Shelagh Larson, RNC, WHNP, NCMP

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1 Shelagh Larson, RNC, WHNP, NCMP

2 UNPRECEDENTED HIGH Total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever, according to the annual more than 1.5 million chlamydia cases reported (1,526,658), nearly 400,000 cases of gonorrhea (395,216), and nearly 24,000 cases of primary and secondary (P&S) syphilis (23,872) Many cases of chlamydia, gonorrhea, and syphilis continue to go undiagnosed and unreported, and data on several additional STDs such as human papillomavirus, herpes simplex virus, and trichomoniasis are not routinely reported to CDC. estimates that nearly 20 million new STDs occur every year in this country, half among young people aged 15 24, and account for almost $16 billion in health care costs.

3 more than half of state and local STD programs have experienced budget cuts, resulting in more than 20 health department STD clinic closures in one year alone. Fewer clinics mean reduced access to STD testing and treatment for those who need these services

5 Patients aged between 15 and 24 years accounted for 2/3 of the more than 1.5 million cases of chlamydia and half of the nearly 400,000 cases of gonorrhea. Men who have sex with men (MSM) accounted for the majority of new gonorrhea and primary and secondary syphilis cases, and may face a higher risk of antibiotic resistant gonorrhea. The rate of syphilis diagnosis among women rose more than 27% since 2014, and there was a 6% increase in congenital syphilis to 487 cases

6 most frequently reported bacterial STI in the United States known as a silent infection because most infected people are asymptomatic and lack abnormal physical examination findings. Easily treated with Azithromycin

7 2015, 1,526,658 cases were reported; 479cases/100,000 population. ^ 5.9% from availability of urine test increased rate in US Men ^ 10.5% compared to ^ women 3.8% from Still women report 2x reported cases than men It is estimated that 1 in 20 sexually active young women aged years has chlamydia.

a total of 1,526,658 chlamydial to a rate of 478.

8 a total of 1,526,658 chlamydial to a rate of cases per 100,000 population infections During , rates increased in 37 states and the District of Columbia.

9 Symptoms (if any) occur 1-3 weeks after exposure Women Abnormal Vaginal Discharge (Odor or Odorless) Spotting/Bleeding Between Periods Painful Periods Pain During Sexual Intercourse Painful Urination Abdominal Pain With Fever Burning and/or Itching in or Around the Vagina Men Cloudy or Clear Discharge From the Tip of the Penis Painful and Swollen Testicles Itching and/or Burning Around the Opening of the Penis Painful Urination

10 Chlamydia in the mouth

12 CDC recommends yearly chlamydia screening of all sexually active women younger than 25, as well as older women with risk factors such as new or multiple partners, or a sex partner who has a sexually transmitted infection Pregnant women should be screened during their first prenatal care visit. Pregnant women under 25 or at increased risk for chlamydia (e.g., women who have a new or more than one sex partner) should be screened again in their third trimester (with GBS). Routine screening is not recommended for men. However, should be considered in clinical settings with a high prevalence of chlamydia (MSM) who had insertive intercourse should be screened for urethral chlamydial infection and MSM who had receptive anal intercourse should be screened for rectal infection at least annually screening for pharyngeal infection is not recommended.

14 AZITHROMYCIN 1 G PO IN A SINGLE DOSE Doxycycline 100 mg BID x7 days Alternative Regimens Erythromycin base 500 mg PO QID x 7 days OR Erythromycin ethylsuccinate 800 mg PO QID x 7 days OR Levofloxacin 500 mg po daily x 7 days OR Ofloxacin 300 mg po BID x 7 days Pregnancy Amoxicillin 500 mg PO TID for 7 days OR Erythromycin base 500 mg PO QID x 7 days or 250 mg orally QID x 14 days OR Erythromycin ethylsuccinate 800 mg PO QID x 7 days or 400 mg PO QID xfor 14 days

15 retested approximately 3 months after treatment.

16 Patients treated for chlamydia, he or she should tell all recent anal, vaginal, or oral sex partners (all sex partners within 60 days before the onset of symptoms or diagnosis) so they can see a health care provider and be treated. Expeditated Partner Therapy Persons with chlamydia should abstain from sexual activity for 7 days after single dose antibiotics or until completion of a 7-day course of antibiotics,

When patients diagnosed with chlamydia or gonorrhea indicate that their partners are unlikely to seek evaluation and treatment, providers can offer patient-delivered

17 When patients diagnosed with chlamydia or gonorrhea indicate that their partners are unlikely to seek evaluation and treatment, providers can offer patient-delivered partner therapy (PDPT), a form of expedited partner therapy (EPT) in which partners of infected persons are treated without previous medical evaluation or prevention counseling

18 EPT is potentially allowable in 7 states: Alabama Delaware Kansas New Jersey Oklahoma South Dakota Virginia EPT is potentially allowable in Puerto Rico. prohibited EPT is prohibited in 2 states: Kentucky South Carolina

20 Gonorhea caused by the bacteria Neisseria gonorrhoeae When symptoms are present they can include thick white or yellow/greenish discharge, painful urination, increased urination, sore throat and severe pain in lower abdomen.

22 At present, the only CDC-recommended treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea is combination therapy with a single dose of ceftriaxone 250 mg IM plus a single dose of azithromycin 1 g po.

23 patient s sex partners from the past 60 days are evaluated and treated with the recommended regimen (ceftriaxone 250 mg IM plus a single dose of azithromycin 1 g orally a single dose of each- cefixime 400mg with azithromycin 1gm, orally

24 Antibiotic resistance is threatening the effectiveness of gonorrhea treatment in the United States health officials have identified a cluster of gonorrhea infections that shows both decreased susceptibility to ceftriaxone and very high-level resistance to azithromycin azithromycin combined with ceftriaxone is still an effective treatment option for gonorrhea Use of azithromycin as the second antimicrobial is preferred to doxycycline because of the convenience and compliance advantages of single-dose therapy and the substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin

25 Screen all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. Screen sexually active MSM at anatomic sites of possible exposure at least annually. Evaluate and treat all patients sex partners from the previous 60 days Obtain cultures to test for decreased susceptibility from any patients with suspected or documented gonorrhea treatment failures Report any suspected treatment failure to local or state public health officials within 24 hours, helping to ensure that any potential resistance is recognized early

26 Pharyngeal infection may cause a sore throat, but usually is asymptomatic

27 Hand, Mouth and Foot Gonorrhea

28 vary greatly from patient to patient no longer have any localized symptoms The classic presentation: an arthritis dermatitis syndrome Joint or tendon pain is the most common

Skin rash in approximately 25% of patients found below the neck and may also involve the palms and soles Lesions varying from maculopapular to pustular, often with

29 Skin rash in approximately 25% of patients found below the neck and may also involve the palms and soles Lesions varying from maculopapular to pustular, often with a hemorrhagic component. Lesions usually number 5-40, are peripherally located, and may be painful before they are visible. Fever is common but rarely exceeds 39 C.

Joint or tendon pain is the most common 25% of

May also have tenosynovitis ; most commonly

30 Joint or tendon pain is the most common 25% of patients complain of pain in a single joint migratory polyarthralgia, especially of the knees, elbows, and more distal joints. May also have tenosynovitis ; most commonly affects the flexor tendon sheaths of the wrist or the Achilles tendon ("lovers' heels").

31 Ceftriaxone 1 g IM or IV every 24 hours PLUS Azithromycin 1 g orally in a single dose Alternative Regimens Cefotaxime 1 g IV every 8 hours OR Ceftizoxime 1 g IV every 8 hours PLUS Azithromycin 1 g orally in a single dose When treating for the arthritis-dermatitis syndrome, the provider can switch to an oral agent guided by antimicrobial susceptibility testing hours after substantial clinical improvement, for a total treatment course of at least 7 days.

32 SYPHILIS

33 is a disease with a highly variable clinical course. called the great imitator, because the various clinical manifestations of syphilis match many other diseases.

37 A presumptive diagnosis of syphilis requires use of two tests: a non-treponemal test [VDRL] or Rapid Plasma Reagin [RPR]) and treponemal test (i.e., fluorescent treponemal antibody absorbed [FTA-ABS] tests, the T. pallidum passive particle agglutination [TP-PA] False-positive non-treponemal test results can be associated with various medical conditions and factors unrelated to syphilis, including other infections (e.g., HIV), autoimmune conditions, immunizations, pregnancy, injection-drug use, and older age

38 Until normal quantities of penicillin G benzathine are available, CDC suggests the following: Refrain from the use of Pen G for treatment of other infectious diseases (e.g., streptococcal pharyngitis) where other effective antimicrobials are available. Adhere to the recommended dosing regimen of 2.4 million units of penicillin G benzathine IM for the treatment of primary, secondary and early latent syphilis (i.e., early syphilis) practitioners have inadvertently prescribed combination benzathineprocaine penicillin (Bicillin C-R) instead of the standard benzathine penicillin product (Bicillin L-A)

40 . doxycycline 100 mg orally BID x 14 days and tetracycline (500 mg QID x 14 days) have been used for many years.

41 Doxycycline (100 mg orally BID) or Tetracycline (500 mg orally QID), each for 28 days

42 Clinical and serologic evaluation should be performed at 6 and 12 months after treatment Failure of nontreponemal test titers to decline fourfold within 6 12 months after therapy for primary or secondary syphilis might be indicative of treatment failure. these persons should receive additional clinical and serologic follow-up and be evaluated for HIV infection

43 The risk for penicillin cross-reactivity between most second-generation (cefoxitin) and all third generation cephalosporins (cefixime and ceftriaxone) is negligible cefoxitin, cefixime, and ceftriaxone do not have an R group side chain similar to penicillin G.

45 Trichomoniasis is considered the most common curable STD. an estimated 3.7 million people have the infection, but only about 30% develop any symptoms of trichomoniasis. Infection is more common in women than in men, and older women are more likely than younger women to have been infected.

48 Vaginal, oral, or anal sex. can be spread even if there are no symptoms. This means you can get trichomoniasis from someone who has no signs or symptoms. Genital touching. A man does not need to ejaculate (come) for trichomoniasis to spread. Trichomoniasis can also be passed between women who have sex with women. About 1 in 5 people get infected again within 3 months after treatment.

49 WET Mount: specimens should be examined within 10 minutes to observe motile parasites, which are diagnostic. Wet mount is an inexpensive diagnostic test; however, sensitivity is estimated at 51-65%, and varies based on the individual performing the test and how promptly the slide is interpreted Neither conventional nor liquid-based (Pap) smears are suitable for routine screening or diagnosis of T. vaginalis, because sensitivity is poor Nucleic acid amplification tests (NAATs) Trichomonas Vaginalis Qx Amplified DNA Assay are the most sensitive tests available for detection launched in Europe in 2012, but is not FDA-cleared in the United States at this time.

50 Metronidazole* 2 g orally in a single dose OR Tinidazole* 2 g orally in a single dose in pregnany: metronidazole 2 g po in a single dose. Alternative Regimen Metronidazole 500 mg po BID x7 days *Metronidazole resistance occurs in 4% 10% and tinidazole resistance in 1% of cases of vaginal trichomoniasis

51 If treatment failure has occurred with metronidazole/tinidazole 2 g single dose and reinfection is excluded, the patient (and their partner[s]) can be treated with metronidazole 500 mg orally twice daily for 7 days. If this regimen fails, clinicians should consider treatment with metronidazole or tinidazole at 2 g orally for 7 days

53 is the most common sexually transmitted infection in the US 40 distinct types can infect the genital tract; about 90% of infections are asymptomatic and resolve spontaneously within two year types 16 and 18 account for approximately 70% of cervical cancers worldwide, Types 6 and 11 are responsible for approximately 90% of genital warts.

54 A quadrivalent HPV vaccine that protects against infection by HPV types 6, 11, 16 and 18 has been licensed in the United States for use in females since June 2006, and in males since October In October 2009, a bivalent HPV vaccine that protects against infection by HPV types 16 and 18 was licensed for use in females. In December 2014, a 9-valent vaccine that protects against infection by the HPV types included in the quadrivalent vaccine (6,11,16,18), as well as five additional cancer causing types (HPV types 31, 33, 45, 52, and 58),

55 YES. If you get them!!! In 2015, a national survey found that 63% of girls aged years had received at least 1 dose of the HPV vaccine, and 42% had received all 3 doses in the series. Vaccine uptake is lower among boys; 50% aged years received at least 1 dose, but only 28% received all 3 doses. 16

56 For females all three vaccines have been recommended for those aged 11 or 12 years, and through age 26 those who have not been vaccinated previously Vaccination is also recommended through age 26 years for immunocompromised persons (including those infected with HIV) who have not been vaccinated previously. For males the quad- and 9-valent vaccines recommended for those aged 11 or 12 years, and through age 21 in those who have not been vaccinated previously. Vaccination of gay, bisexual, and other men who have sex with men (collectively referred to as MSM) through age 26 is also recommended; other males aged years may be vaccinated.

58 If the virus destroys the host cell during replication, sores or blisters filled with fluid appear. Scabs form over the sores or blisters once the fluid is absorbed, then the scabs disappear without scarring. Once the virus makes its way to the dorsal root ganglia, it becomes inactive for an unknown period of time. If symptoms do appear, they are often worse during the initial outbreak than recurring outbreaks. HSV encephalitis is mainly caused by HSV-1, whereas meningitis is more often caused by HSV-2. Screening for HSV-1 and HSV-2 in the general population is not indicated Both HSV-1 &2 may also enter into a finger via breaks in the skin, causing a condition known as herpetic whitlow, in which the fingertip becomes swollen, red, and painful; this condition is most frequently seen in health care workers, who are exposed to body fluids while not wearing gloves

59 IgG testing (Western Blot or Immunoblot) is the best option for accurately diagnosing herpes simplex 1 and 2. The HerpeSelect HSV-1 Elisa is insensitive for detection of HSV-1 antibody. IgM testing for HSV 1 or HSV-2 is not useful, because IgM tests are not type-specific and might be positive during recurrent genital or oral episodes of herpes

60 HSV 1 Cold sores (herpes labialis) most commonly transmitted by kissing or sharing drinks or utensils, but can also be contracted from a partner with genital herpes during oral sex. Many persons with HSV-1 antibody have oral HSV infection acquired during childhood, which might be asymptomatic. as many as 90% of the people in the United States have been exposed to HSV-1 HSV 2 Genital herpes viral STD, and typically results in sores or lesions on the genitals, anus or upper thighs can be contracted from infected bodily fluids, including semen, vaginal fluid, saliva or herpes lesions, sores or blister fluid. can be very dangerous to an infant during childbirth, C-section deliveries are often performed to avoid transmission

61 First Clinical Episode Episodic Therapy Suppressive Therapy for Recurrent outbreaks (6+ /year) Valacyclovir 1 g po BID x 7 10 days Famciclovir 250 mg po TID x 7 10 days Acyclovir 400 mg po TID x 7 10 days Acyclovir 200 mg po five times a day x 7 10 days Valacyclovir 1 g po daily for 5 days Famciclovir 125 mg po BID x 5 days Acyclovir 400 mg po TID(800 mg po BID) for 5 days Valacyclovir 500 mg po BID x 3 days Acyclovir 800 mg po TID x 2 days Famciclovir 1 gram po BID x 1 day Famciclovir 500 mg once, followed by 250 mg BID x 2 day Valacyclovir 500 mg po daily* Valacyclovir 1 g po daily Famiciclovir 250 mg po BID Acyclovir 400 mg po BID

62 Acyclovir 400 mg TID OR Valacyclovir 500 mg BID Suppression treatment recommended starting at 36 weeks of gestation women with recurrent genital herpetic lesions at the onset of labor should deliver by cesarean delivery to reduce the risk for neonatal HSV infection.

63 Acyclovir 20 mg/kg IV every 8 hours for 14 days if disease is limited to the skin and mucous membranes, or for 21 days for disseminated disease and that involving the central nervous system.

64 Vitamin C: mg daily with food Reishi (std. to 13.5% polysaccharides [132.3 mg] and 6% triterpenes [58.8 mg]): 980 mg daily with or without food Vitamin A (as 90% beta-carotene and 10% acetate): 5000 IU daily with food Vitamin D: IU daily, depending on blood levels of 25-OH-vitamin D Zinc: 30 mg one to three times daily with or without food L-lysine: 620 mg one to three times daily on an empty stomach Propolis extract: mg daily; or, propolis ointment: per label instructions Lactoferrin (providing 95% of Apolactoferrin [285 mg]): 300 mg daily with or without food Curcumin (as highly absorbed BCM-95 ): 400 mg daily with food Fucoidan: 75 mg one to two times daily with or without food Lemon balm (topical): per label instructions Licorice root: 450 mg twice daily The following over-the-counter preparations may also be helpful: Cimetidine (Tagamet ) mg daily Topical capsaicin: per label instructions

66 CDC recommends HIV screening for patients aged years in all health-care settings More than 1.2 million people in the US are living with HIV, and 1 in 8 of them don't know it. From 2005 to 2014, the annual number of new HIV diagnoses declined 19%. Gay and bisexual men, particularly young African American gay and bisexual men, are most affected.

67 At the end of 2013, the most recent year for which such data are available, an estimated 1,242,000 adults and adolescents were living with HIV. An estimated 161,200 (13%) had not been diagnosed. Young people were the most likely to be unaware of their infection. Among people aged 13-24, an estimated 51% (31,300) of those living with HIV didn t know.

69 HIV 1 HIV 2 This strain is found worldwide and is more common. more likely to progress and worsen. Average level of immune system activation are higher. During progression, HIV-1 has lower CD4 counts than HIV-2. Plasma viral loads are higher. This strain is found predominantly in West Africa. less likely to progress and many of those infected remain lifelong non-progressors. Progression is slower. Average level of immune system activation are lower. During progression, CD4 counts are higher in this strain. Plasma viral loads are lower.

70 is a way for people who don t have HIV but who are at very high risk of getting it to prevent HIV infection by taking a pill every day. The FDA approved PrEP for HIV prevention in 2012 The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV. When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. But people who use PrEP must commit to taking the drug every day and seeing their health care provider for follow-up every 3 months

71 CDC. Sexually transmitted disease surveillance Accessed Oct. 19, CDC, (2015) Herpes Simplex Virus. Retrieved from CDC. (Sept ) STD Prevention Conference. Retrieved from CDC (Oct, 2016). Other sexually transmitted diseases. Retrieved from: CDC. (Oct. 2016). Legal Status of Expedited Partner Therapy (EPT). Retrieved from CDC, (2016). Guidance on the Use of Expedited Partner Therapy in the Treatment of Gonorrhea. Retrieved from Brocail, M. (2015). Herpes Simplex virus 1 & 2 and HSV tesing. STD check. Retrieved from

4/6/17 UNPRECEDENTED HIGH. Shelagh Larson, RNC, WHNP, NCMP

4/6/17 UNPRECEDENTED HIGH. Shelagh Larson, RNC, WHNP, NCMP Shelagh Larson, RNC, WHNP, NCMP UNPRECEDENTED HIGH Total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever, according to the annualmore than 1.5 million