STIs Flashcards
BV is an overgrowth of ___ bacteria in the vagina Examples?
anaerobic Gardnerella vaginalis (most common) Mycoplasma hominis Prevotella species
T/F: BV is a sexually transmitted infection
False- is caused by LOSS of health vaginal bacteria Can increase risk of STIs occurring
main component of the healthy vaginal flora?
lactobacilli (produce lactic acid that keep pH <4.5) loss of lactobacilli > pH rises > anaerobic bacteria grow > BV
risk factors for BV?
multiple sexual partners excessive vaginal cleaning recent antibiotics smoking copper coil
presentation of BV?
Classic: fishy grey/white vaginal discharge. 50% asymptomatic Not often ass. with itching, irritation or pain (suggests concurrent infection)
Ix in BV?
vaginal swab: pH> 4.5 Charcoal vaginal swab (high if speculum, low if self-taken) for microscopy > clue cells assess risk of additional pelvic infections: swabs for chlamydia and gonorrhoea where appropriate
Treatment of BV?
Asymptomatic: often no treatment, may self-resolve Symptomatic: metronidazole PO/ topical gel Advice: risk reduction (avoiding irritation soaps/ douching)
Advice when prescribing metronidazole?
avoid alcohol throughout treatment causes disulfiram-like reaction (N&V, flushing, sometimes shock and angiodema)
complications of BV?
increased STI risk: chlamydia, gonorrhoea, HIV in pregnancy: miscarriage, preterm delivery, PROM, chorioamnionitis, LBW, postpartum endometritis
T/F: BV occurs more frequently in women taking the COCP
false - less common also less common in those who use condoms effectively
most common cause of thrush?
candida albicans
T/F: candida may colonise the vagina without causing symptoms
true - then cause symptoms in certain situations e.g. pregnancy then progresses to infection with right environment e.g. pregnancy/ post broad-spec Abx that alter the vaginal flora.
risk factors for vaginal candidiasis?
increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause) poorly controlled diabetes immunosuppression (corticosteroids) broad-spec Abx
vaginal candidiasis presentation?
non-smelly thick, white vaginal d/c vulval and vaginal itching, irritation, discomfort more severe: erythema, fissures, oedema, dyspareunia, dysuria, excoriations
Ix in vaginal candidiasis?
often treated empirically swab for vaginal pH can differentiate between BV and trichomonas (pH >4.5) and candidiasis (pH <4.5) charcoal swab for microscopy can confirm diagnosis
initial uncomplicated vaginal candidiasis treatment?
clotrimazole cream (single dose at night 5g 10% cream) or clotrimazole pessary (single 500mg at night or three 200mg over 3 nights) or oral fluconazole (single dose, 150mg)
advice for women taking antifungal creams/ pessaries?
can damage latex condoms/ prevent spermacides from working so alternative contraception needed for at least 5 days after use
most common STI in the UK?
chlamydia (significant cause of infertility)
Chlamydia 1) gram NEGATIVE/ POSITIVE bacteria 2) INTRACELLULAR/ EXTRACELLULAR
1) -VE 2) intracellular
T/F: many cases of chlamydia are asymptomatic
true 75% in women 50% in men
T/F: asymptomatic patients can still pass the infection on
true
what is tested for when a patient attends GUM clinic for STI screening
chlamydia gonorrhoea syphilis HIV
name the 2 types of swabs used in sexual health testing and what they are used for
charcoal swab- microscopy, culture and sensitivities NAAT- test directly for DNA/ RNA of the organism
charcoal swabs can confirm which STIs?
BV (clue cells) candidiasis Gonorrhoea (specifically endocervical) Trichomonas vaginalis (specifically swab from posterior fornix) Other bacteria e.g. group B strep
what kind of swabs can charcoal swabs be used for?
endocervical or high vaginal swabs
NAAT swabs are used to test for which STIs?
gonorrhoea chlaymdia mycoplasma genitalium
In women, what kind of samples can NAAT be performed on? Order of preference?
endocervical vulvovaginal (self-taken lower vaginal swab) first-catch urine (think inside to out)
In men, what kind of samples can NAAT be performed on? Order of preference?
first-catch urine urethral
what swabs can be taken to diagnose chlamydia in the rectum and throat?
rectal or pharyngeal NAAT swabs (consider after oral/ anal sex)
Where gonorrhoea is suspected or demonstrated on a NAAT test, what further test is needed?
endocervical charcoal swab for microscopy, culture and sensitivities
presentation of chlamydia in women?
75% asymptomatic suspect if - Abnormal vaginal discharge/ bleeding - Pelvic pain - dysuria/ pareunia
presentation of chlamydia in men?
50% asymptomatic suspect if - urethral discharge/ discomfort - dysuria - epididymo-orchitis - reactive arthritis
It is worth considering rectal chlamydia and lymphogranuloma venereum in pts presenting with that symptoms?
anorectal symptoms - discomfort, dishcarge, bleeding, change in bowel habits
diagnosis of chlamydia 1) in women 2) in men
1) NAAT vulvovaginal swab 2) NAAT first-catch urine swab are first line tests
Chlamydia treatment 1) 1st line, uncomplicated 2) when is this contraindicated? 3) alternatives in this group?
1) doxycycline 100mg BD 7 days 2) pregnancy, breastfeeding 3) azithromycin, erythromycin, amoxicillin
T/F: test of cure is recommended in chlamydia and gonorrhoea
not routinely in chlamydia (used in: pregnancy, persistent symptoms, rectal chlamydia) yes in gonorrhoea (given the high rate of antibiotic resistance)
Other factors in the management of chlamydia patient?
avoid spread: avoid sex for 7 days during treatment, refer to GUM for contact tracing and notification co-infection: screen for other STIs prevent recurrence: education regarding protection safeguarding: sexual abuse in children
Lymphogranuloma venereum (LGV) Is a condition affecting the ____ tissue around the site of infection with chlamydia. It most commonly occurs in which patient demographic?
lymphoid MSM
3 stages of Lymphogranuloma Venereum?
Primary: painless ulcer on penis/ vaginal wall/ rectum Secondary: lymphadenitis (inflammation and pain or inguinal/ femoral lymph nodes) Tertiary: proctitis, proctocolitis - anal pain, change in bowel habit, tenesum, discharge
1st line treatment of LGV?
Doxycycline 100mg BD 21 days
examination findings in chlamydia?
pelvic/ abdo tenderness cervical motion tenderness (cervical excitation) inflamed cervix (cervicitis) purulent d/c
describe the Neisseria gonorrhoeae bacteria
gram negative diplococcus
T/F: having other STIs increases the risk of getting gonorrhoea
true
T/F: there is a high level of antibiotic resistance to gonorrhoea
true
T/F: gonorrhoea is more likely to be asymptomatic than chlamydia
false 90% symptomatic in men 50% in women
presentation of gonorrhoea in 1) women 2) men
1) odourless purulent discharge (green/ yellow), dysuria, pelvic pain 2) odourless purulent discharge (green/ yellow), dysuria, epididymo-orchitis
presentation of 1) rectal 2) pharyngeal gonorrhoea?
1) often asymptomatic, can cause pain and d/c 2) often asymptomatic, can cause sore throat
diagnosis of gonorrhoea in 1) women 2) men
1) NAAT- vulvovaginal swab 2) NAAT- first catch urine swab are first line
who should receive rectal and pharyngeal swabs for gonorrhoea?
all MSM or risk factors: anal/ oral sex or symptomatic in these areas
T/F: a charcoal endocervical swab should be taken before starting antibiotics in gonorrhoea
true- for micoscopy, culture and sensitivities (imp due to hgih rate of Abx resistance) so NAAT for diagnosis followed by charcoal for confirming antibiotic sensitivities if positive
Gonorrhoea treatment 1) uncomplicated, sensitivities not known 2) uncomplicated, sensitivities not known, needle phobic 3) uncomplicated, sensitivities known
1) IM ceftriaxone 1g (have to TRI something) 2) oral cefixime + oral azithromycin 3) oral ciprofloxacin 500mg
Test of cure in gonorrhoea 1) what test 2) when
1) NAAT if asymptomatic, cultures if symptomatic 2) 72 hours post-treatment for culture. 7 days post-treatment for RNA NAAT (14 for DNA)
other important points in the management of gonorrhoea?
avoid spread: avoid sex for 7 days during treatment, refer to GUM for contact tracing and notification co-infection: screen for other STIs prevent recurrence: education regarding protection safeguarding: sexual abuse in children
Gonococcal infection in neonates can be contracted from the mother during birth What medical emergency can this lead to?
gonococcal neonatal conjunctivitis (ophthalmia neonatorum) can lead to sepsis, perforation of the eye and blindness
complication of untreated gonococcal infection? presentation?
disseminated gonococcal infection- bacteria spreads to the skin and joints Non-specific skin lesions Polyarthralgia Migratory polyarthritis Tenosynovitis Fever, fatigue
Although caused by Chlamydia trachomatis, the majority of patients in the UK with lymphogranuloma venereum will be positive for which other STI?
HIV (must test for that too)
name a bacteria that causes non-gonococcal urethritis other than chlamydia trachomatis
Mycoplasma genitalium
T/F: most cases of mycoplasma genitalium are asymptomatic
true
Presentation of mycoplasma genitalium?
URETHRITIS is key epididymitis cervicitis endometritis PID reactive arthritis preterm delivery tubal infertility
Ix in Mycoplasma genitalium?
NAAT (culture too slow) - first pass urine in men - vaginal swab in women
Rx of Mycoplasma genitalium? what about in pregnancy and breastfeeding?
doxycycline or azithromycin azithromycin in pregnancy and breastfeeding (doxy contraindicated)
what is pelvic inflammatory disease
inflammation and infection of the female pelvic organs (uterus, ovaries, tubes, parametrium, peritoneum) usually due to ascending infection from endocervix
causes of PID? (most common?)
chlamydia- most common gonorrhoea, MG also Gardnerella vaginalis, Haemophilus influenzae and E coli
signs and symptoms of PID?
lower abdo pain, fever, deep dyspareunia, dysuria and menstrual irregularity, discharge, cervical excitation
Ix in PID 1) testing for causative organisms and other STIs 2) the absence of ___ cells on microscopy is a useful test of exclusion (swab vagina/ endocervix) 3) what other test should be performed on sexually active women with lower abdo pain? 4) ___ markers are raised
1) NAAT for gonorrhoea, chlamydia, MG. HIV test, syphilis test. High vaginal swab for BV, candida, trichomonas 2) pus 2) pregnancy- ?ectopic 4) inflammatory- ESR, CRP
What is Fitz-Hugh-Curtis Syndrome?
complication of PID? inflammation of liver capsule > RUQ pain, can refer to shoulder tip
Rx of PID?
PO ofloxacin + PO metronidazole/ IM ceftriaxone + PO doxycycline + PO metronidazole
what is Trichomonas vaginalis where does it live
sexually transmitted protozoan parasite lives in vagina in women and urethra in men
Trichomonas can increase the risk of: 1) contracting ____ 2) bacterial ____ 3) ____ cancer 4) pelvic ___ ___ 5) ____-related complications
1) HIV 2) BV 3) cervical 4) PID 5) pregnancy (preterm)
presentation of Trichomonas?
women- offensive, yellow-green frothy d/c, vulvovaginits, strawberry cervic men- may get urethritis
Trichomonas vaginalis is associated with a vaginal pH LESS/ GREATER than 4.5
GREATER than (same as BV)
Ix in Trichomonas vaginalis?
charcoal swab > microscopy of a wet mount > motile trophozoites
Rx of Trichomonas vaginalis?
oral metronidazole
HSV-1 most often caues ___ lesions
HSV-2 most often caues ____ lesions
(although there’s considerable overlap)
oral (cold sores)
genital
features of genital herpes?
painful genital blisters
may be dysuria, pruritis
neuropathic pain
tender inguinal lymphadenopathy
primary infection typically more severe than recurrences (systemic features: HA, fever, malaise)
Ix of choice in genital herpes?
NAAT
management of genital herpes?
symptomatic
- topical lidocaine
- analgesia
- saline bathing
Oral aciclovir
Treatment of genital herpes in pregnancy + delivery method
- Primary genital herpes contracted before 28 weeks
- Primary genital herpes contracted after 28 weeks
- Recurrent genital herpes in pregnancy
- oral aciclovir + prophylactic doses commenced >36 weeks. Can VD if asymptomatic
- oral aciclovir + prophylactic doses commenced immediately. Must have electic c/s
- low risk of transmission even if symptomatic. Given prophylactic aciclovir from 36 weeks
Syphilis
- causative bacteria?
- average incubation period between the initial infection and symptoms?
- methods of transmission?
- Treponema pallidum (spirochete)
- 21d
- mainly sexual, also: vertical (mother to child), IVDU, blood transfusion
Stages of syphilis?
Primary: single painless chancre ulcer, non-tender local lymphadenopathy
Secondary: systemic symptoms: fever, maculopapular rash on trunks, palms and soles, snail trail buccal ulcers, condylomata lata
Latent: asymptomatic
Tertiary: gummas, aortic aneurysms, neurosyphilis, paralysis, Argyll-Robertson pupil
features of congenital syphilis?
ears, eyes, nose, mouth
- deafness
- keratitis
- saddle nose
- blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars, rhagades (linear scars at the angle of the mouth)
- saber shins
what is an argyll-Robertson pupil?
a constricted pupil that accommodates when focusing on a near object but does not react to light
a finding in neurosyphilis (Tertiary)
aka “prostitutes pupil” – “it accommodates but does not react“.
Ix in syphilis?
dark field microscopy (T. pallidum)
serology
- VDRL: becomes -ve post-treatment
- TPHA: remains +ve post-treatment
treatment of syphilis?
IM benzathine benzylpenicillin
(alt: doxycline)
what reaction is sometimes seen after treatment of syphilis?
Jarisch-Herxheimer reaction
- fever, rash, tachycardia after the first dose of antibiotic
- no wheeze or hypotension (c.f. anaphylaxis)
- Rx: antipyretics
Disseminated gonococcal infection triad
- tenosynovitis
- migratory polyarthritis
- dermatitis
