Infections Flashcards
Cause of candidiasis
MC after abx which destroy the nl vaginal flora
When should one suspect HIV/AIDS or diabetes with candidiasis?
Multiple episodes, esp without antibiotic insult
Confirmation of candidiasis
Wet prep- will see budding and hyphae
Tx of chronic candidiasis
Diflucan 150 mg weekly for 6 mos
Tx of candidiasis
Oral Diflucan or topical agents
Cause of atrophic vaginitis
Lack of estrogen support either d/t menopause or surgical removal of the ovaries or other hypoestrogenic states
Significant cause of dyspareunia
Tx of atrophic vaginitis
Oral hormone therapy if no contraindications or estrogen replacement cream or Osphena (similar CIs to oral estrogens)
Organism of trichomoniasis
Trichomonas vaginalis
S/sx of trichomoniasis
Frothy, yellow-green vaginal d/c with strong odor
May cause discomfort during intercourse and urination and itching of the female genital area
Rarely, lower abdominal pain
PE of trichomoniasis
Vaginal walls and cervix may appear red and irritated
Cervix may have surface hemorrhages or petechiae causing a “strawberry” appearance
Tx for trichomoniasis
Metronidazole 2 gm PO x 1 (or 500 mg BID x 7) is commonly used
Alcohol while taking the med and for 48 hrs afterwards is contraindicated
Avoid sexual intercourse until tx is completed
Treat sexual partners
What is the MC vaginal infection in women of childbearing age?
Bacterial vaginosis
S/sx of bacterial baginosis
Some women have no sx
Others complain of a foul fishy odor, particularly during their period or after intercourse
D/c may be white or gray.
May cause burning and/or itching
Dx of bacterial vaginosis
Wet prep/KOH whiff test
Tx of bacterial vaginosis
May treat with topical or oral meds (metronidazole tablets or gel, Clindamycin gel)
RFs for BV
Abx Douching Vaginal lubricants Some spermicides Anal sex
What is the second most commonly reported notifiable dz in the US?
Gonorrhea
Sx of gonorrhea
In women, the sx of gonorrhea are often mild and can be mistaken for bladder or vaginal infection
Initial sx may include a painful or burning sensation when urinating
Increased vaginal d/c
Vaginal bleeding between periods
Complications of gonorrhea
Left untreated:
- Sepsis
- Gonococcal arthritis
- Fitz-Hugh-Curtis syndrome
Details of septic arthritis
Fever, joint pain, limited ROM, purulent aspirate
CBC, ESR or CRP, admit
Tx requires 2 wks of IV abx
Fitz-Hugh-Curtis syndrome
AKA perihepatitis
Severe RUQ pain in addition to PID sx
Caused by violin string adhesions under liver
Dx of gonorrhea
Through culture of pharynx, vagina, penis or rectum
Wet prep will show TNTC (too numerous to count) WBCs
Tx of gonorrhea
Ceftriaxone 250 mg IM single dose
PLUS
Azithromycin 1 g orally x 1
Once tx is completed, the woman should be retested to ensure complete cure (test of cure) in 3 mos or if she returns for clinic for any reason within 12 mos post-tx
What is the most frequently reported bacterial STI in the US?
Chlamydia
When should chlamydia be suspected?
Frequently has no sx or has very mild sx
If pt has deep internal pain with intercourse. With bimanual exam she will experience intense pain with manipulation of the cervix (chandelier sign)
Dx of chlamydia
Urine (high false-neg) or culture taken from the ectocervix or vagina
Complications of chlamydia
Cervicitis Endometritis PID Urethritis Epididymitis Neonatal conjunctivitis Pediatric PNA Reiter syndrome
Tx of chlamydia
Azithromycin 1 g PO in single dose
OR
Doxycycline 100 mg PO BID x 7 days (not OK in pregnancy)
What anatomic locations are included with PID?
Endometrium Oviducts Ovaries Uterine wall Uterine serosa and broad ligaments Pelvic peritoneum Also, a TOA may form
Dx of PID
Difficult to diagnose bc of the wide variation in s/sx
Many women have subtle or mild signs
Usually based on clinical findings
Delay in dx and tx probably contributes to inflammatory sequelae in the upper reproductive tract
When should empiric tx of PID be initiated?
Sexually active young women and other women at risk for STIs if they are experiencing;
- Pelvic or lower abd pain
- If no cause for illness other than PID can be Id-ed
- AND if one or more of the following minimum criteria are present on pelvic exam:
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
What additional criteria can be used to support a dx of PID?
Oral temp >101 F
Abnl cervical or vaginal mucopurulent d/c
Presence of abundant numbers of WBC on wet prep
Elevated ESR
Elevated CRP
Lab documentation of cervical infection with N. gonorrhea or C. trachomatis
MC organisms of PID
MC are gonorrhea and chlamydia
Usually polymicrobial in nature
Other organisms of PID
Ureaplasma urealyticum
Mycoplasma genitalium
Trichomonas vaginalis
Gardnerella vaginalis
Long-term consequences of PID
MC and serious are tubal factor infertility and ectopic pregnancy Other sequelae: Chronic pelvic pain Dyspareunia Menstrual disturbances Pelvic adhesions
Outpatient tx for PID
Ceftriaxone 250 mg IM PLUS doxycycline 100 mg PO BID x 14 days with or without metronidazole 500 mg PO BID x 14 days
OR
Cefoxitin 2 g IM single dose and probenecid 1 g orally administered concurrently in a single dose plus doxycycline 100 mg PO BID x 14 days with or without metronidazole 500 mg PO BID x 14 days
OR
other parenteral third-gen cephalosporine plus doxycycline 100 mg PO BID x 14 days with or without metronidazole 500 mg PO BID x 14 days
When should PID pts be hospitalized?
Surgical emergencies
Pt is pregnant
Pt does not respond clinically to oral antimicrobial therapy
Pt is unable to follow or tolerate and outpatient oral regimen
Pt has severe illness, nausea and vomiting, or high fever
Pt has TOA
PID inpatient tx
Regimen A:
Cefotetan 2 g IV q12h OR cefoxitin 2 g IV q6h plus doxycycline 100 mgm PO or IV q12 hrs
Regimen B:
Clindamycin 200 mg IV q8h plus gentamicin loading dose IV or IM (2 mg/kg of body wt) followed by a maintenance dose (1.5 mg/kg) q8h
Ways to get a PID partner treated
Pt referral: ask pt to notify partner and ensure tx or have pt bring partner for concurrent tx
Expedited partner tx: pt delivered partner tx or health department field-delivered tx or call in Rx for him at pharmacy
Provider referral for partner
Health department referral for partner
Genital HSV causative organisms
HSV-1 or HSV-2
Presentation of genital HSV
Blisters and ulcerated sores around genitals and anus
Dx of genital HSV
Can be confirmed by viral culture or Tzanck smear
Tx of genital HSV
Acyclovir
Famiclovir
OR
Valacyclovir
Transmission of syphilis
Passed through direct contact with a syphilis sore or contact with condylomata lata. Sores are generally on the external genitalia
Presentation of primary syphilis
Initially presents as a firm, round, painless nodule, called a chancre, where the syphilis entered the body
Lasts 3-6 wks and will resolve with tx
If it is not treated it then proceeds to secondary syphilis
Sx of secondary syphilis
Condyloma lata lesions in moist areas Rash usually on the palms of the hands and soles of the feet, but may be on other parts of the body. Often described as "copper penny" colored lesions Fever Swollen LNs Sore throat HAs Muscle aches Wt loss Sx resolve with or without tx, but without tx will progress to latent or late stage syphilis
Latent and late stage syphilis
Latent stage can last for years
Late stages can appear 10-20 years after infection was first acquired
In late stages, dz may subsequently damage internal organs, including brain, nerves, eyes, heart, blood vessels, liver, bones, and joints
S/sx of late stage of syphilis
Appearance of soft rubbery tumors called gummas Difficulty coordinating muscle movements Paralysis Numbness Blindness Dementia
Definitive dx of syphilis
Darkfield examinations and direct fluorescent antibody tests of lesion exudate or tissue
Presumptive dx of syphilis
Nontreponemal tests (VDRL and RPR) measured in titers OR Treponemal tests (FTA-ABS and TP-PA) If one type is positive the lab should confirm with the other
Tx of syphilis
PCN G 2.4 million units IM in a single dose is preferred for tx of primary, secondary and early latent stages
Late latent or unknown duration should be treated with 2.4 million units weekly x 3 doses
Neurosyphilis: aqueous crystalline PCN G 3-4 million units IV q4h for 10-14 days
All pts with syphilis should be tested for what?
HIV
