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GUM Flashcards

1
Q

Gonorrhoea symptoms per site

A

Men urethra - ax 90%
Women endocervical - 50%
Rectal - most asymp
Pharyngeal - most asymp

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2
Q

NAAT sampling for GC in women, where from?

A

Vulvovaginal recommended

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3
Q

Where to sample for GC if prev hysterectomy

A

VVS and

Urine

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4
Q

GC testing for trans woman with neovagina

A

Swab neovagina and

FPU

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5
Q

GC first line Rx if sensitivities known at all sites

A

Cipro 500mg PO single dose

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6
Q

Ses of cipro

A

Inflam of tendons, muscled, joints and nervous system

Caution if ckd or >60

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7
Q

GC Rx alternatives for penicillin allergic patients

A

2g azithromycin stat plus either:

Cefixime 400mg stat PO or
Gentamicin 240mg IM
Spectinomycin 2g IM (not for throat)

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8
Q

Disseminated GC infection

Rx

A

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

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9
Q

GC Rx options in pregnancy

A

Ceftriaxone 1g IM or
Spectinomycin 2g IM or
Azithromycin 2g stat

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10
Q

GC PN

A

Male symptomatic urethral patients - prev 2 weeks

If other patients or asymp - 3/12

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11
Q

When to push GC TOC

A 
Persistent Sx
Pharyngeal infection 
Rx with alternative to first line
Infection from Asia Pacific region
Pregnancy
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12
Q

When to do TOC for GC

A

If still sx do culture as long as >72 hours from finishing Rx

If asymp - NAAT 14/7 post finishing Rx

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13
Q

When to test for LGV

A

MSM if proctitis
HIV pos MSM who are positive for CT at any other site ( even if asymp)

Women with proctitis

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14
Q

First line Rx for CT

A

Doxycycline 100mg BD for 7 days

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15
Q

Alternative to doxy for CT Rx

A

Erythromycin 500mg BD for 14/7

Ofloxacin 400mg OD for 7 days

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16
Q

HIV positive and CT what is the consideration re RX

A

May have LGV

Test for it but RX for 3/52 of doxy and make sure do TOC

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17
Q

CT Rx in pregnancy

A

Erythromycin 500mg BD for 14/7 or
Amoxicillin 500mg TDS for 7/7

Doxy and oflox contraindicated

TOC 3/52 post Rx

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18
Q

Caution with azithromycin

What is the SE?

A

Prolonged QT

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19
Q

Doxycycline SE

A

Dysphagia- swallow with lots of water

Avoid sunlight

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20
Q

When to do TOC following CT infection?

A

Pregnancy
Poor compliance
Sx persist
MSM with rectal CT if LGV test not done

Perform at least 3/52 post Rx

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21
Q

CT partner notification

A

Men with urethral Sx- 1/12 pre onset

All others 6/12 pre

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22
Q

Hay/ison criteria for BV diagnosis

A

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

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23
Q

Mx options for BV

A

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

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24
Q

Recurrent Candida definition

A

4 documented episodes annually with at least partial resolution of Sx in between

Pos microscopy or culture on 2 occasions when symptomatic

5%

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25
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
26
Causes of recurrent Candida
Diabetes- check random blood glucose HIV or immunosuppressed HRT/cocp high dose oestrogen Broad spectrum abx
27
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
28
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
29
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
30
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
31
Sx of HIV seroconversion and how long post infection?
80% seroconvert within 2-4 weeks Sx- headache, rash, fever, myalgia, pharyngitis
32
If on ART which contraceptives are ok?
Dmpa | IUC
33
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
34
Woman HIV positive and fertility options
If failure to conceive - full fertility screen pre conception
35
If HIV positive which contraceptive method not ok?
Diaphragm as need to use with N9 which damages condoms and causes ulcers of genitals
36
If HIV positive and on ART when to check CD4 count during pregnancy?
On booking and at delivery
37
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
38
Untreated HIV pos woman presenting in labour at term, Mx
Stay nevirapine 200mg | IV zidovudine for duration of labour
39
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
40
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
41
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
42
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
43
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
44
Pepse regime
Truvada (tenofovir and emtricitabine) Plus Raltegrivir Ideally within 24 hours but up to 72 hours and for 28 days
45
Missed pepse rules
< 24 hours - take missed dose and usual dose at same time 24-48 hours - continue > 48 hours - stop pepse
46
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
47
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
48
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)
49
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
50
M gen symptoms in men and women
Men - NGU , d/c and dysuria Women- PID, endometritis, PCB
51
Who to test for M Gen
PID NGU Partners of people infected with MGen
52
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
53
M gen Rx if organism know to be macrolide resistant or where azith has failed
Moxifloxacin 400mg OD for 10/7
54
M gen complicated infection Rx ( PID, epididymorchitis)
Moxifloxacin 400mg OD for 14 days
55
M Gen Rx in pregnancy
If uncomplicated azithromycin for 3/7 If complicated - as per PID
56
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
57
transmission of syphilis
``` Contact with genital lesion IVDU Blood transfusion Placenta - highest risk in early disease STS massively increases the risk of HIV transmission ```
58
Describe primary syphilis
Primary - chancre and lymphadenopathy. Typically 9-90 days incubation. Chancre painless, indurated, single, not pussy 25% go to secondary syphilis
59
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
60
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
61
Pupil defect that can be found in tertiary syphilis
Argyll Robinson pupil Is like a prozzie as it accommodates but doesn’t react
62
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
63
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
64
Causes of false positive STS test
Old age Autoimmune disease IVDU
65
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
66
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
67
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
68
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
69
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
70
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
71
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)
72
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
73
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
74
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
75
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 ```
76
Who to give hep a vaccine to
All MSM single dose IVDU Chronic hep b and c
77
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
78
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
79
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 ```
80
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
81
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 ```
82
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 ```
83
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
84
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
85
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
86
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
87
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
88
PN for PID
Male partners in prev 6/12 screen Test current partners if MGen pos and give doxy 100mg BF for 7/7
89
Rx for LGV
Doxycycline 100mg BD for 3/52 Or Erythromycin 500mg qds for 3/52 if preggers
90
Mx of epididymorchitis
Ceftriaxone 500mg stat plus doxy 100mg BD for 14/7
91
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
92
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

MFSRH (8 decks)

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