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Sexually Transmitted Diseases Mandy Vichas RN, BSN, NPS Scabies Infestation of the skin by an itch mite (Sarcoptes scabiei) Infestation may occur by sexual contact or hand/finger contact It takes approximately 4 weeks from the time of contact for symptoms to appear The most common symptom is severe pruritis especially at night Secondary lesions are common Scabies Management After showering medication is applied to the skin from the neck down and left on for 12-24 hours – Lindane (Kwell) – Crotamiton (Eurax) – Permethrin (Elimite) Treatment is often repeated after 1 week All clothing and bedding need to be washed in hot water and a hot dryer. Dry-cleaning is ok. Pruritis may be persistent after treatment and corticosteroid ointment or antihistamines may be used All family members should be treated! Scabies Gonorrhea Bacterial Infection of the reproductive tract A major cause of PID, tubal infertility, ectopic pregnancy The average incubation period is 2-7 days Often co-exists with chlamydia Symptoms – – – – – Vaginal or penile discharge Dysuria Itching, swelling or pain Painful intercourse Dysmenorrhea 50% of women have NO symptoms Gonorrhea Diagnosis is done by culture Female = culture from cervix Male = culture from penile discharge CDC recommends the treatment for gonorrhea and chlamydia at the same time even if only one is confirmed Antibiotics – Rocephrine – Cipro – Floxin Gonorrhea of the Eye Gonorrhea Discharge Chlamydia Bacterial infection of the reproductive tract Increased risk for ectopic pregnancy and infertility As many as 40% of untreated women develop PID Often co-exists with gonorrhea Often produce no symptoms – Cervical discharge – Dysuria – Bleeding CDC recommends the treatment for gonorrhea and chlamydia at the same time even if only one is confirmed due to the likelihood of concurrent infections (25%) – Doxycylcine – Zithromax Syphilis Acute and chronic infections disease caused by the spirochete Treponema pallidum It is acquired through sexual contact or may be congenital Three stages – Primary – Secondary – Tertiary Syphilis Primary – 2-3 weeks after inoculation a chancre develops A painless round lesion at the site of infections – Untreated these lesions generally resolve spontaneously in 2 months – During this time may have headache or locally enlarged nodes Secondary – Spread of organisms from the primary lesion to a generalized infection – Skin rash on trunk & extremities (including palms and soles) occurs 2 - 8 wks after the primary chancre hair loss fever malaise sore throat lymphadenopathy May feel well – Serology tests are positive at this stage Syphilis Latency – No signs or symptoms of active infection Tertiary – 20 – 40% don’t exhibit any symptoms – Slowly progressive inflammatory disease that affects multiple organs – Aorta – Nervous system – Stroke – Generally not infectious at this late stage – Fatal due to circulatory insufficiency, neurosyphilis, aortic or joint problems Syphilis Diagnosis is done by direct identification of the spirochete obtained from the primary lesion or serology tests (secondary and tertiary) – VDRL – rapid plasma reagin circle card test – FTA_ABS & MHA-TP Syphilis Treatment is generally with penicillin – PCN-G IM x 1 (early & early latent) – PCN-G IM x 3 at 1 week intervals (late latent & latent of unkown duration) Doxycycline if allergic to PCN Serology tests are repeated every 3 months for 1-2 yrs. Primary Syphilis Secondary Syphilis Genital Herpes (Type II) Considerable overlap between type I & type II – Clinically indistinguishable – Can be transmitted asexually from wet surfaces or by self transmission – Incubation period is generally 1-2 weeks Symptoms – Blisters – Flu-like symptoms – Dysuria Viral infections are not curable but treatment is aimed at symptom management Condoms for sexual intercourse to prevent transmission Antivirals – Zovirax – Valtrex – Famvir Oral HSV II Genital HSV II HPV Human papillomavirus is the most common STD among young sexually active people More than 80 strains exist Infections can be latent, sub-clinical, or clinical most common strains are 6 & 11 which usually cause condylomata (genital warts) Strains 16, 18, 31, 33 increase the risk for cervical cancer 50% of all cervical cancers are caused by strains 16 & 18 HPV Treatment may involve topical agents – Podofilox (Condylox) – Imiquimod (Aldara) – Podophyllin (Podofin) Chemotherapeutic agents Injections of interferon Electrocautery Laser removal Gardisil Vaccine Gardisil is a cervical cancer vaccine that helps protect against 4 types of human papillomavirus For girls and young women ages 9 to 26. Is not for women who are pregnant. Does not treat cervical cancer or genital warts. It is important to continue routine cervical cancer screenings. The side effects include pain, swelling, itching, and redness at the injection site, fever, nausea, dizziness, vomiting, and fainting. Gardisil is given as 3 injections over 6 months. Genital Wart Bacterial Vaginosis Caused by an overgrowth of anaerobic bacteria & Gardnerella vaginalis normally found in the vagina in the absence of lactobacilli Characterized by a fish-like odor that is particularly noticeable after intercourse or menstruation Usually accompanied by gray to yellowish-white discharge 50% are asymptomatic Treatment – Flagyl – Cleocin vaginal gel Candidiasis A fungal or yeast infection caused by strains of Candida Symptoms include – Watery or thick discharge which has a white cottage-like appearance – Pruritis – Irritation of the skin – Symptoms are usually more severe before menses Infection is less responsive to treatment during pregnancy Diagnosis is done by microscopic examination Treatment – antifungal agents such as nystatin, Gyne-Lotrimin, used with a vaginal applicator – These over the counter RX should be used judiciously and not unless woman is certain of her diagnosis or if relief not obtained after using – Diflucan one pill dose relief within 3 days Oral Candidiasis Genital Candidiasis Facial Candidiasis Trichomoniasis Caused by flagellated protozoan Second most common STI in the US Symptoms include – Vaginal discharge (Thin sometimes frothy, yellow to yellow green) Malodorous & very irritating Pelvic exam often reveals vaginal & cervical erythema & multiple small petechiae (strawberry spots) Treatment includes – Flagyl for both partners – must abstain from alcohol while taking flagyl due to unwanted side effects Trichomoniasis Pelvic Inflammatory Disease (PID) Inflammation of pelvic cavity Can be caused by gonorrhea or chlamydia (most likely) Can also occur post-partum or post abortion or post invasive procedures (biopsy or hysteroscopy) Symptoms: may be acute & severe or low grade & subtle – – – – – – discharge back or abdominal pain fever nausea dysmenorrhea pain with intercourse or pelvic exam Pelvic Inflammatory Disease (PID) Complications – Generalized peritonitis – Abcesses – Strictures & scar tissue = fallopian tube obstruction = possible ectopic pregnancy or sterility – Adhesions, – Chronic pelvic pain – Septic shock, bateremia, thrombophlebitis Nursing Implications – – – – – – – – – Bedrest in semi-fowler’s to promote drainage Antibiotics IV Local heat & analgesics for pain management if abdominal distention or paralytic ileus may require NG with suction Monitor vital signs Monitor characteristics and amount of vaginal drainage Good peri care Tampons are NEVER used with any presence infection treatment of partners HIV/AIDS In 1982 CDC issued first definition of AIDS after the first 100 cases were reported Since then definition has been revised a number of times African Americans: 50% of all cases of both 2003 Males 72% of cases worldwide AIDS kills 8,000 people/day; 1 person/10 secs (UNAIDS, 2006) 2005 newly infected HIV adults 50/50 men/women unsafe sex predominant mode earliest confirmed case was in 1959 in blood drawn from African man HIV mutates quickly @ a relatively constant rate with 1% of the virus’s genetic material changing annually HIV People with AIDS-indicator conditions (clinical category C) and those in categories A3 or B3 are considered to have AIDS Period from infection with HIV to the development of antibodies to HIV is known as primary infection Symptoms of viremia range from none to severe flu-like symptoms Balance between amount of HIV in body & immune response is viral set point HIV/AIDS Transmission Body fluid containing HIV or infected CD4+ lymphocytes Fluids include blood, seminal fluid, vaginal secretions, amniotic fluid & breast milk Mother to child transmission of HIV-1 may occur in utero at the time of delivery, or through breast feeding although most perinatal infection thought to occur after exposure during delivery Because HIV is harbored within lymphocytes, any exposure to infected blood cells results in a significant risk of infection Donated blood is tested for antibodies to HIV-1, HIV-2 Blood donated during window period (period of time between initial infection with HIV & development of a + test for HIV) after infections is infectious even though it tests negative window can last up to 1 year HIV/AIDS There are more than 20 approved antiretroviral agents belonging to 4 classes used to design combination regimens containing at least 3 medications Patients may be given drug holidays (7 days) if their CD4 count is 500800cells/m3 Medications are resumed if the CD4 count falls below 350-400cells/m3 The HIV Antibody Test The most common and most accurate test to determine if someone is infected with HIV is the HIV antibody test. The test actually consists of two tests: a screening test and a confirmatory test. The screening test procedure is called an ELISA -- Enzyme Linked Immuno-Sorbent Assay or an EIA (Enzyme Immunosorbent Assay). The confirmatory test procedure used is either a Western Blot Assay (WB) or an Indirect Immunofluorescense Assay (IFA). The screening and confirmatory tests are usually done using small samples of blood. If a sample of blood tests positive repeatedly in the screening test, it will be confirmed through the Western Blot test. Except when rapid testing is done, test counselors inform people they are infected with HIV only after both the screening and confirmatory tests have shown a positive (reactive) result. Positive HIV antibody tests results are over 99% accurate when confirmed. Negative HIV antibody tests are over 99% accurate if it has been at least three months after a contact with a potentially HIV-infected partner. False negatives or false positives occur rarely. The window period The time period between a person's actual infection with HIV and until HIV antibodies become detectable in blood or other fluids is called the "window period". Most people will develop antibodies detectable with the latest blood tests within 4-6 weeks after infection with HIV. Some people may take longer; but nearly all (99%) will have antibodies by 3 months following infection. Therefore, we recommend that people wait 3 months from the time of the possible infection with HIV (the date of latest exposure) before being tested for HIV antibodies. The test may not give an accurate negative result if a person gets tested too soon after a potential exposure. People waiting three months from the time of the exposure before testing will have a 99% accurate test result. Very rarely, cases have been reported of people taking longer than three months to develop antibodies to HIV. Rapid testing for HIV The FDA approved a rapid test for detecting HIV antibodies in 1996. The technology used to perform this test is called the Single Use Diagnostic System (SUDS) for HIV. This system is a screening test using a small sample of blood, comparable to the ELISA/EIA. It is more than 99% accurate when used 3 months after possible exposure; however, positive results on a SUDS test need to be confirmed by the usual Western Blot or the Immunoflourescence Assay confirmation tests performed on blood. The results of the SUDS test for HIV are available after 15-30 minutes, but only negative results can be reported at that time. Positive results are provided tentatively, based on the prevalence of HIV infection in the subject’s risk group. Advantages The obvious advantage of rapid HIV testing is that people who are negative for HIV can get results right away. Research has shown that these tests are more acceptable to people at high-risk than the standard HIV test, because it eliminates the week of anxiety that people experience while waiting for results. People involved in high risk behavior can also learn that they are probably HIV-infected when their SUDS is positive. They are more likely to come back to receive their final test results and get help with partner notification, than those who test with the standard method. In certain situations such as occupational exposure, rape or prenatal care and delivery, rapid identification of HIV infection can result in timely initiation of antiviral treatment, which may prevent HIV infection. Disadvantages Positive results from the rapid HIV test need to be confirmed by another test, which takes up to one week. There can be a fairly high level of false positives when the rapid tests are used in lower-risk populations. The level of anxiety in those initially testing positive by the rapid test may be higher than those awaiting results of the regular test.. The rapid tests also cost more than the regular antibody test. However, since so many more people receive test results with rapid testing, it has been shown to be cost-effective in high-risk populations. Rapid testing is currently being used in publicly funded out-reach testing, and its use will likely continue to expand as less expensive and more simple rapid tests become available (several are currently going through clinical trials). Stages of HIV/AIDS Based on clinical history, physical examination, lab evidence of immune dysfunction, signs & symptoms, infections & malignancies Includes rating of CD4+ T-Cell category (AIDS indicator T-cell count)* Stages A: asymptomatic, acute (primary) HIV or PGL (persistent generalized lymphadenopathy) B: symptomatic, (not A or C conditions) – 1. Condition is due to HIV infection or defect in cellular immunity – 2. Is considered to have a course that is complicated by HIV C: AIDS – 1. When CD4+ T-cell level is <200cells/m3 – 2. CD4+ T-cells <14% of total lymphocytes Pneumocystis Carinii Pneumonia (PCP) Respiratory infection: pneumocystis jiroveci is the causative organism Most common opportunistic infection Symptoms may include SOB, dyspnea, cough, chest pain & fever Diagnosis is done by biopsy, sputum induction & bronchial-alveolar lavage In some cases dramatic onset can lead to respiratory failure in 2 – 3 days but often takes weeks-months Tuberculosis Tends to occur in IV/injection drug users TB occurs late in HIV infection Absence of an immune response to TB skin test (anergy) Immune reconstitution (paradoxical reactions) may occur – Includes high fever, worsening symptoms of active TB infection or appearance of new symptoms weeks after Rx. therapy Chest X-Ray of Tuberculosis Mycobacterium Avium Complex (MAC) Usually causes respiratory infection caused by a group of acid-fast bacilli – M. avium – M. intracellulare – M. scrofulaceum Also often found in GI tract, lymph nodes & bone marrow Associated with rising mortality rates in HIV patients GI Complications Symptoms include anorexia, N & V, chronic diarrhea in 50 – 90% of pts. Candidiasis – Can affect oral & whole GI tract – Dysphagia & stomatitis (creamy white patches) – Generally treated with antifungals Wasting Syndrome Profound involuntary weight loss >10% of baseline body weight OR: Chronic diarrhea >30 days OR: Chronic weakness Caused by intermittent or constant fever in the absence of concurrent illness Cytokine induced fever accelerates the metabolism 14% for every 1 degree F Wasting Syndrome Kaposi’s Sarcoma (KS) AIDS patients have higher incidences of cancer Kaposi’s Sarcoma (KS) – – – – Most common HIV-related malignancy Associated with herpes virus (HIHV-8) transmission May be first sx. of HIV infection Cutaneous lesions can appear anywhere on body and are usually brownish pink to deep purple Can lead to venous stasis, lymphedema & pain based on location & size Diagnosis is confirmed by biopsy May be treated with radiation therapy Kaposi’s Sarcoma B-Cell Lymphomas Second most common malignancy in AIDS Tends to develop outside lymph nodes, most commonly in the brain, bone marrow, & GI tract Requires aggressive chemotherapy treatment. – Less successful than in general population r/t hematologic toxicity HIV Encephalopathy 80% of all pts with AIDS have some form of neurologic involvement during HIV infection HIV Encephalopathy – Clinical syndrome resulting in progressive decline in cognitive, behavioral & motor functions HIV triggers the release of toxic lymphokines that result in cellular dysfunction or interference with neurotransmitter function – Early symptoms may include memory deficits, progressive confusion, psychomotor slowing, apathy & ataxia – later symptoms may include global cognitive impairments Difficult to diagnose but can be done by CT, MRI, CSF, brain biopsy Cryptococcus Neoformans (cryptococcal meningitis) Fungal infection Symptoms include fever, headache, malaise, stiff neck, N & V, mental status changes & seizures Confirmed by CSF analysis Progressive Multifocal Leukoencephalopathy (PML) Demyelinating disorder that affects the oligodendroglia Occurs in about 3% AIDS pts. Causes mental confusion & rapidly progresses to include multiple CNS symptoms including blindness, aphasia, muscle weakness, paresis, & death HIV/AIDS NURSING CARE Assessment ID persons at risk r/t Accurate sexual history including behaviors & other risk factors Substance abuse Tattoos Acupuncture Blood products Encourage testing in patients that are high risk or have not been tested Diagnosis & Outcomes is r/t stage of illness & individual Implementation Prevent Infections Constant observation of universal precautions Meticulous hygiene Implementation Basic Care TCDB Good skin care elevate edematous limbs emollients to prevent drying of skin skin lesions washed with separate cloth, wear gloves Monitor alterations in body temperature caused by dehydration or infection Monitor for temp. elevation every 4 hr. Provide adequate fluid Patients may have persistent fevers without known cause Implementation Promote optimal nutrition – – – – Dysphagia N&V Diarrhea Depression Food preferences Daily weights + I & O Good oral hygiene Provide socialization with eating May need parenteral nutrition May need help with shopping & food preparation Implementation Assist with coping (begin early) r/t anxiety, uncertainty anger, denial, hopeful/hopelessness Assist with education & reality Realistic goal setting Encourage patient participate in self care & direction of care Minimize isolation Be a good listener Help the patient find support resources Mandatory Reporting Public health surveillance is the collection, investigation and distribution of data about illness and death. This surveillance helps prevent and control disease in Washington State. Surveillance is used to protect and improve the health of the public by: – – – – describing disease trends identifying and controlling the sources of infection; educating the public preventing disease. In Washington State, legal requirements for disease reporting form the foundation for disease surveillance and require health care providers, health care facilities, laboratories, veterinarians, food service establishments, child day care facilities, and schools to notify public health authorities of suspected or confirmed cases of selected diseases or conditions. These are referred to as notifiable conditions. Local health jurisdictions are required to report information regarding those illnesses or deaths to DOH, which in turn sends disease reports to the Centers for Disease Control and Prevention (CDC). This system is necessary to provide local, statewide and national disease incidence and trends in order to guide public health activities. http://www.doh.wa.gov/notify/ Notifiable Conditions AIDS Chancroid Chlamydia Gonorrhea Hepatitis A Hepatitis B Hepatitis C Hepatitis, unspecified Herpes HIV Infection Meningococcal disease Rare diseases Syphilis Trichinosis Tuberculosis