NANCY CAMPBELL Cervicitis - PowerPoint Presentation

1. NANCY CAMPBELLCervicitis

2. SUMMARYSexually transmitted infections (STIs) continue to present major health, social, and economic problems in the developing world. Gonococcal infections and their complications are amongst the most frequent communicable diseases in many countries (Muthusamy & Elangovan, 2017). This presentation narrated a clinical presentation of a young female, who is seeking medical care with urinary symptomatology. The presentation relevant physical exam findings, differential diagnosis, laboratory test, definitive diagnosis, management and patient education.

3. HPIChief Complaint: “Pain with urination”HPI: Ms. Campbell is a 25-year-old woman who presents with a 3-day history of dysuria, increases urinary frequency and yellow, kind of creamy vaginal discharge. She is sexually active, with recent, unprotected vaginal intercourse, and multiples sexual partners. Her past medical history is remarkable for urinary tract infection and candidiasis last year. Physical exam demonstrated cervical friability and discharge from the os; with a normal bimanual exam.

4. MEDICAL HISTORYMedications:Ibuprofen OTC for menstrual pain and headache.Past Medical History (PMH)Allergies: NoneMedication Intolerance: NoneChronic health problems: NoneMajor traumas: NoneHospitalizations/Surgeries: None

5. Family history

6. SOCIAL HISTORY

7. ROSGeneral Denies weight change, fatigue, fever, chills, night sweats,  and energy level CardiovascularDenies for palpitations, chest pain, PND, orthopnea, and edema SkinDenies for rashes, skin discoloration, bruising or bleeding. Denies no changes on moles, nevus, or skin lesions.  RespiratoryDenies for cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB EyesDenies blurring vision, change of vision or glasses.GastrointestinalDenies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools EarsDenies ear pain, hearing loss, ringing in ears, and discharge Genitourinary/GynecologicalPositive for dysuria and urinary frequency. Urine normal yellow clear.  Positive for yellow creamy vaginal discharge, odorless. Use anti contraceptive pills.

8. R.O.SNose/Mouth/ThroatDenies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain.  MusculoskeletalDenies back pain, joint swelling, stiffens or pain, fracture history. BreastDenies SBE, lumps, bumps, or changesNeurologicalNegative for syncope, seizures, transient paralysis, weakness, paresthesia, black out spells Heme/Lymph/EndoDenies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerancePsychiatricDenies sleeping difficulties. Denies depression, , suicidal ideation/attempts, and previous dx

9. Physical ExamWeight: 135 Lbs. Height 5’ 5’’ BMI: 22.5 Normal Temp 98.7 Pulse: 66 BP 116/64 mm/hg Resp. 12 x minGeneral Appearance: Healthy-appearing elderly hispanic male in no acute distress. Alert and oriented to person, place and situation, confusion on time. Answers questions appropriately. Slightly somber affect. Skin: Skin is pink, warm, dry, and slightly moist with no lesions. Normal skin turgor. No rashes or lesions noted.HEENT: Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is no erythematous and without exudate. Teeth are in good repair.Cardiovascular: S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema is noted.Respiratory: Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

10. Physical ExamGastrointestinal: Abdomen is flat; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.  Breast: DeferredGenitourinary: Bladder is no distended; no CVA tenderness. External genitalia normal public hair distribution. No ulcerations or lesions, skin pink. Speculum exam revealed pink vaginal walls without ulcerations or lesions. Mucopurulent discharge from cervical os, cervix friable. No cervical motion tenderness. Ovaries non palpable, no masses or lesions palpable. No adnexal tenderness to exam. Digital rectal examination: Deferred. Musculoskeletal: Full ROM seen in all four extremities as the patient moved about the exam room.Neurological: Speech clear. Good tone. Posture erects. Balance stable; gait normal. Psychiatric: Alert and oriented. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately..

11. Lab TestsLab TestsHuman Immunodeficiency virus (HIV) antibody: NegativeHuman Chorionic Gonadotropin (hCG), plasma: NegativeCervicitisChlamydia culture.: NegativeNeisseria gonorrhea culture: PositiveCervical swab/Gram stainAmine/whiff testUrinary tract infection :Urine culture: no bacterial growth.Urinalysis: positiveCandida vaginitis : Vaginal ph.: 4.0Potassium hydroxide (KOH) preparation test.Pelvic inflammatory diseaseNeisseria gonorrhea culture (see above)Chlamydia (see above)Candida vaginitisVaginal wet mount/vaginal smear Vaginal pH (see above)

12. PRIMARY DIAGNOSISCERVICITIS: supported by the presence of recent history of dysuria, increases urinary frequency and yellow, kind of creamy vaginal discharge. Physical examination revealed a mucopurulent discharge from os cervix with a normal bimanual exam. Laboratory test confirmation.DIFFERENTIAL DIAGNOSIS:URINARY TRACT INFECTION: This was ruled out by a negative nitrate lab test.PELVIC INFLMATORY DISEASE: Ruled out following absence of discomfort during a pelvic exam and a negative Neisseria gonorrhea culture and Chlamydia tests.BACTERIAL VAGINOSIS: Ruled out because: Normal vaginal PH of 4.0 and negative vaginal wet mount test. 

13. MANAGEMENT/PLANMedication: Ceftriaxone 250 mg IM x 1 dose Azithromycin 1000 mg orally x 1 dose Non-medication treatmentAvoid sexual activity during the treatment. Use condom on the future.tests ordered: No further test needed. Education: Contact and treatment of recent sexual partners, Counseling regarding use of barrier protection and risk of STIs, recommend pap smears per current guidelines, Recommend HIV, Hep B, and syphilis screening, and recommend HPV vaccination, as this patient is less than 26 years old.Follow-up/: in 2 weeks to evaluate medication effectiveness.Referral: None

14. Evidence-based articlesTitle, author, and year of article: Update on treatment options for gonococcal infections. Lancaster, J. W., Mahoney, M. V., Mandal, S., & Lawrence, K. R. (2015) Brief summary / purpose of the study: The incidence of Neisseria gonorrhoeae infections in the United States has grown over the past decade. The most recent data provided by the Centers for Disease Control and Prevention (CDC) indicate that reported cases have increased by almost 10% over the last 5 years. In conjunction with this rise, the presence of multidrug-resistant strains of N. gonorrhoeae has also emerged. The 2015 CDC guidelines recommend dual therapy with intramuscular ceftriaxone and oral azithromycin as first-line treatment, although components of this regimen are met with a high level of resistance. Although ceftriaxone resistance has not yet been reported in the United States, it is only a matter of time before such isolates are detected, thus ushering in a new era of difficult-to-manage uncomplicated gonococcal infection. The potential public health crisis and patient-associated sequelae (e.g., pelvic inflammatory disease, epididymitis, and human immunodeficiency virus infection) linked with untreatable gonorrhea are cause for great concern. To try to stem this tide, a number of new agents targeted against N. gonorrhoeae are being investigated in clinical trials. This article, we review the various agents, both currently available and under clinical investigation, and provide recommendations for the management of gonococcal infections.How did the study support Ms. Campbell’s case: This study is a good resource to create a plan of treatment for Ms. Campbell.

15. Evidence-based articlesTitle, author, and year of article: A systematic review and appraisal of the quality of practice guidelines for the management of Neisseria gonorrhoeae infections. Dickson, C., Arnason, T., Friedman, D. S., Metz, G., & Grimshaw, J. M. (2017)Brief summary / purpose of the study: Clinical guidelines help ensure consistent care informed by current evidence. As shifts in antimicrobial resistance continue to influence first-line treatment, up-to-date guidelines are important for preventing treatment failure. This study was conducted to assess the quality of current gonorrhea guidelines' development processes. Multiple databases was used. As a result, the author identified 10 guidelines meeting the inclusion criteria. The quality of the gonorrhea treatment guidelines varied. The WHO Guidelines for the Treatment of Neisseria gonorrhoeae and UK National Guideline for the Management of Gonorrhea in Adults scored the highest on Rigour of Development. Methods to address conflicts of interest were often not described in the materials reviewed. By limiting the study to English-language guidelines, a small number of guidelines we identified were excluded. The author concluded that Gonorrhoea treatment guidelines may slow antimicrobial resistance. Many current guidelines are not in line with the current guideline development best practices; this might undermine the perceived trustworthiness of guidelines. By identifying current limitations, this study can help improve the quality of future guidelines.How did the study support Ms. Campbell’s case: This study is a good resource to create a plan of treatment for Ms. Campbell.

16. Evidence-based articlesTitle, author, and year of article: Gonorrhea treatment practices in the STD Surveillance Network, 2010–2012. Kerani, R. P., Stenger, M. R., Weinstock, H., Bernstein, K. T., Reed, M., Schumacher, C., ... & Golden, M. (2015). Brief summary / purpose of the study: Neisseria gonorrhoeae has retained antimicrobial resistance to drugs previously recommended for first-line empiric treatment of gonorrhea, and resistance to ceftriaxone, the last option for monotherapy, is evolving. Crucial actions to combat this developing situation include implementing response plans; considering use of dual antimicrobial regimens; enhancing surveillance of gonorrhea, gonococcal antimicrobial resistance, treatment failures and antimicrobial use/misuse and improving prevention, early diagnosis, contact tracing and treatment. The ways forward also include an intensified research to identify novel antimicrobial resistance determinants and develop and evaluate appropriate use of molecular antimicrobial resistance testing, ideally point-of-care and with simultaneous detection of gonococci, to supplement culture-based methods and ideally guide tailored treatment. Replacing oral treatments with ceftriaxone is a central component of public health efforts to slow the emergence of cephalosporin-resistant Neisseria gonorrhoeae in the United States. Six city and state health departments contributed data on all gonorrhea cases reported in 101 counties and independent cities. Treatment data were obtained through local public health surveillance and interviews with a random sample of patients. Cases were weighted to adjust for site-specific sample fractions and for differential nonresponse by age, sex, and provider type. From 2010 to 2012, 135,984 gonorrhea cases were reported in participating areas, 15,246 (11.2%) of which were randomly sampled. Of these, 7,851 (51.5%) patients were interviewed. Among patients with complete treatment data, 76.8% received ceftriaxone, 16.4% received an oral cephalosporin, and 6.9% did not receive a cephalosporin; 51.9% of persons were treated with a regimen containing ceftriaxone and either doxycycline or azithromycin. Ceftriaxone treatment increased significantly by year (64.1% of patients in 2010, 79.3% in 2011, 85.4% in 2012; P = 0.0001). Ceftriaxone use varied widely by STD Surveillance Network site (from 44.6% to 95.1% in 2012). Most persons diagnosed as having gonorrhea between 2010 and 2012 in the United States received ceftriaxone, and its use has increased since the release of the 2010 Centers for Disease Control and Prevention STD Treatment Guidelines How did the study support Ms. Campbell’s case: This study is a good resource to create a plan of treatment for Ms. Campbell.

17. Evidence-based articlesTitle, author, and year of article: Cervicitis: a prospective observational study of empiric azithromycin treatment in women with cervicitis and non-specific cervicitis. Lusk, M. J., Garden, F. L., Cumming, R. G., Rawlinson, W. D., Naing, Z. W., & Konecny, P. (2017)Brief summary / purpose of the study: Treatment with 1 G azithromycin was observed prospectively in 130 women with cervicitis enrolled in a cervicitis etiology study of 558 women at three sexually transmitted infection clinics in Sydney, Australia. Two overlapping groups of women with cervicitis were considered: ‘cervicitis group 1’ (n = 116) excluded women with Trichomonas vaginalis and a subgroup of this, ‘cervicitis group 2’ (non-specific cervicitis) (n = 96) further excluded women with Neisseria gonorrhoea, Chlamydia trachomatis and Mycoplasma genitalium at enrolment. Testing for Chlamydia trachomatis, Mycoplasma genitalium and Trichomonas vaginalis was by PCR and Neisseria gonorrhoea by PCR and culture. Treatment outcomes were cervicitis or vaginal symptoms at follow-up. Effect on cervicitis at follow-up was also assessed after additional reported partner treatment. In ‘cervicitis group 1’ where prevalence of Mycoplasma genitalium and/or Chlamydia trachomatis was 23/116 (19.8%), azithromycin reduced cervicitis at follow-up (RR = 0.62 (95% CI 0.39–0.97) p = 0.035), but there was no significant effect in non-specific cervicitis (‘cervicitis group 2’) (RR = 0.60 (95% CI 0.35–1.01) p = 0.056).  Empiric treatment did not reduce vaginal symptoms at follow-up in either group. No effect of empiric partner treatment was seen. The conclusion was that empiric azithromycin treatment of cervicitis reduces cervicitis at follow-up in populations with high prevalence of Chlamydia trachomatis and/or Mycoplasma genitalium. There are no benefits of empiric azithromycin for non-specific cervicitis or empiric partner treatment..How did the study support Ms. Campbell’s case: This study is a good resource to follow appropriate treatment for Ms. Campbell.

18. Evidence-based articlesTitle, author, and year of article: Screening for gonorrhea and chlamydia: an update for the US Preventive Services Task Force. Zakher, B., Cantor, A. G., Pappas, M., Daegas, M., & Nelson, H. D. (2014). Brief summary / purpose of the study: Objective: Observational studies about screening effectiveness, test accuracy, and screening harms was conducted to update the 2005 and 2007 systematic reviews for the U.S. Preventive Services Task Force on screening for gonorrhea and chlamydia in men and women, including pregnant women and adolescents. Data Sources revised included MEDLINE, and Cochrane databases, including only randomized, controlled trials (RCTs) and controlled observational studies. In 10 new studies of asymptomatic patients, nucleic acid amplification tests demonstrated sensitivity of 86% or greater and specificity of 97% or greater for diagnosing gonorrhea and chlamydia, regardless of specimen type or test. The target populations included asymptomatic, sexually active men and women, including pregnant women and adolescents. There were few relevant studies of screening benefits and harms. Only screening tests and methods cleared by the U.S. Food and Drug Administration for current clinical practice were included to determine diagnostic accuracy. As a conclusion, Chlamydia screening in young women may reduce the incidence of pelvic inflammatory disease. Nucleic acid amplification tests are accurate for diagnosing gonorrhea and chlamydia in asymptomatic persons. Gonorrhea Tests for women included 4 studies testing endocervical specimens using transcription-mediated amplification (TMA); polymerase chain reaction (PCR), including a new rapid test (27); or strand displacement amplification (SDA) reported sensitivities ranging from 90.0% to 100.0%. Sensitivity using self-collected vaginal specimens obtained in a clinician’s office was 98.0% by TMA (26) and 100% by PCR (27). Results of female urine specimens using TMA, PCR, or SDA ranged from 78.6% to 100% (24, 25, 27). However, the study reporting the lowest sensitivities for urine used urine volumes larger than recommended by the manufacturer of the screening test. Chlamydia Tests Among 5 studies of endocervical specimens, sensitivity of TMA was 89.0% to 97.1%, SDA was 86.4% to 96.2%, and PCR was 86.4% to 95.8% (24, 27, 28, 30, 31). Clinician-collected vaginal swabs tested with TMA and PCR provided sensitivities of 89.9% and 98.8% (28), and self-collected vaginal swabs from clinical settings provided sensitivities of 97.0% with TMA (31) and 90.7% (28) and 98.0% (27) with PCR. How did the study support Ms. Campbell’s case: This study is a good resource to order the right laboratory test to confirm diagnosis in Ms. Campbell.

19. ReferencesDickson, C., Arnason, T., Friedman, D. S., Metz, G., & Grimshaw, J. M. (2017). A systematic review and appraisal of the quality of practice guidelines for the management of Neisseria gonorrhoeae infections. Sex Transm Infect, sextrans-2016 Kerani, R. P., Stenger, M. R., Weinstock, H., Bernstein, K. T., Reed, M., Schumacher, C., ... & Golden, M. (2015). Gonorrhea treatment practices in the STD Surveillance Network, 2010–2012. Sexually transmitted diseases, 42(1), 6-12.Lancaster, J. W., Mahoney, M. V., Mandal, S., & Lawrence, K. R. (2015). Update on treatment options for gonococcal infections. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 35(9), 856-868.  Lusk, M. J., Garden, F. L., Cumming, R. G., Rawlinson, W. D., Naing, Z. W., & Konecny, P. (2017). Cervicitis: a prospective observational study of empiric azithromycin treatment in women with cervicitis and non-specific cervicitisMuthusamy, S., & Elangovan, S. (2017). A study on prevalence and antibiotic sensitivity testing methods for Neisseria gonorrhoeae isolates among female outpatients of sexually transmitted infection clinic. International Journal of Health & Allied Sciences, 6(1), 11.Zakher, B., Cantor, A. G., Pappas, M., Daegas, M., & Nelson, H. D. (2014). Screening for gonorrhea and chlamydia: an update for the US Preventive Services Task Force. Ann Intern Med, 23.