STD and Infections Review Flashcards
Danger Signals: Acute HIV Infection Overview
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
Danger Signals: Acquired Immunodeficiency Syndrome
- 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
Danger Signals: Disseminated Gonococcal Infection
- 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
STD Screening Recommended by CDC (2020)
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
Men who have Sex with Men
- 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
STD: Pregnant Women
- 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)
STD Risk Factors
- 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
Chlamydia Trachomatis
1. Definition/Etiology/Guidelines
2. Possible sites of infection & complications
3. Labs/Diagnostics
- 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
- an obligate intracellular bacteria (atypical bacteria)
- 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!
- Females: Cervicitis, endometritis, salpingitis (fallopian tubes), PID
Complications:
- PID
- tubal scarring
- ectopic pregnancy
- infertility
- Reiter’s syndrome (males)
- Fitz-Hugh-Curtis syndrome
- 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
- 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
** NAAT can detect HIV infection in 7-28 days!
Chlamydia Trachomatis
4. Treatment Plan: Uncomplicated Infections
5. Treatment for Sexual Partners
6. Treatment for Pregnant women
- 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)
- 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)
- Administer azithromycin 1 g PO x single dose
→ Refer to CDC website to confirm if EPT is legal in your state
- 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
- Azithromycin 1 g PO x single dose OR
Neisseria Gonorrhoeae
1. Definition/Etiology
2. Clinical Presentation
3. S/S (by site)
- 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
- Gram- infecting urinary and genital tracts , anorectum, pharynx, and conjunctiva (gonococcal ophthalmia neonatorum)
- 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
- hx of new sexual partner <3 months or multiple partners w/ inconsistent or no condom use
- 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
- Cervicitis → mucopurulent cervix, pain, mild bleeding after intercourse
Neisseria Gonorrhoeae
4. Labs/Diagnostic
- 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
- see labs for C. trachomatis
Syphilis
1. Definition/Etiology
2. Clinical Presentation
3. Stages
- 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
- 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
- S/Sx
- Depends on stage (see below) - 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
Condyloma Lata
infectious white papules that looks like white warts] in moist areas
gumma
soft tissue tumors
Syphilis
4. Labs/ Diagnostics
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
Syphilis
5. Treatment Plan (per stage)
- Tx for pregnancy
6. Follow-up
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
- 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
- Recheck RPR or VDRL at 6 & 12 mons after treatment (look for at least a fourfold ↓ in pretreatment and posttreatment titers)
What are the screening tests for syphilis?
RPR and VDRL
If positive RPR and VDRL, what should you order next?
RPR and VDRL (nontreponemal tests)
Confirm w/ FTA-ABS (treponemal test)
If reactive RPR and reactive FTA-ABS, this is diagnostic for syphilis
What should you always cotreat when treating gonorrhea? With what medication(s)?
Chlamydia
Ceftriaxone 250 mg IM x 1 dose (for both uncomplicated and complicated cases) + cotreated w/ chlamydia
Condyloma acuminata vs condyloma lata
Condyloma acuminata = genital warts
Condyloma lata = secondary syphilis
What stage of HIV infection is very infectious?
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
How long will NAAT remain positive for?
2-3 weeks after treatment d/t presence of nonviable organisms
What can cause an false-positive RPR?
- Pregnancy
- Lyme disease
- autoimmune diseases
- chronic/acute disease
When should you recheck syphilitic chancre after injfection?
3-7 days, should start healing
When should nontreponemal titers decline?
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
CDC-Recommended STD Treatment Regimens: Uncomplicated Gonorrheal Infections of the Cervix, Urethra, Rectum, and Pharynx + Tx of sexual partners
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
CDC-Recommended STD Treatment Regimens: Chlamydia trachomatis
1. Uncomplicated
2. Complicated
- 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
- Indications:
- PID
- salpingitis
- tubo-ovarian abscess
- epididymitis
- prostatitis
- males
Tx:
- Doxycycline 100 mg BID x 14 days
CDC-Recommended STD Treatment Regimens: Gonorrhea
1. Uncomplicated
2. Complicated
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
- 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
CDC-Recommended STD Treatment Regimens: Syphilis
1. Uncomplicated
2. Complicated
- 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
- 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)
Complicated Gonorrheal Infections:
1. Indications
2. Treatment
- PID
- Acute Epididymitis
- Acute Prostatitis
- Acute Proctitis
- PID
- 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
- Ceftriaxone (Rocephin) 250 mg IM x 1 dose + cotreat for chlamydia
If Disseminated Gonococcal Infection (Arthritis-Dermatitis Syndrome, Meningitis, Endocarditis)
- Refer to ED or ID specialist for hospitalization
Pelvic Inflammatory Disease (PID)
1. Definition/Etiology/Risk Factors
2. Clinical Presentation
- RF:
- Hx of PID: 25% reoccurrence
- Multiple partners
- ≤25 years - 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
- Acute onset of lower abdominal or pelvic pain; usually one sided or bilateral
Pelvic Inflammatory Disease (PID)
3. Labs/Gram Stain/Other tests
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
Unusual Complications: Fits-Hugh-Curtis Syndrome
1. Definition
2. Clinical Presentation
3. Treatment
- 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) - sexually active female w/ PID sx
- RUQ abdominal pain w/ tenderness to palpation
- LFTs normal
- sexually active female w/ PID sx
- Treat as complicated gonorrheal/chlamydial infection
→ Ceftriaxone (Rocephin) 250 mg IM + doxycycline PO BID x 14 days
Unusual Complications: Jarisch-Herxheimer Reaction (Periphepatitis)
1. Definition/Etiology
2. Clinical presentation
3. Treatment
- 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) - fever
- chills
- headache
- myalgia
- tachycardia
- ↑ RR
- fever
- Supportive:
- antipyretics/NSAIDs
- corticosteroids
Unusual Complications: Reiter’s Syndrome
1. Definition/Etiology
2. Clinical Presentation
3. Treatment
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
- 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)”
- Supportive (e.g., NSAIDs)
What antibiotic is used to treat pregnant women w/ chlamydia? Do you need a test of cure?
Azithromycin; test of cure needed 3-4 weeks after treatment
Where is HSV-1 and HSV-2 more commonly found?
HSV-1 → oral mucosa
HSV-2 → genitals
What differential should you consider if STD sx w/ new onset of swollen red knee on side (or another joint)?
May be caused by disseminated gonococcal infection (DGI)
HIV Infection
1. Definition/Etiology
2. Risk Factors
- 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
- 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
- Sexual intercourse w/ HIV-infected person or w/ gay/bisexual men
HIV Superinfection
when a person w/ HIV gets infected w/ another strain of the virus
HIV Infection
3. Recommendations for Routine HIV Screening
*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
HIV Infection
4. Diagnostic Tests (4th Gen Testing)
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
HIV Infection: CD4 T-Cell Counts + Viral Load
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
HIV Infection: Types of HIV Tests - HIV-1/HIV-2 antibody w/ p24 antigen w/ reflexes
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
HIV Infection: Types of HIV Tests - ELISA
- older screening test (antibody test)
- If POSITIVE → next step is Western blot test (done automatically by lab if ELISA positive)
HIV Infection: Types of HIV Tests - Western blot
- older confirmatory test
- If positive → HIV RNA PCR test
HIV Infection: Types of HIV Tests - Rapid HIV testing kits or point-of-care tests
- also used for screening
- results available in <30 mins (antibody test)
- can be done at home
- if positive → follow-up w/ blood testing
HIV Infection: Types of HIV Tests - HIV RNA PCR
- 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
HIV Infection: Types of HIV Tests - CD4 T-cell counts
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
HIV Infection: Types of HIV Tests - Viral Load (antigen)
- Monitor treating response
- If on ART, monitor Q1-2 months until nondetectable, then Q3-4 months
HIV Infection: Prophylaxis for Opportunistic Infections
- 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
What should you check for before initiating dapsone?
Check for G6PD anemia d/t risk of hemolysis
- 10% of African American males have G6PD anemia
HIV Infection: Opportunistic Infections - Toxoplasma gondii Infections
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
HIV Infection: Monitoring Viral Load - Antiretroviral Therapy
- 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
HIV Infection: Recommended Vaccines
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
HIV Infection
1. HIV Education
2. Preventing HIV Transmission
- 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
- Do NOT handle cat litter or eat uncooked or undercooked meat (risk of toxoplasmosis)
- 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
- Use condom every single time during sex; genital ulcers ↑ risk for HIV
Occupationally Acquired HIV Infection
1. Definition/Etiology
2. Preexposure Prophylaxis
- 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
- 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
- Preexposure prophylaxis (PrEP) → shown to ↓ HIV transmission >90%
HIV Infection: Postexposure Prophylaxis - Healthcare Workers
- 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
- When is PCP prophylaxis advise in HIV infection (viral load)?
- What doe sit mean if CD4 count ↑ while on ART therpay?
- What is the first-line of treatment of opportunistic infections? What if there is an allergy?
- What should be started in HIV-infected pregnant women?
- What should you R/O if pt presents w/ hairy leukoplakia?
- What is acute retroviral syndrome or primary HIV infection? Is this contagious?
- When CD4 is <200 copies/mL
- Means immune system is getting better (e.g., CD4 200 to 400 copies/mL)
- 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 - Start AZT ASAP!
- Rule out HIV infection; hair leukoplakia of the tongue = recurrent candidiasis
- Influenza-like or similar to mononucleosis infection, very infectious at this stage of HIV infection. Best if HIV treated as early as possible!
HIV Infection: Pregnant Women Treatment
- 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
What is the drug of choice to treat HIV in pregnant women and infants?
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
Condyloma Acuminata
1. Definition/Etiology
2. Vaccinations
3. Clinical Presentation
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”
- 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) - Genital sites: warts may appear on vagina, external genitals, urethra, and anus
- Other sites: anus, penis, nasal mucosa, oropharynx, and conjunctiva
- Genital sites: warts may appear on vagina, external genitals, urethra, and anus
Condyloma Acuminata
4. Indications for pretreatment biopsy
5. Treatment Plan
- 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
- Biopsy to R/O underlying CA
- 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
Herpes Simplex: HSV-1 and HSV-2
1. Definition/Etiology
2. Clinical Presentation
- 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
- 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
HSV1/HSV2 - Primary infection
when the greatest viral shedding occurs 9vesicular fluid and crusts are contagious)
Herpes Simplex: HSV-1 and HSV-2
3. Labs/Diagnostic
4. Treatment Plan
5. Evaluation
- 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
- Diagnostic test: Herpes viral culture or PCR assay for HSV-1 and HSV-2 RNA (more sensitive)
Tzanck Smear
- an “old test”
- positive for HSV infection (herpes simplex of varicella)
- shows multinucleated giant cells
- has poor sensitivity and specificity
- 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
- Faor ALL cases of genital ulcers: ALWAYS R/O syphilis
Human Papillomavirus
1. Definition/Etiology
2. Other types of HPV can cause what?
3. Vaccinations
4. CDC Guidelines
- 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 - Cancers of:
- oropharynx
- anus
- vulva/vagina
- penis - HPV vaccine (Gardasil 9) can help prevent infections w/ oncogenic HPV types
- 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)
- HPV vaccine starting at 11-12 years or catch up in older adolescents
Herpes/HSV1/HSV2 treatments contraindicated in pregnancy? what treatment can be used in pregnancy?
- podofilox
- podophylla
- imiquimod
Mechanical methods are used to destroy genital warts
- curio
- laser
- excision
Which HSV strains are oncogenic/carcinogenic?
HSV strains 16 and HSV 18
What is the difference in treatment duration for primary vs breakout/episodic genital herpes infection?
Primary: 7-10 days
breakout/episodic: 5 days
