Infections And Inflammation Of The Genital Tract

Genital Tract Infections Michael Emerson, M.D.

1

Vulva I. Herpes Genitalis A.

Etiology 1. Herpes simplex hominis is an all enveloped DNA virus 2. Herpes virus is usually transmitted sexually 3. Incubation 2-20 days; average 6 days

B.

Incidence 1.

Herpes is the most common cause of vulvar ulcers, second only to gonorrhea as a reason for patients visits to sexually transmitted disease (STD) clinics

2.

Herpes virus type II antibodies have been found in 20% of control patients and 100% of prostitutes

C.

3.

500,000 of cases that occur annually:

4.

Approximately 25 million cases in the United States

Signs and symptoms 1.

Sudden onset of painful erythema and swelling of the vulva

2.

Purulent, odorous discharge

3.

Followed by diffuse swelling and clear vesicles

4.

Later, the vesicles break, and ulcers form. With an initial infection, lesions last 15-21 days and shedding lasts 8-10.4 days

D.

5.

Cystitis. dysuria, and urinary retention may be associated

6.

Malaise, myalgia, and low grade fever sometimes occur

7.

Many subclinical cases occur

Diagnosis 1.

Inspection of vulva, vagina, and cervix

2.

Routine pap smear of lesion and/or cervix will detect 6080%; cytologic changes include the following: a.

Glassy, degenerated appearance of the nuclei

b.

Acidophilic nuclear inclusions (Cowdry type A)

c.

Less commonly, multinuclear giant cell with either balloon degeneration or inclusion bodies in its nuclei

3. E.

Culture of the lesion

Treatment 1.

Acyclovir (Zovirax): a cyclic nucleoside analogue preferentially transports into herpes-infected cells and competitively inhibits viral DNA

2.

Future possibilities a. Interferon

The incidence has dramatically gone up. In the United States there are probably about 500,000 new cases annually. The hard part about herpes is once you have it you always have it so there are approximately 25-30 million Americans with herpes. They did a study on 7,500 patients with herpes and 84% had periodic depression, 53% avoided even potentially intimate situations, 20% were rejected by their partners when they told them they had it and somewhere between 5 and 10% gave up sex altogether. Type-I is more commonly above the waist, maybe 85-90%. Type-II, commonly below the waist. Either can cross the belt line and probably clinically the only significance, type-I above the waist is more likely to occur above the waist. If you have type-I below the waist, it is less likely to recur and vice versa. Type-II is much more common to recur genitally, whereas type-II on the lip is much less likely to recur. So it has some clinical significance. Classically, what happens is a patient comes in contact with somebody with the virus. It has a very short incubation period - two to six days - but only about 25% will have clinical disease. Often it becomes subclinical so when a patient presents with symptoms, it doesn't mean it was from a recent contact. If they have had a monogamous relationship, they shouldn't go home and have a major confrontation with their partner. It could have been something that happened years ago but this is the first clinical episode. Typically, in a primary episode, multiple lesions which everybody in the room here is familiar with. What happens after a couple of weeks is the virus moves down along the sacral ganglia, sits there and periodically comes back to the surface. If it is type-II below the waist, you may get three, four, five or more outbreaks a year. Recurrences usually return to the same location. So if a patient comes in and says, "I have a couple of lesions every couple of months and in the same place and they look like little blisters and they break." You are pretty convinced that the diagnosis is herpes. Classically, primary lesions last about three weeks going through vesicles, ulceration and secondary crusted lesions which may get infected. The same thing with recurrences only every episode is a much shorter duration. Most of the infectious material is in the vesicle stage when the vesicle first breaks. If you are doing cultures, what you should always do, at least the first time, is to confirm the diagnosis. The most ideal is clearly when the vesicle is there, you erupt the vesicle and you actually get clear fluid. That material may have 109 viral particles. It is very easy to culture because the virus is virulent. As it progresses and becomes more dry and crusted, you may be less likely to get a positive culture. In recurrences, most patients will tell you they feel a little funny, they know something is going to happen the day before it happens and that will give us another clue to how we may choose to treat those patients. A significant difference between primary and secondary herpes, much more in the way of systemic infections. Cervical involvement, all with primary. If you look at the involvement of the cervix in cervicitis with primary lesions, 90% to almost 100% are affected with primary episodes which is why really in the unusual case where a primary episode occurs at term there is so much risk to the baby. The baby is going through a cervix that has a high degree of viral particles and the risk may actually be in the 50% range. With recurrences, because the cervix is so minimally involved, the risk to the baby is much, much less and literally under 5%. It may only be in the 1-2% range. Primary lesions, multiple lesions in a very painful situation. Ulceration and secondary infection. Especially with primary lesions, it affects the cervix with recurrences maybe 10%. A very destructive process and I have had patients referred looking like this because somebody thought it may be cervical cancer. But if you take a pap smear, instead of getting neoplastic cells you should see multinucleated giant cells which are pretty much pathognomonic of herpes. Recurrences have fewer lesions and usually are in the same location. So if the patient comes back, you can just say, "As soon as there is any sensation there, come back early" because you are more likely to get a positive culture in the first 48 hours and culture the area where the occurrences occur in.

b. Vaccine 3.

Symptomatic relief a.

Sitz bath (4 oz Betadine)

b.

Topical anesthetics

c.

Oral analgesics

d.

Keep area clean and dry

Here is a type-II above the waist and as I said, 10-15% but actually, clinically, this is less likely to occur because it is type-II above the waist. It is highly infectious and easy to transmit to different parts of your body. This was a nurse who was taking care of a patient with genital herpes. She had a little hangnail and got a herpetic whitlow on her finger. It periodically recurs and creates a problem because how do you come back to the hospital to take care of patients when you have herpes on your finger? Careful hygiene extremely important.

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(1) Corn starch (2) Baby powder (3) Use a hair dryer e. F.

Phenazopyridine tablets (Pyridium) may be useful

Recurrent herpes genitalis 1.

Lesions last for an average of 10 days, with pain and viral shedding for 5 days

2.

Recurrence can occur with menses, stress, fever, or pregnancy

3.

During a latent period, the virus resides within paraspinal ganglia

4.

At intervals, it travels along the axon to the surface

5.

Over time, it seems the recurrences become less frequent; they peak during the early adult years

6.

Eighty percent have prodromal symptoms prior to lesions

7.

Recurrence is four times more common during pregnancy

Patients have to know they can transmit it either from themselves or to their partners. I have one patient that has about three or four lesions on different parts of her body and all she does is she is very nervous and she just scratches from one part to the other. Clean lesions hurt less. Just even soaking it in a tub, patting the area dry, baby powder or corn starch all are very soothing. Again, avoiding direct contact. When lesions are present, probably any direct contact or intimate relations are best avoided. Using a condom is not going to be adequate. It is not going to cover all of the areas involved. Maybe a wet suit would do but I don't think too many people are into that so it is probably best to avoid it all together. What we do is just say "Soak, pat the area dry or just use a hair dryer on low." because it is that sensitive. Then, obviously we will get to acyclovir in a minute. Acyclovir in healthy nonpregnant woman. It comes in topical, oral and intravenous. The intravenous is really reserved for those really severe cases or immunocompromised patients. The topical I think has very little place. It still is 30% of the market but compared to the oral it does so little that I really never prescribe the topical. It just doesn't have any advantage. The oral works extremely well. There is a marked decrease in the amount of new lesions and symptoms and pain. It shortens the duration of viral shedding. So I would say the treatment of choice would be the oral. As everybody in the room knows, there are now a couple of new ones. The patent for acyclovir is over so they have valacyclovir which is 500 mg b.i.d. for five days, famciclovir which is 125 mg. Possibly convenience and less dosing because of the b.i.d. But even with acyclovir, now it is available in the 400 mg tablets. If you use that, it is 400 mg four times a day for initial episodes, three times a day for recurrences or even as little as twice a day for continuous suppressive therapy.

G. Herpes in pregnancy 1.

In patients with a history of herpes or their partner, document the expected date of confinement (serial ultrasound may be helpful), and start weekly exams at 34-36 weeks

2.

Women without clinical evidence of infection at labor should be allowed to give birth vaginally

3.

If there is clinical or cultural evidence of herpes and the bag of waters (BOW) ruptures, try to perform a C-section within 4 hours. In the presence of herpes, a C-section is indicated, even if the membranes have been ruptured over 4 hours

H.

Herpes and cancer 1.

Herpes virus infection could induce atypical metaplasia and dysplasia, and this influences the receptivity of the epithelium to potential mutagens, such as sperm

2.

No definite conclusions can be drawn as of yet

II. Condyloma Acuminatum A.

Etiology 1.

A recognized disease entity since antiquity, it antedates syphilis and gonorrhea

2.

The cause is a papilloma virus

3.

Incubation period varies from weeks to months

B.

Incidence: by far, the most common tumor of the vulva.

C.

Signs and symptoms

D.

1.

Rough, warty papillomas on the genitalia

2.

Secondary pyogenic infections can occur

3.

There is almost always a concomitant vaginitis.

4.

Thrive during pregnancy

5.

Sometimes they disappear spontaneously

Diagnosis

For recurrences, you can either just give the patient a prescription and as soon as they have a prodrome, use it for five days. What we do with any patients who have more than three or four episodes a year is to put them on continuous suppressive acyclovir, 400 mg b.i.d. We will use it for a year straight. Take them off. As soon as they have an outbreak, put them back on. There is good evidence that that not only decreases new recurrences but that it actually decreases asymptomatic viral shedding and probably has a significant advantage that way as well. Immunocompromised patients, certainly patients on Imuran, prednisone, patients with HIV or various organ transplants, intravenous acyclovir is the treatment of choice. There is some controversy in pregnancy. For years, we just said it is really not approved for use in pregnancy. We do use it if it is life threatening to the mother without a doubt and there is an acyclovir registry. There really hasn't been shown to be any negative impact on the baby and in fact there is probably a positive impact. But because of the potential side effects, because we don't know for sure what effect it has on the baby, it is not routinely used for that. At this point, there are a number of studies going on where they are actually using acyclovir in the last trimester or in the last six weeks to decrease the chances of an outbreak at term to allow vaginal delivery. So there are a number of studies going on and eventually we may get to that approach. So it is certainly an evolving area. Primary maternal infections can cause abortion, preterm labor and delivery, IUGR and neonatal infection but fortunately those are uncommon because you are not usually going to have a primary episode during the pregnancy. If you do you, can get transplacental infection but this is less than 50 cases annually in the United States. So it is really at a lower end of the spectrum and not a… we don't go around doing amniocentesis looking for the virus. Far and away the most common, are lesions present at the time of delivery? As I said before, if they are primary lesions, the risk to the baby may be in the range of 50%. Recurrent lesions have a much lower risk to the baby, probably only 1-2%. If lesions are present, vaginal deliveries are usually contraindicated. We will do a cesarean section even if the bag has ruptured for 8, 10, 12, 24 hours. Initially, we used to say if it was more than 6 hours, you weren't sure of the benefit. That study was based on a study of 6 individuals which is clearly not enough to make any difference. So we just simply say doing the section as soon as you can but I don't care if it is 18 hours. I would still do a section because you are decreasing the viral shedding to the baby or at least the viral contact to the baby. No matter what you do, there are no guarantees. They did a study for an 18 month period of time and tried to find as many herpes neonatal cases as they could in the United States. Only 22% of the women even had a history of herpes and this was out of 150 babies with herpes. About 8% of the total actually had had cesarean sections and still the baby had herpes. So no matter what we do there are no guarantees but at least we have to have a protocol that minimizes the risk. What do you do in cases like if there is a herpes lesion on the buttocks or on the

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E.

1.

Inspection of vulva, vagina, and cervix

2.

Larger lesions or lesions in older women may need biopsy

Treatment 1.

Few isolated lesions less than 1 cm a.

Twenty-five percent podophyllin in compound tincture of benzoin. Wash it off I-4 hours later; may need two or three applications one week apart. Do not use podophyllin on vagina or cervix

b.

Bi- or trichloracetic acid (80-90%): observe for 5-10 minute, may need two or three applications 1 week apart. Burning can occur keep soda bicarbonate around to neutralize if necessary

2.

c.

Surgical excision and electrocoagulation of the base

d.

Cryosurgery with liquid nitrogen or cryoprobe

e.

Laser

f.

Stop smoking: 50% lower cure-rate in smokers

Large, bulky or extensive lesion a.

General anesthesia and wire loop cautery

b.

Topical 5-fluorouracil (5-FU) cream may eradicate the

thigh? What we would do is try to do a cervical culture close to term to try to guarantee that there isn't cervical shedding and then if the woman comes in in labor, we just put a Betadine Vi-drape across the lesion to allow vaginal delivery. The closer it is to the vulva or vagina, the less likely we are to do that. But we have certainly delivered babies with a lesion on the thigh, on the buttocks, with negative cultures. The majority are HSV-II. If the baby gets congenital herpes, about half will die. Out of those that survive, about half will have permanent neurologic damage so it is clearly not something to take lightly. The history… but as we've said, even in those cases that the baby had congenital herpes, the majority did not have a positive history. If lesions are present, cesarean section. No lesions, vaginal delivery and we would reserve cultures for those patients that have lesions close to term in hopes that the culture is negative by the time they come in in labor or if they have other lesions on other parts of their body just to try to make sure they are not also shedding the virus from the cervix. Is anybody using Zovirax or acyclovir in the last part of pregnancy routinely? There are some people doing it but it is certainly experimental and not something that I am going around recommending. Moving on to the next virus - HPV - this is truly epidemic. Think this virus is probably on some of the chairs in the room. It just is that common. There are over 60-70 different types - about 22 different types that are of interest to us as OB/GYNs because they affect the general area. They are 6, 11, 16, 18, 31, 33, 35, 45 and 56 seem to be the major players. It affects the entire genital tract and causes a whole spectrum of signs and symptoms - genital warts being the most obvious. But itching, dyspareunia, burning, discomfort. When patients complain of symptoms like that, they are all just variations of how the nerve is getting irritated and it doesn't really rule in or rule out any specific. A couple of percent will be clinical. The vast majority of patients with HPV will have subclinical disease. You may only see it on the pap. You may only see it if you add your 3% acetic acid or on colposcopy.

lesions or reduce their size c. 3.

Laser

Condyloma in pregnancy a

Do not use podophyllin; fetal death has been reported following its use

b.

For small lesions, freezing, electrocauterization, or laser

c.

For large lesions, present at the time of delivery, Csection may be performed to prevent massive bleeding and to protect the newborn from possible laryngeal papillomas

d.

Condyloma from birth canal can cause laryngeal papillomas in the newborn approximately 3-7 months after birth, as well as a low passage rate. C-section is not recommended, but do inform pediatrician

4.

Condyloma and neoplasia a.

This is sexually transmitted certainly most of the time. Probably 2.5% clinically visible but much higher as far as you go to subclinical ways of looking for it. One of the most common, if not the most common reason, for consultations in STDs. Three times more common than herpes. In one study at Berkeley, they looked at 467 coeds who came in for regular exams or for the pill or something. On pap smears, about 2-3% had either some changes, ascus or some koilocytosis. Using viropap, 11% were positive for HPV. Using PCR, what do you think was the percentage of positive PCR for HPV in 467 coeds at Berkeley? It was 46%. That is why I say I think it is in the drinking water but that it is at least extremely common. Obviously, most of them didn't have symptoms. They didn't have any findings on either paps or even putting on 3% acetic acid but the virus is there. We talked a little bit about how it effects the entire generative tract so you can't get rid of it so the treatment is obviously going to be to try to do the minimal amount that is causing the patient symptoms. But even this one says that 15-40%, including the study I just said, you can bring that up to 46%. Macroscopic, colposcopic, paps and obviously biopsies. Nobody would have trouble making the diagnosis in that patient but sometimes it is obviously much more subtle and you may want to take a biopsy as well.

The cytologic changes for cervical intraepithelial neoplasia 1 (CIN 1) and condyloma are the same. They are clinically equivalent and should be managed the same way (ie, colposcopy, extracorporeal circulation ECC, and cervical biopsy). Rule out invasive disease and then use appropriate therapy with careful follow-up

b.

Lots of evidence of associating HPV with both condyloma and now with cervical vaginal vulvar and perianal carcinoma. You can actually see the particles with electron microscopy. With some of the different stains, the viral particles will show up as these brown stains and then we have all of these sophisticated tests. Things like DNA hybridization, hybrid capture and now PCR which are all very sensitive ways of finding the virus which have really created a whole new concept on how common the occurrence of this virus is.

Human papillomavirus (HPV) types 6 and 11 have been associated with early CIN and types 16 and 18 have been associated with advanced CIN or invasive

At least 50-70% of the partners will have evidence of HPV as well. If it is clinical in the female, it often will be clinical in the male as well. We have changed the thinking quite a bit on what we do. But talking about the partner, at some points in time we used to go ahead and send the partner to… we have a urologist who also sees patients in the clinic and he would see the males and he would often find little lesions on the shaft of the penis or on the scrotum. When he was learning, he would kind of first laser them away. Well, sometimes on the scrotal skin that was a little bit of a problem because there wasn't any skin left after you lasered it and obviously it took a very long time to heal. The truth is at this point we are not doing that. The data says you don't get any higher cure rate in the female whether the male is treated or not. We treat the males and the females equally the way they should be. If there are signs or symptoms, if there are lesions, if there are problems, we treat the problem. If there are no signs or symptoms, we don't treat. Again, you can't get rid of the virus so the goal of treatment is not to get rid of the virus. The goal is to get rid of a lesion or the symptoms or in the male or female if there is

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cancer 5.

For recurrences, careful inspection of entire generative tract should be completed; all patients with condyloma should have any concomitant vaginitides treated, and other factors contributing to "wetness" eliminated

6.

For resistant cases, interferon has been tried

III. Chancroid A.

Etiology and transmission 1.

Hemophilus ducreyi, a small ram negative, nonmotile rod, frequently occurs in chains and may occur in parallel chains

2.

It spreads by direct contact, appearing 2-6 days after exposure

B.

Incidence: an uncommon disease in the United States, approximately 1,400 cases annually

C.

Signs and symptoms 1.

May be asymptomatic in women, or present as a mild vaginitis

2.

The disease occurs more in men; women constitute only 1025 % of the reported incidences

3.

In the symptomatic female, lesions progress through stages of macule, papule, and pustule with erythema

4.

The lesions have a jagged edge, with an irregular ulcerated necrotic base. which is tender and highly

infectious

5.

In 25--60% of cases, the regional lymph nodes are enlarged, tender, and matted together, usually

unilaterally

6.

The nodes may gradually soften and resolve or they may suppurate and rupture

7.

The disease is usually self-limiting

D. Diagnosis 1.

Clinical picture consists of tender necrotic ulceration and regional, tender, usually unilateral lymphadenopathy

E.

2.

Recovery of H. ducreyi from lesion or bubo aspirates

3.

Identification by gram stain or Wright's stain

4.

Culture can be done on selective medium

Treatment 1.

Ceftriaxone (Rocephin), 250 mg IM in a single dose, or

2.

Erythromycin, 500 mg qid, or

3.

Trimethoprim/sulfamethoxazole (Bactrim), double-strength, 160/800 mg bid

4.

Treat for a minimum of 7 days and until ulcers and/or lymph nodes have healed

IV.

Granuloma Inguinale(Donovanosis) A.

Etiology and transmission

neoplasia, we treat that. So a different concept and it is just another one of the things that continues to evolve as to what makes the best sense. This is just showing you the value of the 3% acetic acid. It will actually show just some of the white areas. If you want to make a specific diagnosis, you can use a little Xylocaine in a 3 mm Keyes punch and take a little sample of the skin and make the diagnosis. The same thing again. Nothing obvious and then after you put on your acetic acid, you see the whitish areas. Again, Xylocaine and 3 mm Keyes punch will confirm the diagnosis for you. Lots of different appearances. Again, patients are referred because people aren't quite sure what they are looking at. HPV has a whole spectrum of presentations. Evaluating patients with genital condyloma - genital warts. A pap smear because you want to know if the cervix and/or the vagina are involved as well. Biopsies if you are not sure if they look different. Treat concomitant infections because many of the sexually transmitted diseases, where you find one you are going to find others. But specifically with HPV there is a good advantage to treating any other STDs or treating any other vaginal infections because the secretions themselves increase the growth of the virus. So you are going to get a better response if you treat the concomitant infections. Occasionally, a flat lesion, a large lesion or if you are really not sure, we do biopsies. We do not routinely biopsy. Most of the time we just treat. I did have one patient. She was an elderly woman who had a single solitary large condyloma and I did biopsy it and it was verrucous carcinoma. Those are few and far between but if it is really distinct and doesn't quite make sense, then it is worth taking a biopsy. If you do your biopsy, you should see koilocytosis, dry hollow cells. The viral particles are pushing the nucleus off to the side and pushing away the cytoplasm and that is pretty much pathognomonic if it is truly koilocytosis and not just artifact. If there really is a question, go down and look at the slide with a pathologist and be sure that is really what it is. Most of the time, the office will use Bi- or trichloroacetic acid. It is 50-70%. It is acid and it is something you really have to be careful with. One day the nurse went and got the bottle of the shelf for me and the cover wasn't on tight. She spilled a little bit on her uniform and by the time she came into the room, she had holes throughout her uniform. This is acid. It is potent stuff but it is what we think works most expeditiously and you get direct effect. Podophyllin, 5-FU certainly can be used. Not in pregnancy. There have been reported deaths from podophyllin in pregnancy. 5-FU or any of the cytotoxic agents should not be used in pregnancy and 5-FU, although we use it sometimes when there is extensive vaginal condyloma, is very potent stuff and you've got to be very careful using it. It is destructive. How many use BCA routinely in the office? BCA or TCA? How many use podophyllin? How many use 5-FU? It really is potent stuff and sometimes you look in the vagina 10 days later and it looks like a hand grenade went off. There have actually been reported cases of the vagina healing together because it is so denuded that it sticks together and you don't have a vagina after 5-FU. So carefully to be sure. Cryolaser depends if they are extensive. Sometimes we just put local anesthesia and some hot cautery in the office. If it is really extensive and recurrent we will go to laser. Not that there is anything magical about laser. It is just that by the time you do that, you are usually even being more thorough, more cautious and probably getting all the lesions and hopefully decreasing the viral load to the patient. Another thing. Dryness, hygiene and treating any other things are useful, but if the patient smokes, you will get a 50% less cure rate. So the first thing I tell a patient right off the bat is if they smoke that they have just cut my chance of success and their chance of success in half. The same reason that cervical cancer is much, much higher in smokers versus non-smokers. It is doing something to the immune system. It increases the viral load and in the patients who are susceptible, it increases the risk of neoplasia. We do use interferon occasionally. It is expensive and can have a little bit of general systemic side effects like nausea but when everything else fails, we will inject interferon. You can do it a couple of times a week or even just once a week. Most people today would say HPV is a very necessary cofactor for cervicalvaginal-vulvar-perianal carcinoma in situ. There must be some other cofactors as well. Some people would say smoking, irritation, even herpes may be a cofactor. But clearly, smoking increases the risk and there is good evidence of that. We treat the CIN and VIN all just depending on the amount of neoplasia and ignore the virus. We treat the neoplasia. We treat the symptoms. People don't want warts on their bottoms. We will burn those away. We will treat things that cause symptoms and

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1.

Calymmatobacterium granulomeres. A pleomorphic gram

then just follow the patient because we cannot eliminate the virus.

negative rod with an incubation period from a week to a few

We talked a little bit about 6 and 11, the most benign. Usually condyloma acuminatum genital warts. Then 16, 18, 31, 33, 35, 45 and 56 being more associated with malignant changes and in fact HPV 16 and 18 have been shown to go from CIN 1 to CIN 3 in one year's time.

months 2. B.

Spread by sexual contact seems likely

Incidence 1

Granuloma inguinale is of low incidence and low communicability

2.

Recently, only seventeen cases were reported in a year,

making it the least common of the STDs C.

Signs and symptoms 1.

Insidious onset of a painless papule, nodule, or vesicle

2.

Progresses to a soft granulomatous ulcer with a beef, red base and rolled margin

3.

After a secondary infection, progressive putrid and painful ulceration and anatomic distortion may occur

4.

5.

Tubo-ovarian and bladder complications may occur

6.

Fistulas or stenosis may occur in the vagina, rectum, or bladder

7.

Pseudobuboes may be observed

8.

Extragenital areas (eg, mouth, face), occur in approximately 6% of cases Hematogenous spread to liver, spleen, and bones has been reported

D.

Diagnosis: clinical findings plus lab data 1.

Crushed tissue smear showing C. granulomatis

2.

Pathognomonic microscopically are the relatively large mononuclear cells containing intracytoplasmic cysts filled with pleomorphic Donovan bodies

3.

Tissue biopsy may be needed to demonstrate the pathognomonic cell

4.

Culture is not routinely necessary, but the organism car, be cultured in the yolk sac of chick embryos

E.

This virus probably does live on toilet seats. It probably does live in health clubs. It does live on our speculum if we don't autoclave them and they have done cultures of speculums and gotten back positive cultures. They have even gotten positive cultures in the plume of the laser smoke so I would even be careful with that. I don't know of any gynecologists, but there are dermatologists who have been reported to have lesions in their nose or on their skin, probably from treating patients with laser. For awhile, we had these real tight masks that were supposed to even be able to filter out viral particles. The only problem was you couldn't breathe through them either because they filtered out air so we had to kind of give that part up but a caution is appropriate. Obviously having a very good suction device is important. So it is easily transmitted. I want to mention kind of in general, we talked about both herpes and HPV. Herpes, although far and away most commonly they are transmitted sexually, I don't think we have all of the answers. I don't think we should be too judgmental. The incubation period for herpes is short but for HPV it's maybe three months to five years. Nobody really knows so if somebody comes in, again, don't assume that it is their current partner. Also, they may have picked it up at a health club or from a toilet seat. If you plate herpes on a toilet seat and go back and do cultures every half hour, how long will you still get positive cultures? It is about 3 hours before it dries. On a moist towel or wet sponge, 12 hours. So I just don't think we should think we kind of know it all and say that obviously this is sexually transmitted and that is where you got it. That is probably the most likely but it is not the only way so I give everybody the benefit of the doubt. I don't know where it came from and I try to act and treat accordingly. It does occasionally move down into the larynx and we talked about a possibility of that but fortunately it is not common. But when the larynx looks like that or the trachea like that, you have a major problem because now you have a difficult area to treat. They will laser the larynx except that it also does some damage to the larynx. Very rarely it actually moves down all the way into the lung fields which fortunately is very uncommon but can occur.

Treatment 1.

Tetracycline, 500 mg qid, for 3 weeks

2.

For resistant cases, gentamicin (Garamycin), 40 mg IM bid should be used for 2 weeks

V. Lymphogranuloma Venereum A.

In adults, it is transmitted most likely by oral-genital contact. In another study, 101 patients, I think it was about two-thirds female and one-third male, extensive genital condyloma. They sent them all to a dentist. The dentist explored the oral cavity and in 9% he saw something that he was suspicious of but biopsied everybody. What percent showed histologic evidence of HPV in the oral mucosa in patients who had extensive genital condyloma? 48%. So if a patient asks if they can transmit this through oral-genital contact, the answer is a definite yes. I am not sure what to make out of that clinically. These patients didn't have any signs or symptoms but certainly as far as a factual piece of information, yes, the virus is transmitted.

In 20%, secondary elephantoid, enlargement of the external genitals may occur

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It can be transmitted and it does affect the larynx as well but not often. Juveniles. Probably the most commonly is transmitted through vertical transmission from the mother to the child. Low vertical transmission rate not an indication for cesarean section. Again, in a study they followed 106 women with extensive genital condyloma at the time of delivery, they followed the babies for five years. Over the course of the five years, only one baby developed a nasal polyp so the risk is obviously low. We do tell the pediatricians that if the baby has a hoarse cry or something, they probably should do a laryngoscope and check.

Etiology and transmission 1.

Chlamydia trachomatis, an agent that also causes inclusion conjunctivitis, urethritis of cervicitis, and pelvic inflammatory disease (PID)

2.

Chlamydia are small G- obligate, intracellular bacteria-like agents that form characteristic microcolonies

I skipped lymphogranuloma venereum and granuloma inguinale. They are relatively uncommon but can occur. We went on to molluscum contagiosum which is a member of the pox virus which is one of the few viruses that doesn't seem to do any serious harm. Probably the main significance is where you see one sexually transmitted disease, you may see another and any time you have one, you should kind of probably look for the others. Also, look for GC and Chlamydia and any vulvar lesions. Do an RPR. It is important to make that diagnosis and treat it and when we get to syphilis I will tell you about how the incidence is going up and that kind of thing. So it think it is just kind of being aware of looking for the other STDs as well. An individual umbilicated lesion for molluscum contagiosum. If you scrape this and make a slide, you will get molluscum bodies but its main clinical significance is just to look for other STDs. Phthirus pubis. A bloodsucking ectoparasitic louse unable to survive without a blood meal for more than 24 hours. It reminds us of some of the other people we

6

B.

3.

Usually transmitted through coitus or anogenital contact

4.

Average incubation period of 7-12 days

Incidence: relatively minor in reported incidence. Only about 200 cases reported in the United States per annum

C.

Signs and symptoms 1.

Primary lesions begin on the external genitalis, vagina, or cervix as a small, painless, red, puffy erosion or ulcer; they last a few days and then adenitis develops

2.

In a few days to weeks, satellite adenitis develops

3.

Inguinal buboes are common, and perirectal or intrapelvic nodes may be involved

4.

Systemic involvement may cause malaise, anorexia, fever,

have to deal with sometimes. The organisms like pubic hair and eyebrows. Those are the two places where the diameter of the distance of hair is just right for them to hang onto. It is often transmitted sexually but they can occur in nurseries and nursery schools, stuff like that, where little kids are kind of climbing all over each other. They can stay in the linen or bedding. Probably renting a motel by the hour is not a good idea. The life cycle, the eggs hatch. They do need a blood meal. They will self-sterilize. Even both the bedding and clothing if left unused for two weeks will self-sterilize. Treatment is just Kwell shampoo. Because they are outside, on the skin and on the hair, it is easy to treat. Kwell shampoo left on for about 4 or 5 minutes is all that you need to do. In nursing mothers, children under the age of 10, lactating or pregnant, we use RID. It is a little less potent. There hasn't been any reported fetal harm and you leave that on for 10 minutes. Sarcoptes scabiei or the itch mite was actually the first human disease that we knew the etiology of and back in 1654 they saw these little creatures crawling around under the skin. What happens is one drops on the skin, emits a little enzyme and in about 3 minutes dissolves the skin and crawls under the skin and sets up household. What you do is just kind of unroof the lesion and you will actually see the organism, the fecal matter or eggs which make the diagnosis.

chills, abdominal and joint pain, weight loss, pneumonitis,

abscess, salpingitis, pelvic abscess, anorexia, arthritis, and

The same kind of life cycle, same kind of natural history but the treatment has got to be Kwell creme because it is under the skin. You actually shower, put the cream on overnight so it can absorb through the skin and kill the organisms. In pregnant women, nursing mothers, children under the age of 10, use Eurax or crotamiton and use it two nights in a row.

occasionally death

Syphilis. The incidence is dramatically going up.

tachycardia, and rarely, meningitis or splenomegaly 5.

D.

Complications include intestinal obstruction, hepatitis, liver

Diagnosis 1.

Observation of typical clinical picture and a positive chlamydial complement fixation test. The test has a 95% sensitivity, or 5% false-negative. Test becomes positive 2-4 weeks after the onset of illness. A simple titer of 1:32 is suggestive, a fourfold rise in titer indicates active infection

2.

Chlamydia trachomatis can be cultured or detected by other selective tests

3.

Sedimentation rate is elevated, white blood cells WBCs) are elevated, liver enzymes frequently elevated and there is a change in albumin/globulin ratio, due to an increase in globulins

4.

Biopsy may be confirmatory, and help rule out malignancy

5.

A serologic false-positive test for syphilis is found in up to 20% of patients with buboes

E.

Treatment 1.

Doxycycline, 100 mg po bid for 21 days, or

2.

Tetracycline, 500 mg qid, for 21 days. or

3.

Erythromycin, 500 mg qid, for 21 days is generally effective

4.

Surgical revision of destructive or cicatricial lesions may be required

VI.

Molluscum Contagiosum. A.

B.

Etiology and transmission 1.

Produced by a member of the pox virus family'

2.

Spread by sexual or close personal contact

Clinical features 1.

These lesions are common

2.

They are asymptomatic and easily overlooked

It used to be down at 10, 20, 30,000. They are now reporting 50,000 cases of syphilis, primary and secondary, annually in the United States. The CDC assumes that any time… you've got to play with all the numbers because if they say that there are 50,000 reported, there may actually be 150,000 cases out there. They always assume there at least two to three times the number of cases that are not getting reported. Often presents as a primary chancre - a painless lesion - but has a whole multitude of presentations. Syphilis used to be called the great imitator and can present in a number of fashions. It can be very subtle. It can look like herpes, it can look like condyloma. It can look like a whole number of things. Again, if there is a vulvar lesion, do an RPR. Just check it. Be sure because it is certainly important to make the diagnosis. Again, not all chancres occur below the waist and this is a syphilitic chancre on the lip. Initially, the patient may be too early in the disease process to get a positive RDR or VDRL. If you scrape the lesion and look at it you may actually see the spirochetes. Left untreated, after about six weeks at most it often will progress to secondary syphilis which could be very mild like this or it could actually affect more of the skin and actually cause more obvious lesions. What is somewhat pathognomonic is that it actually affects the palms and the soles. There are very few dermatologic conditions that affect the palms and the soles, syphilis being one of them. About 20% affect mucous membranes and can cause irritation or even condyloma lata which we have another slide of. This is really just an inflammatory reaction from the spirochete. It is condyloma lata, not condyloma acuminatum which is from HPV which are the genital warts. It looks different but it is an inflammatory reaction. But the incidence has dramatically gone up. Part of the reason for that is sex for crack cocaine. When you are looking for drugs, I guess apparently you don't much care who your partner is or what they have and that is why most of the CDC believes the incidence has gone up as much as it has. A patient with alopecia areata secondary to syphilis and it is the great imitator. Time will go by in most of these patients, 10, 20, 30 years. Some of them will never develop anything. Left untreated, two different studies, 30-50% will develop tertiary syphilis. It may have a benign gumma in an extremity. They may have it in the cerebellum which obviously creates a few problems. They may have it in the descending arch of the aorta which is life-threatening and actually obviously causes dissecting aneurysms and death. There are two studies done, the Oslo study and the Tuskegee study. The Oslo study was actually back at the turn of the century - 1890, 1900 - and obviously there was no treatment. They followed those patients and actually that is where some of the data came from on the incidence of cardiovascular effects, neurologic effects, soft

7

C.

3.

Usually multiple and far apart

4.

Central umbilication is frequent

5.

The lesions can be spread by autoinoculation

6.

They last from 6 months to many years

Diagnosis 1.

Confirmed by biopsy or by potassium hydroxide (KOH) prep of a curetted lesion, crushed between the slide and cover slip

2. D.

VII. A.

Both show characteristic intracytoplasmic inclusions

Treatment 1.

Sharp dermal curette

2.

Cryosurgery with liquid nitrogen

3.

Electrodesiccation

4.

Topical caustics are not recommended

Pediculosis Pubis (Crabs) Etiology and transmission 1.

Phthirus pubis, a blood sucking, ectoparasitic louse, unable to survive more than 24 hours off the body

2. B.

Often transmitted sexually

Clinical features 1.

Severe itching, may lead to excoriations and secondary bacterial infection

2.

In long-standing cases, nonblanching, blue-gray macules, averaging 0.5-1.0 cm, appear on the abdomen and flanks

3.

The louse is principally found on the pubic hairs

C.

Diagnosis is made by locating nits or adult lice on the hair shafts

D.

Treatment 1.

Permethrin cream 1% should be applied for 10 minutes and washed off

2.

Kwell shampoo, lathered for at least 4 minutes, can be used (not recommended for pregnant or lactating women)

3.

RID (pyrethrins, piperonyl butoxide, petroleum distillate, and benzyl alcohol) nonprescription, applied to the infected and adjacent hairy, area and washed off after 10 minutes. No cases of fetal harm or teratogenicity have been reported

4.

All contaminated clothing and linen need to be laundered, dry cleaned or sprayed: they will become self-sterilized if not worn or used for 2 weeks

VIII. Pubic Scabies A.

Etiology and transmission 1.

A highly contagious infestation caused by the ectoparasitic itch mite, Sarcoptes scabiei, which varies in length from 0.20.4 mm

2.

It is transmitted by intimate contact; it may infrequently be transmitted by infested clothing

tissue effects. The Tuskegee study, on the other hand, which has gotten a lot of appropriate negative press was begun in 1932 and was actually carried out until 1972. They followed several hundred men in Tuskegee, Alabama and just treated kind of minor things but never really even when medications became available… at first, I guess they were using arsenic rubs and then they just kind of quit that but even when penicillin became available, they just didn't use it. The arguments they used were, "Well, you may get a reaction to it. You may be allergic to penicillin or you may get a Jarisch-Herxheimer reaction." The truth was they were just doing a study and they didn't really stop the study until the public became aware and they had national congressional hearings on it in 1972 by which time about half of the males had died. So the study is lousy but there is the data there and it did say that 30-50% progressed with either aortic or central nervous system damage. As we said, the incidence of adult, primary and secondary syphilis has dramatically gone up. So has the incidence of congenital syphilis. In 1978, the total number of cases of congenital syphilis in the United States was 108. In 1991, there were over 100 cases in Chicago. It has dramatically gone up just the same way the incidence has in women. The incidence is directly related to whether the woman has syphilis in the pregnancy, close to the pregnancy or further removed. It is inversely proportional. The closer to the pregnancy, the more likely the baby will be affected. If the mother has syphilis during the pregnancy, there will be like an 80% effect, a 40% miscarriage rate and 40% of the babies will be born with congenital syphilis. It does affect hepatosplenomegaly, the skin, snuffles, obviously very potentially sick babies. All pregnant women have an RPR or a VDRL at the first prenatal visit and again in the third trimester just in case they developed it during the pregnancy because we can treat it and we can make a difference. If you are doing your nonspecific test, VDRL, RPR, it takes a little while, 4-6 weeks for them to become positive. They will stay positive and even untreated, eventually they become negative. The specific test, fluorescent treponemal antibody absorption, stays positive for life. Patients want to know if you do treat it, will the test become negative because in some states for marriage licenses or for some jobs you get an RPR or a VDRL. Two studies, appropriately treated with primary syphilis, all of the RPRs became negative after 12 months. If you had done an FTA absorption, it would still be positive but nobody is going to do that if the screening test is negative. With secondary syphilis, the same result, only it took 24 months. Treatment is 2.4 million units of Bicillin - long acting penicillin - for primary syphilis. For secondary syphilis, three weekly doses, 2.4 million units a week apart is the treatment. The CDC says the treatment is the same whether they are pregnant or not pregnant. I think that is somewhat archaic because if you treat a patient with primary or secondary syphilis with 2.4 million units of Bicillin in pregnancy, you have like a 35% failure rate. So what we would do is bring the patient into the hospital just as an outpatient, put 5 million units of aqueous penicillin in a bottle and hang it. If they are far enough along in the pregnancy to monitor the fetus, we would do that and see what kind of a reaction you are getting. After you give 5 million units, you can even give another 5 million. If you don't get an adverse effect, if you don't get a Jarisch-Herxheimer reaction which is really the penicillin killing so many spirochetes, then all of the enzymes in the organisms are released into the body at the same time and some of them are toxic and they can cause kidney shutdown and kidney damage and liver damage. If you see any negative reaction, you back off and just gradually repeat it. We would then give the 2.4 Bicillins. We are still doing what the CDC says but then we would send the patient home and 2 gm of ampicillin b.i.d. for 10 days because the body still maintains low doses, treats the mother, but doesn't really get high enough doses in the baby, whereas ampicillin readily crosses the placenta and will treat the baby. There are a significant number of sexually transmitted diseases out there and in an ideal world, everybody should have a mutually monogamous relationship. Seeing as how it is not an ideal world, at least in they are not going to have monogamous relationships, they should use foam and condoms. At least it significantly decreases the risk of many of the STDs. It won't really necessarily protect or prevent either herpes or HPV because of the areas involved. It may affect the scrotum, even further out than the condom is going to cover but condoms do offer significant protection and certainly as part of our teaching our patients, if they are not going to be monogamous, then this at least is another reasonable thing to do. This is moving up the generative tract and I just want to kind of show the normal vaginal flora in the vagina. There are five to nine different organisms, more anaerobes than aerobes and ratios vary but all of your usual Bacteroides, fragilis, bivius, the Enterococcus, the Klebsiella, the proteus, all those are normal flora. Group B strep is probably present in 10-20% of female vaginas and rarely important except in pregnancy. So if you can do a culture and you see any of those,

8

B.

Clinical features 1.

The impregnated female mite burrows into the skin

2.

After 1 month, symptoms begin; by 6 weeks, pruritus is

it is not really telling you anything. Now, Group A strep, if it is GC or chlamydia it may be telling you something. But all the rest of these are normal vaginal flora.

sufficient to cause sleep disturbances 3.

A multiform eruption, papules, vesicles, pustules, urticarial wheals, and secondary infectious occur on the hands, wrists, elbows, belt line, buttocks, genitalia, and outer borders of the feet

C.

Diagnosis is confirmed by burrows and observing the parasites, their eggs, larvae, or red fecal compactions under low power

D.

Treatment 1.

Kwell cream or lotion for 8-12 hours, but this time applied to the total body from the neck down (not recommended for pregnant or lactating women)

2.

Kwell shampoo is not adequate therapy

3.

In infants, children under 10, pregnant and lactating women: crotamiton 105% (Eurax), applied to the entire body from the neck down nightly for 2 nights and wash off thoroughly 24 hours after the second application

IX.

Syphilis A.

Etiology, incubation period, and transmission 1.

Treponema pallidum is a slender, corkscrew-like treponeme with regular, evenly spaced spirals

2.

It varies in length from 5-15 microns

3.

The incubation period is 10-90 days; 21 days is average

4.

The disease is almost always transmitted by intimate sexual contact; it may be transmitted in utero to the unborn child after the first 2-3 months of pregnancy

B.

Incidence: recently, there has been a significant increase in the number of primary and secondary cases of syphilis reported in the United States per year

C. Primary syphilis 1.

Solitary lesion, beginning as a nodule, becomes an indurated ulceration (chancre) with a ham-colored, eroded surface and a serous discharge

2.

Usually accompanied by painless, enlarged regional lymph nodes

3.

Ninety-five percent of primary lesions are found on or near the genitalia

4.

Atypical lesions are frequent and may consist of small multiple lesions

5.

Untreated lesions heal in 1-5 weeks

6.

The diagnosis is made by clinical appearance and positive darkfield examination: the serologic test is sometimes negative

9

D.

Secondary syphilis 1.

Secondary signs appear 6-8 weeks after exposure

2.

Bilateral,

symmetrical

papulosquamous

skin

macular,

lesions

are

papular,

or

widespread

and

nonpruritic, and frequently involve the palms, soles, and face, in addition to the trunk and extremities 3.

Mucous membranes are often involved

4.

Generalized nontender lymphadenopathy

5.

Fever

6.

Patchy alopecia

7.

A small percentage have iritis, hepatitis, meningitis

8.

Serologic test is positive in more than 99% of cases: could

be negative because of prozone phenomenon E.

Latent syphilis: the interval between secondary syphilis and late syphilis. The patient has no signs or symptoms, only positive serological tests

F.

Late syphilis: characterized by destruction of tissue, organs, and organ systems 1.

Late benign: gummas occur in skin or bone and do not result in severe incapacity or death

2.

Cardiovascular: medial necrosis of the aorta with dilation of the ascending aorta; this leads to aortic insufficiency or saccular aneurysm of the thoracic aorta

3.

Neurosyphilis a.

Spinal fluid shows elevated WBCs up, elevated total protein, and positive serology

b.

Meningovascular pathology can occur, pupillary changes are common: Argyll Robertson pupil accommodates but does not react to light

c.

Parenchymatous pathology can result in general paresis or tabes dorsalis: degeneration of the ascending sensory neurons in the posterior column of the spinal cord

G. Congenital syphilis 1.

2.

Symptoms at birth a.

Upper respiratory infection (URI)

b.

Rhinitis

c.

Prematurity

d.

Lymphadenitis

e.

Jaundice

f.

Anemia

Late congenital syphilis: if it persists beyond 2 years of age, may see Hutchinson's triad a.

Hutchinson's teeth

b.

Interstitial keratitis

10

c. H.

Eighth nerve deafness

Serology: tests for syphilis are nontreponemal and treponemal 1.

Nontreponemal tests are complement fixation tests [eg, VDRL or rigid plasma reagin (RPR)]. These are the most widely used tests- they become positive 4--6 weeks after infection. They start in low titration and over several weeks may reach 1:32 or higher. After adequate treatment of primary syphilis, the titer falls and, in most cases, is nonreactive within 9-18 months

2.

Treponemal tests are fluorescent treponemal antibody absorption test (FTA-ABS) test, treponemal mobilization test (cardiolipin) (TPI) test, and microhemagglutination assay-T, pallidium (MHA-TP): ie microhemagglutination assay for T. pallidium

I.

Treatment: see STD Treatment Guidelines

J.

Follow-up and retreatment 1.

Early syphilis and congenital syphilis: repeat VDRL at 3, 6, and 12 months

2.

Syphilis more than 1 year. Also repeat VDRL at 24 months. Examine cerebrospinal fluid at last follow-up visit if patient was treated with alternative antibiotics

3.

Neurosyphilis: repeat VDRL for 3 years

4.

Retreatment if a.

Clinical signs or symptoms persist or recur

b.

A fourfold increase in the titer of a nontreponemal test

c.

Failure of an initially high titer nontreponemal test to show a four-fold decrease within a year

5.

Only retreat once; use schedule for syphilis of more than 1 year duration

Vagina I.

Normal Secretions Prevent Dryness Normal secretions are clear and odorless and do not cause external wetness A.

Principal source is mucus from cervical columnar epithelium

B.

Transudation from vaginal epithelium

C. Secretions from sebaceous sweat glands and Bartholin’s glands D. During reproductive years, average pH 3.8--4.2 %; acidity is produced by Lactobacillus bifidus E.

Normal vaginal flora include Döderlein's bacillus, hemolytic and nonhemolytic streptococci, enterococci, Escherichia coli, diphtheroids, and strains of Micrococcus pyogenes

Vaginitides. I have Nitrisine paper in every examination room. If someone comes in with the common vaginitides, you just touch the Nitrisine paper to the secretions. Normal secretions and candida are usually under a pH of 5, both BV and trich are over 5. If they have a pH over 5 and they are itching, they have trich. If they have a pH over 5 and they don't have itching, they have BV. It is a very simple screening mechanism especially if you are running late in the office and I use it every day and it really does work. Candida, far and away the most obstinate. It causes most itching and is very common. Again, a pH under 5. Classically, the cottage cheese kind of thing but that is probably only in 70% of pregnant patients with candida. But also affects the skin and goes more beyond the vaginal introitus. When something goes that far out it is most likely candida because it is yeast. It is more diverse on the skin. Whether we use our KOH or whether we make pap smears, you may actually see the hyphae. Albicans, glabrata, tropicalis. Different kinds. The importance there may be that the over the counter Gyne-Lotrimin, Monistat kind of things may cover some better than others whereas the Terazol prescription may have a little broader coverage. At least, certainly that is what the drug companies say so there is an advantage. Any of the creams if you use them usually for a week. I have no strong preference whether you like Gyne-Lotrimin or Monistat or use the Terazol. Again, they all work pretty well. Taking nystatin orally, all you are trying to do is decrease the amount of yeast in the GI tract which may or may not have any effect on treating the patient. Most of the time, candida is easy to treat. You use it for three days or a week but there are patients who are going to have more complex situations. Either they are immunocompromised or their body is just not handling that fungus. They are going to need to be treated differently for more prolonged periods of time and they are going to be a nuisance and they are going to be hard to treat. I think it is advantageous for us to know that up front because then we can say, "Hey. In part, we've got to work on this together. Your body's immune system has to take care of this. It is not just what medication I am giving you." Hopefully, they quit smoking. I do simple things like tell them to get eight hours of sleep and take vitamins. It is just really that their immune system has to help us because we could go on and on treating it and we may not be successful. We will sometimes go to the oral medications. Sometimes they are helpful in those complex patients that just don't respond to our normal treatment, whether it is ketoconazole or Diflucan. Commonly we will just use something like Terazol for two weeks straight and then use it for three days before the next three periods trying to keep it in check but you need to go onto additional treatments. Sometimes, we will use boric acid tablets in the vagina for two weeks straight and then for two or three times a week for months because the patient just has persistent recurrences. How many people use Diflucan commonly? How many use it as their first line? I presume the rest are using either over the counter or Terazol. How many use Terazol? A good number. I think it is just sometimes that you have to use it for longer periods of time to really get the results we want. Trichomoniasis is very irritating. Lots of discharge, unpleasant for the patient because it literally can be kind of messy. High pH. It creates a great deal of inflammation. If you touch the Nitrisine paper to that, what color is it going to be? Dark blue. Trichomoniasis doesn't live at a pH under 5. It is usually pH 6 or 7 and if you take your finger along either side of the urethra and milk Skene's ducts in this patient, you will see the pus coming out of there as well which is why any local treatment is not going to be very successful and why we use metronidazole. Debris, trich, polys, and if you look at the epithelial cells from the vaginal wall, they are not mature because the amount of inflammation is truly a vaginitis. So if you've got a lot of debris and immature or intermediate vaginal cells, it is trichomoniasis. If you've got a lot of debris and white blood cells in the secretions, but normal vaginal cells, what do you have? This is a written board question. Cervicitis. Coming from the cervix not the vagina because you've got a dirty background. You've got inflammation, white blood cells, debris, but you've got normal vaginal cells so that is not a vaginitis it is a cervicitis and that is a written question on the boards, or at least it was. Here is just kind of showing a lot of debris. If you look at the vaginal cells, they are intermediate. The nucleus to cytoplasmic ratio is increased. Treatment. Most of us would probably use just the 2 gm of metronidazole. You could use the 375 mg capsules b.i.d. for a week. Sometimes you may get a little better cure rate with that but minimally different. You can go as high as like 2 gm a day for longer periods of time if you really have resistant trich. You can't go any higher than that because it starts causing neurologic damage.

11

II.

Leukorrhea Any abnormal vaginal discharge not associated with menstruation: occurs in more than 1/3 of all ,gynecologic patients A. Physiologic factors 1.

Neonatal leukorrhea: several days after birth there is a

withdrawal effect with cellular debridement 2.

3.

Leukorrhea of puberty a.

Production of estrogen increases cervical discharge

b.

Ceases with onset of cyclic progesterone

Leukorrhea of pregnancy: increased steroids cause hypersecretion of cervical glands

B.

Inflammatory factors 1.

During the prepubertal and postmenopausal years, the thin vaginal epithelium is easily infected by a variety of agents, including the gonococcus and many, nonspecific organisms

2.

During the reproductive years, the most frequent offenders are Hemophilus vaginalis (Gardnerella vaginalis), Candida, Trichomonas vaginalis, herpes virus, and Chlamydia

3.

A recent analysis of 10,000 consecutive cases of vaginal discharge found the following causes of the discharge a.

Gardnerella vaginalis: 32 %

b.

Cervicitis: 25%. Most cases of cervicitis are due to the following (1)

Gonorrhea

(2)

Chlamydia

(3)

Herpes

c.

Cancer: 19%

d.

Trichomonas: 11%

e.

Excess mucus from the cervix or an increased

In pregnancy, there is some controversy. Most everything we use is contraindicated in the first trimester. We don't even use Terazol or any of the creams the first trimester. We try to wait until we get to the second trimester. Certainly, metronidazole is contraindicated in the first trimester. The CDC says that you can use 2 gm after the first trimester but we kind of even just limit it to really severely affected patients. I will even give Metrogel or something during the pregnancy and wait until after they deliver and even if they are nursing, just have them not nurse for 24 hours and then give your 2 gm of metronidazole. There is no real data available and there is certainly some controversy. With either the CDC or PDR it says to use it cautiously. I am not sure how you use something cautiously. You either use it or you don't. Gardnerella. Probably the most common. Also, the most benign but the thinking on that has changed and we are being more aggressive in treating it and we will show you a couple of reasons why. Again, the pH is higher than 5. Clue cells. Gardnerella has multiple different names and it really depends on how far back in history you want to go. It is an imbalance in bacteria and nobody really knew which bacteria to blame. Herman Gardner came out with describing the Gardnerella organism so he got some credit and now we call it bacterial vaginosis because it is really just an imbalance in the bacteria. It is very common and in some STD clinics, 30-60%. In the OB population, there are now seven different studies that say that there is an increased risk of premature labor, probably 2 to 3-fold. There is an increased risk in the gynecological population of PID. If you operate on a patient, do a hist on a patient with BV, you have a significant increased risk of postoperative infection. You have a significant increased risk of postpartum infection because what you have done is just dramatically change the ecosystem in the vagina. Many more anaerobes, many more Mobiluncus. Fewer of the good guys - the Lactobacillus - and because of this change in bacteria there is greater risk of infection so we do want to treat it. We kind of touched on each of those. There is an increased incidence of non pueperalendometritis, PID, post surgical cuff infection, post abortion. If you put an IUD in somebody with BV, there is a greater risk of infection because you are really taking all of these organisms from the lower generative tract and bringing them up into the upper generative tract. There are seven different studies that say there is an increased risk of premature labor and so we really do want to diagnose this and we do want to treat it. If you are looking for BV and you want to look for your clue cells, you don't want the specimen to come from the cervix, you don't want it to come from a cul-de-sac. You want it from the vaginal side wall or the anterior wall of the vagina and you should see clue cells. Clean background because there is not very much in the way of inflammation so you don't see a lot of white blood cells or debris. You see nice superficial pyknotic cells but covered with bacteria. Same thing on a pap smear. If you do your KOH and your normal saline, if you put on KOH in a patient with BV, because there are so many bacteria there, the KOH dissolves all this bacteria. Those bacteria have enzymes in them like cadaverine and putrescine and everything starts getting a little fishy. So we have a little fish up there and actually some people would say that is the easiest way of making the diagnosis. The patient can do that test for you if they say there are secretions and that the odor is worse after their period or after intercourse because blood and seminal fluid tends to be more alkaline and so it is going to do somewhat of the same test for you.

discharge of healthy vaginal epithelial cells: 13% C. Conditions 1.

Candidiasis a.

Etiology, (1)

Candida not a true yeast, but is a “yeast-like" organism

(2)

Candida albicans is the most common: Candida tropicalis is also common

b.

Incidence (1)

Most obstinate cause of vaginitis, present in 25-50% of all women

(2)

This is a rare bug - vaginitis emphysematosa. Pregnant patient with either BV or trich and you treat either the BV or the trich and this goes away. That is vaginal mucosa with a cystic cavity under it and sometimes things like this do appear on exams even though they are relatively uncommon. This one is desquamative vaginitis. A patient in the reproductive years and has normal hormones but if you look at it, you would say it looked atrophic because the vaginal cells have not matured and there is a lot of inflammation. Cortone suppositories for prolonged periods of time are the treatment of choice. Chlamydia which does act as a good jumping off point to move off the generative tract. Probably 50% of cervicitis is caused by chlamydia. In other countries, it is a common cause of endemic trichoma. In men, probably one of the most common causes of epididymitis and nongonococcal urethritis.

In 1,000 consecutive gynecological patients, 5.9% had candidiasis

c.

The treatment is metronidazole, p.o. or intravaginally. In pregnancy, we wouldn't use that. We would use the Cleocin and obviously it comes in gel form too as both Metrogel and as Cleocin vaginal cream. The organisms we are interested in do respond to those.

Predisposing factors

Cervicitis, half the cases of cervicitis. Probably about 20% of PID, 25% FitzHugh-Curtis as part of the PID. What is Fitz-Hugh-Curtis as part of the PID? Both GC and chlamydia can cause it and how does it present? Right upper quadrant

12

(1)

Pregnancy

(2)

Just prior to menses

(3)

Contraceptive pills

(4)

Antibiotics

(5)

Systemic corticosteroids

(6)

Diabetes mellitus: high percentage of diabetics

pain. In 5% of the patients, they can present with right upper quadrant pain. What it is, is in the PID and I've got a slide on it later, the pus goes up the right colic gutter and causes a perihepatitis so the pain is really up here. If you scope the patient, you will actually see adhesions between the peritoneum and the liver capsule because there is enough inflammation to cause that and they are called banjo strings.

have candidiasis (7)

Nondiabetic glycosuria

(8)

Diet: especially fruit workers and sweets lovers

(9)

Debilitation

(10) Obesity (11) Male factor: may culture Candida from urethra of regular sex partner d.

e.

Symptoms (1)

Vulvar pruritus is cardinal symptom

(2)

Dysuria

(3)

Usually abrupt onset before menstruation

(4)

Meager discharge

Signs (1)

Erythema of vagina and labia minora

(2)

Edema of labia minora

(3)

Fissuring

(4)

Traumatic excoriation

(5)

Thick, white, adherent discharge, classic, but in most, it is essentially normal

(6)

Overall, 20% have thrush patches, 70% if pregnant

(7)

pH 4.0--4.7, 4.5 is most common; slightly less acid than the normal range of pH 3.8-4.2

f.

Diagnosis: demonstrate Candida and have clinical features present (1)

Wet mount (a)

400-1,000 times in normal saline or 10% KOH on a warmed slide, with the sample taken from the cul de sac

(b) (2)

(3)

Overall sensitivity 40--80%

Pap smear (a)

Sample from vaginal pool

(b)

Sensitivity 20-50%

Can be cultured on Sabouraud's or Nickerson's media, sensitivity 70-100%

g.

Treatment (1)

Nystatin (Mycostatin) antifungal antibiotic (a)

Available in powder, tablets, cream, and ointment

13

(b)

Prescribe nystatin vaginal tabs: #30, 1 bid for 15 days

(2)

Miconazole nitrate 2% (Monistat), prescribe 1 applicatorful qhs for 7 days

(3)

Clotrimazole (Mycelex) (a)

In pregnant patient, prescribe 1 tab in vagina qhs for 7 days

(b)

In nonpregnant patient. 1 tab bid for 3 days

(4)

Terconazole (Terazol): prescribe 80 mg in vagina qhs for 3 days

h.

Treatment for chronic or recurrent candidiasis: the patient candida may have a problem of host defenses (1)

Aci Jel daily for 3 weeks and then 3 times per week for another 3 weeks; continue to use it 5 days prior to each menses

(2)

Povidone iodine (Betadine) qhs for 1 month, with Betadine douche in AM is valuable

(3)

Avoid antiseptic soaps

(4)

Stop birth control pills

(5)

Decrease simple sugars in the diet

(6)

Treat the male partner (a)

Can use "Borafax," a 5% boric acid in lanolin, applied locally bid for 10 days

(b)

Condoms help:

(7)

Avoid cunnilingus

(8)

Avoid tub baths; shower instead

(9)

Avoid pantyhose or nylon panties: use white cotton panties

(10) More complicated problems may require ketoconazole (Nizoral) 2.

Trichomoniasis a.

Etiology (1)

A flagellated protozoa, Trichomonas vaginalis lives in the periurethral glands of males and females, usually begins with deposit of a large inoculum passed in alkaline semen

(2)

It has been shown to survive up to 24 hours in swimming pools

b.

Incidence (1)

One of the most frequently acquired STDs

(2)

Incubation period of 4-28 days

(3)

Approximately 2.5 million annual cases in the United States

14

(4)

Prevalence

ranges

from

13-23%

of

gynecological patients c.

Predisposing factors (1)

Women with high estrogen levels

(2)

Hypoacidity in the vagina

(3)

Bacterial flora: gram positive cocci and gram negative bacilli function symbiotically with Trichomonas

(4)

Frequently seen in patients with other STDs, approximately 50% of patients with GC also have trichomoniasis

d.

Symptoms (1)

Malodorous discharge is cardinal symptom

(2)

Pruritus is second most common problem

(3)

Dysuria

(4)

Dyspareunia

(5)

Chronic symptoms often flare-up just after menstruation

e.

Signs (1)

40% have gross disease of the vulva; erythema, edema, intertrigo, and excoriation can occur

(2)

Chafing is almost pathognomic of trichomonas

(3)

Discharge from Skene's duct is fairly common

(4)

"Cervical erosion": 90%

(5)

Profuse, frothy discharge

(6)

(a)

In acute cases, light green or yellow

(b)

In chronic cases, grey and homogeneous

pH 5.2-5.5; pH less than 5 essentially eliminates Trichomonas

(7)

Any patient with vaginitis in the childbearing age and/or with a vaginal pH of greater than or equal to 5 with pruritus is likely to have Trichomonas; in absence of pruritus, the infection is likely H. vaginalis

f.

Diagnosis (1)

Wet mount-sample from cervix and vaginal vault in normal saline (a)

motile pear-shaped unicellular flagellates, about two times the size of a WBC

(b)

Numerous WBCs and parabasal cells are usually present

g.

(2)

Pap smears: 60-80% reliable

(3)

Can be cultured, but seldom necessary

Treatment: 96.8% have extravaginal sites, so vaginal

15

suppository will not cure (1)

Metronidazole (Flagyl) 500 mg bid for 7 days, approximately 95% cure rate; treat partner simultaneously

(2)

2 g po in 1 day is accepted prescription: approximately 85% cure rate

(3)

In the pregnant patient (a)

Treat locally, eg, 20% salt solution, Aci JeI, clotrimazole, or sitz bath may help

(b) 3.

Treat partner with oral metronidazole

Hemophilus vaginalis vaginitis (bacterial vaginosis) a.

Etiology (3)

b.

This is primarily a STD

Incidence (1)

Women in the reproductive years: 10--20%

(2)

Probably accounts for more than 90% of vaginitides previously classified as nonspecific

c.

Symptoms (1)

Most benign of the common vaginitides

(2)

Mild pruritus and burning

(3)

Only 25 % will complain of discharge, but the majority of patients will report a discharge if asked

(4)

Malodor may be the most significant symptom, less than trichomonas

d.

Signs (1)

Because it is a surface parasite, it rarely produces gross vaginal or vulvar changes

e.

(2)

Grey homogeneous malodorous discharge

(3)

pH greater than 5

Diagnosis: (1)

Wet mount is rapid and reliable (a)

Many epithelial cells are stippled with a tiny, pleomorphic coccobacilli

(b)

Only superficial epithelial cells are present

(c)

There are few WBCs and a motile organ-

ism (2)

"Whiff test:" when KOH is applied, amines are released which cause a fishy odor

(3)

Gram's stain is 90% sensitive

(4)

Cultures for G. vaginalis are not routinely available and are not needed

f.

Treatment (1)

Metronidazole 500 mg po bid for 7 days is the

16

most effective regimen (2)

Clindamycin (Cleocin) 300 mg bid for 7 days is usually effective

4.

Atrophic vaginitis a.

Etiology: as estrogen declines, the vagina atrophies, glycogen diminishes, pH rises, there is a shift to parabasal cells; vaginal folds and rugae disappear, and the walls become smooth and tubular

b.

Symptoms may be mild but dysuria, pruritus, and dyspareunia may develop

c.

Treatment (1)

Estrogen replacement: conjugated estrogen tablets (Premarin) or Dienestrol cream 0.1% qhs for 7 nights, then 2-3 times per week

(2)

Must consider risks of endometrial carcinoma as it is absorbed

(3) 5.

Personal lubricant. Are helpful

Foreign bodies can produce infections and discharge (toilet tissue common in children, forgotten tampons in reproductive years, and neglected pessaries in older women) a.

Diagnosis is made by speculum exam

b.

Treatment consists of complete removal of the object

and possibly a local sulfa cream 6.

Allergic vaginitis a.

Etiology (1)

Contact dermatitis is an eruption from contact with allergenic substances in susceptible individuals

(2)

b.

(a)

Cleansing agents

(b)

Perfumes

(c)

Bubble baths

May cause allergic reactions (a)

Hygienic sprays

(b)

Disposable douches

(c)

Contraceptive foam

Treatment includes lavage of inflamed tissue (1)

Can douche with 4 tablespoons of baking soda in 2 quarts of water

(2) 7.

Cortisone or antihistamine creams are helpful

Nonvenereal bacterial vulvovaginitides may cause 1% of vaginidites a.

Only consider after the common pathogens have been ruled out: rare causes include Streptococcus pyogens, Staphylococcus aureus, and E. coli

17

b. 8.

Treatment is based on culture and sensitivity

Vaginitis emphysematosa a.

Rare condition characterize by multiple discrete gasfilled cystoid cavities of the vaginal and cervical mucosa

b.

More likely to occur in patients with heart failure or pregnancy

c.

Etiology: probably a manifestation of trichomoniasis

PID, post partum endometritis, prematurity. High vertical transmission rate in babies. If the mother has significant chlamydia, half the babies will have conjunctivitis. Probably is the most… if we don't count HPV which is not reported to the CDC so the numbers are hard to come by, there are probably 4 million cases of chlamydia annually in the United States. Several million gonorrhea, 500,000 herpes and probably 150,000 cases of syphilis annually in the United States. Taken as a group, far and away the most infectious disease and actually chlamydia, gonorrhea and probably HIV are some of the most common. If you consider infectious disease in pregnant women, it is probably the most common medical complication in pregnancy. A million cases of GC in men. Probably a million cases of PID with chlamydia causing about 25% of them. Again, conjunctivitis and even pneumonia in the newborn.

or occasionally H. vaginalis d.

Interesting bug. Intracellular. It needs to be within the cell to reproduce. It is a bacteria. It does have both its RNA and DNA but can't produce any energy itself so it needs the cell's mitochondria to reproduce.

Clinical features (1)

Discharge

(2)

Gas-filled cystoid cavities line the vagina and may pop on exam or intercourse

(3)

Foreign body giant cells in the walls of the cavities

(4)

Desquamative inflammatory vaginitis: clinical and microscopic features of postmenopausal atrophic vaginitis occurring in a woman with high estrogen levels a.

Diagnosis (1)

Normal ovarian function

(2)

Persistent localized vaginitis (upper half of vagina) with a discharge

b.

(3)

Many WBCs

(4)

Immature epithelial cells

(5)

No specific cause

Treatment (1)

Estrogens have no effect from estrogens. Little effect from antibiotics

(2)

Intravaginal

corticosteroids

over 3-month

period may be helpful 10. Chronic cervical discharge a.

b.

Most common causes (1)

Trichomonas

(2)

Herpes

(3)

Gonorrhea

(4)

Chlamydia

Incidence: second most common cause of vaginal discharge

c.

Signs and symptoms (1)

If you do a biopsy, you can see chlamydia inclusions in the cervical cells. Occasionally, it will actually exfoliate and you will see it on the pap smear. You will see the inclusions in your exfoliated cells with a lot of polys as well.

Treatment: directed at associated vaginal pathogen

9.

In a patient like this, without doing anything else, 50% have… or actually, with this, 80% have chlamydia. The columnar epithelium is raised up above the squamous epithelium, so without doing any other testing, this is chlamydia.

Patients complain of a mucoid and sometimes yellow discharge; odor or irritation is absent

(2)

Postcoital or intermenstrual spotting is frequent

(3)

Patients often spot or bleed after a Pap smear

Culture is certainly one way but very difficult to do. We used to microtrack where you wipe away the debris, get endocervical cells on the slide, stain them with a monoclonal antibody that is tagged with fluorescein, wash off the debris and try to see these little green spots which are actual chlamydia. What we do in the office and in the hospital now is PCR. PCR is certainly the most sensitive and the most specific and easy to do. Again you wipe off the debris because you want endocervical cells and all you do is you take a cyto brush, take the swab and then shake it in solution and send the solution to the lab. PCR should be 95% sensitive and like 98-99% specific. It is so easy to do. In males, you can just do it on the urine because it is that sensitive and that specific. Chlamydia responds especially to the tetracyclines, doxycycline and erythromycin. In pregnancy, we obviously do not use doxycycline. Non-pregnant, doxicycline 100 mg b.i.d. for ten days. Probably one of the treatments of choice. In pregnancy, erythromycin is very effective. There are two newer drugs that are also currently available. One you could use in pregnancy and one not, where the two newer drugs are effective against chlamydia. Quinoline Floxin is very effective in huge doses, 400 mg b.i.d. which you also cannot use in pregnancy. But Zithromax, azithromycin is the same category as erythromycin. It is a class B drug. You take 1 gm at one time and it is curative. You can either take four of the 250 mg caps or they now have a powder. You just open the package of powder, pour it in a glass of water and it is 1 gm of Zithromax. You drink the glass of water and it is an appropriate treatment. Seeing as how the organism reproduces very slowly and all of the other treatments are 10-14 days, how can we use the Zithromax one dose, one time. How does it work? Very long half life. The half life is three to four days, so if you take a gram, three days later you still have 500 mg around and a week later you still have 250 mg of the stuff in your system. So it is a very useful drug. This is just kind of showing moving up the generative tract. We talked about chlamydia and cervicitis. It also affects endometritis, salpingitis and salpingooophoritis which leads us to PID. One million cases annually in the United States. A significant number of patients have sequelae. There is a 6 to 10-fold increase in ectopics and 18-20% chronic pelvic pain. GC, at least in these series of studies, anywhere from 30-50% of the PID with 4050% Neisseria gonorrhoeae. Probably 25-30% chlamydia. A significant percent nongonococcal, nonchlamydial. A whole spectrum of organisms that cause this disease which probably accounts for why it presents in so many different fashions. PID is not really one distinct entity. It is a series of diseases that present in various fashions. Instead of a "pelvic inflammatory disease", maybe it should be "pretty indistinct diagnosis". Penicillinase producing Neisseria gonorrhoeae. It was thought to be really a curse because we didn't even know how we could treat it because it didn't respond to penicillin. The incidence has progressed. In Miami, 50% of the GC is penicillinase producing Neisseria gonorrhoeae. The only treatment for GC is ceftriaxone, not penicillin. So

18

(4)

Chlamydia infections often produce purulent discharges and hypertrophic cervicitis. The columnar epithelium may be elevated above the plane of the squamous epithelium.

d. Diagnosis (1)

Cervicitis is due to Chlamydia trachomatis is present in about half of the cases; if negative for herpes, gonorrhea, and Trichomonas, chlamydia is the likely cause.

(2)

Most sensitive method of diagnosing chlamydia is to culture the organism on irradiated or idoxuridine-treated McCoy or HeLa cells.

(3)

Antigen detection available through enzyme immunoassay

(EIA).

One

example

is

chlamydiazynase, which uses an enzymelinked immunoabsorbent assay (ELISA) to

in other words, we need to take all of these into account because when we start getting into specific diagnosis and treatment of PID, you need to pick appropriate antibiotics that are going to cover all of the bugs we talked about. IUDs, especially if the patient has BV, the patient has a lot of organisms in the lower generative tract, just mechanically putting the IUD up through that into the uterus is going to increase the risk of infection, especially the first four to five months. Probably treating the patient ahead of time, especially if they had BV or something would decrease the incidence. Cultures, we talked about. In an ideal world, we would have this nice one swab that we do PCR for both GC and chlamydia but there are obviously a lot of different mechanisms out there, gene probes and things. If you do a culture for GC, make sure the transport media is warm. If the transport media just came out of the refrigerator, you will never get a positive culture. You will chill it and it will die. It should be brought the lab very quickly or it should be but in an incubator and then brought to the lab because it is a very sensitive, fastidious organism. Mucopus. GC or chlamydia. Seeing as how we are not talking about GC, I would guess that is what she has. The proof of that is she has her Gram-negative intracellular diplococci on her Gram-stain. With GC, or chlamydia for that matter, in the endocervix, some will progress up to an endometritis-salpingitis-salpingooophoritis. How virulent is this bug? What percent of women with GC in the endocervix will progress to PID? High or low? Low. About 15%, maybe 10-15%. Many will just be carriers. There are even male carriers as well although more males will have symptoms. There are male carriers as well for GC.

measure antigen-antibody reaction

(4)

(a)

Sensitivity: 90%

(b)

Specificity: 92-97%

Direct smear of material with fluorescein-conjugated monoclonal antibody is examined under a fluorescent microscope. One example is Microtrak

e.

(a)

Sensitivity: greater than or equal to 90%

(b)

Specificity: greater than or equal to 98

Treatment for chlamydia cervicitis (1)

Doxycycline: 100 mg po bid for 7 days

(2)

For patients for whom tetracyclines are contraindicated or not tolerated (a)

Erythromycin base or stearate: 500 mg po qid for 7 days

(b)

Erythromycin ethyl succinate: 800 mg po) qid for 7 days

(4)

For patients who cannot tolerate the above regimen: erythromycin base 250 mg qid for 14 days

III.

Significance of Chlamydia Trachomatis Infections in Pregnancy A.

Prevalence 1.

The prevalence of C. trachomatis infection in women seen in STD clinics is 10-40%

2.

Highest prevalence (30-40%) occurs among partners of men with nongonococcal urethritis. Lower prevalence (820%) is found in gynecologic outpatient clinics and in family planning centers (1-6%)

4.

Trachomatis infection generally is much more prevalent

How easily is this spread? If a woman has GC in the cervix and a male has intercourse with her, what is the risk to the male of getting GC? What is the transmission rate (and then how did they do the study)? High or low? One in 20. They did it in a Guatemalan prison. They brought in prostitutes with positive GC cultures and asked for volunteers to have intercourse and then cultured the males and 1 in 20 were positive. So a relatively low rate of transmission. Here there are Fitz-Hugh-Curtis in both GC and chlamydia. It can move up the right colic gutter, either colic gutter and cause a perihepatitis and that can occur in like 5% of patients with PID. Classically, the patient with PID has a fever, elevated white count, discharge, nobody would miss the diagnosis. The problem is that only 20% of patients with PID have the classic symptoms so you would be very specific but not very sensitive to making the diagnosis. If we don't make the diagnosis, then obviously all the sequelae are potentially there. Only 40% with laparoscope diagnosed PID had a fever, a temperature of 100.4º. Only two-thirds had an elevated white count greater than 10.5, so if you look for just a fever or an elevated white count you are going to frequently miss the diagnosis of PID. Have a low threshold for making the diagnosis. If you aren't concerned about other major diseases, make the diagnosis and treat it. All you need to make the diagnosis of PID is low abdominal pain and tenderness, cervical motion tenderness and adnexal tenderness without a competing diagnosis. If the patient has nausea, doesn't feel like eating and has pin point tenderness over McBurney's point, I don't think I would make the diagnosis of PID. If they are a couple of days late with their period and spotting and have a positive pregnancy test, I think I would entertain other diagnoses. Short of another major diagnoses, I will make the diagnosis of PID on this basis alone and treat. The idea is to try to prevent the serious sequelae and treat early and treat often so that you don't have infertility and chronic pelvic pain and all of those kinds of things. The more criteria you add, obviously the more specific the diagnosis. If there is a fever, white count, inflammatory mass, if you do a culdocentesis and get back pus, that is pretty obvious or any test for either GC or chlamydia that is positive. Treatment. You usually need two drugs to treat PID, even outpatient or just inpatient. Floxin is now being said that it can be used as a single agent but obviously if you have too many anaerobes it is not going to work. Ceftriaxone and doxycycline can be used or if you want to stick with pure p.o. medication Floxin and Flagyl. 400 mg of Floxin b.i.d for 10-14 days. 500 mg of Flagyl b.i.d. for 1014 days. If the patient is sicker, if the patient has more symptoms, has an abscess, an IUD, they belong in the hospital. In the hospital, the usual regimes are either doxicycline

19

in STD clinics than in gynecological clinics. B.

Postpartum endometritis 1.

C. trachomatis has been linked to puerperal infections

2.

Women with antepartum C. trachomatis infection who deliver vaginally have a five- to sixfold increased risk of intrapartum fever and late postpartum endometritis, occurring between 48 hours and 6 weeks postpartum

C. Prematurity 1.

The mean duration of pregnancy for women with antepartum C. trachomatis infection was significantly shorter than for controls without such infection

2.

Furthermore, stillbirth or neonatal death occurred more often among C. trachomatis-infected women than among controls.

D. Eye infections 1.

Chlamydial inclusion conjunctivitis is the most common

and Mefoxin or Gentamycin and Cleocin. Community acquired, I usually use doxicycline and Mefoxin. If there is an abscess and IUD, I use Gentamycin and Cleocin which are very effective. Certainly, if somebody lags, you could use Unasyn. It covers the bugs as well but I would also add doxicycline to make sure I am covering the chlamydia. The idea again is to make the diagnosis early and give appropriate treatment so that you can prevent sequelae. So the idea again is early treatment, minimal criteria for treatment and prevent the sequelae. Different things increase or decrease the chances of tubal occlusion. Each episode of PID significantly increases the risk of tubal occlusion. We want to try to catch it early to prevent total destruction of the ovaries. Patients with abscesses. About 5% may come in and actually have a ruptured abscess and need immediate surgery and 95% we are going to treat medically. Most of those, two-thirds, will respond if you pick the right drugs. Those that don't may need to go to laparoscopy. You need the appropriate incisions. A vertical incision or a Maylard so you can explore the entire abdomen. Look for abscesses, restore all the anatomy, as much as you can. Copious, copious irrigation and then really evaluate what is the minimal amount of tissue you can take out and have a reasonable post-op course. If it is totally infected, the patient has said she has completed her family and that, probably the smoothest course is to be able to do a TAH-BSO. But anything in between is acceptable. You can leave an ovary and the uterus. You can leave one ovary, a tube and a uterus. The more infected tissue, the rockier the course but at least you are preserving either hormone function or potential fertility. Copious irrigation, drains and appropriate antibiotics. Leave the wound open because there is a greater risk of infection.

specific cause of purulent conjunctivitis in newborns a.

This eye infection develops in 20-50% of infants born to mothers infected with C. trachomatis

b.

It occurs in 1-2 % of all newborn infants

c.

The incubation period is 5-14 days

d.

Erythromycin eye ointment is effective against C.

Hopefully, we treat early and rarely get to this point where you do a TH-BSO but by being aware and by treating early, you are going to prevent the sequelae and it is going to be cost effective if you add infertility, ectopic pregnancy, chronic pelvic pain to the picture. PID costs 3.5 billion of health care dollars annually in the United States but with early diagnosis and treatment, our patients are going to do fine.

trachomatis 2.

Chlamydial conjunctivitis is difficult to distinguish clinically from other forms of ophthalmia neonatorum. Thus, the diagnosis must be based on specific cultures and microscopic examination of conjunctival smears

E.

Pneumonia 1.

C. trachomatis, respiratory syncytial virus (RSV), and cytomegalovirus (CMV) are the most common causes of pneumonia in infants less than 6 months of age

2.

10-20% of infants born to mothers with C. trachomatis cervicitis will develop chlamydial pneumonia

3.

The incidence of C. trachomatis pneumonia is estimated to be 3-8 per 1,000 live births

4.

Symptoms of chlamydial pneumonia a.

Tachypnea

b.

Staccato cough

c.

Nasopharyngeal congestion

d.

Afebrile course

e. Inspiratory rales on examination 5.

Lung x-ray usually shows bilateral interstitial pneumonia and hyperinflation

6.

Increased peripheral blood eosinophils (300 mm3) and elevated serum immunoglobulins are often found

20

7.

The incubation period varies from 1-3 months, and at least half of the infants present with a history of preceding conjunctivitis

F.

Other infections in neonates 1.

C. trachomatis can also cause otitis media in infants a.

Middle ear abnormalities are present in 59% of 37 infants with chlamydial pneumonia

b.

Myringotomies were done on one or both ears in eleven of these infants

c.

C. trachomatis was recovered from the ear aspirates of three of the eleven infants

d. 2.

None had significant bacterial cultures

In infants with ocular or respiratory tract infection, C. trachomatis can also be recovered from the vagina and/or rectum

Upper Genital Tract I.

PID A. Etiology 1.

PID is a great number of diseases with a diversity in etiology and presentation. Multiple bacteria are usually isolated. a.

Neisseria gonorrhoeae in 40-50 %

b.

Chlamydia trachomatis in 25-30 %

c.

Nongonococcal, nonchlamydial organisms only from the upper genital tract in 40-50 %

d.

Enterobacteriaceae and anaerobic species are frequently present

2.

Intercourse with multiple partners confers a relative risk factor of 4.6 for PID. IUD use confers a relative risk of 3.5

B.

Incidence 1.

Approximately one million American women are treated for PID each year and 250,000 are hospitalized

2.

Between the ages of 15-24, one female in sixty acquires PID each year

C. Epidemiology 1.

Gonorrhea is spread almost entirely by coitus

2.

It has a short (3 to 5 day) incubation and essential immunity to repeat infection. It is not highly infectious; in a Guatemalan prison study, only one man in twenty exposed to an infected prostitute developed the disease

3.

For every symptomatic woman treated for gonococcal infection, there are nine asymptomatic carriers

4.

Approximately 60% of gonococcal or chlamydial infections occurred within 1 week from the first day of the last

21

menstrual period 5.

Only 14 % of the nongonococcal, nonchlamydial salpingitis patients reported onset of symptoms within 1 week

D. The organism 1.

Neisseria gonorrhoeae is a nonmotile, nonspore-forming, nonencapsulated gram negative oval coccus measuring 0.8 by 0.6 u, frequently seen in pairs

2.

The organism succumbs to drying in 1-2 hours and is killed by silver nitrate in a 1:4000 dilution in 2 minutes

E.

Signs and symptoms 1.

Most women with gonorrhea are asymptomatic

2.

Once the organism spreads up to the fallopian tubes, the clinical features of acute PID may develop. a.

Wet smear shows marked increase in inflammatory cells: 100%

3.

b.

Abdominal pain: 94%

c.

Elevated WBC greater than 10,500: 66%

d.

Fever (greater than 38EC [100.4EF]): 40%

e.

ESR greater than 15 mm: 75%

Occasionally, the purulent exudate migrates to the right colic gutter; the patient may experience right subcostal pain from perihepatitis, ie, the Curtis-Fitz-Hugh syndrome

4.

Development of chronic pelvic pain: 18%. The incidence of ectopic pregnancy is increased 6-10 fold. 20-25% have at least 1 recurrence

5.

Development of tubal occlusion after episodes of gonorrhea

6.

a.

After one episode: 13%

b.

After two episodes: 2.4 %

c.

After three episodes: 52%

Tubo-ovarian abscess (TOA) is a well-known sequela, and it occurs in as many as 34% of patients hospitalized with salpingitis

F.

Diagnosis 1.

Based on clinical picture and positive culture, gram's stain may be helpful in the male, but one cannot establish the diagnosis on this basis in the female

2.

Saprophytic Neisseria or Mima species can be found in women not infected with N. gonorrhoeae

3.

A single cervical culture will detect about 82% of gonorrhea in women; adding culture from the anus and the oropharynx can increase the detection rate to 90%.

G. Treatment 1.

See the attached Tables

22

2.

Surgical intervention does not normally play a role in the treatment of acute PID). It may be necessary in patients with pelvic masses who fall to respond to appropriate drugs after 72 hours of treatment

3.

TOA a.

Positive response to medical therapy: 60--70%. Failure to respond may require surgical intervention. Ultrasonography or computed tomographic scans can be helpful

b.

Percutaneous directed catheter drainage with or without laparoscopy is being used. Occasionally, colpotomy for a very low, dependent abscess pointing in the cul de sac can be used. A needle should be inserted into the mass to determine the contents. If purulent material is obtained, a scalpel should be used to incise the abscess wall and blunt dissection done to complete the drainage. The patient may still require a later laparotomy

c.

If patients require a laparotomy (1)

The incision must allow adequate exposure: either a subumbilical vertical or a Mallard incision

(2)

Explore entire abdomen for concealed pockets of pus

(3)

Careful dissection of distorted tissue plans

(4)

Adenectomy or hysterectomy, depending on extent of disease: if hysterectomy, leave vaginal cuff open

(5)

Copious irrigation with 3-4 liters of Ringer's lactate

(6)

Malecot or multiple Jackson-Pratt drains through cuff or posterior colpotomy are attached to closed suction

(7)

Closure (a)

The fascia should be closed with either permanent suture or delayed-absorbable sutures

(b)

In vertical incisions, the Sinearl-Jones technique is preferred

(c)

A delayed primary closure of the skin and subcutaneous tissue is the procedure of choice

(d)

A pack of moist gauze is placed in the subcutaneous layer and covered with a sterile

dressing for 3-4 days, then

23

the incision is rinsed and, if clean, closed with SteriStrips 4.

Ruptured TOA a.

Demands operative intervention. The patient is stabilized, antibiotics begun, and immediate surgical intervention undertaken

b.

Clinical evidence for rupture includes diffuse peritonitis, sudden change in the character and intensity, of pain, tachycardia out of proportion to fever, critically ill appearance, or the development of shock in a patient with a tubo-ovarian complex

c.

In treating a patient with a ruptured TOA, the physician must be aware of potential lethal complications

II.

(1)

Acute respiratory distress syndrome (ARDS)

(2)

Septic shock

(3)

Acute tubular necrosis

(4)

Septic thrombophlebitis

(5)

Local or distant abscesses

(6)

Wound infection and/or wound dehiscence

Tuberculosis (TB) A.

Approximately 35 million people in the United States have positive TB reaction, and thousands of Americans die of TB annually. Genital TB is secondary to TB elsewhere in the body, usually in the lungs

Table 2 The Frequency of TB Involvement of Various Organs in Genital TB

B.

Organ

Percent

Tubes

95-100

Uterus

50-60

Ovaries

20--30

Cervix

5-15

Vagina

1

Incidence: in women who died from pulmonary TB, 8 % had genital TB. In infertility clinics in the United States, approximately 1% have genital TB

C. Presenting manifestations in female genital TB Table 3 Manifestation

Percent

Sterility

45-55

Pelvic pain

50

Poor general condition

26

Menstrual disturbances

20

24

Vaginal discharge

4

D. Diagnosis 1.

Clinical symptoms

2.

"Dough” sensation on palpation of abdomen

3.

Pelvic may show bilateral tubo-ovarian masses; less tender than usual

4.

Chest x-ray (screening)

5.

PPD skin test (screening)

6.

Endometrial curettage a.

Best time is several days before the expected menstrual period, at which time the tubercles reach their maximum growth

b.

Curettings should also be sent to bacteriology for culture

7.

Menstrual blood can be sent for culture

E. Treatment 1.

Minimal genital TB a.

Isoniazid,

300

mg

doses,

and

ethambutol

(Myambutol), 20 mg/kg or approximately 1,200 mg/day b.

Endometrial curettings are examined at 6 and 12 months (1)

If they become positive or if tubo-ovarian masses appear, rifampin 600 mg daily is added for 3 months

(2)

If no complications arise, continue isoniazid and ethambutol for 2 years and then use isoniazid alone indefinitely

2.

Advanced genital TB, ie, tubo-ovarian masses present: as above, plus re-exam every 3--4 weeks

3.

If tubo-ovarian masses are still present after 3--4 months, surgery is indicated a.

Total abdominal hysterectomy and bilateral salpingo-oophorectomy on all patients over 40

b.

In younger women who desire to maintain some function, the extent of surgery depends on findings during the operation (1)

One week before the operation, start streptomycin IM 1 g daily and continue it for 3 weeks postoperatively

(2)

If residual tuberculous foci are left in the abdomen, continue streptomycin twice weekly for a total of 3 months

F.

Pregnancy following treatment of genital TB: review of over 7,000 cases

25

1.

Full-term pregnancies: 155

2.

Abortions: 67

3.

Ectopic pregnancies: 125

Urinary Tract

Urinary tract infections (UTIs) are second only to respiratory infections in frequency. In about 60% of patients, the infection is limited to the bladder: in about 40%, there is renal involvement I.

Incidence A.

School-age girls: approximately 1%

B.

Women of childbearing age: 4%

C. Women over age 60:7% II.

Clinical Syndromes A.

Asymptomatic bacteriuria: The patient has no symptoms but has a urine culture demonstrating 100,000 colonies of a single bacteria genus in two consecutive specimens

B.

Acute infection 1.

Usually seen in young or middle-aged women and often not associated with detectable underlying uropathy

2.

Usually responds to minimal medical management, but on follow-up, at least 20% of the patients have residual asymptomatic bacteriuria

C. Recurrent infection 1.

2.

Patients require complete investigation a.

C&S

b.

Cystoscopy

c.

Excretory urography

d.

Voiding cystourethrography

May reflect a.

Reinfection

b.

Relapse

c.

Superinfection

D. Chronic infection 1.

Unlike acute simple or recurrent infection, often has underlying uropathy: impaired drainage of urine secondary to congenital or acquired obstruction

III.

2.

As many as half may be asymptomatic

3.

Findings a.

Abnormal urinary sediment

b.

Proteinuria

c.

Azotemia

d.

Calyceal changes noted on programs

Symptoms A.

Most patients with acute disease have dysuria frequency and

26

urgency but up to 10% do not B.

Bladder infections: 50% of patients with lower urinary tract symptoms do not have bladder infections

C. Bacterium may increase the incidence of prematurity, principally in women with renal involvement D. Hypertension and its sequelae may be the presenting manifestations E

Rarely, acute infections erode into a blood vessel and hematuria results

IV.

Etiology A.

The source is usually within the host's own intestinal tract Colonic bacteria ÿ perianal region ÿ urethra ÿ bladder ÿ

kidney B.

Single catheterization is followed by infection in 2-4% of patients. When the catheter is indwelling, infection is inevitable

C. Over 75% of all UTIs axe caused by the Enterobacteriaceae family D. Occurrence of bacterial species in asymptomatic bacteria of pregnancy

Table 4

V.

Genus

Percent

E. coli

76

Klebsiella-Enterobacter

16

Proteus species

5

Pseudomonas

1

Staphylococcus species

1

Streptococcus faecalis

1

Diagnosis A.

Two consecutive clean voided specimens with recovery of the same organism with a colony count of at least 100,000 have a 91% chance of indicating a UTI; 80% with one specimen and 96 % with three

B.

Correlation: there is a good correlation between the finding on the microscopic examination of a 's-stained drop of urine that has not been centrifuged and positive results of urine cultures

C. Use of chemicals such as triphemytetrazolium chloride (TTC) for mass detection of significant bacteriuria is simple and inexpensive VI.

Treatment A.

Asymptomatic bacterium and acute simple infection may be treated with short-acting sulfonamides, 1 g qid for 10 days 1.

This gives cure rates of 80--90 % in ambulatory patients

27

with acute infection and of 70-80% in pregnant women with asymptomatic bacteriuria 2.

If this is ineffective, the choice of drug should be governed by the results of in vitro susceptibility studies

3.

If the patient is allergic to sulfonamides, nitrofurantoin 50100 mg qid, or nalidixic acid 0.5-1 g qid may be used

4. B.

Repeat culture 10-14 clays after therapy to ensure cure

Recurrent infection same as above, but if work-up is negative and infection continues to recur, may use the following medications bid to qid for 5-10 days monthly for 6 months 1.

Sulfonamide 0.5 g

2.

Nitrofurantoin 50-100 mg

3.

Nalidixic acid 0.5-1 g

C. Chronic infection may need prolonged treatment, followed by suppressive therapy indefinitely. Nitrofurantoin should be avoided in these patients because of danger of neuropathy or of interstitial pulmonary fibrosis D. For more serious urinary infection, other drugs must be used. Individual drugs must be selected on the basis of C & S and patient response

Toxic Shock Syndrome

I.

Background A.

A new phage type strain of Staphylococcus aureus 29 + 52, first recognized in 1978

B.

Clinical aspects 1.

Acute febrile illness (102EF), associated with multisystem involvement, scarlatiniform skin eruption and shock

2.

Between 1978 and May of 1981, 1,233 cases were reported with a mortality rate between 7 and 10%; nearly 50 cases per month are still being reported to the CDC a.

Women: 94% of cases (especially between ages 1924)

b.

3.

Men and children: (1)

Postoperative wounds

(2)

Furuncles

(3)

Burns

(4)

Abscesses

Tampons carry a mandatory warning about toxic shock syndrome (TSS) a.

All types of tampons involved, but especially the superabsorbent

b.

Usually occurs after the second or third day of menses

28

c.

The risk can be reduced by using less absorbent tampons and/or alternating tampon use with sanitary napkin use

II.

Diagnosis/Toxic Shock Symptoms A.

Sudden onset of high fever (104EF), usually second or third day of menses

B.

Headache

C. Confusion D. Conjunctival hyperemia E.

Muscular weakness

F.

Scarlatiniform rash (often starts on lower abdomen and perineum and spreads)

G. Vomiting H. Watery diarrhea (often more than 10 stools/day) I.

Shock (usually occurs 40-72 hours after onset of fever)

J.

Oliguria, acute renal failure, and DIC may occur

K.

Desquamation over trunk and extremities (particularly palms, soles), usually occurring 1-2 weeks after onset of fever

III.

Treatment A.

Remove tampon

B.

Irrigate vagina

C. Stabilize and support patient D. Antibiotics like Keflin or Staphcillin, 1 g q4h until afebrile for 48 hours IV.

Additional Information A.

A high level of 29-52 phage type Staph aureus has reached a plateau and is expected to recede spontaneously in 3-5 years

B.

TSS is due to an enterotoxin of this staph

C. One-fourth of recurrences in menses-related disease developed in subsequent menstrual periods; warn patients not to resume tampons

Actinomyces I.

Family Actinomycetaceae

II.

Several Species A.

Actinomyces israelii

B.

A. naeslundii

C. Arachnia propionica III.

Anaerobic to Microaerophilic, gram positive, Non-acid Fast, Pleomorphic Parasites A.

They are bacteria, not fungi, although they have mycelial forms

B. IV.

Diameter only 0.3/u

Clumps of Actinomycetes with Other Bacteria May Be on Pap Smears

29

These are called "Gupta bodies' V.

Sulfur Granules A.

Mycelial colonies of actinomycetes with filamentous branches may become embedded in an amorphous granular material that contains calcium phos, antigen, and antibody complexes

B.

Characterized by radiating clubs

C. A tissue response to invasive organisms VI.

8% of IUD Wearers Have Actinomycetes

VII. The Ideal Management for the Asymptomatic Patient with Actinomycetes A.

Remove the IUD, treat the patient with penicillin, 500 mg qid, or tetracycline, 500 mg qid, for 2 weeks, and repeat Pap smear after the next menses Antibiotic Prophylaxis

I.

Studies A.

B.

Most studies say prophylaxis is indicated for the following 1.

Vaginal hysterectomy

2.

High-risk C-sections

Possibly indicated 1.

Abdominal hysterectomy

2.

Infertility surgery

3.

Vaginal reconstruction

4.

Radical operations for cancer

C. Five of eight studies suggest prophylaxis is beneficial in abdominal hysterectomies. Some studies find little or no difference, while others show a reduced rate of infections D. In one study of 400 abdominal hysterectomies, the infection rate was reduced from 21%, to 14% using antibiotic prophylaxis 1.

When prophylaxis was used for high-risk C-section patients, 10-14 trials demonstrated a significant reduction in pelvic and wound infections

2.

Even two of the negative trials show a trend in favor of antibiotics

II.

Regimens A.

In hysterectomy patients, ampicillin or a cephalosporin (cefazolin), 30 minutes to 1 hour prior to surgery and then q6h to q8h, from 3--6 doses, is effective

B.

A randomized double-blind study of 266 high-risk cesarean section patients, given three perioperative doses of 2 g cefoxitin had significantly fewer serious infections (19.5% vs. 4.3%), fewer UTIs (10.7% vs. 4.4%), and less standard febrile morbidity (9.4% vs. 3.6%). It has been shown to be effective when the first dose is given after the cord is clamped

III.

Protocol for Antibiotic Prophylaxis for C-Sections

30

A.

Antibiotic prophylaxis is effective in reducing the expected incidence of postcesarean febrile morbidity. Infectious morbidity following C-section has been reported to range from 2985%.

V.

What Agent to Use A.

Many different antibiotics have been used 1.

Two commonly used drugs a.

First-generation cephalosporins, namely, cefazolin (Ancef, Kefzol)

b.

Second-generation cephalosporin, cefoxitin (Mefoxin)

2.

Both of these antibiotics have been shown to be effective

3.

Once the membranes have been raptured, there is an increase in anaerobic organisms in the lower uterine segment, and cefoxitin may be better able to handle this condition

B.

Specific doses 1.

Cefazolin, 1 g IV piggyback, immediately upon clamping the cord, and then q6h to cover for 24 hours

2.

If cefoxitin were being used, the dose is 2 g IV piggyback immediately on clamping the cord and then 2 g q4h twice and q6h thereafter to complete 24--hour period

3.

In general, the antibiotics would be used to cover the first 24-hour period: however, in patients with multiple highrisk factors, a longer course of antibiotics may be appropriate when subclinical infection was present at the time of the surgery

VI.

Patients With Allergies or Other Problems A.

The cephalosporins can be used cautiously in patients who are allergic to penicillin. A small dose could be given subcutaneously and the site can be observed 1.

For prophylaxis of a patient in whom cephalosporins are contraindicated because of a history of recent penicillin anaphylaxis or cephalosporin allergy, an alternate drug selection would be clindamycin together with gentamicin

2.

In patients with valvular heart disease, the American Heart Association recommendations should be followed

B. In summary, the use of prophylactic antibiotics for C-section has to be individualized. Probably, patients undergoing elective repeat C-sections do not need prophylactic antibiotics 1.

Patients at moderate risk should have the 24-hour dose schedule

2.

Patients with marked risk of significant postoperative morbidity should be covered for a longer period of time

Group B-$ $-Hemolytic Streptococci

31

I.

BASIC CHARACTERISTICS A.

The group B-b-hemolytic streptococcus (GBS or Streptococcus agalactiae) is a gram-positive coccus which grows in chains in vitro and in vivo

B.

GBS lacks the M protein that is characteristic of the group A organisms

C. GBS has been a leading cause of bacteremia/meningitis in the first 2 months of life since the early 1970s D. GBS is a significant cause of post-partum febrile morbidity, and 20-30% of these women have bacteremia E.

The incidence of GBS I.

Early-onset infection: 1.5-3.0/1,000 live births

2.

Late-onset infection: 0.5-1.5/1,000 live births

D. Mean mortality rates for early- and late-onset GBS neonatal disease remain 50% and 20%, respectively III.

GBS Infections in Pregnant Women A.

Clinical features 1.

Most women with genital colonization are asymptomatic

2.

Relationship to fetal demise, premature rupture of membranes (PROM), spontaneous abortion is unknown

3.

May

cause

UTI

(5-29%

of

infections)

and

chorioamnionitis (rarely) 4.

Common cause of early first 48 hours) postpartum febrile morbidity, especially when C-section delivery a.

Patients with postpartum endometritis attributed to GBS: 14%

B.

b.

Postpartum bacteremias due to GBS: 20--25%

c.

Rarely, fatal puerperal sepsis, endocarditis

Diagnosis 1.

2.

Cultures a.

Blood

b.

Amniotic fluid

c.

Endometrium

d.

Wound

CIE

C. Treatment

IV.

1.

Aqueous penicillin G IV, 1-2 MU q4h

2.

If penicillin-allergic, cephalosporins

3.

Duration dependent on severity of infection

Epidemiology of GBS in Women A.

Colonization: presence of bacteria at one or more mucous membrane sites 1.

Pharynx: 5-10%

2.

Genital tract: 5-30% (rates increase as one moves from cervix to introitus)

32

3. B.

Anorectum: 15-20%

Prevalence of colonization 1.

2.

Rates increase in: a.

Primigravidas

b.

Less than 20 years of age

c.

Gravida three or less

d.

IUD users

e.

Patients of STD clinics

f.

Sexually active women

Colonization not influenced by the following a.

Oral contraceptives

b.

Race (may be less in Mexican Americans)

c.

Number of sexual partners

d.

GC infection

e.

Pregnancy

C. GBS colonization in pregnancy 1.

Single culture, positive or negative, cannot accurately predict culture status at delivery

2.

a.

One-third chronic careers

b.

One-third intermittent

c.

One-third negative at delivery

Colonized women who have baby with GBS sepsis: 1%; approximately 65% have baby with asymptomatic mucous membrane colonization

3.

Maternal genital inoculum determines risk for colonization and sepsis

4. VI.

Mother to infant transmission: may occur with C-section

Pathogenesis of Early-onset GBS Infection A. Maternal risk factors 1.

Presence of GBS at delivery in high inoculum: 1-2

2.

Prolonged rupture of membrane more than 24 hours: 11%

3.

For type III infections, low levels of maternal type-specific antibody: 10%

4.

Postpartum bacteremia: 10%

5.

Twin pregnancy (if one twin affected, 35% risk to other twin)

B. Neonatal risk factors 1.

Gestation less that 37 weeks (15% if the mother is culture positive at delivery)

2.

Defective WBC function?

3.

"Physiologic" deficiencies in complement function

4.

Low levels of type Ill-specific antibody either due to maternal deficiency or gestation less than 34 weeks

C. Clinical features

33

1.

Up to 50% of neonates are symptomatic at birth (intrauterine infection): 40% have respiratory distress syndrome (RDS)

2.

Term infants are more likely to develop symptoms at age 2 or 3 days, and frequently have meningitis (up to 30%)

3.

The lower the birth weight, the higher the attack rate for

GBS infection if the mother is culture-positive at delivery VII. Management Suggestions A.

B.

Treatment of women with previously documented GBS baby 1.

Culture several times during pregnancy for GBS

2.

If all cultures negative, no treatment necessary

3.

If any culture positive, ampicillin 1 g q6h during labor

Treat

infected

patients

with

penicillin,

ampicillin,

or

erythromycin 1.

Attempts to treat asymptomatic vaginal colonization during pregnancy have been only partially successful

2.

Transmission of GBS to the fetus during labor and delivery, can be interrupted by giving are ampicillin IV during labor, 1 g q6h

C. Treat patients who have PROM and a positive culture as soon as the culture result is known, without waiting for maternal or fetal symptoms D. Treat all patients with positive urine cultures, whether or not they have symptoms. Ten-day courses of treatment may be repeated if there is recurrent significant urinary colonization E.

Give patients with postpartum endometritis broad-spectrum antibiotics even before the culture result is available. The antibiotics effective against gram-positive bacteria usually are adequate against GBS

F.

Since the organism is a significant pathogen for newborns, notify the pediatrician about any GBS infection that may occur during pregnancy or the immediate postpartum period

G. Consider treating a patient who has a history of pregnancy loss and a positive culture as a possible way of preventing future loss 1.

It is reasonable to include the patient's sexual partner in the treatment effort because this organism can be transmitted by intimate contact

2.

Advise the patient that repeated doses, including treatment during labor may be required

Criteria for the Diagnosis of Acute PID

I.

All must Be Present

34

A.

Lower abdominal pain and tenderness with or without rebound

B.

Cervical motion tenderness

C. Adnexal tenderness II.

In Addition, One or More of the Following must Be Present A.

Fever above 100.4EF

B.

Leukocytosis (greater than 10,500 WBC/mm3)

C. Inflammatory mass documented by pelvic examination and/or sonogram D. Culdocentesis revealing WBCs and bacteria on gram's stain of peritoneal fluid E.

Gram-negative intracellular diplococci on gram's stain from cervix

III.

Indications for Hospitalization of Acute PID A.

Temperature above 100.40 F

B.

Presence of adnexal mass

C. Coexisting pregnancy D. IUD present E.

Uncertain diagnosis

F.

Upper peritoneal signs

G. Unable to tolerate oral medications H. Failure to respond to outpatient therapy in 24--48 hours I.

Possibly all salpingitis

Group B Streptococcal Infection in Pregnant: ACOG Recommendations 1.

In the absence of lower urogenital tract screening cultures for GBS, the following risk factors identify women who should receive intrapartum antibiotic chemoprophylaxis: preterm labor ( <37 weeks), preterm PROM ( <37 weeks), prolonged rupture of membranes ( >18 hours), previous child affected by symptomatic GBS infection, or maternal fever during labor.

2.

In the nonallergic patient, first-line intrapartum chemoprophylaxis should consist of either ampicillin (2 g q6h) or penicillin G (5 million U q6h) until delivery. Penicillin-allergic women may be given clindamycin or erythromycin intravenously.

3.

In populations in which the incidence of neonatal GBS infection is inordinately high, selective or routine screening cultures can be considered. Candidates for selective culture might include women with threatened or arrested premature labor, women with PROM remote from term undergoing expectant management, and women undergoing surgical procedures of the cervix in pregnancy.

4.

One technique for culturing is to obtain a sample through a single swab of the lower vagina and anorectum at 26-28 weeks of gestation, place the sample in selective broth medium, and subculture it onto solid media. If the culture is positive, intrapartum intravenous antibiotics as previously outlined should be used to

35

treat women with the following risk factors: preterm labor (<37 weeks), PROM (<37 weeks), and ruptured membranes (>18 hours). Regardless of maternal carrier status, treatment is indicated if the patient has had a child affected by GBS or if maternal fever is present intrapartum.

36