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Gynecological infections. Gebre K. Tseggay, M. D. Normal Vaginal Flora . Dominated by lactobacilli

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gynecological infections

Gynecological infections

Gebre K. Tseggay, M. D.

normal vaginal flora
Normal 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.
slide3

BACTERIAENDOGENOUSTOTHELOWERGENITALTRACT

GRAM POSITIVEGRAM NEGATIVE

Lactobacillus acidophilusEscherichia coli

CorynebacteriumsppEnterobacter cloacae

Gardnerella vaginalis

Staphylococcus epidermidisKlebsiella

Streptococci Morganella

Enterococcus faecalisProteus

Peptococcus Bacteroides

Peptostreptococcus Fusobacterium

Prevotella

modified from Schlossberg,CTID 2001

slide4

Vaginitis

  • Most common causes include:
    • Vulvovaginal Candidiasis (VVC)
    • Bacterial Vaginosis (BV)
    • Trichomoniasis
    • *In some cases the etiology may be mixed
vaginitis symptoms
VAGINITISSYMPTOMS
  • Often non-specific:
    • Abnormal discharge
    • Vulvovaginal irritation
    • Vulvar itching
    • Odor
vaginitis diagnosis
VAGINITISDIAGNOSIS
  • History
  • Visual inspection
  • Appearance of vaginal discharge: color, viscosity, adherence to vaginal walls, odor
  • Collection of specimen
  • Diagnostictests:
    • Vaginal pH: determine vaginal pH with narrow-range pH paper
    • Whiff test: assessment of a fishy odor after application of 10% KOH to wet mount
    • KOH (wet mount): wet mount of discharge with 10% KOH
    • NaCl (wet mount): wet mount of discharge with 0.9% normal saline
vaginitis diagnosis7
VAGINITIS DIAGNOSIS

Other tests:

  • Cultures: not used routinely, but are available for both T. vaginalis and Candidaspp.
  • New tests for BV(commercially available) :
    • Fem Exam Test Card™: pH and amines
    • Fem Exam vaginalis PIP Activity Test Card™: detects enzyme breakdown from G. vaginalis
  • DNA probe for 3 organisms (T. vaginalis, C. albicans, and G. vaginalis): sensitivity, specificity, and clinical utility are under investigation.
vulvovaginal candidiasis
VULVOVAGINALCANDIDIASIS
  • Not considered to be STD
  • Caused by overgrowth of Candida species (Candida species are normal flora of vagina)
  • 80-90% caused by C. albicans.
  • Non-albicans candida play increasing role
vulvovaginal candidiasis risk factors
Uncontrolled DM

Corticosteroid therapy

Antimicrobial therapy (oral, parental, topical)

Poor hygiene

Estrogen therapy

High-dose estrogen contraceptives

Pregnancy

IUD

HIV infection

Sponge

Nonoxynol-9 (?)

Diaphragm (?)

Increased frequency of coitus

"Candy binge“

Women frequenting STD clinics

Tight-fitting synthetic underclothing

But, most episodes of vulvovaginal candidiasis occur in the absence of a recognizable precipitating factors

VULVOVAGINAL CANDIDIASIS RISKFACTORS
vulvovaginal candidiasis classification
VULVOVAGINAL CANDIDIASIS CLASSIFICATION

UncomplicatedComplicated

Sporadic, infrequent Recurrent

Mild-to-moderate Severe

Likely C albicans Non-albicans

Non-immunocomprised Diabetes, pregnancy,

immunosuppression

vulvovaginal candidiasis manifestations
VULVOVAGINALCANDIDIASISMANIFESTATIONS
  • Vulvar pruritis is most common symptom
  • Thick, white, curdy vaginal discharge ("cottage cheese-like")
  • Erythema, irritation, occasional erythematous "satellite" lesion
  • External dysuria and dyspareunia
v ulvovaginal candidiasis diagnosis
VULVOVAGINALCANDIDIASISDIAGNOSIS
  • Clinical
  • pHnormal (<4.5)
  • Whiff test negative
  • Fungal stain positive
    • 30% may have a negative fungal stain
    • Severity does not depend on No. yeasts present
regimens for the treatment of vulvovaginal candidiasis
Regimens 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 application
    • Clotrimazole 1% cream 5 g intravaginally for 7-14 days†
    • Clotrimazole 100 mg vaginal tablet for 7 days
    • Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days
    • Clotrimazole 500 mg vaginal tablet, 1 tablet in a single application
    • Miconazole 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 days
    • Tioconazole 6.5% ointment 5 g intravaginally in a single application†
    • Terconazole 0.4% cream 5 g intravaginally for 7 days
    • Terconazole 0.8% cream 5 g intravaginally for 3 days
    • Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
  • Oral agent:
    • Fluconazole 150 mg oral tablet, 1 tablet in a single dose

Note: 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

recurrent vulvovaginal candidiasis
RECURRENTVULVOVAGINAL CANDIDIASIS
  • Four or more symptomatic episodes/year
  • Usually NOT from resistance to antifungals
  • Diabetes mellitus or immunosuppression should be considered in refractory/ recurrent cases
  • Simultaneous 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 species

Treatment

  • Initial regimen of 7-14 days topical therapy
  • Fluconazole 150 mg (repeat 72 hrs)
  • Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole
  • ForNon-albicans VVC:
    • Longer duration of therapy
    • Non-azole regimen may even be needed
    • 600 mg boric acid in gelatin capsule vaginally once a day for 14 days
vulvovaginal candidiasis treatment in pregnancy
VULVOVAGINALCANDIDIASISTreatment in Pregnancy
  • Only topical intravaginal regimens recommended (usually for 7 days)
vulvovaginal candidiasis management of sex partners
VULVOVAGINALCANDIDIASISManagement of Sex Partners
  • Treatment not recommended
  • Treatment of male partners does not reduce frequency of recurrences in the female
    • But, male partners with balanitis may benefit from treatment
bacterial vaginosis
BACTERIALVAGINOSIS
  • 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 titers
  • But, 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 procedures
  • Male sex partners may be colonized but asymptomatic
bacterial vaginosis18
BACTERIALVAGINOSIS
  • Gray, homogenous discharge w foul (fishy) odor reported mostly after vaginal intercourse and after completion of menses
  • Without obvious vaginal inflammation
  • Clue cells present
  • pH>4.5
  • Positive Whiff test (KOH)
slide19

NOT a clue cell

Clue cells

NOT a clue cell

slide21

BACTERIAL VAGINOSISOther Diagnostic Tools

  • Culture not recommended; Do not Rx a positive GV vaginal culture in asymptomatic women
  • Newer diagnostic modalities include:
    • FemExam™
    • PIP Activity TestCard™
  • DNA probe
bacterial vaginosis treatment
BACTERIALVAGINOSISTREATMENT
  • Metronidazole 500 mg twice daily x 7 days
  • Metronidazole gel 0.75%,5 g intravaginally once daily x 5 days
  • Clindamycin cream 5%, 5 g intravaginally qhs x 7 days

Alternativeregimens

  • Metronidazole 2 gm in a single dose
  • Clindamycin 300 mg twice daily x 7 days
  • Clindamycin ovules 100 g intravaginally qhs x 3 days
bacterial vaginosis treatment in pregnancy
BACTERIALVAGINOSISTreatment in Pregnancy
  • Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes
  • Do not use of topical agents in pregnancy
  • Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatalvisit; optimal regimen not established
bacterial vaginosis treatment in pregnancy24
BACTERIALVAGINOSISTreatment in Pregnancy

Metronidazole 250 mg three times daily for 7 days

or

Clindamycin 300 mg twice daily for 7 days

bacterial vaginosis management of sex partners
BACTERIALVAGINOSISManagement of Sex Partners
  • Not recommended
    • Woman’s response to therapy and the likelihood of relapse or recurrencenotaffected by treatment of sex partner
trichomoniasis
Etiologic agent

Trichomonas vaginalis – a flagellated protozoa

TRICHOMONIASIS
slide27
Trichomoniasis and other vaginal infections — Initial visits to physicians’ offices: United States, 1966–2003

SOURCE: National Disease and Therapeutic Index (IMS Health)

trichomoniasis28
TRICHOMONIASIS
  • Estimated 7.4 million cases annually in the U.S.
  • Almost always sexually transmitted
  • Causes urethritis in men (usu. asymptomatic)
  • Transmission between female sex partners has been documented
  • Fomite transmission rare
  • Possible association with
    • Pre-term rupture of membranes and pre-term delivery
    • Increased risk of HIV acquisition
trichomoniasis diagnosis
TRICHOMONIASISDIAGNOSIS
  • Copious, yellow-green or grayfrothy discharge, adherent to vaginal walls, w foul odor.
  • Vulvovaginal erythema
  • Punctate cervical microhemorrhages seen in 25%: ‘strawberrycervix’
  • Saline smear 80% sensitive, highly specific (motile trichomonads)
  • Liquid culture, Diamond’s medium, done in persistent cases
  • Gram stain & Pap smear are not sensitive or specific
  • Whiff test (KOH) +/-
trichomoniasis treatment
TRICHOMONIASISTREATMENT

Recommended regimen

Metronidazole 2 gm orally in a single dose

Alternative regimen

Metronidazole 500 mg twice a day for 7 days

Pregnancy

Metronidazole 2 gm orally in a single dose

trichomoniasis treatment failure
TRICHOMONIASISTREATMENTFAILURE
  • Re-treat with metronidazole 500 mgtwice daily for 7 days
  • If above fails, Rx with metronidazole 2 gm single dose x 3-5 days
  • In repeated failure:
    • Confirm diagnosis with culture
    • consider metronidazole susceptibility testing through the CDC
    • Trial of tinidazole
trichomoniasis other management issues
TRICHOMONIASISOther 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
trichomoniasis management of sex partners
TRICHOMONIASISManagementofSexPartners
  • Sex partners should be treated, even if asymptomatic
  • Avoid intercourse until therapy is completed and patient and partner are asymptomatic

.

non infectious vaginitis
NON-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
mucopurulent cervicitis
MUCOPURULENTCERVICITIS
  • Largely caused by Chlamydia trachomatis and Neiserria Gonorrheae
chlamydia trachomatis40
Chlamydia trachomatis
  • Estimated 3 million cases in the U.S. annually
  • Women: bartholinitis, cervicitis, urethritis, PID, perihepatitis, conjunctivitis
      • Men: urethritis, epididymitis
      • M&W: LGV
      • Infants: conjunctivitis, pneumonia
  • Complications: PID, perihepatitis, Reiter’s syndrome, infertility, ectopic pregnancy, chronic pelvic pain, increased risk for HIV
  • Incubation period is 7-21 days.
chlamydia trachomatis risk factors
ChlamydiatrachomatisRiskfactors
  • Adolescence
    • Cervical epithelial cells are developmentally immature (ectopy) making them more susceptible to infection.
    • Risky behaviors also contribute to susceptibility.
  • New or multiple sex partners
  • History of past STD infection
  • Presence of another STD
  • Oral contraceptive use (contributes to cervical ectopy, & OCP users less likely to use barrier protection)
  • Lack of barrier contraception
chlamydia trachomatis42
Chlamydiatrachomatis

Cervicitis

  • Majority 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.

Urethritis

  • 50% of infected women yield chlamydia from both urethra and cervical sites
  • Usually asymptomatic
  • May cause the “dysuria-pyuria” syndrome mimicking acute cystitis. On urinalysis, pyuria present but few bacteria.
chlamydia trachomatis diagnosis
ChlamydiatrachomatisDIAGNOSIS

Culture: high specificity BUT

      • labor-intensive, expensive,
      • variable sensitivity (50%-80%),
      • not suitable for widespread screening

Non-culture methods:

  • Serology: not very useful
  • EIA, DFA, DNA probe : less sensitive(50-75%), nonspecific
  • Nucleic acid amplification tests (NAAT): PCR, LCR:
        • more sensitive than culture (>80%-90%)
        • highly specific (>99%)
        • can use first void urine
        • can use self-obtained vaginal swab
chlamydia trachomatis treatment
ChlamydiatrachomatisTreatment

Azithromycin 1 gm single dose

or

Doxycycline 100 mg bid x 7d

chlamydia trachomatis alternative regimens
Chlamydia trachomatisAlternative regimens

Erythromycin base 500 mg qid for 7 days

or

Erythromycin ethylsuccinate 800 mg qid for 7 days

or

Ofloxacin 300 mg twice daily for 7 days

or

Levofloxacin 500 mg for 7 days

chlamydia trachomatis treatment in pregnancy
Chlamydia trachomatisTreatment inPregnancy

Recommended regimens

Erythromycin base 500 mg qid for 7 days

or

Amoxicillin 500 mg three times daily for 7 days

Alternative regimens

Erythromycin base 250 mg qid for 14 days

or

Erythromycin ethylsuccinate 800 mg qid for 14 days

or

Erythromycin ethylsuccinate 400 mg qid for 14 days

or

Azithromycin 1 gm in a single dose

chlamydia trachomatis screening
ChlamydiatrachomatisScreening
  • Annual screening of sexually active women < 25 yrs
  • Annual screening of sexually active women > 25 yrs with risk factors
  • Sexual risk assessment may indicate need for more frequent screening for some women
  • Screen pregnant women in the first trimester
  • Re-screen women 3-4 months after treatment due to high prevalence of repeat infection
gonorrhea rates united states 1970 2003 and the healthy people 2010 target
Gonorrhea — 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.

gonorrhea50
GONORRHEA
  • Caused 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)
gonorrhea cervicitis clinical manifestations
Gonorrhea CervicitisClinical Manifestations
  • Symptoms are non-specific : abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia
  • Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding
  • 50% of women with clinical cervicitis are asymptomatic
  • Incubation period unclear, but symptoms may occur within 10 days of infection
slide52

Bartholin’s Abscess

Gonorrhea Cervicitis

gonorrhea lab diagnosis
GONORRHEALABDIAGNOSIS
  • Culture (selective media-Thayer Martin, needs CO2)
  • Non-culture tests: DNA probe, nucleic acid amplification
  • Gram-stain, less sensitive in cervicitis(most sensitive for symptomatic urethritis in men)
gonorrhea gram stain of urethral discharge
Gonorrhea:GramStainofUrethralDischarge

Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

neisseria gonorrhoeae cervix urethra rectum
Neisseriagonorrhoeae (Cervix, Urethra, Rectum)

Cefixime 400 mg

or

Ceftriaxone 125 IM

or

1Ciprofloxacin 500 mg

or

1Ofloxacin 400 mg

or

1Levofloxacin 250 mg

PLUS Chlamydial therapy if infection not ruled out

1 Contraindicated in pregnancy and children. Not recommended for infections acquired in California, Asia, or the Pacific, including Hawaii.

neisseria gonorrhoeae cervix urethra rectum56
Neisseriagonorrhoeae(Cervix, Urethra, Rectum)

Alternative regimens

Spectinomycin 2 grams IM in a single dose

or

Single dose cephalosporin (cefotaxime 500 mg)

or

Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg)

PLUS Chlamydial therapy if infection not ruled out

neisseria gonorrhoeae treatment in pregnancy
NeisseriagonorrhoeaeTreatment in Pregnancy
  • Cephalosporin regimen
  • Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM
  • No quinolone or tetracycline regimen

PLUS Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection

slide58

Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2003

Note: Resistant isolates have ciprofloxacin MICs ≥ µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

neisseria gonorrhoeae antimicrobial resistance
NeisseriagonorrhoeaeAntimicrobial Resistance
  • Surveillance is crucial for guiding therapy recommendations
  • No significant resistance to ceftriaxone
  • Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California, Washington.
  • FQ resistance 15% in MSM.
gonorrhea treatment issues
GONORRHEATREATMENT 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 MSM
  • If symptoms persist, perform culture for N. gonorrhoeae.
  • Any gonococci isolated should be tested for antimicrobial susceptibility
  • Co-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.

slide61

GONORRHEAPartner 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.
pelvic inflammatory disease
PELVICINFLAMMATORYDISEASE
  • Estimated about 1 million annual cases in the US
  • Endometritis, salpingitis, tuboovarian abscess, & pelvic peritonitis.
  • Ascending infection from or via cervix
  • Most 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 PID
    • C. trachomatis: recovered from cervix in 20%-40% of women with PID
    • N. gonorrhoeae and C. trachomatis are present in combination in approximately 25%-75% of patients
pelvic inflammatory disease risk factors
PELVICINFLAMMATORYDISEASERISK FACTORS
  • Adolescence (in sexually active teens 3x more than 25-29 yr olds)
  • History of PID
  • GC or chlamydia, or a history of GC or chlamydia
  • Male partners with GC or chlamydia
  • Multiple partners
  • Current douching
  • Insertion of IUD (especially within 4 mos after insertion)
  • Bacterial vaginosis
  • Demographics (lower socioeconomic status)
  • Oral contraceptive use, in some cases (by avoidance of barrier precautions?)
pelvic inflammatory disease66
PELVIC INFLAMMATORY DISEASE

Minimum Diagnostic Criteria

Uterine/adnexal tenderness or cervical motion tenderness

Additional Diagnostic Criteria

Oral temperature >38.3 C Elevated ESR

Cervical Chlamydia or GC Elevated CRP

WBCs/saline microscopy Cervical Discharge

pelvic inflammatory disease more specific criteria
PelvicInflammatoryDiseaseMore SpecificCriteria
  • Endometrialbiopsy: histopathologic evidence of endometritis
  • ImagingStudies: Transvaginal sonography or MRI (showing thickened fluid-filled tubes)
  • Laparoscopy: abnormalities consistent with PID
pelvic inflammatory disease management
PELVICINFLAMMATORYDISEASEMANAGEMENT
  • Antibiotics
  • Bed rest
  • Reevaluation within 72 hrs of treatment
  • All male sex partners should be evaluated for STD and empirically treated with regimen effective for GC/Chlmydia
slide69

PELVIC INFLAMMATORY DISEASEMANAGEMENT

Hospitalize, if:

  • Surgical emergencies not excluded (e.g., appendicitis, ectopic pregnancy..)
  • Pregnant patient
  • Pelvic abscess is suspected
  • Adolescent
  • Severe illness
  • If unable to tolerate outpt regimen
  • If f/up within 72 hrs after starting abx cannot be arranged
  • Non-response to oral therapy
  • HIV infection with low CD4 count
pelvic inflammatory disease parenteral regimen a
Pelvic Inflammatory DiseaseParenteral Regimen A

Cefotetan 2 g IV q 12 hours

or

Cefoxitin 2 g IV q 6 hours

PLUS

Doxycycline 100 mg orally/IV

q 12 hrs

pelvic inflammatory disease parenteral regimen b
PELVIC INFLAMMATORY DISEASEParenteralRegimenB

Clindamycin 900 mg IV q 8 hours

PLUS

Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.

pelvic inflammatory disease alternative parenteral regimens
PELVIC INFLAMMATORY DISEASEAlternativeParenteralRegimens

Ofloxacin 400 mg IV q 12 hours

or

Levofloxacin 500 mg IV once daily

WITH OR WITHOUT

Metronidazole 500 mg IV q 8 hours

or

Ampicillin/Sulbactam 3 g IV q 6 hrs

PLUS

Doxycycline 100 mg orally/IV q 12 hrs

pelvic inflammatory disease oral regimen a
PELVIC INFLAMMATORY DISEASEOralRegimen A

Ofloxacin 400 mg twice daily for 14 days

or

Levofloxacin 500 mg once daily for 14 days

WITH OR WITHOUT

Metronidazole 500 mg twice daily for 14 days

pelvic inflammatory disease oral regimen b
PELVIC INFLAMMATORY DISEASEOralRegimen B

Ceftriaxone 250 mg IM in a single dose

or

Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently

PLUS

Doxycycline 100 mg twice daily for 14 days

WITH or WITHOUT

Metronidazole 500 mg twice daily for 14 days

suspected tuboovarian abscess
SUSPECTEDTUBOOVARIANABSCESS
  • Cultures
  • Broad spectrum antibiotics
    • 85% of abscesses w a diameter of 4-6 cm (& only 40% of those >10 cm) respond to abx alone
  • Surgery for failure to respond to abx.
pelvic inflammatory disease sequelae
PELVIC INFLAMMATORY DISEASESEQUELAE
  • Ectopic pregnancy
    • 7-fold increase in risk after a single episode of PID
  • Infertility:
    • 13% of women after one episode of PID
    • 25-35% after 2 episodes, 50-75% after 3 or more episodes
    • 2/3 unable to conceive after Rx for TOA
  • Dyspareunia
  • Pelvic adhesions
  • Chronic pelvic pain
pelvic inflammatory disease management of sex partners
PELVIC INFLAMMATORY DISEASEManagement of SexPartners
  • Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt’s onset of symptoms
  • Sex partners should be treated empirically with regimens effective against CT and GC
genital herpes initial visits to physicians offices united states 1966 2003
Genital herpes — Initial visits to physicians’ offices: United States, 1966–2003

SOURCE: National Disease and Therapeutic Index (IMS Health)

genital hsv infection
GenitalHSVInfection
  • More than one in five Americans (45 million people)-are estimated infected with genital herpes
  • more 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
estimated annual incidence of selected stds in the u s 2000
Estimated Annual Incidence of Selected STDs in the U.S. , 2000
  • Trichomoniasis   7.4 million
  • Human Papillomavirus (HPV)   6.2 million
  • Chlamydia   2.8 million
  • Herpes Simplex Virus (HSV) Type 2 :  1.6 million
  • Gonorrhea   718,000
  • Syphilis   37,000
hsv serologic tests type specific
HSVSerologicTestsType-Specific
  • HSV-specific glycoprotein G2 for HSV 2 infection and glycoprotein G1 for HSV 1
  • Available gG type-specific assays- POCkit HSV-2, HerpeSelect HSV1/2 IgG ELISA and HerpeSelect 1/2 immunoblot IgG
  • Sensitivity 80-98%, Specificity > 96%
  • Confirmatory testing may be indicated in some settings
genital herpes first clinical episode
GenitalHerpesFirstClinicalEpisode

Acyclovir 400 mg tid

or

Famciclovir 250 mg tid

or

Valacyclovir 1000 mg bid

Duration of Therapy 7-10 days

genital herpes episodic therapy
GenitalHerpesEpisodicTherapy

Acyclovir 400 mg three times daily x 5 days

or

Acyclovir 800 mg twice daily x 5 days

or

Famciclovir 125 mg twice daily x 5 days

or

Valacyclovir 500 mg twice daily x 3-5 days

or

Valacyclovir 1 gm orally daily x 5 days

genital herpes daily suppression
GenitalHerpesDailySuppression

Acyclovir 400 mg bid

or

Famciclovir 250 mg bid

or

Valacyclovir 500-1000 mg daily

genital herpes in hiv infection
GenitalHerpesinHIV Infection
  • May have prolonged or severe episodes with extensive genital or perianal disease
  • Episodic or suppressive antiviral therapy often beneficial
  • For severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary
genital herpes hiv infection episodic therapy
GenitalHerpesHIV Infection/Episodic Therapy

Acyclovir 400 mg three times daily

or

Famciclovir 500 mg twice daily

or

Valacyclovir 1 gm twice daily

Duration of Therapy 5-10 days

genital herpes hiv infection daily suppression
GenitalHerpesHIV Infection/Daily Suppression

Acyclovir 400-800 mg twice to three times daily

or

Famciclovir 500 mg twice daily

or

Valacyclovir 500 mg twice daily

genital herpes antiviral resistance
GenitalHerpesAntiviral Resistance
  • Persistent or recurrent lesions on antivirals
  • Obtain viral isolate for viral susceptability
  • 5% immunocomprised patients
  • Acyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovir
  • Alternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days)
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Herpes in Pregnancy

Risk 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
genital herpes treatment in pregnancy
GenitalHerpesTreatment inPregnancy
  • Acyclovir may be used with first episode or severe recurrent disease
  • Available 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.
genital herpes counseling
GenitalHerpesCounseling
  • Natural history of infection, recurrences, asymptomatic shedding, transmission risk
  • Individualize use of episodic or suppressive therapy
  • Abstain from sexual activity when lesions or prodromal symptoms present
  • Risk of neonatal infection
human papillomavirus
HUMAN PAPILLOMAVIRUS
  • 6.2 million Americans get a new genital HPV infection each year.
  • May cause cancer of cervix, vulva, vagina, or anus
    • the most common sources of genital warts--HPV types 6 and 11--are rarely associated with malignancy
    • the high-risk HPV types 16 and 18 have been found in more than 90% of cervical cancers
  • They appear an average of 3 months after exposure, the latency period can be much longer.
  • Infection can be clinically apparent, subclinical, or latent
  • Frequency 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).
  • Symptoms
  • Genital 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).
human papillomavirus risk for malignancy
HUMANPAPILLOMAVIRUSRisk for Malignancy
  • Externa genital warts
    • HPV types 6, 11.
    • Minimal risk for malignancy
  • Flat warts
    • HPV 16,18, 31, 45…
    • Associated with cancer of cervix, vagina, vulva, anus, penis
    • Most 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.
human papillomavirus diagnosis
HUMANPAPILLOMAVIRUSDIAGNOSIS
  • Inspection usually diagnostic of external warts:, biopsy if in doubt
  • Pap smear, biopsy for flat warts of cervix
  • HPV-DNA studies, PCR, hybrid capture
  • HPV cannot be cultured, and serologic tests are not available to test for HPV antibodies
  • Subclinical 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.
human papillomavirus treatment
HUMANPAPILLOMAVIRUSTreatment
  • Primary goal for treatment of visible warts is the removal of symptomatic warts
  • Therapy may reduce but probably does not eradicate infectivity
  • Difficult to determine if treatment reduces transmission
    • No laboratory marker of infectivity
    • Variable results utilizing viral DNA
human papillomavirus100
HUMANPAPILLOMAVIRUS
  • Choice of therapy guided by preference of patient, experience of provider, resources
  • No evidence that any regimen is superior
  • Locally developed/monitored treatment algorithms associated with improved clinical outcomes
  • Acceptable alternative may be to observe; possible regression/uncertain transmission
papillomavirus
PAPILLOMAVIRUS

Patient-applied

  • Podofilox 0.5% solution or gel
  • Imiquimod 5% cream

Provider-administered

  • Cryotherapy
  • Podophyllin resin 10-25%
  • Trichloroacetic or Bichloroacetic acid 80-90%
  • Surgical removal
human papillomavirus treatment in pregnancy
HUMANPAPILLOMAVIRUSTreatment in Pregnancy
  • Imiquimod, podophyllin, podofilox should not be used in pregnancy
  • Many specialists advocate wart removal due to possible proliferation and friability
  • HPV types 6 and 11 can cause respiratory papillomatosis in infants and children
  • Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction
chorioamnionitis risk factors
Nulliparity

Length of labor

Preterm labor

PROM

Meconium stained amniotic fluid

Internal fetal or uterine monitoring

Presence of GU pathogens (GBS, GC,BV)

No of vag exams in women w ruptured membrane

Underlying Host Factors

No. of lactobacilli,

IgA,

Chronic diseases

Immunosuppression

Nutritional disorders

Drug abuse.

CHORIOAMNIONITISRISK FACTORS
chorioamnionitis diagnosis
CHORIOAMNIONITISDIAGNOSIS
  • 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 tenderness
    • Foul odor of the amniotic fluid
  • AMNIOTIC 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 culture

MICROBIOLOGY:

  • Organisms from vaginal flora, anaerobes, mycoplasma, GBS, E.coli.
  • Usually polymicrobial
chorioamnionitis management
CHORIOAMNIONITISMANAGEMENT
  • Antibiotics
      • Amp/gent/clinda.
      • Other broad-spectrum regimen
  • Delivery

(Note: C-section should be performed only for accepted obstetric indications)

postpartum endometritis diagnosis
POSTPARTUMENDOMETRITISDIAGNOSIS
  • Fever, usually on 1st or 2nd postpartum day.
  • Lower abdominal pain
  • Uterine tenderness
  • Leukocytosis
  • Bimanual exam should be done

Microbiologic 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.
postpartum endometritis predisposing factors
POSTPARTUMENDOMETRITISPREDISPOSINGFACTORS
  • C-section, especially after labor or rupture of membranes is the main predictor
    • Incidence after vaginal delivery 0.9-3.9 %
    • Incidence after C-section 10-50%
  • Other predictors:
    • Duration of labor
    • Rupture of membranes
    • Presence of BV
    • Number of vag. Exams during labor
    • Use of internal fetal monitoring.
postpartum endometritis ppe microbiology
POSTPARTUMENDOMETRITIS(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 rare
    • of 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)
postpartum endometritis management
POSTPARTUMENDOMETRITISMANAGEMENT
  • 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
puerperal ovarian vein thrombosis
PUERPERALOVARIANVEINTHROMBOSIS
  • Acute postpartum thrombosis of ovarian veins
  • Rare, incidence 1/2000 deliveries or 1-2/100 pts w postpartum infection
  • Can 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 diagnosis
  • Rx: Abx, anticoagulation ( usually x 7-10d, in absence of PE)