N ational STI M icrobiological Surveillance Programme David A. Lewis FRCP(UK) PhD

Transcription

1 N ational STI M icrobiological Surveillance Programme David A. Lewis FRCP(UK) PhD Sexually Transmitted Infections Reference Centre National Institute of Communicable Diseases (NHLS) South Africa

2 Mission statement of the NICD To be a resource of knowledge and expertise in regionally relevant communicable diseases to the South African Government, to SADC countries, and to the African Continent at large, in order to assist in the planning of policies and programmes and to support appropriate responses to communicable diseases issues

3 Key players in STI surveillance in South Africa Nat ional Depart ment of Healt h STI Reference Cent re ( co-ordinat ion) Collaborat ing Universit ies Nat ional Healt h Laborat ory Service

4 Patient Issues Prot ocol approved by Sout h African N at ional Depart ment of Healt h Et hics approval from t he HREC ( M edical) - Universit y of t he Wit wat ersrand Clinic-based surveillance syst em Informed writ t en consent Anonymous t est ing Pat ient s managed syndromically Ideally 3 mont hs collect ion period

5 Male urethral syndrome (MUS) Pathogens N eisseria gonorrhoeae Chlamydia t rachomat is Trichomonas vaginalis M ycoplasma genit alium First-line treatment Dox ycycline 100mg bd x 7d. Cefix ime 400mg st at p.o. N on-responders Re-t reat wit h first -line agent s if likely re-infect ion Give ceft riaxone 250mg st at i.m. ( resist ant gonorrhoea) M et ronidazole 2g st at p.o. for ot hers

6 Vaginal discharge syndrome (VDS) Pathogens/ Conditions N eisseria gonorrhoeae Chlamydia t rachomat is Trichomonas vaginalis M ycoplasma genit alium Bact erial vaginosis Candidiasis First-line treatment Dox ycycline 100mg bd x 7d. Cefix ime 400mg st at p.o. M et ronidazole 2g st at p.o. I f candidiasis suspected Give Add clot rimazole pessary + / - cream

7 Genital ulcer syndrome (GUS) Pathogens Herpes simplex virus Treponema pallidum Haemophilus ducreyi Chlamydia t rachomat is L1 -L3 Klebsiella granulomat is First-line treatment Benzat hine penicillin 2.4 M U st at I.M. Eryt hromycin 500mg 6 hourly p.o. x 7 d. Acyclovir 400mg 8 hourly p.o. x 7 days N on-responders Refer

8 Patient Specimens Serum from all pat ient s HIV, RPR, HSV-2 ant ibodies Swabs from genit al ulcers ulcer smear for granuloma inguinale ulcer swab for NAATs M ale uret hrit is syndrome endouret hral smear for Gram st ain* endouret hral cult ure for gonococci endouret hral swab/ urine for NAATs Vaginal discharges high vaginal swab for slide endocervical swab for NAATs * In Gauteng NMS only

9 Gonococcal Culture Isolat ion of N eisseria gonorrhoeae on select ive N ew York Cit y medium M IC determinat ion using E test s Cefix ime, Ceft riaxone and Ciprofloxacin E test s init ially Agar dilut ion M ICs to be later performed on stored isolates ( ot her ant imicrobial agent s)

10 NAAT Testing for STI Pathogens Genit al ulcers - Herpes simplex virus ( herpes) - Treponema pallidum ( syphilis) - Haemophilus ducreyi ( chancroid) - Chlamydia t rachomat is L1-L3 ( LGV) Uret hral/ vaginal discharge - N eisseria gonorrhoeae ( gonorrhoea) - Chlamydia t rachomat is D-K ( chlamydia ) - Trichomonas vaginalis ( t richomoniasis) - M ycoplasma genit alium

11 Prevalence (% Aetiology of MUS by Diagnosis ( Surveys) Gonorrhoea Chlamydia Trichomoniasis M. genitalium Gauteng Western Cape Mpumalanga Northern Cape Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged

12 Prevalence (%) Aetiology of VDS by Diagnosis ( Surveys) Gonorrhoea Chlamydia Trichomoniasis M. genitalium Bacterial vaginosis Candidiasis Gauteng Western Cape Mpumalanga Northern Cape Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged

13 Aetiology of GUD by Diagnosis ( Surveys) Prevalence (%) Herpes Syphilis LGV Chancroid Donovanosis No aetiology Gauteng Western Cape Mpumalanga Northern Cape Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged

14 Prevalence (% Seroprevalence of RPR ( 1:4) by Province ( Surveys) Gaut eng West ern Cape Mpumalanga Nort hern Cape MUS VDS GUS Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged

15 Prevalence (% Seroprevalence of HSV-2 by Province ( Surveys) Gaut eng West ern Cape Mpumalanga Nort hern Cape MUS VDS GUS Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged

16 Prevalence (% Seroprevalence of HIV by Province ( Surveys) Gaut eng West ern Cape Mpumalanga Nort hern Cape MUS VDS GUS Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged

17 Microbiological Resistance (%) Rise of Ciprofloxacin Resistant Gonorrhoea in South Africa 35 Change to Cefixime Year Johannesburg Cape Town In 2007, the ciprofloxacin resistant phenotype was significantly associated with HIV serostatus (p = 0.034) in Cape Town and Johannesburg.

18 New STI Guidelines 2008 Evidence-based Ciprofloxacin removed as first line t reat ment for gonorrhoea Cefix ime for M US/ VDS Ceft riaxone for SSW/ LAP Acyclovir for GUS

19 Conclusions STIs remain a major problem in Sout h Africa and lik ely cont inue t o play a role in driving t he HIV epidemic Gonorrhoea remains t he most frequent cause of t he M US syndrome Q uinolone resist ance has increased mark edly in much of t he world and many count ries have swit ched t herapy t o a 3 rd generat ion cephalosporin Trichomoniasis is t he most common STI in women wit h VDS Genit al herpes is t he major cause of genit al ulcerat ion pat ient s require careful healt h educat ion concerning t his recurring condit ion It is import ant t o follow perform regular aet iological and ant imicrobial resist ance surveillance for STI s