STI's and Vaginitis

Question 1

Low Risk <25 age screening

Answer 1

GC/Chlam

Question 2

High Risk

Answer 2

HIV/Syphilis

HSV/Trich

Question 3

Reportable diseases

Answer 3

GC/Chlam, Syphilis, Chancroid, HIV

Question 4

Chlam treatment

Answer 4

Azithromycin po x1
 Doxycycline 100 mg BIDx 7 days
 Alternatives: Erythromycin
base, Ofloxacin, Levofloxacin
7 days
 Lymphogranuloma venereum Doxy 100 mg BID or Eryth 21D
Pregnancy- Amoxicillin 500 mg orally three times a day for 7 days

Question 5

Systemic chlam

Answer 5

Lymphogranuloma venereum (LGV) systemic infx,
unilateral lymphadenopathy, ulcer

Question 6

Gonorrhea treatment

Answer 6

Ceftriaxone 250 mg IM ; Azithromycin po x 1or Doxycycline 100 mg BID x7 days
 Same day, direct observation
 Alternative (EPT):
 Cefixime 400 mg po ; Azithromycin po x1

 Persistent infection:
 More likely treatment failure/reinfection: repeat Tx
 Consult ID/CDC, susceptibility testing (culture & NAAT)
 Gemifloxacin; Azithromycin po x1
 Gentamicin IM ; Azithromycin po
 Ceftriaxone IM ; Azithromycin po

Question 7

Disseminated Gonorrhea

Answer 7

Ceftriaxone IM/IV daily, 48hrs clinical improvement
 Azithromycin po x1
 Then Cefixime po 7 days

Question 8

Conjunctivitis Gonorrhea

Answer 8

Ceftriaxone IM & Azithromycin po x1

Question 9

PID treatment

Answer 9

Screen for HIV, treat partner (Gc/Chl)
Ceftriaxone IM ,and Doxycycline +/- Metronidazole po 14 days

Gonorrhea negative and allergy

levo 500 mg daily and Flagyl

 Hospitalize 24-48hrs with: pregnancy, surgical
emergency, IM/oral failure (72hrs), severe
illness/pain/fever, TOA
 Inpt Tx IV until 24-48hr improvement

Parenteral: Cefotetan2 gm q12 IV Doxycycline 100 mg q 12 IV/po
◦ Clindamycin 900mg q 8, Gentamycin 3-5mg/kg daily IV
◦ Ampicillin/Sulbactam IV 3gm q6 ,Doxycycline IV/po
 Home: Doxycycline , Metronidazole po 14 days
 Clindamycin & Doxy po 14 days (TOA 14-21D)

Question 10

Mycoplasma genitalium

Answer 10

Emerging issue”, associated with urethritis in men
 Difficult to Dx and Tx (NAAT)
 Moxifloxacin po 14 days

Question 11

TOA

Answer 11

75% of pt with TOA respond to IV Abx
 TOA fails to respond in 72 hrs needs drainage
 > 8cm
 Continued failure laparotomy (4 days)- remove IUD

Question 12

Primary HSV

Answer 12

systemic flulike syndrome
(25% aseptic meningitis)
 2-14D incubation
 Disseminated HSV→hepatitis ; coagulopathy

Question 13

HSV supression

Answer 13

Suppression: ↓ recurrence 80%, ↓ transmission 48%

Question 14

Treatment for HSV

Answer 14

Acyclovir
primary 400 TID 7-10 days
Recurrance 400 TID 5 days
Supression 400 BID

Valtrex
Primary 1000 BID 7-10 days
Recurrance 1000 5 day
Supression 500-1000 daily

Severe acyclovir 5-10/kg IV q 8 hr

Question 15

Syphilis 
Primary
Secondary
Tertiary
Latent

Answer 15

Primary – (10-90 D), painless ulcer/chancre
 if HIV neg, repeat test 3 mo
 Secondary – (6wks-6mo) rash, mucocutaneous lesions,
lymphadenopathy
 Tertiary – cardiac/ophthalmic (aortitis, iritis, uveitis),
auditory, gummatous lesions
 CSF-VDRL evaluation (also if HIV +)
 Latent – asymptomatic (early <1yr)
 Consider CSF evaluation (high titer, >1:32)

Question 16

Diagnosis of Syphilis

Answer 16

Most labs doing automated treponemal
- higher false positive

F/U with RPR or VDRL (non-trep)
- 1-3 weeks till + from chancre
titer- 4 fold titer change is significant

20% can be negative for both tests

Question 17

Treatment for syphilis

Answer 17

Benzathine Penicillin G IM
 Once for 1°, 2° and early latent
 Weekly x3 for 3°, late latent and retreatments
- 9 days late start over
 Jarisch-Herxheimer rxn: fever, HA, myalgia w/in 24hrs (early
disease)
 Desensitize in pregnancy, 3°, neurosyphilis
 Clinical ; serologic exam 6, 12, 24mo
 Persistent symptoms/titer increase: Retreat, check CSF and
HIV
 Failure of titer decline +/- retreat

Alternatives: for 1°/2° (28D for latent)
 Doxycycline 100 mg BID po 14 days
 Ceftriaxone IM/IV 10-15 days
 Neurosyphilis: aqueous crystalline penicillin G IV
10-14 days
 Treat all partners from <90D, notify/test/treat up to
one year

Question 18

Chancroid

Answer 18

Painful ulcer(s) + inguinal adenopathy
 Haemophilus ducreyi, gram - streptobacillus
 Culture sensitivity <80%, limited availability
 Co-infection HSV, HIV and Syphilis
 If HIV/Syphilis neg repeat test 3 mo
 See improvement with 3-7D treatment
 Large nodes may require drainage

Azithromycin po x1
 Ceftriaxone 250mg IM x1
 Ciprofloxacin po 3 days
 Erythromycin base po 7
days
 Tx Partners last 10D

Question 19

Ulcer what is your differential

Answer 19

1) Chancroid: short incubation, last weeks
2) Granuloma Inguinale (Donovanosis) : long incubation, painless, rare in
US, regional lymph (Klebsiella-doxy)
3) HSV: short incubation, last days
4) LGV: longer incubation, painless single ulcer, lasts days
5) Syphilis: longer incubation, painless, lasts weeks

Question 20

PH of vaginitis

BV
Candida
Trich

Answer 20

BV- 5-6
Candida 4-5
Trich 6-7

Normal 3.8-4.5

Question 21

Amsel’s Criteria

Answer 21

Clue Cell >20%
ph >4.7
Thin discharge
+ Whiff

Question 22

Treatment of BV

Answer 22

Flagyl- oral 7 days, vaginal 5 day
Tinidazole
Clindamycin

Recurrent: metro get 10 days than twice weekly x 6 mo

Question 23

Candida diagnosis

Answer 23

DNA probes 81%

Question 24

Recurrent Yeast treatment (>4 times per year)

Answer 24

Fluconazole x3 doses

Itraconazole x 3 doses

Question 25

Candida Glabrata

Answer 25

Itraconazole x 14 days
Boric Acid x14 days
Flucytosine x 14 days

Question 26

Trich on Pap

Answer 26

treat
metronidazole BID x 7-14 days
Tinidazole

Question 27

Condyloma Treatment

Answer 27

Podofilox 3 days on/4 off; 4 cycles
 Imiquimod 3x/wk; max 16 weeks
 Sinecatechins oint TID; 16wks
max
 May weaken condoms/diaphragm
 Trichloroacetic acid (TCA) q wk
 Cryotherapy qwk repeat q1-2 wks
 Surgery

Question 28

Molluscum treatment

Answer 28

Self-limited (6-9mo)
Curettage, cryo,
excision, TCA,
Imiquimod

Question 29

pudiculosis pubis

Answer 29

Permethrin 1% cream;
10min
 Pyrethrins 10 min
 Malathion 0.5% lotion;
12hrs

Question 30

Scabies

Answer 30

Permethrin
cream 5%; 14hrs
Ivermectin po; repeat in 2
wks
Lindane 1% cream/lotion;
8hrs (for failures)

Question 31

Post-exposure ppx for Hep B

Answer 31

HBIG and vaccine

Question 32

Hep C testing for what ages?

Answer 32

 Test adult born 1945-65 for Hep C

Question 33

If patient has Hep C what other screening is needed?

Answer 33

HIV testing annually

Question 34

syphilis in pregnancy

Answer 34

placentomegaly, hepatomegaly, ascites, hydrops

Question 35

HIV in pregnancy

Answer 35

avoid efavirenz

Question 36

Gartner duct cysts

Answer 36

Wolffian remant -lateral vagina

only remove with infection, or acute change