• Vulvovaginitis: pruritus vulvae, soreness
• Thick, white or yellow, cheesy discharge
• Erythema of vulva & vagina
• May cause skin fissure

What the clinical photographs show: white, curd-like material adherent to an erythematous vaginal wall and vulva. Excoriation, oedema and fissures may accompany it. This is a useful visual pattern, but none of these symptoms or signs is specific enough to diagnose Candida without testing when the diagnosis is uncertain ^[8][9].

• Pregnancy (↑ glycogen)
• Diabetes mellitus
• Immunosuppression
• Oral contraceptive pills
• Broad-spectrum antibiotics

• Clinical features (often sufficient for uncomplicated cases)
• Vaginal swab from vaginal fornix for microscopic exam ± culture
• Wet mount: pseudohyphae surrounded by vaginal epithelial cells
• Culture more important if complicated — severe symptoms, pregnancy, recurrent, non-albicans, abnormal host

• Asymptomatic: NO treatment needed
• Genital hygiene (clean & dry, avoid irritants, loose cotton clothing)
• Antifungal agents: topical or oral — clotrimazole, econazole, miconazole
  • Example: clotrimazole pessary 200 mg for 3 nights
• Pregnancy: topical azole for 7 days; avoid oral fluconazole ^[9]
• Maintenance therapy for recurrent candidiasis (weekly oral fluconazole for 6 months)

• Keep genital area clean and dry
• Use vulval moisturisers as soap substitute
• Avoid tight-fitting synthetic clothing
• Avoid local irritants e.g. perfumed products

• Colonisation is NOT associated with low birth weight or premature delivery
• Only treat if symptomatic
• Use a topical azole for 7 days. CDC advises against a single 150 mg oral fluconazole dose in pregnancy because epidemiological studies associate it with spontaneous abortion and congenital anomalies ^[9].

• UTI
• PROM / PPROM
• Preterm labour
• Chorioamnionitis
• Post-partum endometritis

• Neonatal GBS colonisation via vertical (during delivery) or horizontal (postnatal contact) transmission
• 1 in 100–200 babies of GBS-colonised mothers will develop signs/symptoms of infection
• ~1/1000 births in HK

Universal GBS screening started in HK since January 2012

• Low vaginal AND rectal swab at 35–37 weeks
• Screening NOT required if:
  • Intrapartum antibiotic prophylaxis already indicated (e.g. GBS bacteriuria this pregnancy, previous baby with invasive GBS)
  • Planned caesarean section (no labour, no membrane rupture → no vertical transmission)

The bullets above reproduce the lecture-era/local HK slide. Current CDC patient guidance, implementing the ACOG obstetric guidance it links to, recommends screening during the 36th or 37th week of every pregnancy, even when a planned caesarean birth is intended. IAP is unnecessary only if the caesarean actually occurs before labour with intact membranes. Follow the current Hospital Authority/local obstetric protocol for timing and exceptions ^[10].

Historical 2012–2018 surveillance table reproduced from the lecture; source shown on the slide: Centre for Health Protection, Department of Health, HKSAR ^[1]

The lecture mentions screening criteria referencing the Wilson & Jungner principles ^[1]:

• Important problem ✓
• Natural history understood ✓
• Recognisable latent/early state ✓
• Acceptable & effective treatment ✓
• Facilities available ✓
• Cost-effective ✓

The UK National Screening Committee does not recommend a national GBS screening programme. Reasons cited on the lecture slide:

• GBS carriage changes with time — a woman positive at 35–37 weeks may be negative at labour
• No way to predict which babies will develop early-onset GBS disease
• Screening would lead to tens of thousands of women receiving unnecessary intrapartum antibiotics; long-term effects on mother and baby are unknown
• It is unclear whether benefits outweigh harms for the majority of the population
• The proportion of babies affected by EOGBS in the UK is similar to countries that have introduced screening

This is a 2017 policy screenshot, useful for understanding the screening debate rather than as a substitute for a current jurisdiction-specific protocol. The contrast between the HK universal screening approach and the UK risk-factor-based approach is a common exam discussion point. ^[1]

Give IAP if ANY of the following:

1. Previous baby with invasive neonatal GBS disease
2. GBS bacteriuria in current pregnancy
3. Positive GBS screening (unless elective CS)
4. Gestation < 37 weeks (except if negative screening result)
5. Maternal fever > 38°C
6. PROM for > 18 hours
7. Screening results not yet available at leaking/onset of labour

These seven items are the lecture’s exam list. In practice, use the current local algorithm: the interpretation of an unknown screen depends on gestation and intrapartum risk factors, and an elective caesarean exemption requires no labour and intact membranes ^[10].

• First line: Penicillin G (benzylpenicillin) IV
• If allergic:
  • Cefazolin (if not at high risk of anaphylaxis)
  • Clindamycin only when the maternal isolate is susceptible
  • Vancomycin when there is a high anaphylaxis risk and clindamycin is unsuitable

The slide also lists erythromycin, but that is obsolete in current GBS prophylaxis algorithms. Document the allergy phenotype and follow local dosing/susceptibility guidance ^[10].

Important limitation: IAP reduces early-onset GBS but does NOT always prevent late-onset GBS infection. Babies may acquire GBS from contacts postnatally. ^[1]

• 50% asymptomatic
• Offensive, fishy-smelling vaginal discharge
• Thin, white, homogeneous discharge coating vaginal wall/vestibule
• NOT usually associated with vulvovaginitis (no itch/soreness — key differentiator from Candida)

1. Thin, white, homogeneous discharge 2. Clue cells on microscopy (epithelial cells studded with bacteria) 3. pH of vaginal fluid > 4.5 4. Release of fishy odour on adding alkali — 10% KOH ("whiff test")

• PID (though no evidence treating asymptomatic women prevents PID)
• Post-TOP endometritis
• Late miscarriage
• Preterm labour
• PPROM
• Postpartum endometritis
• Vaginal cuff cellulitis and abscess after vaginal hysterectomy

• Advise against vaginal douching, shower gels, antiseptic bath agents
• Treat symptomatic women; apply procedure-specific local guidance before gynaecological surgery
• The lecture lists oral metronidazole 400 mg BD for 5–7 days or a 2 g single dose. Current CDC guidance uses metronidazole 500 mg orally twice daily for 7 days; use the current local formulary rather than mixing regimens ^[11]
• Alternatives: intravaginal metronidazole gel or clindamycin cream
• Routine screening of asymptomatic pregnant women to prevent preterm birth is not recommended ^[11]

• Meta-analyses conclude no evidence of teratogenicity from metronidazole use in the first trimester (Evidence level Ia) ^[1]
• The most recent Cochrane review found little evidence that screening and treating all pregnant women with asymptomatic BV prevents preterm birth
• Symptomatic pregnant women should be treated in the usual way
• Routine screening or treatment of asymptomatic pregnant women to prevent preterm birth is not recommended ^[11]
• Breastfeeding: lower-dose oral metronidazole regimens are considered compatible. Some clinicians advise a 12–24-hour feeding pause only after a single 2 g dose; intravaginal-only treatment is not mandatory ^[11]

• Pruritus
• Vaginitis, dyspareunia, soreness
• Foul smell, frothy, yellowish-green discharge
• Post-coital bleeding in pregnant women
• Strawberry cervix (punctate cervical haemorrhages; supportive and memorable, but uncommon and not exclusive to trichomoniasis)
• May be associated with preterm birth and low birth weight

What the photograph shows: a diffusely erythematous cervix with multiple small red puncta, representing capillary haemorrhages. The image teaches pattern recognition, but laboratory confirmation remains necessary because symptoms and appearance overlap with other vaginitis/cervicitis ^[8][12].

• Specimens must be examined within 10 minutes to observe motile parasites on wet mount

• The lecture lists oral metronidazole 2 g once or 400 mg BD for 5–7 days. Current CDC first-line therapy for women is metronidazole 500 mg orally twice daily for 7 days, which outperformed a single 2 g dose in women ^[12]
• Screen for other STDs
• Screen and treat partner
• Abstain until the patient and partners have completed treatment and symptoms have resolved
• Retest sexually active women at about 3 months because reinfection is common; persistent/recurrent disease also requires reassessment ^[12]

• Metronidazole is likely to cure trichomoniasis, but it is not known whether treatment affects pregnancy outcomes ^[1]
• Meta-analyses conclude no evidence of teratogenicity from metronidazole in the first trimester (Evidence level Ia) ^[1]
• Metronidazole can be used in all stages of pregnancy and during breastfeeding
• Symptomatic women should be tested and treated at diagnosis in any trimester; do not defer solely because of first-trimester pregnancy ^[12]
• Lower-dose metronidazole regimens are considered compatible with breastfeeding; some clinicians advise a 12–24-hour pause after a single 2 g dose ^[12]
• Tinidazole should be avoided in pregnancy, and breastfeeding should be deferred for 72 hours after a 2 g dose ^[12]

• 75% asymptomatic — this is why it's so dangerous
• Increased vaginal discharge
• Dyspareunia
• Intermenstrual bleeding
• Abdominal pain
• Dysuria

Gynaecological:

• PID
• Chronic pelvic pain
• Increased risk of ectopic pregnancy
• Subfertility
• Fitz-Hugh-Curtis Syndrome (perihepatitis — "violin string" perihepatic adhesions)
• Reactive arthritis (historically “Reiter syndrome”) — urethritis, conjunctivitis, arthritis

Pregnancy-related:

• Preterm labour, PPROM, low birth weight, post-partum endometritis

Neonatal:

• Conjunctivitis (5–12 days after birth)
• Pneumonitis (2–3 weeks after birth)

• NAAT is the preferred test. In women, a vaginal swab is optimal; an endocervical swab or first-catch urine is acceptable. Sample rectal/pharyngeal sites according to exposure ^[13]
• The slide’s ELISA, immunofluorescence, cell culture and “PCR is expensive” discussion reflects older laboratory practice

• Doxycycline 100 mg orally BD for 7 days is current first-line treatment for uncomplicated adolescent/adult infection; azithromycin 1 g once is an alternative when adherence is a substantial concern ^[13]
• Pregnancy: azithromycin 1 g orally once; amoxicillin 500 mg TDS for 7 days is an alternative. Erythromycin is no longer recommended because of gastrointestinal intolerance and concern about adherence ^[13]

• Screen for other STDs
• Contact tracing and treatment
• Test of cure: at about 4 weeks after treatment in pregnancy. It is not routine in nonpregnant patients unless adherence is uncertain, symptoms persist or reinfection is suspected. Retest everyone at about 3 months to detect reinfection ^[13]

• 30–60% asymptomatic
• Dysuria, frequency
• Increased vaginal discharge, yellow-green
• Vaginal pruritus, burning
• Post-coital bleeding
• Vaginal erythema
• Vulval swelling/pain → Bartholin's abscess

Gynaecological: PID, ↑ ectopic pregnancy risk, subfertility, chronic pelvic pain Systemic: arthritis, conjunctivitis, pharyngitis, proctitis, urethritis, endocarditis, meningitis, disseminated gonococcal infection (rare)

Pregnancy-related: miscarriage, premature labour, PPROM, chorioamnionitis, SGA, stillbirth, post-partum endometritis and pelvic sepsis

Neonatal: Ophthalmia neonatorum (purulent conjunctivitis in first few days of life) — a notifiable condition; in contrast, Chlamydia conjunctivitis presents at 5–12 days ^[1][2]

• Test all exposed anatomical sites. NAAT is generally preferred for detection; obtain culture before treatment when antimicrobial susceptibility is needed, and always in suspected treatment failure ^[14][16]
• Gram stain may show intracellular Gram-negative diplococci, but sensitivity is limited in asymptomatic women/cervical infection
• The slide’s Thayer–Martin/Martin–Lewis media remain relevant to culture; its “PCR is expensive” framing reflects older laboratory practice

• The lecture’s ceftriaxone 500 mg IM + azithromycin 1 g and its separate BASHH 2019 ceftriaxone 1 g monotherapy screenshot are historical regimens
• Hong Kong CHP alert (January 2024): because of reduced ceftriaxone susceptibility, empirical treatment for uncomplicated urethral, cervical or rectal gonorrhoea was revised to ceftriaxone 1 g IM once plus azithromycin 2 g orally once. Use the latest CHP/Hospital Authority advice because resistance policy can change ^[16]
• Jurisdiction matters: CDC guidance uses ceftriaxone 500 mg IM once for people < 150 kg (1 g if ≥150 kg), adding chlamydia treatment only if chlamydia has not been excluded ^[14]
• Do not use a fluoroquinolone empirically; reserve susceptibility-directed options for specialist/local guidance

• Pregnant and breastfeeding women should not be treated with quinolone or tetracycline antimicrobials ^[1]
• The ceftriaxone 500 mg + azithromycin 1 g and spectinomycin regimens on the slide are lecture-era guidance; seek current obstetric/STI advice and use the current local resistance-based regimen ^[16]
• Pregnancy does not diminish treatment efficacy ^[1]
• Screen for other STDs
• Contact tracing
• Follow-up: follow current local instructions, especially given Hong Kong’s reduced ceftriaxone susceptibility. Under CDC guidance, test of cure is not routine after recommended treatment of uncomplicated urogenital/rectal infection, but pharyngeal infection requires test of cure at 7–14 days; everyone should be retested at 3 months for reinfection. Suspected failure requires culture and susceptibility testing ^[14][16]

Current Hong Kong IMPACT (Sixth Edition): single-dose ceftriaxone 500 mg IM + doxycycline 100 mg orally BD for 14 days, with or without metronidazole 400 mg orally BD for 14 days ^[17].

The slide instead shows ceftriaxone 1 g and metronidazole 400 mg. CDC uses ceftriaxone 500 mg IM once + doxycycline 100 mg BD + metronidazole 500 mg BD, both oral agents for 14 days (ceftriaxone 1 g if documented gonorrhoea in a person ≥150 kg). Do not combine doses from different protocols ^[15].

Why this triple combination?

• Ceftriaxone: covers Neisseria gonorrhoeae
• Doxycycline: covers Chlamydia trachomatis and other aerobes
• Metronidazole: covers anaerobes

The slide lists ofloxacin-, moxifloxacin- and azithromycin-based alternatives. Do not use a fluoroquinolone empirically in Hong Kong because of high gonococcal resistance; specialist-directed alternatives require exclusion or susceptibility assessment for gonorrhoea ^[17].

Admit if:

• Surgical emergency cannot be excluded
• Clinically severe disease
• Tubo-ovarian abscess
• PID in pregnancy
• Lack of response to oral therapy
• Intolerance to oral therapy

Recommended:

• Current Hong Kong IMPACT: IV Ceftriaxone 2 g daily + oral Doxycycline 100 mg Q12H, with or without Metronidazole 400 mg Q12H; step down after improvement to complete 14 days ^[17]
• IV Cefoxitin 1–2 g Q6H
• IV Augmentin + Doxycycline

Alternative:

• IV Clindamycin 900 mg TDS + IV Gentamicin (2 mg/kg loading → 1.5 mg/kg TDS, or 7 mg/kg daily) → then oral Clindamycin 450 mg QID or Doxycycline + Metronidazole to complete 14 days

IV antibiotics continued until 24 hours after clinical improvement, then switch to oral

• An IUD does not need to be removed routinely at diagnosis if the patient wishes to continue it
• Treat and review closely; if no clinical improvement within 48–72 hours, consider removal after discussing contraception and pregnancy risk ^[15]

• Image-guided drainage / laparoscopy / laparotomy — for tubo-ovarian abscess not responding to antibiotics

• Tubo-ovarian abscess
• Septic shock

The 13% → 36% → 75% sequence is a classic historical lecture estimate, illustrating that repeated PID causes cumulative tubal damage. It should not be presented as a precise contemporary prognosis for every patient; risk varies with pathogen, severity, delay to treatment and recurrence ^[1].

• Reassess for clinical improvement within 72 hours; if there is no improvement, reconsider the diagnosis, adherence and need for admission/additional diagnostics
• Abstain from sex until therapy is complete, symptoms resolve and partners have been evaluated/treated
• Test for gonorrhoea, chlamydia, HIV and syphilis; evaluate/treat recent partners
• If PID was gonococcal or chlamydial, retest at 3 months