Use latex condoms because they offer greater protection against HIV and other viral STDs than natural membrane condoms.
Store condoms in a cool, dry place out of direct sunlight.
Do not use condoms in damaged packages or those that show obvious signs of age (for example, those that are brittle, sticky, or discolored).
Handle condoms with care to prevent puncture.
Put on the condom before any genital contact is made to prevent exposure to fluids that may contain infectious agents. Hold the tip of the condom and unroll it onto the erect penis, leaving space at the tip to collect semen. Make sure there is no air trapped in the tip of the condom.
Use only water-based lubricants. Petroleum- or oil-based lubricants such as petroleum jelly, cooking oils, shortening, and lotions should not be used because they weaken the latex and may cause the condom to break.
Use condoms containing spermicide, particularly those containing nonoxynol-9, to provide some additional protection against STDs. Vaginal use of spermicides along with condoms is likely to provide still greater protection.
Replace the condom immediately if it breaks. If ejaculation occurs after the condom breaks, the application of spermicide has been suggested. However, whether a post-ejaculation application of spermicide has protective value in reducing the risk of STD transmission is unknown.
Take care after the ejaculation that the condom does not slip off the penis before withdrawal. The base of the condom should be held throughout withdrawal. The penis should be withdrawn while still erect.
Never reuse a condom.
SOURCE: Centers for Disease Control. Sexually Transmitted Diseases: Treatment Guidelines. Atlanta, GA: U.S. Department of Health and Human Services, September 1989.
Table 1. CDC guidelines for preventing the transmission of tuberculosis in health care settings
I. Early Identification and Treatment of Active TB Cases
The following guidelines will help health care personnel in the early identification and treatment of persons with active TB.
A high index of suspicion for TB should be maintained to identify cases rapidly.
Prompt, effective multidrug therapy should be initiated; this therapy should be based on clinical and drug-resistance surveillance data relative to the given geographical region and population demographics.
II. Preventing the Spread of Infection
The spread of infectious droplet nuclei needs to be prevented by source control methods and by the reduction of microbial contamination of indoor air, using the following precautions.
TB isolation precautions should be initiated immediately for all persons with suspected or confirmed active TB, since they may be infectious to others. Isolation precautions include placing the patient in a private room with negative pressure in relation to surrounding areas (i.e., air flow is from hallway into room and then to outdoors). The isolation room must have a minimum of six air exchanges per hour. Air from the room must be vented directly to the outside.
To supplement proper ventilation, several other means to minimize exposure to TB should be considered. The use of disposable particulate respirators is recommended for staff members. These masks should be worn in clinic areas where aerosol treatments are given or sputum induction is done, as well as by hospital personnel in bronchoscopy suites and in patient isolation rooms. Patients should be instructed to cover their mouths when coughing or sneezing and to wear a mask when going out of isolation rooms.
High-efficiency filtration systems may help reduce the risk of transmission, although their effectiveness has not been adequately evaluated in the clinical setting.
Ultraviolet germicidal irradiation with UV-C in patient care areas, including outpatient clinics, may reduce the risk of transmission, although its effectiveness in the clinical setting has not been demonstrated.
TB isolation precautions should be continued until the following conditions exist:
Three successive sputum samples obtained on different days are smear negative for AFB.
The patient has signs of clinical improvement.
The patient is receiving appropriate antituberculous therapy.
Special respiratory and isolation precautions should be employed during any cough-inducing procedures (i.e., sputum induction; bronchoscopy; administration of aerosolized pentamidine to HIV-infected persons; nebulization treatment for asthma, emphysema; and when suctioning patients whether they are on a ventilator or not).
III. Surveillance for TB Transmission
Surveillance for TB transmission needs to be done to protect patients, health care workers, and visitors.
Surveillance for TB infection should be maintained among health care workers by routine, periodic tuberculin skin testing every 6 to 12 months if there is no known exposure to a patient with active, untreated TB. Programs should recommend and follow up on appropriate preventive therapy for health care workers who meet the criteria for anti-TB prophylaxis. Immunocompromised health care workers, especially those with HIV/AIDS, may not convert their skin test and/or may be anergic. These workers need close medical followup.
Ongoing surveillance for TB cases should be maintained among patients and health care workers.
Contact investigation procedures need to be promptly initiated for any health care workers, patients, and visitors who are exposed to an untreated or ineffectively treated infectious TB patient who did not receive appropriate isolation and ongoing drug therapy. For infected contacts of infectious cases, appropriate anti-TB treatment or prophylaxis should be recommended. The initial therapeutic regimen should be based on the clinical history and on relevant, local drug-resistance surveillance data.
Table 1. Interpretation of tuberculosis skin test results
A reaction of 5 mm or greater is positive, regardless of age, in the following persons:
Persons with known HIV infection
Injection drug users whose HIV status is unknown
Close contacts of newly diagnosed infectious tuberculosis cases, including health care workers
Persons with chest radiographs showing fibrotic lesions
A reaction of 10 mm or greater induration is positive in the following:
Foreign-born persons from high-prevalance countries
Low-income populations, including high-risk minorities
Injection drug users known to be HIV negative
Residents of long-term care facilities (for example, nursing homes, correctional institutions)
Persons with medical conditions that increase the risk of TB. These conditions include silicosis, diabetes mellitus, prolonged corticosteroid therapy, immunosuppressive therapy, hematologic and reticuloendothelial diseases, end-stage renal disease, intestinal bypass, postgastrectomy, chronic malabsorption syndrome, carcinomas of the oropharynx and upper gastrointestinal tract, and being 10 percent or more below ideal body weight.
Recent tuberculin skin test conversions(within a 2-year period) are considered positive: for those less than 35 years old, a 10 mm or more increase; for those 35 years and older, a 15 mm or more increase.
A tuberculin reaction of 15 mm or more is classified as positive in all other persons.
INH (300 mg by mouth daily) for 6 to 12 months to prevent the development of active TB.
HIV-positive persons and persons at high risk for HIV, with unknown HIV status, should receive 12 months of INH.
For persons with a positive PPD after exposure to a known case of INH- resistant TB, rifampin (RIF) (600 mg by mouth daily) should be given for 6 to 12 months.
Table 3. Regimen options for the initial treatment of TB among children and adults
TB Without HIV infection
TB With HIV Infection
Option 1
Administer daily INH, RIF, and PZA for 8 weeks followed by 16 weeks of INH and RIF daily or 2-3 times/week* in areas where the INH resistance rate is not documented to be less than 4%. EMB or SM should be added to the initial regimen until susceptibility to INH and RIF is demonstrated. Continue treatment for at least 6 months and 3 months beyond culture conversion. Consult a TB medical expert if the patient is symptomatic or smear or culture positive after 3 months.
Options 1, 2, or 3 can be used, but treatment regimens should continue for a total of 9 months and at least 6 months beyond culture conversion.
Option 2
Administer daily INH, RIF, PZA, and SM or EMB for 2 weeks followed by 2 times/week* administration of the same drugs for 8 weeks (by DOT§), and subsequently, with 2 times/week administration of INH and RIF for16 weeks (by DOT). Consult a TB medical expert if the patient is symptomatic or smear or culture positive after 3 months.
Option 3
Treat by DOT, 3 times/week* with INH, RIF, PZA, and EMB or SM for 6 months+. Consult a medical expert if the patient is symptomatic or smear or culture positive after 3 months.
* All regimens administered 2 times/week or 3 times/week should be monitored by DOT for the duration of therapy.
+ The strongest evidence from clinical trials is the effectiveness of all four drugs administered for the full6 months. There is weaker evidence that SM can be discontinued after 4 months if the isolate is susceptible to all drugs. The evidence for stopping PZA before the end of 6 months is equivocal for the 3 times/week regimen, and there is no evidence on the effectiveness of this regimen with EMB for less than the full 6 months.
Table 4. Dosage recommendations for the initial treatment of TB among children* and adults
Dosage
Daily
2 times/week
3 times/week
Drugs
Children
Adults
Children
Adults
Children
Adults
Isoniazid
10-20 mg/kg
Max. 300 mg
5 mg/kg
Max. 300 mg
20-40 mg/kg
Max. 900 mg
15 mg/kg
Max. 900 mg
20-40 mg/kg
Max. 900 mg
15 mg/kg
Max. 900 mg
Rifampin
10-20 mg/kg
Max. 600 mg
10 mg/kg
Max. 600 mg
10-20 mg/kg
Max. 600 mg
10 mg/kg
Max. 600 mg
10-20 mg/kg
Max. 600 mg
10 mg/kg
Max. 600 mg
Pyrazinamide
15-30 mg/kg
Max. 2 gm
15-30 mg/kg
Max. 2 gm
50-70 mg/kg
Max. 4 gm
50-70 mg/kg
Max. 4 gm
50-70 mg/kg
Max. 3 gm
50-70 mg/kg
Max. 3 gm
Ethambutol§
15-25 mg/kg
Max. 2.5 gm
15-25 mg/kg
Max. 2.5 gm
50 mg/kg
Max. 2.5 gm
50 mg/kg
Max. 2.5 gm
25-30 mg/kg
Max. 2.5 gm
25-30 mg/kg
Max. 2.5 gm
Streptomycin
20-30 mg/kg
Max. 1 gm
15 mg/kg
Max. 1 gm
25-30 mg/kg
Max. 1.5 gm
25-30 mg/kg
Max. 1.5 gm
25-30 mg/kg
Max. 1 gm
25-30 mg/kg
Max. 1 gm
* Children 12 years of age or less.
§ Ethambutol is generally not recommended
for children whose visual acuity cannot be monitored (< 6 years of age). However, ethambutol should be considered for all children with organisms resistant to other drugs, when susceptibility to ethambutol has been demonstrated, or susceptibility is likely.
SOURCE: Centers for Disease Control and Prevention (1993).
Table 2. Behavioral and other risk indicators for HIV infection
Behavioral risks for acquiring HIV infection by sexual transmission:
Unprotected oral, vaginal, or anal sex with anyone who has risk factors for HIV or with multiple partners
Unprotected sex with an infected person
A man having oral or anal sex with another man
History of exchanging sex for drugs or money
Presence of any sexually transmitted disease
History of incarceration, with sexual contact with a man
Having lived in, or having a sexual partner from, an area where HIV is endemic, such as the Caribbean basin - especially Haiti - and sub-Saharan Africa
Risk indicators for acquiring HIV infection by parenteral transmission:
A history of intravenous or injection drug usage, especially if needles or other drug paraphernalia have been shared
Recipient of blood or blood product transfusions, especially between 1978 and 1985 (includes hemophiliacs, persons with sickle cell disease, and persons undergoing surgery for trauma or other reasons)
Recipients of organ transplants prior to 1985
Health care workers exposed to blood or bodily secretions from HIV-infected persons
Table 3. Clinical manifestations often associated with HIV infection
(The associated signs and symptoms are neither unique to HIV infection nor diagnostic of HIV infection. Findings of these signs or symptoms should alert the caregiver to the possibility of HIV.)
Fever
Unexplained weight loss; loss of appetite
Night sweats
Malaise, myalgias, arthralgias
Cough, shortness of breath
Swollen lymph nodes
Visual changes, including visual field defects
Recurrent or persistent sinusitis
Abdominal pain, diarrhea
Persistent, recurrent Candida vaginitis in women
Cervical/vaginal dysplasia
Neurologic conditions: headaches; difficulty in concentrating; short-term memory loss; pain in extremities, especially feet; photosensitivity; focal neurologic deficits (problems with balance, muscle strength, grasp)
Easy bruising or abnormal bleeding associated with low platelets
Dermatologic conditions
Folliculitis
Molluscum contagiosum
Condyloma acuminata (genital warts)
Herpes simplex: oral, genital, rectal
Rash
Herpes zoster (shingles)
Fungal dermatitis: tinea cruris (jock itch), tinea pedis (athlete's foot); fungal infection of nails, especially toenails
Seborrheic dermatitis: especially of face, scalp
Psoriasis
Nonspecific pruritic rashes
Drug eruption
Kaposi's sarcoma
Oral cavity
Oral lesions; periodontitis, gingivitis
Thrush: Candida infection of tongue, oropharynx
Kaposi's sarcoma: purple maculopapular lesions (especially hard palate)
Hairy leukoplakia: plaques, especially lateral border of tongue
Check for G-6-P-D deficiency; contraindicated if G-6-P-D deficient. Rash, nausea, hemolytic anemia, and methemoglobinemia with or without G-6-P-D deficiency.
Pyrimethamine-dapsone
75 mg pyrimethamine plus200 mg of dapsone once a week
See side effects for dapsone; pyrimethamine: folic acid deficiency, leukopenia, anemia, pancytopenia, nausea, vomiting. Rarely headache, ataxia, tremors, seizures, fatigue, insomnia.
Table 7. Recommended prophylaxis against Mycobacterium avium complex infection for adults and adolescents with HIV infection
Mycobacterium avium complex (MAC) bacteremia or disseminated disease occurs frequently in HIV-infected persons with a CD4 count < 100 cells/mm3.
As prophylaxis against MAC, consideration should be given to instituting lifelong treatment with rifabutin#&151;150 mg orally twice a day.
Side effects of rifabutin include rash, diarrhea, low white blood cell count, low platelet count, increased liver enzymes, especially SGOT.
Drug interactions: rifabutin may alter the metabolism of oral contraceptives, methadone, phenytoin (Dilantin), and AZT.
Women using oral contraception as a form of birth control should be advised to also use barrier contraception while on rifabutin and be advised of the risk of becoming pregnant.
Persons on methadone maintenance may need to have their methadone dosage adjusted to prevent withdrawal symptoms.
Table 2. Percentage of patients with positive serologic test results in untreated syphilis
Stage of Disease
Primary
Secondary
Latent
Late
VDRL
59--87
100
73--91
37--94
FTA--ABS
86--100
99--100
96--99
96--100
MHA-TP
64--87
96--100
96--100
94--100*
*Includes some patients whose treatment status is unknown
SOURCE: Jaffe, H.W., and Musher, D.M. Management of the reactive syphilis serology. In: Holmes, K.; Mardh, P.; Sparling, P.; Wiesner, P.; Cates, Jr., W.; Lemon, S.; and Stamm, W. Sexually Transmitted Diseases. 2d. ed. New York: McGraw-Hill, 1990, p. 935. Copyright 1990. Reprinted with permission of McGraw-Hill, Inc.
Table 5. Recommended treatment regimen for neurosyphilis
Aqueous penicillin G, 24 million units per day intravenously for 10 days; followed by benzathine penicillin G, 2.4 million units intramuscularly weekly for 3 weeks
or
Procaine penicillin G, 2.4 million units per day intramuscularly for 10 days; plus probenecid, 500 mg orally four times a day (every 6 hours) for 10 days; followed by benzathine penicillin G, 2.4 million units intramuscularly weekly for 3 weeks
Treatment for the penicillin-allergic patient:
Desensitization to penicillin in an outpatient or hospital setting with expert advice
Table 6. Recommended treatment regimens for HIV-infected persons
Penicillin is the recommended treatment for all stages of syphilis
For the penicillin allergic patient, densensitization to pencillin is recommended
Treatment of primary and secondary syphilis
Benzathine penicillin G, 2.4 million units (mu) intramuscularly (IM) once
Treatment of early or late latent syphilis
CSF examination before treatment
For patient with normal CSF: Benzathine penicillin G, 7.2 mu (as 3 weekly doses of 2.4 mu each week)
For patient with CSF consistent with neurosyphilis (i.e., CSF leukocyte count greater than 5 WBC/mm3; elevated CSF protein; reactive CSF-VDRL; or reactive CSF FTA-ABS) see table 5 for treatment recommendations for neurosyphilis
Table 1. Guidelines for health care providers exposed to bloodborne pathogens
In accordance with OSHA rules and regulations, the following rules apply for health care workers doing phlebotomy:
Disposable (single use) gloves must be made available to all health care workers.
Contaminated needles and other sharps shall not be recapped or removed, unless no alternative is feasible.
Any recapping or needle removal must be done with a mechanical device or one-handed technique.
Any contaminated needle or sharp that is being disposed of must be placed in an appropriate, approved disposal that is readily available.
Gloves shall be worn when it is anticipated that the employee may have contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin; when performing vascular access procedures including phlebotomy; and when handling or touching contaminated items or surfaces.
Employers must implement and enforce the OSHA Rules and Regulations (Part 1910 of title 29 CFR, Section 1910.1030 - Bloodborne Pathogens).
Table 2. Risk factors for acquisition of viral hepatitis B
Multiple sexual partners (heterosexuals, homosexuals, or bisexuals)
Use of injection drugs, especially with multiple partners
Household contacts of HBV carriers
Use or sharing of contaminated needles, syringes, and other drug paraphernalia
Hemodialysis patients
Perinatal exposure to HBsAg-positive mother
Workers at occupational risk, especially health care workers and public safety workers exposed to blood in the workplace
Inmates of long-term correctional facilities
Patients and staff members in institutions for the developmentally disabled
Persons born in or having resided in parts of the world where hepatitis B infections are endemic, such as Southeast Asia, Africa, the Republic of China, the People's Republic of China, the Amazon Basin, and Alaska (among Alaskan Natives)
Table 7. CDC recommendations for hepatitis B prophylaxis following percutaneous exposure
Prophylaxis of sex partners of persons with HBV infections should include the following:
Test exposed person for anti-HBc.
If the test is negative, the following are recommended:
If the sex partner has acute HBV infection, the exposed person should receive a single dose of HBIG (0.06 mL/kg) and the first dose of the hepatitis B vaccine. The vaccine may be given simultaneously with HBIG but not at the same injection site.
If the sex partner is a chronic carrier (HBsAg positive), the exposed person should receive the hepatitis B vaccine series.
Prophylaxis of household contacts of persons with acute hepatitis B infection should include the following:
An infant less than 12 months of age exposed to a primary caregiver with acute HBV should be given HBIG (0.5 mL) and hepatitis B vaccine.
Household contacts other than exposed infants should receive HBIG (0.06 mL/kg) and hepatitis B vaccine only if they have had potential or known exposure to the blood of the actively infected person (i.e., sharing toothbrushes or razors).
If the person with acute HBV infection becomes a chronic carrier (HBsAG positive after 6 months), all household contacts should receive HB vaccine.
Current CDC guidelines call for all infants to be vaccinated for HBV, regardless of the HBsAg status of the mother. Any infant born to a mother known to be HBsAg positive should begin the vaccine series and receive hepatitis B immune globulin within 12 hours of delivery. If the HBsAg status of the mother is unknown at the time of delivery, the infant should receive the initial vaccine dose within 12 hours of birth. If the mother is found to be HBsAg positive, HBIG should be administered as soon as possible and not later than 1 week after birth.
Table 1. Recommended treatment regimen for uncomplicated urethral, cervical, rectal, or pharyngeal gonorrhea
Ceftriaxone 125 mg intramuscularly in a single dose or one of the following:
Cefixime 400 mg orally in a single doseor
Ofloxacin 400 mg orally in a single doseor
Ciprofloxacin 500 mg orally in a single doseor
Spectinomycin 2.0 gm intramuscularly in a single dose
For patients treated with these regimens, routine followup culture is not necessary. The patients should be reevaluated after 1 to 2 months for possible treatment failure or reinfection.
Concurrent treatment for chlamydia: doxycycline 100 mg orally two times a day for 7 days or azithromycin 1 g orally once.
Table 2. Recommended treatment for chlamydia in pregnancy
Recommended regimen:
Erythromycin base 500 mg orally four times a day for 7 days
or
Erythromycin base 250 mg orally four times a day for 14 days or
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
or
Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days
Note: Tetracycline, doxycycline, and the quinolones, including ofloxacin, should not be given during pregnancy. Erythromycin estolate is contraindicated during pregnancy because of drug-related hepatotoxicity. In women of childbearing potential, a pregnancy test should be done prior to prescribing these drugs. The safety and efficacy of azithromycin for pregnant and lactating women has not been established.
If erythromycin is not tolerated, an effective regimen may be:
Amoxicillin 500 mg orally three times a day for 7 days
Followup cultures to test for cure should be done on all pregnant women 3 or more weeks after therapy, especially if the amoxicillin regimen is used.
Table 1. Recommended treatment regimens for herpes simplex
First Clinical Episode
Acyclovir (Zovirax) 200 mg orally five times a day for 7 to 10 days or until clinical resolution occurs.
Herpes proctitis or severe infection may require higher doses of oral or intravenous acyclovir.
Topical acyclovir is not effective and should not be prescribed.
Recurrent Episodes
Persons with severe recurrent episodes of herpes may benefit from treatment with acyclovir if the drug is begun during the prodrome or within 2 days of the onset of lesions.
For persons with frequent recurrences of herpes infections (more than six per year), suppressive treatment with acyclovir 400 mg orally twice a day or 200 mg orally two to five times a day for most persons will decrease the frequency and severity of recurrent genital herpes.
For persons with chronic and refractory herpes who were HIV negative in the past or whose HIV status is unknown, HIV testing should be done, as they may be HIV infected.
After 1 year of suppressive therapy, the acyclovir should be discontinued, since some persons have no recurrences or have only rare and mild recurrences of HSV infection.
For HIV-Infected Persons
HIV-infected persons may not respond as well to suppressive treatment for recurrent episodes of genital herpes as persons who are not HIV infected. HIV-infected persons may need more prolonged treatment and require higher or increased doses of acyclovir to control the herpes infection.
HIV-infected persons who fail to respond to acyclovir may have developed acyclovir-resistant herpes, and they must be referred to a physician or hospital.
Acyclovir-resistant herpes requires treatment with intravenous foscarnet.
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