7 days or last dose > 7 days ago - pepse
M gen symptoms in men and women
Men - NGU , d/c and dysuria
Women- PID, endometritis, PCB
Who to test for M Gen
PID
NGU
Partners of people infected with MGen
Rx of M gen for uncomplicated cervicitis or urethritis
Doxy 100mg bd for 7/7 Then Azithromycin 1g stat Then Azithromycin 500mg OD for 2 days
( if already had doxy in 2 weeks of m gen diagnosis- just give azith course
M gen Rx if organism know to be macrolide resistant or where azith has failed
Moxifloxacin 400mg OD for 10/7
M gen complicated infection Rx ( PID, epididymorchitis)
Moxifloxacin 400mg OD for 14 days
M Gen Rx in pregnancy
If uncomplicated azithromycin for 3/7
If complicated - as per PID
When to do TOC for M Gen and when can have sex
5/52 post but no sooner than 3/52
Nil sex for 14:7 post Rx
transmission of syphilis
Contact with genital lesion IVDU Blood transfusion Placenta - highest risk in early disease STS massively increases the risk of HIV transmission
Describe primary syphilis
Primary - chancre and lymphadenopathy. Typically 9-90 days incubation. Chancre painless, indurated, single, not pussy
25% go to secondary syphilis
Presentation of secondary syphilis
6 weeks to 6/12 Widespread mucocutaneous rash Lymphadenopathy Palms and soles rash Alopecia Mucous patches (buccal) Condylomata lata
Can also cause glomerulonephritis, hepatitis, splenomegaly
Some get neurological complications meningitis. 8th nerve palsy with hearing loss or optic neuropathy
Tertiary disease of syphilis discuss presentation
20-40 years post initial infection
Gummatous - most common, noses falling off, granulomas lesions with central necrosis, holes in bones and soft tissue - responds well to Rx
CV - 10% - ascending aorta arteritis, dilatation and aortic regurgitation. Saccular aneurysms, MI
Neurological - general paresis of the insane ( cortical neuronal loss can give seizures and hemiparesis), arteritis giving ischaemic stroke
Tabes dorsalis- peripheral neuropathy sensory ataxia due to dorsal column loss and absent reflexes and joint position and vibration sense
Pupil defect that can be found in tertiary syphilis
Argyll Robinson pupil
Is like a prozzie as it accommodates but doesn’t react
Name the other treponemal infections other than palladium
Yaws
Pinta
Bejel
Childhood infections
Yaws - Endemic in Africa, Asia, Pacific
Bejel - Sahel region of Africa
Pinta - American region
Tests to diagnose syphilis
Dark ground microscopy
PCR
Serology - EIA - total antibody igG and igM TPPA - pos for life RPR igM antitreponemal antibody test ( usually pos for 2 years)
Always do second treponemal test to confirm diagnosis. If this doesn’t confirm then do IgG immunoblot
Always repeat RPR on day giving RX
Causes of false positive STS test
Old age
Autoimmune disease
IVDU
When to do an LP in STS
In late syphilis if clinical suspicion of neurological involvement or Rx failure
If RPR hasn’t fallen four fold by 1 year then do LP
Rx for early syphilis
Primary secondary or early latent
Benzathine penicillin 2.4 MU IM
Or
Doxycycline 100mg Po Bd for 14/7
Nil sex for 2/52 post Rx
Late syphilis mx
Late latent, gummatous or CV tertiary disease
Benzathine penicillin 2.4 MU IM weekly for 3 weeks
Or
Doxycycline 100mg BD for 28 days
If cardiac - 24 hours pre and 48hours post of daily pred 40-60mg
Rx of neurosyphilis
Procaine penicillin 2.4 MU IM OD
Plus
Probenecid 500mg PO QDS
( stops urine excretion)
For 14/7
Also give steroids for 24 hrs pre and 48 hours post
If pen allergic - doxy 200mg bd for 28 days
Blood testing post Rx of syphilis
Want to see a four fold drop in RPR
Repeat RPR at 3,6 and 12/12 then 6 monthly until neg
Serofast if 2 readings the same over 6/12
Mx of syphilis in pregnancy
As per normal regime accept if :
In third trimester - give two benzathines within a week of each other
If late syphilis also give steroids if pregnant
Different types of HSV
Type 1 - used to be oral herpes but no most common cause of genital herpes (1 x year)
Type 2 - used to be most common but not now. More likely to cause recurrence (4x a year)
Considerations with HSV serology
When indicated
Useful for recurrent disease of unknown cause
Counselling on initial episodes as to likelihood of recurrence
Pregnant women
Can get false negatives as several weeks to develop type specific igG response
Mx of HSV
First episode
Recurrence
HIV pos
Saline
Analgesia
Topical LA 5% lidocaine ointment
Aciclovir 400mg TDS for 5/7 which reduces duration and severity by 1-2/7
Suppressive HSV MX - aciclovir 400mg BD try for max 1 year and then reassess frequency
Recurrence HSV- over 6 per year
HIV pos - aciclovir 400mg five times daily for 7/7
Risks for transmission of HSV in pregnancy
Risk greatest in third trimester and primary infection, particularly within 6 weeks of delivery
FSE
Vaginal delivery
PROM
Hepatitis A
RNA virus Poor sanitation MSM oral anal or digital rectal Group sex Incubation 28 days Infectious 2 weeks pre and one week post jaundice Sx , promdrome flu illness with RUQ pain then icteric illness with jaundice, nausea < 1% acute liver failure Pos hep a igM. Raised LFTs Mx - rest and oral rehydration Hep A vaccine up to 14/7 post exposure 0,6,12/12 vaccine schedule Usually lifelong immunity post infection
Who to give hep a vaccine to
All MSM single dose
IVDU
Chronic hep b and c
Hep B
DNA virus
Risks MSM IVDU blood donor tattoos sex workers
Most asymp
Same signs and prodrome as hep A
Chronic infection possible uss for fibrosis
Rx if fibrosis and high dna load - tenofovir
High risk of vertical transmission
PN for 2 weeks ore jaundice
Hepatitis B vaccine
Can give within 6 weeks after first exposure
0,7,21
Or
0,1,2/12
Or
0,1,6/12
With booster at 12/12 for both
Test for response 1/12 post last dose
Should be antiHBs antibodies
Hepatitis C
RNA virus Shared needles snorting drugs Also MSM with fisting etc Sex workers prisoners alcoholics Most asymp Chronic hep c - usually asymp worse if other refs for liver disease Mx - fibro scan HCV rna positive - acute infection unless over 6/12 in which case chronic Anti HCV neg- acute HCV core antigen - replication marker
EIA pos
IgM pos
TPPA 1:1280
RPR 1:128
Defo syphilis
IgM pos so prob within past two years
RPR v high - recent infection and prob v infectious
EIA pos
IgM neg
TPPA 1:640
RPR neg
Prev treated an successful Late latent (>2 years ago) Prev exposes to yaws/ pinta or bejel
Hep b serology
HBsAg infection HBeAg marker of replication IgG HBsAg - immune from vaccination IgM HBsAg acute infection IgG HBsAg chronic infection IgG - HBcAg cured prev infection
TV Mx
Metronidazole 2g stat
Or
Metronidazole 400mg BD for 5/7
Nil alcohol for 48 hours afterwards
No sex for 1 week post Rx
Treat partners in prev 4weeks
Mx genital warts
PIL
Condoms
Latex weakened by imiquimod
Soft non keratinised - podophyllotoxin 0.15% cream bd for 3 days then 4 days rest. Avoid in pregnancy
Keratinised - Cryo
Both imiquimod 5% cream - apply 3 x weekly and wash off in 6-10 hours for up to 4/12
Only cryo can be used in pregnancy
Rx of scabies
Premethrin 5% apply to whole body and wash off 8-12 hours later then reapply 1 week later
Or
Malathion 0.5% lotion wash off after 24hours
PID standard Rx
3 alternatives
Ceftriaxone 1g stat IM plus doxy 100mg BD for 14/7 and metronidazole 400mg BD for 14/7
Ofloxacin 400mg BD plus metronidazole 400mg BD for 14/7
Moxifloxacin 400mg Od for 14/7
PID Rx with pregnancy
Ceftriaxone 1g IM then
Azithromycin 1g stat each week for 2 weeks
But Rx as IP for actual pregnant rather than PT risk and give
IV cef plus IV erythromycin plus IV metronidazole
PN for PID
Male partners in prev 6/12 screen
Test current partners if MGen pos and give doxy 100mg BF for 7/7
Rx for LGV
Doxycycline 100mg BD for 3/52
Or
Erythromycin 500mg qds for 3/52 if preggers
Mx of epididymorchitis
Ceftriaxone 500mg stat plus doxy 100mg BD for 14/7
NGU how to diagnose and Rx
Doxycycline 100mg bd for 7/7
Urethral smear
5 or more PMNLs
If smear neg- do early morning smear
Rx partners
Rx of persistent NGU
Recurrence within 1-3/12 of Rx
Azithromycin 500mg stat then 250mg for 4/7 plus metronidazole 400mg BD for 5/7
