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IPFC 5 > Management of STI > Flashcards

Management of STI Flashcards

1
Q

What type of bacterias are chlamydia + gonorrhea?
Gram-positive/negative
Intracellular/extracellular

A

Both Chlamydia and Gonorrhea are GRAM-NEGATIVE bacteria

  • Chlamydia: obligate intracellular gram-negative
  • Gonorrhea: usually intracellular
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2
Q

How is chlymadia process similar and different to a virus?

A

The elementary body enters into cell, forms reticulate body, and bursts out the cell

Similar to a virus, but does NOT take over host cell DNA machinery

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3
Q

How do both chlamydia + gonorrhea spread? (3)
What is the least likely spread.

A

Through infected secretions:
1. Sexual (oral, vaginal, anal)
2. Vertical (intrapartum, through birth)

Less likely:
- Autoinoculation (masturbation followed by touching the eye)
- Sex toys

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4
Q

T/F Receptive partner at greater risk than insertive partner with transmission

A

True

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5
Q

What is the average incubation period for chlamydia and gonorrhea

A

Chlamydia: 2-6 weeks
- difficult to tell who was responsible

Gonorrhea: 2-7 days

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6
Q

What are the type of symptoms associated with STI (3) What do present as?

A

Urogenital infection
- urethral or vaginal discharge
- dysuria (pain urination)
- Abnormal vaginal bleeding
- Lower abdo pain

Rectal infection
- Tenesmus (feeling of needing to poop)
- Rectal pain
- Rectal bleeding
- Mucus discharge

Pharyngeal infection
- sore throat
- pharyngeal exudate
- Cervical lymphadenopathy

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7
Q

Which STI are usually more asymptomatic? Which gender is more likely to have symptoms

A

Chlamydia
- more likely in women to have symptoms

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8
Q

Which STI infection is more symptomatic?
Which gender is more likely to have symptoms?

A

Gonorrhea
- most men will have symptoms

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9
Q

What are complications for both STIs (7)

A
  1. Increased risk of HIV (having and transmitting)
  2. Conjunctivitis (through auto inoculation)
  3. Reactive arthritis
  4. Disseminated gonococcal infection
  5. Epididymitis
  6. Pelvic inflammatory disease (PID)
  7. Ophthalmia neonatorum (child becomes blind)
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10
Q

Which STI is more likely to cause reactive arthritis? Where is the swelling likely to be in the body?

A

Chlamydia
- lower extremities

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11
Q

How does disseminated gonococcal infection present? (3)

A
  • Tenosynovitis (tendon inflammation)
  • Dermatitis (eczema)
  • Polyarthralgia (joint pain)
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12
Q

How can epididymitis present? (4) What can it result in if serious? (2)

A

Swollen scrotum
Unilateral testicular pain
Dysuria
Urinary frequency

Result in
- infertility
- Chronic pain

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13
Q

How can pelvic inflammatory disease present? (6)
What can it result in if serious? (3)

A

Fever
Abdo/pelvic pain
vaginal discharge/bleeding
dyspareunia (painful sex)
Dysuria
Urinary frequency

Result in
- infertility,
- ectopic pregnancy
- preterm premature rupture of membranes (PPROM)

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14
Q

Which STI does the Nucleic Acid Amplification test?

A

Chalmydia + Gonorrhea together

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15
Q

Which STI is culture testing used? Why?

A

Gonorrhea only (since more resistance exists, we run cultures for it)

Allows for better targeted therapy for gonorrhea

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16
Q

How can someone collect a NAAT? Who collects it?
What is preferred method for each gender?

A

Urine or swab
- Patient-collected swabs, from urethra, cervix, vagina, rectum or pharynx

Men: urine sample preferred
Women: Swab - vaginal/cervical preferred

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17
Q

How can someone collect a culture
Who collects it?
From where? (5)

A

PHYSICIAN-collected swab from
- penile discharge
- cervix
- vagina
- rectum
- pharynx

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18
Q

When should NAAT be performed?
Turn around time?

A
  • Request screening
  • Have risk factors for STI
  • Have symptoms of STI
  • During 1st trimester of pregnancy (or all trimesters if high risk)

Recommended ANNUALLY for all sexually active people under 30

turnaround: 3 days

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19
Q

When should culture testing be added on to NAAT patients (2)
Turn around time?

A

Men: with penile discharge

Women: With suspected pelvic inflammatory disease (PID) (cervical culture)

turnaround: 5 days

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20
Q

Are screening rectum and pharynx routinely done?

A

No, depends on sexual history

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21
Q

What are indications for treatment of chlamydia (4)

A
  • Positive NAAT
  • Partner has chlamydia
  • Suspected infection
  • Positive gonorrhea (in partner or self)
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22
Q

What is the preferred treatment of chlyamdia (2)?
Which treatment has higher efficacy if adhered to?

A

Azithromycin 1g PO x 1 dose
OR
Doxycycline 100mg PO BID x 7 days
- has 100% efficacy if adherence is guaranteed

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23
Q

If patient had a RECTAL chlamydia infection, what is the more efficacious treatment

A

Doxycycline 100mg PO BID x 7 days

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24
Q

What is an alternative treatment to chlamydia?

A

Levofloxacin 500mg PO daily for 7 days

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25
Q

What are the treatments of chlamydia in pregnant and lactating people (2)

A

Azithromycin 1g PO x 1 dose
OR
Amoxicillin 500mg PO TID x 7 days

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26
Q

T/F Azithromycin is associated with more side effects than doxycycline

A

False

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27
Q

What is the most common to least common side effect associated with Azithromycin

A
  1. Diarrhea
  2. Nausea
  3. Vomiting
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28
Q

What is the rational of using double-coverage for Gonorrhea?

A
  • May delay the emergence of resistance
  • Increases the odds of actually killing the pathogen
  • May improve effectiveness in pharyngeal infections (cephalosporins have poor penetration there, Azith helps)
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29
Q

What is the preferred treatment of gonorrhea?

A

Ceftriaxone 250mg IM + Azithromycin 1g PO at the same visit

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30
Q

When are you able to give alternate treatments for gonorrhea (2)

A
  • If first-line is not possible
  • Must have a test of cure
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31
Q

What are the 3 alternate therapies of gonorrhea?
Which is least preferred?

A
  1. Cefixime 400mg PO + Azith 1g PO
  2. Gentamicin 240mg IM (2 injections) + Azithromycin 2g PO
  3. Azithromycin 2g PO monotherapy
    (least preferred)
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32
Q

What is ceftriaxone IM diluted with?

A

1% lidocaine w/o epi
(not water)

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33
Q

Why is Cefixime not preferred?

A
  • Associated with treatment failures in ON due to inc MIC
  • gbMSM have the increased MIC
  • Poor penetration into pharynx
  • Concern that lower concentrations of cephalosporins might create resistant strains
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34
Q

Why is Gentamicin not preferred

A

Poor evidence. heterogenous evidence based

(resistance is low tho)

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35
Q

What to do if gonorrhea patient is allergic to azithromycin?
What requirement would they have to meet?

A

Replace with doxycycline
- only use this for confirmed chlamydia ONLY
- OR susceptible gonorrhoea results

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36
Q

What to do if preferred treatment failed for gonorrhea?

A

Increase the dose of preferred treatment

Ceftriaxone 1g IM + Azithromycin 2g PO

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37
Q

What is the treatment for gonorrhea if a patient has a type 1 allergy to penicillin

A

Can still give ceftriaxone or any cephalosporin with a different side chain
+ Azithromycin 1g PO

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38
Q

What are the treatment options for gonorrhea if patient has a cephalosporin allergy?

A

Gentamicin 240mg IM 2 separate injections + Azithromycin 2g PO

OR

Azithromycin 2g PO monotherapy

39
Q

What if a patient had a type 2,3,4 allergy to cephalosporin with gonorrhea

A

Gentamicin 240mg IM 2 separate injections + Azithromycin 2g PO

OR

Azithromycin 2g PO monotherapy

40
Q

What % cut off is tolerated for antimicrobial resistance

A

5%

41
Q

What is the follow up test of cure for chlamydia?
When to take it?
When is it recommended? (4)

A

NAAT test at least 3 weeks after Rx

Recommended only if:
- Pregnancy patient
- Unresolved symptoms
- Alternative regimen used
- Bad adherence (known or suspected)

42
Q

What is the follow up test of cure for gonorrhea?
When to take it?
When is it recommended? (4)

A

Culture test 3-7 days after Rx (preffered)
or NAAT

Recommended for ALL, especially:
* Pregnant
* Pharyngeal infection
* Unresolved symptoms
* Alternative (non first line) regimen used
* Treatment failure in partner
* Bad adherence (known or suspected)
* Strain with reduced cephalosporin susceptibility (like from travel sex- new Asia strain)

43
Q

What are reasons for treatment failure? (4)

A
  • Re-infection
  • Non-adherence
  • Alternative diagnosis (other STI, UTI)
  • Drug resistance: more likely in Gonorrhea
    (unlikely in chlamydia)
44
Q

When should we rescreen all patients after test of cure?

A

In 6 months

45
Q

How long should patients abstain from intercourse after treatment?
Requirements?

A

7 days if single dose or completing the 7-day therapy
AND
Asympotamitc

46
Q

Do we need to test partners or can we treat empirically

A

Treat partners

47
Q

Which group of people is doxycycline prophylactic effective in?
Dose?

A
  • Gay, bisexual men + transgender women who had bacterial STI in the last year

Dose: Doxycycline 200mg po within 72 hours after condomless sex

48
Q

Is HSV (herpes simplex virus) Curable or manageable? Explain its pathophysiology

A

Virus enters through epidermis -> remains dormant in sensory ganglion until reactivation
- Remains there for LIFE (HSV is manageable, not curable)

49
Q

How is HSV spread? When do most transmission occur?

A

Through direct contact with virus in Wet environment
- Lesions
- mucosal surfaces
- oral or genital secretions

Most transmission occurs during asymptomatic shedding

50
Q

T/F Pre-existing HSV-1 infection protects against HSV-2

A

True

51
Q

How does primary genital HSV present
Onset? How long does it last?
Presentation, systemic symptoms (5)?
Atypical symptoms (3)

A

Onset:
- Occurs 6-8 days after infection
- whole thing lasts 10-14 days, re-epithelialization can take 21 days

Presentation:
papules -> vesicles -> pustules rupture to ulcer -> crust -> heal without scarring

Systemic:
- May also involve swollen inguinal lymph nodes (lymphadenopathy),
- malaise
- fever
- myalgia
- headache

Atypical symptoms:
- genital pain
- urethritis
- cervicitis

52
Q

How does presence of preexisting HSV-1 antibodies result if you get genital herpes HSV-2

A

Shorter duration
Less likely to have systemic symptoms

53
Q

T/F HSV-1 recurrences are common than HSV-2

A

False

54
Q

Differentiate between primary and recurrent episodes of genital herpes (3)

A
  • Shorter duration (5-10 days)
  • Unilateral lesions, fewer in number
  • Systemic features less likely
55
Q

What do prodromal symptoms look like (4)

A

Burning
itching
tingling
irritation

56
Q

What are complications of genital herpes

A

Increased HIV risk

Primary infection risks:
- Meningitis
- Extragenital lesions
- Urinary retention

57
Q

How are genital herpes diagnosed?

A

Usually a clinical diagnosis (story is enough)

58
Q

What requirement do you need if you want to perform a NAAT or viral culture?

A

Active lesion
- allows for differentiation type

59
Q

What would be the reasoning of getting a serological testing for antibodies against HSV?
How long does it take to be dectatable?

A

Used commonly for serodiscordant couples (one has HSV and one doesn’t) who want to know if they should use protection
(if they both have antibodies, no need for protection)

Provides evidence of past infection
- may take up to 6 months to be dectatable

60
Q

When should treatment for primary infections of HSV be started within?
For recurrent infections?

A

Primary infection:
- within 7 days of symptoms

Recurrences:
- within 12-24 hours of symptoms
- Start ASAP - ideally in prodromal period (pt may need meds on hand)

61
Q

What are benefits of treatment for PRIMARY HSV infection (2)

A
  • decreased time-to-healing (TTH) and symptom duration by 2-4 days
  • Decreased duration of viral shedding by ≤1 week
62
Q

What are the benefits of treatment for recurrent HSV infection (3)

A
  • decreased time-to-healing (TTH) and symptom duration by 1-2 days
  • Decreased duration of viral shedding by 1 day
  • More likely to have “aborted” episode (prodrome never turns into lesion - if antiviral started early enough)
63
Q

T/F Topical antiviral therapy is useful in HSV therapy

A

False

64
Q

What are the 3 treatment options for primary and recurrent episodes? Duration? Frequency

A

Acyclovir
- Primary: 400mg TID for 7-10 days
- Recurrent: 400mg TID for 5 days

Famiciclovir
- Primary: 250mg TID for 10 days
- Recurrent: 125mg po BID 5 days

Valacyclovir:
- 1000mg BID for 10 days
- Recurrent: 1000mg DAILY for 5 days

65
Q

Benefits of chronic suppressive therapy (3)

A
  1. To prevent recurrences:
    - evidence shows fewer SYMPTOMS, longer TIME BETWEEN recurrences, less asymptomatic shedding (evidence is for ≥1 year of use)
  2. To prevent transmission to seronegative partners (3.6% -> 1.9%):
    - should be continued indefinitely unless partner develops HSV (theoretically)
  3. To prevent transmission to infant at time of delivery:
    - 50% risk if primary infection during 3rd trimester -> reduced to 2-5% risk if lesion present and <0.05% risk if asymptomatic
    - If mother has active lesions or prodromal symptoms upon delivery: C-section indicated
66
Q

Which therapy is the only one studied to prevent transmission to partners

A

Valacyclovir

67
Q

What bug is syphilis caused by? What is its appearance?

A

Treponema pallidum
- Thin, tightly coiled spirochete

68
Q

How is syphilis transmitted?

A

Sexual
- oral, vaginal, anal sex toys

Vertically transferred (through placenta)

Less often transmitted through blood/contact/rash

69
Q

Who is affected most by syphilis (2)

A

Indigenous people

gbMSM

70
Q

T/F Syphilis is curable

A

True
- with early treatment

71
Q

How does primary syphilis form? Incubation period?
How long does it take to resolve spontaneously?

A

upon contact, spirochete penetrates mucous membrane/broken skin to cause primary syphilis

Incubation period: 3 weeks (3-90 days)

Will resolve spontaneously in 3-6 weeks

72
Q

How does primary syphilis present
Main presentation?
Description?
Location?

A

Main presentation: Chancre sore, regional lymphadenopathy (swollen lymph nodes)

Description
- round, painless, firm, sore

Location:
- Usually on or inside the genitals, around anus, inside rectum or on oropharyngeal mucosa

73
Q

How does secondary syphilis form?

A

if primary untreated, spirochetes spread through bloodstream

74
Q

How does secondary syphilis present as? (6)

A

The “great mimicker” - due to diverse/non-specific symptoms (can be confused with other conditions

Presentation
* Fever, Malaise, Headache, Myalgia/Arthralgia, diffuse lymphadenopathy
* Lesions on palms of hands/soles of feet
* Condyloma latum (wart-like lesion on genitals, inner thighs, axillae, umbilicus or in mouth)
* Alopecia
* Headache
* Maculopapular rash, Hepatosplenomegaly (enlargement of spleen and liver)

75
Q

How does the latent stage of syphilis form?

A

if secondary untreated, pathogen will become dormant (latent stage)
- asymptomatic

76
Q

How does latent syphilis present?

A

Asymptomatic

77
Q

How long can a patient transmit syphilis for after initial infection even during latent phase

A

1 year

78
Q

T/F Secondary syphilis does not resolve spontaneously

A

False

79
Q

How does tertiary syphilis present?
Complications (3)

A

Permanent neurological and/or cardiac damage

  • Heart: aortic aneurysm, regurgitation, coronary artery stenosis
  • Brain (neurosyphilis): headache, vertigo, ataxia, dementia, personality changes
  • Tissue: gummas - soft, tumour-like growths with tissue destruction (commonly on liver, skin, bones)
80
Q

How can we lab diagnose syphilis?
Which type of syphilis is this possible in?
Who should it be done for? (2)

A

Only possible during PRIMARY and SECONDARY syphilis

How: Serological antibody tests

Screening: should be done for
* Patients with multiple sexual partners: Every 3-6 months
Pregnant patients: during first trimester (repeat based on risk factors)

81
Q

T/F Syphilis cannot be cultured

A

True

82
Q

What are complications of syphilis in pregnancy

A
  • Miscarriage, still birth
  • Congenital syphilis (asymptomatic at birth, symptoms develop weeks-months later). Signs include:
    ○ Rash, Jaundice, Skeletal abnormalities
    ○ Hepatomegaly, Lymphadenopathy
    ○ Snuffles - rhinitis with white/blood-tinged discharge
  • Late symptoms (>2 years of age): vision loss, hearing loss, intellectual disability
  • Increased risk of acquiring/transmitting HIV
83
Q

What is the treatment of choice for syphilis

A

Penicillin high conc
Benzathine penicillin G IM

84
Q

What is the preferred treatment for early syphilis (primary, secondary, early latent)
Alternate duration? (2)

A

Benzathine penicillin G IM x 1 dose

Alt:
- Doxycycline for 14 days
- Ceftriaxone 1-2g IM/IV daily for 10-14 days

85
Q

What is the preferred treatment for late syphilis (late latent, tertiary)?
Alternate duration? (2)

A

Benzathine penicillin G IM weekly x 3 weeks

Alt
- Doxycycline 4 weeks
- Ceftriaxone 2g IM/IV daily 10-14 days

86
Q

What is the preferred treatment for late syphilis neurosyphilis?
Alternate duration? (1)

A

Penicillin G sodium IV q4h 10-14 days

Alternate
- Ceftriaxone 2g IV daily for 10-14 days

87
Q

When would you consider penicillin desensitization (3)

A
  • late syphilis
  • neurosyphilis
  • Pregnancy
88
Q

How is the test of cure performed in syphilis

A

With serological testing to confirm resolution of the infection

89
Q

Why type of syphilis do JHR reactions most commonly occur in

A

Secondary syphilis

90
Q

What is JHR (Jarisch-Herxheimer Reaction). What is it caused by?
Onset?
Resolution time?

A

acute, self-limiting febrile (FEVER) reaction in first 24 hours after the START OF THERAPY
- Resolves alone after 24 hours

Onset: 2hrs after antimicrobial therapy

Caused by:
Thought to be due to a massive release of toxins/cytokines from killed spirochetes

91
Q

What symptoms can JHR present with

A

Cyclic fluctuations in temperature, fever, chills, rigors, sweating

May include:
- malaise
- headache
- pharyngitis
- worsening of syphilitic symptoms (rash),
- nausea, vomiting
- flushing
- myalgias

92
Q

How do the vital signs look like in JHR

A
  1. Vasoconstriction leading to HYPERtension, hyperventilation THEN –>
  2. Vasodilation leading to HYPOtension and tachycardia
93
Q

What is the management of JHR (2)

A

Fever/pain: NSAID or acetaminophen

Hypotension: may need IV fluids until hemodynamics stabilize

IPFC 5 (10 decks)

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