Sexually Transmitted Diseases

1. Sexually Transmitted Diseases Mandy Vichas RN, BSN, NPS

2. 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

3. 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!

4. Scabies

5. 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

6. 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

7. Gonorrhea of the Eye

8. Gonorrhea Discharge

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. Primary Syphilis

17. Secondary Syphilis

18. 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

19. Oral HSV II

20. Genital HSV II

21. 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

22. HPV • Treatment may involve topical agents • Podofilox (Condylox) • Imiquimod (Aldara) • Podophyllin (Podofin) • Chemotherapeutic agents • Injections of interferon • Electrocautery • Laser removal

23. 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.

24. Genital Wart

25. 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

26. 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

27. Oral Candidiasis

28. Genital Candidiasis

29. Facial Candidiasis

30. 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

31. Trichomoniasis

32. 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

33. 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

35. 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

36. 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

37. 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

38. 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 500-800cells/m3 • Medications are resumed if the CD4 count falls below 350-400cells/m3

39. 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.

40. 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.

41. 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.

42. 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.

43. 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). 

44. 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

45. 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

46. 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

47. Chest X-Ray of Tuberculosis

48. 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

49. 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

50. 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