STD and Infections Review

Question 1

Danger Signals: Acute HIV Infection Overview

Answer 1

Aka Acute Retroviral Syndrome
- ~10-60% of individuals w/ early HIV infection may be asymptomatic
- takes approx 2-4 wks to develop sx
- most people (97%) develop antibodies within 3 months after exposure

• Initial immune response may mimic mononucleosis (fever, headache, sore throat, lymphadenopathy, rash, joint ache, myalgia; may be accompanied w/ diarrhea and weight loss)
• may have painful ulcerative lesions in mouth d/t HIV for from coinfection w/ herpes simplex, sphyilis, or chancroid
• Very infectious d/t extremely high viral load (>100,000 copies/mL) in blood and genital secretions
• If acute HIV infection is strongly suspected → order HIV RNA polymerase chain reaction (PCR) test, which can detect infection 7-28 days after exposure

Question 2

Danger Signals: Acquired Immunodeficiency Syndrome

Answer 2

• Without treatment, people w/ AIDS typically survive ~3 years
• Without antiretroviral therapy, HIV infection usually advances to AIDS within 10 years

AIDS = absolute CD4 cell count of <200 cells/mm3 + certain opportunistic infections and malignancies
- CD4 levels in health people range from 500-16,000 cells/mm3

S/Sx suggesting AIDS:
- caused by AIDS-defining opportunistic infections such as oral candidiasis, TB, pneumocystis jirovecii PNA, CNS toxoplasmosis, histoplasmosis, cryptosporidiosis, Kaposi’s sarcoma (purple-bluish-red bumps on skin
* P. jirovecii is infection causing most deaths in HIV pts

Question 3

Danger Signals: Disseminated Gonococcal Infection

Answer 3

• Very small percentage (0.5-3.0%) of individuals w/ gonococcal infection may progress to disseminated gonococcal infection (DGI)

S/Sx
sexually active adult from high-risk population c/o:
- petechial or pustular skin lesions of hands/soles (acral lesions)
- tenosynovitis
- swollen, red, and tender joints

In young, healthy patients w/ new-onset:
- polyarthralgias
- polyarthritis
OR
- oligoarthritis (arthritis in one large joint such as knee) → DGI is one of the most common causes
* Look for characteristic skin lesions of DGI
- may be accompanied by signs of STD (e.g., cervicitis, urethritis)

If pharyngitis, will have severe sore throat w/ green purulent throat exudate that does NOT respond to usualy antibiotics used for strep throat

• Occasionally complicated by perihepatitis (Fitz-Hugh-Curtis syndrome)
• Endocarditis (rare)
• meningitis (rare)

► Refer to ID specialist

Question 4

STD Screening Recommended by CDC (2020)

Answer 4

Complications of untreated STD/STI are:
- infertility
- ectopic pregnancy
- congenital infections
- cervical cancer
- chronic pelvic pain
- chronic hepatitis
- chronic syphilis
- HIV/AIDS

Some STDs (e.g., chlamydia, gonorrhea, and genital herpes) can be passed from mother to infant during vaginal delivery
- Others (HIV, herpes, syphilis, and hepatitis) can cause serious congenital infections in fetus)

• ~20 million new STD infections every year; almost half are in young people, age 15-24
• Routine annual screening of all sexually active females aged ≤25 for chlamydia trachomatis and gonorrhea → If infected, retest for chlamydia and gonorrhea 3 months after treatment (to check for reinfection, not for test-of-cure)

-Annual testing for syphilis, chlamydia, and gonorrhea in persons w/ HIV infection

• Minors do NOT need parental consent if clinic visit is r/t testing or treating STDs and birth control; NO state requires parental consent for STD care
• PE for STDs includes inspection of skin, pharynx, lymph nodes, anus, pelvic/genital area, and neurologic system

Question 5

Men who have Sex with Men

Answer 5

• Annual screening of chlamydia & gonorrhea at sites of contact (urethra, rectum), regardless of condom use
• screen Q3-6 months if at increased risk
  -annual screening recommended for pharyngeal gonorrhea (throat); screen Q3-6 months if at increased risk
• Annual testing recommended for HIV, syphilis, hepatitis B surface antigen (HBsAg); retest for frequently if at risk
• If hx of anal-receptive intercourse, an anoscopy can be offered as part of STD care

Question 6

STD: Pregnant Women

Answer 6

• Screen pregnant women for HIV, chlamydia, gonorrhea, syphilis, and HBsAg at first prenatal visit
• pregnant women treated for chlamydia/gonorrhea should have a test-of-cure within 3-4 weeks after treatment
• Retest at 3 months for chlamydia and gonorrhea (check for reinfection, not test-of-cure)

Question 7

STD Risk Factors

Answer 7

• Younger ages (females aged 15-24); sex initiated at a younger age
• Multiple sex partners; new sex partner in past 60 days
• Inconsistent condom use; unmarried stats
• Hx of previous STD infection; illicit drug use
• Genital ulceration (↑ risk of HIV transmission)
• Use of alcohol or illicit drugs
• adolescents

Question 8

Chlamydia Trachomatis
1. Definition/Etiology/Guidelines
2. Possible sites of infection & complications
3. Labs/Diagnostics

Answer 8

1. • an obligate intracellular bacteria (atypical bacteria)
     - most chlamydial infections are asymptomatic
     - highest prevalence: among persons ≤ 25 years
     - MOST common STD in US
     - Annual screening of all sexually active women <25 years if recommended as is screening of older women at ↑ risk of infection (e9g.,partners, or a sex partner w/ STI)
     - During first prenatal visit, screen all pregnant women <25 years and older pregnant women at ↑ risk
     - Rescreen younger women <25 years in 3rd trimester
2. • Females: Cervicitis, endometritis, salpingitis (fallopian tubes), PID
     - Males: epididymitis, prostatitis
     - Both genders: Urethritis pharyngitis, proctitis (from receptive anal intercourse)
     ** Up to 20% of women w/ cervicitis d/t gonorrhea will develop PID!

Complications:
- PID
- tubal scarring
- ectopic pregnancy
- infertility
- Reiter’s syndrome (males)
- Fitz-Hugh-Curtis syndrome

3. • NAATs are highly sensitive tests for both gonorrhea and chlamydia; be CAREFUL to use correct NAAT testing kit → Swab samples (vagina, cervix, urethra, rectum, pharynx) or urine specimen can be collected for both males and females
     - Vaginal swab specimens can be collected by a provider or self-collected in a clinical setting; self-collected vaginal swab specimens are equivalent in sensitivity and specificity to those collected by clinician using NAAT
     - Preferred diagnostic test for men: URINE SPECIMEN for NAAT → collect first part of urinary stream (15-20 mL) from the first void of the day
     - For samples of pharynx or rectum, swab using NAAT test
     - Another option for gonorrhea is to order gonorrheal culture (Thayer-Martin or chocolate agar), which takes 2-3 days
     - Chlamydial cultures are NOT used in primary care (use NAAT test)
     - Gram stain (symptomatic men): If pt shows urethritis sx, obtain Gram stain → Polymorphonuclear leukocytes w/ Gram- intracellular diplococci can be used for males w/ gonorrheal urethritis (considered diagnostic) → not commonly used in primary care

** NAAT can detect HIV infection in 7-28 days!

Question 9

Chlamydia Trachomatis
4. Treatment Plan: Uncomplicated Infections
5. Treatment for Sexual Partners
6. Treatment for Pregnant women

Answer 9

4. Chlamydia (Cervicitis, Urethritis [Nongonococcal Urethritis], Sexual Partners)
   - No test-of-cure is necessary for azithromycin or doxycycline regimen
   - FIRST LINE: Azithromycin 1 g PO x single dose (directly observed therapy preferred)
   OR
   - doxycycline 100 mg BID x 7 days
   → Swallow w/ large amount of water; doxycycline may cause esophagitis if tablet gets stuck in throat (difficulty and/or pain w/ swallowing, acute-onset heartburn, N/V)
   → Nausea, GI upset, photosensitivity (avoid sun/use sunscreen)
   → category D drug (stains growing tooth enamel)
   → Advise pt treated w/ 1 dose of azithromycin that it takes up to 7 days for treatment to become effective

*** If STD treated w/ azithromycin 1 g x 1 dose (chlamydia), instruct pt and partner to abstain from sex for at least 7 days

If cervicitis, perform bimanual exam to assess if infection ascended to upper genital tract (R/O PID)

5. • Administer azithromycin 1 g PO x single dose
     - Patient and partner abstain from sex for 7 days
     - Expedited partner therapy (EPT) is practice of treating sexual partner(s) of a patient diagnosed w/ STD w/out sexual partner being seen or evaluated by healthcare provider
     - EPT is permissible in 45 states, District of Columbia, and Commonwealth or the Northern Mariana Islands
     → EPT is potentially allowable in 4 states, Puerto Rico, and Guam
     → EPT is likely prohibited in 1 state (NC)

→ Refer to CDC website to confirm if EPT is legal in your state

6. • Azithromycin 1 g PO x single dose OR
     - Amoxicillin 500 mg PO TID x 7 days
     * Test-of-cure recommended 3-4 weeks after treatment and retest again in 3rd trimester

Question 10

Neisseria Gonorrhoeae
1. Definition/Etiology
2. Clinical Presentation
3. S/S (by site)

Answer 10

1. • Gram- infecting urinary and genital tracts , anorectum, pharynx, and conjunctiva (gonococcal ophthalmia neonatorum)
     - unlike chlamydia, gonorrhea can become systemic or disseminated if left untreated
     - ALWAYS cotreat for chlamydia when treating gonorrhea (even if negative chlamydial tests) d/t high rate of coinfection
     - women more likely to be asymptomatic or present w/ PID
     - males are more likely to present w/ urethritis
     -During first prenatal visit, screen all pregnant women <25 years and older pregnant women at increased risk
     - Rescreen again in 3rd trimester
2. • hx of new sexual partner <3 months or multiple partners w/ inconsistent or no condom use
     - during speculum exam, cervix can appear normal or w/ purulent discharge
     - may bleed easily (friable)
     - Males w/ urethritis may have penile discharge and dysuria
     - may report staining of underwear w/ green purulent discharge
     * S/Sx depends on site infected
3. • Cervicitis → mucopurulent cervix, pain, mild bleeding after intercourse
     - Urethritis → scant-copious purulent discharge, dysuria, frequency, urgency
     - Proctitis → pruritis, rectal pain, tenesmus, urge to defecate even if rectum is empty, or avoidance of defecation d/t pain
     - Pharyngitis → severe sore throat unresponsive to typical antibiotics, purulent green-colored discharge on posterior pharynx
     - Bartholin’s gland abscess → cystic lump that is red and warm or has purulent discharge that is located on each side of introitus or vestibule
     - Endometritis → menometrorrhagia, or heavy, prolonged menstrual bleeding
     - Disseminated gonococcal infection → petechial or pustular skin lesions of hands/fingers, asymmetric polyarthralgia, tenosynovitis, oligoarticular septic arthritis (arthritis-dermatitis syndrome), or meningitis, or endocarditis
     - PID (see note card “Complicated Gonorrheal Infections”)
     - Epididymitis and prostatitis

Question 11

Neisseria Gonorrhoeae
4. Labs/Diagnostic

Answer 11

4. • see labs for C. trachomatis
     - Another alternative is gonococcal culture (Thayer-Martin medium)
     - Retesting is recommended at 3 months after tx for all pts d/t high rates of reinfection

Question 12

Syphilis
1. Definition/Etiology
2. Clinical Presentation
3. Stages

Answer 12

1. • screen for syphilis if HIV infection, men who have sex w/ men (MSM), presence of genital ulcer esp if painless chancre, previous STD, pregnancy, intravenous drug user, or high risk
     - majority are males
     - Treponema pallidum (spirochete) infection becomes syetemic if untreated
2. S/Sx
   - Depends on stage (see below)
3. Stages:
   Primary
   - painless chancre (heals in 6-9 wks if not treated)
   - chancre has clean base, well demarcated w/ indurated margins

Secondary (>2 years)
- Condyloma lata (infectious white papules that looks like white warts] in moist areas)
- maculopapular rash in palms and soles, not pruritic (may be generalized)

Latent stage
- Asymptomatic

Tertiary (3-10 years)
- neurosyphilis
- gumma (soft tissue tumors)
- aneurysms
- valvular damage

Question 13

Condyloma Lata

Answer 13

infectious white papules that looks like white warts] in moist areas

Question 14

gumma

Answer 14

soft tissue tumors

Question 15

Syphilis
4. Labs/ Diagnostics

Answer 15

2 types of syphilis serologic tests:
- treponemal
- nontreponemal
→ required to diagnose syphilis

Step 1: Order screening test (nontreponemal test)
- Rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL).
- If reactive, order confirmatory test

Step 2: Order confirmatory test (treponemal test)
- Fluorescent treponemal antibody absorption (FTA-ABS), microhemagglutination test for antibodies to T. pallidum (MHA-TP), T. pallidum particle agglutination assay (TPPA), etc
- + darkfield microscopy (not commonly use anymore)
* If BOTH RPR and VDRL (nontreponemal test) and FTA-ABS (or other treponemal test) are REACTIVE → Diagnostic for syphilis

During tx, if initial test used is RPR, order sequential RPR to document tx response
- If initial test is VDRL, order sequential VDRL; use same laboratory to monitor*
- If RPR or VDRL shows a fourfold or higher (>1:4) ↓ in titers, pt is responding to tx

Question 16

Syphilis
5. Treatment Plan (per stage)
- Tx for pregnancy
6. Follow-up

Answer 16

Primary Syphilis (chancre), Secondary Syphilis, or Early latent Syphilis (<1 year)
- Benzathine penicillin G (Bicillin L-A) 2.4 million units IM x 1 dose

Latent Syphilis (>1 year), Latent Unknown Duration, Tertiary w/out evidence of neurosyphilis
- Benzathine penicillin G 2.4 million units IMV once per week x 3 consecutive weeks
- PCN allergy → Doxycycline or tetracycline x 28 days
- If neurosyphilis → ceftriaxone
- Use therapies w/ close clinical and lab follow-up
→ Refer to specialist

Pregnancy
- Same treatment as nonpregnant
- For PCN allergy → refer to allergist of PCN desensitization
- Screen ALL pregnant women; repeat at 28 wks and at delivery

6. • Recheck RPR or VDRL at 6 & 12 mons after treatment (look for at least a fourfold ↓ in pretreatment and posttreatment titers)
     - Treat sex partner(s) from previous 90 days before pt’s diagnosis even if their RPR or VDRL is negative
     - Test pt and partner(s) for HIV and other STDs
     - Refer to ID specialist for suspected neurosyphilis, poor response to treatment, PCN allergy, or if primary clinician is not familiar w/ syphilis management

Question 17

What are the screening tests for syphilis?

Answer 17

RPR and VDRL

Question 18

If positive RPR and VDRL, what should you order next?

Answer 18

RPR and VDRL (nontreponemal tests)

Confirm w/ FTA-ABS (treponemal test)

If reactive RPR and reactive FTA-ABS, this is diagnostic for syphilis

Question 19

What should you always cotreat when treating gonorrhea? With what medication(s)?

Answer 19

Chlamydia

Ceftriaxone 250 mg IM x 1 dose (for both uncomplicated and complicated cases) + cotreated w/ chlamydia

Question 20

Condyloma acuminata vs condyloma lata

Answer 20

Condyloma acuminata = genital warts
Condyloma lata = secondary syphilis

Question 21

What stage of HIV infection is very infectious?

Answer 21

acute retroviral syndrome (or primary HIV infection) w/ flu-like or mono-like infection is VERY infectious at this stage of HIV infection
- BEST if HIV is treated as early as possible

Question 22

How long will NAAT remain positive for?

Answer 22

2-3 weeks after treatment d/t presence of nonviable organisms

Question 23

What can cause an false-positive RPR?

Answer 23

• Pregnancy
• Lyme disease
• autoimmune diseases
• chronic/acute disease

Question 24

When should you recheck syphilitic chancre after injfection?

Answer 24

3-7 days, should start healing

Question 25

When should nontreponemal titers decline?

Answer 25

RPR or VDRL usually decline after treatment - in some persons, nontreponemal antibodies can persist for a long time (serofast reaction) - most pts w/ reactive nontreponemal tests will be reactive for the rest of their lives (low titers) but ~15-25% revert to being serologically nonreactive in 2-3 years

Question 26

CDC-Recommended STD Treatment Regimens: Uncomplicated Gonorrheal Infections of the Cervix, Urethra, Rectum, and Pharynx + Tx of sexual partners

Answer 26

First line: - Ceftriaxone (Rocephin) 250 mg IM X 1 dose + co treat for chlamydia - Azithromycin 1 g PO x 1 dose OR doxycycline 100 mg PO x 7 days - Test-of-cure (i.e., repeat testing 3-4 weeks after treatment) is not needed (except pregnant woman); if sx persist, obtain specimen for gonococcal C&S Management of Sexual Partners: - Treat male partners of women w/ PID if sexual contact during the 60 days preceding pt's sx - Avoid sex until both partners finish tx and no longer have sx

Question 27

CDC-Recommended STD Treatment Regimens: Chlamydia trachomatis 1. Uncomplicated 2. Complicated

Answer 27

1. Indications: - Mucopurulent cervicitis - Urethritis - Sexual partner tx Tx: - Azithromycin 1 g x 1 dose OR - doxycycline 100 mg BI x 7 days Pregnancy: azithromycin 1 g x 1 dose 2. Indications: - PID - salpingitis - tubo-ovarian abscess - epididymitis - prostatitis - males Tx: - Doxycycline 100 mg BID x 14 days

Question 28

CDC-Recommended STD Treatment Regimens: Gonorrhea 1. Uncomplicated 2. Complicated

Answer 28

Neisseria gonorrhoeae 1. Indications: - Mucopurulent cervicitis - urethritis - proctitis - sexual partner treatment Tx: - Ceftriaxone 250 mg IV x 1 dose + azithromycin 1 g x 2 dose OR - doxycycline 100 mg BID x 7 days Pregnancy: - Ceftriaxone 250 mg IM x 2 dose + azithromycin 1 g x 1 dose 2. Indications: - PID - salpingitis - tubo-ovarian abscess - epididymitis - orchitis - prostatitis - disseminated gonorrhea - asymmetric arthritis and maculopapular rash - males Tx: Ceftriaxone 250 mg IM x 1 dose + doxycycline 100 mg BID x 14 days ** Use Ceftriaxone (Rocephin) 250 mg IM x 1 dose for BOTH uncomplicated and complicated gonorrheal infection ** ALWAYS cotreat for chlamydia if gonorrheal test is positive!! BUT inverse is NOT true; if chlamydia, do NOT give prophylaxis against gonorrhea unless indicated

Question 29

CDC-Recommended STD Treatment Regimens: Syphilis 1. Uncomplicated 2. Complicated

Answer 29

1. Indications: - primary or secondary syphilis - early latent <1 year - sexual partner treatment Tx: Benzathine penicillin G 2.4 mU IM x 1 dose * Retreat if clinical signs recur or sustained fourfold titers 2. Indications: - >1 year duration or latent syphilis - neurosyphilis → refer Tx: Benzathine penicillin G 2.4 mU IM weekly x 3 consecutive weeks * Follow-up of cases is mandatory (any stage of ds)

Question 30

Complicated Gonorrheal Infections: 1. Indications 2. Treatment

Answer 30

1. - PID - Acute Epididymitis - Acute Prostatitis - Acute Proctitis 2. - Ceftriaxone (Rocephin) 250 mg IM x 1 dose + cotreat for chlamydia - Doxycycline 100 mg PO BID x 14 days w/ or w/out metronidazole (Flagyl) 500 mg PO BID x 14 days If Disseminated Gonococcal Infection (Arthritis-Dermatitis Syndrome, Meningitis, Endocarditis) - Refer to ED or ID specialist for hospitalization

Question 31

Pelvic Inflammatory Disease (PID) 1. Definition/Etiology/Risk Factors 2. Clinical Presentation

Answer 31

1. RF: - Hx of PID: 25% reoccurrence - Multiple partners - ≤25 years 2. - Acute onset of lower abdominal or pelvic pain; usually one sided or bilateral - painful intercourse of (dyspareunia) w/ adnexal pain & cervical motion tenderness on bimanual exam - inflammation of fallopian tube (salpingitis) - may walk in shuffling gait to avoid jarring pelvis, which is painful - jumping/running aggravates pelvic pain - some develop peritonitis and tubo-ovarian pelvic abscess

Question 32

Pelvic Inflammatory Disease (PID) 3. Labs/Gram Stain/Other tests

Answer 32

PID is a clinical diagnosis! Even if both gonorrheal and chlamydial tests are negative, treat sexually active pt who has s/sx of PID combined w/ sexual hx → Better to "overtreat" than to miss treating possible PID infections → large study found that adnexal tenderness is the most sensitive PE finding for PID (compared w/ cervical motion tenderness, which may be negative) Labs - Reproductive-aged females → R/O pregnancy - women can insert a swab inside vagina for NAAT test (vaginal fluid) - Both men and women can obtain urine specimen for NAAT using intial urinary stream (first urine of the day) - Gonorrhea testing (anaerobic cultures), Thayer-Martin or chocolate agar, is alternative to test for rectum or pharynx infection Gram Stain - Useful for gonorrheal urethritis only - look for Gram- diplococci in clusters inside polymorphonuclear leukocytes Tests for Other STDs - HIV, Syphilis, Hep B (HBsAG), HSV-2 - Partners should be tested and treated - no sex until both complete treatment

Question 33

Unusual Complications: Fits-Hugh-Curtis Syndrome 1. Definition 2. Clinical Presentation 3. Treatment

Answer 33

1. Complication of PID (10%) - Chlamydial/gonococcal infection ascent to liver capsule (not the liver itself) - extensive scarring b/t liver capsule and abdominal contents (e.g., colon) - Scars look like "violin strings" 9seen on laparoscopy) 2. - sexually active female w/ PID sx - RUQ abdominal pain w/ tenderness to palpation - LFTs normal 3. Treat as complicated gonorrheal/chlamydial infection → Ceftriaxone (Rocephin) 250 mg IM + doxycycline PO BID x 14 days

Question 34

Unusual Complications: Jarisch-Herxheimer Reaction (Periphepatitis) 1. Definition/Etiology 2. Clinical presentation 3. Treatment

Answer 34

1. Warn pts being treated for syphilis that within a few hours (peaks at 6-8 hrs), they may experience a host immune reaction d/t destruction fo T. pallidum - self-limited reaction - reaction may also occur w/ Lyme ds (caused by Borrelia burgdorferi, a spirochete-type bacteria), leptospirosis (Weil's ds, swamp fever) 2. - fever - chills - headache - myalgia - tachycardia - ↑ RR 3. Supportive: - antipyretics/NSAIDs - corticosteroids

Question 35

Unusual Complications: Reiter's Syndrome 1. Definition/Etiology 2. Clinical Presentation 3. Treatment

Answer 35

Reactive Arthritis 1. - Rare ds; autoimmune-mediated reaction 2º to infection w/ certain bacteria (e.g., chlamydia, salmonella, shigella, campylobacter, Yersinia) that spontaneously resolves - more common in males and young adults 2. Male w/ hx of chlamydia genital infection (e.g., urethritis) c/o: - red and swollen joints that come and go (migratory arthritis) in large joints (e.g., knee) and ulcers on skin of glans penis Mnemonic: "I can't see (conjunctivitis), pee (urethritis), or climb up a tree (migratory arthritis in large joints such as the knee)" 3. Supportive (e.g., NSAIDs)

Question 36

What antibiotic is used to treat pregnant women w/ chlamydia? Do you need a test of cure?

Answer 36

Azithromycin; test of cure needed 3-4 weeks after treatment

Question 37

Where is HSV-1 and HSV-2 more commonly found?

Answer 37

HSV-1 → oral mucosa HSV-2 → genitals

Question 38

What differential should you consider if STD sx w/ new onset of swollen red knee on side (or another joint)?

Answer 38

May be caused by disseminated gonococcal infection (DGI)

Question 39

HIV Infection 1. Definition/Etiology 2. Risk Factors

Answer 39

- HIV attacked CD4 T-lymphocytes - In US → transmission mainly by having anal/vaginal sex w/ someone who has had HVI w/out using condom (or who is not taking meds to prevent/treat HIV) - At risk for HIV superinfection - Without tx, average pt → AIDS in ~10 years - In US & world wide → HIV-1 is the most common strain - HIV-2 accounts for <0.2% of infections - Est 1.1. mil in US who have HIV - ~15% of HIV person are unaware of their HIV infection - CDC recommends PCP conduct routine HIV screening at least once in a lifetime for individuals 13-64 years 2. - Sexual intercourse w/ HIV-infected person or w/ gay/bisexual men - REcieved blood products b/w 1975-March 1985 - Hx of injection drug use/partner - Hx of STDs, multiple partners, homeless status, prisoner in jail, and others

Question 40

HIV Superinfection

Answer 40

when a person w/ HIV gets infected w/ another strain of the virus

Question 41

HIV Infection 3. Recommendations for Routine HIV Screening

Answer 41

*Once a year - Injection drug users and their sex partners - People who exchange sex for money and drugs - Sex partners of people w/ HIV - Heterosexuals (or their partners) who had ≥1 sex partners since their most recent HIV test - People receiving tx for Hep, TB, or an STD - MSM and bisexuals may benefit from more frequent screening (Q3-6 months) - Opt-out screening: Pts should be informed (through practice form/literature/discussion) that an HIV test is included in their standard preventive screen tests and that they may decline the test (opt-out screening); pt's decline for HIV testing should be noted in their records

Question 42

HIV Infection 4. Diagnostic Tests (4th Gen Testing)

Answer 42

Step 1: Order HIV-1/HIV2 antibodies and p24 antigen (4th gen antibody/antigen combination assay) w/ reflexes - "Reflex" means that if positive, lab will automatically perform follow-up test to confirm results ► Detects infection at earlier stages d/t p24 antigen is produced before antibodies (window period) ► If negative, no HIV infection Step 2: If POSITIVE, lab will perform confirmatory HIV-1/HIV-2 antibody differentiation immunoassay (to confirm result of initial combination assay) - Detects if infection is from HIV-1, HIV-2, or both viruses ► If test result is indeterminate, order HIV RNA test (either qualitative or quantitative) * HIV RNA PCR - Detects HIV-1 RNA (actual viral presence) → can detect HIV infection as early as 7-28 days after exposure - Order to test infant if HIV+ mother or if HIV-1/HIV-2 antibody differentiation test is indeterminate - Suspect HIV infection in someone who is in the window period of HIV seroconversion * HIV RNA PCR, CD4 count and percentage, HIV RNA viral load, CBC, w/ differential, lipids * Hep A/B/C, syphilis, and other STDs, cervical cytology * TB testing by PPD or antibody interferon-Y release assay (IGRA), CXR if pulmonary sx, HLAB5701 if abacavir tx, genotypic testing for antiviral resistance

Question 43

HIV Infection: CD4 T-Cell Counts + Viral Load

Answer 43

Normal: 500-1500 cells/mL - Used to stage HIV infection and determine response to antiretroviral therapy (ART) - If CD4 count goes up (w/ decrease in viral load), means pt is responding to ART (immune system improved) - Values vary throughout the day; check at the same time of day using same lab each time you remeasure CD4 Viral Load → # of HIV RNA copies in 1 mL of plasma - Test measures actively replicating HIV virus - progression of disease and response to antiretroviral treatment - best sign of tx success is UNDETECTABLE viral load (<50 copies/uL) - If suspect acute/early HIV infection, order 4th-gen combination antibody/antigen immunoassay w/ viral load test

Question 44

HIV Infection: Types of HIV Tests - HIV-1/HIV-2 antibody w/ p24 antigen w/ reflexes

Answer 44

AKA combination antibody/antigen assay (4th gen) - screening test to diagnose HIV infection - if POSITIVE → lab will perform HIV-1/HIV-2 antibody differentiation immunoassay to confirm initial test * Can detect infection in 2-6 weeks (may be p9ositive within 2 weeks after infection) * NAAT can detect HIV infection in 7-28 days

Question 45

HIV Infection: Types of HIV Tests - ELISA

Answer 45

- older screening test (antibody test) - If POSITIVE → next step is Western blot test (done automatically by lab if ELISA positive)

Question 46

HIV Infection: Types of HIV Tests - Western blot

Answer 46

- older confirmatory test - If positive → HIV RNA PCR test

Question 47

HIV Infection: Types of HIV Tests - Rapid HIV testing kits or point-of-care tests

Answer 47

- also used for screening - results available in <30 mins (antibody test) - can be done at home - if positive → follow-up w/ blood testing

Question 48

HIV Infection: Types of HIV Tests - HIV RNA PCR

Answer 48

- test for HIV virus directly - used for infants of HIV+ mothers - diagnoses acute HIV infection (window stage) - use if indeterminate result on antibody-antigen testing

Question 49

HIV Infection: Types of HIV Tests - CD4 T-cell counts

Answer 49

Normally >500 cells/mm3 - check before starting ART, staging HIV infection, ds progression, and treatment response to ART - If on ART, check at same as viral load

Question 50

HIV Infection: Types of HIV Tests - Viral Load (antigen)

Answer 50

- Monitor treating response - If on ART, monitor Q1-2 months until nondetectable, then Q3-4 months

Question 51

HIV Infection: Prophylaxis for Opportunistic Infections

Answer 51

* Primary Prevention - P. jirovecii PNA (previously known as P. carinii PNA [PCP]) - CD4 lymphocyte count is <200 cells/mm3 FIRST-LINE: Trimethoprim-sulfamethoxazole (Bactrim DS) 1 tab daily - If develops a severe reaction to sulfas, next step is dapsone + trimethoprim Alternatives: Use dapsone, atovaquone, or pentamidine

Question 52

What should you check for before initiating dapsone?

Answer 52

Check for G6PD anemia d/t risk of hemolysis - 10% of African American males have G6PD anemia

Question 53

HIV Infection: Opportunistic Infections - Toxoplasma gondii Infections

Answer 53

Protozoa - CD4 count is <100 cells/mm3 * most common CNS infection is AIDS pts FIRST-LINE - sulfadiazine PO QID + pyrimethamine x 6 weeks OR - trimethoprim-sulfamethoxazole (Bactrim) 1 tab BID x 6 weeks - Infection causes encephalitis/brain abscesses (headaches, blurred vision, confusion) - Avoid cleaning cat litter boxes and eating undercooked meats

Question 54

HIV Infection: Monitoring Viral Load - Antiretroviral Therapy

Answer 54

- Best response if HIV infection is tx w/ ART in early stages - Goal is to ↓ HIV viral load - ART will suppress HIV and ↑ CD4 counts - ↑ CD4 counts indicate the pt is responding to ART and their immune system is improving - Check HIV RNA (viral load) in 2-8 weeks after starting therapy - Then Q1-2 months (or Q4-8 weeks) until viral load falls to undetectable levels - Monitor viral load, CD4, and CBC Q3-4 months the first 2 years of ART - Annual cervical cytology (PAP) regardless of age until 3 negative screens, then Q3 years

Question 55

HIV Infection: Recommended Vaccines

Answer 55

HIV and AIDs pt can receive inactivated vaccines: - Hep A - Hep B - inactivated influenza vaccine - pneumococcal vaccine - Td/Tdap (tetanus diphtheria/tetanus, diphtheria, acellular pertussis) Q10 years - HPV vaccine (until 26 years) * Vaccines work best if CD4 counts >200 copies/mm3

Question 56

HIV Infection 1. HIV Education 2. Preventing HIV Transmission

Answer 56

1. - Do NOT handle cat litter or eat uncooked or undercooked meat (risk of toxoplasmosis) - Avoid bird stool since it contains histoplasmosis spores - Turtles, snakes,a nd other amphibians may be infected w/ salmonella - use gloves when cleaning animal cages or when handling stool - Healthy lifestyle, follow-up visits, and taking ART as directed ↓ risk of infection 2. - Use condom every single time during sex; genital ulcers ↑ risk for HIV - Do NOT share needles/syringes if you inject drugs - Do NOT share any toothbrushes, razors, or other items that may have blood on them - Mothers w/ HIV infection should NOT breastfeed their baby - Limit # of sexual partners

Question 57

Occupationally Acquired HIV Infection 1. Definition/Etiology 2. Preexposure Prophylaxis

Answer 57

1. - Of all healthcare, nurses have highest rate of occupationally acquired HIV/AIDs RF ↑ risk of acquiring HIV after needlestick injury: - deep injury - device visibly contaminated w/ pt's blood - needle placement in vein/artery - terminal illness in source pt Infectious fluids: - blood - semen/preseminal fluid - vaginal fluids - breast milk * Fluid must come in contact w/ mucous membrane or damaged tissue to be directly injected into bloodstream for transmission to occur - mucous membranes are found inside rectum, vagina, penis, and mouth 2. - Preexposure prophylaxis (PrEP) → shown to ↓ HIV transmission >90% - Daily PO PrEP meds are recommended as a prevention option for sexually active individuals at substantial risk of HIV such as: * anyone w/ ongoing sex relationship w/ an HIV-infected partner * Gay, heterosexual, bisexual, or transgender men who do not use condoms and engage in high-risk sexual behaviors * Do NOT confuse w/ postexposure prophylaxis (PEP); check HIV infection before starting meds and check for HIV Q3 months thereafter

Question 58

HIV Infection: Postexposure Prophylaxis - Healthcare Workers

Answer 58

- Best time to start PEP ASAP! - If exposed at work, during sex, through sharing needles, or through sexual assault, go to health provider or ED RIGHT AWAY! - If source pt HIV status unknown, start PEP while awaiting rapid HIV testing (do NOT wait for lab results before starting PEP) Initial action following exposure: - immediate cleansing or irrigation of exposed site - small wounds/punctures can also be cleaned w/ antiseptic or alcohol * Alcohol is virucidal to HIV, Hep B, and Hep C - For mucosal surfaces, flush exposed mucous membranes w/ copious amount of water - irrigate eyes w/ saline or water Baseline labs: - HIV (rapid HIV test and HIV antibody/antigen immunoassay) - Hep C virus RNA - HBsAg, Hep B virus surface antibody - Consider HIV RNA PCR if acute HIV suspected - A min of 3 antiretroviral drugs are used - ~72 hours postexposure is the outer limit of effective PEP

Question 59

1. When is PCP prophylaxis advise in HIV infection (viral load)? 2. What doe sit mean if CD4 count ↑ while on ART therpay? 3. What is the first-line of treatment of opportunistic infections? What if there is an allergy? 4. What should be started in HIV-infected pregnant women? 5. What should you R/O if pt presents w/ hairy leukoplakia? 6. What is acute retroviral syndrome or primary HIV infection? Is this contagious?

Answer 59

1. When CD4 is <200 copies/mL 2. Means immune system is getting better (e.g., CD4 200 to 400 copies/mL) 3. Bactrim DS PO is first-line; if allergic to sulfa, use dapsone 100 mg PO daily - Bacctrim DS is used for both prophylaxis and tx of PCP 4. Start AZT ASAP! 5. Rule out HIV infection; hair leukoplakia of the tongue = recurrent candidiasis 6. Influenza-like or similar to mononucleosis infection, very infectious at this stage of HIV infection. Best if HIV treated as early as possible!

Question 60

HIV Infection: Pregnant Women Treatment

Answer 60

- Fully suppressive ART tx markedly ↓ HIV transmission from mother to infant - can be given anytime in pregnancy; as early as diagnosis * Starting earlier is more effective - prenatal vitamins imoprtant - avoid breastfeeding - Dolutegravir (DTG) exposure at time of conception is associated w/ ↑ risk of neural tube defects Newborns: start prophylaxis w/ zidovudine (Retrovir) within 8 hrs after birth - Recommended for most infants to ↓ vertical transmission

Question 61

What is the drug of choice to treat HIV in pregnant women and infants?

Answer 61

Zidovudine - Check CBC w diff at baseline and monitor for bone marrow suppression - ↓ rate of perinatal transmission by 70% - Start ZDV ASAP as HIV is diagnosed or if established HIV diagnosis, start as soon as pregnancy is diagnosed

Question 62

Condyloma Acuminata 1. Definition/Etiology 2. Vaccinations 3. Clinical Presentation

Answer 62

Genital Warts 1. - external anogenital warts appear as soft flesh-colored pedunculated, flat, or papular growths - HPV high-risk oncogenic types 16 and 18 are sexually transmitted - Cervical HPV infection is usually asympatomatic; infected cervix can appear "normal" 2. HPV vaccine (e.g., Gardasil 0) - Give at age 11-12 (both girls and boys) - Age 9-14: only 2 doses needed (6-12 months apart) * If 1st dose was started at age ≥15, will need total of 3 doses (1, 1-2, 6 schedule) 3. - Genital sites: warts may appear on vagina, external genitals, urethra, and anus - Other sites: anus, penis, nasal mucosa, oropharynx, and conjunctiva

Question 63

Condyloma Acuminata 4. Indications for pretreatment biopsy 5. Treatment Plan

Answer 63

4. - Biopsy to R/O underlying CA - not mandatory before tx but recommended if lesion has suspicious characteristics -- fixation, irregular, bleeding, ulceration, red/blue/black/brown pigmentation, induration, sudden recent growth - recommended also if postmenopausal or immunocompromised - Obtain biopsy from most abnormal area(s) or refer to dermatologist 2. Self-Administered Topical Meds (Patient-applied methods) - Podofilox (Condylox) 0.5% gel/cream (antimitotic drug) → contraindicated in pregnancy → apply to external anogenital warts BID x 3 days (max 0.5 mL/d) → Hold tx for 4 days, then repeat cycle up to 4x - Imiquimod (Aldara) 5% or Zyclara (3.75% imiquimod) immune-modulating (or immune response modifier) drug that stimulates local production f interferon and other cytokines → contraindicated in pregnancy → APply thin layer 3x/week at HS for up to 16 weeks → Do NOT cover w/ dressing → leave cream on skin for 6-10 hourse → wash off skin w/ soap/water after SE: irritation, ulceration/erosions, hypopigmentation - Sinecatechins 10% ointment (Veregne) ► botanical, derived from green tea polyphenols, used for external anogenital warts (not for vagina or anus) → apply 0.5 cm strand of ointment on each wart w/ finger (use gloves), up to 3x day for up to 16 weeks → wash off skin before sexual contact or before inserting tampon in vagina → can weaken condoms an diaphragms Provider-Applied Methods: - ablation (laser, electrocautery) - cryotherapy - topicals (podophyllum resin, imiquimod, sinecatechins, dichloroacetic, or trichloroacetic acid) - surgical excision - Internal vaginal warts are tx w/ trichloroacetic acid, dichloroacetic acid, or interferons by a clinician

Question 64

Herpes Simplex: HSV-1 and HSV-2 1. Definition/Etiology 2. Clinical Presentation

Answer 64

1. HSV-1 → usually oral infection, sometimes genital HSV-2 → Causes most cases of recurrent genital herpes, can be oral - Asymptomatic shedding (intact skin) occurs intermittently - the patient is STILL CONTAGIOUS! - Become slaten in neural ganglia and reactive son mucosa and skin - Transmission is usually by oral contact w/ herpetic lesions, mucosal secretions, or direct skin contact Transmission route: - oral-oral - oral-genital - genital-to-genital Populations at risk: - athletes involved in contact sports (esp wrestlers) teenagers 2. HSV-1 lesions - usually located on lips and mouth (gingivostomatitis) - eyes (herpes keratitis) - pharynx HSV-2 lesions - usually on genitals - with oral-genital contact, either type of HSV can be located on face or genitals Acute onset: - redden base, rupture easily - then becomes small, shallow painful ulcers Oral ulcers → aggravated by eating/drinking/swallowing acidic foods (e.g., lemon, orange juice, tomato sauce) * Children may required hospitalization for dehydration and pain control * Primary infection - more severe than subsequent recurrences - can last 2-4 weeks - subsequent recurrences tend to become less severe w/ time

Question 65

HSV1/HSV2 - Primary infection

Answer 65

when the greatest viral shedding occurs 9vesicular fluid and crusts are contagious)

Question 66

Herpes Simplex: HSV-1 and HSV-2 3. Labs/Diagnostic 4. Treatment Plan 5. Evaluation

Answer 66

3. - Diagnostic test: Herpes viral culture or PCR assay for HSV-1 and HSV-2 RNA (more sensitive) - Female pt may be unable to void d/t burning pain → advise pt to void in a tub filled w/ warm water or pour warm water over genitals when voiding in toilet Tzanck Smear - an "old test" - positive for HSV infection (herpes simplex of varicella) - shows multinucleated giant cells - has poor sensitivity and specificity 4. First Episode (Primary Genital Herpes) - Acyclovir (Zovirax) 400 mg TID x 7-10 days (or 200 mg 5x/d x 7-10 days) - Famciclovir (Famvir) 1 g BID x 7-10 days - Valacyclovir (Valtres) TID x 7-10 days Episodic Treatment (Flare-up) - Best tx started w/in 1 day of lesion onset - Famciclovir (Famvir) 125 mg BID x 5 days - Zovirax BID or TID x 5 days or Valtrex BID x 5 days Suppressive treatment - Acyclovir (Zovirax) 400 m g PO BID OR - famciclovir (Favier) 250 mg PO BID 5. Faor ALL cases of genital ulcers: ALWAYS R/O syphilis

Question 67

Human Papillomavirus 1. Definition/Etiology 2. Other types of HPV can cause what? 3. Vaccinations 4. CDC Guidelines

Answer 67

1. All cases of cervical CA are caused by HPV, transmitted through unprotected penile-vaginal contact - Most cases (70%) are caused by HPV 16 and HPV 19 2. Cancers of: - oropharynx - anus - vulva/vagina - penis 3. HPV vaccine (Gardasil 9) can help prevent infections w/ oncogenic HPV types 4. - HPV vaccine starting at 11-12 years or catch up in older adolescents - Only 2 doses (0, 6-12 months) before 15 years - If first dose given at ≥15 years, 3 doses are needed (0, 1-2, 6 months)

Question 68

Herpes/HSV1/HSV2 treatments contraindicated in pregnancy? what treatment can be used in pregnancy?

Answer 68

- podofilox - podophylla - imiquimod Mechanical methods are used to destroy genital warts - curio - laser - excision

Question 69

Which HSV strains are oncogenic/carcinogenic?

Answer 69

HSV strains 16 and HSV 18

Question 70

What is the difference in treatment duration for primary vs breakout/episodic genital herpes infection?

Answer 70

Primary: 7-10 days breakout/episodic: 5 days