The presence of N gonorrhoeae, yeasts or trichomonads should be excluded. G vaginalis can be isolated by culture. Microscopy of vaginal smears may reveal numerous small gram-negative coccobacilli with no inflammatory cells and an absence of lactobacilli. The ‘clue cell’ with its numerous adherent bacteria is a feature of bacterial vaginosis.
The pH of vaginal secretions on the tip of the speculum can be measured using indicator paper; in bacterial vaginosis the pH is usually between 5 and 6. The presence of semen, a cervical discharge or menstrual blood can raise the pH of vaginal secretions.
Vaginal fluid can be tested for amine using the ‘whiff test; vaginal discharge on a swab is mixed with a drop of potassium hydroxide with production of a putrescent odour.
The nitroimidazoles (e.g. metronidazole 400 mg twice daily for 5 days or
2 g per day for two days) produce a short term cure and are currently the treatment of choice. The nitroimidazoles should not be used in pregnancy and lactation; ampicillin 500 g four times each day for 5 days can be used.
Recurrence is common; treatment of male partners is of no proven value.
*121/56/1*
Detailed information on management is not covered in this handbook. Patients with HIV infection require considerable support, counselling and regular assessment. There is no effective therapy for the immunodeficiency. Several drugs inhibit HIV viral replication in vitro. For patients with AIDS, zidovudine (azidothymidine — AZT) has been shown to decrease mortality, reduce the incidence of opportunistic infections, decrease viraemia and increase the number of T4 lymphocytes. Severe adverse reactions occur with this drug including anaemia and neutropaenia in up to 25% of patients.
Some opportunistic infections can be successfully treated. Treatment of others such as the atypical mycobacteria is usually ineffective. Chemotherapy may be effective in malignancies such as KS and lymphoma particularly if immune function is good.
Hospitalisation and nursing
Patients with HIV infection may be cared for in any hospital and strict isolation is unnecessary. Detailed recommendations can be obtained from publications such as the Infection control guidelines published by the AIDS Task Force.
*95/56/1*
This reaction is a consequence of treponemal destruction. It occurs 6 to 12 hours after commencing treatment and is a mild reaction with fever, headache, malaise, rigors and joint pain. The reaction lasts for several hours and does not recur. Symptoms are controlled by paracetamol and rest.
Retreatment
Only one course of treatment is normally necessary. Further treatment is indicated in the following circumstances:
where clinical symptoms or signs of syphilis persist or recur,
where initially high titres in the reagin test (e.g. VDRL 1/8 or greater or RPR 1/16 or greater) persist for a year or more after treatment; or
where there is a sustained four-fold increase in the titre of the reagin test (as may occur with reinfection in a successfully treated patient).
*70/56/1*
Uncomplicated genital, anal or pharyngeal infections
Single dose regimens cure most cases of uncomplicated gonorrhoea. Treatment for chlamydia may also be given particularly if local experience is that postgonococcal urethritis is common. Sexual abstinence is of benefit during therapy. Admission to hospital is usually indicated for children with gonorrhoea. Pharyngeal infections are less responsive to treatment than genital infections.
Penicillin susceptible infection (first line treatment where PPNG is uncommon)
Adults:
Amoxycillin 3 g given with 1 g probenecid as a single oral dose for anogenital infections and as a daily dose for 3 days for oropharyngeal infection or Aqueous procaine penicillin G 3 g intramuscularly (1.5 g at 2 sites) with probenecid 1 g orally as a single dose.
Children:
Amoxycillin 50 mg/kg given with probenecid 25 mg/kg as a single oral dose or Aqueous procaine penicillin G 100,000 units/kg intramuscularly with probenecid 25 mg/kg orally as a single dose.
*46/56/1*
Demonstration of spirochaetes by dark ground microscopy confirms the diagnosis of early syphilis. Antibiotics or antiseptics should not be used until satisfactory examination has been completed. Dark ground examination is not suitable for oral lesions.
Although the diagnosis can usually be made on clinical grounds, HSV infection should be confirmed by culture of the virus or, more rapidly, by examination of smears for multinucleated cells and characteristic intranuclear inclusions (Tzank smear) or by the use of commercially available kits for the detection of HSV antigens by ELISA or immunofluorescence techniques (see p.34).
The diagnosis of donovanosis is established by the demonstration of the causative organisms in smears from scrapings or in biopsies from lesions. The organism can be identified as bipolar rods in large mononuclear cells (see p.30). The features of chancroid and of lymphogranuloma venereum are described on pages 31 and 32 respectively.
*21/56/1*
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