STD Flashcards
High risk populations for STD
youth (15-24)
Racial/ethnic minorities (black, Hispanic)
MSM (72% syphilis in 2011, high HIV coinfect)
What is Vulvovaginal Candidiasis (VVC) and what causes it
Common “yeast infection” not STD (at least 75% women have 1 episode)
Cause: Candida albicans 90%
(can be caused by other candida sp. or yeasts - candida glabrata, candida tropicalis etc)
What are the presenting sx associated with VVC?
vulvar pruritis, external dysuria, burning, dyspareunia, swelling, redness, excoriation
Thick curd like vaginal dc
Normal vaginal pH (<4.5)
What are risk factors associated with VVC
taking antibiotics (PCN, Augmentin), immunocompromised pt (on steroid, DM, HIV+)
*warm, moist environment
How do you dx VVC?
Clinically
Testing:
- Wet prep (saline & 19% KOH); micro budding yeast and hyphae (spaghetti and meatballs)
- candida culture usually not needed
How do you treat uncomplicated VVC?
short course (1-3d) topical/vaginal azole such as Clotrimazole (OTC)
What is considered a complicated yeast/VVC infection? How do you treat complicated VVC?
Recurrent (>4 episodes in 1 yr), Sever, non-albicans VVC, uncontrolled DM, immunocomprom
- treat longer (7-14d) with topical/vaginal azole [Clotrimazole] or oral fluconazole (Diflucan)
- if non albicans, avoid fluconazole
If pt has non-albicans VVC, how should they be treated
considered complicated VVC Avoid oral fluconazole treat longer (7-14d) topical/vaginal azole
In VVC, does the male partner need to be treated
NO
unless he has balanitis (inflammation of skin covering glans penis)
How should you treat a pregnant pt with VVC
do not give oral Fluconazole, treat pregnant with Topical treatment (Clotrimazole)
If a pt has recurrent or difficult to treat yeast infections, what should you be suspicious of and test for
DM, HIV
What is BV (bacterial Vaginosis) and what is the cause
BV due to disruption of usual “healthy” vaginal microflora (lactobacillus sp), not an STD
- allows overgrowth of bacteria
- cause is usually polymicrobial, often assoc with Gardnerella vaginalis and Mobiluncus sp (gram variable anaerobes)
What sx are associated with BV
vaginal irritation
thin white or gray dc
strong fishy odor
what are risk factors for developing BV? can you get BV if not sexually active
new or multiple sex partners (but not an STD)
Vaginal douching
*yes, can affect women that are not sexually active
How do you dx BV?
Need at least 3/4 Amsel’s criteria
- thin, white homogenous dc
- Clue cells on microscopy
- Vaginal fluid pH >4.5 (alkaline)
- fishy odor when adding KOH solution (+whiff)
what is the best lab test for dx BV?
GRAM STAIN is best lab test to dx BV
- shows anaerobes known to cause BV and lack of lactobacilli
- Gram stain is gold standard but not generally used clinically
How do you treat BV? do you treat everyone
treat all pt with sx, Male partner doesn’t need tx
- Metro (flagyl) po x 7d
* no alcohol while on metro, disulfuram rxn - Metro gel intravaginally for 5d
- Clindamycin po or intravaginally
How do you treat pregnant pt with BV?
Use oral med (Metro po x7d) in order to maker sure treating entire vaginal tract
*opposite of VVC, where you use topical clotrimazole and don’t use oral fluconazole
What are some complications of BV?
Increases risk of acquiring/transmitting HIV
Increases risk fo acquiring herpes, GC, CT
Association with PID (not direct cause)
What is Trichomoniasis, what causes it, and how frequent?
Trich is most common non-viral STD
cause: Trichomonas vaginalis (single celled protozoan parasite)
- common
- sx 1-4 wk post exposure (usually vaginal sx), men usually asymp
Though men are usually asymp in Trich, if have sx, what are they and how often do they occur?
Sx in <10% cases
*sx of urethritis: clear or mucupurulent urethral dc and/or dysuria
How do pt normally present with Trichomoniasis
*Increased vaginal pH >4.5 (like BV)
*vaginal irritation, malodorous/fishy, frothy, yello-green discharge
*petechiae on cervix or vagina
STRAWBERRY CERVIX
How would you diagnose a pt with Trichomoniasis
- largely on wet mount (do quickly), see motile flagellated organisms
- Swab (vaginal, cervical) then culture but may take up to 7 d
- Other: NAAT to detect genetic material: (faster, more sensitive), preferred for males
- May identify on PAP smear
* testing difficult on males, know 5-20% of men with NGU have trich
How do you treat Trichomoniasis
Treat every: pt & partner with METRO (FLAGYL) po
- no sex for pt and partner till tx complete
- consider treating for CT and GC
What are complications of Trichomoniasis
increases risk fo acquiring and transmitting HIV
What should pregnant pt with Trichomoniasis be aware of
Trich increases risk of PROM, preterm delivery, LBW yet tx is not shown to reduce risks
- treat pt with sx
- no breastfeeding will on Metro (flagyl)
What is CT and what causes it
Chlamydia (CT) is the most common bacterial STI in the US, peaks in late teens early 20s
Cause: Chlamydia trachomatis (G- bacterium)
Who should be screened for CT and what do CT pt commonly have
- women <25 screen for chlamydia yearly
- screen older women with risk factors, all preg pt
- routine screening for Males not recommended
- Pt frequently co-infected with gonorrhea
What sx do pt with CT normally have
- often Asymp (50% M, 80% women asymp)
- sx 1-3 wk post exposure
- women: cervical dc, vaginal bleeding, low abdominal, Fever/chill, adnexal/uterine tenderness
- Men: irritated urethra/urethritis, penile dc, dysuria
- can cause oral and rectal infections
Chlamydia and gonorrhea are more _____ where as BV, Trich and VV are more ________
CT and GC = cervicitis
BV, VV, Trich = vaginitis
Chlamydia: what are Women sx
asymp in 80%
vaginal bleeding, cervical dc, low abdominal pain, fever chills, adnexal/uterine/cervical tenderness
Chlamydia: what are Male sx
Penile dc, urethritis, dysuria
How do you dx Chlamydia?
a) Swab: cervical, vaginal or male urethral - NAAT
b) Urine: NAAT
c) Pharynx or rectal swab: NAAT, check with lab
* sensitivity a bit better with swab; plus can test for Trich, GC at same time
How do you treat Chlamydia
Treat everyone: pt/partner (if possible test partner)
*in AZ can treat partner without testing
Doxy po x 7d OR
Azithromycin (Zithromax) po x1dose
No sex during tx (or 7 d post Zithromax)
What are some notes about treating pt with Chlamydia (treated with doxy x 7d or Azithromycin x 1d)? Pregnancy recommendation?
Consider treating for gonorrhea too
no sex during tx or 7d after Zithromax tx
Retest in 3-4 month
*Preg = do Doxy bc Preg cat D
TREAT PREG WITH ZITHROMAX
*retest 3 wk after preg pt tx
What are some complications of Chlamydia
Increases risk of acquiring and transmitting HIV
- left untreated, can cause PID and assoc complications
- in M: can cause epididymitis
What should a pregnant pt with CT be aware of
- May lead to preterm delivery
- transmittable to neonate during delivery:
- conjunctivitis (ophthalmia neonatorum) &
- pneumonia
- can cause other respiratory tract infections
- ocular specimens should be tested for GC, CT
NO DOXY FOR PREG, only zithromax
What causes GC, when do pt get sx and who should you screen
cause: Neisseria gonorrhea (G- diplococci bac)
* screen pt at risk (USPSTF)
- risk: GC, other STD, new/mult partners
* pt often co-infected with chlamydia
sx 1-14 d post exposure
What sx does a pt with GC have
similar to CT but more severe
*more mucupurulent dc, abdominal pain, etc
WOMEN: vaginal dc, low abdominal pain, fever, cervical motion tenderness
MEN: urethritis, white yellow or green penile dc, dysuria
(can cause oral and rectal infections)
How do you dx pt with GC
Swab or urine (like Chlamydia)
How do you treat GC
tx all (pt/partner)
Ceftriaxone (Rocephin) IM injection PLUS azithromycin or doxycycline (to cover CT)
- no sex during tx
- retest 3-4 mth
What are complications of GC
increase risk getting/giving HIV
If untreated can cause PID and associated complications (males can cause epididymitis)
*can cause conjunctivitis, meningitis, endocarditis, disseminated disease
what should a pregnant pt be aware of if they have GC
Transmittable to neonate during delivery
- neonate: sometimes causes ophthalmia neonatorum (can perforate globe, cause blindness)
- -> ,most states require ophthalmia neonatorum prophylaxis: top erythromycin applied both eyes
- in newborns with sx, ocular specimens should be tested for GC and CT (culture before initiating tx)
- rarely can cause sepsis, arthritis, meningitis
What is NGU? sx? dx? tx?
Non gonococcal Urethritis Cause: CT, mycoplasma genitalium, other sx: urethritis dx: test for GC, CT Tx: dependent on testing, empiric for CT (azithromycin or doxycycline) *follow up for persistent sx
What is PID
pelvic inflam dz: gen term referring to spectrum of inflammatory dx of upper genital tract
–> endometritis, salpingitis, tubo-ovarian abscess
What causes PID
most commonly sexually transmitted organisms (CT, GC)
*other: anaerobes, H flu, CMV
What is the freq and pathophysiology of PID
750,000 infections/yr
10-15% become infertile
Patho: ascending infection from vagina or cerix to upper genital tract
What are the sx of PID: acute vs chronic infection (cause of chronic PID?)
May be subtle/mild
acute: vag dc, low ab pain, chandelier sign (cervical motion tenderness), uterine/adnexal tenderness, dyspareunia, fever >101
Chronic: occurs due to insuff tx, vague sx
Risk factors for PID
<25, African Am, early onset sexual activity, multiple partners, douching, IUD w/in 3 wk, *prior hx PID
PID diagnosis and testing
dx largely clinical; other impt testing
*hCG test
*GC, CT
*check WBC on saline microscopy of vaginal fluid
*CBC, ESR, CRP
*US (r/o ectopic preg, thickening in areas of inflammation, tubo-ovarian abscess)
laparoscopy (visualization, can take specimens)
How do you treat PID
treat like GC/Chlamydia *treat empirically: *Outpt: ceftriaxone IM injection & doxy x14d or Zithromax & w or w/o Metro x14 d
- inpt: IV regiment
- follow up in 48 hr
When should you hospitalize for PID
*if surgical emergency cannot be ruled out (ectopic preg, appendicitis, ovarian torsion)
- Pt is preg
- pt not responding to oral abx within 8-72 hr
- pt has tubo-ovarian abscess
- pt very ill (high fever, N/V, looks sick)
Complications of PID
a) infertility
b) ruptured tubo-ovarian abscess (surg emerg)
c) Chronic pelvic pain
d) increased risk ectopic pregnancy
e) Fitz-hugh curtis syndrome (perihepatitis characterized by RUQ pain and adhesions)
Genital Herpes: cause, background?
cause: HSV type 1 or 2
* common
* HSV 2 usu causes genital lesions
* most infected have minimal or no sx
* commonly acquired from asymptomatic partner
What are the 4 designations of Genital Herpes
- Primary
- Non-primary 1st episode
- Recurrent
- Asymptomatic viral shedding
What is the pathophysiology of Genital Herpes
- spread through contact w/ lesions, mucosal surfaces, genital secretions or oral secretions
- viral shedding can occur when lesions not present
- virus remains latent in nerve root ganglion
- virus may be reactivated by change in immune status (stress, menses, infection
what are the presenting sx of genital herpes
prodrome of burning, tingling and/or pruritis followed by outbreak of painful vesicles on erythematous base
*initial/primary outbreak tends to be most severe
dew drops on rose petal, shallow, potentially coalescing ulcers
*can make it difficult to dx
How do you dx herpes
clinically
- direct viral culture from swab (preferred but can get false neg, requires active lesion)
- serology/blood: some tests can detect HSV1 &2 specific antibodies
- limitations: antibodies usually do not appear until 3-4 wks post exposure, lesions may appear in 2-14 days; + test not definitive for genital herpes
How do you treat genital herpes
acyclovir. .. “cyclovirs”
- for initial outbreak: 7-10 d
- recurrent outbreak: 1-5d
- for suppresion: daily dose, discus dc annually, REDUCES not eliminates risk of transmission to partner
Things to consider for pt preg with genital herpes
Can be vertically transmitted to infant before, during or after delivery (during delivery most common)
*C section reduces risk
Risk:
if mom with primary infection: 50% risk
if mom with recurrent HSV: risk 1% (mom’s antibodies are protective)
What perfecnt of infants with neonatal HSV are born to mothers with no known hx of genital HSV
MOST! 70-95%
What types of Neonatal HSV are possible
3 syndromes:
1) localized skin, eye, mouth (SEM) dz
2) CNS dz (encephalitis) *long term morbidity common ie mental retardation
3) Disseminated disease (Organ invovlement) *mortality common (80%)
How can you help prevent neonatal HSV
Offer women with active recurrent genital herpes suppressive viral therapy (acyclovir) at or after 36 wk gestation (may reduce need for C section)
*perform C section if active genital lesions or prodromal sx (ie vuvlvar burning) at time of delivery
What counseling should you provide women
during 3rd trimester….
Pregnant women w/o known genital herpes
- avoid intercourse w/ partner or suspected of having genital herpes
Preg women w/o known orolabial herpes
- avoid receptive oral sex w/ partners known or suspected of having orolabial herpes
Cause and history of HPV
human papillomavirus (>40types)
- can infect genital area (vulva, vagina, penis, anus)
- can also infect mouth, throat)
- MOST COMMON STD
- nearly all sexually active men and women will get at least one type of HPV at some point in their lives (most clear w/in 2 year)
Sx of HPV
*most never have sx
- visible genital warts (condyloma acuminata)
- soft, flesh color, single/mult flat cauliflower like
- precancerous, cancerous changes (anywhere)
- persistent HPV main cause of cervical cancer
How do you dx HPV
- visualize warts: vinegar, biopsy if uncertain
- Abnormal pap: (anal Pap not recommended)
* no test for men*
How do you treat HPV
No cure, just tx for dz HPV causes
- destroy warts:
a) liquid nitrogen, TCA
b) rx: podofilox ointment, topical imiquimod (aldara)
What are complications of HPV
~15 types lead to cervical CA
*types 16,18 account for 70% of cervical CA
How do you prevent HPV
Vaccine (FDA licensed 2006), series of 3 inj
1) Cervarix (bivalent), for girls only: types 16,18 cervical CA protection
2) Gardasil (quad) boys and girls: 16, 18, 6, 11 protects against cervical, vulvar, vaginal, anal CA and warts
What are the CDC recommendations for the HPV vaccine
Recommended for girls and boys
- 11-12 (can start as early as 9)
- 13-26 girls who have not completed series
- 12-21 who have not completed series
*best to start before becoming sexually active
What are things to be aware of if pregnant and have HPV
rarely can be transmitted to neonate during delivery
*rarely causes warts in baby’s throat
What is the cause of syphilis and pathophysiology of transmission?
Cause: Treponema pallidum
- highest rates Men 20-29
- direct contact with infected lesion (genitals, anus, lips, mouth) –> bacteria enter skin –> 10-90 d create painless chancre
What is syphilis known as and describe the infectious process?
"great imitator" Has four potential phases: 1. Primary 2. Secondary 3. Latent 4. Late/tertiary
What does the primary phase of syphilis involve?
Painless chancre appears at location where syphilis entered, lasts 4-6 wk
What does the syphilis chancre appear like
punched out appearance, rolled edges, painless
What does the secondary phase of syphilis involve?
multiple manifestations
a) RASH very common: usually non pruiritic, characteristically on palms and soles of feet, not contagious
b) CONDYLOMA LATA: moist, heaped, wart like papules usually in intertriginous areas, highly contagious
c) MUCOUS PATCHES: painless flat patches involving oral cavity, pharynx, genitals (not painful, pt may be unaware); in 6-30% secondary syphilis, highly infectious
How does secondary syphilis present itself?
besides rash, condyloma lata, mucous patches:
- pt may also experience systemic sx such as malaise, LAD
- secondary syphilis usually lasts 2-6 wks then enters latent phase
Aspects of Latent syphilis?
Asymptomatic, syphilis no longer sexually transmittable, may persist for years
How may lat syphilis present?
may appear 10-20 YEARS after infection acquired, develops in 15% of those untreated
*causes neurologic deficits (blindness, dementia) & damage to internal organs
*neurosyphilis can occur w/in any stage of syphilis
How do you dx syphilis?
- Bacteria from chancre under DARKFIELD MICRO
- Serology: RPR or VDRL
- titer indicates dz activity, may be low if false+ (eg low titer is 1:4)
- confirm RPR with antibody test FTA-ABS
what does RPR stand for? VDRL?
*these are initial serology tests to dx syphilis
RPR: rapid plasma reagin
VDRL: venereal dz research lab test
False positives on RPR and VDRL test for syphilis may be due to
autoimmune dz, illness, possibly pregnancy
If you suspect neurosyphilis (late stage), what should you do
must do LP (lumbar puncture) & VDRL on spinal fluid to confim
*refer to neurologist
How/who should you treat syphilis
Treat everyone (pt/partner) with: * Benzathine PCN G 2.4 mu IM x 1
- additional doses required if syphilis present >1yr
- get pt hx, contact county health dept for advice
If pt with syphilis is allergic to PCN (syphilis tx is Benzathine PCN G 2.4 mu IMx1), then what do you do
treat with Oral DOXYCYCLINE
*however always treat HIV pt & preg pt with PCN
Who should you always treat with PCN for syphilis
HIV and preg Patient
How do you confirm treatment success for syphilis pt
check RPR titer (3, 6, 12, 24 mth)
4 fold decrease = adequate response
What are some complciations of syphilis
chancre ^ risk getting/giving HIV
*late syphilis risk
What is congenital syphilis
untreated syphilis during preg, esp early syphilis can lead to stillbirth, neonatal death or disorders
Disorders: deaf, neuro impairment, bone deform
How do you prevent congenital syphilis
Screen preg women at 1st prenatal visit
- If risk high, screen and obtain sexual hx again at 28 wk and at delivery
- if preg pt is PCN allergic, consider desensitization with oral PCN
- monitor serology closely to confirm successful tx
What is chancroid, what causes it and how does it present?
STD caused y H. ducreyi
- sporadic US outbreaks
- Presents: painful tender genital ulcer, fould smelling contagious dx, inguinal adenitis (buboes)
How do you dx chancroid
r/o syphilis
if chancroid suspected, contact county health dept
What is lymphogranuloma venereum (LGV)
LGV is STD caused by Chlamydia trachomatis, rare in US but most commonly in MSM population usually
How does lymphogranuloma venereum present
systemically
Unilateral inguinal bubo
self limited genital ulcer or papule at site of innoculation
anal dx and rectal bleeding
how do you dx lymphogranuloma venereum (LGV)
r/o syphilis
If LGV suspected, contact Country Health Dept
What is Pediculosis Pubis, how do you dx it and how do you tx it?
STD (pubic lice) caused by parasite pthirus pubis
“crab louse”
dx: clinical presentation
tx: premethrin 1% cream rinse
If you are in doubt of STD dx, what should you do
contact county health dept
Genital lesion.. ddx?
syphilis, LGV, chancroid, HPV, Herpes
For a pregnant women, what should you do at first visit
screen for HIV, syphilis, Hep B, GC, CT
- Hep C for those at risk
- take hx to assess for HSV
How should you approach adolescents and STDs?
realize STDs are highest in adolescents
- minors may consent to STD service in ALL 50 states (some regard HIV tx separately0
- routine screening for GC/chlamydia women <25
- discuss HIV screening (CDC rec for 13-64 yr)
- discuss/offer HPV vaccine
How should you address MSM population and STDs
realize MSM may be at higher risk, take good hx
- screen HIV and syphilis annually
- offer HepA&B vaccines
How should you address WSW and STD
do not assume low risk
what should you do if young children have STD?
prompt involvement of CPS
General considerations STD screening?
screen pt age 13-64 for HIV
- screen those with risk factors annually
- opt out testint
all pt with STD should be screened for HIV (test for HIV with each new STD)
*report communicable STDs
