Section 4: treatment and management

Transcription

Section 4:
Treatment and management
Anaphylaxis.....................................................................................................................2
Atrophic vaginitis . ..........................................................................................................5
Bacterial vaginosis (BV)................................................................................................. 8
Balanitis and balanoposthitis....................................................................................... 15
Candidiasis....................................................................................................................18
Cervicitis........................................................................................................................25
Chancroid......................................................................................................................27
Chlamydia..................................................................................................................... 37
Donovanosis..................................................................................................................43
Dyspareunia . ................................................................................................................50
Epididymo-orchitis........................................................................................................ 57
Genital herpes (HSV)..................................................................................................... 71
Genital warts – human papilloma virus (HPV)............................................................. 82
Gonorrhoea................................................................................................................... 94
HIV and AIDS............................................................................................................... 105
Lymphogranuloma venereum (LGV)............................................................................ 119
Molluscum contagiosum.............................................................................................126
Non gonococcal urethritis (NGU)..................................................................................131
Pelvic inflammatory disease (PID).............................................................................. 137
Proctitis ......................................................................................................................149
Pubic lice.....................................................................................................................160
Scabies........................................................................................................................ 163
Syphilis.......................................................................................................................166
Tinea cruris..................................................................................................................180
Trichomoniasis............................................................................................................183
Urinary tract infection (UTI)........................................................................................189
Vaccination - Hepatitis A (HAV)...................................................................................196
Vaccination - Hepatitis B (HBV)...................................................................................199
Vaccination – HPV .......................................................................................................205
References.................................................................................................................. 209
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Anaphylaxis
1
Anaphylaxis is a severe adverse event with rapid onset, usually occurring within 5 - 30
minutes, but can occur within hours of administration of medication. It is characterised by
respiratory distress, hypotension and/or circulatory collapse. Symptoms can range from mild
to severe with early signs such as generalised widespread erythema and urticaria.
Signs / Symptoms1
Mild
•
urticaria (large itchy red patches or lesions on the skin)
•
erythema
•
swelling around eyes
•
gastrointestinal disturbance i.e. abdominal cramps, diarrhoea, and/or vomiting
•
no airway obstruction.
These signs may progress to become severe anaphylaxis.
Moderate
•
feeling worried or frightened
•
flushed face.
These signs may progress to become severe anaphylaxis.
Severe
•
coughing or wheezing
•
swelling of the tongue, lips and tissue of the face and neck
•
limpness and pallor (particularly in children)
•
noisy inspiration or expiration – indicating obstruction of the upper airway from
angioedema of the hypopharynx, epiglottis, and larynx)
•
subjective feeling of retrosternal tightness, dyspnoea with audible expiratory wheeze –
indicating lower airway obstruction from bronchospasm
•
profound hypotension, shock, rapid or thready pulse
•
tachycardia and central pulse weak or absent
•
loss of consciousness or fitting.
Management
2
•
stop giving medication
•
call for assistance and stay with the client
QUEENSLAND SEXUAL HEALTH
CLINICAL MANAGEMENT GUIDELINES
•
immediately notify a MO
•
call emergency or ambulance (as per internal policy/procedure).
•
maintain Airway, Breathing, and Circulation
•
commence basic life support as indicated
•
if client is conscious, place supine in “head down and feet up” position (unless this
results in breathing difficulties)
•
if client is unconscious, place him/her on the left side in ‘recovery’ position and keep the
airway clear
•
give adrenaline by deep intramuscular injection (see below for dosage or Australian
Immunisation Handbook)
–
adrenaline is indicated for any signs of anaphylaxis with respiratory and/or
cardiovascular symptoms or signs
–
adrenaline is not indicated if erythema (flushing) or itching is the only presenting
symptom
–
if there is no improvement in the client’s condition within five minutes, repeat dose of
adrenaline every five minutes until there is improvement.
•
give 100% oxygen at high flow rate via face mask if available
•
all cases should be transferred to hospital for observation and treatment. Document
details of client management and send this to the hospital with the client
•
clearly document
–
the episode in the client’s record including BP, respiratory rate, localised reaction or
skin eruptions, respiratory involvement, wheezing or coughing
–
the drug responsible for the reaction and mark it in the client’s chart.
Treatment
Name
Adrenaline
Form
Ampoule
Strength
1:1000 (1mg/1ml)
Recommended dose
0.5mg (0.3-0.5ml) unless under 13 years of age or weighs
less than 40 kg (0.01mg/kg to a maximum 0.5mg). Further
information refer to Australian Immunisation Handbook.
Route of admin
Intramuscular Injection
Duration
Stat
Then repeated every five minutes until client condition
improves
Consumer information
May cause headache, restlessness, anxiety and
palpitations in the conscious client
Management of emergencies
Consult MO
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Note: If adrenaline is given when a strong central pulse is present it may cause reactions
such as fear, anxiety, tenseness, restlessness, headache, tremor, weakness, dizziness, pallor,
respiratory difficulty and palpitations. Inform the client of these potential side-effects after
they have stabilised.
Differentiation between Vasovagal episode and Anaphylaxis1
Onset
Vasovagal Episode
Anaphylaxis
Immediate usually within minutes of or during
vaccine administration.
Usually within 10 minutes of vaccine
administration1.
Signs and symptoms
Skin
Generalised pallor, cool,
clammy skin
Itchy skin, erythema, urticaria or
angioedema
Respiratory
Normal, may be shallow
but not laboured
Cough, wheeze, stridor or signs of
respiratory distress (tachypnoea,
cyanosis, costal recession)
Cardiovascular
Bradycardia, weak/absent
peripheral pulse, strong
carotid pulse. Hypotension
is usually transient and
corrects in supine position
Tachycardia, weak or absent central
pulse.
Feel faint, light-headed.
Loss of consciousness improves in supine or head
down position
Sense of severe anxiety and distress.
Neurological
Hypotension, sustained and no
improvement without specific
treatment
Loss of consciousness, no
improvement in supine or head down
position.
Client education
•
ensure client is aware of which medication caused their reaction
•
the client may need to obtain a Medicalert bracelet, so inform them to purchase this from
their chemist.
Follow-up
•
4
all clients with moderate to severe anaphylaxis require follow-up.
Atrophic vaginitis
It is normal for the post menopausal female genital tract to undergo atrophy. The appearance
may be of a pale epithelium or, where the thin epithelium reveals surface blood vessels,
a deeper red colour. No treatment is required if asymptomatic except for Pap smear
management.
Signs / symptoms
•
vaginal dryness
•
dyspareunia
•
asymptomatic with:
–
atrophic appearance of genital tract
–
unsatisfactory pap smear report due to atrophic cellular changes on cytology.
Management
Conditions requiring NO to refer to or at minimum consult with a MO or NP
(if appropriate/available):
•
persistent, recurrent symptoms
•
no response to treatment
•
contraindication to treatment
•
client requests ongoing treatment
•
immunosuppression e.g. HIV positive client
•
abnormal findings of significance
•
findings outside NOs scope of practice.
Treatment
Indicators
Prophylaxis prior to routine pap smear for post menopausal women with:
•
vaginal discomfort on speculum examination
•
unsatisfactory pap smear due to atrophic cellular changes on cytology.
Regimens
•
Non DTP-SRH endorsed NOs are not authorised to administer this regimen and must
refer management to a DTP–SRH endorsed NO, endorsed NP or MO.
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5
•
•
DTP–SRH endorsed NO may progress if within scope of practice and competence, under
the following conditions:
–
only supply one course of treatment
–
pap smear or past history indicates treatment with topical oestrogen will improve
quality of sample.
Endorsed NP may progress if within scope of practice and competence. For all other
cases consult a MO.
Name
Oestriol (Ovestin)
Form
Pessaries or cream
Strength
Pessaries 0.5mg
Cream 1mg/1g
Recommended dose
Pessaries: one pessary (0.5mg)
Cream: one applicator (0.5mg)
Route of admin
Per vagina
Frequency/duration
Pessaries: one pessary (0.5mg) intravaginally at night for 7
days prior to Pap Smear sampling
Cream: one applicator (0.5mg) intravaginally at night for 7 days
prior to Pap Smear sampling
*Cream or pessary not to be used for 24 hrs prior to performing
investigations (for 2-3 weeks TG +AMH).
Pregnancy category
B1
Poison schedule
S4
Emergency management
Consult MO
Contraindications
Oestrogen dependant tumours
Undiagnosed vaginal bleeding
Thrombophlebitis (or past history)
Venous thromboembolism within last two yrs
Endometriosis
Sensitivity to constituents
Pregnancy
Porphyria
Severe liver dysfunction
6
Or
Name
Oestradiol (Vagifem)
Form
Pessaries
Strength
25 microgram
Recommended dose
Pessaries: one pessary intravaginally at night for 7 days prior
to Pap Smear sampling
*Pessary not to be used for 24 hrs prior to performing
investigations. (for 2 weeks TG +AMH).
Route of admin
Per vagina
Frequency/duration
See above
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Oestrogen dependant tumours
Undiagnosed vaginal bleeding
Sensitivity to any constituents
Pregnancy
Breast carcinoma (known, suspected or history)
Acute thrombophlebitis or thromboembolic disorders (or past
history associated with previous oestrogen use).
Client education
•
supply written information on use of cream or pessary
•
advise how to insert cream or pessary and stress the importance of ceasing use prior to
attending for pap smear
•
advise that vaginal preparations may interfere with integrity of condoms
•
provide MIMS Consumer Medicine Information www.ckn.health.qld.gov.au
Contact tracing
Refer to History and assessment (section one).
Follow-up
•
not usually required unless there is a problem with pap smear
•
if the client requires ongoing management of vaginal dryness and other menopausal
symptoms refer to a MO or GP.
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7
Bacterial vaginosis (BV)
Bacterial vaginosis (BV) is a common cause of vaginal discharge in women of childbearing
age2. BV results from a decrease in concentration of normal hydrogen-peroxide producing
lactobacilli flora and an increase in other vaginal organisms, especially anaerobes such as
gardnerella vaginalis2, 3. The absence of inflammation indicates it is vaginosis instead of
vaginitis. BV is considered endogenous in origin3.
Signs / symptoms4-7
Symptomatic with a minimum of three of the following:
•
thin, greyish/white, homogenous discharge that adheres to vaginal walls
•
increased amount of vaginal discharge
•
malodour or “fishy odour” which is more noticeable during menstruation or after sex
•
pH of vaginal discharge is alkaline (>4.5)
•
introital dyspareunia and vulval irritation is usually absent or minimal.
Investigations5 - 8
Testing should be performed when a client presents with vaginal discharge. Always examine
the cervix and vagina.
•
speculum examination
•
take swab from the posterior vaginal wall for M/C/S
•
wet preparation – mix the vaginal secretion with two drops of normal saline on
a microscope slide and examine under 400 x magnification. This allows precise
identification of the three major causes of vaginitis. If BV is suspected, look for clue cells
•
vaginal smear – smear swab from vaginal wall onto a microscope slide, air-dry, heat fix,
gram-stain and examine under 1000 x oil-immersion magnification. This allows precise
identification of clue cells and absence of lactobacilli
•
vaginal culture – place swab from vaginal wall into a suitable transport medium (Amie’s
or Stuart’s medium with added charcoal) and send for culture testing. Positive culture
for gardnerella vaginalis does not necessarily indicate BV as this micro-organism may be
present in low numbers as a commensal in many women.
•
vaginal pH
•
KOH whiff test positive for volatile amines.
In asymptomatic client:
•
8
Treatment is not necessary however it is advisable before invasive procedures (i.e. IUD
insertion, hysteroscopy or termination of pregnancy) as there is association between
bacterial vaginosis and pelvic inflammatory disease.
•
Treatment in pregnancy is advisable, as there are reports of association with premature
rupture of membranes and ascending infection, although effectiveness of this measure
has had variable success in studies to date3.
Management
•
persistent symptoms
•
abdominal or pelvic symptoms e.g. pain or PID
•
client is pregnant or breastfeeding
•
•
•
•
Treatment
Regimens
•
•
DTP–SRH endorsed NO or may progress if within scope of practice and competence. For
all other cases consult a MO or endorsed NP.
•
cases consult a MO.
First line regimens39
Name
Metronidazole
Form
Tablet
Strength
400mg
Recommended dose
400mg
Route of admin
Oral with food
Frequency/duration
Twice a day for 5 3, 8, 9 - 77, 10, 11days
Pregnancy category
B2
Poison schedule
S4
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Contraindications
Pregnancy (first trimester) and lactation (MIMS)
Blood dyscrasias
Active CNS disease
Hypersensitivity to Metronidazole or other imidazole
Special precautions
Pregnancy category B2 (second and third trimester)
Prolonged use
Renal or hepatic impairment
Alcoholic beverages or drugs containing alcohol may cause
flushing, vomiting, tachycardia
Adverse Reactions
Superinfection
G.I. disturbances (e.g. may cause metallic taste in mouth,
nausea)
Leukopenia and thrombocytopenia
Neurological disturbances
Sensitivity phenomena
Pancreatitis
Metallic unpleasant taste
Interactions
Alcohol (avoid for 24 hrs post treatment)
Warfarin
Carmustine (BCNU) (chemotherapy drug)
Cyclophosphamide
Phenytoin, phenobarbitone and other hepatic enzyme inducers
Cimetidine and other hepatic enzyme inhibitors
Lithium
Disulfiram
Cyclosporine
5 Fluorouracil
Busulfan (cancer chemotherapy drug can cause serious adverse
effect if given in combination with Metronidazole
10
Or
Name
Clindamycin Phosphate
Form
Cream
Strength
2%
Recommended dose
5grams (one full applicator)
Route of admin
per vagina
Frequency/duration
One full applicator intravaginally at night for seven nights
Pregnancy category
A
Poison schedule
S4
Contraindications
Hypersensitivity to Clindamycin, Lincomycin or other components
of cream
Precautions
Systemic absorption, regional enteritis, ulcerative, antibiotic
assoc colitis, vaginal intercourse, vaginal products, latex/ rubber
contraceptive devices within 72 hours (contains mineral oil), eye
contact; pregnancy (first trimester), lactation, children
Adverse reactions
Superinfection
Pseudomembranous colitis
Vulval irritation
GI and CNS disturbances
Rash
Interactions
Neuromuscular blocking agents (used in anaesthesia)
Second line regimens
STAT regimens of Metronidazole and Tinidiazole are not recommended as first line treatment
option7,12. Evidence demonstrates that cure rates may be lower with STAT regimens.
Indications for use are based on history and clinical assessment e.g. issues of compliance
with first line regimens.
Name
Metronidazole
Form
Tablet
Strength
400mg
Recommended dose
2grams (5 X 400mg tablets)
Route of admin
Oral with food
Frequency/duration
Stat
Pregnancy category
B2
Poison schedule
S4
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11
Contraindications
Pregnancy (first trimester) and lactation
Blood dyscrasias
Active CNS disease
Hypersensitivity to Metronidazole or other imidazole
Special Precautions
Pregnancy Category B2 (second and third trimester)
Prolonged use
Adverse Reactions
Superinfection
G.I. disturbances (e.g. may cause metallic taste in mouth,
nausea)
Pancreatitis
Interactions
Warfarin
Cyclophosphamide
Phenytoin, phenobarbitone and other hepatic enzyme inducers
Lithium
Disulfiram
Cyclosporine
5 Fluorouracil
Busulfan (cancer chemotherapy drug can cause serious
adverse effect if given in combination with Metronidazole
Or
12
Name
Tinidazole
Form
Tablet
Strength
500mg
Recommended dose
2gram (4 x 500mg tablets)
Route of admin
Oral with food
Frequency/duration
Stat
Pregnancy category
B3
Poison schedule
S4
Contraindications
Hypersensitivity to other five Nitrimidazole derivatives
Blood dyscrasia
History of CNS disease
Special precautions
Renal impairment
Pregnancy (second and third trimester)
Children
Avoid alcohol for 72 hours after completing dose
Adverse reactions
Superinfection
GI - anorexia, nausea, vomiting, abdominal pain, diarrhoea
Neurological disturbances - headache, dizziness, vertigo,
Ataxia
Rash
Leukopenia, neutropenia
Flushing, fever, tiredness
Metallic taste
Interactions
Alcohol
Anticoagulants
Note: COC user taking a short course (<3 weeks) of antibiotics should be advised to use
additional contraceptive protection (i.e. condoms) during treatment and for seven days after
antibiotics have been stopped.13
Client education
•
discuss vulval and vaginal health e.g. no soap or douching
•
reinforce that BV is not a sexually transmissible infection and that compliance is
important
•
treatment is not necessary if asymptomatic, but it is required before invasive procedures
such as IUCD insertion, hysteroscopy or termination of pregnancy
•
recurrence is common and little is understood about why it recurs. It may be related to
sexual activity and menstruation as semen and blood alter the vaginal environment
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13
•
take Metronidazole with food and avoid alcohol for 24 hours post treatment
•
take Tinidazole with food and avoid alcohol for 72 hours post treatment
•
Clindamycin cream contains mineral oil which may weaken latex or rubber such as
condoms or vaginal contraceptive diaphragms, therefore use of the contraceptive
products is not recommended within 72 hours following treatment with Clindamycin
cream 2%. Ingredients can cause burning and irritate eyes. In the event of accidental
contact, rinse eye adequately with cool water
•
client fact-sheet available at www.health.qld.gov.au/sexhealth
•
Contact tracing14
There is some evidence of sexual transmission between women who have sex with women,
so female partners of women should be contacted and offered treatment48. Male partners do
not need to be contact traced or treated
Follow-up2
14
•
if BV recurs soon after initial treatment, client may require longer course of
Metronidazole
•
if treatment is given during pregnancy to reduce risk of pre-term birth, women should be
re-tested 4 – 6 weeks after treatment and retreated if necessary
•
If symptoms have not resolved consult with MO.
Balanitis and balanoposthitis
Balanitis is an inflammation of the glans penis. Balanoposthitis is an inflammation of the
foreskin and glans in uncircumcised men. Neither condition is classified an STI and is
generally a result of an overgrowth of organisms (fungal or bacterial) which are normally
present on the skin of the glans / penis. One of the most common causes is candida albicans
and other causes include contact dermatitis and mechanical trauma15, 16.
Signs / symptoms17
•
rash, inflammation (redness, swelling of skin), pain or irritation
•
yellow/white pustules or superficial skin erosion
•
increased smegma
•
pruritus
•
preputial oedema and phimosis
•
inguinal adenopathy.
Investigations
Lesions (if suspicious refer to MO for review)
•
swab for HSV PCR (if indicated)
•
swab for M/C/S (if indicated)
•
swab for syphilis PCR (if indicated)
•
measure lesions
•
skin scraping (if indicated)
•
additional STI screening as indicated.
Serology
•
syphilis
•
HIV.
Management
•
secondary infection requiring antibiotic treatment
•
severe phimosis or paraphimosis
•
symptoms persist for >2 weeks following symptomatic and/or topical management
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•
uncertain diagnosis
•
•
immunosuppression e.g. HIV positive
•
abnormal findings of clinical significance
•
Treatment
Indicators
•
clinical findings based on history and examination
•
branching hyphae and/or budding yeast identified on KOH wet prep
•
laboratory confirmed diagnosis.
For mild symptoms
•
discuss skin care, hygiene practices and use of non-soap product
•
use warm water (not hot) for washing
•
avoid allergens and irritating factors i.e. heat, sweat or hygiene products.
For moderate symptoms
•
candida – refer to Miconazole 2% topical cream regimen
•
refer to MO if significant or severe inflammation.
Regimens for suspected or confirmed candidiasis
16
•
•
DTP–SRH endorsed NO may progress if within scope of practice and competence. For all
other cases consult a MO or endorsed NP.
•
cases consult a MO.
Name
Miconazole nitrate
Form
Cream
Strength
2%
Recommended dose
Apply to affected area twice daily
Route of admin
Topical
Frequency/duration
Twice a day for 2 weeks
Pregnancy category
A
Poison schedule
S2
Contraindications
Special precautions
Reinfection
Diabetes
Superinfection
Open lesions
Adverse reactions
Infrequent - irritation, burning, skin rash and maceration.
Client education
•
discuss condition and management including over-the-counter medication
•
discuss skin care and genital hygiene issues
•
•
provide MIMS consumer medication information www.ckn.health.qld.gov.au
Contact tracing
N/A.
Follow-up
There is no specific follow-up required.
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Candidiasis
Candida, a yeast that is considered normal flora in the gastrointestinal and genitourinary
tracts, has a tendency to overgrow and cause genital symptoms when there is a change
or imbalance in normal vaginal acidity due to the use of oral contraceptives, pregnancy,
antibiotic use, diabetes mellitus or compromised immune systems. Vulvovaginal candidiasis
(VVC) is generally caused by candida albicans and is the most common form of genital
mucosal candidiasis7,18. It is not considered an STI, however male partners of women with
thrush may become secondarily infected and develop candidal balanitis and female partners
may develop candidiasis.
Signs / symptoms3, 5 - 7
•
vaginal discharge (varying from thick, white ‘cottage-cheese like’ to a thin white
homogeneous discharge)
•
adherent plaques of yeast on vaginal wall
•
pruritus
•
genital discomfort, external dysuria, dyspareunia or vaginal soreness
•
vaginitis, vulvitis or vestibulitis
•
vaginal pH remains normal (around 4.5)
•
fissures, vulvar swelling or excoriations.
•
balanitis
•
erythema of glans
Note: Severe candidiasis can often be confused with genital herpes.
Investigations3, 5 - 7
Test clients presenting with abnormal vaginal discharge, vulval erythema or itch. Perform a
speculum examination if the vulva is not too painful. Always examine the cervix and vagina in
cases of vaginal discharge.
Uncomplicated vulvovaginal candidiasis (VVC)
Characterised by sporadic or infrequent episodes with mild to moderate symptoms, immunocompetence, likely to be caused by candida albicans.
Vaginal
18
•
swab from posterior vaginal wall with transport medium (Amie’s or Stuart’s medium with
added charcoal) for M/C/S
•
swab from posterior vaginal wall for wet preparation/gram stain
(if available this allows precise identification of spores and pseudo hyphae characteristic
of candidiasis)
•
vaginal pH (usually normal below 4)
•
offer additional STI screening if indicated.
Complicated vulvovaginal candidiasis
Characterised by recurrent candidiasis >4 times per year, severe VVC,
immuno-suppression, debilitation or pregnant client.
Vaginal
•
swab from posterior vaginal wall for M/C/S (to check for candida species).
Serology
•
HIV.
Note:
•
Candida albicans may be detected via vaginal smear or M/C/S, however, a positive
culture may not indicate symptomatic infection as it presents in low numbers as part of
normal flora in many asymptomatic women
•
Consider systemic causes of candidiasis in cases of complicated VVC. i.e. people with
diabetes mellitus or a compromised immune system are more susceptible to increased
skin and mucosal colonisation with candida albicans.19 Additional investigation or referral
to a medical officer may be required depending on history and examination e.g. HIV
serology, random or fasting BSL and HbA1C.
Management
•
persistent, recurrent symptoms
•
•
•
abdominal pain or pelvic symptoms i.e. pain or PID
•
client is pregnant
•
•
•
Note:
•
However, if Candida is identified and the client’s symptoms have resolved, discuss with
client refraining from treatment unless symptoms return.
•
If candidiasis recurs frequently, consider underlying causes such as diabetes,
immunosuppression, HIV infection and antibiotic use. Exclude other recurrent vulval
symptoms such as herpes and dermatitis. In most cases, no cause can be found.
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•
Good results are obtained with long-term suppressive anti-fungal therapy, usually with
oral fluconazole (category D in pregnancy). Special diets and alternative treatments are
generally not effective.
Treatment
Indicators
•
symptomatic with yeast spores and hyphae on wet prep and/or gram stained smear
•
symptomatic with laboratory confirmed diagnosis
•
In asymptomatic clients, treatment is not necessary.4
Regimens
Uncomplicated symptomatic: topical
With or without positive wet mount identification of yeast
20
•
•
other cases consult an endorsed NP or MO.
•
cases consult a MO.
Name
Clotrimazole
Form
Pessary
Strength
500mg (this strength not on LAM)
Recommended dose
500mg
Route of admin
Per vagina
Frequency/duration
One dose only
Insert at bedtime
Consult MO
Pregnancy category
A
Poisons schedule
S3
Special precautions
Not for oral ingestion, ophthalmic use, pregnancy (avoid
applicator), lactation
Adverse reactions
Local irritation, oedema
Interactions
Latex products
Or
Name
Clotrimazole
Form
Cream
Strength
1% (35gram)
100mg
Recommended dose
1 x full applicator
100mg
Frequency/duration
At night for six nights
At night for six nights
Route of admin
Per vagina
Insert at bedtime
Pregnancy category
A
Poisons schedule
S3
Special precautions
Not for oral ingestion, ophthalmic use, pregnancy (avoid
applicator), lactation
Consult MO
Adverse reactions
Local irritation, oedema
Interactions
Latex products
Or
Pessaries
Or
Name
Miconazole Nitrate
Form
Cream
Strength
2% (45 gram)
Recommended dose
1 x full applicator
Route of admin
Per vagina
Frequency/duration
At night for seven nights
Insert at bedtime
Pregnancy category
A
Poison schedule
S3
Consult MO
Contraindications
Known hypersensitivity to Miconazole Nitrate, other imidazole
or any ingredient in this product.
Special precautions
Persistent symptoms, reinfection, diabetes, diaphragms,
condoms (rubber damage), pregnancy, lactation, children
<12yrs, anticoagulants
Adverse reactions
Local irritation, burning, pruritus, discharge, headache, pelvic
cramping (rarely)
Note: If non candida albicans species (i.e. candida glabrata) treatment will need to be altered
or duration of therapy increased. Consult with a MO.
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Uncomplicated symptomatic: oral
•
refer management to a DTP–SRH endorsed NO, endorsed NP or a MO.
•
•
cases consult a MO.
Note: Fluconazole oral regimen is not approved as a first line therapy or for ongoing supply. A
single dose is indicated and authorised for use if:
•
extensive vulval irritation is present
•
topical treatment has failed or caused increased allergic reaction, irritation or
hypersensitivity
•
use of topical therapy is not practical e.g. effects on condom integrity.
Name
Fluconazole
Form
Capsule
Strength
150mg (this strength is not available on LAM)
Recommended dose
150mg
Route of admin
oral with or without food
Frequency/duration
one dose (150mg) stat
Pregnancy category
D
Poison schedule
S3
Consult MO
Contraindications
Known azole sensitivity
Coadministration of fluconazole and cisapride is
contraindicated
Special precautions
Proarrhythmic conditions
Renal impairment
Sodium/fluid restriction
Pregnancy and lactation
Children <16
Adverse reactions
Common - headache, nausea, abdominal pain, diarrhoea
Uncommon - rash, urticaria, dry mouth, dizziness, thirst,
insomnia, nervousness, visual changes, polyuria, hot flushes
22
Interactions
Unlikely to be clinically significant with single dose but refer to
MO.
Sulphonylureas
Warfarin
Rifamycin
Celecoxib
Parecoxib
Clinically or potentially significant drug interactions have been
observed between Fluconazole and the following:
Short Acting Benzodiazepines
Cisapride
Coumarin (type anticoagulants)
Cyclosporine
Hydrochlorthiazide
Oral Hypoglycaemics
Phenytoin
Rifampicin
Rifabutin
Tacrolimus
Theophylline
Drug availability
Available on Queensland Health List of Approved Medicines.21
Drug
Formulation
Dosage regimen
Clotrimazole
Vaginal cream
1% cream. One applicator full at bedtime for six
nights
Clotrimazole
Vaginal pessary
100mg. Insert one at bedtime for six nights
Miconazole
Vaginal cream
2%. One applicator full at bedtime for seven nights
Fluconazole
Capsule
150 mg orally stat
Note: 100mg and 50mg capsules available on LAM
not indicated – for Candidiasis unless it is severe/
life threatening + amphotericin is contra indicated
or not tolerated.
SECTION 4
2010
23
Available at most pharmacies (Schedule 3: Pharmacist Only Products).
Drug
Formulation
Regimen
Butoconazole
(Gynazole)
Cream
2%. One applicator full at bedtime once. Not
available on LAM
Clotrimazole
(Canesten, Clozole,
Femizole, Chemists
own brand, Clofem)
Cream
2%. One applicator full at bedtime for three
nights
Econazole (Pevaryl)
Cream/Foaming
solution
1%. Apply at bedtime
Miconazole
Cream
2%. One applicator full at bedtime for seven
nights
10%. One applicator full at bedtime once. (this
strength not available on LAM)
(Resolve)
Client education
•
discuss vulval and vaginal health e.g. no soap or douching
•
discuss condition and management
•
advise that vaginal preparations can interfere with integrity of latex products such as
condoms and diaphragms (refer to product information)
•
advise about availability of over-the-counter medications
•
•
Contact tracing14
•
male partners of women with candidiasis do not require treatment unless they have signs
or symptoms of balanitis
•
female partners may require treatment48
Follow-up
If recurrent episodes or there is no response to treatment.
24
Cervicitis
Signs / symptoms
Symptoms of cervicitis do not always accompany cervical infection. Normal appearance of the
cervix on examination does not exclude infection and/or abnormality3,21
•
intermenstrual or postcoital bleeding
•
pain during penetrative sex
•
low abdominal pain
•
abnormal vaginal discharge
•
mucopurulent cervical discharge
•
oedematous, inflamed and friable ectocervix with contact bleeding
•
sustained cervical bleeding following gentle contact/swabbing.8,22
Investigations
Perform investigations based on risk assessment, clinical findings and local policy
•
•
•
Vaginal
–
high vaginal swab for M/C/S
–
swab for trichomonas PCR (if indicated)
–
gram stain and wet prep (onsite if available)
–
pH and whiff test.
Endocervical
–
swab for chlamydia PCR
–
swab for gonorrhoea M/C/S
–
swab for trichomonas PCR (If indicated and where available for remote communities)
–
HSV PCR (endo/ecto) swab if indicated
–
pap smear +/- thin prep if indicated.
Discuss additional STI screening as indicated.
Management
•
persistent symptoms after treatment
•
SECTION 4
2010
25
•
•
uncertain diagnosis
•
•
•
findings outside NOs usual scope of practice.
Treatment
Consider syndromic management and empirical treatment for gonorrhoea and chlamydia
when:
•
high prevalence of chlamydia and gonorrhoea in the community
•
signs of cervicitis or PID
•
HIV positive client
•
concerned that client may not return for treatment and follow-up.
Syndromically treat HIV positive clients with cervicitis, to reduce risk of cervical HIV shedding
and HIV transmission.7
Client education
•
•
Contact tracing
Offer STI screening for partners if STI diagnosed.
Follow-up
Follow-up is at discretion of the clinician.
26
Chancroid
Chancroid is an acute ulcerative disease caused by the bacteria Haemophilus Ducreyi.4,8 It
is rare in Australia, but is endemic in places such as South-east Asia, India or Africa. It may
be confused with other genital ulcerative disease but should be suspected following sexual
contact in an endemic area or with a person from an endemic area. It is transmitted by direct
contact with discharge from open lesions during sexual activity. Auto-inoculation to nongenital sites is rare, but can occur.
Signs / symptoms7,22, 49
Incubation period is 3 -10 days following sexual exposure.
•
Lesions commence at the site of inoculation as a tender erythematous papule which
becomes pustular, eroded and ulcerates
•
in males, commonly on the prepuce near the frenulum or in the coronal sulcus. In
females, generally at the vaginal entrance and less commonly painless vaginal and
cervical ulcers49.
•
Perianal and extragenital lesions may occur.
•
ulcers are typically painful and nonindurated with ragged edges. Base may be may be
covered with yellow or grey necrotic purulent exudate, ands ulcer frequently bleeds when
scraped.49
•
associated with painful regional adenitis in about 50% of cases
•
10-40% of people with Chancroid have suppurating inguinal lymphadenopathy or
“buboes”.49
•
constitutional symptoms are usually mild (if present at all)
•
painful unilateral adenitis.
Four criteria for formulating a diagnosis of chancroid
•
presence of one or more painful ulcers
•
presence of regional lymphadenopathy
•
a negative Treponema pallidum evaluation or negative serology at least seven days after
the onset of symptoms
•
negative HSV culture from the ulcer exudate.
Investigations
Lesion:
•
GUMP tests – HSV I and II, T. Pallidum, H. Ducreyi, K. Granulomatis
•
culture in specialised medium for haemophilus ducreyi
SECTION 4
2010
27
–
collect from base of ulcer or aspirate from bubo
–
consult MO and laboratory prior to collection.
•
Offer additional STI screening (including HIV) as indicated by history
•
Testing for Chancroid should not occur in isolation.
A PCR test has been developed which is available from Queensland Health Pathology
Services only in the Northern Zone of Queensland as part of the Genital Ulcer Multiplex PCR
(GUMP) test. It is likely that a PCR test will replace the need for culture in the future.
Diagnosis should only be made by a specialist, based on clinical presentation, history of
exposure, and after exclusion of other causes of genital ulcers.
Management
Conditions requiring NO to refer to or at minimum consult with a MO or NP (if appropriate/
available):
•
Suspected or laboratory confirmed chancroid
•
no improvement after three days of treatment
•
no resolution of lymphadenopathy
•
•
•
abnormal findings of significance.
Treatment
Indicators
•
clinical diagnosis is based on history and examination
•
initiate syndromic management and treat for ulcerative disease as appropriate.
Regimens: Symptomatic clients
28
•
•
•
cases consult a MO.
Name
Azithromycin49
Form
Tablet
Strength
500mg
Recommended dose
Route of admin
Oral with or without food
Frequency/duration
Stat (once only)
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Known hypersensitivity to Azithromycin, Erythromycin or any
Macrolide antibiotic
Special precautions
Pneumonia
Elderly
Prolonged QT interval
Renal and hepatic impairment
Children <16 years
Adverse reactions
Superinfection
Angioedema
Cholestatic jaundice
Raised LFT, AST, ALT
Colitis, GI upset
Vaginitis
Interactions
Antacids
Colchicine (AMH)
Ergot Derivatives
Rifabutin
Cyclosporine
Warfarin
Digoxin and drugs that prolong QT interval
Note:
•
COC user taking a short course (<3 weeks) of antibiotics should be advised to use
additional contraception (i.e. condoms) during treatment and for seven days after
SECTION 4
2010
29
Or
Name
Ceftriaxone49
Form
Dry powder (vial for injection)
Strength
250mg (only available in 500mg, 1g or 2g vials)
Recommended dose
250mg
Route of admin
Intramuscular Injection reconstituted with 2ml 1% Lignocaine
solution
Frequency/duration
Stat (once only)
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Allergy to Cephalosporins
Major allergy to Penicillin
Special precautions
Penicillin sensitivity
Sodium restriction/heart failure (contains 83mg
Impaired vitamin K synthesis
GI disease (especially colitis)
Pregnancy, lactation,
Children <12 years, neonates
Adverse reactions
Hypersensitivity
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Pancreatitis and gall bladder concretions
Interactions
Chloramphenicol
Observe client for 30 minutes after administration of Ceftriaxone.
30
Na per gram)
Plus for reconstitution of 1g Ceftriaxone powder use.
Name
Lignocaine Hydrochloride
Form
Liquid for injection
Strength
1% (5ml ampoulel)
Recommended dose
3.5ml to be used to reconstitute 1g Ceftriaxone powder
Route of admin
Intramuscular injection
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Local inflammation/sepsis
Septicaemia
Anticoagulants
CNS or spinal cord disease
Impaired cardiac conduction, intraventricular block,
arrhythmias
Hypersensitivity to amide LAS
Special precautions
High repeated doses - hepatic, renal, cardiac impairment
Hypoxia, severe respiratory depression
Neurological disorders, epilepsy
Elderly, children
Adverse reactions
CNS disturbances
cardiovascular depression
arrhythmias, hypertension
Interactions
Other local anaesthetics
Antiarrhythmics, beta-blockers (especially class 111)
Cimetidine
phenytoin, other anticonvulsants
inhalation anaesthetics
skeletal muscle relaxants
alcohol
SECTION 4
2010
31
Or
Ceftriaxone 250mg Powder Vials are not available in some settings and have been substituted
with Ceftriaxone Dry Powder 1g vial stock.
The regimen using Ceftriaxone Dry Powder is the same Recommended Dose of 250mg
Ceftriaxone stat as above. Only the strength in stock has changed to 1g Ceftriaxone Dry
Powder. Please follow recommended dose calculation.
Name
Ceftriaxone
Form
Dry powder
Strength
1gram (0.4ml)
Volumes for Dose Calculation 23, 24
1g dry powder (0.4ml) + 1% Lignocaine solution 3.5ml = total
volume 3.9ml
Recommended dose
250mg (0.98ml)
Route of admin
Frequency/duration
Stat (once only)
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Children <12 years, neonates
Adverse reactions
Hypersensitivity reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
32
Chloramphenicol
Plus for reconstitution of 1g Ceftriaxone powder use
Name
Form
Strength
1% (5ml ampoule)
Recommended dose
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
arrhythmias, hypersensitivity to amide LAS
Special precautions
Hypoxia, severe respiratory depression
Elderly, children
Adverse reactions
CNS disturbances
Interactions
cimetidine
alcohol
SECTION 4
2010
33
Or
NO consult with a MO prior to supply of Ciprofloxacin
•
As per the Queensland Hospitals List of Approved Medicines (LAM) Ciprofloxacin is
restricted to specialist staff for treatment of serious infections caused by sensitive
organisms, on the advice of an Infectious Diseases Physician21
•
The Pharmaceutical Benefits Schedule (PBS) restricts use of Ciprofloxacin to treatment
of infections due to pseudomonas aeruginosa or other gram-negative bacteria resistant
to all other oral antimicrobials.
•
Because of increasing resistance to Ciprofloxacin 500mg orally as a stat dose, this
regimen is no longer recommended unless a sensitive gonococcal strain has been
identified via laboratory confirmed diagnosis11,12
•
Prior to treatment with Ciprofloxacin, consult a MO for a laboratory diagnosis regarding
sensitivity to Ciprofloxacin
Name
Ciprofloxacin
Form
Tablet
Strength
500mg
Recommended dose
500mg
Route of admin
Oral on an empty stomach
Frequency/duration
Twice a day for three days
Pregnancy category
B3
Poison schedule
S4
Emergency management Consult MO
Contraindications
Hypersensitivity to other Quinolones including Nalidixic Acid
Concurrent administration of ciprofloxacin and ZanaflexTM (US)
Special precautions
Impaired renal and hepatic function
CNS disorders
GI disease
Pregnancy, lactation
Children, neonates
Sunlight
34
Adverse reactions
Hypersensitivity
Superinfection
Nausea and diarrhoea
Phototoxicity
Haemorrhagic cystitis
Achilles tendon rupture
Interactions
Theophylline
Anticoagulants
Antacids (containing Mg, AL or Ca)
Iron supplements
Probenecid
Sucralfate Theophylline
Zinc or iron containing multivitamin
Caffeine
Cyclosporin
Non steroidal anti-inflammatory drugs
Metoclopramide
Glibenclamide
Methotrexate
Note:
•
Choice of treatment depends on local disease and sensitivity patterning
•
COC users taking a short course (<3 weeks) of antibiotics should be advised to use
antibiotics have been stopped13
•
Antibody susceptibility may vary according to geographical region of contact
•
Differentiation of genital ulcerative disease is inaccurate, particularly in areas where
more then one causative organism is endemic or prevalent at high rates.24 This is
compounded by the presence of HIV infection which may alter clinical manifestations
and patterns of GUD occurrence. Recent evidence indicates that HSV 2 is increasing in
many populations as the main cause of GUD.24 After detection of GUD (i.e. chancroid,
donovanosis, LGV or HSV) it is important to consider additional investigation and
treatment based on local sensitivity patterns.
SECTION 4
2010
35
Client education
•
there are only one or two cases notified each year, although no cases have been notified
in Queensland since 1993
•
when taking Ciprofloxacin or Azithromycin, protect skin from sunlight (especially
between 10am – 3pm) as some macrolide antibiotics are associated with increased
sensitivity to sunlight
•
consult a MO if there is a rash, itching, redness or severe sunburn
•
•
Contact tracing14
•
contact trace two weeks before ulcer appeared or since arrival from endemic area
•
partners who had sexual contact with the index case within ten days prior to onset of
symptoms should be examined and treated (even if asymptomatic)
•
offer STI screening to all contacts
•
empirical/presumptive treatment of all contacts is recommended.
Follow-up
36
•
three days after treatment and then weekly until resolution. Improvement is expected
of substantial ulcer with re-epithelialisation within seven days. Resolution of
lymphadenopathy is slower, especially if fluctuant
•
needle aspiration may be necessary, however avoid incision and drainage
•
discuss contact tracing outcomes
•
in the case of treatment failure, consider:
–
co-infection with another STI (i.e. syphilis or herpes simplex virus)
–
drug resistance
–
non-compliance
–
HIV positive.
Chlamydia
Chlamydia is caused by serovar D - K of chlamydia trachomatis, while other serovars are
responsible for causing trachoma and lymphogranuloma venereum (LGV). Chlamydia infects
the columnar epithelial cells of the urethra, endocervix, fallopian tubes, rectum, oropharynx,
epididymis and conjunctiva.3, 21 It is the most common notifiable disease in Australia among
young people and the most common cause of urethritis in males and cervicitis in females.
Signs / symptoms
Female
•
abnormal vaginal discharge or bleeding (i.e. post coital or IMB)
•
dysuria
•
lower abdominal pain, pressure or heaviness
•
chlamydia cervicitis is indistinguishable from other causes of cervical infection on clinical
examination. Signs and symptoms often go unrecognised and include intermenstrual
bleeding, post coital bleeding and PV discharge
•
approximately 10 - 15% of chlamydia cases (in females) are complicated by pelvic
infection, resulting in pelvic inflammatory disease (PID). Tubal damage can increase risk
of ectopic pregnancy and infertility. Symptoms may include lower abdominal pain and
dyspareunia.
Male
•
dysuria
•
mucoid, watery or mucopurulent discharge and urethral irritation 1 – 3 weeks after
exposure
•
epididymo-orchitis presents as a painful swollen testicle and is occasionally a
complication of chlamydia.
Both
•
asymptomatic (most common)
•
anorectal pain or discharge
•
Less common indicators include sore throat, eyes, joints or other signs of complicated
infection.
Investigations
Test symptomatic or asymptomatic clients who identify risk behaviour through unprotected
sexual intercourse and/or known contacts of chlamydia, gonorrhoea, epididymo-orchitis or
pelvic inflammatory disease.
If there is history of the client performing unprotected fellatio or being the receptive partner
in unprotected anal sex, take swabs from the rectum and pharyngeal sites for PCR.
SECTION 4
2010
37
Testing for chlamydia should not occur in isolation, offer additional STI screening as
indicated.
Pharyngeal
•
swab for chlamydia PCR.
Endocervical
•
Urethral
•
first catch urine for chlamydia PCR.
Rectal
•
Note:
•
first catch urine or self-obtained low vaginal swab for chlamydia PCR is appropriate if
unable to do a speculum examination and asymptomatic
•
if males present with urethral symptoms it is recommended to also take a swab of the
urethral discharge for gonorrhoea M/C/S
•
PCR is not validated for pharyngeal, rectal or low vaginal sites, but is recommended.
Positive results should be checked with a supplementary test in the laboratory.
•
PCR has high specificity and sensitivity when used in high prevalence groups, including
those aged 15 - 25 years, symptomatic clients or clients with risk history. Care should be
taken in interpreting PCR results in low prevalence populations.
Management
available):
•
symptoms persistent after treatment
•
intrauterine device in situ
•
complicated infection (e.g. PID or epididymo-orchitis)
•
disseminated infection
•
•
•
•
•
Treatment
38
Indicators
•
diagnosis based on examination findings
•
laboratory confirmed diagnosis
•
contacts have tested positive for chlamydia and/or gonorrhoea.
Regimens
•
refer management to a DTP–SRH endorsed NO, endorsed NP or consult a MO.
•
•
cases consult a MO.
Name
Azithromycin
Form
Tablet
Strength
500mg
Recommended dose
Route of admin
Frequency/duration
Stat (one dose)
Pregnancy category
B1
Poison schedule
S4
As for severe allergic reaction - Anaphylaxis
Consult MO
Contraindications
Special precautions
Pneumonia
Elderly
Children <16 years
SECTION 4
2010
39
Adverse reactions
Superinfection
Angioedema
Colitis, GI upset
Vaginitis
Interactions
Antacids
Ergot Derivatives
Rifabutin
Cyclosporine
Warfarin
Digoxin And drugs that prolong QT interval
Or
Name
Doxycycline
Form
Capsule or Tablet
Strength
100mg
Recommended dose
100mg
Route of admin
Oral with food
Frequency/duration
Twice a day for 710, 11 – 103 days
Pregnancy category
D
Poison schedule
S4
Consult MO
Contraindications
Hypersensitivity to any tetracycline
Concomitant treatment with oral retinoid
Special precautions
Don’t take immediately before going to bed
Take with food or milk
Prolonged use
Children <8 years
40
Adverse Reactions
Photosensitivity
Urticaria
Superinfection
Oesophagitis
GI disturbances
Tooth discolouration
Interactions
Acetazolamide
Antacids (containing Al, Mg, Ca Bismuth Salts)
Anticoagulants
Barbiturates
Carbamazepine
Methoxyflurane (may cause fatal renal toxicity) OCP
Penicillin
Phenytoin
Sodium Bicarbonate
Iron
Note:
•
•
if rectal PCR positive for chlamydia, consider LGV and consult with MO.
Client education
•
client to avoid unprotected sex for a minimum of three days following treatment with
Azithromycin or seven days with Doxycycline, and until all contacts are treated
•
protect skin from sunlight especially between 10am – 3pm and solariums as some
Macrolide antibiotics increase sensitivity to sunlight. If there is a rash, itching, redness or
severe sunburn consult a MO
•
Doxycycline to be taken with one full glass of water and client should sit upright for at
least 30 minutes after taking medication
•
•
provide MIMS Consumer Medicine Information http://ckn.health.qld.gov.au
SECTION 4
2010
41
Contact tracing14
Australian guidelines currently state that all contacts for a period of six months prior should
be screened and treated. These guidelines are under review (2010).
Follow-up
42
•
within two weeks to ensure compliance with medication and follow up of partner
notification
•
PCR proof of cure (POC) cannot be reliably undertaken <8 weeks after treatment , and is
not recommended
•
retesting recommended at three months as re-infection is common
•
refer to a MO if still symptomatic.
Donovanosis
3, 7, 21
Donovanosis is a chronic, progressively destructive genital ulcerative infection caused by the
bacteria klebsiella granulomatis. It generally occurs in tropical climates such as Papua New
Guinea. Infection in Australia is rare, but is more predominant in the Indigenous populations
of northern and central Australia.
Signs / symptoms
Most commonly affected areas include the penile shaft and glans, vulva and perianal skin.
•
starts as a papule or subcutaneous nodule which ulcerates
•
four classical types:
•
–
ulcerogranulomatous – is the most common and may appear as beefy red
granulations or painless ulcers with thick, rolled edges
–
hypertrophic verrucous - like a dry walnut
–
necrotic destructive - deep and foul smelling
–
sclerotic or cicatricial - fibrous scar tissue.
if regional lymph nodes are involved, it can lead to progressive tissue invasion from the
genitals to the groin.
Investigations3
Test all clients who present with ulcerated lesions (especially those living in rural and remote
areas). When investigating suspected cases, always test for common causes of genital
ulceration i.e. herpes and syphilis.
Lesions
•
perform genital ulcer multiplex PCR (GUMP) swab. Use a sterile cotton-tipped swab to
swab the centre and edges of the lesion aiming to moisten the swab with ulcer exudate,
then place into a dry sterile container. This test is used to detect herpes simplex virus,
treponema pallidum, klebsiella granulomatis and haemophilus ducreyi
•
press slide for Donovan bodies. Clean the lesion with saline, then press a glass slide on
the lesion, ensuring that the base and the edges of the lesion are pressed onto the slide.
Allow to air-dry.
•
HSV PCR swab of lesion
•
punch biopsy of lesion and non-infected tissue (advancing edge) for Donovan bodies
should be collected if there is no improvement in lesions after six weeks of treatment
•
serology
•
–
syphilis
–
HIV.
Discuss additional STI screening with the client.
SECTION 4
2010
43
Note:
•
testing for donovanosis should not occur in isolation
•
donovanosis is often diagnosed from clinical evidence and on epidemiological grounds.
Laboratory confirmation of diagnosis is not required for notification or treatment
•
the GUMP test is funded for Indigenous clients who have genital lesions, where
donovanosis is suspected or the cause is unclear. If a non-Indigenous person is
suspected of having donovanosis, reach agreement with the laboratory to process the
GUMP specimen.
Management
available):
•
Directly observed therapy (DOT) is recommended
•
if lesions have not responded to treatment after four weeks
•
if lesions are not healed after six weeks
•
•
client is pregnant or breast feeding
•
consult a specialist for advice on treating babies born to mothers with donovanosis at
time of delivery
•
•
uncertain diagnosis
•
•
Notify Queensland Syphilis Register (1800 032 238) on suspicion of donovanosis and prior to
commencing treatment, complete GUD notification form and send to Syphilis Register.
Treatment
Indicators
44
•
diagnosis based on examination findings and epidemiological evidence
•
manage syndromically
•
treat for donovanosis, syphilis and HSV at time of consultation after
•
specimens have been collected
•
laboratory confirmation. You may need to modify treatment as laboratory results become
available
•
contact of partner who has tested positive or is diagnosed symptomatically for
donovanosis
•
if there is no improvement in six weeks and neoplasm is suspected, take a punch biopsy
of lesion and non-infected tissue (advancing edge). Snip or punch biopsy of donovanosis
lesions can usually be taken with minimal discomfort using local anaesthetic.
Regimens
•
•
•
cases consult a MO.
Name
Azithromycin
Form
Tablet
Strength
500 mg
Recommended dose
1 gram (2 x 500mg tablets)
Route of admin
Frequency/duration
1 gram per week for four weeks or until lesion healed
Pregnancy category
B1
Poison schedule
S4
As for severe allergic reaction – Anaphylaxis
Consult MO
Contraindications
Special precautions
Pneumonia
Elderly
Children <16 years
SECTION 4
2010
45
Adverse reactions
Superinfection
Angioedema
Colitis, GI upset
Vaginitis
Interactions
Antacids
Ergot Derivatives
Rifabutin
Cyclosporine
Warfarin
Plus
Name
Benzathine Penicillin Bicillin (LA)
Form
Suspension
Strength
900mg / 2.3 ml (1,200,000 units)
Recommended dose
1.8 g (2 x 900mg/2ml or 2,400,000 International units)
Route of admin
IM
Frequency/duration
Stat (one dose)
Pregnancy category
A
Poison schedule
S4
Emergency management As for severe allergic reaction – Anaphylaxis
Consult MO
Contraindications
Previous hypersensitivity to Penicillin
Do not inject into or near an artery or nerve
Inadvertent intravascular administration can be dangerous
Special precautions
Anaphylaxis
Lactation
Jarisch-Herxheimer reaction
46
Adverse reactions
Atrophy
Superinfection
Pseudo membranous colitis
Hypersensitivity
Haematological effects
Acute interstitial nephritis
Neuropathy
Nephropathy
Interactions
Tetracycline
Probenecid
or
Benzathine Benzylpenicillin (Pan Benzathine Penicillin)26, 28
Benzathine Benzylpenicillin (Pan Benzathine Penicillin) and Benzathine Penicillin (Bicillin LA)
are the same drug in different presentations. Benzathine Benzylpenicillin (Pan Benzathine
Penicillin) is approved for use where Bicillin LA is unavailable. Recommended dose and
frequency remains the same as for Benzathine LA but the different product means an increase
in required volume and change in preparation process.
Name
Benzathine Benzylpenicillin
(Pan Benzathine Penicillin)
Form
Powder
Strength
900mg (1,200,000 International units)
Recommended dose
1.8g
Route of admin
IM reconstituted with:
(2 x 900mg or 2,400,000 International units)
4ml of water for injection27
Administer 4.6ml (1vial) in each buttock.
Frequency/duration
Stat (one dose)
Pregnancy category
A
Poison schedule
S4
See allergic reaction/anaphylaxis management Consult MO
Contraindications
Allergy to Penicillin
SECTION 4
2010
47
Special precautions
Re-bleed for Syphilis serology at time of treatment for true
baseline RPR titre
Lactation
Anaphylaxis
Adverse reactions
Atrophy
Superinfection
Hypersensitivity
Neuropathy
Nephropathy
Interactions
Tetracycline, Probenecid
Benzathine Benzylpenicillin (Pan Benzathine Penicillin) injection
technique27, 28
To minimise discomfort:
•
reconstitute each 900mg in minimum 4mls of water for injection
•
use a 5ml syringe
•
hold vial vertically and shake until the powder is absorbed
•
prepare immediately prior to administration
•
warm the injection by rolling between palms of hands prior to administration. This can
help reduce discomfort for the client.
Do not heat >50oC
•
if there is a delay in administration following preparation, rotate syringe vertically prior to
administration to ensure powder is mixed. This will reduce obstruction of the needle due
to precipitation of the suspension
•
attach a 21 gauge or 19 gauge needle to the syringe just prior to injecting suspension to
prevent blockage of needle
•
administer in the upper-outer quadrant of the gluteus maximus
•
give two injections - one in each buttock
•
apply pressure to the injection site for at least 10 seconds prior to administration.
Note:
•
48
clinical differentiation of genital ulcerative disease is inaccurate, particularly in areas
where more then one causative organism is endemic or prevalent at high rates.25 This
is compounded by the presence of HIV infection which may alter clinical manifestations
and patterns of GUD occurrence. Recent evidence indicates that HSV 2 is increasing in
many populations as the main cause of GUD25. After detection of GUD (i.e. chancroid,
donovanosis, LGV or HSV) it is important to consider additional investigation and
treatment based on local aetiology and sensitivity patterns.
•
COC users taking a short course (<3 weeks) of antibiotics should be advised to use
Client education
•
keep lesions clean and dry
•
if there is purulent discharge, sitz baths or saline cleansing can relieve discomfort
•
protect skin from sunlight (especially between 10am – 3pm) as some macrolide
antibiotics increase sensitivity to sunlight. If there is a rash, itching, redness or severe
sunburn consult a MO
•
encourage client to refrain from sexual contact until lesions are completely healed and
partner(s) are treated
•
Offer condoms and lube
•
Offer screening for other STIs
•
•
provide MIMS Medication Consumer Information www.ckn.health.qld.gov.au
Contact tracing14
Offer all partners who had sexual contact during the period of active lesions and 40 days
prior to the onset of symptoms, an STI screening and treat presumptively for donovanosis.
Follow-up
•
this condition is highly stigmatised so ongoing support and counselling is important
•
review weekly until healed and symptoms resolved
•
if there is no improvement within six weeks refer to a MO
•
review in three and six months to ensure there is no evidence of reinfection
SECTION 4
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49
Dyspareunia
Recurrent or persistent genital pain experienced before, during, or after sexual intercourse,
penetration or masturbation is classified as dyspareunia. It is situational or generalised
in presentation and can be acute or chronic (acquired or lifelong). 1-5 The Diagnostic and
Statistical Manual of Mental Disorders fourth edition (DSM IV) classifies dyspareunia as a
sexual pain disorder under sexual dysfunction and lists the additional criteria for diagnosis as
a recurrent or persistent genital pain associated with sexual intercourse; and a disturbance
that causes marked distress or interpersonal difficulties.1,2
Dyspareunia can be related to physical, neurological and complex psychosocial issues.2,3
Predisposing risk factors can include anxiety, depression, history of sexual assault or
specifically in females – peri/post menopause and pelvic inflammatory disease.4,5 Identifying
when the pain occurs in relation to the stage of a sexual act is helpful in determining the
cause.6 Dyspareunia is rare in males.
History
A detailed history should include assessment of possible physical, neurological and
psychological causes as ongoing management, treatment and indication for referral to
medical officer is dependant on the suspected cause. Examination and investigations will be
guided by the comprehensive history findings.
Females
A detailed history should include:
•
sexual, medical, surgical and family history including medication history
•
specific questions related to pain:
–
nature (i.e. when and where the pain occurs)
–
onset (i.e. before, on initial penetration, during or after sexual intercourse, with
orgasm or positional)
–
location (i.e. superficial, at vaginal entrance, vaginal or deeper, single or multiple
sites)
–
duration and severity (i.e. is pain lifelong or acquired, how long does it last?)
–
frequency (i.e. permanent or intermittent - does the pain occur with every sexual
encounter? If not, what is different about the times when no pain is experienced?)
–
characteristics (i.e. stinging, cutting, burning, pulling or stabbing)7
–
radiation (i.e. does pain travel to the perineum, rectum, abdomen etc)
–
contributing or aggravating factors:
>Is it situational or general?
>Does it occur with all partners, foreplay and non-penetrative sexual behaviour or
with penetration with fingers, sex toys, tampon
50
> What makes it better – if anything, is it bad enough to take pain medication, does
using lubrication stop the pain?
>Are there any aggravating factors: sex, direct pressure, urination, menses, bowel
movement, diet, orgasms.8
•
treatment – history of previous treatment, did they experience pain with previous vaginal
examinations, has any over the counter preparations been used, of anything out of the
medicine cupboard at home?
•
other physical symptoms: vaginal discharge, abnormal bleeding, associated abdominal
pains, history of STI
•
contraception history
•
sexual function/dysfunction apart from pain
•
pregnancy and delivery history:
•
experience of trauma, lacerations or episiotomy
•
has sex changed since, has the pain begun or changed since birth.
•
recent body art e.g. genital piercing
•
skin disorders
•
bowel or bladder disorders or chronic conditions
•
trauma, neurological disorders or chronic illness
•
psychosocial
–
mood, depression, anxiety, lifestyle and fatigue
–
altered self esteem or coping skills
–
sexual abuse
–
libido
–
social history – relationships/recent changes9
–
impact on partner/relationship
–
cultural, religious impact, conflict or restrictions.
Males
A detailed history should include:
•
sexual, medical, surgical and family history including medication history
•
specific questions related to pain:
–
onset [i.e. lifelong, situational, acute vs chronic (>6months), precipitating factors,
spontaneous or transient]
–
location (i.e. deep in the penis, superficial, in the prostate region or in the testes)
SECTION 4
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51
–
duration (i.e. is it with all sex, oral or masturbation. How long does the pain last, how
long does it take to resolve completely, and is it at the moment of ejaculation only)
–
characteristics [i.e. intense (use pain scale), burning, stinging, pulling, cutting,
stabbing, sharp, dull or tugging. Is it bad enough to take pain medication? Are there
any urinary symptoms? frequency, urgency, dysuria or any blood in semen or urine]
–
contributing or aggravating factors:
> is the pain affected by ejaculation, intercourse, toys (penile enlargers), alcohol,
any objects inserted into the urethra or use of drugs that may lead to ‘violent’
sex,
> does anything makes the pain better (i.e. does using lubrication stop the pain).
–
radiation (i.e. does the pain travel to the testes, perineum, rectum, abdomen etc).
•
treatment (i.e. have any over-the-counter preparations been used or anything out of the
medicine cupboard at home)
•
family history (i.e. pyrones disease or testicular cancer)
•
sexual function/dysfunction apart from pain (i.e. how bothersome is it)
•
associated relationship issues
•
recent surgical history (e.g. vasectomy, pelvic, gastric surgery, penile implants, penile
repair or testicular surgery)
•
recent body art e.g. penile piercing.
Signs / symptoms
•
client experiences recurrent or persistent genital pain before, during or after sexual
intercourse, penetration or masturbation
•
client experiences recurrent or persistent genital pain during or after ejaculation.
Diagnosis3,8,9
Females
•
•
Entry pain
–
vaginismus, vulvodynia, vulvar vestibulodynia (VBY) or vulvovaginitis
–
vulvovaginal atrophy, vaginal dryness or inadequate lubrication
–
skin disorders (i.e. eczema, psoriasis, allergies, vulvar dermatoses or drug reactions)
–
obstetric causes: episiotomy, vulvar varicosities
–
genital mutilation.
Deep pain
–
52
infection (i.e. STI, cystitis or pelvic inflammatory disease)
•
–
endometriosis
–
pelvic congestion or adhesions
–
bowel disorders (i.e. irritable or inflammatory bowel, constipation or proctitis)
–
ectopic pregnancy.
Entry or deep pain
–
neurologic disorders (i.e. pudendal nerve lesions)
–
muscular disorders (i.e. pelvic floor hypertonus or fibromyalgia)
–
anatomic deformities or congenital anomalies (i.e. retroverted uterus, uterine
fibroids, bartholin cysts, genital prolapse, intact or imperforate hymen)
–
post partum, birth trauma, psychological
–
trauma (including surgery, self inflicted, inflicted), back injury, sports injury, radiation
therapy
–
trauma during sex
–
genital cancer.
•
Neuropathic
•
Psychological.
Males4
•
•
Physical
–
infection (i.e. phimosis, epididymo-orchitis, prostatitis, urethritis, cystitis, benign
protatic hypertrophy (BPH) or balanitis
–
torsion of the testes
–
skin disorders (i.e. eczema, psoriasis, dermatitis, allergies or intraurethral lesions)6
–
trauma, back injury or sports injury. Trauma including surgery, self inflicted or
inflicted
–
trauma during sex
–
anatomic deformities (i.e. Peyronie’s disease, tight or scarred foreskin)
–
genital cancers (i.e. penile or prostate)7
–
alcohol and drugs (i.e. recreational, ED drug use especially injectables).
Neuropathic
–
•
compression or entrapment of the pudendal nerve.
Psychological.
SECTION 4
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53
Examination
Females
•
Examination should be guided by comprehensive history findings
•
General examination - include skin, nails, abdomen and extremities
•
Palpate abdomen for tenderness and guarding
•
Examine the vulva and perianal region for erythema, lesions, ulcers, rashes,
abnormalities, anatomical presentation, scarring or tenderness
•
Examine vaginal opening and hymenal membrane for erythema and thickening, presence
or absence of lesions, anatomical abnormalities, vaginal discharge or vulvar soreness
•
Palpate vulva and perineum for pain, tenderness, masses or scarring
–
assess for vestibulodynia by gently parting the labia minora and using a moist
cotton-tipped swab to determine whether there is pain with pressure at one or more
points around the vestibule.
•
Vaginal examination - gently slide a single finger into the vagina and depress the levator
ani muscles at multiple angles looking for hypertonicity, spasm or tenderness.
•
Speculum examination (If tolerated)
•
–
observe for anomalies, discharge, fissures, erosions, ulcers and atrophy
–
examine the vagina for inflammation, discharge, lesions or other abnormalities
–
assess the cervix for inflammation, oedema, discharge, bleeding and other
abnormalities.
Bimanual examination (if tolerated and pregnancy test negative)
–
assess cervix for cervical excitation
–
assess uterus for size, position and tenderness
–
assess adnexae for tenderness and masses.
Males
54
•
General examination – include skin, nails, abdomen and extremities
•
Genital examination – standing and lying down. Look for scarring (from circumcision or
from old piercing), feel for plaques along the shaft, swelling of the glans, prepuce or
shaft, and lesions on the skin
•
Testes – look for symmetry, size, shape, tenderness, heat, skin lesions, and lesions within
the scrotum, testes or epididymis
•
Feel for the vas deferens from the length up to the groin.
•
Examine the groin for inguinal hernias
•
Standing – check for symmetry (one testes is usually slightly lower than the other),
varicosities (varicocele), hernias or abnormal penile curvature (may be difficult to see
with a flaccid penis).
Note: The goal of physical examination is to localise the pain or discomfort, determine the
type and location of any pathology.4,5 In most cases, female dyspareunia requires referral or
at minimum, consultation with a MO for ongoing examination and management. Therefore
the extent of examination performed by a NO is dependant on their experience, setting and
the clinical scenario.
Investigations
Females- (only if indicated)
•
Blood pressure
•
Urinalysis
•
BHCG urine pregnancy test
•
Vaginal
•
•
•
–
high vaginal swab for M/C/S
–
pH
–
gram stain, wet prep (onsite if available, self-collected if client prefers)
–
swab for trichomoniasis PCR.
Endocervical (if indicated and tolerated)
–
–
swab for gonorrhoea M/C/S.
Urethral
–
first catch urine for chlamydia and gonorrhoea PCR
–
first catch urine for trichomoniasis PCR
–
midstream urine (if indicated)
Other sexual health screening as indicated by history.
Males
•
STI screen
•
clinic urinalysis
•
testicular ultrasound (if intrascrotal, testicular or vas deferens lesions)
•
penile ultrasound (if plaques or suspected Peyronie’s disease)
Note: Referral for ultrasound prior to referral to MO may be indicated in some clinical
settings.
SECTION 4
2010
55
Management / treatment
Females
Female sexual dysfunction often involves several aetiologies contributing to the problem.10
Management must be tailored to the sexual issue and take into account underlying physical
and psychological factors (including relationship). Conditions that may alter sexual function
(e.g. depression, sexual issues related to medication or substance abuse) should also be
considered.
Medical referral
available):
•
suspected organic basis to dyspareunia
•
uncertain diagnosis
•
•
ongoing medical management
•
•
•
abnormal findings of significance (i.e. in males – varicocele, hernia, penile curvature,
intrascrotal, testicular torsion, testicular or vas deferens lesions)
•
immunosuppression i.e. HIV positive client
•
For all other cases
•
Refer to management and treatment of specific condition diagnosed.
Note: requirements for referral and medical consultation will depend on history and clinical
findings. For example, if an infection related to STI is obvious, offer treatment according to
findings and refer to a MO as indicated. If any mental health issues are identified refer the
client to a psychologist/counsellor. Consider epididymo-orchitis or testicular torsion with
tender / painful testes in younger males.
Contact tracing
N/A
56
Epididymo-orchitis
Epididymo-orchitis is a common inflammatory infection involving the testes and epididymis.
It can be acute, sub-acute or chronic and is commonly caused by the organisms Chlamydia
Trachomatis and Neisseria Gonorrhoea3, 28.
History of insertive anal intercourse is associated with an increased risk of epididymo-orchitis
due to coliform bacteria.
Signs / symptoms
•
swelling of the testicle (usually unilateral)
•
painful testicle
•
+/- fever
•
urethral discharge
•
dysuria
•
pain in inguinal region or abdominal flank on affected side
•
enlarged tender epididymis on affected testicle
•
erythema of scrotal skin on affected side
•
some may be asymptomatic.
Investigations
•
temperature and pulse
•
testicular examination
•
urethra (examine for discharge)
•
urethral:
–
gram stain (if symptomatic)
–
external swab for gonorrhoea M/C/S and chlamydia PCR
or
–
first catch urine for gonorrhoea and chlamydia PCR if no discharge
–
mid-stream urine for M/C/S.
Management
Refer all suspected cases of epididymo-orchitis to MO. Requires immediate medical
consultation or referral to Emergency Department:
•
testicular torsion
•
acute orchitis
SECTION 4
2010
57
•
•
uncertain diagnosis
•
•
no response to treatment or resolution of symptoms following treatment
•
•
findings outside NOs scope of practice or capacity.
Treatment
Indicators
•
•
syndromic management should be based on:
–
clinical diagnosis of STI according to history and examination
–
presence of signs and symptoms.
Regimens for suspected STI related cause
•
•
•
cases consult a MO.
First line regimens 8, 10, 11, 29
Name
Doxycycline
Form
Capsule or Tablet
Strength
100mg
Recommended dose
100mg
Route of admin
Oral with food
Frequency/duration
Twice a day for 14 days10, 11
Pregnancy category
D
Poison schedule
S4
Consult MO
58
Contraindications
Special precautions
Do not take immediately before going to bed
Prolonged use
Children <8 years
Adverse reactions
Photosensitivity
Urticaria
Superinfection
Oesophagitis
GI disturbances
Interactions
Acetazolamide
Anticoagulants
Barbiturates
Carbamazepine
Penicillin
Phenytoin
Sodium Bicarbonate
Iron
SECTION 4
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59
Plus
Name
Ceftriaxone
Form
Powder
Strength
250mg
Recommended dose
250mg
Route of admin
Intramuscular injection reconstituted with 2ml Lignocaine
1% solution
Frequency/duration
Stat
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Children <12 years
Neonates
Adverse reactions
Hypersensitivity
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
Chloramphenicol
60
And
Name
Lignocaine hydrochloride
Form
Strength
1% (5ml ampoule)
Recommended dose
2 ml to be used to reconstitute 250mg Ceftriaxone powder
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
arrhythmias
Special precautions
Hypoxia, sever respiratory depression
Elderly, children
Adverse reactions
CNS disturbances
arrhythmias
hypertension
Interactions
antiarrhythmics, beta-blockers (especially class 111)
cimetidine
alcohol
SECTION 4
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61
Or
Ceftriaxone 250mg powder vials are not available in some settings and have been substituted
with Ceftriaxone dry powder 1 gram vial stock.
Note: the regimen using Ceftriaxone dry powder is the same recommended dose of 250mg
Ceftriaxone stat as above. Only the strength in stock has changed to 1g Ceftriaxone dry
powder. Please follow recommended dose calculation.
Name
Ceftriaxone
Form
Dry powder
Strength
1g (0.4ml)
1g Dry powder (0.4ml) + 1% Lignocaine solution 3.5ml =
Total volume 3.9ml
Recommended dose
250mg (0.98ml)
Route of admin
Frequency/duration
Stat
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Special precautions
GI disease ( especially colitis)
Children <12 years
Neonates
Adverse reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
62
Allergy to Cephalosporins or Penicillin
And
Name
Form
Strength
1% (5ml ampoule)
Recommended dose
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison Schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
arrhythmias
Special precautions
High repeated doses:
Hepatic, renal, cardiac impairment
Elderly, children
Adverse reactions
CNS disturbances
arrhythmias; hypertension
Interactions
other local anaesthetics
Antiarrhythmics, beta-blockers, especially class 111
cimetidine
alcohol
SECTION 4
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63
Or
64
•
According to the Queensland Hospitals List of Approved Medicines (LAM) Ciprofloxacin
is restricted to specialist staff for treatment of serious infections caused by sensitive
organisms on the advice of an Infectious Diseases Physician 20
•
The Pharmaceutical Benefits Schedule (PBS) places further restriction that Ciprofloxacin
only to be used in the treatment of infections proven to be due to Pseudomonas
aeruginosa or other gram-negative bacteria resistant to all other oral antimicrobials 20
•
Because of increasing resistance to Ciprofloxacin 500mg orally as a stat dose this
identified via laboratory confirmed
diagnosis 10,11
•
Prior to commencing treatment regimens using Ciprofloxacin, consult a MO and/or obtain
a laboratory confirmed diagnosis with sensitivity to Ciprofloxacin.
Second line regimens30
Name
Azithromycin
Form
Tablet
Strength
500mg
Recommended dose
1gram (2 X 500mg tablets)
Route of admin
Frequency/duration
Stat
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
macrolide antibiotic
Special precautions
Pneumonia
Elderly
Children < 16 years
Adverse reactions
Superinfection
Angioedema
Colitis, GI upset
Vaginitis
Interactions
Antacids
Ergot Derivatives
Rifabutin
Cyclosporine
Warfarin
SECTION 4
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65
Plus
Name
Ceftriaxone
Form
Powder
Strength
250mg
Recommended Dose
250mg
Route of admin
Intramuscular Injection reconstituted with 2ml Lignocaine 1%
solution
Frequency/duration
STAT
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Children <12 years
Neonates
Adverse reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
Chloramphenicol
66
And
Name
Form
Strength
1% (5ml vial)
Recommended dose
2ml to be used to reconstitute 250mg Ceftriaxone powder
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
arrhythmias
Special precautions
High repeated doses:
Elderly, children
Adverse reactions
CNS disturbances
arrhythmias
hypertension
Interactions
cimetidine
alcohol
SECTION 4
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67
Or
with Ceftriaxone dry powder 1gram vial stock.
Note: The regimen using Ceftriaxone dry powder is the same recommended dose of 250mg
Ceftriaxone stat as above, only the strength in stock has changed to 1g Ceftriaxone dry
powder. Follow recommended dose calculation.
Name
Ceftriaxone
Form
Dry powder
Strength
1g (0.4ml)
1g Dry powder (0.4ml) + 1% Lignocaine solution 3.5ml = Total
volume 3.9ml
Recommended dose
250mg (0.98ml)
Route of admin
Frequency/duration
Stat (once only)
Pregnancy category
B1
Poison Schedule
S4
Emergency Management
Consult MO
Contraindications
Special precautions
Children <12 years
Neonates
Adverse reactions
Hypersensitivity
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
Allergy to cephalosporins or penicillin
68
Plus
Name
Form
Strength
1% (5ml ampoulel)
Recommended dose
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
arrhythmias
Special precautions
High repeated doses
Elderly, children
Adverse reactions
CNS disturbances
Cardiovascular depression
Arrhythmias
Hypertension
Interactions
Antiarrhythmics, beta blockers (especially class 111)
Cimetidine
Phenytoin, other anticonvulsants
Inhalation anaesthetics
Skeletal muscle relaxants
Alcohol
SECTION 4
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69
Note:
•
for clients where compliance with the Doxycycline regimen is an issue, use Ceftriaxone
stat plus Azithromycin 1g stat and repeat Azithromycin in seven days. This is not an
authorised regimen so refer to a MO prior to administering
•
treatment should include analgesics for pain relief
•
treatment of suspected non-STI related epidiymo-orchitis should be based on history
and potentially include treatment for coliforms. Ensure MSU for MCS is collected to guide
ongoing management29 and refer to a MO.
Client education
•
protect skin from sunlight (especially between 10am – 3pm) and solariums, as some
macrolide antibiotics increase sensitivity to sunlight. If there is a rash, itching, redness or
•
Doxycycline to be taken with one full glass of water. Client to be seated upright for at
•
•
Contact tracing
If STI diagnosed, sexual partner(s) should also be examined and treated accordingly.
Follow-up
70
•
review client in three days to ensure resolution of symptoms and response to treatment.
If no improvement, consider changing treatment regimen, surgical referral3 or alternate
diagnosis (i.e. testicular infarction, abscess formation, mumps, testicular tumour or
tuberculous epididymo-orchitis)
•
recommend retesting for gonorrhoea and chlamydia in three months if confirmed STI
related infection, as reinfection is common.
Genital herpes (HSV)
Genital herpes is the most common cause of genital ulcer disease. It is caused by herpes
simplex virus 1 and 2 (HSV 1 and HSV 2).3 It is a chronic, life-long viral infection7 acquired
by skin-to-skin contact during oral or genital sex. It can be acquired from symptomatic
or asymptomatic partners. About 70% of genital herpes is caused by HSV 2 and is
primarily transmitted by a person unaware of their infective status or during an episode of
asymptomatic shedding.7
Perinatal transmission is a rare but serious infection with high morbidity and mortality.
Transmission is more likely to occur with vaginal delivery at the time of primary maternal
infection. Risk is significantly lower with recurrent HSV lesions or asymptomatic infection at
the time of delivery. A female with a history of genital herpes or an infected partner, should
notify the medical obstetric team immediately. A vaginal delivery is usual for women with a
history of genital herpes, though lesions at the time of delivery would prompt most obstetric
teams to perform a caesarean section.
Signs / symptoms3
Most HSV infections are asymptomatic. Clinical manifestations depend on the site of viral
entry and immunity from previous oral or genital HSV exposure. Manifestations of newly
acquired infection may be severe in non-immune clients, while initial infections are less
severe in clients with prior exposure. Sexually acquired manifestations include genital
ulceration, gingivostomatitis, urethritis, cervicitis and proctitis.
It can be difficult to determine whether a client who presents with herpes for the first time
has a true ‘first’ infection or whether it is a recurrence of previously unrecognised infection.
Multiple, widespread, bilateral lesions, which are at different stages of development and
resolution and at sites of direct mucosal infection are usual indicators of first infection.
In contrast, recurrent lesions are grouped and localised, unilateral, at identical stages of
development and at cutaneous sites along sacral dermatomes.
Primary or initial episode
•
multiple, widespread, painful lesions with associated systemic symptoms
•
atypical presentation may include skin splits, skin irritation, fissures or single lesions.
Recurrent episode
•
localised unilateral painful lesion(s)
•
history of recurrent thrush or lesion(s)
•
atypical presentation can include skin splits, skin irritation or fissures.
HSV infections also present asymptomatically as mild or unrecognised infections. The
severity of presentation depends on existing immunity from previous oral/genital HSV
exposure and the site of infection. Initial infection is less severe in clients with previous
exposure to HSV 1.
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71
Investigations
Test all clients presenting with genital lesions, ulcers, chronic genital skin tears or recurrent
candidiasis.
Lesions
•
HSV PCR swab from the lesion(s)
Serology
•
HSV Serology is not recommended for diagnosis,3 as available tests do not necessarily
distinguish between HSV 1 and HSV 2 antibodies. Type-specific herpes antibody tests are
available but their place in the diagnosis of genital herpes is unclear
•
HIV
•
Syphilis.
Note: Testing for HSV should not occur in isolation. Consider testing for other genital ulcer
diseases and discuss additional STI screening with the client.
Management
available):
•
prescription required for recurrent episodic or suppression therapy, analgesia
•
symptoms persist while taking antiviral treatment
•
disseminated infection i.e. meningitis or neurological problems
•
severe complications i.e. severe pain, secondary infection, urinary retention, tenesmus or
atonic bladder
•
uncertain diagnosis
•
•
•
•
Treatment
Indicators
72
•
diagnosis based on clinical examination
•
Primary or initial episode regimen
•
Non DTP-SRH endorsed NOs are not authorised to administer this regimen and should
•
DTP–SRH endorsed NO may progress if within scope of practice and competence under
the following conditions:
•
–
supply five days of Valaciclovir or Aciclovir for initial episodes
–
consult MO or authorised endorsed NP if 10 day treatment required
–
for all other cases consult a MO or endorsed NP.
cases consult a MO.
Name
Valaciclovir
Form
Oral
Strength
500mg
Recommended dose
500mg
Route of admin
Oral
Frequency/duration
Twice daily for 5 - 10 days
Pregnancy category
B3
Poison schedule
S4
Consult MO
Contraindications
Known hypersensitivity to Aciclovir or Valaciclovir
Special precautions
Dehydration
Immuno-compromised clients
Children and elderly
Adverse reactions
Headache, dizziness
Nausea, G.I. upset
Rash and hypersensitivity
Interactions
No clinically significant interactions have been identified
Note: regimen for primary Herpes treatment is five days.10-11 Duration may be extended to 10
days supply for moderate to severe episodes.3
SECTION 4
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73
Or
Name
Aciclovir
Form
Oral
Strength
200mg
Recommended dose
400mg (2 x 200mg tablets)
Route of admin
Oral
Frequency/duration
Three times a day for five days3
Pregnancy category
B3
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Caution in clients with:
Underlying neurological abnormalities
Significant hypoxia
Electrolyte impairment, dehydration
History of neurological reaction to cytotoxic drugs
Receiving Interferon or intrathecal Methotrexate
Children, Elderly
Adverse reactions
Nausea or vomiting are most frequent adverse effect
Less frequent effects (<1%) include diarrhoea, dizziness,
anorexia, fatigue, oedema, skin rashes, leg pain, inguinal
adenopathy and sore throat
Interactions
Probenecid
Concurrent use of diuretics in clients aged > 60 yrs
Note: Regimen for primary herpes treatment is five days. 10-11 Duration may be extended to 10
days supply for moderate to severe episodes. 3
Both these regimens prevent new lesion formation and rapidly reduce viral shedding,
infectivity and risk of autoinfection. Consider pain relief. In severe cases, client may require
hospitalisation.
74
Primary or initial episode for HIV positive client
Consult a MO for all immuno-compromised clients before initiating treatment for initial or
primary episodes.
Episodic therapy for recurrent episodes
Initiate therapy at first sign of prodome or early lesions.
Name
Valaciclovir
Form
Oral
Strength
500 mg
Recommended dose
500mg
Route of admin
Oral
Frequency/duration
Twice a day for 3 – 5 days
Pregnancy category
B3
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Dehydration
Pregnancy
Lactation
Adverse reactions
Headache, dizziness
Nausea, G.I. upset
Rash & hypersensitivity
Interactions
Note: Regimen for episodic therapy for recurrent episodes is three days.11-12 Duration may be
extended to five days supply for moderate to severe recurrent episodes.4
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75
Or
Name
Famciclovir
Form
Tablet
Strength
125mg, 250mg or 500mg
Recommended dose
1250mg over a two day period
Route of admin
Oral
Frequency/duration
500mg stat
Then
250mg every 12 hours for three doses
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Known hypersensitivity to Famciclovir and Penciclovir
Special precautions
Renal
Pregnancy
Lactation
Children <12 years
Tablets contain lactose (should not be taken by clients with
galactose intolerance, severe lactase deficiency or glucose
malabsorption)
Driving/operating machinery if experiencing dizziness/
somnolence
Adverse reactions
Headache, dizziness
Nausea, G.I. upset
Skin rash
Fatigue / somnolence.
Interactions
Note: 500mg Famciclovir is not available on the Queensland Health List of Approved
Medicines.20
76
Or
Name
Aciclovir
Form
Oral
Strength
200mg
Recommended dose
Route of admin
Oral
Frequency/duration
Three times daily for 5 -10 days
Pregnancy category
B3
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Significant hypoxia
Adverse reactions
Nausea, vomiting and headache are common
Less frequent (<1%) includes diarrhoea, dizziness, anorexia,
fatigue, oedema, skin rashes, leg pain, inguinal adenopathy,
medication taste and sore throat
Interactions
Probenecid.
Concurrent use of diuretics in clients aged over 60 yrs
Episodic therapy for HIV positive (recurrent episodes)
Consult a MO before initiating treatment for recurrent HSV episodes for all immunocompromised clients.
SECTION 4
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77
Suppressive therapy for recurrent episodes
For moderately severe recurrences occurring every 4 – 5 weeks or less consider initiating the
following regimen.3
•
DTP-SRH endorsed and Non DTP-SRH endorsed NO are not authorised to administer/
supply this regimen. Refer to a MO for ongoing management and initiation of suppressive
therapy.
•
cases consult a MO.
Name
Famciclovir
Form
Tablet
Strength
250mg
Recommended dose
250 mg
Route of admin
Oral
Frequency/duration
Twice a day for 3 – 6 months12
Pregnancy category
B1
Poison schedule
S4
Or
78
Name
Valaciclovir
Form
Oral
Strength
500 mg
Recommended dose
500mg
Route of admin
Oral
Frequency/duration
Once daily for 3 – 6 months
Pregnancy category
B3
Poison schedule
S4
Name
Aciclovir
Form
Oral
Strength
200mg
Recommended dose
200mg
Route of admin
Oral
Frequency/duration
Two times per day for 3 – 6 months12
Pregnancy category
B3
Poison schedule
S4
Note: For clients living with HIV, suppressive therapy can be changed to Valaciclovir 500mg
orally twice a day12. Consult a HIV specialist for further advice regarding managing HSV in HIV
positive clients.
Suppressive therapy should be discontinued after six months to assess the need for further
courses. Relapse may occur at the end of prophylaxis. There is no evidence that lysine,
zinc, vitamins or other non-mainstream remedies are any more effective than placebo in the
prevention of recurrences.
Pain management
Analgesics, ural sachets, salt baths and local application of ice packs may help reduce
discomfort. Topical antiseptics such as povidone-iodine may also be of benefit.
Topical Xylocaine jelly 2% is a useful adjunct to Valaciclovir or Aciclovir in managing severe
first episodes. It should be applied frequently but for no longer than 24 - 36 hours as there is
a rare risk of sensitisation.
•
Non DTP-SRH endorsed NOs are not authorised to administer this regimen and should
refer management to a DTP–SRH endorsed NO, endorsed NP or MO
–DTP-SRH endorsed NO may progress if within scope of practice and competence.
•
cases consult a MO.
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79
Name
Xylocaine (lignocaine)
Form
Gel
Strength
2%
Recommended dose
Apply sparingly to affected area
Route of admin
Topical
Frequency/duration
Every 4 - 6 hourly prn
Pregnancy category
A
Poison schedule
S2
Consult with MO
Contraindications
Hypersensitivity to local anaesthetic
Special precautions
absorption from mucous membranes is relatively high, remove
excess jelly.
prolonged use, high doses, frequent use
mucosal trauma
Sepsis
Epilepsy
impaired cardiac conduction
impaired hepatic function
severe shock
severe renal dysfunction
elderly, debilitated, children
Adverse reactions
local reaction
CNS excitation
depression
local reactions
Interactions
other local anaesthetics
antiarrhythmics, beta-blockers (especially class 111)
cimetidine
80
Client education
•
use saline baths, topical betadine and oral analgesia to reduce discomfort
•
encourage rest and fluid intake to avoid dehydration
•
the client may require a medical certificate
•
•
provide MIMS Consumer Medication Information www.ckn.health.qld.gov.au
Contact tracing14
No contact tracing is required,
Follow-up
•
follow-up appointment at one week (if indicated)
•
discuss recurrence and potential for transmission during sub-clinical shedding
•
offer counselling to client
•
inform client to abstain from sex during herpes episodes
•
refer to a MO if extension of medication regimen required or no improvement of
symptoms.
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81
Genital warts – human papilloma virus
(HPV)
There are more than 100 genotypes of the human papilloma virus (HPV). More than 30
of these are known to infect the external and internal anogenital area and may present
as genital warts7. The most common genotypes causing genital warts are type 6 and 11.
High-risk HPV types 16, 18, 31, 33 and 35 are associated with cervical changes, neoplasias7
and other oncogenic anogenital infections3. The majority of anogenital HPV infections
are asymptomatic, unrecognised or subclinical in presentation7. Most HPV infections are
believed to spontaneously regress but infections can persist32. A persistent infection with
high risk HPV types is the most predictive factor in progression to squamous intraepithelial
neoplasia7,32. HPV vaccination is designed to help prevent infection with specific HPV
genotypes and protect against persistent infection.
Genital warts are transmitted by skin-to-skin sexual contact and transmission of HPV can
occur regardless of clinical manifestations3. Incubation period is variable and may be
prolonged. The existence of infectivity and infection in the absence of symptoms makes
interruption of transmission extremely difficult. Transmission rarely occurs perinatally.
Signs / symptoms
•
asymptomatic carriage of the virus, detectable as viral DNA in affected cells
•
cytological changes not apparent to the naked eye but detectable by histological
techniques
•
cervical, vaginal, vulval, anorectal and penile lesions seen by colposcopy but not
apparent macroscopically
•
recognisable genital warts or condylomata acuminata.
Investigations
Clients presenting for a sexual health check should be examined for genital warts. Partners
of people diagnosed with genital warts should also be encouraged to attend a sexual health
check.
82
•
clinical diagnosis
•
discuss additional STI screening
•
pap smear (if indicated)
•
biopsy by a MO (if indicated).
Management
Conditions requiring NO to refer to or at minimum consult with an MO or NP (if appropriate/
available):
•
warts are extensive and potential labour problems are identified
•
no response to therapy after four ablative treatments
•
internal warts
•
abnormal findings of clinical significance or uncertain diagnosis
•
atypical warts including pigmented, indurated, fixed or ulcerated
•
•
immunosuppression e.g. HIV positive or transplant client
•
Treatment
Indicators
Diagnosis of anogenital warts is based on direct visual examination of lesion. If in doubt,
excise and examine histologically. This should be considered if lesions are atypical, there is
ulceration or attachment to underlying structures or there are prompt or frequent recurrences
after treatment.
Non-wart HPV infection is often diagnosed by the presence of cytological changes on a pap
smear.
Assessed risk factors for HPV may indicate need for vaccination.
Clinic treatment regimen
Factors that may influence selection of treatment include size and number of warts, anatomic
site of wart, wart morphology, client preference, cost and convenience of treatment, adverse
effects and provider experience.
•
Non DTP-SRH endorsed NOs are authorised to administer this regimen only if clinical
competency completed, otherwise refer to a DTP–SRH endorsed NO, endorsed NP or MO.
•
•
cases consult a MO.
SECTION 4
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83
Name
Cryotherapy with Liquid Nitrogen
Form
Liquid
Route of admin
Cryospray or topically with cotton buds
Frequency/duration
Once per week until clearance of warts or refer to MO after four
weeks for review
Or
84
Name
Cryotherapy with Nitrous Oxide
Form
Gas
Route of admin
Topically with cryogun
Frequency/duration
Once per week until clearance of warts or refer to MO after four
weeks for review
•
refer to a DTP–SRH endorsed NO, endorsed NP or MO.
•
•
cases consult a MO.
Name
Trichloroacetic acid (TCA) 33, 34
Form
Solution
Strength
90% (4g)
Recommended dose
Apply with cotton tip applicator or pointed wooden stick to external
warts only
Route of admin
Topically
Frequency/duration
Once a week until clearance of warts or refer to MO after four weeks
for review
Pregnancy category
No specific data but not contraindicated in pregnancy
Poison schedule
S6
Emergency
management
Acute (skin)
causes severe burn and blisters
immediately wash affected area with plenty of water continuously
for at least 15 mins. Remove contaminated clothing and wash
before re-use.
seek medical review.
Acute (eye)
causes severe burn and lacrimation
immediately irrigate with plenty of water continuously for at least
15 mins. Hold eyelids open.
Acute (swallowed - do not induce vomiting)
may cause severe pain in abdomen, vomiting, diarrhoea,
hoarseness, rapid and shallow respiration, circulatory collapse and
low body temperature.
Acute (inhalation)
may cause irritation of nose/ soft mucous tissue
asphyxiation may result from laryngeal oedema
inhalation of acid fumes or aspiration of ingested acids may cause
pneumonitis.
Contraindications
internal warts (rectal, urethral, vaginal and cervical).
Special precautions
apply only to wart tissue. Protect surrounding skin.
TCA solutions have low viscosity and can spread rapidly if applied
excessively.
Adverse Reactions
localised skin irritation or ulceration.
Interactions
Nil
Pharmaceutical
Precautions
store in a cool (<25°), dry place away from source of heat or ignition.
SECTION 4
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85
This product is not listed on the Queensland Health Standard Drug List or recommended as a
treatment option for genital warts according to the Therapeutic Guidelines.10, 11
Or
•
refer to a DTP-SRH endorsed NO, endorsed NP or MO.
•
•
cases consult a MO.
Name
Podophyllin
Form
Solution
Strength
25% resin in benzoin compound tincture
Recommended dose
Small amounts applied to external lesion only.
Solution to remain for no longer than four to six hours
Route of admin
Topical
Frequency/duration
Once per week until warts clear. Refer to a MO after four weeks
for review
Pregnancy category
D: "Do not use with any other podophyllin preparation..."
Poison schedule
S4
If signs of toxicity refer to a MO for management
Contraindications
Internal warts (rectal, urethral, vaginal and cervical)
Hypersensitivity to any ingredient
Diabetes
Clients using steroids or with poor blood circulation
Do use with any other podophyllin preparation because of
possible symptoms of toxicity
Do not apply to healthy tissue or friable/bleeding mucosa –
protect skin with Vaseline or other barrier prior to application.
Do not ingest orally
Special precautions
Avoid contact with eyes and mucous membranes
Not for use on internal warts (urethral, intravaginal, cervical or
intrarectal)
Application should be limited to reduce toxicity
Application should be limited to <0.5 ml of Podophyllin or an
area of <5 cm of warts per session
86
Adverse reactions
Local skin reactions (mild to moderate) i.e. localised pain,
burning, pruritus or swelling
Interactions
No human drug interaction data available
Pharmaceutical
Store below 25oC, do not freeze
Precautions
Date bottle when open and discard after one month
Note: Podophyllin is no longer a commercially available product or listed on the Queensland
Health List of Approved Medicines20 as it is a non-standard cytotoxic compound. Studies
demonstrate this product to be less effective than cryotherapy, podophyllotoxin or
imiquimod. Recommend use of client provided podophyllotoxin preparations or Imiquimod as
alternate treatment options.35 - 37
SECTION 4
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87
Pain management
Apply lignocaine-prilocaine (emla) or xylocaine jelly for pain management prior to application
of liquid nitrogen or nitrous oxide via cryotherapy. There are reports of variable efficacy of
lignocaine-prilocaine (emla) on genital skin but FDA has approved its use as a topical local
anaesthetic for adults on genital mucous membranes and skin.38
Name
Lignocaine-prilocaine (emla)
Form
Cream
Strength
5%
Recommended dose
1.5g/10cm2
Route of admin
Topical
Frequency/duration
Prior to procedure, apply a thick layer to ano-genital warts for at
least 1 hour for maximum effect
Pregnancy category
A
Poison schedule
S2
Contraindications
Hypersensitivity to prilocaine, lignocaine or other local
anaesthetics
Congenital or idiopathic methaemoglobinaemia
Glucose-6-Phosphate dehydrogenase (G6PD) deficiency
Special precautions
Traumatized mucosa or non intact skin
Atopic dermatitis
Genital skin and mucous membranes3
Adverse reactions
Mild local irritation
Allergic reaction
Increased methaemoglobin level
Interactions
antiarrhythmics (especially class 111)
beta-blockers
cimetidine
Sulphonamides
88
Or
Name
Xylocaine jelly 2%
Form
Gel
Strength
2%
Recommended dose
5 to 10ml
Route of admin
Topical
Frequency/duration
Apply 5 -10 minutes prior to cryotherapy
Pregnancy category
A
Poison schedule
S2
Contraindications
Hypersensitivity to local anaesthetic
Special precautions
Absorption from mucous membranes is relatively high, remove
excess jelly
Prolonged use, high doses, frequent use
Mucosal trauma
Sepsis
Epilepsy
Impaired cardiac conduction
Impaired hepatic function
Severe shock
Severe renal dysfunction
Elderly, debilitated, children
Adverse reactions
Local reaction
CNS excitation
depression
local reactions
Interactions
antiarrhythmics (especially class 111)
beta-blockers
cimetidine
SECTION 4
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89
Regimens: client provided treatment
90
•
refer to a DTP–SRH endorsed NO, endorsed NP or MO.
•
•
cases consult a MO.
Name
Podophyllotoxin
Form
Liquid in Ethanol and cream base
Strength
0.5% solution
0.15% cream
Recommended dose
Use the minimum amount of solution/cream necessary to cover
lesion
Minimize application to normal surrounding tissue
Allow to dry thoroughly
Route of admin
Topical. Cutaneous use only
Frequency/duration
Twice per day for three consecutive days
Then
Four days with no treatment
Repeat weekly cycle of treatment for a maximum of four weeks
Pregnancy category
D
Poison schedule
S4
Emergency
management
Discontinue use if significant irritation occurs. Consult a MO
Contraindications
Pregnancy "Do not use with any other Podophyllin preparation..."
Existing skin infection, irritation or open wounds
Hypersensitivity to Podophyllotoxin
Special precautions
Avoid contact with eyes and mucous membranes.
To reduce toxicity, applications should be limited.
Systemic toxicity risk increased by treatment of large areas with
excessive amounts for prolonged periods, treatment of friable,
bleeding or recently biopsied warts or inadvertent application to
normal skin or mucous membranes.
Adverse reactions
Local irritation causing tenderness, itching, erythema and
superficial epithelial ulceration
Interactions
Nil
Precautions
Store at temperatures not exceeding 30oC
Or
Only commence Imiquimod regimen following consultation with a MO.
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91
Name
Imiquimod
Form
Cream
Strength
5% (250mg single use sachets)
Recommended dose
Apply in thin layer to affected areas
Rub area until cream is no longer visible
Route of admin
Topical
Frequency/duration
Three times per week (e.g. Mon/Wed/ Fri) at night Leave on for
6 - 10 hours
Continue until warts clear or for a maximum of 16 weeks
Pregnancy category
B1 not recommended in pregnancy or lactation
Poison schedule
S4
Emergency
management
Persistent overuse of Imiquimod can result in severe local skin
reactions (discontinue until skin integrity improves)
Oral ingestion can cause nausea, vomiting and headache (see
MO for management)
Contraindications
"Do not use with any other Podophyllin..."
Hypersensitivity to any ingredient
Do use with any Podophyllin preparation because of possible
symptoms of toxicity
Special precautions
Not for use internally (i.e. meatal, urethral, cervical, rectal, sub
preputial warts)
Take care when treating warts at the opening of the vagina or
under the foreskin of an uncircumcised penis, due to possible
inflammation.
Effectiveness in immunocompromised clients or clients with HIV
unknown
Avoid sexual contact while cream is on skin.
May weaken condoms and vaginal diaphragms
No occlusive dressings
Adverse reactions
Local skin reactions (mild to moderate) i.e.
Erythema, Erosion, Excoriation, Oedema
Uncommon reactions see MIMS full prescribing information
92
Interactions
No known interactions
Precautions
Store below 25oC and do not freeze
Podophyllin, podophyllotoxin and imiquimod are all contraindicated in pregnancy and
lactation.
Client education
•
apply treatment to lesions only, being careful that preparation does not come into
contact with healthy skin
•
Podophyllin
–
•
wash solution off with soapy water within 4 – 6 hours (or immediately if irritation
occurs).
Podophyllotoxin solution and cream
Reinforce the importance of consumer medication information regarding application and
frequency:
•
–
be careful that preparation does not come into contact with healthy skin
–
do not apply to extensive areas
–
avoid sexual contact while preparation applied.
Imiquimod cream
Reinforce the importance of consumer medication information regarding application and
frequency:
–
apply cream to wart before bed, then wash off with mild soapy water in the morning
–
inform the client that erythema may occur due to a pharmacological response of the
body’s immune system
–
if severe reaction occurs discontinue use and return for review.
•
routine pap smear is required according to the National Cervical Screening Program
•
information on cervical cancer available www.health.qld.gov.au/phs/wcss
•
client fact-sheet available www.health.qld.gov.au/sexhealth
•
Contact tracing
•
offer current partners examination and screening
Follow-up
•
follow-up clients during and after treatment and treat relapses as original lesions
•
HPV changes on a pap smear should be managed according to the NHMRC Guidelines on
Management of Abnormal Smears 3
•
recommend routine pap smears.
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Gonorrhoea
Gonorrhoea is caused by Neisseria Gonorrhoeae, a gram negative diplococcus, which infects
the columnar and transitional epithelial cells of the genitourinary tract, rectum, pharynx
and conjunctiva.3 Transmitted predominately by sexual contact it can be transmitted by
autoinoculation or prenatally.
Signs / symptoms
Females
•
dysuria
•
abnormal vaginal discharge or bleeding (i.e. post coital or IMB)
•
lower abdominal pain, pressure or heaviness
•
anorectal pain or discharge.
Gonococcal cervicitis is indistinguishable from other causes of cervical infection on clinical
examination.3 Most cases are asymptomatic. Coexistent pharyngeal and anorectal infections
are common and often asymptomatic. Females can experience rectal infection resulting
from anal sex or the posterior spread of infective secretions from the vagina. Approximately
10 -15% of cases of acute gonococcal cervicitis are complicated by pelvic infection. The
prevalence of penicillinase producing Neisseria Gonorrhoeae (PPNG) varies within Australia
and averages about 5 - 20% of cases. Co-infection with chlamydia is common in cases of
gonorrhoea.
Males
•
dysuria
•
tender, painful or swollen testicles
•
anorectal pain or discharge.
Gonococcal urethritis is often indistinguishable from other causes of urethral infection
on clinical examination.3 It usually presents as purulent discharge within a few days of
exposure and cases are rarely asymptomatic. Coexistent pharyngeal and anorectal infections
are common in men who have sex with men (MSM) and are often asymptomatic. Rectal
infection in MSM results from anal intercourse. Some cases of gonorrhoea are complicated
by epididymo-orchitis. Co-infection with chlamydia is common in heterosexual men and
increasingly common in MSM.
Both (Females / males)
94
•
may be asymptomatic
•
less common indicators include sore throat, eyes, joints or other signs of complicated
infection.
Investigations
Test symptomatic or asymptomatic clients who identify risk behaviours through unprotected
sex. Discuss additional STI screening as indicated.
•
Pharyngeal
–
•
•
Endocervical
–
swab for gonorrhoea PCR
–
–
gram stain (if available).
Urethral
–
gram stain (if symptomatic)
–
external swab for gonorrhoea M/C/S.
or
–
•
swab for gonorrhoea C/S.
first catch urine for gonorrhoea PCR if no discharge.
Rectal
–
gram stain if symptomatic
–
swab for gonorrhoea PCR
–
swab for gonorrhoea C/S.
Females3
•
an endocervical swab for gram-stained smear will detect typical
gram-negative diplococci in most cases of cervical gonococcal infection. A gram-stained
urethral smear may be useful for at risk females with urethral symptoms or who have had
a hysterectomy
•
endocervical swabs for gonococcal culture must be kept at room temperature and
promptly transported to a laboratory in an Amie’s or Stuart’s transport medium
containing charcoal
•
perform a first catch urine test by PCR for nucleic acid amplification to identify
gonorrhoea or chlamydia in asymptomatic clients or during screening programs
•
pharyngeal and anorectal swabs for culture (not smears) should be taken if symptoms
or sexual history suggest infection at these sites. Gram-stained smears should be taken
via proctoscopy if there are symptoms after unprotected anal intercourse. Nucleic acid
amplification testing is not validated at these sites. PCR is still the recommended test
for chlamydia but positive results should be checked with a supplementary test in the
laboratory.
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95
Males3
•
swab urethral discharge for a gram-stained smear. The swab will confirm diagnosis by
demonstrating polymorphs with intracellular and extracellular gram-negative diplococci
in most cases of symptomatic gonococcal infection
•
a swab of urethral discharge for gonococcal culture must be kept at room temperature
and sent to a laboratory in an Amie’s or Stuart’s transport medium containing charcoal.
Gonococci survive poorly in a plain Stuart’s medium without charcoal. Diagnosis and
results of penicillinase testing is available in 24 - 36 hours.
•
perform a first catch urine test by PCR for nucleic acid amplification to identify
gonorrhoea or chlamydia in asymptomatic clients or during screening programs.
•
pharyngeal and anorectal swabs for culture (not smears) should also be taken by blind
sampling MSM, if sexual history suggests infection at these sites. Gram-stained smears
should be taken via proctoscopy if there are symptoms or there is history of unprotected
receptive anal intercourse with casual partners. Nucleic acid amplification testing is not
validated at these sites. PCR is still the recommended test for chlamydia but positive
results should be checked with a supplementary test in the laboratory.
Management
available):
96
•
symptoms persist after treatment
•
intrauterine device in-situ
•
complicated infections e.g. PID or epididymo-orchitis
•
disseminated infection
•
•
contraindications to treatment
•
•
•
Treatment
Indicators
•
diagnosis based on examination findings
•
GNICDC seen on gram stained smear
•
•
contact of partner(s) tested positive for gonorrhoea.
If Chlamydia has not been ruled out, the client should be treated as per chlamydia regimens
in addition to recommended treatment for gonorrhoea.
Regimens
•
•
•
cases consult a MO.
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Name
Ceftriaxone
Form
Powder
Strength
250mg
Recommended dose
250mg
Route of admin
Intramuscular injection reconstituted with 2ml Lignocaine 1%
solution
Frequency/duration
Stat (1 dose)
Pregnancy category
B1
Poison schedule
S4
Emergency
management
Consult MO
Contraindications
Special precautions
Children <12 years
Neonates
Adverse reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
Chloramphenicol
Plus
98
Name
Form
Strength
1% (5ml vial)
Recommended dose
2ml to be used to reconstitute 250mg Ceftriaxone powder
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
Impaired cardiac, intraventricular block arrhythmias
Special precautions
Elderly and children
Adverse reactions
CNS disturbances
arrhythmias
hypertension
Interactions
Antiarrhythmics (especially class 111)
beta-blockers
cimetidine
alcohol
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Or
with Ceftriaxone dry powder 1g vial stock.
Note: The regimen using Ceftriaxone dry powder is the same recommended dose of 250mg
Ceftriaxone stat as above. Only the strength in stock has changed to 1g Ceftriaxone dry
Name
Ceftriaxone
Form
Dry powder
Strength
1gram (0.4ml)
Volumes for dose calculation52-53
1gram dry powder (0.4ml) + 1% Lignocaine solution 3.5ml
= total volume 3.9ml
Recommended dose
250mg (0.98ml)
Route of admin
Frequency/duration
Stat
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Children <12 years
Neonates
Adverse reactions
Hypersensitivity
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
100
Plus
Name
Form
Strength
1% (5ml vial)
Recommended dose
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
Impaired cardiac conduction, intraventricular block, arrhythmias
Special precautions
High repeated doses
Adverse reactions
CNS disturbances
Interactions
Beta-blockers
Cimetidine
Alcohol
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Or
•
As per the Queensland Hospitals’ List of Approved Medicines Ciprofloxacin is restricted to
specialist staff for treatment of serious infections caused by sensitive organisms on the
advice of an Infectious Diseases Physician21
•
The Pharmaceutical Benefits Schedule (PBS) restricts use of Ciprofloxacin to the
treatment of infections proven to be due to pseudomonas aeruginosa or other gramnegative bacteria resistant to other oral antimicrobials21
•
Because of increasing resistance to Ciprofloxacin 500mg orally as a stat dose this
identified via laboratory confirmed diagnosis10,11
•
Prior to commencing treatment regimens using Ciprofloxacin, consult a MO and/or obtain
a laboratory confirmed diagnosis with sensitivity to Ciprofloxacin.
Name
Ciprofloxacin
Form
Tablet
Strength
500mg
Recommended dose
500mg
Route of admin
Oral on empty stomach
Frequency/duration
Stat (one dose)
Pregnancy category
B3
Poison schedule
S4
Consult MO
Contraindications
Hypersensitivity to other Quinolones including Nalidixic Acid
Concurrent administration of ciprofloxacin and ZanaflexTM
(US)
Special precautions
Impaired renal and hepatic function
CNS disorders
GI disease
Children
Neonates
Sunlight
102
Adverse reactions
Superinfection
Nausea and diarrhoea
Phototoxicity
Haemorrhagic cystitis
Achilles tendon rupture
Interactions
Theophylline
Anticoagulants
Antacids
Iron supplements
Probenecid
Sucralfate Theophylline
Zinc or iron containing multi-vitamin
Caffeine
Methotrexate
Metoclopramide
Glibenclamide
Non steroidal anti-inflammatory drugs
Cyclosporine
Note: Choice of treatment is dependent on local disease and sensitivity patterns
COC user taking a short course (<3 weeks) of antibiotics should be advised to use additional
contraceptive protection, such as condoms, during treatment and for seven days after
stopping antibiotics.
Client education
•
reinforce importance of safe sex until all contacts are treated
•
•
Contact tracing14
•
Australian guidelines currently state that all contacts for a period of six months prior
should be screened and treated. These guidelines are under review (2010).
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Follow-up
•
proof of cure - swab for gonorrhoea M/C/S of infected site two weeks after treatment
(if symptoms persist). Do not use swab for gonorrhoea PCR for POC, as it will remain
positive for up to eight weeks after treatment
•
follow-up at 7-10 days to ensure symptoms resolved and check partner(s) have been
treated
•
104
ensure all contacts tested and treated
•
test of cure cultures are only necessary if there is doubt about sensitivity of the
organism (e.g. a drug other than ceftriaxone has been used) or symptoms are persistent
•
because re-infection with gonorrhoea or chlamydia is common, routine follow-up for
screening at three months is recommended.
HIV and AIDS
39
The human immunodeficiency virus (HIV) is a retrovirus which was discovered by French
and American researchers in 1983, and an antibody test for HIV-1 was available the following
year. A less common and less virulent virus is HIV-2, found mainly in West Africa, while only
isolated cases have been detected in Australia39.
The virus causes depletion of CD4 lymphocytes (T4 or T helper cells) and immuno-deficiency
by leaving the immune system open to opportunistic infection and tumours such as
pneumicystis jiroveci, pneumonia, oesophageal candidiasis, cerebral toxoplasmosis,
diarrhoeal diseases, kaposi’s sarcoma and lymphomas. These and many other conditions are
known as AIDS (Acquired Immune Deficiency Syndrome)39.
Australia’s situation
In Australia, HIV is predominantly sexually transmitted and occurs most commonly in
homosexually active men39. However, consider the possibility of HIV infection in any person at
risk of STIs and in those with a history of injecting drug use. In Australia, most incident cases
(>85%) occur in homosexual men, as the virus hasn’t broadly infiltrated injecting drug users
or the heterosexual community. Estimates indicate 17,444 Australians were living with HIV by
the end of 2008. Over the past few years, incident cases of HIV have risen and this is causing
concern. In 2006, 998 HIV infections were diagnosed, an increase of 31% since 2000.
The Asia-Pacific region - particularly Papua New Guinea, Cambodia, Thailand and Myanmar
- are experiencing high growth rates of HIV. Papua New Guinea, Cambodia, Myanmar and
Thailand are experiencing high rates of HIV and there is a significant risk of transmission from
Papua New Guinea to Torres Strait Islander and Cape York communities.
The HIV virus is present in blood, semen, vaginal fluids and breast milk, and can be
transmitted by:
•
sexual intercourse (vaginal or anal)
•
injection of blood, or through mucous membranes contaminated with blood or bodily
fluids
•
infection from mother to infant (in utero, perinatally or through breastfeeding).
Signs / symptoms
HIV disease comprises three phases: acute primary illness, asymptomatic chronic illness and
symptomatic chronic illness. Progression from one stage to another is variable. For further
detail see HIV Management in Australasia: a guide for clinical care58.
History taking
Take a comprehensive history to assess risk behaviours for HIV and conduct a physical
examination to look for clinical manifestations of immune dysfunction or neuropsychiatric
conditions39, 58. Maintain a high index of suspicion because of the varied clinical picture in
HIV58.
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Pre and post test discussion60
Provide pre-test and post-test discussion to a client undergoing HIV antibody testing. Pretest discussion is essential to prepare the client for testing and ensure they understand the
benefits, risks and implications of a positive or negative test result. It also enables you to
clarify essential information regarding transmission of HIV, safe sex and injecting drug use.
This is also the ideal time to discuss the availability of PEP to people in high risk groups.
The National HIV Testing Policy, 200660 provides the principles and framework that guide
approaches to HIV testing in Queensland. The policy is available from the Department of
Health and Ageing website – www.health.gov.au.
People may be tested for the following reasons:
•
sexual health check-up (i.e. occupational screen for sex workers)
•
signs or symptoms of HIV
•
named as a contact of STI or HIV
•
antenatal screening (HIV testing should be offered to all pregnant women)
•
immigration screen
•
insurance medical testing
•
blood bank and tissue donation
•
occupational or non-occupational exposure to HIV
•
prior to some employment
Serology testing
Combined antigen and antibody tests are now more widely available and are performed
when an HIV test is requested. These new tests can generally rule out HIV infection after only
weeks from the date of infection. Formerly, it used to take up to three months for an antibody
to become reactive after infection but the new ‘window period’ from acquiring HIV to test
results becoming positive is now less than six weeks
Diagnosis
If a result is positive, do a repeat HIV antibody test to confirm the original result was correct39.
A positive result is confirmed by the Western Blot analysis. Also perform baseline testing for
a range of other infections (including STIs), CD4 count, HIV quantitative RNA test (viral load),
along with a baseline genotypic resistance assay (now considered routine). The genotypic
resistance assay looks for evidence of resistance virus that may have been transmitted to
the individual39. It is estimated that 10 -15% of transmissions in Australia involve a resistant
virus39.
Primary HIV infection
Have a high index of suspicion for acute primary HIV infection (PHI) in clients presenting with
infectious mononucleosis-like febrile illness and be aware that in the first week of primary
106
infection, HIV antibody assays may remain non-reactive. HIV PCR (viral load) tests will be
positive - usually at high copy count during PHI but low counts (<10,000 copies per ml) may
represent false positive results. Diagnosis depends on careful assessment of risk factors,
clinical picture, serial HIV antibody assays and the viral load test. Laboratory indicators
may be lowered or raised white cell count, atypical lymphocytes in the blood film and liver
transaminitis39.
Refer clients suspected of having primary HIV infection (but who have non-reactive HIV
antibody assays initially) for specialist review and ensure they are followed up with repeat
HIV antibody tests.
Early in the course of PHI, the HIV antibody screening test may be negative but the combined
antigen and antibody test has a much shorter window period. Special tests such as detection
of the p24 antigen and proviral DNA should be discussed with the laboratory and/or an
experienced HIV clinician. If clinical suspicion remains, repeat HIV Ag/Ab testing39.
Client education for people newly diagnosed with HIV
•
provide contact details for groups such as Queensland Association of Healthy
Communities QAHC (previously the AIDS Council) and Queensland Positive People (QPP).
These groups provide information, support, activities and
self-empowerment
•
offer psychological counselling and support to newly diagnosed clients.
•
Instruct regarding correct use of condoms
•
client fact sheet available at www.health.qld.gov.au/sexhealth
•
provide client with booklets/fact-sheets outlining:
–
natural history and prognosis of HIV
–
explanation on prevention of transmission and superinfection
–
health management including complimentary therapies.
•
recommend vaccination for HAV and HBV
•
discuss pneumococcal and influenza vaccination
•
encourage partner(s) testing
•
discuss need for monitoring
•
discuss legal obligations, disclosure of positive status and discrimination issues. Assure
client that confidentiality will be maintained
•
obtain consent for release of information relating to previous medical care.
Contact tracing14
•
discuss informing sexual partner(s) and others at risk of exposure (eg. people who inject
drugs), and agree and document method of identifying and notifying contacts(s)
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•
contact(s) will often require counselling
•
if primary illness confirmed, trace contacts for at least 6 weeks prior to onset
•
if late HIV infection or infection of unknown origin, contact trace depending on risk and
age of index case (may be necessary to trace back to 1980)
•
offer PEP and STI screening to partner(s) exposed within the last 72 hours
•
screen all contacts and offer additional STI screening
•
if client has donated blood or received blood products, contact relevant blood bank.
New client assessment
When HIV infection is diagnosed, management may be considered under the following
headings:58
•
Clinical assessment (history and examination)
•
Assessment of the social context of the infection
•
Assessment of the psychological impact of the diagnosis
•
Laboratory evaluation, including the stage of infection, baseline serological testing
•
Investigation of co-morbidities and co infections
•
Health maintenance, including prevention of co-morbidities and STIs
•
Education and support
•
Risk assessment and prevention
•
Public health measures – contact tracing
This history relates to a new client who may be testing for HIV or already HIV positive and
approaching you for treatment (marked *)
108
•
reason for presenting and expectations of consultation
•
date of last negative result and reason for test
•
date of positive HIV result (include when, where and why tested) *
•
HIV related illness *
•
symptoms suggesting immunodeficiency i.e. weight loss, skin rashes, shingles,
pneumonia, unexplained diarrhoea, unexplained fever, headache *
•
health care provider
•
most recent CD4 and viral load *
•
lowest CD4 count*
•
antiretroviral medication and OI prophylaxis medication*
•
current HIV medication*
•
assess tolerance and adherence to current medication (including health belief model)*
•
assess pregnancy (if indicated)
•
date of last sexual health screen
•
medical (particular attention to cardiac, metabolic, viral hepatitis and renal), surgical and
gynaecological history
•
psychiatric history
•
diet and exercise
•
medications
•
allergies
•
family history – cardiovascular disease, diabetes
•
STI symptoms – discharge, rash, itch, pain, ulcers, sores, post coital bleeding,
intermenstrual bleeding, rectal bleeding, rectal pain
•
sexual history
–
past syphilis and treatment history
–
past urethritis
–
past genital ulcer disease.
•
knowledge/attitudes of safer sex, superinfection and post exposure prophylaxis (PEP)
•
smoking and alcohol use
•
recreational drug use (including injecting drugs)
•
social history i.e. family support, employment, partner(s), social support, financial
situation, housing, Medicare status, MSM/gay community affiliation.
The following is a guide to required baseline tests58:
•
HIV Ab (to confirm)
•
full blood count (FBC)
•
LFT and U&E
•
fasting lipids and glucose
•
syphilis
•
hepatitis A (total),
•
HBsAb, HBsAg, HBcAb
•
HCVC
•
Toxoplasma IgG
•
CMV IgG
•
STI screen – Chlamydia, gonorrhoea, syphilis
•
Urine ACR
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•
lymphocyte subsets (CD4/CD8 lymphocyte counts)
•
genotypic resistance assay
•
HIV PCR RNA (viral load) test
•
HLAB*5701
•
CXR and Mantoux in those potentially exposed to TB
•
PAP smear (if relevant).
Examination
•
skin – look for seborrheic dermatitis, xeroderma, shingles scar, kaposi’s sarcoma
•
oropharynx – look for oral candidiasis, oral hairy leukoplakia, gingivitis
•
lymph nodes – inguinal, cervical and axillary groups
•
chest/lungs
•
cardiovascular including peripheral pulses
•
abdomen – liver and spleen
•
pelvic (in females) - GU, rectum/anus (probably can be left on initial visit)
•
neurological - unilateral weakness, visual field defects, peripheral nerves
•
(reflexes and sensation)
•
muscular/skeletal
•
weight, height and BMI
•
blood pressure
•
urinalysis.
Monitoring
People with HIV should attend regular follow-up at 3 - 6 month intervals58 or more
frequently if their clinical or immunological condition warrants it. At each visit, assess the
person psychologically and reinforce the importance of transmission prevention. Physical
examination should look for evidence of immune dysfunction. Arrange haematological,
biochemical, viral load and immune function testing.
At subsequent visits, repeat testing for full blood count, HIV viral load and CD4/CD8
lymphocyte counts, U & E and liver function tests. Falling CD4 counts and rising viral load (+/the development of signs or symptoms of immunodeficiency) indicate a need for antiretroviral
therapy.
Women living with HIV are at increased risk of cervical dysplasia and current guidelines
recommend annual pap smears after two successive normal smears six months apart. Any
abnormalities should be followed up by colposcopy.
Clients living with HIV do not necessarily cease to be sexually active and recent guidelines
110
recommend regular screening for common STIs such as gonorrhoea, chlamydia, ano-genital
herpes and syphilis. Clinicians should discuss responsibilities for preventing transmission
of HIV as well as safer sex practices periodically with clients as part of their routine
management.
Monitoring response to therapy involves resolution of signs and symptoms attributable to
HIV prior to initiation of antiretroviral therapy, including monitoring changes in weight.
Monitor drug toxicity depending on the antiretroviral agents the client is taking. Refer to HIV
Management in Australasia: a guide for clinical care at www.ashm.org.au
Clients with progressive disease (suggested by HIV-related symptoms or deteriorating
laboratory surrogate markers) or those who have just commenced or altered antiretroviral
therapy require more frequent monitoring. Frequency of monitoring in these circumstances
should be made in conjunction with an HIV specialist.
Monitoring for clients on antiretroviral treatment
Monitoring includes clinical assessment and laboratory testing which aims to document
efficacy of therapy ( initial fall in plasma HIV RNA and subsequent rise in CD4) and detection
of toxicity (clinical and laboratory)58.
Assessment should include58
•
History – new symptoms, side effects, adherence, psychosocial issues
•
Examination – weight, BP, body shape changes, peripheral neuropathy, rash
•
Laboratory – plasma HIV RNA, CD4 count, FBE, liver function tests, electrolytes. Fasting
lipids and glucose 6 monthly.
•
Assessment for co-morbidity – depression, recreational drugs use, STIs
•
Assessment of toxicity – peripheral neuropathy, cardiovascular risk factors, lipodystrophy
Routine monitoring
History
•
symptoms of disease progression e.g. weight loss, fevers, diarrhoea, skin rash
•
symptoms of drug toxicity
•
date of last HIV review, viral load and CD4 count
•
any interactions with health care system:
–GP visits
•
–
hospitalisation
–
sexual health clinics (if appropriate).
Ongoing assessment:
–
sexual and injecting health risk
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–
smoking
–
recreational drug use including alcohol
–
diet, activity, social support, mood, sleep, employment, smoking, alcohol and
recreational drug use.
Examination
•
signs of disease progression (see initial presentation)
•
signs of drug toxicity
•
weight
•
blood pressure.
Available Investigations
•
full blood count
•
UE/LFTs
•
HIV viral load
•
lymphocyte sub population
•
pap smear (as indicated)
•
offer additional screening as indicated or directed by MO
–
annual – fasting lipids, glucose, urine analysis, HBsAb
–
sexual health screening.
Prevention
Current39
112
•
Condoms and community health education focussed on at-risk individuals and
communities have shown to be effective in prevention of HIV.
•
Some of the most cost-effective public health initiatives include needle and syringe
programs, and methadone and buprenorphine substitution programs.
•
Post-exposure prophylaxis (PEP) is a combination of two to three antiretroviral agents
given within 72 hours of significant exposure to HIV (usually sexual or occupational). The
medications are taken for one month and reduce the risk of acquiring HIV.
•
Prevent mother to child transmission by using antiretrovirals for the mother during
pregnancy and for the baby for a short period after birth. Breastfeeding is not
recommended in Australia. The overall risk of vertical transmission is 25-20%58.
•
Early diagnosis of primary HIV infection, counselling of the index client and contact
tracing partners is very important. It is estimated that about half of all HIV infections are
caused by someone who was recently infected. Counselling the index client in this setting
can have benefits in reducing onward transmission.
Future
•
Vaginal and anal microbicidal agents that can be introduced by the person having sex
(without requiring their sexual partner’s permission) are undergoing trials.
•
Pre-exposure prophylaxis (PREP) – HIV medication taken prior to intercourse may reduce
the risk of HIV infection in those at high risk.
•
Increased emphasis on testing and treatment of chlamydia, gonorrhoea, syphilis and
genital herpes – all of which increase the risk of HIV acquisition and transmission. Trials
looking at suppressing HSV-2 in order to prevent HIV transmission are underway, but
early results appear to be disappointing.
Treatment
Clients should be treated according to Australian antiretroviral guidelines58 available at www.
ashm.org.au.
Treatment is usually commenced when the CD4 count drops to 350cells/µl (usual level for
a healthy adult is 450-1200 cells/µL). Combination antiviral therapy (cART) is indicated
in pregnant women, people with HIV-associated nephropathy or HBV co infection when
hepatitis B treatment is indicated58. Antiretroviral treatment during pregnancy is routine and
can reduce the mother-to-child transmission rate to <1%. Without antiretroviral treatment or
caesarean section the rate is approximately 25%58.
Currently available antiretroviral agents are classified as nucleoside reverse transcriptase
inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), entry and fusion
inhibitors (FIs), integrase inhibitor and protease inhibitors (PIs).
Nucleoside Reverse Transcriptase Inhibitors (NRTIs):
•
Abacavir (category B3 in pregnancy)
•
Didanosine (ddI) (category B2 in pregnancy)
•
Emtricitabine (FTC) (category B1 in pregnancy)
•
Lamivudine (3TC) (category B3 in pregnancy)
•
Zidovudine (AZT) (category B3 in pregnancy)
Nucleotide Reverse Transcriptase Inhibitors:
•
Tenofovir (Category B3 in pregnancy)
Non Nucleoside Reverse Transcriptase Inhibitors (NNRTIs):
•
Efavirenz (Category D in pregnancy)
•
Nevirapine (Category B3 in pregnancy)
•
Etravirine (Category B1 in pregnancy)
Entry Inhibitor
•
Maraviroc (Category B1 in pregnancy)
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Fusion Inhibitors (FIs):
•
Enfuvirtide (Category B2 in pregnancy)
Integrase Inhibitor
•
Raltegravir (Category B3 in pregnancy)
Protease Inhibitors (PIs):
•
Amprenavir (Category B3 in pregnancy)
•
Atazanavir (Category B2 in pregnancy)
•
Fosamprenavir (Category B3 in pregnancy)
•
Indinavir (Category B3 in pregnancy)
•
Lopinavir (Category B3 in pregnancy)
•
Ritonavir (Category B3 in pregnancy)
•
Saquinavir (Category B1 in pregnancy)
Co-formulated preparations
•
Atripla ( Tenofovir / Emtricitabine / Efavirenz)
•
Combivir (Zidovudine / Lamiviudine)
•
Kivexa ( Abacavir / Lamivudine)
•
Truvada ( Tenofovir / Emtricitabine)
The gold standard of HIV treatment is triple combination antiretroviral treatment (cART)58.
In general, clients receive two nucleoside analogues in combination with either a nonnucleoside reverse transcriptase inhibitor or a (ritonavir-boosted) protease inhibitor.
Only clinicians who have completed an HIV prescriber’s course, attend regular professional
updates and are experienced in the use of antiretrovirals can prescribe these S100s.
Combination antiretroviral therapy (cART) may cause significant side-effects which can limit
the client’s ability to take the medication effectively. Some side-effects include:
•
nausea and diarrhoea
•
skin rashs
•
lipoatrophy (loss of fat from limbs and face)
•
hyperlipidaemia
•
raised liver transaminases and bilirubin
•
impaired glucose tolerance and diabetes.
Ninety-five percent compliance with cART is essential in order to reduce the risk of resistant
virus developing. People with HIV are more likely to also have other issues which can impact
their health including depression, mental illness, higher rates of tobacco and alcohol misuse,
unemployment and poverty.
114
Prophylactic therapy against opportunistic infections (OIs)
Prophylactic therapy against opportunistic infections in immunocompromised clients is
critical in managing the infection58. Consult an HIV specialist for discussion of opportunistic
disease prevention. Refer to HIV Management in Australasia: a guide for clinical care (2009)
at www.ashm.org.au/publications
Administer primary prophylaxis to clients at risk of developing certain opportunistic
infections such as Pneumocystis Jiroveci Pneumonia PCP (CD4 < 200/µL, CD4 % <14%, or
presence of Oral Candidiasis) or Mycobacterium avium complex disease (CD4 <50/µL)58.
However, primary prophylaxis is not recommended for the following opportunistic infections oropharyngeal/oesophageal candidiasis, CMV disease or cryptococcal meningitis.
Clients with CD4 counts < 50/µL or non-retinal CMV disease are at risk of CMV retinitis and
should have regular HIV specialist ophthalmological review to enable early detection and
treatment of CMV retinitis. Educate clients to notice increased ‘floaters’ or changes to visual
acuity and advise them to seek medical attention if these occur.
Clients who have already experienced opportunistic infection are at risk of recurrent infection
until anti-retroviral therapy induced immune reconstitution occurs. These clients should
receive secondary prophylaxis and consult with an HIV specialist.
Opportunistic infection prophylaxis may cease following antiretroviral therapy induced
immune reconstitution. Consult with an HIV specialist regarding cessation of opportunistic
infection prophylaxis. All clients who are diagnosed with latent tuberculosis should also be
referred to an HIV specialist.
Referral of clients with HIV infection
Clients with HIV should be managed by clinicians experienced in the management of HIV
disease. Optimal models of care involve HIV specialist and general practitioner input.
General practitioners with HIV infected clients would benefit from HIV courses offered by the
University of Queensland at www.som.uq.edu.au/hivandhcvprojects
Post-exposure prophylaxis (PEP) for HIV
If exposed to significant risk of HIV infection through:
•
occupational exposure e.g. deep needle-stick injury
•
non-occupational exposure e.g. unprotected receptive or insertive anal or vaginal
intercourse
•
injecting drug user e.g. needle sharing with a person known or suspected to have HIV
infection
Offer administration of combination antiretroviral therapy for one month. This may provide
benefit if drugs are commenced within 72 hours of exposure. There is little direct evidence of
the effectiveness of PEP, however a substantial body of indirect epidemiological and animal
model evidence now exists for the effectiveness of PEP.
The Queensland Health Guidelines for Management of Occupational and non-Occupational
Exposures to Blood and Body Fluids, 2009 provide detailed advice regarding PEP.
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Expert information network
Advice is provided 24 hours a day, seven days a week by an infectious diseases physician.
•
Brisbane
Princess Alexandra Hospital (07) 3240 2111
Mater Adult Hospital (07) 3840 8111
Royal Brisbane & Women’s Hospital (07) 3636 8111
•
Gold Coast
Gold Coast Hospital (07) 5571 8211
•
Nambour
Nambour General Hospital (07) 5470 6600
•
Townsville
Townsville General Hospital (07) 4796 1111
•
Cairns
Cairns Base Hospital (07) 4050 6333
People seeking PEP may present at an emergency department or sexual health clinic where
starter packs of antiretroviral drugs are available. They will require follow-up within a few
days for counselling, risk review, review of side effects and to receive further prescription
of anti-retroviral drugs by an accredited HIV prescriber for one month (if appropriate).
Counselling for PEP involves exploring the known or suspected risks of HIV infection against
the risks and known side effects of one month’s antiretroviral therapy.
The risk of HIV transmission through single exposure is determined by:
•
method of exposure and its estimated risk
•
risk that the source is HIV positive, if their status is unknown
•
co-factors associated with the source and exposed individuals.
Assess risk
•
establish reason for requesting PEP
•
assess client’s potential risk of exposure to HIV by establishing date, time, and type of
exposure
•
explain relevance for further questioning if exposure was percutaneous, significant mucous
membrane or non-intact skin.
Assess exposure
116
•
determine exposure – what, when, where, whom and exact details (including contributory
factors)
•
amount of blood or body fluid involved (including trauma)
•
first aid measures applied.
Assess exposed person
•
explore possibility that the exposed person may already be HIV infected
•
enquire about most recent HIV test results and reason for testing
•
assess risk exposures since last HIV test and current incident
•
enquire about illnesses since the last test which may be consistent with acute primary
illness
•
previous post-exposure prophylaxis and history of treatment
•
evaluation of current STIs i.e. hepatitis B and hepatitis C
•
pregnancy risk, contraception and lactation (consider emergency contraception)
•
medical history including illnesses, medication and drug allergies
•
psychiatric history
•
drug and alcohol history
•
knowledge of the source (if unavailable for interview).
Assess the source
•
determine HIV status of the source (if known)
•
if source status known to be HIV positive:
–
most recent plasma viral load
–ARV treatment history and any documented resistance
•
–
recent HIV resistance genotyping
–
current or past STI
–
HBV and HCV status.
if HIV status of source unknown:
–
assess source persons potential risk i.e. IDU, MSM, country of origin
–
current or past STI
–
HBV and HCV status.
Explain the principles of PEP
•
explain PEP (including its indications, effectiveness, risks and benefits)
•
explore client understanding of transmission of HIV, correct misinformation, respond to
questions, advise on risk reduction strategies and make appropriate referrals
•
obtain medical, gynaecological, menstrual, contraceptive, social and sexual history
•
enquire about other recent STI and discuss STI screening
•
consider the need for ECP/HBIG
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•
118
provide information on the following:
–
window periods for BBVs and STIs
–
safe sex and injecting practices
–
mode of action/compliance, potential side effects and follow-up.
•
assess support networks and coping strategies
•
inform client how to access further information and support.
Lymphogranuloma venereum (LGV)
Lymphogranuloma venereum (LGV) is an invasive genital disease caused by chlamydia
trachomatis serovars L1, L2 or L3, which results in complex and severe symptoms including
tissue destruction and ulceration. These serovars differ from other chlamydia trachomatis
serovars B - K which are known to cause urethritis and cervicitis. LGV is endemic to tropical
areas such as the Caribbean, Africa, South America, Central America and Asia. Almost all
infections reported in Australia have either been acquired from endemic areas overseas or in
men who have sex with men (MSM). There is reported high incidence of concurrent infection
with HIV, syphilis, gonorrhoea and hepatitis C. LGV may cause proctitis if the infection is
acquired through unprotected anal sex.
Transmission is by direct skin-to-skin contact with open lesions, usually occurring through
sexual contact. Lesions outside the genital area are rare but oral lesions have been reported.
Signs / symptoms
Primary stage49, 50
•
painless blister, usually three to ten days after sexual contact (sometimes up to 30 days)
•
ulceration may occur.
Secondary stage
•
systemic symptoms one to six weeks after sexual contact including inguinal
lymphadenopathy, fluctuant bubo, necrosis of the lymph nodes and abscess formation
•
anorectal symptoms include proctitis, pain, discharge, bleeding, tenesmus, constipation,
inflammation and acute haemorrhagic proctitis which is usually confined to the distal
10cm of the anorectal canal
•
fever, nausea and malaise are common.
Late or tertiary stage
•
development of chronic inflammatory lesions and lymphoedema, sinus formation,
scarring, strictures and fibrosis of the anogenital tract, lymphatic obstruction,
elephantiasis, rectal strictures and fistulae.
Investigations
•
•
Lesion
–
–
rectal or anal swab for LGV PCR (available from Pathology Queensland – Central
Laboratory (RBWH) phone 0437 082 545)
–
swab for HSV PCR.
Rectal
–
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•
–
swab for LGV PCR (indicated if presenting rectal symptoms and/or positive rectal
chlamydia)
–
swab for HSV PCR
–
swab for syphilis TPPA DNA / PCR.
Serology (discuss with a MO or laboratory)
–
LGV complement fixation test (LGV-CFT). Contact laboratory prior to testing. Titres
>1:64 are highly suggestive of LGV in a client with a compatible clinical picture, while
titres <1:32 make the diagnosis unlikely.
LGV testing should be performed as a secondary test for all confirmed. Chlamydia trachomatis
rectal isolates, and for their sexual partner(s). Attempt to isolate the organism from the
lesion, the rectal mucosa or by aspiration from the enlarged nodes or bubo.
Management
available):
•
suspected or laboratory confirmed diagnosis LGV
•
•
uncertain diagnosis
•
•
no resolution of symptoms following treatment
•
•
•
Treatment
Indicators
•
clinical diagnosis based on history and examination
•
•
contact of partner who has tested positive.
Regimens
Treatment only to be instigated following consultation with MO.
•
DTP–SRH endorsed NO or endorsed NP may progress if within scope of practice. For all other
cases consult a MO.
120
Name
Doxycycline
Form
Tablet
Strength
100mg
Recommended dose
100mg
Route of admin
Oral
Frequency/duration
Twice per day for 21 days
Pregnancy category
D
Poison schedule
S4
Consult MO
Contraindications
Hypersensitivity to Tetracycline
Special precautions
Prolonged use
Children aged <8 years
Adverse reactions
Photosensitivity
Urticaria
Superinfection
Oesophagitis
GI disturbances
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Interactions
Acetazolamide
Anticoagulants
Barbiturates
Carbamazepine
Penicillin
Phenytoin
Sodium Bicarbonate
Iron
122
Or
Name
Azithromycin
Form
Tablet
Strength
500mg
Recommended dose
1gram
Route of admin
Frequency/duration
Once a week for three weeks
Pregnancy category
B1
Poison schedule
S4
As for severe Allergic reaction - Anaphylaxis
Consult MO
Contraindications
Known hypersensitivity to Azithromycin, Erythromycin or
any macrolide antibiotic
Special precautions
Pneumonia
Elderly
Adverse reactions
Superinfection
Angioedema
Colitis
GI upset
Vaginitis
Interactions
Antacids
Ergot Derivatives
Rifabutin
Cyclosporine
Warfarin
Digoxin and drugs that prolong QT interval
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Or
Name
Roxithromycin
Form
Tablet
Strength
150mg or 300mg
Recommended dose
150mg
Or
Route of admin
Oral (administer 15 minutes before or three hours after a meal)
Frequency/duration
150mg twice per day for 21 days
Or
300mg (2 x 150mg tablets) once per day for 21 days
Pregnancy category
B1
Poison schedule
S4
Emergency management As for severe allergic reaction – Anaphylaxis
Consult MO
Contradictions
Known hypersensitivity to Erythromycin or Macrolide antibiotics
Severe hepatic impairment
Concomitant therapy with vasoconstrictive ergot Alkoids
Special precautions
Prolonged or repeated use
Pregnancy/lactation
Adverse reactions
Superinfection
GI upset
Altered hepatic function
Interactions
Ergot alkoids
Digoxin
Warfarin
Midazolam
Theophylline Disopyramide
Cyclosporine
124
Note:
•
antibiotics have been stopped13.
•
Clinical differentiation of conditions that cause genital ulcerative disease is inaccurate,
particularly in areas where more then one causative organism is endemic26. This is further
compounded by the presence of HIV infection which may alter clinical manifestations and
patterns of GUD occurrence. Recent evidence suggests that HSV 2 is increasing in many
populations as the main cause of GUD26. Therefore after detection of GUD (i.e. Chancroid,
Donovanosis, LGV or HSV) it is important to consider additional investigations and
treatment regimens based on local aetiology and sensitivity patterns.
Client education
Doxycycline
•
protect skin from sunlight especially between 10am – 3pm and solariums as some
Macrolide antibiotics increase sensitivity to sunlight. If there is a rash, itching, redness or
•
least 30 minutes after taking medication.
Roxithromycin
•
administer 15 minutes before or three hours after a meal
–
–
provide MIMS consumer product information http://ckn.health.qld.gov.au
–
Safer sex information, condoms and lubricant
–
Screen for other STIs
Contact tracing
In suspected and confirmed cases trace all sexual contacts in the previous 30 days and /or
since arrival to onset of systems and treat presumptively.
Follow-up
Follow-up weekly until there is resolution of symptoms. Fibrotic lesions and fistulae may
require surgical attention after treatment is completed. Follow-up contact notification, testing
and treatment.
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Molluscum contagiosum
Molluscum contagiosum is a common benign skin disease caused by a poxvirus49. Lesions
are predominately self-limiting and spontaneously regress in immunocompetent individuals.
In the immunocompromised (i.e. people living with HIV), lesions can become extensive and
persistent51. Treatment is not essential as there are no significant abnormal complications,
however it can be requested for cosmetic reasons. The disease is transmitted by direct skin
contact and fomite transfer49.
Signs / symptoms49
Lesions
•
Generally appear 3 – 12 weeks after contact
•
Flesh coloured, discrete, smooth, firm, dome-shaped papules with central umbilication
•
most have a 3 – 5mm diameter, however giant papules (>15mm diameter) can occur
•
In adults, lesions commonly occur on thighs and buttocks
•
In people with HIV, the infection may be widespread and is common opportunistic
infection49
Investigations
Clients should be examined for molluscum contagiosum in the ano-genital area.
•
clinical diagnosis
•
histology of inner punctum
•
discuss additional STI screening.
Management
available):
126
•
large or extensive lesions
•
atypical presentation
•
•
secondary infection
•
•
•
Treatment
Indicators
Clinical diagnosis is based on examination.
Note: Treatment method should be selected after considering size, quantity and anatomic
site of lesions, client preference, cost, convenience, side effects and provider experience.
Regimens: clinic treatment only
•
Non DTP-SRH endorsed NOs are authorised to administer this regimen only if clinical
competency is completed, otherwise refer management to a DTP–SRH endorsed NO,
endorsed NP or a MO.
•
DTP–SRH endorsed NO may progress if within scope of practice. For all other cases
consult a MO or endorsed NP.
•
Endorsed NP may progress if within scope of practice. For all other cases consult a MO.
Name
Cryotherapy with Liquid Nitrogen
Form
Liquid
Route of admin
Cryospray or topically with Cotton buds
Frequency/duration
Once a week
Or
Name
Cryotherapy with Nitrous Oxide
Form
Gas
Route of admin
Topically with cryotherapy gun
Frequency/duration
Once a week
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Or
Name
Podophyllotoxin
Form
Liquid in Ethanol and cream base
Strength
0.15% cream
Recommended dose
Use the minimum amount of solution/cream necessary to
cover lesion. Minimize application to normal surrounding
tissue and allow to dry thoroughly
Route of admin
Topical
Frequency/duration
Twice a day for three consecutive days
Then four days with no treatment
Maximum of four weeks of treatment
Pregnancy category
D
Poison schedule
S4
Discontinue use if significant irritation occurs and consult a
MO
Contraindications
Pregnancy - Do not use with any other podophyllin
preparation
Existing skin infection, irritation or open wounds
Hypersensitivity to Podophyllotoxin
Special precautions
Avoid contact with eyes and mucous membranes
Limit applications to reduce toxicity
Systemic toxicity is a risk increased by treatment of large
areas with excessive amounts for prolonged periods,
treatment of friable, bleeding or recently biopsied warts
or inadvertent application to normal skin or mucous
membranes
Pain relief
Application of Lignocaine-Prilocaine (emla) can be used for pain management
prior to application of Liquid Nitrogen or Nitrus oxide via Cryotherapy.
128
•
•
DTP–SRH endorsed NO or endorsed NP may progress if within scope of practice. For all
other cases consult a MO.
Name
Lignocaine-Prilocaine (emla)
Form
Cream
Strength
Lignocaine 2.5% and Prilocaine 2.5%
Recommended dose
Apply a thick layer to affected area x 1.5 g/10 cm2
Route of admin
Topical
Frequency/Duration
Apply at least 1 hour prior to cryotherapy
Pregnancy category
A
Poison schedule
S2
Contraindications
Hypersensitivity to prilocaine, lignocaine or other local anaesthetics
Congenital or idiopathic methaemoglobinaemia
Deficiency in Glucose 6 Phosphate Dehydrogenase
Special precautions
Traumatized mucosa or non-intact skin
Atopic dermatitis
Genital skin and mucous membranes
Adverse reactions
Mild local irritation
Allergic reaction
Increased methaemoglobin level
Interactions
Beta-blockers
Cimetidine
Phenytoin
Other anticonvulsants
Sulphonamides
Lesions are usually self-limiting and treatment is not essential.
Treatment options:
•
Lesions can be de-roofed with a sterile needle and the contents or ‘core’ expressed or
removed with very fine forceps.
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Client education
•
avoid picking or scratching , waxing or shaving as this may spread the infection
•
•
provide MIMS consumer product information www.ckn.health.qld.gov.au
Contact tracing
Not required.
Follow-up
Ongoing treatment of lesions may be required.
130
Non gonococcal urethritis (NGU)
7,49
Urethritis can result from a number of infectious and non-infectious causes. Urethritis not
cause by neisseria gonorrhoeae is referred to as non-gonococcal urethritis (NGU).
NGU is commonly caused by chlamydia trachomatis, and less commonly by neisseria
meningitidis, ureaplasma urealyticum, mycoplasma genitalium, trichomonas vaginalis, HSV,
adenoviruses and candida species.
Signs / symptoms
•
urethral discharge
•
dysuria (usually mild)
•
penile or urethral irritation
•
testicular pain or swollen scrotum/testes
•
meatitis.
Investigations
Testing for NGU should not occur in isolation. Discuss additional STI screening.
Urethral
•
gram stain (onsite if available)
•
•
Or
•
first catch urine for gonorrhoea and chlamydia PCR (if no discharge).
Management
•
symptoms persist following treatment
•
associated testicular pain
•
uncertain diagnosis
•
•
•
•
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Treatment
Indicators
•
clinical diagnosis based on examination and history
•
>5 PMLs / HPF on gram stained smear
•
Regimens
•
•
consult an endorsed NP or a MO.
•
·
132
Name
Azithromycin
Form
Tablet
Strength
500mg
Recommended dose
Route of admin
Frequency/duration
Stat (1dose)
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
macrolide antibiotic
Special precautions
Pneumonia
Elderly
Children <16 years
Adverse reactions
Superinfection
Angioedema
Colitis, GI upset
Vaginitis
Interactions
Antacids
Ergot Derivatives
Rifabutin
Cyclosporine
Warfarin
Digoxin And drugs that prolong QT interval.
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Or
Name
Doxycycline
Form
Capsule/tablet
Strength
100mg
Recommended dose
100mg
Route of admin
Oral with food
Frequency/duration
Twice a day for 7-10 days11,12
Pregnancy category
D
Poison schedule
S4
Consult MO
Contraindications
Hypersensitivity to any Tetracycline
Special precautions
Prolonged use
Adverse reactions
Photosensitivity
Urticaria
Superinfection
Oesophagitis
GI disturbances
134
Interactions
Acetazolamide
Anticoagulants
Barbiturates
Carbamazepine
methoxyflurane (may cause fatal renal toxicity)
OCP
Penicillin
Phenytoin
Sodium Bicarbonate
Iron
Note:
•
antibiotics have been stopped13.
•
Duration of treatment with Doxycycline is dependant on the site and severity of
infection9. The Australian Medicines Handbook suggests 1- 3 weeks duration according to
site and severity on presentation. Consult with a MO if clinical presentation and findings
of examination indicate extension beyond the 10 day regimen above.
Client education
•
protect skin from sunlight and solariums as some Macrolide antibiotics increase
sensitivity to sunlight. If there is a rash, itching, redness or severe sunburn consult a MO
•
–
client to refrain from unsafe sex for a minimum of three days following treatment and
until sexual contacts are treated
–
–
provide MIMS consumer medicine information www.ckn.health.qld.gov.au
Contact tracing
All contacts should be screened and offered presumptive treatment according to sexual
history.
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Follow-up
136
•
proof of cure (POC) not required if treated with DOT Azithromycin or Doxycycline
•
swab for PCR POC cannot be reliably undertaken <8 weeks after treatment
•
if symptomatic, review at two weeks to check compliance with treatment and ensure all
contacts are tested and treated. Refer to a MO if still symptomatic.
Pelvic inflammatory disease (PID)
Pelvic inflammatory disease (PID) is a range of inflammatory disorders of the female upper
genital tract which include endometritis, salpingitis, pelvic abscess and pelvic peritonitis8,32.
PID is an acute clinical syndrome often associated with ascending infection due to microorganisms such as neisseria gonorrhoeae or chlamydia trachomatis. This can be termed STI
associated PID32.
Anaerobic bacteria that are considered normal flora of the genitourinary tract (i.e. gardnerella
vaginalis, genital mycoplasms (M. hominins, M. genitalium) or enteric gram-negative rods
are sometimes associated with PID, as are gynaecological procedures such as surgery, TOP,
delivery, intrauterine contraceptive device (IUCD) insertions/removals.
The diagnosis will only be made if symptoms are identified by the client and a bimanual
examination is done on women at risk. This is especially important in symptomatic women
diagnosed with chlamydia or gonorrhoea at screening
NOs must refer to or at minimum consult a MO or authorised endorsed NP regarding all
suspected or confirmed cases of PID and acute abdominal pain.
Signs / symptoms
•
low grade PID is commonly asymptomatic
•
fever
•
nausea and vomiting
•
pain (abdominal, pelvic, bowel or bladder)
•
abnormal vaginal bleeding, irregular menstrual cycles
•
abnormal discharge (urethral, vaginal or rectal)
•
sexually transmitted infection (STI)
•
pregnancy
•
urinary symptoms (e.g. dysuria, frequency)
•
evidence of intrauterine or other gynaecological instrumentation (e.g. intrauterine
contraceptive device insertion).
Factors associated with increased risk of PID
•
young age
•
multiple partners
•
presence of bacterial vaginosis
•
history of STI
•
vaginal douching
•
new partner in previous three months
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•
post-partum endometritis
•
recent history of instrumentation (i.e. TOP, IUCD insertion)
•
from areas of high STI prevalence.
Diagnosis
Diagnosis of PID is clinical and based on signs, history and examination. However, it is
important to remember that clinical diagnosis for PID is imprecise. All women with suspected
PID should have a bimanual examination.
When taking history ensure you ask about the following:
•
last menstrual period (LMP)
•
sexual activity including recent change of sexual partner(s) and previous STIs
•
contraceptive usage e.g. recent insertion of intrauterine systems (IUCS)
•
recent surgical instrumentation e.g. termination of pregnancy (TOP) and/or delivery
•
urinary symptoms
•
medication and drug allergies
•
onset, location, radiation and duration of pain
•
severity of pain and whether any treatment has been received
•
characteristics of pain e.g. acute, chronic or intermittent
•
associated symptoms e.g. nausea, vomiting, anorexia, diarrhoea, bleeding or haematuria
•
recent use of analgesia, narcotics or antibiotics
•
time of last bowel movement.
PID should be suspected if a sexually active young woman or women at risk of STI especially
experiencing all of the following symptoms:
•
pelvic or lower abdominal pain and/or tenderness of recent onset
•
dyspareunia
•
no other illness can be identified
•
has one or more of the following minimum criteria present on pelvic examination.7
Minimum criteria for suspecting/diagnosing PID
138
•
cervical motion tenderness (CMT) with bimanual palpation
•
adnexal tenderness
•
uterine tenderness with bi-manual palpation.
Additional criteria
The following additional criteria may support the diagnosis.
•
mucopurulent discharge from external os
•
elevated temperature (>38.3c)
•
abnormal vaginal discharge
•
presence of abundant numbers of WBC on saline wet prep
(>10 cells per high field)
•
confirmed laboratory diagnosis of chlamydia or gonorrhoea
•
elevated C-reactive protein
•
elevated ESR.
Investigations
Urethral
•
urinalysis and mid stream urine
•
urine BHCG.
Vaginal
•
high vaginal swab for M/C/S for BV or candidiasis
•
high vaginal swab for trichomonas PCR
•
high vaginal swab for wet prep/gram stain (if available)
•
pH
•
whiff test.
Endocervical
•
•
swab for gonorrhoea M/C/S.
Other
•
bi-manual examination (if not pregnant)
•
examine abdomen for rebound, tenderness and guarding
•
temperature, pulse and blood pressure
•
Note: If the client declines or is unable to complete an STI screen, encourage as a minimum:
•
self-administered vaginal swab for chlamydia, gonorrhoea and trichomonas PCR
or
•
first catch urine for chlamydia and gonorrhoea PCR.
All women of childbearing age presenting with lower abdominal pain should have a urine
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pregnancy test to exclude ectopic pregnancy. Negative swabs do not preclude a diagnosis
of PID. Pelvic ultrasound is usually unhelpful in establishing or excluding a diagnosis of PID.
Laparoscopy provides definitive diagnosis but may be difficult to access so diagnosis is
based on pelvic examination.
Management
Conditions requiring NO to refer to or at minimum consult with an MO or NP (if appropriate/
available):
•
suspected or confirmed diagnosis of PID
•
acute abdominal pain
•
surgical emergency e.g. appendicitis
•
persistent pain and/or symptoms following treatment
•
inability to tolerate out-patient treatment
•
recent instrumentation e.g. intrauterine device in-situ or TOP
•
complicated infection e.g. symptoms of Fitz Hugh Curtis syndrome
•
pregnancy test is positive
•
•
•
Note: NOs are recommended to refer all cases of suspected or confirmed PID to an
emergency department if a MO is unavailable for immediate consultation.
Treatment
Indicators
•
clinical diagnosis based on examination and history
•
signs and symptoms
•
laboratory confirmed diagnosis is not required to commence or continue treatment.
For mild to moderate PID (out-patient management)
•
the client should be reassessed at 72 hours
•
refer for further MO consultation or hospitalisation if there is no substantial improvement
within 72 hours.
Regimens
•
140
•
•
Regimen 1: Azithromycin, Doxycycline plus Metronidazole
This regimen may not give adequate cover for gonorrhoea.
Name
Azithromycin
Form
Tablet
Strength
500mg
Recommended dose
1gram
Route of admin
Frequency/duration
Stat (one dose)
Pregnancy category
B1
Poison schedule
S4
Emergency management As for severe allergic reaction - Anaphylaxis
Consult MO
Contraindications
Known hypersensitivity to Azithromycin, Erythromycin or
Special precautions
Pneumonia
Elderly
Adverse reactions
Superinfection
Angioedema
Colitis
GI upset
Interactions
Antacids
Ergot derivatives
Rifabutin
Cyclosporine
Warfarin
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And
142
Name
Doxycycline
Form
Capsule or Tablet
Strength
100mg
Recommended dose
100mg
Route of admin
Oral with food
Frequency/duration
Twice a day for 14 days11
Pregnancy category
D
Poison schedule
S4
Consult MO
Contraindications
Hypersensitivity to any Tetracycline
Special precautions
Prolonged use
Adverse reactions
Photosensitivity
Urticaria
Superinfection
Oesophagitis
GI disturbances
Interactions
Acetazolamide
Anticoagulants
Barbiturates
Carbamazepine
Methoxyflurane (may cause fatal renal toxicity)
OCP
Penicillin
Phenytoin
Sodium Bicarbonate, Iron
And
Name
Metronidazole Form
Tablet
Strength
400mg
Recommended dose
400mg
Route of admin
Oral
Frequency/duration
Twice a day for 14 days
Pregnancy category
B2
Poison schedule
S4
Contraindications
Blood dyscrasias
Active CNS disease
Hypersensitivity to Metronidazole or Imidazoles
Special precautions
Prolonged use
Alcoholic beverages and drugs containing alcohol may cause
flushing, vomiting, tachycardia
Adverse reactions
Superinfection
G.I disturbances
Pancreatitis
Metallic/unpleasant taste
Interactions
Warfarin
Cyclophosphamide
Phenytoin, phenobarbitone and other hepatic enzyme Inducers
Lithium
Disulfiram
Cyclosporine
5-Fluorouracil
adverse effect if given in combination with Metronidazole
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Regimen 2: Azithromycin, Doxycycline, Metronidazole plus Ceftriaxone
for suspected or proven gonorrhoea and/or in areas with high prevalence of gonorrhoea. NO
are required to consult with a MO prior to progressing to Regimen 2.
As per Regimen 1: Azithromycin, Doxycycline and Metronidazole, plus Ceftriaxone and
Lignocaine Hydrocholoride.
Name
Ceftriaxone
Form
Powder
Strength
250mg
Recommended dose
250mg
Route of admin
Intramuscular Injection reconstituted with 2ml Lignocaine 1%
solution
Frequency/duration
Stat
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Allergy to cephalosporins
Allergy to penicillin
Special precautions
GI disease
Pregnancy, lactation, children aged <12 years, neonates
Adverse reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
144
Chloramphenicol
Name
Form
Strength
1% (5ml ampoule)
Recommended dose
2mls to be used to reconstitute 250mg Ceftriaxone powder
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
Impaired cardiac conduction
Intraventricular block arrhythmias
Special Precautions
High repeated doses
Neurological disorders
Epilepsy
Elderly, children
Adverse Reactions
CNS disturbances
Arrhythmias
Hypertension
Interactions
Cimetidine
Phenytoin
Alcohol
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Or
with Ceftriaxone dry powder 1g vial stock.
The regimen using Ceftriaxone dry powder is the same recommended dose of 250mg
Name
Ceftriaxone
Form
Dry powder
Strength
1g (0.4ml)
Volumes for Dose Calculation52,53
1g dry powder (0.4ml) + 1% Lignocaine solution 3.5ml =
total volume 3.9ml
Recommended dose
250mg (0.98ml)
Route of admin
Frequency/duration
Stat (once only)
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Special precautions
GI disease (especially Colitis)
Neonates
Adverse reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
Chloramphenicol
146
Plus
Name
Form
Strength
1% (5ml vial)
Recommended dose
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
Arrhythmias
Special precautions
High repeated doses
Hypoxia
Severe respiratory depression
Elderly, children
Adverse Reactions
CNS disturbances
Arrhythmias
Hypertension
Interactions
Antiarrhythmics
Beta-blockers (especially class 111)
Cimetidine
Phenytoin
Alcohol
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Note:
•
•
•
•
•
Treatment regimens should be effective against N. gonorrhoeae, Chlamydia Trachomatis,
anaerobes and bacterial vaginosis as endocervical screening does not rule out an upper
reproductive tract infection.
Evidence suggests that an effective treatment for mild to moderate PID is Ceftriaxone
250mg IMI plus Doxycycline orally 100mg twice daily for 14 days with or without
Metronidazole 500mg orally twice daily for 14 days7,54. The decision to administer this
regimen with or without Metronidazole is based on clinical judgement of client risk of
anaerobic pathogens such as pelvic abscess; proven or suspected trichomonas vaginalis
and/or bacterial vaginosis, or history of gynaecological instrumentation in the preceding
2 - 3 weeks. Currently this is not an approved regimen so a NO is required to discuss first
with a MO.
Recent studies indicate that a regimen of Azithromycin and Ceftriaxone or Doxycycline
and Ceftriaxone (doses as above) for PID may be equivalent in efficacy for first-line
treatment of mild PID. However, additional research is required before recommendations
can be made54.
additional contraception such as condoms, during treatment and for seven days after
antibiotics have been stopped.
Women with an IUCD insitu should be referred to a MO.
Client education
•
•
•
•
•
•
no unsafe sex for a minimum of three days following treatment and until all contacts are
treated, offer condoms and lubricant
reinforce need to complete remaining treatment regimen
Contact tracing
Contact trace according to requirements of the specific disease or condition diagnosed. Treat
all contacts presumptively.
Follow-up
148
•
review client in 72 hours to ensure symptoms are responding to treatment. If the client
remains symptomatic, refer to a MO immediately
•
review client again at eight days to assess compliance and resolution of symptoms.
Repeat bimanual examination if possible. Reinforce need to complete remaining
treatment regimen. If there is no improvement NO are required to refer to a MO.
Proctitis
Proctitis is indicated by the presence of anal discharge, blood and/or mucous in stools, and
pain during defecation. Proctitis caused by sexually transmitted organisms is usually caused
by Neisseria Gonorrhoeae or the herpes simplex virus, however Chlamydia trachomatis
is increasingly implicated in MSM. Recently, Lymphogranuloma venereum (LGV) has been
identified as a cause of acute proctitis in MSM in Australia, Europe and North America.
Signs / symptoms
•
rectal discharge, itch and/or soreness
•
blood, pus and/or mucus in stools or on underwear
•
discomfort or bleeding on defecation or in association with anal penetration.
The following are possible causes of Proctitis:
•
Chlamydia Trachomatis
•
Neisseria Gonorrhoeae
•
Trichomonas vaginalis
•
Herpes simplex virus
•
Human papilloma virus
•
Treponema Pallidum
•
Lymphogranuloma venereum
•
Enteric pathogens/parasites such as Giardia Lamblia, Entamoeba Histolytica,
Campylobacter, Shigella
•
Inflammatory/Irritable Bowel Syndrome
•
Rectal and/or bowel abnormalities such as malignancy, benign growths or polyps
•
Diverticular disease
•
Anal fissure, tear, sinus or fistula
•
Foreign bodies
•
Trauma.
When taking history be sure to ask about the following:
•
Sexual, medical and surgical history and for females a gynaecological and menstrual
history
•
blood, pus and/or mucus in stools or on underwear
•
discomfort/pain or bleeding on defecation
•
discomfort/pain or bleeding during or after anal intercourse
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•
associated symptoms e.g. tenesmus, pruritus, pain or fever
•
previous history of STIs and treatment history
•
recent change of sexual partner or symptomatic partner
•
recent increase in anal intercourse
•
recent overseas travel or sexual contact with person from endemic country
•
use of foreign objects/sex toys for anal penetration
•
change in bowel motions/habits.
Examination
•
palpate inguinal lymph nodes for enlargement and or tenderness
•
examine perianal region for colour, discharge, erythema, lesions, ulcers, rashes,
excoriation, trauma or abnormalities
•
perform proctoscopy and examine rectal mucosa for colour changes, appearance,
lesions, ulceration, fissures, discharge, inflammation, masses or abnormalities.
Investigations
Perform investigations based on risk assessment, clinical findings and local policy.
•
blood pressure, TPR
•
rectal mucosa swabs for:
•
150
–
gonorrhoea PCR or culture and sensitivity (C/S)
–
chlamydia PCR. If positive also perform LGV serotype (PCR).
–
swab for HSV PCR (if indicated)
–
swab for Treponemal PCR for syphilis
–
press slide and GUMP for donovanosis
–
consider punch biopsy for lesions that are atypical or unresponsive to treatment
(particularly in clients with HIV).
serology
–
syphilis
–
HIV.
•
if diarrhoea is present take a stool sample for microscopy, culture and sensitivity (M/C/S)
•
discuss additional STI screening as indicated by history.
Management
•
all cases of proctitis
Treatment
Indicators
Diagnosis based on examination findings:
•
if anoscopy reveals proctitis (pus, friable mucosa or contact bleeding), initiate
presumptive treatment for chlamydia and gonorrhoea
•
proctitis associated with painful ulceration can suggest herpes simplex virus, so
presumptive anti-viral treatment should also be given.
Laboratory confirmed diagnosis:
•
if rectal PCR positive for chlamydia, perform LGV testing and consult with a MO.
Regimens
•
•
•
cases consult a MO.
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Name
Doxycycline
Form
Capsule
Strength
100mg
Recommended dose
100mg
Route of admin
Oral with food
Frequency/duration
Twice a day for 10 days
Twice a day for 21 days if LGV confirmed
152
Pregnancy category
D
Poison schedule
S4
Consult MO or refer to appropriate emergency services
Contraindications
Special precautions
Don’t take immediately before going to bed
Prolonged use
Children <8 years
Adverse Reactions
Photosensitivity
Urticaria
Superinfection
Oesophagitis
GI disturbances
Interactions
Acetazolamide
Anticoagulants
Barbiturates
Carbamazepine
Penicillin
Phenytoin
Sodium Bicarbonate
Iron
And
Name
Ceftriaxone
Form
Powder
Strength
250mg
Recommended dose
250mg
Route of admin
Intramuscular injection reconstituted with 2ml Lignocaine
1% solution
Frequency/duration
Stat (1 dose)
Pregnancy category
B1
Poison schedule
S4
Contraindications
Special precautions
Children <12 years
Neonates
Adverse reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
Chloramphenicol
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Plus for reconstitution of 1gram Ceftriaxone powder use
154
Name
Form
Strength
1% (5ml ampoule)
Recommended dose
3.5ml to be used to reconstitute 1gram Ceftriaxone powder
Route of admin
Frequency/duration
Stat
Pregnancy category
A
Poison schedule
S4
Consult with MO
Contraindications
Septicaemia
Anticoagulants
arrhythmias
Special precautions
High repeated doses
Adverse reactions
CNS disturbances
Interactions
Beta-blockers
Cimetidine
Alcohol
Or
with Ceftriaxone dry powder 1gram vial stock.
The regimen using Ceftriaxone dry powder is the same recommended dose of 250mg
Name
Ceftriaxone
Form
Dry powder
Strength
1g (0.4ml)
Volumes for Dose Calculation52,53
1g dry powder (0.4ml) + 1% Lignocaine solution 3.5ml =
total volume 3.9ml
Recommended dose
250mg (0.98ml)
Route of admin
Frequency/duration
Stat (once only)
Pregnancy category
B1
Poison schedule
S4
Consult MO
Contraindications
Special precautions
GI disease (especially Colitis)
Neonates
Adverse reactions
Superinfection
Hypoprothrombinemia
Local reactions
Diarrhoea
Interactions
Chloramphenicol
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Note:
•
observe client for 30 minutes after administration of Ceftriaxone
•
Azithromycin is likely to be a suitable substitute for Doxycycline although this has not
been evaluated.
•
•
if rectal PCR positive for chlamydia, consider LGV and consult with a MO.
If associated with painful ulceration add presumptive treatment for HSV.
Name
Valaciclovir
Form
Oral
Strength
500mg
Recommended dose
500mg
Route of admin
Oral
Frequency/duration
Twice daily for 5 – 10 days12
Pregnancy category
B3
Poison schedule
S4
Contraindications
Special precautions
Dehydration
Children, the elderly
Adverse reactions
Headache, dizziness
Nausea, G.I. upset
Rash and hypersensitivity
Interactions
156
Or
Name
Aciclovir
Form
Oral
Strength
200mg
Recommended dose
200mg
Route of admin
Oral
Frequency/duration
One tablet 5 times daily for 10 days12
Pregnancy category
B3
Poison schedule
S4
Contraindications
Special precautions
Significant hypoxia
Children, the elderly
Adverse reactions
Nausea or vomiting are most frequent adverse effect
Less frequent effects (<1%) include diarrhoea, leg pain,
dizziness, anorexia, fatigue, oedema, skin rashes,
inguinal adenopathy, medication taste and sore throat
Interactions
No clinically significant interactions have been
identified
Probenecid
Concurrent use of diuretics in clients aged > 60 yrs
Note: regimen for primary herpes treatment is five days, though duration may be extended to
a 10 day supply for moderate to severe episodes.
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Or
Name
Famciclovir
Form
Tablet
Strength
125mg, 250mg or 500mg
Recommended dose
1250mg over a two day period12
Route of admin
Oral
Frequency/duration
500mg stat
Then
250mg every 12 hours for three doses
Pregnancy category
B1
Poison schedule
S4
Contraindications
Known hypersensitivity to Famciclovir and Penciclovir
Special precautions
Renal
Pregnancy
Lactation
Children <12 years
Tablets contain lactose (should not be taken by clients
with galactose intolerance, severe lactase deficiency or
glucose malabsorption)
Driving/operating machinery if experiencing dizziness/
somnolence
Adverse reactions
Headache, dizziness
Nausea, G.I. upset
Skin rash
Fatigue / somnolence.
Interactions
Note: 500mg Famciclovir is not available on the Queensland Health List of Approved
Medicines.21
Client education
•
158
avoid unprotected sex until all contacts are treated and for a minimum of three
days following treatment with Azithromycin or seven days following treatment with
Doxycycline
•
•
•
•
Contact tracing
Contact trace according to requirements of the specific disease or condition diagnosed. Refer
to History and assessment (section one).
Follow-up
Review the client within four days, to assess resolution of symptoms:
•
refer to a MO if still symptomatic.
If diagnosis confirmed with chlamydia:
•
follow-up within two weeks to ensure compliance with medication
•
follow-up not required if asymptomatic and treatment of DOT Azithromycin or Doxycycline
completed
•
PCR POC cannot be reliably undertaken <8 weeks after treatment
•
re-testing recommended at three months as re-infection is common.
If diagnosis confirmed with gonorrhoea:
•
follow-up at 7-10 days to ensure symptoms resolved and check partner(s) have been
treated
•
proof of cure - swab for gonorrhoea M/C/S of infected site two weeks after treatment if
symptoms persist. Do not use swab for gonorrhoea PCR for POC, as it will remain positive
for up to eight weeks after treatment
•
re-testing recommended at three months as re-infection is common.
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Pubic lice
Pubic lice or pedicular pubis is caused by an infestation of pthirus pubis which usually attach
to hairs in the pubic and perianal regions49. They may also appear on thighs, axilla, axillae,
eye lashes and eyebrows49. Transmitted by intimate contact (including sexual contact), public
lice it can be transmitted by sharing personal articles such as hairbrushes, combs, towels or
clothing49.
Signs / symptoms
•
skin irritation
•
visible louse/eggs
•
blue-grey macules (maculae coeruleae) induced by the bite of the louse
•
brown/red faecal droppings in the pubic hair or underwear
•
secondary bacterial skin infection.
Investigations
•
visualisation of lice/eggs on examination or under light magnification
•
Management
•
secondary skin infection or irritation
•
uncertain diagnosis
•
•
•
•
•
Treatment
Indicators
160
•
•
contact with pubic lice.
Regimens
•
Non DTP-SRH endorsed NOs are authorised to administer this regimen if clinical
competency is completed. If not deemed competent, refer management to a DTP–SRH
endorsed NO, endorsed NP or consult a MO or endorsed NP.
•
•
Name
Permethrin
Form
Cream/lotion/cream rinse
Strength
Cream / Lotion 5%
Cream rinse 1%
Recommended dose
Two applications 7 – 10 days apart
Route of admin
Topical
Frequency/duration
Cream/Lotion
Apply to entire body from neck down, especially between
skin folds
Leave for 8 - 24 hours before washing off
Repeat in 7-10 days if necessary
Cream rinse
Apply liberally to dry hair, massage into hair base.
Leave for 20 mins before washing off, comb hair with fine
tooth comb
Repeat in 7-10 days if necessary
Pregnancy category
B2
Poison schedule
Cream rinse with conditioner: unscheduled
Dermal cream: unscheduled
Scabies treatment lotion: unscheduled
Discontinue use if irritation occurs
If contact with eyes rinse immediately with water
Consult MO
Contraindications
Known hypersensitivity to Permethrin or other ingredients
in the product
Special precautions
Avoid eyes and mucous membranes
Existing skin infection or open wounds
Use with caution during pregnancy/breastfeeding
Children aged 6 mths - 2 yrs (medical supervision)
Elderly
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Adverse reactions
Uncommon
Localised burning, irritation or tingling sensation
Interactions
Recommended that treatment of eczematous skin
conditions with corticosteroid creams is withheld prior to
treatment, as they may worsen the infection
Client education
•
Do not bathe in hot water prior to applying Permethrin. Apply Permethrin to clean, cool
skin.
•
lice/eggs can be removed with a fine toothed comb
•
underwear, pyjamas, bath towels and bed linen should be washed in hot water or dry
cleaned. Expose mattress, blankets and doonas to sunlight for several hours. It is
unnecessary to fumigate living areas
•
if there is an infestation of the eyelashes, do not apply Permethrin. Instead, apply
petroleum jelly to eyelashes twice daily for 7-10 days
•
Contact tracing
•
treat any partner(s) from within the last month
•
close non-sexual contacts such as household members may also need treatment.
Follow-up
162
•
not necessary
•
clients should be re-examined 1-2 weeks after treatment if still symptomatic.
Scabies
Scabies is caused by Sarcoptes scabiei49. Transmission is predominately through close body
contact but it can also spread by sharing clothes or bed linen.
Signs / symptoms
•
papular and eczematous lesions49 with a history of itching which is typically worse at
night
•
scabietic lesions or “burrows” may be visible as a greyish, fine, linear rash or ridge
•
the mite may be visible in the burrow as a raised white oval with dark pigmentation
anteriorly
•
secondary bacterial infection
•
‘Norwegian scabies’ or ‘crusted scabies’
–
infestation from a high quantity of mites. Is more likely in an
immunosuppressed or institutionalised client
–
present as thick crusts affecting areas such as the feet and scalp
–
extremely infectious.
Investigations
Definitive diagnosis is made by microscopic identification of mites or their eggs from skin
scrapings at the site of burrows. Offer STI screening.
Management
available):
•
‘Norwegian scabies’ or ‘crusted scabies’ are suspected
•
•
uncertain diagnosis
•
secondary skin infections or irritations
•
no response after second treatment
•
•
•
•
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Treatment
Indicators
•
•
definitive microscopic identification of mite
•
known contact of scabies.
Regimens
•
Non DTP-SRH endorsed NOs are authorised to administer this regimen if clinical
competence is completed. If not deemed competent, refer management to a DTP–SRH
endorsed NO, endorsed NP or a MO.
•
•
Name
Permethrin
Form
Cream/lotion
Strength
5%
Recommended dose
Approximate amount for each application for adults is
30g (1 tube) – some may require a repeat, but not more
than 60g (2 tubes) in one application
Route of admin
Topical
Frequency/duration
Once a week for two weeks
Apply to entire body from neck down, especially between
skin folds
Leave on for 8 – 24 hours before washing off
Pregnancy category
Dermal cream: category B2
Scabies treatment: category B2
Poison schedule
Dermal cream: unscheduled
Lotion: unscheduled
Discontinue use if irritation occurs
If contact with eyes, rinse immediately with water
Consult MO
Contraindications
164
Known hypersensitivity to Permethrin or other ingredients
in the product
Special precautions
Avoid eyes and mucous membranes
Existing skin infection or open wounds
Use with caution during pregnancy and breastfeeding
Children aged 6mths - 2yrs (need medical supervision)
Elderly
Adverse reactions
Uncommon
Localised burning, irritation or tingling sensation
Burning sensation of higher incidence with symptomatic
HIV infection
Interactions
Treatment of eczematous skin conditions with
corticosteroid creams should be withheld, as they may
worsen the infection
Client education
•
avoid contact with eyes and mucous membranes
•
apply to clean, cool, dry skin, and do not use on broken or infected skin
•
pay attention to webs of the fingers and toes
•
do not wash hands after application or wash off lotion for 8-12 hours
•
pruritus and skin irritation may persist for several weeks after adequate therapy. In
severe cases, systemic antipruritics or topical steroids may be necessary to alleviate
symptoms
•
underwear, pyjamas, bath towels and bed linen should be washed in hot water or dry
cleaned. Expose mattress and doonas to UV light for 48 – 72 hours or spray with insect
repellent
•
•
Contact tracing
•
sexual partners and household contacts should be treated at the same time even if
asymptomatic
•
clients and staff in institutional settings such as nursing homes will require treatment.
Follow-up
•
there is no consensus or evidence regarding follow-up
•
evidence of new burrows and/or secondary skin infections is an indicator for further
treatment.
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Syphilis
Syphilis is caused by the bacterium Treponema pallidum49. T. pallidum is a member of the
spirochaetaceae family which is responsible for Yaws (T. Pertenue) and Pinta (T. Carareum).
Syphilis can be categorised into congenital infection and acquired infection.
Congenital infection is acquired through transplacental infection or during delivery.
Acquired infection is acquired by direct contact with infectious exudate from associated skin
lesions (chancre) and mucous membranes during sexual contact. Transmission may occur
within the injecting drug user population. Acquired infection can be divided into two further
categories:
•
Early infection of <2 years (which includes primary, secondary and early latent infection)
•
Late syphilis of >2 years duration (which includes late clinical stage such as tertiary or
late latent infection).
Signs / symptoms
Primary syphilis
The infecting organism disseminates through the body during this time.
•
10 - 90 days incubation (three weeks on average)
•
skin lesions (chancres):
–
painless ulceration
–
typically presents as a single painless lesion with raised border and indurated clean
base
–
atypical presentations and/or multiple lesions can occur due to
co-infection with HIV, secondary infection or application of topical medication
–
may occur at extra-genital point of treponemal inoculation i.e. fingers, nipples or lips
–
painless regional lymphadenopathy may be present.
Secondary syphilis
Signs and symptoms may appear and regress at intervals over a two year period.
•
Cutaneous or mucosal rash49
•
chancres may still be evident in secondary syphilis
•
flu-like illness
•
skin lesions
•
166
–
bilaterally symmetrical, seldom itchy and generally dry
–
macular, papular, follicular or pustular.
cutaneous and mucosal lesions
–
snail track ulcers
–
mucous patches
–
wart-like lesions (condylomata lata).
•
generalised lymphadenopathy
•
loss of eyelashes and outer-third of eyebrows
•
sometimes alopecia or ‘moth-eaten’ appearance beginning at the occipital scalp
•
systemic dissemination
•
manifestation of neurological involvement (more common in HIV infected clients).
Latency
After the secondary stage there is typically a long period of latency during which the only
finding is positive syphilis serology. This interval may be shorter in those who are HIV
positive.
Tertiary syphilis
Tertiary syphilis is rare but should be excluded in anyone presenting with neurological signs
who has positive syphilis serology and no history of treatment. Management should always
be in consultation with a specialist MO.
Testing
Testing should occur in the following circumstances:
•
known contact of syphilis
•
genital ulceration
•
presence of other STI
•
identified risk through unprotected intercourse including oro-genital
•
symptoms characteristic of second or latent syphilis
•
sexual health check and routine antenatal testing.
Investigations
Testing for syphilis should not occur in isolation. Screen for all STIs and if syphilis is
suspected contact the Syphilis Register on 1800 032 238 for advice.
Serology
•
syphilis
•
HBV
•
HIV.
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Lesion
•
dark ground microscopy (if available)
•
treponemal PCR swab (if available). Discuss with MO and laboratory prior to collection.
Serology
Most syphilis is diagnosed on the basis of serology. In approximately 75% of cases of primary
chancres, serology is positive at the time of presentation. However, negative serology in a
client with a genital ulcer does not exclude syphilis. Dark-field microscopy and PCR testing
can be used if available.
Non-specific (non-treponemal) tests (RPR and VDRL) usually become reactive six weeks after
infection. RPR is the most common test to assess disease activity and monitor response to
treatment. In early syphilis, there will be a four-fold
(2 titre) drop in the RPR titre over 6 - 12 months following adequate treatment. Even without
treatment, the RPR titre gradually declines over many years.
Specific treponemal tests (EIA, TPPA and FTA-ABS) remain positive ‘for life’ in most cases,
regardless of treatment. Some of these tests e.g. FTA - may detect infection at an earlier stage
than RPR. RPR plus a specific treponemal test is typically used for screening purposes to
detect infections where the RPR may have become negative over time. Specific tests cannot
be used for monitoring the efficacy of treatment.
Dark-field microscopy
This allows demonstration of spirochaetes from primary chancres or mucous membrane
lesions of secondary syphilis. The lesion is cleaned with saline, squeezed gently, and a drop
of expressed exudate is placed into a drop of saline on a glass slide. If dark-field microscopy
is immediately available, motile treponemes can be seen directly in the wet preparation.
If dark-field microscopy is not available, allow the sample to dry, then send the slide to a
laboratory for detection of treponemes by an immunofluorescent technique (however this
test is not commonly available in Australia). Check with your local laboratory to confirm
whether dark-field microscopy is available.
PCR testing for Treponema pallidum
PCR testing of a swab taken from a genital ulcer or mucous membrane lesion has good
sensitivity and specificity. In Queensland Health laboratories, this test will only be performed
if it is accompanied by a blood specimen for syphilis serology. In the Northern Zone, the test
is performed as part of a multiplex PCR test for GUMP.
Management
Contact the Syphilis Register on 1800 032 238
•
168
suspected or laboratory confirmed diagnosis
•
suspected long standing untreated syphilis, tertiary syphilis or neurosyphilis
•
suspected treatment failure
•
systemic illness
•
•
contraindication to treatment e.g. allergy to penicillin
•
•
abnormal findings of significance e.g. neurological involvement
•
uncertain diagnosis
•
Treatment
Indicators
•
suspected primary or secondary syphilis
•
•
contact with infectious Syphilis.
Regimens
Prior to initiation of treatment:
•
contact the Syphilis Register on 1800 032 238
•
consult with a MO
•
perform systemic physical assessment including neurological examination
•
repeat syphilis serology before administering initial dose for true baseline RPR.
Note:
•
treatment influenced by infection duration i.e. early or late syphilis
•
if a MO is unavailable for consultation prior to initiation of treatment
(e.g. isolated remote practice) ensure internal procedures are in place to support scope
of practice.
Regimen 1: Syphilis proven to be <2 years duration
(Including primary and secondary syphilis)
•
•
•
cases consult a MO.
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Name
Benzathine Penicillin (Bicillin LA)
Form
Suspension
Strength
900mg / 2.3 ml (1,200,000 International units)
Recommended dose
1.8g (2 x 900mg /2.3ml or 2,400,000 International units)
Route of admin
IMI
Frequency/duration
Stat (once only)
Pregnancy category
A
Poison schedule
Schedule 4
See allergic reaction/anaphylaxis management
Consult MO
Contraindications
Do not inject into or near artery or nerve
Beware of inadvertent intravascular administration
Special precautions
Repeat Syphilis serology at time of treatment for true
baseline RPR titre
Anaphylaxis
Asthma
Lactation
Adverse reactions
Atrophy
Superinfection
Hypersensitivity
Jarisch Herxheimer reaction
Neuropathy
Nephropathy
Interactions
Tetracycline
Probenecid
If there is a supply shortage of Benzathine Penicillin (Bicillin LA) an approved substitute is
Benzathine Benzylpenicillin (Pan Benzathine Penicillin). Recommended dose and frequency
remains the same (see preparation guidelines below).
170
Or
Name
Procaine Penicillin
Form
Suspension
Strength
1.5gram pre-filled syringe
Recommended dose
1gram
Route of admin
IMI
Frequency/duration
Daily for 10 days
Pregnancy category
A
Poison schedule
S4
See allergic reaction/Anaphylaxis management
Consult MO
Contraindications
Allergy to Penicillin or Procaine
Special precautions
Repeat for syphilis serology at time of treatment for true
baseline RPR titre
Do not inject into or near blood vessel or nerve
Super-infection and pseudomembranous colitis
Adverse reactions
GI upsets
Rashes
Urticaria
Pain at injection site
Extreme anxiety, hallucinations, disorientation
Tachycardia
Interactions
Tetracycline
Probenecid
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Regimen 2: Syphilis of >2 years or unknown duration
•
•
consult an endorsed NP or MO.
•
Name
Benzathine Penicillin (Bicillin LA)
Form
Suspension
Strength
900mg / 2.3ml (1,200,000 International units)
Recommended dose
1.8g (2 x 900mg / 2.3ml or 2,400,000 International units)
Route of admin
IMI
Frequency/duration
Once a week for three weeks
Pregnancy category
A
Poison schedule
Schedule 4
Consult MO
Contraindications
Do not inject into or near an artery or nerve
Beware of danger due to inadvertent intravascular administration
Special precautions
Re-bleed for Syphilis serology at time of treatment for true baseline
RPR titre
Adverse reactions
Atrophy
Superinfection
Hypersensitivity
Neuropathy
Nephropathy
Interactions
Tetracycline
Probenecid
172
Benzathine Benzylpenicillin (Pan Benzathine Penicillin)
Benzathine Benzylpenicillin (Pan Benzathine Penicillin) and Benzathine Penicillin (Bicillin LA)
is the same drug in a different form. Benzathine Benzylpenicillin (Pan Benzathine Penicillin) is
an approved substitute for Benzathine Penicillin (Bicillin LA) when Bicillin LA is unavailable.
The recommended dose and frequency remain the same as per Benzathine Penicillin but with
an increase in required volume and change in preparation.
Name
Benzathine Benzylpenicillin (Pan Benzathine Penicillin)
Form
Powder
Strength
900mg (1,200,000 International units)
Recommended dose
1.8g (2 x 900mg or 2,400,000 International units)
Route of admin
IMI reconstituted with:
4ml of water for injection
Administer 4.6ml (one vial) in each buttock.
Frequency/duration
As per Benzathine Penicillin (Bicillin LA), based on duration of
infection
Pregnancy category
A
Poison schedule
S4
Consult MO
Contraindications
Special precautions
Re-bleed for Syphilis serology at time of treatment for true
baseline RPR titre
Lactation
Anaphylaxis
Adverse reactions
Atrophy
Superinfection
Hypersensitivity
Neuropathy
Nephropathy
Interactions
Tetracycline
Probenecid
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Benzathine Benzylpenicillin (Pan Benzathine Penicillin) injection
To minimise discomfort:
•
reconstitute each 900mg in a minimum of 4mls of water
•
use a 5ml syringe
•
hold the vial vertically and mix well until powder is absorbed
•
prepare immediately prior to administration
•
prior to administration, warm injection (do not heat above +50oC) by rolling syringe
between palm of hands, as this may reduce discomfort for the client
•
if there is delay in administration following preparation, ensure syringe is rotated
vertically prior to administration so it mixes adequately. This will reduce obstruction of
the needle due to precipitation of the suspension
•
attach a 19 gauge or 21 gauge needle for injection to the syringe just prior to injecting
suspension, to prevent blockage of needle
•
administer in the upper/outer quadrant of the gluteus maximus and apply pressure to
the injection site at for at least ten seconds prior to administration
•
give two injections (one in each buttock).
Approximately 30% of people treated for primary syphilis and 60% of people treated for
secondary syphilis have a reaction characterised by chills, fever, arthralgias, headaches and
transiently increased prominence of lesions49. The Jarisch-Herxheimer reaction is due to the
release of treponemal constituents and usually occurs within 24 hours of starting treatment.
Advise the client that this may occur and that it can cause signs and symptoms to temporarily
exacerbate.
Signs / symptoms of Jarisch-Herxheimer reaction
•
prodromal phase with aches and pains (<4 hours)
•
rigor or chill (4 - 8 hours)
•
flush with temperature peak and hypotension (8 hours)
•
falling temperature, back to normal (lasting up to 12 hours)
•
fever, sweats, shivering, muscle/joint pains, sore throat or headache
•
sudden worsening of local lesion (i.e. chancre or rash)
•
fast pulse or feeling faint (postural hypotension).
Jarisch-Herxheimer reaction can cause premature labour in some women and fetal distress
during the second half of pregnancy.
Management
•
174
advise client in advance of possible reaction(s)
•
manage with rest and fluids
•
aspirin or paracetamol - two tablets four hourly (as required). Do not exceed four doses
(eight tablets) in 24 hours. Aspirin should not be given during pregnancy
Note: COC users taking a short course (<3 weeks) of antibiotics should be advised to use
additional contraception such as condoms, during treatment and for seven days after
antibiotics have been stopped
Penicillin remains the preferred treatment for all stages of syphilis. Serology should be
repeated at the time of initial treatment as this will provide a baseline RPR for monitoring
response to treatment.
Treatment of early syphilis in clients allergic to penicillin
This includes clients who have a documented cutaneous reaction or history of
hypersensitivity to Penicillin.
Use Doxycycline 100 mg twice daily for 14 days. Doxycycline should not be used in pregnancy
(category D in pregnancy).
Consideration could be given to desensitisation in those who are Penicillin allergic (especially
in pregnancy).
Erythromycin should not be used during pregnancy as it may not prevent congenital
syphilis. Pregnant clients who are allergic to Penicillin pose difficult problems. If Penicillin
desensitisation is not possible, the remaining treatment options are Azithromycin or
Ceftriaxone. However, the baby will always require additional treatment and careful follow-up
if a non-penicillin treatment is used during pregnancy.
Penicillin allergic clients should be managed in consultation with an experienced infectious
disease or sexual health clinician.
Late latent syphilis (>2 years duration)
People with late latent syphilis are not sexually infectious. Vertical transmission can still
occur even though it’s less likely more than two years after initial infection. The principal goal
of treatment is to prevent late complications.
Lumbar puncture in late latent syphilis
T. Pallidum invades the CNS in 25% of clients with syphilis (irrespective of HIV status).
Infection is effectively cleared in about 75% of these clients, while the remaining 25%
harbour organisms in their CNS which can lead to symptomatic neurological disease in
late syphilis. Symptomatic neurosyphilis in secondary or late syphilis is a rare occurrence,
probably due to widespread use of antibiotics for other reasons.
Lumbar puncture is not necessary in secondary or latent syphilis unless there is clinical
evidence of neurological involvement. Seek specialist advice if in doubt.
All clients with positive syphilis serology who have neurological symptoms or signs of late
syphilis should undergo lumbar puncture and CSF examination.
There is no comprehensive test to diagnose neurosyphilis, so all test results should be
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interpreted together and correlated with clinical findings. The VDRL-CSF is a standard
serological test for syphilis in CSF. When reactive in the absence of significant contamination
of CSF with blood, it is considered diagnostic of neurosyphilis. However, the VDRL-CSF may
be non-reactive in clients with neurosyphilis. CSF FTA-ABS is less specific but highly sensitive,
and if negative, neurosyphilis is usually excluded. The CSF leucocyte count is usually elevated
(>5 WBC/mm3) with protein raised and glucose reduced. Seek specialist advice in the management of symptomatic late syphilis and neurosyphilis.
Treating neurosyphilis
Seek specialist advice. Recommended treatment is Benzyl Penicillin 1.8grams IV (depending
on body weight), four hourly for 15 days.
Pregnancy and congenital syphilis
If a client has history of adequate treatment for syphilis with serological follow-up, and reinfection is unlikely, avoid re-treatment and serological examination of the infant. In areas of
high prevalence, it may be necessary to screen for syphilis in pregnancy. Testing should occur
during presentation at the third trimester and time of delivery.
Vertical transmission of syphilis in untreated women is possible but tends to decrease in
probability over time. Pregnant women should be treated with Penicillin at the same dosage
for non-pregnant women at a similar stage of infection. Seek specialist advice about females
allergic to Penicillin. Tetracyclines should not be used in pregnancy and Erythromycin does
not reliably treat an infected foetus.
Contact the Queensland Syphilis Register on 1800 032 238 if a pregnant woman has positive
syphilis serology.
Treatment is adequate if:
•
completed before 29 weeks
•
there is a documented four-fold (two titre) drop in RPR before or at time of delivery.
A baby is at high risk if:
•
the mother has primary or secondary syphilis genital sores at time of delivery
•
the mother was treated with a drug other than Penicillin or treatment was inadequate
•
treatment of mother was within four weeks of delivery
•
the mother’s RPR is greater than or equal to 1:64, or is not falling
•
examination of the baby shows signs of congenital syphilis
•
the mother’s RPR at delivery shows inadequately treated or previously undiagnosed
syphilis.
Any high risk baby needs a lumbar puncture and CSF examination for white cells, protein and
VDRL.
If CSF examination is abnormal:
Benzyl Penicillin 50 mg/kg IM or IV daily in two divided doses for ten days, or Procaine
Penicillin 50 mg/kg IM daily for ten days.
176
If CSF examination is normal:
•
the baby needs single dose treatment at birth.
In the following circumstances, the baby is at low risk and requires only a single dose
treatment of Benzathine Penicillin (Bicillin LA) 50 mg/kg IM at birth.
•
the mother had no syphilis serology performed during pregnancy but there is moderate
- high prevalence of syphilis in her community (e.g. remote Indigenous community). The
mother should have an RPR performed at the earliest opportunity to ensure the baby is
not at high risk
•
the mother was treated for syphilis with Penicillin during pregnancy, treatment was
completed before 36 weeks with an adequate response
•
the baby needed a lumbar puncture but the result is normal.
The baby needs no investigation or treatment if:
•
the mother had all antenatal and pregnancy bloods taken and all syphilis antibody
screens EIA or TPPA or FTA-ABS and RPR are non-reactive
•
the RPR during pregnancy and just prior to pregnancy are stable low titres
•
the mother has a documented record of past treatment.
If in doubt consult a paediatrician or infectious disease clinician. A useful reference is the
Australian Society of Infectious Diseases and the Royal Australian and New Zealand College
of Obstetricians and Gynaecologists. Phone (02) 9256 5475 or email [email protected]
Follow-up for babies
The mother needs follow-up in all cases where she may have had syphilis during pregnancy.
Babies fall into four groups for follow-up:
•
high risk with abnormal CSF - repeat RPR and lumbar puncture at six months and review
by paediatrician
•
high risk with normal CSF but confirmed Congenital Syphilis - RPR at six months and
review by paediatrician
•
high risk with normal CSF and no signs of Congenital Syphilis - follow-up the mother only
•
low risk or no treatment needed - follow-up mother only.
Client education
•
reinforce compliance with treatment
•
inform clients of childbearing age that treatment and follow-up is important
•
sexual contact should be avoided until primary chancre healed
•
•
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Contact tracing
•
contract trace according to sexual history and stage of infection
•
for primary syphilis
•
•
–
notify sexual contacts within the past three months
–
on-the-spot presumptive treatment using Early Syphilis Regimen (Regimen 1) is
recommended for all sexual contacts of primary syphilis.
for secondary/early latent syphilis
–
partner notification can extend up to two years, as sexual transmission may occur
during the first two years of infection
–
on-the-spot presumptive treatment using Early Syphilis Regimen (Regimen 1) is
recommended for all sexual contacts of secondary syphilis.
in late latent infection, if exposure >12 months prior and contact has positive serology,
treat with Regimen 2. Patients with late latent syphilis do not normally transmit the
infection.
The Queensland Syphilis Register
The Queensland Syphilis Register is a state-wide database containing serology and
treatment history of people who have positive syphilis serology recorded in accordance
with requirements of the Public Heath Act 2005. Enhanced surveillance is conducted for all
notifications. Contact 1800 032 238 to request details on serology and past treatment to aid
client management.
Follow-up4
•
follow-up serology is based on presentation, stage of infection and history
•
primary and secondary stage syphilis:
–
repeat serology at three, six and 12 months
–
discuss results of follow-up serology with a MO
–
•
after adequate treatment of early syphilis, a four-fold (two titre) drop in RPR titre should
occur over 6 -12 months. Quantitative RPR or VDRL tests should be taken at six, 12 and 24
months following treatment. If at six months the RPR has fallen by at least two titres and
is 1:16 or less, further follow-up may not be necessary unless reinfection is likely
•
re-treatment should be considered if signs/symptoms persist or recur, if there is a
sustained four-fold increase in the titre of RPR or VDRL or if the initial RPR or VDRL titre
fails to show a four-fold decrease within 12 months
•
consider reinfection or treatment failure and refer to a MO if:
–
178
after adequate treatment of early syphilis, a four-fold (two titre) drop in RPR titre
should occur over 6 - 12 months.
persistent or recurrent symptoms
–
increase in RPR titre
–
failure of RPR to show a four-fold (2 titre) decrease over 6 -12 months.
•
in cases of treatment failure, consult a doctor and consider the possibility of
immunosuppression before proceeding to lumbar puncture
•
follow-up serology is especially important for those clients treated with antibiotics other
than Penicillin. Consider risk of potential reinfection during follow-up period.
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Tinea cruris
Tinea cruris is a superficial fungal infection of the groin and adjacent skin caused by
dermatophytes which cause the skin to become red and itchy. Common etiologic agents for
tinea cruris are trichophyton rubrum and epidermophyton floccosum, while trichophyton
mentagrophytes and trichophyton verrucosum are also known to be involved55. Infection
is more common in men than women and frequently occurs in young men in association
with tinea infection of the feet32 (known as tinea pedis). Tinea cruris can be spread by close
contact, fomites and autoinoculation and is common in hot or humid climates or associated
with wearing tight-fitting or wet clothing/underwear55.
Signs / symptoms
•
macular erythematous scaling, itchy red rash in groin extending to inner thighs, and may
include buttocks, lower back and abdomen
•
edges are sharply demarked with a prominent annular rim
•
rash may have central clearance with satellite lesions
•
pustules of fungal folliculitis
•
autoinoculation from feet can sometimes occur.
Investigations
•
skin scraping (for onsite KOH wet preparation)
•
swab of area for M/C/S (if indicated)
•
exclude other causes of rash
•
Management
available):
180
•
abnormal or atypical presentation
•
uncertain diagnosis
•
clients with severe tinea cruris or suspected inflammatory component
•
•
•
Treatment
Indicators
•
•
branching hyphae and/or budding yeast identified on KOH wet preparation
•
Regimens
•
•
•
Name
Miconazole nitrate
Form
Cream
Strength
2%
Recommended dose
Apply thin layer to affected area
Route of admin
Topical
Frequency/duration
Twice a day for one month
Continue uninterrupted treatment until lesions completely healed
Pregnancy category
A
Poison schedule
S2
Contraindications
Special precautions
Reinfection
Diabetes
Superinfection
Open Lesions
Adverse reactions
Irritation, burning, skin rash and maceration
Client education
•
discuss condition, management and pre-disposing factors
•
discuss skin care and genital hygiene
•
•
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Contact tracing
Not required.
Follow-up
If there is no resolution of condition.
182
Trichomoniasis
Trichomoniasis is caused by the motile flagellated protozoan Trichomonas Vaginalis7, 32.
Infection can result in vaginitis and urethritis in females and urethritis in males. Infection is
relatively uncommon in urban Australian settings, but is prevalent in Indigenous populations
of Australia and countries such as Africa, Asia, and Latin America. Transmission is
predominately through sexual contact but perinatal transmission can also occur. Co-infection
with other STIs is common.
Signs / symptoms
Female
Symptoms can persist for years. About 10 - 50 % of females can remain asymptomatic.
•
vaginal discharge
–
copious greenish/yellow which is sometimes frothy
–
‘fishy odour’ which is more noticeable during menstruation or after sexual
intercourse
–
wet prep reveals trichomonads.
•
Vaginitis or vulvitis
•
vulval irritation
•
cervicitis (strawberry cervix)
•
dysuria
•
dyspareunia
•
sometimes minimal or no symptoms.
Male
Infection is usually asymptomatic and short-lived in comparison to female infection (i.e.
months as opposed to years).
•
dysuria
•
urethral discharge (usually scant or moderate, rarely copious or purulent)
•
urethral irritation
•
urinary frequency
•
prostatitis (rare)
•
balanoposthitis (rare).
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Investigations
There is no reliable test available for males.
Females presenting with persistent, offensive and irritating vaginal discharge should be
tested. This should be a routine part of any sexual health check in high prevalence areas
such as remote Indigenous communities. It is sometimes picked up by an incidental finding
on a pap smear. Ensure that women with a vaginal discharge have a vaginal and cervical
examination.
Vaginal
•
swab for M/C/S
•
swab for PCR
•
urine for PCR
•
wet preparation (onsite if available)
•
pH
•
whiff test.
For microscopy (wet preparation) and culture, transport using Amie’s or Stuart’s medium with
added charcoal.
•
take high vaginal swab for wet prep and culture
•
treat contacts of females with trichomonas or contacts of males with urethral symptoms
(in the absence of gonorrhoea or chlamydia) empirically for trichomonas
•
trichomonads may be seen on a pap smear, however there is a significant
•
rate of false positives. Confirm diagnosis by microscopy and culture of vaginal discharge
•
PCR test for trichomonas is only available through Queensland Health Pathology Service
on specimens from remote communities. Transport a high vaginal swab in a dry sterile
container at room temperature for PCR testing. Theoretically, when validated, the PCR
test should also allow reliable testing of first catch urine specimens for Trichomonas
Vaginalis in males and females.
•
if trichomonas is diagnosed, a full STI assessment is recommended.
Management
available):
184
•
signs of erythrasma, psoriasis, eczema or allergy
•
unresolved symptoms following treatment
•
relapse or reinfection
•
uncertain diagnosis
•
•
contraindication of treatment
•
•
•
Treatment
Indicators
•
laboratory confirmed diagnosis or positive on-site microscopy
•
clinical findings based on history and examination in endemic populations
•
contact of partner who tested positive for trichomoniasis.
Recurrent symptoms may be due to reinfection, relapse and presence of resistant
trichomonas vaginalis or presence of Candida colonisation which frequently occurs after
treatment with Metronidazole.
Regimens
•
•
consult an endorsed NP or MO.
•
Name
Metronidazole
Form
Tablet
Strength
400mg
Recommended dose
2grams
or
400mg (for continuing infection)
Route of admin
Oral take with food
Frequency/duration
2grams stat (5 x 400mg tablets)
or
400mg tablet twice daily for five days9
Pregnancy category
B2
Poison schedule
S4
Consult MO and/or Anaphylaxis management
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Contraindications
Pregnancy (first trimester)
Blood dyscrasias
Active CNS disease
Hypersensitivity to Metronidazole or other Imidazole
Special precautions
Pregnancy and lactation in second and third trimester
(Category B2)
Prolonged use
Alcoholic beverages and drugs containing alcohol may cause
flushing, vomiting or tachycardia
Adverse reactions
Super-infection
G.I disturbances
Leukopenia and Thrombocytopenia
Pancreatitis
Metallic, unpleasant taste
Interactions
Alcohol (avoid for 24hrs post treatment)
Warfarin
Cyclophosphamide
Phenytoin, phenobarbitone and other hepatic enzymeinducers
Cimetidine and other hepatic enzyme-inhibitors
Lithium
Disulfiram
Cyclosporine
5 Fluorouracil
adverse effects if given in combination with Metronidazole)
Continuing infection is generally caused by re-infection or non-compliance with treatment. If
treatment failure is suspected, use the longer course treatment regimen or consider possible
resistance to Metronidazole.
186
Or
Name
Tinidazole
Form
Tablet
Strength
500mg
Recommended dose
2grams (4 x 500mg tablets)
Route of admin
Oral with food
Frequency/duration
Stat
Pregnancy category
B3
Poison schedule
S4
Severe allergic reaction management
Anaphylaxis
Consult MO
Contraindications
Pregnancy (first trimester)
Hypersensitivity to other 5-Nitrimidazole derivatives
Blood dyscrasia
History of CNS disease
Lactation
Special precautions
Renal impairment
Pregnancy (second and third trimester) - refer to MO
Children
Avoid alcohol for 72 hours after completing dose
Adverse reactions
Superinfection
GI
Anorexia
Nausea or vomiting
Abdominal pain
Diarrhoea
Neurological (i.e. headache, dizziness, Vertigo, Ataxia)
Rash
Leukopenia
Neutropenia
Flushing, fever, tiredness
Metallic, unpleasant taste
Interactions
Alcohol
Anticoagulants
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COC user taking a short course (<3 weeks) of antibiotics should be advised to use additional
contraception (i.e. condoms) during treatment and for seven days after antibiotics have been
stopped.
Client education
•
•
Contact tracing14
Current partners evaluated and treated presumptively
Follow-up
If client remains symptomatic.
188
Urinary tract infection (UTI)
Acute uncomplicated urinary tract infections (UTI) are usually caused by a single microorganism with the commonest pathogen being Escherichia Coli32.
Less common causes include:
•
gram negative organisms i.e. pseudomonas
•
gram negative bacilli i.e. enterobacter, klebsiella or proteus
•
gram positive cocci i.e. staphylococcus, streptococcus or enterococcus.
UTI is common during pregnancy and has been associated with increased risk of
pyelonephritis, premature delivery and fetal mortality56. Group B streptococcus (GBS) is
a frequent cause of asymptomatic bacteriuria, urinary tract infection in pregnant women,
clients with diabetes or clients with weaker immune systems.
Uncomplicated UTIs are unusual in healthy young men32.
Signs / symptoms
•
urinary frequency or urgency
•
dysuria
•
hematuria
•
offensive smelling urine
•
nocturia
•
suprapubic discomfort or lower abdominal pain
•
mild back pain
•
incontinence
•
abnormal urinalysis
•
–
reveals nitrites, blood or protein and more than 1+ leucocytes
–
+/- past history of pathology confirmation of E Coli.
other important medical history
–
past history of urological surgery
–
diabetes
–
–
urinary incontinence
–
drug treatments or radiotherapy
–
pregnancy.
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Investigations
•
temperature, blood pressure and pulse
•
urinalysis
•
mid stream urine for M/C/S (as indicated)
•
first catch urine for chlamydia, gonorrhoea and trichomonas PCR
•
(as indicated)
•
perform bimanual examination to exclude mild to moderate PID
•
palpate abdomen for suprapubic, loin pain and bladder distension.
Note: Empricial treatment with antibiotics is recommended in otherwise healthy females
presenting with symptoms/signs of uncomplicated lower UTI. In females with symptoms of
vaginal itch or discharge, explore alternative diagnoses and consider pelvic examination prior
to treatment.
Urinalysis and MSU
•
urinalysis via dipstick is recommended for diagnosis of bacteria in females with limited
urinary symptoms. Empirical treatment is still indicated if symptomatic with negative
urinalysis
•
some evidence suggests MSU for M/C/S is not necessary for uncomplicated UTI in nonpregnant females, prior to initiating empirical treatment
•
MSU for M/C/S is recommended if:
–
unresponsive to syndromic management of uncomplicated UTI
–
symptoms return 2 - 4 weeks post syndromic treatment
–
history of syndromic treatment of uncomplicated UTI without MSU
–
recurrent UTI and suspicion of upper urinary tract involvement
–
the client is pregnant.
Management
available):
190
•
suspected or confirmed UTI (in males)
•
history of syndromic treatment of uncomplicated UTI without MSU
•
•
recurrent or complicated infection
•
•
•
•
•
Treatment
Indicators
Uncomplicated UTI in non-pregnant, immuno-competent women suspected or confirmed by:
•
•
laboratory confirmed diagnosis. May need to modify treatment when MSU results are
available.
Regimens
•
•
•
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Name
Trimethoprim
Form
Strength
Recommended dose
Route of admin
Frequency/duration
Tablet
300mg
300mg
Oral
Women: 300mg at night for three days11,56
or
Men: 300mg at night for 14 days11
Consult MO for suspected or confirmed UTI in men
B3
S4
Pregnancy category
Poison schedule
Contraindications
Special precautions
Adverse reactions
Interactions
192
Consult MO
Hypersensitivity to Trimethoprim
Severe renal and hepatic impairment
Severe haematological disorders
Megaloblastic anaemia due to folate deficiency/ lactation
Prolonged use
Blood dyscrasias
Folate deficiency
Pregnancy
Elderly
Superinfection
Rash, pruritus, exfoliative dermatitis
GI disturbances
Haematological changes and fever
Phenytoin
Anticoagulants
Pyrimethamine
Dapsone
Warfarin
Digoxin
Procainamide
Zidovudine
Zalcitabine
Lamivudine
Rifampicin
Cyclosporin
Diuretics
Methotrexate
ACE Inhibitors
Potassium supplements
Or
Consult a MO prior to supply and/or administration of Nitrofurantoin regimen if there is
history or clinical symptoms of renal impairment.
Avoid use of Nitrofurantoin in cases of moderate to severe renal impairment, as inadequate
urinary concentrations are achieved resulting in toxic concentrations in the plasma9.
Name
Nitrofurantoin
Form
Capsule
Strength
50mg or 100mg
Recommended dose
50mg
Route of admin
Orally (taken with food or milk)
Frequency/duration
Non-pregnant women: 50mg four times daily for five days11,12
or
Men: 50mg four times daily for 14 days11
Consult MO for suspected or confirmed UTI in men
Pregnancy category
A
Poison schedule
S4
Consult MO
Contraindications
Acidifying alkalinising drugs
Anuria
Oliguria
Severe renal impairment
Furan derivative hypersensitivity
Pregnancy (during labour and delivery or when labour
imminent)
Infant aged <1mth
Special precautions
Renal impairment acidosis
Anaemia
Diabetes Mellitus
Electrolyte imbalance
Vitamin B deficiency
Debilitating disease
History of asthma
Young males
G 6 PD deficiency
Prolonged use (monitor liver and renal function, pulmonary
condition)
Pregnancy (category A - only applies to short-term therapy)
Lactation
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Adverse Reactions
GI upset
Polyneuropathy
Haematological disturbances including haemolytic anaemia
Hypersensitivity reactions (i.e. pulmonary, rash,
dermatological, lupus-like syndrome, Anaphylaxis)
Hepatotoxicity
Brown discolouration of urine
Interactions
Acidifying alkalinising drugs
Phenobarbitone
Uricosuric drugs i.e. Probenecid, Sulfinpyrazone
Antacids
Note:
•
Nitrofurantoin is not recommended if there is history or signs of renal impairment.
Treatment is less effective and carries an increased risk of toxicity because of impaired
excretion of the drug9,11. Care should be taken with Nitrofurantoin in Indigenous
populations due to high incidence of renal impairment57.
•
Single dose therapy with Nitrofurantoin is not recommended for use as it is not as
reliable in preventing relapse as multi-dose therapy10,11.
•
COC users taking a short course (<3 weeks) of antibiotics should be
•
advised to use additional contraception such as condoms, during treatment and for
seven days after antibiotics are stopped13.
•
Using intravaginal oestrogen can help reduce recurrent UTI in post menopausal women11.
Client education
194
•
if condition improves throughout treatment still ensure the full-course of antibiotics is
completed
•
increase water intake (minimum two litres per day) and reduce intake bladder irritants
such as caffeine
•
promote correct posture for voiding to empty bladder
•
use urinary alkalinisers to help reduce dysuria, however they are not recommended when
Nitrofurantoin regimen is supplied
•
Nitrofurantoin may stain soft-gel contact lenses
•
take medication with food or liquid to minimise GI disturbance
•
sexual intercourse can contribute to recurrent UTI. Studies have shown that voiding after
sexual intercourse does not reduce incidence or prevent UTI56
•
refer to MO for discussion regarding ongoing preventative management if experiencing
three or more UTIs per year
•
discuss non-antimicrobial strategies
•
randomised trials indicate drinking 200 - 750mls of cranberry or lingonberry juice daily or
taking cranberry concentrate tablets can reduce symptomatic recurrent UTI by 10 - 20%56
•
•
Contact tracing
Not required.
Follow-up
•
review in seven days if symptoms are not resolved
•
if resistant organism, repeat mid stream urine for M/C/S or urinalysis post completion of
therapy
•
refer to MO if still symptomatic or UTI reoccurs after treatment. First discuss with a MO
as further investigations may be needed prior to referral e.g. renal function test and
ultrasound
•
review MSU results and sensitivities of any bacterial growth to determine additional
follow-up requirements
•
routine follow-up is not indicated56.
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Vaccination - Hepatitis A (HAV)
Hepatitis A is an acute infection of the liver caused by the hepatitis A virus (HAV)1. HAV is a
picornavirus [33] that is now classified as a hepatovirus1.
HAV is transmitted by the faecal-oral route by either person-to-person contact or through
contaminated food or water. The incubation period for hepatitis A is 15 to 50 days and it
is able to survive on hands and in the environment for considerable periods of time. It is
important to remember for purposes of infectivity and prevention that HAV can be excreted
in faeces for up to 2 weeks prior to onset of illness and for approximately 1 week after
presentation of illness1. The majority of infections are sub clinical and self limiting (especially
in children) and complications are rare. HAV does not result in chronic infection or chronic
liver disease7.
HAV is endemic at high prevalence rates in many developing countries with majority of the
community infected at a young age1. In developed countries risk factors include: travel to
a high prevalence country, institutional settings such as child care centres, MSM, IDU and
occasional outbreaks related to poor hygiene, food handling and contaminated water.1, 32
Vaccination against HAV should be offered to all clients assessed to be at risk factors of
infection and tested negative HAV Total Ab.
Management
•
check protocols and availability of equipment and drugs necessary for management of
anaphylaxis prior to each vaccination1
•
advise the client of risks and benefits of vaccination and preventable diseases1
•
perform a pre-vaccination assessment1
•
obtain client consent and advise that explicit verbal consent is required prior to
subsequent vaccinations regardless of whether written consent has been previously
recorded.
available):
•
prescription for HAV or combined HBV/HAV vaccine is required
•
contraindication to vaccine
•
•
•
Treatment
Regimens
•
196
refer management to a DTP–SRH, immunisation endorsed NO, endorsed NP or a MO.
•
DTP–SRH endorsed NO and immunisation endorsed NOs may progress if within scope of
practice and competence. For all other cases consult an endorsed NP or MO.
•
cases consult a MO.
Hepatitis A vaccine is not currently listed in the List of Approved Medicines20, but is an approved
vaccine for administration by an appropriately endorsed nurse.
Name
Havrix 1440 (formaldehyde inactivated Hepatitis A virus)
Age
>16years1
Form
Liquid
Strength
1440 ELISA units
Recommended dose
1.0ml
Route of admin
IMI deltoid
Frequency/duration
2 dose schedule at 0 month and repeat at 6 - 12 months
Pregnancy category
B2
Poison schedule
S4
See adverse reactions
Consult MO
Contraindications
Vaccine should not be administered to any client with
a previous anaphylactic reaction to any of the vaccine
components or a previous dose of Hepatitis A vaccine
Severe febrile illness
Never administer vaccine intravenously
Special precautions
Pregnancy, breast feeding
Thrombocytopenia or bleeding disorder
Elderly
Impaired immune responsiveness e.g. HIV positive
Post exposure prophylaxis
Adverse reactions
Mild local events of a short duration
Local soreness at injection site
Induration, redness and swelling
Headache
Malaise/fatigue or fever
Anorexia and nausea are common
Rare reactions:
Guillain-Barre Syndrome and Autoimmune Haemolytic
Anaemia
Anaphylactic reactions
Convulsions
(See full product information for less common reactions)
Interactions
Hepatitis A immune serum globulin
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Pregnancy
Pregnancy is not a contraindication to hepatitis A vaccination in clients for who it would
otherwise be indicated.13
Transport storage and handling1,40,42
•
transport vaccine according to National Vaccine Storage Guidelines
•
store in vaccine refrigerator at 20 - 80C
•
Do not freeze vaccine.
Client education
•
provide personal record card containing details of vaccination(s)
•
provide date for next vaccination
•
clients should remain onsite for observation for at least 15 minutes following vaccination
as most life threatening events begin within 10 minutes of vaccination
•
•
Contact tracing14
•
not applicable unless client has acute hepatitis A
•
if acute hepatitis A notify Public Health Unit
–
refer to MO for management
–
high priority contact tracing of sexual partners, domestic contacts, close social
contacts and food handlers is recommended for up to 50 days from onset of
symptoms
Note: A combined Hepatitis A and B vaccine is available. Refer to MO if indicated or
requested.
Follow-up
Not applicable.
198
Vaccination - Hepatitis B (HBV)
Hepatitis B infection is caused by the hepatitis B virus (HBV), a virus that contains a partially
double stranded DNA1, 32. HBV has an outer surface envelope that contains hepatitis B surface
antigen (HBsAg) and a core containing hepatis B core antigen (HBcAg). HBcAg is not detected
in the blood but excess HBsAg circulates in the blood and is used in HBV screening and
detection of infectivity. HBeAg is also produced by HBV and excreted into the blood. Presence
of HBeAg in serum along with HBsAg indicates an acute infection or ongoing increased
infectivity. Hepatitis B surface antibodies (HBsAb) are produce in response to HBsAg and
indicate immunity due to past infection or vaccination.
HBV prevalence rates varieties across the world and within some countries1, 32. It is important
to understand prevalence rates when screening and offering vaccination in order to ensure
appropriate pre test information. HBV is transmitted perinatally and in early childhood from
close contact in developing countries with high prevalence. But in developed countries
such as Australia the main mode of transmission is from adult exposure to infectious blood
or body fluids (semen, vaginal secretions) by sexual contact or percutaneous routes (e.g.
injecting drug use)1, 7.
Vaccination against HBV should be offered to the following:
•
anyone assessed to be at risk of HBV
•
anyone with HBsAb <10u/L with history of no prior completion of vaccination schedule1
•
opportunities vaccination for all clients of sexual health services
•
SIW and their partners
•
Household and sexual contacts of people who live with acute and chronic HBV as well as
•
members of families who have migrated from high prevalence countries
•
Men who have sex with men and their contacts
•
IDU and their contacts
•
Persons with chronic liver disease and/or HCV
•
Haemodialysis clients, HIV-positive clients and other immunosuppressed clients
•
Health-care workers
•
Recipients of blood/blood products, persons who have sustained a needle stick injury,
sexual
•
assault victims, and persons from areas of endemic Hepatitis B infection7
•
Other at risk groups as outlined in NHMRC (Current Version) The Australian Immunisation
Handbook
Management
•
check protocols and availability of equipment and drugs necessary for management of
anaphylaxis before each vaccination1 as per The Australian Immunisation Handbook and
DTP-SRH
SECTION 4
2010
199
•
advise the client of risks and benefits of vaccination and preventable diseases as per The
Australian Immunisation Handbook1 and refer to the handbook for further detailed advice
re immunosuppression, scheduling, etc.
•
perform a pre-vaccination assessment1
•
obtain client consent and advise that explicit verbal consent is required prior to
subsequent vaccinations regardless of whether written consent has been previously
recorded.
available):
•
prescription for HBV or combined HBV/HAV vaccine is required
•
contraindication to vaccination
•
•
•
Treatment
Regimens
200
•
refer management to a DTP–SRH, immunisation endorsed NO, endorsed NP or a MO.
•
DTP–SRH endorsed NO and immunisation endorsed NOs may progress if within scope of
practice and competence. For all other cases consult an endorsed NP or MO.
•
cases consult a MO.
Name
HB Vax ll (Adult) (Recombinant DNA Hepatitis B vaccine)
Age
Adult (over 20 years of age)
Form
Suspension
Strength
10 microgram in 1.0ml
Recommended dose
3 x 10 microgram /1.0ml
Route of admin
Frequency/duration
3 Dose Schedule: Stat, 1month, 6 months
Pregnancy category
B2
Poison schedule
S4
Emergency
management
See adverse reactions/emergency conditions - Anaphylaxis
Contraindications
Vaccine should not be administered to any client with a previous
anaphylactic reaction to any of the vaccine components or a
previous dose of Hepatitis B vaccine.
Consult MO
Severe febrile illness >38.50C (postpone administration)
Special precautions
Never administer Hepatitis B vaccine intravenously
Do not administer in the gluteal region or intradermally/
subcutaneously since these routes may not result in optimum
immune response
Impaired immune responsiveness in those receiving
immunosuppressive therapy
Severely compromised cardiopulmonary status
Coagulation disorder
Adverse reactions
Common:
Soreness at injection site, induration, erythema, swelling,
fatigue, headache, fever (usually low grade), nausea, dizziness,
myalgia and arthralgia
Rare:
Anaphylaxis, demyelinating disease, Guillain-Barre Syndrome
and Arthritis
Interactions
Inter-changeability of vaccines. Although switching brands is
not recommended, in cases where the brand of the vaccine
used for previous doses is not known, any brand may be used
as there is no reason to believe that use of a different brand will
compromise immunogenicity or safety
Do not mix in the same syringe with other vaccines
No data available.
SECTION 4
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201
Or
Name
HB Vax II (paediatric) (Recombinant DNA Hepatitis B
vaccine)
Age
Children and young adults aged up to 20yrs
Form
Suspension
Strength
5 microgram in 0.5ml
Recommended dose
3 x 5 microgram/0.5ml regimen
Route of admin
Intramuscular injection. For administration to a child, refer
to ‘Standard Techniques’ in NHMRC (current version) - The
Australian Immunisation Handbook
Frequency/duration
3 dose schedule: Stat, 1mth, 6mths
Pregnancy category
B2
Poison schedule
S4
See allergic reactions/emergency conditions - Anaphylaxis
Consult MO
Or
Name
Engerix B (adult) (Recombinant DNA Hepatitis B vaccine)
Age
Adult (over 20 years of age)
Form
Suspension
Strength
20 microgram in 1ml
Recommended dose
3 x 20 microgram /1ml regime
Route of administration
Frequency/duration
3 dose schedule: Stat, 1mth, 6mths
Pregnancy category
B2
Poison schedule
S4
See allergic reactions/emergency conditions- Anaphylaxis
Consult MO
202
Or
Name
Engerix B (Paediatric) (Recombinant DNA Hepatitis B vaccine)
Age
Children and young adults aged up to 20yrs
Form
Suspension
Strength
Paediatric 10 microgram in 0.5ml
Recommended dose
3 x 10 microgram in 0.5ml
Route of admin
Frequency/duration
3 dose schedule: Stat, 1month, 6 months
Pregnancy category
B2
Poison schedule
S4
Anaphylaxis
Consult MO
Alternate two-dose regimens for adolescents (aged 11 – 15 yrs)1
Research indicates that adolescents (aged 11 - 15) vaccinated with HB Vax II 10 microgram
(adult formula) in a two-dose regimen of 0 and 4 - 6 months, develop similar antibody
protection as those vaccinated with the standard three-dose paediatric regimen.
Refer to NHMRC (current version) - The Australian Immunisation Handbook for further
information on hepatitis B Alternate 2-dose regimen and hepatitis B catch-up vaccines.
Accelerated schedule1
In circumstances where rapid protection is required (e.g. vaccination of travellers) there are
two available regimens:
•
Engerix B (adult) 20mg per ml can be administered in an accelerated schedule of 0, 7 and
21 days with a booster at 12 months
•
Engerix B (adult) 20mg per ml at 0, 1, 2 and 12 months.
Pregnancy1
Pregnancy is not a contraindication to hepatitis B vaccination in clients for who it would
otherwise be indicated. 1
Transport, storage and handling1,40,42
•
store in vaccine refrigerator at 20 - 80C
•
do not freeze vaccine.
SECTION 4
2010
203
Client education
•
provide personal record card containing details of vaccination(s)
•
provide date for next vaccination
•
clients should remain onsite for observation for at least 15 minutes following vaccination
as most life threatening events begin within 10 minutes of vaccination
•
•
Contact tracing14
•
not required unless client has acute hepatitis B
•
if acute hepatitis B
–
refer to MO for management
–
high priority contact tracing of sexual partners, domestic contacts and people who
inject drugs is recommended for up to 180 days prior to index case developing
symptoms. If index is asymptomatic, trace according to history.
Follow-up
Post vaccination serological testing (HbsAb) is recommended at four weeks after the third
dose of hepatitis B. This is for high risk clients:
204
•
at significant occupational risk
•
at risk of severe or complicated disease, either immunocompromised or with pre-existing
liver disease not related to hepatitis B
•
in whom a poor response to hepatitis B vaccination is expected
e.g. immunocompromised clients with HIV infection or chronic renal failure
•
who are persistent non-responders. They should be informed about the need for
hepatitis B immunoglobulin to be administered within 72 hours of parenteral exposure to
HBV or 14 days of sexual exposure.1,43 - 46
Vaccination – HPV
There are more than 100 genotypes of Human papilloma virus (HPV) with more than 30 that
are known to infect the external and internal anogenital area and may present as genital
warts7. The most common genotype that cause genital warts on the skin are Type 6 and
11, high risk HPV types (16, 18, 31, 33, 35) are strongly associated with cervical changes,
neoplasias7 and other oncogenic anogenital infections. Majority of anogenital HPV infections
are asymptomatic, unrecognised or subclinical in presentation7. The majority of HPV
infections are believed to spontaneously regress but infections can persist32. A persistent
infection with high risk HPV types is the most predictive factor in progression to squamous
intraepithelial neoplasia7, 32. HPV vaccination is designed to help prevent infection with
specific HPV genotypes and protect against persistent infection.
Offer vaccination for:
•
risk of HPV infection
•
prevention of cervical, vulvar, vaginal cancer, precancerous or dysplastic lesions, genital
warts, infection caused by HPV types 6, 11, 16, 18 in females 9-26 yrs and prevention of
infection caused by HPV types 6, 11, 16, 18 in males 9-15 yrs.
Note:
•
pre-vaccination HPV screening is not recommended
•
vaccination for HPV should not occur in isolation. Discuss pap smear and additional STI
screening with client.
National HPV Vaccination Program39
The Australian Government is funding the Human Papillomavirus (HPV) vaccine Gardasil® to
girls aged 12 and 13 years, through a school-based program, on an ongoing basis as part of
the National Immunisation Program.
Note:
•
HPV vaccine is registered for males aged 9 - 15 years, however it is not funded for males
under the National HPV Vaccination Program39
•
HPV vaccine is not approved for use in females aged < 9 and is registered but not funded
for women > 26 years or males aged < 9 or > 15 years.
Regimens
•
refer to a DTP–SRH or immunisation endorsed NO, endorsed NP or MO.
•
DTP–SRH or immunisation endorsed NO may progress if within scope of practice and
competence. For all other cases consult an endorsed NP or MO.
•
cases consult a MO.
SECTION 4
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205
Name
Human papillomavirus quadrivalent (types 6, 11, 16, 18)
recombinant vaccine - Gardasil®
Age
9 – 26 years (female only)
Form
Suspension
Strength
120 micrograms / 0.5 ml
Recommended dose
0.5ml
Route of admin
Administer in deltoid region of upper arm or higher
anterolateral area of thigh
206
Frequency/duration
3 dose schedule: 0, 2 month, 6 months
Pregnancy category
B2
Poison schedule
S4
See allergic reactions/emergency conditions- Anaphylaxis
(consult MO)
Contraindications
Hypersensitivity to active substances or any components of
the vaccine (including yeast, aluminium phosphate, sodium
chloride, L-histidine, polysorbate and sodium borate)
Hypersensitivity after previous Gardasil doses
Severe febrile illness >38.50C (postpone administration)
IV administration
Moderate to sever febrile illness
Pregnancy
Elderly
Special precautions
Non-HPV related genital ulcer disease/infection
Disease caused by non-vaccine HPV types
Continue routine cervical screening, detection, removal of
lesions after vaccine
Current, recent febrile illness
Impaired immune responsiveness e.g. genetic defect,
immunosuppressive, HIV
Thrombocytopenia, coagulation disorders
Pregnancy
Children <9 yrs
Adverse reactions
Injection site reaction
Fever
Bronchospasm (very rare)
Interactions
Immunosuppressants e.g. systemic corticosteroids,
antimetabolites, alkylating agents, cytotoxics
Observe client for at least 15 minutes after vaccination. Missed or late doses
•
Quadrivalent HPV vaccine has shown to be effective if all three doses are administered
within 12 months
•
if three doses cannot be completed within 12 months it is not recommended to restart
the course
•
missed doses should be administered as soon as possible.39
Accelerated dose
If a shorter vaccination schedule is necessary:
•
administer the second dose at least one month after the first dose
•
administer the third dose at least three months after the second dose.
Booster doses
•
protective immunity demonstrated for five years
•
no indication currently for boosters.39
Pregnancy
•
do not administer Quadrivalent HPV during pregnancy, however it can be administered to
clients who are lactating40 - 41
Interaction with hepatitis B vaccine
•
Quadrivalent HPV vaccine can be administered concurrently with hepatitis B
(recombinant) vaccine12, 40
•
immune response and safety profile equivalent to vaccine administered separately.
Transport, storage and handling41 - 42
•
transport and store in accordance with the National Vaccine Storage Guidelines
•
store in vaccine refrigerator at 20 - 80C.
•
do not freeze vaccine.
The National Human Papillomavirus (HPV) Vaccination Program Register
The Australian Government has developed a national HPV register which collects confidential
data to evaluate the impact of the HPV vaccination program against cervical cancer rates,
issues reminders to complete vaccination course, issues certificate of completion and
provides a mechanism to contact recipients if a booster is required at a later date.
Vaccinated females aged 18 - 26 years are not required to provide their details, but can elect
to have their details included in the HPV register. Information is collected on a consent form
at time of vaccination, then forwarded to the HPV register.
SECTION 4
2010
207
Visit www.hpvregister.org.au for more information about the National Human Papillomavirus
(HPV) Vaccination Program Register or phone 1800 478 734.
Client education
•
clients should remain on site for observation for at least 15 minutes following vaccination
•
provide personal record card containing details of vaccination(s) and date of next
vaccination
•
reinforce importance of completing vaccination regimen
•
provide details of available recall systems to improve immunisation rates
•
advise about the HPV register, which is designed to monitor and evaluate
the impact of HPV vaccination on cervical cancer rates www.access.health.
qld.gov.au/hid/InfectionsandParasites/ImmunisationandVaccination/
nationalHumanPapillomavirusHpvVaccinationProgramRegister_ap.asp
•
obtain informed consent from the client to include their details on the HPV Register. A
Medicare card number is required for registration.
Contact tracing
•
Not applicable.
Follow-up
208
•
follow-up clients during and after treatment and treat relapses as original lesions
•
HPV changes on a pap smear should be managed according to the NHMRC Guidelines on
Management of Abnormal Smears 4
•
recommend routine pap smears.
References
1. NHMRC (current version)
The Australian Immunisation Handbook
2. J.D Sobel, R.L. Barbieri and V.A. Barss, 2008
Bacterial Vaginosis
3. Queensland Health, CD Branch, 2006
Queensland Management Guidelines for the Detection and Treatment of Sexually Transmissible Diseases and
Genital Infections
4. J Ross and C Ison, 2006
Sexually Transmitted Infections: UK national screening and testing guidelines for sexually transmitted infections.
BMJ, (Supp 4)
5. Journal of Internal medicine, P Carr, et al., 2005
“Shotgun” Versus Sequential testing: Cost Effectiveness of Diagnostic Strategies for Vaginitis (20:p793-799)
6. Anderson, M., K. Klink, and A. Cohrssen
Evaluation of Vaginal Complaints. JAMA, 2004. 291(11): p. p1368-1379.
7. Centres for Disease Control and Prevention, 2006
Sexually Transmitted Diseases Treatment Guidelines - Morbidity and Mortality Weekly Report (Volume 55: no
RR-11)
8. Australian Medicines Handbook Editorial Advisory Board, Jan 2007
Australian Medicines Handbook (electronic version)
9.Australian Medicines Handbook Editorial Advisory Board,
Australian Medicines Handbook (electronic version) - current edition
10.Queensland Health, QHEPS Clinicians Knowledge Network site, 2006
Therapeutic Guidelines Limited, Antibiotics
11.Antibiotic Expert Group
Therapeutic Guidelines: Antibiotics,
Therapeutic Guidelines Limited: Melbourne, Editor. Current eTG Version,
12.MIMS, 2009
13. MIMS Annual/On-line
14. Sexual Health and Family Planning Australia, Ashfield,
Contraception: An Australian Clinical Practice Handbook (2nd edition)
15.Australasian Society for HIV Medicine, 2006
Australasian Contact Tracing Manual (3rd Edition)
16. RoyalAdelaide Hospital, 2007
Sexually Transmissible Disease Service (website)
17. eMedicine, 2007
Balanoposthitis
Editor, Osipov, V.O
18. British Association for Sexual Health and HIV, 2008
UK National Guideline on the Management of Balanitis
19.Kauffman, C.A., K.A. Marr, and A.R. Thorner, 2007
Overview of Candida infections
20.Weintrob, A.C., et al., 2006
Susceptibility to infections in persons with diabetes mellitus
SECTION 4
2010
209
21Queensland Health, Clinical and Statewide Services Division (CaSS), 1 February 2010
List of Approved Medicines (LAM)
22Control of Communicable Disease Manual (19th Edition), 2008
D. Heymann
23Department of Health (WA), C.D.C.D.H.P. Group, 2006
Guidelines for Managing Sexually Transmitted Infections
National Guideline for the Management of Chancroid.
Clinical Effectiveness Group (Association for Genitourinary Medicine and the Medical Society for the Study of
Venereal Diseases). (cited)
http://www.bashh.org/guidelines.asp#guides.
25Royal Children’s Hospital Melbourne, 2002
Paediatric Pharmacopoeia (13th edition- p52)
Mayne Pharma, 2006
Ceftriaxone Product Information (Version 3.0)
26. World Health Organisation, 2003
Guidelines for the Management of Sexually transmitted Infections
27.CARPA, 2006
Protocol for alternate use of pan benzathine Penicillin where Bicillin LA is not available
28.Public Health Agency of Canada, 17 May 2005
Protocol for the Preparation of Benzathine Penicillin
29.Eyre, R.C., M.P. O’Leary, and D.M. Rind, 2007
Evaluation of the acute scrotum in adults
30.IP Communication Melbourne, 2005
Penile, epididymal, and testicular conditions in Sexual Health Medicine Aitken, S., D. Russell, D. Bradford, and C.
Fairley, Editors.
31.Queensland Health & Royal Flying Doctor Service (Queensland), 2007
Primary Clinical Care Manual (4th Edition)
32.IP Communication, 2005
Sexual Health Medicine
Russell, D., Bradford. D., and Fairley, C.
33.Micromedex Healthcare series, 2006
DRUGEX Trichloroacetic Acid
Thomson
34.The eMedicine Clinical Knowledge Base, 2008
Condyloma Acuminatum
Higgins, R.V
United Kingdom National Guideline on the Management of Anogenital Warts. Clinical Effectiveness Group
(British Association for Sexual Health and HIV)
36.International Journal of STD and AIDS, 2007
Comparison of the effectiveness of commonly used clinic based treatments for external genital warts. 18(6):
p365 - 368
Sherrard, J. and L. Riddell
37.Dermatology online Journal, 2006.
An evidence-based review of medical and surgical treatments of genital warts. 12(3): p5
Scheinfeld, N. and D.S. Lehman
38.Micromedex Healthcare series, 2007
210
DRUGEX Lidocaine/Prilocaine
Thomson
39.Sexual Health Society of Victoria
National Management Guidelines for Sexually Transmissible Infections
40.Australian Government, updated August 2009
The National HPV Vaccine Program
http://www.health.gov.au/internet/standby/publishing.nsf/Content/home
41.Australian Family Physician, 2007
HPV vaccination: A paradigm shift in public health, 36(3): p106-111
May, J
42.National Centre for Immunisation Research and Surveillance (NCIRS), updated September 2006
Human Papilloma Vaccines for Australians: Information for GPS and Immunisation Providers
43.Commonwealth Australia, 2005
National Vaccine Storage Guidelines: Strive for 5 (Immunise Australia Program)
www.health.gov.au/internet/immunise/publishing.nsf/Content/provider-store
44.British Association of Sexual Health and HIV Clinical Effectiveness Group, 2005
United Kingdom National Guideline on the Management of the Viral Hepatitides A, B & C
BASHH Clinical Effectiveness Guidelines
45.Royal Adelaide Hospital, 2005
Diagnosis and Management of STDs (including HIV infection)
46.World Health Organisation, Department of Communicable Disease Surveillance and Response, 2002
Hepatitis B
47.Queensland Health, 2006
Queensland Health Policy for Hepatitis B Immunisation
48.Australian Family Physician, 2009, 38 (6), 388-393)
Lesbian and bisexual women’s sexual health
McNair, R.
49.McGraw, New York, 2008
Sexually Transmitted Diseases (4th edition)
Holmes K.K, Sparling P.F, Mardh P.A, Lemon S.M, Stamm W.E, Piot P. & Wasserheit J.N
50.Sexual Health, 2006
Lymphogranuloma Venereum in Australia.
Sims, I. et al
51Sexually Transmitted Infections (2nd Ed.), 2000
McMillan, A. and Scott, G.R.
52.Mayne-Pharma, 2006
Ceftriaxone Product Information, version 3.0
53.Paediatric Pharmocopoeia, (13th Ed), 2002, p. 52
Royal Children’s Hospital Melbourne
54.Treatment of pelvic inflammatory disease, 2008
Hynes, N.A
55.Tinea Cruris, eMedicine, December 2009
Wiederkehr, M. and Schwartz, R.A.
56.BMJ, 2006. 332, 94-97
Urinary tract infections in women: diagnosis and management in primary care.
57.eMJA, 2002. 176 (11), 515-516
Kidney disease: Are you at risk?
Cass, A.
SECTION 4
2010
211
58.HIV management in Australasia: a guide for clinical care.
Australasian Society of HIV Medicine, 2009
59.HIV, viral hepatitis and STIs: a guide for primary care.
Australasian Society of HIV Medicine, 2008
60.National HIV Testing Policy 2006
Department of Health and Ageing
212

Section 4: treatment and management

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