Infections/ GUM Flashcards
Barriers to sexual history
embarrassment misunderstanding language fear of judgement or stigmatisation lack of privacy time pressure difficulty understanding patients ICE third party gender age/ capacity
potential concerns of patient in GUM clinic
judgement examination confidentiality infection, cure to infection society
6Cs of sexual history
contraception cycle: periods, LMP, IMB/PCB children cervical smear chlamydia hep C/B
Females/ trans males symptoms
Vaginal discharge Vulval skin problems Genital lumps/ ulcers Intermenstrual bleeding and post-coital bleeding Deep and superficial dyspareunia Dysuria and urinary frequency Abdominal pain STI contact/ sexual assaults/ contraception/ TOP/ sexual dysfunction Rectal symptoms Asymptomatic screens
Males/ trans females symptoms
Urethral discharge Dysuria and urinary frequency Genital lumps/ ulcers Testicular pain/ swelling Rectal symptoms Sexual dysfunction and assaults Asymptomatic screens
Investigations for symptomatic males
urethral smear first pass urine bloods HIV/ syphilis +/- Hep B/C MSM: rectal/pharyngeal swabs urine dip
Investigations for asymptomatic males
first pass urine
bloods HIV/ syphilis +/- Hep B/C
MSM: rectal and pharyngeal swabs
symptomatic females investigations
high vaginal loop swab for microscopy and pH testing
vulvovaginal swab ‘dual NAAT’
bloods- HIV/syph +/- Hep B/C
asymptomatic female investigations
self-taken vulvo-vaginal swab ‘dual NAAT’
serology: STI/ HIV
urinalysis/ pregnancy test
HPV types causing genital warts
6 and 11
Investigations for genital warts
external genital warts: speculum
internal genital warts: colposcopy
anal warts and rectal bleeding: proctoscopy
management of HPV
topical podophyllum and cryotherapy
imiquimod second line
majority clear without intervention within 1-2 years
non-specific urethritis features
Urethral discharge, dysuria, penile irritation
Diagnosed through gram stain and microscopy of urethral sample:
> 5 polymorphonuclear leucocytes per high power field
management of non-specific urethritis
Mx: STI screen, 1 week doxycycline
Inflammation of urethra in absence of diagnosis of chlamydia or gonorrhea
Recurrent diseases requires GUM input
bacterial vaginosis triggers
Sex Menses Receptor oral SI Vaginal douching Perfumed bath products Change in sexual partners Presence of STI
anaerobic bacteria associated with BV
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
risk factors for BV
Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil
presentation of BV
The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
BV investigations
vaginal pH: swab and pH paper >4.5
charcoal vaginal swab for microscopy
clue cells on microscopy
hay-ison criteria and amsel criteria
BV management
asymptomatic resolves without treatment
metronidazole 400mg BD 5days
clindamycin alt as metronidazole makes breast milk bitter
complications in pregnant women BV
Miscarriage Preterm delivery Premature rupture of membranes Chorioamnionitis Low birth weight Postpartum endometritis
Risk factors for vaginal candidiasis
increased oestrogen
poorly controlled diabetes/ immunosuppression
broad spectrum antibiotics
mucosal breakdown: sexual contact, dermatitis
recurrent candidiasis associated with atopy
presentation of candidiasis
Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
Cottage-cheese
Vulval erythema +/- fissures, pH 4
severe candida infection
Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation
Investigations in candidiasis
pH <4.5 (BV TV >4.5)
high vaginal swab
microscopy: spres, pseudohyphase plus neutrophils
culture may grow candida but doesn’t distinguish colonisation
Management options for candida
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator: BD for 2 weeks
Antifungal pessary:
Clotrimazole 500mg
Oral antifungal tablets:
Fluconazole 150mg PO STAT
Avoid in pregnancy/ breast feeding
recurrent candida mx
> 4/yr
6 month regime
Fluconazole 150mg every 72 hours for 3 doses
Fluconazole 150mg once a week for 6 months
Clotrimazole pessaries if fluconazole contraindicated
canesten duo
single fluconazole tablet
clotrimazole cream externally for vulval symptoms
what is the most common STI in the UK?
chlamydia trachomatis
chlamydia trachomatis
gram-negative bacteria
national chlamydia screening programme
screen sexually active
<25 years old
re-test after 3 months if positive
which STIs are patients tested for in a GUM clinic?
chlamydia
gonorrhea
syphilis
HIV
charcoal swabs can confirm which infections
bacterial vaginosis candidiasis gonorrhea (endocervical) trichomonas vaginalis (posterior fornix swab) GBS
chlamydia presentation in women
asymptomatic in majority abnormal discharge pelvic pain abnormal vaginal bleeding (IMB, PCB) painful sex painful urination
chlamydia in men presentation
urethral discharge or discomfort painful urination (dysuria) sexually active epididymo=orchitis reactive arthritis
extra-genital symptoms chlamydia
conjunctivitis
pharyngitis
SA reactive arthritis
proctitis
first line management for chlamydia
doxycycline 100mg BD 7 days
chylamydia pregnancy mx
Azithromycin 1g stat then 500mg once a day for 2 days
Erythromycin 500mg four times daily for 7 days
Erythromycin 500mg twice daily for 14 days
Amoxicillin 500mg three times daily for 7 days
advice after chlamydia diagnosis
Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
Test for and treat any other sexually transmitted infections
Provide advice about ways to prevent future infection
Consider safeguarding issues and sexual abuse in children and young people
complications of chlamydia
Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis
pregnancy-related complications of chlamydia
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)
lymphogranuloma venereum
MSM
condition affecting lymphoid tissue around site of infection with chlamydia
lymphogranuloma venereum
MSM
condition affecting lymphoid tissue around site of infection with chlamydia
lymphogranuloma venerum
primary stage
painless ulcer
penis, vaginal wall, rectum (anal sex)
lymphogranuloma venerum
secondary stage
lymphadenitis
swelling, inflammation, pain in lymph nodes
infected with the bacteria
lymphogranuloma venerum
tertiary stage
proctitis: anal pain, change in bowel habit, tenesmus, discharge
management of lymphogranuloma venerum
doxycycline 100mg BD for 21 days
presentation of gonorrhea in females
50% symptomatic
odourless purulent discharge, green or yellow
dysuria
pelvic pain
male gonorrhea presentation
symptomatic 90%
Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)
gonorrhea investigations
NAAT to detect RNA/DNA
charcoal swab for antibiotic choice: microscopy, sensitivity, culture
uncomplicated gonococcal infection mx
A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
test of cure post gonorrhea treatment
72 hours after treatment for culture
7 days after treatment for RNA NAAT14 days after treatment for DNA NAAT
complications of gonorrhea
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh-Curtis syndrome
Septic arthritis
Endocarditis
features of disseminated gonococcal infection
Various non-specific skin lesions
Polyarthralgia (joint aches and pains)
Migratory polyarthritis (arthritis that moves between joints)
Tenosynovitis
Systemic symptoms such as fever and fatigue
mycoplasma genitalium bug
gram positive
flask-shaped, slightly curved organelle
mycoplasma genitalium infection
urethritis
epididymitis
mucopurulent cervicitis
Endometritis
Pelvic inflammatory disease
Reactive arthritis
Preterm delivery in pregnancy
Tubal infertility
NGU
Sexual partners of persons MG +ve (3 months)
management of mycoplasma genitalium
doxycycline 100mg BD 7 days then
azithromycin 1g stat then 500mg OD 2 days
PID organs involved
endometritis salpingitis oophoritis parametritis peritonitis cervicisits
PID organisms
STi:
Neisseria gonorrhoeae tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium
Non-STI PID:
Gardnerella vaginalis (associated with bacterial vaginosis)
Haemophilus influenzae (a bacteria often associated with respiratory infections)
Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
Vaginal flora introduced by surgery, IUD insertiion
Anaerobes: prevotella, atopobium, leptotrichia
salpingitis features
erythema, oedema, exudate
low bilateral abdominal pain
adnexal swelling, tenderness
endometritis features
menstrual irregularity
midline abdominal pain
cervicitis features
vaginal discharge
inflammation
tenderness
risk factors for PID
Not using barrier contraception
Multiple sexual partners
Younger age, <25
New sexual partner
TOP/ miscarriage
Instrumentation of uterus
Coil insertion
Low socioeconomic status
Low educational attainment
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)
Appendicitis
History of multiple partners
PID symptoms
Pelvic
PID examination
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Lower abdominal tenderness, usually bilateral
Uterine/ adnexal tenderness
Adnexal mass
Muco-purulent vaginal discharge
Contact bleeding/ cervicitis
Fever >38degrees
Tenderness in RUQ
DD PID
Gynaecological:
Ectopic pregnancy
Ovarian cyst (torsion, rupture, haemorrhage)
Endometriosis
Urinary tract infections:
Cystitis
GI tract:
Inflammatory bowel
Appendicitis
Irritable bowel
PID ix
NAAT: gonorrhea, mycoplasma genitalia, chlamydia
HIV, syphilis
high vaginal swab: BV, cadidiasis, trichomoniasis
endocervical/ vaginal swabs: gonorrhea, chlamydia, trichomonas vaginalis, mycoplasma genitalia
pregnancy test
urine dipstick
CRP/ ESR/ WCC
transvaginal USS
laparoscopy
PID management
A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
PID: sepsis or pregnanct
admission to hospital for IV ax
IV ceftriaxone and doxycycline, then oral metronidazole and oral doxycycline
IV for 24 hours after clinical improvement
PID abscess
Review after 72 hours:
IV therapy if no/ minimal improvement
Remove IUC if in-situ
Review in 2-4 weeks:
Ensure symptoms resolved
Check compliance with antibiotics
Follow-up contacts; have they been screened and treated
complications of PID
Sepsis
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
Tubo-ovarian abscess
Fitx-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
syphilis incubation period
21 days
primary syphilis presentation
chancre
resolves over 3-8 weeks
local lymphadenopathy
secondary syphilis presentation
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions: snail track mucous lesions
tertiary syphilis presentation
Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis
neurosyphilis features
Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment
diagnosis of syphilis
Treponemal enzyme immunoassay
Treponema pallidum particular agglutination assay
Rapid plasma reagin test
GUM referral
samples from sites: dark field microscopy, PCR
management of syphilis
Full screening for other STIs
Advice about avoiding sexual activity until treated
Contact tracing
Prevention of future infections
IM benzathine benzylpenicillin
1 dose weekly for early latent, primary and secondary
3 doses weekly for late latent, cardiovascular and gummatous
what can trichomoniasis increase risk of?
Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.
trichomoniasis presentation
Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific:
Vaginal discharge : frothy and yellow-green
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
Vulval soreness/ itching: vulvitis, vaginitis
strawberry cervix: colpitis macularis, cervicitis
vaginal ph>4.5
Non specific urethritis in men
diagnosis of trichomonas vaginalis
The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).
Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.
Wet mount
A urethral swab or first-catch urine is used in men.
Urethral culture or culture FVU in men
trichomonas management
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
Treatment is with metronidazole:
Metronidazole 400mg PO BD 7 days
Metronidazole 2g PO stat
Treat male partners empirically
Partner notification:
Treat male partner empirically
Abstain from sex
Signpost to ‘sexwise’ website
trichomonas complications
Pre-term delivery
Low birth weight
Enhanced HIV transmission
4 stages of genital herpes
Red papules
Blisters
Painful popping of blisters
Crust over and heal
signs/symptoms of genital herpes
Ulcers or blistering lesions affecting the genital area
Neuropathic type pain (tingling, burning or shooting)
Flu-like symptoms (e.g. fatigue and headaches)
Dysuria (painful urination)
Inguinal lymphadenopathy
First infection bilateral, recurrence unilateral
Necritising on cervix
how long do syptoms last in primary herpes infection
3 weeks
diagnosis of genital herpes
Ask about sexual contacts, including those with cold sores, to establish a possible source of transmission. They may have caught the infection from someone unaware they are infected and not experiencing any symptoms.
The diagnosis can be made clinically based on the history and examination findings.
A viral PCR swab from a lesion can confirm the diagnosis and causative organism.
Full STI screen
Syphilis serology
HIV antibody test
HSV1
Orofacial
Up to 80% seropositivity
0-1 recurrences per year
Recurrences after year 1 unusual
HSV2
Genital
7% seropositivity
4 recurrences per year
management of genital herpes
aciclovir
Paracetamol
Topical lidocaine 2% gel (e.g. Instillagel)
Cleaning with warm salt water
Topical vaseline
Additional oral fluids
Wear loose clothing
Avoid intercourse with symptoms
primary genital herpes mx
<28 weeks gestation
aciclovir during initial infection
regular prophylactic aciclovir after 36 weeks gestation
vaginal delivery if asymptomatic at delivery and >6 weeks since initial infection
primary genital herpes mx
>28 weeks gestation
aciclovir during infection
regular prophylactic aciclovir immediately afer
c section
HpV immunisation
Introduced in 2008
Protects against subtypes 6,11,16,18
12-13 year old girls
Reepat dose at 6-12months after 1st
MSM <45 eligible if attending SHS/HIV services since 2018
complications of genital herpes
Urinary retention
Adhesions
Meningism
Emotional distress
Recurrences
HIV spread
Unprotected anal, vaginal or oral sexual activity
Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)
Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye
Examples of AIDS-defining illnesses
Kaposi’s sarcoma
Pneumocystis jirovecii pneumonia (PCP)
Cytomegalovirus infection
Candidiasis (oesophageal or bronchial)
Lymphomas
Tuberculosis
Cryptococcal meningitis
Screening for HIV
Can take up to 3 months for antibodies to develop to infection
repeat testing is needed
verbal consent needed
Risk factors for someone undergoing testing:
High HIV prevalence coutry
Blood transfusion, or other risk-prone procedures in countries who don’t have strong screening for HIV
Paid for sex or been paid for sex
Rape/ sexual assault by those from above
Babies with mothers who have untreated HIV
MSM: bleeding during anal sex
Indications for HIV testing
MSM/ transgender
Female sexual contacts of MSM/ tansgender
Black african
Injecting drug use
STI diagnosis
Sex workers
HIV positive sexual partners
HIV infection entering differential diagnosis:
Recurrent or severe shingles
Recurrent bacterial pneumonia
How often should indicated patients be tested for HIV
Every 3 months for MSM
Annual HIV test indications
Heterosexuals who have changed sexual partners
IVDU
Sex worker
Black african men and women having UPSI with new or casual partners
Types of HIV tests
Antibody testing is the typical screening test for HIV. This is a simple blood test. Patients can request an antibody testing kit online for self sampling at home, which they post to the lab for testing.
Testing for the p24 antigen, checking directly for this specific HIV antigen in the blood. This can give a positive result earlier in the infection compared with the antibody test.
PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.
Window period 45 days
CD4 count in HIV
500-1200 cells/mm3 is the normal range
Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections
How immunosuppressed they area
Indication of how advanced the disease is
viral load HIV
Viral load is the number of copies of HIV RNA per ml of blood. “Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). The viral load can be in the hundreds of thousands in untreated HIV.
prevention of HIV
Safe sex, condom use
Screening and regular testing
Treatment as prevention
U=U, undetectable = untransmissable
Post-exposure prophylaxis
Pre-exposure prophylaxis
HAART HIV medication
Protease inhibitors (PIs):
Always co-prescribed with a booster
Darunavir plus ritonovir
Integrase inhibitors (IIs): Raltegavir, dolutegravir, bictegravir
Nucleoside reverse transcriptase inhibitors (NRTIs):
Tenofovir, abacavir, emtricitabine, lamivudine
Backbone
Non-nucleoside reverse transcriptase inhibitors (NNRTIs): Efavirenz, doravarine Entry inhibitors (EIs)
additional management of HIV
Prophylactic co-trimoxazole (Septrin) is given to patients with a CD4 under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).
HIV infection increases the risk of developing cardiovascular disease. Patients with HIV have close monitoring of cardiovascular risk factors and blood lipids. Appropriate treatment (e.g. statins) may be required to reduce their risk of developing cardiovascular disease.
Yearly cervical smears are required for women with HIV. HIV predisposes to developing human papillomavirus (HPV) infection and cervical cancer, so female patients need close monitoring to ensure early detection of these complications.
Vaccinations should be up to date, including influenza, pneumococcal, hepatitis A and B, tetanus, diphtheria and polio vaccines. Patients should avoid live vaccines.
Preventing HIV transmission during birth
Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml
Caesarean section is considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml
IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml
Prophylaxis for baby with HIV positive mother
Low-risk babies, where the mother’s viral load is < 50 copies per ml, are given zidovudine for four weeks
High-risk babies, where the mother’s viral load is > 50 copies / ml, are given zidovudine, lamivudine and nevirapine for four weeks
Breast feeding HIV
HIV can be transmitted during breastfeeding, even if the mother’s viral load is undetectable. Breastfeeding is not recommended for mothers with HIV. However, if the mother is adamant a
Post-exposure prophylaxis
Post-exposure prophylaxis (PEP) can be used after exposure to HIV to reduce the risk of transmission. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours). The sooner it is started, the better. A risk assessment of the probability of developing HIV should be balanced against the side effects of PEP.
PEP involves a combination of ART therapy. The current regime is Truvada (emtricitabine and tenofovir) and raltegravir for 28 days.
HIV tests are done immediately and also a minimum of three months after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.
Pre-exposure prophylaxis
High risk patients eligible
Truvada either daily or event-based
Reduces risk of acquisition of HIV by at least 86% but likely much more
Doesn’t protect against other STIs/ BBI
HepC disease course
1 in 4 fights off the virus and makes a full recovery
3 in 4 it becomes chronic
Complications: liver cirrhosis and associated complications and hepatocellular carcinoma
management of hepC
Have a low threshold for screening patients that are at risk of hepatitis C
Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases
Refer to gastroenterology, hepatology or infectious diseases for specialist management
Notify Public Health (it is a notifiable disease)
Stop smoking and alcohol
Education about reducing transmission and informing potential at risk contacts
Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma
Antiviral treatment with direct acting antivirals (DAAs) is tailored to the specific viral genotype. They successfully cure the infection in over 90% of patients. They are typically taken for 8 to 12 weeks
Liver transplantation for end-stage liver disease
HepC transmission
Parenteral:
Needle stick
Transfusion
Haemodialysis
Vertical Transmission
Hepatitis C is passed from infected mothers to their babies about 5 – 15% of the time. Hepatitis C antivirals are not recommended in pregnancy and there are no additional measures that are known to reduce the risk of transmission.
Babies and children tend not to have any symptoms or pathology associated with hepatitis C infection. It is very unlikely that children will pass on hepatitis C to others as they do not engage in sexual activity or IV drug use. Parents should be educated about hepatitis C and the modes of transmission.
Sexual transmission very low risk:
Higher risk if HIV co-infected
MSM
Prevention of hepC
Risk modification
No immunoglobulin
No PEP
No vaccine
Testing can reduce the risk of transmission to others- early identification -> RF modification and treatment
No intervention that reduces MTCT:
Consider HepB vaccine for baby
advice for hepC patients
HepC curable
Check for other hepatitis infections- vaccinated against HepB
do not donate blood, semen or organs
Discuss routes of transmission and risk reduction
Screen for STIs
Detailed explanation of condition and long term complications
Acute hepatitis is notifiable
management of hepC
Evaluate if patient is stable
Any signs of acute or chronic liver failure?
Liver function (clotting, platelelts, albumin)
Liver inflammation (enzymes- ALT)
Refer to hepatology for further ix/rx
Direct acting anti-virals for hepC;
Harvoni
Prevents virus completing cell cycle
Curable infection with shorter treatment and less AE
management of hepC in children
Babies to hepatitis C positive mothers are tested at 18 months of age using the hepatitis C antibody test. Breastfeeding has not been found to spread hepatitis C, so mothers are free to breastfeed their babies. If nipples become cracked or bleed breastfeeding should temporarily stop whilst they heal.
Children often clear the virus spontaneously. Chronic infection with hepatitis C does not usually cause issues in childhood. Infected children will require regular specialist follow up to monitor their liver function and hepatitis C viral load.
Medical treatment may be considered in children over 3 years. Treatment in childhood involves pegylated interferon and ribavirin, which are less effective and well tolerated compared with the adult treatments.
Treatment is typically delayed until adulthood unless the child is significantly affected, because children are usually asymptomatic and newly available treatment for adults is highly effective.
hepB transmission
Parenteral
Vertical
Sexual:
MSM higher risk
Multiple partners, condomless anal intercourse
Heterosexual SI
Sporadic:
RF- in LD institutions and geographical areas of high prevalence
incubation of hepB
40-160 days
Virtually all children with acute infection have no symptoms
Acute infection asymptomatic in 10-50% adults
Chronic carries usually no sx
If symptomatic in acute phase, usually similar to hepA with prodrome/ icteric phase but more prolonged
HbsAg
active infection
HBeAg
markers of viral replication and implies high infectivitiy
HbcAb
core antibody
implies past or current infection
HbsAb
surface antibody
implies vaccination or past or current infection
Primary prevention on hepB
Advice to pt: Inform GP/dentist Don’t donate Dont share needles Cover wounds Clean blood spills thoroughly Condoms
Pregnancy:
Antivirals for mother if high viral load
Vaccinate neonate
Consider HBIG if HR
Sexual contacts:
Vaccination
HBIG if recent
Condoms/ dental dams until immature
Household contacts:
Vaccination
Don’t share razors/ toothbrushes
management of hepB
Have a low threshold for screening patients that are at risk of hepatitis B.
Screen for other blood borne viruses (hepatitis A and B and HIV) and other sexually transmitted diseases
Acute infection is notifiable
Acute infection is self-limiting
Refer persistent infection to hepatologist
Vaccinate against hepA if not already immune
Refer to gastroenterology, hepatology or infectious diseases for specialist management
Notify Public Health (it is a notifiable disease)
Stop smoking and alcohol
Education about reducing transmission and informing potential at risk contacts
Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma
Antiviral medication can be used to slow the progression of the disease and reduce infectivity:
Peg interferon alpha 2a
Entecavir, tenofovir
Liver transplantation for end-stage liver disease
post-exposure prophylaxis hepB
HIV: Truvada/ raltegavir Start within 72 hours Duration 28 days Can discontinue if source tests negative
HepB:
May need booster
May need HBIG if inadequate immunity and patient HbsAg positive
HepC:
No prophylaxis available
