Infections Flashcards
What are the causes for vaginal discharge?
Physiological Candida Trichimonas vaginalis Bacterial vaginosis Gonorrhoea Chlamydia Ectropion Foreign body Cervical cancer
What type of discharge is seen in candida infections?
Curd like
Non-offensive
White
What type of discharge is seen in trichimonas?
Yellow, frothy, offensive
Strawberry cervic
What type of discharge is seen in bacterial vaginosis?
Thin
White/grey
Fishy
What type of discharge is seen in gonorrhoea?
Thin
Watery
Yellow
What type of discharge is seen in chlamydia?
Copious amounts of purulent yellow discharge
What type of discharge is seen in ectropion?
Increased amounts of normal discharge
What type of discharge may be seen with foreign bodies?
Foul smelling
+ blood
What type of discharge is seen in cervical cancer?
Persistent discharge which doesn’t respond to treatment
What are the main risk factors for STI’s?
Age <25 Sexual partner positive Recent change in sexual partner Co-infection with another STI Non-barrier contraception
How are STI’s managed in general?
Abstain from sex until both treated
Offer screening for other STI’s
Encourage talking to previous partners
Talk about safe sex in future
What organism causes chlamydia and how long is the incubation period?
Chlamydia trachomatis
Intracellular gram -ve cocci/rod shaped
7-21 day incubation
How is chlamydia transmitted?
Vaginal, oral or anal sex
Skin-skin genital contact
Can infect eye, pharynx and rectum
How does chlamydia present in women?
70% asymptomatic Cervicitis - discharge and bleeding Dysuria Pelvic pain Cervical excitation
How does chlamydia present in males?
50% asymptomatic
Dysuria
Discharge
Testicular pain
How is chlamydia investigated?
NAAT technique on:
Vulvo-vaginal swab
First void urine
How is chlamydia managed?
1 dose azithromycin or
7 days doxycycline (erythromycin if CI)
How is chlamydia followed up?
TOC 5 weeks after treatment start
What are the main complications of chlamydia?
PID
Epididymo-orchitis and epididymitis
Sexually acquired reactive arthritis
What contact tracing is required for chlamydia?
Symptomatic men - 4 weeks prior to symptoms
Women and asymptomatic men - partners from last 6 months
What is important to know about chlamydia in pregnancy?
Risk of premature delivery, low birth weight and still birth
Give azithromycin or erythromycin (doxy is CI)
Neonatal erythromycin
What organism causes gonorrhoea? how long is the incubation period?
Neisseria gonorrhoea - gram -ve cocci
2-5 day incubation
How is gonorrhoea transmitted?
Vaginal, oral or anal sex
Vertical transmission - mother to child
Can infect rectum and pharynx
What is the main additional risk factor for gonorrhoea?
MSM
How does gonorrhoea present in women?
50% asymptomatic Cervicitis - thin watery yellow discharge Dysuria Pelvic pain Easily induced cevical bleeding
How does gonorrhoea present in men?
Purulent discharge
Dysuria
Epididymal tenderness
How is gonorrhoea investigated?
NAAT technique - endocervical/vaginal swab or first pass urine
Microscopy and culture - endocervical/urethral swabs
How is gonorrhoea managed?
Treat while waiting for swab results - IM ceftriaxone
How is gonorrhoea followed up?
TOC 2 weeks after treatment complete
What are the main complications associated with gonorrhoea?
PID Epididymo-orchitis Prostatits Salpingitis --> infertility Disseminated gonococcal infection
How would you contact trace for gonorrhoea?
Symptomatic men - all partners 2 weeks
Women and asymptomatic men - all partners 3 months
What is important to know about gonorrhoea in pregnancy?
Risk of spontaneous abortion, premature labour and early rupture of membranes
IM ceftriaxone and oral azithromycin
How is chlamydia screened in the UK?
Open to all men/women 15-24yo
Rely on opportunistic testing
How does a disseminated gonococcal infection present and how is it managed?
Skin lesions and joint pain
Admit to hospital for management - can lead to sepsis
What organism causes syphilis? How long is incubation?
Treponema pallidum - gram negative spirochete bacteria
2-3 weeks
How is syphilis transmitted? what are the key additional risk factors?
Vaginal, oral, anal sex, vertical transmission, blood products
MSM and HIV
What are the stages of a syphilis infection?
Primary –> secondary –> Latent (asymptomatic) –> Tertiary
How does a primary syphilis infection present?
Papule ulcerate into chancre
Chancre is painless, hard and non-itchy
Heals in 3-10 weeks
How does a secondary syphilis infection present?
3 months post infection
Non-itchy, non-painful rash on hands and soles of feet
Fever, malaise, arthralgia, weight loss
Painless lymphadenopathy
Condylomata lata - elevated wart like plaques in moist skin creases
Can affect kidneys liver and brain
How does a tertiary syphilis infection present?
Many years later:
Gummatous - granulomas form almost anywhere
Neuro - tabes dorsalis, dementia, argyll robertson pupil, stroke
CVS - aortic valvulitis, ascending aorta dilation, angina
How would you investigate syphilis?
Serological tests:
Treponemal test - TPHA (remain +ve after treatment)
Cardiolipin tests - VLDR (go -ve after treatment)
When can false positives for syphilis serological tests occur?
Pregnancy SLE Antiphospholipid syndrome TB Leprosy Malaria HIV
How is syphilis managed?
IM benpen
What is Jarisch-Herxheimer reaction?
Flu like illness after first dose of Abx in syphilis
Due to endotoxins released from dying bacteria
Manage with supportive measures
What organisms cause genital warts?
HPV - esp. 6 and 11
How are genital warts transmitted?
Skin to skin contact - doesn’t need to be penetrative
How would you investigate genital warts?
Generally clinical diagnosis
Females may need speculum - internal warts
Biopsy if lesions atypical
How are genital warts managed?
Not always needed
Physical ablation:
- if 1 or 2
- either cryotherapy, laser or excision
Topical:
- many warts
- Podophyllotoxin or imiquimod - weaken latex condoms
- CI in pregnancy and breastfeeding
How do genital warts present?
Most asymptomatic and resolve spontaneously
- Painless fleshy growths
- Can be hard or soft
- May bleed or itch
What is important to know about genital warts in pregnancy?
No associated complications
Small risk of transmission in birth - usually self resolve
What causes genital herpes?
Herpes simplex 1 and 2
1 - genital and cold sores
2 - genital and anal
How is genital herpes transmitted?
Skin to skin contact
Oral sex from someone with cold sore
What is the pathophysiology of genital herpes?
Remain dormant in nerve root ganglion
Can reactivate
How does genital herpes present?
May be months to years after infection
Small red painful blister - crust and heal in 20 days
Discharge
Itchy genitals
Flu like symptoms
Secondary infections like primary but much shorter
How is genital herpes investigated?
Swab open sore
PCR - differentiate between HSV 1 and 2
If a patient has >5 outbreaks of genital herpes, what should be done?
Test for HIV
How is genital herpes managed?
Oral acyclovir
Painkillers
Petroleum jelly and ice packs
What is important to know about genital herpes in pregnancy?
Pre existing herpes:
- Maternal antibodies cross via placenta
- Option of vaginal or c-section as risk of transmission v low
Herpes contracted in trimester 3:
- No maternal antibodies to pass on
- C-section highly recommended
What causes trichomonas vaginalis? what is the incubation period?
A protozoa
1 month incubation
How is trichomonas vaginalis transmitted? what are the additional risk factors?
Vaginal sex (NOT ORAL OR ANAL) Vertical transmission - mother to child at delivery
Older women
How does trichomonas vaginalis present in men?
Usually asymptomatic in men
Discharge
Dysuria
Urinary frequency
Itching and soreness
How does trichomonas vaginalis present in women?
Vaginal odour Yellow/green frothy discharge Itching and soreness Dyspareunia Dysuria "strawberry cervix" on examination
How would you investigate trichomonas vaginalis?
Microscopy and culture:
F - High vaginal swab
M - Urethral swab or first void urine
How is trichomonas vaginalis managed?
Oral metronidazole
Treat all partners from previous month
What is important to know about trichomonas vaginalis in pregnancy?
Risk of premature labour and low birth weight
Metronidazole can be used but affect taste of breast milk
What are the similarities between BV and trichomonas?
“Offensive” vaginal discharge
Vaginal pH >4.5
Treat with metronidazole
How does BV vary from trichomonas?
Thin white discharge
Microscopy - clue cells
How does trichomonas vary from BV?
Frothy yellow green discharge
Vulvovaginitis
Strawberry cervix
Wet mount - motile trophozoites
What is bacterial vaginosis?
Not an STI
Normal vaginal flora disturbed leading to reduced lactobacilli
Other micro-organisms grow - Gardnerella Vaginalis, anaerobes and mycoplasmas
Why do you have a raised pH in bacterial vaginosis?
Lactobacilli produce hydrogen peroxide to maintain acidity
Reduced lactobacilli
What are the main risk factors for bacterial vaginosis?
Multiple sexual partners Receptive oral sex IUD Concurrent STI Vaginal douching or soaps Recent Abx use
How does bacterial vaginosis present?
Offensive fishy discharge
Thin white/grey discharge
Not normally sore or itchy
How is bacterial vaginosis diagnosed?
High vaginal swab for microscopy:
- Clue cells (vaginal epithelia studded with coccobacilli)
- Reduced lactobacilli
- Absence of pus cells
Vaginal pH >4.5
Positive whiff test - add alkali to discharge and strong fishy odour smelt
How is bacterial vaginosis managed?
Asymptomatic - dont need treating Oral metronidazole - can be vaginal Clindamycin second line Advice regarding risk factors Consider IUD removal
What is the recurrence rate of bacterial vaginosis and how is it managed?
> 50% in 3 months
Oral metronidazole
What is important to know about bacterial vaginosis in pregnancy?
Symptomatic BV can increase risks of premature birth, miscarriage and chorioamnionitis
Treat with metronidazole
What is candidiasis?
Not an STI
Also called thrush
Overgrown of Candida albicans
What is the peak incidence of candidiasis?
20-40yo
What are the main risk factors for thrush?
Pregnancy Diabetes Recent abx use Corticosteroid use Immunocompromised
How does thrush present?
Vulval itching
White curd like discharge - non-offensive
Dysuria
On examination:
- erythematous vulva
- satellite lesions - red pustular lesions with superficial white pseudomembranous plaques that can be scraped off
How is thrush managed?
Intravaginal cream or pessary - clotrimazole
Oral fluconazole
What should you do if thrush management fails?
Measure vaginal pH (<4.5 in thrush) and swab for microscopy
Address risk factors
Treat for longer period
Why is thrush more likely in pregnancy? How is it managed?
Oestrogen levels - increased glycogen create favourable environment. Promote growth and sticks it to walls
Treat with intravaginal not oral meds
