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DipGUM > Treatment > Flashcards

Treatment Flashcards

1
Q

First and second line treatment for neisseria gonorrhoea

A

1st: stat IM ceftriaxone

2nd:
Stat Cefixime 400mg PLUS azithro 2g
Stat IM gent 240mg PLUS azithro 2g
Stat IM spectinomycin 2g PLUS azithro 2g
Potentially ofloxacillin
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2
Q

Treatment of gonorrhoea in pregnancy

A 
Stat IM ceftriaxone 
OR
Stat IM spectinomycin 2g
OR
Stat azithromycin 2g
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3
Q

2nd line trichomonas vaginalis treatment

A

Metronidazole 2g stat
OR
Tinidazole 2g Stat

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4
Q

Persistent trichomonas vaginalis

A

Repeat metronidazole 400mg BD 7d
Then:
High dose metronidazole or tinidazole 2g daily for 5-7d
Then -> resistance testing
Then:
Tinidazole 1g BD/TDS for 14/7 or 2g BD 14/7

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5
Q

Which HSV virus most likely to cause recurrent anogenital symptoms?

A

HSV-2

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6
Q

Median recurrence rate for HSV-2?

A

Approx 4 times per year

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7
Q

When are oral antiviral indicated for herpes?

A

Within 5 days start of episode, whilst new lesions are still forming or if systeic symptoms persist

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8
Q

Preferred treatment for herpes:

A

Aciclovir 400mg TDS

Valaciclovir 500mg BD

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9
Q

Alternative treatment for herpes:

A

Aciclovir 200mg 5x/day

Famciclovir 250mg TDS

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10
Q

First line for episodic management of recurrent herpes:

A

Aciclovir 800mg TDS 2days
Famciclovir 1g BD 1 day
Valaciclovir 500mg BD 3 days

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11
Q

Longer course for episodic management of recurrent herpes:

A

Aciclovir 200mg 5x day 5 days
aciclovir 400mg TDS 3-5 days
Valaciclovir 500mg BD 5 days
Famciclovir 125mg BD 5 days

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12
Q

Recommended HSV suppresive treatment? (Getting at least 6 episodes a year)

A

Aciclovir 400mg BD
Aciclovir 200mg 4X day
Famciclovir 250mg BD
Valaciclovir 500mg OD

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13
Q

What to discsus with patients about herpes transmission:

A

Abstinence from sex when prodrome/lesions
Transmission may occur as result of asymptomatic shedding
Condoms reduce risk but cannot prevent it
Discloure is advised in all relationships (document these discussions)
Reassure cannot be transmitted by towels/sheets etc.
Ensure do not transfer to someone pregnant

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14
Q

Preventing HSV transmission to a pregnant partner:

A

Use condoms, especially last trimester
Abstain from sex at time of lesion recurrent
Abstani from sex in last 6 weeks pregnancy
If partner has history of oro-facial HSV, avoid oral sex

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15
Q

First episode genital herpes when pregnant, who can have vaginal delivery?

A

Providing delivery does not occur in the next 6 weeks, vaginal delivery can be expected.

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16
Q

Following first or second trimester genital herpes acquistion, when to start suppresive treatment?

A

From 36 weeks start daily suppressive aciclovir 400mg TDS

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17
Q

If first episode genital herpes acquired in third trimester:

A

Aciclovir 400mg TDS should be started and continued until delivery, C-secton should be the recommended mode of delivery. (If within 6 weeks of delivery, risk of neonatal herpes as high as 41%).
HSV IgG serology should be taken, if same as isolated on swab then is a recurrence

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18
Q

If woman has first episode genital herpes in third trimester but wants a vaginal delivery:

A

IV aciclovir 5mg/kg TDS, and then neonate 20mg/kg TDS. Aim to avoid invasive procedures.

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19
Q

Most common of the serovars causing LGV

A

L2 most common (L2b most common, of L1/L2/L3)

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20
Q

Stages of LGV:

A

‘Classical LGV’ has 1st stage of papule/ulcer, 2nd stage lymphadenopathy/buboes, 3rd stage chronic inflammatory disease with fistulae/strictures etc. In the MSM outbreak, most present at with primary manifestation of direct infection of rectal mucosa with proctitis

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21
Q

Diagnosis of LGV:

A
  • NAATS, if LGV suspected then PCR looking for LGV specific DNA.
  • On microscopy >10 PMNLs per high power field
  • Culture on cycloheximide treated McCoy cells
  • Chlamydia serology: in general a 4 fold rise in antibody OR single point titre of >1/64 have been considered positive for LGV (lacks sensitivity for earlier infections)
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22
Q

General advice for LGV:

A
  • Bacterial STI that is curable with antibiotics but left untreated can have serious and permanent adverse features
  • Symptoms should resolve in 1-2 weeks of Rx
  • Avoid unprotected sex until they and partners have completed Rx and FU
  • High rates of HIV and HCV infection are observed, discuss risk reductoni such as avoiding UPSI, avoiding traumatic anorectal practices such as fisting or sex toy use, or shared equipment for douching
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23
Q

1st and 2nd line treatment for LGV:

A

1) Doxycycline 100mg BD for 3 weeks (or tetracycline 2g daily, or minocycline 300mg loading then 200mg BD)
2) Erythromycin 500mg QDS for 3 weeks (first choice in pregnant or breast feeding), or azithromycin 1g weekly
(single case of doxy failure, responded to moxifloxacin 400mg daily 10 days)

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24
Q

When to do TOC in LGV?

A

Do TOC 2 weeks after completion of treatment if anything but doxycycline was used.

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25
Q

LGV partner notifcaiton and contact tracing:

A

Anyone that had sexual contact with patient within 4 weeks of onset of symptoms or last 3 months if asymptomatic should be examined, tested and presumptively treated with 3 weeks treatment.

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26
Q

Follow up for LGV:

A

Follow up until signs/symptoms have resolved, usually takes 1-2 weeks, can take 3-6 if londstanding. Routine TOC not usually required,

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27
Q

What microbe causes Chancroid?

A

Haemophilus Ducreyi - gram negative facultative anaerobic coccobacillus

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28
Q

Clinical features of Chancroid

A

Anogenital ulceration and lymphadenitis with progression to bubo formation.
Incubation period 4-7 days
Lesions start as a tender papule then pustule then ulcer or soft sore.
Typically ulcers have a ragged undermined edge with grey/yellow base that bleeds when touched.
Lesions are painful, single or multiple

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29
Q

Diagnosis of H. ducreyi

A
  • PCR but rarely available
  • Culture obtained from ulcer base, grown in high humidity with 5% carbon dioxide, culture media include GC Agar supplemented with bovine haemoglobin, fetal calf serum. Or Mueller-Hinton agar with chocolatised horse blood. Or activated charcoal instead of metal calf serum.
  • Sensitivity still only around 80%
  • Microscopy only 50% sensitive
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30
Q

Recommended regimen for Chancroid

A
  • Azithromycin 1g orally single dose
  • ceftriaxone 250mg IM single dose
  • Ciprofloxacin 500mg BD for 3 days
  • Erythromycin 500mg QDS for 7 days
    (Use cipro or erythromycin if HIV positive)
    (erythro or ceftriaxone if pregnant)
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31
Q

Follow up and PN for chancroid

A
  • Re-examine in 3-7 days to see if ulcers are improving. LN may take longer.
  • TOC not recommended
  • Those with sexual contact 10 days before should be examined and treated even if absent of symptoms
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32
Q

Causative organism for Donovanosis

A
  • Originally Calymmatobacterium granulomatis

- Proposal to reclassify as Klebsiella granulomatis comb nov.

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33
Q

Clinical features of Donovanosis.

A

Genitals are affected in 90%, inguinal area 10%, rarely extrangenital.
Lymphadenitis is uncommon
SCC can mimic and complicate donovonosis, biopsy should follow if Abc fail.
Four types described:
- Ulcerogranulomatous most common- non tender, fleshy. single or multiple red ulcers that bleed when touched
- Hypertrophic or verrous type
- Nectrotic, deep and foul smelling ulcer
- Sclerotic with extensive fibrous tissue

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34
Q

Diagnosis of donovonosis

A
  • Direct microscopy (Giemsa or silver stain best): quickest and most reliable -> large mononuclear cells with intracytoplasmic cysts filled with deeply-stained Gram negative Donovan bodies
  • PCR for C. granulomatis (nil commercially available)
  • Culture not routinely available
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35
Q

Management of donovanosis

A

Following for 3 weeks or until lesions completely healed:
- Azithromycin 1g weekly (or 500mg daily)
- Septrin 160/800mg BD orally
- Doxycyline 100mg BD orally
- Erythromycin 500mg QDS (if pregnant)
- Gentamicin 1mg/kg 8 hourly IV if lesions slow to respond
Children: azithro 20mg/kg OD), consider prophylaxis in neonates born to mothers with lesions (for 3d)

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36
Q

Follow up and PN for donovanosis

A

Check for lesions in all partners for prior 6 months

Follow patient up until lesions resolved

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37
Q

Molluscum infection caused by:

A
  • Molluscum contagiosum, a large DNA virus belonging to Poxviridae family
  • Up to 4 subtypes identified, MCV-1 most common
  • No big difference between the types, MCV-2 relatively more common in the immunocompromised
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38
Q

Most common settings molluscum occurs:

A
  • Through routine physical contact or occasionally formats, children account for 90% infections, often face, neck, trunk, limbs
  • As an STI in young adults, genitals/pubic regions/thighs/buttocks
  • Severe molluscum in setting immunocompromised
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39
Q

Clinical features of molluscum contagiosum:

A
  • Characteristically smooth surfaced, firm, dome shaped papules with central umbilication
  • Pearly white, pink to yellow
  • Usually 2-5mm, unless immunocompromised
  • Commonly 1-30 lesions occurring as clusters
  • Usually asymptotic, sometimes itchy
  • In the immunocompromised can see 100 or more lesions and can coalesce.
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40
Q

Diagnosis of molluscum:

A
  • Usually clinical

- Differential includes BCC, cysts, abscesses, genital warts, disseminated fungal infections

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41
Q

Genera advice for management of molluscum:

A

General advice:

  • Warned of risks of autoinoculation, advised against shaving/waxing genitals, advise against squeezing
  • Don’t share formats whilst active lesions
  • If swimming, cover areas if possible
  • Condoms can reduce transmission but not absolute
  • If genital, do full STI screen
  • Exclude disseminated fungal infection if immunocompromised
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42
Q

Treatment of molluscum:

A
  • No treated is recommended if immunocompetent , usually resolve with no sequelae.
  • If patient wants treatment, advise new lesions may continue to form
  • Podophyllotoxin BD for 3d then 4d pause, for 4 weeks if necessary
  • Imiquimod 5% M, W, F, washed off 6-10 hours later, for up to 16 weeks (has demonstrated some limited efficacy in HIV positive and negative)
  • Liquid nitrogen has been used, but no trials
  • Curettage not suitable for genital lesions, and evidence for efficacy on other lesions is sparse
  • Pregnancy: cryotherapy, avoid podophylotoxin or imiquimid
  • HIV: topical cidofovir has some efficacy in non genital lesions not improving (causes inflammation so not for genital)
  • PN not required
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43
Q

General advice for all vulval conditions:

A
  • Avoid contact with soap, shampoo or bubble bath
  • Simple emollients can be used as soap substitutes
  • Avoid tight fitting garments which may irritate the area
  • Avoid use of spermicidally lubricated condoms
  • Detailed explanation of their condition etc.
  • Inform GP
  • Consider STI screen if itch
  • Assess for sexual dysfunction
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44
Q

Vulval lichen sclerosus- aetiology and clinical features

A
  • Inflammatory disorder of unknown aetiology but thought to be autoimmune factors (increased frequency of other autoimmune disorders in females with LS)
  • Often in women over age 50
  • Extracellular matrix 1 (ECM1) antibodies in 60-80%
  • Symptoms: itch, soreness, dyspareunia, urinary symptoms, constipation if anal invovlement
  • Signs: pale, atrophic areas affecting the vulva (non hair bearing areas) never involves vaginal mucosa, purpura is common, fissuring, erosions, hyperkeratosis, loss of architecture e.g. loss of labia minora, clitoral hood may be sealed over clitoris
  • 10% may have extra-genital lesions, pale white plaques of atrophic, thin skin
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45
Q

Complications of lichen sclerosus

A
  • SCC (<5 %)
  • Clitoral pseudo cyst
  • Sexual dysfunction
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46
Q

Diagnosis of LS:

A
  • Characteristic appearance
  • Vulval biopsy: epidermal atrophy, hyperkeratosis with sub-epidermal hyalinisation of collagen and lichenoid infiltrate
  • Biopsy mandatory if Dx uncertain or atypical features that could be VIN/SCC (reasonable to trial steroids with no biopsy if features are typical)
  • Ix for autoimmune disease if clinically indicated, e.g. TFTs
  • Skin swab if secondary infection suspected
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47
Q

Management of LS:

A
  • General advice: written info, and aware of small risk neoplastic change, advised to contact doctor if see a change e.g. lump or hardening of skin. Often a chronic condition needing long term follow up
  • Recommended regimen (ointment bases are best):
    1) Ultra-potent topical steroid (e.g. clobetasol proprionate/’Dermovate’) e.g. daily for one month, alternate days one month, 3x week 1 month then review at 3 months
    2) Altenative regimens may contain antibac/antifungal as well (e.g. dermovate NN, fucibet)
    3) Unlicensed treatments: topical tacrolimus, oral retinoids e.g. acitretin, UVA phototherapy

1) is safe in pregnancy and breastfeeding, rest are not

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48
Q

Calculation for risk of HIV transmission:

A

Risk that source is HIV positive x risk of exposure

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49
Q

Factors affecting PEP efficacy:

A
  • Delayed initiation
  • Transmission of resistant virus
  • Variable genital tract drug penetration
  • Poor/non-adherence
  • Further high risk sexual exposures
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50
Q

Factors increasing risk of HIV transmission:

A
  • High plasma VL in the source
  • Breaches in the mucosal barrier e.g. trauma or ulcers
  • Menstruation - theoretical risk
  • Ejaculation - increased risk
  • STIs
  • Non-circumcision
  • Discordant HIV VL in the genital tract
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51
Q

Thresholds used for PEPSE initiation

A

Transmission risk:
> 1 in 1000 -> PEPSE recommended
Between 1 in 1000 and 1 in 10,000 -> consider (give if additional factors that increase risk transmission)
<1 in 10,000 -> not recommended

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52
Q

Items to discuss with person starting PEPSE:

A
  • The rationale for using PEPSE ‘reduce dissemination and replication in all tissues’
  • Lack of conclusive data for efficacy
  • Potential risks and side effects
  • Arrangement for early follow up
  • Pre test discussion an 4th gen HIV test
  • The need to continue for 28 days if baseline negative
  • The need for follow up HIV test 8-12 weeks after
  • The need for safer sex for next 2 months
  • EC if relevant
  • Vaccinations
  • U+E, LFT, UPCR, hep screen
  • Coping strategies, social support
  • Sexual health advisor +/- psychology
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53
Q

Recommended and alternative PEPSE:

A

Recommended: Truvada (1 tablet OD) + raltegravir (400mg BD) (avoid antacids and MVT with raltegravir)
Alternative backbone: Combivir (zidovudine + lamivudine)
Alternative 3rd agent: kaletra/darunavir/atazanavir/folutegravir

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54
Q

Recommended monitoring during PEP course:

A

Baseline: Creatinine, ALT, urinalysis, UPCR, HIV, hepBsAg, STS/hep C/Hep B (as per local guidelines), STI testing, pregnancy test, CK (if symptoms myositis)
2 weeks: STI testing, renal/liver ONLY if abnormalities at baseline
8-12 weeks post: HIV, STS, STI if further UPSI, renal/liver ONLY if abnormalities previously

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55
Q

Guidance on missed doses of PEPSE:

A

<24 hours since last dose: take missed dose immediately and subsequent dose at normal time
24-48 hours sine last dose: continue PEPSE
>48 hours since last dose: stop PEPSE

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56
Q

Diagnosis of scabies:

A

1) Mostly clinical: Hx intense itch, worse at night, other members affected, skin burrows, erythematous papules in webspace, flexor aspect wrists, extensor aspects elbows, umbilicus/buttocks, feet etc. (spares the scalp) NB. it is a hypersensitivity rash occurring 4-6 weeks after infestation, few days if re-exposed
2) Dermatoscopy - mite at end of burrow
3) Microscopic identification of the mites, eggs or faecal pellets (scrape skin with scalpel blade and place on glass slide with 10% potassium hydroxide)
4) Burrow ink test

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57
Q

Treatment of scabies:

A

General advice: bedding/clothing/towels used by person or their household/sexual/close contact in 4 days before treatment hot washed 60 degrees/dry-cleaning/sealing in plastic for 72 hours. Itching may continue for 2-4 weeks (can try crotamiton 10% cream)
Recommended: Permethrin 5% cream- whole body from chin/ears down (unless young/immunocompromised/elderly then include face and scalp). Apply to cool, dry skin. Allow to dry before dressing. Wash off after 8-12 hours. Reapply 1 week later. Treat hands again if wash them with soap within 8hours. Ok pregnancy and breastfeeding (wash off nipple)
Alternative: Malathion 0.5% aqueous lotion (use if e.g. allergy to chrysanthemums so can’t have permethrin), same application process as above, but wash off after 24 hours. Reapply in 1 weeks.
Alternative: Ivermectin 200mcg/kg 2 weeks apart in patients weighing >15kg. Used if crusted scabies don’t respond to topical, can cause nausea/vomiting/abdo pain, low risk in pregnancy

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58
Q

Treatment of crusted scabies:

A

Topical permethrin cream one daily for 7 days, then twice weekly until cure
Plus - oral ivermectin (200mcg/kg) on days 1, 2, 8, 9, 15
Isolate immediately, barrier nursing.
All household members treated at same time

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59
Q

Contact tracing for scabies

A

Current sexual partners and household contacts/other close contacts should be examined and treated at same time.
Contact tracing of partners from the previous month
If still symptomatic after 2 weeks or burrows seen, consider re-treatment, use a different regimen

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60
Q

Transmission of public lice (Pediculosis pubis, or pthirus pubis):

A
  • Usually skin to skin, up to 95% sexual contacts of a carrier will develop infestation
  • occasionally by formats
  • unlikely lice can survive more than 24-48 hours if removed from host
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61
Q

Clinical features of pediculosis pubis:

A
  • Itch
  • Erythema
  • Infestation of eye lashes (pediculosis Claris) and eyebrows can occur, where can cause a severe blepharoconjunctivitis
  • Blue macule may be visible at feeding sites
  • ‘Black spots’ may be seen on underwear and are faecal matter or blood spots
  • Concomitant STIs present in 30%
  • Incubation period 5 days to several weeks
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62
Q

Management of pubic lice:

A
  • Avoid close contact until pt and partner treated
  • Contact trace to 3 months, and also those than share bedding
  • Hot wash or dry clean bed linen
  • Full STI screen
  • re-examine 1 week after treatment, give an alternative treatment if treatment failure. Dead nits may remain, can be removed with a comb
  • Lotions are likely to be more effective than shampoos and should be applied to all body hair.
  • Second application in 3-7 days advised
  • Suggested treatments:
  • > Permethrin 1% cream rinse (a pyrethroid, apply to damp hair and wash out after 10 mins)
  • > Malathion 0.5% (an organophosphate, apply to dry hair, leave 2-12 hours and wash out)
  • > Phenothrin 0.2% (also pyrethroid, apply to dry hair and wash out after 2 hours)
  • > Carbaryl 0.5 and 1% (apply to dry hair and wash out 12 hours later)
  • > Ivermectin PO considered in resistant cases

Pregnancy + breastfeeding: permethrin is safe

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63
Q

Management of eyelash lice infestation:

A
  • Keep eyes closed throughout
  • Apply e.g. permethrin 1% cream and keep eyes closed for 10 mins then wash off.
  • Or put ophthalmic ointment with paraffin based BD for 8-10 days to surrogate lice
64
Q

Types of FGM:

A

Type 1: clitoridectomy: partial or total removal of the clitoris (rarely just the prepuce)
Type 2: excision: partial or total removal of the clitoris and labia minora, with or without excision of the labia major
Type 3: infibulation: narrowing of the vaginal opening through creation of a covering seal with either the inner or outer labia, with or without removal of clitoris.
Type 4: All other harmful procedures to female genitalia for non-medical purposes

65
Q

General advice for hepatitis A

A
  • Avoid alcohol, food handling and UPSI until non infectious
  • usually can be monitored as OP
  • Follow up 2 weekly until AST normal
  • notifiable disease, if food handles let local health protection team know
  • PN for at risk contacts within 2 weeks before and 1 week after onset of jaundice, also household contacts etc
  • pregnant women small increased risk miscarriage/preterm labour
  • breast feeding risk uncertain
66
Q

Which asymptomatic patients in sexual health clinic should be screened for past hep A exposure?

A

MSM, PWID, hepb C, hep b and HIV

67
Q

Hepatitis A vaccine schedule?

A

0 and 6-12 months (2 doses)

If CD4<300, revaccinate if CD4 rises to >500 and HAV IgG remains negative on retesting

68
Q

What to do if patient presents as contact of patient with hepatitis A

A

Screen for evidence of immunity or infection

69
Q

Transmission rate regular partners of those with active hepatitis B

A

20-40%

70
Q

Incubation period hep A, B, C

A

Hep A: 2-6 weeks
Hep B: 1-6 months
Hep C: 1-5 months

71
Q

Definition of chronic hep B and percentage adults that get it

A

HbSAg positive >6 months
If inmunocompetent <5% adults get chronic
(Higher then if HIV, renal failure, otherwise immunosuppressive)
(Risk of reactivation if immunosuppressed)

72
Q

Tests in Hepatitis B diagnosis

A

Acute:
HbSAg, HbCAb, HBeAg, Hep B IgM, HBV DNA
Alt, Bill, clotting
(Clearance suggested when HbSAg becomes negative, HBeAb is developed at 6 months, if not is chronic)

Other: HIV, all other heps including hep D

Chronic:
Fibroscan (<6kPa mild, >12 severe/cirrhosis)
USS

73
Q

Management hepatitis B

A

General:
Avoid upsi until loss of HBSAg or partner vaccinated
Decrease or stop etoh
Refer to specialist
Notifiable disease- PN and screening close family and PH involvement for non sexual contacts
Screen for hepatitis A, C, D, hiv, vaccinate against hep A if indicated

Treatment:
Given if hbDNA >2000 with evidence inflammation and or fibrosis
MUST have hiv test first
Options TDF, TAF, entecavir, pegylated interferon
Entecavir not to hiv pos without adequately suppressed hiv as high risk M184V resistant mutation

74
Q

Neonatal hepatitis B prevention

A

Mum might get tenofovir in third trimester depending on VL
Baby vaccinated at birth, 1 month, 2 month and 12 months with serology to check infectious status and immunity

Hepatitis B immunoglobulin (HBIG) within 24 hours of birth if high risk

Works in around 90%

Breastfeeding can continue

75
Q

Sexual and other contacts of hepatitis B

A
  • Infectious period is from 2 weeks before onset of jaundice until pt becomes surface Ag neg
  • if chronic infection, trace as far back as episode of jaundice or when infection may have been acquired, >3 years may be impractical
  • screening of children to women!
  • HBIG 500IU can be given to non immune contact after single UPSI or parenteral exposure if donor known infectious, best within 12hrs, ideally <48 hrs, no use after 7d
  • accelerated course vaccine to all sexual and household contacts (0, 1, 3 weeks or 0, 1, 2 months and booster 12 months
  • contacts prev vaccinated can have boosted
  • contacts should avoid sexual contact until shown no infection
  • those with chronic infection must be advised on disclosure to sexual partners and vaccination of partners.
76
Q

Hep B- who and how to vaccinate

A

Who: MSM, PWID, HIV, sexual assault victims, endemic countries, needlestick, heterosexuals with >10 partners/year, sexual partners of pos or high risk patients

How: HbSAg and Anti hep B core

Ultra rapid: 0,1,3 weeks and 12 months
Rapid: 0, 1, 2 and 12 months
Standard: 0, 1, 6 months

Check Abs 4-12 weeks after last dose, aim >10, ideally >100

If vaccine course not completed in immunocompetent can give 4 or more years later without need to restart

If HIV then double dose and give at 0, 1, 2 and 6 months (if CD4>500 and ultra rapid needed clinically give normal dose). If after 4-8 weeks Abs<10 give 3 further doses at monthly intervals, if between 10 and 100 after primary course, give boosterism

77
Q

Transmission rates hep C

A

VT in as low as 5%, more if hiv pos (no interventions to reduce transmission, no firm evidence on breast feeding)
Heterosexual sex v low <0.1%/10 yrs

78
Q

Percentage hep C that become chronic

A

50-80%

79
Q

Diagnosis hepatitis C

A

Acute:
Hep C antibody may take months to develop but HCV RNA should be positive within 2 weeks after infection

Chronic:
Screening antibody test to confirm, RNA to confirm active infection (if low CD4 only rna may be pos)
Chronic infection confirmed if HCV RNA positive 6 months after first pos test
Do a genotype

Other:
Test all other hepatitis, HIV
Reassure is curable
Tell not to donate blood/semen/organs, safer sex with condoms, avoid trauma, gloves for fisting/single person sex toys (avoid UPSI if acute infection)
Acute hepatitis is notifiable disease
All partners/needle sharers during infective period to be tested, test children born to viraemic mothers
Fibroscan and USS

Screening: annually to MSM eligible for 3 monthly hiv testing or on PrEP. Other MSM don’t need to be routinely screened. HIV pos at diagnosis and then yearly. If cleared and treated then yearly screening

80
Q

Hepatitis C treatment

A

Cure defined as negative HCV RNA 12 weeks after treatment
Treatment in acute phase better- those with acute hep C should have 4 weekly RNA, if <2 log10 decline at week 4, or HCV RNA still pos at week 12, consider for treatment in acute phase

81
Q

Risk factors for bacterial vaginosis

A

Vaginal douching, receptive cunninlingus, black race, recent change in partner, smoking, presence of an STI, variable data about increased risk with IUD, increased fat consumption, WSW

82
Q

Complications BV

A

Persistence (11-29%)
Recurrence (72% by 7 months)
Post abortion PID
Possible contributed to PID and STI acquisition
In pregnancy: chorioamnionitis, low birth weight, preterm, miscarriage, endometritis, PPROM

83
Q

Amsel’s criteria:

A

At least 3 of the following 4:

  • thin, white, homogenous discharge
  • clue cells on microscopy
  • pH >4.5
  • release of fishy odour on adding alkali (KOH)
84
Q

Hay-Ison gran stain criteria:

A

Grade 0: epithelial cells/no bacteria
Grade 1 (normal): lactobacilli only
Grade 2 (intermediate): reduced lactobacilli/mixed bacteria, wouldn’t classify as BV by Amsel’s
Grade 3: mixed bacteria with few or absent lacto, would classify according to Amsel’s
Grade 4: epithelial cells covered with gram pos cocci only

85
Q

Management of BV:

A

General: avoid vaginal douching, no shower gel, shampoo in bath, stop smoking, use soap substitute , advise it is often transient and self limiting
Treatment (all have cure rare of 70-80% after 4 weeks):
- Metronidazole 400mg BD 5-7d (or 2g stat but higher failure rate), or intravaginal 0.75% cream OD 5 nights
- Clindamycin 300mg PO BD 7d, or intravaginal 2% creams 7d (can weaken condoms)
- Tinidazole oral 1g OD 5d, 2g daily 2d, 2g single dose

(Use intravaginal if breastfeeding, treat as normal in pregnancy but no 2g stat doses)

86
Q

Management of persistent or recurrent BV:

A

Persistent (no evidence for) consider:

  • confirm Dx etc and compliance
  • change of treatment from list
  • removing IUD
  • PO co-amox 375mg TDS 7d

Recurrent:

  • confirm Dx + compliance
  • 7d course BD metronidazole
  • If having >=4x per year consider 0.75% metronidazole gel BD for 16 weeks (however, excess of VVC may be seen)
  • 3d metronidazole at menstruation
  • contraception to stop menstrual flow to maintain low pH
  • limited data for probiotic
87
Q

Definition of recurrent VVC:

A

At least 4 episodes per 12 months with 2 episodes confirmed by microscopy or culture when symptomatic (at least 1 must be culture)

88
Q

Diagnosis of VVC:

A

If presenting to level 3 STI care, supporting the diagnosis with routine microscopy is good clinical practice.
- Examine external genitalia
- self-collected sample reasonable alternative (should examine in case of recurrent VVC however)
- HVS swab
- presence of blastospores, pseudohyphae and neutrophils
(spores and neutrophils only in C. Glabrata)
- Culture not required for acute, but in recurrent culture to speciate and assess fluconazole sensitivity

89
Q

Treatment for acute VVC:

A

1st line:

  • Fluconazole 150mg PO single dose
  • If PO contraindicated then clotrimazole 500mg pessary

Alternatives:

  • 5g clotrimazole 10% cream intravaginally
  • Clotrimazole 200mg pessary 2 nights in row
  • econazole, fenticonazole, intraconazole, miconazole etc.
90
Q

Things to think about with fluconazole:

A
  • moderate enzyme inhibitors (CYPP450, CYP3A4) which lasts 4-5 days
  • can be associated with prolongation of QT so don’t with with other products that prolong QT and are metabolised by CYP450 e.g. quinidine and erythromycin
91
Q

Recurrent VVC:

A

1st line:
Induction: fluconazole 150mg every 72 hours for 3 doses, then maintenance with 150mg weekly for 6/12 (remission in 82-90%)
Alternative (e.g. if pregnant):
Induction with topical imidazole for 7-14d, maintenance with weekly pessary (if non pregnant itraconazole 50-100mg daily an option)

92
Q

Treatment for non albicans Candida and azole resistance:

A

1st line:
- Nystatin pessaries 100,000 units intravaginally ON 12-14 nights
Alternative:
- Boric acid, amphotericin B, flucytosine intravaginally 14d

Recurrent:
- nystatin pessaries for 12 nights per month for 6 months

93
Q

Abstinence in early syphilis:

A

Until lesions healed and until 2 weeks following treatment.

94
Q

Recommended and alternative treatment for early syphilis:

A

Recommended:
- Benzathine penicilli 2.4 MU IM single dose
Alternative:
- Procaine penicillin G 600,000 units IM daily 10d
- Doxy 100mg PO BD 14d
- Amoxicillin 500mg PO QDS + probenecid 500mg 14d
- Azithromycin 2g PO stat, or 500mg OD 10d
- Erythromycin 500mg QDS 14d (last resort due to resistance concerns)

95
Q

Late latest/cardiovascular/ gummatous syphilis treatment

A
  • Pred 40-60mg 3d starting 24 hrs before in cardio
  • Benzathine penicillin 2.4 IU IM weekly for 3 doses

Alternative:

  • procaine penicillin 600, 000 units IM OD 14d
  • Doxycyline 100mg PO BD 28 days
  • Amoxicillin 2g PO TDS with probenecid 500mg QDS for 28 days
96
Q

Treatment for neurosyphilis:

A

Steroids 3 days starting 24 hours before
Recommended:
- Procaine penicillin 1.8-2.4 MU IM OD plus probenecid 500mg PO QDS for 14d
- Benzylpenicillin 1.8-2.4g IV 4 hourly for 14d

Alternative:

  • Doxyculine 200mg PO BD 28 days
  • Amoxicillin 2g PO TDS plus probenecid 500mg PO QDS 28 days
  • Ceftriaxone 2g IM or IV OD for 10-14 days
97
Q

Treatment of early syphilis in pregnancy:

A

Recommended:
- Benzathine penicillin 2.4 MU IM single dose (in 1st and 2nd trimester), in third trimester give 2nd dose after 1 week

Alternative:

  • Procaine penicillin G 600,000 units IM daily 10d
  • amoxicillin 500mg QDS and probenecid 500mg QDS 14d
  • Ceftriaxone 500mg IM daily 10d
  • severe pen allergy then erythromycin 500mg PO QDS or azithromycin 500mg PO 10d PLUS evaluation and Rx of neonates
98
Q

Treatment of late syphilis in pregnancy:

A

Same as non pregnant except not doxy.

  • Pred 40-60mg 3d starting 24 hrs before in cardio
  • Benzathine penicillin 2.4 IU IM weekly for 3 doses

Alternative:

  • procaine penicillin 600, 000 units IM OD 14d
  • Amoxicillin 2g PO TDS with probenecid 500mg QDS for 28 days
99
Q

Treatment of congenital syphilis:

A

Recommended:
- Benzyl penicillin sodium 30mg/kg 12 hourly for 7d then 8 hourly for 10 days

Alternative:
- procaine penicillin 50,000m/kg daily IM 10d

100
Q

Define sensitivity.

A

How likely is the test to detect the presence of the disease in someone WITH the disease?

101
Q

Define specificity.

A

How likely is the test to detect the absence of the disease in someone without the disease?

102
Q

Define positive predictive value.

A

How likely is someone with a positive test result to actually have the disease?

103
Q

Define negative predictive value.

A

How likely is someone with a negative test result to actually not have the disease?

104
Q

Calculate sensitivity:

A

True positive/

True positive + false negative

105
Q

Calculate specificity:

A

True negative/

True negative + false positive

106
Q

Calculate PPV:

A

True positive/

True positive + false positive

107
Q

Calculate NPV:

A

True negative/

True negative + false negative

108
Q

Fraser competence:

A
  • The patient can understand medical advice
  • They cannot be persuaded to inform parents
  • She is likely to have sexual intercourse without contraception
  • Her mental/physical health are at risk without treatment
  • Patient’s best interest require treatment or advice.
109
Q

Diagnosis of TV:

A

Microscopy:

  • Wet prep within 10 mins, 100x then 400x
  • Sensitivity highest in women with discharge (40-80%), in men only around 30% but high specificity

Culture:
Higher sensitivity that microscopy, better at detecting TV in men

NAATs:
Test of choice where available
Sensitivity 88-97%, specificity 98-99%

110
Q

Management TV:

A
  • treat sexual partner simultaneously and advise avoid intercourse for at least 1 week until both completed arc

Recommended:
- Metronidazole 2g stat OR 400-500mg BD 5-7d

Alternative:
- Tinidazole 2g stat

Avoid etoh for duration and 48 hours after (72 hours for tinidazole)

111
Q

Management of treatment failure in TV:

A

Exclude non adherence and re-infection

  • repeat 7d standard course
  • high dose course (metro or tinidazole 2g daily 5-7d OR metro 800mg TDS 7d)
  • aim to do resistance test at this point
  • very high dose tinidazole 1g BD/TDS or 2g BD for 14 days and intravaginal tinidazole 500mg BD 14d
  • after this ??paromomycin ??furazolidone
112
Q

Follow up and contact tracing for TV

A

TOC only if ongoing symptoms

Trace all current partners and those within 4 weeks prior, screen for all STIs and treat for TV regardless of result

113
Q

Diagnosis of NGU

A

Microscopy:
5 or more PMNLs per high power (x1000) microscopic fields (average over 5 fields with greatest concentration of PMNL), on a smear from urethra

Dipstick 1+ consistent but not v specific

Ensure all have CT/GC NAATS, m-gen if available

114
Q

Management of NGU:

A
  • General explanation of causes, often infective but not always, importance of PN, abstinence until pt and partner treated, advice on safer sex
  • Treatment Should be initiated as soon as poss, without waiting for CT/GC
    o Difficult to assess Rx effectiveness as ongoing inflammation may not represent ongoing infection
    o Recommended first line:
  • Doxycycline 100mg BD 7d (>95% effective if CT positive. In setting of M-gen failure rate 50-68%)
    o Alternative:
  • Azithromycin 1g once then 500mg OD for 2d
  • M-gen failure rate 13-33%, weak evidence that 5d course may induce less macrolide resistance
  • Ofloxacin 200mg BD or 400mg OD 7d
115
Q

Treatment of persistent and recurrent NGU:

A
  • Occurs in 15-25%. Organism negative in 50%
  • Persistent if never gets better, recurrent if comes back in 30-90 days
  • Ensure initial Rx completed and consider if this is reinfection
  • Consider TV/M-gen PCR if available
  • Recommended Rx:
    o Azithromycin 1g then 500mg 4d (or 500mg + 250mg) PLUS metronidazole 400mg BD 5d
    o If azithromycin already used first line then: moxifloxacin 400mg OD 10-14d PLUS metronidazole 400mg BD for 5d
  • Alternative:
    o Doxycycline 100mg BD plus metronidazole 400mg BD
  • Continuing symptoms:
    o Moxifloxacin 400mg OD 7-14d (if still symptomatic consider quinolone resistant M-gen, no registered Abx for Rx, Pristinamycin registered in France and may be effective)
    o Consider abacterial prostatitis, chronic pelvic pain syndrome and psychosexual
    o Consider retreatment of index and partner concurrently
    o Erythromycin 500mg QDS for 3 week or clarithromycin 500mg BD 3 weeks
116
Q

PN and look back for NGU:

A

4 week look back, all partners should be assessed and offered Rx

117
Q

Diagnosis PID:

A
  • Should be considered + empirically treated in any sexually active young woman who has recent onset lower abdominal pain, with local tenderness on bimanual examination in whom pregnancy and other causes for pain have been excluded
  • PPV of a clinical diagnosis is 65-90% compared to laparoscopic
  • Should do NAATs but negative result does not exclude PID
  • Absence of endocervical or vaginal pus cells on gram stained smear has good negative predictive value (95%), but non specific (PPV 17%)
  • Ultrasound limited benefit unless abscess or hydrosalpix (if systemically v unwell or severe pelvic pain/tenderness, get USS). Cross sectional imaging can be useful in differentiating from other causes
118
Q

Who to admit with PID:

A
  • If surgical emergency cannot be excluded
  • Lack of response or intolerant of PO therapy
  • Clinically severe/systemically very unwell (ie. Temp >38, peritonitis)
  • Presence of abscess
  • Pregnancy
119
Q

Management PID:

A

Out-patient:
- First line: Ceftriaxone 1g IM, doxycycline 100mg BD + metronidazole 400mg BD 14d
- Second line:
o Ofloxacin 400mg BD plus metronidazole 400mg BD 14d
o Oral moxifloxacin 400mg OD 14D (best coverage against M.gen, small but important risk of serious liver complications)
o NB avoid Rx with quinolones if high risk GC PID as high risk resistance (e.g. partner has GC, clinically severe disease, or sexual contact abroad)
- Alternative: IM ceftriaxone 1g then azithromycin 1g/week for 2 weeks

In-patient (continue IV therapy until 24hrs after clinical improvement then PO to complete 14d)
- IV ceftriaxone 2g daily plus doxy 100mg BD IV (PO if tolerated), plus metronidazole 500mg BD 14d
- Clindamycin 900mg TDS IV plus gentamicin 3-6mg/kg IV OD followed by either clindamycin 250mg PO QDS OR doxy + metro for 14d
- If cannot use above:
o Ofloxacin 400mg B D plus metronidazole 500mg TDS 14d
o Ciprofloxacin 200mg BD IV plus doxy + metro 14d

120
Q

Follow up and PN for PID:

A
  • Current partners and those from last 6 months should be contacted and offered screening for GC and CT
  • Consider treating empirically with doxycycline 100mg BD 7 days
  • Avoid oral and vaginal sex until they and index patient treated
121
Q

Treatment for EO likely due to STI:

A

Ceftriaxone 1g IM plus doxy 100mg BD 10-14d

If gram stain negative for GC, and no other GC risk factors (MSM, purulent contacts, multiple recent partners), then could give:
Doxy 100mg BD 10-14d and Ofloxacin 200mg BD 14d

122
Q

Treatment for EO most likely due to enteric pathogen:

A

Any of:

  • Ofloxacin 200mg BD 14d
  • Levofloxacin 500mg OD 10d

If quinolones contraindicated then co-amoxiclav TDS 10d

123
Q

Treatment for EO when not sure of likely causative organism (e.g. MSM practising insertive anal intercourse)

A

Ceftriaxone 1g IM plus ofloxacin 200mg BD for 10d

if m-gen identified, include moxifloxacin 400mg OD 14d

124
Q

In patient IV Rx for EO

Rx EO if cephalosporin/tetracycline allergy

A

In-patient: IV cefuroxime 1.5g IV TDS +/- gent (if pen allergy cipro)

Allergies ceph/tetra: ofloxacin 200mg BD 14d

125
Q

Follow up and PN for EO:

A

If confirmed STI EO then notify and evaluate all partners, arbitrary 4 week look back (2 weeks if GC)

F/U: review cultures to see if can rationalise therapy, if no better 3 days reassessment diagnosis, F/U 2 weeks, TOC if GC, if swelling/tenderness not getting better then USS.
If uropathogen confirmed -> urology referral

126
Q

GC microscopy sensitivity at different sites:

A

x1000 of gram stained specimens reveals gram -ve diplococci within PMNLS

  • Penile urethral in those with discharge: 90-95%
  • -> If no symptoms: 50-75% so not recommended
  • Female cervix 37-50%
  • Female urethra 20%
  • Pharyngeal: microscopy not recommended
  • Rectal: only offer microscopy if rectal symptoms present
127
Q

GC NAATs sensitivity:

A

> 95% in both symptomatic and asymptomatic

  • suitable for male urine, vulvovaginal, endocervical (vulvovaginal more sensitive), female urine less sensitive
  • If population prevalence is low and PPV <90% then a confirmatory test is required
128
Q

Treatment gonococcal conjunctivitis

A
  • Irrigate eye with water

- 1g IM ceftriaxone

129
Q

Treatment disseminated gonococcal infection:

A
  • Ceftriaxone 1g IM/IV 24 hourly OR
  • Cefotaxime 1g IV TDS OR
  • Ciproflox 500mg IV BD OR
  • Spectinomycin 2g IM BD continued for 7d, could be switched to PO depending on sensitivity:
  • Cefixime 400mg bD PO
  • Ciproflox 500mg BD
  • Ofloxacin 400mg BD
130
Q

Partner notification in GC:

A
  • In males with symptomatic urethral infection contact all partners in last 2 weeks (or the last partner if longer than 2 weeks)
  • Test before Rx if presenting 2 weeks after exposure, treat empirically if within 2 weeks of exposure

TOC for all

131
Q

Levels of evidence (UK Oxford)

A

1a. Systematic reviews of RCTS
1b. Individual RCTS
2a. Systematic review of cohort studies
2b. Individual cohort studies or low quality RCT
3a. Systematic review of case control studies
3b. Individual case control studies
4. Case series
5. Expert opinion

132
Q

Phases of clinical trials:

A

1: evaluate safety, safe dose, side effects
2. Effectiveness, further safety
3. Confirm effectiveness + SE, compare to other treatments
4. Additional info after approval, risks/benefits/usage

133
Q

When to do TOC in CT?

A

For rectal infections and in pregnant women

no earlier than 3 weeks after completion of Rx

134
Q

What to treat CT with if allergic or pregnant so cannot have doxy?

A

Azithromycin 1g stat then 500mg daily 2 days (should cover Mgen if pregnant)

Advise women lack of data about azithromycin in pregnancy.

135
Q

HPV types most commonly associated with warts?

A

6 and 11

136
Q

Commonest HPV types associated with cervical cancer?

A

16 and 18

137
Q

Treatment of warts in pregnancy:

A

Pregnancy
• Reasons to consider treatment in pregnancy:
• Minimise patient discomfort
• Attempt to reduce neonatal exposure to virus
• Risk of laryngeal papillomatosis (less than 1 in 1000)
• Reasons to defer/avoid treatment
• Warts may regress spontaneously after delivery • More limited treatment options
• Response to treatment may be poor
• Options
• Cryotherapy
• TCAA
• Surgical excision
• Consider Caesarean section if large cervical or vaginal warts

138
Q

Cervical smear what happens if borderline changes or low grade dyskaryosis?

A

HPV test done, if positive referred for colposcopy, if negative returned to routine recall.

High grade dyskaryosis or more are referred direct to colposcopy.

139
Q

CIN explained

A

CIN 1 – it’s unlikely the cells will become cancerous and they may go away on their own; no treatment is needed and you’ll be invited for a cervical screening test in 12 months to check they’ve gone
CIN 2 – there’s a moderate chance the cells will become cancerous and treatment to remove them is usually recommended
CIN 3 – there’s a high chance the cells will become cancerous and treatment to remove them is recommended
CGIN – there’s a high chance the cells will become cancerous and treatment to remove them is recommended

140
Q

Who is eligible for HPV vaccination?

A

Boys and girls aged 12 to 13 years, 2 doses, 6-24 months apart

MSM<45 years old, 3 doses, 2nd dose at least 1 month after 1st dose, 3rd dose at least 3 months after 2 dose (under 15 2 doses ok)

141
Q

Who should get TOC in chlamydia?

A
  • Where LGV
  • Pregnancy
  • Rectal infection (if only 1 week doxy was given)
  • Repeat testing (for re-infection) in 3-6 months in under 25 year olds
142
Q

Treatment of neonatal chlamydia:

A

Oral erythromycin 50mg/kg/day in 4 divided doses for 14 days

143
Q

Abstinence for CT and GC:

A

GC until 7 days after finishing treatment

CT until treatment is finished (or 7d after if treated with azithromycin)

144
Q

Look back period for CT:

A
  • In male cases with urethral symptoms, 4 weeks prior

- In all others 6 months prior

145
Q

Complications of SARA:

A
  • Usually self limiting with duration 4-6 months
  • Chronicity with symptoms >1 year in approx 17% (increased likelihood if HLAB27 pos.)
  • Erosive joint damage and persistent locomotor disability approx. 15%
146
Q

Investigation in SARA

- Also refer to rheum, ophthalmologists and dermatologist if significant extra-genital involvement

A

Essential:
- Full STI screening, HIV, ESR, CRP, FBC, urinalysis

Often useful:
Renal, liver, HLA-B27, X-rays affected joints, eCG, ECHO, slit lamp

Sometimes useful:
Blood culture, stool culture, CT serology, US or MR joints, joint aspiration, exclusion tests for other diseases e.g. EF, SLE, rate, ACE etc.

147
Q

Treatment SARA:

A

First line:

  • Reassure that usually self limiting
  • Rest, physio, cold packs
  • NSAIDs (if high risk GI bleeding then COX2 selective or use PPI)
  • Intra-articular steroids may be useful for single joints
  • Treat the genital infection

Second line:

  • systemic steroids (e.g. multiple joints, systemically unwell)
  • Sulphasalazine, Methotrexate, azathioprine, biologics (disabling symptoms for 3 or more months and evidences erosive joint damage)
  • Exceptional situations surgery
148
Q

Infant PEP:

A

Very low risk (mother on ART>10 weeks, VL<50 twice 4 weeks apart and at or after 36 weeks): 2/52 zidovudine

Low risk (criteria about not quite fulfilled but maternal VL<50 at or after 36 weeks): 4/52 zidovudine

High risk (VL unknown or likely to be >50): combined PEP e.g. zidovudine, lamivudine, nevirapine

149
Q

Who should be tested for M. gen?

A
  • Those with NGU
  • Signs/symptoms PID
  • Consider in post coital bleeding
  • Consider in epididimytiis
  • Consider in proctitis
  • Partners of persons with M gen.
150
Q

Treatment of M. gen, abstinence and who to TOC.

A

Treatment of uncomplicated M.gen (urethritis, cervicitis):

  • Doxy 100mg BD 7D then azithromycin 1g stat then 500mg OD for 2d
  • Moxifloxacin 400mg OD 10d if known to be macrolide resistant or azithromycin has failed

Treatment of complicated (PID, EO):
- Moxifloxacin 400mg OD 14d

Pregnant:
3d azithromycin (moxiflox contraindicated)

Abstinence: at least 14 days after start of treatment

PN: current partners tested + treated

TOC: all patients

151
Q

Mechanisms of action of:

  • COC
  • POP
  • Mirena
  • IUD
  • Depo injection
A

COC: prevent ovulation by suppressing gonadotrophin
POP: increased cervical mucus (desogestrel also prevent ovulation)
Mirena: direct effect on endometrium, preventing implantation
IUD: prevent implantation
Depo: prevent ovulation (remember BMD issues)
Implant: prevent ovulation

152
Q

ART and contraceptive drug-drug interactions:

A
  • Depo injectable and LNG-IUS have not shown any interactions with any ARV
  • NRTI are really eliminated and NOT metabolised by CYP450 so can be used with all contraceptions
  • NNRTI, PI and elvitegravir boosted by cobi (not other INSTIs) MAY interact, either inhibit or induces CYP.
  • Concurrent use of EFV + NVP with hormonal contraception not recommended (except injection and LNG-IUS)
  • Etravirine + rilpivirine are ok
  • Darunavir, lopinavir NOT recommended (except depo + Milena)
  • Raltegravir and dolutegravir ok with all (elvitegravir with increased EE dose)
153
Q

EC in setting of ARVs:

A
  • If on liver enzyme inducers (EFV, NVP, etravirine) ideally IUD
  • If not, double dose levonorgestrel
  • UPA avoided in women on enzyme inducers in last 28 days
154
Q

Missed pill rules COC:

A

Missed in first week: EC considered if UPSI in pill-free interval or in first week of pill taking
Missed pill 2nd week (pills 8-14): no indication for EC if pills in preceding 7d taking correctly, but recommend condoms
Missed pill in third week (pills 15-21): omit pill free interval

155
Q

Enzyme inducing AEDs (make contraception less effective):

A

Carbamazepine
Phenytoin
Topiramate

156
Q

Breastfeeding and emergency contraception:

A

IUD - can have, slightly increased risk uterine perforation
If UPA, no breastfeeding for 1 week
Levonelle ok

157
Q

How long can DNA be gathered from in vaginal penetration, oral penetration and anal?

A

Vaginal: 7 days
Oral: 2 days
Anal: 3 days

DipGUM (2 decks)

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