Infections in OB/GYN: Vaginitis, STIs

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

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

6. Vaginal Candidiasis • S/Sx • 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 **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 • 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 doseORCefixime400 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. C. trachomatis Obligate intracellular pathogen No cell wall, not susceptible to penicillins Difficult to culture Chlamydia trachomatis

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 ORAmoxicillin 500 mg orally three times a day for 7 days (2006 - 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

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. Pelvic Adhesions chronic pelvic pain, dyspareunia infertility ectopic pregnancy Empiric Treatment Suspected Chlamydia, GC or PID Deemed valuable in preventing sequelae PID Sequelae

30. Recommended Screening • GC/Chlamydia: • women < 25 (**remember urine testing!) • Pregnancy • Syphilis • Pregnancy • 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 • Systemic symptoms • Multiple lesions • Urinary retention • Nonprimary First Episode • Few lesions • No systemic symptoms • preexisting Ab

35. Herpes Rx • First Episode • 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

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 • 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 10-14 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