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OB/GYN > STIs - Zarnek > Flashcards

STIs - Zarnek Flashcards

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1
Q

Who is at higher risk?

A

Young (13-24 yo), pregnancy women, MSM

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2
Q

Which STIs are notifiable infections?

A

Chlamydia, gonorrhea, syphilis, HIV, and Hep B

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3
Q

What is the first test to get in all women of childbearing age? Why?

A
  • Urine or serum beta-HCG
  • Pregnancy alters diagnostic and treatment options
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4
Q

Counseling for STIs?

A
  1. Prevention
  2. Co-infection risks
  3. Follow up for symptoms
  4. Treatment compliance
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5
Q

What history components should you collect in a patient with STI?

A
  1. LMP and OB Hx.
  2. Recent sex hx and type (vaginal, anal, oral).
  3. Use of contraceptives, douches, or tampons.
  4. Recent changes in meds or abx.
  5. Symptoms (pain, burning, itching). Discharge volume and odor.
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6
Q

Etiology Trichomoniasis

A

Trichomonas vaginalis - pear-shaped flagellated protozoa

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7
Q

S/S Trichomoniasis

A

Asx. Sx: vulvar pruritis and erythema. Dysuria. Dyspareunia.

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8
Q

Exam findings Trichomoniasis

A
  • Copious, malodorous discharge. Frothy, yellow-green discharge (worse with menses).
  • Strawberry cervix/cervical petechiae.
  • Diffuse vaginal erythema.

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9
Q

Diagnostics Trichomoniasis

A
  • pH >4.5.
  • Wet prep mount with mobile flagella.
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10
Q

What is the first line tx Trichomoniasis and alt tx?

A
  • Metronidazole 2g PO once
    • Alt: Tinidazole
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11
Q

What should you do if trichomoniasis tx fails?

A
  1. Metronidazole 500mg BID PO for 7 days
  2. Metronidazole 2g PO QD for 5 days
  3. Tinidazole 2g PO single dose or 2g PO QD for 5 days
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12
Q

Complications of Trichomoniasis?

A
  1. Perinatal complications: PROM, preterm labor, low birth weight, neonatal transmission
  2. Increased HIV transmission
  3. Increased risk of PID (esp with HIV)
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13
Q

Screening Trichomoniasis

A
  • Women with high risk
  • HIV+ person: entry to care and then annually
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14
Q

Metronidazole A/E, BBW, CI

A
  • A/E:
    • Disulfiram rxn with ethanol: flushing, hypotension, hang-over like sxs
    • Hepatic impairment
  • BBW: carcinogenic effects
  • CI: 1st trimester
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15
Q

Etiology Chlamydia

A

Chlamydia trachomatis - gram negative

MCC of cervicitis and STI in men/women

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16
Q

S/S Chlamydia

A

Asx.

Sx: mucopurulent cervicitis, increased urinary frequency and dysuria. Abdominal pain, PID, post-coital bleeding. Epididymitis in males.

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17
Q

Diagnostics Chlamydia

A
  1. LCR test
  2. Culture
  3. DNA probe
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18
Q

1st line tx Chlamydia, alt, and 2nd line tx? Pt ed? When do we re-test?

A
  1. Azithromycin 1g PO (safe in pregnancy!)​
    • Alt: Doxycycline 100mg BID for 7 days (chlamydia suspected PID)
  2. Erythromycin, levofloxacin
  3. Abstain from sex for 7 days after tx completion and sxs resolution
  4. 3 weeks later. Test for cure in pregnancy, persitent sxs, or alt regimen used.
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19
Q

Which STIs require partner expedited therapy?

A
  1. Gonorrhea
  2. Chlamydia
  3. Trichomoniasis
  4. Syphilis - partners in last 90 days
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20
Q

Prevention for Chlamydia

A
  1. Avoid intercourse for 7 days after tx
  2. Use condoms, limit partners
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21
Q

Complications Chlamydia

A
  • PID, infertility, ectopic pregnancy, premature labor
  • Bartholin duct cyst and abscess
  • Lymphogranuloma venereum (LGV) in developing countries (painless genital ulcers)
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22
Q

Screening Chlamydia

A
  1. Sexually active women <25 yo
  2. Sexually active women ≥25 yo if increased risk
  3. Pregnant <25, ≥25 if increased risk. Test of cure 3-4 wks after tx.
  4. MSM annually, q3-6 months with increased risk
  5. HIV+ persons annually
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23
Q

Etiology gonorrhea

A

Neisseria gonorrhea - gram negative diplococci

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24
Q

S/S Gonorrhea

A

Asx.

Sx: Purulent vaginal discharge and cervicitis. Increased urinary frequency and dysuria. Pharyngeal infection, proctitis, and epididymitis (M).

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25
Diagnostics gonorrhea
1. Culture 2. DNA
26
1st line tx Gonorrhea and Alt? Co-infection? Test for cure?
1. Ceftriaxone 250mg **IM** * Alt: Cefixime 2. Co-infection w/ chlamydia: + Azithromycin 1g PO once. "a shot and a gram" 3. No test for cure unless alt regimen used.
27
GC/CA?
**G**onorrhea tx: **C**eftriaxone IM **C**hlamydia tx: **A**zithromycin PO
28
Complications Gonorrhea
* PID, infertility, ectopic pregnancy * Disseminated gonorrhea
29
Screening Gonorrhea
1. Women: sexually active \<25, ≥25 if increased risk 2. Pregnant: \<25, ≥25 if increased risk 3. MSM: annually 4. HIV+ person: annually
30
Etiology Chancroid
Haemophilus ducreyi - gram negative bacillus
31
S/S Chancroid
* **Painful** genital ulcer. Soft, shallow. +/- foul discharge. * +/- small vesicles on papules * **Painful** inguinal lymphadenopathy ![]() ![]()
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Diagnostics Chancroid
1. Clinical 2. Culture to r/o HSV and syphilis
33
1st line tx of Chancroid? Alts? Pregnancy tx?
1. Azithromycin 1g PO * Alt: Ceftriaxone 250mg IM *= tx of choice in pregnancy!* * Alt: Erythromycin 500mg PO TID for 7days * Alt: Ciprofloxacin 500mh PO BID for 3 days
34
Complications Chancroid
Secondary infection, scarring
35
Etiology HPV? oncogenic and genital warts strains?
* HPV Virus * Oncogenic: 16, 18, 31, 33, 35 * Genital warts: 6 and 11
36
S/S HPV
Asx Sx: Flat, pedunculated or flesh-colored growths. (Cauliflower like). Post-coital bleeding. ![]()
37
Diagnostics HPV
1. Clinical 2. Whitening w/ 4% acetic acid application 3. Colposcopy
38
Condylomata Acuminata sites, etiology, exam
Genital Warts * Sites: vulva, perianal area, vaginal walls, cervix * HPV 6 and 11 * Exam: vulvar lesions that are wart-like. Diffuse hypertrophy or cobblestoning.
39
Tx options HPV (7)
1. _Trichloracetic acid_ or _Bichloracetic_ carefully applied to lesion. Lesson pain with sodium bicarbonate paste. 2. _Podophyllin resin_ - **do not** use in pregnancy or on a bleeding lesion. 3. _Cryotherapy_ - only a few lesions 4. _Surgery_ 5. _CO2 laser_ - extensive warts 6. _Podofilox_ 5% solution/gel - pt applied 7. _Imiquimod_ 5% cream - pt applied
40
Complications HPV
Cervical dysplasia, cervical cancer, associated w/ oropharyngeal and anal cancer
41
Screening HPV
* Women 21-29 pap q3 years * Women 30-65 cytology q3 years. Or q5 years with combo pap and cytology. * Pregnant: same screening as nonpregnant. * HIV+ person: screen w/in 1 year of HIV infection with cytology. repeat in 6 months.
42
Etiology Syphilis
Treponema pallidum - spirochete that enters skin through mucous membranes.
43
S/S Congenital Syphilis
1. Hutchinson teeth (notches on teeth) 2. Saddle-nose deformity 3. ToRCH syndrome (deaf)
44
S/S and phases of Syphilis
1. Primary Chancre - **painless** genital ulcer. **non-tender** regional lymphadenopathy. 3-4 wks. 2. Secondary - **maculopapular rash** (palms/soles), condyloma lata (wart-like genital lesions), systemic sxs (fever, HA, arthritis) wks-6 months. 3. Tertiary/Latent - 3-20 years after infection
45
Tertiary/Latent Phase findings of syphilis (5)
1. _Gumma_: non-cancerous granulomas 2. _Neurosyphilis_: HA, vision or hearing loss, incontinence 3. _Tabes dorsalis_: demyelination of posterior columns → ataxia, burning pain, weakness 4. _Argyll Robertson Pupil_: small, irregular pupils. Constrict normally to near accommodation, but **not** to light. 5. _Cardiovascular_: aortic regurgitation, aortitis, aortic aneurysm
46
Diagnostics Syphilis
* Darkfield microscopy for chancre or condyloma lata * CDRL/RPR * **Confirmatory test:** FTA (fluorescent treponemal antibody)
47
Tx Syphilis? Alt? Tertiary? Pregnancy?
1. Penicillin G 2.4 U IM once * Alt: Doxycycline BID x 2 weeks 2. Tertiary syphilis: 2.4 U penicillin IM weekly for 3 weeks 3. Penicillin in pregnancy. If allergic to penicillin must desensitize and teat.
48
Syphilis Reaction - Jarish Herxheimer Reaction
* Happens during tx of early syphilis * Results from endotoxin and cytokine release * S/S: acute febrile reaction with HA and myalgias w/in 24 hours of tx
49
Screening syphilis
* Pregnant: 1st prenatal visit. Retest 3rd trimester if high risk * MSM: annually. Q 3-6 months if high risk. * HIV+ person: annually
50
S/S and prodrome HPV
* HSV 1 = oral lesions * HSV 2 = genital lesions * Prodrome for 2-24 hours: Regional pain, tingling, burning. Constitutional symptoms of HA, fever, painful lymphadenopathy, anorexia, and malaise. * Sx: Papules and vesicles on erythematous base and erode. Lesions are **painful.** Serous discharge. ![]()
51
Diagnostics HSV
* Cell culture and PCR testing if active lesions. Unroof vesicles for fluid culture. * PCR based testing - greatest sensitivity and specificity. Determines type of HSV and can detect asx shedding. * Tzanck test * HSV serologic testing
52
Tx HSV
* First episode: Acyclovir, **Valacyclovir**, Famciclovir * Recurrence: 5 day tx * Suppression therapy if sxs if \>6 episodes per year * Severe, recurrent: Acyclovir IV for 2 days, switch to oral therapy.
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Screening HIV
* Men and Women 13-64, all women seeking STI tx * Pregnant: first prenatal visit, retest 3rd trimester if high risk * MSM: annually
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Screening Hep B
* Men and Women at increased risk * Pregnant: Test for HBsAg at 1st prenatal visit * MSM: Test for HBsAg * HIV+ person: Test for HBsAg and anti-HBc +/- anti-HBs
55
Etiology Vaginitis
* Infectious: bacterial, trichomoniasis, candida, HSV, cytolytic * Non-infectious: Atrophy, irritant/allergic reaction, excessive sexual activity, pregnancy
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S/S and Tx Vaginitis
Vaginal burning or itching. Vaginal pain. Vaginal discharge. Tx underlying cause
57
Cytolytic Vaginitis - Etiology, S/S, Exam, Dx, Tx
* _Etiology_: overgrowth of lactobacilli * _S/S_: vaginal/vulvar itching or burning * _Exam_: **non-odorous discharge**, white to opaque * _Dx_: normal pH 3.8-4.2, copious lactobacilli, large numbers of epithelial cells * _Tx_: Discontinue tampon use, sitz bath with sodium bicarbonate
58
Cervicitis - path, etiology
* _Path:_ Purulent, endocervical exudate. easily induced endocervical bleeding. * _Etiology:_ local trauma, radiation, chemical irritation, malignancy, STIs
59
Cervicitis - S/S, Exam
* ![]()_S/S_: vaginal discharge, dysuria, urinary frequency, **intermenstrual bleeding, post-coital bleeding** * _Exam_: erythematous, edematous, easily friable cervix. Mucopurulent cervicitis is **thick, yellow-green pus** in the os or on endocervical swab.
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Cervicitis - Tx
* Treat underlying cause * Azithromycin 1g PO once + doxycycline 100mg PO BID for 7 days * Can do tx for gonorrhea and chlamydia if high risk
61
PID - etiology, RF
* _Etiology_: Polymicrobial infection mcly gonorrhea and chlamydia, anerobes, H. flu. * _RF_: multiple sex partners, unprotected sex, prior PID, young, nulliparous
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PID - S/S, Exam
* _S/S_: Pelvic, lower abdominal, and back pain. Dysuria, dyspareunia, vaginal discharge, N/V, fever, menstrual disturbance, and post-coital bleeding. * _Exam_: **Chandelier sign**, lower abdominal tenderness, fever, purulent cervical discharge, adnexal tenderness. * **Abdominal tenderness** * **Adnexal mass** * **Cervical motion tenderness**
63
PID - Dx, Tx
* _Dx_: pelvic US, laparoscopy, test for HIV * _Tx_: **Doxycycline** 100mg PO BID for 14 days + **Ceftriaxone** (250mg IM) * + **Metronidazole** 500 mg PO BID for 14 days if BV
64
PID Inpt Tx
* **Cefoxitin** 2g IV q6h + **doxycycline** 100mg PO or IV q12h * Clindamycin 900mg IV q8h + Gentamivin IV * Alt: Ampicillin-Sulfabactam + Doxycyline
65
PID - complications
* Tubo-ovarian abscess (TOA) * sepsis, **ectopic pregnancy, infertility** * Chronic pelvic pain * Fitz-Hugh Curtis syndrome (hepatic capsule enhancement)
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Tubo-Ovarian Abscess (TOA) - S/S, Tx
* PID complication * _S/S_: fever, leukocytosis, lower abdominal pain, vaginal discharge * _Tx_: Admit for abx (ampicillin/sulbactam = Unasyn + Doxy) * remove abscess, affected ovary and fallopian tube
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Fitz-Hugh Curtis Syndrome
* PID complicaiton * Inflammation of the liver capsule with adhesions. Hepatic fibrosis/scarring or peritoneal involvement. * _S/S_: RUQ pain and tenderness. Perihepatitis. * _Dx_: CT shows subtle enhancement of liver capsule. GC tests * _Tx_: treat underlying STI, laparoscopy to lyse adhesions.
68
Mycoplasma genitalium - definition, dx, tx
* Nongonococcal urethritis/cervicitis in men/women. Cause PID. * _Dx_: PCR or NAAT. vaginal swab (F), first-void urine (M). Culture is slow growing. * _Tx_: **Moxifloxacin** 400mg PO QD for 7 days
69
Bacterial Vaginosis (BV) - Etiology, S/S, exam, Dx, Tx
* _Etiology_: overgrowth of garderella vaginalis and anaerones * _S/S_: Asx. Sx: **vaginal odor worse after sex/_fishy_**. +/- itching. * _Exam_: **copious,** thin, watery, **white-gray** discharge. **Fish/rotten smell**. * _Dx_: Vaginal pH \>5. **+ Whiff test** with **fishy smell**. **Clue cells** on wet prep. * Amsel diagnostic criteria: Need 3/4 1. Thin homogenous discharge 2. + whiff test 3. Clue cells 4. Vaginal pH \>4.5 * _Tx_: Metronidazole 500mg PO BID for 7 days * Alt: Clindamycin
70
Vulvovaginal Candidiasis - Etiology, RF, S/S, Exam, Dx, Tx
* _Etiology_: candida albicans. * _RF_: diabetes, steroids, pregnancy. Recent abx. Heat, moisture, occlusive clothing. * _S/S_: Vaginal/vulvar erythema, swelling, burning, and itching. Burning if urine contacts skin. Dysuria. Dyspareunia. * _Exam_: **thick, curd-like/cheese** discharge. * _Dx_: pH normal. - whiff test. **hyphae yeast** on KOH prep. * _Tx_: Fluconazole 150mg PO. Use intravaginal tx in pregnancy - Butoconazole, miconazole, clotrimazole, nystatin. ![]()
71
Toxic Shock Syndrome (TSS) - Etiology, S/S, Exam, Dx, Tx
* _Etiology_: S. aureus exotoxins * _S/S_: sudden onset high fever, tachycardia, hypotension, N/V/D. **Diffuse, erythematous macular rash** (palms, soles). **Desquamation,** ulcerations, petechiae, bullae, HA, myalgias. * _Dx_: CBC, Cultures * _Tx_: admit, treat shock, surgical debridement. * Empiric Abx: Vancomycin + clindamycin + piperacillin, tazobactam or cefepime * Anti-staph abx 1-2 wks: Clindamycin + ox ![]()acillin + nafcillin * MRSA: clindamycin + vancomycin (or linezolid)
72
Pediculosis Pubis - S/S, Tx
* _S/S_: pruritus in pubic and perianal areas, axillae, and chest hair. * _Tx_: Permethrin 1% cream, leave on for 10 minutes, then rinse off. Remove nits with fingernails, nit comb, or tweezers.
73
Scabies - S/S, Tx
* _S/S_: pruritus. Multiple small, erythematous papules with excoriations. Burrows, wheals, vesicles, pustules, and bullae. * _Tx_: 5% permethrin cream. Leave on for 8-14 hours, then wash off. Second application 2 weeks later.
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OB/GYN (7 decks)

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