1. PN 134 SEXUALLY TRANSMITTED DISEASES And PHARMACOLOGY

2. Sexually Transmitted Diseases  Previously known as “venereal diseases”  Infections that are transmitted during intimate sexual contact  Other routes of spreading: infected mother to newborn  Long periods of asymptomatic infectivity

3. ANATOMY AND PHYSIOLOGY REVIEW  Major system affected by sexually transmitted diseases is the reproductive system.  Males generally more symptomatic than females, seek medical care more readily.  Any area of sexual contact may also exhibit signs and symptoms of disease.  Increase risk for contracting STD’s: sexual activity with multiple partners  Common characteristics of those infected:  Young, single, urban, poor, male, homosexual

4.  Incidence of STDs increasing worldwide  Among the world’s most common communicable disease.  Some statistics:  Gonorrhea – 250 mil. worldwide; 3 mil. USA  Syphilis – 50 mil. Worldwide; 50,000+ USA  “New generation” STDs – no reliable stats; not reportable to CDC  Trichomoniasis, herpes simplex, venereal warts, scabies  Bowel pathogens may be transmitted sexually

5.  4 main factors contributing to increased incidence worldwide of STDs:  Casual sex/unprotected  Antibiotic resistant organisms  Treatment delay  Sexual behavior patterns and permissiveness  Other:  Asymptomatic carriers of the diseases  Use of non-barrier modes of contraception  Lack of knowledge  Increased consumption of alcohol  Use of illegal drugs

6. OBJECTIVES  Be familiar with different types of STDs  Learn teaching strategies toward prevention  Learn treatments for infected individuals,  including pharmacology

7. CHLAMYDIA  Caused by Chlamydia trachomatis.  This organism can cause: cervicitis, urethritis, salpingitis, epididymitis  It is responsible for 20-30% of PID dx.  Most infections are asymptomatic.  If untreated -> cause tissue inflammation, ulceration, and scar tissue formation in both women and men. May be responsible for sterility.

8. CHLAMYDIA  Clinical Manifestations  Male – scanty white or clear exudate; burning &/or pruritis around urethral meatus; urinary frequency, mild dysuria  Female – vaginal pruritis, burning, dull pelvic pain, vaginal discharge, irregular bleeding

9. CHLAMYDIA  Pharmacology:  Treatment of choice is Doxycycline.  Test and treat both partners.  Doxycycline: Trade name Vibramycin  Is in the Tetracycline group of antibiotics  Broad spectrum  Inhibit bacterial protein synthesis which is necessary for reproduction of the organism  Bacteria either slowed in multiplying or destroyed (bacteriostatic/bacteriocidal)

10. CHLAMYDIA  Pharmacology cont.  Uses (Doxycycline): effective in treatment of wide range of gram-negative and gram-positive bacteria; used if PCN contraindicated; used in treatment of uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis. Other uses as well.

11. CHLAMYDIA  Adverse Reactions: N/V, diarrhea, epigastric distress, stomatits, and sore throat. Photosensitivity may be seen. Not given to children under age 9 years: can cause discoloration of teeth. Long-term use can cause bacterial or fungal growth.  Contraindications: hypersensitivity, pregnancy, category D, during lactation.

12. CLAMYDIA

15. CHLAMYDIA  Nursing focus:  Patient Education:  Disease process, s/sx, importance of early medical treatment  Medication – use, expected effects and side effects  Prevention

16. GONORRHEA  Almost exclusively follows sexual contact  Most commonly reported disease in the USA  About 2 million unreported cases yearly  Common in the 20-24 year old age group; closely followed by the 15-19 year olds.  3x as many men are infected  Increased risk for contracting this disease among sexually active individuals and women who use birth control pills or who are otherwise susceptible to infection.

17. GONORRHEA  Caused by Neisseria gonorrhea.  Primarily an infection of the genital and rectal mucosa  Can infect the mouth and throat through oral sex with an infected partner  Incubation period is 3 -5 days; sx may occur in 2 – 10 days  Clinical Manifestations  Men are more likely to have symptoms  Burning and purulent discharge from penis  Urethritis  dysuria

18. GONORRHEA  Women:  Greenish-yellow discharge from cervix  Urinary frequency  Purulent discharge from urethra  Burning and pain of the vulva  Vaginal engorgement  Abdominal pain/distention  Muscular rigidity and tenderness  As the infection spreads: n/v, fever, tachycardia  Other s/sx: pharyngitis, tonsillitis, rectal burning, pruritus, purulent rectal discharge18

19. GONORRHEA  Medical Management  Diagnostic Tests: cultures; test for chlamydia and syphilis as well

20. GONORRHEA  Medication usually instituted without waiting for culture results esp. is health and social hx. are affirmative for risk.  Pharmacology: traditionally, drug of choice is PCN. However, changes have been made due to resistant strains of organisms and the presence of coexisting chlamydial infection  A penicillinase-resistant cephalosporin has become part of the treatment plan (Rocephin). Other oral antibx. Include: cefixine (Suprax); doxycycline, tetracycline

22. GONORRHEA Pharmacology ▫ Cipro (ciprofloxacin) is a Fluoroquinolone, one of the groups of antibiotics  Actions: bacteriocidal effect by interfering with enzyme needed by bacteria for the synthesis of DNA  Adverse reactions :bacterial or fungal superinfections, hypersensitivity, N/V, diarrhea, headache, abdominal pain, dizziness Contraindications: hypersensitivity, pregnancy (class C), under 18 years of age Precautions: use cautiously in patients with renal impairment, hx of seizures, geriatric patients, patients on dialysis.

23. GONORRHEA  Nursing Interventions and Patient Teaching  Advise patients: loose, absorbent underclothing  Changed frequently after perineal or penile cleansing  Sitz baths  Avoiding infecting sexual partners  Encourage notification of present and past sexual partner(s) and stress need for them to seek medical tx.  Possibility of sterility  Collect lab specimens  Discussion of birth control if appropriate

24. SYPHILIS  Caused by Treponema pallidum. Congenital syphilis occurs in about 1: 10,000 pregnancies  Age group with highest incidence is 20-40 year olds  Occurring primarily among young, heterosexual, minority populations [esp. AfroAmericans]; low educational and socioeconomic level; may be related to cocaine use and exchange of sex for drugs  Transmission is mainly through sexual contact; though also through contact with infectious lesions, and sharing of needles among drug addicts  The organism thrives in warm parts of the body and is destroyed by soap and water.  The spirochete penetrates intact skin as well as openings in the mucous membrane of the genital organs, rectum, and mouth.

25. SYPHILIS  Primary, secondary, latent, tertiary stages  Primary: chancre (a painless erosion or papule that ulcerates superficially with a scooped-out appearance  Secondary: widespread body rash; fever, headache, lymph node swelling, and malaise. Highly infectious moist, broad papules may appear in the perineum along with shallow ulcers in the mouth  Latent: If the disease is not eradicated with antibiotics, it establishes latent infection that may cause multiple destructive changes in many organ systems years later.  Tertiary: tissue destruction in the aorta, CNS, bone, and the skin  aortic aneurysm, meningitis, dementia, gait disturbance, optic atrophy, etc.

26. SYPHILIS  Pharmacology:  Antimicrobial therapy destroys Treponema pallidum at any stage, but damage is irreversible.  Treatment: penicillin G benzathine or other antibiotics.  Penicillin G : has wider spectrum of antibacterial activity.  Actions: prevent bacteria from using a substance that is necessary for the maintenance of the bacteria’s outer cell wall; can be bacteriocidal or bacteriostatic  Culture and sensitivity tests done

28. SYPHILIS  Uses: treatment of bacterial infections due to susceptible organisms; UTIs, septicemia, meningitis, gonorrhea, syphilis, pneumonia, other respiratory infections.  Adverse Reactions: N/V, sore tongue, fever,pain at injection site, superinfection.  Contraindications: hypersensitivity; anaphylactic shock: immediate, severe hypotension, loss of consciousness, and acute respiratory distress.

29. Syphilis - Treponema pallidum

30. Syphilis - Treponema pallidum on darkfield

31. Primary syphilis-chancre

34. Primary syphilis - chancre of anus

35. Primary syphilis - chancre

36. Secondary syphilis - papulosquamous rash

37. Secondary syphilis - papulo- pustular rash

38. Secondary syphilis

41. Secondary syphilis - alopecia

42. Late syphilis - serpiginous gummata of forearm

43. Late syphilis - ulcerating gumma

44. Cardiovascular syphilis - narrowing of coronary ostia in aortus

45. Neurosyphilis - spirochetes in neural tissue

46. Congenital syphilis - mucous patches

47. Congenital syphilis - - Hutchinson’s teeth

48. Congenital syphilis - perforation of palate

49. GENITAL HERPES  Caused by herpes simplex virus (HSV).  An infectious viral disease  Characterized by recurrent episodes of acute, painful, erythematous, vesicular eruptions (blisters) on or in the genitalia or rectum  Types I and II  Most infants are infected with Type I during feeding or kissing by adults  A prior infection with HSV I confers relative immunity to HSV II  HSV II is usually acquired sexually after puberty

50. GENITAL HERPES  Clinical Manifestations  Fluid-filled vesicles after incubation period  In women, usually occur of the cervix which is considered the primary site  May also appear on the labia, rectum, vulva, vagina and skin  In men, same lesions on the glans penis, foreskin, penile shaft, anus, and mouth  Vesicles may rupture and develop into shallow painful ulcers; erythematous with marked edema and tenderness

51. GENITAL HERPES  Clinical Manifestations cont.  Lymph nodes may become involved  Initial lesions last from 3 – to 10 days; recurrent lesions have a duration of 7-10 days  Primary infection may be accompanied by fever, malaise, myalgia, dysuria; and in women, leukorrhea

52. GENITAL HERPES  Medical Management  Diagnostic Tests: diagnosis confirmed by appearance of the virus on tissue cultures  The skin lesions heal spontaneously unless secondary infection occurs  Symptomatic Treatment:  Good personal hygiene; lesions should be kept clean and dry  Loose-fitting cotton underclothing  Sitz baths  Local anesthetic for pain: e.g.. Lidocaine or systemic analgesic

53. GENITAL HERPES  Symptomatic Treatment cont.  Advise to abstain from sexual contact while lesions are present  Note: sexual transmission of HSV has been documented even in the absence of clinical lesions.  Encourage barrier protection during sexual activity (condom, cervical cap, diaphragm)  Medication:  Acyclovir (Zovirax) – inhibits virus replication  Oral medication prescribed for primary infection and for suppression of frequent recurrences

54. GENITAL HERPES  Symptomatic Treatment cont.  Medications cont.  Acyclovir – not a cure; shortens the duration of viral shedding and the healing time of genital lesions; suppresses 75% of recurrences when used daily  Acyclovir ointment – no clinical benefit in tx. of recurrent lesions  Side effect: nephrotoxicity  2 other antiviral agents: valacyclovir (Valtrex) and famciclovir (Famvir )

55. GENITAL HERPES  Nursing Interventions  Same as symptomatic treatment with addition of teaching the following:  Handwashing importance  Encourage pt. to let sexual partner(s) know about the infection  Contribution of of stress, insufficient rest, and poor nutrition to recurrence of s/sx  For women: yearly PAP smears; good prenatal care  Potential for spontaneous abortion  Inform of local herpes support groups

56. Primary herpes, male

57. Recurrent herpes, male

58. Herpes, female

59. Primary herpes, female

60. Same patient, four days later

61. Herpes cervicitis

62. CYTOMEGALOVIRUS (CMV)  Virus  Can cause stomatitis, esophagitis, gastritis, colitis, bloody diarrhea, pain, weight loss  Can cause congenital infection of infants producing mental retardation, blindness, deafness, or epilepsy.  Can become life-threatening in clients with poorly functioning immune systems.  Diagnostic Tests: endoscopic visualization, biopsy, culture  No treatment.

63. GENITAL WARTS  Caused by human papilloma virus (HPV)  Usually painless, soft, fleshy growths appearing in genital area.  Appears to play a role in the development of cervical cancer.  Treatment: removing the warts, but they may recur at any time.

64. Condyloma acuminata, penile

65. Condyloma acuminata, anal

66. Condyloma acuminata, meatal

67. Condyloma acuminata, vulva

68. Condyloma acuminata, vaginal wall

69. AIDS  The advanced stage of a chronic retroviral infection from the HIV virus that gradually destroys the cell-mediated immune system – renders the body unable to fight infection  Sexual contact is a mode of transmission.  AIDS is not curable and is fatal.  leading to an inability of the body to fight off disease.

70. EVOLUTION OF AIDS  Earliest known case of AIDS: blood sample collected from a Bantu man living in the Democratic Republic of Congo in 1959.  It is believed that the worldwide epidemic started here  Early in 1960’s, first in Uganda, strange deaths began to occur from simple common infections; did not respond to usual antibiotics.  By late 1970’s and early 1980’s, same deaths began occurring in Europe and America. Then incidences began to crop up all over the world.

71. EVOLUTION OF AIDS  Occurring within diverse backgrounds  Heterosexual and homosexual men  Intravenous drug users sharing needles  Recipients of transfused blood and blood products  Infectious agent discovered in 1983 by French scientist, Luc Montagnier  Known as human immunodeficiency virus

72. SPREAD OF HIV  An old virus, but grew deadly in humans with rapid change in the world with travel, urbanization, social change.  Organisms that cause clinical complications in AIDS: Parasites, bacteria, fungi, and viruses.

73. AIDS, CON’T  Aids attacks immune system: destroys specific T cells that have a receptor for the virus.  People with Aids succumb easily to disease, including unusual diseases such as parasitic pneumonia and a malignant skin cancer called, Kaposi’s Sarcoma.  Drugs stop virus at different stages of replication. Retroviruses.

74. AIDS COMPLICATIONS

75. KAPOSIS SARCOMA ON FOOT

76. KAPOSIS SARCOMA ON BACK

77. TUBERCULOSIS IN THE LUNG

79. TRICHOMONIASIS  Caused by the protozoan Trichomonas vaginalis.  Affects 15% of sexually active women; abt. 10% of sexually active men  Incubation period is 4-28 days  Transmitted by sexually intercourse; at time, by a dirty douche nozzle, container, and moist washcloths  This microorganism thrives when the vaginal mucosa is more alkaline than normal: frequent douching, use of oral contraceptives, and antibiotics raise the normal pH of the vagina

80. TRICHOMONIASIS  Clinical manifestations:  Most men and women are asymptomatic  Male: mild  severe transient urethritis, dysuria, frequency of urination pruritus, purulent exudate  Women: about 70% asymptomatic. When sx. Present include: profuse, frothy, gray, green, or yellow malodorous discharge; pruritus, edema, tenderness of vagina, dysuria, frequency of urination, spotting, menorrhagia, dysmenorrhea.  S/Sx may persist for a week  several months

81. TRICHOMONIASIS  Medical Management  Diagnostic test: diagnosis confirmed by microscopic examination of vaginal discharge  Treat both/all sexual partners  Medication: Metronidazole (Flagyl)

83. TRICHOMONIASIS  Pharmacology: Metronidazole (Flagyl)  Anti-infective: thought to disrupt DNA and protein synthesis in susceptible organisms  Uses: infections caused by susceptible anaerobic microorganisms, amebiasis, trichomonas  Adverse Reactions: N/V, anorexia, seizures, numbness, severe vomiting if alcohol ingested.  Contraindications: first trimester of pregnancy, caution with seizure disorders,hepatic dysfunction, blood dyscrasias.

84. HEPATITIS B  Caused by Hepatitis B virus (HBV)  Transmitted by:  Contaminated serum via blood transfusion  Use of contaminated needles and instruments  Needlesticks  Illicit IV drug use; sharing needles  Dialysis  Direct contact with body fluids from infected people (e.g. breast milk, sexual contact  General Symptoms: anorexia, vague abdominal discomfort, nausea, vomiting, fatigue, jaundice.  No specific therapy. Treatment is based on relieving symptoms. Bedrest! Nutritional support helpful.

85. LIVER INFECTED WITH HEPATITIS B

86. COMMON DIAGNOSTIC TESTS  Related to STDs:  Blood tests  ELISA – “enzyme-linked immunosorbent assay”; test for autoimmune disorders in early stage  Western Blot – “WB”; check for HIV latter stage  VDRL – “venereal disease research laboratory” test; tests for syphilis  FTA-ABS  RPR – “rapid plasma reagin”; tests for syphilis  Reiter Test

87. COMMON DIAGNOSTIC TESTS  Cultures: Tissue, Discharge  Urinalysis Other –Dark field examination –Microscopic exam