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IC18 STIs Flashcards

1
Q

What is the general mode of transmission of STIs?

A
  • sexual contact
  • direct contact of broken skin w open sores, blood, genital discharge
  • transfusion with contaminated blood & blood pdts
  • mother-to-child (pregnancy, childbirth, breastfeeding)
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2
Q

What are the risk factors for acquiring STIs?

A
  • unprotected sex with infected people
  • multiple sex partners / sexual contact w ppl w multiple sex partners
  • commercial sex workers
  • MSM
  • illicit drug use
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3
Q

What are some methods available to prevent STIs?

A
  • abstinence
  • male latex condom
  • avoid drug use & sharing of needles
  • pre-exposure vax (HPV, Hep B)
  • pre & post exposure prophylaxis (HIV)
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4
Q

What are the STIs taught in the IC?

A
  • gonorrhoea
  • chlamydia
  • syphilis
  • genital herpes
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5
Q

What bacteria causes gonorrhoea?

A

Neisseria gonorrhoea

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6
Q

What are the modes of transmission of gonorrhoea?

A
  • sexual contact
  • mother to child during childbirth
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7
Q

What are some methods for diagnosis of gonorrhoea?

A
  • gram-stain of genital fluids
  • culture
  • NAAT
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8
Q

What is unique about Neisseria gonorrhoea?

A

It can spread and infect multiple sites, such as urethra (urethritis), cervix (cervicitis), rectal area (proctitis), pharynx (pharyngitis), eyes (conjunctivitis) and cause disseminated disease throughout the body

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9
Q

What are the possible clinical presentations of gonorrhoea?

A
  • asymptomatic
  • symptomatic, showing
    > dysuria (pain)
    > urinary frequency
    > genital discharge (purulent urethral discharge for men, mucopurulent vaginal discharge for women)
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10
Q

What are some possible complications of gonorrhoea in males?

A
  • epididymitis
  • prostatitis
  • urethral stricture
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11
Q

What are some possible complications of gonorrhoea in females?

A
  • pelvic inflammatory disease
  • ectopic pregnancy
  • infertility
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12
Q

What is the most dangerous complication of gonorrhoea?

A

disseminated disease
- skin lesions
- monoarticular arthritis
- tenosynovitis (ifxn of joints & tendons)

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13
Q

What is the unique feature of gonorrhoea treatment?

A

as gonorrhoea and chlamydia are hard to differentiate, treat for both unless one test excludes one of them

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14
Q

Do we have to test for cure for gonorrhoea?

A

Yes

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15
Q

What is the first line antibiotic for gonorrhoea?

A

Ceftriaxone

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16
Q

What are the weight based dosings of ceftriaxone for gonorrhoea?

A

<150 kg: 500 mg IM inj single dose
≥150 kg: 1g IM inj single dose

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17
Q

What is the treatment for chlamydia when concurrently treating with gonorrhoea?

A

Doycycline 100mg BD x 7 days

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18
Q

What is the alternative regimen for gonorrhea in the event of penicillin allergy?

A

Gentamicin 240mg IM single inj
+
Azithromycin 2g PO single dose

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19
Q

What is the counselling points for gonorrhoea patients with regards to sexual contact and their sexual partners?

A
  • all sexual contacts within the past 60 days need to be evaluated and treated
  • if there was no sexual contact within the past 60 days, only the most recent sexual contact needs to be evaluated
  • abstain from sex for 7 days after the injection / during the 7 days of treatment for doxy + when symptoms resolve (if symptomatic at the start)
  • abstain from sex until all sex partners have been treated
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20
Q

What is the bacteria that causes chlamydia?

A

Chlamydia trachomatis

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21
Q

What is the mode of transmission of chlamydia?

A
  • sexual contact
  • mother to child during childbirth
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22
Q

What is the method of diagnosis of chlamydia?

A

NAAT

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23
Q

Describe the clinical presentation of chlamydia

A

same as gonorrhea, but might be milder
- asymptomatic
- symptomatic
> dysuria (pain)
> urinary frequency
> genital discharge (purulent urethral discharge in M, mucopurulent vaginal discharge in F)

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24
Q

Is test of cure required for chlamydia?

A

No, unless there are some concerns involving chlamydia eg. pregnancy, non-adherence, symptoms persisting

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25
Q

What is the first line antibiotic for chlamydia?

A

Doxycycline

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26
Q

What is the dosing regimen of doxycycline for chlamydia?

A

100mg BD for 7 days

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27
Q

What is the alternative regimen for chlamydia in the event of penicillin allergy?

A
  • azithro 1g PO single dose (good for non-adherence)
  • levo 500mg OD x 7 days
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28
Q

What is the counselling points for chlamydia patients with regards to sexual contact and their sexual partners?

A
  • all sexual contacts within the past 60 days need to be evaluated and treated
  • if there was no sexual contact within the past 60 days, only the most recent sexual contact needs to be evaluated
  • abstain from sex for 7 days after single azithro dose / during the 7 days of treatment for doxy + when symptoms resolve (if symptomatic at the start)
  • abstain from sex until all sex partners have been treated
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29
Q

What is the bacteria that causes syphilis?

A

Treponema pallidum

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30
Q

What is the mode of transmission of syphilis?

A
  • sexual contact
  • mother to child DURING pregnancy
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31
Q

What are the methods for diagnosis of syphilis?

A
  • darkfield microscopy of exudates from lesions
  • treponemal & nontreponemal serology test
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32
Q

What does treponemal & nontreponemal serology testing detect?

A

Ab against treponemal pallidum bacteria

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33
Q

Since treponemal and nontreponemal testing are considered serology tests, what biological sample do we use for these tests?

A

blood sample
unless neurosyphilis - CSF

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34
Q

What are the two tests conducted for treponemal test?

A
  • TPPA
  • TPHA
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35
Q

What does treponemal testing tell us?

A

to determine if the patient has been exposed to the treponemal pallidum bacteria before

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36
Q

What is the disadvantage of treponemal testing?

A

positive results indicates that patient HAS been exposed to bacterium before, but might be from current infection or past infection

therefore, patient can remain positive for life but no longer have syphilis

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37
Q

Therefore, what can treponemal testing be used for?

A

To confirm the diagnosis of syphilis

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38
Q

What are the two tests conducted for nontreponemal test?

A
  • RPR
  • VDRL
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39
Q

Describe the results reported by RPR/VDRL

A

quantitative RPR/VDRL testing shows the most dilute serum conc with a positive reaction

40
Q

What does nontreponemal test tell us?

A

to tell us if the patient has a current ongoing infection
(+) = any stage of syphilis

41
Q

Describe how nontreponemal testing varies across time

A

Ab titres declines over time after treatment, and patient can become non-reactive over time

42
Q

Therefore, what can nontreponemal testing be used for?

A

To monitor response to treatment

43
Q

What are the stages of syphilis?

A
  • primary
  • secondary
  • latent (early <1 year, late >1 year)
  • unknown
  • tertiary
  • neurosyphilis
44
Q

What is the first line antibiotic for syphilis?

A

penicillin (pen G - parenteral form)

45
Q

Describe 1) different pen G formulations 2) ROA 3) rate of release of penicillin

A

Benzathine - given IM + releases penicillin over a week
Procaine - given IM + releases penicillin over a day
Crystalline - given IV + 100% bioavailability

46
Q

What is the formulation and dosing regimen of penicillin for primary, secondary, early latent syphilis?

A

Benzathine penicillin G
2.4 MU IM injection x single dose

47
Q

What is the alternative antibiotic for primary, secondary and early latent syphilis in the event of penicillin allergy?

A

Doxycycline

48
Q

What is the dosing regimen of doxycycline for primary/secondary/early latent syphilis?

A

100mg BD x 14 days (double of chlamydia duration)

49
Q

What is the formulation and dosing regimen of penicillin for late latent, unknown duration & tertiary syphilis?

A

Benzathine Pen G
2.4 MU IM injection once a week x 3 weeks

50
Q

What is the alternative antibiotic for late latent, unknown duration & tertiary syphilis in the event of penicillin allergy?

A

Doxycycline

51
Q

What is the dosing regimen of doxycycline for late latent/unknown duration/tertiary syphilis?

A

100mg BD x 28 days (double of previous)

52
Q

What are the formulations and dosing regimens of penicillin for neurosyphilis?

A
  1. Crystalline pen G
    3-4 MU IV q4H
    OR
    18-24 MU per day continuous infusion
    x 10-14 days
  2. Procaine pen G 2.4 MU IM injection daily + Probenecid PO 500mg QDS
    x 10-14 days
53
Q

What is the alternative antibiotic for neurosyphilis in the event of penicillin allergy?

A

Ceftriaxone

54
Q

What is the dosing regimen of ceftriaxone for neurosyphilis?

A

IV/IM 2g OD x 10-14 days

55
Q

What happens if patient has severe penicillin allergy for neurosyphilis?

A
  • perform skin test to confirm true penicillin allergy
  • desensitize if necessary
56
Q

What is the reaction that occurs due to syphilis treatment?

A

Jarish-Herxheimer (JH) reaction - occurs within the first 24h of syphilis treatment
> acute febrile episode + headache, myalgia etc
> cannot be prevented

57
Q

When monitoring syphilis, which testing do we use?

A

nontreponemal

58
Q

Can we interchange between RPR and VDRL?

A

NO - stick to the same one during monitoring

59
Q

How frequent do we have to perform nontreponemal testing for primary/secondary/latent syphilis?

A

3 months
6 months
12 months
18 months
24 months

60
Q

What are the COMPULSORY monitoring frequencies for primary/secondary/latent syphilis?

A

6, 12, 24 months

61
Q

What is the definition of treatment success for primary/secondary/latent syphilis?

A

decrease in RPR/VDRL by 4 fold (eg. 1:64 to 1:16)

62
Q

How frequent do we have to perform nontreponemal testing for neurosyphilis?

A

every 6 months

63
Q

What is the definition of treatment success for neurosyphilis?

A

CSF is clear

64
Q

What is considered treatment failure?

A

after 6 months,
- still symptomatic
- failure to decrease RPR/VDRL by 4 fold OR increases

65
Q

Describe the management of sexual partners for syphilis

A
  • all at risk sexual partners need to be evaluated for STIs and treated if +ve
  • abstain from sex until syphilis lesions are completely healed
  • MUST check w Dr if they have been fully treated
66
Q

What is the virus causing genital herpes?

A

HSV type 1 & 2
type 2 > 1 (1 is more a/w cold sores)

67
Q

What are the 5 stages of genital herpes?

A
  1. primary mucocutaneous infection
  2. infection of nerve ganglia
  3. establishment of latency
  4. reactivation
  5. recurrent flares/outbreaks
68
Q

How long do the initial lesions (for first occurence, not recurrence) take to appear?

A

7-10 days

69
Q

How long does these initial lesions take to heal?

A

2-4 weeks

70
Q

How long does it take to be cured of genital herpes?

A

TRICKED!!!
lifelong chronic infection :(

71
Q

Describe the mode of transmission of genital herpes

A
  • transfer of genital fluids
  • intimate skin to skin contact
72
Q

Is genital herpes contagious? Why?

A

yes
due to intermittent viral shedding that can occur even when asymptomatic
triggers (eg. stress, fever, menstruation, infection, trauma, sunlight) may result in reactivation of the virus

73
Q

Describe the clinical presentation of genital herpes

A
  • multiple painful lesions (ulcers, vesicles)
  • local itching, pain, tender inguinal lymphadenopathy
  • flu-like symptoms (fever, headache, malaise) during first few days after appearance of lesions
  • prodromal symptoms eg. mild burning, itching, tingling a few days before lesions develop
74
Q

What are the methods for diagnosis of genital herpes?

A
  • virological test
  • serological test
75
Q

What are the virologic tests performed?

A
  • viral cell culture
  • NAAT PCR (to detect HSV DNA in genital fluids)
76
Q

What are the serologic tests performed?

A

to detect the presence of Ab against HSV-2

77
Q

What is the disadvantage of serologic testing?

A

not useful for first episode
takes 6-8 weeks for Ab titre to be high enough to be detectable

78
Q

What is the criteria for diagnosis for serology testing?

A

presence of HSV-2 Ab = genital herpes

79
Q

What are some adjunctive/supportive treatment for genital herpes?

A
  • warm saline bath
  • analgesics, anti-itch meds (eg. hydrocortisone cream)
  • good genital hygiene
  • counseling regarding natural history (chronic lifelong infection, viral shedding occurs even when asymptomatic, potential to transmit to sexual partners, possibility of reactivation - watch out for it, find out what are the triggers)
80
Q

What are the benefits of antiviral therapy for genital herpes?

A
  • reduces duration of symptoms
  • reduces viral shedding
  • reduces duration to healing of first episode
81
Q

However, what is the crucial factor in order to experience the benefits of antiviral therapy?

A

must be initiated ASAP, ie. within 72h of recurrence/first episode

82
Q

What are the medications available for genital herpes?

A

acyclovir
valacyclovir

83
Q

What is the MOA of acyclovir?

A

inhibits viral DNA polymerase –> inhibits DNA synthesis and replication

84
Q

What are the side effects of acyclovir?

A
  • GI (N/V/D)
  • headache
  • malaise
85
Q

What is the main side effect of valacyclovir?

A

headache

86
Q

What are the counselling points for acyclovir and valacyclovir?

A
  • take w/o regards to food, can take after food if it causes GI upset
  • maintain adequate hydration to prevent crystallisation in renal tubules
87
Q

What is the dose of ORAL acyclovir when used for the FIRST episode of genital herpes?

A

400mg TDS x 7-10 days

88
Q

What is the dose of IV acyclovir for the first episode of more severe cases of genital herpes?

A

IV 5-10mg/kg q8h x 2-7 days
complete with PO for a total of 10 days

89
Q

What is the dose of acyclovir for chronic suppressive therapy (CST)?

A

400mg BD

90
Q

What are the doses of acyclovir for EPISODIC therapy?

A
  • 800mg BD x 5 days
  • 800mg TDS x 2 days
91
Q

What is the dose of valacyclovir for the FIRST episode of genital herpes?

A

1g BD x 7-10 days

92
Q

What are the doses of valacyclovir for CST?

A
  • 500mg OD
  • 1g OD for ppl w frequent recurrences (≥10 episodes/year)
93
Q

What are the doses of valacyclovir for EPISODIC therapy?

A
  • 500mg BD x 3 days
  • 1g OD x 5 days
94
Q

What are the advantages of CST?

A
  • reduces frequency of recurrences for ppl w frequent recurrences
  • reduces risk of transmission
  • increases QoL
95
Q

What are the disadvantages of CST?

A
  • costly
  • treatment fatigue
  • frequency of recurrences decreases 1 year after diagnosis, there depends on whether patient wants to take CST daily and have less recurrences OR not take meds everyday
    (likely to have recurrences the first year after diagnosis, so CST is recommended during this period of time. however, frequency of recurrences decreases, therefore up to patient whether they want to continue CST)
96
Q

What are the advantages of episodic therapy?

A
  • reduces duration and severity of symptoms
  • cheaper
  • higher adherence
97
Q

What are the disadvantages of episodic therapy?

A
  • HAS to be started within 1 day of lesions/prodrome
  • does NOT reduce risk of transmission

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