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Sexually Transmitted Infections NURS 541: Women Healthcare – Diagnosis and Management Sexually Transmitted Infections Interesting facts: At least 50% of Americans will contract an STI in their lifetime Women are biologically more likely to get an STI than men Most STIs are asymptomatic Key factors for clinicians: Prevention, screening, detection, and treatment Sexually Transmitted Infections 2010 CDC STD guidelines http://www.cdc.gov/std/treatment/2010/ Look for updated 2014/2015 guidelines soon! In process…. Sexually Transmitted Infections Comprehensive sexual health history Sexual practices sex with men, sex with women, etc. penetrative, receptive, vaginal, anal, oral, etc. Single partner, multiple partners Pay/get paid for sex IV drug use/partner with IV drug use hx Prevention practices Barrier use (male/female condoms, dental dams, gloves) Past history of STI Sexually Transmitted Infections Screening recommendations Yearly screening for all individuals under the age of 26 Chlamydia and gonorrhea specifically, others if indicated Prior to initiating a new sexual relationship Anyone with high risk sexual practices Anyone with concerns about STI exposure Anyone with concerning symptoms Sexually Transmitted Infections Chlamydia Gonorrhea Pelvic Inflammatory Disease (PID) Human Immunodeficiency Virus (HIV) Herpes Simplex Virus (HSV) Condyloma Accuminata Syphilis Pediculosis pubis Hepatitis B Virus (HBV) Molluscum contagiosum Chlamydia Chlamydia Bacterial etiology – chlamydia trachomatis Most common STI in the U.S. Most commonly seen in younger persons (14-24 years of age), persons of black race, and those with high risk sexual practices For men, often culprit for nongonococcal urethritis (NGU) Chlamydia Signs/symptoms Often asymptomatic Occasional spotting after intercourse, burning with urination (onset of stream), dyspareunia, mucopurulent discharge Exam may show inflammation of the cervix (cervicitis) Lab testing Urine or cervical/vaginal NAAT Chlamydia Management Primary treatment options Azithromycin 1gm orally x 1 dose Doxycycline 100mg orally BID x 7 days Treat patient AND partner(s) Screen for other STIs No intercourse x 7 days Retest in 3 weeks if indicated, and rescreen in 3 months for recurrence Gonorrhea Gonorrhea Bacterial etiology – Neisseria gonorrhoeae Second most common STI in the U.S. Signs/Symptoms Often asymptomatic Occasionally mucopurulent/green/yellow discharge, dyspareunia, labial irritation/swelling, vaginal/rectal pain. May present as dysmenorrhea. May manifest in mouth or anus if exposure is that route Lab testing Urine, vaginal, or cervical NAAT Gonorrhea Management Primary treatment options Ceftriaxone 250mg IM x 1 dose Cefixime 400mg orally x 1 dose PLUS chlamydia treatment Treat patient AND partner(s) No intercourse x 7 days Retest in 3 weeks not necessary, BUT plan to rescreen in 3 months for recurrence Pelvic Inflammatory Disease (PID) Pelvic Inflammatory Disease Upper genital tract infection Potentially serious complication of chlamydia and gonorrhea, but may be caused by other anaerobic bacteria (BV) Pelvic Inflammatory Disease History Risk factors for STIs (sexual health history) Any intrauterine procedure within last month (IUD insertion, termination, dilation of cervix, etc) Review of symptoms Fever, chills, abdominal pain, pelvic pain, sx vaginal infection Physical exam Abdominal tenderness Cervical motion tenderness, uterine/adnexal tenderness Pelvic Inflammatory Disease Lab testing Wet mount or DNA probe for vaginal infections Chlamydia/gonorrhea testing (CT/NG) Other testing if systemic symptoms – CBC, differential, sed rate Differential Any other potential cause for symptoms? Ovarian torsion, endometriosis, pregnancy, inflammatory bowel disease, acute appendicitis Pelvic Inflammatory Disease Need to determine if candidate for out-patient therapy! Primary Management Ceftriaxone 250mg IM x 1 PLUS doxycycline 100mg BID x 7 days WITH OR WITHOUT metronidazole 500mg BID x 7 days Pelvic rest Rescreen for CT/NG/BV in 3-6 months Syphilis Syphilis Bacterial infection – Treponema pallidum Three distinct stages Primary (3-90 days after exposure) Chancre with positive lymphadenopathy Secondary (4-10 weeks after exposure) Papular rash/skin lesions (hands/feet) Systemic illness symptoms (fever, malaise, myalgias) Tertiary (years after exposure) Cardiovascular complications Skin lesions Neurosyphilis (can occur at any stage) Syphilis If untreated in primary/secondary phases: Latent phase Early (≤1 year) Late (> 1 year) May be sexually transmissible through the first year (through early latent phase) Syphilis History Sexual health history, risky behaviors, exposures Exam Look for lymphadenopathy, presence of chancre or skin lesions on genitalia Lab testing Screening: Nontreponemal antibody tests (VDRL, RPR) Confirmatory: Treponemal tests (FTA-ABS, TP-PA) Syphilis Management Primary, secondary, early latent Benzathine penicillin G 2.4 million units IM x 1 dose Late latent or tertiary Benzathine penicillin G 7.2 million units, given as 3 individual doses of 2.4 million units IM q 1-2 weeks Treat patient AND partner(s) Test for other STIs Retesting at 6, 12, 24 month intervals Hepatitis B Virus (HBV) Hepatitis B Virus (HBV) Infection etiology – DNA virus Blood, bodily fluids, vertical transmission routes Signs/Symptoms Largely asymptomatic (> 50%) Fever, arthralgias, nausea/vomiting, fatigue, anorexia, abdominal pain, jaundice, clay-colored stool, dark urine Present on average 90 days after exposure Hepatitis B Virus (HBV) Lab testing HBsAg (Hep B Surface Antigen) detects active infection Anti-HBs (Hep B Surface Antibody) detects immunity from vaccination or previous infection Anti-HBc (Total Hep B Core Antibody) Detects previous or ongoing (chronic) infection IgM anti-HBc (IgM antibody to Hep B Core Antigen) Indicates acute infection within past 6 months Hepatitis B virus (HBV) CDC, 2010 Hepatitis B virus (HBV) Management/Prevention Hepatitis B vaccination Anyone at risk for STI or treated for an STI All children < 19 years of age Medically-at-risk individuals Those with definite exposure to Hepatitis B may receive HBIG (Hepatitis B immunoglobulin) within first 24 hours after exposure to reduce transmission Referral to liver or infectious disease specialist appropriate Human Immunodeficiency Virus (HIV) Human Immunodeficiency Virus (HIV) Incurable viral infection – RNA retrovirus Blood, bodily fluids, vertical transmission routes Signs/Symptoms Largely asymptomatic in early phases Late signs of immunocompromise Lab testing Screening: HIV ELISA/EIA tests (enzyme immunoassay tests) Confirmatory: Western blot or IFA (immunofluorescence assay) Human Immunodeficiency Virus (HIV) Screening CDC recommends: Pre-test counseling Testing Post-test counseling Screen/offer testing for HIV whenever performing other STI tests Treatment Referral to an infectious disease specialist warranted for anti-retroviral (ARV) treatment Herpes Simplex Virus (HSV) Herpes Simplex Virus (HSV) Recurrent, incurable viral infection HSV-1 usually transmitted non-sexually Most often cold sores/fever blisters Potentially up to 80% of people carry HSV-1 virus HSV-2 usually transmitted through sexual contact Most often genital sores Approximately 15-30% of people carry HSV-2 virus Approximately 50% of those infected with HSV-1 or HSV-2 have never had symptoms Herpes Simplex Virus (HSV) Signs/Symptoms Primary outbreak: painful vesicular-like lesions, sometimes with flu-like symptoms, inguinal lymphadenopathy, vulvar edema, vaginal discharge, dysuria, cervicitis New lesions may present over a period of 10 days Lesions take 4-15 days to crust over and heal Recurrent outbreaks: lesions that are less painful in same area as primary outbreak, localized symptoms Lesions usually last 7-10 days Prodromal symptoms are common: tingling, burning, sensitivity in area of lesion activity Herpes Simplex Virus (HSV) Physical exam Temperature/vital signs Lymph node assessment Careful inspection of external genitalia, vagina, cervix, perineum NOTE: speculum exams are very difficult! Herpes Simplex Virus (HSV) Lab testing Specimen collection at site of lesion HSV viral culture HSV PCR Serology testing Type-specific HSV serology (IgG) Culture/PCR positive, yet type-specific serology negative: primary infection Culture/PCR positive, and type-specific serology positive: recurrent infection Herpes Simplex Virus (HSV) Treatment options Primary infection Acyclovir 400mg orally TID x 7-10 days (or 200mg 5x/day) Famcyclovir 250mg orally TID x 7-10 days Valacyclovir 1gm orally BID x 7-10 days Recurrent infection Acyclovir 400mg orally TID x 5 days (or 800mg BID x 5 days) Famcyclovir 125mg BID x 5 days (or 1000mg BID x 1 day) Valacyclovir 500mg orally BID x 3 days (or 1gm QD x 5 days) Suppressive therapy Acyclovir 400mg orally BID, Famcyclovir 250mg orally BID Valacyclovir 500mg or 1gm orally QD Condyloma Accuminata Condyloma Accuminata Caused by human papillomavirus (HPV) Most genital warts are caused by low risk strains (6, 11) As many as 75% of people exposed to genital warts will develop them Signs/Symptoms Flat, flesh colored, wart-like bumps in genital area May have itching, vaginal discharge, irritation Condyloma Accuminata Physical Assessment Thorough inspection of genital area, including vulva, vagina, cervix, perineum, anus Diagnosis is by visual identification Condyloma Accuminata Treatment options Expectant management – most resolve within 1 year Patient-applied modalities Podofilox 0.5% solution or gel, Imiquimod 5% cream (Aldara), or Sinecatechins 15% cream (Veregen) Provider-applied modalities Cryotherapy applied q 1-2 weeks until gone Podophyllin resin 10-25% Trichloroacetic acid (TCA) or bichloracetic acid (BCA) Surgical excision Prevention Quadrivalent HPV vaccine protects against strains 6 & 11 Pediculosis Pubis Pediculosis Pubis A parasitic infection caused by Pediculosis pubis, or pubic lice (“crabs”) The pubic variation of lice most often inhabits the pubis, but may be found in other hair-growing areas of the body Signs/Symptoms/History Pruritis, especially in genital area Seeing lice on skin or clothes Report of family member or partner with lice Pediculosis Pubis Physical exam Thorough assessment of hair-growing areas of body Rule out other causes of pruritis: eczema, seborrheic dermatitis, folliculitis, tinea cruris, scabies Treatment options Permethrin 1% cream rinse, applied to affected areas and washed off after 10 minutes Wash all bed linens, clothing, toys, towels in hot water and dry on hot cycle Molluscum Contagiosum Viral infection common in children; in adults usually sexually transmitted Small painless bumps in genital region, often with induration Treatment options Expectant management Cryotherapy, scraping, laser therapy options Prevention is Paramount! Keys to patient counseling on STIs Provide facts Don’t assume Encourage testing if any concerns present Encourage protection, safer sex