Infections of the Genital Tract - Part III
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Heavily lifted from the CDC STD Treatment Guidelines 2015, this is a discussion of cervicitis, pelvic inflammatory disease and prevention of sexually transmitted infections in victims of sexual assault. This was a lecture delivered to an audience of second year medical students at the Cebu Doctors University College of Medicine.
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Infections of the Genital Tract - Part III
- 1. Infections ofInfections of the Genitalthe Genital TractTract Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG Cebu Doctors University College of Medicine February 2016 @helenvmadamba CDUCM 2016
- 3. LECTURE OUTLINE ā¢ Infections of the Vulva ā¢ Bartholinās gland abscess ā¢ Ectoparasites ā¢ Diseases characterized by Ulcers ā¢ HPV and Anogenital Warts ā¢ Infections of the Vagina ā¢ Diseases Characterized by Vaginal Discharge ā¢ Infections of the Cervix ā¢ Diseases Characterized by Cervicitis @helenvmadamba CDUCM 2016
- 4. LECTURE OUTLINE ā¢ Infections of the Upper Genital Tract ā¢ Pelvic Inflammatory Disease ā¢ Sexual Assault & STDs @helenvmadamba CDUCM 2016
- 5. The Five Pās 1. Partners 2. Practices 3. Prevention of Pregnancy 4. Protection from STDs 5. Past history of STDs @helenvmadamba CDUCM 2016
- 6. INFECTIONS OF THE CERVIX PART III @helenvmadamba CDUCM 2016
- 7. Diseases Characterized by Urethritis and Cervicitis ā¢ Gonococcal infections ā¢ Chlamydial infections @helenvmadamba CDUCM 2016
- 8. CERVIX ā¢ The cervix acts as a barrier between the abundant bacterial flora of the vagina and the bacteriologically sterile endometrial cavity and oviducts @helenvmadamba CDUCM 2016
- 9. Cervicitis ā¢ Vaginal discharge, deep dyspareunia, postcoital bleeding ā¢ Cervix that is hypertrophic and edematous ā¢ Chlamydia trachomatis is the most common etiologic agent @helenvmadamba CDUCM 2016
- 10. Cervicitis ā¢ Vaginal discharge, deep dyspareunia, postcoital bleeding ā¢ Cervix that is hypertrophic and edematous ā¢ Majority of women who have mucopurulent cervicitis are infected by C. trachomatis or N. gonorrhoeae ā¢ Many women harboring sexually transmitted pathogens in the cervix are asymptomatic. @helenvmadamba CDUCM 2016
- 11. Mucopurulent Cervicitis ā¢ Gross visualization of yellow mucopurulent material on a white cotton swab @helenvmadamba CDUCM 2016
- 12. Mucopurulent Cervicitis ā¢ Presence of 10 or more PMN leukocytes per microscopic field on Gram-stained smears obtained from the endocervix ā¢ Erythema and edema in an area of cervical ectopy ā¢ Associated with bleeding secondary to endocervical ulceration ā¢ Friability when endocervical smear is obtained @helenvmadamba CDUCM 2016
- 14. Chlamydia trachomatis ā¢most frequently reported infectious disease ā¢prevalence is high among persons aged 25 years or less ā¢most serious sequelae: ā¢ PID ā¢ ectopic pregnancy ā¢ infertility @helenvmadamba CDUCM 2016
- 15. Chlamydia trachomatis ā¢Diagnostics: urine or swab specimens collected from endocervix or vagina ā¢Others: ā¢ culture ā¢ direct immunofluorescence ā¢ EIA @helenvmadamba CDUCM 2016
- 16. Chlamydia trachomatis This womanās cervix has manifested signs of an erosion and erythema due to chlamydial infection. ā¢ An untreated chlamydia infection can cause severe, costly reproductive and other health problems including both short- and long-term consequences @helenvmadamba CDUCM 2016
- 18. Treatment for nonpregnant women Recommended Regimens ā¢ Azithromycin 1g orally in a single dose OR ā¢ Doxycycline 100mg orally twice a day for 7 days Alternative Regimens ā¢ Erythromycin base 500mg orally four times a day for 7 days OR ā¢ Erythromycin ethylsuccinate 800mg orally four times a day for 7 days OR ā¢ Ofloxacin 300mg orally twice a day for 7 days OR ā¢ Levofloxacin 500mg orally once daily for 7 days @helenvmadamba CDUCM 2016
- 19. Treatment for pregnant women Recommended Regimens ā¢ Azithromycin 1g orally in a single dose OR ā¢ Amoxicillin 500mg orally thrice a day for 7 days Alternative Regimens ā¢ Erythromycin base 500mg orally four times a day for 7 days OR ā¢ Erythromycin base 250mg orally four times a day for 14 days OR ā¢ Erythromycin ethylsuccinate 800mg orally four times a day for 7 days OR ā¢ Erythromycin ethylsuccinate 400mg orally four times a day for 14 days @helenvmadamba CDUCM 2016
- 20. CDC 2015 STD Guidelines @helenvmadamba CDUCM 2016
- 21. Neisseria gonorrhoeae ā¢ second most commonly reported bacterial STD. ā¢ majority of urethral infections caused by N. gonorrhoeae ā¢ among women, several infections do not produce recognizable symptoms until complications (PID) have occurred. ā¢ women aged 25 years or less are at highest risk for gonorrhea infection. @helenvmadamba CDUCM 2016
- 22. Neisseria gonorrhoeae ā¢ Risk factors include previous gonorrhea infection, other sexually transmitted infections, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use. ā¢ Diagnostics: a Gram stain of a male urethral specimen that demonstrates polymorphonuclear leukocytes with intracellular Gram-negative diplococci @helenvmadamba CDUCM 2016
- 23. Treatment Ceftriaxone 250 mg IM in a single dose OR Cefixime 400mg orally in a single dose OR Single dose injectable cephalosporin regimens PLUS Treatment for chlamydia if chlamydial infection is not ruled out @helenvmadamba CDUCM 2016
- 24. CDC 2015 STD Guidelines @helenvmadamba CDUCM 2016
- 25. CDC 2015 STD Guidelines @helenvmadamba CDUCM 2016
- 26. INFECTIONS OF THE UPPER GENITAL TRACT PART IV @helenvmadamba CDUCM 2016
- 27. Infections of the Upper Genital Tract ā¢ Pelvic Inflammatory Disease @helenvmadamba CDUCM 2016
- 28. Pelvic Inflammatory Disease ā¢ An infection in the upper genital tract not associated with pregnancy or intraperitoneal pelvic operations. ā¢ Salpingitis ā infection of the oviducts is the most characteristic and common component of PID. Katz et al. 2007. Comprehensive Gynecology. @helenvmadamba CDUCM 2016
- 29. Pelvic Inflammatory Disease ā¢ A spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis. CDC. 2010 STD Treatment Guidelines. @helenvmadamba CDUCM 2016
- 31. Acute PID ā¢ ascending infection from the bacterial flora of the vagina and cervix in >99% of cases ā¢ <1% of cases, from transperitoneal spread of infectious material from perforated appendix or intraabdominal abscess ā¢ Hematogenous and lymphatic spread to the tubes or ovaries @helenvmadamba CDUCM 2016
- 32. Major Sequelae of PID ā¢ Ectopic pregnancies: ā6 to 10-fold ā¢ Chronic pain: ā4-fold ā¢ Infertility: 6% to 60% depending on severity of the infection, the number of episodes and the age of the patient @helenvmadamba CDUCM 2016
- 33. Reduction of Impact of acute PID ā¢ Aggressive therapy for LGTI ā¢ Early diagnosis and treatment of UGTI ā¢ Primary prevention: safe sexual practices ā¢ Secondary prevention: screening for gonorrhea, chlamydia and active cervicitis, treatment of partners, education to prevent recurrent infection @helenvmadamba CDUCM 2016
- 34. Silent or asymptomatic PID ā¢ CDC emphasized: aggressively treat women if there is any suspicion of the disease, because the sequelae are so devastating and the clinical diagnosis made from the symptoms, signs and laboratory data is often incorrect. @helenvmadamba CDUCM 2016
- 35. Neisseria gonorrheae Chlamydia trachomatis ā¢ These two organisms co-exist 25-50% of the time ā¢ Gonorrheal organisms frequently cultured during first 24 to 48 hours of the disease, but often absent later. @helenvmadamba CDUCM 2016
- 36. Minimum criteria: Initiate empiric treatment in the presence of any ONE of the three: ā¢ Cervical motion tenderness ā¢ Uterine tenderness ā¢ Adnexal tenderness ā¢ Predominance of leukocytes in vaginal secretions, cervical exudates or cervical friability increases specificity of diagnosis CDC 2010 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 37. Additional criteria ā¢ Oral temperature > 38.3 Cā¦ ā¢ Abnormal cervical or vaginal mucopurulent discharge ā¢ Presence of abundant numbers of WBC on saline microscopy of vaginal fluid ā¢ Elevated ESR ā¢ Elevated C-reactive protein ā¢ Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis CDC 2010 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 38. Most specific criteria ā¢ Endometrial biopsy with histopathologic evidence of endometritis ā¢ Transvaginal sonography or MRI showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection ā¢ Laparoscopic abnormalities consistent with PID CDC 2010 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 39. Indications for hospitalization ā¢ Surgical emergencies cannot be excluded ā¢ The patient is pregnant ā¢ The patient does not respond clinically to oral antimicrobial therapy ā¢ The patient is unable to follow or tolerate an outpatient oral regimen ā¢ The patient has severe illness, nausea and vomiting, or high fever ā¢ The patient has tubo-ovarian abscess CDC 2010 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 40. ā¢ Cefotetan 2 g IV every 12 hours OR ā¢ Cefoxitin 2 g IV every 6 hours PLUS ā¢ Doxycycline 100 mg orally or IV every 12 hours CDC 2015 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 41. CDC 2015 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 42. CDC 2015 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 43. CDC 2015 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 44. ā¢ Discontinue parenteral therapy 24 hours after clinical improvement: ļ Doxycycline 100 mg every 12 hours to complete 14 days ā¢ For tubo-ovarian abscess: ā¢ Add oral clindamycin or metronidazole to provide more effective anaerobic coverage CDC 2010 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 45. Follow up ā¢ Clinical improvement within 3 days after initiation of therapy @helenvmadamba CDUCM 2016
- 46. Management of Sex Partners ā¢ Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic. ā¢ should be examined and treated if they had sexual contact during the 60 days preceding the patientās onset of symptoms ā¢ If >60 days, must be treated ā¢ Abstain from sexual intercourse until therapy is completed. CDC 2010 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 47. Management of Sex Partners ā¢ Abstain from sexual intercourse until therapy is completed. CDC 2015 STD Treatment Guidelines @helenvmadamba CDUCM 2016
- 48. SEXUAL ASSAULT & STDs PART V @helenvmadamba CDUCM 2016
- 49. Adolescents and Adults ā¢ Trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydial infection are the most frequently diagnosed infections among women who have been sexually assaulted. ā¢ Chlamydial and gonococcal infections in women are of particular concern because of the possibility of ascending infection. @helenvmadamba CDUCM 2016
- 50. ā¢ HBV infection can be prevented through postexposure vaccination. ā¢ HPV vaccination is also recommended for females through age 26 years. ā¢ Reproductive-aged female survivors should be evaluated for pregnancy. Adolescents and Adults @helenvmadamba CDUCM 2016
- 51. CDC 2015 STD Guidelines @helenvmadamba CDUCM 2016
- 52. These slides will be uploaded onto http://www.slideshare.net/HelenMadamba @helenvmadamba CDUCM 2016
- 53. Infections ofInfections of the Genitalthe Genital TractTract Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG Cebu Doctors University College of Medicine February 2016 @helenvmadamba CDUCM 2016