STIs Flashcards
When do MSM need STI screening every 3 months rather than annually?
New partner or multiple sexual contacts
Group sex
Use of HIV pre-exposure prophylaxis (PrEP)
Use of recreational drugs during sex (chemsex).
Do condoms eliminate risk of getting herpes?
No they just reduce transmission
Does herpes affect fertility?
No
Can the herpes virus be passed on when asymptomatic?
Yes, the virus is usually passed on when there are no sx
Is genital herpes associated with increased risk of cancer?
No
What are the symptoms of Chlamydia?
Urethra – 50% asx; dysuria, penile urethral discharge
Endocervix – 75% asx; vaginal discharge, intermenstrual bleeding, post coital bleeding;
Conjunctivitis
What are the complications of Chlamydia?
Epididymitis or epididymo-orchitis
PID
Subfertility
Chronic pelvic pain
Ectopic pregnancy
Reactive arthritis
What are the indications for testing for Chlamydia?
- If signs and sx; sexual contacts of those with Chlamydia or other STIs
- Pregnancy
- Before TOP
- Before IUD insertion if at risk of STIs
- Suspected epididymo-orchitis
- Suspected PID
- Sexually active under 30
- MSM
- Hx sexual assault or intimate partner violence
- If sexual health check requested
- If asx and requesting testing wait at least 2 weeks
What is the treatment for Chlamydia?
Doxycycline 100mg PO BD for 7/7
Pregnancy/lactation Azithromycin 1g once
Review in 1/52
Do you need to test for cure for Chlamydia?
No test of cure unless pregnant or rectal sx (use NAAT)
Retesting a 3/12 is recommended to look for reinfection
Is Chalmydia a notifiable disease?
No
What are the symptoms of Gonorrhoea?
Urethral discharge (10% asx)
Dysuria
Endocervix – 80% asx
Vaginal discharge
Dyspareunia
Post coital bleeding
Intermenstrual bleeding
Anorectum – usually asx
Rectal discharge, irritation, painful defecation and disturbed bowel function
Conjunctivitis – may be sight threatening
What are the indications for testing for Gonorrhoea?
Sxc
Sexual contact of those with gonorrhoea or other STI’s
Before IUD insertion
Suspected epididymo-orchitis
Suspected PID
Sexually active and under 30 yrs
MSM
Hx sexual assault or intimate partner violence
Pt requesting a sexual health check but if asx wait 2/52
What are the complications of Gonorrhoea?
- PID
- Subfertility
- Ectopic pregnancy
- Chronic pelvic pain
- Adverse pregnancy outcomes including chorioamionitis, premature rupture of memebranes, neonatal conjunctivitis
- Rarely disseminated disease causing arthritis, skin lesions, endocarditis and meningitis
- Epididymitis or epididymo-orchitis
- Proctitis very rarely
How do you treat Gonorrhoea?
Ceftriaxone 500mg IM + Azithromycin 1g PO stat
Same in pregnancy but also require a test of cure 4/52 later and re-screen in the 3rd trimester
If co-infection with Chlamydia swap stat Azithromycin for Doxycyline 100mg PO BD for 7/7
Review in 1 week after treatment
Is Gonorrhoea a notifiable disease?
Yes
When do you need to test for cure if a patient has Gonorrhoea?
Pregnant or with rectal sx (NAAT)
- Retesting a 3/12 is recommended to look for reinfection
How do you test for hepatitis A?
Total HAV antibody. Differential testing for IgG and IgM only if suspected of having acute Hep A (jaundice and deranged LFTs)
Interpretation of Hep A results: HAV <20 means?
Susceptible – offer vaccination if high risk and patient willing to pay for vaccination
Interpretation of Hep A results: Total HAV >20 with no suspicion of acute hep A means?
Previous infection or vaccination
- Reassure; no further action required
Interpretation of Hep A results: Total HAV >20 and sxc or positive HAV IgM means?
Possible acute Hep A infection; request LFTs; supportive care and monitoring; avoid food handling and sexual contact until non infectious (from 2 weeks prior to infection until 1 week after jaundice begins)
Who do you notify if a patient tests positive for Hepatitis A?
Public health
Why is serological testing for Hepatitis B not recommended?
Results will be >10 for 1-2 months post vaccination then become undetectable by 7 years post vaccination despite immune memory remaining (no further vaccination required)
Who should you offer serological testing and vaccination for Hep B to?
Unless known to be immune, offer to:
MSM
Sex workers
People infected with HIV
IDU
Maori, Pacific, Asian born in NZ before 1988
Immigrants of any age from Pacific islands, Asian, Middle eastern, or African countries
People who have been incarcerated
Contacts of people with HBV
Following non consensual sex
What do you test for for Hepatitis B?
Test is HBsAg and HBsAb
How do you interpret Hepatitis B test results?
HBaAg positive = active infection; refer to hepatitis foundation NZ
HBaAb > 10 = immunity
Who should you test for Hepatitis C?
IDU and their sexual partners, people who have shared needles and sharp objects like razors with known Hep C positive person; people with HIV infection (if MSM and HIV + test annually), recipients of blood transfusion prior to 1992; people with tattoos and body piercings in high risk shops/parlours
What is the test for Hep C and how do you interpret the results?
HCV ab;
If positive it indicates past or current infection; request HCV RNA to determine if current infection
What are the symptoms of genital herpes?
Anogenital ulceration and systemic sx of viraemia
Recurrent ulcers or blisters on the anogenitals, lower back, buttocks, thighs, and pubis
Recurrent genital fissures
Erythema with itching and tingling
Cervicitis often with visible ulcers, blisters or erosions;
In primary episodes vaginal discharge
Proctitis, tenesmus
How do you diagnose genital herpes?
HSV swab NAAT from the base of the deroofed ulcer
What is the treatment for genital herpes?
- Valacyclovir 500mg PO BD for 7 days or longer if new lesions appear or healing is incomplete
- Regular analgesia
- Topical lidocaine
- Urinate in shower/bath
- Avoid intimate contact until sx resolved
- If neuropathic bladder – urgently cathetarise and refer
Is genital herpes a notifiable disease
Yes
When can neurosyphilis occur in the disease process?
Neurosyphilis can occur at any stage
What are the signs/sx of primary syphilis?
Painless chancre with well defined margin and indurated base; inguinal LNs usually enlarged, rubbery and non tender; spontaneously heals
What is the incubation period for primary syphilis?
10-90 days, average 3 weeks
What are the symptoms of secondary syphilis?
May have fever, malaise, headache and lymphadenopathy; 90% have skin involvement (generalised rash involving the trunk +/- palms and soles
May have alopecia and condylomata lata (warty lesions on anogenital region)
May get CN palsies, ophthalmic signs, sensorineural deafness and meningitis
When is syphilis infectious?
Primary and secondary early latent
What is the incubation period for secondary syphilis?
Incubation 2-24 weeks; average 6 weeks
When does syphilis become late latent?
> 2 yrs since first symptoms – asx; no longer infectious to sexual partners but can have transplacental transmission
What are the complications of syphilis?
Gummas, cardiovascular or neurological disease
What are the indications for Syphilis testing?
Genital or anal ulcers
Persisting oral lesion in people at risk of STIs
Sexually active people with any genital sx or generalised rash
Any rash affecting the soles or palms of the hands, that is persistent or unexplained
Pyrexia of unknown origin
Unexplained persistent lymphadenopathy Unexplained liver disturbance
Alopecia
Neurological signs or sx including aseptic meningitis, CN palsies, sudden onset unilateral sensorineural deafness, and dementia
Uveitis or optic neuritis
Sexual contacts of people with syphilis
MSM
Antenatal screening
Routine immigration testing
Routine sexual health check
How do you treat infectious syphilis?
With input from a sexual health specialist:
Benzathine Benzylpenicillin tetrahydrate (long acting) 2.4million units IM each buttock as a single dose
How do you treat late syphilis or unknown duration?
Benzathine Benzylpenicillin tetrahydrate (long acting) 2.4million units IM once weekly for 3 weeks
Is syphilis infection notifiable?
Yes
When do you test for cure with infectious syphilis?
3, 6, and 12 months – cure is consistent 4 fold drop in RPR titre; treatment failure if no 4 fold drop within 6 months
When do you test for cure with late latent or tertiary syphilis?
Repeat serology in 6 and 12 months; 4 fold increase in titres suggests reinfection or treatment failure; don’t expect reduction in titres
What are the symptoms and signs of Pubic Lice – Pthirus Pubis?
Pubic or genital itch; may have debris in underwear
Complications uncommon: fever, lethargy, irritability (more common if young or frail), secondary bacterial infection
How do you diagnose pubic lice?
Direct visualisation
How do you treat pubic lice?
Permethin 5% cream or lotion to all hairy parts of the body except eyelids and scalp and wash off 10 mins later. Repeat in 7-10 days if live lice are still found
What are the signs/sx of Scabies – Sarcoptes Scabei var hominis?
Pubic/gential itch especially at night; may see them
Genital papulonodules +/- generalised rash
Complications rare – fever in children; pain with movement; sleep disturbance; secondary bacterial infection
- Scabies survive <48-72 hrs off the host
How do you diagnose scabies?
Dx often clinical; dermatoscopy may be useful to ID burrows (nodule with silvery skin burrow) and mites
How do you treat scabies?
Permethrin 5% cream or lotion top from scalp to soles of the feet with particular attention to the hands and genitalia; avoid eyes; apply under nails; leave on the skin for min 8 hrs then wash
Wash bedding and clothing in hot water
- Repeat treatment and environmental decontamination in 1 week; check +/- treat family members in same household
Who is responsible for contact tracing?
Diagnosing clinician is responsible for initiating a discussion around contact tracing – encouraging and supporting the patient about contact tracing. When complex you may need support from the local sexual health clinic
Why contact trace?
Gives contacts an opportunity to be tested and treated if positive;
Most people with an STI don’t have symptoms but can still pass it on and have complications of the STI; and the more times a person is re-infected the greater the risk of complications.
What do you need to know for contact tracing?
sexual contacts in past 3 months, are these regular or casual contacts; can they contact these people (not expected if insufficient info or threat of violence). Ensure number of contacts is clearly documented. Note if contact details are available.
Need to trace even if they used condoms.
What are the methods of contact tracing?
Patient
Provider with patient consent (if risk of violence do not notify contact) (this is preferred if the contact is incarcerated or for repeated infections with doubt around contact being treated).
How are people contacted with contact tracing?
face to face, text or social media, email, ending HIV tell me tool
Can you do partner delivered therapy in NZ?
No, it is illegal in NZ
Which conditions need contact tracing?
positive cases in the last 3 months of chlamydia, gonorrhoea, trichomonas, syphilis, urethritis, HIV, Hepatitis, PID and epididymo-orchitis
Which conditions is it important not to have sex in the week after being treated and until a week after their sexual contact(s) have been treated?
Chlamydia, trichomonas and gonorrhoea
Which STIs are notifiable diseases and how is this done for each?
- Syphilis – fill out ESR form and post to them. Always consult with sexual health services
- Gonorrhea – fill out ESR web based form – consult sexual health if necessary
- HIV – lab notifies RPH then a questionnaire is sent to requestor within 2 weeks – refer to ID or sexual health services notification form and fax it to RPH on 04 570 9373. A web-based HIV questionnaire link will be sent to the treating health practitioner within 2 weeks of the notification. Refer to ID or SHS.
- AIDS - The treating health practitioner must complete the initial AIDS
- Hepatitis
What are the symptoms of PID?
fever, lower abdominal pain, deep dyspareunia, abnormal uterine bleeding and discharge. Can be asx.
What percentage of patients are asx with PID?
60%
What are common causes of PID?
Chlamydia trachomatis, Neisseria gonorrhoeae, mycoplasmas and mixed anaerobes. Can also occur with IUD insertion, upper gential tract instrumentation, TOP, and postpartum
How do you diagnose PID?
Clinical dx, no single test is diagnostic and STI screens may be negative.
What tests are often done in PID?
Hepatitis B and C serology, urine dip, UPT, vulvovaginal NAAT for chlamydia and gonorrhoea + speculum; endocervical swab gonorrhoea, HVS for trichomonas, BV and candida
What are the criteria for treatment of PID?
Lower abdominal pain + cervical motion tenderness OR adnexal tenderness OR uterine tenderness
Other supportive features are abnormal cervical/vaginal discharge, fever, increased WCC, or increased CRP, or confirmed STI/BV
What is the treatment for PID?
Ceftriaxone 500mg PO stat + doxycycline 100mg PO BD for 14 days and metronidazole 400mg PO BD for 14 days. If likely poor compliance use Azithmycin 1g stat instead of metronidazole and doxycycline
If severe, pregnant, or tubo-ovarian abscess needs O & G review
No sex until abdominal pain is settled and use condoms for 14 days from start of treatment until 1 week after all sexual contacts have been treated.
What defines mild PID?
normal vitals and <5/10 pain score;
What defines moderate PID?
moderate normal vitals and pain >5/10
What defines severe PID?
Pt is septic
Should the IUD be removed in a patient with PID?
IUD should be left in situ initially – if no clinical improvement in 48-72 hrs consider removing. If removing ideally do so once 24 hours of antibiotics is complete and give ECP if sexual intercourse in past 1 week.
What are the complications of PID?
Peri-hepatitis – Fitz-hugh Curtis syndrome
Tubal infertility
Tubo-ovarian abscess
Ectopic pregnancy
Chronic pelvic pain
HIV/AIDs
In NZ should women with HIV breastfeed?
Ideally not, there are suitable nutritional alternatives
Should a women with HIV with an undetectable viral load on ART be referred to Oranga Tamariki if they choose to breastfeed?
NO
What sort of lubricants should patients with HIV use?
Use water based lubricants such as KY Jelly, Sylk and Glide.
What is U=U?
undetectable = untransmittable: people living with HIV who are on antiretroviral treatment and maintain an undetectable viral load for at least 6 months do not sexually transmit HIV
Do patients with HIV have to tell their sexual partners?
No.
New Zealand law requires people living with HIV to take “reasonable precautions” to avoid transmission if they do not disclose their HIV status. “Reasonable precautions” has been interpreted by the courts to mean using condoms for sexual intercourse.
What are the symptoms of acute HIV?
In 50% of patients: fever, rash, lymphadenopathy, pharyngitis, myalgia, arthralgia, headache about 3-6 weeks after exposure
What are the symptoms of immune deficiency in HIV?
Oral thrush, diarrhoea, weight loss, skin infections, herpes zoster
What are well known complications of HIV
Infections such as Pneumocystis jiroveci pneumonia, oesophageal candidiasis, cerebral toxoplasmosis and cancers such as kaposi sarcoma, death
When should you test for HIV after a concerning sexual event?
6 weeks after the last unprotected sexual intercourse
What tests should be done for suspected HIV?
HIV serology or POC HIV testing of blood or saliva (3 months following infection)
