Module 1 - STIs Flashcards
Pap Smear Guidelines
-when to start
21 years
Pap Smear Guidelines
-how often do you test patients between 21-29 years?
q3 years
Pap Smear Guidelines
-how often do you test patients between 30-65 years?
q3 years OR
primary hrHPV q5 years (if +, then PAP) OR
co-testing (cytology + HPV) q5 years
Pap Smear Guidelines
-how often do you test patients >65years?
No screening after adequate negative prior screening results
Which vaginal infection can you use KOH to help diagnose?
Bacterial vaginosis
Which vaginal infection would you choose a saline wet mount vs. KOH?
Trich
Chlamydia
-organism
C trachomatis
What is the most reported bacterial infectious disease in the US? (STI)
Chlamydia
Chlamydia
-transmission
sexual and vertical
Chlamydia
-common R/F
high-risk sexual practices
=adolescence, new/multiple sex partners, hx of STDs or current STD; oral contraceptive user, no barrier protection during sex; drug use; low SES; prostitution; African American Pts.
High-risk sexual practices
adolescence, new/multiple sex partners, hx of STDs or current STD; oral contraceptive user, no barrier protection during sex; drug use; low SES; prostitution; African American Pts.
Chlamydia
-S/S
-Complications
-most are asymptomatic among women and men (healthcare providers often rely on screening for chlamydial infection
-women –> PID
Chlamydia
-screening test
NAAT
-women: gold standard: cervical or vaginal swab; first void urine also acceptable (reserve for women who have never had a pelvic exam)
-men first void culture
Chlamydia
-annual screening
-sexually active: <= 25YR, annually
-sexually active: >25YR, screen if RF present
-pregnancy: 1st prenatal visit; third trimester (again) if <25yo + increased R/F
Chlamydia
-Tx
-first line: doxy 100mg 1 capsule by mouth twice daily 7d
-first line pregnancy: azithromycin 1000mg 1 dose (250mg x4 tablets = take all 4 tablets at one time) - hard on stomach
Chlamydia
-partner treatment
-referred for evaluation testing and presumptive tx if sexual contact w/ partner during 60d preceding pt onset of sx of chlamydia dx
-most recent sex partner should be evaluated even if last sexual encounter was >60d before sx onset or dx
Chlamydia
-education on when okay to resume intercourse
-7 days after single dose therapy
-after completion of doxy tx and resolution of sx
Chlamydia
-test of cure
Complete test 4W after therapy
*pertains to pregnant individuals
-should also be retested 3M after tx
Test of cure not necessary for nonpregnant individuals unless suspicion pt did not take meds correctly or sx persists or reinfection
Gonorrhea
-organism
N. gonorrhea
Gonorrhea
-transmission
sexual; vertical
Gonorrhea
-R/F
high risk sexual practices
-adolescence, new/multiple sex partners, hx of STDs or current STD, oral contraceptive user, no barrier protection during sex, drug use, low SES, prostitution, African A. patients
Gonorrhea
-S/S
asymptomatic in women
-if woman has intermenstrual bleeding w/ hx of regular periods, can be sign of STI
-males will be symptomatic –> clear/cloudy penile discharge (urethritits)
Gonorrhea
-complications
-women: PID
-men: epididymitis (inflammation of the tube at back of testicle that carries sperm); complains of unilateral testicular pain.
Gonorrhea
-screening test
-women: gold standard is a vaginal swab (first void urine is acceptable (reserve for those who haven’t had or those that refuse pelvic exams)
Gonorrhea
-annual screening
-sexually active women: screen ALL who are sexually active (all who are at risk of infection)
-pregnancy: first prenatal visit; again in third trimester
-men: men who have sex with men should be screened annually
Gonorrhea
-tx
-ceftriaxone (500mg IM)
*if positive for both chlamydia and gonorrhea, treat for both w/ 1g azithromycin PO x 1 dose (alternate is doxy 100mg 7d)
-first line tx in pregnancy: ceftriaxone + azithromycin (cannot receive doxy)
Gonorrhea
-partner tx
referred for evaluation testing and presumptive tx if they had sexual contact w/ partner during the 60d preceding pt’s onset of sex or chlamydia dx
-most recent sex partners should be evaluated and treated even if time of last sexual encounter was >60d before sx onset or dx
Gonorrhea
-education
-STI prevention, condom use, minimize disease transmission. Persons tx for gonorrhea should be instructed to abstain from sexual activity 7d after tx and until all sex partners are tx (7d after receiving tx and resolution of sx)
If patient tests positive for gonorrhea, what should you suspect?
Other STI’s
-test for other STI’s (chlamydia, syphilis, HIV)
Gonorrhea
-F/U
Men and women should be retested 3M after tx regardless if sex partner was also treated
-try to schedule R/U appt. at initial visit
-if F/U testing at 3M doesn’t happen, pt. would be retested at next pt. visit (whenever that is) –> would need to be <12M after initial tx
-repeat testing on those that are pregnant should be conducted in 3M
Syphilis
-primary
*is pt aware or unaware of infection?
*presents classically with what?
*pt. can present with what?
*sx resolution
*will serological testing be positive?
*unaware (= spreadable, most contagious time of syphilis)
*painless ulcer or canker at site of infection
*lymphadenopathy (rubbery, painless, enlarged lymph nodes occurring bilaterally)
*sx resolution w/i 3-6w
*may not be positive (too early)
Syphilis
-secondary
*clinical manifestations
*when do these sx appear?
*will serological testing be positive?
*skin rash, mucocutaneous lesions, lymphadenopathy, condyloma lata (smooth flat wart (pink to gray) that develops on genitals/anus/ mouth)
*typically appear 4-8w after appearance of first canker and persists for weeks to months
*serological testing is positive (highest than at any other stage!)
Syphilis
-tertiary
*timeline
*what can become involved
*1-20Y
*cardiac involvement, lesions, tabes dorsalis, general paresis
Syphilis
-latent
*how is this detected?
*symptomatic?
*serological testing
*asymptomatic
Stages of syphilis
primary
secondary
tertiary
latent
Syphilis
-organism
Treponema pallidum (T pallidum)
Syphilis
-transmission
sexual; vertical
Syphilis
-is the disease local or systemic?
systemic
neurosyphilis
-what causes neurosyphilis?
T pallidum can infect CNS, which can occur at any stage of syphilis and results in neurosyphilis
neurosyphilis
-when to refer to ER
any neurologic clinical manifestations –> cranial nerve dysfunction, meningitis, meningiovascular syphilis, stroke, altered mental status
neurosyphilis
-when does this usually present?
w/i first few months or years after infection
neurosyphilis
-what are the late neurological manifestations
tabes dorsalis, general paresis can occur >30Y after infection
Syphilis
-R/F
men having sex with men (highest risk population)
Syphilis
-screening tests
**must use two tests (must use both)
1. nontreponemal (VDRL/RPR)
2. treponemal (FTA-ABS; EIA; CIA)
-RPR/VDRL will be positive for life
-treponemal tells you how tx is working (if its eradicating disease)
*if VDRL/RPR (nontreponemal) is positive, but treponemal test is negative, the initial RPR/VDRL is deemed false positive
Syphilis
-when do patients have a false positive result?
when RPR is positive but the trep confirmatory test is negative
Syphilis
-what can cause a false positive test?
pregnancy, aging, immunizations (including influenza), lyme disease, Hepatitis, TB, mononucleosis, HIV
Syphilis
-annual screening
- should screen all sexually active patients who have HIV for syphilis => often these coexist together
- performed at first prenatal visit; if high risk, test TWICE in third trimester (28 weeks and at delivery)
- screening men who have sex with men can be conducted annually
how often should pregnant women be tested for syphilis?
first prenatal visit; if high risk, test TWICE in third trimester (28w and at delivery)
Syphilis
-tx
first line: penicillin (used in all stages of syphilis)
*preparation, dosage, and length of tx depends on stage and clinical manifestations of disease. Use Trep test to tell you range, titers - this correlates to stage pt is in.
-pregnant women at any stage of syphilis w/ penicillin allergy should be desensitized and treated with penicillin
desensitization therapy
-used for people with penicillin allergy (important in pts needing tx for syphilis)
-admit pt to hospital; receive penicillin but closely watched by medical staff in order to recieve it
Jarish-Herxheimer Reaction
acute febrile rxn frequently accompanied by HA, myalgia, fever that occurs w/i 24 hours after any initiation of syphilis therapy
-THIS IS NOT A RXN TO PEN
-inform patient of this possible rxn and how to handle it if it occurs (antipyretics)
-most frequently seen in early syphilis because the bacterial loads are much higher during these stages
*this rxn might induce early labor or cause fetal distress in pregnant women; this should not prevent or delay therapy
Syphilis
-partner tx
-persons who have had sex w/ a pt who received a dx of syphilis, less than 90d before the dx should be treated presumptively for early syphilis even if serologic tests results are negative
-persons who have had sex w/ a pt who received a dx of syphilis, more than 90d before dx, should be treated presumptively for early syphilis if serologic tests results are not immediately available and opportunity for F/U is uncertain
*if serologic tests are negative, no tx is needed
*if serologic tests are positive, tx should be based on the clinical and serologic evaluation and syphilis stage
HPV
-what are the high risk types of HPV?
-what can HPV lead to?
-HPV 16 and HPV 18
-cervical cancer
HPV
-transmission
sexual
HPV
-R/F
high risk sexual practices
-adolescence, new/multiple sexual partners, hx of STDs or current STD, oral contraceptive user, no barrier protection during sex, drug use, low SES, prostitution, African A. pts.
HPV
-S/S
-low risk pts: genital warts; asymptomatic
*genital warts either regress spontaneously or may need some sort of provider/patient applied tx in office
*condylomata acuminata (specific type of wart): manifests as a raised growth on skin on outside of anus
-high risk pts: presents with cervical abnormalities
condylomata acuminata
type of wart found with HPV
HPV
-how to treat warts
scrape wart and test for differentials
HPV
-screening
-women: pap smear regularly w/ HPV co-testing according to ACOG guidelines
-men and women: screen any new genital warts
any patient who presents with genital warts should be screened for what?
sexual abuse (refer to SANE exam)
HPV
-prevention
HPV vaccine
HPV
-tx
-genital warts: provider applied tx (i.e. cryotherapy, TCA/BCA, surgical removal); patient applied tx (i.e. topical creams)
-treatment in pregnancy: cryotherapy or surgical removal
*no cryotoxic agent should be used
STD’s not reportable
HPV
Is a partner exam necessary for chlamydia?
Yes
Is a partner exam necessary for gonorrhea?
Yes
Is a partner exam necessary for syphilis?
Yes
Is a partner exam necessary for HPV?
No
HPV
-F/U
depends on ACOG guidelines (if found on your PAP smear)
Pelvic Inflammatory Disease
-def
-most common sexually transmitted organisms contributing to PID
-spectrum of inflammatory disorders of the upper female genital tract
*any combination of endometritis, salgingitis, tubo ovarian abscess
-chlamydia and gonorrhea
Pelvic Inflammatory Disease
-R/F
-anything that falls under high risk sexual practices
-adolescence w/ hx of PID, douching, IUD insertion, hx of bacterial vaginosis
Pelvic Inflammatory Disease
-Dx
minimum criteria dx (only need one criteria met)
-uterine tenderness OR
-adnexal tenderness OR
-cervical motion tenderness
one or more of advanced criteria can increase specificity
-temp >101
-abnormal cervical/vaginal discharge; cervical friability
->WBCs on wet mount
-Inc. ESR/CRP
-Laboratory documentation or cervical infection w/ chlamydia or gonorrhea
**majority of women with PID have either mucopurulent cervical discharge or evidence of WBC on wet mount (if no WBC, PID dx unlikely)
Pelvic Inflammatory Disease
-what sx do a majority of women have?
mucopurulent cervical discharge or evidence of WBC on wet mount (if no WBC, PID dx unlikely)
Pelvic Inflammatory Disease
-complications
ectopic pregnancy, infertility, chronic pelvic pain
Pelvic Inflammatory Disease
-screenings
-use clinical guidelines for gonorrhea and chlamydia
-annual screenings of all sexually active women at increased risk for infection
-pregnancy –> should be performed at first prenatal visit and again in 3rd trimester (GC and chlamydia)
Pelvic Inflammatory Disease
-tx
-first line tx: ceftriaxone (rocephin) 500mg given in clinic; doxycycline 100mg sx for 7d (100mg 2x/day x 14d) with flagyl (500mg PO 2x/day x 14d)
**if no improvement w/i 72 hours, refer to hospital to receive IV antibiotics (can become septic!)
**no alcohol 24 before or after, during flagyl
Is a partner exam necessary for PID?
Yes; sex partners should be referred for evaluation testing and presumptive tx if had sex with partner w/i 60d preceding dx for chlamydia or gonorrhea
Pelvic Inflammatory Disease
-F/U testing
SAME as gonorrhea and chlamydia
~3M
Herpes Simplex Virus (HSV) Type 2
-bacterial or viral?
-what reactivates it?
-viral
-stress, extremes or heat, trauma, fever
Herpes Simplex Virus (HSV) Type 2
-transmission
sexually and perinatally (can be passed to baby at delivery)
Herpes Simplex Virus (HSV) Type 2
-R/F
high risk sexual practices
-adolescence, new/multiple sex partners, hx or STDs or current STD, oral contraceptive user, no barrier protection during sex, drug use, low SES, prostitution, African A. pts.
Herpes Simplex Virus (HSV) Type 2
-S/S
-first episode: (primary infection) first time pt has outbreak
*sx more severe; bilateral, present with numerous bilateral genital lesions w/ associated sx of pain, itching, tender, inguinal lymphadenopathy
*duration: 7-10d
Herpes Simplex Virus (HSV) Type 2
-tx
acyclovir (dose and how often depends (do they need episodic or suppressive therapy))
Herpes Simplex Virus (HSV) Type 2
-impact on pregnancy
high risk for neonate to acquire herpes for first time near the time of delivery
*prevention: don’t get herpes late in pregnancy
*ask all pregnant women if they have a hx of genital herpes (moms w/ recurrent genital herpes should be prescribed acyclovir at 36W to reduce change of outbreak and need for c section)
-ask at onset of labor if pt has any current sx of herpes outbreak or prodromal sx (examine mother for any lesions)
**women w/o sx or signs of genital herpes/or prodromal sx can deliver vaginally
Can women with Herpes type II deliver vaginally?
Yes, if no outbreak/visible lesions/prodromal sx
Bacterial Vaginosis
-is BV an STD?
-def
-NO
-condition that happens when there’s too much of a certain bacteria in the vagina = changes pH balance of bacteria
Bacterial Vaginosis
-organism
G vaginalis
What is the most common vaginal condition in ALL women ages 15-44Y?
BV
Bacterial Vaginosis
-R/F
douching, not using condoms, having new/multiple sex partners
Bacterial Vaginosis
-S/S
-thin white or gray vaginal discharge; pain, itching, burning in the vagina
-STRONG fishy-like odor (esp. after sex)
-burning when peeing, itching around/outside vagina
Bacterial Vaginosis
-screening test
gram stain via wet prep (peppery over-easy eggs)
-perform wet prep in clinic
-diagnostically, look for clue cells; pH > 4.5
-a minimum or 3/4 of these testing criteria are needed for dx
Bacterial Vaginosis
-tx
flagyl is first line, BID x7d PO OR
flagyl gel 1 dose daily x5d
**educate patient not to drink alc at least 24hr before and after last dose, and during therapy
Trichomoniasis
-organism
T vaginalis
Trichomoniasis
-S/S
-green frothy foul smelling vaginal discharge, itching, burning in vagina; bleeding after sex (POST COIDAL BLEEDING), burning w/ urination
*w/ pelvic exam, may note punctate hemorrhages on cervix (strawberry cervix) from organism eating away at cervix (cervical tissue)
Trichomoniasis
-screening test
gram stain wet prep
-can perform in clinic
-diagnostically you look for trichomonias parasite
Trichomoniasis
-tx
first line:
-women: flagyl 500mg PO BID x7d
-men: flagyl 2g PO x1 dose
**educate regarding alcohol interaction with flagyl (do not drink alc 24 hours before or after last dose or during therapy)
Which STI has a high rate of reinfection?
Trichomoniasis
