MYCOPLASMA GENITALIUM A PRACTICAL GUIDE

Transcription

1 MYCOPLASMA GENITALIUM A PRACTICAL GUIDE DR JENNY HAYWARD FRANZCOG FACHSHM NEW ZEALAND SEXUAL HEALTH CONFERENCE SATURDAY 9 TH SEPTEMBER 1

2 ACKNOWLEDGE FRUSTRATIONS AWARENESS EVOLVING AREA TESTING OFTEN MULTIPLE ANTIBIOTICS OFTEN MULTIPLE PRACTITIONERS ANTIBIOTIC RESISTANCE ACCESS TO TREATMENT TIMEFRAMES 2

3 MYCOPLASMA GENITALIUM A PRACTICAL GUIDE WHO TO TEST TESTS FROM WHERE WITH WHAT MANAGEMENT OF POSITIVE TESTS TREATMENT SEXUAL CONTACTS TEST OF CURE 3

4 BOTTOM LINE DOXYCYCLINE FIRST LINE FOR NON GONOCOCCAL URETHRITIS TALK TO LABORATORY PREVENTION REINFECTION - CONDOMS CAN BE FRUSTRATING ASK ADVICE MYCOPLASMA IS ONE OF THE CAUSES OF URETHRITIS 4

5 TESTING WHO SYMPTOMATIC RECURRENT OR PERSISTENT URETHRITIS PID NOT RESPONDED TO TREATMENT CERVICITIS NOT RESPONDED TO TREATMENT CONTACTS LAST 3/12 HOW URETHRAL FVU CERVICAL RECTAL BE VERY CLEAR ON LAB FORM WHAT YOU ARE REQUESTING 5 TEST OF CURE 3/52

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7 MANAGEMENT OF POSITIVE TESTS TREATMENT 500MG OF AZITHROMYCIN DAY 1, THEN 250MG DAILY DAYS 2-5 IF ALREADY HAD AZITHROMYCIN MOXIFLOXACIN 400MG DAILY FOR 7 DAYS - SPECIAL AUTHORITY MACROLIDE RESISTANT MOXIFLOXACIN 400MG DAILY FOR 7 DAYS SPECIAL AUTHORITY APPLY FOR WAIVER 7

8 RE SPECIAL AUTHORITY APPLICATIONS. IF YOU HAVE ANY QUERIES REGARDING THE PROCESSING OF PAPER BASED OR DECLINED SPECIAL AUTHORITY APPLICATIONS, PLEASE CONTACT SECTOR SERVICES ON CALL TO DISCUSS FAST-TRACKING APPLICATION AND WAIVERS 8

9 MANAGEMENT OF POSITIVE TESTS DISCUSS CONDITION GIVE WRITTEN INFORMATION CONTACT TRACING 3/12 AVOID REINFECTION NO SEX UNTIL 1/52 POST TREATMENT THEN CONDOMS UNTIL NEG TOC 1/52 FOLLOW UP VISIT/CALL TOC 3/52 9

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11 FOLLOW UP RESULTS 1/52 FOLLOW UP VISIT/CALL SYMPTOM RESOLUTION ADHERENCE TO TREATMENT CONTACT TRACING RISK REINFECTION REMIND RE NO SEX UNTIL 1/52 AFTER COMPLETION TREATMENT THEN CONDOMS UNTIL NEGATIVE TOC BOOK TOC IF NOT ALREADY DONE SO ADD TO RECALL SYSTEM TEST OF CURE 3/52 IF POSITIVE TREATMENT DEPENDS ON: PREVIOUS TREATMENTS? REINFECTION? RESISTANT 11

12 MANAGEMENT SEXUAL CONTACTS BE CLEAR CONTACT OF M. GENITALIUM WRITE IT / TEXT IT / PRINT IT!!!!!!! CONTACTS PENILE / VAGINAL / ANO-RECTAL 3/12 TEST? TREAT BEFORE RESULTS SYMPTOMATIC AZITHROMYCIN 500MG DAY 1, 250MG DAYS 2-5 ASYMPTOMATIC DEPENDS ON HISTORY EXPOSURE NO SEX WITH SEXUAL CONTACTS FROM THE LAST 3 MONTHS UNTIL 7 DAYS AFTER BOTH THE PATIENT AND ONGOING SEXUAL CONTACTS HAVE COMPLETED THEIR TREATMENT, THEN CONDOMS UNTIL BOTH NEGATIVE TOC 12

13 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 1 FROM ONSET SYMPTOMS 1/52 Urethral irritation Penile discharge, clear WHAT DO YOU DO? Background 2/7 ago penetrative penile anal no condom, partner, regular sexual contact 3/52 ago receptive penile anal, condom, regular sexual contact 3/12 ago, penetrative penile vaginal, condom STI screening 12/12 ago NAD Nil else of note O/E NAD except clear colourless fluid urethral meatus 13

14 TREATMENT URETHRITIS DOXYCYCLINE 100MG BD 1/52 DISCUSS DIAGNOSIS URETHRITIS TEST CHLAMYDIA AND GONORRHOEA NAAT PO PA FVU SEROLOGY HIV, SYPHILIS EXPLANATION OF WHAT TESTING FOR INCLUDING WINDOW PERIODS ETC DISCUSS + OFFER CONDOM NO SEX UNTIL 7/7 AFTER COMPLETED TREATMENT CHECK CONTACT DETAILS FOR TEST RESULTS DISCUSS CONTACT TRACING LAST 2/12 FOLLOW UP 1/52 14

15 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 3 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS DOXYCYCLINE 100MG BD 1/52 WHAT DO YOU DO? 2/52 TESTS NAD CALLED TO GIVE RESULTS, NO ANSWER, DIDN T REPLY TO MESSAGES 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC HAS FOLLOWED YOUR ADVICE EXAM NAD 15

16 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 3 FROM ONSET SYMPTOMS Persistent urethritis o Discuss possible causes including M.genitalium o Testing M. genitalium FVU, rectal swab, timeframe results other testing as guided by history and exam findings o Treatment o Azithromycin 500mg day 1, then 250mg days Metronidazole 400mg bd 1/52 o If already treated with Azithromycin 1g, Doxycycline 100mg bd 1/52 o Re reinfection + transmission no sex until 1/52 post completion treatment 16 CONDOMS o Contact tracing 3/12

17 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 5 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM WHAT DO YOU DO? 18

18 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 5 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM PLAN DISCUSS + GIVE WRITTEN INFO CHECK SYMPTOMS CONTACT TRACING ENSURE THEY KNOW ITS M.GENITALIUM DISCUSSION TRANSMISSION REINFECTION CONDOMS IF ASYMPTOMATIC TOC 3/52 19

19 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 8 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM ASYMPTOMATIC 6/52 TEST OF CURE 8/52 NEGATIVE M GENITALIUM 20

20 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 5 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM IF STILL HAS SYMPTOMS WHAT DO YOU DO? 21

21 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 5 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM IF STILL HAS SYMPTOMS MOXIFLOXACIN 400MG OD 7/7 WRITTEN INFO DISCUSSION TRANSMISSION REINFECTION CONTACT TRACING ENSURE THEY KNOW ITS M.GENITALIUM CONDOMS 1/52 FOLLOW UP TOC 3/52 22

22 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 10 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM SYMPTOMATIC, MOXIFLOXACIN 400MG OD 7/7 8/52 TEST OF CURE 10/52 NEGATIVE M GENITALIUM 23

23 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 10 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM SYMPTOMATIC, MOXIFLOXACIN 400MG OD 7/7 8/52 TEST OF CURE 10/52 POSITIVE M GENITALIUM SEEK ADVICE! 24

24 32 YEAR OLD URETHRAL IRRITATION AND PENILE DISCHARGE WEEK 10 FROM ONSET SYMPTOMS TIME FROM ONSET SYMPTOMS 1/52 1 ST CLINIC APPOINTMENT HX, EXAM, TESTS, DOXYCYCLINE 100MG BD 1/52 3/52 CALLED CLINIC, STILL HAS SYMPTOMS, SEEN AT CLINIC STILL SYMPTOMATIC, HAS FOLLOWED YOUR ADVICE, EXAM NAD AZITHROMYCIN 500MG DAY 1, THEN 250MG DAYS 2-5 5/52 POSITIVE M. GENITALIUM SYMPTOMATIC, MOXIFLOXACIN 400MG OD 7/7 8/52 TEST OF CURE 10/52 NEGATIVE M GENITALIUM BUT WHAT ABOUT THE CONTACTS?! 1. 2/7 AGO PENETRATIVE PENILE ANAL NO CONDOM, PARTNER, REGULAR SEXUAL CONTACT 2. 3/52 AGO RECEPTIVE PENILE ANAL, CONDOM, REGULAR SEXUAL CONTACT 3. 3/12 AGO, PENETRATIVE PENILE VAGINAL, CONDOM 26

25 INDEX PERSONS PARTNER WEEK 4 SINCE INDEX PERSONS SYMPTOMS STARTED INDEX PERSONS PARTNER WEEK 4 SINCE INDEX PERSONS SYMPTOMS STARTED INDEX PERSON HAS HAD DOXYCYCLINE, NO BETTER, NOW HAVING AZITHROMYCIN 500MG D1, 250MG DAY 2-5 THEY HAVE REGULAR PENILE ANAL SEXUAL CONTACT CONDOMLESS AWARE MG TESTING, NO RESULT YET SYMPTOMATIC URETHRITIS BARRIERS TO CONDOM USE CLEAR URETHRAL DISCHARGE MEATUS WHAT DO YOU DO? 27

26 INDEX PERSONS PARTNER WEEK 4 SINCE INDEX PERSONS SYMPTOMS STARTED INDEX PERSONS PARTNER WEEK 4 SINCE INDEX PERSONS SYMPTOMS STARTED INDEX PERSON HAS HAD DOXYCYCLINE, NO BETTER, NOW HAVING AZITHROMYCIN 500MG D1, 250MG DAY 2-5 THEY HAVE REGULAR PENILE ANAL SEXUAL CONTACT CONDOMLESS AWARE MG TESTING, NO RESULT YET SYMPTOMATIC URETHRITIS BARRIERS TO CONDOM USE CLEAR URETHRAL DISCHARGE MEATUS PLAN TEST FVU + RECTAL SWAB EPIDEMIOLOGICAL TREATMENT WITH AZITHROMYCIN 500MG OD, 250MG OD DAYS 2-5 ALSO REITERATE NO SEX RESISTANT BUGS CONDOMS (DONT FORGET CONSIDERING OTHER CAUSES URETHRITIS, STI TESTING, FOLLOW UP RESULTS ETC) \ 28

27 ASYMPTOMATIC CONTACT 7 WEEKS FROM START INDEX PERSONS SYMPTOMS ASYMPTOMATIC CONTACT WHAT WOULD YOU DO? REGULAR ANAL RECEPTIVE AND INSERTIVE, CONDOMS NOT HAD SEX WITH INDEX CASE 7/52 TEXT SAYING TREATED STI BEEN TESTED AND NAD, ANOTHER SAYING?MG 29

28 ASYMPTOMATIC CONTACT 7 WEEKS FROM START INDEX PERSONS SYMPTOMS ASYMPTOMATIC CONTACT REGULAR ANAL RECEPTIVE AND INSERTIVE NOT HAD SEX WITH INDEX CASE 7/52 TEXT SAYING TREATED STI BEEN TESTED AND NAD, ANOTHER SAYING?MG AZITHROMYCIN 5/7 PLAN - TEST AND WAIT - IF SYMPTOMATIC - AZITHROMYCIN 500MG DAY 1, 250MG DAYS ALSO USUAL CONSULTATION HAVE WITH CONTACTS, STI TESTING ETC 30

29 ASYMPTOMATIC CONTACT 10 WEEKS FROM START INDEX PERSONS SYMPTOMS 3 /12 AGO WHAT DO YOU DO? RECEPTIVE PENILE VAGINAL CONDOM NO SYMPTOMS EXAMINATION NAD 31

30 ASYMPTOMATIC CONTACT 10 WEEKS FROM START INDEX PERSONS SYMPTOMS 3 1/12 AGO RECEPTIVE PENILE VAGINAL X1 CONDOM NO SYMPTOMS PLAN - TEST AND WAIT - IF SYMPTOMATIC / INDICATIVE FINDINGS -? ANY MORE INFORMATION AVAILABLE RE TEST RESULTS AND TREATMENTS? - AZITHROMYCIN 500MG DAY 1, 250MG DAYS ALSO USUAL CONSULTATION HAVE WITH CONTACTS, STI TESTING ETC 32

31 MYCOPLASMA GENITALIUM A PRACTICAL GUIDE USE DOXYCYCLINE FOR PEOPLE WHO PRESENT WITH URETHRITIS THAT YOU DON T THINK IS CAUSED BY GONORRHOEA M.GENITALIUM TREATED WITH AZITHROMYCIN 500MG DAY 1, 250MG DAYS 2-5 MOXIFLOXACIN 400MG OD 7/7 SPEAK TO SPECIAL AUTHORITY TEAM CAN FASTTRACK AND DO WAIVERS FOR MACROLIDE RESISTANT TESTING KNOW HOW TO ORDER SPEAK TO YOUR LAB WHAT TO USE BE CLEAR ON THE LAB FORM BE MINDFUL OF THE TIMEFRAMES AND POTENTIAL DELAYS! PRESENTATIONS, TESTING, RESULTS, APPROVAL FOR MEDS, GETTING THE MEDS, TAKING THE MEDS.TESTS OF CURE AND CONTACT TRACING WITH RISKS REINFECTION AS WELL AS RESISTANCE WRITE MYCOPLASMA GENITALIUM DOWN / TEXT / PRINT INFO FOR PEOPLE SO CONTACTS CAN BE TESTED AND TREATED APPROPRIATELY ASK FOR ADVICE 33

32 REFERENCES NZ SHS WEBSITE EUROPEAN GUIDELINES MG BASHH URETHRITIS SPECIAL AUTHORITY FORMS 34