Update on Sexual Health: Screening, Diagnosing and Treating STIs

Transcription

1 Update on Sexual Health: Screening, Diagnosing and Treating STIs Dr Gila Metz Medical Director, Health Sexuality and Risk Reduction Unit Ottawa Public Health November 28, 2013

2 Objectives To review current evidence regarding risk factors, presentation, diagnosis and treatment of common sexually-transmitted infections (STIs) To increase awareness of resources for community physicians in assessing and treating patients for STIs. 2

3 Faculty/Presenter Disclosure Faculty: Gila Metz Program: 51 st Annual Scientific Assembly Relationships with commercial interests: NONE 3

4 Disclosure of Commercial Support This program has received NO financial support This program has received NO in-kind support Potential for conflict(s) of interest: NONE 4

5 Mitigating Potential Bias N/A 5

6 Case #1: 21-year old woman who wants to be tested for everything What else do you want to know about her? 6

7 STI History Recent contacts number, gender, type, travel history? Condom use? Prior STIs? Substance use/street involvement? Vaccine history Hep B and HPV? Symptoms? Contraception? 7

8 General Risk Factors for STIs Sexual contact with person with known STI Prior STI Higher number of sexual contacts Under 25 No contraception or non-barrier methods only Substance misuse (including IDU) Street involvement Sex workers and Survival Sex 8

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10 Case # 1 (cont d) Attending university, lives with a roommate, no drug use. Using combined hormonal contraceptive ring x 3 years. Most recent contact last week with expartner of 8 months. Was having unprotected oral and vaginal intercourse with him. She is concerned he has had other partners. 10

11 Which STI tests will you It depends on: order? Risk factors and local epidemiology (e.g. Syphilis, HIV) Patient preferences and reason for testing Ability to mitigate outcomes with intervention Incubation period for different infections Patient readiness for positive or negative results (for HIV) 11

12 Incubation Periods Chlamydia hours for NAAT GC 3 days for culture, hours for NAAT Syphilis 4 to 6 weeks HIV 12 weeks Case #1 would like all four tests at her initial visit. 12

13 Chlamydia - Epidemiology Most common reportable STI in sexually-active youth aged14-24 In Ontario, 72% increase in rates of Chlamydia over the last 10 years ( ). 65% of cases in women (to 2009). Frequently reported risk factors: Lack of condom use (84%), Multiple sex partners in the last 6 months (16%), New partner in the last 2 months (16%) 13

14 Chlamydia - Epidemiology From: Ontario Annual Infectious Diseases Epidemiology Report, 2009 (published June 2011) 14

15 Chlamydia Epidemiology From: Ontario Annual Infectious Diseases Epidemiology Report, 2009 (published June 2011) 15

16 Gonorrhea - Epidemiology Second-most frequentlyreported STI in Ontario Highest in males aged and females aged Increased risk in MSM. Most frequently-reported risk factors were: Failure to use a condom (81%), Multiple sex partners in the last 6 months (28%), Same-sex sexual contact among males (35% of male cases) New partner in the last 2 months (17%) 16

17 Gonorrhea Epidemiology 17

18 Gonorrhea - Epidemiology 18

19 CT and GC - presentation CT: Asymptomatic 70% of cervical (women) 50% of urethral (men) Most pharyngeal and rectal infections Opportunistic urine screening advised. GC: Asymptomatic 30-50% of cervical infections (women) 10% of urethral infections (men) Most pharyngeal and rectal infections 19

20 CT and GC - presentation Women: discharge, abnormal vaginal bleeding, lower abdominal pain, deep dyspareunia Men: itch, dysuria, discharge, testicular pain. Rectal pain or discharge if proctitis In GC, rare presentations include conjunctivitis Bartholinitis, disseminated infection. 20

21 Cervicitis and Urethritis Mucopurulent Cervicitis Urethritis 21

22 CT and GC - Sequelae CT and GC: Women: PID, chronic pelvic pain, ectopic pregnancy, infertility Men: Epididymitis GC only: Bartholinitis (women), Reiter syndrome, disseminated gonococcal infection 22

23 Testing for Chlamydia and Gonorrhea Cervical Swabs Endocervical: For NAAT leave in endocervix for s. Chlamydia: Endocervical swab for NAAT Gonorrhea: If asymptomatic Endocervical swab for NAAT (as for chlamydia). If symptomatic bacterial swab in charcoal media for gonorrhea culture and sensitivity. 23

24 Testing for Chlamydia and Gonorrhea Urethral site: Chlamydia Urine sample for NAAT Gonorrhea If asymptomatic urine for NAAT. If symptomatic bacterial swab in charcoal media for gonorrhea culture and sensitivity. 24

25 Testing for Chlamydia and Gonorrhea Pharynx and Rectum Pharynx receptive oral sex with male partner Rectum receptive anal sex No NAAT testing available for pharyngeal or rectal sites in Ontario. Chlamydia: viral swab in pink media Gonorrhea: bacterial swab in charcoal media. 25

26 Case #1 (cont d) She agrees to a pelvic examination with cervical swabs for chlamydia and gonorrhea as well as baseline syphilis and HIV testing. Results are negative. She will return in 3 months to repeat syphilis and HIV testing when she is out of the window periods. 26

27 Case #2: 38-year-old male who presents with purulent urethral discharge, burning at the urethral meatus and dysuria. 27

28 Case #2 (cont d) Denies any other symptoms. He reports 4 casual male partners in the last 60 days, 2 of whom were anonymous. Has had unprotected oral contact (performing and receiving) with all partners, and protected receptive anal contact with two of the partners. 28

29 Case #2: (cont d) How would you test him? Pharyngeal swabs for Chlamydia and GC Rectal swabs for Chlamydia and GC Urine sample for Chlamydia NAAT Urethral swab for C+S for GC Serology for syphilis and HIV (to be repeated after window periods). Given that he is symptomatic, you decide to treat him empirically. 29

30 Chlamydia Treatment Preferred: Azithromycin 1g x 1 dose or Doxycycline 100 mg po bid x 7 days Alternate: Ofloxacin 300 mg po bid x 7 days or erythromycin (2 different dosing options) 30

31 Chlamydia Test of Cure Required when: Pregnant Pre-pubertal children Alternative treatment regimen Compliance suboptimal NAAT 3-4 weeks post-treatment (Pharyngeal or rectal infections: culture only) 31

32 GC Treatment PHO 2013 First line for uncomplicated GC in ALL clients over 9 years of age: Ceftriaxone 250 mg IM x 1 dose plus Azithromycin 1 g po x 1 dose WHY?? From: Guidelines for Testing and Treatment of Gonorrhea in Ontario

33 Gonorrhea Antimicrobial Susceptibility Increasing GC resistance to all available classes of antibiotics. Multi-drug resistant GC rapidly evolving Reduced effectiveness of single dose treatment regimens worldwide. Cephalosporin co-resistance with penicillin, tetracyclines, quinolones; not yet with macrolides. 33

34 Gonorrhea Antimicrobial Susceptibility Ontario Data Limited data re. resistance due to widespread use of NAAT. In Ontario, 10% of GC isolates in 17 jurisdictions had decreased susceptibility to cefixime. At least 9 clinical treatment failures of GC with oral cephalosporins in Ontario. 34

35 Cephalosporin Resistance in Ontario Ontario Comparison of Cefixime MIC for Neisseria gonorrhoeae Isolates in 2005 and 2011 Source: unpublished data from the Canadian Neisseria gonorrhoeae surveillance program, Courtesy of the National Microbiology Laboratory, Public Health Agency of Canada. MIC - minimum 35

36 Ceftriaxone 250 mg IM IM injection to gluteal region. Ceftriaxone 250 mg powder in single use vial Re-suspend with 0.9 ml 1% lidocaine (or water if lidocaine allergy) Give at same time as Azithromycin 1g po x 1 dose. 36

37 Gonorrhea Test of Cure Required when: First-line regimen not used Pharyngeal or rectal infection Pregnancy Persistent signs/symptoms post-treatment Previous treatment failure Documented reduced cephalosporin susceptibility on culture (MIC >= 0.12 mcg/ml), or sexual contact with cephalosporin-resistant GC case. PID or disseminated gonococcal infection Re-exposure to an untreated partner Concern over a false-positive non-culture result. 37

38 Gonorrhea Test of Cure Ideally with C+S 3-4 days posttreatment If NAAT: 2 weeks post-treatment 38

39 CT and GC: Other Counselling Points For oral medication, re-treat if emesis <1 hour post-treatment. Abstain from sexual contact for at least 7 days (14 days if PID or epididymitis). Condom use to decrease transmission and prevent re-infection. Case reporting/contact tracing through Public Health Repeat STI screening in 6 months For women: higher risk of infertility, ectopic pregnancy. 39

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41 Case #2 Treatment You treat him with: Azithromycin 1 g po x 1 dose and Ceftriaxone 250 mg IM x 1 dose. Test results received 3 days later urethral C+S positive for GC, MIC <0.12 mcg/ml for Ceftriaxone. Chlamydia, Syphilis and HIV testing are negative 41

42 Resources Public Health Unit Contact your local Public Health Unit for: Free condoms Free antibiotics for STI treatment Patient handouts re. STIs, contraception (e.g. index.html Case Management support for reportable infections 42

43 Case #3: 25-year-old woman who was referred to your clinic by a previous partner who tested positive for Chlamydia. She is asymptomatic and wondering if she needs to be tested and treated? YES! 43

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45 Case #3 cont d Denies any increased discharge or abdominal pain Normal speculum and bimanual examination; IUD string visible. You send cervical swabs for NAAT for CT and GC and treat her with Azithromycin 1 g x 1 dose. Her tests come back and she is +ve for CT and negative for GC 45

46 Case #3 - continued The patient returns to your office 1 month later. She vomited ½ hour after taking the azithromycin 1g, but did not return for re-treatment. Now she is having lower abdominal pain and continued discharge. What are you worried about? 46

47 Pelvic Inflammatory Disease Infection of the female upper genital tract involving any or all of endometrium, fallopian tubes, ovaries, pelvic peritoneum, adjacent structures (e.g. perihepatitis) Polymicrobial infection sexuallytransmitted and endogenous organisms. 47

48 Rates of Hospitalization for PID 48

49 PID Risk Factors Past history of PID Multiple partners, symptomatic partner Age (15-25) Unprotected sex After first 3 weeks following insertion, IUDs DO NOT increase the risk of PID. 49

50 PID - Sequelae Short term: Tubo-ovarian abscess, perihepatitis Long term: Infertility, ectopic pregnancy, chronic pelvic pain. 50

51 PID - Diagnosis Low threshold for treatment if minimum criteria met, risk factors, no other clear cause. 51

52 PID - Assessment Abdominal, pelvic examination including bimanual exam Cervical swabs for GC, CT (Other STI Testing) Vaginal swabs for BV, Trich Beta-HCG to rule out ectopic pregnancy If unsure of diagnosis, ultrasound, CBC, ESR. 52

53 Case #1 continued. Negative HCG; T 37.5C Tender lower abdomen, no guarding or rebound, tender inguinal lymph nodes bilaterally. Speculum exam mucopurulent discharge, cervicitis. Bimanual examination moderate cervical motion tenderness, uterine and adnexal tenderness. No masses. 53

54 PID Outpatient Treatment Low threshold for treatment Regimen 1: Ceftriaxone 250 mg IM x 1 dose Doxycycline 100 mg po bid x 14 days +/- metronidazole 500 mg po bid x 14 days. Regimen 2: ofloxacin 400 mg po bid x 14 days +/- metronidazole 500 mg po bid x 14 days. (Note: does not cover for gonorrhea) Always re-assess in 2-3 days. 54

55 PID Treatment Send to ED if: Unable to exclude surgical emergency. Pregnant. No improvement at reassessment in 2-3 days. Severe illness, high fever or unable to tolerate oral treatment. 55

56 Case #3 cont d Should you remove her IUD? Not necessary - can treat with IUD in place. If patient would like IUD removed, treat with 1-2 doses prior to removal. If no improvement at re-assessment in 2-3 days, consider removal of IUD. 56

57 PID Take-home messages Clinical diagnosis - maintain high index of suspicion. Minimum Criteria: Lower abdominal tenderness, adnexal tenderness, CMT. Testing for: GC, Chlamydia, vaginal swabs, B- HCG. (Other STIs including HIV) Always re-assess in 2-3 days; no sexual contact until treatment complete. To ED if pregnant, poor response to oral treatment, fever or severe symptoms, abscess Do not need to remove IUD for first occurrence of PID. Warn about risk of ectopic, infertility. 57

58 Case #4 - Persistent Urethritis? 26-year-old male with a 2-week history of itching at the distal urethra, mild dysuria and clear discharge. 58

59 Case #4 cont d Seen 10 days ago at another clinic, treated empirically with Azithromycin 1g po x 1 dose. Does not recall giving urine sample for testing. Symptoms never resolved, returning for re-assessment. 59

60 Recurrent or Persistent Urethritis? Re-infection vs non-resolution? Did he complete medication regimen? Right medication? Right dose? Antibiotic resistance? A different pathogen than the one treated? 60

61 Other Causes of Urethritis: Mycoplasma Ureaplasma Trichomonas HSV Adenovirus Candida 61

62 Case #5 19-year-old woman, 2-day history of painful ulcers in the vulvar area. New partner for 3 months who denies any history of similar symptoms. Partner has history of cold sores. No fevers, no systemic symptoms. Bilateral tender inguinal lymphadenopathy. 62

63 HSV - Epidemiology No current Ontario data re. prevalence of HSV1 and HSV BC data: 17% HSV2 antibodies in leftover serum from antenatal testing Prevalence increasing, variable incidence. Proportion HSV1 vs HSV2 dependent on geographical area, age of patient. HSV1 (fewer recurrences) vs HSV2 (more frequent recurrences; asymptomatic viral shedding). Can be transmitted within long term discordant couples. Prior HSV1 infection increases likelihood of subclinical HSV2 acquisition [1] 63

64 HSV Transmission and Pathogenesis Virus contacts mucosal surface or small crack in skin. Infects cells of dermis and epidermis. Sensory nerve endings become infected, latency in sacral ganglia. Viremia on infection in 25% of patients. [1] Average incubation period 6 days. 64

65 HSV Transmission and Pathogenesis Higher risk of transmission in women, HIV +ve. In heterosexual couples: females at higher risk of acquiring from male partner than vice versa (11-17% vs 3-4%/year) [2] With HSV2, 70% of transmission during asymptomatic shedding. (Less with HSV1) Regular condom use decreases risk by 50%. HSV at least doubles risk of acquiring HIV. 65

66 HSV Diagnosis HSV culture use viral culture media Improve sensitivity by: Swab lesion as soon as possible. [1] Where possible, sample vesicle fluid rather than ulcer base. [1] Moisten swab with media prior to swabbing lesion. Clinical pearl: swab any open areas for HSV! 66

67 Role of serology? 70% seroconvert 12 weeks after exposure HSV Serology generally not useful unless Type-specific 67

68 Role of Serology? Type-specific serology: History of genital lesions, cultures have never been positive. Prior to or during pregnancy in a woman whose partner is known to have genital HSV. In presumed sero-discordant couples where infected partner is considering starting or stopping suppressive therapy. Screening of asymptomatic individuals not currently recommended. 68

69 HSV Primary Outbreak - Presentation 60% of people with HSV have never had a primary outbreak Of 40% who are symptomatic with contracting virus, 80% have painful, extensive vesicular +/- ulcerative lesions. Atypical presentation in other 20% - includes genital pain, urethritis, cervicitis, aseptic meningitis Tender regional lymphadenopathy (80%) 50-60% have systemic symptoms 10-28% extragenital lesions; Generally resolve in 16 days (men), 23 days (women) 69

70 HSV Treatment First Episode Oral antivirals (as topical antivirals ineffective) Other treatment for symptom control (e.g. analgesia, laxatives) Clinical Pearl: Treat with antivirals even if patient presents >5 days after onset of symptoms to decrease likelihood of recurrence within first month. 70

71 Treatment for First Episode 71

72 HSV Reactivation Symptomatic or asymptomatic. More localized lesions and shorter duration than primary outbreak Often in response to triggers (e.g. stress) More frequent in HSV2 than HSV1; 75% of mucosal reactivations of HSV2 are subclinical (i.e. asymptomatic shedding). Prodromal symptoms (50%) Purpose of episodic treatment to decrease duration and severity of sx. 72

73 HSV Treatment Recurrences 73

74 HSV Suppressive Therapy Decrease likelihood of reactivations (symptomatic or asymptomatic) during treatment by about 50%. Valacyclovir reduced transmission by 50-75% (proportion of days with asymptomatic reactivations from 10% to 2%) [5] Generally recommended for: Frequent recurrences (>6/yr) Last 4 weeks of pregnancy Other reasons on a case-by-case basis Partner of pregnant woman? 74

75 HSV Suppressive Therapy 75

76 Case #2 cont d You send a swab for HSV culture, and treat her for a primary infection. Her results are back 2 weeks later, and are positive for HSV1. How will you counsel her? 76

77 HSV - Patient Counseling First occurrence is generally most severe! Chronic illness, likelihood of reactivations both symptomatic and asymptomatic. Risk of transmission can be decreased by: Using condoms (appears to decrease transmission by 50%) Daily suppressive antiviral therapy (can decrease transmission by 50%) Avoiding contact between onset of prodrome and when lesions have completely healed. 77

78 HSV Patient Counseling (2) Higher risk of acquiring HIV when lesions present. Episodic treatment options for reducing severity and duration of individual outbreaks. Suppressive treatment if >6 outbreaks/year, pregnant, or HSV-negative partner is pregnant. Advise both men and women of risks of neonatal HSV. Prenatal caregivers need to be advised if either pregnant woman or her partner has HSV. 78

79 HSV Neonatal Herpes 65% mortality, 80% long term disability even with anti-retroviral therapy. Generally transmitted to baby during delivery. Higher risk of transmission with primary infection in late 3 rd trimester (30-50%) than reactivation at delivery (<1%); Primary HSV1 has particularly high likelihood of transmission. Due to high prevalence, most cases related to reactivation. 79

80 SOGC Guidelines for Management of HSV in Pregnancy (2008) Advise re. risks of neonatal HSV early in pregnancy Antiviral therapy from 36 weeks, c-section if prodrome or lesion suggestive of HSV. C-section for women with primary HSV infection in 3 rd trimester For serodiscordant couples, type specific serology early in pregnancy, again at weeks. 80

81 HSV - References 1. Schiffer JT, Corey L: New concepts in understanding genital herpes. Current Infectious Disease Reports 2009, 11: Public Health Agency of Canada: Canadian Guidelines on Sexually- Transmitted Infections Lebrun-Vignes B, Bouzamondo A, Dupuy A et al.: A meta-analysis to assess the efficacy of oral antiviral treatment to prevent genital herpes outbreaks. Journal of the American Academy of Dermatology 2007, 57: Gupta R, Wald A, Krantz E et al. Valacyclovir and acyclovir for suppression of shedding of herpes simplex virus in the genital tract. Journal of Infectious Diseases 2004; 190: Corey L, Wald A, Patel R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med 2004;350: Patel R, Rompalo A. Managing Patients with Genital Herpes and their Sexual Partners. Infectious Disease Clinics of North America 2005: 19:

82 Resources Public Health Agency of Canada: Canadian Guidelines on STIs. Peer-reviewed Evidence-based For all except gonorrhea 82

83 Guidelines for Testing and Treatment of Gonorrhea in Ontario pic/infectiousdiseases/pages/gonorrhea- Guideline.aspx Guidelines released by Public Health Ontario in May 2013 Full report and 2-page summary reference sheet. Based on provincial epidemiology and resistance data (rather than PHAC which is based on national.) 83

84 Syphilis Resources Toronto Public Health Syphilis Lab Interpretation and Treatment _diseases/pdf/syphilis_lab_interpretation.pdf PHAC Chapter on syphilis: 84

85 Other Resources Edwards L, Lynch PJ. Genital Dermatology Atlas 2 nd Ed, Wolters Kluwer/Lippincott Williams and Wilkins Sexually-Transmitted Diseases 4 th Ed, McGraw-Hill Medical NACI Update on Human Papillomavirus Vaccines: Center for Disease Control (CDC): 85

86 Update on STIs Questions? 86

87 Case #5 23-year-old man who has come to see you about a 1 month history of some bumps on his penis here. 87

88 And here 88

89 Human Papilloma Virus Skin-to-skin transmission, field effect Occasional vertical transmission/oral lesions. Multiple serotypes: Low risk types cause genital warts High risk types cause anogenital cancer Most common types: Low risk - 6, 11 High risk 16, 18 89

90 HPV Risk Factors Number of sex partners! Other presumed risk factors: Smoking/exposure to smoke. Age at first sexual contact. Long term OCP use. Other STIs. Poor diet. Immune suppression. Genetic susceptibility. 90

91 AGW - Counseling Anogenital warts (AGW) NOT cancer! Caused by low risk types of HPV (most common types: 6 and 11) Most common STI - lifetime incidence of HPV infection: 50-70% 1.1% of sexually active adults have AGW at any given time. Transmission skin-to-skin; decreased but not eliminated with condom use. Incubation period 1-8 months or longer (for AGW) 91

92 AGW Counseling (2) Lifestyle changes smoking cessation, diet, exercise % resolve without intervention within 6 months; 80% clear virus within 2-3 years. Multiple treatment options HPV vaccine can prevent acquisition of other HPV types For anal warts: needs DRE or anoscopy to rule out internal AGW. 92

93 AGW Self-Applied Treatment Options Modality Method Advantages Disadvantages Podophyllotoxin (0.5% solution Imiquimod cream (5% 3x/wk) (3.75% daily) Apply q12hours for 3 days each week Maximum: 6 weeks Apply at hs, wash off in AM for maximum 16 weeks (5%), maximum 8 weeks (3.75%) Low cost, low toxicity Easier to use, efficacious, low recurrence rates Variable penetration, contraindicated in pregnancy, ulceration, application difficult; not on mucosal surfaces. High cost, delayed response, irritation. Source: SOGC HPV Guidelines 93

94 AGW Provider-Applied Treatment Options Modality Method Advantages Disadvantages Trichloroacetic acid (85%) (weekly x 4-6 weeks) Cryotherapy (liquid nitrogen, CO2) Laser Vaporization Apply directly to lesions, petroleum gel to surrounding area. Blanch lesion and allow to thaw x 3 per treatment Low cost, safe in pregnancy, easy to use, low potential for systemic reactions, can be used on mucosal surfaces. Safe in pregnancy, easy to use, no systemic reactions, can be used in all areas. Efficacious, precise, no systemic reactions Source: SOGC HPV Guidelines Variable penetration, pain, ulceration. Pain, ulceration, duration of treatment, risk of scarring. High cost, training needed, pain, long healing time. 94

95 When is a referral needed? For biopsy: Massive, non-healing, ulcerated warts Bleeding, persistent pruritis, recalcitrant For surgical removal: Warts in urethral meatus Internal anal warts 95

96 HPV - Vaccines Do you offer him the HPV Vaccine? Why? Which one? Prevention of infection with additional HPV types, HPV-related cancers. Bivalent (16, 18) women 9-26 Quadrivalent (6, 11, 16, 18) recommended by NACI for women 9-45, men 9-26, and all MSM 96