GUM Flashcards
(214 cards)
1
Q
Symptoms of candidal vulvovaginitis
A
Soreness
Itching
Red skin - possible peeling, pustules or apples
White discharge
2
Q
When to refer candidal vulvovaginitis
A
Unclear diagnosis No improvement despite treatment Immunocompromised patient Systemic treatment needed Recurrent candida - specialist GUM clinic
3
Q
Treatment of candidal vulvovaginitis
A
Topical imidazole e.g clotrimazole, ketoconazole, econazole
Alternative = topical terbinafine
If problematic itch/ inflammation add mild steroid cream
If tx ineffective try - oral fluconazole 50mg 2-4 wks
4
Q
Types of candida species
A
Candida albicans Candida tropicalis Candida glabrata Candida krusei Candida parasilosis
5
Q
Common species involved in bacterial vaginosis
A
Gardnerella vaginalis
Mycoplasma hominis
Bacteroides
Mobilincus
6
Q
Which STI is a flagellate Protozoan
A
Trichomonas vaginalis
7
Q
Symptoms of Trichomonas vaginalis in women
A
10 - 50% asymptomatic non-specific symtoms Vaginal discharge Vulval soreness + itching Odour Discharge may be frothy / green Dysuria occasionally - low abdominal pain, vulval ulcers
8
Q
Diagnosis of Trichomonas vaginalis
A
Microscopy of vaginal discharge
and TV NAATs
9
Q
Treatment of Trichomonas vaginalis
A
Metronidazole (2g) single dose
Both partners simultaneously
10
Q
signs of TV on examination of female patients
A
Vaginal discharge in 70% Frothy yellow / green discharge Vulvitis Strawberry cervix (punctate haemorrhages) - 2% Frothy discharge 5-15% NAD
11
Q
Symptoms of TV in men
A
15 - 50% asymptomatic Urethral discharge dysuria Urethral irritation Urinary frequency
12
Q
signs of TV on examination of male patients
A
urethral discharge - 20-60%
No signs - up to 70%
rare - balanoposthitis
13
Q
what is balanoposthitis
A
inflammation of the foreskin and glans
14
Q
Complications of TV
A
impact on pregnancy - low birth weight, pre-term delivery, maternal post-partum sepsis
Association with HIV
May enhance HIV transmission
15
Q
diagnostic findings of TV on microscopy
A
detection of motile trichomonads by light field microscopy from wet prep slide
16
Q
general advice when treating TV
A
Treat both partners simultaneously
Avoid sexual intercourse until 1 week after both partners completed treatment
17
Q
Treatment used for TV
A
metronidazole 2g PO STAT
or metronidazole 400-500mg BD 5-7 days
Alternative = tinidazole 2g PO STAT (expensive)
18
Q
can metronidazole be used in pregnancy and breastfeeding
A
Safe in all trimesters
Non Teratogenic
Safe in breastfeeding but may affect milk taste (avoid STAT dose)
19
Q
Can tinidazole be used in pregnancy and breastfeeding
A
No - unsafe in animal trials
No evidence re human use in pregnancy and breastfeeding
20
Q
Treatment of TV in a HIV positive patient
A
Use metronidazole 500mg BD for 7 days
21
Q
what possible reaction should patients be warned about when taking metronidazole
A
disulfram-like reaction if taken with alcohol
Avoid all alcohol for duration of treatment and 48 hours afterwards
22
Q
causes of treatment failure in TV
A
inadequate therapy
re-infection
resistance
23
Q
Follow up recommendations for patient with TV
A
window period tests and bloods
No FU for TV unless symptoms continue
24
Q
treatment protocol for non-response to standard TV therapy
A
repeat 7 day course of metronidazole 500mg BD - 40% respond to second course
if 2nd regimen failed - use metronidazole 2g OD for 5-7 days
if 3rd regimen failed complete resistance testing and use tinidazole 1g BD - TDS for 14/7 and intravaginal tinidazole 500mg BD 14/7
25
Symptoms of bacterial vaginosis
Malodorous fishy discharge
Asymptomatic carriers
More prominent during menstruation
Cream / grey discharge - commonly adheres to wall of vagina
26
What do clue cells suggest
Bacterial vaginosis
| Clue cell = epithelial cell covered in bacteria
27
What is a clue cell
Clue cell = epithelial cell covered in bacteria
28
Management of bacterial vaginosis
metronidazole 400-500mg BD 5-7 days or metronidazole 2g PO STAT (not in pregnancy)
29
Problems with bacterial vaginosis in pregnancy
In 1st T can --> second trimester miscarriages or preterm labour
Treat with metronidazole
30
Which STI is a gram -ve diplococcus
Neisseria gonorrhoea
31
Symptoms of gonorrhoea
```
Asymptomatic
Increased vaginal discharge
Abdo / pelivic pain
Dysuria
Urethral discharge
Proctitis / rectal bleeding
Cervical bleeding on contact
Cervical excitation
```
32
Causes of cervical excitation
Ectopic pregnancy
PID
gonorrhoea
33
Treatment of gonorrhea
Uncomplicated ano-genital / pharyngeal infection
- IM ceftriaxone 1g intramuscularly
(Monotherapy 2019 guidelines)
- ciprofloxacin 500mg PO STAT if sensitivities from all sites are available before treatment
34
primary sites of infection of Gonorrhoea
```
columnar lined epithelium of
urethra
endocervix
rectum
pharynx
conjunctiva
```
35
Which STI is an obligate intracellular pathogen
Chlamydia
36
symptoms of male urethral gonorrhea
```
90% symptomatic
mucopurulent urethral discharge
+/- offensive smell
dysuria
rare - testicular / epididymal pain and swelling
```
37
signs of male urethral gonorrhoea
mucopurulent urethral discharge on examination
| Rare - tenderness of testicles / epididymis
38
Typical time frame for symptom development in men exposed to gonorrhoea
2-5 days
39
female presentation of urethral gonorrhoea
dysuria WITHOUT urinary frequency
| 50% of women with GC are asymptomatic
40
female symptoms of endocervical gonorrhoea
altered / increased discharge
lower abdominal pain
rare - IMB, PCB, HMB
50% of women with GC are asymptomatic
41
what proportion of men and women have symptoms with gonorrhoea
90% men
| 50% female
42
female signs of urethral gonorrhoea on examination
mucopurulent endocervical discharge
contact cervical bleeding
uncommon - pelvic tenderness
43
symptoms of rectal gonorroea
usually asymptomatic
anal discharge
peri-anal / anal pain
44
symptoms of pharyngeal gonorrhoea
usually asymptomatic
| sore throat
45
complications of gonorrhea infection
transluminal spread - epididymo-orchitis, prostatitis, PID
| Haematogenous dissemination - skin lesions, arthralgia, arthritis, tenosynovitis
46
features of gonorrhoea on microscopy
monomorphic gram-negative diplococci within polymorphonuclear leucocytes
47
when should microscopy got gonorrhoea be carried out
penile urethral discharge
| ano-rectal symptoms
48
what sample is used for GC testing in men
first pass urine NAAT
| +/- pharyngeal and rectal NAAT swab
49
what sample is used for GC testing in women
vulvovaginal swab NAATs
50
what sample is used for GC testing in hysterectomised women
vulvovaginal swab NAATs
| AND first pass urine
51
what is the role of cultures in gonorrhoea management
primary role is susceptibility testing
52
when should culture plates for gonorrhoea be taken
alongside NAATs if clinically suspected GC or a contact of GC
before treatment for GC diagnosed by NAATs
53
what percentage of gonorrhea patients have concurrent chlamydia
~20%
54
recommended testing for transgender patients after gential reconstruction surgery
transwomen - swabs of neovagina and first pass urine
Transmen - first pass urine of the neopenis
+/- pharyngeal and rectal
55
look back period for partner testing for a patient with TV
current partner and last 4 weeks
56
window period for CT and GC
2 weeks
57
treatment of gonorrhoea when anti-microbial sensitivities is not known
ceftriaxone 1g IM STAT
58
treatment of gonorrhoea when anti-microbial sensitivities are known
Ciprofloxacin 500mg STAT if sensitive at all sites
59
prevalence of ciprofloxacin resistant gonorrhea in the UK
~36%
60
serious side effects of quinolone and fluroquinolone antibiotics
```
prolonged (months -years)
serious, disabling and potentially irreversible drug reactions
Tendonitis / tendon rupture, Arthralgia
Gait disturbance, Neuropathies
Depression
Fatigue
Memory impairment
Sleep disorders
Impaired hearing / vision / taste / smell
```
61
In what patients should ciprofloxacin be used with caution (or avoided)
Older
Renal impairment
Solid organ transplantation Treated with a corticosteroid All are at higher risk of tendon damage
Avoid if previous adverse reaction with quinolone or fluroquinolone
62
When should fluroquinolone treatment (such as ciprofloxacin) be discontinued due to SE
First sign of tendon pain or inflammation
| consider stopping if symptoms of neuropathy - pain, burning, tingling, numbness/ weakness
63
treatment of gonorrhoea with penicillin allergy
ceftriaxone 1g IM STAT
| or cefixime 400mg PO STAT and azithromycin 2g PO STAT (only if IM refused or CI)
64
Treatment of gonorrhoea if IM treatment is refused or contraindicated
cefixime 400mg PO STAT
| AND azithromycin 2g PO STAT
65
treatment of gonoccocal PID
Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7
66
symptoms of PID
```
lower abdominal / pelvic pain
Deep dysparunia
PCB
IMB
HMB
Vaginal discharge
Fever / generally unwell
```
67
signs of PID
```
abdominal or pelvic tenderness
Adnexal tenderness
fever >38 degrees
Cervicitis
Mucopurulent discharge
```
68
management of gonococcal epididymo-orchitis
Ceftriaxone 1g IM STAT
| AND doxycycline 100mg BD 10-14 days
69
Management of gonoccocal conjunctivitis in adults
Ceftriaxone 1g IM STAT
| saline irrigation
70
management of disseminated gonoccocal infection
Ceftriaxone 1g IM or IV every 24 hrs
OR Cefotaxime 1g IV 8 hourly
OR ciprofloxacin 500mg IV 12 hourly if susceptible.
Switch to PO 24-48hrs after syx improving - total treatment 7/7 min
71
What PO medication can be used for disseminated gonoccocal infection 24-48 hours after symptoms start improving
after IV abx switch to PO 24-48 hours after syx improving
- Cefixime 400mg BD
- OR ciprofloxacin 500mg BD
- OR ofloxacin 400mg BD
72
Treatment of gonorrhoea in pregnancy
```
Pregnancy doesnt diminish treatment effect
AVOID ciprofloxacin or tetracyclines
1st = Ceftriaxone 1g IM STAT
or Spectinomycin 2g IM STAT
or Azithromycin 2g PO STAT
```
73
Treatment of gonorrhoea in HIV positive patients
HIV does not effect treatment
Ceftriaxone 1g IM
OR Ciprofloxacin 500mg STAT if sensitive at all sites
74
Treatment of gonorrhoea with co-existing chlamydia
Ceftriaxone 1g IM
OR Ciprofloxacin 500mg STAT if sensitive at all sites
AND doxycycline 100mg BD 7/7
75
Partner notification look back period for gonorrhoea
Symptomatic urethral infection in males - look back 2 weeks (or last partner if >2/52 ago)
All other sites of infection or asymptomatic patients - look back 3 months
76
Treatment of contacts of gonorrhoea
Window period is 2 weeks
If patient presents >2/52 after exposure treat only if positive test
If patient presents <2/52 consider epidemiological treatment, if asymptomatic consider repeat test once 2/52 and only treat if positive
77
Follow up and TOC for gonorrhea
ALL patients with GC should have a TOC at 14 days
Emphasis especially on:
- patients with persisting signs / symptoms.
- pharyngeal infection
- Treated with non-first line treatment
- infection acquired in Asia-Pacific area
78
What should be discussed at a FU visit after treatment of GC
```
TOC at 14/7 and repeat screening
Confirm treatment compliance
Ensure symptoms resolved
Enquire about adverse reactions
Sexual history to exclude re-infection or new infection
Pursue partner notification
Health promotion
```
79
When does PHE need to be notified of gonorrhea infections
If possible treatment failure / resistance
80
Symptoms / signs of chlamydia infection
```
Asymptomatic
Vaginal discharge
Lower abdo pain
Intermenstrual bleeding
Cervical discharge
Post-coital (contact) bleeding
Dysuria
Urethral discharge
```
81
Complications of chlamydia
```
PID
endometritis
salpingitis
tubal infertility
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome =peri-hepatitis
Neonatal or adult conjunctivitis
Neonatal pneumonia
conjunctivitis
Sexually acquired reactive arthritis
Epididymo-orchitis
```
82
what Serotypes and serovars of chlamydia exist
Genital chlamydial infection is caused by serotypes D–K. Serovars L1-L3 cause
LGV.
83
what is the rate of concomittant Mycoplasma Genitalium with chlamydia infection
3-15%
84
1st line treatment for uncomplicated chlamydia
Doxycycline 100mg BD 7/7
85
When is a TOC required for chlamydia infection
rectal chlamydia requires TOC at 3/52
| In pregnant women
86
treatment of chlamydia in pregnancy
Azithromycin 1g STAT and 500mg for 2/7
| TOC at 3/52
87
risk factors for chlamydia infection
Age <25yo
new sexual partner
>1 partner in 12m
Inconsistent condom use
88
Symptoms of chlamydia in women
```
Most Asymptomatic
Vaginal discharge
PCB
IMB
dysuria
lower abdominal / pelvic pain
deep dysparunia
```
89
Signs of chlamydia in women
Mucopurulent discharge
contact bleeding of cervix
pelvic tenderness
cervical motion tenderness
90
Symptoms of chlamydia in men
Asymptomatic
urethral discharge
dysuria
91
signs of chlamydia in men
urethral discharge
92
symptoms of rectal chlamydia
asymptomatic
anal discharge
anorectal discomfort
93
symptoms of pharyngeal chlamydia infections
usually asymptomatic
94
symptoms of chlamydia conjunctivitis in adults
```
usually unilateral (can be bilateral)
chronic, low grade irritation
```
95
% risk of developing PID after genital chlamydia infection
between 1-30%
96
what reproductive and gynecological morbidity is associated with symptomatic PID
tubal infertility
ectopic pregnancy
chronic pelvic pain
97
% of tubal infertility after CT PID
1-20%
98
symptoms of LGV
tenesmus
anorectal discharge - often bloody
anal discomfort
diarrhoea / altered bowel habit
99
When should testing for LGV be done?
any patient with symptoms of proctitis
| HIV positive MSM with CT at any site
100
management of chlamydia with and IUD / IUS in situ
doxycycline 100mg BD 7/7
| Leave IUCD in situ
101
2nd line treatment for uncomplicated chlamydia
Azithromycin 1g PO STAT and 500mg OD for 2/7
102
treatment of rectal chlamydia
Doxycycline 100mg BD 7/7
| and TOC at 3/52
103
treatment of pharyngeal or urethral / vulvo-vaginal chlamydia in HIV positive patients
1st line = Doxycycline 100mg BD 7/7
| 2nd line = Azithromycin 1g PO STAT and 500mg OD for 2/7
104
treatment of rectal chlamydia in HIV positive patients
if no result for LGV treat with 3/52 of Doxycycline 100mg BD
| and TOC
105
can ofloxacin be used in pregnancy
no
106
treatment of chlamydia in pregnancy
AVOID doxycyline or ofloxacin
| Azithromycin 1g STAT and 500mg OD 2/7
107
Common side effects of Azithromycin, erythromycin, doxycycline, ofloxacin and amoxicillin
GI upset - N+V
abdominal discomfort
Diarrhoea
108
What cardiac side effect can occur with azithromycin
prolongation of the QT interval
109
Advice for taking doxycycline
take with plenty of water or with food to avoid oesophageal irritation / dysphagia
Avoid sunlamps / sunbathing / strong sunlight
110
what group of patients who test positive for chlamydia are advised to be re-tested in 3-6months
<25yrs due to high rates of repeat infection
111
common manifestations of neonatal chlamydia from vertical transmission
opthalmia neonatorium
| pneumonia
112
treatment of neonatal chlamydia
PO erythromycin 50mg/kg/day given in 4 divided doses for 14 days
Topical treatment not required
OR azithromycin 20mg/kd/day PO for 3/7
113
Treatment of PID
Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7
114
look back period for partner notification for men with symptomatic urethral chlamydia
4 weeks before symptom onset and any partners since symptom onset / testing
115
look back period for partner notification for asymptomatic chlamydia
all contacts in preceding 6m
116
Possible complications of Intravenous drug
Multiple medical complications,
- cellulitis
- abscesses at injecting sites
- deep vein thrombosis
- pulmonary embolism
- bacterial endocarditis
- septic embolization
- rhabdomyolysis
- death through overdose or contamination with toxins.
Sharing needles and syringes contributes to the risk for
- HIV
- hepatitis B and C
- syphilis,
Other drugs such as cocaine, crack cocaine and crystal methamphetamine can lead to
- cardiovascular disease
- neurological disease
- immunosuppression
117
Potential medical benefits of circumcision
reduces the risk of penile cancer
reduces the risk of UTI
reduces the risk of acquiring sexually transmitted infections including HIV
118
Medical indications for circumcision
```
Medical indications for circumcision
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
```
119
What virus causes kaposi's sarcoma
Kaposi's sarcoma - caused by HHV-8 (human herpes virus 8)
120
presentation of Kaposi's sarcoma
Purple papules or plaques on the skin or mucosa
skin lesions may later ulcerate
respiratory involvement may cause massive haemoptysis and pleural effusion
121
Management of infants born to HBV +ve mothers
Infants of mothers who are hepatitis B surface antigen positive, or high risk of hepatitis B,
Should receive 1st dose HBV vaccine soon after birth
+ 0.5ml HBV immunoglobulin within 12 hours if mother is surface antigen positive
2nd HBV vaccine at 1-2 months and 3rd at 6 months.
122
Advice re breastfeeding for HBV +ve patients
hepatitis B cannot be transmitted via breastfeeding
123
What is epididymo-orchitis?
Pain, swelling, inflammation of the epididymis/ testis
124
What is the most common route of infection for epididymo-orchitis?
Local extension - from urethra (STIs) or bladder
125
Most common pathogen causing epididymo-orchitis in <35yo
CT
| GC
126
Most common pathogen causing epididymo-orchitis in >35yo
Gram negative enteric organisms causing UTIs
| Esp if recent catheterisation or instrumentation
127
What are possible infective causes of epididymo-orchitis?
```
STIs
UTI
TB
Mumps
Ureaplasma urealyticum
Mycoplasma genitalia
Brucellosis
Candida
```
128
possible non-infective causes of epididymo-orchitis?
Behçet's disease
| SE of amiodarone
129
Symptoms of epididymo-orchitis?
Unilateral scrotal pain and swelling
Relatively acute
If STI - urethritis / urethral discharge
Urinary symptoms
130
Symptoms of testicular torsion
Acute onset
Severe pain
Testicular swelling
Usually <20yo
131
Signs of epididymo-orchitis on examination
```
Tenderness on palpation
Swollen epididymis
May be - urethral discharge / secondary hydrocele
Erythema / oedema of scrotum
Pyrexia
```
132
Complications of epididymo-orchitis
Reactive hydrocele
Abscess
Infarction of testicle
Infertility
133
Investigations for epididymo-orchitis
Gram stained urethral smear - for urethritis
CT and GC NAATS
MCS of MSU
Full STI screen
If urinary tract pathogen is causative send for KUB uss
134
General advice for epididymo-orchitis
Rest
Analgesia - NSAID
Scrotal support
abstain from SI
135
What empirical treatment of epididymo-orchitis is recommended
If likely STI related - ceftriaxone 1g IM STAT
AND doxycycline 100mg po bd 14/7
If likely enteric organisms - ofloxacin 200mg BD 14/7
Or ciprofloxacin 500mg BD 10/7
136
Cefuroxime 1.5g TDS
| +/- gentamicin 3-5 days
What IV treatment is recommended for severe epididymo-orchitis
137
Management if epididymo-orchitis tenderness and swelling persists after antimicrobial treatment
Confirm compliance and sensitivities
If GC confirm TOC
Ref for testicular USS
138
Causative agents of PID
```
GC
CT
Gardnerella vaginalis
Anaerobes (prevotella, atopobium, leptotrichia)
Mycoplasma genitalium
```
Pathogen negative PID is common
139
Most common causative agent of PID
CT - 14-35%
140
Symptoms of PID
```
Low abdo pain
Vaginal discharge
Deep dysparunia
PCB
IMB
HMB
Secondary dysmenorrhea
```
141
Signs of PID
Low abdo tenderness - usually bilateral
Adnexal tenderness
Cervical motion tenderness
Fever >38 in moderate / severe disease
142
Complications of PID
```
More severe symptoms in women with HIV
Fitz-Curtis syndrome
Tubo-ovarian abscess
Future ectopic pregnancy
Future subfertility
Chronic pelvic pain
```
143
First line treatment of PID
IM ceftriaxone 1g STAT
And doxycycline 100mg BD
And metronidazole 400mg BD 14/7
144
When May IV treatment of PID be indicated
```
Severe disease
Lack of response to oral treatment
Pregnancy
Tubo-ovarian abscess
Intolerance of oral treatment
```
145
General management advice for PID
Rest if severe disease
Analgesia
Avoid sexual contact until treatment complete and partner treated
Explain condition and long term risks
146
Management of M. Gen PID
Moxifloxacin 400mg OD 14/7
147
Potential serious side effect of moxifloxacin
Serious Liver reaction (uncommon, no deaths reported)
| Disabling potentially permanent damage to tendons, muscles, joints and nervous system
148
Timeframe for M. Gen test of cure in PID
4 weeks
149
Treatment of gonorrhoea if anaphylaxis to any beta-lactam
Gentamycin 240mg IM STAT
| and 2g Azithromycin PO STAT
150
window period for STS
3 months (12/52)
151
window period for HIV
4weeks with 4th generation test
| otherwise 3m
152
Sexually transmitted causes of genital ulcers
```
Herpes Simplex
Syphilis
Chancroid
Granuloma inguinale
LGV
```
153
What % of patients with gonorrhoea are co-infected with chlamydia?
19%
154
Sensitivity of NAATs test for gonorrhoea
>95% sensitive for gonorrhoea in symptomatic and asymptomatic patients
155
Sensitivity of microscopy for gonorroea for:
- a penile sample with discharge
- Penile sample without discharge
- Penile sample with discharge = 90% sensitivity
| - Penile sample without discharge = 50 - 75% sensitivity
156
Sensitivity of microscopy for gonorroea for:
- Female urethral sample
- Endocervical sample
- Female urethral sample = 20% sensitivity
| - Endocervical sample = 37-50% sensitivity
157
Look back interval for PN for chancroid
10 days before symptoms
158
Look back interval for PN for CT
M with urethral symptoms - 4 weeks before symptoms
M without urethral symptoms / all F - last 6 months
159
Look back interval for PN for Epididymo-orchitis
If CT and GC +ve - use these look back intervals
If CT / GC negative - 6m before symptoms
160
Look back interval for PN for GC
M with urethral symptoms - 2 weeks before syx
| M without urethral symptoms / all F - last 3 months
161
Look back interval for PN for Hep A
With jaundice - 2 weeks before jaundice onset
without jaundice - try to estimate when infection occured and notify 2 weeks before
Inform PH if outbreak suspected
162
Look back interval for PN for Hep B
Any sexual contact or injection sharing person during the 2 weeks before jaundice onset
if no jaundice - estimate when infection likely or consider long look back
163
Look back interval for PN for Hep C
usually acute infection unknown
usually acquired by IVDU
or sexual contact where one of both partners is HIV positive
look back to likely time of infection
164
Look back interval for PN for HIV
estimate when infection likely to have occurred
Ask re possible sero-conversion type illness
PN for all contacts since and 3m before estimated date
or all prev partners since last negative test
165
Look back interval for PN for LGV
4 weeks before symptoms
166
Look back interval for PN for NGU
4 weeks before syx
167
Look back interval for PN for PID
if CT or GC +ve use these look back periods
Otherwise - 6m before symptom onset
168
Look back interval for PN for pubic lice
3m before symptoms
169
Look back interval for PN for scabies
all contacts - 2m before symptoms
| and non-sexual contacts with prolonged skin contact / share bed or clothes / towels
170
Look back interval for PN for STS
For early STS - primary - 3m before symtoms
Early STS - secondary and early latent - 2 years before symptoms
late latent STS / late STS - All partners since last negative STS test or lifetime if no prev test
171
Look back interval for PN for TV
4 weeks before symptoms
172
GC treatment
antimicrobial susceptibility is not known =
Ceftriaxone 1g IM STAT
If antimicrobial susceptibility known
Ciprofloxacin 500mg PO STAT
173
Alternative regimens for GC treatment
| if needle phobic or absolute CI to ceftriaxone / ciprofloxacin
Cefixime 400mg PO STAT + azithromycin 2g PO
Gentamicin 240mg IM STAT + azithromycin 2g PO
Spectinomycin 2g IM STAT + azithromycin 2g PO
Azithromycin 2g PO
174
CT treatment
Doxycycline 100mg PO BD 7/7 (CI in pregnancy)
Azithromycin 1g PO STAT then 500mg OD 2/7
175
Alternative tx for CT if doxy and azithro CI
Erythromycin 500mg BD PO 10–14 days
Ofloxacin 200mg BD or 400mg OD for 7/7
176
CT treatment in pregnancy
Avoid doxycyline and ofloxacin CI in pregnancy
```
Azithromycin 1g PO STAT and 500mg OD 2/7 d
or
Erythromycin 500mg QDS PO 7/7
or
Erythromycin 500mg BD 14/7
or
Amoxicillin 500mg TDS 7/7
```
177
When is TOC recommended for CT
- Pregnancy
- poor compliance suspected
- Symptoms persist
178
TREATMENT OF FIRST EPISODE NGU
Doxycycline 100mg twice daily for 7 days
179
Alternative treatment for NGU
Azithromycin 1g STAT then 500mg OD 2/7
or
Ofloxacin 200mg BD or 400mg OD 7/7
180
TREATMENT OF RECURRENT OR PERSISTENT NGU
| If treated with doxycycline regimen first line:
Azithromycin 1g STAT then 500 mg OD 2/7 d
PLUS metronidazole 400mg BD 5/7
Azithromycin should be started within 2 weeks of finishing doxycycline. This is not necessary if the person has tested Mgen-negative.
181
TREATMENT OF RECURRENT OR PERSISTENT NGU
| If treated with Azithromycin 1ST LINE
```
Moxifloxacin 400mg OD 10/7
AND metronidazole 400mg BD 5/7
or
Doxycycline 100mg BD 7/7
plus metronidazole 400mg BD 5/7
```
182
Indications for testing for M. genitalium
Based on symptoms - testing recommended ror
people with NGU
people with signs /symptoms of PID
Consider testing for
people with muco-purulent cervicitis / PCB
people with epididymitis
people with sexually-acquired proctitis
Based on risk factors: recommend testing for
current sexual partners of persons infected with M. genitalium
183
Specimen choice for M. genitalium testing
```
first void urine in cisgender men
vaginal swabs (clinician- or self-taken) in cisgender women
where possible - all M. genitalium-positive specimens be tested for macrolide resistance mediating mutations
```
184
Treatment of uncomplicated urogenital M. genitalium
M. genitalium urethritis / cervicitis - treat with
Doxycycline 100mg BD 7/7 days
followed by azithromycin 1g PO STAT then 500mg PO OD 2/7
or
Use Moxifloxacin 400mg PO OD 10/7 if known macrolide-resistant or treatment with azithromycin failed
Treatment of complicated M. genitalium urogenital infection = PID / epididymo-orchitis
Moxifloxacin 400mg PO OD 14/7
185
Treatment of uncomplicated urogenital M. genitalium in pregnancy / breastfeeding
azithromycin 1g PO STAT then 500mg PO OD 2/7
Moxifloxacin is CI
Doxycycline considered safe in first trimester by FDA but BNF advises against it
186
Treatment of TV
Metronidazole 2g PO STAT
or
Metronidazole 400-500mg BD 5-7 days
Alternative - Tinidazole 2g PO STAT
187
When is treatment for BV indicated?
Symptomatic women
Women undergoing some surgical procedures
Pregnant women <20/40 with additional risk factors for preterm birth - may benefit
Women who do not volunteer symptoms may elect to take treatment if offered - may report a beneficial change in their discharge following treatment
188
treatment of BV
Metronidazole 400mg BD 5-7 days
Or
Metronidazole 2 g PO STAT
or
Intravaginal metronidazole gel (0.75%) OD 5/7 days
or
Intravaginal clindamycin cream (2%) OD 7 days
189
Managing recurrent BV
Suppressive 0.75% metronidazole vaginal gel - 2x per wk for 16 weeks
Probiotic therapy - probiotic lactobacilli applied daily
Antibiotics and probiotic therapy
clindamycin cream and lactobacilli
Lactic acid gel (or acetic acid gel - no longer available in UK) - not been evaluated adequately in well designed RCTs
190
General advice for 1st episode anogenital HSV
. Saline bathing
. Analgesia
. Topical anaesthetic agents, e.g. 5% lidocaine ointment esp prior to micturition
191
Antiviral treatment for HSV
Oral antiviral drugs indicated within 5 days of start of episode - while new lesions still forming or if systemic symptoms persist.
Aciclovir, valaciclovir, and famciclovir all effective
Aciclovir 400 mg TDS 5/7
Valaciclovir 500 mg BD 5/7
Review after 5 days + continue if new lesions still appearing or systemic symptoms still present
192
When may hospitalisation be required for HSV
Management of complications
- urinary retention
- meningism
- severe constitutional symptoms.
193
Episodic treatment for recurrent HSV
reduction in duration is 1–2 days.
Patient-initiated treatment started early is most effective
Treatment prior to the development of papules is best
- Aciclovir 800 mg TDS for 2 days
- Famciclovir 1 g BD for 1 day
- Valaciclovir 500 mg BD for 3 days
194
When is suppressive treatment indicated for recurrent HSV
six recurrences per annum
or
patients suffering from psychological morbidity for who the diagnosis causes significant anxiety
195
Recommended regimens for suppressive treatment for HSV
Recommended regimens
- Aciclovir 400 mg BD or 200mg QDS
- Valaciclovir 500 mg OD
- Famciclovir 250 mg BD (expensive)
196
Management of recurrent HSV in pregnancy
Recurrent HSV - treat with Aciclovir 400 mg TDS 5/7
Consider aciclovir 400 mg TDS from 36/40 gestation
197
Management of Primary acquisition of HSV in pregnancy
1st /2nd trimester - treat with Aciclovir 400 mg TDS 5/7
Consider aciclovir 400 mg TDS from 36/40 gestation
3rd trimester - treat with Aciclovir 400 mg TDS 5/7
Consider Aciclovir 400 mg TDS until delivery
Recommend planned CS - esp if within 6/52 of delivery
Inform neonatologist - monitor for 24hr - if well - home
198
Clinical features of primary STS
Primary Syphilis
Incubation 21 days
Signs - Chancre (develops from a single papule)
Anogenital, single, painless and indurated with clean base, non-purulent
Can be multiple, painful and purulent
Resolve over 3-8 weeks
199
Clinical features of secondary syphilis
secondary syphilis
If primary syphilis untreated - 25% develop secondary syphilis
Occurs 4-10 weeks after initial chancre
Multi-system
Signs - Rash / Widespread mucocutaneous - May be itchy - Can affect palms and soles
Mucous patches (buccal, lingual and genital)
Condylomata lata (higly infectious, mainly affecting perineum and anus)
Hepatitis
Splenomegaly
Glomerulonephritis
Neurological complications
Acute meningitis
Cranial nerve palsies
Uveitis
Optic neuropathy
Interstitial keratitis and retinal involvement
200
Clinical features of latent STS
Latent disease
Secondary syphilis will resolve spontaneously in 3–12 weeks
Disease enters an asymptomatic latent stage
Approximately 25% will develop a recurrence of secondary disease during the early latent stage
201
Clinical features of Late (tertiary) STS
Occurs in approximately 1/3 untreated patients
20-40 years after intial infection
Divided into gummatous, cardiovascular and neurological complications.
202
Clinical features of Early Congenital syphilis
Early (within two years of birth) Congenital syphilis
2/3 will be asymptomatic at birth but develop signs within 5 weeks
```
Common:
rash
haemorrhagic rhinitis
generalised lymphadenopathy
hepatosplenomegaly
skeletal abnormalities
```
```
Other signs:
condylomata lata
vesiculobullous lesions
osteochondritis / periostitis
pseudoparalysis
mucous patches
perioral fissures
non-immune hydrops
glomerulonephritis
neurological ocular involvement,
haemolysis / thrombocytopenia
```
203
Clinical features of late Congenital syphilis
late Congenital syphilis (after two years)
```
interstitial keratitis;
Clutton’s joints;
Hutchinson’s incisors;
mulberry molars (
high palatal arch;
rhagades (peri-oralfissures);
sensineural deafness;
frontal bossing;
short maxilla;
protuberance of mandible;
saddle-nose deformity;
sterno-clavicular thickening;
paroxysmal cold haemoglobinuria;
neurological involvement
(intellectual disability, cranial nerve palsies)
```
204
STS serology
EIA +ve
TPHA / TPPA +ve
RPR ≤16
Consistent with treponemal infection at some time.
Could be consistent with recent infection if
seroconversion,
repeat test to look for a four-fold rise in RPR titre
RPR titre ≤16 does not exclude active infection
especially if signs of syphilis or if
adequate treatment of prev dx is not documented / unknown
205
STS serology
EIA +ve
TPHA / TPPA +ve
RPR >16
recent or active treponemal infection
206
STS serology
EIA +ve
TPHA / TPPA -ve
Request further sample for repeat testing - to confirm
207
STS serology
| with persisting RPR titre of >16
persisting RPR titre of >16 is seldom seen in patients with adequately treated infection.
Failure to achieve a fourfold fall in RPR titre by six months post-treatment
or an eightfold fall by one year post-treatment
raises concerns about treatment failure or reinfection.
A significant rise in RPR titre suggests reinfection
208
Follow up testing advice after STS treatment
suggested at 3, 6, 9 and 12 months.
RPR titre is expected to decline at least fourfold by 6 months after treatment of primary, secondary and early latent syphilis.
Further FU if necessary 6-monthly until RPR negative or serofast
no clear criterion for serological response in late latent syphilis
209
Serology results suggestive of early congenital syphilis
```
Do not use cord blood
IgM +ve
RPR - +ve with titre ≥4 times higher than mother’s RPR
titre
TPPA - +ve
```
Repeat to confirm and use RPR to monitor response to treatment
210
Treatment of Early syphilis (primary, secondary and early latent)
```
Early syphilis (primary, secondary and early latent)
Benzathine penicillin G 2.4 MU IM single dose
```
211
Treatment of Neurosyphilis
| including neurological/ophthalmic involvement in early syphilis
```
Procaine penicillin 1.8 MU–2.4 MU IM OD
plus
probenecid 500mg PO QDS for 14 days
or
Benzylpenicillin 1.8–2.4g IV every 4h for 14 days
```
212
define Late latent syphilis
Late latent syphilis: asymptomatic syphilis of two years' duration or longer
213
Treatment of late latent, cardiovascular and gummatous syphilis
Benzathine penicillin 2.4 MU IM weekly for three weeks (three doses)
214
what is the Jarisch-Herxheimer reaction
Reaction to syphilis treatment
Jarisch-Herxheimer reaction = acute febrile illness
headache, myalgia, chills and rigours
resolves within 24 hours
