STIs Flashcards
List the ABCDEs of preventing the spread of STIs
Abstinence Barrier protection Contacts Drug therapy Education and counseling
List infections that can facilitate the transmission of HIV
Chlamydia trachomatis Neisseria gonorrhoeae Bacterial vaginosis Genital HSV-1 and HSV-2 Treponema pallidum Haemophilus ducreyi Klebsiella granulomatis Chlamydia trachomatis L1, L2, L3- lymphogranuloma venereum or LGV
Chancroid is caused by
Haemophilus ducreyi
Granuloma inguinale or Donovanosis is caused by
Klebsiella granulomatosis
List causes of non-gonococcal urethritis in men
Chlamydia trachomatis Mycoplasma genitalium Ureaplasma urealyticum Trichomonas vaginalis (uncommon) Enteric GNRs (uncommon, consider if hx of insertive anal intercourse) HSV Unknown- 30% of urethritis
Compare and contrast urethritis caused by Neisseria gonorrhoeae vs non-gonococcal urethritis
Gonococcus:
- incubation less than 4 days
- discharge will be profuse and yellow
- dysuria is severe
NGU:
- incubation 7-14 days
- slight grey or clear discharge
- moderate, intermittent dysuria
Describe the diagnostic work up for urethritis in men
- physical exam
- gram stain of urethral discharge (high sensitivity and specificity if symptomatic)
- urinalysis
- nucleic acid amplification test
Describe the gram stain seen in gonococcal urethritis
WBCs
Gram negative intraceullular diplococci
Describe what is seen on urinalysis in gonococcal urethritis
WBCs and positive for leukocyte esterase
Must be first a.m. voided urine
All patients empirically treated for gonococcus should also be treated for _______
chlamydia
How can non-gonococcal urethritis be treated?
Azithromycin 1x po
Doxycycline bid 7 days
Other than medication, what measures must be taken to treat urethritis?
- Abstain from sex for 7 days
- partner notification and testing (partners within last 60 days)
- test for STDs including HIV, syphilis
- test of cure not recommended
- follow up testing in 3-6 months
What is a complication of Chlamydia trachomatis in men?
epididymitis
reactive arthritis
List causes of mucopurulent cervicitis in women
gonococcal: Neisseria gonorrhoaea
non-gonococcal: Chlamydia trachomatus Mycoplasma genitalium Trichomonas vaginalis bacterial vaginosis HSV1 and HSV2 frequent douching
What are common presentations of mucopurulent cervicitis in women?
often asymptomatic
abnormal vaginal discharge
intermenstrual bleeding
bleeding after intercourse
What are the two main diagnostic features of mucopurulent cervicitis in women?
- Purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab
- sustained endocervical bleeding induced by gentle passage of a cotton swab through the cervical os
In general, in mucopurulent cervicitis, endocervical bleeding is (painful/ painless)
painless
pain suggests diagnosis of PID
All women who seek medical attention for cervicitis must also be evaluated for _____
PID
Cervicitis can be a sign of upper genital tract disease
In a women with cervicitis, what other conditions should be tested for?
PID
Chlamydia trachomatis and Neisseria gonorrhoeae with sensitive and specific testing- NAAT of cervical specimins
Trichomonas vaginalis by microscopy and culture
Bacterial vaginosis
Other STIs- HIV, syphilis
What is a complication of cervicitis in women?
PID
Pregnant women can pass Chlamydia trachomatis to their infant during delivery, causing _________ or _______
neonatal inclusion conjunctivitis/ opthalmia neonatorium
or
neonatal C. trachomatis pneumonia
__________ is the most common bacterial STI in the US
Chlamydia trachomatis
Who should be screened annually for chlamydia?
Sexually active women < 25 years old
Highest rates of infection in men and women 14-24 years old
Why are teens and younger women at increased risk of contracting chlamydia?
The cervix is not fully mature
What cells can be infected by chlamydia?
- squamocolumnar cells of the endocervix and upper genital tract
- epithelial cells in the urethra and rectum
- epididymal cells
- conjunctival cells and pulmonary columnar cells of neonates
Up to 70% of women have asymptomatic ______ infection
chlamydia
List complications of chlamydia infection in men
epididymitis
prostatitis
reactive arthritis
List complications of chlamydia infection in women
PID
tubal infertility
ectopic pregnancy
chronic pelvic pain
Contrast how proctitis occurs from chlamydia in MSM vs in women
MSM- direct inoculation
women- secondary spread from cervical secretions
True or false: infection with chlamydia can cause impaired fertility in men
false, only in women
List complications of chlamydia infection in pregnancy
- neonatal inclusion conjunctivitis/ opthalmia neonatorium (develops within 12 days of birth)
- neonatal trachomatis pneumonia (develops within 8 weeks)
How are neonatal inclusion conjunctivitis and C. trachomatis pneumonia due to chlamydia treated?
Systemic antibiotics
How can neonatal chlamydia infection be prevented?
Perinatal screening
List specimens that can be used to diagnose chlamydia infection by NAAT
men: urethral swab
women: endocervical swab, vaginal swab
both: urine, rectal swab
What groups should be routinely screened for chlamydia?
sexually active women < 25
women with high risk factors
all pregnant women
** high risk men presenting to STI clinics, correctional facilities, etc
How is chlamydia treated?
azithromycin 1 dose
doxycycline bid for 7 days
_________ is the second most common bacterial STI in the US
Neisseria gonorrhoeae
Describe symptoms of gonococcal urethritis in men
onset 4 days after exposure
most men are symptomatic- purulent discharge, dysuria
Describe symptoms of gonococcal cervicitis in women
very often asymptomatic, possible bleeding with intercourse
List complications of gonococcus in men
epididymitis
disseminated gonococcal infection
List complications of gonococcus in women
PID disseminated gonococcal infection tubal infertility ectopic pregnancy chronic pelvic pain
List the two syndromes that comprise disseminated gonococcal infection
- arthritis/ dermatitis syndrome- migratory, additive arthritis and cutaneous papules and pustules on the extremities
- gonococcal septic arthritis
List complications of gonococcal infection in pregnancy
opthalmia neonatorum, conjunctivitis within 2 days of delivery- can be prevented at birth with erythromycin ointment- contrast to chlamydia
other complications: scalp abscess, meningitis, bacterial sepsis
List samples that can be used for diagnosis of gonococcal infection
NAAT: urine, vaginal swab, endocervical swab, urethral swab
Culture: rectal swab, pharyngeal swab
What groups should be targeted for gonococcal screening?
high risk
How is gonococcus treated?
First Line
- Ceftriaxone IM 1 dose PLUS azithromycin 1 dose
- Ceftriaxone IM 1 dose PLUS doxycycline bid for 7 days
Alternatives:
- cefixime 1 dose plus azithromycin 1 dose
- cefixime 1 dose plus doxycycline bid for 7 days
- *increasing resistance against cefixime so must test for cure with those regimens within 1 week of therapy
List risk factors for PID
teens multiple sexual partners new sexual partner prior PID IUD insertion douching
Describe the pathogenesis of PID
Polymicrobial infection, direct extension of microorganisms from the vagina or endocervix to upper reproductive
structure leads to scar tissue formation
Scar tissue blocks normal movement of egg from falopian tube to uterus, leading to infertility or ectopic pregnancy
List symptoms of PID
lower abdominal pain fever vaginal discharge with foul odor painful intercourse dysuria intermenstrual bleeding Fitz-Hugh-Curtis syndrome of upper quadrant peri-hepatitis
How is PID diagnosed?
Clinical suspicion is key
- cervical motion tenderness, uterine tenderness, adnexal tenderness
AND
- presence of WBCs in vaginal secretions or mucopurulent cervicitis
Supportive findings: bacterial vaginosis, fever, elevated ESR or CRP
How is PID treated?
broad spectrum antibiotics including activity against Chlamydia trachomatis and Neisseria gonorrhoeae as well as strep, GNRs, anaerobes
testing for HIV, syphilis
What are sequelae of PID?
ectopic pregnancy
chronic pelvic pain
How can PID be prevented?
screening for chlamydia
_________ is the most common cause of vaginal discharge in the US
bacterial vaginosis
Describe the pathogenesis of bacterial vaginosis
Replacement of lactobacillus (produce H2O2) with anaerobic bacteria
Can be a risk factor for acquisition of other STIs and post-operative infections
List risk factors for bacterial vaginosis
Multiple male or female sexual partners New sex partner Lack of condom use Douching Lack of vaginal Lactobacillus sp.
**BV increases the risk for acquisition of HIV, C. trachomatis, N. gonorrhoeae, HSV 2
Describe clinical exam findings in bacterial vaginosis
white or grey discharge with fishy odor
wall contains grey homogenous discharge
no inflammation of vaginal wall or cervix and no tenderness (BV does not cause PID, cervicitis, or cervical/ uterine/ adnexal tenderness, if inflammation is present there are two diagnoses)
How is bacterial vaginosis diagnosed?
Must meet 3 of 4
- homogenous thin white discharge with fishy odor
- positive whiff test with 10% KOH
- vaginal pH > 4.5
- wet mount of vaginal fluid shows clue cells (epithelial cells coated with coccobacilli)
How is bacterial vaginosis treated?
Metronidazole or clindamycin
avoid intercourse
What are complications of bacterial vaginosis?
Increased risk of other STIs
Increased risk of post-op complications
Can cause PROM, early labor, preterm birth, postpartum endometritis
List 5 infectious causes of genital ulcers
Haemophilus ducreyi (chancroid) Klebsiella granulomatis (donovanosis) Chlamydia trachomatis L1, L2, L3 (LGV) Treponema palladum (syphilis) HSV
Describe the epidemiology of HSV
50 million people with genital infection, 1/5 adolescents and adults
more common in women
HSV-1 replicates in the _____ ganglia; HSV-2 replicates in the _____ ganglia
HSV1 in trigeminal
HSV2 in sacral
Describe the pathophysiology of genital HSV infection
HSV penetrates mucosal surfaces to replicate in the epidermis and dermis. The virus enters nerve cells, is transported within the neuron to bodies of ganglia
After initial infection, the virus
remains latent in the ganglia (episomal, not integrated into the host DNA).
During reactivation, the virus spreads to skin and mucosal surfaces by peripheral sensory nerves, which can result in asymptomatic shedding or formation of new blisters.
Describe primary HSV infection, non-primary first episodes, and recurrence
Primary: symptomatic or asymptomatic infection with no antibodies developed
Non-primary first episode: fever, headache, malaise, myalgia with local ulcers and adenopathy
Recurrence: subsequent episodes tend to be milder, resolve faster, and decline over 5+ years
How are HSV1 and HSV2 diagnosed?
PCR
Serologic assays
cell culture- cytopathic effect, lower sensitivity than PCR
Tzanck prep- giant cells with inclusions, not specific
How is genital herpes treated?
Acyclovir, Valacyclovir, Famciclovir.
All people get therapy for first episode
Then can chose episodic or suppressive therapy
What are complications of HSV in pregnancy?
Greatest risk if HSV is acquired during pregnancy
Neonatal transmission via infected vaginal secretions during birth
Prevention: acyclovir starting at 36 weeks, avoid intercourse with positive partners during 3rd trimester; delivery by Cesarean if lesions are present at delivery
Syphilis is caused by ______
treponema pallidum, a spirochete
Describe the pathogenesis of syphilis
T. pallidum penetrates mucous membranes then enters the bloodstream and lymphatics to widely disseminate throughout the body. Disseminated disease lasts until a sufficient immune response develops to control T. pallidum replication.
The incubation period is directly proportional to the size of the inoculum and clinical lesions appear when 10^7 organisms/ mg tissue
The pathologic lesion characteristic for all stages of syphilis is _____
obliterative endarteritis
Describe the stages of syphilis
- Primary syphilis: development of chancre at sit of inoculation with painless lymphadenopathy
- Secondary syphilis: constitutional symptoms plus rash (palms and soles), condyloma lata, mucous patches, alopecia, syphilitic rash
Latent syphilis: symptoms disappear. In early syphilis, there can be relapses of mucocutaneous symptoms but no relapses in late latent syphilis - Tertiary syphilis: involvement of neural and vascular tissue, gummatous local tissue damage
List complications of congenital syphilis
Greatest risk early in infection when there is spirochetemia
late abortion, still birth, neonatal death, neonatla disease
How is syphilis diagnosed?
Serology, PCR
Two different serologic methods must be used for diagnosis
- nontreponemal: VDRL, RPR, used to monitor response to therapy; will decline with therapeutic success
- treponemal: TPA-ABS, TPPA, TPHA, MHA-TP; used as confirmation of diagnosis and will remain positive for life
How is syphilis treated?
penicillin
- 1 IM dose if Primary, secondary, early latent
- 1x weekly doses for late latent, tertiary
- IV for neurosyphilis
The etiologic agent of granuloma inguinale (also known as Donovanosis) is _______, which is an encapsulated gram-negative rod that infects mononuclear cells
Klebsiella granulomatis
Describe the presentation of granuloma inguinale
The initial lesion is a small, painless papule or nodule that begins within 1-3 months after sexual exposure and develops into a beefy red, granulomatous ulcer with rolled edges and bleeds easily on contact
Lesions are NOT painful and there is no lyphadenopathy or bubo formation
How is granuloma inguinale diagnosed and treated?
Diagnosis based on clinical presentation, biopsy shows Donovan bodies in mononuclear cells
Tx= doxycyclin bid for ~3 weeks until lesions heal
________ are the etiologic agents of lymphogranuloma venerum
Chlamydia trachomatis serovars L1, L2, L3
Describe the stages of lymphogranuloma venereum
Primary stage: painless papule or pustule that develops into an ulcer that is often unnoticed
and resolves on its own (painless, self-limited ulcer).
Secondary stage: Painful inguinal of femoral lymphadenopathy (bubo) that is usually
unilateral, can be above and below the inguinal ligament (groove sign)
Tertiary stage: chronic inflammation of untreated infection leads to fibrosis of tissues and obstruction of lymphatics (elephantiasis) and widespread destruction of external genitalia
How is lymphogranuloma venereum diagnosed and treated?
Diagnosis: presentation and serology, aspiration of bubo
Tx= doxycyclin bid for 21 days
Which serotypes of HPV are high risk for cancer? Which cause genital warts?
16 and 18 are oncogneic
6 and 11 cause cancer
Describe the pathogenesis of genital warts
HPV DNA does NOT integrate into the host genome and replicates as extrachromosomal DNA in the nucleus of infected keratinocytes. HPV
infection begins with entry into the basal keratinocytes of the stratum basale. As the basal
cells divide, differentiate and progress to the surface, HPV replicates and induces
excessive proliferation of non-basal epithelial layers (e.g. stratum spinosum, stratum
granulosum, stratum corneum) to result in warts.
Describe the pathogenesis of HPV malignancy
HPV DNA is generally integrated into the host genome and induces basal cells to undergo excessive replication, which results in accumulation of deleterious mutations that result in dysplasia and progression to
malignancy
What is a complication of infection with HPV during childbirth?
Recurrent respiratory papillomatosis (RRP): occurs following inhalation of HPV-infected secretions during childbirth
result in altered cry, hoarseness, stridor and respiratory distress.
Most common HPV
genotypes to cause RRP= 6 and 11.
List treatments for genital warts
Patient applied: imiquimod, podofilox, sinectachin
Provider administrated: liquid nitrogen, podophyllin, trichloroacetic acid, bichloroacetic acid, surgical
Prevention: 2 vaccine options (quadrivalent and bivalent)
What is appropriate treatment for pediculosis pubis?
Pubic lice
permethrin cream + decontamination of bedding and clothing
evaluate for other STIs
_______ is usually sexually transmitted in adults but not in children
Sarcoptes scabiei- scabies
What is appropriate treatment of scabies?
Permethrin cream + decontamination of bedding and clothing
List the 5 P’s of taking a sexual history
Partners Practices Protection from STDs Past history of STDs Prevention of pregnancy
In chlamydia infection, the _____ body is the infectious particle that infects the cell. The ______ body replicates within the cell. The ____ body assembles and exits the cell
Elementary body- enters and exits
Reticulate body- replicates within the cell
