Clinical Guidelines Update (aka Know Your NAATs)

Transcription

1 Clinical Guidelines Update (aka Know Your NAATs) WARNING: contains adult themes, sexual references and pictures that may be disturbing! Dr Heather Young Christchurch Sexual Health Centre

2 Updates Swab taking MSM testing guidelines STI serology includes hepatitis C testing recommendations Epidemiology

3 Disclosures NZSHS Guidelines Writing Group Professional Advisory Board of STIEF Why?

4 Resource website Responsive, central repository Collaborative links Youth STI information

5 Publications

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8 There is insufficient evidence to recommend pharyngeal testing in females who report fellatio - other than for contacts of STIs (especially gonorrhoea) or for sex workers with specific risk factors There is insufficient evidence to recommend pharyngeal testing for heterosexual males

9 Framing a sexual history As part of your general health I need to update myself on your sexual health and whether you might have any symptoms or concerns I could help you with When was the last time you had a sexual experience? How many different persons have you had sexual contact with in the last 3 months? Were the persons male or female or both? What types of sex did you have (oral? vaginal? anal?) and were they with or without a condom?

10 Swabs???

11 Goo or No Goo Culture swab (Amies agar/transport media) versus other

12 What is a NAAT? Nucleic Acid Amplification Test Highly sensitive method of amplifying target organism DNA, RNA or protein Doesn t require live organisms (no goo in the swab) Particularly good for picking up infection where there are low numbers of organisms such as asymptomatic patients or extragenital sites Sensitivity allows for sampling from different sites +/- self sampling methods Extraction (DNA/RNA) Amplification /hybridization Detection

13 Technology Company Isothermal Target Enzymes PCR Roche Abbott No DNA DNA polymerase TMA Gen Probe Yes RNA Reverse transcriptase + RNA polymerase NASBA SDA Organon Teknika Becton Dickinson Yes RNA Reverse transcriptase, Rnase H, RNA polymerase Yes DNA DNA polymerase + Restriction endonuclease

14 STI Testing asymptomatic screen Female vulvovaginal NAAT swab (independent of condom use - may be self inserted) +/- Anorectal NAAT swab (independent of condom use - may be self inserted) Male first catch urine +/- Pharyngeal NAAT swab (MSM) +/- Anorectal NAAT swab (MSM) (independent of condom use may be self inserted)

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18 Symptomatic Testing Symptomatic females require speculum visualisation Symptomatic patients require gonorrhoea culture (standard culture swabs) in the usual way eg endocervix, urethral, rectal Add a high vaginal culture swab for females for BV/Trich/thrush Don t forget pharyngeal and anorectal NAAT swabs Any +ve NAAT gonorrhoea results require culture (if available) prior to antibiotic treatment Some sentinel laboratories will continue doing gonorrhoea culture for resistance surveillance

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20 Serology BASHH and CDC recommend routine HIV and syphilis serology and have amended hepatitis B testing from universal to targeted testing of risk groups. MOH immunisation handbook has specific NZ recommendations regarding groups requiring testing. Hepatitis C testing is targeted. ASHM have specific recommendations regarding groups to be tested

21 Addition of Contact Tracing Letters Management of sexual contact of a person diagnosed with Date Dear Dr Chlamydia May we suggest that you screen for chlamydia, gonorrhoea, and other sexually transmissible infections, including pharyngeal and/or rectal swabs as indicated plus serology for syphilis, Hepatitis B and HIV. New Zealand guidelines recommend empiric treatment of sexual partners, irrespective of negative test results. Treatment is with Azithromycin 1.0grams orally as a stat dose or Doxycycline 100mg twice a day for 1 week plus condoms. Gonorrhoea or chlamydia diagnosed on testing should be treated appropriately. See NZ Sexual Health Society Abstinence from sexual intercourse is recommended until 1 week after both partners have been treated. Sincerely

22 Gonorrhoea DUAL therapy has been the standard for gonorrhoea treatment since 2011 irrespective of chlamydia test results to delay the onset of ceftriaxone resistance and to improve clearance of pharyngeal infection Ceftriaxone 500mg IM + azithromycin 1g P.O (for uncomplicated gonorrhoeal infection) From October 1 st 2005 ceftriaxone and azithromycin have been available on Section E Part 1 of the MPSO Extragenital gonorrhoea or gonorrhoea in pregnancy requires a test of cure in 3 to 5 weeks

23 Total Gono stats Christchurch SHC, 2014 Total isolates available for susceptibility testing = Sensitive% Intermediate Resistant% Cipro Tetr Peni Cxon Number of positive patients 70 Average age 37yrs >50% exclusively from throat or rectal sites Number culture positive 48 % Male 93% Age range 17-75yrs % Female 7%

24 35 N.gonorrhoeae Ceftriaxone MIC: % at each level,

25 National chlamydia rates,

26 Chlamydia Rectal chlamydia is treated with 1 week of doxycycline 100mg bd Evidence suggests concomitant rectal and cervical infection in females is more common than previously thought There is a slight advantage of doxycycline over azithromycin for symptomatic chlamydial urethritis but only where compliance is assured Extragenital chlamydia and chlamydia in pregnancy requires a test of cure in 5 weeks Rectal chlamydia with proctitis symptoms may be referred to Sexual Health Clinics for consideration of LGV testing

27 Syphilis cases in New Zealand SHCs 70 Infectious syphilis diagnosed at Sexual Health Clinics in New Zealand* *Includes heterosexual males and females. Source: ESR STI Clinic Surveillance: Quarterly Reports Apr-Jun 2015

28 Syphilis and Sexual Behaviour The infectious syphilis outbreak in Christchurch continues and is evolving cases median age 42yrs cases median age 24yrs cases median age 37.5yrs cases all male all male all male 2 females median age 35yrs (range 18-74) (June 30 th ) median age 29.5yrs 3 females

29 Test for Syphilis All men who have sex with men (annually) Any male with a rash or genital symptoms Unusual clinical presentations eg lymphadenopathy, unexplained abnormal liver function tests, alopecia, PUO Any person with a rash on the palms or soles Any genital ulceration Refer painless or HSV-negative genital ulcers to the Sexual Health Clinic

30 Thank You

31 Acknowledgements Dr Edward Coughlan Clinical Director CSHS New Zealand Gonorrhoea Guideline Writing Group Julie Creighton - CHL Maureen Coshall Health Advisor Christchurch Sexual Health Selina Takanashi ESR Joe Rich - NZAF