STIs Flashcards
What is the most common STI in the UK?
Chlamydia
For Neisseria gonorrhoea state:
- Gram stain
- Shape
- What mucous membranes it infections
- How it spreads
- Gram -ve
- Diplococcus
- Mucous membranes with columnar epithelium e.g. endocervix, urethra, rectum, conjunctiva & pharynx
- Spread via mucous secretions from infected area
There is a high level of abx resistance to gonorrhoea; true or false?
True
Is gonorrhoea often symptomatic; discuss for both mena & women
- Men: 90% symptomatic
- Women: 50% symptomatic
*Gonorrhoea more likely to be symptomatic than chlamydia
Describe presentation of Neisseria gonorrhoea; include both male & female symptoms
Female
- Odourless discharge
- Discharge may be green or yellow
- Dysuria
- Pelvic pain
Male
- Odourless discharge
- Discharge may be green or yellow
- Dysuria
- Testicular pain and/or swelling (epididymo-orchitis)
May have:
- Rectal infection causing discomfort & discharge (often asymptomatic)
- Pharyngeal infection causing sore throat (often asymptomatic)
- Conjunctivititis
All pts with suspected gonorrhoea should be referred to GUM clinic for diagnosis and treatment. Discuss how gonorrhoea is diagnosed
*If pt won’t go to GUM clinic or unable to access can do in GP
-
Nucleic acid amplification test (NATT) to detect DNA or RNA of gonorrhoea
- Women: vulvovaginal swab
- Men: first-catch urine sample
- Endocervical charcoal swab or charcoal swab of discharge for microscopy, culture & sensitivity
- Rectal swab (in MSM, anal sex)
- Pharyngeal swab (oral sex)
Why do we do charcoal swabs aswell as NAATs?
NAATS only test if infection is present or not by looking for gonococcal RNA or DNA; do not tell us about sensitivities and resistance. This info is required to guide treatment
Discuss the conservative management of gonorrhoea
- Test contacts
- Test for (and treat) any other infections
- Abstain from sex for 7 days following treatment of all partners to reduce risk reinfection
- Advice about reducing infection risk in future
- Consider safeguarding issues & sexual abuse in children & young people
Discuss the pharmacological management of gonorrhoea
- Sensitivities unknown= single dose of IM ceftriaxone 1g
- Sensitivies known= oral ciprofloxacin 500mg
AND TEST CONTACTS!
*NOTE: regimes may vary dependent on local guidelines and complications
All pts treated for gonorrhoea should have a follow up “test of cure” due to high abx resistance. Tests can be cultures, NAAT for DNA and NAAT for RNA. When can you do each?
If asymptomatic do NAAT, if symptomatic do cultures. BASHH recommends test of cure at least:
- 72hrs post treatment if using a culture as test of cure
- RNA NAAT 7 days post treatment
- DNA NAAT 14 days post treatment
State some potential complications of gonorrhoea
- PID
- Infertility
- Prostatitis
- Conjunctivitis
- Urethral strictures
- Fitz-Hugh Curtis syndrome
- Septic arthritis
- Gonococcal conjunctivities in neonate (ophthalmia neonatorum)
What is a disseminated gonococcal infection?
GDI= complication untreated gonoccoal infection where bacteria spreads to skin & joints causing:
- Skin lesions
- Polyarthralgia
- Migratory polyarthritis
- Tenosynovitis
- Systemic symptoms e.g. fever, fatigue
For Chlamydia trachomatis, state:
- Gram stain
- Shape
- Intra- or extra-cellular
- Gram -ve
- Rod
- Intra-cellular
Is chlamydia often symptomatic; discuss for men & women
- Men: 50% symptomatic
- Women: 25% symptomatic
Majority of women with chlamydia are asymptomatic; if they do get symptoms, state some symptoms they can experience
- Vaginal discharge
- Pelvic pain
- Abnormal vaginal bleeding
- Dyspareunia
- Dysuria
50% of men with chlamydia are symptomatic; state some symptoms they may present with
- Urethral discharge
- Urethral discomfort
- Dysuria
- Epididymo-orchitis
What may you find on examination of woman with chlamydia?
- Pelvic or abdominal tenderness
- Cervical motion tenderness
- Cervicitis
- Purulent discharge
All pts with suspected chlamydia should be referred to GUM clinic for diagnosis and treatment. Discuss how chlamydia is diagnosed
NAAT testing for chlamydia RNA or DNA. This could be done via:
- Vulvovaginal swab (women)
- Endocervical swab (women)
- First catch urine sample (men or women)
- Urethral swab (men)
- Rectal swab (if had anal sex)
- Pharyngeal swab (after oral sex)
Discuss the conservative management of chlamydia
- Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
- Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
- Test for and treat any other sexually transmitted infections
- Provide advice about ways to prevent future infection
- Consider safeguarding issues and sexual abuse in children and young people
Discuss the pharmacological management of chlamydia
- Doxycycline 100mg BD for 7 days
- **NOTE:* The guidelines previously recommended a single dose of azithromycin 1g orally as an alternative. This recommendation has been removed due to Mycoplasma genitalium resistance to azithromycin, and azithromycin being less effective for rectal chlamydia infection.
Doxycycline is contraindicated in pregnancy; state some alternatives
- Azithromycin 1g stat, then 500mg for 2 days
- … and others e.g. erythromycin, amoxicillin
Is a test of cure reccommended in chlamydia?
No not routinely; only in cases of rectal chlamydia, pregnancy and if symptoms persist
State some potential complications of chlamydia
- PID
- Infertility
- Ectopic pregnancy
- Reactive arthritis
- Lymphogranuloma venereum
State some potential pregnancy-related complications of chlamydia
- Preterm delivery
- Premature rupture of membranes
- Low birth weight
- Postpartum endometritis
- Neonatal infection (conjunctivitis and pneumonia)
Bacterial vaginosis is an overgrowth of anaerobic bacteria of vagina; remind yourself of the most common bacteria that can cause it
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
Discuss the pathophysiology of bacterial vaginosis
- Loss of lactobacilli
- They usually produce lactic acid to keep pH <4.5
- Acidic environment helps prevent other bacteria from overgrowing
- Hence loss of lactobacilli increases pH allowing other bacteria to grow
State some risk factors for bacterial vaginosis
- Excessive vagina cleaning (douching, use of cleaning products)
- Recent abx
- Smoking
- IUD
50% of women with BV are asymptomatic; if they do get symptoms describe the presentation of bacterial vaginosis
- Fishy smelling watery grey or white vaginal discharge
- *NOTE: itching, irritation and pain not usually associated so suggest alternative cause or co-occurring infection*
Discuss how BV is diagnosed
- Vaginal pH
- Vaginal swab for microscopy
- High vaginal during speculum exam
- or low vaginal taken by pt
What would you see on microscopy if woman has BV?
Clue cells (epithelial cells that have bacteria stuck inside them)
Discuss the management of clue cells
Conservative
- Avoid douching
- Clean with gentle soaps e.g. femfresh, baby wash
Pharmacological
- Metronidazole (PO or vaginan gel)
- Clindamycin is alternative
What must you advise pts when prescribing metronidazole?
Avoid alcohol for duration of treatment as it can cause disulfiram-like reaction with N&V, flushing and sometimes severe symptoms of shock & angioedema
State some potential complications of BV
- Increased risk of catching STIs
- Pregnancy complications:
- Miscarriage
- Preterm delivery
- Low birth weight
What is vaginal candidiasis?
Vaginal inection with yeast of candida family most commonly Candida albicans
Candida can colonise in vagina without causing symptoms then progresses to infection when right environment occurs e.g.g pregnancy, abx
State some risk factors for candidiasis
- Increased oestrogen
- Poorly controlled diabetes
- Immunosupression
- Broad spec abx
Describe presentation of vaginal candidiasis
- Thick white discharge
- Not smelly
- Vulval or vaginal itching, irritation, discomfort
Vaginal candidiasis is mainly clinical diagnosis, however, what investigations may be done?
- Test vaginal pH
- BV & trichomonas= >4.5
- Vaginal candidiasis= <4.5
- Charcoal swab with microscopy
Discuss the managment of vaginal candidiasis
Correct modifiable conditions (such as uncontrolled diabetes mellitus), where possible.
Antifungal medications:
- Cream e.g. clotrimazole inserted into vagina using applicator (single dose)
- Pessary e.g. clotrimazole (single 500mg or three 200mg doses at night)
- Tablet e.g. fluconazole (single dose)
Canesten Duo is an OTC treatment which contains fluconazole tablet and clotrimazole cream.
NOTE: immuncompromised or diabetic pts mayr equire longer treatment e.g. 10 days
What must you warn pts when giving them antifungal creams and pessaries?
Can damage latex condoms & prevent spermicides working so use alternative contraception for 5 days after use
For trichomoniasis, state:
- What is is
- Presentation
- Appearance of cervix
- Infection with trichomonas vaginalis; a protzoan with flagella
- Presentation (up to 50% asymptomatic):
- Vaginal dishcarge- frothy yellow green, +/- fishy smell
- Ithcing
- Dysuria
- Dyspareunia
- Balanitis
- Strawberry cervix
How is trichomoniasis diagnosed?
Charcoal swab with microscopy
- Women: posterior fornix of vagina or low vaginal swab
- Men: urethral swab or first catch urine
Pts with trichomoniasis should be referred to GUM; what medication will they be given?
Metronidazole
