Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

CHAPTER 3
Gynecologic Infection

3–1. Vaginal flora of a normal, asymptomatic reproductive-aged woman includes multiple anaerobic, aerobic, and facultative bacterial species. Anaerobes predominate over aerobic species by approximately what factor?

a. 5

b. 10

c. 50

d. 100

3–2. Normal colonization of the vaginal mucosa by bacteria serves what main physiologic function?

a. Unknown

b. Produces lubrication

c. Stimulates epithelial differentiation

d. Facilitates production of beneficial antibodies

3–3. In normal, healthy women, bacterial species can be recovered from what locations?

a. Endocervix

b. Endometrial cavity

c. Peritoneal fluid of cul-de-sac

d. All of the above

3–4. What is the typical range of normal vaginal pH?

a. 3.0 to 3.5

b. 4.0 to 4.5

c. 5.0 to 5.5

d. 6.0 to 6.5

3–5. The rise in vaginal pH observed after menopause is correlated with which of the following?

a. Low serum estradiol levels

b. Decrease in vaginal cellular glycogen content

c. High serum follicle-stimulating hormone levels

d. All of the above

3–6. Which of the following is NOT one of the three clinical diagnostic criteria for bacterial vaginosis described by Amsel and associates (1983)?

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Photograph contributed by Dr. Lauri Campagna and Mercedes Pineda, WHNP.

a. Abnormally high vaginal pH

b. Presence of an abnormal discharge and erythema of the vagina

c. Clue cells seen on vaginal saline preparation by light microscopy (shown here)

d. Characteristic fishy odor release with addition of potassium hydroxide to vaginal secretions

3–7. Bacterial vaginosis is associated with which of the following?

a. Postabortal endometritis

b. Pelvic inflammatory disease

c. Posthysterectomy pelvic infection

d. All of the above

3–8. Which of the following is NOT one of the three treatment options proposed by the Centers for Disease Control and Prevention (CDC) (2010) for the treatment of bacterial vaginosis in nonpregnant women?

a. Oral clindamycin

b. Oral metronidazole

c. Intravaginal clindamycin

d. Intravaginal metronidazole

3–9. Recurrence of altered vaginal flora and symptoms is common (up to 30 percent) after initial treatment of bacterial vaginosis with antibiotics and can be frustrating for the patient. Which of the following has been consistently shown to decrease recurrence rates?

a. Treatment of male partners

b. Use of acidifying vaginal gels

c. Douching with lactobacillus-rich products such as live culture yogurt

d. None of the above

3–10. Which of the following is NOT a β-lactamase inhibitor?

a. Sulbactam

b. Probenecid

c. Tazobactam

d. Clavulanic acid

3–11. In addition to exfoliative dermatitis (shown here), which of the following are potential manifestations of a reaction to penicillins?

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Photographs contributed by Dr. Meadow Good.

a. Drug fever

b. Interstitial nephritis

c. Liver function abnormalities

d. All of the above

3–12. Which of the following is treated most effectively with a member of the penicillin family of antibiotics?

a. Syphilis

b. Breast cellulitis

c. Actinomyces infections related to intrauterine device (IUD) use

d. All of the above

3–13. Which of the following antibiotic groups is best suited for prophylaxis against postoperative pelvic infections?

a. Carbapenems

b. Penicillins

c. Cephalosporins

d. Aminoglycosides

3–14. Serious toxicities of aminoglycosides include all EXCEPT which of the following?

a. Ototoxicity

b. Nephrotoxicity

c. Hepatotoxicity

d. Neuromuscular blockade

3–15. Your patient has a serious posthysterectomy pelvic infection. She relates a history of anaphylaxis (type I allergic reaction) after use of oral penicillin and a lesser allergic reaction (hives and pruritis) after being given a cephalosporin intravenously. Which of the following antibiotics poses the greatest risk of allergic reaction for this patient?

a. Imipenem

b. Doxycycline

c. Ciprofloxacin

d. Trimethroprim-sulfamethoxazole

3–16. Clindamycin is least useful for the treatment of which of the following?

a. Pelvic abscess

b. Pyelonephritis

c. Bacterial vaginosis

d. Soft tissue infections

3–17. Which of the following is NOT a potential adverse effect of vancomycin administration?

a. Ototoxicity

b. “Red man” syndrome

c. Back and chest muscle spasms

d. Clostridium difficile colitis

3–18. Metronidazole is commonly used to treat trichomonal infections and bacterial vaginosis. When prescribed, patients should be warned against concurrent ingestion of which of the following due to an increased incidence of associated side effects?

a. Alcohol

b. Benzodiazapines

c. Grapefruit juice

d. Monoamine oxidase inhibitors

3–19. Fluoroquinolones are contraindicated in children, adolescents, and breast-feeding women due to possible adverse effects on the development of which of the following tissues?

a. Bone

b. Liver

c. Cartilage

d. Dental enamel

3–20. Your patient is a healthy 30-year-old with a 2-cm vulvar abscess but with significant surrounding edema (shown here). She is otherwise healthy. You decide to start her on oral antibiotics while awaiting bacterial culture results following incision and drainage. Which of the following tetracyclines offers the least activity against methicillin-resistant Staphylococcus infections?

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Photograph contributed by Dr. Kathryn Grande.

a. Doxycycline

b. Minocycline

c. Tetracycline

d. All of these are equally effective

3–21. You prescribe oral doxycycline to your patient for the treatment of mucopurulent cervicitis. You should caution her against which of the following while she takes this medication due to the increased potential for an adverse reaction?

a. Sun exposure

b. Alcohol consumption

c. Contemporaneous use of muscle relaxants

d. Standing upright quickly from sitting or lying positions

3–22. Your patient is a 28-year-old with her first episode of painful vulvar lesions, which first appeared as “blisters.” Which of the following statements regarding this type of infection is true?

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Photograph contributed by Dr. Thoa Ha.

a. Antibody testing is more sensitive than viral culture.

b. Men manifest a higher proportion of active cases than women.

c. More than 90 percent of genital infections caused by this pathogen will be diagnosed during the initial infection.

d. The average immune response to this infection lowers the risk of subsequent human immunodeficiency virus (HIV) infection.

3–23. Your patient is a 45-year-old woman with confirmed primary syphilis. She has a history of respiratory distress and hives with past penicillin use. She refuses to undergo skin testing to confirm her penicillin allergy and to complete subsequent desensitization. What is the best alternative oral antibiotic regimen?

a. Doxycycline

b. Azithromycin

c. Erythromycin

d. Ciprofloxacin

3–24. Your patient is a 32-year-old recently diagnosed elsewhere with HIV/acquired immunodeficiency syndrome (AIDS). She is currently not taking any medications. She presents with genital lesions that have been present for 1 week. She reports having had a single sore 4 months ago that was not painful and subsided without treatment after approximately 2 weeks. Which of the following tests specific to these lesions do you expect to be positive?

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Photograph contributed by Dr. Laura Greer.

a. Rapid plasma reagin

b. Wright-Giemsa stain

c. Herpes simplex 2 antibody assay

d. Positive skin punch biopsy staining for Candida

3–25. Your patient is a 24-year-old woman who presents with recent painless vulvar nodules that have now developed into red ulcers that bleed easily. Inguinal lymphadenopathy is minimal on examination. She has been in a mutually monogamous, heterosexual relationship for a year. Wright-Giemsa stain of a swab from one of the lesions shows Donovan bodies (shown here). What is her diagnosis?

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Reproduced, with permission, from Hart G: Donovanosis. In Fauci AS, Braunwald E, Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine, 17th ed. New York, McGraw-Hill, 2008, Figure 154-2.

a. Chancroid

b. Primary syphilis

c. Granuloma inguinale

d. Lymphogranuloma venereum

3–26. Risk factors for the vaginal pathogen seen here on potassium hydroxide (KOH) preparation include which of the following?

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Reproduced, with permission, from Brooks GF, Carroll KC, Butel JS, et al (eds): Medical mycology. In Jawetz, Melnick, & Adelberg’s Medical Microbiology, 25th ed. New York, McGraw-Hill, 2010, Figure 45-20.

a. Obesity

b. Orogenital sex

c. Broad-spectrum antibiotic use

d. All of the above

3–27. Your 32-year-old patient has no complaints when presenting for a routine health maintenance visit, but is found to have a clinically abnormal vaginal discharge during speculum examination of the vagina. A saline preparation of vaginal secretions demonstrates the motile pathogens shown here and marked by arrows. Your patient is at highest concurrent risk for which of the following?

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Photograph contributed by Dr. Lauri Campagna and Rebecca Winn, WHNP.

a. Infertility

b. Cervical neoplasia

c. Acute pelvic inflammatory disease

d. Coinfection with other sexually transmitted pathogens

3–28. Treatment of uncomplicated gonorrhea of the cervix recommended by 2011 Centers for Disease Control and Prevention (CDC) guidelines takes into account recent development of antibiotic resistance. Recommended treatment includes which of the following?

a. Erythromycin

b. Ciprofloxacin

c. Ceftriaxone plus azithromycin

d. Ciprofloxacin plus azithromycin

3–29. 2010 Centers for Disease Control and Prevention (CDC) guidelines include annual screening of all sexually active women aged 25 years and younger, regardless of risk factors, for all EXCEPT which of the following sexually transmitted infections?

a. Syphilis

b. Gonorrhea

c. Chlamydia infection

d. Human immunodeficiency virus

3–30. Your patient presents with vulvar lesions similar to those shown here. Approximately 8 weeks ago, she acquired a new sexual partner. Which of the following patient-applied topical therapies for this infection has shown superiority over the others in clinical trials with nearly 100-percent initial clearance rates?

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Reproduced, with permission, from Hemsell DL: Gynecologic infection. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 3-17.

a. Imiquimod

b. Sinecatechins

c. Podophyllotoxin

d. None of the above

3–31. Your patient is a 20-year-old college student with acute onset of urinary frequency and dysuria 2 days ago. She is otherwise healthy and is afebrile. She had one similar episode 15 months ago that resolved quickly with oral antibiotics. Studies have shown that the minimum evaluation required before antibiotics are prescribed for uncomplicated cystitis includes which of the following?

a. Urinalysis

b. Physical examination

c. Urine culture with bacterial sensitivities

d. None of the above are required

3–32. Which of the following can cause a falsely positive leukocyte esterase testing of a urine specimen?

a. Trichomonas vaginitis

b. Contamination with colonic or vaginal bacteria

c. Delayed testing or a poorly preserved specimen

d. All of the above

3–33. Your patient is a 20-year-old nulligravida with generalized abdominal pain (worse in both lower quadrants), vaginal discharge, anorexia, fever, and chills. She rates her pain as a “9” on a scale of 10. She became sexually active for the first time 1 year ago and has had three sexual partners since. She uses condoms for contraception. Her oral temperature is 39.1°C. Abdominal examination shows diffuse tenderness with bilateral lower quadrant guarding. Her cervix has the appearance shown. Lateral movement of the cervix during bimanual examination elicits increased pain. There are sheets of leukocytes on her vaginal saline wet prep. Her urine pregnancy test result is negative. Which of the following tests would be LEAST likely to aid the diagnosis and management of this patient?

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Reproduced, with permission, from Buckley RG, Knoop KJ: Gynecologic and obstetric conditions. In Knoop KJ, Stack LB, Storrow AB, et al (eds): The Atlas of Emergency Medicine, 3rd ed. New York, 2010, Figure 10-4.

a. Urinalysis

b. Pelvic sonography

c. Complete blood count

d. Endometrial biopsy for bacterial culture

3–34. The patient in Question 3–31 is admitted to the hospital inpatient gynecology service. Which of the following parenteral antibiotic regimens would NOT be appropriate for initial therapy?

a. Cefotetan plus doxycycline

b. Clindamycin plus gentamicin

c. Ciprofloxacin plus metronidazole

d. Ampicillin/sulbactam plus doxycycline

3–35. Your 42-year-old patient underwent an uneventful vaginal hysterectomy for adenomyosis 10 days ago. She received perioperative prophylactic antibiotics. She presents to your office today complaining of diffuse lower abdominal pain. This began several days ago as left-sided lower abdominal pain, but has worsened and become more generalized. She developed subjective fever and anorexia yesterday. On examination, she appears ill. Her temperature is 39.5°C, pulse 110, blood pressure 90/55. Her abdominal and pelvic examinations suggest peritonitis with extreme tenderness and a possible mass in the left adnexal region. Which of the following true gynecologic emergencies does this likely represent?

a. Ovarian abscess

b. Pelvic cellulitis

c. Vaginal cuff cellulitis

d. Infected pelvic hematoma

3–36. You are called to the emergency department to consult on a 26-year-old patient presenting with 36 hours of progressive malaise, fever, muscle aches, anorexia, diarrhea, and confusion. Her last menstrual period began 2 to 3 days ago as expected. She has had an intrauterine device in place for 1 year without problems. She has a new sexual partner as of 1 month ago. Her temperature is elevated, she is hypotensive, and she has erythema of her oropharynx and vaginal mucosa. Her skin demonstrates a diffuse macular rash. Abdominal and bimanual pelvic examinations are mildly tender, but no specific or localized findings are present. After obtaining appropriate laboratory tests and bacterial cultures, you quickly start parenteral antibiotics effective against which of the following pathogens?

a. Neisseria gonorrhoeae

b. Staphylococcus aureus

c. Streptococcus pyogenes

d. Clostridium perfringens

References

Amsel R, Totten PA, Spiegel CA, et al: Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 74:14, 1983

Centers for Disease Control and Prevention: Cephalosporin susceptibility among Neisseria gonorrhoeae isolates—United States, 2000–2010. MMWR 60(26):873, 2011

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines, 2010. MMWR 59(12):1, 2010

Chapter 3 ANSWER KEY

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