Chapter 57: Sexually Transmitted Infection Drug Therapy

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Welcome back to the Deep Dive.

Today we are tackling a subject that is, well, it's absolutely critical for anyone heading into the healthcare field, specifically nursing.

But honestly, it's knowledge that shapes public health on a massive scale.

We're diving into chapter 57 of pharmacology, a patient -centered nursing process approach.

It's good to be here.

And you are so right.

This is a heavy chapter.

We're looking at sexually transmitted infections or STIs.

And before we even get into the, you know, the weeds of the pharmacology, I think we have to acknowledge the weight of this topic.

Oh, absolutely.

It's heavy.

It's uncomfortable for some people to talk about for sure.

There's stigma.

So much stigma and embarrassment and just a lot of misinformation out there.

But our mission today is really to cut through all of that.

Exactly.

We need to strip away the judgment and just look at the biology and the chemistry because if we don't, patients get hurt.

Our goal is to master the pharmacology and the nursing implications of STIs.

And yes, the text is dense.

I mean, it's packed with drug regimens, dosages, and some pretty uncomfortable topics.

It is.

But it is absolutely essential for patient safety.

And just to set the stage, this isn't just about memorizing a list of bugs and drugs.

I mean, yes, we are going to do that.

We have to.

We have to master the pharmacology.

But the stakes here are so incredibly high.

When I was reading through the source material, the numbers just, they just jump off the page.

They are staggering.

Okay.

And when you look at the source material, specifically the data provided in the text, we're seeing over one million new STI cases.

One million?

Every single day worldwide.

That number blew my mind.

One million a day.

That's like a city the size of San Jose or Austin, Texas, getting infected every single day.

It really puts it into perspective, doesn't it?

It does.

And if we look specifically at the CDC data that's provided in the text, the trend lines are, they're worrying.

Going the wrong way.

Exactly.

Between 2016 and 2020, there was an 11 % increase in STIs.

So despite all our medical advancements, despite all the public health campaigns, the numbers are climbing.

And I think the assumption is often that this is just a young person problem.

College campuses, young adults figuring things out.

And sure, young adults are a high -risk group, but the text specifically points out that male infections are rising across the board.

Right.

And later on, we're actually going to talk about a demographic you might not expect, older adults.

Oh, interesting.

We see spikes in populations that most people assume have sort of aged out of these risks.

So our roadmap for today is pretty clear.

We're going to walk through this chapter linearly, just like the nursing students listening to this have to do.

Yeah.

We'll start with a pathology, how these infections actually happen.

The how is just as important as the what.

Okay.

Then we need to go through the bacterial pathogens, you know, the big ones, chlamydia, gonorrhea, and syphilis.

And I noticed the drug protocols for those have changed recently.

They have.

The 2021 guidelines are in here, and they're significantly different from what people might have learned even five years ago.

That's a huge point.

It is.

If you're practicing with old information, you are mistreating your patients.

It's that simple.

Then we'll move to the viral pathogens, herpes, HIV, HPV.

And that's where the focus really shifts from cure to management.

Which is a huge psychological shift for the patient and for the nurse counseling them.

Then we'll touch on the parasitic infections, which are, well, uncomfortable is a polite way to put it.

The things that crawl.

Exactly.

But they are treatable, which is the good news.

And finally, we have to land on the nursing process.

How do you actually talk to patients about this?

Because you can know all the drugs in the world.

But if you can't get the information from the patient.

If you can't ask the right questions, you'll miss the diagnosis entirely.

So quick tone check before we start.

This is a judgment free zone.

The text emphasizes this and we're emphasizing it.

Our job here is factual pharmacology and patient safety.

Absolutely.

The bacteria don't judge.

They don't care about your morals, your marriage or your history.

They just need an entry point.

They just want to host.

And the nurse shouldn't judge either.

OK, let's unpack the landscape of transmission.

How do these infections actually get in?

The text mentions something called microfissures, and I feel like this is a detail that really changes how you visualize the whole infection process.

This is a really important physiological detail.

I'm glad you brought it up.

It explains why transmission is so common.

So what's happening on that microstopic level?

Well, pathogens enter through breaks in the mucosal linings, the vagina, the cervix, the penis, the rectum.

But when we say breaks, people imagine a big cut or a wound.

Right.

Like an open sore or something obvious.

But it's not just about open wounds.

The text explains that every act of coitus creates tiny friction -induced fissures.

Every single time.

Every time.

You can't see them with the naked eye.

They're microscopic.

But they are there.

So simply, the act of sex itself creates the doorway for the bacteria or the virus.

Precisely.

These microfissures act as entry points.

It just disrupts that physical barrier that keeps the outside world out and the inside world in.

And the text notes that anal penetration is particularly risky in this context.

It is.

Why is that specifically?

What's the mechanism there?

There are a couple of reasons.

First, the tissue there is thinner and less elastic than, say, the vagina.

So it's more prone to trauma.

So bigger fissures, more of them.

Exactly.

More and larger entry points.

But second, you have the added factor of enteric microorganisms.

Bacteria from the gut.

Right.

Bacteria from the gut being introduced to the partner.

So you have a higher bacterial load meeting a more compromised barrier.

It's a double whammy, really.

That makes total sense.

And then you layer on the behavioral risk factors.

Multiple partners seems to be the biggest multiplier of risk.

It is, by far.

The CDC data shows a marked increase in risk for individuals with more than one partner per year.

And there's a staggering stat in there.

What is it?

21 .8 % of males and 10 .6 % of females between 15 and 44 report having 15 or more sexual partners in their lifetime.

Wow.

15 or more.

That really highlights why the spread can just happen so fast within a community.

It does.

And from a pharmacological perspective, this leads us to something the text calls the multiple infection rule.

The multiple infection rule.

OK.

Unpack that for us.

What does that mean for a nurse on the floor?

It means if a patient comes in with one STI, you can't just treat that one and call it a day.

You have to assume there could be others.

You most assume they might have others.

They share the same transmission routes and the same risk factors.

It's just logical.

So if you find gonorrhea, you look for chlamydia.

Always.

Every time.

And the text is very specific.

If there are genital ulcers, like from syphilis or herpes, you especially need to test for HIV.

Why the specific link with ulcers?

Because that ulcer is a massive open entry point for the HIV virus.

It's like rolling out the red carpet.

The risk of transmission skyrockets.

Speaking of testing and tracking, we have the reportable diseases.

These are the ones where the government says, hey, we need to know about this.

Who are the big five?

The big five nationally notifiable STIs are chlamydia, gonorrhea, syphilis, chancroid, and HIV.

And what happens when a nurse reports these?

Is it just for, you know, a spreadsheet somewhere in an office?

Not at all.

It's for public health intervention.

These get reported to local and state health departments to track outbreaks.

So they can see clusters.

Exactly.

But it also triggers what's called partner services.

The health department can help notify partners that they've been exposed, often anonymously.

Oh, that's a huge service.

It's critical.

It helps break that chain of transmission.

Before we get into the specific drugs, there's one more transmission route we have to cover.

And it's arguably the most tragic,

vertical transmission.

This is mother to neonate transmission.

This is where pharmacology becomes about protecting the most vulnerable patient possible.

So how does it happen?

What are the routes?

Well, it can happen through the placenta while the baby is still in the womb.

Syphilis is notorious for this.

It can happen during passage through the birth canal, which is a huge risk for herpes simplex virus and gonorrhea.

Or it can happen through breast milk, like with HIV.

And there's a standard protocol for this, right?

It's done within the first hour of birth for every baby.

I think parents see the nurse doing this and don't always realize why it's happening.

Yes.

This is a standard preventive pharmacology intervention.

We administer erythromycin, ophthalmic ointment, into the eyes of all neonates.

That's the greasy eye look that newborns have.

That's the one.

And this is specifically to prevent blindness caused by Chlamydia trichomatis and Neisseria gonorrhea.

Blindness.

Yes, permanent blindness.

The baby might pick it up in the birth canal.

And these bacteria can destroy eye tissue incredibly fast.

So we treat prophylactically immediately.

So you don't wait for a test result?

Never.

You just protect the eyes.

It's a non -negotiable standard of care.

Okay, let's dive into the specific conditions.

We're starting with something that isn't technically an STI, but the text calls it a precursor or a risk factor.

Bacterial vaginosis or BV?

Right.

BV is interesting because it's a dysbiosis.

Dysbiosis?

That sounds like something out of a sci -fi movie.

What does it mean?

It essentially means an ecosystem collapse.

It's not an invasion from an outside enemy per se, but a replacement from within.

So the balance gets thrown off.

Exactly.

The healthy vagina is dominated by lactobacilli.

These are the good guys.

They keep the pH acidic and hostile to other bugs.

In BV, those good guys get wiped out or reduced.

And something else takes over.

Right.

They're replaced by anaerobic bacteria like Gardnerella vaginalis.

So the neighborhood changes.

The bad neighbors move in and they're thrown a party.

And the symptoms are pretty distinct from what the text says.

Yes.

The classic presentation is a homogenous, thin, white discharge.

But the hallmark is the odor.

It has a very distinct fishy odor, especially after intercourse.

Okay, pharmacology time.

How do we treat it?

The text focuses on a class called the nitroimidazoles.

Specifically, metronidazole.

The standard dosage is 500 mg orally, twice a day for seven days.

They can also use a vaginal gel form.

Now, if you are the nurse handing this prescription to a patient, there is one instruction that is arguably more important than the dosage itself.

I feel like this is a classic exam question, but also a critical, critical safety point.

The alcohol warning.

The alcohol warning.

Let's scream this from the rooftops.

We have to.

This is critical.

Metronidazole can cause a disulfiram -like reaction.

Can you drink that down?

What does a disulfiram -like reaction actually look like for the patient?

Because if we just say, don't drink, they might think, oh, I'll just get a little extra tipsy.

No, no.

It's not about getting tipsy.

It is violent.

We are talking severe nausea, projectile vomiting, flushing of the face and chest, palpitations, chest pain, difficulty breathing.

Wow.

It feels like you are having a heart attack or dying.

It happens because the drug stops the body from breaking down alcohol properly, which leads to a buildup of a very toxic byproduct.

And we aren't just talking about a glass of wine or a beer, are we?

No.

We have to be detectives about hidden alcohol.

The text specifically mentions mouthwash.

Yes.

Mouthwash, cough syrups, some vanilla extracts used in uncooked foods, even hand sanitizer if they accidentally ingest it.

So the rule is what, exactly?

The rule is strict.

No alcohol during treatment and for 48 hours after the treatment ends.

Why the 48 hours after?

That's a key detail.

You have to give the drug time to fully clear the system.

If they have a celebratory drink the night they finish their pills, they can still end up in the ER.

That's a huge clinical pearl.

You have to explain that clearly because patients won't intuitively think that their morning mouthwash could make them vomit all day.

Not at all.

Are there alternatives if someone really can't take metronidazole?

Yes.

Clendamycin cream is an option.

It's an antibiotic cream you insert vaginally, but,

and here is another safety alert that the text highlights, clendamycin cream is oil -based.

Why does the oil -based matter?

Is it just messy?

It's not about messiness.

It's about physics.

Oil weakens latex.

Ah.

So if a patient is using clendamycin cream, any latex, condoms, or diaphragms they might use could be compromised for three to seven days after use.

So you're treating a vaginal infection, but if they have sex using a condom for protection, that condom might dissolve or tear.

Exactly.

Leading to an unintended pregnancy or another STI, it's a domino effect of risk.

It's these little details that make nursing so complex.

You fix one thing, you have to be so careful not to break another.

What about in pregnancy?

BV is risky for pregnancy, isn't it?

Extremely.

It is clearly linked to preterm delivery and low birth weight, so treating it is critical.

Are the drugs safe?

Metronidazole and clendamycin are generally considered safe for use in pregnancy.

But there is another drug, pinidazole, which is similar to metronidazole.

That one is avoided in the first trimester.

Got it.

Okay, moving on to the heavy hitters now, let's talk about the silent infection, chlamydia.

Chlamydia trachomatis.

And it is the most common STI in young adults.

And why do we call it silent?

Because it is most often asymptomatic, maybe 75 % of the time in women.

Most people have zero idea they are carrying it.

Which is terrifying, because if you don't know you have it, you don't treat it, and the bacteria just hangs out and causes damage over time.

Exactly.

In females, untreated chlamydia can migrate upward from the cervix.

It moves into the uterus and the fallopian tubes and causes Pelvic Inflammatory Disease, or PID.

And PID isn't just a simple infection, it's a scarring process, right?

It is a scarring process.

It scars the tubes.

This leads to ectopic pregnancy, where the pregnancy implants in the tube instead of the uterus, which is a life -threatening emergency.

Oh, infertility.

Or permanent infertility.

That's why the guidelines recommend annual screening for all sexually active females under 25.

You have to go looking for it because it won't announce itself.

Now, the treatment guidelines for chlamydia have changed.

This is a big deal.

I feel like for years, everyone just said, isithromycin, one dose, you're done.

It was the convenient option.

It was.

But the text highlights the 2021 CDC update, and that's not the case anymore.

No.

The landscape has shifted.

The primary first -line treatment is now doxycycline.

Okay, doxycycline.

The dosage is 100 mg orally, twice a day for seven days.

So why the change from the easy one -dose isithromycin?

Why make it harder for the patient to be compliant?

It all comes down to effectiveness.

The data showed that isithromycin wasn't doing a good enough job clearing rectal chlamydia specifically.

Ah!

And since we treat the whole patient, and rectal colon infection is common even from vaginal sex, we need a drug that works everywhere.

Doxycycline just has better cure rates across all sites.

So isithromycin is completely out?

Not completely out, but it's been downgraded.

The isithromycin 1 gram single dose is now listed as an alternative alongside another antibiotic levoflaxacin, but doxycycline is the new go -to.

But, and this is a big but, we can't give doxycycline to everyone.

There is a specific population where doxy is a hard no.

Correct.

Doxycycline is a tetracycline antibiotic.

It is absolutely contraindicated in the second and third trimesters of pregnancy.

Why?

What does it do to the fetus?

It has a high affinity for calcium, so it gets into the developing fetal system and to calcium in the bones and teeth.

What does that look like?

It causes permanent discoloration of the teeth.

They can turn gray or yellow -brown, and it could actually inhibit long bone growth.

So you could literally affect the skeletal structure of the baby.

Exactly.

So if your patient is pregnant, you hit a hard stop sign with doxycycline.

It's a teratogen in this context.

So what's the pregnancy protocol then?

We still have to treat the chlamydia.

It's dangerous for the baby too.

Right.

In that case, we go back to isithromycin.

The one gram single dose.

Or we can use amoxicillin.

Those are safe for the fetus.

And for patient education, we've treated the patient, they have their pills.

What are the key points we have to tell them?

First, abstain from sex for seven days after treatment is complete.

You need to let the antibiotics work and the infection clear.

And the partner.

And this is often the hard part for patients.

You have to treat all partners from the last 60 days.

60 days?

That's a two month look back.

That can be a really tough conversation to have.

It is, but it's non -negotiable from a public health standpoint.

If you don't treat the partner, the patient just gets reinfected the next time they have sex.

The ping pong effect.

The ping pong effect.

Exactly.

Back and forth.

Okay.

Let's slide right into its partner in crime.

Gonorrhea.

The clap.

Nasiria gonorrhea.

The text calls this one the resistance battle.

That sounds ominous.

It really is.

Gonorrhea is smart.

I mean, as far as bacteria go, it evolves incredibly fast.

It's developed resistance to almost every single antibiotic we've ever thrown at it over the decades.

Like what?

Sulfonamides.

Penicillins.

Tetracyclins.

Fluoroquinolones.

It has beaten them all at some point.

That is genuinely scary.

It's like a superbug in the making.

What are the symptoms?

How does it present?

In males, it's usually quite obvious.

They get a profuse greenish -yellow discharge and burning urination.

It hurts.

They usually seek help early because the symptoms are just impossible to ignore.

And in females, I'm guessing it's a different story?

Often asymptomatic, just like chlamydia.

Or the symptoms are mild and get misstated for a bladder infection or a yeast infection.

So again, the risk is PID and infertility because the diagnosis gets delayed.

Exactly.

The damage is done before she even knows she's sick.

And there's a pharyngeal version, too.

From oral sex?

Yes.

Oral sex can lead to pharyngeal gonorrhea.

And it looks just like strep throat.

Redness, sore throat, puts pockets on the tonsils.

So if a patient comes in with a sore throat that just won't go away and they're sexually active?

You have to swab for gonorrhea, not just strep.

It's a common miss.

So how do we kill this resistant bug?

The guidelines have changed here, too.

I remember hearing about dual therapy, giving two drugs at once.

We used to do that.

For years, it was ceftriaxone plus azithromycin.

The idea was to hit it with two different mechanisms to prevent resistance from developing.

But not anymore.

Not anymore.

The text says that for uncomplicated cases, dual therapy is no longer recommended.

And the reason is because we're seeing macrolide resistance to the azithromycin part.

It wasn't helping anymore and was just driving more resistance.

So what's the gold standard now?

What's the one thing we use?

It's a single shot.

Ceftriaxone, 500mg, intramuscular, I am.

Just the shot.

That seems simpler.

Just the shot for the gonorrhea itself.

It's a powerful cephalosporin antibiotic.

It targets the bacterial cell wall.

However, and pay attention to this, listeners.

This is a big exam point.

There's a caveat.

A big one.

Huge caveat.

If chlamydia has not been ruled out, meaning you do not have a negative test result in your hand right this second, you must add the doxycycline.

So the full course of doxy.

The full course.

Doxycycline, 100mg, twice a day for seven days.

So the coinfection rule kicks in again.

Always.

You treat for both unless you have absolute proof.

So the patient usually leaves with a sore arm from the shot and a prescription for a week's worth of pills.

That I am shot, 500mg, that's a decent volume of fluid.

It is.

It's not a comfortable injection.

It's usually given in the glute or another large muscle.

But it's necessary to ensure a cure.

And again, for neonates, preventing gonococcal ophthalmia is why we use that erythromycin ointment at birth.

It covers both.

Okay.

Let's talk about the great imitator.

Syphilis.

Treponema pallidum.

This one is fascinating and terrifying because it plays the long game.

It has these distinct stages that can span years, even decades.

Let's walk through them.

Stage one.

Primary syphilis.

The primary stage is characterized by the chancre.

It's a sore that develops at the site of entry.

Okay.

What does it look like?

Is it painful?

It's an ulcer.

But the key characteristic, the thing you absolutely have to remember, is that it is painless.

Painless.

So if it's on the cervix or inside the rectum, you might not even feel it or see it.

Exactly.

You might have no idea it's there.

And the really tricky part is it heals on its own in three to six weeks with no treatment.

The body appears to fix it.

But the bacteria isn't gone.

No, it's just moving deeper into the body.

It's going systemic.

Yeah.

And during this primary stage, the person is highly, highly contagious.

Then comes secondary syphilis.

This happens about two to eight weeks after the chancre heals.

Now it's hysteric.

You get symptoms all over the body.

What kind of symptoms?

The classic sign is a skin rash.

And specifically on the palms of the hands and the soles of the feet.

That's a very specific finding for secondary syphilis.

Okay.

You might also get fever, swollen lymph nodes, lymphadenopathy, sore throat.

Again, highly contagious at this stage.

And if you don't treat it then?

You enter the latent stage.

This can last anywhere from one year to 20 years.

20 years with no symptoms?

No symptoms at all.

You feel fine, you look fine.

The only way to diagnose it is with a blood test.

But all that time, the bacteria is hiding, potentially doing slow, silent damage to your organs.

And finally, tertiary syphilis.

This is the end game.

This is where you see the severe systemic damage.

Cardiovascular syphilis, which attacks the aorta.

Ocular syphilis, causing blindness.

And neurosyphilis.

Neurosyphilis.

That sounds horrific.

It is.

It attacks the brain and spinal cord.

It can cause dementia, psychosis, paralysis.

It literally destroys the nervous system.

It's so crucial to catch it early then.

The text says diagnosis requires two tests, right?

Yes, you need a two -step process to be sure.

You start with a non -trippanemal test, like a VDRL or RPR.

This is a screening test.

And if that's positive?

If that's positive, you have to confirm it with a trippanemal test, like an FTA -ABS.

Why do both?

Why not just use the better test first?

Because the first test, the screening test, can have false positives.

Other conditions like Lyme disease, autoimmune disorders, even pregnancy can trigger a positive on the screen.

You need that second, more specific test to confirm it is actually syphilis.

Okay, let's talk drugs.

Syphilis has a very specific nemesis, penicillin.

Penicillin G is the only drug that reliably cures syphilis.

It has been the cure since the 1940s, and it still works just as well today.

That's incredible.

It is.

Syphilis, for whatever reason, has never developed resistance to it.

But the form of penicillin matters immensely.

This is a huge nursing safety point.

You can't just grab any vial -labeled penicillin.

This is a critical safety point.

For primary, secondary, and early -latent syphilis, we use benzathine penicillin G.

Benzathine.

What makes that formulation special?

It's a depo formulation.

It's thick and milky.

You inject it deep into the muscle, IM, and it sits there, releasing slowly over weeks.

And why is that slow release important?

Because treponema, the syphilis bacteria, replicates very, very slowly.

So you need that long, low -level exposure to the antibiotic to kill all of them as they divide.

The dose is 2 .4 million units IM.

Usually it's a single dose.

But what if it's a neurosyphilis?

You said that attacks the brain.

That changes everything.

Benzathine penicillin doesn't cross the blood -brain barrier well enough.

It can't get to the brain to kill the bugs hiding there.

So what do you use?

For neurosyphilis or ocular syphilis, you must use aqueous crystalline penicillin G.

Aqueous, like water.

Yes.

It's water -soluble.

It's given IV, not IM.

It can cross into the spinal fluid in the brain.

So you can't just swap the formulations.

A nurse could make a fatal error there.

Absolutely not.

Giving benzathine IM for a neurosyphilis would be a complete treatment failure.

The patient would continue to have brain damage.

You need the IV aqueous form given every four hours or as a continuous infusion for 10 to 14 days.

It's a huge commitment, always requiring hospitalization.

And this is where it gets really intense, pregnancy.

Syphilis in pregnancy is devastating.

It crosses the placenta and causes congenital syphilis, which can lead to stillbirth, horrific deformities, and severe developmental delays in the child.

And penicillin is the only treatment that works for the fetus.

Correct.

It's the only one.

So here's the classic nursing school scenario.

You have a pregnant patient with syphilis and she is allergic to penicillin.

She says, I get hives, my throat closes up.

What do you do?

This is the ultimate nursing dilemma.

And the answer is there is no alternative.

You cannot use doxycycline that harms the baby's bones.

Other antibiotics don't reliably cross the placenta to cure the fetus.

So the patient must undergo desensitization.

Desensitization?

That sounds intense.

Describe that process.

It is extremely high risk.

You admit them to the hospital, usually to the ICU.

You have a crash cart at the bedside.

Wow.

And you give them tiny, incrementally increasing doses of penicillin, starting with a minuscule microdose every 15 to 20 minutes over several hours.

You are essentially tricking their immune system into temporarily tolerating the drug.

And once you reach the full dose.

You give the full therapeutic treatment dose.

It's a wild process, but it's the only way to save the baby.

It really highlights how irreplaceable penicillin is for this specific bug.

Before we leave bacteria, let's do a quick run through of table 57 .1 in the text.

There are some less common bacterial STIs that we still need to know for exams.

Right.

Let's hit the highlights.

Chancroid.

This one causes painful ulcers.

That's the key difference from syphilis, right?

Syphilis is painless.

Chancroid is painful.

Exactly.

That's the big tell.

It's treated with azithromycin or ceftriaxone.

And partners from the last 10 days must be treated.

Okay.

Then there's granuloma inguinali.

This one causes these beefy red lesions that bleed very easily.

The treatment is long.

It's azithromycin or doxycycline for at least three weeks and until all the lesions have completely healed.

Lymphogranuloma venarium or LGV.

That's actually a specific, more invasive serivar of chlamydia.

It invades the lymph nodes causing massive swelling, especially in the groin.

It's treated with doxycycline, but not for seven days, for 21 days.

A much longer course.

And finally, mycoplasma genitalium.

Why is this one tricky from a pharmacology perspective?

This is a great pharmacology recall moment.

Mycoplasma species lack a cell wall.

Ah, so beta -lactams like penicillin and cephalosporins, they won't work.

Exactly.

Their whole mechanism is attacking the cell wall.

So for mycoplasma, they are totally useless.

We used doxycycline followed by moxifloxacin for complicated cases.

Okay, let's shift gears.

We are leaving the world of cure and entering the world of management, the viral pathogens.

And this is a huge psychological shift for the patient.

With bacterial infections, you take a pill, it's gone, you're cured.

Viral infections like herpes and HIV, they are largely forever.

That's a heavy thing to hear.

Let's start with herpes simplex virus, HSV.

There are two main types.

HSV1, which traditionally causes oral cold sores but can also cause genital herpes, and HSV2, which is almost exclusively genital.

And the text makes a very clear point to say that antivirals for herpes are palliative.

Yes, that's the perfect word.

They control symptoms, they shorten the duration and severity of outbreaks, they can reduce transmission to a partner.

But they don't cure it.

They do not eradicate the virus from the nerve ganglia where it lies dormant.

The virus stays in the body for life.

The drugs here all have a similar sound.

The cyclovirs.

That's right.

A cyclover, valiciclover, and famsiclover are the main ones.

And the text talks about two ways to use them.

Episodic therapy and suppressive therapy.

What's the difference?

Episodic is reactive.

You wake up, you feel that prodrome, that classic tingling, itching, or burning sensation before the blister appears.

You start the drugs immediately within one day of onset.

It can significantly shorten the misery.

And suppressive.

Suppressive therapy is proactive.

It's taking a low dose of the antiviral every single day.

This reduces the frequency of recurrences by 70 to 80 percent.

It's for people who have frequent, severe, or psychologically distressing outbreaks.

What about pregnancy?

We know neonatal herpes is incredibly dangerous.

It's life -threatening for the baby.

If the baby passes through a birth canal with active lesions, it can get disseminated herpes, which causes brain damage, organ failure, and often death.

So what's the pharmacological intervention?

If a pregnant woman has a known history of genital herpes, we start suppressive therapy, usually acyclover or valacyclover, at 36 weeks gestation.

36 weeks.

That's the magic number.

The goal is to ensure there is no active viral shedding when she goes into labor.

But if there are any active lesions at the time of delivery, she needs a C -section.

No exceptions.

Next up, human papillomavirus, HPV.

This is the most common STI in the world.

So common that most sexually active people get it at some point.

Most people's immune systems clear it on their own.

But some strains don't clear, and those are the dangerous ones.

Exactly.

The high -risk strains, particularly the 16 and 18, cause cancer.

Cervical, penile, anal, and throat cancer.

And the low -risk strains.

The low -risk strains, like 6 and 11, cause genital warts.

Unsightly, but not cancerous.

So how do we treat HPV?

Is there an antiviral?

No.

We don't treat the virus itself.

We treat the manifestation of the virus.

If it's warts, we can freeze them off cryotherapy, or use topical chemicals, or cut them out.

If it's cancer, we treat the cancer.

There's no drug that cures the underlying HPV infection.

So the focus really has to be on prevention.

Absolutely.

The 9 -valent vaccine, Gardasil -9, it covers the two main cancer -causing strains, the two main wart -causing strains, and five other high -risk strains.

It's one of the most effective cancer prevention tools we have in modern medicine.

And briefly on HIV and hepatitis, we aren't covering the whole pharmacopoeia for those today, but in the context of STIs.

For HIV, the key is acute identification.

Acute HIV infection can look just like the flu.

Fever, rash, sore throat.

But the viral load is sky -high during that phase, making transmission very likely.

So you have to think about it.

You have to have it on your radar.

For hepatitis, for HIV and HPV, we have vaccines for prevention.

For HCV, there are amazing new antiviral cures, but no vaccine.

Okay, let's move on to the things that crawl.

The parasitic infections.

The ectoparasites.

Now everyone listening is going to start itching just thinking about it.

Let's start with pediculosis pupus, also known as crabs or pubic lice.

And then there's scabies.

Both cause intense, intense itching pruritus.

Scabies is caused by a tiny mite that actually burrows under the skin to lay its eggs.

Just the thought of that.

Okay, what's the drug of choice to kill them?

The go -to is permethrin.

But the concentration and application are different for each.

How so?

For lice, or crabs, it's a 1 % cream rinse.

You apply it to the affected area and wash it off after 10 minutes.

For scabies, it's a stronger permethrin 5 % cream.

And the application for scabies is more intense.

Much more intense.

You have to cover the entire body from the neck down, every inch of skin, between the fingers and toes, everywhere, and you leave it on for 8 to 14 hours, then wash it off.

The text has a specific warning about an older drug called lindane.

Yes.

Lindane is still out there, but it is neurotoxic.

It can be absorbed through the skin and can cause seizures.

The text is explicit.

Do not use lindane in pregnant patients or in children under 10 years old.

It's a last resort.

If even that, because permethrin is so much safer.

And for these parasites, treating the body isn't enough, is it?

No.

This is critical.

You have to treat the environment.

The mites and lice can live on bedding, clothing, towels for a couple of days.

So what's the protocol?

Anything that can be washed should be machine washed in hot water and dried on a high heat setting.

What if you can't wash it, like a stuffed animal or a heavy coat?

You seal it in a plastic bag and you remove it from all human contact for 72 hours.

By 72 hours, what's the magic in that number?

The mites and lice need a human host to feed on.

They need blood.

If they don't eat for about 3 days, they starve and die.

So time becomes the disinfectant.

And one more parasite, trichomoniasis.

Crichomonas vaginalis.

This one is a protozoan.

It's a single -celled organism with a little tail that actually swims.

What are the symptoms for that?

The classic symptom is a malodorous, frothy, yellow -green discharge.

And the treatment?

We're back to the nitroimidazoles.

Metrodidazole usually is a big 2 gram single dose or tinidazole.

Which means?

The alcohol rule applies here, too.

No alcohol.

Desulfuram -like reaction.

You have to warn the patient every single time.

Okay, we've covered the bugs and the drugs.

Now let's put it all together and talk about the nursing process.

How do we actually apply this in a clinical setting?

It all starts with assessment.

And the text gives some really good practical advice on how to ask the hard questions.

Instead of asking, are you married?

Or do you have a boyfriend?

You ask.

Do you have sex with men, women, or both?

Simple, direct, and neutral.

Use the term partner, not boyfriend or wife.

You're not making any assumptions.

And then you have to do a physical exam.

You have to look.

Inspect the mouth, the throat, the lymph nodes, and the genitalia.

You can't diagnose what you don't see.

And the text outlines the five P's of sexual health.

This is a great framework.

It is.

It's a mental checklist to make sure you get the full picture.

Partners, prevention of pregnancy, protection from STIs, practices, and past history of STIs.

The text also includes a puzzle piece image about condom use.

It seems so basic, but people get it wrong all the time.

What are the key dos from that image?

Do check the expiration date latex degrades over time.

Do use water -based or silicone -based lubricant.

Never oil.

Never oil -based lube, like baby oil or Vaseline with latex condoms.

It literally dissolves them.

Put the condom on before any sexual contact and store them in a cool, dry place, not a hot wallet or a car's glove compartment.

There is a special box in the text about older adults, box 57 .1.

And the stats in there were really surprising to me.

It shouldn't be.

But it is for a lot of people.

The rates of chlamydia, gonorrhea, and syphilis all doubled in adults over 50 in recent years.

Doubled.

Why is that happening?

It's sort of a perfect storm of factors.

You have ED drugs extending sexual lifetimes.

You have divorce and new dating later in life.

So more partners.

More partners.

And a lack of pregnancy concern means they often stop using condoms.

They think of condoms only as birth control, not infection control.

And there's a biological reason too, right?

Yes.

Post -menopausal biological changes in women like vaginal dryness and thinning tissue can increase the likelihood of those microfissures we talked about at the beginning.

That is a massive education gap the nurse has to fill.

You can never assume your 70 -year -old patient isn't sexually active.

Never.

Let's bring this all together with the case study from the text.

We have a 16 -year -old female patient.

Okay.

Let's look at her profile.

Multiple partners.

Four in the last two years.

No barrier method used.

She vapes.

And her partner is symptomatic.

He has burning with urination.

And she has a sore throat.

That's a big clue.

That's a huge clue.

You have to be thinking about pharyngeal gonorrhea.

So clinical judgment time.

What are our nursing actions?

First, treatment.

Based on the partner's symptoms and her sore throat, you treat presumptively.

She gets Ceftriaxone 500 -milligram IM.

That's for the likely gonorrhea.

Do we wait for the test results to come back?

In this case, with a symptomatic partner, presumptive treatment is often warranted to prevent further spread and complications.

We also absolutely have to think about chlamydia co -infection.

So she gets the doxycycline.

She gets the doxycycline 100 -milligrams twice a day for seven days.

What about education?

Condoms, obviously.

But also, she needs to abstain from sex for seven days after her and her partner are treated.

And her partner must be treated.

If we treat her and she goes right back to an untreated partner, she just gets reinfected.

There's that ping pong infection again.

And there's a social aspect here, too.

The case says she's living with her grandmother and there's a history of abuse.

Right.

And you can't ignore that.

You have to assess her support systems.

Is she safe?

Does she feel empowered to talk to her partner about getting treated?

Nursing is holistic.

The shot fixes the bacteria, but the nurse has to help the patient navigate the situation.

So what does this all mean?

Let's recap the big ideas, the main takeaways from this deep dive.

I think it boils down to this.

Bacterial equals antibiotics.

But you have to watch for resistance and know the pregnancy rules.

Viral equals antivirals.

But the goal is suppression, not cure.

And parasitic.

Parasitic means decontamination is key.

And for almost all of these, you have to treat the patient and the partner.

And my big takeaway, I keep coming back to the asymptomatic nature of so many of these diseases.

That's the scariest part, isn't it?

It is.

The nurse is often the detective who stops the chain of transmission simply by asking the right questions, by being non -judgmental, and by knowing the screening guidelines.

Absolutely.

The questions you ask and the education you provide save lives just as much as the drugs you administer.

A huge thank you to everyone listening.

This was a dense one, but so, so important.

Good luck on your exams and in your clinicals.

You've got this.

Thanks for joining the Last Minute Lecture Team.

We'll see you in the next deep dive.