Genital Chlamydia and Gonorrhea Epidemiology, Diagnosis, and Management. William M. Geisler M.D., M.P.H. University of Alabama at Birmingham

Transcription

1 Genital Chlamydia and Gonorrhea Epidemiology, Diagnosis, and Management William M. Geisler M.D., M.P.H. University of Alabama at Birmingham

2 Chlamydia and Gonorrhea Current Epidemiology

3 Chlamydia Epidemiology Public health problem worldwide Incidence in the U.S. increasing and at highest rates ever >1 million cases reported in 2006 Estimated >3 million new cases annually Majority of men and women with chlamydia are asymptomatic Highest rates in younger people (age < 30 years) Highest rates in the Southeast U.S Rates 8X higher in African Americans vs. Caucasians Rates higher in women vs. men Reinfection common within months (10-20%) Significant morbidity, especially in women Costly disease CDC STD Surveillance 2006 Report

4 Estimated New Cases of Chlamydia 1999 North America 4 million Latin America & Caribbean 9.5 million Western Europe 5 million Eastern Europe & Central Asia 6 million North Africa & Middle East 3 million Sub-Saharan Africa 16 million East Asia and Pacific 5.3 million South & Southeast Asia 43 million Australia & New Zealand 340,000 Total 92 million WHO, 2001

5 Chlamydia Rates: Total and by sex: United States, Rate (per 100,000 population) Men Women Total Note: As of January 2000, all 50 states and the District of Columbia had regulations requiring the reporting of chlamydia cases.

6 Chlamydia Age- and sex-specific rates: United States, 2006 Men Rate (per 100,000 population) Women Age Total 517.0

7 Chlamydia Rates by state: United States and outlying areas, 2006 Guam VT 191 NH 152 MA 241 RI 292 CT 312 NJ 232 DE 429 MD 390 DC 612 Rate per 100,000 population <= >300 (n= 1) (n= 21) (n= 32) Puerto Rico 130 Virgin Is. 187 Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was per 100,000 population.

8 Chlamydia Rates by race/ethnicity: United States, Rate (per 100,000 population) American Indian/AK Native Asian/Pacific Islander Black Hispanic White

9 Gonorrhea Epidemiology Incidence in the U.S. declined in the 80 s and 90 s, but has increased in the last 2 years > 350,000 cases reported in 2006 Estimated > 600,000 new cases annually Majority of women with gonorrhea are asymptomatic Significant morbidity, especially in women Highest rates in younger people (age < 30 years) Rates 18X higher in African Americans vs. Caucasians Rates now slightly higher in women Highest rates in the Southeast, and in inner cities Drug use and prostitution are also risk factors Quinolone-resistant N. gonorrhoeae (QNRG) rising nationally CDC STD Surveillance 2006 Report

10 Estimated New Cases of GC,1999 North America 1.5 million Latin & South America 7.5 million Western Europe 1 million North Africa & Middle East 1.5 million Sub- Saharan Africa 17 million Eastern Europe & Central Asia 3.5 million East Asia & Pacific 3 million South & Southeast Asia 27 million Australia & New Zealand 120,000 Total 62 million WHO, 2001

11 Gonorrhea Rates: United States, and the Healthy People 2010 target Rate (per 100,000 population) Gonorrhea 2010 Target Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

12 Gonorrhea Rates: Total and by sex: United States, and the Healthy People 2010 target Rate (per 100,000 population) Male Female Total 2010 Target Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

13 Gonorrhea Age- and sex-specific rates: United States, 2006 Men Rate (per 100,000 population) Women Age Total 124.6

14 Gonorrhea Rates by state: United States and outlying areas, 2006 Guam VT 11.6 NH 13.7 MA 38.0 RI 47.2 CT 74.4 NJ 63.0 DE MD DC Rate per 100,000 population <= >100 (n= 5) (n= 27) (n= 22) Puerto Rico 7.7 Virgin Is Note: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was per 100,000 population. The Healthy People 2010 target is 19.0 cases per 100,000 population.

15 Gonorrhea Rates by race/ethnicity: United States, Rate (per 100,000 population) American Indian/AK Native Asian/Pacific Islander Black Hispanic White

16 Chlamydia and Gonorrhea Clinical Presentation

17 Uncomplicated Chlamydia or Gonorrhea Males Urethritis Most common manifestation (other uncomplicated manifestations include conjunctivitis, pharyngitis [GC] and proctitis [in MSM]) Chlamydia usually asymptomatic (over 50%) Acute gonorrhea often symptomatic Co-infection with gonorrhea and chlamydia common Symptoms and signs Dysuria Urethral discharge > 5 PMNs/oif on urethral Gram stain Intracellular Gram-negative diplococci on urethral Gram stain (representing GC)

18 NGU (e.g. chlamydia) Urethral Discharge Gonorrhea Photographed by Dr. James Sizemore

19 Uncomplicated Chlamydia or Gonorrhea Females Cervicitis Most common manifestation (other uncomplicated manifestations include urethritis, bartholinitis, proctitis, conjunctivitis, and pharyngitis [GC]) Majority are asymptomatic (over 75% for chlamydia) Symptoms nonspecific Vaginal discharge Intermenstrual bleeding Painful sex Abdominal pain Dysuria

20 Uncomplicated Chlamydia or Gonorrhea Females Cervicitis Signs Cervical examination usually normal Mucopurulent discharge from endocervix Easily induced endocervical bleeding Hypertrophic ectopy Edema Erythema Bleeding

21 Cervicitis Normal Textbook/Discharge/Discharge.htm

22 Complications Upper Genital Tract Infection Pelvic Inflammatory Disease (PID) in women Epididymitis in men Complications from Upper Genital Tract Infection Infertility (women and men) Ectopic pregnancy Other Complications Reiter s syndrome (Chlamydia) Disseminated infection (Gonorrhea) Increase in HIV transmission/acquisition risk

23 Chlamydia and Gonorrhea Screening Recommendations Diagnostic Testing

24 Screening Considerations Annual chlamydia screening for all sexually active females <25yo and those >25yo with risk factors (new or multiple sex partners) is recommended by the CDC Screening 15-25yo females is a HEDIS measure Chlamydia screening recommended for males in high chlamydia prevalence venues or when resources permit Compliance with screening recommendations is low This can be significantly improved with availability of urine-based nucleic acid amplification tests (NAATs) Screening, universal or selective, can have a dramatic impact on prevalence and complications of chlamydia Marrazzo et al. Sex Transm Dis 1997;24 Scholes et al. N Engl J Med 1996;334

25 Screening Considerations Gonorrhea screening recommended in subjects with risk factors and in areas of high gonorrhea prevalence Most nucleic acid amplification tests include gonorrhea testing along with chlamydia testing

26 Chlamydia Diagnosis Overview Serology (C. trachomatis IgG) cannot distinguish past from current infection Culture or Direct Fluorescence Antibody (DFA) technically difficult and not widely available only performed on genital swab specimens, not urine DNA Probe or Enzyme Immunoassay least sensitive assays available only performed on genital swab specimens, not urine Nucleic Acid Amplification Test most sensitive tests available (sensitivity >90%) highly specific ( %) performed on urine (first void) or genital swab specimens can also test for gonorrhea on same specimen cost-effective in most settings facilitates screening, especially when exam not feasible

27 Gonnorhea Diagnosis Overview Gram Stain of Genital Swab Specimen (presumptive diagnosis) Useful in symptomatic men (95% sensitivity) Limited utility (low sensitivity) in women and asymptomatic men Culture performed on genital swab specimens, not urine useful if antimicrobial susceptibility testing desired DNA probe or Enzyme Immunoassay least sensitive assays available performed on genital swab specimens, not urine Nucleic acid amplification test most sensitive tests available (sensitivity >90%) highly specific ( %) performed on urine (first void) or genital swab specimens can also test for chlamydia on same specimen facilitates screening, especially when exam not feasible

28 Nucleic Acid Amplification Tests (NAATs) The new gold standard in chlamydia and gonorrhea testing The preferred diagnostic test for screening Readily available in most commercial diagnostic laboratories Approved NAATs APTIMA TM Combo 2 Assay (Gen-Probe, Inc.) Uses transcription-mediated amplification Genital swabs and first-void urine specimens similar efficacy ProbeTec TM ET Assay (BD Diagnostics) Uses strand displacement amplification Genital swabs and first-void urine specimens similar efficacy COBAS AMPLICOR TM, CT or GC (Roche Diagnostic Systems) Uses polymerase chain reaction For CT testing, genital swabs and first-void urine specimens similar efficacy For GC testing, AMPLICOR TM not approved for female urines or asymptomatic male urethral swabs due to lower sensitivity (< 90%)

29 Chlamydia and Gonorrhea Treatment

30 2006 CDC STD Treatment Guidelines Uncomplicated Chlamydia: Nonpregnant Recommended: Azithromycin 1 g PO single dose OR Doxycycline 100 mg BID 7 days Alternative: Erythromycin base 500 mg QID 7 days Ofloxacin 300 mg BID 7 days Levofloxacin 500 mg daily 7 days (Quinolones approved for adolescents >45kg) * New recommendation compared to 1998 CDC guidelines

31 2006 CDC STD Treatment Guidelines Uncomplicated Chlamydia in Pregnancy Recommended: Azithromycin 1 g PO single dose OR Amoxicillin 500 mg PO TID x 7 days Alternative: Erythromycin base 500 mg QID 7 days * New recommendation compared to 1998 CDC guidelines

32 2006 CDC STD Treatment Guidelines (Updated for GC in Apr 13, 2007 MMWR) Uncomplicated Gonococcal Infections Recommended: Cefixime 400 mg PO single dose Ceftriaxone 125 mg IM single dose Additionally: Empiric treatment to cover co-infection with chlamydia Quinolones no longer recommended to due an increase in quinolone-resistant Neisseria gonorrhoeae nationwide Alternatives include spectinomycin 2G IM single dose, oral cephalosporin single dose (cefpodoxime 400mg or cefuroxime 500mg), or azithromycin 2G oral single dose * New recommendation compared to 1998 CDC guidelines

33 Gonococcal Isolate Surveillance Project (GISP) Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, Percent Resistant Intermediate resistance Note: Resistant isolates have ciprofloxacin MICs 1 µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

34 Other Treatment Issues No test of cure in nonpregnant persons unless symptoms persist or re-exposed Test of cure with NAATs > 3 weeks post-therapy in pregnant women Rescreen all chlamydia-infected women in about 3 months posttreatment (due to high recurrence rate) Consider rescreening chlamydia-infected men in about 3 months post-treatment Repeat positive tests most likely due to reinfection (untreated or new partner) Sexual partners should be evaluated and treated Recommend abstinence until patient and partner treated

35 Self-Referral Partner Treatment Expedited Partner Therapy (EPT) Patient-delivered or provider-delivered Consider for partners of heterosexual patients with chlamydia and/or gonorrhea Not yet standard of care Has advantages and disadvantages Legal issues

36 CDC collaborated with the Center for Law and the Public s Health at Georgetown and Johns Hopkins Universities to assess the legal framework concerning EPT across all 50 states and other jurisdictions (the District of Columbia and Puerto Rico).

37 Summary Reported rates of chlamydia and gonorrhea are increasing The majority of chlamydia-infected individuals are asymptomatic Sexually active adolescents and young adults are at highest risk for chlamydia Annual chlamydia screening is recommended for this population Chlamydia screening for this population is a HEDIS measure Repeat chlamydia screening recommended 3 months post-therapy Compliance with chlamydia screening is low NAATs are the recommended test Both chlamydia and gonorrhea testing performed Testing can be performed on urine (noninvasive and should improve compliance with screening) In addition to CDC-recommended antibiotic treatment for infected patients, partner treatment is crucial