ch 56

Ch 56 STDs

•    Overview

•    Also known as STDs and venereal disease – infections spread through sexual activity with a person who is infected; Term STI used to emphasize that a person can be infected without experiencing symptoms

•    Factors attributing to incidence of STIs include:

•     Ignorance of how STIs are transmitted or prevented

•     Asymptomatic sexual partner(s)

•     Casual sex with partner(s) about whom little is known

•     Sex with high-risk partners/more than one concurrent or sequential partner(s)

•     Failure to appropriate contraceptive techniques

•     Sexual contact between infection and manifestation of symptoms

•     Failure to seek early treatment; nonadherence to treatment or failure to refrain from sexual contact until treatment is complete

•     Mutation and resistance of microorganisms to antimicrobial drug therapy

•    Gerontologic Considerations

•    Stereotype that older adults are not sexually active is inaccurate

•    Some older adults with STIs may have limited knowledge of STIs or may be embarrassed to talk about symptoms

•    Older adults in nonmonogamous relationships who are no longer concerned about an unplanned pregnancy are at risk for STIs if they fail to use barrier or chemical contraceptive methods at the time of sexual intimacy

•    Epidemiology

•    Some are undiagnosed and untreated, some are treated and unreported, some are misdiagnosed

•    Reporting is kept confidential and protected from subpoena

•    Difficult to document accurate statistics

•    Occur more often in women than in men.

•    Important to obtain sexual history of clients presenting with signs or symptoms of STI:  sexual partners, sexual practices, pregnancy prevention, protection from STIs, past history of STIs

•    Chlamydia

•    Most common nationally reportable STI disease in the United States

•    Causative microorganism is Chlamydia trachomatis, which is a bacterium that lives inside the cells it infects; invades urethra in women and urethra and epididymis in men

•    Spread by sexual intercourse or genital contact without penetration

•    Tissue irritation may be permanent despite successful eradication of the bacteria and puts individuals at greater risk for acquiring other STIs such as gonorrhea and HIV/AIDS

•    If left untreated, can cause sterility in women who are infected; can be transmitted to infants during birth

•    Can be spread to eyes by autoinoculation; ophthalmic infections can cause granulation of the cornea and blindness

•    Assessment and Management of Chlamydia

•    If symptoms occur, appear 1-3 weeks after infection; sparse, clear urethral discharge, redness and irritation of the infected tissue, burning on urination, lower abdominal pain in women, testicular pain in men

•    Diagnosis made by microscopic exam and culture of secretions; nucleic acid amplification testing (NAAT) detects genetic DNA of the organism

•    Single oral dose of azithromycin or 7-day regimen of doxycycline bid; if they have an allergy to erythromycin, ofloxacin, levofloxacin

•    Nursing – obtaining sexual history, follows precautions for preventing infection transmission, assists in collecting a specimen, explains course of treatment, discusses methods for preventing transmission and reinfection

•    See Client and Family Teaching 56-2, 56-3, pp. 1030-1031

•    Gonorrhea

•    Second most frequently reported sexually communicable infection in the United States; highest incidence occurs in the 15-24 year old age group

•    Many women are asymptomatic, contributing to the spread of disease

•    Caused by bacterium, Neisseria gonorrhoeae, which can be transmitted heterosexually or homosexually; invades urethra, vagina, rectum, or pharynx

•    In untreated men, localized infection may spread to prostate, seminal vesicles, epididymis; urethral strictures may develop requiring dilation of urethra or reconstructive surgery

•    In women, infection may progress to cervix, endometrium, fallopian tubes; symptoms of PID may develop

•    May be transmitted to an infant’s eyes at time of birth; may facilitate HIV transmission

•    Assessment of Gonorrhea

•    More than half of women experience no symptoms; white or yellow vaginal discharge, metrorrhagia due to cervicitis, painful urination

•    Symptoms usually appear 2-6 days after infection in men; urethritis with purulent discharge and pain on urination

•    Painful bowel elimination and purulent rectal discharge with anal infection; sore throat with pharyngeal infection; may have skin rash, fever, and painful if scattered throughout the body

•    Microscopic examination, NAAT testing; C&S(culture and sensitivity)

•     Management of Gonorrhea

•    Resistant to sulfonamides, penicillin, tetracyclines, fluoroquinolones

•    Single IM dose of ceftriaxone; single IM dose of gentamicin plus single dose of azithromycin

•    Oral doxycycline if also infected with Chlamydia trachomatis

•    Sexual partners in preceding 60 days should also be treated

•    May need IV antibiotics and may need multiple doses, just depends on how early caught and bad it is.

•    Complicated infections - hospitalized and treated with IV multiple-drug therapy; repeat therapy with different antibiotics may be required

•    Nursing management and client teaching similar for those clients with chlamydia

•    Syphilis

•    Curable if treated early; can be transmitted from blood of a person who is infected, directly from a lesion, or across the placenta to an unborn infant

•    Caused by bacterium by the spirochete Treponema pallidum; average time between infection and first occurrence of symptoms is 21 days, but may be 10-90 days

•    Untreated, progresses through 3 stages; infectious only during primary and secondary stages; client becomes demented and dies from complications involving other organ systems in third stage

•    Assessment of Syphilis

•    Primary stage – chancre (painless ulcer) appear on genitals, anus, cervix, or other parts of the body, resembling a small papule which later ulcerates; heals in several weeks and progresses to secondary stage if untreated

•    Secondary stage – fever, malaise, lymph node enlargement; rash on truck, back, arms, palms, or soles of feet that do not itch; patchy hair loss, headache, sore throat; all disappear but progress to tertiary stage if untreated

•    Tertiary stage – noninfectious because microorganism invades CNS and other organs of the body; tabes dorsalis( severe CNS infection) , gammas (like skin tags), neuropathic joint disease (Charcot joints)

•    Diagnostic findings – nontreponemal antibody test (rapid plasma regain RPR), venereal disease research laboratory (VDRL) test; cerebrospinal fluid if CNS symptoms develop

•    Management of Syphilis

•    Single dose of parenterally administered penicillin G is used to treat primary and secondary infection; 14-day regimen of tetracycline or doxycycline if allergic to penicillin

•    Multiple doses of treatment for 10-14 days for tertiary; poor response with cardiovascular syphilis

•    Follow-up exams and laboratory tests recommended 3, 6, and 9 months after initial treatment

•    If it goes to the third stage will need multiple doses of antibiotics and if it gets to the heart, then they are going to die.

•    Herpes Simplex Virus Infection

•    Highly contagious STI that is controllable but not curable

•    HSV-1 – associated with cold sores around the nose and lips, can also cause anogenital lesions(cold sores,)

•     HSV-2 – genital herpes; primarily responsible for genital and perineal lesions; increases risk of cervical cancer and infection with HIV

•    Transmission by direct contact with oral or genital secretions from person during active stage, by sexual contact during asymptomatic viral shedding, or by autoinoculation; may also occur from mother to infant during vaginal birth; high rate of neonatal mortality

•    May be introduced into eye, mouth, genital area, skin site

•    Herpes Simplex Virus infection-2

•    Recurs due to virus remaining dormant in the ganglia of the nerves after initial infection; symptoms are usually more severe and subsequent episodes are usually shorter and less intense; shedding viral particles are infectious when virus is active; may also be shed when asymptomatic

•    May have at least one outbreak per year; 5-10 outbreaks per year

•    Stress, emotional situations, exposure to sunlight, menstruation, and fever may reactivate disease

•    Assessment of Herpes Simplex Virus

•    HSV-2 causes single or multiple vesicles on penis, prepuce, buttocks, thighs, introitus, or cervix after a short incubations; lesions burn and itch before becoming fluid-filled blisters; vesicles rupture in 1-3 days and are followed by painful, reddened ulcers that scab over and eventually disappear

•    May be accompanied by swelling of inguinal lymph nodes, flu-like symptoms, and headache; initial attack lasts 3-4 weeks; subsequent attacks usually last 10 days

•    Diagnosis – smears and scrapings from lesions, C&S; polymerase chain reaction testing on cells or fluid from the ulceration or other body fluid to identify DNA

•    Management of Herpes Simplex Virus

•    Acyclovir, valacyclovir, famciclovir; episodic (for 3-5 days to shorten duration, beginning with 1 day of lesion onset or immediately preceding outbreak when aware of early symptoms) or continuously as suppressive therapy to reduce frequency of outbreaks and decrease potential for transmission to others, although client may still transmit virus

•    IV acyclovir for severe episode of HSV-2 or if immunocompromised

•    Can still spread the disease while on antibiotics.

•    Genital Human Papilloma Infection

•    Most commonly transmitted sexual disease in the United States, currently affecting 79 million people; more than 100 strains of HPV, 40 strains can affect genitals, mouth, and throat, 13 strains have potential for causing cancer

•    Strains 6, 11, 16, 18, 31, 33 and 35 cause genital warts (condyloma); AIDS/immunodeficiency more susceptible to strains that cause genital warts; untreated genital warts may resolve on their own, remain unchanged, or increase in size and number

•    Pathophysiology and Etiology of HPV

•    Transmitted by genital-genital, genital-anal, genital-oral contact with person who is infected and may or may not be symptomatic; nongenital contact less likely to transmit HPV

•    Most infections clear within a few years with clinical manifestations; those that persist are linked to various forms of cancer

•    Genital HPV can be transmitted to infant’s respiratory passages at time of delivery

•    Associated with uterine cervical abnormalities, leading to cervical, penile, anal, oropharyngeal cancer

•    Strains of HPV that cause genital warts are different than those that cause cervical cancer

•    Assessment of HPV

•    Most people do not have symptoms if their immune system is functioning optimally

•    Virus may lead to cancerous changes over time

•    Genital warts are usually painless and appear as a single lesion or cluster of soft, fleshy growths on genitalia, cervix, vagina, perineum anus, throat, mouth; may be so small that they are inconspicuous or large and raised, resembling a cauliflower

•    Large genital warts may narrow or obstruct the urethra, vagina, anus, or throat

•    Genital warts turn white when vinegar is applied to the lesion, which is then examined with magnifying glass

•    Management of HPV

•    No antivirals for treatment; abstaining from sex or using protection (condom or dental dams); vaccination before sexual activity occurs

•    Local treatment for genital warts – podofilox solution or gel, imiquimod cream

•    Removal of warts by surgical excision with scalpel or scissors, laser therapy, electrocautery, cryotherapy with liquid nitrogen, local applications of chemicals (trichloroacetic acid, bichloroacetic acid, podophyllin resin in tincture of benzoin, 5-fluorouracil cream), parenteral administration or natural or recombinant interferon

•    Nursing Management of HPV

•    Nurses provide information about transmission of STIs to sexually active people and prepare those with possible STIs for medical examination, diagnosis, and treatment. It is important to have continued assessment for the development of cervical, anal, penile, and oropharyngeal cancers that are associated with an HPV infection.

•    Avoid intimate contact until the warts are removed.

•    Advise all sexual contacts to be examined and treated.

•    Seek treatment at an STD/STI clinic or with a private primary provider when, and if, the warts return.

•    Use a condom even when the lesions are absent (see Client and Family Teaching 56-2), and suggest that the sexual partner wash their genitals or other skin areas immediately after intimate contact; condoms may not fully protect against HPV transmission when all areas of the penis are not fully covered.

•    Provide information about the diagnosis and treatment in future health histories, especially if a pregnancy occurs.

•    Avoid stress and genital trauma, which appear to be factors in reactivating the virus

•    Zika Virus

•    Usually infected through bit of female mosquitoes belonging to species that require blood to lay their eggs; may also be spread through sexual contact

•    Woman infected can transfer virus to unborn fetus at any time during pregnancy; infected infant is likely to be born with microcephaly, developmental delays, mental retardation, other neurologic effects

•    Diagnosis made by identifying presence of virus in semen, vaginal, and cervical mucus with a reverse transcription PCR test

•    Chancroid

•    Caused by Haemophilus ducreyi bacillus

•    Characterized by appearance of macule, followed by vesicle-pustule formation, and finally a painful genital ulcer and enlarged, tender lymph nodes in the inguinal area

•    Treated and cured with azithromycin, ceftriaxone, ciprofloxacin, or erythromycin