Infections Flashcards
What causes vaginal candidiasis
80% candida albicans
20% other species
How to diagnose candidiasis
Should be able to on examination however if need a high vaginal swab
RFx for candida
DM
Steroids
Immunosuppressed
Pregnant
Presentation of candida
Cheese like discharge which does not smell
Vulval itching, fissuring, erythema and satellite lesions
Superficial dyspareunia
Dysuria
Management of candida if breastfeeding
Topical clotrimazole creams
Management of candidiasis if aged 12-15
Topical clotrimazole creams
Management of candidiasis
Advise about only using emollients and not soaps, bath bubbles etc
1st line oral fluconazole 1 dose
If contraindicated can use intravaginal clotrimazole (pessary)
If itching use topical clotrimazole cream
Management of severe candida
Use a second dose of oral fluconazole 3-4 days later
Come back in a week if not better
What can use if oral fluconazole contraindicated in candida treatment
Oral itraconazole
Intravaginal clotrimazole or meconazole
When refer for candida
Failure to respond to treatment after a week
12-15
Diagnostic uncertainty
What is defined as recurrent candida
4 episodes a year
How investigate recurrent candida
Examination to confirm
Check compliance with previous medications
DM test
How manage recurrent candida
Induction and maintenance regime
Induction- 3 doses of fluconazole, 1 every 3 days
Maintenance- fluconazole once a week for 6 months
What is bacterial vaginosis
Get overgrowth of anaerobic bacteria and less lactic acid producing lactobacilli which increases pH of the vagina
Which bacteria often colonises in BV
Gardnerella vaginalis
Mycoplasma hominis
Presentation of BV
Thin white/grey and offensive discharge
Management of BV
Oral metronidazole for 7 days
Can use 1 big dose if wish
If CI or not preferred can use intravaginal metronidazole or clindamycin
Management of persistent BV
Reconsider diagnosis- do speculum and take a sample
Prescribe alternative treatment to one initially used
If not improved after days of oral metro contact GUM
RFs for BV
Regular sex
Copper IUD
Douching and bubble bath etc
What do if reccurrent BV
At least 4 times a year
Can give metronidazole gel or contact GUM
How is BV diagnosed
Amsel criteria- 3 of 4 at least
- pH above 4.5
- clue cells on microscopy
- thin discharge
- positive whiff test
How is BV investigated
High vaginal swab for gram staining and microscopy
pH can test using swab from vaginal wall
What is whiff test
Add potassium hydroxide and get fishy smell if positive
What is management of genital herpes in a woman
Advise about washing in salt water and not using douches etc
Refer to GUM clinic
If not willing/unable to then can prescribe aciclovir or famiciclovir and then recommend follow-up in specialist sexual or at GP in a week
What is management of recurrent herpes
1st line- encourage bathing technique measures
2nd line- if fewer than 6 times a year can offer aciclovir for episodic treatment
if over 6 can offer suppressive therapy every day
How does herpes present genitally
Crops of blisters which burst quickly and then form ulcers
Management of trichomoniasis
Metronidazole in a weeks dose or in 1 large dose
Or can do tinidazole
Trichomoniasis presentation
Discharge thats yellow and green
Strawberry cervix
High vaginal pH
Investigations for trichomoniasis
Wet mount- motile trophozytes
In treatment of candida with fluconazole which medications must rule out and why
SSRI as increases QT
What do you do with coil and LNG-IUS during PID
Discuss removing it at first meeting
If symptoms have not improved within 72 hours then remove
What is PID
Infection of uterus, fallopian tubes and ovaries
Causes of PID and most common
Chlamydia- most common
Neisseria gonorrhoea
Mycoplasma genitalum
Mycoplasma hominis
Presentation of PID
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
Management of PID
Ceftriaxone, doxycycline and metronidazole
OR
Ofloxacin or levofloxacin and metronidazole
Moxifloxacin
If high suspicion of gonorrhoea (partern positive, symptoms severe or from abroad) use ceftriaxone, doxycline and metronidazole
Contact partners of last 6 months
What is best treatment if PID swab reveals mycoplasma genitalum
Moxifloxacin
Complications of PID
Fitz-Hugh curtis syndrome
Infertility
Chronic pelvic pain
Ectopic pregnancy
Abscess
Investigations for PID
Pregnancy test
Endocervical swab for chlamydia, gonorrhoea and mycoplasma genitalum
What is fitz hugh curtis syndrome
RUQ pain with peri-hepatitis most associated with chlamydia
What needs to happen for an ecoptic pregnancy to happen
Egg be fertilised in a place other than uterine cavity
Implant somewhere with a sufficient blood supply
Pathophysiology of ectopic pregnancy
If egg implants in ampulla of fallopian tube then egg will grow as per typical pregnancy
Then size will become too big for the fallopian tube and it will burst
Possible presentation of ectopic
Nausea and fullness of breath
Missed period
Slight abdo pain which can refer to shoulder
Then pain will become very severe which perforates the fallopian tube
Can get vaginal bleeding here too
Risk factors for ectopic pregnancy
Smoking
History of ectopic
Gynae surgery
PID history
IUD
Endometriosis
How long into pregnancy will get pain in an ectopic
If in fallopian tube 6-8 weeks however in somewhere with more space it can increase
What is most common site for ectopic
Ampulla of fallopian tubes
Possible sites for an ectopic
Tubal
- ampulla
- isthmal
- fimbrial
Cervical
Ovarian
Abdomen
Intersitial
Most dangerous site for an ectopic pregnancy
Isthmus as narrowest
Initial management of suspected ectopic pregnancy
Assess for immediate ambulance
- tachycardia
- pallor
- hypotensive
- presyncope
If not then do a pregnancy test which if comes back positive do an abdo exam
- if tenderness or pain suspect ecoptic and sent to early pregnancy unit or out of hours gynae
If no abdo pain do light pelvic exam
- if tenderness then EPU or out of hours gynae
If no pelvic tenderness assess whether under or over 6 weeks pregnant
- under 6 weeks do pregnancy test in a week and return if positive if symptoms return
- over 6 weeks refer to early pregnancy unit
What imaging used for ectopic pregnancy
Transvaginal USS the most sensitive
Transabdominal if gynae disease like fibroids or unacceptable
MRI second line if C-section scar ectopic suspected
When consider expectant management for ectopic pregnancy
Minimal symptoms
Unruptured
No fetal heartbeat
Serum HCG under 1000
Mass under 35mm
What does expectant management of an ectopic involve
Send home for 48 hours and assessing if is decrease in bHCG
When consider methotrexate management for ectopic
Adnexal mass under 35mm
No fetal heartbeat
In pain but not significant
Willbe follow-up
How does intrauterine pregnancy affect management of ectopic
If present then medical management not possible
How does methotrexate work in ectopic pregnancy
Stops enzymes which maintain pregnancy
When operate on ectopic pregnancy
Ruptured
Mass over 35mm
Fetal HB
HCG over 5000
When can give choice of medical or surgical management in ectopic
Criteria for medical but HCG 1500-5000
What are surgical options for ectopic and what determines
Saplingectomy 1st line if no rfx for infertility
Saplingotomy if rf for infertility
Give anti-RHD to all rhesus negative people who have had removal of ectopic surigcally
Longer term mangement of ectopic
Unless has had saplingectomy must be followed up to have HCG levels monitored to see how long take to return to non-pregnant levels
May take 6 weeks
What is a pregnancy of unknown location
Positive pregnancy test but no sign on US of a location
What do with pregnancy of unknown location
Serial HCG measurements however if very symptomatic this should determine plan
Look at serum bHCG as over 1500 indicates an ectopic
How to investigate menorrhagia
FBC
Consider USS if post-coital bleeding, intermenstrual, pain, compression symptoms or signs on abdo exam
If patient haemodynamically unstable what is best operation for ruptured ectopic
Laparotomy
What are differentials for PCB
STI
Cervical
- ectropian
- cancer
- CIN
Vaginal atrophy
- post menopausal
- breastfeeding
Vaginitis
Causes of vaginitis
STI
Poor hygiene
BV
Atrophy
What are clue cells
Stippled
What happens in fitz hugh curtis syndrome
Peri hepatic inflammation where adhesions between the liver and abdominal wall (glissons capsule)
Treated for UTI as increased frequency but then comes back with discharge, what has happened
Candida infection as abx immunosuppress
What does serum bHCG do in normal pregnancy
Increase of 60% suggests uterine birth however less than this and suspect ectopic
What do if vulval symptoms in candida
Clotrimazole cream
When refer for PID
Severe symptoms- fever over 38, N&V
Peritonitis
Abscess
Can not rule out appendicitis
What are differences in whats done between HVS and endocervical swabs
HVS- MC&S
Endocervical- NAAT
Management plan for uncomplicated chlamydia infection
Refer to GUM
If refuses treat in primary care
1st doxycycline
2nd azithromycin
Treat current partners
What do you do after chlamydia treatment
Repeat testing 3-6 months later to rule out PID
What do you do after gonorrhoea treatment
Test of cure week later
Gonorrhoea treatment
Ceftriaxone IM
Management of HPV infections
None
What is normal physiological discharge like
Clear white mucoid
What can change physiological discharge
Around menstrual cycle
Mid cycle is thicker then becomes waterier
COCP
Sexual excitation
How should PID be treated in pregnancy
IV abx
How does disseminated gonococcal infection present
Polyarthritis
Vasculitic rash
Fever
What is cobblestoned appearance of cervix seen in
Chlamydia
What is granuloma inguinale
Donovanoss from klebsiella granulomatis
How does donovanosis present
Papule which spreads along skin folds
If immunocompromised and come into conract withsomone chick pox positive what do
Give VZIG
What can you offer for a Bartholin’s cyst if they want to avoid surgery
Balloon catheter insertion
Management of severe PID
IV abx
What is chandelier sign
Cervical motion tenderness caused by PID
What is most likely cause of bartholins abscess
E coli
