Sexually Transmitted Infections CMT Genital Discharge Dr.U.Y.Joshi. Consultant in Genitourinary Medicine and HIV Hull and East Yorkshire

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1 Sexually Transmitted Infections CMT Genital Discharge 2017 Dr.U.Y.Joshi. Consultant in Genitourinary Medicine and HIV Hull and East Yorkshire

3 Sex superbug -Head line news 2015

4 Important Sexually Transmitted Infections in the UK

5 Important Sexually Transmitted Infections in the UK Bacterial Syphilis Gonorrhoea Chlamydia Viral Genital Herpes Genital Warts Hepatitis B HIV Hepatitis C Molluscum Contagiosum Fungal Candidiasis Protozoal Trichomoniasis Parasitic Scabies Pediculosis Pubis? Pubic Lice Others?Bacterial Vaginosis

6 Risk of Transmission of STI following single act of intercourse Gonorrhoea From infected man to woman 60%-90% From infected woman to man 20% -40% HIV From infected man to female partner 0.2% From infected male to male partner %

7 STIs & HIV HIV is an STI -therefore same risk factors for acquiring infection Presence of many STIs increase risk of acquiring HIV Presence of many STIs increase shedding of HIV virus in an infected individuals and therefore increase risk of transmitting HIV to sexual partners

8 IMPORTANT CO-FACTORS Primary and untreated late stage HIV infection (Due to increased viral load) Cervical ectopy Presence of foreskin Menstruation Genital tract trauma and Genital Infection/ inflammation or ulcer of the reproductive tract or rectal or oral mucosa) due to STI

9 Sexual Health Screening All new clients and clients with new risk screened for Gonorrhoea Chlamydia Syphilis HIV As any of the above infections may remain asymptomatic

11 John aged 21 attended your surgery on Friday afternoon with - Urethral discharge and dysuria for the last 5 days. Came back from Bangkok night before. LSI -6 days ago with a Thai girl he met in Bangkok in the nightclub Noticed discharge 2 days later Saw local GP in Bangkok who gave him some antibiotics. Ciproxin?Penicillin?? No improvement. What would you do?

15 Specimen Collection

16 Bacterial culture transport medium

17 Investigations Urethral swab for microscopy,c&s FPU for Chlamydia by NAAT FPU for N.gonorrhoeae by NAAT

18 Other Tests? Syphilis serology Hepatitis B Serology HIV antibody test

19 Treatment: Cephalosporins Azithromycin. Offer Hepatitis B vaccination Ref patient to GUM on the next available clinic for further management.

Antimicrobial prescribing practice & resistance trends: England & Wales, 2001-2011 Data source: Gonococcal Resistance

cefixime, ceftriaxone and ciprofloxacin; right axis shows the resistance and decreased susceptibility for

21 Antimicrobial prescribing practice & resistance trends: England & Wales, Data source: Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) Data type: service data Left axis shows the prescribing data for cefixime, ceftriaxone and ciprofloxacin; right axis shows the resistance and decreased susceptibility for ciprofloxacin and cefixime, respectively. 53 Public Health England: 2012 STI Slide Set Presentation title - edit in Header and Footer

22 Jim aged 24 has attended your surgery and has been complaining of pain in right testicle for the last 2 weeks. What questions would you ask?

23 Jim aged 24 has attended your surgery and has been complaining of pain in right testicle for the last 2 weeks. What questions would you ask? No discharge No dysuria or frequency. No h/o trauma

24 Sexual history: L.S.I. 6 weeks ago with a girl he met on holiday in Blackpool. He used a condom but it split. LSI with regular female partner 2 weeks ago. How would you mange in primary care

27 Investigations Take urethral swab for microscopy, C&S First pass urine (FPU) for Chlamydia and Gonorrhoea by NAAT MSU for microscopy, C&S

28 Treatment: Doxycycline 100 mg twice daily x 14 days NSAIDS Scrotal support Ref pt to GUM for further management and Partner Notification.

30 Aetiology microorganism prevalence C trachomatis 11-50% M genitalum 6-50% Ureaplasmas 11-26% T vaginalis 1-20% Adenoviruses 2-4% HSV 2-3%

31 Other causes UTI- 6% EBV, N. meningitides,haemophilus sp, candida, urethral stricture, FB Pathogen negative asymptomatic Urethritis- BV associated bacteria- non infective urethritis Evidence is weak Asympt men should not be tested for NGU

32 Diagnosis Sympt and/ or with visible discharge or presence of balanoposthitis- assessed for urethritis 5 or more PMNLs per HPF( averaged over 5 fields with the greatest conc of PmNLs) 10-20ml of centrifuged FPU- 10 or more PMNLs per HPF G staining of threads

33 Management Gen advice- written info and document Treatment-initiated ASAP Azithro and Doxy < 85% effective recent RCTs from US Chlamydial urethritis- Doxy for 7 days or Azithro 1gm If contraind: Erythro 500mg BD for days or Ofloxacin 2oomg BD or 400mg od for 7 days

Mycoplasma Ureaplasmas Doxy failure rate of 69% Azithro- failure rate is 13-33%- asso with macrolide antimicrobial resistance by inducing 23sRNA gene mutations 5 day regime of Azithro not asso with

34 Mycoplasma Ureaplasmas Doxy failure rate of 69% Azithro- failure rate is 13-33%- asso with macrolide antimicrobial resistance by inducing 23sRNA gene mutations 5 day regime of Azithro not asso with antimicrobial res-weak evidence Ofloxacin and ciprofloxacinnot effective Moxifloxacin-appear to be effective- 14 day regime Azithro and Doxy similar efficacy Moxifloxacin is more effective that ofloxacin Resistant mutants to quinolones can occur

35 Recommended regimens Doxy 100mg BD for 7 days Or Azithro 1 gm stat Or if Myco positive( pt or partner) Azithro500mg st then 250 daily for next 4 days Rx of partners- Look back period 4 weeks Follow up- only if Chlamydia positive or with persistent symptoms. Doxy- >95% effective in Chlamydia Only < 50% eff in Mycoplasma No antimicrobial res in mycoplasma In ureaplasma as eff as Azithro Azithro- < 90% effective in Mycoplasma and can also produce macrolide resistance in pts who fail to respond

36 Alternative regimen Ofloxacin 200mg BD or 400mg Od for 7 days Or Azithromycin 500mg stat and 250mg od for 4 days

37 Partner Notification Important aspect of STI service and provided by Health Advisers Offer help for contact tracing Prevention of onward transmission of STI Check compliance

39 Any Questions?

40 UK National Guidelines for HIV Testing 2008 Late diagnosis of HIV infection associated with: Increased morbidity Impaired response to HAART Increased costs to Healthcare services

41 HIV Testing Guidelines Who should be offered a test? A. Universal (Opting out) HIV testing is recommended in all of the following settings: 1. GUM or Sexual Health clinics 2. Antenatal services 3. Termination of pregnancy services 4. Drug dependency programmes 5. Healthcare services for those diagnosed with Tuberculosis, Hepatitis B, Hepatitis C and Lymphoma

42 Dermatological manifestations Psoriasis (newly presenting or worsening) Acne Itchy folliculitis Drug reactions Seborrhoeic dermatitis Xeroderma Dermatophytosis tinea pedis, corporis, capitis, cruris, onychomycosis HSV recurrent, disseminated, atypical severe HZV recurrent chicken pox, shingles, multidermatomal shingles Crusted scabies Thrush recurrent, severe Molluscum contagiosumgiant, facial Recalcitrant or mucosal warts S T IF

43 HIV Testing Guidelines B. An HIV test should be considered in the following settings where diagnosed HIV prevalence in the local population (PCT/LA) exceeds 2 in 1000 population. 1. All men and women registering in general practice 2. All general medical admissions The introduction of universal HIV testing in these settings should be thoroughly evaluated for acceptability and feasibility and the resultant data made available to better inform the ongoing implementation of these guidelines.

44 HIV Testing Guidelines C. HIV testing should also be routinely performed in the following groups in accordance with existing Department of Health guidance: 1. Blood donors 2. Dialysis patients 3. Organ transplant donors and recipients

45 HIV Testing Guidelines Clinical indicator diseases for adult HIV infection AIDS defining conditions Other conditions where HIV testing should be offered Respiratory Tuberculosis Bacterial pneumonia Pneumocystis Aspergillosis Neurology Cerebral toxoplasmosis Aseptic meningitis/encephalitis Primary cerebral lymphoma Cerebral abscess Cryptococcal meningitis Space occupying lesion of unkown cause Progressive multifocal Guillain-Barré syndrome Leucoencephalopathy Transverse myelitis Peripheral neuropathy Dementia Leucoencephalopathy Dermatology Kaposi s sarcoma Severe or recalcitrant seborrhoeic dermatitis Severe or recalcitrant psoriasis Multidermatomal or recurrent herpes zoster

46 HIV Testing Guidelines Clinical indicator diseases for adult HIV infection AIDS defining conditions Other conditions where HIV testing should be offered Gastroenterology Persistent cryptosporidiosis Oral candidiasis Oral hairy leukoplakia Chronic diarrhoea of unknown cause Weight loss of unknown cause Salmonella, shigella or campylobacter Hepatitis B Infection Heptatis C Infection

47 HIV Testing Guidelines Table 1: Clinical indicator diseases for adult HIV infection AIDS defining conditions Other conditions where HIV testing should be offered Oncology Non-Hodkin s lymphoma Anal cancer or anal intraepithelial dysplasia Lung cancer Seminoma Head and neck cancer Hodkin s lymphoma Castleman s disease Gynaecology Haematology Cervical cancer Vaginal intraepithelial neoplasia Cervical intraepithelial neoplasia Grade 2 or above Any unexplained blood dyscrasia including: - thrombocytopenia - neutropenia - lymphopenia

48 HIV Testing Guidelines 1: Clinical indicator diseases for adult HIV infection AIDS defining conditions Other conditions where HIV testing should be offered Opthalmology Cytomegalovirus retinitis Infective retinal diseases including herpes viruses and toxoplasma Any unexplained retinopathy ENT cause Other infection) Lymphadenopathy of unknown Chronic parotitis Lymphoepithelial parotid cysts Mononucleosis like syndrome (primary HIV Pyrexia of unknown origin Any lymphadenopathy of unknown cause Any sexually transmitted infection

Protocol for HIV testing of adults outside the HIV specialist setting

Protocol for HIV testing of adults outside the HIV specialist setting TEMPLATE A page 1 Protocol for testing of adults outside the specialist setting Introduction In September 2007 the Chief Medical Officer and Chief Nursing Officer sent out a Dear Colleague 1 letter calling