Infections

Question 1

Cause of candidiasis

Answer 1

MC after abx which destroy the nl vaginal flora

Question 2

When should one suspect HIV/AIDS or diabetes with candidiasis?

Answer 2

Multiple episodes, esp without antibiotic insult

Question 3

Confirmation of candidiasis

Answer 3

Wet prep- will see budding and hyphae

Question 4

Tx of chronic candidiasis

Answer 4

Diflucan 150 mg weekly for 6 mos

Question 5

Tx of candidiasis

Answer 5

Oral Diflucan or topical agents

Question 6

Cause of atrophic vaginitis

Answer 6

Lack of estrogen support either d/t menopause or surgical removal of the ovaries or other hypoestrogenic states
Significant cause of dyspareunia

Question 7

Tx of atrophic vaginitis

Answer 7

Oral hormone therapy if no contraindications or estrogen replacement cream or Osphena (similar CIs to oral estrogens)

Question 8

Organism of trichomoniasis

Answer 8

Trichomonas vaginalis

Question 9

S/sx of trichomoniasis

Answer 9

Frothy, yellow-green vaginal d/c with strong odor
May cause discomfort during intercourse and urination and itching of the female genital area
Rarely, lower abdominal pain

Question 10

PE of trichomoniasis

Answer 10

Vaginal walls and cervix may appear red and irritated

Cervix may have surface hemorrhages or petechiae causing a “strawberry” appearance

Question 11

Tx for trichomoniasis

Answer 11

Metronidazole 2 gm PO x 1 (or 500 mg BID x 7) is commonly used
Alcohol while taking the med and for 48 hrs afterwards is contraindicated
Avoid sexual intercourse until tx is completed
Treat sexual partners

Question 12

What is the MC vaginal infection in women of childbearing age?

Answer 12

Bacterial vaginosis

Question 13

S/sx of bacterial baginosis

Answer 13

Some women have no sx
Others complain of a foul fishy odor, particularly during their period or after intercourse
D/c may be white or gray.
May cause burning and/or itching

Question 14

Dx of bacterial vaginosis

Answer 14

Wet prep/KOH whiff test

Question 15

Tx of bacterial vaginosis

Answer 15

May treat with topical or oral meds (metronidazole tablets or gel, Clindamycin gel)

Question 16

RFs for BV

Answer 16

Abx
Douching
Vaginal lubricants
Some spermicides
Anal sex

Question 17

What is the second most commonly reported notifiable dz in the US?

Answer 17

Gonorrhea

Question 18

Sx of gonorrhea

Answer 18

In women, the sx of gonorrhea are often mild and can be mistaken for bladder or vaginal infection
Initial sx may include a painful or burning sensation when urinating
Increased vaginal d/c
Vaginal bleeding between periods

Question 19

Complications of gonorrhea

Answer 19

Left untreated:

• Sepsis
• Gonococcal arthritis
• Fitz-Hugh-Curtis syndrome

Question 20

Details of septic arthritis

Answer 20

Fever, joint pain, limited ROM, purulent aspirate
CBC, ESR or CRP, admit
Tx requires 2 wks of IV abx

Question 21

Fitz-Hugh-Curtis syndrome

Answer 21

AKA perihepatitis
Severe RUQ pain in addition to PID sx
Caused by violin string adhesions under liver

Question 22

Dx of gonorrhea

Answer 22

Through culture of pharynx, vagina, penis or rectum

Wet prep will show TNTC (too numerous to count) WBCs

Question 23

Tx of gonorrhea

Answer 23

Ceftriaxone 250 mg IM single dose
PLUS
Azithromycin 1 g orally x 1
Once tx is completed, the woman should be retested to ensure complete cure (test of cure) in 3 mos or if she returns for clinic for any reason within 12 mos post-tx

Question 24

What is the most frequently reported bacterial STI in the US?

Answer 24

Chlamydia

Question 25

When should chlamydia be suspected?

Answer 25

Frequently has no sx or has very mild sx If pt has deep internal pain with intercourse. With bimanual exam she will experience intense pain with manipulation of the cervix (chandelier sign)

Question 26

Dx of chlamydia

Answer 26

Urine (high false-neg) or culture taken from the ectocervix or vagina

Question 27

Complications of chlamydia

Answer 27

``` Cervicitis Endometritis PID Urethritis Epididymitis Neonatal conjunctivitis Pediatric PNA Reiter syndrome ```

Question 28

Tx of chlamydia

Answer 28

Azithromycin 1 g PO in single dose OR Doxycycline 100 mg PO BID x 7 days (not OK in pregnancy)

Question 29

What anatomic locations are included with PID?

Answer 29

``` Endometrium Oviducts Ovaries Uterine wall Uterine serosa and broad ligaments Pelvic peritoneum Also, a TOA may form ```

Question 30

Dx of PID

Answer 30

Difficult to diagnose bc of the wide variation in s/sx Many women have subtle or mild signs Usually based on clinical findings Delay in dx and tx probably contributes to inflammatory sequelae in the upper reproductive tract

Question 31

When should empiric tx of PID be initiated?

Answer 31

Sexually active young women and other women at risk for STIs if they are experiencing; 1. Pelvic or lower abd pain 2. If no cause for illness other than PID can be Id-ed 3. AND if one or more of the following minimum criteria are present on pelvic exam: - Cervical motion tenderness - Uterine tenderness - Adnexal tenderness

Question 32

What additional criteria can be used to support a dx of PID?

Answer 32

Oral temp >101 F Abnl cervical or vaginal mucopurulent d/c Presence of abundant numbers of WBC on wet prep Elevated ESR Elevated CRP Lab documentation of cervical infection with N. gonorrhea or C. trachomatis

Question 33

MC organisms of PID

Answer 33

MC are gonorrhea and chlamydia | Usually polymicrobial in nature

Question 34

Other organisms of PID

Answer 34

Ureaplasma urealyticum Mycoplasma genitalium Trichomonas vaginalis Gardnerella vaginalis

Question 35

Long-term consequences of PID

Answer 35

``` MC and serious are tubal factor infertility and ectopic pregnancy Other sequelae: Chronic pelvic pain Dyspareunia Menstrual disturbances Pelvic adhesions ```

Question 36

Outpatient tx for PID

Answer 36

Ceftriaxone 250 mg IM PLUS doxycycline 100 mg PO BID x 14 days with or without metronidazole 500 mg PO BID x 14 days OR Cefoxitin 2 g IM single dose and probenecid 1 g orally administered concurrently in a single dose plus doxycycline 100 mg PO BID x 14 days with or without metronidazole 500 mg PO BID x 14 days OR other parenteral third-gen cephalosporine plus doxycycline 100 mg PO BID x 14 days with or without metronidazole 500 mg PO BID x 14 days

Question 37

When should PID pts be hospitalized?

Answer 37

Surgical emergencies Pt is pregnant Pt does not respond clinically to oral antimicrobial therapy Pt is unable to follow or tolerate and outpatient oral regimen Pt has severe illness, nausea and vomiting, or high fever Pt has TOA

Question 38

PID inpatient tx

Answer 38

Regimen A: Cefotetan 2 g IV q12h OR cefoxitin 2 g IV q6h plus doxycycline 100 mgm PO or IV q12 hrs Regimen B: Clindamycin 200 mg IV q8h plus gentamicin loading dose IV or IM (2 mg/kg of body wt) followed by a maintenance dose (1.5 mg/kg) q8h

Question 39

Ways to get a PID partner treated

Answer 39

Pt referral: ask pt to notify partner and ensure tx or have pt bring partner for concurrent tx Expedited partner tx: pt delivered partner tx or health department field-delivered tx or call in Rx for him at pharmacy Provider referral for partner Health department referral for partner

Question 40

Genital HSV causative organisms

Answer 40

HSV-1 or HSV-2

Question 41

Presentation of genital HSV

Answer 41

Blisters and ulcerated sores around genitals and anus

Question 42

Dx of genital HSV

Answer 42

Can be confirmed by viral culture or Tzanck smear

Question 43

Tx of genital HSV

Answer 43

Acyclovir Famiclovir OR Valacyclovir

Question 44

Transmission of syphilis

Answer 44

Passed through direct contact with a syphilis sore or contact with condylomata lata. Sores are generally on the external genitalia

Question 45

Presentation of primary syphilis

Answer 45

Initially presents as a firm, round, painless nodule, called a chancre, where the syphilis entered the body Lasts 3-6 wks and will resolve with tx If it is not treated it then proceeds to secondary syphilis

Question 46

Sx of secondary syphilis

Answer 46

``` Condyloma lata lesions in moist areas Rash usually on the palms of the hands and soles of the feet, but may be on other parts of the body. Often described as "copper penny" colored lesions Fever Swollen LNs Sore throat HAs Muscle aches Wt loss Sx resolve with or without tx, but without tx will progress to latent or late stage syphilis ```

Question 47

Latent and late stage syphilis

Answer 47

Latent stage can last for years Late stages can appear 10-20 years after infection was first acquired In late stages, dz may subsequently damage internal organs, including brain, nerves, eyes, heart, blood vessels, liver, bones, and joints

Question 48

S/sx of late stage of syphilis

Answer 48

``` Appearance of soft rubbery tumors called gummas Difficulty coordinating muscle movements Paralysis Numbness Blindness Dementia ```

Question 49

Definitive dx of syphilis

Answer 49

Darkfield examinations and direct fluorescent antibody tests of lesion exudate or tissue

Question 50

Presumptive dx of syphilis

Answer 50

``` Nontreponemal tests (VDRL and RPR) measured in titers OR Treponemal tests (FTA-ABS and TP-PA) If one type is positive the lab should confirm with the other ```

Question 51

Tx of syphilis

Answer 51

PCN G 2.4 million units IM in a single dose is preferred for tx of primary, secondary and early latent stages Late latent or unknown duration should be treated with 2.4 million units weekly x 3 doses Neurosyphilis: aqueous crystalline PCN G 3-4 million units IV q4h for 10-14 days

Question 52

All pts with syphilis should be tested for what?

Answer 52

HIV