STI 1 and 2 Flashcards
What are the 5 āPās of taking a good sexual history?
partners practices protection from STDs past STDs precaution of pregnancy
Why is it important for all patients with an STD to be evaluated for HIV?
many STDs facilitate the transmission of HIV: Chlamydia Gonorrhoeae BV HSV 1,2 Syphilis Chancroid Granuloma inguinal (Klebsiella granluomatosis)
Is the immunity due to prior infection durable in the case of STIs?
no, in general, prior infection does not protrect against re-infection
Define cervicitis.
visible purulent endocervical exudate and/or sustained endocervical bleeding induced by gentle passage of a cotton swab through the cervical os
Contrast the presentation of gonococcal and nongonococcal uretheritis.
gonococcal infection incubation is less than 4 days, presents with severe dysuria and the discharge is profuse yellow or green
NGU incubation is in the range of 7-14d, with mild dysuria and slight discharge that is gray (minor)
Describe the diagnostic tests that would differentiate GU and NGU.
GU: gram stain shows many WBC with intracellular gram negative diplococci
NGU: gram stain shows WBC and no diplococci (suggestive for C. trachomatis)
both show > WBC per oil immersion or >10 WBC on first void UA of AM (alternate PCR of urethral swab or urine specimen)
What is the standard tx. for GU and NGU.
GU: ceftriaone 250 IM plus: azithromycin 1000mg PO x1 OR doxycycline 100mg PO BIDx 7
NGU: Azithromycin 1g PO x1 or doxycycline 100mg BID x 7d
this regimen also treats for chlamydia
What are the suite of recommendations that usually accompany STI treatment.
abstain from sex for 7d
notify partners for eval, tx and testing
test for other STDs including HIV
repeat testing recommended in 3-6mo
What is the clinical presentation of mucopurulent cervicitis?
common that patient is asymptomatic, symptoms can include abnormal vaginal discharge and intermetnstrual bleeding (esp. after sex)
Name important criteria and considerations for diagnosis of mucopurulent cervicitis?
at least one of the major diagnostic criteria: mucopurulent endocervical exudate or sustained endocervical bleeding induced by passage of a cotton swab
gram stain or NAAT of cervical, vaginal or urine specimens can be helpful
MUST ALWAYS evaluate for upper tract disease (PID)
When is test of cure recommended in the treatment of mucopurulent cervicitis?
if the patient is pregnant
if the GC regimen did not include cefrtriaxone
Which STI are women and men more likely to get based on gender
women 2.5x more likely to get Chlamydia
women have a higher incidence of Gonorrhea
men have a greater incidence of Syphilis
What is the target for Chlamydia screening?
annal screening for women <25yo, highest rates seen in women ages 15-24
Describe the pathogenesis of Chlamydia.
C. trachomatis is an intracellular bacterial pathogen that infects urethral, rectal, cervical, and upper reproductive tract epithelial cells, epidermal cells in men and conjunction and pulmonary columnar cells
C. trachomatis reproduces through and elementary (enters and /reticulate body lifecycle
Contrast complication of Chlamydia in men and women
men: epidiymitis, prostatitis and reactive arthritis
Women: PID, tubal infertility, ectopic pregnancy, chronic pelvic pain
Discuss the presentation of neonatal infection with chlamydia and its treatment.
Neonatal inclusion conjunctivitis occurs within 5-12d of birth and requires ORAL antibiotics
Neonatal C. trachomatis pneumonia occurs within 8 weeks of birth and requires ORAL antibiotics
perinatal screening can eliminate 90% of infections
What is the standard treatment for chlmydia?
Azithromycin 1g PO x1
OR
Doxycycline 100mg PO BIDx7d
Describe the risk of transmission man > woman vs. woman > man for gonorrhea
male > female 50-70% per exposure
female > male 20% per exposure
Describe the gram stain of N. gonorrhea.
intracellular bacterial pathogen that is a diplococcus with prominent pilli
** it is important to gram stain and culture all sites of sexual contact
Who is more likely to be asymptomatic with N. gonorrhoeae, men or women?
men <10% asymptomatic
women up to 80% asymptomatic
Describe the symptoms of Pharyngeal and anorectal gonorrhea
pharyngeal gonorrhea is almost always asymptomatic
anorectal gonorrhea presents with pruritus, tenasmus, discharge and bleeding
Describe the presentation of the two syndromes associated with disseminated gonoccocal infection.
- Arthritits-Dermatitis: additive, asymmetric polyarthritis, papules and pustules on extremities
- Septic Arthritis: usually involves 1 joint, often the knee
How is gonococcal conjunctivitis prevented in newborns?
prevented at birth with erythromycin ointment, if not treated ophthalmia neonatorum can lead to blindness
associated symptoms include scalp abscesses, meningitis and bacterial sepsis
What is the 1st line treatment of N. gonorrhea?
ceftriaxone 250 mg IM x1 + azithromycin 1000mg PO x1 or doxycycline 100mg PO BID x7d
alternate regimens replace ceftriaxone with cefixime (increasing resistance) or azithromycin 2g PO x1 followed by test of cure in those with cephalosporin allergy
DGI will require hospitalization and longer course of cephalosporins with antibiotic susceptibility testing
Define pelvic inflammatory disease.
any combination of cervicitis, endometritis, salpingitis, turbo-ovarian abscess, and peritonitis including peri-hepatitis (Fitx-Hugh-Curtis Syndrome)
classically a polymicrobial infection that can include C. trachomatis, N. gonorrhoeae + bacteria that are a normal part of the vaginal flora
Name non-sexual causes of PID.
within the 1st three weeks of insertion of IUD
douching- changes the vaginal flora and forces bacteria into the upper reproductive tract
Of women who are symptomatic (only ā of those infected) what are symptoms of PID?
lower abdominal pain, fever, vaginal discharge with foul odor, dysuria, painful intercourse and peri hepatitis pain
How is dx of PID made?
lineal diagnosis based on cervical motion tenderness or uterine tenderness or adnexal tenderness WITH WBC in vaginal secretion or mucopurulent cervititis
What are the keys to management of PID given that the dx. is made clinically and is assumed to be polymicrobial? (2)
broad antibiotics are needed
antibiotics should be started as soon as dx.
What are complication os PID and how can it be prevented?
tubal infertility (increases with #epidsodes)
ectopic pregnancy
chronic pelvic pain
prevented by screening for chlamydia
Describe the pathogenesis of BV
an undefined chance promotes the replacement of lactobacillus species (produces hydrogen peroxide) with high concentrations of G. vaginalis and other anaerobic bacteria
apparent by the presence of clue cells (highly stippled cytoplasm)
What is the presentation of BV?
vaginal discharge that is gray, whitish ad has a fish odor
there is no inflammation of the vaginal was and endocervix (if present due to another cause- BC increases the risk for acquisition of other STI)
How do you diagnose BV?
gram stain is the gold standard (notes the relative concentration of lactobacilli to other bacteria) which not often used in clinic
Clinically meet 3 of 4 criteria
- homogenous, thin, whitish gray discharge that coats vaginal walls
- positive whiff test when KOH is added to vaginal discharge
- vaginal pH >4.5
- clue cell: vaginal epithelial cells coated with cocobacilli
Who should be recommended treatment of BV and what is the management
all pregnant women should be treated- prevent PROM, early labor, preterm birth and postpartum endometritis; symptomatic women should be treated but male partners do not need to be treated
metronidazole 500mg PO BID for 7d or metronidazole gell or clindamycin cream intravaginally QID 5-7d
What organisms should be considered for genital ulcer disease?
H. ducreyi (Chancroid) K. granulates (Donovanosis) C. trachomatis (L1-3) T. palladium (Syphillis) HSV
Contrast primary infection and non-primary 1st episode of HSV.
primary infection is usually asymptomatic or can include symptoms of 1st episode without antibodies
non-primary 1st episode: fever, headache, malaise, myalgia, pain and itching, dysuria, tender inguinal adenopathy
tender widely spaced bilateral ulcers in various stages (vesicles, pustules, ulcers) that develop over 4-10d
How is HSV diagnosed?
usually by clinical appearance of lesion, can be confirmed by PCR, or type specific IgG antibodies
culture will show cytopathic effects, Tzanch prep was used historically
How is HSV treated
acyclovir, famciclovir and valacyclovir can be used as suppressive or episodic therapy- suppressive therapy decreases shedding and decreases but does not eliminate transmission
What is the most important risk factor for neonatal transmission?
acquisition of primary HSV infection during pregnancy is the greatest risk to fetus- contact with infected secretion at birth can result in cutaneous lesions and invasion of the CNS to cause encephalitis
new onset of HSV requires antiviral tx and lesions at the time of delivery indicates cesarian section
targeted screening can be done for pregnant woman and partner
Describe the pathogenesis of Syphilis.
T. palladium penetrates intact mucosa or gains access through abraded membranes
it enters blood stream and lymphatics to disseminate throughout the body
creates the classic obliterative endarteritis
cutaneous lesions contain many oraganisms
Describe the clinical manifestation of primary syphilis.
painless ulcer (chancre) that develops at the site of inoculation, associated with LAD within 90d of exposure and takes 2-8wks to heal
Describe the clinical manifestation of secondary syphillis.
constitutional symptoms and lesions
fever chills, malaise, poor appetite
rashes: maculopaular or pustular rash (VERY INFECTIOUS), alopecia, mucous patches (mucosa) and condyloma lata (painless plaques in intertriginous areas)
**key rash on palms and soles of the feet
What is the difference between latent and tertiary syphilis?
latent syphilis onset after resolution of secondary syphilis (relapses occur in early latent> late latent)
tertiary syphilis progresses to neural (tabies dorsalis) and vascular destruction; gummatous: granulomatous inflammation and destruction of tissue can effect the bones and mucocutaneous tissue
Describe dianosis of syphilis.
darkfield shows spiral organism, serology remains the mainstay of dx.
How do you treat syphilis?
penicillin is the drug of choice for all stages of syphillis, even those with penicillin allergy or pregnant women; duration of therapy depends on the stage of syphilis
partners within 90d should be notified
What is the gram stain of Chancroid? What is the clinical presentation
H. ducreyi is a gram negative coccobacillus that presents with painful ulcer with ragged and undermined edges that bleeds easily
50% will have enlarged inguinal LN (bubos) which can spontaneously rupture
What is the clinical criteria for Chancroid and how is it treated?
all for dx: > 1 painful ulcer, appearance of ulcer c/w chancroid, no evidence of syphilis or HSV
tx. with Azithromycin 1g PO x1 or ceftriaxone 250 mg IM x 1
What is the organism and presentation of Granuloma inguinale?
Klebsiella granulomatis found largely in tropical regions presents with painless, beefy red ulcer with rolled edges and bleeds easily (no LAD, no bubos)
untreated lesions can lead to extensive scarring
How is Granuloma inguinale dx and how is it treated?
donavan bodies in mononclear cells is diagnostic, treat with doxycycline 100mg PO BID until all lesions are healed
What is the organism and stages of lymphogranuloma venereum?
LGV is due to C. trachomatis, associated with groove sign
stages
- painless ulcer
- bubo- mostly unilateral- groove sign,
- scarring
dx. clinically, with aspiration of bubo and serology; tx. with doxycyline for 21d
Which subtypes of HPV cause integration of viral DS DNA into the host genome?
types 16 and 18 (oncogenic)
What are symptoms of recurrent respriatory papilomatosis?
HPV 6 and 11 causes altered cry, hoarsness, stridor and respiratory distress
List ectoparasites that can be transmitted sexually with their treatment.
pediculosis pubis: public lice- permethrin cream/ decontaminate clothing and bedding
sarcoptes scabiei- scabies (note burrows)- treated with permethrin cream or ivermectin PO
