Dr John Short. Obstetrician and Gynaecologist Christchurch Women s Hospital Oxford Women's Health Christchurch. 8:55-9:20 Infections in Gynaecology

Transcription

1 Dr John Short Obstetrician and Gynaecologist Christchurch Women s Hospital Oxford Women's Health Christchurch 8:55-9:20 Infections in Gynaecology

2 Infections in Gynaecology John Short Gynaecologist Oxford Women s Health

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4 Infections in Gynaecology Vaginal Discharge Candida Bacterial vaginosis Urinary Tract Infection

5 Why? Common Difficult to manage Antibiotic Stewardship Colonisation vs infection

6 Vaginal Discharge

7 Vaginal Discharge - what s normal? Normal secretions can appear clumpy At mid-cycle secretions become abundant, clear and stretchy

8 Normal discharge may include- Secretions from specialised vulval glands Bartholin s and Skene s glands Moisture that comes through the vaginal walls (transudate) Epithelial cells shed from the vaginal walls (superficial, intermediate and parabasal) Mucus from the cervix Fluid from the fallopian tubes and uterus Products from bacteria that live in the vagina

9 Normal discharge 1-4ml in 24 hours Inoffensive odour Colour ranges from white to clear White or yellow plaque when dry 1-7: 8-13: 14-16: 17-25: 26-1: minimal secretions increase maximum clear mucus thicken / turn yellow lowest secretions ph 4-4.5

10 Abnormal vaginal discharge Physiological Non-infective Infective, STI Infective, Non-STI

11 physiological Remember what s normal Think hormones Think ph

12 Non infective Foreign bodies (e.g., retained tampons, condoms, mesh) Cervical polyps and ectopy Genital tract malignancy Fistulae Dermatological disease Inflammatory conditions

13 Infective, STI Chlamydia trachomatis Neisseria gonorrhoeae Trichomoniasis

14 Infective non-sti Bacterial Vaginosis Candida

15 Practice Points History Examination, inc speculum. Bimanual if pelvic pain. STI screen if appropriate. NB contact notification if +ve. BV/Candida can be treated empirically

16 Consider PID Consider clinical findings, eg polyps, dermatosis Advise patients to avoid vaginal douching, using shower gel, and using antiseptic agents or shampoo in the bath Acidifying agents may help if tests -ve, but limited evidence (may also help prevent recurrence of BV following treatment)

17 Trichomoniasis If suspected, treat immediately Scalded appearance of the skin similar to napkin dermatitis Profuse yellow frothy discharge "Strawberry" cervix

18 treatments Candida: topical or oral antifungals BV: metronidazole 400mg BD 1/52 Trichomonas: metronidazole 400mg BD 1/52 Chlamydia: Gonorrhoea: Azithromycin 1g stat OR Doxycycline 100mg BD 1/52 Ceftriaxone 500mg IM and Azithromycin 1g PO, OR Ciprofloxacin 500mg PO and Azithromycin 1g PO

19 Swabs Testing method changed 26 June 2017 Refer to healthpathways for info

20 Candidiasis Vulvovaginitis Affects 75% of women Recurrent in 5-8%

21 candida infection 90% of cases occur with Candida albicans. The remainder are non-albicans species such as Candida glabrata. Candida may be a commensal organism and is isolated in 20% of healthy asymptomatic women.

22 Treatment not required if asymptomatic Partner treatment not required If symptomatic can be treated empirically

23 Symptoms itching, soreness, and burning in the vagina and vulva. heavy white curd-like vaginal discharge. bright red rash affecting inner and outer parts of the vulva, sometimes spreading widely in the groin to include pubic areas, inguinal areas, and thighs.

24 Symptoms may last just a few hours or persist for days, weeks, or rarely, months. Vulvovaginal candidiasis may recur just before each menstrual cycle (cyclic vulvovaginitis).

25 Predisposing factors for acute candidiasis Diabetes using antibiotics Pregnancy immunosuppression.

26 Yeast is an oestrogen dependent organism Topical oestrogens can cause thrush

27 Recurrent / chronic Candidiasis Recurrent VVC commonly defined as >4 or more proven cases in 12 months or at least 3 episodes unrelated to antibiotic use that occur within one year Chronic VVC defined as a proven episode of VVC that does not respond to conventional antifungal therapy after 2 weeks of treatment Most women have same strain of candida

28 Recurrent / chronic Candidiasis Common Difficult to treat Limited guidance available

29 Guidance Culture is essential Induction and maintenance therapy Topical therapy in pregnancy Explore risk factors Avoid potential irritants, eg bubble bath, perfumed soap, tight garments

30 Induction therapy 7-14 days of topical therapy Oral Fluconazole 150mg every third day for a total of 3 doses

31 Maintenace therapy Sobel regime 150mg fluconazole weekly for 6 months 42.9 % symptom free at 12 months Donders regime 3x 200mg fluconazole week 1 Once/week, weeks 2-8 Once fortnight, months 3-6 Once month, months % symptom free at 12 months

32 Alternatives Topical treatments 1-2x weekly Boric acid 600mg vaginally 2-3/52

33 NZ Pharmacy Schedule

34 Treatment of recurrent candidiasis There is some evidence that the following measures can be helpful: Cotton or moisture-wicking underwear and loose fitting clothing avoid occlusive nylon pantyhose. Soaking in a salt bath. Avoid soap use a non-soap cleanser or aqueous cream for washing. Apply hydrocortisone cream intermittently, to reduce itching and treat secondary dermatitis affecting the vulva. Test FBC, blood glucose if other indications Review contraception avoid high oestrogen contraceptives, consider depo, consider Cerazette BASHH 2007

35 Treatment of non-albicans yeast C. glabrata low vaginal virulence and rarely causes symptoms even when identified on culture Exclude other co-existent causes of symptoms 50% treatment failure with azoles No good data on efficacy of nystatin Intravaginal boric acid 600mg nocte 2/52 (65-70% success)

36 Treatment of non-albicans yeast C.krusei Usually resistant to fluconazole Highly susceptible to topical azoles clotrimazole, miconazole use 7-14 days

37 Cyclical vulvovaginitis Recurrent burning and itching sensation that occurs at he same stage of every menstrual cycle Pain typically worsens just before or during menstruation Due to recurrent thrush take cultures to confirm Induce remission, monthly fluconazole If not candida may be due to dermatitis associated with oestrogen hypersensitivity Use progesterone

38 Fluconazole resistance Some evidence that frequent and prolonged use of fluconazole can select for fluconazole resistant strains in C.albicans Discuss with lab re. fluconazole MIC Fluconazole may be increased dose or frequency Use itraconazole/ketoconazole High level pan-azole resistance boric acid/nystatin

39 Bacterial vaginosis

40 Microbiology and pathogenesis Bacteria detected in BV Gardnerella vaginalis Prevotella species Porphyromonas species Bacteroides species Peptostreptococcus species Mycoplasma hominis Ureaplasma urealyticum Mobiluncus species Fusobacterium Atopobium vaginae

41 Risk factors Sexual activity Douching Smoking Other STIs Condoms and oestrogen containing contraceptives may be protective

42 Diagnosis Grey, white, yellow homogenous discharge ph> 4.5 Fishy odour Clue cells

43 Who to treat Resolves 1/3 non-pregnant women Resolves in 50% pregnant women Symptom relief in symptomatic women Asymptomatic women to prevent postoperative infection

44 Treatment Metronidazole 400mg PO BD 7 days 0.75% Metronidazole vaginal gel 5gm (1x full applicator) OD 5 days Clindamycin 300mg PO BD for 7 days 2gm metronidazole single dose not recommended due to lower efficacy

45 Recurrent BV Common 30% successfully treated have a symptom recurrence within 3 months 50% have a recurrence within 12 months

46 Treatment of recurrent BV Longer course of metronidazole days Metronidazole 400mg BD 3/7 monthly 6/12 Monthly oral metronidazole 2gm with fluconazole 150mg 0.75% metronidazole vaginal gel twice weekly 4-6 months Oral metronidazole 400mg BD 7 days followed Intravaginal boric acid 600mg/day 21 days If in remission, commence 0.75% metronidazole gel twice weekly for 4 months

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49 Recurrent Urinary tract infection 3 in one year or 2 in 6 months

50 Identify any triggers Arrange urine culture to check for resistant or atypical organisms Consider Chlamydia Consider recent surgery, previous radiation or cancer

51 Complicated UTI Suspected pyelonephritis Nausea and vomiting UTI recurrence within 1 week or persistent symptoms pregnancy Catheterisation or recent urinary tract instrumentation Abnormal urinary tract (inc. incomplete emptying) Impaired immunity or diabetes Haematuria Spinal issues

52 Consider imaging UTI associated with suspected renal stone. difficult to treat UTI with significant clinical symptoms not settling despite antibiotics. recurrent pyelonephritis. urine culture shows Proteus, Klebsiella, or Pseudomonas infections as these are associated with a high risk of stones. recurrent UTI not responding to prophylactic antibiotics.

53 Most recurrences are due to a reinfection rather than a relapse. Prevention important Reduce potential bowel contamination Reduce risk of intercourse related infections Vaginal oestrogens for postmenopausal women

54 Consider other causes for symptoms Overactive bladder Painful Bladder syndrome (interstitial cystitis) vulvovaginitis

55 Prophylactic antibiotics Following a trigger event, eg intercourse or menstruation stand-by course of antibiotics for self-treatment Low dose prophylactic antibiotics 6/52 to 6/12. 50mg nitrofurantoin or 150mg trimethoprim daily

56 Other points Cranberries are out NSAIDs vs antibiotics for uncomplicated UTI Bladder friendly diet

57 Other challenges 20 % of symptomatic patients test ve for UTI 80 % of these have a UTI

58 Bacterial behaviour

59 D-Mannose

60 UTI vaccine uromune Immunomodulator Contains inactive bacteria Sublingual spray 3 month course Not registered and not funded

61 Thank you Any questions?