name the 5 componants of STD prevention and control.
pre-exposure vacination
identify persons unlikely to seek evaluation
education and counseling of persons at risk (including partners)
diagnois and treatment
evaluation, treatment
what is the adolescent risk of aquiring an STD (chlamydia, gonorrhea or trich)?
1 in 4
In regards to minors access to STI (sexually transmitted infections) which statements are true?
minors may consent to STI services, including HIV testing
Minors can not consent to HIV treatment
Minors are not required to notify parents
all true
they can be tested but not treated and do not have to notify parents of the test results.
What are the 5 P's of STD prevention?
Partners: men/women/both? # in last 12 months
Prevention: contraception
Protection: safe sex
Practices: what type of sex are they engaged in?
Past history: of infection or infected partner
Problems : patient or partner IV drug use, sex 4 $.
Condoms are 80% effective in preventing sexual transmission of HIV and can reduce risk of the STD's and PID. They are more effective in preventing infections transmitted by fluids from mucosal surfaces then those transmitted by skin-skin contact. what STD's are condoms more effective in preventing?
fluid transmission GC,CT, Trich & HIV (80% effective)
less effective with those that are aquired through skin-skin like
HSV (only 30% preventative)
HPV (only 70% effective
Are condoms lubricated with N-9 recommended for STD/HIV prevention?
NO.
frequent use is associated with disruption of genital epithelium =increased UTI's
(N-9 is monoxinil 9)
what does the lower rate of reported chlamydia among men suggest?
sex partners of infected women are not being identified or treated.
what is the most common BACTERIAL STD in the US?
chlamydia
Risk factors: age 20-24 AA, OCP (birth control pills) may coexist with other STD, inflammation of pap
What STD might this be?
Chlamydia
A client presents with mucopurulent cervicitis or discharge (yellow, white or amber), a friable edematous cervix. She denies dysuria, urinary frequency, noticed discharge, adnexal, uterine or cervical pain. what might this be?
chlamydia (75% of women reprot no sx.)
what are the CD recomendations for screening for chlamydia?
all sexually active females <26yrs old
all women with inconsistent or no use of barrier contraceptives
all women with new or multiple sex partners
all pregant women
what is the big deal about chlamydia and pregancy?
can cause blindness in a new born!
how do you dx chlamydia?
PAP-culture for antigen antibody repsonse
URINE TEST nucleic acid amplification test-1st void urine and only 10 ml. must not have voided in the last 2 hours, the longer since last void the better.
complications assoicated with chlamydia?
PID
INFERTILITY
D/T tubal scarring
ECTOPIC PREGNANCY
5x increase in contracting HIV
BABY:prematurity, conjunctivitis, pneumonia
treatment of chlamydia?
treat for gonorrhea if culture not done
azithromycin 1gm PO X1 (ok with pregancy)
alternative doxycline 100mg PO bid x7 days
Amoxicillin 5600 mg TId x7days (ok with pregnancy)
Abstain for intercourse until 7 days after tx started.
when treating chlamydia in pregnancy what antbx should you NOT use?
doxycycline
(choose azithormycin or amoxicillin instead)
what are the CDC treatment recommendations for follow up after treatment for chlamydia?
follow up "not needed"
If symptoms return or high risk or pregnanct then follow-up like this: TOC 3 weeks after tx--rescreen 3 months after tx ESPECIALLY adolescents & pregnant women.
retest high risk women in 3rd trimester
risk factors for Gonorrhea are similar to chlamydia since they tend to coexist. what are they?
Afe 15-24
Drug use
hx of past exposure (may coexist with other STD's)
muliple partners
no prenatal care
Gay and Bi men
AA
gonorrhea symptoms include
dysparenunia
low Abdominal pain/discomfort
YELLOW GREE PURULENT DISCHARGE
dysuria and frequency
tender bartholin glands/skeens glands in women ages 15-24
painful swollen testicles in males
most Gonorrhea infections that recurr following treatment result from re-infection not failure of cure. So do you need to retest (TOC)?
nope. if symptoms don't return and partners have been tested/treated it should be done.
However if high risk then TOC in 3-4 weeks and again at 3 months.
how far back do you go for partners in recommending they get checked when your client is postive for gonorrhea?
go back 60 days. if no partner in last 60 days treat last partner.
how is HPV transmitted?
skin to skin so condoms are not as effective in prevention.
the type of HPV that causes genital warts is not the type that causes cancer . True or false?
true
what type of HPV causes 90% of genital warts?
6 & 11
what kind of HPV cause cancer?
types 16,18,31,33,35 & 45
where does squamous cell cervical carcinoma occur?
at the transformation zone at squamolcolumnar junction.
Guardasil is recommended for women ages 9-26 it is a 3 dose series. intitial injections, then again @ 2 months than final @ 6 months. It is quadrivalent and protects against which HPV ?
16,18, 6 & 8
CERVARIX is similar to Guardisil in side effect. is also a 3 dose series ( 0, 1 & 6 months) and is approved for females ages 11-25. It potects against which HPV?
16 & 18
also believed to proect agains 31, 33 & 35.
most cases of first episode genital herpes are caused by ?
HSV-1
most cases of recurrent genital herpes are caused by ?
HSV-2
herpes lies dormant in the dorsal root ganglion making it a recurrent incurable viral disease. true or false?
true
how is herpes transmited?
skin to skin-oral vaginal and anal--condoms have limited assistance
direct contact, kissing-sexual contact
client presents with multiple ulcerations in the vaginal area. They are in several locations and they are vaiable in size. there is some inguinal adenopathy and pain. there are complaints of malaise, myalgia headache a fever. what might this be?
genital herpes primary out break will last about 14-28 days
what are the differences between recurrent and primary herpes?
primry lesions are more diffuse and larger. duration lesions tend to last 14-28 days while recurrent last 5-10 days and get prodromal sxs 12-24 hours before the outbreak.
Herpes primary outbeaks usually occur within 2 weeks of transmission. asymptomatic shedding is greatest when?
when outbreak resolves!
it is hard to culture herpes. where is the best place to get a good culture?
the vesicle or the ulcer, but the vesicle is best.
how are HSV recurrent episodes best confirmed?
viral culture but only have 2-3 days to catch viral shedding with recurent outbreaks.
serilogical testing
symptoms and clinical presentations
r/o syphillis, condylomata and chancroid.
what is the treatment for herpes?
Acyclovir (zovirax) 400/800 TID 5days/2 days
Famiciclovir (Famvir) 125/1000BID 5deays/1day
Valacyclovir (Valtrex) 500BID 2days/3days
Valacycloriv (Valtrex) 1g BID x1 day
treatment must begin during prodrome or w/i 1 day of onset of lesions
acyclovir and famiciclovir ok with pregancy they prevent 70% recurence and 90% viral shedding.
what is the treatment for primary herpes-first clincial episode?
acyclovir 400mg TID or 200mg 5x/day 7-10 days
famcycilovir 250mg TID 7-10 dyas
valacyclovir 100mg BID 7-10days
what is the episodic therapy recommendations for herpes?
acyclovir 400mg 2x daily for 5 days or 800mg TID x2 days or 800mg BID x5days
famiciclovir 125 BID x5days or 1000mg BID x 1 day (within 6 hours of prodrom or sx)
Valacyclovir 500mg on day 1 then BID for 2 days or BID x3 days or 1000mg 1x daily x5days
what is the therapy for daily suppression of genital herpes?
Acyclovir 400 mg BID
Famciclovir 250mg BID
Valacyclovir 500 mg dialy
or Valacyclovir 1gm daily for use with patient with >/= 10 outbreaks a year
dosing for 9 mo-2yrs
which STD is caused by a spirochete?
syphilis
which STD's are skin 2 skin transmitted?
syphilis, HSV & HPV
Which STD's are transmitted through mucous member or fluids?
*condoms are very effective at providing a barrier to transmission of these
Gonorrhea, clamydia, trich, HIV
Client has the following risk factors which lead you to consider which STD? IV drug use, multiple partnersw, MSM, AA
syphilis
Clent has the following risk factors which lead you to consider which STD? Age < 25,unprotected sex, early age of activity, multiple partners, immunocomprosed, uncircumsided male.
Trichaomonas
this STD is a flagellated protozoan, which one is it?
Trichomonas
STD is usually harbored in male urethra and it prefers a high pH symptoms usually appears 5-28 days after exposure, which one is it?
Trichomonas
These STD's invate tissue which causes erythema and friable lesions which ones are they?
HPV, TRich & Clamydia
Client has strawberry cervic which STD should you consider?
Trich
This client has gellow-Green purulent drainage and tender or inflmmed Barhtolin and skenes glands what STD are you considering testing her for?
Gonorrhea
This 21 year old client exchanges sex for money and comes in for a check up. She denies any symptoms buty you notice mucopurulent discharge that is white clear or amber and a friable cervix, what STD do you think she might have?
Chlamydia
what STD's can you run off a PAP?
Chlamydia, Gonnorrhea, HPV
What is the treatment for Tichomonas?
Flagyl (metrondazole) 2 gm PO x1 or
Tinidazole (Tindamax) 2gm PO x1
What is an improtant teaching point with Trichomonas treatment (flagyl or tinidazole)?
no ETOH for 24 hours after dose of flagyl
no ETOH for 72 hours after tinidazole
*flagyl is ok with pregancy
Client has risk factors for STD. On exam you find a friable cervix that is very red. she has some dysuria and yellow green discharge, she thinks she might have a UTI. what symptoms point you to STD rather than UTI or bacterial vagenitis?
no sytemic symtoms like fever or maliase, which are usually assoc with UTI
Red cervic and inflammation are not characteristic of vagenitis
the yelow green discharge, red and inflammed cervic and sysparenuria are more suggestive of Trichomonas infection. run a rapid trich test.
what is the incubation period for HPV?
3 weeks to 8 months
is HPV bacterial or Viral?
Viral
Are you infected for life with HPV?
maybe maybe not.. your body can clear it some do not. factors that inhibit clearing include, stress, smoking and comorbidities like being immunocompromised or immunosuppressed.
what are some diferential DX to consider when client presents with vaginal warts, external?
Other infections:condylom lata--warts that are smooth, moist, rounded and darkfield + for T pallidum (syphilis). molluscum contagiosum- caused by a px these are papules with central dimple rarely on mucosal surfaces
Aquired derm conditions: like Seborrheic Keratosis, Lichen Planus, polyps or a nevus.
Normal anatomic varients: pink pearly penile wart or a skin tag.
Client is HPV + how do you dx cervical abnormalities?
colposcopy/biopsy of
outward growing lesion
when PAO HSIL + or ASC-H+ or LSIL+
How do you treat vaginal wart that occur or worsen during pregnancy?
unless they are problematic you don't . If needed use Cryotherapy, TCA/BCA or surgery. no topicals.
How do you treat Vaginal warts?
crotherapy or TCA/BCA acid 80-90% cure rate
How would you treat urethral or meatal warts?
Cryotherapy or podophyllin . only 10-25% cure rate
How would you treat anal warts?
cryotherapy
TCA/BCA acids
or surgery
What are the treatment options with external warts?
podofilox o.5 solution/gel
Imiquimud 5% cream
Sinecatechnins 15% oint (don't use condoms or diaphram while using this product, do not use if you have herpes or HIV.
Gonorrhea discharge is__________
Chlamydia discharge is ________________
Trichomonas discharge is _________
HSV presentations is ______________
HPV presentation is _______________
syphilis presentations is ______________
Gonorrhea discharge is mucopurulent yellow green
Chlamydia discharge is white, amber, clear
Trichomonas discharge is maloderous frothy green yellow
HSV presentation is lesions multiple varied primary few and inone area secondary
HPV presentation is warts
Syphillis is a smooth base rounded border chancre or rash on palms of hands and soles of feet.
treatment for gonorrhea
cefTRIAXONE 250mg IM x1
or cefIXIME 400mg PO x1 plus Azythromycin 1gm PO x1
the only STD that requires serial testing and follow up?
syphillis
how can you differentiate primary herpes outbreaks from secondary outbreaks?
duration: primary lasts 14--28 days while secondary lasts only 5-10.
When are herpes outbreask more frequent?
during the first year following the 1st recurrent or HSV2 outbreak.
Who is candidate for seriological testing for herpes?
persons who have clinical sx or hx suggestin HSV
sx present but client does not believe you
anyone STD screen should include a herpes test
when partner(s) are known to be +
Pregnant woman @ risk
When should you consider suppression therapy for a client with Herpes?
when outbreaks are frequent, cause anxiety, depression, or otherwise disrupt quality of life.
consider tx for 9mo-2years reassess after 1 yr.
famcyclovir is least effect for supprssion.
What are some comfort measure clients can use during an outbreak?
oral analgesics/topical anesthetics
sitz bath in burrows solution
perineal squirt bottle with cold water use while voiding
hair dryer
tea bags
loose cotton clithing and undies
with herpes episodic treatmetn reduces viral shedding by how much?
only 1-2 days.
what is the episodic treatment for recurrent herpes.
2 days of Acyclovir 800mg TID
1 day of Famcyclovir 1g BID (must start w/i 6 hr onset)
1x on day one then 2 days BID of Valacyclovir 500mg
which STD's are viral?
Herpes, HPV,
Which STD's are bacterial?
Syphilis, Gonorrhea, Chlamydia
Is Trichomonas bacterial or Viral
It is a protozoan
an STD with symptoms of yellow or gray vaginal discharge, vaginal itching, smelly vaginal discharge, and painful urination
Trichomonas
As many as 1 in 4 men with chlamydia have no symptoms. In men, chlamydia may produce symptoms similar to gonorrhea. Symptoms may include:
Burning sensation during urination
Discharge from the penis or rectum
Testicular tenderness or pain
Rectal discharge or pain
Only about 30% of women with chlamydia have symptoms. Symptoms that may occur in women include:
Burning sensation during urination
Painful sexual intercourse
Rectal pain or discharge
Symptoms of PID, salpingitis, liver inflammation similar to hepatitis
Vaginal discharge
What is the risk of not dx someone with chlamydia?
PID-infertility
increase risk for HIV
Premature births
Baby may have conjunctiviits within `1-5 days of delivery or they could develop afebrile pneumonia between 1-3 months following birth.
screening recommendations for Chlamydia?
re-screen teens at 3 weeks & 3 months folling treamtent
rescreen pregnant women 3 months following treatment and during 3rd trimester.
