6/11/15. BACTERIAL STDs IN A POST- HIV WORLD. Learning Objectives. How big a problem are STIs in the U.S.?

Transcription

1 BACTERIAL STDs IN A POST- HIV WORLD Tracey Graney, PhD, MT(ASCP) Monroe Community College Learning Objectives Describe the epidemiology and incidence of bacterial STDs in the U.S. Describe current detection methods of syphilis, gonorrhea, and chlamydia Discuss antibiotic resistance and options for treating bacterial STDs 2 How big a problem are STIs in the U.S.? 3 1

2 4 the- u- s- the- hiv- prevention- fight- has- stalled/ (Data from HI Hall et al, JAMA 2008 Aug 6;300(5):520-9) 5 Diagnoses of HIV Infection among Adults and Adolescents, by Sex, United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. 2

3 Diagnoses of HIV Infection among Adults and Adolescents, by Transmission Category, United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified. HIV peak 8 posters/02.html 9 3

4 Syphilis Treponema pallidum Spirochete Stages of disease Primary Firm, round, painless chancre Secondary Skin rashes and/or mucous membrane lesions Latent & late stage Neurosyphilis Demographics for 1 & 2 Male Black, Hispanic (1/2) South & West regions of the US Ages Laboratory Testing for Syphilis Darkfield microscopy is definitive test Non- treponemal tests RPR, VDRL Simple, inexpensive screening tests Detect antibodies to non- specific antigens Low sensitivity in very early or very late disease Revert to negative after successful treatment Titers reported; reactive samples need confirmation 11 Laboratory Testing for Syphilis, cont d Treponemal tests FTA- ABS, TP- PA, EIA, chemiluminescence IA, multiplex flow IA Detect antibodies against specific T. pallidum antigens Remain positive even after successful treatment 12 4

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6 Syphilis: Treatment Early disease (primary, secondary, early latent): Single IM injection of benzathine penicillin G Late latent: 3 IM doses of benzathine penicillin G at weekly intervals Alternatives: doxycycline, tetracycline Can be cured, but patient can be reinfected Gonorrhea Neisseria gonorrhoea (GC) Gram negative diplococcus Disease Uncomplicated Urethral, vaginal, rectal, pharyngeal Often asymptomatic, esp in women Complicated Pelvic inflammatory disease (PID), epididymitis, disseminated gonococcal infection (DGI) Infertility (PID); life threatening (DGI) Demographics South & Midwest Ages (**20-24) Blacks, American Indians (1/3); males females 18 6

7 Laboratory Testing for Gonorrhea Nucleic acid amplification tests (NAATs) for symptomatic & asymptomatic men & women Genital tract: vaginal swabs for women, clean catch urine for men Rectal or oropharyngeal: CDC recommends, but as of 1/2014, none are approved Culture Evaluating suspected treatment failure & monitoring antimicrobial susceptibility Gram stain In urethral samples from symptomatic men, PMNs with intracellular gram negative diplococci = diagnostic EIAs, nucleic acid probe, and genetic transformation tests are not recommended 19 stain/3194- gram- stain- of- urethral- discharge- with- intracellular- neisseria- gonorrhoeae 20 NAATs As of 1/2014, five manufacturers have been cleared Abbott RealTime CT/NG (Abbott Molecular Inc) Aptima COMBO 2, CT, and GC assays (Hologic/Gen- Probe, Inc) BD ProbeTec ET CT/GC, Q x CT, & Q X GC Amplified DNA assays (Becton Dickinson & Co) Xpert CT/NG assay (Cepheid) Cobas CT/NG test (Roche Diagnostics) An example: Cepheid uses real- time PCR to amplify and detect 2 distinct regions on the bacterial chromosome Advertise < 1 min hands- on time & results in 90 min 21 7

8 Gonorrhoea- getting- meaner- Pan- London- funded- campaign bacteria- cartoon.html 22 Treatment & Resistance Since 1986: Gonococcal Isolate Surveillance Project (GISP) Isolates from clinic patients are collected and tested for resistance 1993: ciprofloxacin & the cephalosporins ceftriaxone & cefixime were the recommended treatments Cipro resistance found about 2000; by 2006 ~14% were resistant; 2007 fluoroquinolones no longer recommended Decreasing cephalosporin sensitivity noticed; 2010 dual therapy and increased ceftriaxone dose 2012 ceftriaxone + azithromycin or doxycycline Only first- line treatment; so far so good

9 Chlamydia Chlamydia trachomatis Obligate intracellular bacterium Most common notifiable disease Disease Cervicitis, urethritis, proctitis Many asymptomatic PID Demographics Blacks; American Indians & Native Hawaiians (1/2) South & Midwest Females > males Ages (**20-24) 25 Laboratory Testing for Chlamydia Nucleic acid amplification tests (NAATs) for symptomatic & asymptomatic men & women Genital tract: vaginal swabs for women, clean catch urine for men Rectal or oropharyngeal: CDC recommends, but as of 1/2014, none are approved Cultures Specimen collected with select swabs & inoculated onto monolayer of cells McCoy, HeLa229 or Buffalo green monkey kidney Monolayers are reacted with specific antibodies & visualized on the microscope EIAs, nucleic acid probe, and serology tests are not recommended 26 Treatment for Chlamydia Single dose azithromycin or 7 days doxycycline Alternatives: erythromycin, levofloxacin or ofloxacin 27 9

10 So are bacterial STDs still relevant? Absolutely! Potential for systemic disease Significant morbidity Spread of antibiotic resistance 28 References Fact sheets, MMWR, GISP report, laboratory testing guidelines, STD treatment guidelines Other sources as noted on slides 29 10