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Sexually transmitted infection

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Katie Young

on 29 October 2014

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Transcript of Sexually transmitted infection

Sexually transmitted infection
By: Diana Holte, Amygrace Davis, Mimi Yemmana, Katie Crossiant, Tasha Parsons, Katie Young
What STI am I?
SYPHILIS
HPV
GONORRHEA
C H L A M Y D I A
“The Silent Disease”

Chlamydia Trachomatis
Invades the epithelium of the:
A
B
C
D

Basic Pathophysiology
Clinical Manifestations
“Silent Disease” – >50% of women have no symptoms
Cervicitis
Mucopurulent discharge
Edematous, friable cervix (bleeds easily)
Urethritis
Dysuria and frequency
Bartholinitis
Purulent discharge
Lower abdominal pain, pain with intercourse, menstrual abnormalities

Complications
Pelvic Inflammatory Disease
Increased risk for HIV transmission
Infertility (Fallopian Tubes)
Ectopic pregnancy
Preterm labor, PROM, and SGA
Newborn exposure:
Conjunctivitis
Chlamydial pneumonia


Risk Factors
Women <25yrs of age
African-American ethnicity
Lower SES and less than high school education
New or multiple partners
Current or past STIs
Inconsistent or improper use of barrier contraceptives

Diagnosis
Nucleic acid amplification testing (NAAT)
Most sensitive and specific test available
Vaginal, oral, rectal, or urine specimens
Also cell culture, enzyme immunoassay (EIA), nucleic acid hybridization, & direct immunofluorescence

Treatment Options
Standard Therapy
Azithromycin single dose
Doxycycline BID for 7 days
NO sexual intercourse for 7 days on either antibiotic regimen
Alternative Therapy
Erythromycin, levofloxacin, or ofloxacin
First dose given in-office
Education and Prevention
Primary - Preventing initial infection
Vaginal, anal, or oral sexual acts
Condom or cervical diaphragm use
Mutually monogamous relationship
Secondary - Early identification & treatment
Educate on symptoms
Screening
Partner Therapy

Current Screening Recommendations
STD Treatment Guidelines, CDC, 2010
Routine Screening
Age <25yrs & sexually active
Age >25yrs, sexually active, with risk factors
Prior STD infection
High risk for HIV
New or multiple sexual partners
Inconsistent use of barrier protection
Partner diagnosed with chlamydia

Pregnancy Considerations
NO doxycycline
Azithromycin one-time dose
Amoxicillin TID for 7 days
Retest 3 weeks after treatment complete
Partner Therapy – ACOG recommended
Prevent reinfection when partners unable to seek care
Medication, pt counseling, and written instructions

Screening during pregnancy
All woman at first prenatal visit
Potential rescreening in third trimester
Three weeks after completion of treatment

PID
Pelvic Inflammatory Disease
Statistics and Risk Factors
Occurs in approximately 1% of women between ages 15-39

Pathophysiology
Acute inflammatory process caused by infection
Most often caused by chlamydia and gonorrhea
Microbes ascend from infected cervix
May involve any organ of upper genital tract—the uterus, fallopian tubes, or ovaries
Salpingitis: inflammation of fallopian tubes
Oophoritis: inflammation of the ovaries

Possible Long-Term Complications
After one episode of PID, 15-25% of women develop long-term problems such as:
Infertility
Ectopic pregnancy
Chronic pelvic pain
Dyspareunia
Pelvic adhesions
Perihepatitis
Tubo-ovarian abscess

Clinical Manifestations
Vary from sudden/severe abdominal pain to asymptomatic


S/S can include:
Bilateral sharp/cramping pain in lower quadrants
Fever greater than 101F
Chills
Mucopurulent cervical drainage or vaginal discharge
Irregular bleeding
Cervical motion tenderness during intercourse
Malaise
Nausea
Vomiting
Dysuria
Physical Examination Findings
Direct abdominal tenderness with palpation
Adnexal tenderness on bimanual examination
Cervical and uterine tenderness with movement (Chandelier sign)
May be palpable mass
Evaluated with ultrasonography

Diagnosis
Diagnosis based on:
History
Hx of PID
Physical examination findings and s/s
Labs
Also test for chlamydia and gonorrhea
Exclude other reasons for pelvic pain
WBC on Gram stain or wet mount of cervical discharge
Leukocytosis
Increased erythrocyte sedimentation rate
Elevated C-reactive protein
Common Labs
Medication
Treatment
In-patient treatment:
IV fluids, pain meds, and IV antibiotics
IV Cefotetan (2 g IV q12 hrs) or Cefoxitin (2 g IV q6 hrs), plus Doxycycline (100 mg IV or PO q12 hrs)
IV therapy can be stopped when acute symptoms resolve, but oral Doxycycline 100 mg twice a day for 14 days is necessary
Out-patient treatment
Ceftriaxone 250 mg IM once, followed by Doxycycline 100 mg twice a day for 14 days

Follow-up appointment within 48-72 hours (sooner if symptoms worsen)
Increased oral fluids (up to 2 liters per day)
Continued bed rest or pelvic rest
Acetaminophen for fever
Pain relievers for abdominal pain
To prevent recurrence, sexual partners also treated with antibiotics

Supportive Care
Discuss risk factors and s/s to look for with patients
Stress the importance of completing antibiotics and follow-up appointment
Discuss the complications that could result
Educate the patient to see doctor promptly if she thinks she was exposed to an STD or has unusual symptoms
Importance of early diagnosis and treatment

Patient Education
human papilloma virus
Introduction
Syphilis is a chronic infection caused by the spirochete
Treponema pallidum.

Commonly acquired through vaginal, oral, or anal sex
Less commonly, it can result from nonsexual exposure to exudates from an infected individuals.
Vertical transmition (Mother-baby)

Pathophysiology
The understanding of T. pallidum pathophysiology is impeded by the inability to grow the organism in culture.
Treponema pallidum initiates infection when it gains access to subcutaneous tissues via microscopic abrasions and establishes the initial ulcerative lesion called the Chancre.

Signs and Symptoms
Syphilis develops in four stages, each with different S/S

Primary Stage
Chancre arise at the site of initial inculation of the organism, and is often painless.
It persists for about 4 weeks and then disappears
Usually found in the anus, mouth, or genital area
Symptoms during the first 4 weeks include: slight fever, loss of weight, and malaise

Secondary Stage

Infection spread through contact any area where a skin rash is
In 6 weeks to a few months later secondary symptoms appear and systemic illness develops
Condylomata lata (warltlike plaques )
Rash (including palms and soles)
Acute arthritis
Enlargement of liver and spleen
Nontender enlarged lymph nodes
Chronic sore throat with hoarseness
Ocular syphilis
Latent Syphilis

No symptoms
Untreated patients during the earlier stages of syphilis may develop late or tertiary syphilis.

Late or Tertiary Syphilis

It can cause serious health problems
The most common manifestations:
Central nervous system involvement (neurosyphilis)
Cardiovascular syphilis (aortitis)

Diagnosis
Dark-field examination (during the early primary stage)
Rapid Plasma Reagin (RPR)
Microhemagglutination assay-Treponema pallidum (MHA-TP)
Fluorescent treponemal antibody absorption test (FTA-ABS)

Treatment
Early detection and treatment is vital!
Long acting penicillin is the primary tx for all stages
If infection is less than a year in duration, 2.4 million units benzathine penicillin G IM single dose (if allergic to penicillin, tetracycline)
If infection is >1 year or unknown duration, 2.4 million units benzathine penicillin G IM once a week for 3 weeks. (If allergic to penicillin doxycycline 100mg BID for 28 days)
Jarisch-Herxheimer Reaction

Pregnancy Concerns
Spirochetes cross placenta after 16th – 18th week of gestation
Untreated syphilis pregnancies are at increased risk of
Intrauterine growth restriction
Stillbirth
Neonatel death
Preterm birth
Congenital infection and anomalies
Tx of early maternal syphilis at least 30 days before delivery is very important
Pregnant women who are allergic to penicillin should be desensitized and then treated with penicillin.

Care of the Newborn with Infection
Asymptomatic at birth but develop symptoms within first 3 months of life
Nurses should check perinatal history for positive maternal serology
Standard precautions should be initiated
Penicillin will be administered
Parents may need emotional support

Patient Education and Prevention
Use condoms properly and consistently
Avoid sexual intercourse when any lesions are visible
Avoid contact with infected tissue and body fluids of an infected person.
All pregnant women should be tested for syphilis.
Educate treated patients that they can be re-infected

"The clap"
Gram-negative gonococcus
Can grow in warm, moist areas
Reproductive tract (cervix, uterus, fallopian tubes, urethra)
Mouth
Throat
Anus
Transmission through sexual contact with the penis, vagina, mouth or anus of an infected partner. Can also be spread perinatally from mother to baby during childbirth.

Neisseria Gonorrhoeae
Gonorrhea in WOMEN
Most Common S/S in Women
*Many are asymptomatic until complications like PID occur.
Purulent, greenish-yellow vaginal discharge
Dysuria
Urinary frequency
Inflammation & swelling of vulva
Bilateral lower abdominal or pelvic pain
Swollen cervix, secreting a foul-smelling discharge
Intermenstrual bleeding
Pain during intercourse

Female Physical Exam Findings
Purulent vaginal, urethral or cervical discharge
Vaginal bleeding
Cervical friability- tendency to bleed upon manipulation
Cervical motion tenderness during bimanual pelvic exam
Lower abdominal pain

Gonorrhea in MEN
S/S in Men
Greenish-yellow discharge from penis
Burning with urination
Burning in the throat (d/t oral sex)
Painful or swollen testicles
Swollen glands in the throat (d/t oral sex)
*usually appear 2014 days after infection.

Male Physical Exam Findings
Purulent urethral discharge
Epididymitis
Penile edema
Signs and Symptoms of DGI
Arthritis-dermatitis syndrome
Joint or tendon pain
Septic arthritis
Potentially life-threatening

Complications with Pregnancy
Chorioamnionitis, PROM, spontaneous abortion
Infants born to untreated, infected mother may have lower mean birth rate, ophthalmia neonatorum, pharyngitis, arthritis, and gonococcemia.

Diagnosis
Nucleic acid amplification testing (NAAT)
Culture
*Any testing for N. gonorrhoeae should prompt testing for C. trachomatis. Both cause similar clinical syndromes and coexist in a significant proportion of patients

Treatment
For uncomplicated gonococcal infections of the cervix, urethra, and rectum
Ceftriaxone 125 mg IM single dose or
Cefixime 400 mg PO single dose
Combined with Azithromycin or Amoxicillin to address risk of coinfection with chlamydia.
For disseminated gonococcal infection
Ceftriaxone 1 g IM or IV every 24 hr
All sexual partners must be treated
Erythromycin eye drops for newborns

Patient Education
Recommend abstinence for 7 days following treatment
Pt. should tell all recent sex partners (within 60 days prior to the onset of symptoms) so they can be tested and treated.
Prevention with use of barrier methods (condoms)
Surest prevention is abstinence, or a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

GONORRHEA
PELVIC INFLAMMATORY DISEASE
HPV
CHLAMYDIA
SYPHILIS
Statistics on HPV
Approximately 79 million Americans are currently infected with HBV
Approximately 14 million become newly infected each year (HPV is so common that most sexually-active men and women will get at least one type of HPV at some point in their lives)
About 360,000 people in the US develop genital warts each year
More that 10,000 women in the US develop cervical cancer each yea

Pathophysiology
Human papillomaviruses are small, double-stranded DNA viruses that infect cutaneous and mucosal epithelial tissues in the anogenital tract
There are more than 100 types of HBV that exist, of which more than 40 can infect the genital area
Oncogenic, or high-risk HPV types (including HPV types 16, 18,31,33,45), are associated with the development of cervical cancer
Nononcogenic, or low-risk HPV types (including HPV types 6 and 11), will induce only benign genital warts

Nononcogenic HPV Types
HPV types, such as 6 and 11, are the cause of genital warts and recurrent respiratory papillomatosis
Asymptomatic genital HPV infection is common and usually self-limited
According to the CDC, it is estimated that more than 50% of sexually active persons become infected at least once in their lifetime

Genital Warts
Oncogenic HPV Types
HPV types, such as 16 and 18, are the cause of cervical cancers
These types are also associated with other anogenital cancers in men and women (including penile, vulvar, vaginal, and anal cancer, as well as a subset of oropharyngeal cancers)
Presistent oncogenic HPV infection is the strongest risk factor for development or precancers and cancers

Cervical Cancer
Diagnosis
Depending of the type of HPV, is diagnosed through appearance of genital warts or pap smear, colposcopy, or even an HPV DNA test
Pap test- the cervix is swabbed and a sample of these cervical cells are obtained and cultured
Colposcopy- a colposcope is used, in addition to a vinegar solution that is placed on the cervix. The solution turns the abnormal cells (that are HPV infected) white, so they can be easily seen
HPV DNA test- looks directly for the genetic material of the HPV within the sample of cells. This test can determine the type of HPV connected to cervical cancer. Sample used is usually removed at the same time as a Pap test

Treatment
When treatment is indicated, the goal is to relieve symptoms by removing any visible warts and abnormal cells in the cervix
Treatments that may be used include:
Cryosurgery- freezing off warts with liquid nitrogen
Electrocautery- burning off warts with an electrical current
Laser therapy- using an intense light to destroy warts and any abnormal cells
Loop electrosurgical excision procedure (LOOP)- using a special wire loop to remove the abnormal cells
Prescription cream- applying medicated cream directly to warts

Prevention
Two HPV vaccines are licensed in the United States
Cervarix (a bivalent vaccine)- containing HPV types 16 and 18
Gardasil (a quadrivalent vaccine)- containing HPV types 6,11,16,and 18

Both vaccines offer protection against the HPV types that cause 70% of cervical cancers and the quadrivalent HPV vaccine also protects against types that cause 90% of genital warts

Pregnancy and Breastfeeding Considerations
Genital warts can proliferate and become friable during pregnancy
Though rarely, HPV types 6 and 11 can cause laryngeal papillomatosis in infants
Whether cesarean section prevents respiratory papillomatosis in infants is unclear (therefore, cesarean delivery should not be performed solely to prevent transmission of HPV infection in the newboorn
Cesarean delivery is indicated for women with genital warts if the pelvic inlet is obstructed

Patient Education
The use of condoms can help reduce the risk of contracting HPV
Routine screening for women 21-65 years of age for cervical cancer
Get vaccinated. HPV vaccines are safe and effective
Get regular Pap tests. Cervical cancer can be prevented or cured if precancerous changes are detected and treated early
Pregnant women with genital warts should be counseled concerning the low risk for warts on the larynx in their infants (respiratory papillomatosis)

Purulent Discharge
Genital Warts/ Microscopic Cell
Edematous, Friable Cervix that Bleeds Easily
Inflammation of Cervix, Fallopian Tubes
Sores throughout the Hands, Feet, Lips, and Back
More common in women who:
Have multiple sexual partners
Have a history of PID
Had early onset of sexual activity
Had recent insertion of IUD
Douche regularly
References:
American Congress of Obstetricians and Gynecologists. (2011, September). Expedited partner therapy in the management of gonorrhea and chlamydia by obstetrician-gynecologists. Obstetrics and Gynecology, 118, 761-766. Retrieved from http://acog.org/Resources-And-Publications/Committee-Opinions
Batteiger, B. E. (2014, July 21). Screening for chlamydia trachomatis. UpToDate. Retrieved from http://www.uptodate.com
Centers for Disease Control & Prevention. (2014, January). Gonorrhea – CDC Fact Sheet. Retrieved from www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm
Davidson, M. R., London, M. L., Ladewig, P. A. (2014). Olds’ maternal-newborn nursing and women’s health across the lifespan (9th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Division of STD Prevention (2014, January). Pelvic inflammatory disease (PID)-CDC fact sheet. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov
Gay, C. L., Cohen, M. S. (2013, November 6). Prevention of sexually transmitted infections. UpToDate. Retrieved from http://www.uptodate.com
Ghanem, K. G., Hynes, N. A., Bloom, A. (2014, June). Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents. UpToDate. Retrieved from http://www.uptodate.com
Lewis, S. L., Dirksen, S. R. Heitkemper, M. M., Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). St. Louis, MO: Elsevier Mosby
Norwitz, E. R. (2014, March 26). Syphilis in pregnancy. UpToDate. Retrieved from http://www.uptodate.com
Workowski, K. A., Berman, S., Center for Disease Control and Prevention. (2010, December 17). Sexually transmitted disease treatment guidelines, 2010. Morbidity and Mortality Weekly Report, 59 (RR-12), 1-110. PubMed: 21160459
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