STIs Flashcards by Jane Keery

NORMAL VAGINAL FLORA

What organism predominates in the healthy vagina?

This produces which chemicals to suppress the growth of other organisms?

What are some other organisms which can be found in small quantities?

What is the normal pH of the vagina?

Lactobacillus spp.

Lactic acid +/- hydrogen peroxide

Strep Viridians, Group B strep (beta haemolytic), Candida spp.

4-4.5

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CANDIDA INFECTION

30% of vaginas are symptomatically colonised with candida - what is the most common type?

What is significant about candida which is not this type?

Candida albicans

Less responsive to treatment than normal, and more common in the immunosuppressed

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CANDIDA INFECTION

What are some factors predisposing to candida infection?

Recent antibiotic therapy

High oestrogen levels

Poorly controlled diabetes

Immunocompromised

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CANDIDA INFECTION

What are the main symptoms in females?

How can it present in males?

Is this sexually transmitted?

Itch and white vaginal discharge

Candida balanitis on the penis

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CANDIDA INFECTION

How is this tested for?

What are the treatment options?

Clinical diagnosis usually, can use high vaginal swab for culture

Topical clotrimazole pessary or cream (available OTC)

Oral fluconazole

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BACTERIAL VAGINOSIS

What is the pathology behind this condition?

It is sexually transmitted?

A lack of balance replaces normal vaginal flora with Gardnerella Vaginalis and other species of anaerobic bacteria

No, but it is much more common in people who are sexually active

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BACTERIAL VAGINOSIS

How does this present?

Produces a discharge which is white, homogenous and may produce bubbles. It also has a very bad smell.

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BACTERIAL VAGINOSIS

Women with this condition are more at risk of what other conditions?

Upper infection e.g. endometritis or salpingitis

PROM and preterm delivery (if pregnant)

HIV

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BACTERIAL VAGINOSIS

Describe the ‘whiff test’ for diagnosis?

A wet mount will reveal what?

Large numbers of leukocytes in the wet mount suggests what?

What happens to the vaginal pH?

Adding 10% potassium hydroxide to the discharge elicits a fishy odour

Absence of bacilli and their replacement with clumps of coccobacilli (clue cells)

Coinciding infection

Elevated

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BACTERIAL VAGINOSIS

How is this treated?

What is its relapse rate?

Metronidazole for 7 days

30%

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CHLAMYDIA

This is more common in which gender?

What is the presentation in 70-80% of women and 50% of men?

What is the highest age of incidence?

What types of sex can cause this?

Females

Asymptomatic

20-24

Vaginal, oral, anal

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CHLAMYDIA

This can affect where in the body?

What type of bacteria is it and what does this mean?

What gram stain is it?

Urethra, rectum, endocervix, eyes and throat

Intracellular bacteria - does not replicate outside a host

Does not stain with gram stain

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CHLAMYDIA

There are three serological groupings. What does each of the following cause:

Serovars A-C?

Serovars D-K?

Serovars L1-L3?

Eye infection

Genital infection

Lymphogranuloma venereum

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LYMPHOGRANULOMA VENEREUM

Who is this more common in?

What can it present with?

There is a high risk of what?

Tropical countries and MSM

Rectal pain, bleeding and discharge

Concurrent STIs

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CHLAMYDIA

In females, what are some risks of developing a chlamydia infection?

What is a complication which is more common in males?

PID

Tubal factor infertility

Chronic pelvic pain

Increased risk of ectopic pregnancy

Reactive arthritis (Reiter’s syndrome)

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CHLAMYDIA

What are the main symptoms in women?

What are the main symptoms in men?

Abnormal bleeding, lower abdominal pain, dyspareunia, discharge

Discharge, dysuria

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CHLAMYDIA

When can testing take place?

What is the screening test used?

What should be used to obtain a sample in females?

What should be used to obtain a sample in males?

What should you add in MSM who have had receptive anal sex?

14 days after exposure

NAATs

Vulvovaginal swab

First pass urine

Rectal swab

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CHLAMYDIA

What is the usual treatment?

What is the treatment for lymphogranuloma venereum?

What is the management if people cannot take the first line antibiotic?

Doxycycline 100mg bd for 7 days

Doxycycline 100mg bd for 3 weeks

Azthromycin 1g stat followed by 500mg od for 2 days

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GONORRHOEA

What is the incubation period of gonorrhoea in men?

Which sex is it more commonly seen in?

What is the risk of passing on this infection from an infected female to male partner?

What is the risk of passing on this infection from an infected male to female partner?

2-5 days

Males

20%

50-90%

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GONORRHOEA

What type of organism is this?

Where does it infect?

This is a fastidious organism - what does this mean?

It produces a tap of what?

Gram - intracellular diplococcus

The mucus membranes of the urethra, endocervix, rectum, throat and eyes

Does not survive in less than ideal growth conditions

Pus

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GONORRHOEA

In males, how often is this asymptomatic?

Infections where are more likely to be asymptomatic?

What symptom is seen in > 80% of cases in males?

What is another potential feature in males?

< 10%

Throat and rectum

Purulent urethral discharge

Dysuria

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GONORRHOEA

In females, how often is this asymptomatic?

What are some features in females?

Around 50% of cases

Increased/altered vaginal discharge, dysuria, pelvic pain

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GONORRHOEA

What is the screening test for this infection?

What investigation is done if the person is symptomatic?

If the above test is positive, what is done next?

NAATs

Endocervical/urethral swabs for microscopy

Culture on selective agar plates

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GONORRHOEA

Pharyngeal gonococcal infection results from what?

What type of oral sex more commonly passes this on?

Pharyngeal infection is mostly asymptomatic, but what are some symptoms it could cause?

Isolated pharyngeal infection is common in who?

Orogenital exposure

Oral sex on the penis

Exudative pharyngitis and cervical lymphadenopathy

MSM

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**_GONORRHOEA_** Who gets screened for rectal gonorrhoea? How is this done?

MSM NAATs

**_GONORRHOEA_** What is the current treatment? Where does this have to be given? What is the second line treatment and when should it be used? A test of cure is required when?

Ceftriaxone IM 500mg In secondary care Cefiximine 400mg oral - used when IM is contraindicated or patient refuses 2 weeks after treatment

**_MYCOPLASMA GENITALIUM_** This is an emerging sexually transmitted pathogen which is associated with what? How is it tested for? It carries high levels of resistance to what antibiotic?

Non-gonococcal urethritis and PID NAATs Azithromycin

**_ACUTE BACTERIAL PROSTATITIS_** This presents with symptoms of a UTI, but what other symptoms may also be present? This arises as a result of what? What organism is it most commonly caused by? What should you check for in patients aged \< 35?

Lower abdominal or back pain, tender prostate on examination A complication of a UTI E. Coli Chlamydia and gonorrhoea

**_ACUTE BACTERIAL PROSTATITIS_** How is this tested for? If the patient is aged \< 35, what other sample should you do? How should it be treated?

MSSU for culture and sensitivity First pass urine for chlamydia and gonorrhoea Ciprofloxacin for 28 days

**_SYPHILIS_** What organism causes this? What specific type of organism is this? What gram stain is it?

Treponema pallidum Spirochaete bacteria Does not stain with gram stain

**_SYPHILIS_** Treponema pallidum cannot be grown on artificial culture so diagnosis requires what? The organism can be seen on what?

PCR or serological tests to detect antibodies Dark ground microscopy

**_SYPHILIS_** What is the lesion of primary syphilis known as? What is its incubation period? Where does this arise? What might be associated with it? Is this painful? What happens if this heals without treatment?

Chancre 9-90 days (mean 21) At the site of inoculation / local non-tender lymphadenopathy No It does not mean that the syphilis is treated

**_SYPHILIS_** What happens at the point of secondary syphilis? What clinical picture can this cause? What is the incubation time? What is the most highly infectious lesion in syphilis known as?

Large numbers of bacteria circulate in the bloodstream Multiple manifestations at different sites 6 weeks - 6 months Condylomata Lata

**_SYPHILIS_** What are some examples of clinical presentations of secondary syphilis?

'Snail trail' ulcers in the mouth Generalised rash on the palms and soles Flu like symptoms Patchy alopecia

**_SYPHILIS_** What is occurring during the latent phase of the disease? What can happen in terms of treatment at this point?

No symptoms, but there is low-level multiplication of bacteria in small blood vessels Some patients will self-cure or will be treated incidentally

**_SYPHILIS_** What are some complications which may occur in late stage syphilis? When does this usually occur?

Cardiovascular or neurological complications Years after the initial infection

**_SYPHILIS_** The Treponema organism can cause multiple different condiions which cannot be determined by a blood test. How can the presence of Treponema Pallidum be demonstrated?

Dark field microscopy or PCR from lesions or infected lymph nodes

**_SYPHILIS_** What is the serology screening test used to detect this? Is this Treponemal specific? If the above test is positive, what are some confirmatory tests which can be done? Are these Treponemal specific? What is a good serology test to measure response to treatment?

ELISA - specific TPPA - specific and RPR - non-specific RPR

**_SYPHILIS_** How long can it take after infection for a person to develop serology? How many serology tests should you do?

Up to 6 weeks Always do more than 1

**_SYPHILIS_** What is the treatment for early syphilis? What is the treatment for late syphilis? These patients should be followed up until when?

1 dose of 2.4MU of IM benzathine penicillin 3 doses of 2.4MU of IM benzathine penicillin RPR is negative

**_GENITAL HERPES_** What organism causes this? How could this organism be described? How is it transmitted?

Herpes simplex type 1 and 2 Encapsulated virus containing double stranded DNA By being in close contact with someone shedding the virus (genital/genital or oropharyngeal/genital)

**_GENITAL HERPES_** What is the incubation period for primary infection What is the duration of the primary infection? Viral shedding is more common with which type of HSV?

3-6 days 14-21 days HSV2

**_GENITAL HERPES_** What are some factors which make viral shedding more likely? How can this shedding be reduced? Who qualifies for this?

Being in the first year since infection, or in people who get frequent recurrences Suppressive therapy (aciclovir 400mg bd for 1 year) If there are 6+ attacks in one year

**_GENITAL HERPES_** What is a primary first episode? What is a non-primary first episode? How may a primary episode appear clinically?

Never been exposed to the virus before, has no antibodies to either type Has been exposed to the virus before (e.g. cold sores) and have antibodies to this, but not the current specific strain Can be asymptomatic, or very florid

**_GENITAL HERPES_** Where does the herpes simplex virus replicate? It gets into nerve endings of sensory and autonomic nerves which causes what? Where does the virus migrate to and lie dormant?

In the dermis and epidermis Small, multiple, painful vesicles which are easily deroofed Sacral root ganglion

**_GENITAL HERPES_** What symptoms can occur as a prodrome to this? What happens to the external genitalia? What are some other symptoms which can occur?

Fever and myalgia Painful blistering and ulceration Discharge, dysuria and local lymphadenopathy

**_GENITAL HERPES_** Recurrent episodes are often misdiagnosed as what? Will there be systemic symptoms in a recurrent episode? How long with a recurrent episode take to resolve?

Thrush No 5-7 days

**_GENITAL HERPES_** What happens if this infection is picked up in the 3rd trimester of pregnancy? What tests need to be done? What can neonatal herpes cause? What is the management for this?

There will be no antibodies developed and passed onto the baby Type specific serology and HSV NAATs Local CNS disease or disseminated disease Inform obstetrics to review the birth plan

**_GENITAL HERPES_** How should symptomatic cases be tested for? Is there a good test for determining carriers of HSV?

Swab a deroofed blister in viral transport medium for HSV PCR No

**_GENITAL HERPES_** If taken early enough, what can be used as a treatment for this? What are some supportive management options?

Aciclovir 400mg tds for 5 days Topical lidocaine, pee in the shower

**_HPV_** What is the lifetime risk of acquiring this infection? What is the chance of developing anogenital warts? How many types of HPV affect the anogenital region? What are the main low risk types of HPV and what do they cause? What are the main high risk types of HPV and what do they cause?

80% 1% 40 6 and 11, cause genital warts 16 and 18, cause anal, penile, oropharyngeal and cervical cancers

**_HPV_** How often will genital warts clear without treatment? How often will they clear with treatment? How often will they persist despite treatment? What do these people usually have?

20-30% 60% 20% - usually have an underlying immune dysfunction

**_HPV_** What are some home treatments for this and what can they be used for?

Topical cytotoxic - only for genital warts Immune modifier - first line if there are also perianal warts

**_HPV_** What are some treatment options for genital warts which are not home treatments?

Cryotherapy Electrocautery Surgical removal

**_HPV_** What is important to be aware of about cryotherapy treatment? Who is this the only treatment option for? What is important to be aware of about surgical removal treatment?

May need repeared treatments, it is the only treatment option for pregnant women It only removes the lesion and doesn't treat the underlying virus

**_TRICHOMONAS VAGINALIS_** What type of organism causes this infection? How does this present in females? How may it present in males? How is it diagnosed? How is it treated?

A single celled protozoal parasite Vaginal discharge and irritation Urethritis High vaginal swab for microscopy Oral metronidazole

**_PHTHIRUS PUBIS_** How is this acquired? What does it present with? How is it treated?

Close genital contact Itching of the genital region Malathion lotion

**_TESTING_** What are the two main ways of testing for gonorrhoea and chlamydia? How are they generally performed on males? How are they usually performed on females When should an endocervical swab be used in females?

NAATs and PCR First pass urine sample Self take vulvovaginal swab If the patient is having a speculum exam anyway

**_TESTING_** If you are re-testing a patient for chlamydia, how long should you wait? You should only do NAATs when?

5 weeks There is a high index of clinical suspicion

**_TESTING_** What are the advantages of NAATs over culture? What are the disadvantages of NAATs over culture?

More sensitive and can use more easily obtained samples Can't check sensitivities and possible false positives