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Infections in OB/GYN: Vaginitis, STIs

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Presentation on theme: "Infections in OB/GYN: Vaginitis, STIs"— Presentation transcript:

1 Infections in OB/GYN: Vaginitis, STIs
Lisa Rahangdale, MD, MPH Dept. of OB/GYN

2 Objectives Diagnose and treat a patient with vaginitis
Interpret a wet prep Differentiate the signs and symptoms, PE findings, diagnostic evaluation of the following STI’s: Gonnorhea Chlamydia Herpes Syphillis HPV Describe pathogenesis, signs and symptoms and management of PID �Diagnose and treat a patient with vaginitis�Interpret a wet prep�Differentiate the signs and symptoms, physical exam findings, diagnostic evaluation and management of the following STI痴: Gonorrhea, Chlamydia, herpes simplex virus, Syphilis, Human papillomavirus infection, �Describe the pathogenesis, signs

3 Vaginal Discharge DDXS
Candidiasis Bacterial Vaginosis Trichomonas Atrophic Physiologic (Leukorrhea) Mucopurulent Cervicitis Uncommon Foreign Body Desquamative

4 Vaginitis/Vaginosis Characteristics of the discharge pH Amine odor
Wet mount Cultures?

5 Vaginal Candidiasis Part of normal flora Majority Candida albicans
Predisposing factors: Diabetes Antibiotics Increased estrogen levels (preg, OCP, HRT) Immunosuppression ?Contraceptive devices, behaviors Part of nl flora 20-50% women Candida Albicans 80-92% (C. glabrata and C. parapsilosis) Antibiotics — One-quarter to one-third

6 Vaginal Candidiasis S/Sx Dxs: KOH prep Treatment Pruritis
White, clumpy discharge pH 4-4.5 Dxs: KOH prep Treatment Fluconazole 150 mg PO x1 Topical azoles (OTC)

7 Bacterial Vaginosis Disruption of healthy vaginal flora
Gardnerella, mycoplasmas, anaerobic overgrowth Dxs criteria: Gram stain OR 3 out of 4 Homogenous, thin, white d/c “CLUE CELLS” Whiff test: “amine odor” when d/c mixed w/ KOH pH >4.5

8 Bacterial Vaginosis

9 BV Treatment Metronidazole 500 mg BID x 7 days OR
Metronidazole gel, 0.75%, one full applicator (5g) PV QD x 5 days OR Clindamycin cream, 2%, one full applicator (5g) PV QHS x 7 days **No gels during pregnancy, different dosing** **Avoid alcohol during metronidazole use**

10 Trichomonas Flagellate parasite “Strawberry”Cervix
pruritis, frothy green discharge Vag pH >4, neg KOH whiff test NaCl Microscopy: +WBCs, Trichomonads Rx: Metronidazole 2 gm po X 1 Tinidazole 2 gm PO x 1 Partner tx Same doses in pregnancy

11 SEXUALLY TRANSMITTED DISEASES
Causative Agent Method of Transmission Symptoms Physical Signs Diagnostic Methods Treatment Screening

12 Neisseria gonnorhea: Symptoms
A single encounter with an infected partner 80-90% transmission rate Arise 3-5 days after exposure Initially so mild as to be overlooked Malodorous, purulent vaginal discharge 15% develop acute PID

13 Physical Diagnosis Mucopurulent discharge flowing from cervix
To be distinguished from normal thick yellow white cervical mucous(adherent to ectropion) Cervical Motion Tenderness

14 Gonorrhea: DXS Elisa or DNA specific test Culture for legal purposes
Cervical swab Combined with Chlamydia Urine tests Culture for legal purposes Gram Stain for WBCs with intracellular gram negative diplococci

15 Physical Diagnosis Mucopurulent discharge flowing from cervix
To be distinguished from normal thick yellow white cervical mucous(adherent to ectropion) Cervical Motion Tenderness

16 Disseminated GC Gonococcal bacteremia (rare)
Pustular or petechial skin lesions Asymetrical arthralgia Tenosynovitis Septic arthritis Rarely Endocarditis Meningitis

17 Gonorrhea Rx Ceftriaxone 125 mg IM in a single dose    OR Cefixime400 mg orally in a single dose      PLUS Tx FOR CHLAMYDIA IF NOT RULED OUT Do NOT use Quinolones in U.S. - resistant GC common

18 Chlamydia trachomatis
C. trachomatis Obligate intracellular pathogen No cell wall, not susceptible to penicillins Difficult to culture

19 Chlamydia Diagnosis Usually asymptomatic
Best to screen susceptible young women Mucopurulent cervicitis Intermenstrual bleeding Friable cervix Postcoital bleeding Elisa or DNA probe

20 Chlamydia Rx Uncomplicated cervicitis (no PID)
Azithromycin 1 gm po OR Doxycycline 100 mg BID for 7 days Repeat testing in 3 mons Annual screen in age < 25

21 Chlamydia in Pregnancy
Azithromycin 1 g orally in a single dose OR Amoxicillin 500 mg orally three times a day for 7 days ( Poor efficacy of erythromycin – now alternative regimen) Test of cure in 3 weeks

22 Pelvic Inflammatory Disease
Polymicrobial Initiated by GC, Chlamydia, Mycoplasmas Overgrowth by anaerobic bacteria, GNRs and other vaginal flora (Strep, Peptostrep) Bacterial Vaginosis - associated with PID flora characteristic of BV isolated from endometrium/fallopian tubes in PID

23 PID Symptoms Acute or chronic abdominal/pelvic pain Deep Dyspareunia
Fever and Chills Nausea and Vomiting Epigastric or RUQ pain (perihepatitis)

24 PID Physical Diagnosis
Minimum criteria: one or more of the following- Uterine Tenderness Cervical Motion Tenderness Adnexal Tenderness Additional support: Fever > 101/38.4 Mucopurulent Discharge Abdominal tenderness +/- rebound Adnexal fullness or mass Hydrosalpinx or TOA

25 PID Diagnostic Tests WBC may be elevated, *often WNL
ESR >40, Elevated CRP-neither reliable Ultrasound Hydrosalpinx or a TuboOvarian Complex due to Adhesions are to be distinguished from TuboOvarian Abcess Fluid in Culdesac nonspecific Fluid in Morrison’s Pouch is suggestive if associated with epigastric/RUQ pain

26 PID Treatment Needs to incorporate Rx of GC and Chlamydia (tests pending) Outpatient Ceftriaxone 250mg IM + Doxycycline x 14 d w/ or w/out Metronidazole 500mg bid x 14 d Levofloxacin 500 mg QD or Ofloxacin 400 mg BID + Metronidazole x14 days (No Quinolone unless allergy) Regimens:http://www.cdc.gov/std/treatment/2006/pid.htm

27 PID Inpatient Rx Criteria (2006 CDC STD guidelines) Peritoneal signs
Surgical emergencies not excluded (appy) Unable to tolerate/comply with oral Rx Failed OP tx Nausea, Vomiting, High Fever TuboOvarian Abcess Pregnancy

28 PID Inpatient Rx Cefoxitin 2 gm IV q 6 hr OR Cefotetan 2 gm q 12 hr
Plus Doxycycline 100mg IV or po q 12 hr For maximal anaerobic coverage/penetration of TOA: Clindamycin 900mg q 8 hr and Gentamycin 2 mg/kg then 1.5mg/kg q 8 hr

29 PID Sequelae Pelvic Adhesions Empiric Treatment
chronic pelvic pain, dyspareunia infertility ectopic pregnancy Empiric Treatment Suspected Chlamydia, GC or PID Deemed valuable in preventing sequelae Alt regimens Levofloxacin 500 mg IV once daily*    WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours    OR Ofloxacin 400 mg IV every 12 hours*    WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours    OR Ampicillin/Sulbactam 3 g IV every 6 hours     PLUS Doxycycline 100 mg orally or IV every 12 hours

30 Recommended Screening
GC/Chlamydia: women < 25 (**remember urine testing!) Pregnancy Syphilis HIV age 13-64, (? Screening time interval) One STD, consider screening for others PE, Wet mounts, PAP, GC/CT, VDRL, HIV

31 24 yo G 0 lesion on vulva HPI Pertinent review of systems Focused exam
Laboratory Treatment Counseling re partner

32 Genital Ulcers Syphilis Herpes Chanchroid Lymphogranuloma Venereum
Granuloma Inguinale

33 Herpes Herpes Simplex Virus I and II Spread by direct contact
“mucous membrane to mucous membrane” Painful ulcers Irregular border on erythematous base Exquisitely tender to Qtip exam Culture, PCR low sensitivity after Day 2

34 Herpes Primary Nonprimary First Episode Systemic symptoms
Multiple lesions Urinary retention Nonprimary First Episode Few lesions No systemic symptoms preexisting Ab

35 Herpes Rx First Episode Recurrent Episodic Rx: Suppressive therapy
Acyclovir, famciclovir, valcyclovir x 7–10 days Recurrent Episodic Rx: In prodrome or w/in 1 day of lesion) 1-5 day regimens Suppressive therapy Important for last 4 weeks of pregnancy Treatment might be extended if healing is incomplete after 10 days of therapy

36 Syphilis Treponema Pallidum- spirochete
Direct contact with chancre: cervix, vagina, vulva, any mucous membrane Painless ulceration Reddish brown surface, depressed center Raised indurated edges Dx: smear for DFA, Serologic Testing

37 Syphilis Stages Clinically Manifest vs. Latent Primary- painless ulcer
chancre must be present for at least 7 days for VDRL to be positive Secondary- Rash (diffuse asymptomatic maculopapular) lymphadenopathy, low grade fever, HA, malaise, 30% have mucocutaneous lesions Tertiary gummas develop in CNS, aorta

38 Primary & Secondary Syph

39 Latent Syphilis Definition: Asx, found on screen Testing
Early 1 year duration Late >1 year or unknown duration Testing Screening: VDRL, RPR- nontreponemal Confirmatory: FTA, MHATP- treponemal

40 Syphilis Treatment Primary, Secondary and Early Latent
Benzathine Penicillin 2.4 mU IM Tertiary, Late Latent Benzathine Penicillin 2.4 mU IM q week X 3 Organisms are dividing more slowly later on NeuroSyphilis IV Pen G for days

41 Chancroid Endemic to some areas of US, outbreaks Hemophilus Ducreyi
Painful ulcers, tender LNs Can aspirate a suppurative LN for Dx Coexists with HIV, HSV, Syphilis Culture is < 80% sensitive, PCR ? Rx: Azithro, Rocephin, Cipro

42 Lymphogranuloma Venereum
Chlamydia trachomatis Different serovars Rare in US Brief ulcer, inflammation of perirectal lymphatic tissues, strictures, fistulas Lymph nodes may require drainage Dx: Serologic Testing CT serovars L1-3 Rx: Doxycycline, Erythromycin

43 Granuloma Inguinale Outside US, Tropics
Calymmatobacterium granulomatis Highly Vascular, Painless progressive ulcers without LAD Dx: Histologic ID of Donovan bodies Coexists with other STDs or get secondarily infected with genital flora Rx: Septra, Doxycycline, Cipro, Erythro

44 Vulvar Lesions Human Papilloma Virus Molluscum Contagiosum
Pediculosis Pubis Scabies

45 HPV – genital warts Most common STD HPV 6 and 11 – low risk types
Verruccous, pink/skin colored, papillaform DDxs: condyloma lata, squamous cell ca, other Treatment: Chemical/physical destruction (cryo, podophyllin, 5% podofilox, TCA) Immune modulation (imiquimod) Excision Laser Other: 5-FU, interferon-alpha, sinecatchins High rate of RECURRENCE Low risk – do not integrate into host genome Podophyllin, an extract of Podophyllum peltatum, contains the antimitotic agent podophyllotoxin, which arrests the cell cycle in metaphase and leads to cell death. Imiquimod is a positive immune response modifier, which acts by local cytokine induction


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