Bacterial Vaginosis - PDF

Bacterial Vaginosis By: Jay Aries T. Gianan, RM, RN, LPT, MAN Assistant Professor II Learning Objectives: What is Bacterial Vaginosis? Causes Signs & symptoms Pathophysiology Com...

Bacterial Vaginosis By: Jay Aries T. Gianan, RM, RN, LPT, MAN Assistant Professor II Learning Objectives: What is Bacterial Vaginosis? Causes Signs & symptoms Pathophysiology Complications How to manage Bacterial Vaginosis? Across 1 2 1. small single-celled organisms 3 2. visible, external part of the genitals 1 3. single-celled living organism with a mighty big job in baking Down 1. genus of Gram-positive, aero- tolerant anaerobes or micro- aerophilic, rod-shaped, non-spore- forming bacteria 2 2. antibiotic & antiprotozoal medication sold under the name Flagyl 3. unicellular, eukaryotic, heterotrophic organisms 3 What is Bacterial Vaginosis? Vaginitis inflammation or infection of vagina Types 1. Bacterial vaginosis Most common type 2. Trichomoniasis Protozoan infection 3. Vaginitis candidiasis Fungal (yeast) infection 4. Others types Atrophic vaginitis Desquamative vaginitis Vulvodynia Bacterial Vaginosis (BV) an imbalance of the normal vaginal flora loss of vaginal acidity too much of certain bacteria in the vagina. d/t loss of the normal vaginal “lactobacilli” l/t ↑ Anaerobic organisms Currently not considered a STD! but acquisition appears to be r/t sexual activity Causes Gardnerella vaginalis Most common Aka “Haemophilus vaginalis” Prevotella spp. Mobiluncus spp. Mycoplasma hominis Bacteroides species Peptostreptococcus species Fusobacterium species Prevotella species Atopobium vaginae Risk factors Two or more sex partners in previous six months new sex partner Frequent douching Intra-utérine contraceptive devices (IUD) Pregnancy African American Lack of hydrogen peroxide (H2O2)-producing lactobacilli  Causes Bacterial Vaginosis Loss of vaginal acidity Gardnerella vaginalis Prevotella spp. What really happen? Mobiluncus spp. Mycoplasma hominis Alteration of normal vaginal Bacteroides species flora Peptostreptococcus species Decrease of lactobacillus dominance in vaginal flora Increase alkalinity of vagina Leading to Overgrowth of normal vaginal flora Invasion and damage to host tissues Thin milky-white to grey Endometritis homogenous vaginal Complications Pelvic inflammatory discharge disease (PID) Malodorous (fishy Vaginal cuff cellulitis Bacterial Vaginosis S/S smelling) vaginal discharge Preterm labor Fishy odor Preterm birth Pruritus Spontaneous abortion Signs & symptoms Most women are asymptomatic! Thin milky-white to grey homogenous vaginal discharge Malodorous (fishy smelling) vaginal discharge after sex or during menstruation Fishy odor more pronounced after adding KOH- whiff test Pruritus Presence of “clue cells” Symptoms may remit spontaneously Complications ↑ risk of STD Endometritis Pelvic inflammatory disease (PID) Vaginal cuff cellulitis Premature rupture of membranes Preterm labor Preterm birth Spontaneous abortion Intra-amniotic infection Postpartum endometritis  How to manage Bacterial Vaginosis? Diagnostic assessment Amsel Criteria - Must have 3 out of 4: 1. Vaginal pH >4.5 N: 3.8 – 4.5 2. Presence of >20% per high-power field (HPF) of "clue cells" on wet mount examination 3. Positive amine or "whiff" test 4. Homogenous, non-viscous, milky-white discharge adherent to the vaginal walls Gram stain gold standard for identifying the causative agent Cervical smear (+) clue cells presence of Gardnerella vaginalis Nursing Diagnosis Acute pain Anxiety Knowledge deficit Risk for infection Question: "Clue cells" were discovered in a clinical specimen taken from a college sophomore experiencing vaginitis. Which organism listed below caused this infection? a. Candida albicans b. Escherichia coli c. Gardnerella vaginalis d. Mycoplasma hominis e. Trichomonas vaginalis Goal Relief of vaginal S/S of infection Reduction of the risk for complications during pregnancy other infections (HIV, STDs), premature birth in women who are at high risk post-abortion PID Nursing intervention Therapy not recommended For male partners of women with BV female partners of women with BV should be examined & treated if BV is present condom use might be helpful Screen & treat women prior to surgical abortion or hysterectomy Treatment 30% of bacterial vaginosis cases may resolve without treatment CDC-recommended regimens: Metronidazole 500 mg orally BID for 7 days or Metronidazole gel 0.75% one full applicator (5g) intravaginally OD for 5 days or Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days Treatment Alternative Regimens Tinidazole 2 g orally OD for 2 days or Tinidazole 1 g orally OD for 5 days or Clindamycin 300 mg orally BID for 7 days or Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days Treatment Abstain from alcohol 24 hours after completion of the metronidazole course 72 hours after the tinidazole course to avoid the disulfiram-like reaction Nausea Vomitng Flushing Dizziness Throbbing headache Chest & abdominal discomfort Treatment Multiple recurrences Metronidazole gel 2x weekly for 6 months may reduce recurrences Oral nitroimidazole followed by intravaginal boric acid 600 mg daily for 21 days then Suppressive 0.75% metronidazole gel twice weekly for 4 to 6 months. Treatment Pregnant women PO metronidazole or clindamycin preferred Clindamycin cream prior to 2nd half of pregnancy use after 2nd half can cause low birth weights and/or neonatal infections Prevention: Abstinence Use Condoms estrogen-containing contraceptives Good hygiene Monogamous Question: A pt. diagnose of bacterial vaginosis ask you if yogurt food rich in lactobacillus is effective in treating bacterial vaginosis. As a nurse, what will be your answer? Data do not support yogurt therapy or exogenous oral lactobacillus treatment Question: How can you prevent Bacterial Vaginosis? a. Help keep bacteria in the vagina balanced by cleaning it with warm water b. Do not douche c. Practice safe sex d. All of the above Question: A 26-year-old woman presents for routine gynecologic examination and Pap smear. A thin, homogenous vaginal discharge is noted, and a sample is taken. When potassium hydroxide is added to a wet mount of the sample, a fishy odor is noted. In addition, the Pap smear reveals the presence of "clue cells." Which of the following organisms is likely to be present in increased numbers? a. Staphylococcus aureus b. Neisseria gonorrhoeae c. Candida albicans d. Trichomonas vaginalis e. Gardnerella vaginalis Question: Which organism is not classically associated with bacterial vaginosis? a. Bacteroides species b. Gardnerella vaginalis c. Histoplasma capsulatum d. Mobiluncus species e. Mycoplasma hominis  Trichomoniasis By: Jay Aries T. Gianan, RM, RN, LPT, MAN Assistant Professor II Learning Objectives: What is Trichomoniasis? Cause Signs & symptoms Pathophysiology Complications How to manage Trichomoniasis? Across 1E P I T H E L I 1U M 1. a thin, continuous, protective layer of compactly packed cells with a little T intercellular matrix. E 2. produces an ovum 2C R 3. self-enforced restraint from indulging in bodily activities E U 2O V A R I E S Down V 1. hollow, pear-shaped organ in a woman's 3A B S T I N E N C E pelvis 2. allows fluids to flow inside & out of your C X uterus 3. any hydrogen-containing substance that I is capable of donating a proton (hydrogen ion) to another substance. D What is Trichomoniasis? Trichomoniasis Aka “trich” Most common curable STI most common non-viral STD worldwide. “Protozoan” parasite Women are affected more often than men. Cause Trichomonas vaginalis A protozoa flagellated motile organisms transmitted by sexual intercourse less commonly transmitted by contaminated douche equipment or moist washcloths Grows best in more alkaline than normal pH about 5.5 to 5.8 Risk factors New sex partner or multiple partners ↓ vaginal acidity Unhygienic conditions History of STIs Contact with an infected partner Abusing IV drugs Not using any type of barrier contraception Signs & symptoms Mostly Asymptomatic! Greenish- yellow discharge or Thin, yellow discharge or Green and foamy Women Asymptomatic or Strawberry cervix Vulvar pruritus Burning upon urination Foul smelling w/ yellow or green vaginal discharge Dyspareunia Post-coital bleeding Men Asymptomatic or Penile discharge Testicular pain, dysuria, urinary frequency, or cloudy urine  Direct sexual contact with Trichomoniasis infected person Cause Trichomonas Vaginalis What really happen? Organism resides in the lumen of the urogenital tract Microorganism releases cytotoxic proteins that destroy the epithelial lining Incubation period of 5 – 28 days Leading to Local inflammation occur in the cervix Recruitment of inflammatory cells into the genital tract Strawberry cervix Complications PID Yellow green or grey Infertility discharge Risk of HIV & STIs Trichomoniasis S/S Bad odor Preterm or low birth Dyspareunia weight neonate Vaginal itching Complications Female Urethral stricture disease Pelvic inflammatory disease Infertility ↑ Risk of HIV & STIs In pregnant women: Preterm or low-birth-weight neonate Male Epididymitis Prostatitis Infertility How to manage Trichomoniasis? Diagnostic assessment Nucleic acid amplification tests (NAATs) Gold standard Culture w/ wet prep microscopy on symptomatic pt. Most common diagnostic testing Previous gold standard Vaginal pH N: 3.8 – 4.5 Cervical examination via colposcopy punctate cervical hemorrhages cervix a strawberry appearance Whiff test adding drops of potassium hydroxide to a sample of vaginal discharge Result: fishy smell Nursing diagnosis Acute pain Anxiety Impaired skin integrity Impaired urinary elimination Ineffective sexuality patterns Sexual dysfunction Nursing intervention Abstinence from sexual intercourse until cured & symptoms disappeared limiting the number of sexual partners using condoms Sitz baths to help relieve symptoms comfort from itching & drainage Avoidance of alcohol when metronidazole is prescribed N: may turn urine dark brown Can l/t feeling & being sick stomach pain hot flushes confusion, headache, cramps, vomiting, & seizures Nursing intervention Avoid using tampons. Provide emotional support verbalize feelings & concerns. Urge the patient to talk with her partner about the need for treatment. Practice standard precautions. Perform meticulous hand hygiene Provide skin & perineal care. Nursing intervention Avoid OTC douches & vaginal sprays can alter vaginal pH Wearing loose-fitting, cotton underwear allowing ventilation ↓ the risk of genitourinary bacterial growth Follow-up checkup if symptoms do not abate Need for rescreening in 3 months for all sexually active women high rate of reinfection. Treatment Metronidazole 1st line given to both sexual partners for 7 days 2g orally in single dose Single dose of oral tinidazole or alternative 2g orally in single dose given to both sexual partners or Alternative treatment metronidazole 500mg orally twice daily for 7 days Treatment Pregnancy metronidazole 2 g orally in single dose at any stage of pregnancy metronidazole during pregnancy may ↓ rate of trichomoniasis but may ↑ rate of preterm birth Lactation with metronidazole withhold breastfeeding during Tx & for 12-24 hours after last dose with tinidazole withhold breastfeeding during Tx & for 3 days after last dose Question: A nurse is assessing a 27-year-old female patient who visits her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect? a. Human papillomavirus (HPV) b. Syphilis c. Trichomoniasis d. Herpes simplex virus Question: Which of the following is the most effective treatment for trichomoniasis? a. Clindamycin (Cleocin) b. Tinidazole (Tindamax) c. Miconazole (Monistat) d. Clotrimazole (Gyne-Lotrimin)  Candidiasis By: Jay Aries T. Gianan, RM, RN, LPT, MAN Assistant Professor II Learning objectives: What is candidiasis? Causes Risk factors Signs & symptoms Pathophysiology Complications How to manage candidiasis? Across 1 2 1. any member of the group of eukaryotic organisms 1 2. act of cleaning one's hands with soap and water 3 3. eukaryotic, single-celled microorganisms classified as members of the fungus kingdom Down 1. aka “anti-mycotic medication” 2. uppermost and widest part of your uterus 2 3. practice or state of being married to one person at a time. 3  What is candidiasis? Candidiasis Aka “moniliasis” “candidosis” or “thrush” most common oral ”fungal infection” occurs most commonly as a 20 infection in immuno- compromised individuals. Cause Candida albicans! most common an opportunistic yeast fungus naturally occurring fungus that lives on your body. Candida tropicalis C. albicans C. glabrata C. tropicalis C. krusei C. parapsilosis C. briglis C. limbica C. lipolytica C. lusitaniae  Risk factors Altered normal flora Long term antibiotic therapy concurrent disease Immune suppression Immunosuppressant drugs corticosteroids cancer drugs Damaged mucosa Burns Indwelling urinary catheter Concurrent local disease Diabetes mellitus Oral contraceptives Pregnancy Types 1. Pseudomembranous (Thrush) Aka “thrush” Most common 2. Erythematous 3. Central Papillary Atrophy Median Rhomboid Glossitis 4. Denture Stomatitis Angular Chelitis 5. Mucocutaneous Change in the patient's Candidiasis resistance to infection Causes What really happen? Candida Albicans Candida Tropicalis Sudden proliferation of Candida albicans Superficial infection occurs Overgrowth of the organism on the mucous membranes due to Leading to changes in the normal flora Invasive infections result when the organism colonizes on the mucocutaneous surfaces Organism to enter the body and travel to the bloodstream Thick white cottage Systemic infection Complications cheese-like discharge Intertrigo Oral thrush Sepsis Intense itching & irritation Candidiasis S/S Intestinal candidiasis Pain in urination Low birth weight & Vaginal itching premature baby Signs & symptoms Thick white cottage cheese-like discharge Oral “Thrush” oral infection Intense itching and irritation vagina and vulva Burning sensation with urination Vaginal soreness/itching Pain Dry erythematous rash Systemic candidemia fever, chills, hypotension, & confusion. Laryngeal Candida infection – rare dysphonia Complications Systemic infections in neonates low birth weight (LBW) premature baby Intertrigo - intertriginous dermatitis an inflammatory condition of skin folds Sepsis Intestinal candidiasis Bronchopulmonary candidiasis rare Septicemia, endocarditis, & meningitis How to manage candidiasis? Diagnostic assessment Blood culture for systemic candidiasis Culture of vaginal discharge budding yeast is visible Scrapings of the rash reveals hyphae, pseudohyphae, or budding yeast cells. Physical assessment oral thrush Nursing diagnosis Acute pain Hyperthermia Impaired oral mucous membrane Impaired skin integrity Impaired urinary elimination Risk for aspiration Sexual dysfunction Nursing intervention Follow standard precautions Handwashing Give prescribed drugs. I.V. amphotericin B or caspofungin If the patient is receiving I.V. amphotericin B Pre-medicate with acetaminophen or ibuprofen as ordered to minimize the risk of fever & rigors Ensure a patent I.V. access site. Obtain a blood specimen for laboratory testing electrolyte levels, complete blood count, & renal function Provide a non-irritating mouthwash to loosen tenacious secretions soft toothbrush to avoid irritation provide frequent mouth care as indicated Nursing intervention Inspect skin closely for changes perform meticulous skin care provide care to lesions or areas of skin breakdown, as ordered Observe high-risk pts. daily patchy areas, irritation, sore throat, oral & gingival bleeding, other signs of superinfection. Assess the pt. for an underlying systemic cause institute measures to alleviate the cause. Prepare the pt. & family for possible drainage of the abscess as appropriate provide wound care & dressing changes to site as ordered. Question: A pt. diagnosed of candidiasis ask you about management of itchiness in the skin. As a future nurse, what should you teach the pt. about overcoming this problem? Keep the skin & bed linens clean & dry Inspect skin fold areas frequently Nursing intervention No restrictions unless oral infection Food & fluids tepid in temp & non-irritating to mucous membranes With oral infection Eat: lean proteins, healthful fats, non- starchy vegetables, & probiotics Avoid: sugar, white flour, yeast & cheese Spicy food only as tolerated Activity As tolerated Anti-fungal drugs -azole drugs Fluconazole 1st line agent for non-neutropenic pts. with candidemia or suspected invasive candidiasis Avoid in 1st trimester of pregnancy Clotrimazole Miconazole Voriconazole ↑ the level or effect of quinidine Mild or moderate fungal infection Antifungal vaginal cream 1, 3, or 7-day treatment Econazole or fluconazole 150 mg orally one-time dose Anti-fungal drugs Recurrent vaginal candida infections Fluconazole dosing is on days 1, 4, & 7 then weekly for 6 months Oral thrush Oral lozenges Clotrimazole lozenges Systemic candidiasis Oral or IV antifungal Caspofungin, Fluconazole, Amphtericin B Anti-fungal drugs Amphotericin B Most important action Check for premedication prescriptions Watch out for adverse effects Kidney problems Nystatin Most common for oral candidiasis Anti-fungal drugs Denture stomatitis No denture for at least two weeks With the topical application of antifungal meds Oral probiotics adjuvant in treating oral candidiasis Prevention Abstinence Monogamy Proper use of condoms Maintain normal flora bacteria keep yeast under control. Question: Which of the following would cause a child to be at risk for oral candidiasis? a. Corticosteroid use b. Cancer of the eye c. Reuse of pacifiers d. Family history Question: The nurse is administer Mycostatin the child who has been diagnosed with having oral thrush. Which of the following should the nurse include in the plan of administration? a. Administer this medication with every meal b. Avoid using a cotton tipped applicator as this interferes with the medication mechanism of action c. Plan on administering the medication once a day d. The mother may need to be treated as well as the child