Pediatric Primary Care (96 page)

a.  Recommended regimens:

•  Acyclovir 400 mg PO bid, OR

•  Famciclovir 250 mg PO bid, OR

•  Valacyclovir 500 mg PO daily, OR

•  Valacyclovir 1 g PO daily.

H.  Follow up.

1.  Follow patient's emotional adjustment to having HSV.

2.  Test for other STIs.

I.  Complications.

1.  Daily medication may not suppress recurrent outbreaks.

2.  Immune-suppressed patients may have prolonged/severe outbreaks requiring IV therapy.

3.  Transmission to neonate from infected mother is highest among women who acquire genital HSV near time of delivery.

J.  Education.

1.  Psychologic burden may be great. Counseling includes supportive groups, CDC website, written materials. If depression is identified, refer to mental health provider.

2.  Latex condoms may reduce transmission if used correctly.

3.  Patients should refrain from sexual contact if lesions are present.

4.  Sexual partners should be notified by patient.

5.  Sexual transmission may occur with asymptomatic viral shedding.

6.  Explain risk of neonatal infection to male and female patients; they should inform provider during pregnancy.

V.  GENITAL WARTS

A.  Etiology.

1.  Human papilloma viruses (HPVs) are DNA viruses and include 100 types; 30 types can infect genital tract.

2.  Types 16, 18, and 45 are associated with cervical cancer.

B.  Occurrence.

1.  Anogenital HPV occurs in 40% of sexually experienced adolescent females.

2.  HPV is etiology of 90% of cervical cancers.

C.  Clinical manifestations.

1.  May have no symptoms.

2.  When present, warts are epithelial tumors of skin/mucous membrane.

3.  Immunocompromised individuals may have larger quantity of warts.

4.  Incubation unknown; likely ranges from 3 months to several years.

5.  May regress spontaneously or may persist for years.

D.  Physical findings.

1.  Skin-colored lesions with cauliflower-like surface may be several millimeters to several centimeters wide; may be painless or itch, burn, bleed; can be found on vagina, cervix, vulva, penis, anus, perianal area, scrotum.

E.  Diagnostic tests.

1.  For women younger than 30 years but older than age 20, HPV tests are available to detect (DNA or RNA) viral nucleic acid or capsid protein.

2.  Four Food and Drug Administration (FDA)-approved tests are available for use in the United States: Hybrid Capture (HC) II High-Risk HPV test (Qiagen), HC II Low-Risk HPV test (Qiagen), Cervista HPV 16/18 test, and Cervista HPV HR (high risk) test (Hologic).

F.  Differential diagnosis.

1.  Molluscum contagiosum.

2.  Condyloma lata (syphilis).

3.  Pink, pearly, penile papules.

G.  Treatment.

1.  Recommended regimens.

a.  Patient applied:

•  Podofilox 0.5% solution or gel, OR

•  Imiquimod 5% cream, OR

•  Sinecatechins 15% ointment.

b.  Provider administered:

•  Cryotherapy with liquid nitrogen or cryoprobe.

•  Podophyllin resin 10–25%.

•  Trichloroacetic acid or bichloroacetic acid 80–90%.

•  Surgery.

H.  Follow up.

1.  Females: regular Pap smears to assess for cellular damage.

I.  Complications.

1.  Recurrences common due to reactivation of virus. May persist for life. Duration of contagiousness unknown.

2.  Local treatment can damage normal surrounding skin.

J.  Education.

1.  Females: regular Pap smears to assess for cellular damage from HPV.

2.  Screen for other STIs.

3.  Partners should be informed.

4.  Teach safer sex.

K.  Vaccinations.

1.  Cervarix (bivalent) vaccine contains HPV types 16 and 18.

2.  Gardasil (quadrivalent) vaccine contains HPV types 6, 11, 16, and 18.

3.  Both vaccines protect against 70% of cervical cancers and Gardasil offers protection against 90% of genital warts.

4.  Either vaccine can be administered to girls aged 11–12 years and as young as age 9. They can also be administered to women ages 12–26 who have not started or completed the vaccine. It is most beneficial if given before onset of sexual activity. Gardasil can be used in males aged 9–26 to prevent genital warts. Both vaccines are administered in a 3-series injection schedule over a 6-month period. After injection 1 is given, the second is given 1–2 months later, then at 6 months after the first injection for a total of 3 injections. Women should still receive routine cervical cancer screening after receiving the vaccine.

VI. GONORRHEA

A.  Etiology.

1.  Neisseria gonorrhoeae is Gram-negative, oxidase-positive diplococcus.

B.  Occurrence.

1.  650,000 new cases of gonorrhea per year in the United States.

2.  15- to 19-year olds have highest incidence of infection.

3.  Co-infection with chlamydia is common.

C.  Clinical manifestations.

1.  Males tend to have symptomatic infections of urethra.

2.  Females may have cervicitis, PID, perihepatitis, bartholinitis.

3.  Rectal and pharyngeal infections may be asymptomatic.

4.  Disseminated infections occur in up to 3% of untreated persons.

a.  Bacteremia causes arthritis-dermatitis syndrome.

b.  More common in females infected within 1 week of menstrual period.

5.  Incubation is 2–7 days.

D.  Physical findings.

1.  May be no symptoms.

2.  Males may experience penile discharge, dysuria.

3.  Females may have vaginal discharge, abdominal pain.

E.  Diagnostic tests.

1.  Culture is excellent but may require special handling.

2.  Nucleic acid amplification is highly sensitive; may be used with mucosal discharge/urine.

3.  Gram stain showing Gram-negative intracellular diplococci are most useful in acutely ill patients.

F.  Differential diagnosis.

1.  Chlamydia may cause similar symptoms.

2.  Non-gonococcal urethritis (NGU): 40% of cases caused by chlamydia; 20–30% caused by
Ureaplasma urealyticum;
and 30–40% uncertain but may include HSV,
Trichomonas vaginalis, Escherichia coli
, and others.

G.  Treatment.

1.  Dual treatment for chlamydia should be considered in populations where chlamydia is found with 10–30% of gonococcal infections.

2.  Recommended regimens for uncomplicated gonococcal infections of cervix, urethra, rectum:

a.  Cefixime 400 mg one dose PO, OR

b.  Ceftriaxone 125 mg one dose IM, OR

c.  Ciprofloxacin 500 mg one dose PO, OR

d.  Ofloxacin 400 mg one dose PO, OR

e.  Levofloxacin 250 mg one dose PO.

f.  PLUS, if chlamydial infection is not ruled out: azithromycin 1 g PO one dose, OR doxycycline 100 mg PO bid for 7 days.