Sexually Transmitted Diseases

A sexually transmitted disease (STD) is a disease acquired through sexual contact with an infected person. Table 70-4 identifies diseases that can be classified as STDs. Other organisms can be transmitted during sexual contact, although they are generally not considered to be STDs. For example, G. lamblia, usually associated with contaminated water, can also be transmitted through sexual exposure. STDs are the most common infectious diseases in the United States and are epidemic in most parts of the world (Chart 70-3). Portals of entry of STD microorganisms and sites of infection include the skin and mucosal linings of the urethra, cervix, vagina, rectum, and oropharynx. In June 2001, U.S. Surgeon General Satcher published a document entitled, The Surgeon Generals Call to Action to Promote Sexual Health and Responsible Sexual Behavior. This document discusses the public health impact of sexually transmitted diseases and other problems associated with lack of sexual responsibility. The Surgeon General reports that approximately 12 million Americans become infected with an STD each year. He encourages educators and health care providers to study methods of influencing irresponsible behavior and to provide education and services appropriate to the communities they serve (Satcher, 2001). STDs (eg, human papillomavirus, herpesvirus, Chlamydia, gonorrhea) are also discussed in Chapter 47.

risk factors and behaviors that can lead to infection. Included in this education is information about the relative value of condoms in reducing risk for infection. The use of a condom to provide a protective barrier from transmission of STD-related organisms has been broadly promoted, especially since the recognition of HIV/AIDS. At first referred to as a method to ensure safe sex, the use of condoms has been shown to reduce but not eliminate the risk of transmission of HIV and other venereal diseases. The term safer sex more appropriately connotes the public health message to be used when promoting the use of condoms.

Significance
STDs provide a unique set of challenges for nurses, physicians, and public health officials. Because of perceived stigma and possible threat to emotional relationships, those with symptoms of STDs are often reluctant to seek health care in a timely fashion. Similar to many other infectious diseases, STDs may progress without symptoms. A delay in diagnosis and treatment is potentially harmful because the risk of complications for the infected individual and the risk of transmission to others increase over time. Infection with one STD suggests the possibility of infection with other organisms as well. After one STD is identified, diagnostic evaluation for others should be performed. The possibility of HIV infection should be pursued when any STD is diagnosed

Prevention
Education about prevention of STDs includes information about

HUMAN IMMUNODEFICIENCY VIRUS

HIV is the causative agent of AIDS. The definition of AIDS, as determined by the CDC, has changed several times since the syndrome

was first recognized in 1981. In general, the definition sets a point in the continuum of HIV pathogenesis in which the host has clinically demonstrated profound immune dysfunction. Many opportunistic infections and neoplasms serve as markers for immunosuppression severity. Since 1993, the AIDS definition has also included a CD4-positive (CD4) cell count of less than 200 as a threshold criterion. CD4cells are a subset of lymphocytes and one of the targets of HIV infection. HIV is transmitted through sexual contact, percutaneous injection of contaminated blood, or perinatally from infected mother to fetus. Most people infected by the percutaneous route are intravenous or injecting drug users who share contaminated needles, but transmission is also remotely possible through contaminated blood transfusion. Since 1985, all blood transfusions have been screened, and transfusion-related transmission of HIV is now extremely unlikely. Additional information on HIV is provided in Chapter 52.

previous or current partners until they have been treated.

Stages of Syphilis
In the untreated person, the course of syphilis can be divided into three stages: primary, secondary, and tertiary. These stages reflect the time from infection and the clinical manifestations observed in that period, and are the basis for treatment decisions. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve spontaneously within about 2 months. Secondary syphilis occurs when the hematogenous spread of organisms from the original chancre leads to generalized infection. The rash of secondary syphilis generally occurs about 2 to 8 weeks after the chancre and involves the trunk and the extremities, including the palms of the hands and the soles of the feet. Transmission of the organism can occur through contact with these lesions. Generalized signs of infection may include lymphadenopathy, arthritis, meningitis, hair loss, fever, malaise, and weight loss. After the secondary stage, there is a period of latency, during which the infected person has no signs or symptoms of syphilis. Latency can be interrupted by a recurrence of secondary syphilis. Tertiary syphilis is the final stage in the natural history of the disease. It is estimated that between 20% and 40% of those infected do not exhibit signs and symptoms of this final stage. In this stage, syphilis presents as a slowly progressive, inflammatory disease with the potential to affect multiple organs. The most common

SYPHILIS
Syphilis is an acute and chronic infectious disease caused by the spirochete Treponema pallidum. It is acquired through sexual contact or may be congenital in origin. PREVENTION: The patient is instructed to complete the full course
of therapy if multiple penicillin injections are required. The patient with primary or secondary syphilis is assured that with proper treatment, skin lesions and other sequelae of infection will improve, and serology eventually will reflect cure. The patient is instructed to refrain from sexual contact with

manifestations at this level are aortitis and neurosyphilis, as evidenced by dementia, psychosis, paresis, stroke, or meningitis.

Assessment and Diagnostic Findings

Because syphilis shares symptoms with many diseases, clinical history and laboratory evaluation are important. The conclusive diagnosis of syphilis can be made by direct identification of the spirochete obtained from the chancre lesions of primary syphilis. Serologic tests used in the diagnosis of secondary and tertiary syphilis require clinical correlation in interpretation. The serologic tests are summarized as follows: Nontreponemal or reagin tests, such as the Venereal Disease Research Laboratory (VDRL) or the rapid plasma reagin circle card test (RPR-CT), are generally used for screening and diagnosis. After adequate therapy, the test result is expected to decrease quantitatively until it is read as negative, usually about 2 years after therapy is completed. Treponemal tests, such as the fluorescent treponemal antibody absorption test (FTA-ABS) and the microhemagglutination test (MHA-TP), are used to verify that the screening test did not represent a false-positive result. Positive results usually are positive for life and therefore are not appropriate to determine therapeutic effectiveness.

should receive three injections at 1-week intervals. Patients who are allergic to penicillin are usually treated with doxycycline. The patient treated with penicillin is monitored for 30 minutes after the injection to observe for a possible allergic reaction. Treatment guidelines established by the CDC are updated on a regular basis. Recommendations provide special guidelines for treatment in the setting of pregnancy, allergy, HIV infection, pediatric infection, congenital infection, and neurosyphilis (CDC, 2002d).

Nursing Management
Syphilis is a reportable communicable disease. In any health care facility, a mechanism should be in place to ensure that all patients who are diagnosed are reported to the state or local public health department to ensure community follow-up. The public health department is responsible for interviewing the patient to determine sexual contacts, so that contact notification and screening can be initiated. Lesions of primary and secondary syphilis may be highly infective. Gloves are worn when having direct contact with lesions, and hands are washed after gloves are removed. Isolation in a private room is not required (Chart 70-4).

GONORRHEA
N. gonorrhoeae is a gram-negative bacterium that is transmitted primarily through sexual contact. Infection can also occur in neonates as a result of contact during birth. N. gonorrhoeae can cause mucosal, local, or disseminated infection. Asymptomatic infection is somewhat common.

Medical Management
Treatment of all stages of syphilis is administration of antibiotics. Penicillin G benzathine is the medication of choice for early syphilis or latent syphilis of less than 1 years duration. It is administered by intramuscular injection at a single session. The same therapy is recommended for patients with early latent syphilis. Patients with late latent or latent syphilis of unknown duration

Clinical Manifestations

Gonorrhea most frequently manifests with local manifestations. In men, urethritis and epididymitis are the most common symptoms. Gonorrhea is more likely to be asymptomatic in women than in men. The uterine cervix is the primary site of local infection, and symptoms often include urinary tract infection, increased vaginal discharge, and itching. The most common complication of localized gonococcal infection in women is pelvic inflammatory disease (PID), in which the organism infects the uterus, fallopian tubes, or peritoneal fluid. A complication of gonococcal PID is increased risk for ectopic pregnancy and bilateral tubal occlusion, which results in infertility. In rare circumstances, the organism may disseminate in untreated, infected people. Other systemic signs, such as arthritis or dermatitis, can accompany bacteremia. In rare instances, valves of the heart can be infected with N. gonorrhoeae, or gonococcal meningitis can develop.

are susceptible to environmental changes, specimens must be delivered to the laboratory immediately after they are obtained.

Medical Management
The CDC-recommended treatment for gonorrheal infections is administration of ceftriaxone (Rocephin) (or cefixime [Suprax], ciprofloxacin [Cipro], or ofloxacin [Floxin]) along with doxycycline. Doxycycline is added to first-line therapy to treat presumptive Chlamydia trachomatis, which commonly causes coinfection in patients with gonorrhea. Patients with uncomplicated gonorrhea who are treated with CDCrecommended therapy do not routinely need to return for a proof-of-cure visit. If the patient reports a new episode of symptoms or tests reveal gonorrhea again, the most likely explanation is reinfection rather than treatment failure. Serologic testing for syphilis and HIV should be offered to patients with gonorrhea, because any STD increases the risk for other STD infections.

Assessment and Diagnostic Findings

The patient is assessed for fever; for urethral, vaginal, and rectal discharge; and for signs of arthritis. Culture and sensitivity studies are the usual and preferred methods of diagnosing and verifying effectiveness of therapy. In the male patient, specimens are obtained from the urethra, anal canal, and pharynx. In the female patient, cultures are obtained from the endocervix, pharynx, and anal canal. When obtaining these cultures, the nurse should wear disposable gloves and wash hands thoroughly after glove removal. Lubricating jelly is not used for the vaginal examination because it may contain substances that inhibit growth or kill some pathogens, decreasing the microbiologic test accuracy. Instead, water is used as the lubricant. Because N. gonorrhoeae organisms

Nursing Management
Gonorrhea is a reportable communicable disease. In any health care facility, a mechanism should be in place to ensure that all patients diagnosed with gonorrhea are reported to the local public health department to ensure follow-up of the patient. The public health department also is responsible for interviewing the patient to identify sexual contacts, so that contact notification and screening can be initiated.

CHLAMYDIA TRACHOMATIS
C. trachomatis is a bacterium that requires attachment to the host cell, invasion, intracellular growth, and replication. This requirement

for intracellular growth, which is similar to that of viruses, has made the identification and laboratory testing more difficult than for organisms that grow and replicate independently, but advances have made diagnosis and screening much more available.

doxycycline or azithromycin. Neither of these antibiotics is recommended during pregnancy. CDC guidelines should be used to determine alternative therapy for the patient who is pregnant or allergic or who has complicated chlamydial infection. The patient and the sexual partner must be treated.

Clinical Manifestations
In women, the most frequent clinical manifestation is PID, but symptoms often are so subtle that pathologic progression can occur without detection. Long-term effects may include chronic pain, increased risk for ectopic pregnancy, postpartum endometritis, and infertility. Transmission of infection from an infected pregnant woman to her vaginally born infant is common. About 20% to 50% of infected infants develop chlamydial conjunctivitis, and about 20% develop chlamydial pneumonia (Schacter & Grossman, 2001). Although men infected with Chlamydia are frequently asymptomatic, they easily transmit the infection to their sexual partners. Urethritis is the most common illness associated with infection in the heterosexual man with symptoms. Among homosexual men, the rectum is the common site of infection.

Prevention and Patient Education

The target group for preventive patient teaching about C. trachomatis is the adolescent and young adult population. Abstinence, postponing the age of initial sexual exposure, limiting the number of sexual partners, and use of condoms for barrier protection should be promoted. It should also be stressed that screening for Chlamydia and treating infection at an early stage are important to decrease disease progression common to women and to decrease the likelihood of infection in infants.

Assessment and Diagnostic Findings

Chlamydia should be suspected in cases of gonorrhea, nongonorrheal urethritis, PID, and epididymitis. Diagnostic tools include cell culture techniques and a relatively wide range of nonculture techniques, including immunologic assays, DNA probes, and enzyme-sensitive tests.

Medical Management
Treatment of chlamydial infection is usually administration of