Infections Flashcards
What is bacterial vaginosis most commonly caused by?
Gardnerella vaginalis.
Classic presentation of bacterial vaginosis
- Vaginal discharge: watery, grey-white, thin, foamy
- fishy smell esp after sex or menstruation
- vulvar/vag itch.
Dx bac vaginosis (4)
Amsel’s criteria
Presence of 3 or more: 1. Typical vaginal discharge: greyish thin homogenous 2. Vag ph >4,5 3. Positive amine whiff test (add 10% KOH to discharge-enhance fishy odour). 4 presence of clue cells on smear microscopy (vag epithelial cells studded with adherent coccobacilli)
Rx bac vaginosis
Only treat symptomatic , pregnant or planning pregnancy.
Metronidazole 500 mg oral twice daily for 7 days. If pregnant, only begin end of first semester.
Alternative: vaginal preparations metronidazole gel 0,75% 5g daily for 5 days or clindamycin cream 2% 5 g nightly 7 days or clindamycin 300 mg oral bd 7 days
How is bac vaginosis spread
STI
What is condyloma acuminata
Genital warts
What is condyloma acuminata caused by
HPV 6 and 11
How are genital warts transmitted
STI
diagnosis condyloma acuminata
- colposcopy after apply 3-5% acetic acid. Show acetowhite lesions
- schiller’s test: stain with iodine solution. Healthy tissue stain dark brown, abnormal tissue unstained-appear white or yellow
Rx condyloma accuminata if small
- Aldara(imiquimod) (immune response modifier)
- podofilox (podophyllotoxin)
Rx medium size condyloma accuminata (3)
- Cryotherapy
- electrocautery
- laser
Rx large size condyloma accuminata
Electrocautery under general anaesthesia
Rx condyloma accuminata in pregnancy
Laser therapy. Medical rx not known if safe.
How often test mothers for HIV? (6)
- Universal at first prenatal visit. If negative:
- repeat 3 monthly in pregnancy
- at labour/ delivery
- at 6 week immunisation EPI visit
- 3 monthly while breastfeeding
- 6 weeks after completing bf
How manage mother with positive rapid HIV test? (7)
- Confirm with second rapid
- hb, CD4, creatinine
- stage HIV clinically
- initiate art ( if Tb confirmed before art, initiate Tb therapy and AZT. 2 weeks later once stable switch AZT to fdc)
- review in 1 week for hb, CD4, creatinine results
- screen for Tb at each visit ( may delay rx), acute neuropsychiatric illness ( efavirenz contraindicated), renal impairment (no tenfovir )
- check vl 3 months after started art
Name contraindication efavirenz
Neuropsychiatric illness
Name contraindication tenofovir
Renal disease creat >85
(Switch to azt)
Name 4 side effects HIV FDc
- Dizzy
- strange dreams
- potential renal toxicity (tenofovir)
- rash (unlikely)
How manage newly diagnosed HIV with CD4 < 200
Start Bactrim 1 week after FDC
How manage newly diagnosed HIV with CD4 < 100
Test for cryptococcal antigen and give Bactrim
Management positive HIV test at labour? (3)
- Single dose NvP + single dose Truvada (emtricitabine + tenofovir) + AZT 3 hourly in labour
- start FDC next day regardless of CD4
- HIV PCR to neonate. Start nvp 12 weeks + AZT 6 weeks; follow up in 1 week to retest
Name 4 causes bacterial vaginosis
- gardnerella vaginalis
- mobiluncus spp
- Mycoplasma hominis (rx azithromycin); Ureaplasma
- Bacteroides spp : prevotella
Normal vaginal ph?
3,5 - 4,2
Cause vulvovaginal candidiasis?
Mostly c albiccans but can also be C globrata
Risk factors vulvo vaginal candidiasis? (4)
- Diabetes and other immunosuppressive
- pregnancy
- hormonal contraceptives
- recent antibiotic use
Clinical presentation vulvo vaginal candidiasis (5)
- Pruritis
- dyspareunia
- dysuria from erythema
- thick curdy discharge
- erythema, swelling, excoriations from itching
Diagnosis vulvo vaginal candidiasis
Mostly clinical but can do -
Wet preparation (saline, 10% koh ) or gram stain of vaginal discharge showing budding yeasts, hyphae or pseudohyphae
Consider swab from anterior fornix for MCs if recurrent or suspected resistant
Treatment vulvo vaginal candidiasis (3)
- OTC: clotrimazole 2 % cream 5g intravaginally daily 3 days (can also use miconazole, tioconazole)
- Prescription: butoconazole 2% cream (single dose bioadhesive) 5g intravaginal (can also use terconazole)
- Oral: fluconazole 150 mg single dose
In Pregnancy can only be treated with topical azoles and longer, 7-14 days
If complicated/recurrent (>4/year) , longer therapy and suppression therapy with fluconazole weekly for 6 months in recurrent.
Cause syphilis?
Treponema pallidum (spirochete)
Name the 4 stages syphilis and their time frames and contagion
Primary: 3-4 weeks after exposure. Highly contagious
Secondary: 2-6 months after initial infection. Contagious
Latent: early latent a year or less after infection, late latent more than 1 year.
Tertiary: not contagious
Clinical presentation primary syphilis?
- Single painless ulcer/ chancre on vulva, vagina, cervix
- erodes and heals spontaneously within 1 -8 weeks
- painless inguinal lymphadenopathy
Serological tests negative.
Clinical presentation secondary syphilis?
- Non-specific: malaise, anorexia, headache, diffuse lymphadenopathy
- generalised maculopapular rash. on palms, soles, trunk, limbs which resolves within 4-10 weeks but may reoccur any time within 4 years
- condyloma lata: anogenital, broad based, fleshy grey lesions
Serological tests positive
Clinical presentation latent syphilis?
Asymptomatic
25% will progress to tertiary/ neurosyphilis
Clinical presentation tertiary syphilis? (3)
- Vulva gumma: nodules that enlarge, ulcerate and are necrotic
- neurological
→ early: cn palsy, meningitis, stroke, altered mental status, auditory/ophthalmic abnormalities
→ late: tabes dorsalis (dorsal column degeneration), general paresis - cardiovascular: aortic aneurysm, dilated aortic root
Microscopic diagnostic tests syphilis? (2)
- Dark field microscopy
- direct fluorescent antibody for t pallidum (dfa - tp) (better)
Serologic diagnostic tests syphilis? (5)
Nontreponemal (screening) (monitor rx)
- venereal disease research lab (vdrl) slide test
- rapid plasma reagin (rpr) test
Treponemal (confirmation) (positive for life)
- fluorescent treponema antibody absorption (fta-abs)
- t palladium haemagglutination assay (tpha)
- t palladium particle agglutination assay (tppa)
Treatment primary/ secondary/early latent syphilis? (3)
Benzathine penicillin G 2,4 million units IM stat
Follow up: quantative titres (nontreponemal test) at 6 and 12 months for primary + secondary syphilis
6,12,24 months early latent syphilis
More frequent in HIV
Treatment late latent syphilis? (2)
Benzathine penicillin G 2,4 million units IM weekly X3 doses
Follow up after 6,12 and 24 months
Treatment neuro syphilis? (2)
Iv aqueous penicillin G 3-4 million units
4 hourly
for 10-14 days
Follow up: CSF evaluation every 6 months until normal values
Clinical presentation gonorrhoea? (10)
Local symptoms, if present:
- Mucopurulent cervical/vaginal discharge
- postcoital bleed
- AUB
- cervical excitation tenderness
- concomitant UTI - dysuria
Mostly asymptomatic, present with complications later:
- PID (15.%)
- Tubal factor infertility
- ectopic
- chronic pelvic pain
- disseminated gonococcal infection: tender necrotic skin lesions, tenosynovitis, monoarticular arthritis
Who should be screened for gonorrhoea
- All sexually active women <25 (and for chlamydia)
- high risk sexual behaviour
- genital symptoms
Not done in sa but ideal
Diagnosis gonorrhoea (3)
- nucleic acid amplification test (naat) (preferred): endocervical or vaginal dry swab held for 15-30 sec
- gram stain: gram negative diplococci with atypical kidney bean shape
- culture (valuable in resistant disease)
Treatment uncomplicated gonorrhoea cervicitis (2)
- ceftriaxone 250 mg IM stat +
- azithromycin 1 mg po stat OR doxycycline 100 mg po bd x7 days
(Also covers chlamydia)
Treatment disseminated gonorrhoea Infection (2)
- Ceftriaxone 1 g IM or iv daily until response then switch to
- oral cefixime 400 mg po bd for 7 days
Prophylaxis gonorrhoea conjunctivitis to infants
Erythromycin 0,5% ointment
Clinical presentation chlamydia? (4)
Even more asymptomatic than gonorrhoea. But if present:
- mucopurulent endocervical discharge
- urethral syndrome: dysuria, frequency, pyuria, no bacteria on culture
- postcoital/intermenstrual bleeding due to cervicitis
- chronic: chronic pelvic pain, fitz-hugh - Curtis syndrome (peritonitis)
Diagnosis chlamydia (2)
- NAAT test
- culture
Treatment chlamydia (2)
Azithromycin 1g oral +
Doxycycline 100 mg oral bd x 7 days
(Also give ceftriaxone because high rate gonorrhoea co-infection)
What is lymphogranuloma venereum?
Caused by chlamydia trachomatis stereotypes L1, L2 or L3.
lymphogranuloma venereum clinical course? (4)
- Within 1-6 weeks after infection: small, painless, primary papule/ulcer on vulva / vagina
- then: unilateral regional inguinal/femoral lymphadenopathy +/- systemic symptoms
- untreated→ buboes (conglomerate of pustular abscess) → sinus drainage / inguinal ulceration
- anogenitorectal syndrome if acquired by anal sex: genital fistula, lymphoedema, perirectal abscess, proctitis, rectal stricture.
Treatment lymphogranuloma venereum?
Doxycycline 100mg po bd x21 days
