Pelvic Inflammatory Disease (PID)/STDs Flashcards
What are the management options for PID (& organisms)
-IM 1g Ceftriaxone (gonorrhoea)
-100g Doxycycline (BD, PO) for 14 days (chlamydia and mycoplasma genitalium)
-400g Metronidazole (BD, PO) for 14 days (anaerobes eg Gardnerella vaginalis which causes BV)
What are management options for penicillin allergy?
PO ofloxacin and metronidazole for 14 days (400mg, BD)
What are some organisms that cause PID (severe,3, vs less common,3,)
Severe:
1.Chlamydia trachomatis (most common, C>G)
2. Neisseria gonorrhoea
3. Mycoplasma genitalium
Less common:
1. Gardnerella vaginalis (BV)
2. Haemophilus influenza
2. Escherichia coli
What are some investigations for PID?
Bedside:
-Basic obs (signs of shock)
-Abdominal exam (tenderness, masses eg tuboovarian abscess)
-Bimanual exam (cervical motion tenderness)
-Speculum
-NAAT swabs
-pregnancy test
Bloods:
-FBC (WCC)
-CRP
-Blood culture
Imaging:
-TVUSS (eg for tuboovarian abscess, perihepatitis)
-Laporoscopy (gold standard for Fitz-Hugh-Curtis syndrome)
What are other considerations for patients?
- contact tracing
- STI screen
- Consider IUD removal
- Counsel about subfertility/contraception
what is normal vaginal pH?
The vaginal pH is normal in such patients (around 4.0-4.5 in women of reproductive age, although this can vary slightly)
how is vaginal PH affected by BV?
the vaginal pH would be raised (> 4.5).
how is recurrent thrush defined?
> 4 episodes a year
what is the induction/maintenance regime for thrush?
-induction: oral fluconazole every 3 days for 3 doses (150mg once on day 1, 150mg once on day 4, 150mg once on day 7)
-maintenance: oral fluconazole weekly for 6 months
what is the criteria for BV diagnosis?
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
1. thin, white homogenous discharge
2. clue cells on microscopy: stippled vaginal epithelial cells
3. vaginal pH > 4.5
4. positive whiff test (addition of potassium hydroxide results in fishy odour)
what is the criteria for BV diagnosis?
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
1. thin, white homogenous discharge
2. clue cells on microscopy: stippled vaginal epithelial cells (loss of lactobacilli)
3. vaginal pH > 4.5
4. positive whiff test (addition of potassium hydroxide results in fishy odour)
vaginal discharge most common causes
what % of men and women are asymptomatic for chlamydia?
In women, 80% have no symptoms – hence screening is important. In men approximately 50% are asymptomatic.
what swabs should be done for STDS?
-A high vaginal Amies swab for bacterial and fungal culture (NAAT for chlamydia and gonorrhoea) should be performed
-endocervical culture for gonorrhoea (due to increasing rates of resistance to first line cephalosporin therapies).
what % of PID are organisms detected? what are the most common organisms?
50% (50% no organism)
-the majority will be due to Chlamydia trachomatis and Neisseria gonorrhoeae.
what is alternative treatment for gonorrhoea (if all sites of exposure are cultured and found to be sensitive)
ciprofloxacin (alternative to IM 1g STAT ceftriaxone)
what is used to treat chlamydia in pregnant women?
-Azithromycin 1g STAT, followed by 500mg OD for 2 days is first line therapy in pregnancy.
-Erythromycin 500mg QDS for 7 days is an acceptable second line therapy as per BASHH Guidelines 2017 for Chlamydia management
what are some non-STD causes of vaginal discharge?
-Allergies to soaps and spermicides e.g.nonoxynol-9 can also cause vaginal discharge
-Lichen sclerosis if severe
Bacteria present in BV (bacterial vaginosis):
Gardnerella vaginalis
organism that causes syphilis:
Treponema pallidum
symptoms & treatment of syphilis:
chancre (painless hard ulcer in genital area)
-1st line = IM stat benzylpenicillin or doxycycline BD for 14 days.
syphilis stages
Management of severe PID:
IV ceftriaxone (until improving clinically), oral doxycycline and metronidazole (for 14 d)
complications of PID:
Chronic pelvic pain (40%)
Infertility (15%)
Ectopic pregnancy (1%)
Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule to the anterior abdominal wall or diaphragm, on a background of pelvic inflammatory disease. Liver function tests are often normal. An abdominal ultrasound should be used to exclude stones. Laparoscopy is required for a definitive diagnosis and treatment involves the use of antibiotics.
symptoms/signs of thrush:
The symptoms of vaginal candidiasis are:
-Thick, white discharge that does not typically smell
-Vulval and vaginal itching, irritation or discomfort
More severe infection can lead to:
Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation
investigations for candida:
Often treatment for candidiasis is started empirically, based on the presentation.
Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
A charcoal swab with microscopy can confirm the diagnosis.
management options for thrush:
Treatment of candidiasis is with antifungal medications. These can be delivered in several ways:
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)
The NICE Clinical Knowledge Summaries (2017) recommend for initial uncomplicated cases the options of:
A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
A single dose of clotrimazole pessary (500mg) at night
Three doses of clotrimazole pessaries (200mg) over three nights
A single dose of fluconazole (150mg)
Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.
They also recommend recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications. This is an off-label use.
Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
thrush counselling:
o Given the history you have given us and the findings of the investigations, we think that you have got thrush
o It’s a common fungal infections that tends to cause some irritation but can be treated using this medication
o It is not regarded an ‘STI’ however it can be triggered by sexual contact
o It is possible that, in your case, the thrush has happened because the control of your diabetes hasn’t been quite as good as it usually is recently
o If you are struggling with managing your diabetic medication we can arrange an appointment with a diabetic nurse or a doctor specialising in diabetes (or their own diabetes consultant) to review it
Advice:
o Return if symptoms have not resolved in 7-14 days
o Avoid predisposing factors: washing and cleaning the vulval area with soap or shower gels, cleaning the vulval area more than once per day, washing underwear with biological washing powder and fabric conditioners, vaginal douching, wearing tight-fitting or non-absorbent clothing
o Wash vulval area with a soap substitute and use simple emollients to moisturise the vulval area
o Consider probiotics (e.g. yoghurts) oral or topical
how is thrush managed in pregnancy?
cream (topical) or a tablet inserted in the vagina (a pessary) that contains clotrimazole (not oral medication!)
how is thrush managed in 12-15 yr olds?
topical antifungals only (not oral or pessary)
