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Toronto Notes 2019
Common Presenting Problems
Family Medicine FM43
Table 23. Diagnosis and Treatment of Common STIs
Gonococcal Urethritis/ Cervicitis
(Neisseria gonorrhoeae)
Non-Gonococcal Urethritis/Cervicitis (Usually Chlamydia trachomatis**)
Human Papillomavirus
(genital warts, cervical dysplasia)
Genital Herpes
(HSV-1 and -2)
Infectious Syphilis
(Treponema pallidum)
Signs and Symptoms
M: urethral discharge, unexplained pyuria, dysuria, irritation, testicular swelling, Sx of epididymitis
F: mucopurulent endocervical discharge, vaginal bleeding, dysuria, pelvic pain, dyspaurenia
M and F: often asymptomatic, can involve rectal symptoms in cases of unprotected anal sex
~70% asymptomatic
If symptoms appear (usually 2-6 wk after infection) then similar to gonococcal symptoms (see above)
Most are asymptomatic
M: cauliflower lesions (condylomata acuminata) on skin/mucosa of penile or anal area
F: cauliflower lesions and/or pre-neoplastic/neoplastic lesions on cervix/vagina/vulva
1° episode: painful vesicoulcerative genital lesions ± fever, tender lymphadenopathy, protracted course Recurrent episodes: less extensive lesions, shorter course may have “trigger factors”
1°: chancre (painless sore), regional lymphadenopathy
2°: rash and flu-like symptoms, meningitis, headache, uveitis, retinitis, condyloma lata, mucus lesions, alopecia
Latent Phase: asymptomatic
3°: neurologic, cardiovascular, and tissue complications
Investigations
M: urethral swab for Gram stain and culture
F: urine PCR, endocervical swab for Gram stain and culture, vaginal swab for wet mount (to rule out trichomonas)
M and F: urine PCR, rectal/ pharyngeal swabs if indicated
Same as above
None needed if simple condylomata
Potential biopsy of suspicious lesions
F: screening for cervical dysplasia through regular Pap smears
Swab of vesicular content for culture, type-specific serologic testing for HSV-1 vs. HSV-2 antibodies and to determine 1° vs. recurrent episode
Specimen collection from 1° and 2° lesions, screen high
risk individuals with serologic syphilis testing (VDRL), universal screening of pregnant women
Treatment
Ceftriaxone 250 mg IM single dose*
If risk factors for treatment failure (e.g. pregnancy, pharyngeal/rectal infection, potentially reduced susceptibility)
Test of cure: culture 4 d post-treatment (preferred) or urine PCR 2 wk post treatment (alternative)
If no risk factors, rescreen 6-12 months post treatment
Azithromycin 1 g PO single dose + gonococcal urethritis/cervicitis Rx* Same follow-up as above
For condylomata: cryotherapy, electrocautery, laser excision, topical therapy (patient-applied or office-based)
For cervical dysplasia: colposcopy and possible excision, dependent on grade of lesion
1° Episode
Acyclovir 200 mg PO 5x/d x 5-10 d or Famciclovir 250 mg PO tid x 5 d or Valacyclovir 1,000 mg PO bid x 10 d
Recurrent Episode
Acyclovir 200 mg PO 5x/d x 5d or 800 mg PO tid x 2 d or
Famciclovir 125 mg PO bid x 5 d or Valacyclovir 500 mg PO bid x 3 d or 1,000 mg PO OD x 3 d
Benzathine penicillin G IM (dose depends on stage and patient population. Check Public Health Canada guidelines )
Notify partners (last 3-12 mo)
Continuous follow-up and testing until patients are seronegative
Complications
M: urethral strictures, epididymitis, infertility
F: PID, infertility, ectopic pregnancy, perinatal infection, chronic pelvic pain
M and F: Arthritis, increased risk of acquiring and transmitting HIV
Same as above
M and F: anal cancer MSM and F who have receptive anal sex: rectal cancer
F: cervical/vaginal/vulvar cancer
Genital pain, urethritis, cervicitis, aseptic meningitis, increased risk of acquiring and transmitting HIV
Chronic neurologic and cardiovascular sequelae, increased risk of acquiring and transmitting HIV
F = females; M = males
*N.B. if urethritis/cervicitis is suspected, always treat for both gonococcal and non-gonococcal types (i.e. ceftriaxone AND azithromycin) **Most common reportable STI in Canada
Sinusitis
• seeOtolaryngology,OT24
Etiology
• viraletiologyismorecommon
• viral: rhinovirus, influenza, parainfluenza
• bacterial: S. pneumoniae, H. influenzae, M. catarrhalis
Management of Acute Sinusitis
• forsymptomrelief:oralanalgesics(acetaminophen,NSAIDs),nasalsalinerinse,short-termuseof topical/ or oral decongestants
• donotprescribeantihistamines
• mild to moderate acute bacterial sinusitis: intra-nasal corticosteroids
• severeacutebacterialsinusitis:antibioticsandintra-nasalcorticosteroids
■ first-line antibiotic is amoxicillin, and second line is amoxicillin-clavulanic acid or a fluoroquinolone ■ ENT referral if: anatomic defect (e.g. deviated septum, polyp, adenoid hypertrophy), failure of
second-line therapy, or ≥4 episodes/yr, refer urgently when there is development of complications (e.g. orbital extension, meningitis, intra-cranial abscess, venous sinus thrombosis), altered mental status, headache, systemic toxicity, or neurological findings
Red Flags for Urgent Referral
• Altered mental status
• Headache
• Systemic toxicity
• Swelling of the orbit or change in visual
acuity or EOM
• Hard neurological findings
• Signs of meningeal irritation
• Suspected intra-cranial complications
(meningitis, intra-cranial abscess,
cavernous sinus thrombosis)
• Involvement of associated structures
(periorbital cellulitis, Pott’s puffy tumour)