STI

Question 1

Emergency contraception options and time windows

Answer 1

Levenogestrel 1.5mg (72 hours), ulipristal acetate 30mg (120 hours), copper IUD (120 hours)

Ulipristal more effective if BMI >26, contraindicated in severe asthma, liver impairment, cautious in breastfeeding.

Question 2

Post sexual assault - issues to address

5

Answer 2

Contraception, STI screening, emotion/mental support (Psychosocial, LIVES) , forensic (CASA), legal (police)

1800 respect, STI screening 2 weeks post (3mo for blood)

Question 3

MSM - what screening tests are recommended 3 montly?

Answer 3

Oropharyngeal swab, anorectal swab & FPU for gonorrhoea/chlamydia PCR. Bloods for HIV, syphilis, Hep A + Hep B if unvaccinated

Annual Hep C if HIV or IVDU, rec vaccinate Hep A and B.

Question 4

Genital warts treatment options. Other considerations

Pregnancy, partners.

Answer 4

Imiquimod 5% 3x week (8-16 weeks) OR podophyllotoxin 0.5% paint BD for 3 days, 4 days off for 4 weeks. Cryotherapy weekly, excision but risks spread. Avoid shaving/waxing. Consider biopsy for cancer

Can delivery baby if pregnant with warts. Consider HPV vaccination of partners.

Question 5

What factors acutely increase risk of HIV transmission?

Answer 5

High viral load, source uncircumcised, drug use during sex, other STI (ulcers, gonorrhoea), breach in mucosa (trauma, piercing), ejaculation in vagina or rectum.

Question 6

What are the eligibility requirements for post exposure prophylaxis?

Answer 6

<72hours, Condomless receptive or insertive intercourse or contaminated injecting equipment.
Source must have HIV or be high risk (MSM, IVDU, from a high prevelance country or sex worker outside Australia)

Question 7

Points to consider for a patient with newly diagnosed HIV (6)

Answer 7

Consider ART immediately, discuss supports, consider psychology, contact tracing and PEP if <72hr, complete STI screen, notify health department

Question 8

What needs to be checked before starting PrEP? What are the SE and followup?

Answer 8

HIV negative within 7 days, eGFR >60, STIs, HepA, B and C. SE: nausea/headaches, long term renal toxicity and reduced bone density. 3 monthly reviews (STIs, kidney function).

Kidney function checked 6mo after 1st 3mo. Recommend review at 1mo when first starting. Vaccinate against Hep A and B at baseline.

Question 9

How is gonorrhoea tested for and treated?

Answer 9

PCR site if screening, culture if symptomatic & before treatment. Ceftriaxone 500mg in 2ml of 1% lignocaine IM, azithromycin 1g PO (genital infection)

2g azith for pharynx. 1g ceftriaxone for conjunctivitis.

Question 10

What is the followup for gonorrhoea?

Answer 10

No sexual contact for 7 days, contact trace and no sex with partners from last 2 months until they are tested, test of cure in 2 weeks from each site, test of re-infection in 3 months.

Can treat recent partners (< 2 weeks) presumptively

Question 11

How is chlamydia tested for and treated?

Answer 11

Nucleic acid amplification test on urine or swabs. Doxycycline 100mg BD for 1 week (3 weeks if sx anorectal)

Alt: Azithromycin 1g PO single dose (2 doses for anorectal)

Question 12

What is the followup for chlamydia?

Answer 12

No sexual activity for 7 days, contact trace and no sex with partners from last 6mo. Test of re-infection in 3 months

Test of cure if pregnant or anorectal infection treated with azith, after >4 weeks. Consider patient delivered partner therapy, can treat recent partners (< 2 weeks) presumptively

Question 13

What are the treatment options for initial episode of oral herpes?

Answer 13

Mild: benzydamine 1% gel PRN or lidocaine 2% viscous solution q3h. Severe: famciclovir 500mg or valacilclovir 1g BD for 1 week

Aciclovir 2nd line

Question 14

What are the treatment options for recurrent oral herpes?

Answer 14

Mild: aciclovir 5% cream 5x day for 5 days OR famiciclovir 1500mg STAT. Severe: Famciclovir 1500mg OR Valaciclovir 2g BD for 1 day.

Aciclovir second line.
Frequent recurrences treated for 6 months (F 250mg BD, V 500mg D)

Question 15

What is the most common cause of PID? How is it treated?

Answer 15

Chalmydia. Mild: Ceftriaxone 500mg IM/IV STAT, metronidazole 400mg BD + doxycyline 100mg BD for 2 weeks. Severe: IV cef, azith, metro.

Often polymicrobial with no cause found. Azith 1g and repeat in 1 week instead of doxy if breastfeeding. Can leave IUD if mild.

Question 16

What is a late and missed OCP?

Answer 16

Late if between 24-48 hours since previous pill, will still be effective. Missed if 48 hours since last pill, need condoms for 7 days.

Question 17

Advice in the setting of a missed pill?

Answer 17

Use condoms for 7 days. If early cycle (within 7 days of sugar pills): need emergency contraception if unprotected sex within last 5 days. Late cycle (within 7 days of next sugar pills): skip sugar pills.

Question 18

What are the diagnostic features of bacterial vaginosis?

Answer 18

Thin white homogenous discharge, fluid pH >4.5, clue cells, fishy odour with KOH.

3 needed for amsel criteria.

Question 19

How is bacterial vaginosis treated?

Answer 19

Metro 400mg BD 7 days, 0.75% gel IV 5 days. 2nd line/pregnant: clindamycin 7 days.

High dose metro as stat dose, poor cure rate.

Question 20

What are the 4-5 ways syphilis can present?

Answer 20

Primary: painless ulcer w firm base. Secondary 6-12 weeks: fever, fatigue, lymphadenopathy, rash on trunk + palms/soles. Latent = asymptomatic. Early if < 2y from acquisition. Late not infectious but can transmit in pregnancy. Tertiary: months later, destructive skin lesions (gumma), CV or neuro disease.

Question 21

What are 3 types of tests used for syphilis and their usage? How is cure tested?

Answer 21

Primary: NAAT swab. Treponemal tests for antibodies (EIA, TPPA, TPHA) - will remain active in any infection. Non-treponemal tests for activity - RPR. Negative after treatment or in latent. RPR at 3 and 6mo, should drop by 4-fold.

Question 22

How is syphilis treated - early vs late, options, alternatives. Risk.

Answer 22

Benzathine benzylpenicillin 2.4M units (1.8g) IM, 2nd line is procaine benzylpenicillin for 10d or doxy BD for 14d. If late syphilis, treat weekly for 3 weeks. Risk of reaction: Jarisch-Herxheimer reaction, fevers/pain 6-12h post.

Question 23

Infection control measures for treated syphilis

Answer 23

Notifiable disease. No sex for 7 days after treatment. Contact trace for primary - 3mo + duration of symptoms or neg test, secondary 6mo, latent: 12mo.

Question 24

How is genital herpes treated? Initial and recurrence. 5 other fx of mx.

Answer 24

Aciclovir 400mg TDS 10d (5 if quick), fam and val ok. Recur: 800mg 1-3 days. No contact tracing/notification, topical lignocaine can help, avoid contact until resolved, test for other STIs, review in 1 week for education/support.

Question 25

When is mycoplasma genitalium tested for? How? Treatment and followup.

Answer 25

Only if sx - urethritis, cervicitis, PID. PCR to test. Mx: doxy 100mg BD 1 week THEN azith 3 days or moxiflox 7 days. Avoid UPSI for 2-3 weeks, contact tracing recommended, test of cure only if symptomatic.

Question 26

Who is at risk of trichomonas? How to test and treat? Followup

Answer 26

More in rural, older, ATSI or sex workers. Less in urban. PCR swab or urine. Metronidazole 400mg BD for 1 week, no sex 1 week and contact trace. Test of cure if symptomatic.

Question 27

What are 3 infectious and 4 non-infectious causes of genital ulcers?

Answer 27

HSV (pain), syphilis - MSM, ATSI, donovanosis - remote ATSI. NI: dermatitis, fixed drug eruption, SCC, behcet disease.