Gynecological infections
Gebre K. Tseggay, M. D.
Normal Vaginal Flora




Dominated by lactobacilli
Lactobacilli convert glucose to lactic acid, to maintain an
acidic vaginal pH of 3.8 to 4.2. This acidic environment
inhibits the overgrowth of bacteria and other organisms
with pathogenic potential.
Some lactobacilli also produce hydrogen peroxide (H2O2), a
potential microbicide.
After onset of sexual activity, increase in Gardnerella
vaginalis, lactobacilli, mycoplasmas, ureaplasmas is seen.
BACTERIA ENDOGENOUS TO THE LOWER
GENITALTRACT
GRAM POSITIVE
GRAM NEGATIVE
Lactobacillus acidophilus
Escherichia coli
Corynebacterium spp
Enterobacter cloacae
Gardnerella vaginalis
Staphylococcus epidermidis
Klebsiella
Streptococci
Morganella
Enterococcus faecalis
Proteus
Peptococcus
Bacteroides
Peptostreptococcus
Fusobacterium
Prevotella
modified from Schlossberg,CTID 2001
Vaginitis
Most common causes include:

Vulvovaginal Candidiasis (VVC)

Bacterial Vaginosis (BV)

Trichomoniasis
*In some cases the etiology may be mixed
VAGINITIS
SYMPTOMS

Often non-specific:
 Abnormal discharge
 Vulvovaginal irritation
 Vulvar itching
 Odor
VAGINITIS
DIAGNOSIS





History
Visual inspection
Appearance of vaginal discharge: color, viscosity,
adherence to vaginal walls, odor
Collection of specimen
Diagnostic tests:




Vaginal pH: determine vaginal pH with narrow-range pH paper
Whiff test: assessment of a fishy odor after application of 10%
KOH to wet mount
KOH (wet mount): wet mount of discharge with 10% KOH
NaCl (wet mount): wet mount of discharge with 0.9% normal saline
VAGINITIS
DIAGNOSIS
Other tests:
 Cultures: not used routinely, but are available for both
T. vaginalis and Candida spp.

New tests for BV (commercially available) :



Fem Exam Test Card™: pH and amines
Fem Exam vaginalis PIP Activity Test Card™: detects enzyme
breakdown from G. vaginalis
DNA probe for 3 organisms (T. vaginalis, C. albicans,
and G. vaginalis): sensitivity, specificity, and clinical
utility are under investigation.
VULVOVAGINAL CANDIDIASIS




Not considered to be STD
Caused by overgrowth of Candida species
(Candida species are normal flora of vagina)
80-90% caused by C. albicans.
Non-albicans candida play increasing role
VULVOVAGINAL CANDIDIASIS
RISK FACTORS









Uncontrolled DM
Corticosteroid therapy
Antimicrobial therapy (oral,
parental, topical)
Poor hygiene
Estrogen therapy
High-dose estrogen contraceptives
Pregnancy
IUD
HIV infection







Sponge
Nonoxynol-9 (?)
Diaphragm (?)
Increased frequency of coitus
"Candy binge“
Women frequenting STD clinics
Tight-fitting synthetic underclothing
But, most episodes of vulvovaginal
candidiasis occur in the absence
of a recognizable precipitating
factors
VULVOVAGINAL CANDIDIASIS
CLASSIFICATION
Uncomplicated
Complicated
Sporadic, infrequent
Mild-to-moderate
Likely C albicans
Non-immunocomprised
Recurrent
Severe
Non-albicans
Diabetes, pregnancy,
immunosuppression
VULVOVAGINAL CANDIDIASIS
MANIFESTATIONS

Vulvar pruritis is most common
symptom

Thick, white, curdy vaginal discharge
("cottage cheese-like")

Erythema, irritation, occasional erythematous
"satellite" lesion

External dysuria and dyspareunia
VULVOVAGINAL CANDIDIASIS
DIAGNOSIS
Clinical
 pH normal (<4.5)
 Whiff test negative
 Fungal stain positive

30% may have a negative fungal stain
 Severity does not depend on No. yeasts present

Regimens for the Treatment of Vulvovaginal Candidiasis


Intravaginal agents:
 Butoconazole 2% cream, 5 g intravaginally for 3 days†
 Butoconazole 2% sustained release cream, 5 g single intravaginally application
 Clotrimazole 1% cream 5 g intravaginally for 7-14 days†
 Clotrimazole 100 mg vaginal tablet for 7 days
 Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days
 Clotrimazole 500 mg vaginal tablet, 1 tablet in a single application
 Miconazole 2% cream 5 g intravaginally for 7 days†
 Miconazole 100 mg vaginal suppository, 1 suppository for 7 days†
 Miconazole 200 mg vaginal suppository, 1 suppository for 3 days†
 Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days
 Tioconazole 6.5% ointment 5 g intravaginally in a single application†
 Terconazole 0.4% cream 5 g intravaginally for 7 days
 Terconazole 0.8% cream 5 g intravaginally for 3 days
 Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
Oral agent:
 Fluconazole 150 mg oral tablet, 1 tablet in a single dose
Note: The creams and suppositories in this regimen are oil-based and may weaken latex condoms and diaphragms. Refer to condom
product labeling for further information.
† Over-the-counter (OTC) preparations
RECURRENT
VULVOVAGINAL CANDIDIASIS
Four or more symptomatic episodes/year
 Usually NOT from resistance to antifungals
 Diabetes mellitus or immunosuppression should be considered in refractory/
recurrent cases
 Simultaneous Rx of sex partners has no effect on recurrence (but 3-10% of sex
partners may have balanitis)
 Vaginal culture useful to confirm diagnosis and identify unusual species
Treatment





Initial regimen of 7-14 days topical therapy
Fluconazole 150 mg (repeat 72 hrs)
Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole
For Non-albicans VVC:
 Longer duration of therapy


Non-azole regimen may even be needed
600 mg boric acid in gelatin capsule vaginally once a day for 14 days
VULVOVAGINAL CANDIDIASIS
Treatment in Pregnancy

Only topical intravaginal regimens
recommended (usually for 7 days)
VULVOVAGINAL CANDIDIASIS
Management of Sex Partners

Treatment not recommended

Treatment of male partners does not reduce
frequency of recurrences in the female

But, male partners with balanitis may benefit from
treatment
BACTERIAL VAGINOSIS

Not a classical STD

Overgrowth of vaginal normal flora with anaerobic bacteria and
decrease or loss of protective lactobacilli (Disturbed vaginal ecosystem)
Gardrenella vaginalis (GV) & other microrganisms in high titers
But, GV found in 50% of vaginal cultures in asymptomatic
women too.
BV linked to: premature rupture of membranes, premature
delivery and low birth-weight delivery, acquisition of HIV,
development of PID, and post-operative infections after
gynecological procedures
Male sex partners may be colonized but asymptomatic




BACTERIAL VAGINOSIS





Gray, homogenous discharge
w foul (fishy) odor reported mostly
after vaginal intercourse and after
completion of menses
Without obvious vaginal
inflammation
Clue cells present
pH>4.5
Positive Whiff test (KOH)
NOT a clue cell
Clue cells
NOT a clue cell
BV Diagnosis: Amsel Criteria
Amsel Criteria:
Must have at least
three of the following
findings:

Vaginal pH >4.5

Presence of >20% per HPF of
"clue cells" on wet mount
examination

Positive amine or "whiff" test

Homogeneous, non-viscous,
milky-white discharge adherent
to the vaginal walls
BACTERIAL VAGINOSIS
Other Diagnostic Tools

Culture not recommended; Do not Rx a positive GV
vaginal culture in asymptomatic women


Newer diagnostic modalities include:

FemExam™

PIP Activity TestCard™
DNA probe
BACTERIAL VAGINOSIS
TREATMENT
Metronidazole
500 mg twice daily x 7 days
Metronidazole
gel 0.75%, 5 g intravaginally once daily x 5 days
Clindamycin cream 5%, 5 g intravaginally qhs x 7 days
Alternative regimens
Metronidazole
2 gm in a single dose
Clindamycin 300 mg twice daily x 7 days
Clindamycin ovules 100 g intravaginally qhs x 3 days
BACTERIAL VAGINOSIS
Treatment in Pregnancy

Symptomatic pregnant women should be treated
due to association with adverse pregnancy
outcomes

Do not use of topical agents in pregnancy

Some experts recommend screening and
treatment of asymptomatic women at high risk
for preterm delivery (previous preterm birth) at
the first prenatal visit; optimal regimen not
established
BACTERIAL VAGINOSIS
Treatment in Pregnancy
Metronidazole 250 mg three times
daily for 7 days
or
Clindamycin 300 mg twice daily for 7
days
BACTERIAL VAGINOSIS
Management of Sex Partners
Not

recommended
Woman’s response to therapy and the
likelihood of relapse or recurrence not
affected by treatment of sex partner
TRICHOMONIASIS

Etiologic agent

Trichomonas vaginalis – a
flagellated protozoa
Trichomoniasis and other vaginal infections
— Initial visits to physicians’ offices: United
States, 1966–2003
Visits (in thousands)
4,500
Trichomonal
Other Vaginitis
3,600
2,700
1,800
900
0
1966
69
72
75
78
81
SOURCE: National Disease and Therapeutic Index (IMS Health)
84
87
90
93
96
99
2002
TRICHOMONIASIS






Estimated 7.4 million cases annually in the U.S.
Almost always sexually transmitted
Causes urethritis in men (usu. asymptomatic)
Transmission between female sex partners has been
documented
Fomite transmission rare
Possible association with


Pre-term rupture of membranes and pre-term delivery
Increased risk of HIV acquisition
TRICHOMONIASIS
DIAGNOSIS







Copious, yellow-green or gray frothy
discharge, adherent to vaginal walls, w
foul odor.
Vulvovaginal erythema
Punctate cervical microhemorrhages
seen in 25%: ‘strawberry cervix’
Saline smear 80% sensitive, highly
specific (motile trichomonads)
Liquid culture, Diamond’s medium, done
in persistent cases
Gram stain & Pap smear are not
sensitive or specific
Whiff test (KOH) +/-
TRICHOMONIASIS
TREATMENT
Recommended regimen
Metronidazole 2 gm orally in a single dose
Alternative regimen
Metronidazole 500 mg twice a day for 7 days
Pregnancy
Metronidazole 2 gm orally in a single dose
TRICHOMONIASIS
TREATMENT FAILURE

Re-treat with metronidazole 500 mg twice daily for 7 days

If above fails, Rx with metronidazole 2 gm single dose x 3-5 days

In repeated failure:

Confirm diagnosis with culture

consider metronidazole susceptibility testing through the
CDC

Trial of tinidazole
TRICHOMONIASIS
Other management issues


No alcohol for the duration of treatment and
for at least 24 h after the last dose.
Trich is an STD, so:
GC and Chlamydia testing should be done, &
 Syphilis, HIV, and hepatitis B serologic testing
should be considered

TRICHOMONIASIS
Management of Sex Partners

Sex partners should be treated, even
if asymptomatic

Avoid intercourse until therapy is
completed and patient and partner
are asymptomatic
.
VAGINITIS DIFFERENTIATION
Normal
Symptom
presentation
Vaginal discharge
Clear to
white
Trichomoniasis
Candidiasis
Bacterial
Vaginosis
discharge, itch,
50% asymptomatic
Itch, discomfort,
dysuria, thick
discharge
Odor, discharge,
itch
Thick, clumpy,
white “cottage
cheese”
Homogenous,
adherent, thin,
milky white;
malodorous
“foul fishy”
Frothy, gray or
yellow-green;
malodorous
Cervical petechiae Inflammation and
“strawberry cervix”
erythema
Clinical findings
Vaginal pH
3.8 - 4.2
> 4.5
Usually < 4.5
> 4.5
KOH “whiff ” test
Negative
Often positive
Negative
Positive
NaCl wet mount
Lactobacilli
Motile flagellated
protozoa, many
WBCs
Few WBCs
Clue cells (>
20%), no/few
WBCs
KOH wet mount
Pseudohyphae
NON-INFECTIOUS VAGINITIS



Vaginal foreign bodies, especially in prepubescent
girls, may present with a heavy white discharge but
would be unaccompanied by vulvar erythema or the
microscopic appearance of hyphae.
Atrophic vaginitis is commonly found in
postmenopausal women and is distinguished from
candidal vaginitis by mucosal dryness, atrophy,
dyspareunia, minimal discharge, and itching.
Contact dermatitis, local irritation secondary to tightfitting underwear, and contact dermatitis from toiletry
items, latex condoms, diaphragms, spermicides
MUCOPURULENT
CERVICITIS

Largely caused by
Chlamydia trachomatis and
Neiserria Gonorrheae
Chlamydia trachomatis
Chlamydia — Rates: United States, 1984–2003
Rate (per 100,000 population)
350
280
210
140
70
0
1984
86
88
90
92
94
96
98
2000
02
Chlamydia — Rates by sex: United States,
1984–2003
Rate (per 100,000 population)
500
400
300
Men
Women
200
100
0
1984
86
88
90
92
94
96
98
2000
02
CDC
Chlamydia trachomatis


Estimated 3 million cases in the U.S. annually
Women: bartholinitis, cervicitis, urethritis, PID,
perihepatitis, conjunctivitis





Men: urethritis, epididymitis
M&W: LGV
Infants: conjunctivitis, pneumonia
Complications: PID, perihepatitis, Reiter’s syndrome,
infertility, ectopic pregnancy, chronic pelvic pain,
increased risk for HIV
Incubation period is 7-21 days.
Chlamydia trachomatis
Risk factors

Adolescence







Cervical epithelial cells are developmentally immature (ectopy) making
them more susceptible to infection.
Risky behaviors also contribute to susceptibility.
New or multiple sex partners
History of past STD infection
Presence of another STD
Oral contraceptive use (contributes to cervical ectopy, &
OCP users less likely to use barrier protection)
Lack of barrier contraception
Chlamydia trachomatis
Cervicitis

Majority of cervical infections are asymtpomatic-70% to 80%.

When symptomatic, S+S may be non-specific:

spotting, or mucopurulent cervicitis, with mucopurulent endocervical
discharge, edema, erythema, and friability w easily induced bleeding within
the endocervix or any zones of ectopy.
Urethritis



50% of infected women yield chlamydia from both
urethra and cervical sites
Usually asymptomatic
May cause the “dysuria-pyuria” syndrome mimicking
acute cystitis. On urinalysis, pyuria present but few
bacteria.
Chlamydia trachomatis
DIAGNOSIS
Culture: high specificity BUT
 labor-intensive, expensive,
 variable sensitivity (50%-80%),
 not suitable for widespread screening
Non-culture methods:

Serology: not very useful

EIA, DFA, DNA probe : less sensitive(50-75%), nonspecific

Nucleic acid amplification tests (NAAT): PCR, LCR:
 more sensitive than culture (>80%-90%)
 highly specific (>99%)
 can use first void urine
 can use self-obtained vaginal swab
Chlamydia trachomatis
Treatment
Azithromycin 1 gm single dose
or
Doxycycline 100 mg bid x 7d
Chlamydia trachomatis
Alternative regimens
Erythromycin base 500 mg qid for 7 days
or
Erythromycin ethylsuccinate 800 mg qid for 7 days
or
Ofloxacin 300 mg twice daily for 7 days
or
Levofloxacin 500 mg for 7 days
Chlamydia trachomatis
Treatment in Pregnancy
Recommended regimens
Erythromycin base 500 mg qid for 7 days
or
Amoxicillin 500 mg three times daily for 7 days
Alternative regimens
Erythromycin base 250 mg qid for 14 days
or
Erythromycin ethylsuccinate 800 mg qid for 14 days
or
Erythromycin ethylsuccinate 400 mg qid for 14 days
or
Azithromycin 1 gm in a single dose
Chlamydia trachomatis
Screening





Annual screening of sexually active women
< 25 yrs
Annual screening of sexually active women
> 25 yrs with risk factors
Sexual risk assessment may indicate need for
more frequent screening for some women
Screen pregnant women in the first trimester
Re-screen women 3-4 months after treatment
due to high prevalence of repeat infection
GONORRHEA
Gonorrhea — Rates: United States, 1970–2003
and the Healthy People 2010 target
Rate (per 100,000 population)
500
Gonorrhea
2010 Target
400
300
200
100
0
1970
73
76
79
82
85
88
91
94
97
Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000
population.
2000
03
GONORRHEA



Caused by Neisseria gonorrhoeae, a gram-neg intracellular
diplococcus.
Estimated 700,00-800,000 persons infected annually in
the US.
Manifestations in women may include:
 cervicitis, PID, urethritis, pharyngitis, proctitis,
disseminated (bacteremia,arthritis, tenosynovitis)
 Accessory gland infection (Bartholin’s glands,
Skene’s glands)

Fitz-Hugh-Curtis Syndrome (Perihepatitis)
Gonorrhea Cervicitis
Clinical Manifestations




Symptoms are non-specific : abnormal vaginal
discharge, intermenstrual bleeding, dysuria, lower
abdominal pain, or dyspareunia
Clinical findings: mucopurulent or purulent
cervical discharge, easily induced cervical bleeding
50% of women with clinical cervicitis are
asymptomatic
Incubation period unclear, but symptoms may
occur within 10 days of infection
Gonorrhea Cervicitis
Bartholin’s Abscess
GONORRHEA
LAB DIAGNOSIS

Culture (selective media-Thayer Martin, needs CO2)

Non-culture tests: DNA probe, nucleic acid
amplification

Gram-stain, less sensitive in cervicitis (most sensitive for
symptomatic urethritis in men)
Gonorrhea: Gram Stain of
Urethral Discharge
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Neisseria gonorrhoeae (Cervix, Urethra, Rectum)
Cefixime 400 mg
or
Ceftriaxone 125 IM
or
1Ciprofloxacin 500 mg
or
1Ofloxacin 400 mg
or
1Levofloxacin
250 mg
PLUS Chlamydial therapy if infection not ruled out
1 Contraindicated
in pregnancy and children. Not recommended for infections
acquired in California, Asia, or the Pacific, including Hawaii.
Neisseria gonorrhoeae
(Cervix, Urethra, Rectum)
Alternative regimens
Spectinomycin 2 grams IM in a single dose
or
Single dose cephalosporin (cefotaxime 500 mg)
or
Single dose quinolone (gatifloxacin 400 mg,
lomefloxacin 400 mg, norfloxacin 800 mg)
PLUS Chlamydial therapy if infection not ruled out
Neisseria gonorrhoeae
Treatment in Pregnancy

Cephalosporin regimen

Women who can’t tolerate cephalosporin regimen may
receive 2 g spectinomycin IM

No quinolone or tetracycline regimen
PLUS Erythromycin or amoxicillin for presumptive or
diagnosed chlamydial infection
Gonococcal Isolate Surveillance Project (GISP) —
Percent of Neisseria gonorrhoeae isolates with resistance or
intermediate resistance to ciprofloxacin, 1990–2003
Percent
7.5
Resistance
6.0
Intermediate resistance
4.5
3.0
1.5
0.0
1990
91
92
93
94
95
96
97
98
99
2000
01
Note: Resistant isolates have ciprofloxacin MICs ≥ µg/ml. Isolates with
intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 µg/ml.
Susceptibility to ciprofloxacin was first measured in GISP in 1990.
02
03
Neisseria gonorrhoeae
Antimicrobial Resistance

Surveillance is crucial for guiding therapy
recommendations

No significant resistance to ceftriaxone

Fluoroquinolone resistance in SE Asia, Pacific,
Hawaii, California, Washington.

FQ resistance 15% in MSM.
GONORRHEA
TREATMENT ISSUES





Fluoroquinolones are no longer recommended for
therapy for gonorrhea acquired in Asia, the Pacific
Islands (including Hawaii), and California.
CDC no longer recommends fluoroquinolones as a
first-line therapy for gonorrhea in MSM
If symptoms persist, perform culture for N. gonorrhoeae.
Any gonococci isolated should be tested for
antimicrobial susceptibility
Co-infection with Chlamydiae in up to 50% of pts,
hence anti-Chlmydia Rx added.
Note : A test of cure is not recommended, if a
recommended regimen is administered.
GONORRHEA
Partner Management



Evaluate and treat all sex partners for N. gonorrhoeae and
C. trachomatis infections if contact was within 60 days of
symptoms or diagnosis.
If a patient’s last sexual intercourse was >60 days
before onset of symptoms or diagnosis, the patient’s
most recent sex partner should be treated.
Avoid sexual intercourse until therapy is completed and
both partners no longer have symptoms.
PELVIC INFLAMMATORY DISEASE
(PID)
PELVIC INFLAMMATORY DISEASE






Estimated about 1 million annual cases in the US
Endometritis, salpingitis, tuboovarian abscess, & pelvic
peritonitis.
Ascending infection from or via cervix
Most cases of PID are polymicrobial: Chlamydia, GC,
vaginal organisms, anaerobes, enteric GNR, GPC).
May be unrelated to STD.
Most common pathogens:
 N. gonorrhoeae: recovered from cervix in 30%-80% of
women with PID
 C. trachomatis: recovered from cervix in 20%-40% of
women with PID
 N. gonorrhoeae and C. trachomatis are present in
combination in approximately 25%-75% of patients
PELVIC INFLAMMATORY DISEASE
RISK FACTORS

Adolescence (in sexually active teens 3x more than 25-29 yr olds)
History of PID
GC or chlamydia, or a history of GC or chlamydia
Male partners with GC or chlamydia
Multiple partners
Current douching
Insertion of IUD (especially within 4 mos after insertion)
Bacterial vaginosis
Demographics (lower socioeconomic status)

Oral contraceptive use, in some cases (by avoidance of barrier precautions?)








PID Classification
Subclinical/
silent
60%
Mild to
moderate
symptoms
36%
Overt
40%
Severe
symptoms
4%
CDC
PELVIC INFLAMMATORY
DISEASE
Minimum Diagnostic Criteria
Uterine/adnexal tenderness or cervical motion
tenderness
Additional Diagnostic Criteria
Oral temperature >38.3 C
Cervical Chlamydia or GC
WBCs/saline microscopy
Elevated ESR
Elevated CRP
Cervical Discharge
Pelvic Inflammatory Disease
More Specific Criteria

Endometrial biopsy: histopathologic evidence of
endometritis

Imaging Studies: Transvaginal sonography or MRI
(showing thickened fluid-filled tubes)

Laparoscopy: abnormalities consistent with PID
PELVIC INFLAMMATORY DISEASE
MANAGEMENT




Antibiotics
Bed rest
Reevaluation within 72 hrs of treatment
All male sex partners should be evaluated for STD
and empirically treated with regimen effective for
GC/Chlmydia
PELVIC INFLAMMATORY DISEASE
MANAGEMENT
Hospitalize, if:
 Surgical emergencies not excluded (e.g., appendicitis, ectopic
pregnancy..)
 Pregnant patient
 Pelvic abscess is suspected
 Adolescent
 Severe illness
 If unable to tolerate outpt regimen
 If f/up within 72 hrs after starting abx cannot be arranged
 Non-response to oral therapy
 HIV infection with low CD4 count
Pelvic Inflammatory Disease
Parenteral Regimen A
Cefotetan 2 g IV q 12 hours
or
Cefoxitin 2 g IV q 6 hours
PLUS
Doxycycline 100 mg orally/IV
q 12 hrs
PELVIC INFLAMMATORY DISEASE
Parenteral Regimen B
Clindamycin 900 mg IV q 8 hours
PLUS
Gentamicin loading dose IV/IM (2 mg/kg) followed by
maintenance dose (1.5 mg/kg) q 8 hours. Single daily
dosing may be substituted.
PELVIC INFLAMMATORY DISEASE
Alternative Parenteral Regimens
Ofloxacin 400 mg IV q 12 hours
or
Levofloxacin 500 mg IV once daily
WITH OR WITHOUT
Metronidazole 500 mg IV q 8 hours
or
Ampicillin/Sulbactam 3 g IV q 6 hrs
PLUS
Doxycycline 100 mg orally/IV q 12 hrs
PELVIC INFLAMMATORY DISEASE
Oral Regimen A
Ofloxacin 400 mg twice daily for 14 days
or
Levofloxacin 500 mg once daily for 14 days
WITH OR WITHOUT
Metronidazole 500 mg twice daily for 14 days
PELVIC INFLAMMATORY DISEASE
Oral Regimen B
Ceftriaxone 250 mg IM in a single dose
or
Cefoxitin 2 g IM in a single dose and Probenecid 1 g
administered concurrently
PLUS
Doxycycline 100 mg twice daily for 14 days
WITH or WITHOUT
Metronidazole 500 mg twice daily for 14 days
SUSPECTED TUBOOVARIAN ABSCESS


Cultures
Broad spectrum antibiotics


85% of abscesses w a diameter of 4-6 cm (&
only 40% of those >10 cm) respond to abx alone
Surgery for failure to respond to abx.
PELVIC INFLAMMATORY DISEASE
SEQUELAE

Ectopic pregnancy


Infertility:






7-fold increase in risk after a single episode of PID
13% of women after one episode of PID
25-35% after 2 episodes, 50-75% after 3 or more episodes
2/3 unable to conceive after Rx for TOA
Dyspareunia
Pelvic adhesions
Chronic pelvic pain
PELVIC INFLAMMATORY DISEASE
Management of Sex Partners

Male sex partners of women with PID should
be examined and treated for sexual contact 60
days preceding pt’s onset of symptoms

Sex partners should be treated empirically with
regimens effective against CT and GC
Genital herpes — Initial visits to physicians’
offices: United States, 1966–2003
Visits (in thousands)
250
200
150
100
50
0
1966
69
72
75
78
81
84
SOURCE: National Disease and Therapeutic Index (IMS Health)
87
90
93
96
99
2002
Genital HSV Infection







More than one in five Americans (45 million people)-are estimated infected
with genital herpes
more common in women than men, infecting approximately one out of four
women, versus one out of five men.
In a national house-hold survey, less than 10 percent of people who tested
positive with herpes knew they were infected (Fleming, 1997). ---Silent
epidemic--Genital herpes is a recurrent, lifelong viral infection.
Asymptomatic shedding occurs (Most sexual transmission occurs while
source case is asymptomatic).
Incubation period is 2-12 days (average is 4 days).
Can be transmitted between sex partners, from mothers to newborns, and can
increase a person's risk of becoming infected with HIV
Estimated Annual Incidence of
Selected STDs in the U.S. , 2000






Trichomoniasis 7.4 million
Human Papillomavirus (HPV) 6.2 million
Chlamydia 2.8 million
Herpes Simplex Virus (HSV) Type 2 : 1.6
million
Gonorrhea 718,000
Syphilis 37,000
HSV Serologic Tests
Type-Specific

HSV-specific glycoprotein G2 for HSV 2
infection and glycoprotein G1 for HSV 1

Available gG type-specific assays- POCkit
HSV-2, HerpeSelect HSV1/2 IgG ELISA
and HerpeSelect 1/2 immunoblot IgG

Sensitivity 80-98%, Specificity > 96%

Confirmatory testing may be indicated in
some settings
Genital Herpes
First Clinical Episode
Acyclovir 400 mg tid
or
Famciclovir 250 mg tid
or
Valacyclovir 1000 mg bid
Duration of Therapy 7-10 days
Genital Herpes
Episodic Therapy
Acyclovir 400 mg three times daily x 5 days
or
Acyclovir 800 mg twice daily x 5 days
or
Famciclovir 125 mg twice daily x 5 days
or
Valacyclovir 500 mg twice daily x 3-5 days
or
Valacyclovir 1 gm orally daily x 5 days
Genital Herpes
Daily Suppression
Acyclovir 400 mg bid
or
Famciclovir 250 mg bid
or
Valacyclovir 500-1000 mg daily
Genital Herpes
in HIV Infection

May have prolonged or severe episodes with
extensive genital or perianal disease

Episodic or suppressive antiviral therapy
often beneficial

For severe cases, acyclovir 5-10 mg/kg IV q 8
hours may be necessary
Genital Herpes
HIV Infection/Episodic Therapy
Acyclovir 400 mg three times daily
or
Famciclovir 500 mg twice daily
or
Valacyclovir 1 gm twice daily
Duration of Therapy 5-10 days
Genital Herpes
HIV Infection/Daily Suppression
Acyclovir 400-800 mg twice to three times daily
or
Famciclovir 500 mg twice daily
or
Valacyclovir 500 mg twice daily
Genital Herpes
Antiviral Resistance

Persistent or recurrent lesions on antivirals

Obtain viral isolate for viral susceptability

5% immunocomprised patients

Acyclovir resistant isolates-resistant to
valacyclovir, most resistant to famciclovir

Alternatives: Foscarnet 40 mg/kg IV q 8 or
topical cidofovir gel 1% (daily x 5 days)
Herpes in Pregnancy
Risk for transmission to neonate from infected mother is :
 high (30%-50%) among women who acquire genital herpes near
the time of delivery, but low (<1%) in women with histories of
recurrent herpes at term or who acquire genital HSV during the
first half of pregnancy.
 Prevention of neonatal herpes depends on avoiding acquisition
of HSV during late pregnancy and avoiding exposure of the
infant to herpetic lesions during delivery.
 Women without symptoms or signs of genital herpes or its
prodrome can deliver vaginally
Genital Herpes
Treatment in Pregnancy

Acyclovir may be used with first episode or severe
recurrent disease

Available data do not indicate an increased risk of
major birth defects (first trimester)

The safety of acyclovir, valacyclovir, and famciclovir
therapy in pregnant women has not been established.
Genital Herpes
Counseling

Natural history of infection, recurrences,
asymptomatic shedding, transmission risk

Individualize use of episodic or suppressive
therapy

Abstain from sexual activity when lesions or
prodromal symptoms present

Risk of neonatal infection
HUMAN PAPILLOMAVIRUS












6.2 million Americans get a new genital HPV infection each year
.
May cause cancer of cervix, vulva, vagina, or anus

the most common sources of genital warts--HPV types 6 and 11--are
rarely associated with malignancy

the high-risk HPV types 16 and 18 have been found in more than 90%
of cervical cancers
They appear an average of 3 months after exposure, the latency period can
be much longer.
Infection can be clinically apparent, subclinical, or latent
Frequency of spontaneous regression is unclear. A few studies indicate a
regression rate of 10%-30% within 3 months.
Persistence of infection occurs, but frequency and duration is unknown.
Recurrences after treatment are common (20%-50% recurrence rate at 3-6
months).
Symptoms
Genital warts usually cause no symptoms other than the warts themselves.
Vulvar warts can cause dyspareunia, pruritis, and burning discomfort.
Urethral meatal warts occasionally cause hematuria or impairment of
urinary stream.
Vaginal warts occasionally cause discharge, bleeding, or obstruction of
birth canal (due to increased wart growth in pregnancy).
HUMAN PAPILLOMAVIRUS
Risk for Malignancy


Externa genital warts
 HPV types 6, 11.
 Minimal risk for malignancy
Flat warts
 HPV 16,18, 31, 45…
 Associated with cancer of cervix, vagina, vulva, anus, penis
 Most women with persistent HPV infection do not develop
cervical cancer precursors or cervical cancer.
 Over 99% of cervical cancers have HPV DNA detected
within the tumor.
 Persistent infection with a high-risk HPV type is necessary
but not sufficient for the development of cervical cancer.
HUMAN PAPILLOMAVIRUS
DIAGNOSIS
Inspection usually diagnostic of external warts:,
biopsy if in doubt
 Pap smear, biopsy for flat warts of cervix
 HPV-DNA studies, PCR, hybrid capture
 HPV cannot be cultured, and serologic tests are not
available to test for HPV antibodies
 Subclinical infections may be detected by applying
3% to 5% acetic acid solution for 5 to 10 minutes.
The lesions then become visible, and can be further
visualized via colposcopy.

HUMAN PAPILLOMAVIRUS
Treatment

Primary goal for treatment of visible warts
is the removal of symptomatic warts

Therapy may reduce but probably does not
eradicate infectivity

Difficult to determine if treatment reduces
transmission
No laboratory marker of infectivity
Variable results utilizing viral DNA
HUMAN PAPILLOMAVIRUS

Choice of therapy guided by preference of patient,
experience of provider, resources

No evidence that any regimen is superior

Locally developed/monitored treatment algorithms
associated with improved clinical outcomes

Acceptable alternative may be to observe; possible
regression/uncertain transmission
PAPILLOMAVIRUS
Patient-applied


Podofilox 0.5% solution or gel
Imiquimod 5% cream
Provider-administered




Cryotherapy
Podophyllin resin 10-25%
Trichloroacetic or Bichloroacetic
acid 80-90%
Surgical removal
HUMAN PAPILLOMAVIRUS
Treatment in Pregnancy

Imiquimod, podophyllin, podofilox should not be
used in pregnancy

Many specialists advocate wart removal due to
possible proliferation and friability

HPV types 6 and 11 can cause respiratory
papillomatosis in infants and children

Preventative value of cesarean section is unknown;
may be indicated for pelvic outlet obstruction
CHORIOAMNIONITIS
RISK FACTORS








Nulliparity
Length of labor
Preterm labor
PROM
Meconium stained amniotic fluid
Internal fetal or uterine
monitoring
Presence of GU pathogens
(GBS, GC,BV)
No of vag exams in women w
ruptured membrane
Underlying Host Factors

No. of lactobacilli,

IgA,
 Chronic diseases
 Immunosuppression
 Nutritional disorders
 Drug abuse.
CHORIOAMNIONITIS
DIAGNOSIS


Maternal fever >38C(>100.4) AND at least 2 of the following:
 Maternal leukocytosis (>15,000 cells/cubic mm)
 Maternal tachycardia (>100 beats/min)
 Fetal tachycardia (>160 beats/min)
 Uterine tenderness
 Foul odor of the amniotic fluid
AMNIOTIC FLUID ANALYSIS:
 Gram stain: bacteria & leukocytes (> 6 leukocytes/hpf)
 Glucose (<15mg/dl abnormal)
 WBC (Abnormal >30 cells/cc)
 Leukocyte esterase (strips) +
Abnormal glu + wbc + Leuk/esterase= sensitivity 90%, specificty 80%
for pos culture
MICROBIOLOGY:
 Organisms from vaginal flora, anaerobes, mycoplasma, GBS, E.coli.
 Usually polymicrobial
CHORIOAMNIONITIS
MANAGEMENT
1.
Antibiotics


2.
Amp/gent/clinda.
Other broad-spectrum regimen
Delivery
(Note: C-section should be performed only for accepted
obstetric indications)
POSTPARTUM ENDOMETRITIS
DIAGNOSIS

Fever, usually on 1st or 2nd postpartum day.
Lower abdominal pain
Uterine tenderness
Leukocytosis

Bimanual exam should be done



Microbiologic diagnosis:
 Transvaginally obtained cultures are controversial (contaminants)
 Blood cultures should be done (10-20% have bacteremia)
 Chlamydia testing (culture, antigen, PCR) should be done for high
risk pts & with late-onset PPE.
POSTPARTUM ENDOMETRITIS
PREDISPOSING FACTORS


C-section, especially after labor or rupture of membranes is
the main predictor
 Incidence after vaginal delivery 0.9-3.9 %
 Incidence after C-section 10-50%
Other predictors:
 Duration of labor
 Rupture of membranes
 Presence of BV
 Number of vag. Exams during labor
 Use of internal fetal monitoring.
POSTPARTUM ENDOMETRITIS (PPE)
MICROBIOLOGY



Polymicrobial (GBS, enterococci, G. vaginalis, E. coli, Prevotella
bivia, Bacteroides spp, peptostreptococci, Ureoplasma
urealyticum, Mycoplasma hominis)
Chlamydia trachomatis may cause a late form of PPE (>2days
to 6 wks postpartum, after vag delivery)
Group A Strep PPE is rare


of exogenous source, usually caregiver.
Major epidemiologic significance: HCW screening (all at the delivery
& those who did vag exam before delivery should be screened w
cultures of nares, throat, vagina, rectum, skin. If culture + should
refrain from patient care for the 1st 24h of abx therapy)
POSTPARTUM ENDOMETRITIS
MANAGEMENT

Antibiotics (broad-spectrum)

until pt is afebrile, pain-free, & with normal wbc count.
FAILURE TO RESPOND may indicate:
 multi-drug resistant bacteria,
 inadequate regimen,
 abscess,
 puerperal ovarian vein thrombosis,
 non-infectious fever (e.g., drug-fever, breast engorgement)
PROPHYLAXIS:
 Abx prophylaxis for any c-section after labor or rupture of
membranes of any duration
PUERPERAL OVARIAN VEIN
THROMBOSIS











Acute postpartum thrombosis of ovarian veins
Rare, incidence 1/2000 deliveries or 1-2/100 pts w postpartum infection
Can occur after c-section or vaginal delivery.
Usually associated with post-c-section endometritis. Previously diagnosed
w “PPE failing to respond to abx”
Onset mostly 2-4 days after delivery.
Acute onset, pt appears ill, febrile/chills, lower abd pain (usually rt sided),
tachycardia disproportionately elevated c/w temp.
EXAM: tenderness, tender sausage-shaped mass may be palpable (1/22/3).
If PE has occurred may have respiratory complaints too.
Usually a diagnosis of exclusion.
Sono, CT, or MRI may confirm diagnosis
Rx: Abx, anticoagulation ( usually x 7-10d, in absence of PE)