Infections/STDs Flashcards
Lab testing for PID
pregnancy test, microscopic examination of vaginal discharge, nucleic acid amplification testing for C. trachomatis and N. gonorrhoeae, HIV screening, and syphilis screening
TVUS for PID
used to evaluate for a tubo-ovarian abscess, especially if there is unilateral adnexal tenderness
Outpatient treatment for PID
empiric antibiotic coverage with ceftriaxone 500 mg IM in a single dose (1,000 mg if the patient is ≥ 150 kg), doxycycline 100 mg PO bid for 14 days, and metronidazole 500 mg PO bid for 14 days with follow-up in 72 hours
Indications for hospitalization PID
Patients with PID with high fever, inability to tolerate oral fluid intake, severe abdominal pain, or suspected abscess or pregnancy should be hospitalized
Tx for hospitalized pt w PID
cefoxitin 2 g IV every 6 hours (or cefotetan 2 g IV every 12 hours) and doxycycline 100 mg PO or IV every 12 hours. Patients with PID should refrain from sexual activity until therapy is completed, and all partners should be evaluated and treated
Major complications of PID
tubo-ovarian abscess, chronic pelvic pain, infertility, and ectopic pregnancy
the most common bacterial cause of sexually transmitted infections
Chlamydia trachomatis
what type of bacteria is Chlamydia trachomatis
gram-negative
sx Chlamydia trachomatis
asymptomatic = MC
changes in vaginal discharge, bleeding between menses, and postcoital bleeding
PE chlamydia trachomatis
mucopurulent endocervical discharge, endocervical bleeding, or edematous ectopy
discharge comparison btwn chlamydia and gonorrhea
the discharge associated with chlamydial infections is less painful, less purulent, and more watery
UA for chlamydia
pyuria with no organisms on Gram stain (chlamydia is hard to stain)
best test for dx of chlamydia
nucleic acid amplification test
Complications of C. trachomatis
pelvic inflammatory disease, ectopic pregnancy, and infertility
Bacterial vaginosis is due to
a shift in the vaginal flora that causes a rise in the vaginal pH
the shift is typically due to a decrease in hydrogen peroxide- and lactic acid-producing lactobacilli and an increase in anaerobic bacteria
RF for BV
sexual activity, douching, and cigarette smoking
sx BV
asx = MC
vaginal discharge or vaginal odor. The discharge is classically thin, white, and homogeneous.
BV does not typically cause
Bacterial vaginosis does not typically cause vaginal erythema or edema, dysuria, dyspareunia, vaginal pruritus, or vaginal burning
dx BV
at least three of the four Amsel criteria: homogeneous, thin, grayish-white discharge; vaginal pH > 4.5; positive whiff-amine testing; and clue cells on saline wet mount
tx BV
metronidazole or clindamycin (oral or topical)
Patient ed for tx for BV
educate patients to not consume alcohol while taking metronidazole and to not use latex condoms when using clindamycin cream
Rxn for patients drinking alcohol when taking Metronidazole
disulfiram-like reaction, including nausea and vomiting
clindamycin cream and condoms patient ed
Clindamycin cream can reduce the efficacy of latex condoms
tx BV for frequent recurrences
preventive therapy, either oral metronidazole or oral tinidazole daily for 1 week and vaginal boric acid daily for 3 weeks. Patients who are in remission after this regimen can then use metronidazole gel twice weekly for 4–6 months
anogenital warts are also called
Condylomata acuminata
MC cause of Condylomata acuminata
HPV 6 and 11
what is the most common sexually transmitted infection in the world
HPV
appearance of condyloma acuminata
soft to palpation and appear as flat, dome-shaped, verrucous, and cauliflower-shaped
sx condyloma acuminata
usually ASX
may have itching
dx anogenital warts
based on clinical appearance
self therapy at home for anogenital warts
miquimod, podophyllotoxin, sinecatechins
office based therapy for anogenital warts
trichloroacetic acid, cryotherapy, or surgical removal
Lymphogranuloma venereum
genital ulcer disease caused by specific serotypes of Chlamydia trachomatis
where is Lymphogranuloma venereum MC
most common in tropical and subtropical climates, such as West and East Africa, India, parts of Southeast Asia, and the Caribbean
Increased prevalence in US and Europe in men who have sex with men
stages of Lymphogranuloma venereum
primary infection, secondary infection, and late lymphogranuloma venereum
primary infection of Lymphogranuloma venereum
painless and small genital ulcer at the site of inoculation. The painless ulcer resolves spontaneously within a few days and thus often goes unnoticed
secondary infection of Lymphogranuloma venereum
occurs 2 to 6 weeks following the primary infection. The secondary stage is due to inflammation from direct extension to the superficial and deep inguinal or femoral lymph nodes. The secondary stage may manifest as an inguinal syndrome or as anorectal symptoms.
sx in secondary infection of Lymphogranuloma venereum
unilateral painful inguinal lymph nodes associated with lymphogranuloma venereum are often called buboes. The inguinal syndrome of lymphogranuloma venereum is less common in women because the vaginal and cervical lymph nodes drain predominantly to the retroperitoneal area. The secondary stage of lymphogranuloma venereum may lead to severe inflammation, causing systemic symptoms. Anorectal symptoms due to lymphogranuloma venereum include rectal discharge, tenesmus, anal pain, and constipation
late lymphogranuloma venereum
(typically in untreated cases) include strictures or fibrosis of the genitourinary tract, infertility, genital elephantiasis, and esthiomene, which is defined as destruction of the genitalia
dx lymphogranuloma venereum
Lymphogranuloma diagnosis is difficult but can be confirmed with laboratory testing, which may include cultures, serology, or nucleic acid amplification testing (most accurate)
tx lymphogranuloma venereum
21-day course of doxycycline. The buboes are sometimes drained for symptomatic relief
what should occur in all sexual partners of the patient with lymphogranuloma venereum
all sexual partners of the patient evaluated and treated and to have the patient tested for hepatitis B, hepatitis C, and HIV infection
what type of bacteria is gonorrhea
gram negative diplococcus
sx gonorrhea
mucopurulent vaginal discharge and vaginal pruritus
MC asx
PE gonorrhea
May be normal
vaginal discharge
friable cervix
complications gonorrhea
pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain
best diagnostic test gonorrhea
nucleic acid amplification testing
tx gonorrhea in a pregnant woman
Combo of ceftriaxone 500 mg IM + azithromycin 1 g orally
when should you repeat testing for gonorrhea
3 months
should sexual partners of pts w gonorrhea be treated
yes
cause of trichomoniasis
parasite trichomans vaginalis
pear-shaped protozoan with four polar flagella
sx trichomoniasis
vaginal pruritus or discomfort
dysuria
lower abdominal pain
malodorous, yellow-green, frothy discharge and punctate hemorrhages on the cervix (strawberry cervix)
tx trichomoniasis
single dose of metronidazole 2 g PO
avoid alcohol for 48 hours after
other ADE of metronidazole
metallic taste
cause of syphilis
spirochete treponema pallidum
4 types of syphilis
primary
secondary
latent
tertiary
when do sx begin for syphilis after initial infection
~3 weeks
primary syphilis
a single, erythematous, painless genital ulcer (called a chancre) appears and usually lasts for 4 weeks.
highly infectious ulcer
they are solitary, erythematous, raised and firm to the touch and will ulcerate over time, creating a surrounding crater w elevated edges (usually heal within 3-6 weeks)
may have associated regional lymphadenopathy
secondary syphilis
ay occur weeks to months after resolution of the chancre
A maculopapular rash on the palms of the hands and soles of the feet is the most recognized physical exam finding in secondary syphilis - rash is nonpruritic
condyloma lata (highly infectious) may appear near the site of the original chancre. These appear as small, verrucous lesions in mucocutaneous areas.
moth-eaten alopecia
Additional symptoms associated with secondary syphilis are fever and lymphadenopathy.
develops 4-10 weeks after chancre appears
Latent stage syphilis
can persist for 25 years. This is an asymptomatic stage of disease.
pts are seroreactive
Tertiary syphilis
characterized by gummatas, or small, benign growths found throughout various tissues. The patient may also have focal neurologic findings, including hearing and vision loss. Additional findings as a result of syphilis infection include congenital and neurosyphilis
slowly progressive
mainly affects the cardiovascular system and central nervous system - but can affect any organ
Having syphilis increases the transmissibility of
HIV
nontreponomal test for syphilis dx
Venereal Disease Research Laboratory (VDRL)
treponema test for syphilis
fluorescent treponemal antibody absorption (FTA-ABS) or T. pallidum enzyme immunoassay
tx of choice regardless of stage of syphilis
IM PCN G
what does the stage of syphilis determine in terms of treatment
the dose of IM PCN G
What is the name of the physical exam finding common in neurosyphilis where small pupils will accommodate near objects but do not react to bright light?
Argyll Robertson pupil.
Chancroid
sexually transmitted infection that is caused by Haemophilus ducreyi
what type of bacteria is haemophilus ducreyi
gram negative fastidious rod that clumps in long parallel strands producing the so called “school of fish” or “railroad track” appearance
btwn what ages is haemophilus ducreyi MC
15-19
sx chancroid/haemophilus ducreyi
painful genital ulcer that has a ragged border and a purulent base. The ulcer starts initially as a papule that progresses into a pustule and then into an ulcer within a few weeks. Patients may also report dysuria and dyspareunia, particularly in women
PE chancroid/haemophilus ducreyi
unilateral tender inguinal lymphadenopathy (buboes) that appears 1 to 2 weeks after onset of the ulcer.
does a serologic test exist for haemophilus ducreyi
no
is culture of haemophilus ducreyi practical
no bc it is fastidious and requires a special medium that is not readily available
what testing should be obtained when you suspect haemophilus ducreyi
Serologic tests (rapid plasma reagin, venereal disease research lab) should be obtained to exclude syphilis
tx chancroi
drainage of a fluctuant inguinal lymph node
abx - azithromycin, ceftriaxone, erythromycin
inpatient tx PID
parenteral therapy with a second-generation cephalosporin, such as cefoxitin or cefotetan, and doxycycline.
Metronidazole is added for anaerobic coverage in patients with a pelvic abscess or recent gynecologic instrumentation
Indications for admission PID
severe illness (high fever, nausea and vomiting, or severe abdominal pain), suspected pelvic abscess, or pelvic inflammatory disease occurring in pregnancy
what structures are involved in PID infection
uterus and fallopian tubes caused by ascending infection from the vagina and cervix
another causative agent of PID that is not gonorrhea or chlamydia
mycoplasma genitalium
Laparoscopic findings in PID
tubal wall edema and presence of exudates and visible hyperemia on the tubal surfaces
MC cause BV - and describe it
facultative anaerobe Gardnerella vaginalis
what are clue cells in BV
epithelial cells that have a stippled appearance due to coccobacilli that adhere to the edge of the cell
gold standard dx BV
gram stain of vaginal discharge demonstrating the presence of gardnerella vaginalis
sx herpes simples virus (HSV)
painful vesicular lesions on an erythematous base that eventually rupture and form ulcers
individuals w genital ulcers often have recurrent outbreaks
types of infection for HSV
primary
nonprimary first episode
recurrent infection
primary infection HSV
lab testing confirms genital herpes but the pt has no antibodies to HSV-1 or HSV-2
indicates that this is the first infection
which type of HSV infection causes the most severe sx
primary infection
sx primary HSV
painful genital fluid-filled vesicular lesions that ulcerate, dysuria, tender local lymphadenopathy, and systemic manifestations, such as fever, malaise, and headache
nonprimary first episode HSV
lab evidence confirms genital herpes but the individual has antibodies to the other HSV subtype
sx nonprimary first episode HSV
The manifestations of nonprimary first episode are less severe compared to primary infection. There are fewer lesions and less systemic symptoms.
recurrent HSV infection
individual has HSV infection confirmed w lab testing and also has serum antibodies to the same subtype
it is possible for an individual to have a recurrent infection without prior sx
sx recurrent HSV infection
less severe than primary or nonprimary first episode
systemic sx are absent
lesions tend to heal quicker
dx HSV
viral culture or polymerase chain rxn testing
tx HSV
acyclovir or Valacyclovir
acyclovir (400 mg tid for 7–10 days), famciclovir (250 mg tid for 7–10 days), and valacyclovir (1,000 mg bid for 7–10 days)
low risk types of HPV
6, 11, 42
high risk types of HPV
16
18
31
33
why are high risk types of HPV more likely to progress to carcinoma
they produce E6 and E7 proteins that result in the destruction of p53 and RB genes, genes that are important in tumor suppressor pathways
cervical intraepithelial neoplasia (CIN) is characterized by
koilocytic change, disordered cellular maturation, nuclear atypia, and increased mitotic activity within the cervical epithelium
CIN1
involving 1/3 of the epithelium
CIN2
involving 2/3 of the epithelium
CIN3
involving more than 2/3 of the epithelium
carcinoma in situ
involving the entire thickness of the epithelium
dx HPV
HPV viral typing
USPSTF recs for cervical CA screening
women between the ages of 21 and 29 years should undergo screening for cervical cancer every 3 years with cervical cytology alone. In women ages 30 and 65 years, screening should be done every 3 years with cervical cytology alone, every 5 years with high-risk HPV testing alone, or every 5 years with high-risk HPV testing in combination with cytology (cotesting)
what can be used to treat genital warts caused by HPV
Podophyllin, trichloroacetic acid, or podofilox
what HPV types does the recombinant human papilloma virus 9-valent vaccine cover
covers HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58
What are some side effects of imiquimod?
Dermal ulcer, abrasion, edema, application site reaction, skin erosion, and erythema of the skin.
