15-01-2015

Herpes Simplex Virus (HSV) Infection

Herpes Encephalitis

Genital Herpes

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

After the primary infection, the virus is latent in the sacral dorsal root ganglia.
From 50% to 80% of patients have recurrent infections
(generally less severe and of shorter duration).
Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

15-01-2015

Treatment can partly control symptoms

but does not affect the risk, frequency, or severity
of recurrences.

Symptoms:
Itching
Genital burning
Ulcer formation
Vesicle formation

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

Drug

Dose

Frequency

Duration

Initial HSV
infection

Acyclovir
Acyclovir
Famciclovir
Valacyclovir

200 mg orally
400 mg orally
250 mg orally
1 g orally

Five times daily

three times daily
three times daily
twice daily

for 7 days
for 710 days
for 710 days
for 710 days

Recurrent HSV
infection

If treatment is initiated within 1 day of lesion onset,

patients with recurrent infections may benefit.
Acyclovir
Acyclovir
Famciclovir
Famciclovir
Famciclovir
Valacyclovir
Valacyclovir

Daily
suppressive
therapy
6
episodes/year

400 mg orally
800 mg orally
125mg orally
500m g orally once
Then 250mg Orally
1000mg orally
500m g orally
1000mg/day Orally

three times daily

Five times daily
Twice daily
Once then
Twice daily
Twice daily
Twice daily
once

for 5 days
for 2 days
for 5 days
For 2 days
For 1 day
For 3 days
For 5 days

recommended in patients with six or more episodes yearly

(reassess annually the need for suppressive therapy)
Acyclovir
Famciclovir
Valacyclovir
Valacyclovir

400 mg orally
250 mg orally
500 mg orally
Yasminorally
ElSobky, BCPS
1 000mg

Twice daily
Twice daily
Once daily
Once daily

Daily

Yasmin ElSobky, BCPS

15-01-2015

Herpes Encephalitis
Primarily caused by HSV-1
Spreads through neural routes during Primary infection or
Recurrent infection
Primarily temporal lobe involvement with eventual hemorrhagic
encephalitis

High mortality if untreated

and frequent neurologic sequelae
Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

Diagnosis of Herpes Encephalitis

1. Presence of Sign and symptoms
2. CSF analysis
3. Brain biopsy (rarly performed)

Herpes encephalitis Therapy:

Acyclovir IV 510 mg/kg q8 h for 27 days,
followed by oral antiviral therapy for at least 10
days of total therapy

CSF Analysis Report

WBC: Moderate Pleocytosis
(lymphocytosis)
Glucose: Normal
Protein: Elevated

Yasmin ElSobky, BCPS

When symptoms resolve shift to oral

Yasmin ElSobky, BCPS

15-01-2015

Types

Description

Primary
syphilis

From 10 to 90
days after
exposure
(mean = 21
days)

Secondary
syphilis/
Early
latent
syphilis

From 4 to 10
weeks after
exposure

Late latent
syphilis

(more than 1
year in
duration) or
unkn duration:

Yasmin ElSobky, BCPS

Neurosyphilis

Tertiary
syphilis

Symptoms
The primary symptom
is the development of a
chancre.
It resolves
spontaneously in 26
weeks even without
treatment.

Skin lesions:
Characteristically on
the palms and soles
Latent phase begins
when all symptoms
have resolved.

Infectious granulomas
cardiovascular effects:
-Aortic insufficiency
-Aortitis
At any stage

Personality
change (cognitive
and/or behavioral
impairment) - 33%

Ataxia - 28%
Stroke - 23%

Yasmin ElSobky, BCPS

3ry Syphilis

Infectious granulomas and

cardiovascular effects:
Aortic insufficiency and aortitis

Skin lesion
Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

15-01-2015

Yasmin ElSobky, BCPS

Types

Description

Primary
syphilis

From 10 to 90
days after
exposure
(mean = 21
days)

Secondary
syphilis/
Early
latent
syphilis

From 4 to 10
weeks after
exposure

Late latent
syphilis

(more than 1
year in
duration) or
unkn duration:

Neurosyphilis

Tertiary
syphilis

Symptoms

Recommended treatment

The primary symptom

is the development of a
chancre.
It resolves
spontaneously in 26
weeks even without
treatment.

Personality change
(cognitive and/or
behavioral impairment)

33%
Ataxia - 28%
Stroke - 23%

Penicillin allergy

If penicillin allergy:
Doxycycline orally bid
or tetracycline 500 mg four
times daily for 2 weeks

Syphilis
Treatment of sexual partners
a. Sexual partners should be presumptively treated if exposed

within 90 days preceding the diagnosis in their partner.

Skin lesions:
Characteristically on
the palms and soles
Latent phase begins
when all symptoms
have resolved.

Infectious granulomas
cardiovascular effects:
-Aortic insufficiency
-Aortitis
At any stage

Benzathine penicillin G
2.4 million units IM
in a single dose (adults)

Yasmin ElSobky, BCPS

Benzathine penicillin G
2.4 million units IM every week
for 3 weeks
(total dose 7.2 million units)

If penicillin allergy:
Doxycycline bid
or tetracycline 500 mg four
times daily for 4 weeks

Aqueous crystalline penicillin G

If penicillin allergy:
Ceftriaxone 2 g/day IM/IV
for 1014 days or
patients should be
desensitized & given
penicillin

34 million units IV q4h or continuous

inf. 1014 days

Alternative regimen
Procaine penicillin 2.4 million
units/day IM plus probenecid
four times
Yasmin ElSobky,
BCPSdaily for 1014 days

(see CDC recommendations for

skin testing &desensitization)

b. If exposure occurred more than 90 days prior, sexual partners

should be tested and monitored closely or treated presumptively
if serologic test results are not available immediately.

Yasmin ElSobky, BCPS

15-01-2015

Can lead to
PID,
Ectopic pregnancy
Infertility
Less dysuria and
Less penile discharge in men
compared with gonococcal infection

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

Chlamydial Treatment
Drug Of choice (DOC)

Diagnosis:
Chlamydial infection

Rx:
Azithromycin 1G
or
Doxycycline for 7 days

Chlamydial infection
Abstain from sexual intercourse for at least 7 days
and until sexual partners are adequately treated.
All sexual partners within the past 60 days should be
assessed and treated.

Erythromycin
Levofloxacin
Ofloxacin

Alternatives

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

15-01-2015

women are often asymptomatic

(which can lead to PID);
symptoms in women include
Vaginal discharge
Dysuria

Yasmin ElSobky, BCPS

Ceftriaxone 250mg IM or
cefixime** 400mg Oral
+

treatment of chlamydia
if not ruled out

Infection of Pharynx

Cephalosporin
allergy

Yasmin ElSobky, BCPS

Gonococcal Treatment

Site of infection

Infections of cervix,
urethra & rectum

Penile discharge and

dysuria common in men,

Ceftriaxone only (not cefixime) +

treatment of chlamydia

Chlamydial infection

Rx:
Azithromycin 1G
or
Doxycycline for 7 days

Gonococcal infection
Abstain from sexual intercourse for at least 7 days
and until sexual partners are adequately treated.
All sexual partners within the past 60 days should
be assessed and treated.

Azithromycin 2G Oral
(GI side effects, resistance increasing )
test for cure in 1 week

**New in 2012 Alternative if ceftriaxone not an option

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

15-01-2015

Gonococcal infection

Chlamydial infection

Symptoms of Urethritis
Symptoms in Women
Some signs of urethritis in women include:
More frequent urge to urinate
Discomfort during urination
Pain in the abdominal area
Fever (chills)
An abnormal vaginal discharge

Urethritis

Symptoms in Men
Males with urethritis may experience the
following symptoms:
Burning sensation while urinating
Itching or burning near the penis opening
The presence of blood
in semen and/or urine
Yasmin ElSobky, BCPS

Urethritis
Undiagnosed

Nongonococcal

Yasmin ElSobky, BCPS

Treatment
Treat for Chlamydia and Gonococcus

Treat for Chlamydia ONLY

Urethritis infection
All sexual partners within the past 60 days
should be assessed and treated.

Ensure adherence &

NO reinfection from infected partner
Recurrent or persistent
Then
Treat for trichomonas vaginalis &
azithromycin (not doxycycline)
Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

15-01-2015

Trichomoniasis symptoms

Trichomoniasis
(Trichomonas vaginalis)
Vaginal discharge
(Malodorous)
Vaginal irritation

Yasmin ElSobky, BCPS

Asymptomatic

Yasmin ElSobky, BCPS

Trichomoniasis Treatment
Metronidazole 2G (Single)
Tinidazole 2G (Single)

DOC

Alternative regimen

Metronidazole-allergic patients

Metronidazole 500mg 2 times/day for

7 days

Pelvic inflammatory diseases

Bacterial Vaginosis
Vulvovaginal Candidiasis

Patient should be desensitized

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

15-01-2015

PID Clinical Presentation

Yasmin ElSobky, BCPS

PID
Neisseria gonorrhoeae

Caused by

Chlamydia trachomatis

Clinical presentation
a. Lower abdominal tenderness
b. Adnexal tenderness
c. Cervical motion tenderness
d. Oral temperature greater than 101F (38.3)
e. Abnormal cervical or vaginal discharge
f. Menorrhagia
g. Dysuria
Lab Investigation:
Elevated ESR erythrocyte sedimentation rate
Elevated CRP C-reactive protein
Abscess in pelvic or fallopian tubes, tubal
Yasmin ElSobky, BCPS
occlusion, fibrosis, infertility

Parenteral treatment
Regimen A:

Cefotetan
Or Cefoxitin

Regimen B:

Clindamycin

Alternative
regimens:

Ampicillin/
Sulbactam

IV
Plus Doxycycline
or Doxycycline orally q12 hrs.
Plus Gentamicin IV/ IM
IV or
Plus Doxycycline
Doxycycline orally every 12 hrs

Parenteral therapy can be discontinued 24 hours after clinical improvement

and changed to oral therapy for 14 days.

Anaerobes

Oral treatment

Streptococci

Ceftriaxone 250 mg IM once

1g
Plus Probenecid
or Cefoxitin 2 g IM
orally once

Metronidazole

gram-ve facultative bacteria

14 days
Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

10

15-01-2015

Bacterial vaginosis diagnosis:

Symptoms

Bacterial vaginosis

Malodorous
vaginal discharge

High in PH
Clue cells
Whiff test positive
(10% KOH fishy odor)

> 50% are

Asymptomatic

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

Bacterial Vaginosis Treatment

Nonpregnant women
Metronidazole (oral) 7 days
Metronidazole 0.75% (intravaginal) 5 days
Clindamycin 2% (intravaginal) 7 days
Alternative regimen

Bacterial Vaginosis
Treatment of sexual partners is not necessary

Clindamycin ovules 3 days

Clindamycin oral 7 days
Tinidazole 2G for 2 days
Tinidazole 1G for 5 days

Pregnant women
Oral regimens ONLY
Metronidazole or clindamycin (oral) for 7 days
Yasmin ElSobky, BCPS

Sexual transmission
Yasmin ElSobky, BCPS

Increased infection
risk ONLY

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15-01-2015

Predisposing factor for Vulvovaginal Candidiasis

Vulvovaginal candidiasis

Obesity & DM

Yasmin ElSobky, BCPS

Symptoms

OCs & corticosteroids

Chemotherapy & Antibiotics

Yasmin ElSobky, BCPS

Pregnancy

Diagnosis

Pruritis (irritation)

Symptoms
KOH smears

Vaginal discharge
Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

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15-01-2015

Vulvovaginal candidiasis treatment

Recurrent ( 4 /year) Use prescription NOT OTC

Loading

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

Initial therapy for 7-14 days

Or
Fluconazole 100, 150, 200 every third day for 3
doses

Maintenance

Fluconazole 100, 150, 200 every week for 6

months

Prophylaxis
(While taking
antibiotics)

Use one full applicator at bed time

If infection 7 days OTC

Pregnant women

7 days OTC azoles

Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

13

15-01-2015

Prostatitis
Primarily gram-negative organisms
trachomatis, N. gonorrhoeae, Escherichia coli

Acute bacterial Prostatitis

Epididymitis

Symptoms
Urethritis
Asymptomatic
Yasmin ElSobky, BCPS

Yasmin ElSobky, BCPS

Prostatitis Treatment

Epididymitis

Acute bacterial prostatitis Chronic bacterial prostatitis

(symptoms should have been
present for at least 6 months)

Fluoroquinolones:
Fluoroquinolones:
TMP/SMX
TMP/SMX
Trimethoprim/sulfamethoxazole
Trimethoprim/sulfamethoxazole
Gonorrhea:
Ceftriaxone 250 mg IM

Therapy duration:
1428 days

Difficult to treat
1- 4 month
Yasmin ElSobky, BCPS

< 35 years old

Initial therapy; most likely
gonococcal or chlamydial
infection.
Ceftriaxone 250 mg IM once
plus doxycycline 100 mg bid
for 10 days

> 35 years old

If most likely caused by enteric
organisms*

Ofloxacin 300 bid

orally
for 10 days (not for gonorrhea)
Levofloxacin 500
mg/day orally for 10
days (not for gonorrhea)
Therapy duration:
10 days
To 4 weeks

Therapy duration:
10 days

Yasmin ElSobky, BCPS

*Enteric bacteria are bacteria that found in the GIT.

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15-01-2015

References
ACCP book

Yasmin ElSobky, BCPS

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