Return to Course Calender
updated 8/04
The student will be able to:
1. Describe the epidemiology of selected STD's AND vaginal infections.
2. Discuss prevention plans for populations at risk for STD's
3. Plan care for treatment of selected STD's
4. Discuss characteristics of acute and chronic pelvic inflammatory disease
5. Plan care for women with acute or chronic pelvic inflammatory disease
The web page of the CDC (Centers for Disease Control) will link you to the newest guidelines, . www.cdc.gov/std then select hyperlink to other Treatment Guidelines. If you cannot hyperlink, type in the URL on your computer.
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Infectious Complications-Vaginal/STD |
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| Disease | Vulvovaginal candidacies (Yeast) | Bacterial Vaginosis | Trichomoniasis | Chlamydial infection |
|---|---|---|---|---|
| Organism | Candida albicans | Gardnerella vaginalis | Trichomonas vaginalis | Chlamydia trachomatis |
| Transmission | Increased with pregnancy, DM, & antibiotics. Avoid nylon undies, tight fitting pants, etc. | Exact unknown. May be STD | STD | STD (more common than GC) |
| Symptoms | Thick, white, curdy discharge. Severe itching, dysuria, dyspareunia. | Thin, watery, yellow-gray discharge with foul, ("fishy"), odor. | Frothy greenish-gray discharge, pruritus, urinary symptoms. May be asymptomatic | Usually mild, Women often asymptomatic. May have thin or purulent discharge, urinary burning and frequency, or lower abdominal pain. Friable cervix. |
| Diagnosis | Presence of hyphae and spores in wet mount (KOH) | Presence of "clue cells" in Wet mount (KOH)- +"Whiff" test | Wet mount (NS) shows motile flagellated trichomonads. Strawberry patches may be visible on vaginal walls or cervix. | DNA probe (Should culture for GC at same time)--monoclonal antibodies |
| Fetal/Neonatal Effects | Thrush in newborns | Possible increased risk of PROM and preterm birth. Confirming studies needed (CDC 1993). Metronidazole has potential teratogenic effects. | Possible increased risk of PROM and preterm birth. (CDC 1993). Metronidazole has potential teratogenic effects. | Premature labor, stillbirth & neonatal death rate 10 x normal population. Neonatal conjunctivitis, pneumonia. |
| Maternal Effects | See symptoms | See symptoms | See symptoms | See symptoms. Sequelae may include infertility if PID is extensive |
| Management | Intravaginal miconazole
or clotrimazole. Newborn thrush: Nystatin oral. |
1st Trimester:
clindamycin. 2nd & 3rd: Metronidazole vaginal gel or clindamycin cream (CDC 1993). |
Early pregnancy: control with clotrimazole vaginal suppositories. After 1st trimester, single dose metronidazole 2g may be used (CDC 1993). Treat both partners. | Doxycycline or Azithromycin. Treat sexual partner. |
Infectious Complications-Vaginal/STD - CONTINUED |
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| Disease | Syphilis | Gonorrhea (GC, "Clap") | Condyloma acuminata | AIDS |
|---|---|---|---|---|
| Organism | Treponema pallidum | Neisseria gonorrhoeae | HPV | HIV |
| Transmission | STD (Incubation period 10-60 days) | STD (Easily transmitted--from infected men to women in 90% of exposures/ only transmitted from infected woman to man in 20% of exposures | STD | Mother: STD, IV drug
use, body fluids. Infant: transplacental, during birth, via breast milk |
| Symptoms | Primary stage: Chancre (x 4 weeks), slight fever, malaise. Secondary stage: (6 wks - 6 mos after infection) Condyloma lata, arthritic sx, liver enlargement, iritis, chronic sore throat with hoarseness. | Most women are asymptomatic--often dxd during routine prenatal cervical culture. Sx: purulent vag discharge, dysuria, urinary frequency, inflammation & Vulvar swelling. Cervix may be eroded. | Soft, grayish-pink lesions on vulva, vagina, cervix, or anus. Lesions may be confluent | May be asymptomatic. Symptoms include fatigue, AIDS related infection such as CMV, P. carinii pneumonia, Pulmonary or esophageal Candida, etc. |
| Diagnosis | VDRL, RPR, FTA-ABS | Gram stain
(diplococci), DNA probe,GC culture. Pelvic exam findings: +CMT. lower abdominal tenderness, bilateral adnexal tenderness. |
Visual inspection, biopsy | ELISA (antibodies 6 to 12 weeks after exposure), confirm with Western blot test. Follow with CD4 cell counts. |
| Fetal/Neonatal Effects | Congenital infection: iritis, hydrocephalus, "snuffles". 10-30% fetal mortality. Second trimester spont. ab., stillbirth. | Infection at birth may cause ophthalmia neonatorum--prophylaxis of all infants’ eyes (AGNO3, Ilotycin) . May also cause SGA, RDS, pneumonia in newborn. | Use of podophyllin may cause fetal abnormalities. It should not be used during pregnancy. | Itching, vaginal discharge. Secondary ulceration & infections. More frequent and active in pregnancy. |
| Maternal Effects | See symptoms. Progresses from primary to secondary to tertiary if untreated | See symptoms. Sequelae may include PID, ectopic pregnancy, infertility | Itching, vaginal discharge. Secondary ulceration & infections. More frequent and active in pregnancy. | See symptoms. Also impaired immune system |
| Management | Infection <1 year:
2.4 million U benzathine penicillin G IM. Infection >1 year: 2.4 million U benzathine penicillin G weekly for 3 weeks. Treat sexual partner. |
Ceftriaxome plus erthromycin (during pregnancy) Ceftriaxome plus doxycycline (non-pregnant) (CDC 1993). If allergic to ceftriaxome, then spectinomycin. Treat sexual partner(s). | If pregnant: Refer--
Trichoracetic acid (80-90%) topically to warts is applied at weekly intervals. If not pregnant: Podophyllin. May also use liquid nitrogen or cryotherapy CO2 laser therapy under colposcopy (CDC 1993. |
Identify early. REFER!! If pregnancy is continued, evaluate for other STD's. Assess CD4 cell counts frequently. After 1st trimester Zidovudine may be used--Some say wait till postpartum. If cell count <200mm3 start prophylaxis |
Infectious Complications-Vaginal/STD - CONTINUED |
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| Disease | Hepatitis B | Beta Strep Infection | Acute Urethral Syndrome ( NGU) | PID |
|---|---|---|---|---|
| Organism | HBV | Group B Streptococcus | N. gonorrhoeae C. trachomatis |
N. gonorrhoeae C. trachomatis |
| Transmission | More common than AIDS. Immunization is helping. If negative may give vaccine. | Infant through contact during birth. Mother: exact mechanism unknown--increased incidence following UTI with strep as organism during pregnancy. | ||
| Symptoms | Fatigue, nausea, flu-like illness. | Mother is most often asymptomatic--found during routine culture or when infant develops symptoms | Treat empirically
(minimum criteria) Lower abdominal tenderness Adenexal tenderness, and Cervical motion tenderness Additional
criteria |
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| Diagnosis | Test all pregnant women for HBsAG (CDC 1991. | Vaginal culture at 28 and 37 weeks. (AAP and CDC) | ||
| Fetal/Neonatal Effects | Perinatal transmission occurs at or near time of birth. If not treated risk of infection raises. | Early onset occurs within hours of birth or within 1st week. Late onset from 1 week to 3 months. Severe respiratory distress (grunting & cyanosis). May become apneic or demonstrate symptoms of shock. Meconium stained amniotic fluid often seen at birth. May develop into meningitis or overwhelming sepsis. | ||
| Maternal Effects | Does not usually affect course of pregnancy. Chronic disease = liver failure | See Symptoms. Treat with subsequent pregnancies (CDC) | ||
| Management | REFER!! Provide
immunoprophylaxis to newborns of HBsAG positive women. Provide routine
vaccinations to all neonates born to HBsAG negative women (CDC 1991). For infected women, treatment is supportive and symptomatic |
Recommendation by CDC and AAP is to culture at 37 weeks (some also say 28 weeks) and treat all women who test positive with IV antibiotics throughout labor. If labor is very short, some recommend treating infant prophylactically. Risk increased with subsequent pregnancies. | ||
Note: These are not yet updated to 2002. BLB
Alphabetical Presentation of Reproductive Tract Infection 1998 CDC Treatment Guidelines
Adapted from: Hatcher, et al. (1998).
Acute urethral syndrome - Recommended Regimens
| Drug | Regimen |
|---|---|
| Ciprofloxacin (Cipro) | 250 mg BID X 3 days |
| Ofloxacin | 200 mg BID X 3 days |
| See treatment for clamydia and GC |
Bacterial vaginosis - Recommended Regimens
| Drug | Regimen |
|---|---|
| Metronidazole (Flagyl) | 500 mg PO BID for 7 days |
| Clindamycin cream 2% | 1 full applicator (5 GMS) per vagina X 7 days @ night |
| Metronidazole gel 0.75% | 1 full applicator (5 GMS) per vagina BID X 5 days |
Alternative regimens
| Drug | Regimen |
|---|---|
| Metronidazole | 2 GMS PO as a single dose |
| Clindamycin | 300 mg PO BID X 7 days |
Note: Do not use clindamycin in pregnancy.
Candidiasis - Recommended Regimens
| Drug | Regimen |
|---|---|
| Fluconizole (Diflucan) | 150 mg PO one time |
| Miconazole Vaginal Cream 2 % | 1 applicator HS X 3 days |
| Miconazole Suppositories | 200 mg per vagina HS X 3 days |
| Butoconazole cream 2% | 1 applicator HS X 3 days |
Chancroid - Recommended Regimens
| Drug | Regimen |
|---|---|
| Azithromycin (Aithromax) | 1 gm PO in a single dose |
| Ceftriaxone (Rocephin) | 250 mg IM in a single dose |
| Ciprofloxacin (Cipro) | 500 mg PO BID X 3 days |
| Ethromycin base | 500 mg PO QID X 7 days |
Note: Floroquinalones are contraindicated for pregnant and lactating women and for persons under age 18.
Clamydia - Recommended regimens
| Drug | Regimen |
|---|---|
| Azithromycin | 1 gm PO as a single dose |
| Doxycycline | 100 mg PO BID X 7 days |
Alternative
| Drug | Regimen |
|---|---|
| Erythromycin base | 500 mg PO QID X 7 days |
| Erythromycin ethylsuccinate | 800 mg PO QID X 7 days |
| Ofloxacin | 300 mg PO BID X 7 days |
Treatment in Pregnancy
Doxycycline and Ofloxacin contraindicated
Azithromycin may be safe/effective
| Drug | Regimen |
|---|---|
| Erythromycin base |
500 mg PO QID X 7 days |
| Amoxicillin | 500 mg PO TID X 7 days |
| Azithromycin | 1 gm PO as a single dose |
| Erythromycin ethylsuccinate | 800 mg PO QID X 7 days or 400 mg PO QID X 14 days |
Treatment of opthalmia neonatorum or infant pneumonia
| Drug | Regimen |
|---|---|
| Erythromycin base | 50 mg/kg/day PO QID x 10-14 days |
Treat sex partners
Reportable
Genital Herpes - First Clinical Episode
| Drug | Regimen |
|---|---|
| Acyclovir | 400 mg PO TID X 7-10 days |
| Acyclovir | 200 mg PO 5x/day X 7-10 days |
| Famciclovir | 250 mg PO TID X 7-10 days |
| Valacyclovir | 1 gm PO BID X 7-10 days |
Recurrent Infection
| Drug | Regimen |
|---|---|
| Acyclovir | 400 mg PO TID X 5 days or 200 mg PO 5 X /day X 5 days or 800 mg PO BID X 5 days |
| Famciclovir | 125 mg PO BID X 5 days |
| Valacyclovir | 500 mg PO BID X 5 days |
Daily Suppressive Therapy
| Drug | Regimen |
|---|---|
| Acyclovir | 400 mg PO BID daily |
| Famciclovir | 250 mg PO BID daily |
| Valacyclovir | 250 mg PO BID daily |
| Valacyclovir | 500 mg PO q day |
Pregnancy
CDC does not recommend systemic treatment for women without life threatening illness. Labor. Low chance of transmission unless new onset near delivery. C/S generally not indicated.
Genital Warts (Condyloma acuminata) Patient-Applied
| Drug | Regimen |
|---|---|
| Podofilox 0.5% solution or gel | Applied with a cotton swab or gel with a finger to visible genital warts BID X 3 days followed by 4 days of no therapy. Cycle may be repeated for a total of four cycles |
| Imiquimod 5% cream | Apply cream with finger at bedtime 3 X weekly, up to 16 weeks. Wash with mild soap and water after 6 - 10 hours. Not for use during pregnancy. |
Practitioner Applied
| Drug | Regimen |
|---|---|
| Cryotherapy with liquid nitrogen or cyroprobe | Repeat applications every one to two weeks. Avoid normal tissue. Wash off in 1-4 hours. Not for use during pregnancy. |
| Podophyllin resin 10-25% in compound tincture of benzoin | Repeat weekly if necessary |
| Trichloracetic acid (TCA) or
Bichloracetic acid (BCA) 80-90% |
Repeat weekly |
| Surgical removal. Scissors or shaving excision, curette, or electrosurgery are possible. |
Gonorrhea
| Drug | Regimen |
|---|---|
| Cefixime | 400 mg PO in a single dose |
| Ceftriaxone | 125 mg IM in a single dose |
| Azithromycin | 1 gm PO in a single dose |
| Doxycycline | 100 mg PO BID X 7 days |
Lymphygranuloma venereum (LGV)
| Drug | Regimen |
|---|---|
| Doxycycline | 100 mg PO BID X 21 days |
| Erythromycin base | 500 mg PO QID X 21 days |
Mulluscum contageosum
Mucopurulent cervicitis (MPC).
Treat when diagnosis of GC or clamydia
Nongonococcal urethritis (NGU)
30% Chlamydia; 10-45% Ureaplasma urealyticum, Trichomonas.
Pelvic Inflammatory Disease, oral
Regimen A
| Drug | Regimen |
|---|---|
| Ofloxacin | 400 mg PO BID X 14 days PLUS |
| Metronidazole | 500 mg PO BID X 14 days |
Regimen B
| Drug | Regimen |
|---|---|
| Ceftriaxone | 250 mg IM X 1 OR |
| Cefoxitin | 2 gm IM plus Probenecid 1 gm PO X 1 as a single dose OR |
| Other 3rd generation cephalosporin PLUS Doxycycline | 100 mg BID X 14 days |
Syphilis