STIs from book

Bacterial vaginosis

A third common infection of the vagina is bacterial vaginosis caused by the gram-negative bacillus G. vaginalis. It is the most prevalent cause of vaginal discharge or malodor, but up to 50% of women are asymptomatic. Bacterial vaginosis is a sexually associated infection characterized by alterations in vaginal flora in which lactobacilli in the vagina are replaced with high concentrations of anaerobic bacteria. The cause of the microbial alteration is not fully understood, but is associated with having multiple sex partners, douching, and lack of vaginal lactobacilli. Bacterial vaginosis can increase a woman's susceptibility to other STIs such as HIV, herpes, chlamydia, and gonorrhea (CDC, 2015a). Research suggests that bacterial vaginosis is associated with preterm labor, premature rupture of membranes (PROM), chorioamnionitis, postpartum endometritis, and PID Treatment for bacterial vaginosis includes metronidazole (oral or gel) or clindamycin cream. Treatment of the male partner has not been beneficial in preventing recurrence because sexual transmission of bacterial vaginosis has not been proven Assess the client for clinical manifestations of bacterial vaginosis. Primary symptoms are a thin, white homogeneous vaginal discharge and a characteristic "stale fish" odor. Figure 5.3 shows the typical appearance of bacterial vaginosis. To diagnose bacterial vaginosis, three of the four criteria must be met: Thin, white homogeneous vaginal discharge Vaginal pH 4.5 Positive "whiff test" (secretion is mixed with a drop of 10% potassium hydroxide on a slide, producing a characteristic stale fishy odor) The presence of clue cells on wet-mount examination (CDC, 2015a) The nurse's role is one of primary prevention and education to limit recurrences of these infections. Primary prevention begins with changing the sexual behaviors that place women at risk for infection

Syphillis effects on newborn

Can be passed in utero Can result in fetal or infant death Congenital syphilis symptoms include skin ulcers, rashes, fever, weakened or hoarse cry, swollen liver and spleen, jaundice and anemia, various deformations

Chlamydia info

Chlamydia is the most commonly reported bacterial STI in the United States. The CDC (2014b) estimates that there are 2.8 million cases in the United States annually; the highest predictor for this infection is age. The highest rates of infection are among those aged 15 to 19 years, mainly because their sexual relations are often unplanned and are sometimes the result of pressure or force, and typically happen before they have the experience and skills to protect themselves. The rates are highest among this group regardless of demographics or location The young have the most to lose from acquiring STIs, since they will suffer the consequences the longest and might not reach their full reproductive potential. The most common risk factors associated with chlamydia are age less than 25 years, recent change in sexual partner or multiple sexual partners, poor socioeconomic conditions, exchange of sex for money, nonwhite race, single status, and lack of use of barrier contraception. Worldwide, it is likely the most common infectious cause of infertility in women. An estimated 106 million cases of chlamydia occur globally among both men and women each year, so the global burden is substantial Asymptomatic infection is common among both men and women. Men primarily develop urethritis. In women, chlamydia is linked with cervicitis, acute urethral syndrome, salpingitis, ectopic pregnancy, PID, and infertility Chlamydia causes half of the 1 million recognized cases of PID in the United States each year, and treatment costs run over $701 million yearly. The CDC recommends yearly chlamydia testing of all sexually active women aged 25 years or younger, older women with risk factors for chlamydial infections (those who have a new sex partner or multiple sex partners), and all pregnant women. Chlamydia trachomatis is the bacterium that causes chlamydia. It is an intracellular parasite that cannot produce its own energy and depends on the host for survival. It is often difficult to detect, and this can pose problems for women due to the long-term consequences of untreated infection. Moreover, lack of treatment provides more opportunity for the infection to be transmitted to sexual partners. Ophthalmia neonatorum is an acute mucopurulent conjunctivitis occurring in the first month of birth. It is essentially an infection acquired during vaginal delivery. The most frequent infectious agents involved in are Chlamydia trachomatis and Neisseria gonorrhea Antibiotics are usually used in treating this STI. The CDC treatment options for chlamydia include doxycycline 100 mg orally twice a day for 7 days or azithromycin 1 g orally in a single dose. Because of the common coinfection of chlamydia and gonorrhea, a combination regimen of ceftriaxone with doxycycline or azithromycin is prescribed frequently Additional CDC guidelines for client management include annual screening of all sexually active women aged 20 to 25 years old; screening of all high-risk people; and treatment with antibiotics effective against both gonorrhea and chlamydia for anyone diagnosed with a gonococcal infection (CDC, 2014a). Except in pregnant women, test-of-cure (repeat testing 3 to 4 weeks after completing therapy) is not recommended for women treated with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected Assess the health history for significant risk factors for chlamydia, which may include: Being an adolescent Having multiple sex partners Having a new sex partner Engaging in sex without using a barrier contraceptive (condom) Using oral contraceptives Being pregnant Having a history of another STI Assess the client for clinical manifestations of chlamydia. The majority of women (70% to 80%) are asymptomatic (CDC, 2014a). If the client is symptomatic, clinical manifestations include: Mucopurulent vaginal discharge Urethritis Bartholinitis Endometritis Salpingitis Dysfunctional uterine bleeding The diagnosis can be made by urine testing or swab specimens collected from the endocervix or vagina. Culture, direct immunofluorescence, enzyme immunoassay (EIA), or nucleic acid amplification methods such as GenProbe or Pace2) are highly sensitive and specific when used on urethral and cervicovaginal swabs. They can also be used with good sensitivity and specificity on first-void urine specimens. The chain reaction tests are the most sensitive and cost-effective. The CDC (2015b) strongly recommends screening of asymptomatic women at high risk in whom infection would otherwise go undetected. Chlamydia is an important preventable cause of infertility and other adverse reproductive health outcomes. Effective prevention interventions are available to reduce the burden of chlamydia and its sequelae, but they are underutilized. Although many prevention programs are available, improvements can be made in raising awareness about chlamydia, increasing screening coverage, and enhancing partner services. In addition, nurses can focus their efforts on reaching disproportionately affected racial/ethnic groups. To break the cycle of chlamydia transmission in the United States, health care providers should encourage annual chlamydia screening for all sexually active females aged >25 years, maximize use of effective partner treatment services, and rescreen infected females and males 3 months after treatment

Genital herpes effects on newborn

Contamination can occur during birth. Newborn may develop skin or mouth sores Mental retardation, premature birth, low birth weight, blindness, death

Gonorrhea

Curable STI Adolescent often coinfected with Chlamydia trachomatis Neisseria gonorrhoeae (bacteria) Vaginal, anal, and oral sex and by childbirth Gram stain or culture directly for the bacterium or same noninvasive, non-culture-based test, NAAT, as chlamydia Females: screen annually Male: screen high-risk adolescents May be asymptomatic or no recognizable symptoms until serious complications such as pelvic inflammatory disease Dysuria Urinary frequency Vaginal discharge (yellow and foul) Dyspareunia Endocervicitis Arthritis May lead to pelvic inflammatory disease, ectopic pregnancy, infertility Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood Most produce symptoms, but can be asymptomatic Dysuria Penile discharge (pus) Arthritis May lead to epididymitis and sterility Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood At this time, due to concerns about N. gonorrhoeae resistance to certain antimicrobials, the CDC currently recommends only one regimen, dual therapy with ceftriaxone and azithromycin Sexual partners need evaluation, testing, and treatment also Abstinence from sexual activity until therapy complete and symptoms no longer present Retesting in 3 months to rule out recurrence

Chlamydia

Curable STI Seen frequently among sexually active adolescents and young adults Chlamydia trachomatis (bacteria) Vaginal, anal, and oral sex and by childbirth Culture fluid from urethral swabs in males or endocervical swabs for females Noninvasive, non-culture-based testing is available using nucleic acid amplification and testing (NAAT) from urine—single test can test for chlamydia and gonorrhea Conjunctival secretions in neonates Females: screen annually May be asymptomatic Dysuria, urinary frequency. dyspareunia Cervical discharge (mucus or pus) Endocervicitis May lead to pelvic inflammatory disease, ectopic pregnancy, infertility Can cause inflammation of the rectum and conjunctiva Can infect the throat from oral sexual contact with an infected partner Azithromycin (Zithromax) Doxycycline (Vibramycin) Erythromycin (EES) Levofloxacin Ofloxacin (Floxin) Sexual partners need evaluation, testing, and treatment also Abstinence from sexual activity until therapy complete and symptoms no longer present Retesting in 3 months to rule out recurrence

Genital Herpes Simplex

Genital herpes is a recurrent, lifelong viral infection that has the potential for transmission throughout the lifespan. The CDC estimates that one out of six people 14 to 49 years old have genital herpes simplex (HSV) infection, with 500 million worldwide new cases annually (CDC, 2015e). Two serotypes of HSV have been identified: HSV-1 and HSV-2. Today, a smaller portion of genital herpes infections are thought to be caused by HSV-1 and the bulk of them by HSV-2. HSV-1 mostly causes the familiar fever blisters or cold sores on the lips, eyes, and face. HSV-2 typically invades the mucous membranes of the genital tract and is known as herpes genitalis. Most people infected with HSV-2 have not been diagnosed. The herpes simplex virus is transmitted by contact of mucous membranes or breaks in the skin with visible or nonvisible lesions. Most genital herpes infections are transmitted by individuals unaware that they have an infection. Many have mild or unrecognized infections but still shed the herpes virus intermittently. HSV is transmitted primarily by direct contact with an infected individual who is shedding the virus. Kissing, sexual contact, including oral sex, and vaginal birth are means of transmission. The virus replicates at the site of infection, then travels to the dorsal root ganglia and remains latent until stimuli such as fever, stress, ultraviolet radiation, or immunosuppression occurs and reactivates it Having sex with an infected partner places the individual at risk for contracting HSV. After the primary outbreak, the virus remains dormant in the nerve cells for life, resulting in periodic recurrent outbreaks. Recurrent genital herpes outbreaks are triggered by precipitating factors such as emotional stress, menses, and sexual intercourse, but more than half of recurrences occur without a precipitating cause. Immunocompromised women have more frequent and more severe recurrent outbreaks than normal hosts Living with genital herpes can be difficult due to the erratic, recurrent nature of the infection, the location of the lesions, the unknown causes of the recurrences, and the lack of a cure. Further, the stigma associated with this infection may affect the individual's feelings about herself and her interaction with partners. Potential psychosocial consequences may include emotional distress, isolation, fear of rejection by a partner, fear of transmission of the disease, loss of confidence, and altered interpersonal relationships No cure exists, but antiviral drug therapy helps to reduce or suppress symptoms, shedding, and recurrent episodes. Advances in treatment with acyclovir 400 mg orally three times daily for 7 to 10 days, famciclovir 250 mg orally three times daily for 7 to 10 days, and valacyclovir 1 g orally twice daily for 7 to 10 days have resulted in an improved quality of life for those infected with HSV. However, these drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after the drug is discontinued Suppressive therapy is recommended for individuals with six or more recurrences per year. The natural course of the disease is for recurrences to be less frequent over time. The management of genital herpes includes antiviral therapy. The safety of antiviral therapy has not been established during pregnancy. Disclosure of this lifelong viral infection is often a challenge for individuals living with genital herpes. Therapeutic management also includes counseling regarding the natural history of the disease, the risk of sexual and perinatal transmission, and the use of methods to prevent further spread. The following are a few guidelines to delivering information in a time-limited environment: (a) use all available client reading materials; (b) have another knowledgeable staff member in the office who can spend extra time with women who need it; (c) refer clients to good and accurate websites such as the American Social Health Association (d) know the phone numbers of herpes support groups in your area; (e) educate the client to abstain from all sexual activity until HSV lesions resolve; (f) use good hand washing technique to prevent spread; (g) educate that there is no cure, and that practicing safe sex (using condoms) with every sex act is essential to prevent transmission; and (h) encourage all clients to inform their current sex partners that they have genital herpes and to inform future partners before initiating a sexual relationship. Finally, many experts recommend a sympathetic, nonjudgmental approach. The nurse can state in clear terms that having herpes does not change the core of the person or make them less worthwhile Assess the client for clinical manifestations of HSV. Clinical manifestations can be divided into the primary episode and recurrent infections. The first or primary episode is usually the most severe, with a prolonged period of viral shedding. Primary HSV is a systemic disease characterized by multiple painful vesicular lesions, mucopurulent discharge, superinfection with candida, fever, chills, malaise, dysuria, headache, genital irritation, inguinal tenderness, and lymphadenopathy. The lesions in the primary herpes episode are frequently located on the vulva, vagina, and perineal areas. The vesicles will open and weep and finally crust over, dry, and disappear without scar formation. This viral shedding process usually takes up to 2 weeks to complete. Recurrent infection episodes are usually much milder and shorter in duration than the primary one. Tingling, itching, pain, unilateral genital lesions, and a more rapid resolution of lesions are characteristics of recurrent infections. Recurrent herpes is a localized disease characterized by typical HSV lesions at the site of initial viral entry. Recurrent herpes lesions are fewer in number and less painful and resolve more rapidly Diagnosis of HSV is often based on clinical signs and symptoms and is confirmed by viral culture of fluid from the vesicle. Papanicolaou (Pap) smears are an insensitive and nonspecific diagnostic test for HSV and should not be relied on for diagnosis. The woman should be tested for all common STIs, especially if she has a new sexual partner. Hopefully, the woman would initiate an open conversation with her sexual partner about the risk of transmission and the need for safer sexual practices.

Nursing management of herpes and syphillis

Genital ulcers from either herpes or syphilis can be devastating to women, and the nurse can be instrumental in helping her through this difficult time. Referral to a support group may be helpful. Address the psychosocial aspects of these STIs with women by discussing appropriate coping skills, acceptance of the lifelong nature of the condition (herpes), and options for treatment and rehabilitation Abstain from intercourse during the prodromal period and when lesions are present. Wash hands with soap and water after touching lesions to avoid autoinoculation. Use comfort measures such as wearing nonconstricting clothes, wearing cotton underwear, urinating in water if urination is painful, taking lukewarm sitz baths, and air-drying lesions with a hair dryer on low heat. Avoid extremes of temperature such as ice packs or hot pads to the genital area as well as application of steroid creams, sprays, or gels. Use condoms with all new or noninfected partners. Inform health care professionals of your condition.

Vulvovaginal Candidiasis

Genital/VVC is one of the most common causes of vaginal discharge. It is also referred to as yeast, monilia, and a fungal infection. It is not considered an STI because Candida is a normal constituent in the vagina and becomes pathologic only when the vaginal environment becomes altered Treatment of candidiasis includes one of the following medications: Miconazole cream or suppository Clotrimazole tablet or cream Terconazole cream or intravaginal suppository Fluconazole oral tablet (CDC, 2015a) Most of these medications are used intravaginally in the form of a cream, tablet, or suppositories for 3 to 7 days. If fluconazole is prescribed, a 150-mg oral tablet is taken as a single dose. Topical azole preparations are effective in the treatment of VVC, relieving symptoms and producing negative cultures in 80% to 90% of women who complete therapy (CDC, 2015a). If VVC is not treated effectively during pregnancy, the newborn can develop an oral infection known as thrush during the birth process; that infection must be treated with a local azole preparation after birth. Assess the client's health history for predisposing factors for VVC, which include: Pregnancy Use of oral contraceptives with a high estrogen content Use of broad-spectrum antibiotics Diabetes mellitus Obesity Use of steroid and immunosuppressive drugs HIV infection Wearing tight, restrictive clothes and nylon underpants Trauma to vaginal mucosa from chemical irritants or douching Assess the client for clinical manifestations of VVC. Typical symptoms, which can worsen just before menses, include: Pruritus Vaginal discharge (thick, white, curd-like) Vaginal soreness Vulvar burning Erythema in the vulvovaginal area Dyspareunia External dysuria Speculum examination will reveal white plaques on the vaginal walls. The vaginal pH remains within normal range. Definitive diagnosis is made by a wet smear, which reveals the filamentous hyphae and spores characteristic of a fungus when viewed under a microscope Reduce dietary intake of simple sugars and soda. Wear white, 100% cotton underpants. Avoid wearing tight pants or exercise clothes with spandex. Shower rather than taking tub baths. Wash with a mild, unscented soap and dry the genitals gently. Avoid the use of bubble baths or scented bath products. Wash underwear in unscented laundry detergent and hot water. Dry underwear in a hot dryer to kill the yeast that clings to the fabric. Remove wet bathing suits promptly. Practice good body hygiene. Avoid vaginal sprays/deodorants. Avoid wearing pantyhose (or cut out the crotch to allow air circulation). Use white, unscented toilet paper and wipe from front to back. Avoid douching (which washes away protective vaginal mucus). Avoid the use of super-absorbent tampons (use pads instead).

Gonorrhea info

Gonorrhea is a serious, and potentially very severe, bacterial infection. It is the second most commonly reported infection in the United States, and is an urgent problem globally because it is now capable of developing resistance to multiple antibiotic classes. Gonorrhea is highly contagious and is a reportable infection to the health department authorities. Gonorrhea increases the risk for PID, infertility, ectopic pregnancy, and HIV acquisition and transmission It is rapidly becoming more and more resistant to cure. In the United States, an estimated 800,000 new gonorrhea infections occur annually. In common with all other STIs, it is an equal-opportunity infection—no one is immune to it, regardless of race, creed, gender, age, or sexual preference. The cause of gonorrhea is an aerobic gram-negative intracellular diplococcus, Neisseria gonorrhoeae. The site of infection is the columnar epithelium of the endocervix. Gonorrhea is almost exclusively transmitted by sexual activity. In pregnant women, gonorrhea is associated with chorioamnionitis, premature labor, PROM, and postpartum endometritis. It can also be transmitted to the newborn in the form of ophthalmia neonatorum during birth by direct contact with gonococcal organisms in the cervix. Ophthalmia neonatorum is highly contagious and if untreated leads to blindness in the newborn. Gonorrhea can be cured with the right treatment. CDC now recommends dual therapy (i.e., using two drugs as the treatment for gonorrhea). Dual therapy is recommended to prevent drug resistance and is also effective against chlamydia. The treatment of choice for uncomplicated gonococcal infections is azithromycin 1 g orally in a single dose and ceftriaxone 250 mg intramuscular (IM) in a single dose Azithromycin orally or doxycycline should accompany all gonococcal treatment regimens if chlamydial infection is not ruled out (CDC, 2015a). Pregnant women with gonorrhea should not be treated with quinolones or tetracyclines. Pregnant women with a positive test for gonorrhea should be treated with the same recommended dual therapy of ceftriaxone with either azithromycin or amoxicillin To prevent gonococcal ophthalmia neonatorum, a prophylactic agent should be instilled into the eyes of all newborns; this procedure is required by law in most states. Erythromycin or tetracycline ophthalmic ointment in a single application is recommended With use of recommended treatment, follow-up testing to document eradication of gonorrhea is no longer recommended. Instead, rescreening in 2 to 3 months to identify reinfection is suggested Assess the client's health history for risk factors, which may include low socioeconomic status, living in an urban area, single status, inconsistent use of barrier contraceptives, age under 20 years old, and multiple sex partners. Assess the client for clinical manifestations of gonorrhea, keeping in mind that between 50% and 90% of women infected with gonorrhea are totally symptom-free Because women are so frequently asymptomatic, they are regarded as a major factor in the spread of gonorrhea. If symptoms are present, they might include: Abnormal vaginal discharge Dysuria Cervicitis Enlarged lymph glands locally Abnormal vaginal bleeding Bartholin abscess PID Neonatal conjunctivitis in newborns Mild sore throat (for pharyngeal gonorrhea) Rectal infection (itching, soreness, bleeding, discharge) Perihepatitis Sometimes, a local gonorrhea infection is self-limiting (there is no further spread), but usually the organism ascends upward through the endocervical canal to the endometrium of the uterus, further on to the fallopian tubes, and out into the peritoneal cavity. When the peritoneum and the ovaries become involved, the condition is known as PID. The scarring to the fallopian tubes is permanent. This damage is a major cause of infertility and is a possible contributing factor in ectopic pregnancy If gonorrhea remains untreated, it can enter the bloodstream and produce a disseminated gonococcal infection. This severe form of infection can invade the joints (arthritis), the heart (endocarditis), the brain (meningitis), and the liver (toxic hepatitis). Figure 5.4 shows the typical appearance of gonorrhea. The CDC recommends screening for all women at risk for gonorrhea. Pregnant women should be screened at the first prenatal visit and again at 36 weeks of gestation. Nucleic acid hybridization tests (GenProbe) are used for diagnosis. Any woman suspected of having gonorrhea should be tested for chlamydia also because coinfection (45%) is extremely common

Human Papillomavirus Virus

HPV is the most common viral infection in the United States. Genital warts or condylomata (Greek for "warts") are caused by HPV. Nursing assessment of the woman with HPV involves a complete health history and assessment of clinical manifestations, physical examination, and laboratory and diagnostic testing. Health History and Clinical Manifestations Assess the client's health history for risk factors for HPV, which include having multiple sex partners, age 15 to 25 years old, sex with a male who has had multiple sexual partners, and first intercourse at 16 years or younger Risk factors contributing to the development of cervical cancer include smoking, few or no screenings for cervical cancer, multiple sex partners, immunosuppressed state, nulliparity, long-term contraceptive use (more than 2 years), coinfection with another STI, pregnancy, nutritional deficiencies, and early onset of sexual activity Assess the client for clinical manifestations of HPV. Most HPV infections are asymptomatic, unrecognized, or subclinical. Visible genital warts are usually caused by HPV types 6 or 11. In addition to the external genitalia, genital warts can occur on the cervix and in the vagina, urethra, anus, and mouth. Depending on the size and location, genital warts can be painful, friable, and pruritic, although most are typically asymptomatic. The strains of HPV associated with genital warts are considered low risk for development of cervical cancer, but other HPV types (16, 18, 31, 33, 45, 52, and 58) have been strongly associated with cervical cancer Physical Examination and Laboratory and Diagnostic Tests Clinically, visible warts are diagnosed by inspection. The warts are fleshy papules with a warty, granular surface. Lesions can grow very large during pregnancy, affecting urination, defecation, mobility, and descent of the fetus. Large lesions, which may resemble cauliflowers, exist in coalesced clusters and bleed easily. Serial Pap smears are performed for low-risk women. These regular Pap smears will detect the cellular changes associated with HPV. The FDA has recently approved an HPV test as a follow-up for women who have an ambiguous Pap test. In addition, this HPV test may be a helpful addition to the Pap test for general screening of women aged 30 years and above. The HPV test is a diagnostic test that can determine the specific HPV strain, which is useful in discriminating between low-risk and high-risk HPV types. A specimen for testing can be obtained with a fluid-phase collection system such as Thin Prep. The HPV test can identify 13 of the high-risk types of HPV associated with the development of cervical cancer and can detect high-risk types of HPV even before there are any conclusive visible changes to the cervical cells. If the test is positive for the high-risk types of HPV, the woman should be referred for colposcopy. Upon physical examination, it is determined that Sandy has genital warts. The nurse finds out that Sandy engaged in high-risk behavior with a stranger she "hooked up" with recently at college. She couldn't imagine that he would give her an STI because "he looked so clean-cut." She wonders how she could possibly have genital warts. What information should be given to Sandy about STIs in general? What specific information about HPV should be stressed? There is currently no medical treatment or cure for HPV. Instead, therapeutic management focuses heavily on prevention through the use of the HPV vaccine and education and on the treatment of lesions and warts caused by HPV. The FDA has approved three HPV vaccines to prevent cervical cancer: Cervarix, Gardasil, and Gardasil 9. The CDC's Advisory Committee on Immunization Practices (ACIP) has recommended the vaccine for routine administration to 11- and 12-year-old girls and boys. The ACIP also endorsed the use of a HPV vaccine for girls and boys as young as 9 years and recommended that women between the ages of 13 and 26 years receive the vaccination series, which consists of three injections over 6 months. All three are prophylactic HPV vaccines designed primarily for cervical cancer prevention. Cervarix is effective against HPV-16, 18, 31, 33, and 45, the five most common cancer-causing types, including most causes of adenocarcinoma for which we cannot screen adequately. Gardasil is effective against HPV-16, 18, and 31, three common squamous cell cancer-causing types. In addition, Gardasil is effective against HPV-6 and 11, causes of genital warts and respiratory papillomatosis. The most important determinant of vaccine impact to reduce cervical cancer is its duration of efficacy. Cervarix is used only in females, whereas Gardasil 9 is used for both boys and girls. Gardasil 9 is effective against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. According to the FDA, the new vaccine (Gardasil 9) can potentially prevent about 90% of cervical, vulvar, vaginal, and anal cancers (Gearhart, Higgins, & Randall, 2015). Prophylactic HPV vaccines are safe, well tolerated, and highly efficacious in preventing persistent infections and cervical diseases associated with vaccine-HPV types among young females. The vaccine is administered intramuscularly in three separate 0.5-mL doses. The first dose may be given to any individual 9 to 26 years old prior to infection with HPV. The second dose is administered 2 months after the first, and the third dose is given 6 months after the initial dose. The deltoid region of the upper arm or anterolateral area of the thigh may be used. The most common vaccine side effects include pain, fainting, redness, and swelling at the injection site; fatigue; headache; muscle and joint aches; and gastrointestinal distress. The vaccine is given in a series of three injections over a 6-month period If the woman doesn't receive primary prevention with the vaccine, then secondary prevention would focus on education about the importance of receiving regular Pap smears and, for women over age 30 years, including an HPV test to determine whether the woman has a latent high-risk virus that could lead to precancerous cervical changes. Finally, treatment options for precancerous cervical lesions or genital warts caused by HPV are numerous and may include: Topical trichloroacetic acid 80% to 90% Liquid nitrogen cryotherapy Topical imiquimod 5% cream Topical podophyllin 10% to 25% Sinecatechins 15% ointment Laser carbon dioxide vaporization Client-applied podofilox 0.5% solution or gel Simple surgical excision Loop electrosurgical excisional procedure (LEEP) Intralesional interferon therapy The goal of treating genital warts is to remove the warts and induce wart-free periods for the client. Treatment of genital warts should be guided by the preference of the client and available resources. No single treatment has been found to be ideal for all clients, and most treatment modalities appear to have comparable efficacy. Because genital warts can proliferate and become friable during pregnancy, they should be removed using a local agent. A cesarean birth is not indicated solely to prevent transmission of HPV infection to the newborn, unless the pelvic outlet is obstructed by warts An HPV infection has many implications for the woman's health, but most women are unaware of HPV and its role in cervical cancer. The average age of sexual debut is in early adolescence; therefore, it is important to target this population for use of the HPV/cervical cancer vaccine. Key nursing roles are teaching about prevention of HPV infection and client education and promotion of vaccines and screening tests in order to reduce the morbidity and mortality associated with cervical cancer caused by HPV infection. Teach all women that the only way to prevent HPV is to refrain from any genital contact with another person. Although the effect of condoms in preventing HPV infection is unknown, latex condom use has been associated with a lower rate of cervical cancer. Teach women about the link between HPV and cervical cancer. Explain that, in most cases, there are no signs or symptoms of infection with HPV. Strongly encourage all young women aged between 9 and 26 years to consider getting Gardasil 9, the vaccine against HPV. For all women, promote the importance of obtaining regular Pap smears and, for women over 30 years, suggest an HPV test to rule out the presence of a latent high-risk strain of HPV. Education and counseling are important aspects of managing women with genital warts. Teach the woman that: Even after genital warts are removed, HPV still remains and viral shedding will continue. The likelihood of transmission to future partners and the duration of infectivity after treatment for genital warts are unknown. The recurrence of genital warts within the first few months after treatment is common and usually indicates recurrence rather than reinfection

Genital herpes

Lifelong recurrent viral disease Most people have not been diagnosed There is no cure Herpes simplex virus 1 and 2 (HSV-1 and HSV-2) HSV-1 is spread through oral secretions; can be spread to genitals through poor handwashing of infected person or oral-genital contact HSV-2 is spread by having sexual contact (vaginal, oral, or anal) with someone who is shedding the herpes virus either during an outbreak or during a period with no symptoms; can be spread to an infant through childbirth Visual inspection and symptoms or culture from swabs taken from lesions (success depends stage of lesion— optimum is during vesicular stage) Polymerase chain reaction is more sensitive than culture Serologic tests, such as antibody-based testing (herpes Western blot assay is the most sensitive) Type specific laboratory testing important Routine screening not recommende Initial symptoms include itching, tingling, and pain in genital area followed by small pustules and blister-like genital lesions that then crust over and gradually heal. Recurrence episodes are usually milder than the initial episode Dysuria, dyspareunia, and urine retention Fever, headache, malaise, muscle aches Antivirals used to treat first episode, recurrence, and suppression Acyclovir, Valacyclovir, and Famciclovir mainstay in treatment Does not cure; just controls symptoms Counseling important to help adolescent cope and to prevent transmission Sexual partners benefit from evaluation and counseling. If symptomatic, need treatment If asymptomatic, offer testing and education

Trichomoniasis effects on newborn

Low birth weight, increased risk of PROM, and preterm birth

Nursing assessment for STIs

Many health care providers fail to assess adolescent sexual behavior and STI risks, to screen for asymptomatic infection during clinic visits, or to counsel adolescents on STI risk reduction. Nurses need to remember that they play a key role in the detection, prevention, and treatment of STIs in adolescents. All states allow adolescents to give consent to confidential STI testing and treatment.

Chlamydia effects on newborn

Newborn can be infected during delivery Eye infections (neonatal conjunctivitis), pneumonia, low birth weight, increased risk of premature rupture of the membranes (PROM), preterm birth, and stillbirth

Gonorrhea effects on newborn

Newborn can be infected during delivery. Increased risk of miscarriage, PROM, and preterm birth Rhinitis, vaginitis, urethritis, inflammation of sites of fetal monitoring Gonococcal ophthalmia neonatorum can lead to blindness and sepsis (including arthritis and meningitis)

Nursing mgmt for STIs

Nurses working with adolescents need to convey their willingness to discuss sexual habits. Provide effective guidance that promotes sexual health so that primary and/or repeat infections can be avoided. Adolescents bear disproportionate burdens when it comes to STIs, so nurses need to educate them to protect their client's reproductive futures. Encourage the client to complete the antibiotic prescription (specific management for each type of STI is discussed further in the chapter). Prevention of STIs among adolescents is critical. Health care providers have a unique opportunity to provide counseling and education to their clients. Adapt the style, content, and message to the adolescent's developmental level. Identify risk factors and risk behaviors and guide the adolescent to develop specific individualized actions of prevention. The nurse's interaction and conversation with the adolescent needs to be direct and nonjudgmental. Encourage adolescents to postpone initiation of sexual intercourse for as long as possible, but if they choose to have sexual intercourse, explain the necessity of using barrier methods, such as male and female condoms (Teaching Guidelines 5.1). For teens who have already had sexual intercourse, the clinician can encourage abstinence at this point. If adolescents are sexually active, they should be directed to teen clinics where contraceptive options can be explained. In areas where specialized teen clinics are not available, nurses should feel comfortable discussing sexuality, safety, and contraception with teens. Encourage adolescents to minimize their lifetime number of sexual partners, to use barrier methods consistently and correctly, and to be aware of the connection between drug and alcohol use and the incorrect use of barrier methods. Table 5.3 discusses barriers to condom use and means to overcome them.

Venereal warts

One of the most common STIs in the United States Could lead to cancers of the cervix, vulva, vagina, anus, or penis No cure; warts can be removed but virus remains Vaginal, anal, or oral sex with an infected partner Visual inspection Abnormal pap smear may indicate cervical infection of human papillomavirus (HPV) Wart-like lesions that are soft, moist, or flesh colored and appear on the vulva and cervix, and inside and surrounding the vagina and anus Sometimes appear in clusters that resemble cauliflower-like bumps, and are either raised or flat, small or large May disappear without treatment Treatment is aimed at removing the lesions rather than HPV itself No optimal treatment has been identified, but there are several ways to treat depending on size and location Most methods rely on chemical or physical destruction of the lesion: Imiquimod cream 20% Podophyllin antimitotic solution 0.5% Podofilox solution 5% 5-fluorouracil cream Trichloroacetic acid (TCA) Small warts can be removed by: • Freezing (cryosurgery) • Burning (electrocautery) • Laser treatment • Surgical excision Large warts that have not responded to treatment may be removed surgically Vaccination recommended starting around age 12 and may lead to decrease in cancer associated with HPV Abstinence from sexual activity during treatment to promote healing

Pelvic Inflammatory Disease

PID is an infection-induced inflammation of the female upper reproductive tract. PID rates remain unacceptably high. PID may involve the uterine lining (endometritis), the connective tissue adjacent to the uterus (parametritis), the Fallopian tubes (salpingitis), or the serous membrane that lines part of the abdominal cavity and viscera (peritonitis), or it may manifest as tubo-ovarian abscess PID results from an ascending polymicrobial infection of the upper female reproductive tract, frequently caused by untreated chlamydia or gonorrhea. An estimated 750,000 women are diagnosed annually, resulting in over 250,000 hospitalizations Complications include ectopic pregnancy, pelvic abscess, subfertility, recurrent or chronic episodes of the disease, chronic abdominal pain, pelvic adhesions, and depression. Because most PID cases are secondary to STIs, especially chlamydia, the most effective approach to control it is prevention. Because of the seriousness of the complications of PID, an accurate diagnosis is critical Healthy People 2020. Broad-spectrum antibiotic therapy is generally required to cover chlamydia, gonorrhea, and/or any anaerobic infection. A parenteral cephalosporin in a single injection with doxycycline 100 mg twice a day for 14 days is the current CDC recommendation PID in pregnancy is uncommon, but a combination of cefotaxime, azithromycin, and metronidazole for 14 days may be used. The client is treated on an ambulatory basis with a single-dose injectable antibiotic or is hospitalized and given antibiotics intravenously. The decision to hospitalize a woman is based on clinical judgment and the severity of her symptoms (e.g., severely ill with high fever, a tubo-ovarian abscess is suspected, woman is immunocompromised or presents with protracted vomiting). Treatment then includes intravenous antibiotics, increased oral fluids to improve hydration, bed rest, and pain management. Follow-up is needed to validate that the infectious process is gone to prevent the development of chronic pelvic pain. Nursing assessment of the woman with PID involves a complete health history and assessment of clinical manifestations, physical examination, and laboratory and diagnostic testing. Health History and Clinical Manifestations Explore the client's current and past medical health history for risk factors for PID, which may include: Adolescence or young adulthood Non-White female Having multiple sex partners Early onset of sexual activity History of PID or STI Sexual intercourse at an early age Alcohol or drug use Having intercourse with a partner who has untreated urethritis Recent insertion of an intrauterine contraceptive (IUC) Nulliparity Cigarette smoking Recent termination of pregnancy Lack of consistent condom use Lack of contraceptive use Douching Prostitution Assess the client for clinical manifestations of PID, keeping in mind that because of the wide variety of clinical manifestations of PID, clinical diagnosis can be challenging. To reduce the risk of missed diagnosis, the CDC has established criteria to establish the diagnosis of PID. Minimal criteria (all must be present) are lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness. Additional supportive criteria that support a diagnosis of PID are: Abnormal cervical or vaginal mucopurulent discharge Oral temperature above 101°F Cervical motion tenderness Elevated erythrocyte sedimentation rate (inflammatory process) Elevated C-reactive protein level (inflammatory process) N. gonorrhoeae or C. trachomatis infection documented (causative bacterial organism) White blood cells on saline vaginal smear Prolonged or increased menstrual bleeding Dysmenorrhea Dysuria Painful sexual intercourse Nausea Vomiting Inspect the client for presence of fever (usually over 101°F) or vaginal discharge. Palpate the abdomen, noting tenderness over the uterus or ovaries. However, the only way to diagnose PID definitively is through an endometrial biopsy, transvaginal ultrasound, or laparoscopic examination. If the woman with PID is hospitalized, maintain hydration via intravenous fluids, if necessary and administer analgesics as needed for pain. Semi-Fowler's positioning facilitates pelvic drainage. A key element to treatment of PID is education to prevent recurrence. Depending on the clinical setting (hospital or community clinic) where the nurse encounters the woman diagnosed with PID, a risk assessment should be done to ascertain what interventions are appropriate to prevent a recurrence. To gain the woman's cooperation, explain the various diagnostic tests needed. Discuss the implications of PID and the risk factors for the infection; her sexual partner should be included if possible. Sexual counseling should include practicing safer sex, limiting the number of sexual partners, using barrier contraceptives consistently, avoiding vaginal douching, considering another contraceptive method if she has an intrauterine system (IUS) and has multiple sexual partners, and completing the course of antibiotics prescribed Review the serious sequelae that may occur if the condition is not treated or if the woman does not comply with the treatment plan. Ask the woman to have her partner go for evaluation and treatment to prevent a repeat infection. Provide nonjudgmental support while stressing the importance of barrier contraceptive methods and follow-up care. Advise sexually active girls and women to insist their partners use condoms. Discourage routine vaginal douching, as this may lead to bacterial overgrowth. Encourage regular STI screening. Emphasize the importance of having each sexual partner receive antibiotic treatment.

Syphillis info

Syphilis is a chronic, multistage, curable bacterial infection caused by the spirochete Treponema pallidum that is typically transmitted sexually with an infected partner or congenitally from an infected mother to her fetus. It is a serious systemic disease that can lead to disability and death if untreated. Rates of syphilis in the United States are increasing. It continues to be one of the most important STIs both because of its biologic effect on HIV acquisition and transmission and because of its impact on infant health. Because there is no vaccine to prevent syphilis, control is mainly dependent on the identification and treatment of infected individuals and their contacts with penicillin G, the first-line drug for all stages of syphilis The spirochete rapidly penetrates intact mucous membranes or microscopic lesions in the skin and within hours enters the lymphatic system and bloodstream to produce a systemic infection long before the appearance of a primary lesion. The site of entry may be vaginal, rectal, or oral The syphilis spirochete can cross the placenta at any time during pregnancy. One out of every 10,000 infants born in the United States has congenital syphilis. Maternal infection consequences include spontaneous abortion, low birth weight, fetal growth restriction, prematurity, stillbirth, and multisystem failure of the heart, lungs, spleen, liver, and pancreas, as well as structural bone damage and nervous system involvement and mental retardation Most newborns born with congenital syphilis are exposed in utero after the fourth month of pregnancy, although syphilis acquired late in the third trimester can also be transmitted to an infant through exposure to an active genital lesion at the time of birth. If untreated, syphilis is a lifelong infection progressing in orderly staging. The five stages of syphilis infection are: (1) primary, (2) secondary, (3) early latent, (4) late latent, and (5) tertiary Fortunately, there is effective treatment for syphilis. Benzathine penicillin G, administered by either the IM or intravenous route, is the preferred drug for all stages of syphilis. For pregnant or nonpregnant women with syphilis of less than 1 year's duration, the CDC recommends 2.4 million units of benzathine penicillin G intramuscularly in a single dose. If the syphilis is of longer duration (more than 1 year) or of unknown duration, 2.4 million units of benzathine penicillin G is given intramuscularly once a week for 3 weeks. The preparations used, the dosage, and the length of treatment depend on the stage and clinical manifestations of disease Other medications, such as doxycycline, are available if the client is allergic to penicillin. Women should be re-evaluated at 6 and 12 months after treatment for primary or secondary syphilis with additional serologic testing. Women with latent syphilis should be followed clinically and serologically at 6, 12, and 24 months and also tested for HIV Assess the client for clinical manifestations of syphilis. Syphilis is divided into four stages: primary, secondary, latency, and tertiary. Primary syphilis is characterized by a chancre (painless ulcer) at the site of bacterial entry that will disappear within 1 to 6 weeks without intervention Motile spirochetes are present on dark-field examination of ulcer exudate. In addition, painless bilateral adenopathy is present during this highly infectious period. If left untreated, the infection progresses to the secondary stage. Secondary syphilis appears 2 to 6 months after the initial exposure and is manifested by flu-like symptoms and a maculopapular rash of the trunk, palms, and soles. Alopecia and adenopathy are both common during this stage. In addition to rashes, secondary syphilis may present with symptoms of fever, pharyngitis, weight loss, and fatigue The secondary stage of syphilis lasts about 2 years. Once the secondary stage subsides, the latency period begins. This stage is characterized by the absence of any clinical manifestations of disease, although the serology is positive. This stage can last as long as 20 years. If not treated, tertiary or late syphilis occurs, with life-threatening heart disease and neurologic disease that slowly destroys the heart, eyes, brain, central nervous system, and skin. Clients with a diagnosis of HIV or another STI should be screened for syphilis, and all pregnant women should be screened at their first prenatal visit. Dark-field microscopic examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis. A presumptive diagnosis can be made by using two serologic tests: Nontreponemal tests (Venereal Disease Research Laboratory [VDRL] and rapid plasma reagin [RPR]) Treponemal tests (fluorescent treponemal antibody absorbed [FTA-ABS] and T. pallidum particle agglutination [TP-PA]). Dark-field microscopic examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis

Nursing management of gonorrhea and chlamydia

The prevalence of chlamydia and gonorrhea is increasing dramatically, and these infections can have long-term effects on people's lives. Sexual health is an important part of a person's physical and mental health, and nurses have a professional obligation to address it. Be particularly sensitive when addressing STIs because women are often embarrassed or feel guilty. There is still a social stigma attached to STIs, so women need to be reassured about confidentiality. The nurse's knowledge about chlamydia and gonorrhea should include treatment strategies, referral sources, and preventive measures. It is important to be skilled at client education and counseling and to be comfortable talking with, and advising, women diagnosed with these infections. Provide education about risk factors for these infections. High-risk groups include single women, women younger than 25 years, African American women, women with a history of STIs, those with new or multiple sex partners, those with inconsistent use of barrier contraception, and women living in communities with high infection rates Assessment involves taking a health history that includes a comprehensive sexual history. Ask about the number of sex partners and the use of safer sex techniques. Review previous and current symptoms. Emphasize the importance of seeking treatment and informing sex partners. The four-level P-LI-SS-IT mode can be used to determine interventions for various women because it can be adapted to the nurse's level of knowledge, skill, and experience. Of utmost importance is the willingness to listen and show interest and respect in a nonjudgmental manner. In addition to meeting the health needs of women with chlamydia and gonorrhea, the nurse is responsible for educating the public about the increasing incidence of these infections. This information should include high-risk behaviors associated with these infections, signs and symptoms, and the treatment modalities available. Stress that both of these STIs can lead to infertility and long-term sequelae. Teach safer sex practices to people in nonmonogamous relationships. Know the physical and psychosocial responses to these STIs to prevent transmission and the disabling consequences. Nurses must also inform their pregnant clients that they should avoid quinolones or tetracyclines to prevent risks associated with malformation of teeth, bones, and joints in the fetus and possible hepatotoxicity and pancreatitis in the mother If the epidemic of chlamydia and gonorrhea is to be halted, nurses must take a major front-line role now.

Syphillis

Treponema pallidum (spirochete bacteria) Sexual contact with an infected person Serologic testing mainstay for diagnosis Venereal Disease Research Laboratory (VDRL), rapid plasma reagin (RPR), and treponemal tests (e.g., fluorescent treponemal antibody absorbed [FTA-ABS]) can lead to a presumptive diagnosis and are useful for screening. Use of 2 tests required Darkfield examination and direct fluorescent antibody tests of lesion exudate or tissue provide definitive diagnosis of early syphilis New tests are in development such as enzyme immunoassay Screen based on epidemiology and personal risk factors Course of disease divided into stages Primary infection: • Chancre on place of entrance of bacteria (usually vulva or vagina but can develop in other parts of the body) Secondary infection: • Maculopapular rash (hands and feet) • Sore throat • Lymphadenopathy • Flu-like symptoms Latent infection: • No symptoms • Can be infective during first 1-2 years of latency • Many people if not treated will suffer no further signs and symptoms Some people will go on to develop tertiary or late syphilis Tertiary infections: • Tumors of skin, bones, and liver • Central nervous system symptoms • Cardiovascular symptoms • Usually not reversible at this stage Course of disease divided into stages Primary infection: • Chancre on place of entrance of bacteria (usually on penis but can develop in other parts of the body) Secondary, latent, and tertiary infections: All similar to female symptoms Benzathine penicillin G injection (if penicillin allergy, doxycycline, tetracycline, or erythromycin) Sexual partners need evaluation and testing

Trichomoniasis

Trichomonas vaginalis (protozoa) Vaginal intercourse with an infected partner May be picked up from direct genital contact with damp or moist objects, such as towels Highly sensitive and specific testing available and recommended, such as NAAT Microscopic evaluation of vaginal secretions or culture still common but less sensitive Many women have symptoms but some may be asymptomatic Dysuria Frequency Vaginal discharge (yellow, green, or gray and foul odor) Dyspareunia Irritation or itching of genital area Most men infected are asymptomatic Dysuria Penile discharge (watery white) Metronidazole (Flagyl) or tinidazole Sexual partners need evaluation, testing, and treatment also Abstinence

Proper condom use

Use latex condoms. Use a new condom with each act of vaginal, anal or oral sex. Never reuse a condom. Handle condoms with care to prevent damage from sharp objects such as fingernails and teeth. Ensure condom has been stored in a cool, dry place away from direct sunlight. Do not store condoms in wallet or automobile or anywhere where they would be exposed to extreme temperatures. Do not use a condom if it appears brittle, sticky, or discolored. These are signs of aging. Put condom on before any genital contact. Put condom on when penis is erect with rolled side out. Ensure it is placed so it will readily unroll. Hold the tip of the condom while unrolling. Ensure there is a space at the tip for semen to collect (about ½ in), but make sure no air is trapped in the tip (air bubbles can cause breakage). Ensure adequate lubrication during intercourse. If external lubricants are used, use only water-based lubricants such as KY jelly with latex condoms. Oil-based or petroleum-based lubricants, such as body lotion, massage oil, or cooking oil, can weaken latex condoms. If you feel the condom break, stop immediately, withdraw, remove broken condom, and replace. Withdraw while penis is still erect, and hold condom firmly against base of penis. Remove carefully to ensure no semen spills out. Dispose of properly.

Vaginitis

Vaginitis is a generic term that means inflammation and infection of the vagina. There can be hundreds of causes for vaginitis, but more often than not the cause is infection by one of three organisms: Candida, a fungus Trichomonas, a protozoa Gardnerella, a bacterium The complex balance of microbiologic organisms in the vagina is a key element in the maintenance of health. Subtle shifts in the vaginal environment may allow organisms with pathologic potential to proliferate, causing infectious symptoms. The nurse's role in managing vaginitis is one of primary prevention and education to limit recurrences of these infections. Primary prevention begins with changing the sexual behaviors that place women at risk for infection. Avoid douching to prevent altering the vaginal environment. Use condoms to avoid spreading the organism. Avoid tights, nylon underpants, and tight clothes. Wipe from front to back after using the toilet. Avoid powders, bubble baths, and perfumed vaginal sprays. Wear clean cotton underpants. Change out of wet bathing suits as soon as possible. Become familiar with the signs and symptoms of vaginitis. Choose to lead a healthy lifestyle.

Trichomoniasis info

richomoniasis is another common vaginal infection that causes a discharge, but is not always sexually transmitted. The organism can live on damp/wet surfaces and poorly cleaned/maintained hot tubs and drains. The woman may be markedly symptomatic or asymptomatic. When symptoms are present, they include vulvar itching and a malodorous foamy vaginal discharge. Men are asymptomatic carriers. Although this infection is localized, there is increasing evidence of preterm birth and postpartum endometritis in women with this vaginitis. The high prevalence of this infection globally and frequency of coinfection with other STIs make trichomoniasis a public health concern. Notably, research finds that an infection with trichomoniasis increases the risk of HIV transmission in both men and women. Trichomonas vaginalis is an ovoid, single-cell protozoan parasite that can be observed under the microscope making a jerky swaying motion. A single 2-g dose of oral metronidazole or tinidazole for both partners is a common treatment for this infection. Sex partners of women with trichomoniasis should be treated to avoid recurrence of infection. Assess the client for clinical manifestations of trichomoniasis, which include: A heavy yellow/green or gray frothy or bubbly discharge Vaginal pruritus and vulvar soreness Dyspareunia Cervix may bleed on contact DysuriaVaginal odor, described as foulVaginal or vulvar erythema Petechiae on the cervix The diagnosis is confirmed when a motile flagellated trichomonad is visualized under the microscope. In addition, a vaginal pH of greater than 4.5 is a typical finding. FDA-cleared tests for trichomoniasis in women include OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, Massachusetts), an immunochromatographic capillary flow dipstick technology, and the Affirm VP III (Becton Dickenson, San Jose, California), a nucleic acid probe test that evaluates for T. vaginalis, Gardnerella vaginalis, and Candida albicans Instruct clients to avoid sexual activity until they and their sex partners are cured (i.e., when therapy has been completed and both partners are symptom-free) and also to avoid consuming alcohol during treatment because mixing the medications and alcohol causes severe nausea and vomiting In addition, it is important to provide information regarding infection cause and transmission, effects on reproductive organs and future fertility, and the need for partner notification and treatment. Follow-up testing is not indicated if symptoms resolve with treatment.