Transcript Pediatric Resident Academic Half Day

Pediatric Resident Academic
Half Day
March 21, 2013
Dr. A. Bates, PGY5
Pediatric Infectious Disease Fellow
http://www.youtube.com/watch?v=D4Y3QXOZY6E
Background
•
World Health Organization 2005:
•
Sexually transmitted infections among
adolescents: the need for adequate health
services
•
Since the International Conference on
Population and Development in Cairo in 1994,
recognition of young people’s specific sexual
and reproductive health needs has gradually
increased
Background
•
Attempts to date to promote the sexual health of
young people have tended to focus on prevention,
education and counselling for those who are not
yet sexually active
•
While the provision of health services to those who
have already engaged in unprotected sexual
activity and faced the consequences, including
pregnancy, STIs or sexual violence, has lagged
behind
Background
challenges - global and local
•
•
increasing populations
•
antimicrobial resistance
•
global travel
•
co-infections
Objectives
recognize common sexually transmitted infections in
adolescents
create a general management plan
special circumstances:
HIV
Post exposure prophylaxis
sexual abuse
What is a sexually transmitted
Infection
The term STI (Sexually Transmitted Infection) is
now commonly used in the place of STD
(Sexually Transmitted Disease)
it is more encompassing
it includes infections that may be asymptomatic
What is happening on the
Canadian Front?
three nationally reportable STIs
chlamydia, gonorrhea and syphilis
increasing rate of all three infections since 1997
Epidemiology
15-24 yo represent ~ 25% of the sexually
experienced population
they acquire ~ half of all new STDs
Compared with older adults, sexually active
adolescents aged 15–19 years and young
adults aged 20–24 years are at higher risk of
acquiring STDs for a combination of
behavioral, biological, and cultural reasons.
Epidemiology
multiple factors involved
adolescent females have an increased
susceptibility to Chlamydia trachomatis because
of increased cervical ectopy
multiple barriers lack of transport, discomfort with the
facility/service design, concerns re:
confidentiality
Canadian Stats 2009
Chlamydia
AB - 366 cases/100 000 ppl
Rates (per 100 000)
10-14 yo - 29.1
15-19 1041.7
20-24 yo - 1373.8
steadily increasing in Canada since 1997
Canadian Stats 2009
Gonorrhea
AB - 42 cases/100 000 ppl
Rates (per 100 000)
10-14 yo - 3.8;
15-19 102.5
20-24 yo - 145.2
from 1997-2004 - rate has increased by ~ 94%
resistance - quinolones (up to 15.7% in 2005)
Canadian Stats 2009
Syphilis
15-19 yo - 52 cases
20-24 yo - 193 cases
previously rare - by 2006 in Canada - incrased to 1 493
cases (regional outbreaks)
risk groups - MSM (HIV positive and neg)
sex workers and their clients
acquisition in endemic regions
Further Epidemiology of
Canadian STIs
HPV - very common
not reportable so true incidence not known
Most affected - adolescent and young adult woment and
ment
HSV - 1 & 2 - common
not reportable but seroprevalence indicate rates of at
least 20%
very common in both adolescent and adult men and
women (women > men)
Why the Increase?
better diagnostics (NAATs)
suboptimal youth awareness and knowledge of risk-reduction
behaviours
sex is occurring at an early age (and longer throughout life)
high rates of serially monogamous relationships
adolescents (and public in general) have a poor understanding of
transmission risks
vaginal, anal and oral
“party drugs” are increasingly linked to unsafe sexual behaviours
Why the Increase?
other unique factors with adolescents
where do they get there education from?
where do they get testing/treatment from?
social factors - peer pressure, games, etc.
Approach
Primary prevention
Secondary prevention
Approach
Primary prevention
aims to prevent exposure
identify at-risk individuals
thorough assessments
patient centred counselling
education
Approach
Secondary prevention
reduction of STI prevalence
detection of infection in at-risk populations
counselling
timely partner notification and treating infected
individuals and contacts
goal: preventing and/or limiting further spread
Which Statement Is True?
1) The presence of an acute infection can increase the
risk of co-infection
2) Sequelae of women from untreated CT/GC can
include infertility
3) Persistent HPV infections plays a role in cervical
dysplasia and carcinoma
4) Chronic viral STI (i.e. HSV) can have long standing
negative impacts on patient’s psychosocial well-being
5) All the above
Which Statement Is True?
1) The presence of an acute infection can increase the
risk of co-infection (ie chancre and HIV)
2) Sequelae of women from untreated CT/GC can
include infertility (chronic pelvic pain, ectopic pregnancy,
PID)
3) Persistent HPV infections plays a role in cervical
dysplasia and carcinoma (role for vaccine)
4) Chronic viral STI (i.e. HSV) can have long standing
negative impacts on patient’s psychosocial well-being
5) All the above
Approach to Adolescents with
Sexually Transmitted Infections
History
Exam
Investigations
Managements
HISTORY
think about STI risk factors ...
STI Risk Factors
sexual contact with a person with a known STI
sexually active youth under 25 yo
new sexual pertner or more than 2 in the past year
serially monogamous relationships
no contraception or SOLE use of non-barrier contraception
IVDU
substance use - ETOH, rec Rx (esp if assoc with having
sex)
STI Risk Factors
engaging in unsafe sexual practices (sharing sex toys, sex
with blood exchange, unprotected sex - oral/genital/anal)
sex workers
survival sex
street involvement, homelessness
anonymous sexual partnering (rave party, internet,
bathhouse)
victims of sexual assault/abuse
previous STI
History
very thorough HEADDSSS history
confidentiality
empathy
non judgemental
focused sexual history
Sexual History
Patient comfort
systemic symptoms
genital signs and
symptoms
fever
discharge
weight loss
dysuria
lymphadenopathy
abdominal pain
prevention immunizations, condoms
testicular pain
Rx treatments, allergies
rashes and lesions
Sexual History
relationships: are you sexually active now or have you
ever been?
incl oral, anal, and vaginal
do you have any concerns about sexual or
relationship violence or abuse?
Sexual History
sexual risk behaviour
number of partners
sexual preference, orientation
sexual activities - give or receive oral sex? anal sex?
personal risk - sex with people from other countries,
bathhouses, travelling
use of condoms?
Sexual History
STI history
have you ever been tested for an STI/HIV? last
screening date?
have you ever had an STI in the past? if yes, what
and when?
how long have symptoms been on going
Sexual History
Reproductive health history
use of contraception? frequency? problems?
ever been pregnant? used emergency contraception?
Other High Risk Behaviors
Substance use
ETOH, IVDU, sex while intoxicated
tattoos or piercings
Psychosocial history
traded sex for money, drugs, shelter? paid for sex? forced to have
sex?
sexually abused (mentally, physically)
have a home? live with anyone other than family?
Encounters with the law
Exam
Common to both sexes
systemic signs - weight loss, fever, enlarged LNs
mucocutaneous regions (incl pharynx)
external genitalia - lesions, inflammations, genital d/c,
anatomical irreg
perianal inspection
Exam
adolescent males
palpate scrotal contents (attn to epididymis)
retract foreskin to inspect the glans
“milk” the urethra - discharge
adolescent females
separate labia - visualize vaginal orifice
speculum exam - cervix, vaginal walls
bimanual exam - uterine or adnexal masses or tenderness
Investigations
Urine - first void - CT/GC (NAATs)
Serum - Syphilis EIA/RPR
anti-HIV 1/2 antibodies
HepBs Ag, HepBs Ab
HepC Ab
HepA Ab
Cervix:
Endocervical canal - swab for CT and GC culture/NAAT (12 cm - columnar epithelial cells); direct inoculate for N.
gonorrhoeae onto culture plate or transport medium
Exocervical samples - HSV, HPV
Investigations
Lesions
vesicles - deroof and swab - HSV PCR
ulcers - HSV PCR; Syphilis - dark field microscopy,
PCR, DFA/IFA
Pharynx - posterior pharynx and tonsillar crypts
(culture)
Rectum - CT, GC, HSV
Investigations
Urethra
thin, dry flex swab, moistened (3-4 cm males; 1-2 cm females)
rotate slowly -> prepare a slide; inoculate on culture/transport
medium
“milking” penis 3-4x helps
Vaginal
collect pooled vaginal secretions; or swab in posterior fornix
(usually done during speculum exam)
Warts/Other HPV infections
scrape exocervical for superficial epithelial cells; use cytobrushes
to collect from squamo-columnar junction
HPV DNA
Post Test Counselling
organism/syndrome specific advise
education about transmission, safer sex practices
case reporting requirements
partner notification
use of motivational interviewing strategies (both
primary and secondary prevention)
Common Signs/Symptoms
Which of the Statements are
True?
1) patients with organisms causing urethritis almost
always have symptoms
2) patients should abstain from unprotected sex until 7
days after starting treatment
3) when collecting urine for NAAT for CT/GC, collection
of mid-stream urine is recommended
4) if abuse is suspected, NAAT testing is sufficient
Which of the Statements are
True?
1) patients with organisms causing urethritis almost
always have symptoms - up to 25% are
asymptomatic (esp NGU)
2) patients should abstain from unprotected sex
until 7 days after starting treatment
3) when collecting urine for NAAT for CT/GC, collection
of mid-stream urine is recommended - first-catch
urine
4) if abuse is suspected, NAAT testing is sufficient need a culture
Asymptomatic
Neisseria gonorrhoaea
Chlamydia trachomatis
Syphilis
HSV 1 & 2
HPV
HIV
Viral hepatitis
Urethritis
urethral discharge
burning on urination
irritation of the distal urethra or meatus
meatal erythema
Gonococcal urethritis - urethritis develops 2 to 6 days
NGU urethritis - 1 to 5 wks (avg 2-3) after acquisition
Urethritis Pathogens
Urethritis Pathogens
N. gonorrhea
C. trachomatis
Trichomonas vaginalis
HSV
Mycoplasma genitalium
Ureaplasma urealyticum
* Adenovirus
* Candida albicans
Chlamydia Background
caused by Chlamydia trachomatis serovars D to K
under diagnosed
usual incubation is 2 to 3 wks (up to 6 wks)
without treatment, infection can persist for many
months
individuals with N. gonorrhea are usually co-infected
with C. trachomatis
Screen sexually active females under 25 years
Chlamydia Signs/Symptoms
females - most often asymptomatic; cervicitis, vaginal
discharge, dysuria, conjunctivitis
males - often asymptomatic; urethral discharge,
urethritis, dysuria, conjunctivitis, proctitis
neonates/infants - conjunctivitis in neonates;
pneumonia in infants < 6 months
Chlamydia Testing
NAATs are the most sensitive and specific
done on urine, urethral and cervical (blood and mucus
can affect test)
culture preferred for medico-legal purposes and
recommended for throat specimens
serology not useful for acute genital chlamydial infections
conjunctival swab for culture, DFA
Chlamydia Treatment
Preferred:
Azithromycin 1g PO x 1 or Doxy 100mg PO BID x 7/7
Infants with conjunctivitis:
need systemic treatment - Erythromycin x 14 d (can
use Azithro once > 1 mo)
Chlamydia Aftermath
Major sequelae:
female - PID, ectopic pregnancy, chronic pelvic
pain, reactive arthritis, infertility
males - epididymo-orchitis, reactive arthritis
Chlamydia Followup
Test of cure not routine
Required if:
poor compliance
alternative Tx used
prepubertal children
pregnant women
done at 3-4 wks (avoid FP)
Gonnorhea Background
Neisseria gonorrhea, gram negative diplococci
concerns of drug resistance
quinolones - not recommended in Canada (> 3-5% R)
incubation - 2 to 7 days
most affected 15-19 yo females and 20-24 yo males
Gonnorhea Signs/Symptoms
Neonates/Infants - Ophthalmia, neonatal AF infection
and disseminated gonococcal infection (sepsis)
Females - cervicitis, PID, urethritis, perihepatitis,
batholinitis
Males - urethritis, epididymitis
Both - pharyngeal infection, conjunctivitis,
disseminated infection - arthritis, dermatitis,
endocarditis, meningitis
Gonnorhea Testing
gram stain - 95% sense/spec on urethral specimens young males;
45-65% sense and 90% spec on endocervical specimens
CULTURE - susceptibilities
sexual abuse/assault, pharynx, blood (disseminated)
treatment failure
NAATs - cervical, urethral swabs, urine; some for vaginal swabs
URINE preferred
no serology
Gonnorhea Treatment
2012 PHAC STI
Low risk* - Cefixime 800mg PO x 1
High risk* - MSM, treatment failures - Ceftriaxone 250
mg IM x 1
Fluoroquinolones ONLY IF
susceptibility testing demonstrates susceptible
local R is < 5% and TOC can be done
Tx all patients for Chlamydia
Gonnorhea Followup
Test of cure
all pharyngeal infections
persistent symptoms or signs post-Tx
those treated with alternative regimen
cases linked to drug resistant/Tx failures treated with
the same antibiotic
sexual abuse, neonates
Gonnorhea Aftermath
Sequelae females - PID, infertility, ectopic pregnancy, chronic
pelvic pain, reactive arthritis, disseminated
gonococcal infection
males - epididymo-orchitis, reactive arthritis, infertility
(rare), disseminated gonococcal infection
Which of the statements re:
PID is True?
1) the most common infectious cause of lower
abdominal pain in young women is cystitis
2) Most PID is associated with more than one organism
3) Most cases of PID present to ER
4) There is no long-term sequelae from PID
Which of the statements re:
PID is True?
1) the most common infectious cause of lower
abdominal pain in young women is cystitis - PID
2) Most PID is associated with more than one
organism
3) Most cases of PID present to ER - 2/3 go
unrecognized and underreported
4) There is no long-term sequelae from PID - tubal
factor infertility, ectopic preg, chronic pelvic pain
directly related to number of episodes
Pelvic Inflammatory Disease
lower abdominal pain and fever
deep dyspareunia
abnormal bleeding
Bimanual exam - cervical motion tenderness, adenexal
tenderness and/or mass
RUQ pain
cervicitis
Pelvic Inflammatory Disease
PATHOGENS??
Pelvic Inflammatory Disease
STI - Chlamydia, Gonorrhea, (HSV and Trich - rare)
Endogenous - Genital tract mycoplasma - M
genitalium, U urealyticum
Anaerobic - Bacteroides, Peptostreptococcus,
Prevotella
Facultative (aerobic) - E coli, Gardnerella vaginalis,
Streptococcus sp, H influenzae
Pelvic Inflammatory Disease
cervical swab - gram stain and gonorrhea culture; CT
NAAT or culture
Urine +/- serum bHCG r/o ectopic pregnancy
following ESR/CRP
pelvic u/s
vaginal swab - culture, gram stain, pH, whiff test and
wet mount**
Pelvic Inflammatory Disease
GOALS 1) control acute infection 2) prevent long-term
sequelae
Cover - CT, GC, GNEB, streptococci +/- anaerobic
1) IV Cefoxitin PLUS PO Doxy
2) IV Clindamycin PLUS Gentamicin
3) IV Cipro PLUS Doxy +/- Metro
PO step down to complete 14 days with Doxycycline
** Doxy and fluoroquinolones CI in pregnancy
Pelvic Inflammatory Disease When to Hospitalize
surgical emergencies (appendicitis) cannot be excluded
patient is pregnant
patient does not respond clinically to PO Abx
patient is unable to follow/tolerate outpatient PO regimen
severe illness, nausea and vomiting or high fever
tubo-ovarian abscess
** HIV
** youth/adolescents - poor compliance
Vaginal Discharge – a few
words
vaginal discharge, odor, vaginal/vulvar
pruritus/erythema, dysuria
Etiology:
Bacterial Vaginosis
Vulvovagnial candidiasis
Trichomonas
If high STI risk - send urine or cervical swab for CT/GC
NAAT (or culture)
BREAK TIME
5 minute stretch break ....
Which statement is false?
• 1) About 70-80% of genital ulcers are due to HSV-1 and
HSV-2
• 2) Syphilis is only a concern in men who have sex with
men (MSM)
• 3) Genital ulcer disease in sexually active teens can be
associated with 2 or more pathogens
• 4) There are other non-infectious conditions causing
genital ulcers that need to be on the differential.
Which statement is false?
• 1) About 70-80% of genital ulcers are due to HSV-1 and
HSV-2
• 2) Syphilis is only a concern in men who
have sex with men (MSM)
• 3) Genital ulcer disease in sexually active teens can be
associated with 2 or more pathogens
• 4) There are other non-infectious conditions causing
genital ulcers that need to be on the differential.
Genital Ulcers
• Description of the lesion - erosive vs.
pustular, vesicles, papules, inguinal
lymphadenopathy
• location
• indurated
• painful
• associated symptoms
Pathogens Genital Ulcers
Pathogens of Genital Ulcers
• Painful
• Painless
Pathogens of Genital Ulcers
• Painful - Herpes simplex virus 1 and 2
• Haemophilus ducreyi (Chancroid)
• Painless - Treponema pallidum
(Syphilis)
• C. trachomatis (LGV serovars - L1, L2, L3) - painless
papule -> ulcer
• Klebsiella granulomatis (granuloma inguinale or
donovanosis)
Genital HSV 1 & 2
• herpes - greek - “to creep”
• dsDNA virus - mucocutaneous, CNS, visceral infections
• latent in neuronal cells --> reactivation --> reoccurrence
of lesions (genital - sacral nerve root)
• infectious - while asymptomatic usually ~ 2 d (greater
than woman), active lesions
• incubation - avg 6 days
Genital HSV 1 & 2
• SITE - boxer short area for both sexes
• males - glans, prepuce, penile shaft, anus and rectum
(for MSM)
• women - cervix, vulva, vagina, perineum, legs and
buttocks
Genital HSV 1 & 2
• grouped vesicles evolving toward superficial circular
ulcers on an erythematous base
• smooth margin and base
• ulcers are painful and/ore pruritis
• genital pain
• constitutional (MC with primary infection)
•
enlarged, non-fluctuant and tender LNs
•
fever, malaise, pharyngitis
Genital HSV 1 & 2
• Viral culture
• NAATs - CSF, vesicle fluid, ulcer swabs
• Tzanck smear cytology, Ag detection - poor accuracy
• Antibody tests - HSV 1&2 (12 wks post primary)
•
a) patients with apparent first-episode genital herpes with
neg culture/NAAT
•
b) ID of a seropositive preg woman with no history of herpes
•
c) counselling HSV serologically discordant couples
Genital HSV 1 & 2
• Treatment:
• Primary - Acyclovir 200 mg PO 5x/d for 5-10 days or
Valacyclovir 1 g PO BID x 10/7
• Secondary - Valacyclovir 500 mg PO BID x 3/7
• Prophylaxis - Valacyclovir 500 mg PO OD (double up x
3/7 with outbreak)
Neonatal Herpes
• CNS, disseminated or SEM disease
• highest risk in primary infection of mom
• 50% with primary and 2-8% with recurrent
• c-section if active lesions
• suppression in third trimester to mom
• Tx with Acyclovir IV 21 d for CNS and
disseminated and 14 d for SEM
• Prophylaxis to babes after infection is still controversial
Which statement is false?
• 1) All babies born to mom’s with a lifetime history of
syphilis (even if Tx before pregnancy) require serology
• 2) 2/3 of babies born with congenital syphilis are
asymptomatic
• 3) ulcers carry spirochetes and are infectious
• 4) Adequate Tx of syphilis is a fourfold drop in RPR titre
at 6 months
Which statement is false?
• 1) All babies born to mom’s with a lifetime history of
syphilis (even if Tx before pregnancy) require
serology
• 2) 2/3 of babies born with congenital syphilis are
asymptomatic
• 3) ulcers carry spirochetes and are infectious
• 4) Adequate Tx of syphilis is a fourfold drop in RPR titre
at 6 months (ie 1:32 to 1:8)
Syphilis
• Spirochete – Treponema pallidum
• Motile, corkscrew-shaped, microaerophilic
• present in serous secretions from lesions
• other endemic spirochetes
• yaws (Caribbean), pinta (Central America), or bejel
• Lyme disease
Syphilis
• Primary - painless, indurated, single (70%) ulcer
•
firm, enlarged, non-fluctuant, non-tender lymphadenopathy
•
incubation avg 3 wks (up to 3 mo)
• Secondary
•
rash, fever, malaise, lymphadenopathy, mucus lsions,
condyloma lata, patchy or diffuse alopecia, meningitis,
headaches, uveitis, retinits
•
incubation 2 - 12 wks (up to 6 mo)
Syphilis
• Latent asymptomatic
• early vs. late
• Tertiary
• cardiovascular - aortic aneurysm, AR, coronary a.
ostialstenosis - 10-30 y
• neurosyphilis - asymptomatic to headaches, vertigo,
personality changes, dementia, ataxia, argyll-robertson
pupil (<2 y to 20y)
• gumma - tissue destruction of any organ (most 15 yrs)
Syphilis
• Lesions - primary, secondary, congenital - infectious
• darkfield exam - spirochetes
• direct/indirect fluorescent antibody
• PCR
Syphilis
• Serum (positive in 2-4 wks from exposure)
• Treponemal - Syphilis EIA/INNO-Lia/FTA-ABS/TPPA
(highly sensitive, less specific)
• Non-treponemal testing - RPR/VDRL/TRUST - false
positives
• CSF - usual tests PLUS VDRL
Syphilis
• Knowledge of previous RPR/INNO-Lia & EIA as well as
treatment is useful
• Pos EIA and RPR reactive with clinical signs and
symptoms --> treat
• Primary, secondary, early latent - IM Benzathine
penicillin G 2.4 million units x 1
• Late latent, unknown, tertiary - IM Pen G weekly x 3
doses
• Neurosyphilis - Pen G 3-4 million units q3-4h x 1014d
Syphilis
• Antibodies are life long (EIA
positive)
• some patients stay serofast (low
RPR 1:1 and 1:2 titres, but not
actively infected)
• if not 4 fold decrease, require rpt
Tx
• Penicillin desensitization indication
Congenital Syphilis
• highest risk in primary and secondary syphilis (80%)
especially in 2nd trimester
• early (onset < 2y) - 2/3 may be asymptomatic
• hydrops/stillbirth, fulminant disseminated infection,
mucocutaneous lesions, osteochondritis, anemia,
HSM, neurosyphilis, necrotizing funisitis
• late (onset > 2 y + persistent) - interstitial keratitis,
lymphadenopathy, HSM, bone involvement, anemia,
Hutchinson’s teeth, Mullberry molars, neurosyphilis
Congenital Syphilis
Congenital Syphilis
• if mom treated before pregnancy and not reinfected don’t do anything with baby
• if mom infected during pregnancy and adequately
treated (> 4 wks b/f delivery) - assess signs/symptoms x
3 mo; RPR 0, 3, 6, 18 mo
• NO Tx
• NO further w/u
Congenital Syphilis
• mom inadequately treated, not treated, or baby RPR > 4
fold mom’s or reactive at 12 mo
• close f/u
• Treat 10d IV Pen G crystalline
• RPR 0, 3, 6, and 18 mo
• Xray long bones, CBC, CSF, ophtho and hearing
Congenital Syphilis
• unconventional treatment of mom in pregnancy, not a
confirmation RPR done, treated within 4 wks delivery
• full exam
• assess risk - may treat
• RPR 0, 1, 2, 3, 6, 12, 18 mo
• usually do full w/u
• if not treated
Just a few more viruses…
Human Papillomavirus
• DNA virus
• one of the most common STIs
• MC condylomata acuminata - 6 and 11
• High risk precancerous/cancerous lesions - 16, 18 (31,
33, 45, 58, 59)
• 70% of adult population will have at least one genital
HPV infection over their lifetime
• women 15-49 routine cervical cancer screen Ontario prev of high risk HPV 12.7%
• often acquired early (15-19 yo)
Human Papillomavirus
• Diagnosis
• External genital warts - clinical Dx (typical location,
appearance)
• get worse in pregnancy, other defects of CMI
• Tx
• Cryotherapy - local liquid nitrogen
• Imiquimod - topical
• Podofilox
Human Papillomavirus
• most infections (>80%) clear spontaneously within 18
months
• 15-19 yo in US, external genital warts were noted in 1%
of sexually active adults
• infection of one HPV genotype DOES NOT protect
against others
• Gardasil **
• avg of 20 yrs from acquiring high risk genotype to
detection of cervical cancer
Which statement is true?
• 1) patients with HIV must disclose to their partners their
HIV status
• 2) Babies born to HIV infected moms have a 5% chance
of acquiring HIV
• 3) Sexual transmission of HIV is enhanced by the
presence of other STIs
• 4) All sexual abuse/assault patients should be started on
PEP
Which statement is true?
• 1) patients with HIV must disclose to their partners their
HIV status
• 2) Babies born to HIV infected moms have a 5% chance
of acquiring HIV
• 3) Sexual transmission of HIV is enhanced by the
presence of other STIs
• 4) All sexual abuse/assault patients should be started on
PEP
Human Immunodeficiency
Virus
• Prevention -
• Education
• Identifying those at risk
• Testing
• HAART
• vertical transmission
• PEP
• risk assessment
• started ASAP, less effective if after 72 hrs
Human Immunodeficiency
Virus
• Clinical Dx
• primary or acute HIV – “mono-like” illness
• fever > 80%
• arthralgia/myalgia, rash, lymphadenopathy, sore
throat, fatigue, headache - 40-80%
• oral ulcers and/or genital ulcers, wt loss, n/v or
diarrhea - 10-40%
• chronic asymptomatic HIV infection
• chronic symptomatic HIV infection
HIV in children
Human Immunodeficiency
Virus
• infants/children
• FTT
• lymphopenia
• chronic diarrhea
• opportunistic infections
• more ill from usual childhood infections
Human Immunodeficiency
Virus
•
POC testing and STAT ELISA testing
•
serum - EIA (detect antibodies by 3 wks after infection, but can take
up to 6 months)
•
p24Ag - included in the most recent 4th gen. testing
•
positives - confirmed using a different EIA & Western blot
•
PCR - babies born to HIV infected mothers
•
RNA 10 days after infection)
•
DNA shows virus integration
•
Quantitative PCR - Viral Load testing
•
Genotyping - drug resistance
•
** CD4 and VL NOT used as screening
Human Immunodeficiency
Virus
• Diagnosis in pregnancy is important!
• undetectable VL in pregnancy
• AZT x 6wks after birth to babe
• no breast feeding
• < 1%
Sexual Abuse
• needs to be considered in prepubertal children
with genital, rectal, or pharyngeal chlamydia or
gonorrhea infection
• need a Test of Cure at 3-4 wks after
completion of Tx
• genital warts present in a child older than 18
months (particularly > 2 y)
Sexual Abuse
• HIV serology
• HepBsAg and Ab
• Hep C Ab
• Syphilis EIA
• cultures - Chlamydia, Gonorrhea
Review
• Chlamydia trachomatis
• Neisseria Gonorrhea
• Genital Herpes (HSV 1 & 2)
• Syphilis (congenital syphilis)
• Genital warts (HPV)
• HIV
• Sexual Abuse
Resources
• CDC website
• PHAC 2012 STI guidelines
• CPS position statements
Questions?