Infectious diseases Flashcards
What are gram +ve cocci?
staphylococci + streptococci (including enterococci)
What are 3 gram -ve cocci?
Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis
Name 5 gram postive rods
ABCD L
Actinomyces Bacillus anthracis (anthrax) Clostridium Diphtheria: Corynebacterium diphtheriae Listeria monocytogenes
Name 6 gram -ve rods
Escherichia coli
Haemophilus influenzae
Pseudomonas aeruginosa
Salmonella sp.
Shigella sp.
Campylobacter jejuni
What 5 agents can cause CAP?
What is seen in alcoholics?
Streptococcus pneumoniae (accounts for around 80% of cases)
Haemophilus influenzae
Staphylococcus aureus: commonly after influenza infection
atypical pneumonias (e.g. Due to Mycoplasma pneumoniae)
viruses
Klebsiella is seen in alcoholics
What is the most common cause of CAP?
Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia
Give 4 characteristic features of pneumococcal pneumonia?
Characteristic features of pneumococcal pneumonia
rapid onset high fever pleuritic chest pain herpes labialis (cold sores)
What are the two types of pnuemococcal vaccine currently in use?
There are two type of pneumococcal vaccine currently in use:
pneumococcal conjugate vaccine (PCV) pneumococcal polysaccharide vaccine (PPV)
Who is routinely offered the pneumococcal vaccine?
The PCV is given to children as part of their routine immunisations (at 3 and 12-13 months).
The PPV is offered to all adults over the age of 65 years, to patients with chronic conditions such as COPD and to those who have had a splenectomy (see below).
What 9 groups of people should be given the pneumococcal vaccine?
Groups who should be vaccinated:
asplenia or splenic dysfunction
chronic respiratory disease: COPD, bronchiectasis, cystic fibrosis, interstitial lung disease. Asthma is only included if ‘it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant’
chronic heart disease: ischaemic heart disease if requiring medication or follow-up, heart failure, congenital heart disease. Controlled hypertension is not an indication for vaccination
chronic kidney disease
chronic liver disease: including cirrhosis and chronic hepatitis
diabetes mellitus if requiring medication
immunosuppression (either due to disease or treatment). This includes patients with any stage of HIV infection
cochlear implants
patients with cerebrospinal fluid leaks
Adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years.
How is influenza vaccine given to children? when is this given? is this a live vaccine?
it is given intranasally
the first dose is given at 2-3 years, then annually after that
it is a live vaccine (cf. injectable vaccine below)
Why would a child be given an injectable influenza vaccine? is this effective?
children who were traditionally offered the flu vaccine (e.g. asthmatics) will now be given intranasal vaccine unless this is inappropriate, for example if they are immunosuppressed. In this situation the inactivated, injectable vaccine should be given
only children aged 2-9 years who have not received an influenza vaccine before need 2 doses
it is less effective than the intranasal vaccine
What are 7 contraindications of influenza vaccine in children?
Contraindications
immunocompromised aged < 2 years current febrile illness or blocked nose/rhinorrhoea current wheeze (e.g. ongoing viral-induced wheeze/asthma) or history of severe asthma (BTS step 4) egg allergy pregnancy/breastfeeding if the child is taking aspirin (e.g. for Kawasaki disease) due to a risk of Reye's syndrome
What are 4 side effects of the influenza vaccine?
Side-effects
blocked-nose/rhinorrhoea headache anorexia
What groups of adults get the flu vaccine due to personal health?
The Department of Health recommends annual influenza vaccination for all people older than 65 years, and those older than 6 months if they have:
chronic respiratory disease (including asthmatics who use inhaled steroids) chronic heart disease (heart failure, ischaemic heart disease, including hypertension if associated with cardiac complications) chronic kidney disease chronic liver disease: cirrhosis, biliary atresia, chronic hepatitis chronic neurological disease: (e.g. Stroke/TIAs) diabetes mellitus (including diet controlled) immunosuppression due to disease or treatment (e.g. HIV) asplenia or splenic dysfunction pregnant women adults with a body mass index >= 40 kg/m²
What groups of people get the flu vaccine due to personal circumstance i.e. occupationally
Other at risk individuals include:
health and social care staff directly involved in patient care (e.g. NHS staff) those living in long-stay residential care homes carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill (at the GP's discretion)
The influenza vaccine
-is this live?
-How should this be stored?
-What is a contraindication?
-is this effective?>
-How long does this take to work?
The influenza vaccine
it is an inactivated vaccine, so cannot cause influenza. A minority of patients however develop fever and malaise which may last 1-2 days should be stored between +2 and +8ºC and shielded from light contraindications include hypersensitivity to egg protein. in adults the vaccination is around 75% effective, although this figure decreases in the elderly it takes around 10-14 days after immunisation before antibody levels are at protective levels
What treatment is used for Exacerbations of chronic bronchitis
Amoxicillin or tetracycline or clarithromycin
What treatment is used for Uncomplicated community-acquired pneumonia
Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)
What treatment is added if you are considering atypical pneumonia?
Clarithromycin
What treatment is used for HAP?
Within 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
Describe the primary infection of TB
A non-immune host who is exposed to M. tuberculosis may develop a primary infection of the lungs. A small lung lesion known as a Ghon focus develops. The Ghon focus is composed of tubercle-laden macrophages. The combination of a Ghon focus and hilar lymph nodes is known as a Ghon complex
In immunocompetent people, the initial lesion usually heals by fibrosis. Those who are immunocompromised may develop disseminated disease (miliary tuberculosis).
Describe the secondary infection of TB? what can lead to this?
If the host becomes immunocompromised the initial infection may become reactivated. Reactivation generally occurs in the apex of the lungs and may spread locally or to more distant sites. Possible causes of immunocompromise include:
immunosuppressive drugs including steroids HIV malnutrition
Where can secondary infection of TB occur?
The lungs remain the most common site for secondary tuberculosis. Extra-pulmonary infection may occur in the following areas:
central nervous system (tuberculous meningitis - the most serious complication) vertebral bodies (Pott's disease) cervical lymph nodes (scrofuloderma) renal gastrointestinal tract
Describe the standard treatment of TB
The standard therapy for treating active tuberculosis is:
Initial phase - first 2 months (RIPE)
Rifampicin Isoniazid Pyrazinamide Ethambutol (the 2006 NICE guidelines now recommend giving a 'fourth drug' such as ethambutol routinely - previously this was only added if drug-resistant tuberculosis was suspected)
Continuation phase - next 4 months
Rifampicin Isoniazid
What is the treatment of latent TB?
The treatment for latent tuberculosis is 3 months of isoniazid (with pyridoxine) and rifampicin OR 6 months of isoniazid (with pyridoxine)
What is the treatment for meningeal TB?
Patients with meningeal tuberculosis are treated for a prolonged period (at least 12 months) with the addition of steroids
Who would warrant directly observed therapy for TB?
Directly observed therapy with a three times a week dosing regimen may be
indicated in certain groups, including:
homeless people with active tuberculosis patients who are likely to have poor concordance all prisoners with active or latent tuberculosis
What is immune reconstitution disease in the treatment of TB?
Immune reconstitution disease
occurs typically 3-6 weeks after starting treatment often presents with enlarging lymph nodes
Which drug side effects?
potent liver enzyme inducer
hepatitis, orange secretions
flu-like symptoms
Rifampicin
Which drug side effects?
peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
hepatitis, agranulocytosis
liver enzyme inhibitor
isoniazid
Which drug side effects?
hyperuricaemia causing gout
arthralgia, myalgia
hepatitis
Pyrazinamide
What has to be checked before starting ethambutol?
optic neuritis: check visual acuity before and during treatment
What 8 groups of people get a BCG
all infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater
all infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. The same applies to older children but if they are 6 years old or older they require a tuberculin skin test first
previously unvaccinated tuberculin-negative contacts of cases of respiratory TB
previously unvaccinated, tuberculin-negative new entrants under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater
healthcare workers
prison staff
staff of care home for the elderly
those who work with homeless people
What does the BCG vaccine contain? What else does this offer protection against?
The vaccine contains live attenuated Mycobacterium bovis. It also offers limited protection against leprosy.
Describe the administration of the BCG vaccine
any person being considered for the BCG vaccine must first be given a tuberculin skin test. The only exceptions are children < 6 years old who have had no contact with tuberculosis
given intradermally, normally to the lateral aspect of the left upper arm
BCG can be given at the same time as other live vaccines, but if not administered simultaneously there should be a 4 week interval
What are 5 contraindications to the BCG vaccine? what age is this not given to?
Contraindications
previous BCG vaccination a past history of tuberculosis HIV pregnancy positive tuberculin test (Heaf or Mantoux)
The BCG vaccine is not given to anyone over the age of 35, as there is no evidence that it works for people of this age group.
Mycoplasma pneumonia:
-what is this a cause of?
-what is this assoc. with?
-Is this common?
Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger patients. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma pneumoniae classically occur every 4 years. It is important to recognise atypical pneumonia as it may not respond to penicillins or cephalosporins due to it lacking a peptidoglycan cell wall.
What are 3 features of mycoplasma pneumoniae?
Features
the disease typically has a prolonged and gradual onset flu-like symptoms classically precede a dry cough bilateral consolidation on x-ray
What are 7 complications of mycoplasma pneumoniae?
cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia
erythema multiforme, erythema nodosum
meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases
bullous myringitis: painful vesicles on the tympanic membrane
pericarditis/myocarditis
gastrointestinal: hepatitis, pancreatitis
renal: acute glomerulonephritis
What investigations are used for mycoplasma pneumoniae?
Investigations
diagnosis is generally by Mycoplasma serology positive cold agglutination test → peripheral blood smear may show red blood cell agglutination
What is the management of mycoplasma pneumoniae?
Management
doxycycline or a macrolide (e.g. erythromycin/clarithromycin)
What is legionnaires disease caused by? where does this typically colonise? can you get person-person transmission?
Legionnaire’s disease is caused by the intracellular bacterium Legionella pneumophilia. It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen
Give 8 features of legionnaires disease?
Features
flu-like symptoms including fever (present in > 95% of patients) dry cough relative bradycardia confusion lymphopaenia hyponatraemia deranged liver function tests pleural effusion: seen in around 30% of patients
What is the diagnostic testof choice for legionnaireS? what is seen on CXR?
Investigations
diagnositic test of choice:urinary antigen
chest x-ray findings are non-specific but may include:
a mid-to-lower zone predominance of patchy consolidation
pleural effusions in around 30%
What is the management of legionnaires disease?
Management
treat with erythromycin/clarithromycin
What is the treatment for Throat infections
Phenoxymethylpenicillin (erythromycin alone if penicillin-allergic)
What is infectious mononucleosis? what is this caused by?
Infectious mononucleosis (glandular fever) is caused by the Epstein-Barr virus (EBV, also known as human herpesvirus 4, HHV-4) in 90% of cases. Less frequent causes include cytomegalovirus and HHV-6. It is most common in adolescents and young adults.
What is the classic triad of infectious mononucleosis?
The classic triad of sore throat, pyrexia and lymphadenopathy is seen in around 98% of patients:
sore throat lymphadenopathy: may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged pyrexia
What are 6 features outwith the triad that are seen in glandular fevers?
Other features include:
malaise, anorexia, headache palatal petechiae splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture hepatitis, transient rise in ALT lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes haemolytic anaemia secondary to cold agglutins (IgM)
What happens if you treat glandular fevers with amoxicillin?
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
How long do symptoms last for in glandular fever?
Symptoms typically resolve after 2-4 weeks.
What is the diagnosis of glandular fever?
Diagnosis
heterophil antibody test (Monospot test)
NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.
What is the management of glandular fever?
Management is supportive and includes:
rest during the early stages, drink plenty of fluid, avoid alcohol simple analgesia for any aches or pains consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
What is mumps caused by?
Mumps is a caused by RNA paramyxovirus and tends to occur in winter and spring
Describe the spread and the pathophysiology of mumps? what is the incubation period?
Spread
by droplets respiratory tract epithelial cells → parotid glands → other tissues infective 7 days before and 9 days after parotid swelling starts incubation period = 14-21 days
What are 3 features of mumps?
Clinical features
fever
malaise, muscular pain
parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70%
What is the prevention of mumps?
Prevention
MMR vaccine: the efficacy is around 80%
What is the management of mumps?
Management
rest paracetamol for high fever/discomfort notifiable disease
What are 4 complications of mumps?
Complications
orchitis - uncommon in pre-pubertal males but occurs in around 25-35% of post-pubertal males. Typically occurs four or five days after the start of parotitis hearing loss - usually unilateral and transient meningoencephalitis pancreatitis
What does Respiratory syncytial virus cause?
bronchiolitis
What does Parainfluenza virus cause?
croup
What does Rhinovirus cause?
common cold
what does Haemophilus influenzae cause?
COPD exac, Community-acquired pneumonia
Most common cause of bronchiectasis exacerbations
Acute epiglottitis
What does staph., aureus cause in the respiratory tract?
Pneumonia, particularly following influenza
What is given for sinusitis?
Phenoxymethylpenicillin
What is given for otitis media?
Amoxicillin (erythromycin if penicillin-allergic)
What is given for otitis externa?
Flucloxacillin (erythromycin if penicillin-allergic)
What is given for Periapical or periodontal abscess
Amoxicillin
What is given for Gingivitis: acute necrotising ulcerative
metronidazole
What is given for impetigo?
Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread
What is cellulitis most commonly caused by?
Cellulitis is most commonly caused by infection with Streptococcus pyogenes or less commonly Staphylcoccus aureus. The majority of cases resolve with oral antibiotics.
How is cellulitis diagnosed?
The diagnosis of cellulitis is clinical. No further investigations are required in primary care. Bloods and blood cultures may be requested if the patient is admitted and septicaemia is suspected.
What classification system is used to guide how cellulitis is managed?
Eron classification
Class Features
I There are no signs of systemic toxicity and the person has no uncontrolled co-morbidities
II The person is either systemically unwell or systemically well but with a co-morbidity (for example peripheral arterial disease, chronic venous insufficiency, or morbid obesity) which may complicate or delay resolution of infection
III The person has significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable co-morbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromize
IV The person has sepsis syndrome or a severe life-threatening infection such as necrotizing fasciitis
Who should be admitted for IV antibiotics to treat cellulitis? 6
They recommend the following that we admit for intravenous antibiotics the following patients: CKS
Has Eron Class III or Class IV cellulitis. Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin). Is very young (under 1 year of age) or frail. Is immunocompromized. Has significant lymphoedema. Has facial cellulitis (unless very mild) or periorbital cellulitis.
What is the management of eron class 1 cellulitis?
Eron Class I
oral antibiotics NICE oral flucloxacillin as first-line treatment for mild/moderate cellulitis oral clarithromycin, erythromycin (in pregnancy) or doxycycline is recommended in patients allergic to penicillin
what is the treatment of eron class III-IV cellulitis?
Eron Class III-IV
admit NICE recommend: oral/IV co-amoxiclav, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone
What is the management of animal bites?
The majority of bites seen in everyday practice involve dogs and cats. These are generally polymicrobial but the most common isolated organism is Pasteurella multocida.
Management
cleanse wound. Puncture wounds should not be sutured closed unless cosmesis is at risk current BNF recommendation is co-amoxiclav if penicillin-allergic then doxycycline + metronidazole is recommended
What are the common bacteria found in human bites? what is the treatment?
Human bites commonly cause multimicrobial infection, including both aerobic and anaerobic bacteria.
Common organisms include:
Streptococci spp. Staphylococcus aureus Eikenella Fusobacterium Prevotella
Co-amoxiclav is recommended, as for animal bites.
The risk of viral infections such as HIV and hepatitis C should also be considered.
what is cat scratch disease caused by? what are 4 features?
Cat scratch disease is generally caused by the Gram negative rod Bartonella henselae
Features
fever history of a cat scratch regional lymphadenopathy headache, malaise
What is the treatment of Cellulitis (near the eyes or nose)
Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)
What is the treatment of Erysipelas?
Flucloxacillin* (clarithromycin, erythromycin or doxycycline if penicillin-allergic)
Who would benefit from post-exposure prophylaxis to chicken pox? what is given?
The following criteria should be met to determine who would benefit from active post-exposure prophylaxis:
1. significant exposure to chickenpox or herpes zoster
e.g. exposure to limited, covered-up shingles may not warrant post-exposure prophylaxis
2. a clinical condition that increases the risk of severe varicella; this includes immunosuppressed patients, neonates and pregnant women
e.g. long-term steroids, methotrexate and other common immunosuppressants
3. no antibodies to the varicella virus
ideally all at-risk exposed patients should have a blood test for varicella antibodies
this should not, however, delay post-exposure prophylaxis past 7 days after initial contact
Patients who fulfill the above criteria should be given varicella-zoster immunoglobulin (VZIG).
Bed bugs
-What is this caused by?
-How is this managed?
-How can this be controlled/prevented?
Bed bugs describes a variety of clinical problems including itchy skin rashes, bites and allergic symptoms secondary to infestation with Cimex hemipteru.
Bedbug infestation seems to be an increasingly common presentation within UK general practice. Bedbugs thrive in mattresses or fabrics, and can be extremely difficult to eradicate. Topical hydrocortisone is suitable to control itch, but definitive management is through a pest management company and fumigation of the house.
Bed bug numbers may be controlled by hot-washing bed linen and using mattress covers.
What is lyme disease caused by?
Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks.
Describe erythema migrans seen in lyme disease? what other systemic features occur within 30 days?
Early features (within 30 days)
erythema migrans
'bulls-eye' rash is typically at the site of the tick bite
typically develops 1-4 weeks after the initial bite but may present sooner
usually painless, more than 5 cm in diameter and slowlly increases in size
present in around 80% of patients.
systemic features
headache
lethargy
fever
arthralgia
What are 5 later features of lyme disease? (after 30 days)
Later features (after 30 days)
cardiovascular
heart block
peri/myocarditis
neurological
facial nerve palsy
radicular pain
meningitis
What investigations are recommended for lyme disease?
Investigation
NICE recommend that Lyme disease can be diagnosed clinically if erythema migrans is present
erythema migrans is therefore an indication to start antibiotics
enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test
if negative and Lyme disease is still suspected in people tested within 4 weeks from symptom onset, repeat the ELISA 4-6 weeks after the first ELISA test. If still suspected in people who have had symptoms for 12 weeks or more then an immunoblot test should be done
if positive or equivocal then an immunoblot test for Lyme disease should be done
What is the management of asymptomatic tick bites?
Management of asymptomatic tick bites
tick bites can be a relatively common presentation to GP practices, and can cause significant anxiety if the tick is still present, the best way to remove it is using fine-tipped tweezers, grasping the tick as close to the skin as possible and pulling upwards firmly. The area should be washed following. NICE guidance does not recommend routine antibiotic treatment to patients who've suffered a tick bite
What is the manageemnt of suspected/confirmed lyme disease? What reaction can be seen after initiating therapy?
Management of suspected/confirmed Lyme disease
doxycycline if early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)
people with erythema migrans should be commenced on antibiotic without the need for further tests
ceftriaxone if disseminated disease
Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
What is given to treat lower UTI?
Trimethoprim or nitrofurantoin. Alternative: amoxicillin or cephalosporin
When is urine culture sent in UTI
send a urine culture if:
aged > 65 years visible or non-visible haematuria
How is UTI managed in a symptomatic pregnant lady?
-what is first line?
-what is second line?
if the pregnant woman is symptomatic:
a urine culture should be sent in all cases should be treated with an antibiotic for first-line: nitrofurantoin (should be avoided near term) second-line: amoxicillin or cefalexin trimethoprim is teratogenic in the first trimester and should be avoided during pregnancy
How is asymptomatic bacteruria treated in pregnant women?
asymptomatic bacteriuria in pregnant women:
a urine culture should be performed routinely at the first antenatal visit Clinical Knowledge Summaries recommend an immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis a further urine culture should be sent following completion of treatment as a test of cure
How is UTI treated in men?
Men
an immediate antibiotic prescription should be offered for 7 days as with non-pregnant women, trimethoprim or nitrofurantoin should be offered first-line unless prostatitis is suspected a urine culture should be sent in all cases before antibiotics are started NICE Clinical Knowledge Summaries state: 'Referral to urology is not routinely required for men who have had one uncomplicated lower urinary tract infection (UTI).'
What is given to treat acute pyelonephritis>
Broad-spectrum cephalosporin or quinolone
What is given to treat prostatitis?
Quinolone or trimethoprim
What is the treatment of gonorrhoea?
IM ceftriaxone
What is gonorrhoea caused by? what is the incubation period?
Gonorrhoea is caused by the Gram-negative diplococcus Neisseria gonorrhoeae. Acute infection can occur on any mucous membrane surface, typically genitourinary but also rectum and pharynx. The incubation period of gonorrhoea is 2-5 days
What are the features of gonorrhoea in males? in females?
Features
males: urethral discharge, dysuria females: cervicitis e.g. leading to vaginal discharge rectal and pharyngeal infection is usually asymptomatic
Describe the management of gonorrhoea?
-first line
-if sensitivities are known
-if the partient has refused first line treatment
Management
ciprofloxacin used to be the treatment of choice. However, there is increased resistance to ciprofloxacin (around 36% in the UK) and therefore cephalosporins are now more widely used there was a change in the 2019 British Society for Sexual Health and HIV (BASHH) guidelines. Previously the first-line treatment was IM ceftriaxone + oral azithromycin. The new first-line treatment is a single dose of IM ceftriaxone 1g (i.e. no longer add azithromycin). If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used
What are the complications of gonorrhoea?
-what is the triad of symptoms?
-What are later complications?
Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of DGI is not fully understood but is thought to be due to haematogenous spread from mucosal infection (e.g. Asymptomatic genital infection). Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis. Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)
What are three key features of disseminated gonococcal infection
Key features of disseminated gonococcal infection
tenosynovitis migratory polyarthritis dermatitis (lesions can be maculopapular or vesicular)
What is the treatment of chlamydia?
Doxycycline or azithromycin
what causes chlamydia?
-is this common?
-what is the incubation period?
Chlamydia is the most prevalent sexually transmitted infection in the UK and is caused by Chlamydia trachomatis, an obligate intracellular pathogen. Approximately 1 in 10 young women in the UK have Chlamydia. The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic
What is LGV? how is this treated?
Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis. Typically infection comprises of three stages
stage 1: small painless pustule which later forms an ulcer stage 2: painful inguinal lymphadenopathy stage 3: proctocolitis
LGV is treated using doxycycline.
What are the features of gonorrhoea is women? in men?
Features
asymptomatic in around 70% of women and 50% of men women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria
What are 7 potential complications of chlamydia?
Potential complications
epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome)
Describe the investigations for chlamydia? what is first line investigation for women vs men? when should chlamydia testing be carried out?
Investigation
traditional cell culture is no longer widely used nuclear acid amplification tests (NAATs) are now the investigation of choice urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique for women: the vulvovaginal swab is first-line for men: the urine test is first-line Chlamydiatesting should be carried out two weeks after a possible exposure
Describe the screening for chlamydia
Screening
in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years relies heavily on opportunistic testing
What is the first line treatment of chlamydia?
doxycycline (7 day course) if first-line
this is now preferred to azithromycin due to concerns about Mycoplasma genitalium. This infection is often coexistant in patients with Chlamydia and there is evidence of rising levels of macrolide resistance, hence why doxycycline is preferred if doxycycline is contraindicated / not tolerated then either azithromycin (1g od for one day, then 500mg od for two days) should be used
What is the treatment of chlamydia if pregnant?
if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice ‘following discussion of the balance of benefits and risks with the patient’
who should be offered a choice of provider for initial partner notification for chlamydia? who should be contacted?
patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM
for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)
What is the treatment for PID?
Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
What is the treatment for syphilis?
Benzathine benzylpenicillin or doxycycline or erythromycin
What is syphilis caused by? how many stages of infection can occur? what is the incubation period?
Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. The incubation period is between 9-90 days
Describe the primary features of syphilis?
Primary features
chancre - painless ulcer at the site of sexual contact local non-tender lymphadenopathy often not seen in women (the lesion may be on the cervix)
What are the secondary features of syphilis? when does this occur?
Secondary features - occurs 6-10 weeks after primary infection
systemic symptoms: fevers, lymphadenopathy rash on trunk, palms and soles buccal 'snail track' ulcers (30%) condylomata lata (painless, warty lesions on the genitalia )
What are the tertiary features of syphilis?
Tertiary features
gummas (granulomatous lesions of the skin and bones) ascending aortic aneurysms general paralysis of the insane tabes dorsalis Argyll-Robertson pupil
what are 5 features of congenital syphilis?
Features of congenital syphilis
blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars rhagades (linear scars at the angle of the mouth) keratitis saber shins saddle nose deafness
What is the treatment of BV?
Oral or topical metronidazole or topical clindamycin
What is BV? what happens to vaginal pH?
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
What is the criteria used for diagnosis of BV? how many points should be present for diganosis?
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH > 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour)
What is the management of BV in an asymptomatic woman?
Management
if the woman is asymptomatic, treatment is not usually required CKS
e.g. picked up on a swab done for different reasons
exceptions include if a woman is undergoing a termination of pregnancy
What is the management of BV in a symptomatic woman? what is the cure rate? what is the relapse rate?
if symptomatic: oral metronidazole for 5-7 days CKS
70-80% initial cure rate relapse rate > 50% within 3 months a single oral dose of metronidazole 2g may be used if adherence may be an issue the BNF suggests topical metronidazole or topical clindamycin as alternatives
What is the management of BV in pregnancy?
if pregnant CKS
results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy if asymptomatic: discuss with the woman's obstetrician if treatment is indicated if symptomatic: either oral metronidazole for 5-7 days or topical treatment. The higher, stat dose of metronidazole mentioned above is not recommended
What is trichomonas vaginalis?
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).
What are the 5 features of trichomonas?
Features
vaginal discharge: offensive, yellow/green, frothy vulvovaginitis strawberry cervix pH > 4.5 in men is usually asymptomatic but may cause urethritis
What is done in the investigation of trichomonas?
Investigation
microscopy of a wet mount shows motile trophozoites
What is the management of trichomonas?
Management
oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
What is non-gonococcal urethritis? describe a typical case?
Non-gonococcal urethritis (NGU, sometimes referred to as non-specific urethritis) is a term used to describe the presence of urethritis when a gonococcal bacteria are not identifiable or the initial swab. A typical case would be a male who presented to a GUM clinic with a purulent urethral discharge and dysuria. A swab would be taken in clinic, microscopy performed which showed neutrophils but no Gram-negative diplococci (i.e. no evidence of gonorrhoea). Clearly, this patient requires immediate treatment prior to waiting for the Chlamydia test to come back and hence an initial diagnosis of NGU is made.
