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01 Family Medicine > STIs and Vaginitis > Flashcards

STIs and Vaginitis Flashcards

AAFP Lecture: STI, Vaginitis, Vaginosis

1
Q

Name the diagnosis:

Painful vesicles that ulcerate

A

Herpes Simplex Virus

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2
Q

Name the diagnosis:

Malodorous discharge, strawberry cervix, sometimes pelvic pain, cervical tenderness, or vulvar/vaginal irritation

A

Trichomonas Vaginalis

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3
Q

Name the diagnosis:

Itchy, thick white discharge

A

Candida albicans infection

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4
Q

Name the diagnosis:

Malodorous discharge, vulvar itching, no cervicitis or pelvic pain

A

Bacterial Vaginosis

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5
Q

What is the primary treatment of Trichomonas?

A

Metronidazole 2g single dose

Or 500 mg BID x 7 days

  • gel less efficacious than oral
  • Treat partner also
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6
Q

What are alternative treatments for Trichomonas?

A

If metronidazole allergy: Clindamycin 300 mg BID x7 days

If metronidazole resistant: Tinidazole 2g single dose

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7
Q

How should Trichomonas be treated if the initial treatment fails?

A

Make sure partner was actually treated

If reinfection is excluded, use Metronidazole 500 mg BID x7 days, if that fails Tinidazole 2 g PO x5 days

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8
Q

When should women who were treated for Trichomonas be tested for reinfection?

A

Within 3 months of initial treatment

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9
Q

What is the treatment for pregnant women with Trichomonas?

A

Metronidazole 2g, single dose

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10
Q

What is the diagnostic criteria for Bacterial Vaginosis?

A

3 of 4 of the following:

  • gray white discharge
  • pH > 4.5 on vaginal pH paper
  • Clue cells on microscopy
  • Positive Whiff test with KOH
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11
Q

Risk of untreated bacterial Vaginosis?

A 
Premature rupture of membranes
Preterm delivery
Postpartum endometritis 
Salpingitis, PID
Postoperative Infections
Vaginitis
Acquisition of HIV
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12
Q

What is the primary treatment of Bacterial Vaginosis?

A

Metronidazole 500 mg BID x7 days

Metronidazole (0.75%) gel 5g in vagina daily x5 days

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13
Q

Alternative treatments for bacterial vaginosis?

A

Tinidazole PO, clindamycin PO or cream

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14
Q

Define recurrent bacterial vaginosis and the treatment

A

3+ episodes in 12 months

Metronidazole (0.75%) 5g in vagina 2 times per week for 4-6 months

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15
Q

Prevention for bacterial vaginosis?

A

Lactobacillus- eating yogurt, vaginal suppositories

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16
Q

Risk factors for candidal vulvovaginitis?

A

Poorly controlled diabetes
Immunosuppression
HIV

OCP, IUD or sponge use
Tight clothing
Antibiotic use
Pregnancy

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17
Q

What are risk factors for Nonalbicans candidal vulvovaginitis?

A

Increased OTC treatment use

Incomplete courses of therapy

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18
Q

Treatment of uncomplicated candidal vulvovaginitis?

A

Azoles

PO or topical treatment is equally effective

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19
Q

Symptoms and Treatment of severe candidal vulvovaginitis?

A

Extensive vulvar erythema, edema, excoriation, fissures

7-14 days of topical azole
Fluconazole 150 mg 2 doses 3 days apart

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20
Q

Define recurrent candidal vulvovaginitis

A

4+ episodes in 12 months

At least 3 episodes unrelated to antibiotic use

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21
Q

Treatment of recurrent candidal vulvovaginitis?

A

Induction therapy: Fluconazole 150 mg q72 hours x3 doses or 7-14 days of topical treatment

Maintenance: Fluconazole 150 mg weekly for 6 months

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22
Q

What is the USPTF recommendation for HSV screening?

A

Routine serologic screening in asymptomatic persons is not recommended

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23
Q

What is an effective method for reducing HSV transmission?

A

Latex condoms

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24
Q

Describe primary HSV infection

A

75% asymptomatic

Lesions 2-14 days after exposure
Fever, Headache, myalgias

Viral shedding for 12 days

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25
Q

How to treat first clinical episode of HSV?

A

Acyclovir 400mg TID for 7-10 days

Can also use Famciclovir or Valacyclovir

Can extend treatment past 10 days if healing is incomplete

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26
Q

What is the treatment of recurrent HSV?

A

Acyclovir 800 mg TID x2 days or 400 mg TID x5 days

Can also use Famciclovir or Valacyclovir also

*Start with onset of prodrome or outbreak

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27
Q

Who needs HSV suppressive therapy?

A

Pregnant women with HSV at 36 weeks until delivery

People with 6+ outbreaks per year

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28
Q

What is used for suppressive HSV therapy?

A

Acyclovir 400 mg BID

Can also use Famciclovir or Valacyclovir

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29
Q

What is the treatment for uncomplicated Gonorrhea?

A

Ceftriaxone 250 IM and azithromycin 1 g PO

Or

Doxycycline 100 mg BID

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30
Q

What are some alternative treatments for Gonorrhea?

A

Cefixime and azithromycin or doxycycline

Azithromycin 2g single dose

31
Q

Who needs a test of cure for gonorrhea?

A

14 days after treatment

Patients with pharyngeal gonorrhea treated with an alternative antibiotic (aka Ceftriaxone not used)

32
Q

Should patients treated for gonorrhea get retested?

A

Yes at 3 months

Due to high prevalence and reinfection rate

33
Q

How is gonorrhea treated in pregnant women?

A

Can’t use tetracyclines

Use cephalosporins, azithromycin or amoxicillin

34
Q

Per USPTF, Who should be screened for gonorrhea and chlamydia?

A 
All sexually active adolescent girls and women:
-24 years old and younger 
-25 or older and high risk:
—Multiple partners
—No condom use
—Incarcerated
—Illicit drug use
  • No evidence to screen high risk men
  • Do not screen low risk men or women older than 25
35
Q

What is the treatment for Chlamydia?

A

Azithromycin 1 g single dose

Or

Doxycycline 100 mg BID x7 days

36
Q

Who needs test of cure after being treated for chlamydia?

A

Pregnant women

3-4 weeks after

37
Q

Who needs test of reinfection after chlamydia treatment?

A

All men and women

3 months after treatment

*Also high risk of trichomonas infection after chlamydial treatment

38
Q

What is the gold standard of Gonorrhea/Chlamydia diagnosis?

A

DNA amplification test (Urine test, endocervical swab, urethral swab)

39
Q

Who should get empiric treatment for Chlamydia?

A

Males with Mucopurulent discharge, dysuria, urethral pruritus

High risk, unlikely to return

First void urine with +leukocytes or 10+ WBC

40
Q

If you diagnose a patient with gonorrhea, chlamydia or trichomonas, can you send a prescription for their partner?

A

Yes

41
Q

How is Pelvic Inflammatory disease diagnosed?

A

Clinical diagnosis:

  • Uterine or adnexal tenderness
  • Cervical motion tenderness
  • No other explanation for symptoms
42
Q

What is the management of pelvic inflammatory disease?

A

Empiric treatment:
Ceftriaxone 250 IM (single dose) and Doxycycline 100 mg BID x14 days with or without metronidazole 500 mg BID x14 days

Or

Cefoxitin 2 g IM and probenecid 1 g PO (single dose) and Doxycycline 100 mg BID x14 days with or without metronidazole 500 mg BID x14 days

Treat partners from past 60 days

43
Q

When should a patient be admitted to the hospital for pelvic inflammatory disease?

A
  • Uncertain diagnosis
  • Severe illness
  • Unable to rule out surgical emergencies (ex: appendicitis)
  • Suspected pelvic abscess
  • Patient pregnant
  • High risk or low compliance concern, can’t get follow up in 72 hours
  • Can’t tolerate outpatient regiment
  • No response to 72 hours of treatment
  • Concurrent HIV infection
44
Q

Inpatient treatment for pelvic inflammatory disease?

A

Cefotetan 2 g IV q12 hours or Cefoxitin 2 g IV q6 hours with doxycycline 100 mg q 12 hours (PO or IV)

Clindamycin 900 mg IV q8 hours with gentamicin IV

45
Q

USPSTF guideline for HIV screening?

A

All patients ages 15-65 regardless of risk level

46
Q

What is the most common type of test for HIV screening?

A

4th generation assays:

-Combined antigen, antibody immunoassay

47
Q

What is the next step when a patient is found to be HIV positive?

A

Must give results in person

Provide education and resources- link to further care

Partner notification

Local/state health authorities notification

48
Q

What are two ways to prevent HIV infection?

A

Treating patients to reduce viral load and prevent spread on the community level

PrEP therapy- prevention for individual patients

49
Q

Men with what characteristics should be considered for PrEP therapy?

A

-Have sex with other men and have one of the following:

  • Have a partner with HIV
  • Inconsistent condom use
  • Treated for syphilis, gonorrhea, or chlamydia in the past 6 months
50
Q

Women with what characteristics should be considered for PrEP therapy?

A

-Have sex with men and have one of the following:

  • Have a partner with HIV
  • Inconsistent condom use with HIV unknown/high risk partner
  • Treated for syphilis, gonorrhea or chlamydia in the past 6 months
51
Q

Should patients who inject drugs be considered for PrEP therapy?

A

Yes if they share equipment/needles or if they have high risk of sexual acquisition

52
Q

What baseline tests should be completed prior to starting PrEP therapy?

A

HIV antibody- rule out HIV infection

Hepatitis B surface antigen- to assess for chronic Hep B

Creatinine- clearance must be greater than 60 mL/min

53
Q

For patients taking PrEP therapy, what type of monitoring do they need?

A

HIV and pregnancy testing every 3 months

Serum Creatinine at 3 months then every 6 months if stable

Screening for STIs every 6 months

54
Q

How effective is PrEP?

A

Reduces risk of sexual transmission by 90%

Reduces risk for those who inject drugs by 70%

55
Q

What is the process for Nonoccupational Postexposure Prophylaxis?

A
  • HIV testing for patient and source if possible
  • Initiate treatment within 72 hours of exposure
  • 28 day course of 3 drug antiretroviral regiment
56
Q

What is the treatment for Nonoccupational Postexposure Prophylaxis?

A

28 days of:

Tenofovir 300 mg daily

(Truvada) Emtricitabine 200 mg daily

Raltegravir 400 mg BID or Dolutegravir 50 mg daily

57
Q

What is a quick differential for genital ulcers?

A

Herpes, Syphilis, Chancroid

58
Q

What are some initial tests to order for genital ulcers?

A

Serology for T. Pallidum

Culture or antigen for HSV

Culture for H. Ducreyi

HIV testing

59
Q

If a genital ulcer does not respond to initial therapy, what is the next step in management?

A

Biopsy the ulcer

60
Q

What are the Nontreponemal v. Treponemal testing methods for syphilis?

A

Nontreponemal:
RPR and VDRL
Screening tests
Correlates with disease activity

Treponemal antibody:
FTA-ABS 
Confirmatory testing
Does not correlate with disease activity 
May remain positive for life
61
Q

What is the definitive test for syphilis?

A

Dark field microscopy

62
Q

What test could indicate neurosyphilis?

A

VDRL-CSF

High specificity, low sensitivity

63
Q

Per USPTF guidelines, who should be screened for syphilis?

A

Men who have sex with men
People with HIV
Hx of Incarceration or commercial sex work
Males younger than 29 years in high prevalence areas

*Recommend against screening persons that are low risk

64
Q

What is the treatment for syphilis?

A

Benzathine PCN G 2.4 m units IM

*For all stages except late latent/tertiary neurosyphilis

If PCN allergy, desensitize

65
Q

What is the treatment for late latent/tertiary syphilis or neurosyphilis?

A

Late latent/tertiary: Benzathine PCN G 7.2 m units (2.4 m units IM q week for 3 doses)

Neurosyphilis:
Aqueous crystalline PCN G 3-4m units IV q 4 hours for 10-14 days

Or

Procaine penicillin 2.4 m units IM daily with probenecid 500 mg QID for 10-14 days

66
Q

Per USPTF guidelines, who needs screening for Hepatitis B?

A

All pregnant women

HIV+

Injection drug users

Household contacts of persons with HBV infection

Men who have sex with men

On hemodialysis or immunosuppression

Persons born in regions with high HBV prevalence

US born but not vaccinated as infants with parents born in regions with high HBV prevalence

67
Q

What regions have high HBV prevalence?

A

Sub Saharan Africa

Southeast and Central Asia

68
Q

What is the prophylactic treatment for healthcare workers exposed to HBsAg positive patients?

A

Hep B immune globulin after exposure

Hep B Vaccination series if not previously vaccinated

69
Q

What is the prophylactic treatment for newborns born of mothers with HBV infection?

A

Hep B immune globulin after delivery

Start Hep B vaccination series

70
Q

Per USPTF guidelines, who needs screening for Hep C?

A

One time screening for all adults 18-79

Any high risk person

71
Q

If Hep C screen is positive, what is the next step in management?

A

HCV RNA testing

If positive, link to care

72
Q

True or false: Expedited partner treatment lessens risk of reinfection for patients treated for gonorrhea or trichomonas

A

True

73
Q

True or False: Tinidazole is not an adequate treatment option for metronidazole resistant trichomonas

A

False

It is an appropriate treatment option

01 Family Medicine (16 decks)

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