STIs in Primary Care. Dr Eleanor Draeger 19 th January 2016

Transcription

1 STIs in Primary Care Dr Eleanor Draeger 19 th January 2016

2 Poli=cs! 2012! Health and Social Care act! Sexual Health commissioning moved to local authority! 2015! 200 million cuts to public health! 40% reduc=on in local authority spending! 2017! University Hospital Bristol awarded contract for integrated sexual health in Bristol, North Somerset and South Glos

3 Number of STI diagnoses among women: England, ,000 45,000 40,000 Herpes: anogenital herpes Gonorrhoea Warts: anogenital warts (first episode) Syphilis: primary, secondary & early latent Number of diagnoses 35,000 30,000 25,000 20,000 15,000 10,000 5, Year Data from routine GUM service returns Chlamydia data excluded due to high numbers (see slide 14) Data type: service data 12 Public Health England: 2015 STI Slide Set

4 Number of STI diagnoses among men: England, ,000 45,000 40,000 Herpes: anogenital herpes Gonorrhoea Warts: anogenital warts (first episode) Syphilis: primary, secondary & early latent Number of diagnoses 35,000 30,000 25,000 20,000 15,000 10,000 5, Year Data from routine GUM service returns Chlamydia data excluded due to high numbers (see slide 13) Data type: service data 11 Public Health England: 2015 STI Slide Set

5 Total number of chlamydia diagnoses among women: England, , ,000 GUM services Community services Number of diagnoses 100,000 80,000 60,000 40,000 20, Year Data from routine GUM service returns & chlamydia data from community services Chlamydia data from 2012 onwards are not comparable to data from previous years (please see Notes slide for more details) Data type: service data 14 Public Health England: 2015 STI Slide Set

6 Total number of chlamydia diagnoses among men: England, ,000 90,000 80,000 GUM services Community services Number of diagnoses 70,000 60,000 50,000 40,000 30,000 20,000 10, Year Data from routine GUM service returns & chlamydia data from community services Chlamydia data from 2012 onwards are not comparable to data from previous years (please see Notes slide for more details) Data type: service data 13 Public Health England: 2015 STI Slide Set

7 Ways STIs can present! Discharge vaginal, rectal or urethral! Itching! Pain dysuria, abdominal, rectal, dyspareunia! Lumps! Ulcers / rashes! Asymptoma=c

8 Vaginal Discharge Infec=ous! Gonorrhoea! Chlamydia! Trichomonas! Bacterial Vaginosis! Thrush Non- infec=ous! Physiological! Inflammatory! Foreign Body! Fistulae! Trauma

9 Thrush or BV?! THRUSH! BV! Thick, white discharge! O^en itchy! Superficial dyspareunia! External dysuria! Thin, watery discharge! Not itchy! Offensive smell! Abdominal pain

10 Thrush! Candida albicans (80-92%) Ø Ø Normal commensal organism in vagina Infec=on when Corynebacterium suppressed! Approx 75 % of have Candida at least once in life=me

11 Thrush Treatment! Topical! Clotrimazole pessary nocte! Clotrimazole cream top bd! Oral! Fluconazole 150mg once (contraindicated in pregnancy)! Rule out diabetes/hiv/immunosuppression if it recurs! Refer to GUM if 4 episodes in a year

12 Bacterial Vaginosis (BV)! Commonest cause of abnormal vaginal discharge! Overgrowth of commensal bacteria! Gardnerella vaginalis! Mycoplasma hominis! Associated with:! Non- white ethnicity; IUD; Douching; Use of sex toys! Anal sex prior to Vaginal sex

13 Is BV an STI?! YES! NO! Lower mean age of first having sex! New or mul=ple partners! Not using condoms! Associated with Chlamydia and GC! Similar rates in sexually and non- sexually ac=ve teens! Trea=ng partners doesn t reduce recurrence! Spontaneous onset and remission

14 BV treatment Treatment Metronidazole 400mg po bd 5/7 Metronidazole 2g po stat Metronidazole PV gel 0.75% daily 5/7 Clindamycin PV cream 2% daily 7/7 Cure rate at 1 month 78-88% 72-73% 71-79% 61-94%

15 What tests should I do?! Chlamydia / Gonorrhoea! TV NAAT (if available)! HVS! HIV/STS

16 Urethral Discharge! Ideally all men with urethral discharge should have microscopy! Blind treatment should be done only if no microscopy available! MC&S recommended as well as NAATs

17 Chlamydia! Caused by Chlamydia Trachoma1s! Most common bacterial STI in UK! 5-10% of men and women under 24 infected! 186,000 cases in 2011 in UK! Transmimed via! Oral, anal and vaginal sex! Genital contact! Ver=cal transmission

18 Chlamydia presenta=on! WOMEN! Endocervix! 70-80% asymptoma=c! Can cause discharge and abdominal pain! Rectal! Almost all asymptoma=c! Pharyngeal! Can cause symptoms, but mostly asymptoma=c! MEN! Urethral! 50% asymptoma=c! If symptoma=c: Dysuria; Discharge; Tes=cular pain! Rectal! Almost all asymptoma=c! If symptoma=c, suspect LGV

19 Chlamydia Treatment! Azithromycin 1g stat! Doxycycline 100mg bd for 7 days! In pregnancy! Azithromycin (unlicensed, but safe) 1g stat! Could use Erythromycin

20 Gonorrhoea! Caused by Neisseria Gonorrhoeae! 2 nd most common bacterial STI in UK! Transmimed via! Oral, anal and vaginal sex! Sharing sex toys! Genital contact! Ver=cal transmission (at delivery)

21 Number of gonorrhoea diagnoses by sexual risk: England, ,000 Heterosexual men MSM Heterosexual women WSW 20,000 Number of diagnoses 15,000 10,000 5, Year Data from routine GUM service returns Data type: service data 21 Public Health England: 2015 STI Slide Set

22 Gonorrhoea - Presenta=on! MEN! Urethral! Discharge (>80%)! Dysuria (>50%)! Asymptoma=c (<10%)! Rectal! Anal discharge (12%)! Pain/discomfort (7%)! Pharyngeal! Usually asymptoma=c (>90%)! WOMEN! Endocervical! Discharge (up to 50%)! Lower abdominal pain (25%)! Asymptoma=c (>50%)! Urethral! Dysuria (12%) but no frequency! Rectal! Almost all asymptoma=c! Pharyngeal! Usually asymptoma=c (>90%)

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24 Ophthalmia Neonatorum! Typically shows within 1 st 5 days of life! Can be complicated by corneal ulcera=on and blindness if untreated! Don t forget to test the parents

25 Gonorrhoea Treatment! Ce^riaxone 500mg (2 vials of 250mg) IM PLUS! Azithromycin 1g PO! Before treatment of GC! send MC&S (charcoal) swab! Even if pa=ent asymptoma=c and/or contact BASHH UK na=onal guideline for the management of gonorrhoea 2011

26 Alterna=ve Treatment! Pt refuses injec=on! Cefixime 400mg PLUS Azithromycin 1g! Severe penicillin allergy! Azithromycin 2g po stat OR! Spec=nomycin 2g im stat

27 What tests to do - WOMEN * Asymptoma=c * Vulvo- vaginal NAAT * Asymptoma=c GC contact * NAAT and MC&S from all relevant sites * Symptoma=c GC contact or high risk * NAAT and MC&S from all relevant sites * Microscopy if possible Where did the penis go?

28 What tests to do - MEN * Asymptoma=c * Urine NAAT (+ throat and rectal if MSM) * Asymptoma=c GC contact * NAAT and MC&S from all relevant sites * Symptoma=c GC contact or high risk (MSM) * NAAT and MC&S from all relevant sites * Microscopy if possible Where did the penis go?

29 Do I have to do a speculum?

30 Data from Leeds! Comparison of VVS and endocervical swabs to detect chlamydia! 3973 women in an urban sexual health centre! All pa=ents took a VVS before rou=ne examina=on! Clinicians took endocervical swab during examina=on Schoeman et al; Assessment of best single sample for finding chlamydia in women with and without samples: a diagnostic test study: BMJ Dec 12;345:e8013. doi: /bmj.e8013.

31 Leeds Results! Overall 10.3% were infected with Chlamydia! Sensi=vi=es: Symptoma,c Asymptoma,c Vulvo- Vaginal Swab Endocervical swab 97% 97% 88% 89%

32 Drug Resistant Gonorrhoea! Ciprofloxacin resistance! 10-40% in 2011! Cefixime resistance! 2-15% in 2011! Azithromycin resistance! 0.5% in 2011! Spec=nomycin! 0% in 2011 Source: GRASP programme, HPA hmp://

33 2011

34 2015

35 Terminology is everything! MSM men who have sex with men! Not all MSM iden=fy as gay! Ques=ons to ask:! When did you last have sex?! Was that with a man or a woman or both?! Pa=ents are only embarrassed if you are

36 MSM Sexual Health! 2-5% of the male popula=on is es=mated to be MSM! In 2013 >80% of all syphilis diagnoses in men were in MSM >60% of GC diagnoses in men were in MSM

37 Take- home messages! Symptoma=c men should be offered microscopy! Swab and culture ALL relevant sites! Don t forget TOC and partner no=fica=on

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39 Take home messages! Many simple STIs can be diagnosed and treated in primary care! MSM should be directed to GUM! Don t forget partner notification! If in doubt, examine the patient

40 Questions?