5/1/2017. Sexually Transmitted Diseases Burning Questions

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1 Sexually Transmitted Diseases Burning Questions Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health University of California Los Angeles Los Angeles, California FORMATTED: Financial Relationships With Commercial Entities Dr Klausner has received research grants or donations of testing supplies from Gilead Sciences, Inc, Hologic, Inc, and Cepheid. (Updated 04/03/17) Slide 2 of 44 Learning Objectives After attending this presentation, learners will be able to: Diagnose and manage gonorrhea List treatment options for chlamydia Describe manifestations of syphilis Slide 3 of 44 1

2 Slide 4 of year old HIVinfected man with urethral discharge Case Slide 5 of 44 Differential Diagnosis of Urethritis Infectious Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma genitalium Trichomonas vaginalis Herpes simplex virus 1 and 2 Oral flora---streptococci, anaerobes, haemophilus Non-infectious Trauma physical, chemical, sex-play related Autoimmune Reactive arthritis Slide 6 of 44 2

3 Uncomplicated gonococcal infection Neisseria gonorrhoeae Gram-negative intracellular diplococci Urethra Cervix Pharynx Rectum Slide 7 of 44 Detection of N. gonorrhoeae infection Sensitivity Specificity Gram stain 92% 90% Culture 95% 100% DNA/RNA amplification* 95% 99% *May be used on clinician- or self-collected vaginal, cervical, rectal, pharyngeal specimens and urine Slide 8 of 44 Gonorrhea Rates of Reported Cases by Race/Ethnicity, United States, * AI/AN = American Indians/Alaska Natives; NHOPI = Native Hawaiian/Other Pacific Islanders. 3

4 Proportion of MSM Attending STD Clinics with Primary and Secondary Syphilis, Gonorrhea (GC) or Chlamydia (CT) by HIV Status, STD Surveillance Network, Slide 10 of 44 Susceptibility changes of Neisseria gonorrhoeae to cefixime and ceftriaxone Multi-drug treatment for gonorrhea Ceftriaxone 250 mg IM once Azithromycin 1 gm PO once Plus partner treatment Retesting at 3 months Slide 12 of 44 4

5 Slide 13 of 44 CID, 2017 Case 28 year old HIV-infected male presents for a check-up. He has one regular partner and occasional partners he meets at various venues, clubs He has no symptoms What STD screening tests are appropriate? Slide 15 of 44 5

6 STI screening in Men who have Sex with Men Chlamydia trachomatis/ Neisseria gonorrhoeae throat, rectum, urine Syphilis (Treponemal, if reactive then RPR) Avoid Anal PAP smear Routine HSV-1/2 antibody testing US CDC 2015; USPSTF, 2013 Slide 16 of 44 Test results Throat CT/NG negative Urine CT/NG negative Rectum CT positive, NG negative Blood TPPA positive, RPR negative Slide 17 of 44 What is the best chlamydia treatment? 1) Azithromycin 1 gm orally once 2) Doxycycline 100 mg orally twice daily for 7 days 3) Amoxicillin 500 mg po tid x 7 days 4) Levofloxacin 500 mg po qd x 7 days Slide 18 of 44 6

7 What is the best chlamydia treatment? 1) Azithromycin 1 gm orally once 2) Doxycycline 100 mg orally twice daily for 7 days 3) Amoxicillin 500 mg po tid x 7 days 4) Levofloxacin 500 mg po qd x 7 days Slide 20 of 44 Proportion of MSM Attending STD Clinics with Primary and Secondary Syphilis, Gonorrhea (GC) or Chlamydia (CT) by HIV Status, STD Surveillance Network,

8 Case 44 year old HIV-infected man with new lesion near his anus Slide 22 of 44 Differential diagnosis of genital ulcer STDs Genital herpes Primary syphilis Chancroid Other Fixed drug reactions Staph/strep Autoimmune Slide 23 of 44 Treponema pallidum pallidum, bacterial spirochete Slide 24 of 44 8

9 Primary syphilis penile chancres Slide 25 of 44 Secondary syphilis: trunk rash Slide 26 of 44 Secondary syphilis: palmar and plantar lesions Slide 27 of 44 9

10 Slide 28 of 44 Slide 29 of 44 Secondary syphilis: split papules, moth-eaten alopecia, mucous patches and condyloma lata J. Engelman Split papule (mucous patch) Moth-eaten alopecia Katz Condyloma lata Mucous patch J. Engelman Katz Klausner Slide 30 of 44 10

11 Latent syphilis This page intentionally left blank! Slide 31 of 44 Those syphilis tests Non-treponemal tests (RPR, VDRL) Antibody to cardiolipin-lecithin-phospholipids Rise and fall with infection and treatment over time 4-fold change in titer (1:2 to 1:8 or 1:64 to 1:16) is significant Specificity = 98% (false-positives in IDU, auto-immune, etc) Treponemal tests (FTA-Abs, TPPA, TP EIA) Antibody to Treponemal antigen More sensitive and develop earlier Stay positive for life (85%) Indicate past or current infection Klausner, Current STD Diagnosis and Management 2007 Slide 32 of 44 Syphilis and HIV-infection Overlapping primary and secondary stage Slower titer decline No difference in therapy Two-fold increased risk for neurosyphilis Slide 33 of 44 11

12 No difference in single vs. 3 doses in therapy HIV-infected Slide 34 of 44 Injectable penicillin is treatment of choice for early syphilis Single intramuscular injection 2.4 MU benzathine penicillin Prophylactic treatment: Syphilis case contacts < 90 days Doxycycline Slide 35 of 44 Syphilis Rates of Reported Cases by Stage of Infection, United States, NOTE: Data collection for syphilis began in 1941; however, syphilis became nationally notifiable in Refer to the National Notifiable Disease Surveillance System (NNDSS) website for more information: 12

13 Slide 37 of 44 What are recommended indications for lumbar puncture? 1) RPR titer > 1:32 2) CD4 T cell count < 350 cells/μl 3) Visual changes 4) Headache Slide 38 of 44 Slide 39 of 44 13

14 What are recommended indications for lumbar puncture? 1) RPR titer > 1:32 2) CD4 T cell count < 350 cells/μl 3) Visual changes 4) Headache Slide 40 of 44 CDC recommended indications for lumbar puncture 1) Neurologic symptoms or signs 2) Suspected ocular syphilis 3) Treatment failure 4) Tertiary syphilis HIV infection, immunosuppression or elevated RPR titer while associated with increased risk for neurosyphilis are not indications for CSF analysis Slide 41 of 44 PREVENTION Slide 42 of 44 14

15 Slide 43 of 44 Sources for more STD information CDC Current STD Textbook Slide 44 of 44 Thank you Slide 45 of 44 15

16 Sexually Transmitted Diseases Burning Questions Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health University of California Los Angeles Los Angeles, California FORMATTED:

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