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

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

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

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

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

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)

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

Bacterial Vaginosis

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**

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

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

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

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

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

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

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

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

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

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

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

Chlamydia in Pregnancy Azithromycin 1 g orally in a single dose OR Amoxicillin 500 mg orally three times a day for 7 days (2006 - Poor efficacy of erythromycin – now alternative regimen) Test of cure in 3 weeks

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

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

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

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

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

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

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

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

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

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

Genital Ulcers Syphilis Herpes Chanchroid Lymphogranuloma Venereum Granuloma Inguinale

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

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

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

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

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

Primary & Secondary Syph

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

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 10-14 days

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

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

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

Vulvar Lesions Human Papilloma Virus Molluscum Contagiosum Pediculosis Pubis Scabies

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