Infections Flashcards
PID definition and causes
Spectrum of inflammatory disorders of the upper female genital tract including endometritis, salpingitis, Tubo-ovarian abscess & pelvic peritonitis.
Pathogens: chlamydia, gonorrhea, mycoplasma, normal flora (not always an STI)
infection is often poly microbial -> requires broad spectrum antibiotics
PID SX and EX
pelvic pain fever, rigors, sweats dyspareunia AUB D/C
Chronic: low grade fever, LOW, abdominal pain
peritonitis: tachy, hypotension, fever
Pelvic examination: adnexal tenderness, cervical motion tenderness
PID IX
FPU, BHCG
Endocervical swab or high vaginal swab for STIs
FBE/CRP/ESR, blood cultures
TVUS to exclude other causes of pain
Laparoscopy: best for diagnosis
MX of Mild PID
young, mild SX, !!hemodynamicaly stable!!, non ATSI, no CX
outpatient MX: IM Ceftriaxone stat + Doxycycline/Azithromycin PO + Metronidazole PO for 14d
monash EMQ: Azitho, doxy, metro
mild ->CDM or Monash DAM
MX of severe PID
Pregnant, hemodynamically unstable, septic, high fever (>38), tubo ovarian abscess suspect
in patient ABX with IV: ceftriaxone, azithromycin, metronidazole
IV CAM severe
oral DAM mild or IM ceftriaxone + oral D/A + oral M
PID other MX
educate, condom use, one partner, immunizations, notify to DHHS, screen and treat partners with 1 dose of Azithromycin, follow up with GP for test of cure
no sex for during and for 7 days after treatment ideal. if not possible, please use barrier protection.
Analgesia
abscess -> surgical workup
NBM/NGT, antiemetic, analgesia, surgical referral -> laparoscopy
PID CX
Tubo-ovarian abscess (TOA). If no improvement after ABX. Can present like appendicitis.
infertility and ectopic pregnancy due to adhesions
chronic pelvic pain: >6mo of pain due to permanent damage to reproductive tract.
Fitz-hugh-curtis syndrome: RUQ pain in the context of PID. due to peri-hepatitis (violin string perihepatic adhesions)
Genital Herpes
HSV2 (1 possible too),
Genital Herpes
HSV2 (1 possible too)
can acquire from asymptomatic or symptomatic. oral or genital sexual contact
SX: painful vesicular lesions (recurrent, painful, itchy)
IX: NAAT swab base of lesion or unroofed lesion + HSV serology
concurrent STI screen
MX:Do not need to confirm HSV with IX prior to starting IX
acyclovir -> valaciclovir
lignocaine gel, paracetamol/codeine for pain relief
Chlamydia Trachomatis SX
Asymptomatic
Men: urethritis, D/C, proctitis, dysuria
Women: cervicitis, D/C, PCB, proctitis
D/C is thick, foul smelling
oral SX: painless sores in mouth, tonsilitis, strep throat
Chlamydia Trachomatis IX
NAAT w endocervical swab ideally or self collected high vaginal swab
FPU if swabs cannot be taken
Oral, anoerectal swab if indicated based on sexual practices
Swab discharge where possible
Chlamydia trachomatis MX
Notify DHHS, contact trace 6mo
encourage to tell partner (let them know app)
Avoid sex during ABX and 7d after TX
encourage barrier protection
Uncomplicated or pharyngeal infection -> oral Doxycycline 100mg BD for 7days or oral Azithromycin 1g Stat (non compliance)
Pregnant -> doxy CI -> azithromycin 1g PO stat and test of cure in 4wk (pregnancy)
Repeat test in 3mo to exclude re infection (probably means contact tracing not done properly)
Neisseria Gonorrhoea SX
Asymptomatic
urethritis, cervicitis
D/C -> thicker and more purulent than C
Pharyngitis: sore throat, pharyngeal exudate, cervical lymphadenitis
N. Gonorrhea IX
NAAT with endocervical swab. if not possible self collected high vaginal swab
FBU if above not possible
anorectal/oral swab if appropriate
If gonorrhoea NAAT is positive then a cervical swab for gonorrhoea culture should be obtained antimicrobial susceptibility testing
Start on empirical ABX though: IM ceft + PO Azithromycin Stat
N. Gonorrhea MX
Uncomplicated genital or anorectal gonorrhoea: ceftriaxone IM stat + azithromycin oral stat (azithromycin to cover for chlamydia)
Pharyngeal Gonorrhea: Ceftriaxone IM and PO Azithromycin
Start ABX empirically. then also need return of sensitivities
For pharyngeal, anal or cervical infection, a test of cure by NAAT should be performed 2 weeks after Tx (test of cure in everyone in 2wk due to high ABX resistant). Then re test in 3mo for re infection
contact tracing: 2months
no sex during or 7days after
N. Gonorrhea CX
Conjunctival infection can occur in neonates born to infected mothers & in adults via exposure to infected genital secretions
Disseminated gonococcal infection, characterized by arthritis & skin lesions is rare
Candidiasis (Candida albicans)
Proliferation of endogenous vaginal yeasts
Candidiasis does not occur in non-estrogenized vaginal environment i.e., prepubertal or post menopausal (not on estrogen Tx)
Candidiasis SX
intense itching
Thick white curd like odourless D/C
excoriation, fissures, edema on examination
Chronic presentation (4 or more symptomatic episodes/year)
- Signs are cyclical, increasing pre-menses. Can present with vaginal dryness rather than D/C . - Sex aggravates signs -> burning, superficial dyspareunia, vulvar dysuria
Candidiasis IX
- Microscopy with pH evaluation on vaginal swab -> low PH + budding yeasts
Candidiasis MX
Acute candida: clotrimazole/ niacin vaginal cream or pessary for 3-6 nights or single dose oral fluconazole (second line)
○ + topical 1% hydrocort if severe vulvitis
○ Warn pts all PV Tx can weaken latex condoms)
- Chronic/ recurrent: induction Tx followed by suppression w different doses of fluconazole & antifungal cream
NB fluconazole should not be taken during pregnancy
Bacterial Vaginosis Cause
Polymicrobial syndrome characterized by profound change in vaginal microbiota from lactobacilli dominant state to high diversity & quantities of anaerobic bacilli including Gardnerella vaginalis.
Not an STI because it does not colonize the male reproductive tract. Thought to be an imbalance of the female reproductive system
Bacterial Vaginosis RX
Copper IUD, increased vaginal PH, increased sex partners, ABX, decreased estrogen
BV Sx
thin, white/grey, fishy malodourous discharge (Whiff Test)
Associated w increased risk of spontaneous abortion, premature labour, chorioamnionitis, post partum endometritis & PID
BV IX
Amsel’s criteria
Vaginal swab -> DX with 3 of
-Clinician observed vaginal discharge, thin, white or grey often adherent homogenous appearance
-Vaginal pH > 4.5
-Clue cells on gram stain or wet preparation of high vaginal secretions (vaginal epithelial cells that have coccobacilli on their edges)
- Positive amine (whiff) test - if you can smell the malodor (fishy) on examination this is a positive test
BV MX
Metronidazole 400mg PO BD for 7d
Refrain from sex or use condoms during Tx
no treatment for males
Avoid douching & intravaginal cleaning - associated w non-optimal vaginal microbiota
CX of untreated -> Miscarriage, chorioamnionitis, endometritis, PID, increased RX of STIs
BV in the first trimester can lead to late second trimester miscarriages & preterm labour w it associated Cx (oral clindamycin to reduce risk)
Trichomoniasis SX
STI caused by protozoan parasite
must odour
pale green frothy D/C
Cervicitis: strawberry cervix due punctate hemorrhages)
tenderness, dysuria, dysparaunia, pruritis
Trichomoniasis IX
Wet prep & micro of vaginal or urethral swab: Visualize motile flagellated organism
NAAT high vaginal, cervical swab
Trichomoniasis MX
Metronidazole 400mg BD for 7d
TX partners too
Molluscum Contagiosum
benign spontaneously resolving, painless infection lasting 3mo
kids lesions anywhere on body. aduts STI affecting genitals, pubic region, abdomen, thighs
poxvirus of skin. skin to skin contact
SX: lesion in cluster presenting as smooth surfaced firm shaped dome with central umbilication
IX: clinical
Resolves in 3mo, can use iquimod cream or cryotherapy
STI screen
Asymptomatic MSM
- First pass urine: C and G
- Serology: HIV, syphilis, Hep B/C
- Rectal swab: C G
- Throat swab: C G
if symptomatic swab D/C
Asymptomatic women
- Endocervical swab (ideally)
- self collected high vaginal swab
- First pass urine same sensitivity as endocervical if pregnant
- Serology
- Rectal
- Oral swab as above
if symptomatic swab D/C
All tests at NAAT
Syphilis Cause and SX
Spirochete Treponema Pallidum (G-ve)
Primary
- Painless, singular ulcer on genital => swab
Secondary
- Flu like illness, generalized macular papular rash
Tertiary
- years after untreated infection
- Gummatous (internal ulcers on organs)
- Neurosyphilis: vision, hearing loss, meingism
Syphilis IX
Swab lesion NAAT first line IX!!
Serology
EIA/CMIA -> if positive -> syphilis serology
need trep and non trep for + diagnosis (values are positive for life
Treponemal test
- TPHA, TPPA
non Treponemal test
- VDRL, RPR
- values change with treatment
syphilis MX
infectious 1,2, early latent-> IM benzathine penicillin G
non infectious -> 3 doses spaced weekly apart
- primary or secondary infectious
- tertiary non infectious
- secondary latent: no rash -> non infectious
Abstain from sex until d7 after both have received Tx
1o contact trace 3mo -> test of cure in 3mo
2o contact treat 6mo -> test of cure 6mo
3o IV Benzathine pen -> contact 12mo -> test of cure 12
Re-test in 6mo
Notify DHHS
Jarisch-Herxheimer reaction
possible ADR to Tx, occurs 1-12h after injection.
Presents w malaise, pyrexia, headache, vasodilation tachycardia, leukocytosis
If have these symptoms present to hospital
Sexual contacts of syphilis
Individuals who report sexual contact w a person w syphilis: single dose benzathine penicillin w/o waiting for serology results
Syphilis in pregnancy
Vertical transmission from mother to fetus can occur during pregnancy
Screening at first pregnancy appt w treponema pallidum antibody (TPA) enzyme immunoassay
Congenital syphilis may result in premature birth, low birth weight, FDIU or neonatal death & severe infant morbidity
Early (primary): benzathine penicillin 1.8g IM single dose
Late (>2yrs) or indeterminate duration: benzathine penicillin 1.8g IM once per week for 3wks
Asymptomatic STI is always?
Chlamydia -> treat with Azithromycin
