Key Facts Flashcards
Sexual health screening offered to asymptomatic patients
HIV and Syphilis
Chlamydia and Gonorrhoea
Which patients should be offered Hep A screening
- MSM in the context of a local outbreak.
- Injecting drug users.
- Persons infected with HBV, HCV or HIV.
Which patients should be offered Hep B screening
- MSM.
- CSW.
- Injecting drug users.
- Persons infected with HCV or HIV.
- Sexual assault victims.
- Person born in (or sexual partner born in) a country with high prevalence of HBV.
- Needlestick injury.
- A sexual partner was infected with HBV or was at high risk of HBV.
- Born to a mother infected with HBV.
Which patients should be offered Hep C screening
- Injecting drug users.
- HIV-infected MSM (and sex partners of).
- Needlestick injury.
- Born to a mother infected with HCV.
Which patients should be offered GC culture
GC NAAT positive cases, prior to treatment.
GC culture considered in patients who are contacts of GC if immediate epidemiological treatment is to be given
What sexual health screening is offered for patients reporting oral sex
Male Insertive Oral Sex = 1st pass urine GC/CT NAAT
Male receptive Oral Sex = Pharyngeal swab GC/CT NAAT
Female receptive fellatio = pharyngeal GC/CT NAAT
cunnilingus does not require a pharyngeal swab
What sexual health screening is offered for patients reporting oro-anal sex
Receptive oro-anal: - consider rectal swab GC/CT NAAT
What sexual health screening is offered for women who have sex with women
Test as per heterosexual female if any previous heterosexual contact
otherwise no testing is routinely recommended
What testing is recommended for patients presenting with genital ulcers
Screen ALL patients for GC, CT, HIV and STS
ALL patients with genital ulceration routinely tested for HSV - PCR using a swab from the ulcer
Perform dark ground microscopy immediately if available in addition to STS POCT / serology
MSM - consider LGV testing - chlamydia NAAT taken from the lesion followed by LGV test if CT +ve
Consider tropical genital ulcerative diseases (Chancroid / Donovanosis)
In what circumstances is testing from the female urethra recommended
Only if a culture is being taken for gonorrhoea in a woman who has had a hysterectomy
What testing is recommended for men with urethral symptoms
- microscopy of urethral slide if urethral symptoms
- 1st pass urine GC/CT NAAT
- GC culture if GC strongly suspected
- HIV and STS
+/- HAV / HBV / HCV as indicated
What testing is recommended for patients with rectal symptoms
- Rectal swab - GC/CT NAAT (and LGV CT if CT+ in HIV-positive MSM or if proctitis)
- Rectal microscopy - if proctitis
- Rectal - HSV PCR - if proctitis
- consider rectal GC culture if GC suspected or contact
+ routine screening / other tests as indicated
Treatment of GC
Ceftriaxone 1g IM STAT - if antimicrobial susceptibility not known
Ciprofloxacin 500mg PO STAT - When antimicrobial susceptibility known prior to treatment
Treatment of GC if IM injection contraindicated or refused
Cefixime 400mg PO STAT
AND
Azithromycin 2g PO STAT
Treatment of GC PID
Ceftriaxone 1g IM STAT AND Metronidazole 400mg BD PO 14/7 AND Doxycycline 100mg BD 14/7
Treatment of GC epididymo-orchitis
Ceftriaxone 1g IM STAT
AND
Doxycycline 100mg PO BD 10-14 days
Treatment regimen for donovanosis
Azithromycin 1g PO weekly for 3 weeks or until lesions have fully healed
Treatment regimen for donovanosis in pregnancy
Erythromycin 500mg QDS PO
OR
Azithromycin could be used: 1 g weekly
both for 3 weeks or until lesions have fully healed
Treatment of GC in pregnancy
Ceftriaxone 1g IM STAT or Spectinomycin 2g IM STAT or Azithromycin 2g PO STAT (if susceptible)
AVOID - quinolones - (ciprofloxacin, ofloxacin, levofloxacin and Moxifloxacin)
AVOID - Tetracyclines - (doxycycline, erythromycin, minocycline, rifampicin, streptomycin)
Treatment of Gonococcal conjunctivitis
Ceftriaxone 1g IM STAT
Treatment of disseminated gonococcal infection
Ceftriaxone 1g IM or IV every 24 hours OR Cefotaxime 1g IV every 8 hours OR Ciprofloxacin 500mg IV every 12 hours (if susceptible) OR Spectinomycin 2g IM every 12 hours
Continue treatment for 7 days Switch to oral 24–48 hours after symptoms improve (check sensitivities) - Cefixime 400mg BD - Ciprofloxacin 500mg BD - Ofloxacin 400mg BD
Treatment of epididymo-orchitis
If most likely due to an STI:
Ceftriaxone 1g IM STAT single dose
AND Doxycycline 100mg PO BD for 10-14 days
If most likely due to CT or other non-gonococcal organism could consider:
Doxycycline 100mg PO BD 10-14 days
OR
Ofloxacin 200mg PO BD for 14 days
If most likely due to enteric organisms:
Ofloxacin 200mg PO BD for 14 days
OR
Ciprofloxacin 500mg PO BD for 10 days
Treatment of chlamydia
Doxycycline 100mg PO BD for 7 days
OR
Azithromycin 1g PO STAT followed by 500mg OD for 2 days
Treatment of chlamydia in pregnancy
Azithromycin 1g PO STAT followed by 500mg OD for 2 days OR Erythromycin 500mg QDS for 7 days OR Erythromycin 500mg BD for 14 days OR Amoxicillin 500mg TDS for 7 days
AVOID doxycycline or ofloxacin
Alternative treatment of chlamydia if doxycycline and azithromycin are contraindicated
Erythromycin 500mg BD for 10–14 days
OR
Ofloxacin 200mg BD or 400mg OD for 7 days
When is a TOC indicated for chlamydia
treatment in pregnancy
if symptoms persist
if poor treatment compliance is suspected
When is a TOC indicated for gonorrhoea
For all patients
Minimum of 2 weeks after treatment
Treatment of first episode NGU
Doxycycline 100mg BD for 7 days
Alternative NGU treatment options if doxycycline is not suitable
Azithromycin 1g STAT then 500mg OD for 2 days
OR
Ofloxacin 200mg BD (or 400mg OD) for 7 days
TREATMENT OF RECURRENT OR PERSISTENT NGU
If treated with doxycycline regimen first line:
- Azithromycin 1g STAT then 500mg OD for 2 days
AND metronidazole 400mg BD for 5 days
If treated with azithromycin first line:
- Moxifloxacin 400mg OD for 10 days
AND metronidazole 400mg BD for 5 days
Treatment of mycoplasma genitalium causing uncomplicated urethritis or cervicitis
Doxycycline 100mg BD for 7 days
followed by azithromycin 1g PO STAT then 500mg PO OD for 2 days
OR
Moxifloxacin 400mg PO OD for 10 days if organism macrolide-resistant or azithromycin treatment failed
Treatment of mycoplasma genitalium causing complicated urogenital infection (PID, epididymo-orchitis)
Moxifloxacin 400mg PO OD for 14 days
When is a TOC indicated for mycoplasma genitalium
TOC at 5+ weeks for ALL patients diagnosed with M. gen
Treatment of trichomonas
Metronidazole 2g PO STAT
OR
Metronidazole 400-500mg BD daily for 5-7 days
Alternative regimen
Tinidazole 2g PO STAT
Treatment of trichomonas in pregnancy or breastfeeding
In pregnancy = Metronidazole 400-500mg BD daily for 5-7 days
(BNF advises against high dose regimens in pregnancy)
In breastfeeding = Metronidazole 2g PO STAT and discontinue feeds for 12-24 hours to reduce infant exposure
OR
Metronidazole 400-500mg BD daily for 5-7 days - but may affect milk taste
Treatment of BV
Metronidazole 400mg BD for 5-7 days OR Metronidazole 2g STAT OR PV metronidazole gel (0.75%) OD for 5 days OR PV clindamycin cream (2%) OD for 7 days
Management of recurrent BV
Suppressive 0.75% metronidazole vaginal gel 2x per week
OR
probiotic treatment with lactobacilli
Lactic acid gel - not adequately evaluated
Treatment of acute Vulvovaginal candida
Fluconazole capsule 150mg PO STAT
OR if oral therapy contraindicated:
Clotrimazole pessary 500mg STAT PV
clotrimazole 1% or 2% cream applied 2–3 times a day
Treatment of severe vulvovaginal candida
Fluconazole 150mg PO day 1 and 4
+/- clotrimazole 1% or 2% cream applied 2–3 times a day
Treatment of recurrent vulvovaginal candida
Induction: fluconazole 150mg PO every 72 hours x 3 doses
Maintenance: fluconazole 150mg PO once a week for 6 months
Treatment of acute Vulvovaginal candida in pregnancy
AVOID Fluconazole
Clotrimazole pessary 500mg PV at night for up to 7 consecutive nights
+/- clotrimazole 1% or 2% cream applied 2–3 times a day up to 10-14 days
Longer course recommended in pregnancy
Treatment of recurrent Vulvovaginal candida in pregnancy
Induction: topical clotrimazole 1% or 2% cream applied 2–3 times a day for 10-14 days
Maintenance: Clotrimazole pessary 500mg PV weekly
Treatment of acute Vulvovaginal candida whilst breastfeeding
Breastfeeding can be continued after a single dose of
Fluconazole 150mg PO STAT
AVOID breastfeeding with repeated or high doses of fluconazole
alternative = Clotrimazole pessary 500mg PV at night
+/- clotrimazole 1% or 2% cream applied 2–3 times a day
Treatment of acute vulvovaginal candida in diabetic women
Improve diabetic control
Fluconazole capsule 150mg PO STAT
OR if oral therapy CI:
Clotrimazole pessary 500mg STAT PV
+/- clotrimazole 1% or 2% cream applied 2–3 times a day
Management of first episode of genital herpes
. Saline bathing
. Analgesia
. Topical anaesthetic agents - e.g. 5% lidocaine ointment
Oral antiviral drugs indicated within 5 days of start of episode / while new lesions still forming / if systemic symptoms persist
Aciclovir 400 mg TDS for 5/7 (or 200mg 5x daily)
Valaciclovir 500 mg BD for 5/7
Famciclovir 250 mg TDS 5/7
Management of recurrent genital herpes
Episodic short course antiviral therapies: . Aciclovir 800 mg TDS for 2 days . Famciclovir 1g BD for 1 day . Valaciclovir 500mg BD for 3 days OR suppressive antiviral therapy . Aciclovir 400mg BD (or 200mg QDS) . Famciclovir 250mg BD . Valaciclovir 500mg OD
Management of first episode of herpes in pregnancy
in the first and second trimester
First or second trimester acquisition (until 27 +6 weeks)
- Paracetamol / topical lidocaine 2% gel / saline bathing
- Plan for vaginal delivery unless delivery expected within the next 6 weeks
- Daily suppressive aciclovir 400mg TDS from 36 weeks reduces HSV lesions and asymptomatic shedding at term
Aciclovir safe and well tolerated
Aciclovir 400 mg TDS
Management of first episode of herpes in pregnancy
in the third trimester
from 28 weeks
Daily suppressive aciclovir 400mg TDS until delivery
Recommend caesarean, particularly if episode is within 6 weeks of expected delivery
Type-specific HSV antibody (IgG) testing advised to distinguish primary and recurrent genital HSV infections
Management of pregnant women with recurrent genital herpes
Recurrences usually resolve within 7–10 days without antiviral treatment
Supportive measures - saline bathing / paracetamol / topical lidocaine
Vaginal delivery should be anticipated
Consider daily suppressive aciclovir 400mg TDS from 36 weeks
Management of women with primary genital herpes at the onset of labour
History to ascertain if primary or recurrent episode
Viral swab from the lesion(s) - may influence management of the neonate
Inform neonatologist
Primary episode - recommend CS if possible
Benefit of CS may be reduced if membranes ruptured >4 hours - but may be some benefit
If VD: -
Consider maternal intrapartum IV aciclovir (5 mg/kg 8 hourly)
and neonatal IV aciclovir (20 mg/kg 8 hourly) until active infection is ruled out
Management of babies born by spontaneous vaginal delivery in mothers with a primary HSV infection within the previous 6 weeks
High risk of HSV infection
Liaise with the neonatal team.
If baby is well:
- swab skin, conjunctiva, oropharynx + rectum - HSV PCR
- lumbar puncture is not necessary
- IV aciclovir (20 mg/kg 8 hourly) until active infection is ruled out
- Breastfeeding is recommended unless herpetic lesions around nipples
If baby is unwell / has skin lesions:
- swab skin, conjunctiva, oropharynx + rectum - HSV PCR
- lumbar puncture - even if no CNS features
- IV aciclovir (20 mg/kg 8 hourly) until active infection is ruled out
Treatment of early syphilis
primary, secondary and early latent
Benzathine penicillin G 2.4 MU IM STAT
Alternative treatment regimens for early syphilis
primary, secondary and early latent
Procaine penicillin G 600,000 units IM daily 10 days
Doxycycline 100mg PO BD 14 days
Ceftriaxone 500mg IM daily 10 days
Amoxycillin 500mg PO QDS PLUS Probenecid 500mg QDS 14 days
Azithromycin 2g PO STAT
or
Azithromycin 500mg OD 10 days
Erythromycin 500mg PO QDS 14 days
Treatment of late latent syphilis
Benzathine penicillin 2.4 MU IM weekly for 3 weeks
Treatment of gummatous syphilis
Benzathine penicillin 2.4 MU IM weekly for 3 weeks
Treatment of cardiovascular syphilis
Steroids - 40–60mg prednisolone OD for 3 days starting 24h before the antibiotics
+
Benzathine penicillin 2.4 MU IM weekly for 3 weeks
Alternative treatment regimens for late latent syphilis
Doxycycline 100mg PO BD for 28 days
Amoxycillin 2g PO TDS + probenecid 500mg QDS for 28 days
Treatment of neurosyphilis
Steroids - 40–60mg prednisolone OD for three days starting 24h before the antibiotics
Procaine penicillin 1.8 – 2.4 MU IM OD
AND probenecid 500mg PO QDS for 14 days
OR
Benzylpenicillin 1.8–2.4g IV every 4h for 14 days
Treatment of Early syphilis in pregnancy
Trimesters one and two (up to and including 27 weeks):
- Benzathine penicillin G 2.4 MU IM. STAT
Trimester three (from week 28 to term): - Benzathine penicillin G 2.4 MU IM on days 1 and 8
AVOID - Erythromycin or Azithromycin - do not cross the placenta well and high rates of resistance
Alternative treatment options
- Procaine penicillin G 600,000unit IM OD for 10 days
- Amoxycillin 500mg PO QDS + probenecid 500mg PO QDS for 14 days
- Ceftriaxone 500mg IM OD for 10 days
Treatment of late latent / cardiovascular / gummatous syphilis in pregnancy
all three trimesters:
- Benzathine penicillin G 2.4 MU IM weekly on days 1, 8 and 15
+ Steroids for cardiovascular syphilis
- 40–60mg prednisolone OD for 2 days starting 24h before the antibiotics
Treatment of Neurosyphilis in pregnancy
Steroids for Neurosyphilis syphilis
- 40–60mg prednisolone OD for 2 days starting 24h before the antibiotics
Procaine penicillin G 1.8–2.4 MU IM OD 14/7
PLUS probenecid 500mg PO QDS 14/7
or
Benzylpenicillin 1.8–2.4g IV every 4h for 14/7
Treatment of congenital syphilis
Benzyl penicillin sodium 60–90 mg/kg daily IV
(in divided doses given as – 30 mg/kg 12 hourly)
in the first seven days of life
and 8 hourly thereafter for a further 3 days
for a total of 10 days
What is the advice regarding drug interruptions during syphilis treatment
for late and congenital syphilis
if drug administration is interrupted for more than one day at any point during the treatment course
it is recommended that the entire course is restarted
Treatment of LGV
First line:
Doxycycline 100mg PO BD for 21 days
or Tetracycline 2g PO OD 21/7
or Minocycline 300mg loading dose then 200mg BD 21/7
2nd Line: + TOC
Erythromycin 500mg PO QDS for 21 days
or Azithromycin 1g weekly for 3 weeks
Alternatives
Ofloxacin / moxifloxacin 2 weeks - expected to be effective (need TOC)
Treatment of LGV in pregnancy / breastfeeding
Erythromycin 500mg PO QDS for 21 days
+ TOC
Treatment of chancroid
Azithromycin 1g PO STAT or Ceftriaxone 250mg IM STAT or Ciprofloxacin 500mg PO BD for 3 days or Erythromycin base 500mg PO QDS for 7 days
Treatment of chancroid in HIV positive patients
Ciprofloxacin 500mg PO BD for 3 days
or
Erythromycin base 500mg PO QDS for 7 days
Treatment of chancroid in pregnancy or breastfeeding
Ceftriaxone 250mg IM STAT
or
Erythromycin base 500mg PO QDS for 7 days
Treatment of PID
Ceftriaxone 1g IM STAT AND Doxycycline 100mg PO BD 14 days AND Metronidazole 400mg PO BD 14 days
or
Ofloxacin 400mg BD AND metronidazole 400mg BD 14/7
or
moxifloxacin 400mg PO OD 14/7
Treatment of moderate / severe PID as an inpatient
IV therapy continued until 24 hours after clinical improvement then switch to oral
Ceftriaxone 2g IV daily
AND doxycycline 100mg IV BD (oral if tolerated)
Followed by:
Doxycycline 100mg PO BD 14 days
Metronidazole 400mg PO BD 14 days
Management of SARA
self limiting disease in the majority of patients
Rest
NSAIDs
Cold / heat pads
Antibiotic treatment of any identified STI cause
+/- steroid injection of the joint
or systemic steroids if severe multi-joint pain
+/- Sulphasalazine / methotrexate / Azathioprine - if disabling symptoms persist >3m or erosive joint changes
How to use PEPSE
Initiate ASAP after exposure
Considered up to 72h post exposure
Duration = 28 days
Truvada (tenofovir-DF and Emtricitabine) and Raltegravir
Investigations before starting PEPSE
Medication history including OTC / herbal remedies and recreational drugs
4th generation HIV POCT + serology
Syphilis serology (+/- POCT)
STI screening + repeat @ window period
Hep B / Hep C tests if indicated
Ultra-rapid Hep B vaccination if indicated
EC or Pregnancy test if indicated
Creatinine
ALT
Urinalysis or Urine protein/creatinine ratio
Height, weight, BP
Guidance on missed PEPSE doses
<24h elapsed since last dose = take missed doses immediately and subsequent doses at usual time
24–48 h elapsed since last dose = continue PEPSE
> 48hr elapsed since last dose = stop PEPSE
Advice in the event of a further high-risk sexual exposure on the last two days of the PEPSE course
continue PEPSE for 48hr after the last high-risk exposure
When is universal HIV testing recommended
- GUM or sexual health clinics
- antenatal services
- termination of pregnancy services
- drug dependency programmes
- healthcare services for those diagnosed with TB, hep B, hep C and lymphoma
Which patients should HIV testing be routinely offered to?
- all patients where HIV, including primary HIV infection, enters the differential diagnosis
- all patients diagnosed with an STI
- all sexual partners of men / women known to be HIV positive
- all men who have sex with men
- all female sexual contacts of men who have sex with men
- a history of injecting drug use
- from a country of high HIV prevalence (>1%*)
- sexual contact abroad or in the UK with individuals from
countries of high HIV prevalence
How often should HIV testing be offered?
- Offer repeat tests if the initial test is negative but there has been a possible exposure within the window period
- MSM – annually or more frequently if clinical symptoms suggestive of seroconversion
- injecting drug users – annually or more frequently if clinical symptoms are suggestive of seroconversion
- antenatal care – offer at booking. If declined re-offer. If declined a 2nd time re-offer a 3rd time at 36 weeks. If declined again offer POCT in labour
What do 4th generation HIV tests test for
HIV antibody AND p24 antigen simultaneously
What do 3rd generation HIV tests test for
HIV antibody only
Who should be offered PrEP
- HIV-negative MSM at high risk of HIV - from condomless anal sex within 6 months and ongoing
- Patients who have a HIV +ve partner (unless on ART for >6m with suppressed VL)
- heterosexual men / women with factors putting them at high risk of HIV
- HIV-negative trans-women at high risk of HIV from condomless anal sex within 6 months and ongoing
NOT recommended for IVDU
How to take PrEP
On-demand dosing
= 2 tablets taken 2–24 hours before sex then one tablet OD until 48 hours after the last sexual risk.
Daily dosing
= one tablet every day - start 7 days before sex and continue OD - continue at least 7 days after last sexual risk
If the risk is from vaginal sex daily dosing is recommended
If the risk is from anal sex either regimen can be used
Baseline testing for starting PrEP
4th generation HIV test - POCT and send serology
Hep B / Hep C test - if indicated
Syphilis POCT / serology
STI screening
Creatinine / eGFR
Urinalysis or Urine protein/creatinine ratio
Height, weight, BP
What monitoring should be carried out for patients on PrEP
3 monthly HIV testing
3 monthly STI screening
3-monthly HCV testing in MSM, trans-women / others at on-going risk of HCV
Annual eGFR if baseline eGFR >90 and the person aged <40 y
6 monthly or more frequent eGFR if baseline eGFR 60–90 and/or aged >40 years and/or concomitant risk factors for renal impairment
Which tests should be done if there is suspected HIV seroconversion whilst on PrEP
4th generation HIV test
AND viral load
Baseline resistance testing as soon as HIV confirmed
Treatment of Molluscum contagiosum
Expectant management - no treatment
Some treatments may shorten the disease course
No treatment is advocated over another
Patient choice
- Podophyllotoxin 0.5%. BD for 3/7 then 4/7 break and repeat for upto 4 weeks
- Imiquimod 5% cream (unlicensed) 3x per week - non consecutive days - wash off 6–10h later - up to 16 weeks
- Liquid nitrogen therapy
Treatment of Molluscum contagiosum in pregnancy / breastfeeding
Liquid nitrogen therapy - Cryotherapy
Or other destructive methods are safe.
AVOID - Podophyllotoxin
AVOID - imiquimod
Treatment of Molluscum contagiosum in immunocompromised HIV patients
Can be difficult to treat in late-stage HIV using conventional means
Usually responds to ARV initiation
An immune reconstitution inflammatory syndrome (IRIS) reaction to molluscum may occur when starting ARVs.
Treatment of Phthirus pubis infestation
For all treatments a repeat application in 3-7 days is advised
• Malathion 0.5% - Apply to dry hair, wash out after 2 - 12hrs
• Permethrin 1% cream - Apply to damp hair, wash out after 10 minutes
• Phenothrin 0.2%. - Apply to dry hair, wash out after 2 hours
• Carbaryl 0.5 and 1% (unlicensed). Apply to dry hair, wash out after 12hrs
Treatment of Phthirus pubis infestation of the eyelashes
• permethrin 1% lotion - keeping the eyes closed during the 10 minute application
OR
• inert ophthalmic ointment with a white or yellow paraffin base e.g. vaseline
applied to the eyelashes BD daily for 8-10 days
works by suffocating lice and avoids risk of eye irritation
Treatment of Phthirus pubis infestation in pregnancy / breastfeeding
• Permethrin is safe during pregnancy and breastfeeding
1% cream - Apply to damp hair, wash out after 10 minutes
repeat in 3-7 days
Treatment of scabies
Apply treatment to the whole body from chin / ears dow - special attention to between the fingers + toes / under nails.
Reapply after 1 week
• Permethrin 5% cream - Wash cream off after 8 to 12 hours
OR
• Malathion 0.5% aqueous lotion - wash the treatment off after 24 hours
Treatment of crusted scabies
Combination regimen
- topical permethrin cream 5% OD for 7 days
then 2x weekly until cure
(Wash cream off after 8 to 12 hours)
AND
oral ivermectin - 200 mcg/kg on days 1, 2, 8, 9 and 15
Treatment of scabies which is not responding to topical treatment alone
Ivermectin
200 mcg/kg
2 weeks apart
in patients weighing >15kg
Management of post-scabetic itch
Crotamiton 10% cream - BD to TDS
OR
if the scabies mites have definitely been eradicated
use topical hydrocortisone 1%
Night time sedative antihistamine may help
Emollient if dry skin/eczema
Treatment of scabies in pregnancy / breastfeeding
• Permethrin 5% cream - Wash cream off after 8 to 12 hours
OR
• Malathion 0.5% aqueous lotion - wash the treatment off after 24 hours
Breastfeeding mothers should remove the cream from the nipples before breastfeeding and reapply afterwards
Treatment of anogenital warts
• Podophyllotoxin (Warticon® and Condyline®)
BD application for 3 days, then 4 days rest
Repeat for 4-5 weeks
- Imiquimod 5% cream - Apply 3x weekly and wash off 6-10 hours later. For up to 16 weeks - apply on non consecutive days
- Cryotherapy - liquid nitrogen - weekly for 4 weeks
- Excision - Under local anaesthetic
- Electrocautery / hyfrecation / monopolar surgery
treatment of anogenital warts in pregnancy
Cryotherapy or Hyfrecation
Transmission of Hepatitis A
Faeco-oral (via food, water, close personal contact)
Outbreaks previously reported in MSM, linked to oro-anal or digital-rectal contact / multiple sexual partners / anonymous partners / sex in public places / group sex
Management of acute Hep A
bed rest
fluids
Notifiable disease - inform PHE
Transmission of Hep B
Sexual transmission Vertical Unscreened blood / blood products Sharing injecting equipment Occupational needlestick injuries non-sterile acupuncture or tattoo needles
Management of chronic Hep B
Screen for Hep C, Hep D and Hep A immunity
Vaccinate for Hep A if non-immune
Refer chronic HBsAg+ve patients to a specialist
Decision to treat depends on pattern of disease, HBV DNA level + presence / absence of necro-inflammation and hepatic fibrosis.
Tenofovir-DF or tenofovir-AF
or entecavir
or pegylated interferon
If a patient is on ART for HIV
which medications also suppress Hep B
Lamivudine Emtricitabine Tenofovir DF Tenofovir AF will suppress hepatitis B viral replication
Management of Hep B in pregnancy
Consider Tenofovir monotherapy
or pregnant women with HBV DNA >100,000,000 IU/ml
in the third trimester
to reduce risk of HBV transmission
Vaccinate infant at birth
+ Hepatitis B specific Immunoglobulin 200 i.u. IM given if the mother is highly infectious
What is the Ultra rapid Hep B vaccination schedule
Ultra rapid = 0, 1, 3 weeks and 12 months
What is the standard Hep B vaccination schedule
Standard = 0, 1, 6 months
What is the rapid Hep B vaccination schedule
Rapid = 0, 1, 2 and 12 months
Transmission of Hep C
Most = Parenteral
- shared needles/syringes
- unscreened blood / blood products
- re-use of needles in healthcare / acupuncture / tattoos
- needlestick injury
- sharing razors
- sharing straws / notes for snorting recreational drugs.
Sexual transmission is extremely unlikely in heterosexual relationships (<0.1% /10years)
rate increases if the index patient is also HIV infected
- Vertical transmission occurs at a low rate ~5% or ~7% if F HIV co-infected
Treatment of chronic Hep C
Direct acting antivirals
empirical treatment of proctitis
Cover GC / CT and LGV
Ceftriaxone 1g IM STAT
AND doxycycline 100mg BD 3/52
Treatment of GC in penicillin allergy
0.5 - 6.5% of penicillin sensitive patients will also be allergic to cephalosporins
Can use ceftraixone or cefotaxime if non severe allergy
If anaphylaxis use: - Gentamycin 240mg IM STAT \+ Azithromycin 2g STAT or - Spectinomycin 2g IM STAT \+ Azithromycin 2g PO STAT
