Infections in OB/GYN: Vaginitis, STIs Lisa Rahangdale, MD, MPH Dept. of OB/GYN.
-
Upload
kara-trickey -
Category
Documents
-
view
222 -
download
3
Transcript of Infections in OB/GYN: Vaginitis, STIs Lisa Rahangdale, MD, MPH Dept. of OB/GYN.
Infections in OB/GYN:Infections in OB/GYN:Vaginitis, STIsVaginitis, STIs
Lisa Rahangdale, MD, MPHLisa Rahangdale, MD, MPH
Dept. of OB/GYNDept. of OB/GYN
ObjectivesObjectives Diagnose and treat a patient with vaginitisDiagnose and treat a patient with vaginitis Interpret a wet prepInterpret a wet prep Differentiate the signs and symptoms, PE findings, Differentiate the signs and symptoms, PE findings,
diagnostic evaluation of the following STI’s:diagnostic evaluation of the following STI’s: GonnorheaGonnorhea ChlamydiaChlamydia HerpesHerpes SyphillisSyphillis HPVHPV
Describe pathogenesis, signs and symptoms and Describe pathogenesis, signs and symptoms and management of PIDmanagement of PID
Vaginal Discharge DDXSVaginal Discharge DDXS
CandidiasisCandidiasis Bacterial VaginosisBacterial Vaginosis TrichomonasTrichomonas AtrophicAtrophic Physiologic (Leukorrhea)Physiologic (Leukorrhea) Mucopurulent CervicitisMucopurulent Cervicitis UncommonUncommon
Foreign BodyForeign Body Desquamative Desquamative
Vaginitis/VaginosisVaginitis/Vaginosis
Characteristics of the dischargeCharacteristics of the discharge pHpH Amine odorAmine odor Wet mount Wet mount Cultures?Cultures?
Vaginal CandidiasisVaginal Candidiasis
Part of normal floraPart of normal flora Majority Majority Candida albicansCandida albicans Predisposing factors:Predisposing factors:
DiabetesDiabetes AntibioticsAntibiotics Increased estrogen levels (preg, OCP, HRT)Increased estrogen levels (preg, OCP, HRT) ImmunosuppressionImmunosuppression ?Contraceptive devices, behaviors?Contraceptive devices, behaviors
Vaginal CandidiasisVaginal Candidiasis
S/SxS/Sx PruritisPruritis White, clumpy dischargeWhite, clumpy discharge pH 4-4.5pH 4-4.5
Dxs: KOH prepDxs: KOH prep TreatmentTreatment
Fluconazole 150 mg PO x1Fluconazole 150 mg PO x1 Topical azoles (OTC)Topical azoles (OTC)
BacterialBacterial Vaginosis Vaginosis Disruption of healthy Disruption of healthy
vaginal floravaginal flora Gardnerella, mycoplasmas,Gardnerella, mycoplasmas,
anaerobic overgrowthanaerobic overgrowth
Dxs criteria: Gram stain Dxs criteria: Gram stain OROR 3 out of 4 3 out of 4 Homogenous, thin, white d/cHomogenous, thin, white d/c ““CLUE CELLS”CLUE CELLS” Whiff test: “amine odor” when d/c mixed w/ KOH Whiff test: “amine odor” when d/c mixed w/ KOH pH >4.5pH >4.5
BV TreatmentBV Treatment
MetronidazoleMetronidazole 500 mg BID x 7 days 500 mg BID x 7 days OROR
Metronidazole gelMetronidazole gel, 0.75%, one full , 0.75%, one full applicator (5g) PV QD x 5 days applicator (5g) PV QD x 5 days OROR
Clindamycin creamClindamycin cream, 2%, one full , 2%, one full applicator (5g) PV QHS x 7 days applicator (5g) PV QHS x 7 days
**Avoid alcohol during metronidazole use**
TrichomonasTrichomonas
Flagellate parasiteFlagellate parasite ““Strawberry”CervixStrawberry”Cervix pruritis, frothy green dischargepruritis, frothy green discharge Vag pH >4, neg KOH whiff testVag pH >4, neg KOH whiff test NaCl Microscopy: +WBCs, TrichomonadsNaCl Microscopy: +WBCs, Trichomonads Rx: Metronidazole 2 gm po X 1 Rx: Metronidazole 2 gm po X 1 Tinidazole 2 gm PO x 1Tinidazole 2 gm PO x 1
Partner txPartner tx Same doses in pregnancySame doses in pregnancy
SEXUALLY TRANSMITTED SEXUALLY TRANSMITTED DISEASESDISEASES
Causative AgentCausative Agent Method of TransmissionMethod of Transmission SymptomsSymptoms Physical SignsPhysical Signs Diagnostic MethodsDiagnostic Methods TreatmentTreatment ScreeningScreening
Neisseria gonnorheaNeisseria gonnorhea: : SymptomsSymptoms
A single encounter with an infected A single encounter with an infected partnerpartner 80-90% transmission rate 80-90% transmission rate
Arise 3-5 days after exposure Arise 3-5 days after exposure Initially so mild as to be overlookedInitially so mild as to be overlooked Malodorous, purulent vaginal discharge Malodorous, purulent vaginal discharge 15% develop acute PID15% develop acute PID
Physical DiagnosisPhysical Diagnosis
Mucopurulent discharge flowing from Mucopurulent discharge flowing from cervixcervix To be distinguished from normal thick yellow To be distinguished from normal thick yellow
white cervical mucous(adherent to white cervical mucous(adherent to ectropion)ectropion)
Cervical Motion TendernessCervical Motion Tenderness
Gonorrhea: DXSGonorrhea: DXS
Elisa or DNA specific testElisa or DNA specific test Cervical swabCervical swab Combined with ChlamydiaCombined with Chlamydia Urine testsUrine tests
Culture for legal purposes Culture for legal purposes Gram Stain for WBCs with intracellular gram Gram Stain for WBCs with intracellular gram
negative diplococcinegative diplococci
Physical DiagnosisPhysical Diagnosis
Mucopurulent discharge flowing from Mucopurulent discharge flowing from cervixcervix To be distinguished from normal thick yellow To be distinguished from normal thick yellow
white cervical mucous(adherent to white cervical mucous(adherent to ectropion)ectropion)
Cervical Motion TendernessCervical Motion Tenderness
Disseminated GCDisseminated GC
Gonococcal bacteremia (rare)Gonococcal bacteremia (rare) Pustular or petechial skin lesionsPustular or petechial skin lesions Asymetrical arthralgiaAsymetrical arthralgia TenosynovitisTenosynovitis Septic arthritisSeptic arthritis RarelyRarely
EndocarditisEndocarditis Meningitis Meningitis
Gonorrhea RxGonorrhea Rx
CeftriaxoneCeftriaxone 125 mg IM in a single dose 125 mg IM in a single dose ORORCefiximeCefixime400 mg orally in a single dose 400 mg orally in a single dose
PLUSPLUS
Tx FOR CHLAMYDIA IF NOT RULED Tx FOR CHLAMYDIA IF NOT RULED OUT OUT
Do NOT use Quinolones in U.S. - resistant GC commonDo NOT use Quinolones in U.S. - resistant GC common
Chlamydia trachomatisChlamydia trachomatis
C. trachomatisC. trachomatis Obligate intracellular Obligate intracellular
pathogenpathogen No cell wall, not No cell wall, not
susceptible to susceptible to penicillinspenicillins
Difficult to cultureDifficult to culture
Chlamydia DiagnosisChlamydia Diagnosis
Usually asymptomaticUsually asymptomatic Best to screen susceptible young womenBest to screen susceptible young women Mucopurulent cervicitisMucopurulent cervicitis Intermenstrual bleedingIntermenstrual bleeding Friable cervixFriable cervix Postcoital bleedingPostcoital bleeding
Elisa or DNA probeElisa or DNA probe
Chlamydia RxChlamydia Rx
Uncomplicated cervicitis (no PID)Uncomplicated cervicitis (no PID) Azithromycin 1 gm po Azithromycin 1 gm po
OROR
Doxycycline 100 mg BID for 7 daysDoxycycline 100 mg BID for 7 days
Repeat testing in 3 monsRepeat testing in 3 mons Annual screen in age Annual screen in age << 25 25
Chlamydia in PregnancyChlamydia in Pregnancy
AzithromycinAzithromycin 1 g orally in a single dose 1 g orally in a single dose OROR AmoxicillinAmoxicillin 500 mg orally three times a 500 mg orally three times a day for 7 days day for 7 days
(2006 - Poor efficacy of erythromycin – now alternative regimen)(2006 - Poor efficacy of erythromycin – now alternative regimen)
Test of cure in 3 weeksTest of cure in 3 weeks
Pelvic Inflammatory Pelvic Inflammatory DiseaseDisease
PolymicrobialPolymicrobial Initiated by GC, Chlamydia, MycoplasmasInitiated by GC, Chlamydia, Mycoplasmas Overgrowth by anaerobic bacteria, GNRsOvergrowth by anaerobic bacteria, GNRs
and other vaginal flora (Strep, Peptostrep)and other vaginal flora (Strep, Peptostrep) Bacterial Vaginosis - associated with PIDBacterial Vaginosis - associated with PID
PID SymptomsPID Symptoms
Acute or chronic abdominal/pelvic painAcute or chronic abdominal/pelvic pain Deep DyspareuniaDeep Dyspareunia
Fever and ChillsFever and Chills Nausea and VomitingNausea and Vomiting Epigastric or RUQ pain (perihepatitis)Epigastric or RUQ pain (perihepatitis)
PID Physical DiagnosisPID Physical Diagnosis
Minimum criteria: Minimum criteria: oneone or more of the following- or more of the following- Uterine Tenderness Uterine Tenderness Cervical Motion Tenderness Cervical Motion Tenderness Adnexal TendernessAdnexal Tenderness
Additional support:Additional support: Fever > 101/38.4Fever > 101/38.4 Mucopurulent DischargeMucopurulent Discharge Abdominal tenderness +/- reboundAbdominal tenderness +/- rebound Adnexal fullness or massAdnexal fullness or mass
Hydrosalpinx or TOAHydrosalpinx or TOA
PID Diagnostic TestsPID Diagnostic Tests
WBC may be elevated, *often WNLWBC may be elevated, *often WNL ESR >40, Elevated CRP-neither reliableESR >40, Elevated CRP-neither reliable UltrasoundUltrasound
Hydrosalpinx or a TuboOvarian Complex Hydrosalpinx or a TuboOvarian Complex due to Adhesions are to be distinguished due to Adhesions are to be distinguished from TuboOvarian Abcessfrom TuboOvarian Abcess
Fluid in Culdesac nonspecificFluid in Culdesac nonspecific Fluid in Morrison’s Pouch is suggestive if Fluid in Morrison’s Pouch is suggestive if
associated with epigastric/RUQ painassociated with epigastric/RUQ pain
PID TreatmentPID Treatment Needs to incorporate Rx of GC and Needs to incorporate Rx of GC and
Chlamydia (tests pending)Chlamydia (tests pending) OutpatientOutpatient
Ceftriaxone 250mg IM + Doxycycline x 14 d Ceftriaxone 250mg IM + Doxycycline x 14 d w/ or w/out Metronidazole 500mg bid x 14 dw/ or w/out Metronidazole 500mg bid x 14 d
Levofloxacin 500 mg QD or Ofloxacin 400 Levofloxacin 500 mg QD or Ofloxacin 400 mg BID + Metronidazole x14 days mg BID + Metronidazole x14 days
(No Quinolone unless allergy)(No Quinolone unless allergy) Regimens:http://www.cdc.gov/std/treatment/Regimens:http://www.cdc.gov/std/treatment/2006/pid.htm2006/pid.htm
PID Inpatient RxPID Inpatient Rx
Criteria (2006 CDC STD guidelines)Criteria (2006 CDC STD guidelines) Peritoneal signsPeritoneal signs Surgical emergencies not excluded (appy)Surgical emergencies not excluded (appy) Unable to tolerate/comply with oral RxUnable to tolerate/comply with oral Rx Failed OP txFailed OP tx Nausea, Vomiting, High FeverNausea, Vomiting, High Fever TuboOvarian AbcessTuboOvarian Abcess PregnancyPregnancy
PID Inpatient RxPID Inpatient Rx
Cefoxitin 2 gm IV q 6 hrCefoxitin 2 gm IV q 6 hr OR Cefotetan 2 gm q 12 hrOR Cefotetan 2 gm q 12 hr
PlusPlus Doxycycline 100mg IV or po q 12 hrDoxycycline 100mg IV or po q 12 hr For maximal anaerobic For maximal anaerobic
coverage/penetration of TOA:coverage/penetration of TOA: Clindamycin 900mg q 8 hr andClindamycin 900mg q 8 hr and Gentamycin 2 mg/kg then 1.5mg/kg q 8 hrGentamycin 2 mg/kg then 1.5mg/kg q 8 hr
PID SequelaePID Sequelae
Pelvic AdhesionsPelvic Adhesions chronic pelvic pain, chronic pelvic pain,
dyspareuniadyspareunia infertilityinfertility ectopic pregnancyectopic pregnancy
Empiric Treatment Empiric Treatment Suspected Chlamydia, GC Suspected Chlamydia, GC
or PIDor PID Deemed valuable in Deemed valuable in
preventing sequelaepreventing sequelae
Recommended ScreeningRecommended Screening
GC/Chlamydia: GC/Chlamydia: women < 25 (**remember urine testing!)women < 25 (**remember urine testing!) PregnancyPregnancy
SyphilisSyphilis PregnancyPregnancy
HIV HIV age 13-64, (? Screening time interval)age 13-64, (? Screening time interval)
One STD, consider screening for othersOne STD, consider screening for others PE, Wet mounts, PAP, GC/CT, VDRL, HIVPE, Wet mounts, PAP, GC/CT, VDRL, HIV
24 yo G 0 lesion on 24 yo G 0 lesion on vulvavulva
HPIHPI Pertinent review of systemsPertinent review of systems Focused examFocused exam LaboratoryLaboratory TreatmentTreatment Counseling re partnerCounseling re partner
Genital UlcersGenital Ulcers
SyphilisSyphilis HerpesHerpes ChanchroidChanchroid Lymphogranuloma VenereumLymphogranuloma Venereum Granuloma InguinaleGranuloma Inguinale
HerpesHerpes
Herpes Simplex Virus I and IIHerpes Simplex Virus I and II Spread by direct contact Spread by direct contact
““mucous membrane to mucous membrane”mucous membrane to mucous membrane”
Painful ulcersPainful ulcers Irregular border on erythematous baseIrregular border on erythematous base Exquisitely tender to Qtip examExquisitely tender to Qtip exam Culture, PCR low sensitivity after Day 2Culture, PCR low sensitivity after Day 2
HerpesHerpes
PrimaryPrimary Systemic symptomsSystemic symptoms Multiple lesionsMultiple lesions Urinary retentionUrinary retention
Nonprimary First EpisodeNonprimary First Episode Few lesionsFew lesions No systemic symptomsNo systemic symptoms preexisting Abpreexisting Ab
Herpes RxHerpes Rx
First EpisodeFirst Episode Acyclovir, famciclovir, valcyclovir x 7–10 Acyclovir, famciclovir, valcyclovir x 7–10
daysdays
Recurrent Episodic Rx: Recurrent Episodic Rx: In prodrome or w/in 1 day of lesion)In prodrome or w/in 1 day of lesion) 1-5 day regimens1-5 day regimens
Suppressive therapySuppressive therapy Important for last 4 weeks of pregnancyImportant for last 4 weeks of pregnancy
SyphilisSyphilis Treponema Pallidum- spirocheteTreponema Pallidum- spirochete Direct contact with chancre: cervix, vagina, Direct contact with chancre: cervix, vagina,
vulva, any mucous membranevulva, any mucous membrane Painless ulcerationPainless ulceration Reddish brown surface, depressed centerReddish brown surface, depressed center Raised indurated edgesRaised indurated edges Dx: smear for DFA, Serologic TestingDx: smear for DFA, Serologic Testing
Syphilis StagesSyphilis Stages
Clinically Manifest vs. LatentClinically Manifest vs. Latent Primary- painless ulcer Primary- painless ulcer
chancre must be present for at least 7 days for chancre must be present for at least 7 days for VDRL to be positiveVDRL to be positive
Secondary- Secondary- Rash (diffuse asymptomatic maculopapular) Rash (diffuse asymptomatic maculopapular)
lymphadenopathy, low grade fever, HA, malaise, lymphadenopathy, low grade fever, HA, malaise, 30% have mucocutaneous lesions30% have mucocutaneous lesions
Tertiary gummas develop in CNS, aortaTertiary gummas develop in CNS, aorta
Latent SyphilisLatent Syphilis
Definition: Asx, found on screenDefinition: Asx, found on screen Early 1 year duration Early 1 year duration Late >1 year or unknown durationLate >1 year or unknown duration
TestingTesting Screening: VDRL, RPR- nontreponemal Screening: VDRL, RPR- nontreponemal Confirmatory: FTA, MHATP- treponemal Confirmatory: FTA, MHATP- treponemal
Syphilis TreatmentSyphilis Treatment Primary, Secondary and Early LatentPrimary, Secondary and Early Latent
Benzathine Penicillin 2.4 mU IMBenzathine Penicillin 2.4 mU IM
Tertiary, Late LatentTertiary, Late Latent Benzathine Penicillin 2.4 mU IM q week X 3Benzathine Penicillin 2.4 mU IM q week X 3 Organisms are dividing more slowly later onOrganisms are dividing more slowly later on
NeuroSyphilisNeuroSyphilis IV Pen G for 10-14 daysIV Pen G for 10-14 days
ChancroidChancroid Endemic to some areas of US, outbreaksEndemic to some areas of US, outbreaks Hemophilus DucreyiHemophilus Ducreyi Painful ulcers, tender LNsPainful ulcers, tender LNs Can aspirate a suppurative LN for DxCan aspirate a suppurative LN for Dx Coexists with HIV, HSV, SyphilisCoexists with HIV, HSV, Syphilis Culture is < 80% sensitive, PCR ?Culture is < 80% sensitive, PCR ? Rx: Azithro, Rocephin, CiproRx: Azithro, Rocephin, Cipro
Lymphogranuloma Lymphogranuloma VenereumVenereum
Chlamydia trachomatisChlamydia trachomatis Different serovarsDifferent serovars
Rare in USRare in US Brief ulcer, inflammation of perirectal Brief ulcer, inflammation of perirectal
lymphatic tissues, strictures, fistulaslymphatic tissues, strictures, fistulas Lymph nodes may require drainageLymph nodes may require drainage Dx: Serologic Testing CT serovars L1-3Dx: Serologic Testing CT serovars L1-3 Rx: Doxycycline, ErythromycinRx: Doxycycline, Erythromycin
Granuloma InguinaleGranuloma Inguinale
Outside US, TropicsOutside US, Tropics Calymmatobacterium granulomatisCalymmatobacterium granulomatis Highly Vascular, Painless progressive Highly Vascular, Painless progressive
ulcers without LADulcers without LAD Dx: Histologic ID of Donovan bodiesDx: Histologic ID of Donovan bodies Coexists with other STDs or get Coexists with other STDs or get
secondarily infected with genital florasecondarily infected with genital flora Rx: Septra, Doxycycline, Cipro, ErythroRx: Septra, Doxycycline, Cipro, Erythro
Vulvar LesionsVulvar Lesions
Human Papilloma VirusHuman Papilloma Virus Molluscum ContagiosumMolluscum Contagiosum Pediculosis PubisPediculosis Pubis ScabiesScabies
HPV – HPV – genital wartsgenital warts
Most common STDMost common STD HPV 6 and 11 – low risk typesHPV 6 and 11 – low risk types Verruccous, pink/skin colored, papillaformVerruccous, pink/skin colored, papillaform DDxs: condyloma lata, squamous cell ca, otherDDxs: condyloma lata, squamous cell ca, other Treatment:Treatment:
Chemical/physical destruction (cryo, podophyllin, 5% Chemical/physical destruction (cryo, podophyllin, 5% podofilox, TCA)podofilox, TCA)
Immune modulation (imiquimod)Immune modulation (imiquimod) ExcisionExcision LaserLaser Other: 5-FU, interferon-alpha, sinecatchinsOther: 5-FU, interferon-alpha, sinecatchins
High rate of RECURRENCEHigh rate of RECURRENCE