2Normal Vaginal Flora Dominated by lactobacilli Lactobacilli convert glucose to lactic acid, to maintain an acidic vaginal pH of 3.8 to 4.2. This acidic environment inhibits the overgrowth of bacteria and other organisms with pathogenic potential.Some lactobacilli also produce hydrogen peroxide (H2O2), a potential microbicide.After onset of sexual activity, increase in Gardnerella vaginalis, lactobacilli, mycoplasmas, ureaplasmas is seen.
3BACTERIA ENDOGENOUS TO THE LOWER GENITALTRACT GRAM POSITIVE GRAM NEGATIVELactobacillus acidophilus Escherichia coliCorynebacterium spp Enterobacter cloacaeGardnerella vaginalisStaphylococcus epidermidis KlebsiellaStreptococci MorganellaEnterococcus faecalis ProteusPeptococcus BacteroidesPeptostreptococcus FusobacteriumPrevotellamodified from Schlossberg,CTID 2001
4Vaginitis Most common causes include: Vulvovaginal Candidiasis (VVC) Bacterial Vaginosis (BV)Trichomoniasis*In some cases the etiology may be mixed
5VAGINITIS SYMPTOMS Often non-specific: Abnormal discharge Vulvovaginal irritationVulvar itchingOdor
6VAGINITIS DIAGNOSIS History Visual inspection Appearance of vaginal discharge: color, viscosity, adherence to vaginal walls, odorCollection of specimenDiagnostic tests:Vaginal pH: determine vaginal pH with narrow-range pH paperWhiff test: assessment of a fishy odor after application of 10% KOH to wet mountKOH (wet mount): wet mount of discharge with 10% KOHNaCl (wet mount): wet mount of discharge with 0.9% normal saline
7VAGINITIS DIAGNOSIS Other tests: Cultures: not used routinely, but are available for both T. vaginalis and Candida spp.New tests for BV (commercially available) :Fem Exam Test Card™: pH and aminesFem Exam vaginalis PIP Activity Test Card™: detects enzyme breakdown from G. vaginalisDNA probe for 3 organisms (T. vaginalis, C. albicans, and G. vaginalis): sensitivity, specificity, and clinical utility are under investigation.
8VULVOVAGINAL CANDIDIASIS Not considered to be STDCaused by overgrowth of Candida species (Candida species are normal flora of vagina)80-90% caused by C. albicans.Non-albicans candida play increasing role
9VULVOVAGINAL CANDIDIASIS RISK FACTORS Uncontrolled DMCorticosteroid therapyAntimicrobial therapy (oral, parental, topical)Poor hygieneEstrogen therapyHigh-dose estrogen contraceptivesPregnancyIUDHIV infectionSpongeNonoxynol-9 (?)Diaphragm (?)Increased frequency of coitus"Candy binge“Women frequenting STD clinicsTight-fitting synthetic underclothingBut, most episodes of vulvovaginal candidiasis occur in the absence of a recognizable precipitating factors
11VULVOVAGINAL CANDIDIASIS MANIFESTATIONS Vulvar pruritis is most common symptomThick, white, curdy vaginal discharge ("cottage cheese-like")Erythema, irritation, occasional erythematous "satellite" lesionExternal dysuria and dyspareunia
12VULVOVAGINAL CANDIDIASIS DIAGNOSIS ClinicalpH normal (<4.5)Whiff test negativeFungal stain positive30% may have a negative fungal stainSeverity does not depend on No. yeasts present
13Regimens for the Treatment of Vulvovaginal Candidiasis Intravaginal agents:Butoconazole 2% cream, 5 g intravaginally for 3 days†Butoconazole 2% sustained release cream, 5 g single intravaginally applicationClotrimazole 1% cream 5 g intravaginally for 7-14 days†Clotrimazole 100 mg vaginal tablet for 7 daysClotrimazole 100 mg vaginal tablet, 2 tablets for 3 daysClotrimazole 500 mg vaginal tablet, 1 tablet in a single applicationMiconazole 2% cream 5 g intravaginally for 7 days†Miconazole 100 mg vaginal suppository, 1 suppository for 7 days†Miconazole 200 mg vaginal suppository, 1 suppository for 3 days†Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 daysTioconazole 6.5% ointment 5 g intravaginally in a single application†Terconazole 0.4% cream 5 g intravaginally for 7 daysTerconazole 0.8% cream 5 g intravaginally for 3 daysTerconazole 80 mg vaginal suppository, 1 suppository for 3 daysOral agent:Fluconazole 150 mg oral tablet, 1 tablet in a single doseNote: The creams and suppositories in this regimen are oil-based and may weaken latex condoms and diaphragms. Refer to condom product labeling for further information.† Over-the-counter (OTC) preparations
14RECURRENT VULVOVAGINAL CANDIDIASIS Four or more symptomatic episodes/yearUsually NOT from resistance to antifungalsDiabetes mellitus or immunosuppression should be considered in refractory/ recurrent casesSimultaneous Rx of sex partners has no effect on recurrence (but 3-10% of sex partners may have balanitis)Vaginal culture useful to confirm diagnosis and identify unusual speciesTreatmentInitial regimen of 7-14 days topical therapyFluconazole 150 mg (repeat 72 hrs)Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazoleFor Non-albicans VVC:Longer duration of therapyNon-azole regimen may even be needed600 mg boric acid in gelatin capsule vaginally once a day for 14 days
15VULVOVAGINAL CANDIDIASIS Treatment in Pregnancy Only topical intravaginal regimens recommended (usually for 7 days)
16VULVOVAGINAL CANDIDIASIS Management of Sex Partners Treatment not recommendedTreatment of male partners does not reduce frequency of recurrences in the femaleBut, male partners with balanitis may benefit from treatment
17BACTERIAL VAGINOSIS Not a classical STD Overgrowth of vaginal normal flora with anaerobic bacteria and decrease or loss of protective lactobacilli (Disturbed vaginal ecosystem)Gardrenella vaginalis (GV) & other microrganisms in high titersBut, GV found in 50% of vaginal cultures in asymptomatic women too.BV linked to: premature rupture of membranes, premature delivery and low birth-weight delivery, acquisition of HIV, development of PID, and post-operative infections after gynecological proceduresMale sex partners may be colonized but asymptomatic
18BACTERIAL VAGINOSISGray, homogenous discharge w foul (fishy) odor reported mostly after vaginal intercourse and after completion of mensesWithout obvious vaginal inflammationClue cells presentpH>4.5Positive Whiff test (KOH)
20BV Diagnosis: Amsel Criteria Must have at least three of the following findings:Vaginal pH >4.5Presence of >20% per HPF of "clue cells" on wet mount examinationPositive amine or "whiff" testHomogeneous, non-viscous, milky-white discharge adherent to the vaginal walls
21BACTERIAL VAGINOSIS Other Diagnostic Tools Culture not recommended; Do not Rx a positive GV vaginal culture in asymptomatic womenNewer diagnostic modalities include:FemExam™PIP Activity TestCard™DNA probe
22BACTERIAL VAGINOSIS TREATMENT Metronidazole 500 mg twice daily x 7 daysMetronidazole gel 0.75%, 5 g intravaginally once daily x 5 daysClindamycin cream 5%, 5 g intravaginally qhs x 7 daysAlternative regimensMetronidazole 2 gm in a single doseClindamycin 300 mg twice daily x 7 daysClindamycin ovules 100 g intravaginally qhs x 3 days
23BACTERIAL VAGINOSIS Treatment in Pregnancy Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomesDo not use of topical agents in pregnancySome experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatal visit; optimal regimen not established
24BACTERIAL VAGINOSIS Treatment in Pregnancy Metronidazole 250 mg three times daily for 7 daysorClindamycin 300 mg twice daily for 7 days
25BACTERIAL VAGINOSIS Management of Sex Partners Not recommendedWoman’s response to therapy and the likelihood of relapse or recurrence not affected by treatment of sex partner
26TRICHOMONIASIS Etiologic agent Trichomonas vaginalis – a flagellated protozoa
27Trichomoniasis and other vaginal infections — Initial visits to physicians’ offices: United States, 1966–2003SOURCE: National Disease and Therapeutic Index (IMS Health)
28TRICHOMONIASIS Estimated 7.4 million cases annually in the U.S. Almost always sexually transmittedCauses urethritis in men (usu. asymptomatic)Transmission between female sex partners has been documentedFomite transmission rarePossible association withPre-term rupture of membranes and pre-term deliveryIncreased risk of HIV acquisition
29TRICHOMONIASIS DIAGNOSIS Copious, yellow-green or gray frothy discharge, adherent to vaginal walls, w foul odor.Vulvovaginal erythemaPunctate cervical microhemorrhages seen in 25%: ‘strawberry cervix’Saline smear 80% sensitive, highly specific (motile trichomonads)Liquid culture, Diamond’s medium, done in persistent casesGram stain & Pap smear are not sensitive or specificWhiff test (KOH) +/-
30TRICHOMONIASIS TREATMENT Recommended regimenMetronidazole 2 gm orally in a single doseAlternative regimenMetronidazole 500 mg twice a day for 7 daysPregnancy
31TRICHOMONIASIS TREATMENT FAILURE Re-treat with metronidazole 500 mg twice daily for 7 daysIf above fails, Rx with metronidazole 2 gm single dose x 3-5 daysIn repeated failure:Confirm diagnosis with cultureconsider metronidazole susceptibility testing through the CDCTrial of tinidazole
32TRICHOMONIASIS Other management issues No alcohol for the duration of treatment and for at least 24 h after the last dose.Trich is an STD, so:GC and Chlamydia testing should be done, &Syphilis, HIV, and hepatitis B serologic testing should be considered
33TRICHOMONIASIS Management of Sex Partners Sex partners should be treated, even if asymptomaticAvoid intercourse until therapy is completed and patient and partner are asymptomatic.
35NON-INFECTIOUS VAGINITIS Vaginal foreign bodies, especially in prepubescent girls, may present with a heavy white discharge but would be unaccompanied by vulvar erythema or the microscopic appearance of hyphae.Atrophic vaginitis is commonly found in postmenopausal women and is distinguished from candidal vaginitis by mucosal dryness, atrophy, dyspareunia, minimal discharge, and itching.Contact dermatitis, local irritation secondary to tight-fitting underwear, and contact dermatitis from toiletry items, latex condoms, diaphragms, spermicides
36MUCOPURULENT CERVICITIS Largely caused by Chlamydia trachomatis and Neiserria Gonorrheae
39Chlamydia — Rates by sex: United States, 1984–2003 CDC
40Chlamydia trachomatis Estimated 3 million cases in the U.S. annuallyWomen: bartholinitis, cervicitis, urethritis, PID, perihepatitis, conjunctivitisMen: urethritis, epididymitisM&W: LGVInfants: conjunctivitis, pneumoniaComplications: PID, perihepatitis, Reiter’s syndrome, infertility, ectopic pregnancy, chronic pelvic pain, increased risk for HIVIncubation period is 7-21 days.
41Chlamydia trachomatis Risk factors AdolescenceCervical epithelial cells are developmentally immature (ectopy) making them more susceptible to infection.Risky behaviors also contribute to susceptibility.New or multiple sex partnersHistory of past STD infectionPresence of another STDOral contraceptive use (contributes to cervical ectopy, & OCP users less likely to use barrier protection)Lack of barrier contraception
42Chlamydia trachomatis CervicitisMajority of cervical infections are asymtpomatic-70% to 80%.When symptomatic, S+S may be non-specific:spotting, or mucopurulent cervicitis, with mucopurulent endocervical discharge, edema, erythema, and friability w easily induced bleeding within the endocervix or any zones of ectopy.Urethritis50% of infected women yield chlamydia from both urethra and cervical sitesUsually asymptomaticMay cause the “dysuria-pyuria” syndrome mimicking acute cystitis. On urinalysis, pyuria present but few bacteria.
43Chlamydia trachomatis DIAGNOSIS Culture: high specificity BUTlabor-intensive, expensive,variable sensitivity (50%-80%),not suitable for widespread screeningNon-culture methods:Serology: not very usefulEIA, DFA, DNA probe : less sensitive(50-75%), nonspecificNucleic acid amplification tests (NAAT): PCR, LCR:more sensitive than culture (>80%-90%)highly specific (>99%)can use first void urinecan use self-obtained vaginal swab
44Chlamydia trachomatis Treatment Azithromycin 1 gm single doseorDoxycycline 100 mg bid x 7d
45Chlamydia trachomatis Alternative regimens Erythromycin base 500 mg qid for 7 daysorErythromycin ethylsuccinate 800 mg qid for 7 daysOfloxacin 300 mg twice daily for 7 daysLevofloxacin 500 mg for 7 days
46Chlamydia trachomatis Treatment in Pregnancy Recommended regimensErythromycin base 500 mg qid for 7 daysorAmoxicillin 500 mg three times daily for 7 daysAlternative regimensErythromycin base 250 mg qid for 14 daysErythromycin ethylsuccinate 800 mg qid for 14 daysErythromycin ethylsuccinate 400 mg qid for 14 daysAzithromycin 1 gm in a single dose
47Chlamydia trachomatis Screening Annual screening of sexually active women < 25 yrsAnnual screening of sexually active women > 25 yrs with risk factorsSexual risk assessment may indicate need for more frequent screening for some womenScreen pregnant women in the first trimesterRe-screen women 3-4 months after treatment due to high prevalence of repeat infection
49Gonorrhea — Rates: United States, 1970–2003 and the Healthy People 2010 target Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.
50GONORRHEACaused by Neisseria gonorrhoeae, a gram-neg intracellular diplococcus.Estimated 700,00-800,000 persons infected annually in the US.Manifestations in women may include:cervicitis, PID, urethritis, pharyngitis, proctitis, disseminated (bacteremia,arthritis, tenosynovitis)Accessory gland infection (Bartholin’s glands, Skene’s glands)Fitz-Hugh-Curtis Syndrome (Perihepatitis)
51Gonorrhea Cervicitis Clinical Manifestations Symptoms are non-specific : abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareuniaClinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding50% of women with clinical cervicitis are asymptomaticIncubation period unclear, but symptoms may occur within 10 days of infection
53GONORRHEA LAB DIAGNOSIS Culture (selective media-Thayer Martin, needs CO2)Non-culture tests: DNA probe, nucleic acid amplificationGram-stain, less sensitive in cervicitis (most sensitive for symptomatic urethritis in men)
54Gonorrhea: Gram Stain of Urethral Discharge Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
55Neisseria gonorrhoeae (Cervix, Urethra, Rectum) Cefixime 400 mgorCeftriaxone 125 IM1Ciprofloxacin 500 mg1Ofloxacin 400 mg1Levofloxacin 250 mgPLUS Chlamydial therapy if infection not ruled out1 Contraindicated in pregnancy and children. Not recommended for infections acquired in California, Asia, or the Pacific, including Hawaii.
56Neisseria gonorrhoeae (Cervix, Urethra, Rectum) Alternative regimensSpectinomycin 2 grams IM in a single doseorSingle dose cephalosporin (cefotaxime 500 mg)Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg)PLUS Chlamydial therapy if infection not ruled out
57Neisseria gonorrhoeae Treatment in Pregnancy Cephalosporin regimenWomen who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IMNo quinolone or tetracycline regimenPLUS Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection
58Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2003Note: Resistant isolates have ciprofloxacin MICs ≥ µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.
59Neisseria gonorrhoeae Antimicrobial Resistance Surveillance is crucial for guiding therapy recommendationsNo significant resistance to ceftriaxoneFluoroquinolone resistance in SE Asia, Pacific, Hawaii, California, Washington.FQ resistance 15% in MSM.
60GONORRHEA TREATMENT ISSUES Fluoroquinolones are no longer recommended for therapy for gonorrhea acquired in Asia, the Pacific Islands (including Hawaii), and California.CDC no longer recommends fluoroquinolones as a first-line therapy for gonorrhea in MSMIf symptoms persist, perform culture for N. gonorrhoeae.Any gonococci isolated should be tested for antimicrobial susceptibilityCo-infection with Chlamydiae in up to 50% of pts, hence anti-Chlmydia Rx added.Note : A test of cure is not recommended, if a recommended regimen is administered.
61GONORRHEA Partner Management Evaluate and treat all sex partners for N. gonorrhoeae and C. trachomatis infections if contact was within 60 days of symptoms or diagnosis.If a patient’s last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated.Avoid sexual intercourse until therapy is completed and both partners no longer have symptoms.
63PELVIC INFLAMMATORY DISEASE Estimated about 1 million annual cases in the USEndometritis, salpingitis, tuboovarian abscess, & pelvic peritonitis.Ascending infection from or via cervixMost cases of PID are polymicrobial: Chlamydia, GC, vaginal organisms, anaerobes, enteric GNR, GPC).May be unrelated to STD.Most common pathogens:N. gonorrhoeae: recovered from cervix in 30%-80% of women with PIDC. trachomatis: recovered from cervix in 20%-40% of women with PIDN. gonorrhoeae and C. trachomatis are present in combination in approximately 25%-75% of patients
64PELVIC INFLAMMATORY DISEASE RISK FACTORS Adolescence (in sexually active teens 3x more than yr olds)History of PIDGC or chlamydia, or a history of GC or chlamydiaMale partners with GC or chlamydiaMultiple partnersCurrent douchingInsertion of IUD (especially within 4 mos after insertion)Bacterial vaginosisDemographics (lower socioeconomic status)Oral contraceptive use, in some cases (by avoidance of barrier precautions?)
66PELVIC INFLAMMATORY DISEASE Minimum Diagnostic CriteriaUterine/adnexal tenderness or cervical motion tendernessAdditional Diagnostic CriteriaOral temperature >38.3 C Elevated ESRCervical Chlamydia or GC Elevated CRPWBCs/saline microscopy Cervical Discharge
67Pelvic Inflammatory Disease More Specific Criteria Endometrial biopsy: histopathologic evidence of endometritisImaging Studies: Transvaginal sonography or MRI (showing thickened fluid-filled tubes)Laparoscopy: abnormalities consistent with PID
68PELVIC INFLAMMATORY DISEASE MANAGEMENT AntibioticsBed restReevaluation within 72 hrs of treatmentAll male sex partners should be evaluated for STD and empirically treated with regimen effective for GC/Chlmydia
69PELVIC INFLAMMATORY DISEASE MANAGEMENT Hospitalize, if:Surgical emergencies not excluded (e.g., appendicitis, ectopic pregnancy..)Pregnant patientPelvic abscess is suspectedAdolescentSevere illnessIf unable to tolerate outpt regimenIf f/up within 72 hrs after starting abx cannot be arrangedNon-response to oral therapyHIV infection with low CD4 count
70Pelvic Inflammatory Disease Parenteral Regimen A Cefotetan 2 g IV q 12 hoursorCefoxitin 2 g IV q 6 hoursPLUSDoxycycline 100 mg orally/IVq 12 hrs
71PELVIC INFLAMMATORY DISEASE Parenteral Regimen B Clindamycin 900 mg IV q 8 hoursPLUSGentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.
72PELVIC INFLAMMATORY DISEASE Alternative Parenteral Regimens Ofloxacin 400 mg IV q 12 hoursorLevofloxacin 500 mg IV once dailyWITH OR WITHOUTMetronidazole 500 mg IV q 8 hoursAmpicillin/Sulbactam 3 g IV q 6 hrsPLUSDoxycycline 100 mg orally/IV q 12 hrs
73PELVIC INFLAMMATORY DISEASE Oral Regimen A Ofloxacin 400 mg twice daily for 14 daysorLevofloxacin 500 mg once daily for 14 daysWITH OR WITHOUTMetronidazole 500 mg twice daily for 14 days
74PELVIC INFLAMMATORY DISEASE Oral Regimen B Ceftriaxone 250 mg IM in a single doseorCefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrentlyPLUSDoxycycline 100 mg twice daily for 14 daysWITH or WITHOUTMetronidazole 500 mg twice daily for 14 days
75SUSPECTED TUBOOVARIAN ABSCESS CulturesBroad spectrum antibiotics85% of abscesses w a diameter of 4-6 cm (& only 40% of those >10 cm) respond to abx aloneSurgery for failure to respond to abx.
76PELVIC INFLAMMATORY DISEASE SEQUELAE Ectopic pregnancy7-fold increase in risk after a single episode of PIDInfertility:13% of women after one episode of PID25-35% after 2 episodes, 50-75% after 3 or more episodes2/3 unable to conceive after Rx for TOADyspareuniaPelvic adhesionsChronic pelvic pain
77PELVIC INFLAMMATORY DISEASE Management of Sex Partners Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt’s onset of symptomsSex partners should be treated empirically with regimens effective against CT and GC
79Genital herpes — Initial visits to physicians’ offices: United States, 1966–2003 SOURCE: National Disease and Therapeutic Index (IMS Health)
80Genital HSV InfectionMore than one in five Americans (45 million people)-are estimated infected with genital herpesmore common in women than men, infecting approximately one out of four women, versus one out of five men.In a national house-hold survey, less than 10 percent of people who tested positive with herpes knew they were infected (Fleming, 1997). ---Silent epidemic---Genital herpes is a recurrent, lifelong viral infection.Asymptomatic shedding occurs (Most sexual transmission occurs while source case is asymptomatic).Incubation period is 2-12 days (average is 4 days).Can be transmitted between sex partners, from mothers to newborns, and can increase a person's risk of becoming infected with HIV
81Estimated Annual Incidence of Selected STDs in the U.S. , 2000 Trichomoniasis 7.4 millionHuman Papillomavirus (HPV) 6.2 millionChlamydia 2.8 millionHerpes Simplex Virus (HSV) Type 2 : 1.6 millionGonorrhea 718,000Syphilis 37,000
87Genital Herpes in HIV Infection May have prolonged or severe episodes with extensive genital or perianal diseaseEpisodic or suppressive antiviral therapy often beneficialFor severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary
88Genital Herpes HIV Infection/Episodic Therapy Acyclovir 400 mg three times dailyorFamciclovir 500 mg twice dailyValacyclovir 1 gm twice dailyDuration of Therapy 5-10 days
89Genital Herpes HIV Infection/Daily Suppression Acyclovir mg twice to three times dailyorFamciclovir 500 mg twice dailyValacyclovir 500 mg twice daily
90Genital Herpes Antiviral Resistance Persistent or recurrent lesions on antiviralsObtain viral isolate for viral susceptability5% immunocomprised patientsAcyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovirAlternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days)
91Herpes in PregnancyRisk for transmission to neonate from infected mother is :high (30%-50%) among women who acquire genital herpes near the time of delivery, but low (<1%) in women with histories of recurrent herpes at term or who acquire genital HSV during the first half of pregnancy.Prevention of neonatal herpes depends on avoiding acquisition of HSV during late pregnancy and avoiding exposure of the infant to herpetic lesions during delivery.Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally
92Genital Herpes Treatment in Pregnancy Acyclovir may be used with first episode or severe recurrent diseaseAvailable data do not indicate an increased risk of major birth defects (first trimester)The safety of acyclovir, valacyclovir, and famciclovir therapy in pregnant women has not been established.
93Genital Herpes Counseling Natural history of infection, recurrences, asymptomatic shedding, transmission riskIndividualize use of episodic or suppressive therapyAbstain from sexual activity when lesions or prodromal symptoms presentRisk of neonatal infection
96HUMAN PAPILLOMAVIRUS6.2 million Americans get a new genital HPV infection each year.May cause cancer of cervix, vulva, vagina, or anusthe most common sources of genital warts--HPV types 6 and 11--are rarely associated with malignancythe high-risk HPV types 16 and 18 have been found in more than 90% of cervical cancersThey appear an average of 3 months after exposure, the latency period can be much longer.Infection can be clinically apparent, subclinical, or latentFrequency of spontaneous regression is unclear. A few studies indicate a regression rate of 10%-30% within 3 months.Persistence of infection occurs, but frequency and duration is unknown.Recurrences after treatment are common (20%-50% recurrence rate at 3-6 months).SymptomsGenital warts usually cause no symptoms other than the warts themselves.Vulvar warts can cause dyspareunia, pruritis, and burning discomfort.Urethral meatal warts occasionally cause hematuria or impairment of urinary stream.Vaginal warts occasionally cause discharge, bleeding, or obstruction of birth canal (due to increased wart growth in pregnancy).
97HUMAN PAPILLOMAVIRUS Risk for Malignancy Externa genital wartsHPV types 6, 11.Minimal risk for malignancyFlat wartsHPV 16,18, 31, 45…Associated with cancer of cervix, vagina, vulva, anus, penisMost women with persistent HPV infection do not develop cervical cancer precursors or cervical cancer.Over 99% of cervical cancers have HPV DNA detected within the tumor.Persistent infection with a high-risk HPV type is necessary but not sufficient for the development of cervical cancer.
98HUMAN PAPILLOMAVIRUS DIAGNOSIS Inspection usually diagnostic of external warts:, biopsy if in doubtPap smear, biopsy for flat warts of cervixHPV-DNA studies, PCR, hybrid captureHPV cannot be cultured, and serologic tests are not available to test for HPV antibodiesSubclinical infections may be detected by applying 3% to 5% acetic acid solution for 5 to 10 minutes. The lesions then become visible, and can be further visualized via colposcopy.
99HUMAN PAPILLOMAVIRUS Treatment Primary goal for treatment of visible warts is the removal of symptomatic wartsTherapy may reduce but probably does not eradicate infectivityDifficult to determine if treatment reduces transmissionNo laboratory marker of infectivityVariable results utilizing viral DNA
100HUMAN PAPILLOMAVIRUSChoice of therapy guided by preference of patient, experience of provider, resourcesNo evidence that any regimen is superiorLocally developed/monitored treatment algorithms associated with improved clinical outcomesAcceptable alternative may be to observe; possible regression/uncertain transmission
101PAPILLOMAVIRUS Patient-applied Provider-administered Podofilox 0.5% solution or gelImiquimod 5% creamProvider-administeredCryotherapyPodophyllin resin 10-25%Trichloroacetic or Bichloroacetic acid 80-90%Surgical removal
102HUMAN PAPILLOMAVIRUS Treatment in Pregnancy Imiquimod, podophyllin, podofilox should not be used in pregnancyMany specialists advocate wart removal due to possible proliferation and friabilityHPV types 6 and 11 can cause respiratory papillomatosis in infants and childrenPreventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction
105CHORIOAMNIONITIS RISK FACTORS NulliparityLength of laborPreterm laborPROMMeconium stained amniotic fluidInternal fetal or uterine monitoringPresence of GU pathogens (GBS, GC,BV)No of vag exams in women w ruptured membraneUnderlying Host FactorsNo. of lactobacilli,IgA,Chronic diseasesImmunosuppressionNutritional disordersDrug abuse.
106CHORIOAMNIONITIS DIAGNOSIS Maternal fever >38C(>100.4) AND at least 2 of the following:Maternal leukocytosis (>15,000 cells/cubic mm)Maternal tachycardia (>100 beats/min)Fetal tachycardia (>160 beats/min)Uterine tendernessFoul odor of the amniotic fluidAMNIOTIC FLUID ANALYSIS:Gram stain: bacteria & leukocytes (> 6 leukocytes/hpf)Glucose (<15mg/dl abnormal)WBC (Abnormal >30 cells/cc)Leukocyte esterase (strips) +Abnormal glu + wbc + Leuk/esterase= sensitivity 90%, specificty 80% for pos cultureMICROBIOLOGY:Organisms from vaginal flora, anaerobes, mycoplasma, GBS, E.coli.Usually polymicrobial
107CHORIOAMNIONITIS MANAGEMENT AntibioticsAmp/gent/clinda.Other broad-spectrum regimenDelivery(Note: C-section should be performed only for accepted obstetric indications)
109POSTPARTUM ENDOMETRITIS DIAGNOSIS Fever, usually on 1st or 2nd postpartum day.Lower abdominal painUterine tendernessLeukocytosisBimanual exam should be doneMicrobiologic diagnosis:Transvaginally obtained cultures are controversial (contaminants)Blood cultures should be done (10-20% have bacteremia)Chlamydia testing (culture, antigen, PCR) should be done for high risk pts & with late-onset PPE.
110POSTPARTUM ENDOMETRITIS PREDISPOSING FACTORS C-section, especially after labor or rupture of membranes is the main predictorIncidence after vaginal delivery %Incidence after C-section 10-50%Other predictors:Duration of laborRupture of membranesPresence of BVNumber of vag. Exams during laborUse of internal fetal monitoring.
111POSTPARTUM ENDOMETRITIS (PPE) MICROBIOLOGY Polymicrobial (GBS, enterococci, G. vaginalis, E. coli, Prevotella bivia, Bacteroides spp, peptostreptococci, Ureoplasma urealyticum, Mycoplasma hominis)Chlamydia trachomatis may cause a late form of PPE (>2days to 6 wks postpartum, after vag delivery)Group A Strep PPE is rareof exogenous source, usually caregiver.Major epidemiologic significance: HCW screening (all at the delivery & those who did vag exam before delivery should be screened w cultures of nares, throat, vagina, rectum, skin. If culture + should refrain from patient care for the 1st 24h of abx therapy)
112POSTPARTUM ENDOMETRITIS MANAGEMENT Antibiotics (broad-spectrum)until pt is afebrile, pain-free, & with normal wbc count.FAILURE TO RESPOND may indicate:multi-drug resistant bacteria,inadequate regimen,abscess,puerperal ovarian vein thrombosis,non-infectious fever (e.g., drug-fever, breast engorgement)PROPHYLAXIS:Abx prophylaxis for any c-section after labor or rupture of membranes of any duration
113PUERPERAL OVARIAN VEIN THROMBOSIS Acute postpartum thrombosis of ovarian veinsRare, incidence 1/2000 deliveries or 1-2/100 pts w postpartum infectionCan occur after c-section or vaginal delivery.Usually associated with post-c-section endometritis. Previously diagnosed w “PPE failing to respond to abx”Onset mostly 2-4 days after delivery.Acute onset, pt appears ill, febrile/chills, lower abd pain (usually rt sided), tachycardia disproportionately elevated c/w temp.EXAM: tenderness, tender sausage-shaped mass may be palpable (1/2-2/3).If PE has occurred may have respiratory complaints too.Usually a diagnosis of exclusion.Sono, CT, or MRI may confirm diagnosisRx: Abx, anticoagulation ( usually x 7-10d, in absence of PE)