Adult Care - Chapter 11 - Communicable Diseases

First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care.

The content of this chapter was revised in February 2017.

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Table of contents

Introduction

Communicable diseases common in children and adults

For information about communicable diseases more commonly seen in children, but also seen in adults, refer to the “Communicable Diseases” chapter of the FNIHB Pediatric and Adolescent Care Clinical Practice Guidelines. The section covers the following topics:

  • Chickenpox (varicella)
  • Diphtheria
  • Erythema Infectiosum (Fifth Disease)
  • Measles (Rubeola)
  • Mumps (Parotitis)
  • Pertussis (Whooping Cough)
  • Pinworms
  • Roseola Infantum
  • Rubella (German Measles)
  • Scarlet Fever
  • Tuberculosis
  • Meningitis

Immunization

Immunization represents the single most important preventative measure for many communicable diseases. Immunizations are safe and effective and represent a cornerstone of public health. They make a significant contribution to the control of infectious diseases in Canada. Immunizations are for children, adolescents and adults alike. Lapses in immunization at any age represent a risk to the overall population. When a communicable disease is listed as vaccine preventable it is advisable for the nurse to thoroughly review the immunization records of the individual to ensure the series is complete and all vaccines were administered at correct intervals. For more information on specific immunization, refer to the Canadian Immunization Guide. Consult local, provincial/territorial vaccination schedules and regional protocols.

Assessment of communicable diseases

History of present illness and review of systems

When a communicable disease is suspected, a thorough history is essential. Because microorganisms can affect every system, a thorough review of every body system is indicated. Some of the more common symptoms are detailed below. 

The following points should be emphasized:

  • Onset (date and time) and duration of illness
  • Fever, chills or rigors
  • Pain
  • Rash: site, colour, consistency
  • Involvement of mucous membranes or conjunctiva
  • Coryza (head cold)
  • Cough
  • Sore throat
  • Vomiting
  • Diarrhea
  • Level of consciousness
  • Seizures
  • Contact with a person with similar symptoms or known communicable disease
  • Travel history (specifically, recent travel to an area where a communicable disease is endemic)
  • Dietary history: raw fish, raw or undercooked meat

Physical examination

Many communicable diseases affect more than one body system, so a thorough head to toe examination is indicated. The most common signs are detailed below.

Vital signs
  • Temperature
  • Heart rate
  • Respiratory rate
  • Oxygen saturation
  • Blood pressure
Inspection
Palpation
  • Neck for rigidity
  • Tactile characteristics of rash
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Joint movement
  • Skin turgor and hydration
Auscultation (heart and lungs)
  • Breath sounds
  • Crackles
  • Wheezing
  • Stridor
  • Heart sounds
  • Pleural or pericardial rubs
  • Murmurs

Common Communicable Diseases

Botulism

Overview

Please refer to Provincial/territorial guidelines for Botulism where available.

Botulism is a neuroparalytic disease caused by a neurotoxin that is produced by the bacterium Clostridium botulinum (C. botulinum).Footnote 1 Botulism develops if a person ingests the toxin or if the organism grows in the intestines or wounds and toxin is released. For recommended practices related to the reporting of botulism, see Provincial/territorial guidelines in Appendix, Section B of this guideline.

Botulism is a serious illness that should be treated as a medical emergency and may require medical evacuation based on clinical acuity. Consult with physician/nurse practitioner immediately when there is suspicion of botulism.

  • There are four naturally occurring forms of botulism:Footnote 1Footnote 2
    • Foodborne botulism
    • Adult intestinal colonization botulism
    • Infant botulism
    • Wound botulism
  • Untreated, botulism can have a case fatality rate of 40 to 50%Footnote 3
Causes

Foodborne botulism

  • Caused by the ingestion of preformed botulinum toxin in contaminated food or drinkFootnote 1

Adult intestinal colonization botulism

  • Occurs when C. botulinum germinates and produces toxin in the digestive system
  • Affects adults with altered gastrointestinal anatomy and/or microflora (e.g., those who have had previous intestinal surgery, inflammatory bowel disease, Crohn’s disease, recent antibiotic therapy or immunocompromised condition)Footnote 1Footnote 4Footnote 5

Infant botulism

  • Caused by the ingestion of C. botulinum spores. These germinate in the intestine and produce bacteria that releases botulinum toxin
  • Source rarely determined, but instances have been related to honeyFootnote 6

Wound botulism

  • Rare and results when a wound becomes infected with C. botulinum. This results in the production of toxin, which is absorbed systemically
  • Occurs almost exclusively with intravenous drug use (e.g., black tar heroin)Footnote 7Footnote 14
Transmission

Secondary person-to-person transmission of botulism does not occurFootnote 7

Incubation period

Foodborne botulism

  • Symptoms usually begin 12 to 36 hours after eating contaminated food, with a presentation range of 6 hours to 10 days after ingestionFootnote 1

Adult intestinal colonization botulism

  • Incubation period is unknownFootnote 14
  • Infant botulism
  • Incubation period is estimated to be 3 to 30 daysFootnote 2
  • Wound botulism
  • Incubation period averages 4 to 14 daysFootnote 2

Assessment

Medication review: Review current medications and over-the-counter, complementary and alternative medicines, including any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Table 4: Point-of-c
Risk factors
  • Improperly prepared fish, land and marine mammals (i.e., raw, partially cooked, smoked or fermented)Footnote 8
  • Improperly prepared home-canned, low acid foods (e.g., corn, green beans, peas, asparagus, beets, mushrooms, spaghetti sauce, salmon, tuna, salted fish)Footnote 7Footnote 9
  • Improperly prepared meat products, such as ham and sausageFootnote 7
  • Improperly stored low-acid fruit/non-fruit juices (e.g., carrot juice)Footnote 9
  • Leftover baked potatoes stored in aluminium foil for more than 2 hours at room temperatureFootnote 8Footnote 9
  • Ingestion of honey by infants under 1 year of age (honey has been linked to cases of infant botulism and should not be ingested by infants under 1 year)Footnote 2Footnote 9
History of present illness
  • Review Risk factors and collect History of present illness (for additional information on symptoms of the different forms of botulisms, see Table 1: History of present illness Symptoms)
  • Determine toxin source (e.g., food sources, wound)
  • Ask client about dietary, travel, activity and work history (e.g., working in a laboratory, abbatoir, etc.), as well as history of injection drug use
  • Obtain a food history for the entire suspected Incubation period
  • Ask whether close contacts have shared the same foodsFootnote 10
Table 1: History of present illness symptomsFootnote 1Footnote 6
Foodborne, adult intestinal, and wound botulism Infant botulism
Foodborne, adult intestinal and wound botulism
  • May have history of fatigue, weakness, vertigo, nausea, vomiting and/or diarrhea, abdominal cramps initially.
  • Visual disturbance
  • Dysphagia
  • Dry mouth and dysphonia
  • Constipation is a common symptom later in presentation
Wound botulism only
  • History of a wound; symptoms as above, however, no gastrointestinal symptoms
  • Clinical symptoms usually start with constipation
  • Loss of appetite
  • Drooling
  • Weak suck
  • Weak cry or voice
  • Infant and/or infant’s head is ‘floppy’
Physical findings

Perform a physical examination using the IPPA approach.

  • Include cranial nerve palsies with full neurological assessment
  • All forms of botulism produce the same distinct clinical syndrome of symmetrical cranial nerve palsies followed by descending, symmetric flaccid paralysis of voluntary muscles
  • For more information on the function of each cranial nerve, see Table 3: Cranial nerves and function in Appendix, Section A of this guideline
  • Client is usually afebrileFootnote 1
  • Client may have any of the following cranial nerve palsy manifestations:Footnote 1
    • Ptosis
    • Visual disturbance
    • Dilated and sluggishly reactive/fixed pupils
    • Facial paralysis, expressionless facies
    • Dysphonia
    • Dysphagia
    • Dysarthria
    • Weak voice
    • Paralysis of the diaphragm and accessory muscles, which may result in respiratory compromise or arrest
  • Additional findings related to infant botulism may be:
    • Disconjugate gaze
    • Weak cry/suck
    • Decreased anal sphincter control
    • Hypotonia
    • Significant loss of head control

Wound botulism may appear as a wound or dermal abscess and may resemble mild cellulitisFootnote 6

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Table 2: Differential diagnosis for BotulismFootnote 1Footnote 11Footnote 12
General Additional differential for infant botulism
  • Guillain-Barré syndrome
  • Myasthenia gravis
  • Poliomyelitis and other enterovirus paralytic infections
  • Stroke
  • Paralytic shellfish poisoning
  • Tick paralysis
  • Toxic exposures (organophosphates, atropine, carbon monoxide, aminoglycosides)
  • Electrolyte-mineral imbalance
  • Meningitis
  • Neuromuscular disorders and muscular disorders (e.g., congenital myopathy)
  • Metabolic encephalopathy
  • Reyes syndrome
  • Sepsis
Complications
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Laboratory
  • Testing should be carried out as per provincial/territorial or BRS policies and procedures, which will provide guidance on client specimen collection and retrieval of food samples for lab analysis.
  • Botulinum toxin may be detectable in serum, stool, gastric aspirate or food
  • For specimen collection:Footnote 1
  • Consult Environmental Health Officer (EHO) for guidance on retrieval of food sample
  • Collect client specimens as per guidance provided by the BRS (or alternate)

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment
  • Prevent complications
  • Provide supportive care
  • Investigate promptly to determine whether a common source outbreak has occurred
Non-Pharmacological interventions
  • The client with clinical signs, symptoms, or history suspicious for botulism may require intensive care and monitoring for signs of respiratory failureFootnote 6Footnote 9
  • Position client for maximal comfort and to optimize respiratory function
  • Client should not lie flat
  • Provide oxygen if indicated
  • Prepare to provide ventilatory support if client experiences respiratory failure
  • Maintain client NPO
  • For wound botulism, wound debridement, drainage and irrigation may be requiredFootnote 14
Client education

Inform client and family about ways to prevent foodborne illnesses.

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

IV therapy
Potential pharmacological interventions
  • Consult with Public Health Physician and Infectious Diseases Specialist as per provincial/territorial policies and procedures
  • The only available treatment for botulism is the administration of botulism antitoxin or immune globulin, which can arrest the progression and duration of paralysis and dependence on mechanical ventilation
  • If treatment is required, arrange for medical evacuation as soon as possible
Foodborne Botulism
  • Within 1 hour of ingesting suspected food, administer the following:
  • Gastric lavage
  • Enema
  • Cathartic agent (e.g., sorbitol, polyethylene glycol (PEG))Footnote 14
Wound Botulism

Monitoring and Follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring
  • Monitor vital signs and respiratory status, including oxygen saturation as indicated by client’s condition.Footnote 1
  • Monitor for cranial nerve palsiesFootnote 1
  • Monitor intake and output
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
Follow-up
  • Physician/nurse practitioner to be guided by BRS and EHO for investigation of food source and tracing of other persons who consumed the same sources of suspect foods
Referral

Arrange for medical evacuation if clinically indicated.

Reporting
  • Botulism is reportable. Follow provincial/territorial policies and procedures for notifiable diseases. For more information, see Provincial/territorial guidelines in Appendix, Section B of this guideline

Appendix

Section A: Supplemental clinical management information
Table 3: Cranial nerves and functionsFootnote 15
Cranial nerve Function
I Olfactory Sense of smell
II Optic Vision
III Oculomotor Motor control of some eye muscles and eyelid
IV Trochlear Motor control of some eye muscles
V Trigeminal Chewing muscles and facial sensation
VI Abducens Motor control of some eye muscles
VII Facial Motor control of some facial muscles, salivation, taste and cutaneous sensations
VIII Vestibulocochlear Equilibrium, sense of balance and hearing
IX Glossopharyngeal Tongue and pharyngeal
X Vagus Motor control of heart and viscera, sensation from the throat, pharynx and abdominal viscera
XI Accessory Motor supply to sternocleidomastoid and trapezius
XII Hypoglossal Motor supply to the tongue
Progression of nerve paralysis in botulism and cranial nerve palsiesFootnote 16
  • Cranial nerve palsies are characteristically followed by flaccid descending, completely symmetrical paralysis of voluntary muscles
  • The extent of paralysis (from a few cranial nerves only, to quadriplegia) depends on the toxin dose
  • Paralysis of the diaphragm and accessory breathing muscles may result in respiratory compromise or arrest and death
  • Pharyngeal collapse secondary to cranial nerve paralysis may compromise the airway and may require intubation in the absence of respiratory muscle compromise
  • Botulism ranges from a mild condition to severe disease that can result in death within 24 hours
Prevention

The following information may be useful to the client in preventing botulism:Footnote 17

Appearance

  • Foods contaminated with C. botulinum toxin might look, smell and taste normal. The spores of C. botulinum are not necessarily destroyed by cooking

Canning or bottling low-acid foods at home

  • Use up-to-date recipes and equipment, and follow all instructions carefully
  • Boil home-canned foods for 10 minutes before eatingFootnote 18
  • Keep all work surfaces, food, utensils, equipment, and hands clean during all stages of the canning process
  • Date and label all preserves and canned goods

Honey

  • Don’t give honey (even pasteurized honey) to children under 1 year old
  • Healthy children over 1 year of age can safely eat honey because they have a very low risk of developing infant botulism

Canned foods

  • Avoid eating food from cans that are damaged

Aluminum foil for cooking and storing

  • Do not use aluminium foil to wrap potatoes or other vegetables for baking, unless the vegetables will be cooked and eaten right away
  • If you want to store them after they have been cooked, unwrap and refrigerate them right away

‘Keep Refrigerated’ label

  • Store all low-acid juices (like carrot juice) and other products labelled ‘keep refrigerated’ in the refrigerator

Home-prepared foods stored in oil

  • Be careful with home-prepared foods stored in oil (like garlic, vegetables, herbs and spices)
  • If these products are prepared using fresh ingredients, they must be kept refrigerated and be used within 10 days

Check with EHO for additional information available about food safety including information sessions and courses on safe food handling. For more information on how to prevent botulism infection, see Prevention in Appendix, Section A of this guide.

Section B: Supplemental resources
Provincial/territorial guidelines

Alberta

Alberta Health and Wellness. Public Health Notifiable Disease Management Guidelines: Botulism.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Management of Specific Diseases: Botulism. (PDF, 171 Kb, 14 pages)

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Botulism. (PDF, 514 Kb, 11 pages)

Nova Scotia

Nova Scotia Department of Health and Wellness. Nova Scotia Communicable Disease Manual: Botulism. (PDF, 66 Kb, 6 pages)

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. By selecting HSS Professionals (staff only) and entering authorized username and password.

Newfoundland and Labrador

Department of Health and Community Services. Newfoundland and Labrador Disease Control Manual: Section 2 Enteric, Food and Waterborne Diseases.

Ontario

Ontario Ministry of Health and Long-Term Care. Diseases and Conditions: Botulism Guide for Health Care Professionals. (PDF, 455 Kb, 16 pages)

Yukon

Yukon Health and Social Services. Yukon Communicable Disease Control: Botulism.

Other resources

Botulism (Clostridium botulinum): How do I avoid getting sick?

Food safety for First Nations People of Canada: A Manual for Healthy Practices.

Food Safety for First Nations.

Home Canning Safety.

Home canning, bottling of seafood.

Food safety.

Safe Food Handling Tips.

Bibliography

The following references and other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Canadian Pharmacists Association. Compendium of Therapeutic Choices: Canada’s Trusted Reference for Primary Care Therapeutics (CTC 7). Ottawa: Canadian Pharmacists Association; c2014.

Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Gastroenteritis

Overview

Please refer to Provincial/territorial guidelines for Gastroenteritis where available.

Gastroenteritis represents the inflammation of the stomach and intestines. It causes diarrhea, vomiting, abdominal pain, and cramping. Infectious gastroenteritis is caused by viruses, bacteria, or parasites. Other causes of gastroenteritis are drugs and chemical toxins (e.g., metals such as lead, plant substances).Footnote 19

Gastroenteritis is generally caused by the consumption of contaminated food or water, or by contact with the feces of infected humans or animals.Footnote 19

Diarrhea is the presence of 3 or more abnormally loose or watery stools in the preceding 24 hours.Footnote 20

  • Acute diarrhea: 14 days or less in durationFootnote 21
  • Persistent diarrhea is an acute episode of diarrhea lasting more than 14 daysFootnote 21
  • Dysentery is the presence of visible blood in stoolsFootnote 20
Causes

See the following tables in the Assessment section of this guide:

BacteriaFootnote 19Footnote 20Footnote 22
  • Nontyphoidal Salmonella species, Campylobacter species, Escherichia coli 0157:H7 (E. coli), Shigella
  • Clostridium difficile (C. difficile) is the main cause of nosocomial antibiotic-associated diarrhea.
ParasitesFootnote 22
  • Giardia intestinalis (also known as Giardia lamblia and Giardia duodenalis) and Cryptosporidiosis
  • Other parasites include Cyclospora, and Dientamoeba fragilis
VirusesFootnote 19Footnote 22
  • Rotavirus, norovirus

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine when and what type of reaction occurred.

Risk factors
  • The elderly, young children, pregnant women, and immunocompromised individuals are at greater risk of experiencing severe infection and complications from gastroenteritis.Footnote 20Footnote 25
History of present illness

Review Risk factors and collect History of present illness.

  • Diarrhea (record onset), stool frequency, consistency and volume, presence of blood or mucousFootnote 20Footnote 22Footnote 23
  • Anorexia, vomitingFootnote 19
  • Abdominal discomfortFootnote 19
  • Epidemiologic clues (e.g., exposure to unsafe foods, untreated water, animals or ill persons, daycare, travel history, recent use of antimicrobials, history of oral-anal sexual activity)Footnote 23Footnote 24
Physical findings

Note: Vomiting and diarrhea may cause fluid deficits and electrolyte disturbances. In severe cases, fluid depletion may result in hypotension and tachycardia.Footnote 19 Medical evacuation may be required.

Table 1: Campylobacteriosis, nontyphoidal salmonellosis, e. coli
Characteristics Campylobacteriosis Non-typhoidal salmonellosis E. coli (EHEC,** STEC***)
Transmission
  • Ingestion of contaminated food or water
  • Food preparation
  • Contact with infected animals and their feces
  • Person-to-person is occasional (young children, neonate of infected mother)Footnote 25
  • Fecal-oral
  • Ingestion of contaminated food or water
  • Food preparation
  • Improperly cooked food
  • Contact with infected animals and their feces
  • Person-to-person
  • Fecal-oralFootnote 26
  • Ingestion of contaminated food or water
  • Food preparation
  • Person-to-personFootnote 27
  • Fecal-oral
High risk foods
  • Raw or undercooked poultry, beef, pork, lamb
  • Raw eggs
  • Unpasteurized milk and milk products
  • Raw vegetables
  • Shellfish
  • Untreated waterFootnote 25
  • Poultry, beef, eggs
  • Dairy products
  • Unpasteurized milk and milk products
  • Raw fruits and vegetables (e.g., sprouts, cantaloupes and their juices)
  • Homemade products (e.g., salad dressings, hollandaise sauce, mayonnaise)
  • Ice cream, cookie dough, frostingsFootnote 26
  • Raw beef
  • Undercooked ground beef
  • Raw fruits and uncooked vegetables (e.g., sprouts and raw leafy vegetables)
  • Untreated drinking water
  • Unpasteurized milk and milk products, including raw milk cheese, unpasteurized apple juice or ciderFootnote 27
Communicability Low: person-to-person transmission occurs occasionallyFootnote 28
  • For as long as it is excreted in the feces.
  • Some carriers shed the bacteria for years.Footnote 29
  • For as long as it is excreted in the feces (7-9 days)
  • Some children: up to 21 daysFootnote 27
Incubation period 1-10 daysFootnote 25 6-72 hoursFootnote 26 1-10 daysFootnote 27
Physical findings
  • Diarrhea (blood or mucus)
  • Abdominal pain
  • Nausea and vomiting
  • Malaise
  • Fever
  • May be dehydratedFootnote 25
  • Diarrhea
  • Abdominal cramps
  • Nausea and vomiting
  • Headache
  • Fever up to 39˚C and chills
  • Dysentery (multiple small, bloody mucoid stools with tenesmus*) is uncommonFootnote 26
  • Severe abdominal cramps and pain
  • Diarrhea, initially watery (bloody after 2-3 days)
  • Vomiting
  • No fever or low-grade fever (usually less than 38.5˚C)
  • DehydrationFootnote 27Footnote 30
Complications
  • Reactive arthritis
  • Meningitis
  • Guillain-Barré syndrome
  • Chronic colitis
  • Sudden gallbladder inflammation
  • Irritable bowel syndrome
  • Myocarditis
  • PericarditisFootnote 25
  • Bacteremia
  • Serious illness
  • Sometimes death
  • Reactive arthritisFootnote 26
* Tenesmus is feeling the need to pass stools; may involve straining, pain and cramping.
** EHEC: Enterohemorrhagic E. coli
*** STEC: Shiga toxin-producing E. coli
Table 2: Shigellosis, c. difficile
Characteristics Shigellosis (bacterial) C. difficile
Transmission
  • Fecal-oral
  • Ingestion of contaminated food or water (or water in swimming pools)
  • Food preparation
  • Person-to-person (anal sexual activity)
  • Flies may be a vectorFootnote 32
Risk factors
  • Foods exposed through handling
  • Foods exposed through polluted water
  • Contaminated water/swimming pools
  • Risk factors:
  • Caregivers of affected children
  • Living in crowded conditions
  • Men who have sex with men
  • Unsanitary conditions and limited clean waterFootnote 32Footnote 35
  • Antibiotics (e.g., amoxicillin, ampicillin, clindamycin, cephalosporins, floroquinolones)
  • Multiple and/or longer duration of antibiotics
  • Proton pump inhibitor (PPI) therapy
  • Immunocompromised condition
  • Severe underlying illness
  • Antineoplastic agents, antivirals and narcotics
  • Hospitalization
  • Nursing home/Long-term care stayFootnote 33Footnote 34
Communicability
  • As long as the organisms are present in excrement
  • The carrier state usually ceases within 1-4 weeks after onset of illnessFootnote 32
  • Depends on amount of toxin in the stool; may persist for weeks
  • Nosocomial transmission from contaminated hands, instruments and environmentFootnote 36
Incubation period 1-7 daysFootnote 32 1 day to several weeks following antibiotic treatment for associated antibiotic diarrheaFootnote 33
Physical findings Symptoms range from mild watery diarrhea with minimal or no symptoms, to severe symptoms:
  • Mucoid stools with or without blood
  • Nausea
  • Vomiting
  • Loss of appetite
  • Abdominal cramps (may be severe)
  • Tenesmus*
  • Fever
  • Hypoglycemia occurs more frequently than in other types of diarrheal diseaseFootnote 32Footnote 35
  • Watery diarrhea (rarely bloody)Footnote 23
  • Diarrhea may range from a few days of intestinal fluid loss to life-threatening pseudomembranous colitis
  • Nausea
  • Loss of appetite
  • Abdominal cramps, pain/tenderness
  • Fever may be presentFootnote 33Footnote 34
Complications
  • Severe dehydration
  • Intestinal perforation, toxic mega colon
  • Septicemia
  • In children: seizures attributed to high fever and electrolyte abnormalities
  • Hemolysis
  • Hemolytic uremic syndrome
  • Reactive arthritisFootnote 32Footnote 35
  • Severe or life-threatening pseudomembranous colitis
  • Toxic megacolon
  • Intestinal perforation
  • Sepsis
  • Systemic inflammatory response syndrome (SIRS)
  • DeathFootnote 33Footnote 34
Table 3: Rotavirus, norovirus
Characteristics Rotavirus Norovirus
Transmission
  • Fecal-oral
  • Person-to-person or contact with contaminated environmental surfaces
  • Fecally contaminated food and waterFootnote 20Footnote 37
  • Fecal-oral
  • Person-to-person or contact with contaminated environmental surfaces, aerosolsFootnote 38
  • Fecally contaminated food and waterFootnote 20
Risk factors Rare: contaminated food, waterFootnote 37
Communicability Highly contagiousFootnote 23 Highly contagiousFootnote 23
Incubation period 1-8 daysFootnote 37 12-48 hours, may persist for 3 weeks or moreFootnote 38
Physical findings
  • Abrupt vomiting
  • Abdominal cramps
  • Nausea
  • Diarrhea, may be mucus in stool, dehydration
  • FeverFootnote 38
Complications DehydrationFootnote 20
Table 4: Giardiasis, cryptosporidiosis
Characteristics Giardiasis Cryptosporidiosis
Transmission
  • Fecal-oral
  • Contaminated food or water (or water in swimming pools)
  • Person-to-person (oral-anal sexual activity)
  • Soil and fomitesFootnote 39Footnote 40
  • Fecal-oral
  • Contaminated drinking water (or water in swimming pools)
  • Person-to-person
  • Contact with infected animal and their feces
  • Contaminated foodFootnote 41
Risk factors
  • Contaminated water
  • Contaminated swimming pools
  • Contaminated hands, food preparation
  • Oral-anal sexual activityFootnote 40
  • Increased crowding
  • Poor sanitary conditions
  • Immunocompromised individuals at risk for more severe and prolonged disease
  • More prevalent in childrenFootnote 41
Communicability
  • As long as the parasites are present in excrementFootnote 42
  • As long as the parasites are present in
    excrement
Incubation period
Physical findings
  • Sudden onset of watery diarrhea; stools are often foul smelling, may float, may be pale-coloured (steatorrhea stools)
  • Abdominal tenderness and cramps
  • Flatulence, eructation that smells sulphur-like
  • Weight loss
  • Signs of malnutrition
  • Low-grade feverFootnote 39
  • Scant or voluminous diarrhea; may be acute or chronic, transient, intermittent or continuous
  • Malaise
  • Nausea
  • Anorexia
  • Crampy abdominal pain
  • Low-grade fever
  • Weight loss in clients with chronic diarrheaFootnote 41
Complications
  • Dehydration
  • Intestinal malabsorption and weight loss
  • Anemia
  • Long-term complications (rare) include chronic fatigue syndrome, reactive arthritis, myopathy, irritable bowel syndrome, rash, urticariaFootnote 40
  • Dehydration
  • Persistent diarrhea
  • Intestinal malabsorption and weight loss
  • Biliary tract involvementFootnote 41
  • Respiratory involvementFootnote 43
Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Gastrointestinal: inflammatory bowel disease, appendicitis, intussusception, lactose intoleranceFootnote 40 or intestinal tapewormsFootnote 45
  • Other bacterial infections, e.g., listeriosis, YersiniosisFootnote 44Footnote 45
  • Food poisoning secondary to toxins, or toxin-mediated illnesses, e.g.:
    • Staphylococcus aureus and Bacillus cereus which may cause symptoms between 1 to 6 hours after a contaminated mealFootnote 45Footnote 46
    • Clostridium perfringens may cause symptoms within 8 to 16 hours of a contaminated mealFootnote 46
    • Shellfish and mushroom toxins may cause gastrointestinal and neurological disturbancesFootnote 45
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is to be based on client history, Risk factors, Physical examination findings and test availability.

LaboratoryFootnote 20Footnote 23Footnote 47

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

Recommended samples

  • Blood glucose
  • Electrolytes, BUN, creatinine may be consideredFootnote 19
  • If nosocomial diarrhea suspected (onset is more than 3 days after hospitalization), or if there has been recent antibiotic use (e.g., within last 3 months), stool for C. difficile cytotoxin assay for one sample
  • If a viral cause is considered, ensure samples are taken as per provincial/territorial policies and procedures
  • Ova and parasite testing may be considered for client at-risk for parasitic infection with Giardia and Cryptospiridium; cysts can be excreted intermittently; therefore, multiple stool collections are required to increase sensitivity (i.e., 3 stool samples for ova and parasites are to be collected on separate days)Footnote 42Footnote 43
  • Blood for culture and sensitivity (C+S) if immunocompromised or with severe infection
  • Stool for C+S if 6 or more unformed stools in 24 hours for greater than 5 daysFootnote 21Footnote 47
  • Consider collecting stools with diarrhea for less than 5 days’ duration if there are additional clinical considerations if the client:Footnote 21Footnote 47
  • Has severe, inflammatory diarrhea (including bloody diarrhea)
  • Has a temperature greater than or equal to 38.5˚C
  • Has a comorbid condition
  • Has a systemic illness with diarrhea, especially if pregnant
  • Is immunocompromised
  • Is of an advanced age

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

For more information on the management of gastroenteritis, see:

Goals of treatment
  • Manage dehydration
  • Relieve symptoms
  • Prevent complications
  • Prevent transmission of disease
Non-pharmacological interventions
Interventions
  • Weigh client and assess for degree of dehydration and shock (frequency depends on client’s condition)
  • Calculate known losses, PLUS maintenance fluids, PLUS replacement fluids. If the client is eating, calculate fluid intake at 75% of the total. For information about hourly maintenance fluid requirements in adults, see Table 6: Hourly Maintenance Fluid Requirements in Adults Weighing 20-80 kg (1 hour periods) in Appendix, Section A of this guideline
  • Encourage oral fluids and early feeding to reduce illness duration and to improve nutritional outcomes
Oral rehydration therapy (ORT)
  • For mild to moderate dehydration, ORT with a commercially available oral rehydration solution (e.g., Gastrolyte)Footnote 20Footnote 48
  • ORT is contraindicated in the initial management of severe dehydration.Footnote 20 Intravenous fluids are required for the client with severe dehydration and for the client who is unable to tolerate oral rehydration therapy
  • If client is able to take in oral fluids, offer small volumes of ORT frequently
Diet
  • Consumption of solid food should be guided by appetite.Footnote 20 Foods such as soups, crackers, rice, pasta, lentils, peas, mashed potatoes, breads, fresh fruits, lean meats, yogurt, and vegetables are all recommendedFootnote 48
  • When dehydration is corrected, encourage a regular diet as tolerated
  • Avoid carbonated drinks or commercial juices with a high concentration of simple carbohydrates.Footnote 48 Other drinks that do not contain caffeine or alcohol can also help with mild dehydration; however, these drinks may not replace the nutrients and minerals lost during illness
Client education
  • For information on preventing gastroenteritis, see Prevention in Appendix, Section A of this guideline
  • Educate client and family members on proper handwashing, including before and after preparing food, touching soiled material, or after using the washroom
  • Provide client/caregiver and family with food safety information (for more information, see Food Safety in Appendix, Section B of this guideline)
  • If the potential cause is a water-borne illness, recommend water purification by boiling all water used for drinking or cooking for one minute at a rolling boilFootnote 49
  • Educate client about the signs of dehydration and advise to return to the clinic if any signs occur
  • If metronidazole ordered, advise client to avoid alcohol during, and for 48 hours after completion of treatment
  • Counsel client about the appropriate use of medications; dose, frequency, importance of compliance, potential side effects and interactions

Note: Shigella infection is highly contagious; the client should not handle food, provide childcare, or care for others until Follow-up stool cultures are negative. A child who is sick with Shigellosis should be kept at home from daycare or school, and contact with other children should be reduced.

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

IV therapy

If a client is dehydrated on presentation, care consists of restoration of volume status through oral rehydration or IV administration of a crystalloid solution. For more information, see FNIHB Adult Care Clinical Practice Guidelines –Chapter 5 – Gastrointestinal System – Dehydration (Hypovolemia ).

Note: Anti-diarrheal agents such as loperamide or diphenoxylate-atropine (Lomotil) are not recommended. These agents slow bacterial clearance and prolong the exposure of bacteria to intestinal mucosa, thus increasing the risk of precipitating toxic megacolon or systemic illness. They are contraindicated in bloody or suspected inflammatory diarrhea (febrile clients).Footnote 20Footnote 50

Antibiotic therapy

Antibiotic therapy is usually not required or recommended. Consult with physician/nurse practitioner before initiating antibiotics.

Analgesic/antipyretic

Acetaminophen

  • Acetaminophen 325 to 650 mg PO q4-6h PRN
  • Maximum from all sources: acetaminophen 4,000 mg in 24 hours
Antiprotozoan for GiardiasisFootnote 42

Metronidazole

  • Metronidazole 250 mg PO TID for 5 days
Antinausea/antiemetic
  • DimenhyDRINATE (Gravol) 25 to 50 mg PO/IM/IV q4-6h PRN

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring
  • Monitor vital signs as indicated by client’s condition
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
Follow-up
  • Instruct client to return for Follow-up in 24-48 hours if symptoms are becoming worse or not improving
  • Household contacts or contacts may require assessment and may require stool samples based on provincial/territorial policies and procedures
  • For Giardia or Cryptospiridium infection, in addition to the initial three stool samples, repeat stool collection for ova and parasitology in 1-2 weeks to ensure resolution of infection or as per provincial/territorial policies and procedures
Referral

Arrange for medical evacuation if clinically indicated.

Reporting
  • Suspected and confirmed cases are to be reported to the provincial/territorial Public Health Physician as per provincial/territorial policies and procedures
  • If potential water contamination, notify the Environmental Health Officer/Water Technician for water sampling

Appendix

Section A: Supplemental clinical management information
Table 5: Physical findings in association with degree of dehydration (adult)
Clinical sign Mild dehydration Moderate dehydration Severe dehydration
Fluid loss (% of body weight) < 6 % 6 % to 10 % > 10 %
Radial pulse Normal Rapid, weak Very rapid, feeble
Respiration Normal Deep Deep, rapid
Systolic blood pressure Normal Low or orthostatic >10 mm Hg change Very low or undetectable
Skin turgor Retracts rapidly Retracts slowly Retracts very slowly
Eyes Normal Sunken Very sunken
Mentation Alert Restless Drowsy, comatose
Urine output Normal Scant Oliguria
Note: If dehydration is moderate to severe, there may be associated electrolyte disturbances.
Table 6: Hourly Maintenance Fluid Requirements in Adults Weighing 20-80 kg (1 hour periods)
Calculation
  • 4 mL/kg/hour for first 10 kg of body weight
  • Plus 2 mL/kg/hour for the next 10 kg of body weight (over the initial 10 kg of body weight)
  • Plus 1 mL/kg/hour for each kilogram over 20 kg of body weight
PreventionFootnote 34

Handwashing is one of the best ways to prevent the spread of foodborne illness. Ensure thorough hand washing with warm water and soap after using the washroom, after changing diapers and before preparing food. Ensure proper disposal of dirty diapers. For more information, see Food Safety - Public Health Agency of Canada.

Section B: Supplemental resources
Food safety
Fact Sheets

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources
  • Anti-infective Review Panel. Anti-infective Guidelines for Community-acquired Infections. Toronto: MUMS Guideline Clearinghouse. c2013.
  • Canadian Pharmacists Association. Dimenhydrinate (Gravol). Ottawa, ON: eTherapeutics; 2012. Available with authorized username and password.
  • Canadian Pharmacists Association. Compendium of Therapeutic Choices: Canada’s Trusted Reference for Primary Care Therapeutics (CTC 7). Ottawa: Canadian Pharmacists Association; c2014.
  • Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.
  • Dimenhydrinate. Hudson, OH: Lexi-Comp. Inc.; 2015. Available with authorized username and password.

Human immunodeficiency virus (HIV)

Overview

Please refer to Provincial/territorial guidelines for Human Immunodeficiency Virus where available.

Human Immunodeficiency Virus (HIV) is a chronic viral infection typically acquired by sexual contact. Among the Aboriginal population, injection drug use (IDU) accounts for a greater infection rate.Footnote 52 In self-identified Aboriginal youth, IDU accounts for most of the identified HIV cases.Footnote 53

HIV progresses over time, from the transmission phase to early infection, to chronic HIV and finally to Acquired Immunodeficiency Syndrome (AIDS), which results in the development of severe opportunistic infections due to immunocompromise.

Current antiretroviral therapy (ART) has significantly reduced the number of AIDS-related opportunistic infections (OIs) and deaths, improving life expectancy and quality of life for adults and children.

Pediatric HIV infection occurs almost exclusively through vertical transmission (i.e., mother-to-child). Advances in effective strategies to prevent this mode of transmission significantly reduces the risk to less than 2%.Footnote 54

Phases of HIV
Transmission
  • Viral acquisition through exposure to infected blood or body fluids. For more information, see Risk factors in the Assessment section of this guideline
Early HIV infectionFootnote 56
  • Refers to the first 6 months following viral acquisition when seroconversion occurs
  • Most clients are asymptomatic in early HIV

Acute symptomatic HIV infection

  • Clients may present with a mononucleosis-like syndrome (acute retroviral syndrome)Footnote 56
  • Typically, the Incubation period post-HIV exposure is 2 to 4 weeks, although it may take up to 10 months to exhibit symptomsFootnote 56Footnote 57
Chronic HIV infectionFootnote 58
  • Period following the first 6 months after viral acquisition
  • Clients may be initially asymptomatic, but usually have persistent lymphadenopathy
  • Gradual decline in immune function in most clients in the absence of treatment
AidsFootnote 58
Causes

Human Immunodeficiency Virus (HIV type 1)Footnote 57

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine when and what type of reaction occurred.

Risk factors

Note: A high index of clinical suspicion for HIV should be maintained when clients present with symptoms commonly associated with HIV infection as they may be reluctant to fully disclose their high-risk behaviours.Footnote 56

Sexual transmission risk factors
  • Viral load; an individual infected with HIV, with a higher viral load, is more likely to transmit the virusFootnote 58
  • Concomitant sexually transmitted infections (STIs); genital ulceration increases the risk of transmission four-foldFootnote 58
  • Sexual practices that cause mucosal disruption and bleeding are considered higher risk.Footnote 61 Higher risk sexual practices include:Footnote 56Footnote 61
    • Unprotected receptive anal intercourse
    • Partner with concurrent STIs
    • Known HIV infected sexual partner
    • Multiple sexual partners
  • Uncircumcised malesFootnote 58
  • Host and genetic factorsFootnote 58
Blood-borne transmission risk factors
Perinatal transmission risk factors

For an HIV-infected mother, mother-to-child transmission may occur in utero, intrapartum or with breastfeeding.Footnote 62 The risk of transmission is variable between 15 and 45%, but improves markedly with risk reduction strategies.

History of present illness

Review Risk factors and collect History of present illness.

Early HIV infection

Opportunistic infections may be the presenting illness; oral and esophageal candidiasis are the most frequent.Footnote 56

Acute symptomatic HIV infection

  • Present commonly with a constellation of acute symptoms, may be referred to as the acute retroviral syndrome
  • Constitutional symptoms commonly associated with acute HIV include:Footnote 56
    • Fever
    • Fatigue
    • Myalgias, arthralgias
  • Additional acute symptoms may include:Footnote 56
    • Lymphadenopathy
    • Sore throat
    • Rash; typically the rash occurs after the onset of fever and persists for up to 8 days
    • Diarrhea, nausea, anorexia, weight loss
    • Headache and other neurologic manifestations

Note: None of these symptoms are specific to HIV infection, but prolonged duration combined with the presence of mucocutaneous ulcers, are suggestive.

Table 1: Estimated per-act risk for acquisition of HIV, by exposure typeFootnote 60
Exposure route Risk per 10,000 exposures to an infected source (risk)
Blood-borne exposure Blood transfusion 9000 (9/10)
Needle-sharing injection drug use (IDU) 67 (1/150)
Percutaneous needle stick 23 (1/435)
Mucous membrane exposure to blood (e.g., splash to eye) 10 (1/1,000)
Other Biting, spitting, throwing body fluids (including semen and saliva), sharing sex toys Negligible
Chronic HIV infectionFootnote 59

Non-specific symptoms (e.g., headache, fatigue, low-grade fever, night sweats or weight loss)

AidsFootnote 58
  • AIDS-defining conditions present as opportunistic infections, malignancy, or associated conditions (e.g., encephalopathy or wasting)
  • Clients may report a variety of mucocutaneous lesions
Physical findings

Perform a Physical examination using the IPPA approach.

Note: 10 to 60% of individuals with acute HIV infection will be asymptomatic.Footnote 56

Acute and early HIV infectionFootnote 56
  • Most common signs associated with acute infection include:
    • Elevated temperature between 38 to 40ºC
    • Lymphadenopathy
    • Oropharyngeal features: pharyngeal edema and hyperemia, painful mucocutaneous ulceration (typically white bases with a ring of erythema)
    • Rash: generalized lesions, small (5 to 10 mm), demarcated, circular, pink to deep red, maculopapular lesions primarily over face, upper thorax, throat
    • Mucocutaneous ulcers may be located on mucosa of the oral cavity, esophagus, anus, or penis
    • Weight loss

Infants and childrenFootnote 63

  • Presenting clinical manifestations are variable, and may be nonspecific
  • Early findings may include hepatosplenomegaly and lymphadenopathy
  • Other findings: failure to thrive, oral candidiasis, and developmental delay are common presenting features
Chronic HIV infection

Chronic HIV infection without severe immunosuppressionFootnote 58

  • Full skin examination is indicated
    • Skin or mucous membrane involvement are predominant, including: vulvovaginal or oral candidiasis, hairy leukoplakia, seborrheic dermatitis, or folliculitis
  • Persistent generalized lymphadenopathy is common on examination; it refers to 2 or more non-contiguous sites of lymphadenopathy persisting for more than 3 to 6 months, with no alternate explanation
  • Focused examinations for indicators of immunocompromise or opportunistic infection:
    • Mental health screen
    • Visual fields and ocular fundi
    • Abdominal and chest examination
    • Pelvic and rectal examination
Aids and advanced HIV infection
  • As with chronic AIDS, focused examinations for indicators of immunocompromised or opportunistic infection, including a detailed mucocutaneous examinationFootnote 58
Opportunistic infections
  • Clinical features of bacterial infections may include classic signs (e.g. elevated temperature, elevated WBC count), but may not be consistent in HIV infected childrenFootnote 55
  • Methods to prevent exposure and reduce the risk of OIs are expanded in the Prevention section in Appendix, Section A of this guidelineFootnote 60
Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Acute HIV infection
  • Mononucleosis-type syndrome secondary to:Footnote 56
    • Cytomegalovirus
    • Epstein-Barr virus
  • Toxoplasmosis
  • Rubella
  • Syphilis
  • Disseminated gonococcal infection
  • Viral hepatitis

Clinical findings to distinguish acute HIV from other clinical diagnoses

  • Mucocutaneous ulcers are rare in all the above, except syphilis and herpes, and their presence should heighten suspicion of HIV
  • Generalized rash rare in the other disorders
  • Abrupt symptom onset, especially pharyngeal edema, diarrhea may be seen in acute HIV
Complications

Complications of HIV relate to disease progression and side effects of treatment.Footnote 64

  • In the absence of antiretroviral therapy (ART), HIV will progress more quickly to AIDS
  • AIDS is a condition that occurs with advanced HIV infection
  • Post- antiretroviral therapy (ART) initiation, Immune Reconstitution Inflammatory Syndrome (IRIS) may impact both adults and childrenFootnote 55
    • Immune reconstitution inflammatory syndrome (IRIS) refers to a disease- or pathogen-specific inflammatory response in HIV-infected patients that may be triggered after the initiation or re-initiation of anti-retroviral therapy or change to more active anti-retroviral therapy. IRIS is usually accompanied by an increase in CD4 cell count and/or a rapid decrease in viral loadFootnote 78
  • HIV-infected youth on ART have higher rates of long term sequelae (e.g. dyslipidemia, asthma, eczema, hypertension, diabetes mellitus and thyroid disorders)Footnote 65
  • HIV-infected youth commonly develop psychiatric conditions (e.g., mood and anxiety disorders) and neurodevelopmental disorders (e.g., learning and communication disorders)Footnote 65
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

Adult

Note: A fourth generation HIV antigen-antibody screening test may not become positive until 15-20 days after infection.Footnote 70 If confirmatory HIV testing is indeterminate or clinical suspicion is high, testing should be repeated using a Nucleic Acid Amplification Test (NAAT) for HIV RNA. NAAT has the shortest window period of all types of HIV tests and can detect HIV infection as early as 7-14 days after infection.Footnote 71

HIV testing

  • Fourth-generation HIV tests can detect HIV infection in 50% of people by 18 days after infection; 95% of people by 34 days after infection; and 99% of people by one and a half months after infectionFootnote 71
  • For individuals undergoing HIV testing, full information regarding HIV testing procedures can be found in the Human Immunodeficiency Virus HIV Screening and Testing Guide

Infants and children

  • For diagnosis of HIV infection in infants and children, virologic assays are used: HIV RNA or HIV DNAFootnote 54Footnote 69
  • For children with or without perinatal exposure who are older than 24 months, HIV antibody testing is used
  • For an infant or young child of an HIV-infected mother, serial HIV virologic assays testing are requiredFootnote 66
Screening for concurrent infections or conditionsFootnote 69

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment
  • Reduce HIV-associated morbidity and mortality
  • Improve quality of life
  • Slow disease progression
  • Decrease viral replication
  • Delay emergence of drug-resistant HIV strains
  • Prevent transmission
Non-pharmacological interventions
Interventions
  • As part of the initial evaluation, screen all clients infected with HIV for co-infections to consider the need for immunization, treatment or prophylaxis (for more information, see the Screening for Concurrent Infections or Conditions section of this guideline)Footnote 69

Prevention of mother-to-child HIV transmissionFootnote 62

  • Risk reduction/prevention strategies for pregnant clients include:
    • Referral to a specialist with related expertiseFootnote 59
    • Antiretroviral therapy (ART) is the foundation of prevention strategies during pregnancy, and labour/delivery
    • Planned delivery at a health facility capable of providing maternal ART, intrapartum prophylaxis and neonatal prophylaxis is recommended
    • Breastfeeding is contraindicated in HIV-infected mothersFootnote 59
    • Replacement feeding is recommended to infants of HIV-infected mothersFootnote 68
Client education

For information on methods to prevent acquisition of HIV, see Prevention in Appendix, Section A of this guideline.Footnote 60

  • Counsel client on behaviours to minimize sexual and blood-borne transmission (e.g., proper condom/barrier use for all sexual activity, not sharing equipment for injection drug use (IDU)Footnote 56 and opioid substitution programsFootnote 61
  • For clients who are pre-diagnosis; counsel client regarding the ‘window period:’ i.e., as a result of variations in Incubation periods, individuals may initially test negative following an HIV exposure because antibodies have not been producedFootnote 70
  • For individuals undergoing HIV testing, full information regarding HIV testing procedures can be found in the Human Immunodeficiency Virus HIV Screening and Testing Guide
  • Counsel client on living with HIV/AIDS; treatment can protect immune system and allow for healthy livingFootnote 72
  • Counsel client/family/caregiver about appropriate use of medications: dose, frequency, importance of adherence, potential side effects and interactions
Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Note: HIV medication availability is variable by provincial/territorial formulary; please refer to the Non-Insured Health Benefit (NIHB) list.

Antiretroviral therapyFootnote 59

Combination antiretroviral therapy (cART)

  • cART is the standard of care for HIV infection and is a combination of a minimum of 3 antiretroviral medications:
    • First-line therapy includes a combination of two nucleoside (NRTI) or nucleotide (NtRTI) reverse transcriptase inhibitors, plus either a non-nucleoside transcriptase inhibitor (NNRTI) or a ritonavir-boosted protease inhibitor (PI), or an integrase strand transfer inhibitor (ISTI)
    • Additional drug information and pill identification tools can be found at Canadian AIDS Treatment Information Exchange - CATIE
  • cART in adolescents mirrors adult principlesFootnote 67
  • cART is recommended in pregnant women to reduce mother-to-child transmissionFootnote 74
  • cART reduces the rate of OIs and improves survivalFootnote 55
    • Initiation of cART during an acute OI requires expertise; challenges include drug-drug interactions which may increase toxicity and decrease efficacyFootnote 55
  • The specific medication used is based upon each client’s viral load, genotype and the following specific comorbid conditions, including:Footnote 73
    • Kidney dysfunction (eGFR)
    • Heart disease; either present or positive Risk factors for heart disease
    • HBV co-infection
    • Presence of osteoporosisFootnote 57
  • cART initiation may provide the following benefits:Footnote 74
    • Improved morbidity and mortality
    • Attenuation of symptom severity
    • Decreased risk of transmission
    • Decreased viral reservoir and improved ability of immune cells to control the virus
  • Potential risks of initiation include:Footnote 74
    • Risk of drug-resistant mutations with non-adherence; to counter this, strict adherence is important
    • Toxicity, e.g. negative impact on bone density and renal function
Prophylaxis for HIV transmission
  • Treatment-as-prevention (TAsP): antiretroviral therapy used to reduce transmission risk to sexual partner(s)
  • Pre-exposure prophylaxis (PrEP): ongoing antiretroviral therapy for individuals at high risk for HIV acquisition
  • Postexposure prophylaxis (PEP): short-term antiretroviral therapy following potential HIV exposure (either occupational or non-occupational)
Prophylaxis for opportunistic infections in persons with HIVFootnote 59
  • Prophylaxis for Pneumocystis pneumonia (PCP) may be indicated if CD4 count below 200 cells/microlitre
  • Prophylaxis for Toxoplasma gondii (toxoplasmosis), if CD4 count below 100 cells/microlitre
  • Prophylaxis for Mycobacterium avium complex (MAC) may be considered, once active infection is ruled out, and when CD4 is below 50 cells/microlitre
  • For HIV-infected children with severe immunocompromise and recurrent or invasive bacterial infections, appropriate antimicrobial treatment may be requiredFootnote 55
IRIS treatmentFootnote 55
  • IRIS treatment is provided based on disease severity:
  • Mild cases are monitored with laboratory and clinical monitoring
  • Moderate cases may be given NSAIDs to manage symptoms
  • Severe cases may be given corticosteroids, e.g. dexamethasone
VaccinationFootnote 59
  • Clients with advanced HIV infection and low CD4 counts should not receive live-attenuated vaccinesFootnote 55
  • Vaccination status should be optimized to protect against vaccine-preventable diseases. In adults with HIV infection the following vaccinations are recommended:
    • Annual Influenza vaccination
    • Pneumococcal vaccination
    • Hepatitis A and Hepatitis B
    • Children with HIV infection should be optimized to protect against vaccine-preventable diseases, as age appropriateFootnote 55

For detailed information on vaccination of HIV-infected individuals, see Table 5: Vaccination of HIV-infected persons. Public Health Agency of Canada. .

Note: BCG immunization is contraindicated for immunocompromised clients, including clients with HIV infection.Footnote 75

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring
  • Monitor vital signs as indicated by client’s condition
  • Post initiation of cART, clinical and laboratory evaluation should monitor for side effects and toxicityFootnote 55
  • For clients on cART:
    • Screen for cardiovascular disease and hyperlipidemia at regular intervalsFootnote 58
    • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
Follow-up Footnote 76

Note: More frequent monitoring may be indicated if any signs of clinical deterioration develop.Footnote 55

  • For asymptomatic HIV infected clients, every 3 to 6 months, if not on treatment
  • For HIV-infected clients on treatment, Follow-up intervals will vary
  • Clients on cART: regular laboratory viral load and CD4 count as directed by HIV or internal medicine specialist
  • For HIV-infected clients:
    • Vaccination status should be reviewed with each visit and required vaccinations providedFootnote 55
    • Tuberculosis (TB) skin test at baseline, then as clinically indicated
    • Infant monitoring (infants of HIV-infected mothers) to include: growth monitoring, immunization adherence, ongoing screening for HIV
Referral
  • Arrange for medical evacuation if clinically indicated
  • Coordinate referral request(s) as required:
    • HIV specialist/local resources for ongoing management, treatment and/or counselling
Reporting
  • HIV infection is reportable in all provinces and territories in Canada.Footnote 77 Consult provincial/territorial policies and procedures for notifiable diseases

For more information, see Chapter 3, HIV Testing and Surveillance Systems in Canada from Public Health Agency of Canada.

Appendix

Section A: Supplemental clinical management information
Table 2: AIDS-defining conditionsFootnote 58
Conditions associated with AIDS
  • Bacterial infections, multiple or recurrent
  • Candidiasis of bronchi, trachea, or lungs
  • Candidiasis of esophagus
  • Cervical cancer, invasive
  • Coccidioidomycosis, disseminated or extrapulmonary
  • Cryptococcosis, extrapulmonary
  • Cryptosporidiosis, chronic intestinal (>1 month’s duration)
  • Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month
  • Cytomegalovirus retinitis (with loss of vision)
  • Encephalopathy, HIV-related
  • Herpes simplex: chronic ulcers (>1 month’s duration) or bronchitis, pneumonitis, or esophagitis (onset at age >1 month)
  • Histoplasmosis, disseminated or extrapulmonary
  • Isosporiasis, chronic intestinal (>1 month’s duration)
  • Kaposi sarcoma
  • Lymphoma, Burkitt (or equivalent term)
  • Lymphoma, immunoblastic (or equivalent term)
  • Lymphoma, primary, of brain
  • Mycobacterium avium complex (MAC) or Mycobacterium kansasii, disseminated or extrapulmonary
  • Mycobacterium tuberculosis of any site, pulmonary, disseminated, or extrapulmonary
  • Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
  • Pneumocystis jirovecii [PJP (previously known as ‘Pneumocystis carinii’)] pneumonia
  • Pneumonia, recurrent
  • Progressive multifocal leukoencephalopathy
  • Salmonella septicemia, recurrent
  • Toxoplasmosis of brain, onset at age >1 month
  • Wasting syndrome attributed to HIV
PreventionFootnote 60
  • For individuals with HIV infection, particularly adolescents, strategies to reduce the risk of transmission include condom use and reducing high-risk sexual practices.Footnote 67 Male condoms afford a high degree of protection; consistent correct use reduces HIV transmission by 80 to 97%Footnote 57
  • For individuals at risk for HIV acquisition, pre- and post-exposure prophylaxis may prevent acquisition. Routine screening with HIV testing to identify early infection and initiate treatment is key to preventing transmission
  • Risk reduction strategies are aimed at minimizing the risk of transmission and acquisition. In children of HIV-infected mothers, reducing the risk of vertical transmission is important. Prevention challenges that impact efficacy include:
    • Women who are pregnant and unaware that they are HIV-infected
    • Access to prenatal care
    • Women who require education regarding active steps to minimize transmission risk
    • Interruption in antiretroviral therapy (ART) during pregnancy, e.g., due to nausea or vomiting

For additional information on HIV in pregnant women, infants and children, see HIV Among Pregnant Women, Infants, and Children from Centers for Disease Control and Prevention.

Section B: Supplemental resources
Provincial/territorial guidelines

Alberta

Alberta Government. Alberta Guidelines for Non-Occupational, Occupational and Mandatory Testing and Disclosure Act Post-Exposure Management and Prophylaxis: HIV, Hepatitis B, Hepatitis C, and Sexually Transmitted Infections.

British Columbia

Other resources

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Harris M, Montessori V, Montaner JSG. HIV Infection. In: Jovaisas B, Arman L, Dandachi F, Hutsul J, Lewis G, Pearson NL, Raghuveer A, editors. Compendium of Therapeutic Choices. 7th edition. Ottawa, ON: Canadian Pharmacists Association; c2014. p. 1361-1377.

Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Health Canada. Non-Insured Health Benefits First Nations and Inuit Health Branch Drug Benefit List. 2015.

Kim KK, Bridges CB, Harriman KH. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older - United States, 2016. Centers for Disease Control and Prevention (US). Morbidity and Mortality Weekly Report.

Invasive Group A Streptococcal (GAS) Infection

Overview

Please refer to Provincial/territorial guidelines for Invasive Group A Streptococcal (GAS) infection where available.

Invasive group A Streptococcal (GAS) infection is a serious and potentially life-threatening disease in which GAS bacteria invade parts of the body in which bacteria are usually not found. Invasive GAS infections may manifest as any of several clinical syndromes, including pneumonia, cellulitis, bacteremia, puerperal sepsis, necrotizing fasciitis and streptococcal toxic shock syndrome.Footnote 79

Two of the most serious, but least common forms of invasive GAS are necrotizing fasciitis and streptococcal toxic shock syndrome.Footnote 79

This Clinical Practice Guideline will primarily focus on necrotizing fasciitis – a relatively rare subcutaneous infectionFootnote 80 characterized by fulminant tissue destruction, systemic signs of toxicity, and high mortality.Footnote 79

For more information on streptococcal toxic shock syndrome, see FNIHB Adult Care Clinical Practice Guidelines – Chapter 11 – Communicable Diseases – Toxic Shock Syndrome.

Necrotizing fasciitis is a surgical and medical emergency. All clients with suspected necrotizing fasciitis must be medically evacuated. Consult with a physician/nurse practitioner immediately.

Causes
  • Monomicrobial necrotizing fasciitis is typically due to Group A StreptococciFootnote 79

Note: Group A Streptococci may occur alone or in combination with other pathogens, most commonly Staphylococcus aureus.Footnote 79

Transmission
  • Respiratory droplets
  • Direct contact with nasal discharge and infected lesionsFootnote 85
Incubation period
  • Usually 1 to 3 days, but depends on the route of inoculationFootnote 86
Communicability

7 days prior to symptom onset to 24 hours post-effective antibiotic treatmentFootnote 84

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine when and what type of reaction occurred.

Risk factors
  • Diabetes mellitus
  • Arteriosclerotic vascular disease
  • Venous insufficiency with edema
  • Venous stasis or vascular insufficiencyFootnote 80
  • Skin breakdown, including surgical and traumatic wounds, varicella, childbirth, injection drug use, and ulcersFootnote 79Footnote 80
  • ObesityFootnote 79
  • Immunocompromised hostFootnote 79Footnote 81
  • Recent close contact with someone who has necrotizing fasciitisFootnote 81
  • Chronic disease, including heart, lung or liver diseaseFootnote 81
History of present illness

Review Risk factors and collect History of present illness.

  • High fever
  • Rapidly spreading, red, severely painful, hot swelling of the skin (sometimes the swelling starts at the site of a minor injury, such as a small cut or bruise, but in other cases there is no obvious source of infectionFootnote 81
  • Systemic symptoms include malaise, myalgias, diarrhea and anorexiaFootnote 79
Physical findings

Perform a Physical examination using the IPPA approach.

  • Acute, rapidly escalating symptoms
  • Affected area may be erythematous (without sharp margins), swollen, warm, shiny and extremely tenderFootnote 79
  • An overlying cutaneous inflammation that may resemble cellulitisFootnote 80
  • Features that suggest involvement of deeper tissues include:
    • Severe pain that seems disproportional to the Physical examination findings
    • Systemic toxicity including elevated temperature, tachycardia, hypotension, altered mental status, e.g. disorientation, lethargyFootnote 79Footnote 80
    • Failure to respond to initial antibiotic therapyFootnote 80
    • Hard, wooden feel of the subcutaneous tissue (such that the underlying muscle groups cannot be distinctly palpated) that extends beyond the area of apparent skin involvementFootnote 79Footnote 80
    • Edema or tenderness extending beyond the cutaneous erythemaFootnote 80
    • Palpable crepitus, indicating gas in the tissuesFootnote 79
    • Bullous lesions (skin breakdown with bullae containing thick pink or purple fluid)
    • Skin necrosis or ecchymoses, gangrene and anesthesiaFootnote 79Footnote 80
  • Lymphangitis and lymphadenitis are infrequent.Footnote 79
Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Cellulitis
  • Deep venous thrombosis
  • Gas gangreneFootnote 79
  • Toxic shock syndromeFootnote 82
  • Necrotizing fasciitis due to other aerobic and anaerobic pathogens (monobacterial or polymicrobial infections)Footnote 80
Complications
  • Systemic toxicity/sepsis/shock
  • Compartment syndrome
  • Limb loss/amputation
  • DeathFootnote 79
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

  • CBC
  • Serum creatinine kinase, lactate and creatinine
  • Blood for culture and sensitivity (C+S)Footnote 79

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Note: Necrotizing fasciitis is a surgical emergency that requires aggressive debridement of all necrotic tissue, which may include amputation to control the infection. Use of antibiotic therapy without surgical debridement is associated with almost 100% mortality rate.Footnote 79

Note: Consult a physician/nurse practitioner immediately if there is suspicion of invasive GAS infection/necrotizing fasciitis. Inclusion of the Public Health Physician will also be necessary to help identify contacts of an index case of invasive GAS/necrotizing fasciitis.

Goals of treatment
  • Reduce morbidity
  • Prevent complications
  • Eradicate the infection
  • Prevent spread of infection to others
Non-pharmacological interventions

Interventions

Client education

  • Educate client and family about infection prevention and transmission to others
  • Wound care Client education:Footnote 83
    • Keep draining or open wounds covered with clean, dry bandages until healed
    • Do not delay first-aid of non-infected wounds such as blisters, scrapes or any break in the skin, even if they appear minor
    • If client has an open wound or active infection, counsel to avoid using whirlpools, hot tubs, swimming pools until infections are healed
    • Wash hands often with soap and water or – if washing is not possible, use an alcohol-based hand rub
    • Take proper care of minor wounds and cuts. Wash the affected area in warm soapy water, and keep it clean and dry with a bandageFootnote 81
Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

IV therapy

  • If client presents with signs of sepsis or septic shock, aggressive fluid resuscitation is necessary, as follows:
    • Start 2 large-bore IV lines with 0.9% sodium chloride

For more information on management of shock see FNIHB Adult Care Clinical Practice Guidelines – Chapter 14 – General Emergency and Major Trauma – Shock.

Antibiotic therapy

Surgical exploration is the only way to definitely establish the diagnosis of necrotizing fasciitis and to obtain the specimens used to identify the causative pathogen(s).Footnote 79 Therefore, empiric antibiotic therapy for necrotizing fasciitis should consist of broad-spectrum antibiotic therapy, including activity against aerobes, MRSA, and anaerobic organisms; special consideration for GAS and Clostridium species should also be taken.Footnote 79Footnote 80

Note: There are multiple agents which may be used in combination as part of empiric antibiotic therapy for necrotizing fasciitis. If MRSA is present or suspected, vancomycin is recommended.Footnote 80 Consult with transferring health facility to select antibiotics to be initiated while awaiting medical evacuation.

The following are examples of agents which may be used as part of an empiric antibiotic therapy regime:Footnote 80

Vancomycin
  • Vancomycin 15 mg/kg IV q12h

Or

cefTRIAXone
  • cefTRIAXone 1 to 2 g IV q24h

and

Metronidazole
  • metronidazole 500 mg IV q6h

or

Fluoroquinolone and Metronidazole
  • A fluoroquinolone and metronidazole

If GAS is confirmed as the causative pathogen, the following regimen should be used:Footnote 80

Penicillin
  • Penicillin G 12 to 24 million units IV in 24 hours divided q4-6h

And

Clindamycin
  • Clindamycin 600 to 900 mg IV q8h

Chemoprophylaxis for close contacts

The close contacts of any client diagnosed with severe invasive GAS/necrotizing fasciitis may be considered for treatment with antibiotic therapy according to provincial/territorial public health guidelines and in consultation with the Public Health Physician.

For more information on close contacts, see Close contacts in Appendix, Section A of this guideline, and consult here for details on chemoprophylaxis for close contacts.

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring
  • If administering an agent with risk of anaphylaxis, monitor client closely for 30 minutes.
  • Monitor vital signs as indicated by client’s condition
  • Monitor intake and output
  • Monitor wound progression
Follow-up

Referral

  • Arrange for medical evacuation if clinically indicated.
  • Consult with Public Health Physician and/or provincial/territorial public health guidelines for all suspected or confirmed cases of invasive GAS.

Reporting

Invasive GAS/necrotizing fasciitis is reportable in every province and territory in Canada. Each province/territory has procedures in place for the rapid notification of cases to the Public Health Physician and timely reporting to the appropriate provincial/territorial public health official.Footnote 84

Appendix

Section A: Supplemental clinical management information
Close contact:Footnote 84
  • The household contacts of a case who have spent at least 4 hours/day on average with the case in the previous 7 days or 20 hours/week
  • Non-household persons who share the same bed with the case or who have had sexual relations with the case
  • Persons who have had direct mucous membrane contact with the oral or nasal secretions of a case (e.g., mouth-to-mouth resuscitation, open-mouth kissing) or unprotected direct contact with an open skin lesion of the case
  • Injection drug users who have shared needles with the case
  • Selected long term care facility contacts
  • Selected child care contacts – especially those who are infected with varicella
  • Selected hospital contacts

Note: In order to be considered a close contact, a person must have been exposed to the case between 0-7 days prior to the onset of symptoms and/or within 24 hours after the initiation of antimicrobial therapy.

Section B: Supplemental resources
Provincial/territorial guidelines

Alberta

Alberta Health and Wellness Public Health. Notifiable Disease Management Guidelines: Streptococcal Disease – Group A, Invasive.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Manual: Communicable Disease Control: Invasive Group A Streptococcal Disease.

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Reporting of Streptococcal invasive disease (Group A) (Streptococcus pyogenes). (PDF, 347 347, 13 pages)

Newfoundland and Labrador

Department of Health and Community Services. Newfoundland and Labrador Disease Control Manual : Section 3 Diseases Transmitted by Respiratory Routes.

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Nova Scotia Department of Health and Wellness. Nova Scotia Communicable Diseases Manual: Streptococcal Toxic Shock Syndrome [STSS] General Information. (PDF, 347 388, 1 pages)

Ontario

Ontario Ministry of Health and Long-Term Care. Infectious Diseases Protocol: Group A Streptococcal Disease, invasive (iGAS). (PDF, 239 239, 13 pages)

Yukon

Yukon Health and Social Services. Yukon Communicable Disease Control: Invasive Group A Streptococcal Disease. (PDF, 256 347, 11 pages)

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Canadian Pharmacists Association. Compendium of Therapeutic Choices: Canada’s Trusted Reference for Primary Care Therapeutics (CTC 7). Ottawa: c2014.

Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Mononucleosis (infectious)

Overview

Please refer to Provincial/territorial guidelines for Mononucleosis where available.

Infectious mononucleosis is an acute, usually self-limited viral infection characterized by fever, fatigue, malaise, pharyngitis and cervical lymphadenopathy. The duration of the illness is variable: uncomplicated illness can typically last 1 to 4 weeks, while malaise and fatigue can last several months. Infectious mononucleosis is most common among teenagers and young adults, especially college students.Footnote 87Footnote 88

Causes

Epstein-Barr virus (EBV), also known as human herpesvirus 4Footnote 89

Transmission
  • Transmission of infectious mononucleosis occurs mainly by person-to-person contact with saliva of an infected person (hence the other name by which it is sometimes referred: “the kissing disease”)Footnote 89Footnote 90
  • Transmission may also occur via:
    • Sexual contact (EBV has been isolated in both cervical epithelial cells and in seminal fluid)
    • Blood transfusion
    • Organ transplantationFootnote 88
Incubation period

30 to 50 daysFootnote 90

Communicability
  • The period of communicability is prolonged and indeterminateFootnote 87
  • After primary infection, EBV remains within the host for life and undergoes intermittent asymptomatic shedding from the oropharynxFootnote 87
  • Shedding increases in frequency and titre levels in immunocompromised patients (e.g., organ allograft recipients and people with human immunodeficiency virus (HIV) infection)Footnote 87

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine when and what type of reaction occurred.

Risk factors
  • Individuals:
    • Between 15 and 24 years of ageFootnote 89
    • Living in close quarters with a large number of peopleFootnote 91
    • With lowered immune resistance due to other illness, stress, or fatigueFootnote 91
History of present illness

Review Risk factors and collect History of present illness.

The following may be reported by the client:

  • Fever
  • Sore throat
  • Extreme fatigue, malaise (usually maximal during the first 2 to 3 weeks; may last for months)
  • Head and body aches
  • Abdominal pain, nausea, or vomitingFootnote 92
Physical findings

Perform a Physical examination using the IPPA approach.

Note: The diagnostic triad of fever, pharyngitis, and adenopathy is present in most clients.

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications
  • Splenic ruptureFootnote 90
  • HepatitisFootnote 87
  • Hemolytic anemiaFootnote 90
  • ThrombocytopeniaFootnote 87
  • AgranulocytosisFootnote 95
  • Aseptic meningitisFootnote 89
  • EncephalitisFootnote 93
  • Guillain-Barré syndromeFootnote 89
  • MyocarditisFootnote 93
  • Tonsillar hypertrophy (may be severe leading to airway obstruction)Footnote 93
  • Orchitis (rare)Footnote 96
  • Post-transplant lymphoproliferative disease (PTLD) is a recognized complication of both solid organ transplantation and allogeneic hematopoietic stem cell transplantation; PTLD is a common post-transplant malignancy. PTLD is frequently associated with EBV infection, either as a consequence of EBV post-transplantation or from primary EBV infection. Primary infection with EBV may be acquired from the donor graft or, less commonly, from environmental exposureFootnote 97
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The following tests are for consideration:

  • Heterophile antibody (mononucleosis spot) test

Note: The mononucleosis spot test misses about one-third of cases in the first week of illness but is more than 80% sensitive in the second week of illness.

  • CBC (lymphocytosis is characteristic)Footnote 93
  • Throat swab/rapid antigen detection test (RADT) to rule out Group A streptococcal pharyngitis
  • Liver function tests (e.g., ALT, AST, bilirubin)
  • HIV serology to rule out acute HIV infection for at-risk clients; primary HIV infection resembles acute EBV infectionFootnote 87

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment
  • Provide supportive care until recovery
  • Prevent complications
  • Prevent transmission
Non-pharmacological interventions
Client education
  • Advise parent(s)/caregiver(s)/client to:
  • Ensure adequate fluid intake, eat foods as tolerated, but emphasize the importance of well-balanced nutrition
  • Undertake activity as tolerated
  • Decrease stress if possible
  • Avoid heavy liftingFootnote 87
  • Avoid contact sports for at least 1 month until splenomegaly has resolved
  • Return for further assessment if no improvement in signs and symptoms of presenting condition
  • Use medications appropriately; dose, frequency, importance of adherence, potential side effects and interactions
  • The pediatric client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye’s syndrome which can damage the liver and brain

To decrease the risk of spreading mononucleosis advise client to:

  • Avoid bodily fluid exposure, especially saliva
  • Avoid sharing drinks, foods, cups, utensils or cigarettesFootnote 88Footnote 93
  • Use good hand-washing technique
  • Avoid donating blood until fully recovered from the infection and as advised by Canadian Blood Services
Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Analgesic/antipyretic

Acetaminophen

  • Acetaminophen 325 to 650 mg PO q4-6h PRN
  • Maximum from all sources: 4,000 mg in 24 hours

Ibuprofen

  • Ibuprofen 200 to 400 mg PO q4-6h PRN**

**Maximum from all sources: Ibuprofen 1200 mg in 24 hours. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used.

Consult physician/nurse practitioner for children less than 12 years of age.

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring
  • Monitor vital signs as clinically indicated
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
Follow-up
  • Follow-up once weekly until symptoms such as fatigue, sore throat and/or splenomegaly resolve
  • Follow-up if there are complications or if no improvement in presenting condition

Bibliography

The following References and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Canadian Pharmacists Association. Acetaminophen (Tylenol). Ottawa, ON: eTherapeutics; 2012 [cited 2015 May 13th]. Available with authorized username and password.

Canadian Pharmacists Association. Ibuprofen (Advil). Ottawa, ON: eTherapeutics; 2012 [cited 2015 May 13]. Available with authorized username and password.

Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Ibuprofen. Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 May 13]. Available with authorized username and password.

Acetaminophen. Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 May 13]. Available with authorized username and password.

Rabies Exposure

Overview

Please refer to the Provincial/territorial guidelines for rabies exposure where available.

Rabies is a rare, almost invariably fatal, viral infection affecting the central nervous system (CNS).Footnote 98 For more information, see Canadian Immunization Guide: Part 4 – Active Vaccines – Rabies Vaccine.

Causes

Rabies virusFootnote 98

Transmission
  • Bites from an infected wild or domestic animal are the main route of exposure:Footnote 98
    • Animals such as bats, foxes, skunks, racoons, dogs and cats are the most common sources of transmission to humans. However, ferrets, coyotes, squirrels, chipmunks, beavers, groundhogs, cows, and horses can also potentially transmit the infection
    • Bites from bats may not be felt and may not leave any visible mark
  • The virus then gains access to the central nervous system through peripheral nerves and causes acute encephalitis and meningoencephalitisFootnote 98 Footnote 99
  • Rare instances of transmission involving saliva of an infected animal have been noted to occur through a scratch, broken skin, the mucous membranes or the respiratory tract and following an organ transplantation from a contaminated individualFootnote 98
Incubation period

The Incubation period may vary from days to years (most commonly between 3 to 8 weeks), depending on the distance from the portal of entry to the brain.Footnote 98

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine when and what type of reaction occurred.

Risk factors

The following groups of people are considered to be at a higher risk for exposure to rabies:Footnote 98

  • Individuals whose activities (such as hunting and trapping) place them in close proximity to potentially rabid animals where rabies is found
  • Individuals who work closely with animals, or whose work may expose them to the rabies virus (e.g., veterinarians and veterinary staff, animal control and wildlife workers, laboratory workers, etc.)
  • Individuals bitten in the face by a wild animal
  • Individuals who may approach animals but be unlikely to report any bites or scratches (e.g., children)
History of present illness
  • Review Risk factors and collect History of present illness.
  • Obtain a client health history and complete a risk assessment related to the exposure to the potentially rabid animal and evaluate the client’s need for post-exposure prophylaxisFootnote 98
    • Obtain a history of the following:Footnote 98
    • Species of the animal
    • Behaviour of the animal (e.g., unusual behaviour, foaming at the mouth)
    • Type of exposure (e.g., bite, scratch, or contact with a bat) and severity
    • Circumstance of the exposure (provoked or unprovoked)
    • The anatomical location of bite or scratch, as this may have implications for the Incubation period (depending
      on the proximity to the brain)
    • Vaccination status
    • Age of the exposed client

For more information on factors to consider, see Table 1: Risk Assessment Related to the Exposure to the Potentially Rabid Animal. If rabies is suspected, follow your provincial/territorial policies and procedures/guidelines for consultation and reporting.

Physical findings

Note: The wound must be cleansed immediately. For more information, see Initial Wound Management in the Non-pharmacological interventions section of this guideline.

Perform a Physical examination using the IPPA approach.

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Conditions mimicking the paralytic presentation of rabies include the following:

Conditions mimicking the encephalitic presentation include the following:

Complications

For an infected, unimmunized individual whose wound is untreated, complications of rabies include:Footnote 98 Footnote 99

  • Delirium
  • Convulsions
  • Flaccid paralysis
  • Respiratory depression
  • Coma
  • Death
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures for laboratory confirmation of infection.

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Follow your provincial/territorial policies and procedures/guidelines for consultation management and reporting; also follow direction from the Environmental Health Officer.

Post-exposure to rabies (potential and actual) management may include all of the following:Footnote 98

  • Immediate initial wound management (for more information, see Initial Wound Management in the Non-pharmacological interventions section of this guide)
  • Evaluating the exposure to the potentially rabid animal
  • Provision of post-exposure rabies prophylaxis
  • Tetanus prophylaxis and antibiotic prophylaxis may also be considered
  • Management of the potentially rabid animal, if it is available

For more information, see Table 2: Summary of Post-exposure Prophylaxis for Persons Potentially Exposed to Rabies, by Animal Type.

Goals of treatment
  • Prevent rabies disease
  • Provide supportive care
  • Prevent complications
Non-pharmacological interventions
Interventions

The objective of post-exposure management is to neutralize the rabies virus at the site of infection before the virus can enter the central nervous system (for additional information on wound management, see Table 1: Post exposure management of the wound).

Table 1: Post exposure management of the wound
Initial wound managementFootnote 98 Footnote 99 Footnote 103
Things to know
  • Immediate wound treatment is essential even if the client presents long after exposure
  • Care should be taken to clean the wound to its full depth and avoid making the wound largerFootnote 98 Footnote 99
Wound treatment Wound treatment consists of:
  • Immediate washing and flushing for 15 minutes with soap and water, or water alone
  • Disinfecting wound with detergent, ethanol (70%), iodine (tincture or aqueous solution), or other substance with virucidal activityFootnote 103
Wound closure Primary wound closure is not recommended; suturing should be delayed.
  • The exception may be the face; however, the decision to suture any wound should be individualized and in consultation with the physician/nurse practitionerFootnote 98 Footnote 99
Bleeding Bleeding at any wound site indicates potentially severe exposure.Footnote 99 Footnote 103
  • The wound may require infiltration with rabies immune globulin (RabIg) as per provincial/territorial policies and procedures
Client education
  • Teach client or parent(s)/caregiver(s) wound care and signs of infection (e.g., fever, purulent wound drainage, increased pain at the wound site)
  • Counsel the client to return for further assessment if signs and symptoms of infection occur
  • Advise client to return for Follow-up and stress the importance of completing the vaccine schedule
  • Provide client and/or parent(s)/caregiver(s) with a planned schedule to return for Follow-up
  • The client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye’s syndrome which can damage the liver and brain
  • If metronidazole ordered, advise client to avoid alcohol during, and for 48 hours after completion of treatment
  • Counsel client or parent(s)/caregiver(s) about appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactions
Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Intravenous (IV) therapy
Rabies post-exposure prophylaxisFootnote 98
  • If exposure to rabies is considered highly likely, start post-exposure prophylaxis as soon as possible
  • Follow provincial/territorial policies and procedures for accessing rabies vaccine and rabies immune globulin (RabIg) as necessary

Note: Rabies vaccine and rabies immune globulin should never be mixed in the same syringe and are to be administered at different anatomical sites.

Post-exposure prophylaxis with rabies vaccineFootnote 98
  • All rabies cases and certain suspected rabies cases will require rabies vaccine
  • The number of doses will be dependent on several factors
  • Consult your Public Health Physician or physician/nurse practitioner as per provincial/territorial policies and procedures
  • For general vaccination guidelines, see Rabies Vaccine Post-Exposure Schedule in Appendix, Section A of this guideline
Recommended administration sites
  • Children less than 2 years of age: Anterolateral thigh
  • Children 2 years of age or older and adults: Deltoid muscleFootnote 105

Note: Rabies vaccine must never be administered into the gluteal muscle because the fat content in this region delays the absorption of antigen and hence impairs the generation of optimal immune response.

Post-exposure rabies immune globulin (RabIg)Footnote 98
  • RabIg (along with rabies vaccine) is required for the client who has not received rabies vaccine in the past
  • If, for any reason, RabIg is not administered at the initiation of the rabies vaccine series, it can be administered up to and including day 7 after the initiation of the vaccine. It should not be administered after that time
  • Prior to starting wound infiltration with RabIg, ensure the area has been washed, flushed and cleansed as directed in the Wound Management section of this guideline, under Non-Pharmacological interventions. For more information, see FNIHB Adult Care Clinical Practice Guidelines – Chapter 9 – Skin – Skin Wounds  of Traumatic Origin
  • The recommended dose for RabIg is 20 units/kg on day 0, with as much as possible infiltrated into and around the wound. For additional guidance, see provincial/territorial policies and procedures or Provincial/territorial guidelines in Appendix, Section B of this guideline
  • If RabIg is administered, advise client that he or she should not receive live vaccines for 4 monthsFootnote 104
Tetanus prophylaxis
  • The need for active immunization with tetanus toxoid vaccine, with or without passive immunization with tetanus immune globulin (TIg), depends on the condition of the wound and the client’s vaccination history
  • To determine if tetanus prophylaxis is required, refer to the Canadian Immunization Guide
Analgesic/antipyretic

For adult clientsFootnote 106 Footnote 107

Acetaminophen

  • Acetaminophen 325 to 650 mg PO q4-6h PRN
  • Maximum from all sources: acetaminophen 4,000 mg in 24 hours

Ibuprofen

  • Ibuprofen 200 to 400 mg PO q4-6h PRN**

**Maximum from all sources: Ibuprofen 1200 mg in 24 hours. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used.

For Pediatric clients

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness.Footnote 108 Footnote 109 Consult physician/nurse practitioner particularly for children less than 3 months of age.

AcetaminophenFootnote 110 Footnote 111

  • Acetaminophen 10 to 15 mg/kg/dose PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg in 24 hours or 4,000 mg in 24 hours, whichever is less

IbuprofenFootnote 112 Footnote 113

Infants <6 months

  • Limited data available in infants

For 6 months to 12 years of age

  • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
  • Maximum 400 mg/dose*

For greater than 12 years of age

  • Ibuprofen 200 to 400 mg PO q4-6h PRN*

*Maximum from all sources for all ages:

  • Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours, whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used
Antibiotic prophylactic therapy for adult and pediatric clients
  • Prophylaxis with antibiotics for bites is controversial, but almost always recommended for high-risk wounds to prevent secondary bacterial infection due to mixed bacteria typically found in animal bites, particularly Pasteurella speciesFootnote 114 Footnote 115
  • Prophylactic antibiotic therapy for 3 to 5 days is recommended for the following:Footnote 115
    • Clients who are immunocompromised or asplenic, or
    • Clients who have advanced liver disease, pre-existing or resultant edema of the affected area, moderate to severe injuries (especially in the hands or face), or injuries that have penetrated the periosteum or joint capsule
    • Intravenous antibiotics may be required in some circumstances and will be initiated at the discretion of the physician/nurse practitioner

For more information on antibiotics, see Table 2: Antibiotic dosing for adults and pediatric clients.

Table 2: Antibiotic dosing for adults and pediatric clients
Antibiotic Adult dosing Pediatric dosing
Preferred Treatment
Amoxicillin/clavulanic acid
  • 875 mg/ 125 mg PO BID, or
  • 500 mg/ 125 mg PO TIDFootnote 116
Less than 38 kg: Greater than 38 kg:
Alternate Treatment: If Known or Suspected Allergy to Penicillin and/or Cephalosporin
Doxycycline Day 1:
  • 100 mg PO BID

Then:
Greater than 8 years of age, less than/equal to 45 kg:

Day 1:
  • Calculate 2 to 4 mg/kg in 24 hours PO divided BID on first day
Then: Greater than 8 years of age, greater than
45 kg:
Footnote 118
  • Use adult dose
Or
Trimethoprim/sulfamethoxazole


Avoid in infant less than 2 months of age due to risk of kernicterusFootnote 119

with/without
  • Calculate using trimethoprim 8 to12 mg/kg in 24 hours PO divided BID;
  • Maximum 160 mg of trimethoprim/doseFootnote 115 Footnote 120
Metronidazole

Note: Clindamycin may be used as an alternate treatment to metronidazole.Footnote 114 Consult with physician/nurse practitioner
  • Calculate 15 to 30 mg/kg in 24 hours PO divided TID;
  • Maximum 2,000 mg of metronidazole in
    24 hoursFootnote 121

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-up
  • Follow-up wound management as indicated
  • Schedule for vaccination and/or immune globulin as indicated
  • Update the immunization record
Referral
  • Arrange for medical evacuation if clinically indicated
Reporting

Appendix

Section A: Supplemental clinical management information
Rabies vaccine post-exposure schedule

Note: Refer to provincial/territorial policies and procedures.

For the client who has previously been immunized with rabies vaccine
  • Arrange for administration of a repeat rabies vaccine 1 mL IM on day 0 and day 3 (total of 2 doses)Footnote 98
For the client who has NOT been previously immunized with rabies vaccine
  • Arrange for administration of repeat rabies vaccine 1 mL IM on day 0, day 3, day 7 and day 14 (total of 4 doses)Footnote 98
For the immunocompromised client or the client on antimalarial drugs who has NOT been previously immunized with rabies vaccine
  • Arrange for administration of rabies vaccine 1 mL IM on day 0, day 3, day 7, day 14 and day 28 (total of 5 doses)Footnote 98
Rabies immune globulin (RabIg) administrationFootnote 98
  • Because of possible interference of RabIg with the immune response to the rabies vaccine, the dose of RabIg is not to be exceeded
  • If possible, the full dose of RabIg should be thoroughly infiltrated into the wound and surrounding area
  • Any remaining volume of RabIg should be injected IM at a site distant from the vaccine administration
  • When more than one wound exists, each wound should be locally infiltrated with a portion of the RabIg using a separate needle
  • In such instances, RabIg can be diluted 2-3 fold in a solution of 0.9% sodium chloride to provide RabIg in sufficient volume for thorough infiltration of all wounds
  • If the site of the wound is unknown, the entire dose should be administered IM at a separate site from the site of rabies vaccination; for more information on acceptable injection volumes see Table 3: Intramuscular Injection Site Max Volumes – Adults in Appendix, Section A of this guideline
Table 3: Intramuscular injection site max volumes – adultsFootnote 122
Injection site Max injection volume Advantages Disadvantages
Deltoid 0.5 to 2 mL Accessible Limited capacity for number, and volume of injections: small area
Dorsogluteal 4 mL   Nerves and vessels present, slow absorption
Ventrogluteal 2.5 to 5 mL No nerves or vessels, less fat (vs. dorsogluteal)  
Rectus femoris 5 mL Client self-injection Pain
Vastus lateralis 5 mL Accessible
No nerves or vessels
 
Note: The above volumes are for considerations when RabIg administration is required.

For more information, see Provincial/territorial guidelines in Appendix, Section B of this guideline.

Rabies spectrum of clinical illnessFootnote 98
  • Early symptoms of rabies may include: headache, malaise, fever, fatigue and discomfort or pain at the exposure site (i.e., the site where the person was bitten)
  • Symptoms progress quickly as the CNS is attacked. The illness generally presents in one of two ways:
    • The more common, agitated (furious) form presents with the classic symptoms of hydrophobia and aerophobia (severe laryngeal or diaphragmatic spasms and a sensation of choking when attempting to drink or when air is blown in the face) with a rapidly progressing encephalitis and death
    • The paralytic (often called dumb) form of the disease manifests in progressive flaccid paralysis, has a more protracted course, and is more difficult to diagnose
Prevention

Client education

  • Have pets vaccinated regularly according to the veterinarian recommendations
  • Report unusual animal behaviour to veterinarian and environmental health officers
  • Be vaccinated if at high risk of occupational exposure

Pre-exposure prophylaxis rabies vaccine recommended dose, schedule, and injection site

  • Pre-exposure prophylaxis is warranted for people who are considered to be a higher risk for exposure to rabies (for more information, see Risk factors in the Assessment section of this guideline)
  • Rabies vaccine 1 mL IM should be administered on day 0, day 7 and any time between days 21 to 28 for a total of 3 doses
  • Pre-exposure immunization is not publicly funded
  • Note: Rabies vaccine must never be administered into the gluteal muscle because the fat content in this region retards the absorption of antigen and hence impairs the generation of optimal immune responseFootnote 98
  • Rabies vaccine may be administered in the deltoid muscle in older children and adults or into the anterolateral thigh in infantsFootnote 98
  • For more information, see Canadian Immunization Guide: Part 3 – Vaccination of Specific Populations
Section B: Supplemental resources
Provincial/territorial guidelines

Alberta

Alberta Health and Wellness. Public Health Notifiable Disease Management Guidelines: Rabies.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Manual: Management of Specific Diseases: Rabies. (PDF, 1,352 Kb, 28 pages)

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Rabies, Protocol for Management of Human Rabies and Management of Animal Exposures to Prevent Human Rabies. (PDF, 6,235 Kb, 24 pages)

Nova Scotia

Nova Scotia Department of Health and Wellness. Rabies Response Plan. (PDF, 1,288 Kb, 36 pages)

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Newfoundland and Labrador

Department of Health and Community Services. Newfoundland and Labrador Disease Control Manual: Section 6, Vectorborne and other Zoonotic Diseases: Rabies.

Ontario

Ontario Ministry of Health and Long-Term Care. Diseases and Conditions: Rabies.

Yukon

Yukon Health and Social Services. Communicable Disease Guidelines: Rabies. (PDF, 1,352 Kb, 28 pages)

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Sexually transmitted infections (STIs)

Overview

Please refer to Provincial/territorial guidelines for Sexually Transmitted Infections (STIs) where available.

Sexually transmitted infections (STIs) are acquired by sexual contact. They are passed person-to-person in blood and bodily fluids. For more information on specific syndromes and infections, see the latest Canadian Guidelines on Sexually Transmitted Infections.

Causes

STIs may be caused by bacteria, viruses, parasites or fungi.

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine when and what type of reaction occurred.

Risk factors Footnote 123Footnote 124Footnote 125

Individuals at risk of contracting an STI include those who:

  • Have had sexual contact with a person(s) with a confirmed STI
  • Are sexually active and under 25 years of age
  • Have a new sexual partner
  • Have had 2 or more sexual partners in the past year
  • Practice serial monogamy (a series of one-partner relationships)
  • Do not use contraception
  • Use non-barrier contraception methods (e.g., oral contraceptives or IUDs)
  • Inject drugs or engage in other substance use, especially if associated with sexual activity
  • Engage in unsafe sexual practices such as:
    • Unprotected sex
    • Sexual activities with blood exchange
    • Sharing of sex toys
    • Are men who have sex with men (MSM)
    • Engage in ‘survival sex,’ (e.g., exchanging sex for money, drugs, shelter or food; sex workers and their clients)
    • Are on the streets and/or homeless
    • Engage in anonymous sexual partnering
    • Are the victims of sexual assault or abuse
    • Have been previously infected with an STI

Clients with STIs are often asymptomatic. If a client is asymptomatic but has one or more Risk factors, consider screening for STIs according to the Canadian Guidelines on Sexually Transmitted Infections, or consult provincial/territorial policies and procedures.

History of present illness

Review Risk factors and collect History of present illness.

  • A detailed, comprehensive sexual history is mandatory:Footnote 125
    • Site(s) of sexual contact (vaginal, oral, anal)
    • Sexual orientation (homosexual, bisexual, heterosexual)
    • Use of condoms to prevent STIs
    • Use of other birth control methods
    • Number of sexual partners in recent past
    • History of sex with injection drug users
    • Injection drug use, needle-sharing
    • Exchange of sex for money or drugs
    • Present symptoms of STIs in client and in his or her partner(s)
    • Previous history of STIs (including HIV); either testing or treatment
    • History of last sexual contact
    • History of sexual assault or abuse
  • Systemic symptoms:Footnote 125
    • Fever or chills
    • Weight loss
    • Enlargement of lymph nodes
  • Joint painFootnote 124
  • ConjunctivitisFootnote 124
  • RashFootnote 126
  • Review immunization history with client to determine if at increased risk due to incomplete vaccination:
    • Key immunization history for sexual health: hepatitis A, B, and human papillomavirus (HPV)
Men
  • Testicular pain or inguinal pain or swelling
  • Genital rashes or lesions; may be painless or painful
  • Rectal discharge or pain
  • Urethral irritation, urethral itch, painful discharge; note amount, colour, time of day that the discharge is most noticeable (urethritis finding - discharge from urethra most prominent after a long period without voiding)
Women
  • Dysuria
  • Painful intercourse; may be painful at introitus, or with penetration, or felt as deep dyspareunia (dyspareunia primarily associated with gonorrhea)
  • Bleeding post-coital, mid-cycle or excessive menstrual blood loss
  • Last menstrual period and possibility of pregnancy
  • Genital rashes or lesions; may be painless or painful
  • Vaginal or rectal:
    • Pruritus or pain
    • Discharge; note amount, colour, and time of day the discharge is most noticeableFootnote 123
Social

For more information on social STI Risk factors, see Risk factors of this guideline.

Physical findings

Perform a Physical examination using the IPPA approach.Footnote 125

  • Assess conjunctiva, pharynx and all mucous membranes; skin on the lower abdomen, thighs, buttocks, palms, forearms and soles for rash and for signs of infection
  • Perform a comprehensive genitourinary examination including:
    • Inspect and palpate external genitalia for lesions, inflammation, irregularities or discharge
    • Inspect perianal region for lesions, fissures, discharge

Note: Additional examination, including anoscopy or digital rectal examination may be required if client reports rectal symptoms and has practiced receptive anal intercourse.

  • Inspect pubic hair for lice and nits
  • Palpate for inguinal lymphadenopathy
MenFootnote 125
  • Inspect glans; if foreskin present, retract and examine
  • Assess for urethral discharge: milk urethra (client or examiner) from base of penis to glans 3 or 4 times
  • Palpate testicles and epididymis for heat, tenderness, swelling or nodules
WomenFootnote 125
  • Separate the labia to visualize the
    vaginal introitus
  • Perform a speculum exam with adequate visualization of the vaginal walls and cervix to evaluate for vaginal and endocervical discharges, erythema, friability, edema or lesions. This examination may be deferred in circumstances such as presence of primary herpes (visible lesions) or vaginitis for client comfort
  • Perform a bimanual exam to detect uterine or adnexal masses, or tendernessFootnote 125
Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

The following table provides an overview of some STI-associated signs and symptoms, and the possible conditions or related diagnoses.

Table 1: Signs and symptoms of some sexually transmitted infectionsFootnote 127
Signs and Symptoms Possible Condition Common Causes
  • Urethral discharge
  • Burning on urination
  • Urethral or meatal erythema
  • Irritation or itch
  • Urethritis
  • Prostatitis
  • Chlamydia
  • Gonorrhea
  • Herpes (HSV)
  • Mycoplasma
  • Ureaplasma
  • Trichomonas
  • Mucopurulent cervical discharge
  • Cervical friability
  • Strawberry cervix
  • Vaginal discharge
  • Cervicitis
  • Chlamydia
  • Gonorrhea
  • HSV
  • Trichomonas
  • Painful internal or external
    genital ulcers or lesions
  • Painful inguinal lymph nodes
  • Genital Ulcer Disease
  • HSV 1 or 2
  • Lymphogranuloma venereum (LGV)
  • Painless genital lesion(s) usually singular with or without lymphadenopathy
  • Genital Ulcer Disease
  • T. pallidum (syphilis)
  • Asymmetrical, multiple and/or polymorphic growths in genital or anal region or on mucous membranes; may be itchy, may bleed or cause obstruction
  • Papular anal/genital lesions
  • Human papillomavirus (HPV)
  • Molluscum contagiosum (with dimpled center)
  • Skin tags
  • Carcinoma
  • Unilateral testicular pain/swelling, with/without urethral discharge
  • Fever
  • Epididymitis
  • Chlamydia
  • Gonorrhea
  • Coliforms
  • Pseudomonas
  • Lower abdominal pain
  • Deep dyspareunia
  • Abnormal bleeding
  • Fever
  • Cervical motion tenderness
  • Chlamydia
  • Gonorrhea
  • Genital tract mycoplasma
  • Anaerobic and other bacteria
Vaginal:

  • Discharge
  • Odour
  • Pruritus
  • Dysuria
  • Erythema
  • Vaginal discharge
  • Bacterial vaginosis
  • Candidiasis
  • Trichomoniasis
  • Rectal discharge
  • Anorectal pain, constipation
  • Bloody stools
  • Diarrhea
  • Nausea
  • Abdominal pain/cramps, bloating
  • Fever
Intestinal and enteric syndromes:

  • Proctitis
  • Proctocolitis
  • Enteritis
  • Chlamydia (including LGV)
  • Gonorrhea
  • T. pallidum (syphilis)
  • HSV
  • Entamoeba histolytica
  • Campylobacter
  • Salmonella
  • Shigella
  • Giardia lamblia

For a complete discussion of the clinical presentation and treatment of STIs, refer to the Canadian Guidelines on Sexually Transmitted Infections.

Complications
  • Numerous complications can arise from STIs; each infection has specific sequelae
  • Cervical cancer and increased risk of viral transmission (including HIV)Footnote 123Footnote 126
  • Gonorrhea and chlamydia complications can include:
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

For selected screening and serology tests, see Section 2: Primary Care and Sexually Transmitted Infections and Section 3: Laboratory Diagnosis of Sexually Transmitted Infections, in the Canadian Guidelines on Sexually Transmitted Infections.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The following tests are for consideration when there are no provincial/territorial policies available.

Recommended sites for testing:Footnote 130

  • Endocervix
  • Rectum
  • Urethra (males)
  • Pharynx
  • Vagina (prepubescent females, women without a cervix)
  • Lesion
  • Urine

Recommended samples

  • Remove any overlying blood or secretions prior to obtaining cervical specimens
  • Swabs for culture and/or nucleic acid amplification test (NAAT) can be used to collect samples from sites, as appropriate
  • Urine sample for NAAT testing is commonly used
  • Urine for culture and sensitivity, if appropriate
  • Viral culture for genital lesions
  • Wet mount or a ‘whiff test’ of vaginal secretions may aid in diagnosing bacterial vaginosis, trichomoniasis and candidiasis as differential diagnoses. For more information, see FNIHB Adult Care Clinical Practice Guidelines – Chapter 11 – Communicable Diseases – Vulvovaginitis
  • Obtain serology samples for syphilis, HIV, hepatitis B and hepatitis C
  • Serology samples are not diagnostically useful for acute chlamydial or gonococcal infectionsFootnote 123

For information on recommended sites and tests, refer to Section 3, in the Canadian Guidelines on Sexually Transmitted Infections.

NAAT urine test for Chlamydia and Gonorrhea can diagnostically replace urethral, endocervical and vaginal swabs. NAAT testing does not provide sensitivity results to guide choice of anti-infective agent. Availability of NAAT testing varies; refer to provincial/territorial lab resource guidance.

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Many STIs are reportable diseases. Be aware of which STIs are reportable in your province/territory. Contact tracing is a critical strategy to maintain control of a number of STIs. For more information, see Contact tracing in Appendix, Section A of this guideline.

Goals of treatment
  • Cure infection, when possible
  • Relieve symptoms
  • Prevent recurrence, when possible
  • Prevent STI (including HIV) transmission
  • Prevent complications
Non-Pharmacological interventions
Client educationFootnote 124
  • To avoid gonococcal and chlamydial reinfections, instruct clients and their contacts to abstain from unprotected sexual contact until:
    • 7 days after completion of a single-dose anti-infective therapy; or
    • Completion of multi-dose anti-infective regimen; and
    • Treatment of all partner(s) is completed
  • Educate client on how to decrease their risk for sexually transmitted and blood-borne infections (STBBIs).
  • Recommend HIV testing and offer counselling as per provincial/territorial policies and procedures (obtain informed consent if client agrees to HIV testing)
  • Teach client about proper use of condoms, lubricants and other barriers such as dental dams
  • Advise sexually active clients to avoid products containing nonoxynol-9 as they irritate the mucosa and can actually increase infection risk. See additional information on risks associated with nonoxynol-9
  • Counsel client about appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactions
Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment

  • Unless treating client presumptively for syndromic management (e.g., PID, epididymitis), consider management choices based on the site of infection, available lab results, and provincial/territorial policies and proceduresFootnote 123Footnote 124
  • Directly observed therapy (DOT) with single-dose regimens is preferredFootnote 123Footnote 124
  • If lab samples are required, they should be obtained prior to initiating treatment
GonorrheaFootnote 124

Note: If treated for gonorrhea, clients should also be treated for chlamydial infectionFootnote 124Footnote 129

  • Consult physician/nurse practitioner for other gonococcal presentations and for treatment of children
  • Combination gonorrhea therapy using medications with 2 different mechanisms of action is thought to improve treatment efficacy and potentially delay the emergence of resistant gonorrhea
  • If treated for gonorrhea, clients should also be treated for chlamydial infectionFootnote 124Footnote 129 as chlamydia occurs frequently in the presence of gonococcal infectionFootnote 124

Uncomplicated anogenital infection MSM

  • For MSM , the preferred treatment is cefTRIAXone 250 mg IM, together with azithromycin 1 g PO for 1doseFootnote 124
    • CefTRIAXone is the preferred treatment in this group due to reported cefixime treatment failures primarily among MSMFootnote 124

Other populations

  • For other populations, the preferred treatment is cefTRIAXone 250 mg IM or cefixime 800 mg PO for 1 dose, together with azithromycin 1 g PO for 1 doseFootnote 124

Pharyngeal infection

  • For all populations, the preferred treatment is cefTRIAXone 250 mg IM, together with azithromycin 1 g PO for 1 doseFootnote 124
    • CefTRIAXone is recommended as the preferred treatment because it has higher tissue penetration in the oropharynx to achieve cure compared to cefiximeFootnote 124

Gonorrhea resistanceFootnote 124

  • Canadian data shows increasing rates of antimicrobial resistance for N. gonorrhoeae; combination antibiotic therapy aims to improve treatment efficacy and delay resistanceFootnote 124
  • Quinolones such as ciprofloxacin or ofloxacin are no longer routinely recommended

For more information on gonorrhea diagnosis and management of resistant gonorrhea, see Appendix, Section A and Antimicrobial Resistance in N. gonorrhoeae: In Brief. PowerPoint version (279 Kb, 7 pages)

Alternative treatment optionsFootnote 124

  • If anaphylactic allergy to penicillin, or known sensitivity to a 3rd generation cephalosporin, monotherapy with azithromycin may be considered; consult with provincial/territorial Public Health guidelines
  • A test of cure should be performed when an alternative treatment option is used
ChlamydiaFootnote 123

Non-pregnant, non-lactating adults

  • For non-pregnant, non-lactating adults with urethral, endocervical, rectal, or conjunctival infection, use azithromycin 1 g PO for 1 doseFootnote 123Footnote 124 or doxycycline 100 mg PO BID for 7 daysFootnote 123Footnote 130
    • Client adherence to treatment duration of 7 days may be problematic in certain individuals

Pregnant or lactating clients

Azithromycin 1 g PO for 1 dose is preferred for the pregnant or lactating client.Footnote 131

Children

For treatment of children, additional consideration is needed; consult with physician/nurse practitioner.

Management of other sexually transmitted infections

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-upFootnote 123Footnote 124
  • Counsel client to return for further assessment if there is no improvement in signs and symptoms of presenting condition following treatment
  • Rescreening is recommended 6 months after treatment for chlamydia and gonorrhea due to the high re-infection rate
Test of cure for gonorrhea
  • Test of cure is recommended after treatment in all cases and is particularly important under the following circumstances:
    • For all children
    • For all pregnant women, including women undergoing therapeutic abortion
    • If treatment adherence is a concern
    • If persistent symptoms post-treatment
    • If there is re-exposure to an untreated partner
    • For all treated pharyngeal infections
    • If an alternative treatment regimen has been used
    • If positive history of treatment failure for gonorrhea
    • If antimicrobial resistance is suspected or documented in the individual
    • If the individual is linked to a case with documented antimicrobial resistance to the given treatment
    • For disseminated gonococcal infection
    • For pelvic inflammatory disease if gonorrhea was isolated
  • Test of cure by culture should be done 3 to 7 days after completion of treatment
  • If culture is not available, test of cure using a NAAT should be done 2 to 3 weeks after completion of treatment
Test of cure for chlamydia
  • Test of cure for chlamydia is not usually indicated if a recommended treatment is taken and there are no persisting signs or symptoms and there is no repeat exposure to an untreated partner. Test of cure is recommended under the following circumstances:Footnote 123
    • If treatment adherence is a concern
    • If an alternative treatment regimen has been used
    • For all children
    • For all pregnant women
  • Test of cure using a NAAT, if needed, should be performed 3 to 4 weeks after completion of treatment
Reporting diseases and contact tracing general principlesFootnote 123Footnote 124

Reporting: children

Any child with rectal, genital, or pharyngeal gonorrhea and/or chlamydia should be considered at risk of sexual abuse.

  • Consultation with physician/nurse practitioner and/or health care provider experienced with suspected sexual abuse is required
  • Legislation requires that suspected or confirmed sexual abuse of children is to be reported to provincial/territorial Children and Family Services agencies

Reportable diseases

Chlamydia and gonorrhea are reportable diseases. Follow provincial/territorial policies and procedures for notifiable diseases. For more information regarding contact tracing, see Contact tracing in Appendix, Section A of this guideline.

Treatment failures

  • Treatment failure is determined by a positive test of cure following a course of treatment
  • Treatment failure with cefixime, cefTRIAXone, or azithromycin should be reported to the provincial/territorial public health department; PHAC uses treatment failure data to track patterns of antimicrobial resistance

Appendix

Section A: Supplemental clinical management information
Antimicrobial resistance in gonorrhea
  • A national enhanced surveillance protocol that tracks laboratory, epidemiologic, and treatment failure data is in place
  • Resistance to penicillin and/or tetracycline is high in Canada
  • Provincial/territorial public health department to be notified of all treatment failures with cefixime, azithromycin or cefTRIAXone
  • Refer to your provincial/territorial public health offices for detailed information on antimicrobial resistance patterns

For additional information on diagnosis and management of gonorrhea, refer to Antimicrobial Resistance in N. gonorrhoeae. PowerPoint version (279 Kb, 7 pages)

Specimen collection
Contact tracing

An index case is a term describing the first case reported to authorities.Footnote 124

  • Clients who present with STI symptoms should be considered an index case until proven otherwise
  • Obtain a list of all sexual contacts in the past 60 days or longer if warranted by historyFootnote 123Footnote 124
  • Reassure client that their confidentiality will be maintained at all times if their contacts are called
  • Refer to your provincial/territorial Public Health offices for detailed information on requirements

If the test results are negative for an STI

Further steps are not required.

If the test results are positive for an STI

  • Follow-up with contacts while maintaining confidentiality of the index case
  • Fill out appropriate reporting forms and send them to your provincial/territorial Public Health Department or as per protocol
  • Treat each contact as if he or she were a new index case and complete appropriate testing
  • Treat each contact with the appropriate medication(s) without waiting for test results. This prevents delays in treatment of potential positive cases and decreases the risk of re-infecting the partner(s)
Prevention

Patient education/counselling

Topics commonly addressed when providing STI education or counselling include:

  • Serial monogamy considerations
  • Initiation of sexual activity
  • Contraceptive advice
  • Safer sex counselling
  • STI prevention steps, including barrier methods

See here for additional information on patient education/counseling.

Section B: Supplemental resources
Provincial/territorial guidelines

Alberta

Government of Alberta. Alberta Treatment Guidelines for Sexually Transmitted Infections (STI) in Adolescents and Adults.

British Columbia

BC Centre for Disease Control. British Columbia Treatment Guidelines - Sexually Transmitted Infections in Adolescents and Adults 2014. PDF Version (346 Kb, 11 pages)

Saskatchewan

Saskatchewan Ministry of Health. Communicable Disease Control Manual - Section 5: Sexually Transmitted Infections. PDF Version (1,571 Kb, 75 pages)

Manitoba

Manitoba Health. Communicable Disease Control - Sexually Transmitted and Blood-Borne Infections.

Public Health and Primary Health Care. Communicable Disease Management Protocols.

New Brunswick

Office of the Chief Medical Officer of Health (Public Health). Sexually Transmitted and Blood-Borne Infections (STBBI).

Newfoundland and Labrador

Department of Health and Community Services. Newfoundland and Labrador Disease Control Manual: Section 5 Sexually Transmitted Infections and Bloodborne Pathogens.

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Nova Scotia Department of Health and Wellness. STI Guidelines for Gonococcal Infections. PDF Version (735 Kb, 29 pages)

Ontario

Ontario Ministry of Health and Long-Term Care. HIV and AIDS in Ontario. PDF Version (925 Kb, 124 pages)

Provincial Infectious Diseases Advisory Committee. Sexually Transmitted Infections Case Management and Contact Tracing Best Practice Recommendations.

Quebec

Ministère de la Santé et des Services Sociaux. Guide québecois de depistage des infections transmissibles sexuellement et par le sang.

Yukon

Yukon Health and Social Services. Yukon Treatment Guidelines for Sexually Transmitted Infections (STI) in Adolescents and Adults. PDF Version (661 Kb, 10 pages)

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Toxic shock syndrome (TSS)

Overview

Please refer to Provincial/territorial guidelines for Toxic Shock Syndrome where available.

Toxic shock syndrome (TSS) is a life-threatening illness characterized by sudden onset of high fever, hypotension, diffuse erythematous rash, and multiorgan failure (e.g., acute respiratory distress syndrome (ARDS)), coagulopathy, liver failure, renal failure, altered mental status.Footnote 133Footnote 134 TSS is precipitated by an infection and it may progress rapidly.Footnote 135 Morbidity and mortality associated with TSS is high, particularly when caused by Group A Streptococci (GAS).Footnote 133Footnote 134

Toxic shock syndrome is a medical emergency. All clients with suspected toxic shock syndrome must be medically evacuated as soon as possible. Consult with a physician/nurse practitioner immediately.

Causes
  • Staphylococcus aureus (S. aureus)Footnote 134
  • Group A Streptococci (GAS)Footnote 133
  • Clostridium sordelli, an uncommonly reported condition that is associated with gynecologic procedures, childbirth and abortion (spontaneous, surgical and medical)Footnote 136

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

Colonization with S. aureus or GASFootnote 133Footnote 134

Risk factors associated with S. aureus TSSFootnote 134
  • Using high absorbency tampons
  • Using tampons continuously for more days of the menstrual cycle
  • Keeping a single tampon in place for a long period of time
  • Surgical or postpartum wound infections
  • Secondary to other infections, including:
    • Burns
    • Scalds
    • Mastitis
    • Septorhinoplasty
    • Sinusitis
    • Osteomyelitis
    • Arthritis
    • Skin lesions (especially of the extremities, perianal and axillae)
    • Respiratory infections (e.g., influenza) and enterocolitis
Risk factors associated with invasive GAS TSSFootnote 133
  • Minor trauma, including injuries resulting in hematoma, bruising or muscle strain
  • Recent surgery, e.g. liposuction, hysterectomy, bunionectomy, bone pinning, caesarean section
  • Recent viral infection, e.g. influenza, varicella
  • Postpartum
  • Clients with chronic diseases including Human Immunodeficiency Virus (HIV), diabetes mellitus, cancer, ethanol abuse
History of present illness

Review Risk factors and collect History of present illness. The following may be reported by the client.

  • Symptoms and signs that develop rapidly and may include:Footnote 133Footnote 134
    • Fever and chills
    • Malaise
    • Headache
    • Sore throat
    • Myalgias
    • Fatigue
    • Nausea and vomiting
    • Abdominal pain and diarrhea
    • Dizziness or syncopeFootnote 133Footnote 134
  • Median onset of menstrual-associated toxic shock syndrome is 2 to 3 days after onset of menstruationFootnote 134
  • The most common presenting symptom of clients with streptococcal toxic shock syndrome is pain that precedes Physical findings of infectionFootnote 133
  • The pain typically involves soft tissue of an extremity but may also mimic other conditions, including:Footnote 133
    • Peritonitis
    • Pelvic inflammatory disease
    • Pneumonia
    • Acute myocardial infarction
    • Cholecystitis
Physical findings

Perform a Physical examination using the IPPA approach. Signs of TSS usually include some or all of the following:

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

  • Diagnosis of toxic shock syndrome is based on clinical presentationFootnote 134
  • Laboratory diagnosis can support a clinical diagnosis of toxic shock syndrome and can direct antibiotic therapyFootnote 133Footnote 134
  • Tests that may be considered to assess organ failure include:Footnote 133Footnote 134
    • CBC
    • BUN
    • Creatinine
    • Liver function tests
    • Creatinine phosphokinase
  • Tests that may confirm the causative organism:
    • Culture and sensitivity (C+S) to isolate the organism (i.e., using blood, wound or mucosal swabs)Footnote 135
    • Staphylococcal TSS (usually negative for blood cultures but can be recovered from local wounds and mucosal sites)Footnote 134
    • Streptococcal TSS (positive for blood cultures at least 60% of the time)Footnote 133

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Note: Inclusion of the Medical Officer of Health will also be necessary to help identify contacts of an index case of toxic shock syndrome, particularly caused by invasive GAS. The Medical Officer of Health will also be able to provide advice on the appropriate management of these contacts.

Goals of treatment
Non-pharmacological interventions
Interventions
  • Stabilize airway, ABCs and provide aggressive supportive care to treat shock and multiorgan failure (e.g., fluid resuscitation, ventilatory and circulatory support)Footnote 135
  • Protect infected area from further injury
  • If menstrual-related TSS is suspected, remove menstrual products
  • If wound is involved, cleanse wound

Oxygen therapy

Administer oxygen therapy as required.

Client education

Counsel client about appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactions.

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Supportive therapy

IV therapy

Antibiotic therapy
  • Antibiotic therapy is needed to eradicate organisms and to prevent recurrencesFootnote 134
  • Antibiotic therapy may be started while waiting for medical evacuation
  • In consultation with physician/nurse practitioner and in consideration of provincial/territorial susceptibility data to guide treatment, consider the following for management of TSS:

Staphylococcal TSS

For suspected methicillin sensitive S. aureus (MSSA):Footnote 142Footnote 143

ceFAZolin

  • ceFAZolin 2 g IV q8h

and

Clindamycin

  • Clindamycin 600 to 900 mg IV q8h

For suspected methicillin-resistant S. aureus (MRSA) or if known or suspected allergy to penicillin and/or cephalosporin:Footnote 142Footnote 143Footnote 144

Vancomycin

  • Vancomycin 15 mg/kg/dose IV divided q12h (maximum 2,000 mg in 24 hours)

and

Clindamycin

  • Clindamycin 600 to 900 mg IV q8h

Streptococcal TSS

Clindamycin

  • Clindamycin 600 to 900 mg IV q8h

and

Penicillin

  • Penicillin G 12 to 24 million units in 24 hours IV divided q4-6h

or

If known or suspected allergy to penicillin and/or cephalosporin:

Vancomycin

  • Vancomycin 15 mg/kg/dose IV divided q12h (maximum 2,000 mg in 24 hours)

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring
  • Monitor vital signs
  • Monitor respiratory status
  • Monitor intake and output
  • Monitor wound progression
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
Follow-up
Referral

Arrange for urgent medical evacuation.

Reporting

Toxic shock syndrome may be reportable. Follow provincial/territorial policies and procedures for notifiable diseases. For more information on provincial/territorial policies and procedures, see Communicable Diseases Provincial/Territorial Resources for Toxic Shock Syndrome in Appendix, Section B of this guideline.

Appendix

Section A: Supplemental clinical management information
PreventionFootnote 146
  • Instruct client to keep any skin wounds clean to help prevent infection
  • Instruct client to avoid scratching any skin lesions
  • Avoid using tampons and barrier contraceptives during the first 12 weeks after childbirth
  • Follow the directions on package inserts for tampons and barrier contraceptives regarding appropriate use
  • Recommend proper handwashing hygiene, particularly after contact with any lesions

Note: If the client has had staphylococcal toxic shock syndrome, instruct client not to use tampons, barrier contraceptives, or an intrauterine device (IUD).

Chemoprophylaxis for household contacts

The close contacts of any client diagnosed with toxic shock syndrome may be considered for treatment with antibiotic therapy according to provincial/territorial public health guidelines and in consultation with the Medical Officer of Health.

Section B: Supplemental resources
Provincial/territorial guidelines

Alberta

Alberta Health and Wellness Public Health. Notifiable Disease Management Guidelines: Toxic Shock Syndrome (Staphylococcus aureus).

Alberta Health and Wellness. Public Health Notifiable Disease Management Guidelines: Streptococcal Disease – Group A, Invasive.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Management of Specific Diseases: Invasive Group A Streptococcal Disease. (PDF, 85 Kb, 13 pages)

Manitoba

Public Health and Primary Health Care. Invasive Group A Streptococcal Disease. (PDF, 347 Kb, 13 pages)

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Department of Health and Wellness. Nova Scotia Communicable Diseases Manual: Streptococcal Toxic Shock Syndrome [STSS] General Information.

Ontario

Ministry of Health and Long-Term Care. Infectious Diseases Protocol: Group A Streptococcal Disease, invasive (iGAS). (PDF, 239 Kb, 13 pages)

Yukon

Yukon Health and Social Services. Yukon Communicable Disease Control. Communicable Disease Guidelines: Invasive Group A Streptococcal. (PDF, 256 Kb, 11 pages)

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources
  • Canadian Pharmacists Association. Compendium of Therapeutic Choices: Canada’s Trusted Reference for Primary Care Therapeutics (CTC 7). Ottawa: Canadian Pharmacists Association; c2014.
  • Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Tuberculosis (TB)

Overview

Please refer to Provincial/territorial guidelines for TB where available.

Tuberculosis (TB) is an infectious bacterial disease which most commonly affects the lungs (‘pulmonary TB’).Footnote 147 The term, ‘non-respiratory TB’ refers to TB disease in any site not associated with the lungs.Footnote 148 Infection occurs when airborne droplet nuclei particles containing Mycobacterium tuberculosis bacteria are inhaled.

Causes

Mycobacterium tuberculosis bacteriaFootnote 149

TB subgroups

Active tuberculosis disease (active TB)

  • Active TB is the presence of disease and active replication of TB bacteria in the lungs or other organ systems.Footnote 149 This requires prompt assessment and treatment to avoid complicationsFootnote 150
  • Features of active TB include:Footnote 151
    • M. Tuberculosis organisms recovered from pulmonary or non-pulmonary specimens
    • Abnormal chest x-ray (in pulmonary TB)
    • Symptomatic presentation (cough, fever and weight loss are the most common features)
    • Clinical signs and symptoms related to non-respiratory TBFootnote 150

Early disease progression (primary TB)Footnote 149

  • Some individuals recently infected with TB are unable to contain the infection
    • As a result, there is progression to early active disease in a matter of months
    • This is more likely to happen in young children and immunocompromised individuals
  • In severely immunocompromised individuals, early disease often manifests as intrathoracic adenopathy

Latent tuberculosis infection (LTBI) or inactive TB

  • LTBI is the presence of latent or dormant infection with M. tuberculosis
  • Clients with LTBI are non-infectious and have:Footnote 152
  • No evidence of clinically active disease
  • No radiographic changes suggestive of active disease
    • Negative microbiologic tests
    • The risk of transition from LTBI to active TB is largely dependent on the immune competence of the hostFootnote 153
  • Risk of progression to active TB is greatest during the first 2 years after infection, and disease may be referred to as either primary or reactivation TB

Late disease progression (reactivation TB)Footnote 149

  • In Canada, most TB is understood to be ‘reactivation’ TB (i.e., occurring 18 to 24 months (or more) after the initial infection)
  • It usually presents as adult-type pulmonary disease, although it may also present as nonrespiratory TB
  • In any population group, reactivation of LTBI that leads to active TB disease occurs more frequently in immunocompromised individuals and young children under 5 years of ageFootnote 154

For more information on tuberculosis, see Canadian Tuberculosis Standards, 7th edition.

TransmissionFootnote 149
  • Transmission from a case of active pulmonary, laryngeal and/or cavitary TB is airborne
  • Bacilli in minute droplets of moisture (droplet nuclei) are inhaled by individuals and go on to produce TB infection or disease
  • TB is rarely acquired by ingestion or percutaneously
  • The likelihood of transmission increases if the source individual has any of the following:
    • Frequent and severe cough
    • Close and prolonged contact with others
    • Crowded living conditions with poor ventilation
  • The initial TB infection is usually self-limited and followed by a period of latency (latent infection [LTBI]), which can transition to active TB in a proportion of those infected
  • The most effective ways to reduce transmission risk include early diagnosis and treatment of clients with active pulmonary TB and following infection prevention and control procedures
Communicability
  • Primary or Active TB is spread through infectious airborne droplet nucleiFootnote 149
  • LTBI is not communicableFootnote 155
  • Non-respiratory TB is rarely communicable

Assessment

Medication review: Review current medications, as well as over-the-counter, complementary and alternative medicines, and any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factorsFootnote 156
  • Individuals with a history of active TB disease
  • Individuals exposed to a source case of active TB
  • Recreational injection drug users
  • Individuals with HIV
  • Aboriginal Canadians living in communities at high risk for TB and with high rates of LTBI
  • Staff and residents of homeless shelters
  • Correctional staff and inmates (including individuals previously incarcerated)
  • Healthcare workers serving at-risk groups
  • Individuals living or working in crowded areas with poor ventilationFootnote 149
  • Immunocompromised individualsFootnote 149
  • Individuals who are malnourishedFootnote 149

For more information on the risks of - and those at risk for - TB, see Who is most at risk? in Risks of tuberculosis (TB).

History of present illness
  • Review Risk factors and collect History of present illness
  • Tuberculosis should be considered if a client from a high risk group presents with:
    • An unexplained cough and/or
    • Concerning symptoms that persist for more than a few weeks or
    • Pneumonia that fails to resolve in any clientFootnote 157
  • The following symptoms may be reported by the client:
    • Chronic cough (productive or non-productive) for 2 or more weeks
    • Fever (may be absent in children and elderly)
    • Night sweats (may be absent in children and elderly)
    • Fatigue
    • Hemoptysis (generally associated with advanced disease)
    • Decreased appetite (anorexia generally associated with advanced disease)
    • Weight loss (generally associated with advanced disease)
Past medical history
  • Exposure to active TB
  • History of active TB and questionable adequacy of previous treatment
  • History of positive Tuberculin Skin Test (TST) and questionable prophylaxis adequacy, if the client previously received LTBI prophylaxis
Physical findings
  • Perform a complete Physical examination using the IPPA approach
  • Respiratory and non-respiratory TB can occur concurrently; it is important to rule out evidence of respiratory TB when nonrespiratory TB has been diagnosed, and vice versa. A normal examination is the most common physical finding in pulmonary TBFootnote 157

Common findings:Footnote 148Footnote 157

  • Fever
  • Weight loss
  • Chest findings:
    • Adventitia: bronchial breathing, rales or crepitations
    • Signs of pleural effusion on chest examination and auscultation
    • Lymphadenopathy, particularly cervical lymph nodes
    • Abdominal or bone and joint involvementFootnote 148
    • Other signs based on site of TB infection
Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnosis of active TB is based on characteristic diagnostic findings and clinical presentation. Clinicians are recommended to have a high index of suspicion for TB in at-risk individuals.

Differential diagnosis may include:

  • Bronchiectasis
  • Chronic obstructive pulmonary disease
  • Infections (e.g., fungal infection (including fungal pneumonia), non-tuberculosis mycobacterial infection)Footnote 156
  • Lymphoma, Kaposi sarcoma,Footnote 158 lung cancer or other malignancy
  • Pulmonary embolismFootnote 158
Complications
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

Recommended samples

  • Three 5 to 10 mL sputum samples (one of which should be an early morning specimen, if possible) for:Footnote 157
    • Acid-fast bacilli (AFB) and
    • M. tuberculosis culture +/− PCR
  • 3 sputum specimens can be collected on the same day, at least 1 hour apart, in a well ventilated area or outdoorsFootnote 157

For more information on the collection of sputum samples see Appendix, Section A, of this guideline.

Additional lab investigations

  • CBC
  • Liver function tests (e.g., ALT, AST, bilirubin)
  • Creatinine
  • HIV serology
  • Hepatitis B and C serology (P. Jessamine, the Ottawa Hospital; 2017 January.)
  • If there is reason to suspect genitourinary TB, obtain 3 to 6 first morning void urine samples for AFB smear and cultureFootnote 148
X-ray
  • X-rays may be required to confirm a diagnosisFootnote 157 or monitor response to treatmentFootnote 159
  • Frequency of films will vary and are at the discretion of the attending respirologist or TB expert

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment
Non-pharmacological interventions
Interventions

Recommendations for home isolationFootnote 159

  • It is recommended that clients suspected of having active respiratory TB disease be isolated immediately rather than waiting for confirmation of disease
  • Home isolation may be required at outset of treatment or until the client may be transferred out of the community to a tertiary hospital

For more information on conditions for home isolation, see Appendix, Section A of this guideline.

Client educationFootnote 156
  • Provide caregiver(s)/client with information about:
    • TB
    • the signs and symptoms of TB
    • the difference between TB disease and LTBI
    • the expected treatment plan

For more information, see Health Canada’s Tuberculosis is Curable, Information about TB fact sheet. (PDF, 2,736 Kb, 2 pages)

Treatment
  • Explain the purpose, process and importance of directly observed treatment (DOT)
  • Stress the importance of strict adherence to medication regimen to ensure cure of TB and to prevent drug resistance
  • Encourage use of DOT to promote adherence and monitoring. All medication should be taken at the same time of day
  • Stress the importance of close Follow-up to successful treatment and early detection of drug side effects
    • Explain to client that TB medications may cause side effects that are best managed promptly; careful monitoring for side effects, especially during the first 3 months of treatment, includes blood tests and self-monitoringFootnote 150
  • Stress that self-monitoring is recommended for clients on TB medications and that they must notify their healthcare provider immediately if they experience any of the following signs/symptoms:Footnote 161
    • Change in visionFootnote 162
    • Nausea and/or vomiting
    • Loss of appetite
    • Jaundice
    • Dark urine
    • Fever that lasts 3 or more days and has no obvious cause

Medication

Counsel client/caregiver(s) about:

Advise client/caregiver(s) to avoid:

  • Ingestion of alcohol and
  • Other potential hepatotoxins as they may potentially worsen drug-induced hepatitisFootnote 162

If client smokes, assess tobacco use status at each visit and offer smoking cessation support. Smoking cessation products are an open-benefit through the FNIHB program (for more information, see FNIHB Adult Care Clinical Practice Guidelines – Chapter 15 – Mental Health – Nicotine Dependence.)

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Active diseaseFootnote 150

TB medications are routinely prescribed by TB specialists. In some provinces/territories however, they may be initiated and/or prescribed by an alternate physician/nurse practitioner. All oral TB medications are provided to clients through Provincial/Territorial Public Health Programs.

Isoniazid (INH) and pyrodoxine (vitamin B6)

  • When isoniazid (INH) is prescribed, vitamin supplementation with pyridoxine (vitamin B6) should also be prescribed because of the increased risk of symptoms related to pyridoxine deficiency, especially in clients with diabetes, renal failure, malnutrition, substance abuse, seizure disorders, HIV infection, and/or women who are pregnant and/or breastfeeding

Notes: Pyridoxine dose of 25 mg per day is sufficient as higher dose may interfere with INH activity.

Ethambutol (EMB)

  • Ethambutol (EMB) should be discontinued as soon as drug susceptibility testing (DST) result is available indicating that the bacterium is fully susceptible, or if the source case is known to be fully drug-susceptible

Treatment length

  • Treatment length will vary depending on the TB infection sites, prescribed anti-TB medications regimen, disease severity and client Risk factorsFootnote 148
  • Initiating TB therapy
  • Initiating TB therapy requires the client to be followed closely to monitor and minimize the risk of toxicity and to ensure therapy is completedFootnote 163
  • For effective TB treatment, 100% of prescribed doses must be taken
  • DOT is recommended at a minimum for clients with Risk factors for non-adherence
  • Consider alternate methods of DOT (e.g., videoconference) where available

Phases of therapy

Active disease therapy is always with multiple drugs for 6 months or longer. Therapy is initiated in 2 phases:

  • The initial phase, which lasts 2 months
  • The continuation phase, which lasts 4 months or longer

Initial phase of treatment (duration: 2 months)Footnote 150

  • Standard regimen: 4 medications should be prescribed (INH, rifampin, ethambutol, pyrazinamide)
  • Alternate regimen (owing to the toxicity of pyrazinamide): at least 3 medications (INH, rifampin, ethambutol). When only 3 medications are used in this phase, the continuation phase with INH and rifampin is 3 months longer
  • Pyrazinamide (PZA) is the most toxic of the standard first-line drugs and the most common cause of drug-induced hepatotoxicity in clients treated for TB disease
  • Clients at risk of hepatotoxic effects, such as those with a history of alcoholism, the elderly, and/or clients with pre-existing mild to moderate liver dysfunction may not tolerate this agent

Continuation phase of treatment (duration: 4 months or longer)Footnote 150

  • Standard regimen: At least 2 effective medications should be prescribed (INH and rifampin for 4-7 months except in cases of drug resistant isolates)
  • If antituberculosis drugs are to be given intermittently (for example, a schedule of 3 times a week in the continuation phase), the client must be fully supervised for DOT
  • Prolonging the continuation phase beyond 4 months (in which case the total course of treatment would be beyond 6 months) is recommended in the following circumstances:
Latent tuberculosis infection (LTBI)

Treatment regimens for LTBI may vary according to provincial/territorial treatment guidelines. TB control offices are to be consulted for further information

  • Standard regimen: INH for 9 months dailyFootnote 164
  • Alternative regimens:Footnote 164
    • INH plus rifampin daily for 3-4 months
    • Rifampin daily for 4 months

Note: When isoniazid (INH) is prescribed, vitamin supplementation with pyridoxine (vitamin B6) should also be prescribed because of the increased risk of symptoms related to pyridoxine deficiency, especially in clients with diabetes, renal failure, malnutrition, substance abuse, seizure disorders, HIV infection and/or women who are pregnant and/or breastfeeding. Pyridoxine dose of 25 mg per day is sufficient as higher dose may interfere with INH activity.Footnote 150

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-up

Clients on antituberculosis treatment require close Follow-up. Consider the following:

  • Chest x-ray should be performed at certain intervals during therapy to assess response, potential complications and risk of relapseFootnote 150
  • For a client suspected of treatment failure, two sputum smears and cultures (with drug susceptibility testing if culture-positive) are recommendedFootnote 150
  • Clients who are sputum direct smear AFB should be closely followed for clinical and objective response to therapy. The quality of a sputum sample is directly related to the effort expended by the client in producing the sample. Smear examination should be collected no more frequently than on alternate weeks (P. Jessamine, the Ottawa Hospital, 2017 January)
  • 3 consecutive negative AFB sputum samples are required from clients who have smear positive and culture positive TB before isolation can be stoppedFootnote 159
  • When sputum direct smears are AFB negative, a culture should be done at the end of the second month of therapy to assess risk of relapse, then again towards the end of therapyFootnote 150
  • During active TB treatment, clients should be seen at least monthly to assess adherence (DOT), response to therapy, and to detect adverse events; response to treatment should be gauged clinically, radiographically and microbiologically. Microbiologic monitoring is considered the most reliable method.Footnote 150 Consult provincial/territorial policies and procedures for additional guidance
  • Monitor clients on standard first-line anti-tuberculosis treatment for signs and symptoms of hepatotoxicity
  • Liver function tests should be checked regularly, as per physician/nurse practitioner directionFootnote 150
Clients on ethambutol (EMB)
  • Clients receiving ethambutol should have a baseline visual acuity and red-green color discrimination screen monthly (frequency may vary according to the provincial/territorial treatment guidelines and/or the treating physician/nurse practitioner)
  • Clients who take ethambutol for longer than just the initial phase of treatment should be referred to an ophthalmologist for periodic assessment of visual acuity, colour vision and visual fieldsFootnote 150
Referral
  • Arrange for medical evacuation if clinically indicated
  • Clients with suspected active TB may require medical evacuation for investigation and treatment
  • If suspected or confirmed active TB, clients may need to follow additional precautions during transportation; refer to provincial/territorial policies and procedures for guidance

Appendix

Section A: Supplemental clinical management information
PreventionFootnote 156
  • Adequate balanced nutrition, which aids in healing, may help prevent active TB in those with latent infection
  • TB education may help to increase knowledge and decrease any stigma associated with TB in the community
  • Promotional activities may help to encourage early detection of active disease
  • Training may help to highlight the importance of identifying individuals in the community who would benefit from LTBI treatment, as well as the reasoning behind LTBI treatment
Contact tracing principles
  • Guidelines for contact tracing may vary slightly by province/territory. Check with the TB control officer in the province/territory of residence for additional information. For more information, see Canadian Tuberculosis Standards, 7th edition – Chapter 12
  • Young children less than 5 years old and the immune-compromised are a high priority as they are more likely to progress to active disease if infectedFootnote 160
  • All TST of high priority contacts who were negative should be repeated 8 weeks after last contact with infectious client
  • Medium and low priority contacts should have a TST done only once at 8 weeks after last contact with an infectious caseFootnote 160
Conditions for home isolationFootnote 159
  • The person does not share common airspace with non-household members and the household air is not being recirculated to other housing units
  • All household members should have been previously exposed to the source case
  • If any household members are TST nonreactive, they should be informed and understand the potential risk
  • No children under 5 or persons with immunocompromising conditions are present in the home (an exception would be if they are receiving treatment for active TB disease or preventive treatment for latent TB infection)
  • No visitors should be allowed in the home except for health care workers
  • The person is counselled on, and is willing and able to comply with limitations to their movement outside of the home (e.g., does not go to work, school or any other public indoor environment)
  • The person should not be allowed to use any form of public transportation (if absolutely necessary, a taxi can be used to attend essential healthcare appointments, provided the person is wearing a mask)
  • The person should be allowed to ambulate outdoors since the risk of transmission is negligible provided they are not in very close contact with susceptible individuals for prolonged periods of time
  • Home isolation may be discontinued by the treating physician/nurse practitioner when the client has clinical evidence of improvement, 3 consecutive negative sputum smears for AFB and there is evidence of adherence to at least 2 weeks of effective therapy
Tuberculin skin test (TST) (Mantoux test)Footnote 153
  • This diagnostic test is used to identify LTBI
  • The TST consists of the intradermal injection of 0.1 ml of purified protein derivative (PPD) from M. tuberculosis bacteria
  • Improper intradermal injection technique may result in inaccurate results
  • Individuals with cell-mediated immunity to tuberculin antigens may have a delayed hypersensitivity reaction within 48-72 hours
    • The reaction will cause localized swelling and will manifest as an induration of the skin at the injection site
  • Indications for TST testing include:
    • Diagnosis of LTBI in individuals at increased risk of development of active TB and who would therefore benefit from treatment
    • Only those who would benefit from treatment should be tested, so a decision to test presupposes a decision to treat if the test is positive. In general, elderly clients should not be tested because the risk of treatment of LTBI in elderly clients outweighs the benefits
    • Supportive evidence of active disease in young children and those with nonrespiratory TB
    • Identification of newly infected LTBI cases in contact tracing; initial plus 8 week post-exposure TST is recommended for household and other high-priority contactsFootnote 160
    • A single TST 8 weeks post-exposure is recommended for contacts who are medium or low priorityFootnote 160

The TST should not be performed on clients in the following situations:

  • Previous severe blistering reactions to the TST
  • Documented reactive or significant TST result in the past that was read by a knowledgeable health care practitioner
  • Known to have active TB or who has been treated adequately in the past for active TB
  • Extensive burns or eczema present over intended testing site
  • Client has had a viral infection (such as measles, mumps, and varicella) in the past month or has received vaccination with a live-virus vaccine in the past month, as TST result may be false negative. However, in this situation a clinician may still choose to administer a TST even with a risk of a theoretical false negative. TST may be administered on the same day as a live vaccine

Interpreting TST results:

  • Window for reading TST results is between 48 to 72 hours
  • Reaction to the TST includes: measuring the diameter of the induration in millimetres, not the erythema

False negative results:

  • May occur in infants less than 6 months of age, the elderly, the seriously ill, or anergic people (e.g., those with HIV/AIDS, other immune deficiencies or those on corticosteroids), or those with active TB

False positive results:

  • Client history of the Bacille Calmette-Guérin (BCG) vaccination may trigger a positive TST result
How to perform a TSTFootnote 153

Handling the tuberculin solution:

  • Tubersol 5 tuberculin units (5-TU) of PPD-S (purified protein derivative-standard) is recommended in Canada
  • The solution can be adversely affected by exposure to light. PPD should be stored in the dark
  • Discard the solution if the vial has been in use for longer than 1 month or for an undetermined amount of time (the potency of the solution may be diminished)

Preparing the client to be tested:

  • Use the inner aspect of the forearm, preferably the nondominant arm about 10 cm (4 inches) below the elbow; avoid areas with abrasions, swelling, visible veins or lesions. If there is a localized rash, a burn or localized eczema, avoid this area
  • Do not use local anesthetic cream as application has been reported to cause localized edema, which could easily be confused with a positive TST result

Injecting the PPD tuberculin solution:

  • Use a 0.6 to 1.3 cm (¼ to ½ inch), 26- or 27-gauge needle with a disposable plastic tuberculin syringe
  • Position the bevel of the needle so that it opens facing up
  • Administer the PPD by the slow intradermal injection of 0.1 mL of 5-TU
  • A discrete, pale elevation of the skin (a wheal) 6 to 10 mm in diameter should appear. The wheal will typically disappear in 10 to 15 minutes. The size of the wheal is not completely reliable, but if a lot of liquid runs out at the time of injection and there is no wheal, repeat the injection on the opposite forearm, or on the same forearm as before, but at least 5 cm from the previous injection site
  • Clients should be advised not to massage the site to avoid squeezing out the PPD and disrupting the test
  • Do not cover the site with a bandage
  • Advise the client that they should not scratch the site but may perform all normal activities, including showering/ bathing
  • The TST should be read by a trained health professional. Individuals without experience in reading a TST may not feel a slight induration
  • When interpreting a reactive or significant TST, it is important to consider much more than simply the size of the reaction
  • Reading should be performed 48-72 hours after administration, as maximum induration can take up to 48 hours to develop, but after 72 hours it is difficult to interpret a reaction. Reactions may persist for up to one week
  • If the TST cannot be read within 72 hours due to unforeseen circumstances, it should be repeated at an injection site far enough from that of the previous test that the reactions do not overlap. No minimum wait time is required before the repeat test
  • The forearm should be supported on a firm surface and slightly flexed at the elbow
  • See the Mantoux Tuberculosis Skin Test Facilitator Guide (PDF, 895 Kb, 31 pages) for detailed instructions on the correct method of reading the skin test results
  • Record TST result in millimetres. No induration is recorded as 0 mm
  • Disregard and do not record erythema when reading results
  • Approximately 2-3% of people tested will have localized redness or rash (without induration) occurring within the first 12 hours. These are minor allergic reactions, are not serious and do not indicate TB infection. They are not a contraindication to future TSTs
Interferon gamma release assays (IGRAs)
  • IGRAs are in vitro blood tests of cell-mediated immune response; they measure T cell release of interferon gamma (IFN-gamma) following stimulation by antigens specific to M. tuberculosis. IGRAs require fresh blood samples
  • IGRAs are not affected by BCG vaccination status, and are useful for evaluating LTBI in BCG-vaccinated individuals. Further, although the finding is based on limited evidence, IGRAs appear to be unaffected by most infections with non-tuberculosis mycobacteria, which can cause false-positive TSTs. IGRA sensitivity is diminished by HIV infection. Confirm provincial/territorial availability of IGRA testing
Collection of sputum samplesFootnote 165

Provide clients with detailed instructions on the number and timing of sputum samples to be collected.

  • Key information to provide clients regarding collection:
    • Collect your sputum sample away from other people; outdoors or with an open window
    • Take two deep breaths and exhale slowly, then cough hard until sputum comes into your mouth, then spit it into the collection container
    • After sample collection, wash hands

For more information on sputum collection for TB testing, see Sputum Collection for Tuberculosis (TB) Testing. (PDF, 137 KB, 2 pages)

Table 1: Dosages for first line antituberculosis medications in adultsFootnote 150
Medications Usual daily doses
Isoniazid 5 mg/kg, maximum 300mg
Rifampin 10 mg/kg, maximum 600 mg
Pyrazinamide 20-25 mg/kg, maximum 2000 mg
Ethambutol 15-20 mg/kg, maximum 1600 mg
Monitoring for adverse events to antituberculosis therapy
Table 2: Possible adverse events to first-line antituberculosis therapyFootnote 150
Medications Common adverse events Uncommon but important adverse events
Isoniazid Rash, hepatitis, neuropathy Central nervous system toxicity, anemia
Rifampin Drug interactions, rash Hepatitis, flu-like illness, neutropenia, thrombocytopenia
Pyrazinamide Hepatitis, rash, arthralgia Gout
Ethambutol Eye toxicity Rash
Section B: Supplemental resources
Provincial/territorial guidelines

Alberta

Alberta Health and Wellness. Tuberculosis Prevention and Control Guidelines for Alberta.

British Columbia

BC Centre for Disease Control. Chapter 4: Tuberculosis Manual.

Manitoba

Public Health Branch Communicable Disease Control - Manitoba Tuberculosis Protocol. (PDF, 184 Kb, 18 pages)

Newfoundland and Labrador

Department of Health and Community Services. Guideline for Preventing the Transmission of Mycobacterium tuberculosis across the Continuum of Care. (PDF, 3, 431 Kb, 126 pages)

Northwest Territories

Northwest Territories Health and Social Services. NWT Tuberculosis Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Nova Scotia Department of Health and Wellness. Communicable Disease Prevention and Control, Tuberculosis.

Ontario

Ontario Ministry of Health and Long-Term Care. Ontario Public Health Standards: Tuberculosis Prevention and Control Protocol. (PDF, 458 Kb, 11 pages)

Saskatchewan

Government of Saskatchewan Tuberculosis.

Yukon

Yukon Health and Social Services TB Control Manual.

Other resources

Alvarez GG, Orr P. Wobeser WL, Cook V, Long R. Chapter 14: Tuberculosis Prevention and Care in First Nations, Inuit and Metis Peoples. In: Canadian Tuberculosis Standards. 7th ed. Her Majesty the Queen in Right of Canada; 2014.

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Viral Hepatitis

Overview

Please refer to Provincial/territorial guidelines for Viral Hepatitis where available.

Hepatitis is a condition associated with inflammation of the liver, usually due to viral infection.Footnote 166 In Canada, viral hepatitis types include hepatitis A, B, C, D and E, with A, B, and C the most common.Footnote 166 Although other virus types can induce hepatitis, they will not be discussed in this clinical practice guideline. All types of viral hepatitis can be transmitted. When appropriate, supportive care is provided; the majority of clients with acute hepatitis A or B will recover completely and will not experience chronic complications.Footnote 167 By contrast, the majority of clients with hepatitis C will become chronically infected. Hepatitis is a significant health concern due to the burden of illness for each individual, the potential for outbreaks and the spread to contacts.

Causes
Other causes of viral hepatitis include:Footnote 167
  • Coxsackie virus
  • Cytomegalovirus
  • Epstein-Barr virus
Hepatitis A Virus (HAV)Footnote 168
  • HAV is vaccine-preventable
  • HAV occurs primarily in children
  • Children often present asymptomatically, and may have some mild viral symptomsFootnote 169
  • Clinical illness is more severe in adults than in children
  • Clinical features typically appear within 3 to 5 weeks of infection and include:
    • Jaundice
    • Hepatomegaly
    • Hepatitis
  • HAV usually resolves spontaneously in 4 to 8 weeks, without complications, and without chronic infection
  • No specific antiviral treatment required; only supportive care is indicated
Hepatitis B virus (HBV)Footnote 170
  • HBV is vaccine-preventable
  • Most children with HBV present asymptomatically
  • Immunocompromised adults and children under 7 are more likely to develop chronic infection
  • Acute clinical illness occurs in 30 – 50% of individuals with HBV greater than 5 years of age. Clinical features include non-specific, mild viral symptoms (e.g., fever, malaise, nausea, and right upper quadrant (RUQ) abdominal painFootnote 171
  • Acute HBV infection in adults varies in clinical presentation, with 70% of cases manifesting sub-clinically, 30% of cases manifesting with icteric hepatitis, and less than 1% manifesting with fulminant hepatitis During the chronic phase, HBV manifests in a number of ways: as an asymptomatic carrier, chronic hepatitis, cirrhosis, and/or hepatocellular carcinomaFootnote 167
Hepatitis C virus (HCV)Footnote 173
  • Most acute cases of HCV are asymptomatic
    • 25% have jaundice or mild viral symptoms
  • 50-85% of acutely infected clients progress to chronic HCV infection
  • The most common cause of liver disease in Canada
Hepatitis D virus (HDV)Footnote 166
  • HDV occurs either as:
    • An acute infection with acute HBV or
    • a superinfection with chronic HBVFootnote 174
  • Acute HDV may present with viral symptoms, including:
    • Jaundice
    • Gastrointestinal symptoms
    • Fever
    • Discoloured urine or stool
    • Fatigue
  • HDV has been shown to:
    • Accelerate liver fibrosis (cirrhosis) and
    • May progress to fulminant hepatitis in association with HBVFootnote 174
Hepatitis E virus (HEV)
  • Acute HEV clinically presents the same way as HAVFootnote 176
  • Chronic HEV is occasionally encountered in immune compromised patients, including liver transplant recipientsFootnote 175
  • HEV is more common in endemic regions outside North AmericaFootnote 176
  • HEV is rare in CanadaFootnote 176
  • The infection is generally self-limitingFootnote 176
  • Results in a high mortality rate in pregnant women (15 to 20%)Footnote 175
Transmission
HAV and HEV
  • Transmitted via the fecal-oral routeFootnote 168
    • Fecal-oral route of transmission involves person-to-person spread by close contact or consumption of contaminated water and/or foodFootnote 166
HBV, HCV, HDV and HEV
  • Transmission occurs person-to-person via blood and/or bodily fluidsFootnote 166
  • The common modes of transmission are:
    • Percutaneous (injection drug use)
    • Perinatal
    • Horizontal
    • Sexual
    • Transfusion
    • Organ transplantation
    • Nosocomial (e.g., needle stick injury)
  • Injection drug users who are HBV-positive have a high prevalence of HDV
  • HBV is highly contagious

For more information about transmission, see Table 1, Comparison of Five Forms of Viral Hepatitis.

Incubation period
Table 1: Comparison of five forms of viral hepatitisFootnote 166
Form Transmission Incubation time Chronicity (risk of chronic
infection in infected clients)
A Adult or Pediatric: 15-50 days None
B Adult or Pediatric:
  • Parenteral
  • Sexual
  • Vertical
  • Blood
  • Organs
45-180 days Yes; chronicity occurs in:
  • 70 to 90% of infants
  • 10 to 30% of children under 7
  • 5% of adults
C Adult or Pediatric:
  • Parenteral
  • Vertical
  • Sexual
14-180 daysFootnote 177 Yes; chronicity occurs in:
  • 50 to 85% of cases
D Adult or Pediatric:
  • Parenteral; always coexists with hepatitis B
14-56 days Yes
E Adult and Pediatric:
  • Fecal-oral
  • Blood transfusion

Pediatric:

  • Vertical
14-60 days Usually not, except in immune-compromised individuals

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as chemical or substance intake that may impact management

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors
HAVFootnote 169
  • Travel or work in regions with high rates of HAV
  • Household or close contact of a person with acute HAV
  • Attends childcare or works in a childcare centre
  • Men who have sex with men (MSM)Footnote 178
  • Illicit drug users
  • Contact with contaminated food or water
  • Residents of some Aboriginal communities (may be attributed to inadequate water supply and overcrowding)
  • Residents of certain institutions (including correctional facilities)
HBVFootnote 179
  • High risk sexual activities (e.g., unprotected sex, multiple sexual partners, MSM)
  • Substance use that includes sharing of equipment (i.e., injection and inhalational)
  • Infants born to infected mothers
  • Household and sexual contacts of HBV carriers
  • Sharing personal care items (e.g., razors, toothbrushes, nail clippers) with HBV-positive person
  • Occupational exposure to blood or body fluids
  • Blood or blood product transfusion or medical procedure in Canada prior to 1970
  • Contaminated medical or personal services equipment (e.g., instruments used for tattooing or piercing)
  • Birth or living in/travelling to a region of HBV endemicity
  • Residents of certain institutions (including correctional facilities)
HCVFootnote 180Footnote 181
  • Substance use with sharing of equipment (injection and inhalation)
  • Blood or blood product transfusion and organ transplantation prior to 1992
  • Contaminated medical, dental or personal services equipment (e.g., instruments used for tattooing or piercing)
  • Occupational exposure to blood
  • Infants born to infected mothers
  • Multiple sexual partners and risky sexual behaviours leading to blood-to-blood contact
  • Co-infection with other sexually transmitted infections (STIs)
  • Sharing personal care items (razors, toothbrushes, nail clippers) with HCV-positive person
  • MSM
  • Incarcerated populations
  • Aboriginal peoples
  • Immigrants from countries with high HCV prevalence
History of present illness
  • Review Risk factors and collect History of present illness
  • Hepatitis, regardless of type, presents with similar clinical features but is variable in severity; lab investigations confirm the type of hepatitis
Acute hepatitis
  • Prodromal symptoms (which may precede the cardinal symptoms):Footnote 168
    • Fever
    • Skin rash
    • Arthralgia
    • Arthritis

Note: Fever is common in HAV cases but rare with hepatitis B or C.

  • Cardinal symptoms:Footnote 168
    • Nausea
    • Fatigue
    • RUQ abdominal pain
    • Loss of appetite
    • Jaundice (common)
    • Vomiting
    • Headache
    • Pale-coloured stools
    • Pruritus
    • Dark urine
Chronic hepatitis
  • Most clients present asymptomatically or may have non-specific constitutional symptoms (e.g. fatigue).Footnote 168
  • In the presence of advanced, decompensating/decompensated liver disease, clients may be symptomatic with signs of end-stage liver disease (ESLD):
    • Ascites
    • Bleeding
    • Encephalopathy
Physical findings

Perform a Physical examination using the IPPA approach. Physical findings vary depending upon the phase of illness (i.e., acute or chronic).

Acute phase of hepatitis:Footnote 168
  • Client may appear mildly to moderately ill
  • Findings may vary and early signs may include right upper quadrant pain, dark urine, pale stools, fever followed by jaundice
  • Extrahepatic manifestations may include: skin rashes, arthralgia, arthritis and fever
  • Most patients with acute HCV are asymptomaticFootnote 173 but they may also have these typical findings
Chronic phase of hepatitis:Footnote 182
  • Prevalent clinical features include palmar erythema, jaundice (sclera, skin), spider nevi, splenic or hepatic enlargement, abdominal findings (e.g., ascites)
  • Increased jugular venous distension
  • Peripheral edemaFootnote 172
  • Extrahepatic manifestations (e.g., fever, skin rashes, arthralgia, arthritis)

Note: Behavioural changes (e.g., lethargy, encephalopathic behaviours) may occur in either acute or chronic phase. For more information, see Hepatic Encephalopathy in Appendix, Section A of this guideline.Footnote 190Footnote 168

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications

Note: HAV is usually a self-limiting disease, with a low rate of complications.Footnote 168

Clients presenting with signs of fulminant hepatitis are at risk for severe decompensation and require medical evacuation.

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment
  • Provide supportive care
  • Prevent spread of infectionFootnote 167
  • Minimize liver damage and reduce mortalityFootnote 167
Non-pharmacological interventions
Interventions for acute hepatitis A, B and CFootnote 168

Supportive care is appropriate for clients who are symptomatic with acute hepatitis. Supportive care consists of:

  • Adequate fluid intake with rehydration if clinically appropriate
  • Healthy diet with no dietary restriction
  • Activity as tolerated
Client education

For clients with HAV

Interventions to minimize infection spread:Footnote 169

  • Stringent hand-washing
  • Sanitary disposal of feces
  • Avoid alcohol with appropriate support
  • Client with HAV should be excluded from school, work or daycare until a week after jaundice resolvesFootnote 184
  • Client with HAV should not prepare food until a full week after jaundice resolves
  • In the event of school exposure, mass vaccination is not recommended

For clients with HBV and HCV

  • Inform all healthcare providers of viral status (e.g., HBV positive)Footnote 167
  • Do not donate organs,Footnote 167 tissue, blood or semenFootnote 183
  • Do not share personal hygiene materials, recreational drug equipment or needlesFootnote 167Footnote 187
  • Clean up blood spills with diluted bleach and water (1 part bleach to 9 parts water)Footnote 179
  • Reduce and avoid hepatotoxic medicationsFootnote 179
  • Avoid alcohol with appropriate supportFootnote 167
  • Recommend smoking cessation program if availableFootnote 167Footnote 179
  • Ensure all susceptible close contacts are vaccinated (HBV only)Footnote 179
  • Use condoms during sexual activities until partners are immune (HBV only)Footnote 179
  • Advise client and parent(s)/caregiver(s) that the client (pediatric) should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye’s syndrome which can damage the liver and brain
  • Counsel client and parent(s)/caregiver(s) about appropriate use of medications, dose, frequency, importance of adherence, potential side effects and interactions
Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Acute hepatitis

By definition, acute viral hepatitis is a systemic viral infection that has been present for less than 6 months (often less than 6 weeks), causing inflammation of the liver.Footnote 185 In most cases of acute viral hepatitis, specific antiviral therapy is not recommended. Since clinical presentations are the same for all types of acute viral hepatitis until confirmed by serologic testing, it is important to provide appropriate supportive care.

IV therapy

If the client is dehydrated, initiate an IV line and run IV fluid (e.g., 0.9% sodium chloride), at a rate sufficient to maintain hydration, as necessary. For the adult client, see FNIHB Adult Care Clinical Practice Guidelines – Chapter 5 – Gastrointestinal System. For the pediatric client, see FNIHB Pediatric and Adolescent Care Clinical Practice Guidelines – Chapter 4 – Fluid Management.

Other supportive therapiesFootnote 185

  • If required, use the following Pharmacological interventions with caution and consult with physician/nurse practitioner: acetaminophen, anti-inflammatory agents such as ibuprofen, and/or anti-emetic such as dimenhyDRINATE (Gravol) or ondansetron
  • Vitamin K and/or lactulose may be required to manage coagulopathy and hepatic encephalopathy, respectively, as required
  • Review all of the client’s medications, including herbal products, with a physician/nurse practitioner/pharmacist to consider stopping medications that are hepatotoxic (e.g., oral contraceptive)
  • Provide appropriate supportive treatment to clients with history of chronic alcohol use to avoid alcohol withdrawal
Chronic hepatitis

Antiviral treatment is recommended for some clients with chronic hepatitis B, and all clients with chronic hepatitis C. Treatment is complex and routinely prescribed by a specialist, yet in some provinces/territories, it may be initiated and/or prescribed by an alternate physician/nurse practitioner. Antiviral medications may be accessed for clients through the Non-Insured Health Benefit (NIHB) Program.

Chronic hepatitis BFootnote 185

  • For clients with chronic hepatitis B, antiviral treatment may be either with an injection (peginterferon alfa-2a), or an oral antiviral (tenofovir, entecavir), depending on the client-specific characteristics, the results of hepatitis B virus serum markers, and the client’s co-morbidities
  • The duration of treatment with peginterferon alfa-2a injection is finite with weekly injection for 48 weeks; whereas the optimal duration of therapy for the oral drugs is not well-established. Most patients receiving oral antiviral therapy will require at least 4 to 5 years of treatment, and some may require indefinite treatment (e.g., in the presence of advanced liver fibrosis)
  • Clients on peginterferon alfa-2a injection may experience numerous side effects, such as depression, severe cytopenias and anemia; thus close monitoring is recommended

For more information on side effects and contraindications of antiviral treatment, see the most up-to-date Compendium of Pharmaceuticals and Specialties (CPS), manufacturer drug monograph, or other approved drug information systems.

Chronic hepatitis C

  • It is recommended that all clients with chronic hepatitis C are considered for antiviral therapy, especially those with advanced liver fibrosis and extrahepatic manifestations (i.e., vasculitis, glomerulonephritis) regardless of liver disease severityFootnote 180
  • Dual therapy with peginterferon and ribavirin is no longer the standard of careFootnote 180
  • New oral antiviral medications are recommended as first-line therapy because of the significantly improved efficacy, tolerability, ease of administration and shortened duration of treatment (8 to 12 weeks)Footnote 180
  • New oral antivirals are known as direct-acting-antiviral agents (DAAs), where they interfere directly in replication processes of the hepatitis C virus, and are classified as polymerase inhibitors (-buvir), replication complex inhibitors (-asvir), and protease inhibitors (-previr).Footnote 186 An example of a common oral combination treatment is sofosbuvir (400mg)/ledipasvir (90mg) (Harvoni®)
  • For more information on management of hepatitis C and their side effects
  • The potential for drug interactions must be reviewed prior to starting DAA therapy. Some drug interactions with DAAs may be serious. For example, sofosbuvir and amiodarone can lead to significant symptomatic bradycardia. To access information on drug interactions with antiviral medications

Other supportive therapies (for chronic hepatitis B or C)

  • If required, use the following Pharmacological interventions with caution and consult with physician/nurse practitioner: acetaminophen, anti-inflammatory agents such as ibuprofen, and/or anti-emetics such as dimenhyDRINATE (Gravol) or ondansetron
  • Lactulose may be used to prevent the recurrence of hepatic encephalopathy (30 to 60 mL in 2 to 3 divided doses so that the client passes 2 to 3 soft stools per day)Footnote 186
Active and passive immunization

Vaccines are available for HAV and HBV, but not for HCV.Footnote 167

  • Hepatitis A:
    • HAV vaccine is recommended for pre-exposure immunization of individuals 6 months of age and older at increased risk of infection or severe hepatitis A
    • For adult clients and children older than 6 months who are exposed to an infectious case of HAV, HAV vaccine should be administered as soon as possible (preferably within 14 days of last exposure)Footnote 178
    • For children younger than 6 months or if HAV vaccine is contraindicated or unavailable, immune globulin (Ig) is recommended for post-exposure prophylaxis to HAV (administered up to 14 days after last exposure)
    • For immunocompromised individuals, those with chronic liver disease and susceptible adults 60 years of age and older, both Ig and HAV vaccine should be considered for post-exposure prophylaxisFootnote 178
    • Clients with HBV should be vaccinated against HAV if not immuneFootnote 167
  • Hepatitis B:
    • Consult provincial/territorial immunization guidelines for HBV routine immunization schedule
    • Post-exposure HBV vaccination and hepatitis B immune globulin (HBIg) should be given to infants born to HBV-positive mothersFootnote 187
    • HBIg provides immediate, short-term passive immunity against HBV.Footnote 167 Immune globulin may be indicated in clients with acute exposure, or who are at higher risk of contracting the virus
    • Clients with HCV should be vaccinated against HAV and HBV if not immuneFootnote 167
  • To access standard immune globulin (for Hepatitis A) and Hepatitis B immune globulin (HBIg), follow provincial/territorial policy and procedures as necessary

For additional information, contact the immunization coordinator and/or see the Canadian Immunization Guide – Part 4 – Active Vaccines.

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring
  • Monitor vital signs, ABCs, as indicated by client’s condition
  • Monitor for deterioration or change in neurological status, cognitive status or alertness
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
Follow-up
Acute hepatitis

HAV

  • Follow-up as clinically indicated. HAV is typically a self-limiting illness with complete recovery

HBV and HCV

  • Follow up for acute hepatitis B and C is variable depending on clinical presentation. The following tests are generally recommended. Consultation with nurse practitioner or physician is recommended for guidance
  • Liver studies should be monitored until normalizedFootnote 167
  • For clients with acute HBV, HBsAg should be repeated at 6 months to determine if infection has resolvedFootnote 168
  • For clients with acute HCV, HCV RNA should be monitored regularlyFootnote 168
Chronic hepatitis (HBV and HCV)
Referral
  • Arrange for medical evacuation if clinically indicated, particularly if client presents with decompensation/ hepatic encephalopathy
  • Coordinate referral request(s) as required:Footnote 179
    • HBV and HCV cases are usually seen by Infectious Disease or other specialists, e.g., Internal Medicine, hepatologyFootnote 167
    • For clients using interferon who experience suicidal symptoms or depression, consult physician/nurse practitioner and consider mental health referral
    • Provincial/territorial resources for urgent referral if deteriorating clinical status/signs of complications and/or chronic hepatitis management
Reporting
  • Follow provincial/territorial policies and procedures for notifiable diseases
  • Conduct contact tracing, with screening and vaccination as clinically appropriate

Appendix

Section A: Supplemental clinical management information
Table 2: Serologic features of viral hepatitisFootnote 168
Virus Serologic Marker Interpretation
A IgM anti-HAV Current or recent infectionFootnote 179
IgG anti-HAV Remote infection and immunity
B* Anti-HBs Immunity due to natural infection or vaccination
HBsAg Acute or chronic disease
HBeAg Active replication and at increased risk of transmission of HBV
IgM anti-HBcAg Acute disease
Total Anti-HBcAg (IgM and IgG) Acute or chronic disease
HBsAg positive Acute or chronic disease
HBsAg negative Not infected
C Anti-HCV test Acute, chronic or unresolved disease
HCV RNA
*Additional information on interpretation of HBV serologic markers:Footnote 167
  • Persistence of HBsAg beyond 6 months is likely in chronic HBV infection
  • If IgM anti-HBcAg is absent (HBcAg), it excludes acute HBV. A positive HBcAg does not provide sufficient distinction between acute disease and a flare-up of existing hepatitis
  • HbeAg correlates with a high level of active viral replication
Lab investigations for clients on anti-viral therapy

Laboratory investigations for clients on anti-viral therapy should be done periodically to provide information on response to treatment and any adverse effects of medications.

HBV

The frequency of monitoring is individualized according to client clinical status, complexity, and response to therapy.Footnote 188

HCVFootnote 168
  • HCV viral load
  • CBC, INR
  • Liver function tests (e.g., albumin,Footnote 180 alkaline phosphatase (ALP), ALT, AST, bilirubin, and GGT)
  • Creatinine
Fulminant hepatitis

Clients presenting with signs of fulminant hepatitis are at risk for severe decompensation and require medical evacuation.

Fulminant hepatitis, also referred to as acute liver failure, describes a rare and severe presentation of acute viral hepatitis. Fulminant hepatitis and its related liver damage results in coagulopathy and encephalopathy. If untreated, the prognosis of fulminant hepatitis is poor. Clients require urgent consultation and will likely require medical evacuation.

  • Cardinal signs of fulminant hepatitis are hepatic encephalopathy and prolonged bleeding time.Footnote 189
  • Other clinical signs may include:
    • RUQ tenderness
    • Hepatomegaly
    • Jaundice
Hepatic encephalopathyFootnote 190

Hepatic encephalopathy is a term used to describe a range of brain dysfunctions related to liver dysfunction. Symptoms may be either acute or chronic. It presents with a range of cognitive, neurologic or muscular findings that range from memory issues to significant impairment, including progression to coma if untreated.Footnote 190 Findings may include:

  • Cognitive changes:
    • Reduced level of consciousness
    • Sleep pattern inversion
    • Slow response time
    • Lethargy
    • Disorientation
    • Somnolence
    • Confusion
    • Semi-stupor
    • Coma
  • Intellectual function changes:
    • Subtle impairments with numerical computation
    • Decreased attention span
    • Gross impairment
    • Disorientation
    • Loss of self
    • Minimal intellectual function
  • Behaviour/personality changes:
    • Exaggerated behaviour
    • Depression or euphoria
    • Talkativeness
    • Irritability
    • Lowered inhibitions
    • Inappropriate or atypical behaviour
    • Bizarre behaviour
    • Paranoia or anger
    • Rage
    • Flat personality and behaviour
  • Neurologic/coordination changes:
    • Tremor
    • Incoordination
    • Asterixis (liver flap)
    • Inability to handwrite
    • Speech slurring
    • Ataxia
    • Abnormal reflexes
    • Nystagmus
    • Rigidity
    • Dilated pupils
    • Coma
Antiviral therapy side effects

Note: Antiviral treatment using interferon and ribavirin require close monitoring as there is a risk of suicide and depression.

Clients on antiviral therapy report flu-like side effects and significant mental health alterations (including suicidal ideation and depression); frequent monitoring is recommended.Footnote 180

  • Antiviral side effects may include:
    • Dose-dependent renal toxicity, with modifications required for renal dysfunctionFootnote 191
    • Depression (one of the most common side effects)Footnote 180
    • Suicide (clients are at highest risk during the first 12 weeks of therapy)
Prevention
  • Vaccination and risk behaviour modification may decrease the risk of acquiring and spreading viral hepatitisFootnote 183
  • Prophylactic vaccination for HAV and HBV
  • Avoid exposure to blood; practice safer sex, avoid sharing personal items
  • Universal precautions for blood and body fluids should be observed
  • Household surfaces contaminated by blood from a person infected with hepatitis require cleaning using gloves and a diluted bleach solution (1 part bleach to 9 parts water)
Section B: Supplemental resources
Other resources

For additional information on immunization for HAV or HBV, see the Canadian Immunization Guide.

For additional information on prevention of hepatitis C, see Prevention of hepatitis C.

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

Other sources

Canadian Pharmacists Association. Compendium of Therapeutic Choices: Canada’s Trusted Reference for Primary Care Therapeutics (CTC 7). Ottawa: Canadian Pharmacists Association; c2014.

Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Vulvovaginitis (candidiasis, trichomonas and bacterial vaginosis)

Overview

Please refer to Provincial/territorial guidelines for Vulvovaginitis (candidiasis, trichomonas and bacterial vaginosis) where available.

Vulvovaginitis is an infection and/or inflammation of the vagina, vulva and/or abnormal vaginal discharge.Footnote 193 This clinical practice guideline is for use with the adolescent or adult female with signs and symptoms of vulvovaginitis. For additional information on this content, see Canadian Guidelines on Sexually Transmitted Infections – Section 4 – Management and Treatment of Specific Syndromes.

Causes

Bacterial vaginosis (BV), Vulvovaginal candidiasis (VVC) and Trichomoniasis are the most common infections associated with abnormal vaginal discharge.Footnote 193

Bacterial vaginosisFootnote 193Footnote 194
  • BV is a polymicrobial clinical syndrome wherein normal vaginal flora are replaced with anaerobic bacteria
  • Typical microbiologic findings of vaginal specimens show increased concentrations of Gardnerella vaginalis, Mycoplasma hominis, Prevotella species, Mobiluncus species, and Ureaplasma species
Vulvovaginal candidiasisFootnote 193Footnote 194

90% of VVC is caused by Candida albicans; the remaining 10% is caused by various other species, including Candida glabrata.

TrichomoniasisFootnote 194Footnote 195
  • Trichomonas vaginalis, a protozoa, causes trichomoniasis and is the most common non-viral sexually transmitted infection (STI) globally
  • It commonly co-exists with other conditions, particularly with Neisseria gonorrhoeae (N. gonorrhoeae) and Chlamydia trachomatis (C. trachomatis) infections and BV
Transmission

Trichomonas is considered a sexually transmitted infection, while BV and VVC are not usually considered sexually transmitted. For more information, see Table 1: Sexual Transmission Risk factors and Predisposing Risk factors of this guideline.

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors
Table 1: Sexual transmission risk factors and predisposing risk factorsFootnote 193
  Bacterial vaginosis Candidiasis Trichomonas
Sexual Transmission
  • Not usually considered sexually transmitted
  • Not usually considered sexually transmitted
  • Sexually transmitted
Predisposing Factors
  • Often absent
  • More common if sexually active
  • New sexual partner
  • Intrauterine device (IUD) use
  • Often absent
  • More common if sexually active
  • Current or recent antibiotic use
  • Pregnancy
  • Corticosteroids
  • Poorly controlled diabetes
  • Immunocompromised
  • Multiple partners
History of present illness

Review Risk factors and collect History of present illness. The severity of inflammation correlates with severity of symptoms. History findings do not allow for a definitive diagnosis since there is considerable overlap in symptoms among the different etiologies of vulvovaginitis. For more information, see Table 2: Symptoms and Signs of Vulvovaginitis of this guideline.

The following may be reported by the client:Footnote 193

  • Vaginal irritation, itching or burning
  • May or may not have vaginal discharge
  • Change in vaginal discharge or odour
  • Vaginal bleeding or spotting
  • Superficial dyspareunia (pain felt at entry/introitus)Footnote 196
  • Urinary symptoms (e.g., dysuria, frequency)
Physical findings

Perform a Physical examination, including a speculum and bimanual examination, using the IPPA approach. Assess for signs and symptoms associated with vulvovaginitis (various causes) as presented in Table 2: Symptoms and Signs of Vulvovaginitis of this guideline.

Table 2: Symptoms and signs of vulvovaginitisFootnote 193Footnote 197Footnote 199
  Bacterial vaginosis candidiasis trichomonas
Symptoms
  • Vaginal discharge
  • Fishy odour
  • 50% asymptomatic
  • Vaginal discharge
  • Vaginal/vulvar pruritus
  • External dysuria
  • Superficial dyspareunia
  • Up to 20% asymptomatic
  • Vaginal discharge
  • Burning
  • Pruritus
  • Dyspareunia
  • Post-coital bleeding
  • Dysuria and frequency
  • Lower abdominal pain
  • 10-50% are asymptomatic
Signs
  • Grey to white, thin, ‘fishy’ foul-smelling vaginal discharge; often copious amounts
  • Inflammation and erythema of vagina are unusual with Bacterial Vaginosis
  • White, clumpy, curdy discharge
  • Erythema and edema of vagina and vulva
  • Profuse amount of foul-smelling off-white/green/yellow, frothy discharge (occurs in 10 to 30% of symptomatic women)
  • Erythema of vagina and exocervix
  • ‘Strawberry cervix’ (hemorrhagic spots that bleed easily)
Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications
Bacterial vaginosisFootnote 194
  • Premature rupture of membranes
  • Preterm labour
  • Spontaneous abortion
  • Chorioamnionitis
  • Postpartum endometritis
  • Subclinical pelvic inflammatory disease (PID)
  • Increased risk of acquisition and transmission of HIVFootnote 193 and N. gonorrhoeae, C. trachomatis, Herpes Simplex Virus Type 2Footnote 202
  • PID and vaginal cuff cellulitis following invasive procedures (e.g., placement of an IUD, endometrial biopsy, uterine curettage)Footnote 193Footnote 194
  • Post-caesarean delivery wound infections

Vulvovaginal candidiasis

  • VVC is often recurrent and more severe in HIV-positive females and/or in women with diabetesFootnote 194
Trichomoniasis
Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, Risk factors, Physical examination findings and test availability. Definitive diagnosis is based upon laboratory testing.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests in Table 3: Diagnostic Features and Laboratory Diagnosis of this guideline are for consideration. For point-of-care specimen collection guidelines, see Table 4: Point-of-Care Specimen Collection in Appendix, Section A of this guideline.

  • Obtain a vaginal swab for Gram stain smear for diagnosis of BV, trichomoniasis and candidiasisFootnote 193
  • Point-of-care tests that may aid in diagnosisFootnote 193Footnote 204 include vaginal pH, wet mount and ‘whiff test,’ where available

Additional lab investigations

Table 3: Diagnostic features and laboratory diagnosis Footnote 193Footnote 197Footnote 199Footnote 204
Test Bacterial vaginosis candidiasis trichomonas
Vaginal pH > 4.5 4.0 to 4.5 > 4.5
Saline wet mount Polymorphonuclear leukocytes (PMNs)
Clue cells (vaginal epithelial cells covered with numerous coccobacilli)
Budding yeast
Pseudohyphae
Motile flagellated protozoa (38–82% sensitivity)
Potassium hydroxide (KOH) wet mount and whiff test Whiff test: Positive amine (fishy) odour Whiff test: negative Whiff test: negative
KOH not appropriate for testing cells, PMNs for diagnosing BV* Budding yeast
Pseudohyphae
KOH not appropriate for testing cells, PMNs for diagnosing Trichomonas*
Gram stain Clue cells
Decreased normal flora
Predominant Gram-negative curved bacilli and coccobacilli
PMNs
Budding yeast
Pseudohyphae
PMNs
Trichomonads
*While KOH destroys cellular debris and allows the clear detection of yeast cells and pseudohyphae (branching structure of a fungus), it also destroys the epithelial cells in the clue cells required to diagnose BV and lyses trichomonads. Therefore, saline is necessary for vaginitis.Footnote 193

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment
  • Cure infection, when possible
  • Relieve symptomsFootnote 205
  • Prevent recurrence, when possible
  • Decrease risk of acquisition of other STIsFootnote 205
  • Prevent complications
Non-pharmacological interventions
Client education
  • Teach client to:
    • Perform proper perineal hygiene
    • Avoid scented soap, perfumed products and bubble baths
    • Take showers rather than baths
    • Avoid tightly fitting synthetic underwear
  • Instruct clients being treated for Trichomoniasis to:
    • Abstain from intercourse until client and partner have finished treatment and are asymptomatic
  • Instruct client with male partner with candidal balanitis to:
    • Abstain from intercourse until client and partner have completed treatment and both are asymptomatic
  • Counsel client that oil-based ovules and creams (e.g., clotrimazole) may cause latex condoms or diaphragms to failFootnote 193
  • Counsel client about appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactions; counsel client to complete the full course of antibiotics to help prevent resistance
  • If metronidazole is ordered, advise client to avoid alcohol during, and for 48 hours after completion of treatment

For more information on Client education, see Prevention in Appendix, Section A of this guideline.

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Unless treating presumptively for syndromic management, consider management choices based on site of infection and available lab results.Footnote 206 Results of microbiologic testing are not immediately available in most nursing stations.

  • When particular symptoms and signs are present, a syndromic diagnosis may be made and treatment and post-test counselling provided
  • STI syndromes include chlamydia, gonorrhea, genital herpes, trichomoniasis, PID, cervicitis, non-gonococcal urethritis, genital ulcer disease and syphilisFootnote 207
Suspected co-existing STI
Asymptomatic bacterial vaginosisFootnote 193
  • Asymptomatic BV requires treatment only in the following cases:
    • High-risk pregnancy (history of preterm delivery)
    • Prior to IUD insertion, gynecologic surgery, therapeutic abortion or upper genitourinary (GU) tract instrumentation
Symptomatic bacterial vaginosisFootnote 193

Preferred treatment

  • Metronidazole 500 mg PO BID for 7 days

Alternate treatment

Higher failure rates have been reported with single dose metronidazoleFootnote 208

  • Metronidazole 2 g PO for 1 dose,

or

  • Clindamycin 300 mg PO BID for 7 days

Treatment of recurrent bacterial vaginosisFootnote 193

The definition for recurrent BV is 3 or more episodes of BV in a 12 month period.Footnote 209 Recurrence occurs in 15 to 30% of clients within the first 1 to 3 months after treatment.

  • If recurrence is suspected, reconfirm diagnosis.
  • Metronidazole 500 mg PO BID for 10 to 14 days may be ordered

Note: Consultation with the physician/nurse practitioner is required and discussion should occur regarding treatment choices.

Uncomplicated vulvovaginal candidiasis
  • Asymptomatic VVC does not require treatment
  • For symptomatic, uncomplicated VVC, consider one of the following:

Clotrimazole

  • Clotrimazole 1% cream :
    • Apply intravaginally daily at bedtime for 6 days
  • Clotrimazole 2% vaginal tablet (3-day combination pack):
    • Insert 1 tablet intravaginally daily at bedtime for 3 consecutive days;

and

  • Apply external vaginal cream topically daily or BID PRN for up to 7 days

Fluconazole

  • Fluconazole 150 mg PO for 1 dose (contraindicated in pregnancy)
Complicated vulvovaginal candidiasis

For more information on vulvovaginal candidiasis, see Canadian Guidelines on Sexually Transmitted Infections – Section 4 – Management and Treatment of Specific Syndromes - Vaginal Discharge (Bacterial Vaginosis, Vulvovaginal Candidiasis, Trichomoniasis).

Note: Consultation with the physician/nurse practitioner is required and discussion should occur regarding treatment choices and possible referrals.

Complicated VVC is defined as any the following:Footnote 193

  • Recurrent VVC (i.e., 4 or more episodes of VVC within a 12-month period)
  • Severe VVC (i.e., extensive vulvar erythema, edema, excoriation or fissure formation)
  • VVC with a non-albicans species
  • VVC occurring in an immunocompromised host (e.g., client on corticosteroids, uncontrolled diabetes)

Recurrent vulvovaginitis candidiasisFootnote 193

  • Conventional antimycotic agents are not as effective against non-albicans species. Therefore, consider culture and sensitivity of yeast for these clients
  • For clients with diabetes, improving blood glucose control can reduce the recurrence of vulvovaginitis candidiasis
  • For recurrent infection due to Candida albicans, physician/nurse practitioner may consider ordering fluconazole 150 mg PO every 72 hours for 3 doses, then weekly for 6 monthsFootnote 193Footnote 202Footnote 208

Severe vulvovaginitis candidiasisFootnote 193

Physician/nurse practitioner may consider ordering fluconazole 150 mg PO every 72 hours for 2 doses or a topical azole (e.g., clotrimazole).

Non-albicans vulvovaginitis candidiasisFootnote 193

Immunocompromised hosts and women with diabetes are more susceptible. For treatment, see the Canadian Guidelines on Sexually Transmitted Infections: Section 4, Management and Treatment of Specific Syndromes; Vaginal Discharge (Bacterial Vaginosis, Vulvovaginal Candidiasis, Trichomoniasis) – Table 8: Treatment of non-albicans vulvovaginal candidia.

Trichomonas vaginalis

Metronidazole

  • Metronidazole 2 g PO for 1 dose now (preferred)

or

  • Metronidazole 500 mg PO BID for 7 days

Treatment of sexual partner

Treat sexual partner(s) with metronidazole 2 g PO for one dose. Follow provincial/territorial policies and procedures or guidelines for Follow-up with sexual partner(s).

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-up
  • Ensure client knows to return to clinic if fever, chills or pain develop.
  • Counsel client to return for further assessment if no improvement in signs and symptoms of presenting condition following treatment.
Bacterial vaginosisFootnote 193
  • No Follow-up is necessary unless the client is pregnant or symptoms recur
  • Treatment of sexual partner is not indicated and does not prevent recurrence
  • If client is pregnant, testing should be repeated after 1 month to ensure that therapy was effective
Vulvovaginal candidiasisFootnote 193
  • No Follow-up necessary for VVC unless symptoms persist or recur
  • If VVC is not responding to appropriate therapy, or if infection recurs, consider culture and sensitivity of yeast
  • If VVC is recurrent, check blood glucose
  • Routine screening and treatment of male partners is not indicated. However, male partner should be treated if Candida balanitis is presentFootnote 193
  • For oral contraceptive pill (OCP) users with frequent infections, the OCP may be a contributing factor
TrichomonasFootnote 193
  • No Follow-up necessary unless symptoms recur, usually due to reinfection
  • Treatment of sexual partner is indicated
Reporting
  • BV is not a reportable disease
  • VVC is not a reportable disease
  • Trichomoniasis is reportable in some provinces/territories

Appendix

Section A: Supplemental clinical management information
Table 4: Point-of-care specimen collectionFootnote 193Footnote 204
Test Procedure Normal result
Vaginal pH
  • Apply a narrow range pH test paper (4.0 to 5.5) for a few seconds to the vaginal sidewall
  • or
  • Swab vaginal sidewall with a dry swab and roll swab onto the pH paperFootnote 207
4.0 to 4.5
Saline wet mount
  • Place a drop of vaginal discharge on a slide
  • Mix with a drop of normal saline (0.9%)
  • Apply a cover slip
  • Examine under microscope at low and high power

Examine for:

  • polymorphonuclear leukocytes (PMNs)
  • clue cells (vaginal epithelial cells covered with numerous coccobacilli)
  • lactobacilli
  • yeast
  • trichomonads
Note: a negative wet mount does not rule out an infectious cause of vaginitis
Epithelia cells and rare white blood cells
KOH wet mount and whiff test
  • Place a drop of vaginal discharge on a slide
  • Mix with a drop of 10% KOH
  • An amine (fishy) odour after applying the KOH is a positive test
  • Apply a cover slip
  • Examine under a microscope at low and high power
  • Examine for yeast
Negative
While KOH destroys cellular debris and allows yeast cells and pseudohyphae (branching structure of a fungus) to be more easily detected, it also destroys the epithelial cells in clue cells which are needed to diagnose BV and lyses trichomonads. Therefore, saline is necessary for vaginitis.Footnote 193

For interpretation of the point of care test(s), see Table 3: Diagnostic Features and Laboratory Diagnosis of this guideline.

PreventionFootnote 210Footnote 211
  • Trichomoniasis is sexually transmitted and can be prevented by practicing safer sexFootnote 212
  • Rinse genitals with water and/or pat dry after toileting
  • Avoid use of baby wipes or scented toilet paper
  • Avoid tight and restrictive clothing; cotton underwear is preferred
  • Avoid douching which can upset the normal healthy balance of bacteria in the vagina and can flush harmful bacteria into the upper genital tracts (uterus, fallopian tubes)
  • Use condoms consistently
  • Limit the number of sexual partners; women with multiple sex partners have a higher risk of developing BV and STIs
  • Bacterial vaginosis may be passed between women during sexual contact
  • Bacterial vaginosis is generally not considered an STI, but if you are exposed to an STI while you have bacterial vaginosis, you are more likely to develop the STI

Bibliography

The following references and Other sources have informed the updating of this Clinical Practice Guideline.

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